Keeping vaccines safe

In a youth sports complex near the gently lapping waves of the Mediterranean in the suburb neighborhood of La Marsa, a building has been commandeered to be used as a Covid-19 vaccination center. A line of people, some of them parents with their children, stretches up the block from the vaccination building’s outer gate. Inside, soon-to-be-vaccinated Tunisians sit in orderly rows, waiting for their turn to go behind a small white curtain to get their Covid-19 vaccine. In an abutting room, medical staff pulls vaccines and dilution liquids from a specialized refrigerator, mixing the solutions and noting stocks of each vaccine.

One of those medical staff, Doctor Alia Hajjem, while noting numbers of vials and giving directions to nurses, spoke about the importance of the refrigeration equipment supplied by UNICEF to the Tunisia’s Ministry of Health thanks to funding from the Japanese government, USAID and the Gavi Alliance.

“We’re been using this refrigerator since April of 2021,” not long after the delivery of the first vaccines to Tunisia, she said. “Even in the extremely hot summer months, the fridge kept going and kept the five types of vaccines we are using cold. And we know that UNICEF, in collaboration with the COVAX Initiative, got us the vaccines early on.”

Up until last summer, the Covid-19 pandemic was catastrophic in Tunisia. Tunisia had the highest death rate in all of Africa, and had close to half a million infections—out of a population of 11.8 million Tunisians. There were few if any beds available in most hospitals in the country, and at the peak of infections, the health system all but collapsed.

Although children were much less infected by COVID-19 than adults, the psychological damage of quarantine, lockdowns, school closures, and the dramatic rise in poverty are significant. All of this led to increased risks of child dropouts from school, increased domestic violence towards children, and inability of families to meet their children’s basic needs like food, clothing, education and shelter.

Children have special needs and are more vulnerable than adults to shocks: if they do not go to school today they reduce their opportunities of success.

Since July, the Tunisian government has implemented mass vaccination campaigns, with well over five million people vaccinated so far.

A key element that has played a role in the success of the vaccination campaign is cold chain infrastructure. UNICEF and its partners took action to protect children and their caretakers by building up cold chain infrastructure to safely transport and store vaccines in Tunisia.

UNICEF, with a donation from the Government of Japan, bought equipment that was handed over to the Ministry of Health between February and July 2021—a critical element to start the vaccination of the frontline workers. The equipment included 184 refrigerators and 3 freezers, all at the Performance, Quality and Safety (PQS) World Health Organization standards, and 955 vaccine temperature recorders – an essential requirement for the safe storage of Covid vaccines.

The necessity of refrigerators, freezers, temperature registers, vehicles and trained human resources is essential. Without an optimal cold chain, the vaccines would be rendered impotent after delivery to Tunisia.

Dr. Hajjem, at the vaccination center, spoke further about how the system works.

“Here we use Pfizer, Astrazeneca, Sinovac-Coronavac, Johnson & Johnson, Sinopharm and Moderna. I work at Monji Slim, a nearby hospital, but I, like the other pharmacists here, come in to this vaccination center one day out of every ten, from 8am to 6pm.”

And the workload for Dr. Hajjem is only increasing of late, as the Omicron variant of Covid spreads throughout Tunisia, and the government takes stringent measures to blunt its impact.

“The center is getting packed lately because as of the 22nd of December 2021, the government will demand vaccination passes for all public establishments. And since people know that a third dose can help to fight Omicron, many are streaming in to get a booster shot.”

Reinforcing cold chain infrastructure in Tunisia has been a collective effort.

Japanese ambassador in Tunisia, Mr. Shinsuke Shimizu, said, “We have cooperated with UNICEF Tunisia on the equipment side, providing refrigerators and freezers for vaccines. We called this the ‘Last One Mile Cooperation,’ because vaccines in storage at the wrong temperature are not useful.”

And speaking of the interior and southern provincial areas of Tunisia badly underserved by infrastructure, Mr. Shimizu said, “We provide this equipment so that the vaccines can reach the [interior and southern provincial] areas that are far from Tunis.”

USAID is another major funder of cold chain infrastructure development in the fight against Covid-19 in Tunisia. Scott Dobberstein, Director of the U.S. Agency for International Development in Tunisia described USAID’s support. He said that building cold chain infrastructure has benefits on the health of children in Tunisia well beyond anti-Covid vaccines.

Children get numerous vaccines in their early years to protect them against a number of illnesses, such as measles and rubella. This is called routine immunization. A UNICEF-supported study, however, showed that the cold chain for routine immunization in Tunisia was weak before the Covid-19 pandemic hit, and with the arrival of large quantities of Covid vaccines the cold chain risked getting overloaded, jeopardizing the essential routine vaccination system.  For example, the study found that 98% of the refrigerators used were domestic refrigerators, not the WHO-recommended pharmaceutical (PQS) type, and that there was not enough storage capacity for vaccines at both central and regional level.

“The United States is proud of its partnership with UNICEF to provide Tunisia with much needed cold chain reinforcement capabilities essential for the management of COVID-19 vaccines.  Through USAID, the U.S. was able to support the upgrading of equipment to meet global standards, including the installment of remote temperature monitoring sensors that are required for safe storage.  Since the beginning of the pandemic, the U.S. has provided Tunisia with over $46 million in assistance, in addition to over 2.8 million life-saving vaccines, as a demonstration of our continued commitment to ending this global pandemic,” said U.S. Ambassador to Tunisia Mr. Donald Blome.

Dobberstein added that, “Improving cold chain infrastructure has considerable advantages in terms of reducing response costs, reducing risk of vaccine damage, and improving access to life-saving vaccines among children living in rural areas.”

For Marilena Viviani, the UNICEF Representative in Tunisia, “The Covid crisis has been terrible in Tunisia, but it has been also an opportunity to invest, with the Ministry of Health and our partners, in particular with WHO not only to ensure the arrival of the COVAX vaccines but also to make sure that the government could renew its cold chain system. In the longer term this will help us reach more children with routine vaccination.”

Cold chain infrastructure, she said, “Beyond the current immediate need of ensuring the safe storage of Covid vaccines, is vital for the safety of children’s vaccines, and as such for their health and wellbeing.”

Back at the vaccination center in La Marsa, Alex Cherif, 15 years old, was waiting in line outside to get a vaccination shot.

Through his mask, he said, “Corona has been really hurting us. I haven’t had the Covid vaccine yet. But I think that when I do the vaccine, I’ll be protecting myself and protecting others.”