Icelined refrigerators have become a dominant standard worldwide for the safe storage of vaccine in areas of unreliable electricity supplies. In the 35 years since the start of the Product Information Sheets not a single upright, domestic compression refrigerator has been posted in the pre-qualified catalogue of WHO for a sustained period. Yet upright, domestic refrigerators that are used to store vaccines are far more numerous than the Icelined refrigerator in spite of the published risks of exposing vaccines to heat and freezing. Industrialized countries with multi-national manfacturers of refrigerators use domestic refrigerators in immunization clinics or pharmaceutical refrigerators in larger facilities. Even low to middle income countries are increasingly commercialising their own domestic refrigerators under license from the multi-nationals. Countries such as Morocco, Tunisia and Algeria use domestic refrigerators bought on the local market and only a few Icelined refrigerators in larger stores.
Looking forward to the near future, two changes are likely to alter procurement preferences for Icelined refrigerators. First, there is a new acceleration of demand for storage of vaccines and for medicines for non-communicable diseases classified for refrigeration or controlled room temperature. Not only are quantities and volumes increasing but the diversity of presentations of vaccines is also growing. Until now the icelined refrigerator has been top opening due to the original parent, the chest freezer. Managing stocks of meat is easy in a chest freezer but as vaccines and presentations increase managing stocks becomes increasingly difficult. Front opening refrigerators provide better access to shelving where vaccine containers can be arranged for better identification. A recent trend may make it possible to improve vaccine management and swtich more domestic refrigerators to Icelined.
Motivated by the recent market popularity of American double-door domestic refrigerators, European manufacturers are offering their biggest refrigerators and freezers in pairs with identical external casing at prices far lower than the US counterparts. Converting the heavily insulated freezer of this pair to an icelined refrigerator for vaccine should be practicable by using an icebank situated at the top of the appliance. In this way the high prices of pharmaceutical refrigerators can be avoided and the Icelined refrigerator could be incorporated into the assembly lines of european and other international manufacturers product lines. A voltage regulator and highspeed circuit breaker should be incorporated as standard and a set of thermal sensors to link with proprietary temperature monitoring instruments procured separately. Two more stimulae to the use of the Icelined refrigerator worldwide would be first to regulate the vaccine refrigerator as a medical product to steer procurement away from standard doemstic refrigerators. The second would be to organise regional pooled procurement of the Icelined, front-opening refrigerators to assure a big enough market to interest manufacturers.
Dear John,
I could not agree more.
In 2009, I proposed the use of modified domestic refrigerators (at TLAC). I bought a domestic refrigerator and made an insulated wooden box as an environmental chamber, with a little heater to maintain +32. I tested, using the WHO testing protocol for ILRs. After a lot of tests and changes to the original design, mainly adding a fan pulling cold air from freezing compartment, adding an electronic thermostat, fixing ice-packs in front of the evaporator, in order to prevent freezing, I finally got it working. It is cheap and it works, the only thing needed is a manufacturer
Front opening refrigerators provide better access to shelving where vaccine can be arranged for better identification. Vaccines are being kept nice and orderly
My guess for the price would be $ 1000, the only existing upright in the PQS is almost $ 3000
The attached document gives more details.
Soren, I think that there may be good justification for the price difference for three reasons: (1) a single event that led to loss of all vaccines may well cost more than that given the cost of the vaccines - the value of the content will of course vary. (2) the lifetime of the fridge; though we do not yet have data on this; but even if lifetime was only double, it would justify more than twice the price because of the other costs of replacement/repair; (3) running costs - including for care and repair, (including dealing with temp excursions) though again I am not sure we have any data to support this.
John, I think I like the direction of your re-think, but I am not certain that I have fully understand the direction you are proposing. Personally, I have always thought that if there is good temp-monitoring of performance, as well as active management in case of disruptions there really is no objection to not using PQS fridges - though it may not in fact be so economic because of the points above - does anybody have any data to support or challenge these assertions?
If not, is that not the main problem we have with these discussions: the lack of field data on performance. If we can get all vaccine fridges to have a 30-day temp-recorder (ie, Fridge-Tag or LogTag device), and systematically collect the alarm data....
Oz, re.1 and 2 It is hard for me to understand what you mean. As I read it, you pre-empt that the cheaper model is not same quality, as the more expensive PQS listed, which is not the case. If you compare various PQS listed, you will see huge price differences that tells nothing about the quality or longevity.
There are domestic refrigerators have a life of more than 20 years of age. Those in the PQS is not of better quality, they use same components as the domestic, they are designed in a different way, like the ice-lining.
Re. 3 as for the running cost, that depends on how well insulated the fridge is. Care and repair, I do not see any difference.
best
soren
Oz,
I am hoping and expecting to publish an article shortly on the impact of continuous temperature monitoring on the rate of freeze exposure in domestic refrigerators, the case study being Tunisia. We showed that, as you say, there was a positive impact but not sufficient to eliminate the risk. Domestic refrigerators have been thoroughly monitored and their performance has repeatedly shown the risk for vaccine storage. A powerful case has been made by CDC, Atlanta where a study linked Pertussis morbidity increase related to the use of domestic refrigerators.
Front opening refrigerators and freezers are manufactured in many countries at low prices. The issue is that pharmaceutical front opening refrigerator models are also manufactured by all the big labels who license assembly in middle income countries. These appliances are marketed specifically for medicines or biologicals and cost around 4-6000 $US. By asking to modify domestic models for PQS we are crossing market partitions with different pricing. To achieve this, I believe that we will need a direct appeal to the multi-national parent companies to open the door for asssembly of this special product in these countries.
I think we are more likely to succeed to make available ILRs in producing countries by this strategy than by encouraging importation of existing top opening models, especially if we can also have vaccine refrigerators regulated nationally as medical appliances in each country.
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