Reverse cold chain in supply chain management

1. REVERSE COLD CHAIN
Presented by:
Palka Mittal
Sahdev Bishnoi
M.Voc. (Public Health)

2. CONTENT
• INTRODUCTION
• NEED OF REVERSE COLD CHAIN
• SURVEILLANCE STANDARDS
• CLASSIFICATION SCHEME
• STANDARDS FOR SAMPLE COLLECTION
• STORATGE AND TRANSPORT CONDITIONS
• REPORTING CRITERIA
• INNOVATIONS

3. Reverse Cold Chain
The process of maintaining the cold chain when heat sensitive items are stored
and transported in the reverse direction i.e. upward from the clinic to a depot
or laboratory.

4. Reverse Cold Chain-WHO
“If a cold chain is what you call the transport chain that goes from a laboratory
to the field – where vaccines must be kept at a certain temperature from the
moment they are produced, until they are administered in order for them to
work – a reverse cold chain is the process of stool samples that need to be
tested getting back to the laboratory from the field at certain temperatures so
that the virus that might be in the sample will still be identifiable.”

5. Why reverse cold chain?
• Poliomyelitis is targeted for eradication. Highly sensitive surveillance for
acute flaccid paralysis (AFP), including immediate case investigation, and
specimen collection are critical for documenting the absence of poliovirus
circulation for polio-free certification
• When any case of acute flaccid paralysis is found anywhere in the world,
stool samples from the affected child must be transported carefully to the
laboratory so that they can be tested to identify whether the poliovirus was
the cause.

6. Surveillance Standards of Poliomyelitis
As per WHO
Clinical case definition
• Any child under 15 years of age with AFP* or any person of any age with
paralytic illness if polio is suspected
Case classification
• Suspected case: A case that meets the clinical case definition
• Confirmed case

7. Final Classification Scheme for AFP
Cases

8. Standards for Sample collection
• Collect two samples 24-48 hours apart and within 14 days of the onset of
paralysis
• Volume of specimen must be adequate(approximately 8-10g)
• Appropriate documentation (i.e. laboratory request form)
• Sample must be in good condition, i.e. with no leakage or desiccation
• Evidence that the reverse cold chain has been maintained (presence of ice
or temperature indicator)

9. Specimen-Based Data
• Unique identifier
• Specimen number: 1 = first specimen; 2 = second specimen; 3 = other; 9 =
unknown
• Date of onset of paralysis
• Date of last OPV dose
• Date of collection of stool specimen
• Date stool specimen sent to laboratory
• Date stool specimen received in laboratory
• Condition of stool: 1 = good; 2 = poor; 9 = unknown
• Date final culture results sent from laboratory to EPI(Expanded Program on
Immunization)

10. Rules for Specimen Storage and
Transport
Poliovirus is sensitive to heat, therefore
• After collection, the specimens must be placed immediately in a refrigerator or, for
shipment, in a cold box at 0–8°C between frozen ice packs.
• Aim for the specimens to arrive at the laboratory within 72 hours of collection.
• If this is not possible, the specimens must be frozen (at -20°C) and then shipped
frozen, preferably with dry ice or with cold packs that have also been frozen at -
20°C.
• Try to limit repeated freezing and thawing to a minimum. This process of keeping
the specimen refrigerated or frozen is called a “reverse cold chain”.

11. Remember
• Avoid storing samples in refrigerators or cold boxes used for vaccines or
medicines.
• If separate storage is unavoidable, seal specimens in 2-3 layers of plastic
bags and separate them properly from vaccines.

12. Diagrammatic Representation
(a) 30-60 ml faeces container with
external screw cap.
(b) Sealed polyethylene bag to hold
faeces containers.
(c) Sealed polyethylene bag to hold
report form.
(d) Absorbent material (cotton wool
absorbs 8-10 times its own weight).
(e) Icepacks obtainable from national
EPI.
(f) High-density (30-35 kgs/m3)
polystyrene (small bubbles and firm
when squeezed).
(g) Infectious substance label.
(h) Outer carton of double-ply
corrugated cardboard or plastic.

13. Reporting Criteria
• Aggregated data on AFP cases should be included in routine monthly
surveillance reports
• Designated reporting sites at all levels should report at a specified
frequency (e.g. weekly or monthly) even if there are zero cases (often
referred to as "zero reporting")
• All outbreaks should be investigated immediately
• All AFP cases under 15 years of age or with paralytic illness at an age
where polio is suspected should be reported immediately and investigated
within 48 hours
• Active surveillance: Regular weekly visits should be made to selected
reporting sites that are most likely to admit acute flaccid paralysis patients
(e.g. major hospitals, physiotherapy centers) to look for unreported AFP
cases

14. Innovations in the reverse cold
chain
• Introduction of continual temperature recording probes known as ‘Log
Tags’ to track specimens during their journey to the lab.
• Incentives are paid for informants who report a case.

15. THANK YOU!!!
ANY QUESTIONS?