#8. A scanned image of vaccinators training document during 2014 Measles Rubella National Vaccination campaign as well as a caption of a facility guide showing the directive to always observe and write down the status of VVM during receipt and use

#9. A scanned image of vaccine stock ledger showing integrated information including status of VVM during arrival from the Central Vaccine Store

#2. Vaccine stored in an intermediate vaccine store with a vial showing valid VVM sticker of a sampled batch

#3. Vaccine arranged in RCW25 cold box (with temperature/freeze monitors) at Ilala Municipal vaccine store (DVS) ready for dispatch to vaccinating health facilities

#10. A picture of Mr. Bonaventura (eVVM Mar-May 2017) holding a vial of bOPV with attached VVM sticker at use stage when visited the Vaccine section of the Medical Stores Department (MSD) in Dar es Salaam, Tanzania

 #9. Scanned image of a stock ledger with VVM information integrated.

This is not a ledger. It is a voucher issue when vaccines were deliveried from province store to district store. In this voucher the VVM status of MR and tOPV was noted because the storekeeper regcornized that VVM was not at start point, at stage 2.

 #8. Scanned image of a document related to a VVM policy.

 Image 1.

 Image 2.

  Image 3.

Image 1 and 2 are scanned image of a document related to a VVM policy in my country that I have taken. This is attached with a decision which was issued by Vietnam MoH in 2014, namely "Guideline storage of vaccine".
This Guideline explained about VVM, how to read VVM, 4 stage of VVM.
Image 3 is a photo of a poster which is attached at all vaccine stores. This poster contain image explaining about VVM. This is easy for storekeeper to check VVM.

Task#5: A health worker during immunization outreach session at Ntambaruka village in Nkasi district Tanzania

Freezer without a temperature monitoring device

Refrigerator with a faulty temperature meeter

https://lh3.googleusercontent.com/-37hcjgetz1M/Vyw_r-BLpcI/AAAAAAAAAVA/3o4OfU-2xdUmqYXpZWZoo-AlYIONTsc9wCHM/s1024/160505_0001.jpg

Temperature monitoring devices in refrigerator

Temperature monitoring devices in refrigerator at health facility in Kano, Nigeria

While the VVM and expiry dates of the vaccine are good, fridge tag reading has shown series of negative temperature excursions which indicates exposure of vaccines to temperature below the minimum limit for extended period.
Good understanding of VVM and other temperature monitoring device is necessary by all health care workers involve in vaccine management at all level to ensure quality of vaccines.

#10: Yourself showing a vial of vaccine with VVM in very good condition (NAGLAA)

Photos taken at health centers showing a vial of OPV with VVM in very good condition (photo 1, 2)

and open OPV vial with darker VVM

#5: A health worker in immunization outreach (NAGLAA)

5- A health worker in immunization outreach

These photos were taken in Syrian refugee camp in Kurdistan in 2014, health workers administrating OPV as immediate response the Polio Middle East Outbreak

Number 4: Refrigerator with vaccines organised

Bivalent OPV and Rotarix picked from a fridge at a vaccination clinic in Rumphi district. Both VVM changes are quite obvious but not yet reached discard point . There were 40 vials of rotatrix and five OPV vials. The VVM   of the same status . The bOPV  has VVM 2 and rotarix has VVM 7. Due to frequent power cuts, OPV and rotarix are fast changing the VVM status.

Number 6. A health worker giving a vaccination with the VVM visible on the vial

Number 6. A health worker about to give a TTV  vaccination

VVM on TTV:  A student nurse (health care worker)  holding an open vial  of TTV ready to give a dose during an MCH clinic. This is at a clinic in Rumphi district, Northern Malawi. The picture taken on 3 April 2017

A health worker in immunization outreach (TRANG)

1. Immunization measle and rubella (MR) vaccines at post health in Viet Nam.
The immunization is ỏganization two days per  month for all children aged 9-14 years.

2. Health workers issue immunization certificates.

Vaccine dispatch from a storage facility TRANG)

 1. Vaccine Quinvaxem (made in Korea) is sponsored by Gavi. Vaccine are transported from Korea to Viet Nam.

 2. Vaccines are transported from the Noi Bai airport to the Primary store.

3. Vaccines are packed in many boxes.

4. Temperature electronic device (Q-tag)  have in each box.

Vaccines priority to use (TRANG)

 Quinvaxem use priority because the expridate. VVM status 2.

#3 - Vaccine dispatch from a storage facility (NAGLAA)

Vaccine dispatch from district storage facility to health center. the photo shows the health worker uploading the vaccine in open truck.

#4 - Storage vaccine in health post (TRANG)

This photo was taken during a surveillance voyage to use in the market.

Vaccine Quinvaxem, the stage I for Immunization day.

This located too far away from the vaccine storage, where will be supply  a TCW50 fridge. Vaccine will be store in this for 2-3 days.

At the end of the Immunization day, vaccine will be delivered to the central storage

.

#4 - A refrigerator with vaccines organised showing VVM labels attached on the vials (BONAVENTURA)

A picture showing twelve (12) vials of DTP-HepB-Hib vaccines stored in the vaccine refrigerator at a health facility. All VVMs labels were at usable stage and some were given to children during visit day.

Observation:

During observation it was found that there were two (2) batches of vaccine but the health worker were not aware. One is expiring on Oct 2017 and the other on Apr 2018.

Recommendation:

Health workers were mentored on effective vaccine management and proper stock rotation so as to minimize wastage at service delivery points. Also, they were mentored on proper recording of arrivals and issues on the vaccine ledgers, with all important information such as batch numbers, VVM status, expiry dates etc.

#6 - Different types of temperature monitoring devices in a vaccine refrigerator (Fridge-tag2 and VVM) (BONAVENTURA)

A picture taken at health facility refrigerator showing two temperature monitoring devices used.

The Fridge-tag2, indicates a temperature reading of 3.6 degree centigrade during a day and time of visit (indicated on the device). This device shows that, for the past 29 days there was no alarm (high or low) recorded by the respective cold chain equipment (RCW50EG from Dometic). However, the device can show a maximum of 60 days temperature records if its USB is plugged into a computer/laptop for further data analysis.

Above it is 20 vials of PCV13 vaccine stored in a box. All VVM lables on the vial caps indicates a usable stage.

I really felt very happy to find a well functioning vaccine refrigerator and good temperature monitoring practice of the healthcare worker.

PREVENTION IS BETTER THAN CURE!!

#7 - A health worker giving a vaccination with visible VVM label attached on the ampoule/vial (BONAVENTURA)

This picture was taken after requesting consent and explaining it's purpose to the vaccinator and mother of the child. It is showing a vaccinator giving Rotarix vaccine with VVM label attached on the ampoule to a child during session. This was the first visit of a child to immunization services in the country.

#2 Primary or intermediate vaccine storage facility showing vaccines in storage – show a vial with VVM (CHINDO AHMAD)

Chindo Ahmad Supportive Supervision Experience.

Routine Immunization (R.I) vaccine in VVM stage 2

Immunization Plus Days bOPV Vaccine in VVM stage 1



Observation:

Above are two different VVM stages of vaccine supplied by NW zonal cold store to one of the states under it in Nigeria as their allocations for both R.I and campaign purposes. the first picture is a vial from the R.I bOPV vaccine which are all in stage 2 and to be used for a period of 3 months during R.I sessions and outreaches. While the other picture is a vial from 2.7 million doses supplied for 4 days immunization campaign to the same state, same cold store and all are in stage 1.


Recommendation:

When I observed these, the cold chain officer was directed to exchange all the R.I bOPV vaccine in VVM stage 2 with the same quantity from Immunization Plus Days bOPV Vaccine in VVM stage 1 in order to avoid the risk of those R.I vaccines going to stage 3 during the 3 months consumption period.

#2 Primary or intermediate vaccine storage facility showing vaccines in storage – show a vial with VVM (CHINDO AHMAD)

the above picture is a display of measles vaccine vials with different stages of VVM but all were returned unopened vials after Routine Immunization (RI) session in the same ziplog. However, it is expected that all must have gone through the temperature history.

#1 - International arrival of vaccines (HOA)

                             
                                 1. Temperature monitoring devices in international shipments.

                                               
                                                   2. One of the Shipping documents

                                                     3. One of the Shipping documents

I took these photos about 2 years ago.
That shipment did not contain vaccines for vaccination, It contained reference standard Dengue vaccines. Sanofi Pasteur's dispatch sent it from France to Vietnam. In each shipment, along with shipping documents, temperature monitoring divices.
I am so sorry because at that time, I did not mention to this point/problem. I stopped the tampTale; It's OK. I wrote down the time I got the shipment and all informations necessary. I received the samples and stored them in my storage. I did not take the photos or scan the device at all.
These pictures are taken after that when I had to find a way to send back the tempTale to Sanofi Pasteur, France.

Increase your powers of observation on items related to VVM based vaccine management

Scavenger hunt is a game in which the organizers prepare a list defining specific items.  Then, the participants seek to gather all the items on the list and take photographs of the items, as specified.  For fun and learning purposes throughout the course, we will be hunting a list of items as described below.  You need to find these items in your own settings, searching and finding others’ photographs in the web is not acceptable. 

We want each of you to find as many items as possible and post your hunt (the photograph and the story behind it) to EPELA’s e-VVM SCAVENGER HUNT blog.  You do not need to wait until you compile all of them, post your hunt as you find one and then the other.  Increase your powers of observation on items related to VVM.

1. International arrival of vaccines
2. Primary or intermediate vaccine storage facility showing vaccines in storage – show a vial with VVM
3. Vaccine dispatch from a storage facility
4. Refrigerator with vaccines organized (need to see VVM)
5. A health worker in immunization outreach
6. A health worker giving a vaccination which the VVM is visible on the vial/ampoule
7. Temperature monitoring devices in a refrigerator (need to see at least two different types of temperature monitoring device including VVM)
8. Scanned image of a document related to a VVM policy
9. Scanned image of a stock ledger with VVM information integrated
10. Yourself showing a vial of vaccine with VVM in very good condition