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HASIL ANALISIS PEMANTAUAN SUHU 6 LEMARI ES

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					REPORT
ON

EVALUATION OF ALTERNATIVE REFRIGERATOR MODELS FOR PRIMARY HEALTH FACILITIES

Anton Widjaya, Widyati Santoso, Vanda Moniaga, Olivia Simbolon, Wasito, Suparno, Budiono, Juhartini

Directorate for Epidemiology, Immunization and Matra Health Director General for Communicable Disease Control and Environmental Health Ministry of Health Republic of Indonesia and Program for Appropriate Technology in Health (PATH)

2006

1

EVALUATION OF ALTERNATIVE REFRIGERATOR MODELS FOR PRIMARY HEALTH FACILITIES
Anton Widjaya1, Widyati Santoso1, Vanda Moniaga1, Olivia Simbolon2, Wasito2, Suparno3, Budiono3, Juhartini1

EXECUTIVE SUMMARY Cold chain forms one backbone of the immunization program at all levels of service, and has been the focus of the Ministry of Health’s optimization effort in the past few years. One area that has been identified as needing particular attention is storage at the primary health facilities (health center) based on several field studies on vaccine management that the Ministry of Health and Program for Appropriate Technology in Health (PATH) conducted from 2000 – 2005. The studies revealed violations of storage temperatures at the health center level caused partly by suboptimal refrigerator performance, lack of clear guidance on the most suitable refrigerator and its standard operating procedure. As the responsibility for equipment provision is shifted to the provincial and district level as part of the decentralization process, the variety of refrigerators that are in use at the health center level increases; from the WHO-recommended top-opening refrigerators to domestic refrigerators, to solar refrigerators in the eastern provinces of Indonesia. There is however no solid data comparing the performance of different refrigerators, causing difficulty in selecting an optimum refrigerator for the health center. The Ministry of Health in collaboration with PATH conducted monitoring on several refrigerators that are currently in use (Electrolux RCW 42 EK, Electrolux RCW 50 EK, domestic refrigerator, domestic refrigerator with modification) or can become candidates (Electrolux RCW 50 EG, Vestfrost MK 144, Dove) for use at the health center level. Temperature stability with electricity and / or an alternate energy source (kerosene or gas) during routine use and during simulated challenges was assessed. Several parameters that should be respected in order to maintain a stable temperature were noted and reported, while an operating cost efficiency based on electricity/fuel consumption per liter capacity of each refrigerator was calculated. A matrix of criteria starting with temperature stability, followed by operating cost efficiency, ease of operation and storage capacity was established to rate each refrigerator for suitability of use at the health center level. The results concluded the Vestfrost MK 144 as the most suitable refrigerator for use at the health center level, followed sequentially by the Dove refrigerator, domestic refrigerator with WHO modification, domestic refrigerator without modification, Electrolux RCW 50 EG, Electrolux RCW 50 EK, and lastly the Electrolux RCW 42 EK. The information gained from this activity is expected to provide input for the Ministry of Health as well as the local government in making equipment provision decisions.

1 2

PATH, Jakarta, Indonesia Immunization Sub Directorate, Ministry of Health Republic of Indonesia, Jakarta, Indonesia 3 Immunization Unit, Central Java Provincial Health Office, Semarang, Central Java, Indonesia 2

BACKGROUND Cold chain is one pillar of support to the immunization program at all levels of service, and is essential to the quality of the immunization program. Up to now provision of cold chain equipment is largely centrally determined, but there has been an increasing trend of local provision of equipment as part of the decentralization process. The shift of responsibility for equipment provision to the provincial and district level has resulted in procurement of mostly domestic refrigerators for primary health facilities (health center) based on affordability and availability of after-sales service at the local level. A range of refrigerators are therefore currently in use at the health center level: from the WHO-recommended top-opening refrigerators that are included in the WHO-UNICEF Performance, Quality, Standard (PQS), to domestic refrigerators with or without WHO modification. Solar refrigerators are also in use mainly in remote health centers in the eastern provinces of Indonesia. Not all refrigerators perform equally however, and there has not been any solid data comparing the different refrigerators’ performance in a typical health center situation where several external factors such as fluctuating voltage, electricity discontinuity, fuel (kerosene / gas) quality, etc. are involved. Poor refrigerator performance had been documented through field studies on vaccine management1,2, 3 that the Ministry of Health and Program for Appropriate Technology in Health (PATH) conducted from 2000 – 2005. Those studies discovered several violations of storage temperature at the health center level that resulted in deterioration of vaccines and were caused partly by suboptimal refrigerator performance. These findings emphasize the urgency of obtaining field data on the performance of the different refrigerators. This monitoring activity was therefore performed on several refrigerators that are either already commonly used, or can become candidates for use at the health center level. Each refrigerator was assessed for its temperature stability with electricity and / or an alternate energy source, with and without challenges. A challenge procedure in the form of electricity discontinuation, and frequent door openings was designed to simulate the real usage condition in a typical health center in Indonesia. Several parameters that should be respected in order to maintain a stable temperature were noted and reported. In addition the operational cost based on the electricity/fuel consumption of each refrigerator was calculated. A list of service network available for each brand of the refrigerators tested was also established. It is hoped that the information provided will assist the Ministry of Health and the local government in making decisions for provision of cold chain equipment based on technical performance, ease of maintenance and repair, and affordability.

OBJECTIVES 1. To obtain data on the field performance of refrigerators using different energy sources. 2. To monitor the temperature stability and holdover capability of different refrigerators following a set of challenges. 3. To analyze the operational cost of refrigerators operating with different energy sources. 4. To collect information on the perception of cold chain staff regarding maintenance and repair of refrigerators.

3

STUDY IMPLEMENTATION Personnel The activity was conducted by the Immunization Sub Directorate of the Directorate for EPIMKESMA, Ministry of Health, and Central Java Provincial Health Office in collaboration with Program for Appropriate Technology in Health (PATH). Location Central Java Provincial Health Office. Timeline
No 1 2 3 4 5 6 7 8 9 Activity Preparation Electricity consumption measurement Temperature stabilization period and interview Temp monitoring with electricity as energy source First challenge procedure Second challenge procedure Temp monitoring using an alternate energy source Challenge procedure Final interview, data collection March’05 April May June

MATERIALS AND METHODS Materials The refrigerators and monitoring equipment used in this study are as follows: 1. Six new refrigerators and one 10-year-old refrigerator. Details of the refrigerators are provided in Table 1 on the next page (page 5). 2. Tinytalk Range G temperature data loggers (Tinytalk Range G temperature data logger is a trademark of Gemini Data Loggers Ltd., UK). 3. Multilog sensor to monitor the room temperature at the provincial store (8-sensor Multilog #30025-2, Remonsys Ltd., UK; installed at the Central Java provincial cold store in December 2003). 4. Electricity consumption meter (Voltcraft, Energy Check 3000, Germany). 5. Kerosene and gas as alternate energy source. 6. Questionnaire, checklist, and monitoring forms.

4

Table 1 Details of Refrigerators used in the Monitoring
No. 1 2 Refrigerators Electrolux RCW 42 EK** Electrolux RCW 50 EK Type Absorption Absorption Capacity (Manufacturer's Specification) Vaccine Storage Cap = 18.2 Lt 70 Lt ; Vaccine Storage Cap = 24 Lt., Freezing comp = 4.7 Lt 70 Lt ; Vaccine Storage Cap = 24 Lt., Freezing comp = 4.7 Lt 85 Lt. Net Cap. Calculated Storage Volume (liter) 18.2 24 Effective Volume (liter) (66% = 2/3) 11.0 15.8 Dummy vaccine vol* (liter) 47 68

3

Electrolux RCW 50 EG

Absorption

24

15.8

68

4

Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHOmodified by adding cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator

Absorption

59.2

39.1

168

5

Compression

150 Lt Net Cap

48

31.7

137

6 7

Compression Compression

170 Lt. Net Cap. 46 Lt. Net Cap.

63.5 18

41.9 11.0

181 68

* Dummy vaccine used = 0.232 liter / box of 10 vials of DT vaccine
(pictures not drawn to scale)

**has been used for more than 10 years. Other refrigerators are brand new.

Dove

RCW 42 EK

RCW 50 EK, RCW 50 EG

Vestfrost MK144

Domestic refrigerator (unmodified & modified)

5

Methods Each refrigerator was filled to 2/3 of its capacity with dummy vaccines to mimic the typical storage condition at the health center level. WHO modification on the domestic refrigerator was done using cool packs as pictured in the previous page. Temperature was monitored by 2 data loggers that had been programmed to record temperature every hour and placed in the top and bottom vaccine compartment in each refrigerator. In addition a twice daily visual temperature record was maintained by the provincial cold chain staff following the standard procedure at the province throughout the monitoring period. A challenge procedure of electricity discontinuation and frequent door openings at certain time intervals was designed to simulate the actual situation commonly seen during working hours at a typical health center in Indonesia. An interview with the cold chain staff to obtain their perception regarding maintenance and repair of refrigerators was performed prior to and after the temperature monitoring. Questionnaires, and checklist used in the monitoring are available upon request. The temperature inside each refrigerator was stabilized for one to seven days by adjusting the thermostat prior to the start of monitoring. The operational cost for each refrigerator was calculated by measuring the consumption of energy source. For electricity an energy meter was used, while the consumption of gas and kerosene was estimated from the total volume of fuel that was used during the monitoring. The results were multiplied with the current unit price of the different types of fuel to arrive at the operational cost for each refrigerator. To take into account the different storage capacity of different refrigerators, the monthly operational cost was divided by the storage capacity to arrive at operating cost efficiency for each refrigerator. Temperature monitoring was divided into 4 periods: 1. Week 1-4: 4 weeks of use with electricity as energy source. 2. Week 5: 8 days of several challenges with electricity as energy source.  Electricity cut off for 48 hours (Day 1-2)  Leaving the refrigerator door open 1x (at 08:00) for 5 min during the day (Day 3)  Leaving the refrigerator door open 2x (at 08:00 and 15:00) for 5 min each during the day (Day 4)  Leaving the refrigerator door open 3x (at 08:00, 12:00 and 15:00) for 5 min each during the day (Day 5)  Leaving the refrigerator door open 4x (at 08:00, 11:00, 13:00 and 15:00) for 5 min each during the day (Day 6)  Leaving the refrigerator door open 5x (at 08:00, 10:00, 12:00, 13:00, and 15:00) for 5 min each during the day (Day 7)  Leaving the refrigerator door open 6x (at 08:00, 10:00, 11:00, 12:00, 13:00 and 15:00) for 5 min each during the day (Day 8) 3. Week 6-8: 3 weeks of routine use with an alternate energy source: kerosene and gas for RCW 50 EK, and RCW 50 EG respectively. 4. Week 9: 4 days of challenges with the alternate energy source for the appropriate refrigerators.  Leaving the refrigerator door open 1x (at 08:00) for 5 min during the day (Day 1)  Leaving the refrigerator door open 2x (at 08:00 and 15:00) for 5 min each during the day (Day 2)

6

 

Leaving the refrigerator door open 3x (at 08:00, 12:00 and 15:00) for 5 min each during the day (Day 3) Leaving the refrigerator door open 4x (at 08:00, 11:00, 13:00 and 15:00) for 5 min each during the day (Day 4)

Temperature data and interviews results were analyzed and presented as: 1. temperature stability (2 – 8 ºC) of each refrigerator during use without challenges. 2. temperature stability (2 - 8 ºC and up to 10 ºC) of each refrigerator following a set of challenges (holdover time). 3. the time required by each refrigerator to achieve a stable temperature of 2 – 8 ºC at startup, and after the challenge procedures. 4. operational cost and cost efficiency of each refrigerator. 5. perception of cold chain staff regarding refrigerator maintenance and repair.

RESULTS A. Electricity as energy source 1. Temperature stability without challenges All refrigerators were able to maintain a temperature of 2 - 8 ºC during routine use without challenges. This ability however depends on several factors:  Proper thermostat setting.  Input electrical voltage. Details are provided in Table 2 below: Table 2 Temperature Range of Refrigerators during Routine Use
Temp (ºC) No. 1 2 3 4 5 Refrigerator Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHOmodified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator RCW 50 EK (kerosene) RCW 50 EG (gas) Bottom Min Max 4.3 6.9 3.1 2.3 1.9 2.3 6.2 4.6 3.1 3.5 Min 5.8 2.3 2.7 1.9 2.3 Top Max 8.0 6.5 4.5 2.7 3.5 Thermostat setting 6.5 3 3 6 5 28.3 35.1 Ambient temp (ºC) Min Max

6

3.1

6.5

1.1

2.3

Normal

7 8 9

3.1 2.3 2.3

5.4 5.4 3.5

4.6 3.1 3.5

6.5 6.9 6.5

2 3 3 21 21 27 27

7

2. Temperature stability during electricity cut off (Holdover capability) Temperature of 2 – 8 ºC was maintained by all refrigerators when electricity cut off was only 4 hours. The domestic refrigerator without WHO modification was the one with the shortest holdover time, having temperature above 10 ºC after 8 hours of no electricity. WHO modification only added 2 hours to a domestic refrigerator’s holdover capability. The RCW 42 EK was next. At 8 hours of no power its temperature was already above 8 ºC, and at 12 hours, its temp climbed to above 10 ºC. When the electricity was cut off for a full 24 hours only the Vestfrost MK144 and the Dove were able to maintain their 2 - 8 ºC temperature. These latter two also lost their holdover capability after 48 hours of no power. At 48 hours none of the 7 refrigerators were able to maintain the recommended temperature, instead their temperatures ranged from 13.9 ºC to 28.1 ºC. Details are provided in Figure 1 and 2 on page 11-12 and Table 3 and 4 below: Table 3 Starting and Final Temperature of Refrigerators following Electricity Cut off
Temp (ºC) in the Top Vaccine Compartment N O Refrigerator 4 hrs Start (ºC) Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator 8.4* 3.5 4.6 2.7 End (ºC) 9.9 5.0 6.2 3.1 8 hrs Start (ºC) 9.5 1.5 3.9 2.7 End (ºC) 11.0 4.6 6.5 3.1 12 hrs Start (ºC) 10.2 2.7 4.3 3.1 End (ºC) 12.0 5.8 9.1 3.5 24 hrs Start (ºC) 10.6 2.7 5.4 3.1 End (ºC) 19.8 11.3 16.7 3.9 48 hrs Start (ºC) 19.8 11.3 16.7 3.9 End (ºC) 27.3 23.4 25.2 10.2

1 2 3 4

5

5.4

6.5

2.3

5.4

3.1

6.0

3.1

8.0

8.0

14.2

6

4.3

7.7

3.5

14.9

3.9

19.8

4.6

23.4

23.4

28.1

7

5.0

6.2

4.6

6.5

3.1

3.9

3.9

7.7

7.7

20.6

Note: The shaded columns indicate temperatures above 8 ºC *Change in vaccine dummy load to all refrigerators 2 days before the simulation exercise caused the starting temp of RCW 42 EK to be above 8°C at the time the electrical plug was disconnected.

8

Table 4 Starting and Final Temperature of Refrigerators following Electricity Cut off
Temp (ºC) in the Bottom Vaccine Compartment N O Refrigerator 4 hrs Start (ºC) Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator 6.9 5.4 4.6 2.3 End (ºC) 8.4 7.3 5.8 3.5 8 hrs Start (ºC) 8.0 4.3 3.5 2.3 End (ºC) 9.5 7.3 5.8 2.7 12 hrs Start (ºC) 8.8 5.0 3.9 3.1 End (ºC) 10.6 8.8 7.7 3.9 24 hrs Start (ºC) 9.1 4.6 5.0 2.3 End (ºC) 19.5 13.8 15.6 3.9 48 hrs Start (ºC) 19.5 13.8 15.6 3.9 End (ºC) 27.0 24.8 24.8 11.3

1 2 3 4

5

8.4*

9.5

6.9

9.1

7.7

10.2

6.5

11.0

11.0

16.0

6

5.0

9.9

4.6

13.8

5.0

18.1

5.8

21.6

21.6

28.1

7

3.9

5.4

3.1

3.9

1.5

1.9

1.9

5.4

6.5

19.1

Note: The shaded columns indicate temperatures above 8 ºC *Change in vaccine dummy load to all refrigerators 2 days before the simulation exercise caused the starting temp of the modified domestic refrigerator to be above 8°C at the time the electrical plug was disconnected.

After 48 hours connection to the electricity was restored and each refrigerator was left to return to a stable temperature of 2 - 8 ºC. The ones that were able to do so the fastest were the Vestfrost MK144 and the Dove refrigerators (4 – 5 hours), followed by the domestic refrigerator without modification (8 hours), then sequentially by the domestic refrigerator with WHO modification (13 hours), and the RCW 50 EK (18 hours). The RCW 50 EG required 26 hours, while the RCW 42 EK took the longest time (a full 48 hours) to return to a stable temperature of 2 - 8 ºC. Table 5 below listed the time period required by each refrigerator. Table 5 Time required by each refrigerator to return to a stable temperature of 2 - 8 ºC following electricity cut off for 48 hours
NO 1 2 3 4 5 6 7 Refrigerator Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator Time required 48 hours 18 hours 26 hours 4 hours 13 hours 8 hours 5 hours

9

3. Temperature Stability with Frequent Door Openings Opening the refrigerator door once or twice a day for 5 minutes each did not significantly influence the temperature stability of the refrigerators. Of the 7 refrigerators tested RCW 42 EK was the least stable, with temperatures above 8 ºC after door openings of three times. Opening the refrigerator door once more raised its temperature by another 2 ºC. As had been reported elsewhere domestic refrigerators are sensitive to frequent door openings. In this study the one without WHO modification had its temperature above 8 ºC after 4 times of 5-minute door openings. The domestic refrigerator with WHO modification was only slightly more stable and had a similar performance as the RCW 50 EK. Their temperatures were between 8 – 10 ºC after 5 door openings. The other refrigerators (RCW 50 EG, MK 144, Dove) remain below 8 ºC even after 6 door openings. Details are provided in Table 6 below and Figure 1, and 2 on page 11-12. Table 6 Average temperature increase following frequent openings of the refrigerator door
Average temp increase above the starting temp of 2 - 8 ºC following door openings No. Refrigerator 1à 5 min/day Bot (ºC) 1 2 3 4 Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator RCW 50 EK (kerosene) RCW 50 EG (gas) Note: ND = not done 0 4.4 0.4 0 Top (ºC) 2.2 1.1 0 0 2à 5 min/day Bot (ºC) 1.5 5.4 0.9 0 Top (ºC) 3.1 1.8 0.8 0,2 3à 5 min/day Bot (ºC) 1.4 1.3 0.6 0.3 Top (ºC) 2.2 1.6 0.5 0,1 4à 5 min/day Bot (ºC) 1.1 2.1 0.5 0.3 Top (ºC) 1.6 0.6 0.5 0.3 5à 5 min/day Bot (ºC) 0.6 2.3 0.5 0.4 Top (ºC) 1.5 0.8 0.6 0.3 6à 5 min/day Bot (ºC) 0.9 1.5 0.4 0.2 Top (ºC) 0.9 0.5 0.5 0.1

5

1.8

3.5

2.5

3.5

1.8

2.5

1.5

2.7

0.8

1.4

0.8

1.0

6

3.1

0

2.4

0.2

2.0

0.1

1.4

0.4

1.2

0.2

1.1

0.2

7 8 9

0 1.2 0.8

1.9 1.5 0.8

0.2 0.6 1.1

2.1 0.8 0.4

0.1 0.3 0.8

1.6 0.9 0.4

0.3 0.3 0.9

0.9 0.5 0.3

0.3 ND ND

1.1 ND ND

0.3 ND ND

0.7 ND ND

10

Figure 1 Refrigerator Temperature with Electricity as Energy Source (bottom vaccine compartment)

RCW 42 EK – bottom bottom RCW 50 EK – bottom RCW 50 EG – bottom MK 144 - bottom

Domestic, WHO modific Domestic, no modific – bottom LE DOVE - bottom

Thermostat adjustment period

Temp. mon. no challenges (8-27 Apr 2005)

1st challenge (2- 8 May 2005): Electr. cut off (4, 8, 12, 24, 48 hrs)

2 challenge (9 – 14 May 2005): Door openings 1x, 2x, 3x, 4x, 5x, 6x 5 in a day (5 min ea)

nd

11

Figure 2 Refrigerator Temperature with Electricity as Energy Source (top vaccine compartment)

RCW 42 EK – top RCW 50 EK – top RCW 50 EG – top MK 144 - top

Domestic, WHO modific - top Domestic, no modific – top LE DOVE - top

Thermostat adjustment period

Temp. mon. no challenges (8-27 Apr 2005)

1st challenge (2- 8 May 2005): Electr. cut off (4, 8, 12, 24, 48 hrs)

2 challenge (9 – 14 May 2005): Door openings 1x, 2x, 3x, 4x, 5x, 6x 5 in a day (5 min ea)

nd

12

B. Kerosene or gas as energy source 1. Temperature Stability without Challenges Both refrigerators (RCW 50 EK, and RCW 50 EG) were able to maintain a temperature of 2 - 8 ºC during routine use without challenges. The RCW 50 EK however requires strict continuous monitoring and control to the heating system, namely on:  cleanliness of the funnel and wick  wick length  availability of adequate fuel. Without continuous monitoring the temperature in RCW 50 EK fluctuates significantly as can be observed in Figure 3 and 4 on the following pages. From initial start up the RCW 50 EK required 8 hours to achieve a stable temperature while the RCW 50 EG required 11 hours. The range of temperatures obtained with the 2 refrigerators using their alternate energy source is listed in Table 7 below: Table 7 Temperature Range of Refrigerators under Routine Use with an Alternate Energy Source
Temp (ºC) No. 1 2 Refrigerator RCW 50 EK (kerosene) RCW 50 EG (gas) Bottom Min Max 2.3 5.4 2.3 3.5 Min 3.1 3.5 Top Max 6.9 6.5 Thermostat setting 3 3 Ambient temp (ºC) Min 21 21 Max 27 27

Details are provided in Figure 3 and 4 on the following pages. 2. Temperature Stability with Frequent Door Openings Both of the refrigerators tested were still able to maintain a stable temperature of 2 – 8 ºC when the refrigerator door was opened up to four times in a day. Details are provided in Figure 3 and 4 on the following pages and Table 6 on page 10.

C. Vaccine Storage Capacity The storage capacity of each refrigerator is listed in Table 1 on page 5. The largest storage capacity of 59.2 liter is provided by Vestfrost MK 144 ice-lined refrigerator. Domestic refrigerators also give a large storage capacity (63.5 liter), but the capacity is reduced to approximately ¾ (48 liter) with WHO modification. The smallest capacity of only 18 liter is provided by RCW 42 EK and Dove refrigerators. All refrigerators monitored in this activity have adequate capacity to store a 1- to 2-month stock (approximately 20-25 liter) at the health center level. The storage space need increases with the introduction of vaccines in single-dose presentations/prefilled syringes and during campaign activities (National Immunization Day/NID and School Children Immunization Month/BIAS). In those situations, the RCW 42 EK, and Dove refrigerator will not have sufficient capacity to accommodate the additional volume of vaccines.
13

Figure 3 Refrigerator Temperatures with Kerosene / Gas as Energy Source (bottom vaccine compartment)

RCW 50 EK – bottom RCW 50 EG – bottom

Thermostat adjustment period

Temp mon. no challenges (6 – 24 June 2005)

Challenge procedure (27 – 30 June 2005): Door openings for 1x, 2x, 3x, 4x in a day (5 min ea)

14

Figure 4 Refrigerator Temperatures with Kerosene / Gas as Energy Source (top vaccine compartment)

RCW 50 EK – top RCW 50 EG – top

Thermostat adjustment period

Temp mon. no challenges (6 – 24 June 2005)

Challenge procedure (27 – 30 June 2005): Door openings for 1x, 2x, 3x, 4x in a day (5 min ea)

15

D. Operational Cost The monthly operational cost for these refrigerators with electricity as the energy source varies from Rp.31,000 to Rp.56,000. The lowest and highest cost was borne by the Dove refrigerator and the Vestfrost MK 144 respectively. The operational cost calculation does not take into account the storage capacity of each refrigerator based on the assumption that the cost will remain the same irrespective of whether or not a refrigerator is used up to its full capacity. It is expected that the operational cost for a large-capacity refrigerator such as the MK 144 will decrease with an increasing storage load. Analysis of the overall cost takes into account the operating cost efficiency (operating cost divided by storage capacity) and purchase price of each refrigerator. The monthly operational cost for RCW 50 EK and RCW 50 EG using kerosene and gas is Rp. 30,000 and Rp. 25,000 respectively. Details are provided in Table 8 below: Table 8 Monthly Cost of Refrigerators with Electricity and/or Other Energy Source
Electricity (watt/hr) / Fuel Consumption Ave Electrolux RCW 42 EK Electrolux RCW 50 EK Electrolux RCW 50 EG Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHOmodified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator RCW 50 EK (kerosene) RCW 50 EG (gas) Absorption Absorption Absorption Compression Compression 81.1 114 108.3 129 86.5 Min 78 113 102 128 84 Max 111 114 110 160 87 Manuf.'s Specs. (Watt/hr) 85 120 120 120 65 Monthly Usage (KW/hr)* 58.392 82.08 77.976 92.88 62.28 Monthly Cost (Rp)** 35,035 49,248 46,786 55,728 37,368 Monthly Cost ($) 3.89 5.47 5.20 6.19 4.15

Refrigerator

Type

Compression

86.5

86

118

74

62.28

37,368

4.15

Compression Absorption Absorption

73.4 25 liter 6 kg

73

74

40

52.848

31,709 30,000 25,000

3.52 3.33 2.78

* Monthly Usage: Unit cost: **Fee (Rp per KW/h): 1 US$ 1 tank of gas (13 kg) 1 liter kerosene

Average electricity consumption per hour x 24 hrs x 30 days x 1000 KW/h Rp. 600 Rp. 9,000 Rp. 51,000 Rp. 1,200 16

E. Perception of Cold Chain Staff regarding Refrigerator Maintenance and Repair Interviews with cold chain staff prior to and after the monitoring activities recorded the following information:  Maintenance and simple repair can be performed by cold chain staffs at all levels of service.  Use of kerosene, and to some degree gas as well, requires close and continual attention to the various details of the heating system in order to achieve and maintain a stable temperature. As a result electricity is still preferred over kerosene or gas due to the former’s simpler handling procedure.

F. Availability of Service Network Contact information for distributors and suppliers for refrigerator service is listed as a separate attachment.

CONCLUSION A comparative observation on the performance of 7 different types of refrigerators that are in use or appropriate for use in primary health facilities (health center) was conducted to obtain data on the most suitable refrigerator for the health center level. The observation did not include a solar refrigerator due to inavailability of the unit that are mostly located in remote areas in the Eastern provinces of Indonesia. Based on temperature stability, storage capacity and operational cost efficiency the Vestfrost MK144 was observed to be the best refrigerator for use in a health center setting, followed by the Dove refrigerator. The other refrigerators tested can also be used at the health center level provided a set of precautions are respected. These precautions include proper thermostat setting, close attention to the heating system, adherence to the WHO domestic refrigerator modification procedure, and proper vaccine loading to prevent freezing and overheating. These precautions had been incorporated into the latest cold chain training module. In the absence of electricity the RCW 50 EK and RCW 50 EG can be operated using their alternate energy source (kerosene and gas respectively) but gas was found to provide better temperature stability and easier operational procedure than kerosene. The temperature performance, cost and storage capacity of each refrigerator are summarized in Table 9 on the next page. An overall score for each refrigerator was established based on a priority scale of temp stability followed sequentially by operating cost efficiency, ease of operation, and storage capacity (Table 10). It is expected that the information gained through this activity will assist the Ministry of Health and the local government in making decisions for provision of cold chain equipment based on technical performance, ease of maintenance and repair, and affordability.

17

Table 9 Summary of Refrigerator Temperature Performance, Storage Capacity, Purchase Price and Monthly Operational Cost
Monthly cost
(as of June’05)

TEMP STABILITY (2 – 8 º C) Purchase Price* (Rp.) No challe nges + + + + Electricity cut off (holdover time) 4 hrs + + + + 8 hrs X + + + 12 hrs X + + + 24 hrs X X X + 48 hrs X X X X Refrigerator door openings (5 min each) 1x + + + + 2x + + + + 3x X + + + 4x X + + + 5x X X + + 6x X X + +

NO

REFRIGERATOR

Storage capacity (liter)

(Rp) 1 2 3 4 Electrolux RCW 42 EK Electrolux RCW 50 EK (electric) Electrolux RCW 50 EG (electric) Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator RCW 50 EK (kerosene) RCW 50 EG (gas) 18.2 24 24 59.2 35,035 49,248 46,786 55,728 17 million (MOH est.) 37.5 million 34 million 12.5 million

5

48

37,368

2 million

+

+

+

X

X

X

+

+

+

+

X

X

6

63.5

37,368

2 million 14.85 million 37.5 million 34 million

+

+

X

X

X

X

+

+

+

X

X

X

7 8 9

18 24 24

31,709 30,000 25,000

+ + +

+
N/A N/A

+
N/A N/A

+
N/A N/A

+
N/A N/A

X
N/A N/A

+ + +

+ + +

+ + +

+ + +

+ ND ND

+ ND ND

Note: + = stable at 2 – 8 º C X = showed temp deviation outside 2 – 8 º C * 2005 price list (incl. tax, and delivery cost up to Jakarta)

N/A= not applicable ND = not done

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Table 10 Overall Rating of Refrigerator
Monthly cost efficiency (monthly
cost/capacity)

No

REFRIGERATOR

Storage capacity (liter)

Purchase Price

Ease of operation

Temp stability (2-8°C)

Overall Score poor fair good Very good

1 2 3 4

Electrolux RCW 42 EK (using electricity) Electrolux RCW 50 EK (using electricity) Electrolux RCW 50 EG (using electricity) Vestfrost MK 144 Sanyo LV179IF Domestic Refrigerator (WHO-modified using cool packs) Sharp VR161 Domestic Refrigerator (without modification) Dove Top-opening Refrigerator Electrolux RCW 50 EK (using kerosene) Electrolux RCW 50 EG (using gas)

+ + + ☼ ☼ ☼ ‫ס‬ ‫ס‬ ‫ס‬

+ ‫ס‬ ‫ס‬ ☼ ☼ ☼ + ‫ס‬ ‫ס‬

X X X

☼ ☼ ☼ ☼ ☼ ☼ ☼
X

X

‫ס‬ ‫ס‬ ☼ +
X

‫ס‬ ☼ ☼ ‫ס‬
X X

5

6 7 8 9 Note:

☼ ‫ס‬ ‫ס‬

+

☼ very good ‫ ס‬good + fair
X poor

Criteria used in determining the overall score (in order of priority): temp stability operating cost efficiency ease of operation storage capacity

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REFERENCES 1. Carib, et al, Hepatitis B vaccine Freezing in the Indonesian Cold Chain: evidence and solutions, Bulletin of the World Health Organization 82: 99 – 105, February 2004. 2. Depkes – PATH, Studi rantai dingin di 2 propinsi (Jawa Tengah dan Jambi) 2003 – 2004. 3. Depkes dan PATH, A plan to reduce freezing in the Indonesian Cold Chain, Cold Chain Task Force Meeting, Jakarta February 2003.

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