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Location-based services have become widespread in the last few years thanks to the mass availability of location chips in every internet-enabled mobile and portable device: smartphones, wearable or embedded devices, and low-cost computing platforms, e. Such devices combine motion, location, environmental and physiological sensors that enable advanced location and tracking Yang et al. Besides tracking locations or the movement of humanitarian supplies, monitoring the safety of vaccines is vital.

The only reliable way to verify the integrity of the cold chain is continuous temperature monitoring. While it is still common practice in developing countries that thermometers are put into refrigerators and temperatures are checked at given intervals Thakker and Woods, ; Lloyd et al. The amount and complexity of vaccine campaigns, however, make vaccine tracking difficult: vaccines are often packed in small containers that cannot individually be monitored due to the high cost and effort in monitoring and updating temperature logs Carullo et al.

Therefore, the design of cold chain tracking and monitoring systems needs to balance the investment in the monitoring system and the potential gains in terms of reduced waste rates or improved immunization coverage. The sparse academic literature there is on the topic largely focuses on the results of monitoring in terms cold chain disruptions see e.

Lloyd et al.

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From a supply chain perspective, monitoring and tracking technologies support data collection that is directly related to the material flows. In this sense, they offer the opportunity to complement existing information flows by reliable information about individual vaccines. However, their impact on supporting coordination and steering the material flows can only be used successfully if they support existing information management practices and systems. Information management covers the various stages of information processing from production to storage and retrieval to dissemination toward the better working of an organization.

Increasingly, information technology is playing a key role in enabling effective and efficient information management.

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Information management systems integrate the technology within the work processes of the humanitarian actors Van de Walle et al. In a review by Dasaklis et al. The humanitarian information management literature, on the other hand, is largely focused on case studies, e. Yet, while the contributions emphasize the need to tailor information flows to support specific decisions and problems and the role for ICT in broader logistics operations, none of them specifically addresses the problems of cold chains.

The dichotomy between different coordination layers and time frames has been documented for other humanitarian operations and is often reported as a source of friction Van de Walle and Comes, Given the fragmented and emergent state of the literature, there is a need to systematically analyze how cold chain information systems can be designed to serve its three-fold purpose: facilitating coordination and adaptive planning at national or reginal level;.

Introduction of technology can support data collection, but also, in turn, requires data to work efficiently. This implies that any new technology will make information management more complex, and requires systems that facilitate and foster information sharing in a decentralized network respecting the context of the respective users, decision makers or operators. From a supply chain perspective, information flows are to support coordination and align flows of material Van Wassenhove, However, it is still common practice that planning and advocacy dominate information management.

Instead of supporting coordination along, the chain data are collected, verified, triangulated and aggregated only at national coordination or headquarters level before redistributing to the field, leading to long information lead times. To adapt to the local and dynamic challenges for cold chains, humanitarian information management needs to refocus and contextualize information to support the core functions of a cold chain, i.

As discussed in the two preceding sections, technology innovations have the potential to overcome cold chain disruptions caused by fragile, damaged or missing infrastructures. Information gaps can be addressed by deploying management information systems, and the storage and delivery can be monitored and tracked by dedicated systems.

Despite the technical weaknesses of immature technologies, and the precariousness of deploying technology in unpredictable and insecure contexts, these technologies are changing the conditions and possibilities for decision makers. To support decision making, particularly in complex and uncertain problems, the humanitarian operations management literature has developed a broad set of decision support systems, optimization tools and simulation models. These models and systems typically assume that the conditions for the decisions to be made are given, for instance, in terms of preferences and objectives, or in the way uncertainties are represented.

Here, however, we are interested in the question on how the changing technology on the information and capacity layers is changing the characteristics of the decision-making problems that are addressed, and in particular in how far they help to address the problem of irreversibility which is pivotal for successful cold chains. In the academic literature, decision support studies for vaccine cold chains falls squarely into two categories: case studies, largely from a medical background, or operations research models that consider cold chain requirements as constraints.

Within the first category, Date et al. Anderson et al. For the second category of operational research modeling, a number of recent review papers are relevant. Problem areas related to general healthcare or pharmaceutical supply chains are identified by Privett and Gonsalvez and Christian et al. Lemmens et al. They point out that the majority of publications focus on strategic decisions at planning level. Operational decisions, particularly real-time adaptations that are so characteristic for humanitarian disasters, are largely neglected in the literature.

The authors also emphasize the difficulty of modeling all relevant decisions or constraints as derived from local communities. Similarly, for models that address uncertainty, the clear focus is on variations of demand. Neither the first nor the second category of relevant literature, however, explicitly considers disruptions of infrastructure, technology solutions as well as problems related to the use of technology.

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  5. Table II provides an overview of important decision characteristics in humanitarian vaccine cold chain management, differentiating between long-term decisions made during the planning phase, and real-time decisions made during the implementation phase. While, in the planning phase, there is time for deliberative processes and the development of models or simulations, during the implementation phase, decision makers must act quickly on the basis of incomplete information, relying on their experience and intuition — an approach prone to possible cognitive biases Comes, ; Gralla et al.

    Table II illustrates the differences in scope time and geography , in the decision makers and the level at which they make decisions, as well as in the location of the power to implement for the two phases. Moreover, the decision makers have different sets of options or alternatives, and need to maximize different objective functions to make decisions at a different frequency. The decision paradigms greatly differ between the two phases: in the planning phase, decision makers typically make use of operational research models, while the decision makers in the field often rely on heuristics shaped by their experience.

    Decisions made in the planning phase are typically irreversible, for instance, because of long lead times to source the necessary equipment or medicine. In the field, decision makers often are unaware whether a decision can be reversed or not, depending on the level of disruption that is expected or is known. Last but not least, uncertainty plays a key role in both phases. Whereas in the planning phase, uncertainty is taken into account in probabilistic forecasting or scenario models, uncertainty in the field often stems from missing or conflicting information on the environment in which the decision makers deploy the cold chain.

    Drawing from the above discussion on the respective cold chain layers, we now put forward an encompassing research agenda in order to address the most critical problems in cold chain management. We have argued that technology is promising to improve local capacity and reduce uncertainty. Through our review and analysis on cold chain management, we identified major gaps primarily related to the question how technology supports actions on the ground, and helps decision makers to ensure the integrity of the chain.

    We therefore focus on the information and decision layers in our research agenda, and derive three key areas of research that are critical for advancing successful cold chain management: planning and implementing cold chains under conditions of uncertainty; the role of information in implementing cold chains in the field; and coping with decision irreversibility at the planning and implementation phase. An important driver behind data collection effort is the need to reduce uncertainty and make evidence-based decisions Darcy et al. Acknowledging that the nature of uncertainty in humanitarian disasters is such that they cannot be completely reduced, drones and refrigerators offer different ways to manage uncertainty by providing flexibility and buffer capacity.

    Time is a driver of deep uncertainty as it limits the possibilities to collect and analyze data. As such, time determines the approaches that can be taken to manage and model uncertainty. Both can be applied in the planning phase because there is time for data collection, modeling and simulations, or deliberation and discussion. Moreover, for planning purposes, it is vital to establish an aggregate overview of the campaign including international sourcing decisions to the layout of a distribution network at national level.

    The time horizon considered will typically encompass the campaign itself, plus longer term strategic considerations and partnerships. Contrarily, real-time decisions that need to be made at local level during the implementation require only information about few locally feasible alternatives. Uncertainties in the implementation phase stem often from gaps, flaws or insufficient updates in data collection. Because of the time pressure, those uncertainties cannot be reduced or fully modeled.

    Rather, decisions need to be made based on incomplete information, using rapid heuristics, experience or the proverbial gut-feeling of many responders. While most models are deterministic or stochastic assuming that the nature of uncertainties is known Galindo and Batta, , systems to support real-time decisions need to be developed to acknowledge lacking information and deep uncertainty.

    To fit to the setting of the implementation phase of a vaccine campaign, such methods need to be adapted to take into account real-time scenario construction as, for instance, proposed by Comes,Wijngaards and Van de Walle, as well as the impact of shocks on forecasting and decision making Durbach and Montibeller, By using appropriately sourced and field-tested new technologies such as drones or solar refrigerators, the number of options available to safely store and transport vaccines increases, and thus also the flexibility of cold chains.

    The impact of the increased number of options, however, critically depends on the ability of decision makers at all levels to access, understand and process information before vaccine temperatures exceeds the safe range. This includes the time to note that a disruption may be occurring, the time to adapt the plans and decide, and the time for implementation.

    Along with the information explosion driven by new technologies, many generic information products are developed, hinting at a growing lack of clarity on whose decisions should be supported Altay and Labonte, Indeed, the problem often is the sheer number and heterogeneity of decision makers in the field and the choices they need to make Gralla et al. The very set-up of a cold chain provides only a limited and clear set of options to keep vaccines cold within the relatively short time frames available.

    The cold chain distribution network and the strict requirements on vaccine temperatures limit the numbers of feasible options at local level. For instance, the number of warehouses equipped with cooling facilities that a transport can reach will, in most cases, be very small. As such, vaccine campaign information systems that support and empower local planning can make use of rapid heuristics, and does not require a global overview of the supply chain. The local information about access, infrastructure, capacity needs to be updated continuously.

    If such information is not available, at least knowing under which conditions a planned route or schedule leads to a disruption of the cool chain provides an indication of the most crucial information needs and critical thresholds. Information that is being collected is intended to improve the cold chain implementation and the timely delivery of vaccines to those affected by disaster.

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    Yet, this very information can become a threat endangering these very lives, if it is inaccurate, misleading or falls in the hands of malevolent groups. In the past decade, so-called humanitarian information principles have been identified to guide the processes of collecting, checking, sharing and using information Van de Walle et al. Earlier findings from field research in a natural and complex disaster setting indicate that in both disaster types the application of these humanitarian principles can be extremely challenging Van de Walle and Comes, The resulting automation of standard products, however, may reduce the flexibility in tailoring to actual needs, or even prevent the actual verification altogether whether the products meet the needs for which they were generated in the first place.

    In complex disaster response, information sensitivity and a lack of adequate procedures to handle it may lead to an exaggerated concern for security, and only that information of which one is absolutely certain is considered for the planning and implementation decision processes. More research is needed to elucidate the role of information in disaster settings, natural or complex, in the implementation of cold chains.

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    Many optimization models assume that decisions are taken at a single point in time and that the events that affect their results can be modeled exhaustively Altay and Green, In practice, however, each choice influences the options that can be implemented in future, in other locations, or at another hierarchical level Comes, For instance, if vaccines do not reach their destination because the cold chain has been disrupted, decision makers need to arrange for another transport, shifting inventories and re-allocating resources.

    Hence, decisions should be modeled as a nested series of interdependent decisions that need to be aligned. One fundamental aspect of restricting future choices, which is particularly relevant in cold chains, is the reversibility of a decision. Although many decisions within a vaccine chain can be irreversible in nature — because vaccines cannot be used any more, or even turn into harmful substances — there is thus far no published research that addresses irreversible cold chain decisions. A long time in one decision problem may be a short time in another.

    This qualification implies that we should be concerned over actions that are costly to reverse within a relevant time frame. While there has recently been some work on responsive supply chains Balcik et al. Because of the long lead times many strategic decisions in the planning phase are irreversible within the time frame of the upcoming vaccine campaign: it is often prohibitively costly to source and order further vaccines, or to install additional cooling equipment, once a campaign has been announced for launch.

    The resulting lack of flexibility has important implications for the implementation phase. Theories of flexible decisions in supply chain management emphasize that strategies whose initial decisions limit future options as little as possible have advantages in the uncertain and often chaotic environment of disasters Charles et al. Intuitively, a flexible strategy should be preferred over a rigid one, for it offers the possibility to adapt upon receiving new information.

    During a vaccination campaign, a series of decisions at operational and tactical level must be made. Given the typical lack of information about infrastructure status or cooling capacity, decision makers will frequently not know whether their decision will be irreversible. For crises, Pauwels et al. As such, any allocation, scheduling or routing decision should be supported by information about the critical points that can prevent a decision to become irreversible.

    For instance, this can be the information about back-up cooling capacity that can still be reached on time, or surplus inventories that can be used to replace vaccines if cold chains are disrupted. Humanitarian disasters often result in mass population movements and resettlement in camps that are often short of clean water and nutrition, and have poor sanitation and waste management. In addition, disasters also cause disruptions of routine health services. These risk factors place particularly vulnerable populations like children and pregnant or nursing women at risk.

    Many diseases that typically spring up in the aftermath of disasters, such as cholera in Haiti after Hurricane Matthew [8] or polio in refugee camps in the Middle East [9] , can be prevented by vaccines. As such, vaccine campaigns are an important component in humanitarian operations to break the downwards spiral for the most vulnerable populations. Cold chains are vital for vaccine campaigns. Our motivation for writing this review is a concern with the current push for technology as a solution to broader problems in the humanitarian field, where claims and expectations toward technologies are frequently made in the general absence of crosscutting analysis of technology, information and planning processes.

    Problematically, some actors have also perceived the humanitarian setting as an appropriate a site for experimental testing of products that have either been too immature or too controversial for testing in non-emergency jurisdictions.

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    The vaccine cold chain is a particularly emotive aspect of humanitarian logistics that lends itself to both branding and experimentation agendas. An important objective of the paper has been to caution against this type of de-contextualized understanding of the cold chain, its problems and possible solutions. But we have also tried to contribute to a better understanding of how, with appropriate testing and procurement, these technologies can soon also be a significant contribution to keeping the cold chain intact.

    Delivery of vaccines through drones, the use of solar refrigerators or implementing tracking and monitoring systems may in the near future change the constraints and parameters for the cold chain management problem. For these innovations to be fully effective, however, several key problems need to be further researched in order to achieve responsive supply chains.

    Indeed, the granularity, scope, frequency and time for the cold chain decision-making process vary across the different decision levels and phases of a campaign. A better understanding of uncertainty, information and irreversibility in the planning and implantation phase, as argued in this paper, is therefore key to advance the effectiveness and efficiency of humanitarian vaccine cold chains.

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