Decommissioning and Safe Disposal of Vaccine Cold Chain Equipment in Low- and Middle-Income Countries: Focusing on Processes, Risks, and Practical Challenges.

Immunization programs in low- and middle-income countries (LMICs) rely on large fleets of powered cold chain equipment (CCE), much of which is now aging, inefficient, or technologically obsolete. While substantial investments have expanded and modernized CCE inventories, formal frameworks for end-of-life management lag behind, and obsolete units frequently accumulate in facilities, yards, and warehouses. Inadequate decommissioning and disposal create environmental, occupational, programmatic, and financial risks that are poorly documented and weakly integrated into cold chain and healthcare waste management policies. We conducted a narrative, process-focused review of electrical vaccine refrigerators and freezers in low- and middle-income settings. Normative guidance from global health, environment, and waste agencies was combined with national policies, program and evaluation reports, healthcare waste management assessments, and selected peer-reviewed literature. Sources were included if they described policies, procedures, or practices for decommissioning, removing, or disposing of vaccine CCE. Extracted information was organized along end-of-life lifecycle stages and synthesized narratively. The review identifies a systems framework in which end-of-life CCE presents a complex hazard profile, including ozone-depleting and high-GWP (global warming potential) refrigerants, compressor oils, foams, electronics, and, for some solar units, batteries. Decommissioning can be structured into a governance setup followed by six operational steps from notification and technical condemnation through decontamination, removal, transport, and licensed final treatment, supported by cross-cutting documentation and reporting. When these steps are absent or weak, environmental and climate risks, occupational and community exposures, vaccine potency loss,