2014年天津市预防接种门诊疫苗冷链事故调查分析

摘要:目的　了解天津市预防接种门诊疫苗冷链事故发生情况,分析存在问题并提出解决对策。方法　收集整理2014年天津市预防接种门诊冷链设备档案资料以及冷链事故发生情况,利用描述性流行病学分析方法进行统计分析。结果　全市预防接种门诊冷链冰箱使用年限在6～10年的占31.80%,≥11年的占12.55%。全年共发生疫苗冷链事故15次,涉及冰箱22台,造成疫苗损失8166支（粒）,其中第一类疫苗7295支（粒）,占89.33%;第二类自费疫苗871支,占10.67%。事故发生时间主要在5-10月份,占86.67%。事故原因中冰箱机械故障、电源断电、温度超标、雷击发生率分别为2.13%、1.77%、1.06%、0.12%。结论　我市预防接种门诊冷链运转情况整体良好,但仍存在部分设备老旧、运行稳定性不足、缺失有效管理措施等问题,未来应重视冷链设备的更新维护以及配套管理机制的制定与落实,并可逐步利用信息化技术手段,提升冷链监测管理水平。     

杭州市2004—2008年城乡免疫规划接种点冷链管理调查

目的：了解杭州市各区、县（市）免疫规划接种点冷链管理现状,找出不足之处,以利改进。方法：采用调查表对杭州市各区、县（市）免疫规划接种点冷链管理和使用情况进行调查。结果：目前杭州市免疫规划接种点冷链设备以普通家用冰箱为主,疫苗存放符合要求占97．51％,安装符合要求96．26％,测温记录符合要求89．41％。测温记录符合要求,城区好于郊县,差异有统计学意义（X^2=10．29,P〈0．05）。结论：杭州市各城区免疫规划接种点冷链管理较好。     

Global measles control and regional elimination, 1998-1999

In 1989, the World Health Assembly adopted the goal of reducing measles morbidity and mortality by 90% and 95%, respectively, by 1995, compared with estimates of the disease burden in the prevaccine era. In 1990, the World Summit for Children adopted a goal of vaccinating 90% of children against measles by 2000. Three regions of the World Health Organization (WHO) have targeted elimination: in 1994, the American Region (AMR) targeted elimination by 2000; in 1997, the Eastern Mediterranean Region (EMR) targeted elimination by 2010; and in 1998, the European Region (EUR) targeted elimination by 2007. This report updates progress since 1997 toward global measles control and regional elimination of measles, and includes vaccination coverage and disease surveillance data received by WHO as of August 14, 1999. Data for 1998 suggest that routine measles vaccination coverage has declined in some regions, the number of countries reporting cases and coverage to WHO has decreased, and measles continues to be an important cause of morbidity and mortality.     

Root cause analysis underscores the importance of understanding,addressing, and communicating cold chain equipment failures to improve equipment performance

Vaccine cold chain equipment (CCE) in developing countries is often exposed to harsh environmental conditions, such as extreme temperatures and humidity, and is subject to many additional challenges, including intermittent power supply, insufficient maintenance capacity, and a scarcity of replacement parts. Together, these challenges lead to high failure rates for refrigerators, potentially damaging vaccines and adversely affecting immunization coverage. Providing a sustainable solution for improving CCE performance requires an understanding of the root causes of failure.Project teams conducted small-scale studies to determine the root causes of CCE failure in selected locations in Uganda and Mozambique. The evaluations covered 59 failed refrigerators and freezers in Uganda and 27 refrigerators in Mozambique. In Uganda, the vast majority of failures were due to a cooling unit fault in one widely used refrigerator model. In Mozambique, 11 of the 27 problems were attributable to solar refrigerators with batteries that were unable to hold a charge, and another eight problems were associated with a need to adjust thermostat settings.The studies showed that tracking and evaluation of equipment performance and failure can yield important, actionable information for a range of stakeholders, including local CCE technicians, the ministry of health, equipment manufacturers, and international partners such as the United Nations Children’s Fund, World Health Organization, and Gavi, the Vaccine Alliance. Collaborative efforts to systematically collect and communicate data on CCE performance and causes of failure will help to improve the efficiency and reach of immunization programs in low- and middle-income countries.     

Innovations in cold chain equipment for immunization supply chains

BackgroundSince 2010, numerous new technologies have entered the immunization cold chain equipment market. The World Health Organization (WHO) Immunization Devices Programme—Performance, Quality and Safety (PQS)—has played a key role in bringing these to market. In this article, the authors explore the emergence of new cold chain equipment technologies from 2004 to 2016 and the role of PQS in this evolution.MethodsThis review focuses on three major vaccine cold chain technology innovations—solar direct-drive refrigerators, long-term passive cold boxes, and equipment with user-independent freeze prevention. For the review, we used online data from WHO PQS, a literature search, and unpublished research reports.ResultsTimelines with key milestones in the emergence of the three focus technologies show delays of between one and three years between earliest field trials and publication of WHO specifications; procurement builds after the WHO prequalification of initial devices.DiscussionThe timelines show the role of PQS as both gatekeeper and enabler for cold chain equipment technologies. The use of target product profiles by PQS has increased its ability to signal preferred attributes and to engage with manufacturers during the product-development stage. Procurement data show how demand for solar direct-drive refrigerators increased over time. Gavi, the Vaccine Alliance, is employing demand-generation strategies to try to drive procurement of technologies with favorable technical attributes.Conclusions

• •PQS plays an important role in early product development.
• •Target product profiles have proven to be a successful way to communicate desired attributes and focus developer research.
• •Field evaluations provide PQS with invaluable data to help refine specifications in line with actual performance in immunization settings.
• •Establishing more systematic post-market surveillance systems for cold chain equipment after large-scale deployment could have positive effects.
• •Efforts to communicate to countries and other immunization stakeholders about new technologies is needed to accelerate their uptake.

     

Opportunities to improve vaccination coverage in a country with a fledgling health system: Findings from an assessment of missed opportunities for vaccination among health center attendees—Timor Leste, 2016

IntroductionSince its independence in 2002, Timor Leste has made significant strides in improving childhood vaccination coverage. However, coverage is still below national targets, and children continue to have missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. Timor Leste implemented the updated World Health Organization methodology for assessing MOV in 2016.MethodsThe MOV data collection included quantitative (caregiver exit interviews and health worker knowledge, attitudes, practices surveys (KAP)) and qualitative arms (focus group discussions (FGDs) with caregivers and health workers and in-depth interviews (IDIs) with health administrators). During a four-day period, health workers and caregivers with children <24 months of age attending the selected eight facilities in Dili Municipality were invited to participate. The researchers calculated the proportion of MOV and timeliness of vaccine doses among children with documented vaccination histories (i.e., from a home-based record or facility register) and thematically analyzed the qualitative data.ResultsResearchers conducted 365 caregiver exit interviews, 169 health worker KAP surveys, 4 FGDs with caregivers, 2 FGDs with health workers, and 2 IDIs with health administrators. Among eligible children with documented vaccination histories (n = 199), 41% missed an opportunity for vaccination. One-third of health workers (33%) believed their knowledge of immunization practices to be insufficient. Qualitative results showed vaccines were not available at all selected health facilities, and some facilities reported problems with their cold chain equipment.ConclusionThis study demonstrates that many children in Timor Leste miss opportunities for vaccination during health service encounters. Potential interventions to reduce MOV include training of health workers, improving availability of vaccines at more health facilities, and replacing unusable cold chain equipment. Timor Leste should continue to scale up successful MOV interventions beyond Dili Municipality to improve vaccination coverage nationally and strengthen the health system overall.     

江苏省儿童预防接种门诊服务能力现况分析

目的 了解江苏省预防接种门诊服务能力现况,为提高预防接种工作水平与服务质量提供依据。方法 采用描述性分析方法分析江苏省不同地区儿童预防接种门诊基本设置、工作人员配置、信息化建设与冷链装备情况。结果 江苏省所有儿童预防接种门诊均实现以周门诊（40.1%）或以日门诊（59.9%）为周期开展疫苗接种服务,大多数门诊接种人员门诊日人均接种量在80剂次以下。79.4% 的预防接种门诊只有1～2名专职工作人员。数字化预防接种门诊覆盖率达到82.4%,2岁以下儿童预防接种APP/微信绑定率达到70.0%。25.4%的预防接种门诊配备了医用冰箱。结论 江苏省儿童预防接种门诊目前能够满足辖区适龄儿童疫苗接种服务,信息化程度较高。但应加强免疫规划专职工作人员配置,同时加快医用冰箱与电子温度监控系统薄弱地区的冷链装备更新换代。     

Progress toward poliomyelitis eradication--South-East Asia Region, 1998-1999

In 1988, the World Health Assembly resolved to eradicate poliomyelitis by the end of 2000 (1). To achieve this goal, the 10 member countries of the World Health Organization (WHO) South-East Asia Region (SEAR) began implementing polio eradication strategies in 1994. In 1999, most polio cases worldwide were reported in SEAR (i.e., 48% of reported polio cases and 62% of cases with wild poliovirus isolation) (2,3). This report summarizes progress in achieving high routine and supplemental vaccination coverage, the surveillance of cases of acute flaccid paralysis (AFP), and the impact of these activities on polio eradication in the region during 1998-1999.     

Modelling the relative benefits of using the measles vaccine outside cold chain for outbreak response

IntroductionRapid outbreak response vaccination is a strategy for measles control and elimination. Measles vaccines must be stored and transported within a specified temperature range, but this can present significant challenges when targeting remote populations. Measles vaccine licensure for delivery outside cold chain (OCC) could provide more vaccine transport/storage space without ice packs, and a solution to shorten response times. However, due to vaccine safety and wastage considerations, the OCC strategy will require other operational changes, potentially including the use of 1-dose (monodose) instead of 10-dose vials, requiring larger transport/storage equipment currently achieved with 10-dose vials. These trade-offs require quantitative comparisons of vaccine delivery options to evaluate their relative benefits.MethodsWe developed a modelling framework combining elements of the vaccine supply chain - cold chain, vial, team, and transport equipment types - with a measles transmission dynamics model to compare vaccine delivery options. We compared 10 strategies resulting from combinations of the vaccine supply elements and grouped into three main classes: OCC, partial cold chain (PCC), and full cold chain (FCC). For each strategy, we explored a campaign with 20 teams sequentially targeting 5 locations with 100,000 individuals each. We characterised the time needed to freeze ice packs and complete the campaign (campaign duration), vaccination coverage, and cases averted, assuming a fixed pre-deployment delay before campaign commencement. We performed sensitivity analyses of the pre-deployment delay, population sizes, and two team allocation schemes.ResultsThe OCC, PCC, and FCC strategies achieve campaign durations of 50, 51, and 52 days, respectively. Nine of the ten strategies can achieve a vaccination coverage of 80%, and OCC averts the most cases.DiscussionThe OCC strategy, therefore, presents improved operational and epidemiological outcomes relative to current practice and the other options considered.     

Have purpose‐built vaccine refrigerators reduced the cost of vaccine losses in South Australia?

Objectives: There is limited epidemiological data on the performance of different refrigerator types for vaccine storage in the real world. This study aims to measure if the introduction of purpose‐built vaccine refrigerators has reduced the cost of vaccine losses in South Australia. Methods: Data were taken from a register for all recorded vaccine storage cold chain events in South Australia from 2008 to 2009 and a survey of vaccine providers conducted in 2009. Results: There were 531 respondents to the survey (51% response rate). A greater proportion of cold chain breaches in purpose‐built vaccine refrigerators did not lead to a loss of vaccine (10.3%) compared with the other refrigerator types. Purpose‐built vaccine refrigerators had a relative risk of 3.31 (95% CI, 2.15–5.11) of a heat event (as opposed to cold event) and were more likely to have a cold chain breach from electrical failure (relative risk ratio 15.05, 95% CI 4.04–56.05) than bar refrigerators. The average cost of loss of vaccine for purpose‐built vaccine refrigerators was $2,321.20, which was greater than the cost of vaccine loss from a bar refrigerator of $1,339.06 (95% CI $61.47–1,902.82). Conclusions: Although purpose‐built vaccine refrigerators were less likely to lead to vaccine loss per cold chain breach, they had a greater average cost of vaccine loss per cold chain event because they held a greater volume of vaccine. There is a need for development of Standards to guide purpose‐built vaccine refrigerators manufacturing and a review of the National Vaccine Storage Guidelines to place a greater emphasis on the need for back up plans in the event of electrical failure.     

Progress toward poliomyelitis eradication--Nigeria,January 2002--March 2003

Since 1988, when the World Health Assembly resolved to eradicate poliomyelitis globally, the annual estimated incidence of polio has decreased >99%. Nigeria is the most populous country in Africa (estimated 2000 population: 127 million) and a major poliovirus reservoir. This report summarizes progress toward polio eradication in Nigeria during January 2002--March 2003, highlighting progress in acute flaccid paralysis (AFP) surveillance and evidence of wild poliovirus (WPV) circulation in areas of lower vaccination coverage. The findings underscore the importance of achieving high-quality supplementary immunization activities (SIAs).     

Reducing the loss of vaccines from accidental freezing in the cold chain: The experience of continuous temperature monitoring in Tunisia

Accidental freezing of vaccines is a growing threat and a real risk for national immunization programs when the potency of many vaccines can be compromised if these are exposed to sub-zero temperatures in the cold chain. In Tunisia, this issue is compounded by using sub-standard domestic cold chain equipment instead of equipping the program with medical refrigerators designed specifically for storing vaccines and temperature sensitive pharmaceuticals. Against this backdrop, this paper presents the findings of a demonstration project conducted in Tunisia in 2012 that tested the impact of introducing several freeze prevention solutions to mitigate the risk of accidental freezing of vaccines. The main finding is that, despite the continued use of underperforming domestic refrigerators, continuous temperature monitoring using new technologies combined with other technological interventions significantly reduced the prevalence of accidental exposure to freezing temperatures. These improvements were noticed for cold chain storage at regional, district and health center levels, and during the transport legs that were part of the demonstration conducted in the regions of Kasserine in the South-Eastern part of Tunisia. Subsequent to introducing these freeze prevention solutions, the incidence of freeze alarms was reduced and the percent of time the temperatures dropped below the 2 °C recommended threshold. The incidence of freeze alarms at health center level was reduced by 40%. Lastly, the solutions implemented reduced risk of freezing during transport from 13.8% to 1.7%. Although the solution implemented is not optimal in the longer term because domestic refrigerators are used extensively in district stores and health centers, the risk of accidental freezing is significantly reduced by introducing the practice of continuous temperature monitoring as a standard. The management of the cold chain equipment was strengthened as a result which helps protect the potency of vaccines to the areas of most difficult access.     

山西省计划免疫冷链设备现状调查

为了解山西省计划免疫冷链设备现状,于2001年5月对全省各级卫生防疫站进行了调查.结果显示截止调查时全省装备的6种主要冷链设备共4419台(件,下同),其中前10年(1986～1995年)装备2489台,占56.3%;后6年(1996～2001年)装备1930台,占43.7%.在4419台中,当前正常运转的1930台(43.7%),尚可使用的1057台(23.9%),损坏报废的1432台(32.4%).为满足当前需要,全省尚需增补1888台,其中县、乡两级需增补普通冰箱1011台,低温冰箱805台,疫苗运输车35辆;省、市两级需增补普通冷库4台,低温冷库10台,冷藏车9辆,疫苗运输车14辆.说明需增补的重点在基层.     

Diphtheria in the postepidemic period, Europe, 2000-2009

Diphtheria incidence has decreased in Europe since its resurgence in the 1990s, but circulation continues in some countries in eastern Europe, and sporadic cases have been reported elsewhere. Surveillance data from Diphtheria Surveillance Network countries and the World Health Organization European Region for 2000-2009 were analyzed. Latvia reported the highest annual incidence in Europe each year, but the Russian Federation and Ukraine accounted for 83% of all cases. Over the past 10 years, diphtheria incidence has decreased by >95% across the region. Although most deaths occurred in disease-endemic countries, case-fatality rates were highest in countries to which diphtheria is not endemic, where unfamiliarity can lead to delays in diagnosis and treatment. In western Europe, toxigenic Corynebacterium ulcerans has increasingly been identified as the etiologic agent. Reduction in diphtheria incidence over the past 10 years is encouraging, but maintaining high vaccination coverage is essential to prevent indigenous C. ulcerans and reemergence of C. diphtheriae.     

Childhood vaccination: achievements and challenges

As the goal of eradicating smallpox was being met, the World Health Organization created its Expanded Programme on Immunisation (EPI) in 1974 and reached its initial goal of achieving full vaccination of 80% of the world's children by 1990. This effort was aided by the creation of "cold chain" delivery systems and resulted in the annual saving of 3.5 million children in less-developed countries. Current EPI vaccination goals include 1) eradication of poliomyelitis by the year 2000, 2) elimination of neonatal tetanus by the year 1995, 3) control of measles and hepatitis B, and 4) immunization of 90% of the world's children 1 year or younger by the year 2000. Goals of the Children's Vaccine Initiative (formed in 1991) include 1) provision of an adequate supply of affordable, safe, and effective vaccines; 2) production of improved and new vaccines; and 3) simplification of the logistics of vaccine delivery. Future challenges are to sustain high vaccination coverage, reach the unreached, achieve proper storage of vaccines and reduce waste, integrate new vaccines into national programs, and achieve vaccine self-sufficiency. The fact that these challenges will be difficult to achieve is illustrated by the situation in Africa where the high immunization levels achieved in 1990 have dropped dramatically. Those who must act to implement immunization programs are health personnel, families, governments, and development partners. In order to achieve equity in health, every child must be reached, governments must be made accountable for programs, health workers must convince families of the importance of vaccination, delivery systems must be in place to take advantage of the new vaccines being delivered, and a multisectoral approach must be taken to assure sustainability.     

Racial/ethnic disparities in influenza and pneumococcal vaccination levels among persons aged > or =65 years--United States, 1989-2001

Influenza and pneumococcal diseases are key causes of mortality among persons aged > or =65 years, accounting for approximately 36,000 and 3,400 deaths per year, respectively, during 1990-1999. Substantial racial/ethnic disparities in adult vaccination have been documented in national surveys. Although the national health objective for 2000 of 60% receipt of influenza vaccination during the preceding 12 months by persons aged > or =65 years (objective no. 20.11) was met in 1997, and the objective of 60% for pneumococcal vaccination was nearly met in 2000, vaccine coverage levels among non-Hispanic blacks and Hispanics were 31% and 30%, respectively, compared with 57% for non-Hispanic whites. To characterize these disparities, CDC analyzed data from the 2000 and 2001 National Health Interview Surveys (NHIS) and examined trends in NHIS results for 1989-2001. This report summarizes the results of these analyses, which indicate that marked differences in vaccination coverage by race/ethnicity are observed even among persons most likely to be vaccinated (e.g., persons with the highest education level and persons with frequent visits to health-care providers). Racial/ethnic disparities in influenza and pneumococcal vaccination coverage have persisted over time. Several approaches to reduce these disparities are needed, including increasing demand for vaccination among racial/ethnic minority populations and the use of standing orders and other systems changes that promote vaccination.     

Progress toward measles mortality reduction and elimination--Eastern Mediterranean Region, 1997-2007

In 2005, the World Health Assembly set a goal of achieving a 90% reduction in global measles mortality by 2010, compared with levels in 2000. Eight years earlier, in 1997, the 22 countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) had resolved to eliminate measles from their region by 2010. To reach these two goals, the WHO Regional Office for the Eastern Mediterranean developed a four-pronged strategy: 1) achieve and maintain > or =90% vaccination coverage of children with the first dose of measles-containing vaccine (MCV1) in every district of each country through routine immunization services, 2) achieve > or =90% vaccination coverage with the second dose of measles-containing vaccine (MCV2) in every district either through a routine 2-dose vaccination schedule or through supplementary immunization activities (SIAs), 3) establish case-based surveillance with investigation and laboratory testing of all suspected cases of measles, and 4) provide optimal clinical-case management, including supplementation of diets with vitamin A. This report summarizes the progress made in the EMR during 1997-2007 toward reducing mortality from measles and eliminating measles from the region. Countries in the EMR reduced the number of measles-related deaths by approximately 75% from 2000 to 2007. However, large measles outbreaks continue to occur throughout the region, suggesting that much work remains to eliminate measles in the EMR.     

Global routine vaccination coverage, 2009

The widespread use of vaccines has greatly improved global public health, preventing millions of childhood hospitalizations and deaths each year. Vaccination of children also is projected to avert adult deaths through the prevention of hepatitis B (HepB) virus--related chronic liver disease and liver cancer and human papilloma virus--related cervical cancer. When the World Health Organization (WHO) began the Expanded Programme on Immunization in 1974, <5% of the world's children had been fully vaccinated with bacille Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP) vaccine, oral poliovirus vaccine, and measles-containing vaccine (MCV) during the first year of life. Since then, increased vaccination coverage has resulted in substantial reductions in morbidity and mortality, including a >99% decline in polio incidence since 1988, with eradication on the horizon, and a 78% decline in measles-associated mortality from 2000 to 2008 With the introduction of Haemophilus influenzae type b (Hib) vaccine, HepB vaccine, pneumococcal conjugate vaccine (PCV), and rotavirus vaccine into many countries' routine vaccination schedules, further reductions in morbidity and mortality are expected. However, based on an annual global birth cohort of approximately 130 million, an estimated 23 million infants worldwide still do not receive the benefits of routine vaccination (i.e., 3 doses of DTP during the first year of life). The Global Immunization Vision and Strategy (GIVS), developed in 2005 by WHO and UNICEF, assists countries in strengthening immunization programs and vaccinating more persons. GIVS aims to achieve 90% national 3-dose DTP (DTP3) coverage by age 12 months in all countries, and 80% coverage in every district or equivalent administrative unit by 2010 (and to sustain these levels through 2015). This report summarizes global routine vaccination coverage during 2000--2009 and progress toward achieving GIVS goals.     

智能手机在预防接种工作管理中的国内外应用现状

尽管预防接种工作取得了巨大的成就,部分地区仍面临着接种率低和接种不及时、常规免疫接种报告数据质量不高、疫苗管理不规范、疫苗温度监测不到位、人员能力不足等挑战。针对上述问题,文章综述了智能手机用于预防接种提醒、预防接种信息管理、疫苗管理、冷链设备温度监测预警和手机预防接种应用软件五个方面的国内外应用现状,提出了运用智能手机支持预防接种管理工作的初步设想。