Cold Chain and Logistics Management for Expanded … CHAIN AND LOGISTICS’ MANAGEMENT FOR EXPANDED PROGRAM ON IMMUNIZATION IN BUSIA AND NAMAYINGO DISTRICTS Mangeni Mathias Namuhaywa.

COLD CHAIN AND LOGISTICS’ MANAGEMENT FOR EXPANDED PROGRAM ON

IMMUNIZATION IN BUSIA AND NAMAYINGO DISTRICTS

Mangeni Mathias Namuhaywa.

Msc. HSM, BEHS, Ad. Dip HP&E, Cert. EHS, Cert. CH.

Head, Community Health - Dabani hospital, Tororo Catholic Arch Diocese

P.O.Box 1, Busia Uganda.

Tel: +256 772 648 129 / +256 702 648 129; Mail: [email protected]

EXECUTIVE SUMMARY

Cold chain and logistics’ management (CCLM) is a systematic process of coordinating resources so as to

ensure that vaccines given to people are safe and effective (Snow 2009) - vaccines are managed within

optimum temperature range (between +2°C and +8°C) from the manufacturer up to use. The objectives of

this study were to: establish the availability of EPI minimum supplies at all EPI service units; assess the

storage of EPI vaccines and related supplies at all EPI service units and assess availability of cold chain

and logistics management information system for EPI at all EPI service units; assess the logistics cycle

for at all EPI service units and to assess the organizational support systems (procedures and policies) used

in the distribution and inventory management of EPI supplies at all EPI service units. This was a cross-

sectional study that employed both qualitative and quantitative data collection techniques. A total of 59

respondents (EPI staff) were interviewed as respondents.

All the EPI service units had EPI vaccines available according to the EPI protocol. Both districts did not

have enough gas cylinders. All EPI service units had enough storage capacities- majority of the EPI

service units did not have their EPI rooms used exclusively for EPI services. All EPI service units had

Measles vaccines and diluents not correctly stacked/matched. None of the EPI service units practiced

MDVP or issued their stocks according to FEFO and FIFO. Some few refrigerators had been staffed with

non EPI items. Majority of the functional refrigerators had optimal temperature range of +2oc to + 8

oc. It

was further established that some few refrigerators had been used to store non EPI items. Less than a half

of the Vaccine and Injection Materials Control Books had been balanced off for vaccines. Ordering and

distribution of EPI supplies in both districts were done without any standard formula. It was established

that none of the EPI service units either had guidelines / policies on stock management or had evidence of

EPI support supervision done during the previous quarter. It was also noted that none of the EPI service

units either had evidence of quarterly visits for O&M for the previous quarter or had the inventory of the

working status of EPI equipment.

Keywords: Expanded Program on Immunization, vaccines, cold chain and logistics’, optimum

temperature range, refrigerators

Introduction

Cold chain and logistics management (CCLM) is a systematic process of coordinating people, policies,

procedures, vehicles; fuel, equipment, and technologies that work mutually to ensure that vaccines given

to people are safe and effective (Snow 2009). However cold chain refers to all activities aimed at

ensuring that vaccines are managed within an optimal temperature range (between +2°C and +8°C) from

manufacturer up to use. Vaccines have specific temperature requirements hence need for an effective cold

chain and logistics management system so as to prevent excessive heat and excessive cold from damaging

the vaccines (Wirkas et al.,2006, Munck et al,. 2008). The purpose of CCLM therefore is to get the right

quantities, of the right goods, to the right places, at the right time and in the right condition for

immunization service delivery. Poorly maintained or out-of-date refrigeration equipment, poor

observance of the cold chain measures, inadequate monitoring of the cold chain and poor understanding

of the menace of vaccine freezing contribute to the weakness of the existing CCLM. Previously and to

date, emphasis has been put on keeping vaccines cold, with less attention committed to preventing

vaccine damage by freezing. Some literatures reveal that freezing of vaccines in the cold chain is

commonly potentially resulting in the widespread dissemination of vaccines whose potency has been

compromised by the dissociation of antigen from the adjuvant (WHO 2005).

A malfunctioning cold chain system can lead to wasted vaccines and missed opportunities due to lack of

vaccines. An effective logistics system and a well-maintained cold chain are essential for safe and

effective immunization service delivery.

Whereas CCLM is fundamental to success of immunization programs, there are fewer global systems

aimed at strengthening CCLM systems hence threatening old and new vaccine innovations. Global

support for immunization as catalyzed by the formation of the Global Alliance for Vaccines and

Immunization (GAVI) in 1999 had a strategy to improve and strengthen vaccine-management systems

over the years: yet without a corresponding attention to strengthening CCLM systems (Magan 2007). This

approach is aimed at ensuring that the vaccine delivery systems are as advanced and innovative just like

the vaccines they are designed to support.

Globally, as governments and donors have increased investments in new vaccines, there is mounting

pressure for countries to demonstrate CCLM preparedness up to the point of vaccine delivery at the health

facility and the beneficiaries. Despite such pressure, key stakeholders at global, national and local levels

still lack standardized up-to-date cold chain equipment and logistics inventories. Procurement plans from

most low income countries at both national and local levels have failed to prioritize their maximum need

for new equipment, repair services or optimize new equipment selection in response to a facility’s local

energy/power availability or storage capacity needs (Elias 2011).

The Program for Appropriate Technology in Health (PATH) developed a software tool called Cold Chain

Equipment Manager (CCEM) with the aim of helping vaccination programs manage equipment

requirements up to the facility level. It also helps to forecast equipment needs for different scenarios and

generate procurement lists according to country specific national policies (Suraratdecha 2011).

In Africa at least four countries; Kenya, Malawi, Uganda, and Zimbabwe have successfully implemented

cold chain inventories in CCEM by generating equipment plans - mainly limited to the advance of new

vaccine introduction. CCEM has supported cold chain management in Uganda: and in 2009, Uganda

presented to the Japan International Cooperation Agency (JICA) with an evidence-based investment

plan/case for cold chain equipment in preparation for the introduction of pneumococcal vaccine. Uganda

is using this strategy of CCEM as it plans for introduction of the rotavirus vaccine in 2013 (PAHT 2011).

In Uganda, although the Uganda National Expanded Program on Immunization (UNEPI) was established

during the early 1980’s, the countrywide cold chain management was well established by 1995. The

primary goal of UNEPI is to ensure that every child is fully vaccinated with high-quality and effective

vaccines against the target diseases. Government of Uganda with support from development partners has

invested a lot of resources in UNEPI. The Japanese government provided financial support to buy cold

chain equipment and transport to deliver vaccines and other supplies during the period 2001-2005.

However, currently UNEPI does not have the complete inventory of cold chain equipment in the country

in terms of type, capacity, location and date of installation (Ahmed 2007, MoH 2012). In Uganda EPI

commodities include vaccines; Measles, Bacillus Calmette Guerin (BCG), Oral polio vaccine (OPV),

Tetanus toxoid (TT), Diphtheria Pertussis Tetanus-Hepatitis B- Haemophilus influenza type B (DPT-

HepB-Hib). They also include injection safety materials (auto disposable syringes, reconstitution

syringes, droppers, safety boxes, cotton wool) and administrative forms (Child health cards, tally sheets,

vaccines and injections materials control books). Other equally important commodities include cold chain

equipment such as refrigerators, freezers, cold boxes, vaccine carriers, icepacks, thermometers and

gas/gas cylinders. Information education and communication (IEC) materials such as posters and EPI

protocols are key in influencing management decisions and uptake of EPI services.

Globally, EPI has encountered a number of challenges at various levels of management. Some of the

challenges include poor refrigeration capacity, age and poor condition of equipment used, unreliable

sources of power, inappropriate transport system and limited skilled human resource. Vaccines are still

able to reach the beneficiaries at community levels in most of districts inspite of the above challenges.

Ministry of Health (MoH) Uganda is committed to ensuring that every district implements immunization

activities focusing on Reaching Every District (RED). RED primarily aims at ensuring that all eligible

children benefit from quality and sustainable immunization in all the districts. The achievement of RED is

hence dependant on supportive supervision, re-establishment of outreaches, monitoring EPI services and

liking EPI services to the community services planning and management (Braka, 2007 p. 4).

Methodology

The study was conducted in the districts of Busia and Namayingo respectively. The goal of the study was

to assess the cold chain and logistics’ management for expanded program on immunization in Busia and

Namayingo districts so as to generate information that will, if used by stakeholders contribute towards

improved health services. This was a cross-sectional study that employed both qualitative and quantitative

data collection techniques. The study considered a census of all the EPI service units (41). A total of 59

respondents (EPI staff) were interviewed as respondents.

Busia and Namayingo districts were selected using purposive sampling technique. The two districts were

considered because of their geographical location (rural districts in eastern Uganda), share common

boundaries and have staffing levels of less than 40% (MoH Uganda 2011).

Results

Background and social-demographic characteristics of the respondents

During the study I visited 41 EPI service units out of which majority 51% (21) were health centre IIs

while health centre IIIs were 34% (12) as shown in table 1 below.

Table 1: Category of EPI service units by district

n = 41

Category of EPI service unit District Frequency Percentage

(%) Busia Namayingo

District vaccine stores 01 01 02 05

General hospitals 02 00 02 05

Health centre four (IVs) 01 01 02 05

Health centre three (IIIs) 08 06 14 34

Health centre two (IIs) 11 10 21 51

Total 23 18 41 100

I interviewed a total of 59 respondents (health workers working as EPI staff at EPI service units) out of

whom 29% were males. Enrolled Midwifes were 36% (21), Nursing Assistants were 27% (16) -

vaccinators were 24% (14) while enrolled Nurses were 5% (3).

Table 2: Category of respondents from each of the districts by cadre

n = 59

Category of

Respondents

District Frequency Percentage

(%) Busia Namayingo

Nursing officer

(nursing)

02 01 03 05

Cold chain assistant 01 01 02 03

Enrolled nurse 03 00 03 05

Enrolled midwife 17 04 21 36

Nursing assistant 04 12 16 27

Vaccinator 06 08 14 24

Total 33 26 59 100

Availability of EPI minimum supplies at EPI service units

All the EPI service units had EPI vaccines available according to the EPI protocol on the date of data

collection and within three months retrospective review period. The EPI vaccines included, Oral Polio

Vaccine (OPV), Measles (lyophilised), DPT/DPT-HepB + Hib, Bacillus Calmette Guerin (BCG) and

Tetanus toxiod (TT) as per table 3 below. A small number (20% [8]) of the EPI service units had

transferred their vaccines to other health centres for refrigeration / storage because they had no gas to

power their refrigerators.

It was established that while most refrigerators were RCW 24 EG - powered by gas, both districts did not

have enough gas cylinders to maintain a consistent power supply of two cylinders per refrigerator. I

further found out that both districts had a total of 68 gas cylinders (53% [36] and 47% [32] for Busia and

Namayingo districts respectively). At the time of data collection, both DVS had no emergency gas

cylinders yet all EPI service units did not have standby power sources or gas cylinders. However DVS-

Busia had 10 empty gas cylinders while DVS-Namayingo had 4 empty gas cylinders to be collected and

replaced by UNEPI.

Storage (cold and dry storage) of EPI vaccines and related supplies at all EPI service units

Table 3 below shows that both Busia and Namayingo districts had a total of 62 refrigerators with 50%

(31) per refrigerators district and almost a half 47% (29) were RCW 24 EG refrigerators. It was also

established that the only deep freezer for Namayingo district belonged to the district production

department and it had been temporarily borrowed for use during the national immunization days’

program. Ice liner refrigerators were very few (contributed 8% [5]) of the total number of refrigerators,

although Namayingo had no Ice liner. Brocken down refrigerators were 10% (6). However the highest

proportion (83% [5]) of the broken down refrigerators was from Namayingo district.

Table 3: Type of refrigerators

n = 62

Type of refrigerator District Frequency Percentage

(%) Busia Namayingo

Sibir 02 07 09 15

RCW 24 EG 17 12 29 47

RCW 24 GE 01 00 01 02

RCW 24 solar 01 01 02 03

Ice liner solar 01 00 01 1.5

Ice liner 05 00 05 08

Deep freeze 02 01 03 05

Brocken down 01 05 06 10

RCW 24 EG 01 00 01 1.5

Sibir 00 03 03 05

RCW 24 solar 00 02 02 03

Total 31 31 62 100

During the study, I established that although all EPI service units had refrigerators with enough storage

capacities, majority of the EPI service units (76% [31]) did not have their EPI rooms used exclusively for

EPI services and only 46% had enough storage (floor space) of at least 80 sq ft. It was also noted that

none of the EPI service units had Measles vaccines and diluents correctly stacked/matched. None of the

EPI service units practiced either stock taking of EPI supplies done quarterly or issued their stocks

according to FEFO and FIFO. Results also show that that majority 68% (28) of the EPI service units had

vials opened at static clinics & kept in a refrigerator yet none of them practiced MDVP as reflected by

table 4 below. The table also shows that some few refrigerators (5% [2]) had been staffed with non EPI

items and 29% (12) had ice of more than 3mm thick. All EPI service units had measles vaccines and

diluents with deferent batch numbers, expiry dates and some of them were from deferent manufacturers.

It was observed that majority of the functional refrigerators (83% [34]) had optimal temperature range of

+2oc to + 8

oc and 88% (36) had evidence of use of temperature monitoring charts. I established that some

few (12% [5]) of the vaccine storage refrigerators (3 from Busia and 2 from Namayingo) had their

temperatures ranging from 13oc to 21

oc with their gas used up yet unnoticed by the facility EPI team. The

CCA for Namayingo district lacked a tool kit to facilitate O&M. During the study, I observed that

majority (88% [36]) of the refrigerators had frozen icepacks, some few (29% [12]) had ice of more than

3mm thick and 17% (7) had the floor/base of the refrigerator covered with water. It was further

established that some few (5% [2]) had been used to store non EPI items.

Table 4: Storage status of EPI supplies

n=41

Storage of EPI supplies (cold and dry storage) District Frequency

(Yes)

Percentage

Busia

Namayingo

Available storage space enough (at least 80sq ft) for EPI

supplies

11 08 19 46

EPI storage room also used for non- EPI services 16 15 31 76

Stock taking of EPI supplies done quarterly 00 00 00 00

Stocks issued according to first expiry first out (FEFO) 00 00 00 00

Supplies with shorter shelf life are placed on the external part of

the refrigerator

00 00 00 00

Stocks of the same expiry dates but received on different days,

issued according to first in first out (FIFO)

00 00 00 00

Management of refrigerators and cold boxes

Refrigerator clean externally 17 10 27 66

Refrigerator clean internally 19 11 30 73

Evidence of use of a temperature monitoring chart 22 14 36 88

Temperature range of the refrigerator between 2oc to 8

oc 14 10 34 83

Evidence of vials opened at static clinic & kept in a refrigerator 19 09 28 68

Opened malt dose vaccines, vials marked accordingly 00 00 00 00

Measles vaccines and diluents correctly stacked/matched 00 00 00 00

DPT/DPT-HepB + Hib vaccines correctly stacked/matched 23 18 41 100

Rubber seal on the lid of the refrigerator in a sound state 23 18 41 100

Refrigerator having ice of more than 3mm thick 08 04 12 29

Floor/base of the refrigerator covered with water 05 02 07 17

Refrigerator used to store non EPI items 1 1 02 5

Refrigerator having frozen icepacks 20 16 36 88

O&M done at least once within the previous quarter 00 00 00 00

Vaccine carriers clean 07 02 09 22

Refrigeration temperatures ranging from 13oc to 21

oc 3 2 5 12

Availability of cold chain and logistics management information system for EPI at all EPI service

units

It was established that only less than a half (41% [17]) of the Vaccine and Injection Materials Control

Books had been balanced off (up to date) for vaccines (Table 5). However none of the EPI service units

had their VIMCB entries made for other immunization materials. Accuracy of tally sheets (+/- 5) as

compared with HMIS monthly report forms (May 2012) was relatively good (61% [25]). Although close

to all, (92% [37]) the EPI service units used requisitions and issue vouchers, only 68% (28) of the EPI

service units had their requisitions and issue vouchers filled up-to-date as per table 5 below.

Table 5: The procurement process and management of cold chain logistics

n = 41

Description District Frequency Percentage

Busia Namayingo

Cold chain and logistics management information

system for EPI

Vaccine and Injection Materials Control Book (VIMCB)

balanced off for vaccines

11 06 17 41

VIMCB balanced off for other immunization materials 00 00 00 00

Tally sheets for May 2012 filled up-to-date 13 07 20 49

Accuracy of tally sheets (+/- 5) as compared with HMIS

monthly report forms (May 2012)

10 15 25 61

Requisitions and issue vouchers used 24 13 37 92

Requisitions and issue vouchers filled up-to-date 17 11 28 68

The logistics cycle for EPI (procedure used to forecast, estimate, order and receive supplies) at all

EPI service units

Findings from this study revealed that estimation, ordering and distribution of EPI supplies in both

districts were done without any standard formula. However majority, 78% (32) of the EPI service units

had been monitoring their vaccine wastage monthly as per table 6 below.

Table 6: Procurement and management of EPI supplies at EPI service units

n = 41

Description

Frequency

(Yes)

Percentage (%)

Estimation of vaccines and other EPI materials based on target

population

00 00

Estimation of vaccines and other EPI materials based on previous

consumption and doses on schedule

00 00

Ordering of EPI supplies put into account stock at hand 00 00

Ordering of EPI supplies put into account wastage/losses and stock

out adjustments

00 00

Ordering of EPI supplies put into account lead time 00 00

Ordering of EPI supplies put into account maximum stock levels 00 00

Ordering of EPI supplies put into account reserve stock 00 00

Monitoring of vaccine wastage done monthly 32 78

Organizational support systems at EPI service units

Table 7 below shows that at only few (20% [8]) of the EPI service units had information, education and

communication (IEC) materials on immunization but none of them had put them under appropriate use. It

was established that none of the EPI service units either had guidelines / policies on stock management or

had evidence of EPI support supervision done during the previous quarter. It was also noted that none of

the EPI service units either had evidence of quarterly visits for O&M for the previous quarter or had the

inventory of the working status of EPI equipment.

Table 7: Organizational support systems at EPI service units

n = 41

Section G: EPI organizational support Frequency Percentage

(%)

Presence of guidelines / policies on stock management 00 00

Presence of supportive IEC materials 08 20

Appropriate use of supportive IEC materials 00 00

Evidence of EPI support supervision done during the previous quarter 00 00

Presence of inventory of the working status of equipment maintained 00 00

Evidence of quarterly visits for O&M for the previous quarter 00 00

Discussion

Availability of vaccines at EPI service units

The study findings revealed that all the EPI service units had EPI vaccines available according to the EPI

protocol on the date of data collection and within three months retrospective review period - a sign of

compliance with UNEPI requirements. These findings were in agreement with EPI standards that provide

that no health facility should have stock out of any of the vaccines (Zaramba 2003, MoH Uganda 2005,

Snow 2009).

Ahmed (2007) found out that in Uganda there were numerous cases of vaccine shortage due to stock out

of some antigens in most districts. These results suggest that the two districts (Busia and Namayingo)

were either better-off than the national average or UNEPI delivery systems had improved since 2007.

However some few EPI service units 20% (8) had transferred their vaccines to other health centres for

refrigeration / storage because they had no gas to power their refrigerators. This meant that although

stocks were available on record, the immunization services could only be available on a planned schedule.

This therefore meant that some of the intended beneficiaries of the vaccines, could not get the vaccines at

the right time.

Management of EPI refrigerators

It was established that most refrigerators were RCW 24 EG that were powered by gas. However, neither

of the districts had enough gas cylinders to maintain a standby gas cylinder / power source per

refrigerator. At the time of the data collection, both DVS of Busia and Namayingo had no emergency gas

cylinders. The two districts had empty gas cylinders awaiting to be collected/replaced by UNEPI. This

implied that such empty gas cylinders had not been replaced at facility levels. According to Ahmed

(2007) and Tumwine (2007 p 2), Uganda had inadequate gas cylinders amidst poor collection practices of

empty gas cylinders at various levels yet releases of funds to the contractor (Shell) to procure the gas were

also irregular.

It was further established that inadequacy of standby power source was responsible for the temporal non

functionality of some RCW 24 EG refrigerators whose vaccines had been transferred to other EPI service

units for safety. This hence, posed a challenge to the entire cold chain system within the study area since

it was practically impossible to replace the gas as soon as it got used up.

Most of the refrigerators were well managed and monitored although some few (12%) did not use

temperature monitoring charts appropriately. UNEPI standards provide for 100% compliance to

appropriate use of temperature monitoring charts (Zaramba 2003, MoH Uganda 2005). There was no

evidence of O&M done at all EPI service units and Namayingo district did not even have a tool kit for

cold chain maintenance. These findings therefore could have affected the overall quality of EPI services

in both districts. These could pose adverse effects on cold chain management since UNEPI would be

responding mainly to major breakdowns. The above findings were in line with a study by Ahmed (2007),

who reported lack of O&M at UNEPI headquarters and DVS in Uganda at the time of his study (July

2007).

Namayingo district (DVS) lacked a deep freezer for EPI and the DVS had temporarily borrowed one from

the production department. This could therefore imply that either there was no submission of EPI needs

by the district due to poor planning at the DVS or UNEPI had failed to fulfill its obligations by delivering

a deep freezer to Namayingo district. Snow (2009) suggested that most districts in Uganda delayed to

review and submit their equipment requirements yet UNEPI, UNICEF and WHO determined such needs

annually according to district requirements – this was primarily responsible for inadequate cold chain

equipment such as refrigerators, gas cylinders and tool box for cold chain maintenance.

Whereas WHO recommended for the introduction of new models of ice-lined refrigerators (ILRs) for EPI

globally by March 2009, so as to mitigate freezing of vaccines during storage, our study established that

only few of the refrigerators were ILRs. However Namayingo district did not have any ice liner. These

results suggest that compliance to the WHO recommendation by UNEPI was relatively poor, especially

for Namayingo district. A cost effective analysis by WHO revealed that ILRs were quite superior to other

refrigerators in performance and that they also provided better security to vaccines in addition to a lower

cost price as opposed to pharmaceutical refrigerators. They were also cost effective in conditions of

intermittent electricity (WHO 2008 pp. 10-12).

It is generally recommended that EPI refrigerators should never store none EPI items; a few of the

refrigerators had staffed none EPI items. During the study, I also observed that some of the refrigerators

had no frozen icepacks, had their floor/base covered with water, and a few of them also had ice of more

than 3mm thick. These findings are some of the proxy indicators of poorly managed EPI refrigerators.

These results were not in agreement with EPI standards that provide that EPI refrigerators must have

100% compliance to EPI standards (Zaramba 2003, MoH Uganda 2005, WHO 2008).

Management of vaccines and other related EPI supplies

Estimation of stock requirements

Findings from this study revealed that estimation, ordering and distribution of EPI supplies in both

districts were done without any standard formula. UNEPI guidelines provide that estimation of vaccines

and other EPI materials should be based on target population, previous consumption and doses on

schedule - including maximum stock levels, wastage and stock out adjustments, stock at hand and reserve

stock (Zaramba 2003, MoH Uganda 2005). These findings were in line with Ahmed (2007), who

established that in Uganda, lack of estimation of vaccines and other materials was a major problem in

cold chain management. The above findings suggest that all EPI service units in both Busia and

Namayingo districts were not aware of their EPI stock requirements hence at risk of either under

estimating or over estimating their stock requirements.

Majority of the EPI service units were noted to have been monitoring their vaccine wastage monthly

although Ahmed (2007) reported that in Uganda, most health facilities never monitored their vaccine

wastages. This finding was a positive indicator of vaccine management and it cold positively contribute

towards good practices in CCLM.

EPI stores and office space

Generally EPI service units in the studied districts had inadequate space for EPI activities. The situation

had been worsened by use of EPI rooms for other non-EPI related activities. This finding is in agreement

with Zaninka (2007) who stated that most DVS and health facilities in Uganda lacked office space and

storage space for EPI supplies. This is an indicator that EPI is not prioritized during either infrastructural

design or space allocation at both national and district levels.

Vaccine storage and management

It was generally observed that the cold storage (refrigeration) space for vaccines was enough because all

refrigerators had enough storage capacities. As noted earlier that O&M had never been done in both Busia

and Namayingo districts, this suggested that there would be lack of space whenever refrigerators broke

down. However Zaninka (2007) reported that UNEPI lacked a cold chain rehabilitation plan that could

put into consideration the expansion of vaccine storage capacities. According to Tumwine (2007 p. 2),

Uganda’s cold chain system had a number of management challenges. Some of the challenges included,

limited refrigeration capacity and lack of adequate dry storage space for other EPI supplies.

It was also noted that none of the EPI service units had Measles vaccines and diluents correctly

stacked/matched. All EPI service units had measles vaccines and diluents with deferent batch numbers,

expiry dates and some of them were from deferent manufacturers. These findings are not in agreement

with the available literature that suggests that in vaccine management, care should always be taken to

ensure that both the vaccines and the diluents bear the same or corresponding manufactures instructions

or details (MoH Uganda 2005, Suraratdecha 2011). These results imply that the vaccine were either

poorly procured or indiscriminately delivered without adherence to WHO standards. Such inconsistencies

could lead to loss of vaccine potency hence pore vaccination outcomes.

The study established that none of the EPI service units practiced either stock taking of EPI supplies

quarterly or issued their stocks according to FEFO and FIFO. Results also reflected that there was

evidence that most EPI service units had vials opened at static clinics & kept in refrigerators yet there was

no evidence of adherence to MDVP. These findings therefore suggested that lack of compliance to FEFO

and FIFO and adherence to MDVP could lead to wide spread expiry incase earlier-to-expire vaccines

continue being stored in the current state – a situation that could be worsened by over estimation as none

of the units estimated vaccine requirements according to standards. Poor adherence to MDVP could

aggravate the situation by causing high wastage rate of multi- dose vaccines. A study that analyzed the

impact of wastage on single and multi-dose vaccine vials and their implications while introducing

pneumococcal vaccines in developing countries revealed that poor adherence to MDVP had adverse

effects to immunization program. The major effects included high wastage rates of multi-dose vaccines,

the cost implications associated to such wastages and vaccination outcomes (Parmar et. al. 2010).

It was also established that most EPI service units had not balanced off (up to date) their Vaccine and

Injection Materials Control Books. The study further found out that none of the EPI service units had

their VIMCB entries made for other immunization materials. This suggested that most EPI service units

were not effectively monitoring their EPI stock.

EPI supportive systems

Although some studies suggest that the success of EPI is highly influenced by organizational support

systems (Munck et.al. 2008), this particular study revealed that the supportive environment was generally

poor. It was noted that very few EPI service units had Information, Education and Communication (IEC)

materials on immunization and none of them had put such materials under appropriate use. It was further

established that none of the EPI service units either had guidelines / policies on stock management,

evidence of EPI support supervision done during the previous quarter or presence of inventory of the

working status of equipment. Such a poor supportive could cause multiple system failures in CCLM at

district and health facility levels.

Conclusion

The findings herein generally suggest that Busia and Namayingo districts performed poorly in CCLM.

This is shown by: not estimating EPI requirements based on standard EPI guidelines; shortage of gas

cylinders; and inadequacy of space for operations and dry storage space for EPI supplies. Other evidence

of poor CCLM include: poorly stacked/matched Measles vaccines and diluents, poor management of EPI

refrigerators, lack of O&M for EPI refrigerators and non adherence to EPI standards on vaccine

management and handling including lack of support supervision of EPI services from without and within

– augment the poor performance of CCLM in the two districts.

Acknowledgements

I wish to extend my sincere acknowledgement to all people who extended their support to me throughout

this study. This research would not have been a success if they had not rendered to me their support either

directly or indirectly.

In a special way, I wish to thank Mr. Anguyo Robert DDM Onzima who supervised me from the study

design, data collection and report writing. His technical guidance to me greatly influenced the outcome of

this study. I also wish to thank the DHOs of Busia and Namayingo districts for the worm reception and

support extended to me during the data collection.

My other thanks go to the Medical Director and Hospital Administrator, Dabani hospital and Head

mistress St Teresa Dabani girl’s primary school Sr. Bernadette Ikallet for the logistical assistance

rendered to me throughout the study.

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Annex: Photography during data collection

A pile of empty gas cylinders at the DVS/office of the secretary to the DHO awaiting replacement by

UNEPI head quarters

A deep freezer from production department used by the DVS in Namayingo district

Non EPI pharmaceuticals stuffed in an RCW 24 EG EPI refrigerator at a Health Centre II