Planning an Emergency Vaccination Campaign Sara is the head of logistics for Doctors on the Road (DOR), an international humanitarian organization pro- viding medical assistance in South Sudan. It is Monday morning. At her office in South Sudan's capital, Juba, in the Central Equatorial State, she receives an e-mail notification outlining a potential measles outbreak in Warrap State, approximately 500 km to the northwest. Field teams have been monitoring the slow but steady increase in cases over the past two weeks and are concerned about the future progress of the disease, since they have also been receiving some reports of cases in the neighboring state of Western Bahr el Ghazal. Sara shares this information with her European HQ and receives the go-ahead to receive European vaccines at an existing Juba central warehouse. It will be distributed to Kuajok city in Warrap State and the city of Wau in the State of Western Bahr el Ghazal. There seems to be no need to transport the shipment immediately because the state health centers report they still have a supply of vaccine. The stockpile means there is no need to order vaccines from the manufacturer. DOR operates a hub in the Puerto de la Torre district of the city of Mlaga, Spain, near its international airport. A few hours after contacting the hub to discuss preparations for a possible shipment of vaccines, Sara gets a call from the Kuajok health center. Field teams now have reliable reports of many measles cases in nearby villages. The same update comes from the Wau health center and from a new source, the health center in the city of Jallab, far to the west of Wau. These reports make it clear that the existing stockpile of vaccines in Abstract Sara, the head of logistics for an international humanitarian organization, must find the safest, most effective way to deliver vaccines to a number of locations in South Sudan experiencing an outbreak of measles, one of the deadliest, vaccine-preventable diseases. Speed is essential. So is protecting the vaccine from damage. Emergency situations, however, mean unpredictability, uncertainty, and uncon- ventional conditions. This case enables students to put themselves in Sara's shoes to plan a success- ful emergency vaccine delivery strategy using a logistics method known as cold chain management. Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 4 of 15 Chain Logistics Strategy South Sudan will not be sufficient to cover the need. Therefore, the shipment has to be dispatched to the Warrap State as soon as possible. Sara's specific task is to plan safe vaccine transport from the Puerto de la Torre hub to all outbreak sites in Kuajok, Wau and Jallab. South Sudan The Republic of South Sudan became the world's youngest nation in July 2011. However, the civil war out- breaks in December 2013 and in July 2016 affected the country's development and caused a severe, long- term humanitarian crisis (World Bank, 2022). According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA, n.d.), more than two-thirds of the population need protection or humanitarian as- sistance. Around 7.7 million people face severe food insecurity and the country deals with climate shocks as well as economic crises exacerbated by the global food shortages and the COVID-19 pandemic (WFP, 2022). Due to water contamination and poor sanitation, many South Sudanese people are at risk for epidemics such as cholera (WHO, 2019). In addition, ongoing problems of human rights violations and violence force people to flee their homes, leaving more than 2 million people internally displaced. At the same time, another 2.3 million South Sudanese refugees search for safety in neighboring countries (UNHCR, 2023). South Sudan's total estimated track length is around 90,200 km. Approximately 14,000 km are primary and secondary roads and 6,000 km are tertiary tracks. South Sudan has only one rail connection, from Babanusa (in Sudan) to Wau. The country controls the Nile river's upper reaches, offering 1,400 km of navigable in- land waters. Although South Sudan is easily accessible by air, thanks to hundreds of helicopters and fixed- wing landing sites, large aircraft can be handled only at Juba, Wau, Malakal, and Paloich airports, which are equipped with asphalted runways (Logistics Cluster, n.d.). Figure 1 shows the map of South Sudan and its major cities. Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 5 of 15 Chain Logistics Strategy Figure 1. South Sudan Map Source: NordNordWest/Wikipedia, 2011 South Sudan experiences only two seasons, rainy and dry. Therefore, the country is at risk for both flooding and drought. The rainy season negatively affects infrastructure. For example, only around 5,000 km of roads may remain passable and some parts of the country can be entirely inaccessible for months. Also, large num- bers of airstrips become unusable by fixed-wing planes because of their gritty surfaces. But weather condi- tions are not the only danger to infrastructure. Most incidents of conflict are recorded during dry seasons, with the highest numbers in Warrap, Upper Nile, Lakes, Jonglei, and Unity states (Logistics Cluster, n.d.). Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 6 of 15 Chain Logistics Strategy Humanitarian Logistics Humanitarian logistics is integral to disaster response (Besiou et al., 2011) because it covers "mobilising peo- ple, resources, skills and knowledge to help vulnerable people" affected by natural and human-made disas- ters (Thomas, 2003, p. 3). Even though humanitarian logistics share many processes with commercial opera- tions, the differences lie in conditions of unpredictability, uncertainty, and unconventionality specific to a given emergency situation (Sheu, 2005). The full range of humanitarian logistics activities includes (Thomas, 2003): preparedness; assessment/appeals; resource mobilization; procurement; transportation; tracking and tracing; stock/asset management; delivery; and performance evaluation. As the head of logistics, Sara is formally responsible for all these tasks. However, she is directly involved only in preparedness, assessment/appeals, procurement (orders over USD 5,000), resource mobilization, and per- formance evaluation. After a disaster strikes, epidemics often thrive due to health standards deterioration, destroyed infrastructure, and limited access to clean water and sanitation facilities (Watson et al., 2007). Examples include the polio outbreak in Syria in 2014 (Whewell, 2014) and cholera in Haiti after Hurricane Matthew in 2016 (Strochlic, 2016). In most such cases, delivering vaccines is an essential need with many challenges. Vaccines must be stored within a limited temperature range "from the time they are manufactured until the moment of vaccination" (UNICEF, n.d.). The safe range for most vaccines is a chilled environment between 2 and 8C. Some vaccines are more sensitive to heat; others are sensitive to freezing temperatures. Heat-sen- sitive vaccines include oral poliovirus vaccine and vaccines for Japanese encephalitis and measles. Those sensitive to freezing temperatures include hepatitis A/B, human papillomavirus and meningitis C (UNICEF, 2016). Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 7 of 15 Chain Logistics Strategy What is a Cold Chain? A cold chain is a specialized part of logistics used when food, medicine, and other perishable products require strict temperature regimes (Qi and Hu, 2020). UNICEF (n.d.) defines the cold chain as a "chain of precisely coordinated events in temperature-controlled environments to store, manage and transport life-saving prod- ucts." Cold chains are systems composed of multiple elements, such as "human, material and financial re- sources, and certain norms and standards that ensure the high quality of vaccines" (World Health Organi- zation [WHO], 2017a, p. 3). The elements' various levels are known as links. These links follow the vaccine orders and supplies, transportation, storage, and distribution from the manufacturer to the point of adminis- tration to the affected population. Practical cold chain challenges include "the size and weight of packages, implementation of quality control checks at reception, ensuring environmental sustainability, and maintaining required temperatures during the journey" (WHO, 2020, p. 14). That makes it desirable for all relevant stakeholders to conduct risk assess- ments. An organization's whole cold chain system should be assessed and revised periodically. Cold chain decisions are unique due to the irreversibility of the process: once lost, vaccine potency cannot be regained (UNICEF, n.d.). When vials cannot be kept within the safe temperature range at each step, the cold chain is disrupted (Comes et al., 2018). In 2011, more than 2.8 million vaccine doses were wasted due to cold chain breakdowns in five countries (WHO, 2014). Historically, polio outbreaks in southern African nations have been subject to vaccine damaged due to cold chain disruptions (Schoub & Cameron, 1996). Cold chain defects get even more attention these days because the continuous increase in vaccine prices (Comes et al., 2018) makes every cold chain failure ever more costly. Understanding Vaccine Delivery There are three phases of vaccine campaigns: planning, implementation, and evaluation (Comes et al., 2018). The planning process consists of these steps (WHO, 2017a): Situation analysiswhat are the problems? Objectives and targetswhat do we want to do? Strategies and activitieshow can we do that? Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 8 of 15 Chain Logistics Strategy Budget and resource quantificationwhat do we have and need? Implementation schedulewhen are we getting there? The evaluation phase answers the question, "How do we know we got there?" The planning phase includes a cold chain emergency plan (WHO, 2017a). This plan should make provisions for common emergencies such as: breakdowns of cold/freezer rooms, refrigerators, freezers; electric power outages or fuel shortages; vaccines freezing due to weather; breakdown or non-availability of vehicles; delivered quantity of vaccine exceeds storage capacity; understaffed health centers; and destruction of the vaccine store. Cold Chain Infrastructure The cold chain starts with vaccine manufacturers such as pharmaceutical companies like Pfizer, GSK or HARTMANN. To maintain the proper quality of their products, manufacturers must meet the World Health Organization standards and obtain a certificate of Good Manufacturing Practice (Yadav et al., 2011; Sukkar, 2015). Some goods may be procured at local markets depending on their quality, price, importation regula- tions, and capacity (Dolinskaya et al., 2018). In this case, the local market is represented by global whole- salers operating in South Sudan. However, DOR policy forbids the purchase of vaccines locally. There are two main cold chain types: slow and fast. A slow cold chain: Relies on storage using cold-generating equipment such as cold rooms, refrigerators or freezers. This option reduces overall vaccination costs but increases the number of vaccines handled. The whole transport and distribution system can become expensive and unreliable when equipment is not maintained properly. Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 9 of 15 Chain Logistics Strategy A fast cold chain is all about speed to reduce vaccine handling. It: Relies on passive containers such as cold boxes or vaccine carriers. These containers are not able to generate cold but can maintain temperature (WHO, 2017a). They are often used to transport vac- cines from one store to another or from immunization activity in the field. Cold boxes are insulated containers lined with coolant packs with a storage capacity between 5 and 25 liters. Short range cold boxes offer a minimum cold life of 48 hours at 43C outside temperature. Long range ones maintain a minimum cold life of 96 hours at the same ambient temperature. Cold boxes are also used when refrigerators are out of order or being defrosted (UNICEF, 2021). Vaccine carriers are insulated containers with coolant packs. They are smaller and easier to carry, with a capacity between 0.8 and 3.4 liters. Short range vaccine carriers maintain cold for a minimum of 15 hours at 43C outside tem- perature. Long range carriers have a cold life up to 30 hours with the same outside temperature (UNICEF, 2021). Carriers can lead to higher transportation costs which are partially offset by lower storage costs (WHO, 2017a). New evidence shows that some vaccines can be handled outside the strict temperature range for the last mile under a so-called controlled temperature chain or flexible cold chain (MSF, 2014). This is not possible, however, for the measles vaccines Sara has to transfer to South Sudan. Preparing Vaccines for Transport Selecting the right cold chain equipment means considering "cold storage capacity, capacity for producing/re- cycling coolant packs, temperature zone, source of energy, hold over time, and total life cost" (WHO, 2017a, p. 18). There are several options for how to maintain the proper conditions when packing vaccines for trans- port. Frozen ice packs: they do not cause sensitive vaccines to freeze. Conditioned ice packs: usable for any vaccine. Cool water packs: only for vaccines with vaccine vial monitor, which is a small indicator "that adheres to vaccine vials and changes colour as the vaccine is exposed to cumulative heat." This lets health Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 10 of 15 Chain Logistics Strategy workers know whether the vaccine has reached or exceeded the discard point (WHO, 2021). Cool water packs: protect freeze-sensitive vaccines for short journeys in unheated vehicles in sub- zero temperatures. Warm water packs: protect freeze-sensitive vaccines for long journeys in unheated vehicles in sub- zero temperatures. Decisions About Transport Cold chains are systems with a complex structure and, in general, call for a combination of air and road trans- port. Typically, when facing long travel distances, the leg from the vaccine manufacturer to a transit storage facility means air transport. When responding to the Western Africa Ebola epidemic in 2014-2015, Doctors without Borders transferred 8,294 tons of material, most of it by air (MSF, 2017). In later stages, road trans- port is usually in place. If there is significant travel distance between primary and intermediate vaccine stores, that may also call for air transport. The available modes can range from trucks and cars to motorbikes, bikes and animals. Last-mile distribution is the most challenging part of the humanitarian supply chain. Disaster or flooding may have destroyed roads. The point of delivery may be in an area very difficult to get to. There may be significant security concerns. These obstacles become even more challenging when handling delicate cargo such as vaccines, especially when the receiving country's storage and transit equipment are older (UNICEF, 2019). Logistics planners like Sara work within transport structures. For instance, Sudan's Ministry of Health can op- erate transportation using a combination of public-private partnerships or outsourced service providers. While this scenario does not apply to Sara, it is worthwhile to know the advantages and disadvantages of various options (WHO, 2017a). For example: Ministry of Health-operated transport offers the possibility of vehicle sharing with other programs and in-house maintenance service that can be linked to vaccine supply. The negative side of this option is higher costs. The cost-effectiveness of domestic boat or air transport can be a positive aspect of a public-private transport system, which reduces ministry of health responsibilities. On the negative side, this system has been associated with the risk of goods damage or loss and the inability of the private sector to Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 11 of 15 Chain Logistics Strategy provide transport needed. The outsourced transport service provider will have high maintenance standards for vehicles and makes it possible to transfer vehicle operations and responsibilities to an experienced provider with more diverse competencies than a Ministry of Health. The disadvantage of this option is whether an experienced and reliable provider will be quickly available. Transportation and third-party companies such as Kuehne + Nagel, United Parcel Service or Deutsche Post often handle goods through various levels of the supply chain. When the vaccines reach the country of des- tination, governmental agencies have to approve the shipment arrival and authorize entry of an international humanitarian organization (Dolinskaya et al., 2018). Cold Chain Storage Points Conditions must be considered at every level and stage. Levels may vary due to different travel distances and routes used. Figure 2 shows DOR's cold chain storage points for the South Sudanese measles vaccine mission. Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 12 of 15 Chain Logistics Strategy Figure 2. Cold Chain Storage Points Source: adapted from Abikova, 2017; Comes et al., 2018 Different storage technologies are used at different cold chain levels. Walk-in cold and freezer rooms are usu- ally built for manufacturers' storage units, distribution centers, and sometimes for the central storage facility (Comes et al., 2018). Cold/freezer rooms are engineering structures that can be used for storing vaccines over 1.5-2 m3 of net storage space. Vaccines should be placed inside these rooms on shelves and not on the floor while maintaining air circulation (WHO, 2017a). Cold/freezer rooms are equipped with an integral alarm system with elements such as temperature sensors or a door open sensor (UNICEF, 2016). Health centers and central storage facilities build walk-in cold and freezer rooms when cold rooms are un- Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 13 of 15 Chain Logistics Strategy available (Comes et al., 2018). Refrigerators can be vertical- or chest-style and stored vaccines must be ap- propriately arranged (UNICEF, 2016). Health posts in this case are the places where immunization is carried out. Not everyone can visit South Su- danese health centers, so medical teams will travel to villages instead. These health posts use cold boxes and vaccine carriers (Comes et al., 2018). The Challenge of Monitoring Temperature Temperature monitoring is crucial in cold chain management (Logistics Operational Guide, 2021). The tem- perature monitoring technology depends on the storage/transport device: Cold/freezer rooms have installed temperature and event loggers and alarm systems. Refrigerators and freezers have analog thermometers and digital data loggers. A specific example of a data logger is 30 DTR, the 30-day electronic temperature record. This device checks the temperature at 10-minute intervals or less for 30 days and records the history of any heat and freeze alarm violations. Transport containers use chemical indicators, so-called markers, or phase-change indicators, which signal when vaccine is exposed to a higher or lower temperature than the predetermined range (Lo- gistics Operational Guide, 2021). Some types, such as vaccine vial monitors, track cumulative heat exposure (WHO, 2015). Another device is the electronic freeze indicator, whose alert is triggered when the vaccines are exposed to temperatures lower than 0.5C for 60 minutes. Once this alert is triggered, the device is no longer usable. Electronic shipping indicators record temperatures at regular intervals and show whether vaccines have been exposed to temperatures beyond the alarm thresholds. WHO recommends using an integrated digital thermometer, electronic freeze indicators, vaccine vial mon- itors, and a stem thermometer for backup. Stem thermometers offer only instantaneous reading, so WHO does not recommend them as the primary monitoring device. However, they remain helpful because they do not need a power source (WHO, 2015). Standard practice for temperature monitoring routines is to control and record temperatures at least twice a day, usually first thing in the morning and at the end of the working day (Logistics Operational Guide, 2021). Sage 2024 Jana Abikova Sage Business Cases End Humanitarian Nightmares With a Cold Page 14 of 15 Chain Logistics Strategy When and How Cold Chains Fail A cold chain fails when vaccines are exposed to too cold or too hot temperatures. As a result, vaccines lose their effectiveness and can become deadly to vulnerable people (Comes et al., 2018). In 2017, 15 children in South Sudan died of toxicity and severe sepsis from compromised vaccines (BBC, 2017) caused by a four- day storage period in a building with no cold chain facility (WHO, 2017b). There are other sources of cold chain failure. One is failure of key infrastructure, such as closed warehouses or transportation network breakdowns (Schoub & Cameron, 1996), power blackouts or lack of fuel and spare parts (WHO, 2014). Failure of monitoring and tracking systems or incorrect use of monitoring devices is an- other possibility (Lloyd et al., 2015). Deficiencies in training (Setia et al., 2002), planning (Trostle et al., 2003) or ability to manage the complex information chain (Comes et al., 2018) also contribute to failures. Although heat exposure is often named as a dominant threat, researchers identified freezing as a problem for the majority of vaccine chains (Lloyd et al., 2015), a phenomenon reported in the United States (Setia et al., 2002), Indonesia (Nelson et al., 2004) and Tunisia (Lloyd et al., 2015).

Based on this case study,how would one assist sarah in planning this emergency vaccination campaign referencing to the project life cycle model in detail and aligning it to the cold chain logistics strategy