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Refrigerator ownership accompanies socio-economic development, with the potential to change human diets. Household refrigerator ownership in Vietnam has increased from 13% to 59% between 2004-2014. This study estimates changes in food consumption and diet linkages with household refrigerator ownership in Vietnam, while controlling for socioeconomic variables. We use a two-step instrumental variable regression model on two panels of the Vietnam Household Living Standards Survey covering 2004-2014. Our study finds refrigerator ownership to be significantly associated with decreases in per-capita calorie intake over both periods. Refrigerator ownership may be connected with households substituting lower-nutrient foods with higher ones, with substantial decreases in starchy staple food consumption connected with refrigerator ownership in both panels. For both periods, refrigerator ownership is significantly connected with increased dairy consumption, potentially reflecting the refrigerator increasing a household's ability to store dairy products., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Cold chain equipments (CCEs) at health facilities (HFs) are an essential part of the immunization supply chain (ISC). The CCEs in government HFs of Delhi were never assessed using the World Health Organization-United Nations Children's Fund (WHO-UNICEF) Effective Vaccine Management (EVM) tool except that of state vaccine store during National EVM assessment 2013., Objectives: The objective of the study was to assess the CCEs and their management in government HFs using the WHO-UNICEF EVM tool in a district of Delhi., Methods: The assessment was done during December 2017-March 2018 in one randomly selected district of Delhi. Sample size and site selection were done using the WHO EVM site selection tool. A total of 29 HFs were assessed along with District Vaccine Store. Questions on CCEs in EVM tool 1.0.9 were used for data collection., Results: Out of 56 electrical CCEs, 8.9% were nonfunctional, 48.2% were noncompliant with WHO standards, 5.4% were not chlorofluorocarbon free, 4.7% did not have temperature monitoring device, and 18.8% did not have stabilizer. Eighty-six percent of passive containers were compliant with the WHO standards. The storage capacity of electrical vaccine storage equipment was insufficient in 3.4%, passive container capacity in 65.5%, and ice packs preparation and storage capacity in 24.1% of HFs. There was no planned preventive maintenance of CCEs and no standard operating procedures for emergency event management., Conclusion: There was a shortage of vaccine storage, ice packs preparation and storage, and passive container capacity. Many CCEs used in ISC of assessed sites were noncompliant to the WHO standards. There was no PPM of CCEs and no guidelines for emergency event management., Competing Interests: None

Objectifs: Évaluer le rôle des commodités familiales dans l'occurrence de la diarrhée chez les enfants de moins de 5 ans en Haïti, selon leur type (eau potable, toilettes et réfrigérateur) et leur nombre.MÉTHODE : Nous avons mis en commun les données de quatre Enquêtes démographiques et de santé réalisées en Haïti entre 1994-1995 et 2012. Nous avons retenu un échantillon de 14 481 enfants de 1-59 mois. Nous avons évalué le rôle des commodités familiales dans l'occurrence de la diarrhée selon le groupe d'âge d'enfants à risque (1-5; 6-11; 12-23; 24-59 mois), au moyen des modèles de régression logistique.RÉSULTATS : La prévalence de la diarrhée chez les enfants de 1-59 mois en Haïti est estimée à 29,31 %. Elle atteint 42,14 % chez les enfants de 6-11 mois. Elle est plus faible pour les enfants dont les familles ont accès à une eau potable améliorée, des toilettes améliorées ou un réfrigérateur. Elle est d'autant plus faible que les familles possèdent au moins deux commodités simultanément. Nous ne trouvons pas de différences significatives dans l'occurrence de la diarrhée infanto-juvénile selon l'accès à l'eau potable (p > 0,10). Prenant en compte l'effet de période, une occurrence réduite de la diarrhée est significativement associée aux toilettes améliorées chez les enfants de 24-59 mois (RC : 0,62; p < 0,05) et au réfrigérateur chez les 6-11 mois (RC : 0,11; p < 0,05). Pour le nombre de commodités, seuls les 24-59 mois ayant au moins deux commodités ont une occurrence de la diarrhée statistiquement inférieure de celle des plus défavorisés (RC : 0,45; p < 0,05)., Conclusion: Augmenter l'accès aux commodités familiales et leur nombre par ménage demeure essentiel dans la lutte contre la diarrhée en Haïti. Une intervention intégrée serait donc à préconiser dans l'environnement sociosanitaire haïtien.

Background: Introduction of inactivated polio vaccine creates challenges in maintaining the cold chain for vaccine storage and distribution., Methods: We evaluated the cold chain in 23 health facilities and 36 outreach vaccination sessions in 8 districts and cities of Bangladesh, using purposive sampling during August-October 2015. We interviewed immunization and cold-chain staff, assessed equipment, and recorded temperatures during vaccine storage and transportation., Results: All health facilities had functioning refrigerators, and 96% had freezers. Temperature monitors were observed in all refrigerators and freezers but in only 14 of 66 vaccine transporters (21%). Recorders detected temperatures >8°C for >60 minutes in 5 of 23 refrigerators (22%), 3 of 6 cold boxes (50%) transporting vaccines from national to subnational depots, and 8 of 48 vaccine carriers (17%) used in outreach vaccination sites. Temperatures <2°C were detected in 4 of 19 cold boxes (21%) transporting vaccine from subnational depots to health facilities and 14 of 48 vaccine carriers (29%)., Conclusions: Bangladesh has substantial cold-chain storage and transportation capacity after inactivated polio vaccine introduction, but temperature fluctuations during vaccine transport could cause vaccine potency loss that could go undetected. Bangladesh and other countries should strive to ensure consistent and sufficient cold-chain storage and monitor the cold chain during vaccine transportation at all levels., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.)

Aim: The purpose of this study was to analyse vaccine refrigerator and vaccine management in primary care and to identify physician- and practice-related influencing factors. Background: Adequate cooling of vaccines in a temperature range of 2-8°C is essential to assure vaccine effectiveness. Studies from various countries have demonstrated cooling chain problems. We surveyed general practitioners about the quality of their vaccine refrigerator and vaccine management and aimed at identifying physician- and practice-related influencing factors. Methods: A cross-sectional, web-based questionnaire survey was performed among 3 physician populations in primary care: a 10% random sample of general practitioners (n=954), all teaching physicians of the Universities Duisburg-Essen (n=221) and Halle-Wittenberg (n=92). Surveyed were items on the following 6 aspects: (1) responsibilities within practice teams, (2) vaccine ordering and storing, (3) criteria for the vaccine pre-selection, (4) stocking system inside the refrigerator, (5) wrapping, and use of stocking boxes, (6) refrigerator and temperature control. The quality indicator "comprehensive refrigerator management" was defined to include 4 aspects: (1) separate refrigerator, (2) written temperature documentation (temperature-logbook), (3) regular storage control (wrapping, temperature and expiration date), and (4) storage in original wrappings. Results: A total of 278 physicians participated in the survey (22%). Of these, 80% had a separate refrigerator, 52% reported written temperature documentation, 93% documented regular storage control addressing vaccine wrappings, temperature and expiration dates, and 95% reported vaccine storage in original card box wrappings. A "comprehensive refrigerator management" was realised by 42% of the practices. This indicator was reached more frequently by practices with 3 or more physicians (p=0.01) and those with an additional qualification in travel medicine (p=0.036). Conclusion: Our survey showed good results for most aspects of the refrigerator and vaccine management but room for improvement with regard to temperature documentation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Cold chain control is one of the most important facts to ensure the effectiveness of vaccines links, which requires specific material and human resources for management. The principal objective is to evaluate the interruptions in cold chain of the last 6 years and the possible cost savings that would result in further improvements., Method: A retrospective and descriptive study based on a review of all cold chain interruptions during the last 6 years, at Valdefierro Primary Health Center., Results: We had 5 interruptions, the maximum temperature reached was 23.1±3.4°C and the longest interruption lasted 25.2±20.7hours. 1611 vaccines were affected and 165 discarded. Total economic loss was 2.098,10 € and 33.611,64 € were savings. The electrical failure was the disruption cause in 5 cases., Conclusions: Equipment and staff are essential. The center did some corrective actions, such as minimizing refrigerator time control, minimum stock control, considering population changes, and the center has requested a electrical supply system., (Copyright © 2016 Elsevier España, S.L.U. All rights reserved.)

Objective: To examine the integrity (pH, bacterial counts, host defense factors, nutrient contents, and osmolality) of freshly expressed and previously refrigerated human milk subjected to long-term freezer storage., Study Design: Mothers donated 100 mL of freshly expressed milk. Samples were divided into baseline, storage at -20°C (fresh frozen) for 1, 3, 6, and 9 months, and prior storage at +4°C for 72 hours (refrigerated frozen) before storage at -20°C for 1 to 9 months. Samples were analyzed for pH, total bacterial colony count, gram-positive and gram-negative colony counts, and concentrations of total protein, fat, nonesterified fatty acids, lactoferrin, secretory IgA, and osmolality., Results: Milk pH, total bacterial colony count, and Gram-positive colony counts decreased significantly with freezer storage (P < .001); bacterial counts decreased most rapidly in the refrigerated frozen group. The gram-negative colony count decreased significantly over time (P < .001). Nonesterified fatty acid concentrations increased significantly with time in storage (P < .001). Freezing for up to 9 months did not affect total protein, fat, lactoferrin, secretory IgA, or osmolality in either group., Conclusions: Freezer storage of human milk for 9 months at -20°C is associated with decreasing pH and bacterial counts, but preservation of key macronutrients and immunoactive components, with or without prior refrigeration for 72 hours. These data support current guidelines for freezer storage of human milk for up to 9 months for both freshly expressed and refrigerated milk., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: to assess the cold chain capacity, health workers' immunobiological product conservation knowledge and practices in Primary Healthcare Centers (PHC) in São Paulo city, Brazil., Methods: this descriptive study included 24 randomly selected PHC in the South and Midwest regions of the city; between December 2011 and July 2012, we interviewed the health workers on their vaccine conservation knowledge/practice and observed the local infrastructure, using a form developed for this project; we assigned points to items of the form and classified each PHC as sufficient, regular or insufficient., Results: most of the 24 PHC evaluated were administered by Social Organizations; all of them had vaccine storage chambers; 5 PHC reported using their maximum storage capacity; 9 PHC were classified as having sufficient knowledge/practice and 15 as having regular knowledge/practice., Conclusion: in these PHC, cold chain utilization was close to its maximum capacity; many health workers did not have basic knowledge about vaccine conservation.

Background: Adverse temperature recording in vaccine's cold chain is a major issue worldwide and this condition is known to compromise the quality of vaccines very rapidly. In Cameroon, with tropical climate, vaccines exposure to abnormal temperatures is very common. This study was conducted to identify factors associated to abnormal temperature recording in cold chain in the North West region., Results: A total of 65 vaccinating health facilities were visited for the study from eight health districts. Concerning type of health facility, 48 (73.8%) of the health facilities were governmental facilities. About 50 (76.0%) of the facilities had a functional thermometer. Among the 50 health facilities with functional thermometer, abnormal temperatures were registered in 10 (20%) health facilities during data collection and 12 (24%) in the 2 months preceding collection. Factor significantly associated with abnormal temperature recording was the absence of an alternative power source (OR = 6.5, p = 0.03)., Conclusion: The absence of an alternative source of power was significantly associated with abnormal temperature exposure in the 2 months preceding data collection. To improve on the quality of vaccines administered in North West region, each vaccinating health facility must have at least two sources of power supply.

Objective: To estimate the proportion of time the vaccines in the cold-chain system in India are exposed to temperatures of < 0 or > 8 °C., Methods: In each of 10 states, the largest district and the one most distant from the state capital were selected for study. Four boxes, each containing an electronic temperature recorder and two vials of diphtheria, pertussis and tetanus vaccine, were placed in the state or regional vaccine store for each study state. Two of these boxes were then shipped - one per facility - towards the two most peripheral health facilities where vaccine was stored in each study district. The boxes were shipped, handled and stored as if they were routine vaccine supplies., Findings: In state, regional and district vaccine stores and peripheral health facilities, respectively, the temperatures in the boxes exceeded 8 °C for 14.3%, 13.2%, 8.3% and 14.7% of their combined storage times and fell below 0 °C for 1.5%, 0.2%, 0.6% and 10.5% of these times. The boxes also spent about 18% and 7% of their combined times in transit at < 0 and > 8 °C, respectively. In shake tests conducted at the end of the study, two thirds of the vaccine vials in the boxes showed evidence of freezing., Conclusion: While exposure to temperatures above 8 °C occurred at every level of vaccine storage, exposure to subzero temperatures was only frequent during vaccine storage at peripheral facilities and vaccine transportation. Systematic efforts are needed to improve temperature monitoring in the cold-chain system in India.

Background: Human milk remains the preferred feeding for all infants, including premature and sick newborns. However, mother's milk is not sterile, and expressed milk can be a source of commensal and pathogenic microorganisms. Microbiological quality standards for the use of expressed human milk in hospitals are not available, unlike for donor or formula milk., Methods: To document current practices for the use of human milk in the neonatal intensive care units (NICU) in Belgium and Luxembourg, both for mother's own milk and donor milk, a questionnaire was sent to all 20 neonatal units., Results: Of the 19 units that completed the survey, 47% perform bacteriological testing of expressed milk. Applied bacterial count limits for the acceptable level of contamination differ among units, for both commensals and pathogens. Only six units have a device for pasteurizing milk at their disposal. Storage time in the refrigerator for fresh milk varies between 24 hours to 7 days before use. Access to donor milk is limited., Conclusions: Routines for handling of human milk differ widely among NICUs in Belgium and Luxembourg. An assessment of current issues through a structured survey is a useful tool in the development of best practice guidelines.

We used an ecological approach to determine the correlation between vegetable, fruit and salt intakes, refrigerator use, and gastric cancer mortality in Korean population. Information on fruit and vegetable intakes per capita from the National Health and Nutrition Survey, death certificate data from the National Statistical office, refrigerator per household data from Korean Statistical Information Service, and salt/sodium intake data from a cross-sectional survey were utilized. Correlation coefficients were calculated between vegetable and fruit intakes, refrigerator per household, and gastric cancer mortality and between salt and sodium intakes, and gastric cancer mortality and incidence in the four areas. With 5, 10, and 15 years lag time, refrigerator usage and fruit intake were negatively associated with gastric cancer mortality (p < 0.01), but vegetable intake was not associated with gastric cancer mortality. When estimates of salt/sodium intake evaluated by 24-h urine collection in four areas of Korea were compared to the gastric cancer mortality and incidence in these regions, positive correlation was shown between salt/sodium intake, and gastric cancer incidence and mortality. Negative associations between refrigerator use, fruit intake, and gastric cancer mortality and positive associations between salt/sodium intake and gastric cancer mortality and incidence were suggested.

The dangers of accidental freezing of vaccines in the cold chain have prompted studies throughout the globe to better characterize the risk. To date, there has been no systematic review of these studies. This analysis highlights that accidental freezing is pervasive and occurs across all segments of the cold chain. Between 14% and 35% of refrigerators or transport shipments were found to have exposed vaccine to freezing temperatures, while in studies that examined all segments of distribution, between 75% and 100% of the vaccine shipments were exposed. More rigorous study designs were associated with higher levels of freeze exposure. As more expensive, freeze-sensitive vaccines are introduced into immunization schedules, freeze prevention will become increasingly critical for ensuring that the world's children are receiving fully potent vaccine.

Background: In transfusional setting introduction of nucleic amplification technique (NAT) for HBV-DNA, HCV-RNA and HIV-RNA in biological qualification of blood units suggest some problems. At first the opportunity to operate on mini-pool, at second the need to store the samples at +4 degrees C. The authors therefore have tried to estimate the impact of these conditions on the operativity of NAT testing in the transfusional setting., Methods: The following parameters has been estimated: distribution of viral-load in untreated subjects, stability of nucleic acids during storage at +4 degrees C, stability of nucleic acids after repeated cycles of freezing and defrosting, robustness of the test to the cross-contamination, definition of the detection-limit (95%). Quantitative tests has been performed by using the following kits: Cobas Amplicor HBV Monitor, Cobas Amplicor HCV Monitor, Cobas Amplicor HIV Monitor; the qualitative tests has been performed by using the following kits: Ampliscreen HBV, Ampliscreen HCV 2,0, Ampliscreen HIV 1,5 all supplied by Roche Molecular System (Brancburg, NJ)., Results: Viral load in untreated subjects showed wide variation for HBV, HCV and HIV. HBV has been demonstrated much stable to the conservation +4 degrees C also until 168 h while for HCV and HIV a greater decrease of the viral-load was observed. For all and three virus the conservation to +4 degrees C until 72 h does not seem to involve meaningful fall in the viral-load. A remarkable reduction of the viral-load has been observed after five cycles of freezing and defrosting. All the tests showed a good robustness to cross-contamination. The detection-limit (95%) was 8 U/ml for HBV, 21 U/ml for HCV and 27 copy/ml for HIV., Conclusions: Samples for NAT testing, can be stored until 72 h to +4 degrees C without appreciable lowering of the viral-load. Repeated cycles of changes of state should be avoided. The tests showed a good robustness to cross-contamination. NAT tests for biological qualification of blood units had a minimal sensibility around 50 (copy/unit/ml). In our experience the detection-limit (95%) was 21 U/ml for HCV, 27 copies/ml for HIV, 8 U/ml for HBV. The availability of NAT test for HBV-DNA, HCV-RNA e HIV-RNA, sensitive and reliable, together with epidemiological data, suggest the opportunity to place side by side, in the biological qualification of the blood units, to add the tests for HBV-DNA and HIV-RNA to the test for HCV-RNA mandatory by low, in Italy in the biological qualification of blood units.

Background: Child immunisation is among the most cost-effective ways of preventing premature child deaths, and the potency of vaccines, crucial for vaccine efficacy, is dependent on effective management of the cold chain at all levels of vaccine handling., Objective: To assess the status of the cold chain at peripheral vaccine stores in Ethiopia., Design: Institution based cross-sectional survey in two rural and one urban administrative areas were included in the study. Sixty seven health institutions providing static vaccination services were included in the study but cold chain system was assessed fully in only sixty four. Data were collected by interviewing health workers and by directly observing the cold chain equipment and records using structured forms., Results: Conditions of the cold chain system were described based on 64 of the 67 centres visited, three were excluded because of non-functioning cold chain. Complete temperature record was observed in 37 (57.8%) of the centres. Thermometer was not available in four (6.3%) and thermometer reading was found to be outside the optimal range in another seven (10.9%) centres. Vaccine storage in the refrigerator was not proper in 47 (73.4%) centres. Majority of the centres had neither trained personnel nor budget for maintenance of the cold chain., Conclusion: There is a real danger of vaccines losing their potency at these centres even if they were potent on arrival. Relevant training for those handling the cold chain, improving the maintenance conditions of refrigerators and introduction of cold chain monitoring devises are recommended.

Pharmacies on the Central Coast of NSW were surveyed to assess the ability of refrigerators used for vaccine storage to maintain the recommended temperature range (2 to 8 degrees C). Refrigerators used for vaccine storage were monitored over a 3-day period using a temperature data logger. Fifty-nine (59) retail pharmacies were identified. The response rate was 90% (53/59) and 52 refrigerators were monitored successfully. Only 10 (19%) of the refrigerators maintained temperatures wholly within the recommended range for the 3-day monitoring period. The remaining refrigerators were considered in three groups--refrigerators keeping temperatures in the range 0.1 to 11.9 degrees C, below 0 degree C and above 8 degrees C for most of the time. There were 15 (29%), 12 (23%) and 15 (29%) refrigerators in these groups respectively keeping temperatures in the recommended range for 91%, 19% and 30% of the time. Of the refrigerators achieving temperatures below 0 degree C, none went below -5 degrees C and on average they kept temperatures less than 0 degree C for 49% of the time. This survey highlights the need for vigilance in vaccine storage for immunisation programs to be successful. Of the vaccines affected by freezing, hepatitis B vaccine was identified as being most at risk.

A collaborative study was undertaken to investigate the effect of storage conditions on the measured reticulocyte count in venous blood samples. It was designed to cover variation in the three main determinants, namely time, temperature and anticoagulant. The aim was to determine the time for which samples could be stored for subsequent analysis for clinical purposes.