Auto-disable syringes are not for needle programmes

    WHO and its partners recommend the use of auto-disable syringes, "bundled" with the supply of vaccines when donor

dollars are used, in all mass immunization campaigns, and also strongly advocate their use in routine immunization programmes. Because of the relatively high price of auto-disable syringes,

WHO's Technical Network for Logistics in Health recommends that activities be initiated to encourage the transfer of production technology for these syringes as a means of promoting

their use and enhancing access to the technology. The present article examines factors influencing technology transfer, including feasibility, corporate interest, cost, quality assurance,

intellectual property considerations, and probable time frames for implementation. Technology transfer activities are likely to be complex and difficult, and may not result in lower prices

for syringes. Guidelines are offered on technology transfer initiatives for auto-disable syringes to ensure the quality of the product, the reliability of the supply, and the feasibility of

the technology transfer activity itself.

    UNICEF is working to buy 1 billion syringes by the end of 2021 for COVID-19 vaccination efforts in countries participating in the COVAX Facility.  Although the vaccines secured by

the Facility may vary in their formulation and storage requirements, the syringes will all be of the auto-disable (AD) type, approved by the World Health Organization.   

    AD syringes are recommended for immunization programmes because they are designed to prevent re-use by locking automatically after a single use. They are the best way of ensuring that

people receive their shots safely, without a risk of contracting an infection due to contaminated needles. The AD syringes bought for this immense operation are similar to those routinely

procured and delivered by UNICEF for the vaccination of children worldwide.

    Joint efforts for safe injection

    Until a few decades ago, children were vaccinated using safety syringe, which exposed them to the risk of

transmission of bloodborne diseases like Hepatitis B and HIV. “Sometimes, these used syringes were resold and reused, and we have encountered instances of children using them as toys”,

tells Robin Nandy, UNICEF Chief of Immunization.

    According to a study sponsored by WHO in 2014, up to 1.7 million people contracted hepatitis B, up to 315 000 with hepatitis C, and 33,800 with HIV through unsafe injections.

    The situation started to improve in 1999, when UNICEF, the World Health Organization and the United Nations Population Fund (UNFPA) jointly called for the improvement in injection

safety standards. In a statement, the organizations noted that AD syringes were already available and affordable and declared that they should be the device of choice for administering

vaccines in both routine services and during mass campaigns.

    Since then, several initiatives have driven progress in injection safety for immunization. An example of collective advocacy was taken by the Measles and Rubella Initiative (M&RI),

launched in 2001 and led by the American Red Cross, the United Nations Foundation, the U.S. Centers for Disease Control and Prevention, UNICEF and the World Health Organization. The

partnership required that safe injection equipment, including AD syringes, were used as part of the support they provided countries to carry out vaccination campaigns.

    With the support of major donors, UNICEF has been playing a key role in the global effort for safe injection. The number of auto disable syringe UNICEF procured grew from 11 million in 1997 to around 600-800 million per year. UNICEF is also the world’s largest buyer of AD syringes,

procuring 40% of the global market. This growth has been accompanied by a significant price drop. Three decades ago, UNICEF paid US$ 0.12 per unit of an AD syringe. The price has since

fallen to US$ 0.03 per unit.

    “All these developments have been the result of a global programmatic decision to use AD syringes for immunization supported by a variety of stakeholders”, says Robert Matthews, head

of the Medical Devices Unit in UNICEF Supply Division. He explains that a number of elements, including funding from donors like Gavi and M&RI, have helped influence and shift the market

away from traditional disposable reusable syringes towards the use of AD syringes for immunization.

    Through COVAX, UNICEF is keeping its commitment to safe injection by exclusively buying AD syringes for the COVID-19 vaccination. “With safe injection equipment we strive to guarantee

that the good intention embodied in the vaccine does not do harm”, says Robert.

    As you may have seen in the media recently, the World Health Organisation (WHO) has launched new guidelines on medical injections and a global campaign to switch all medical and

vaccination injections to syringes that cannot be used more than once. These "safety-engineered syringes" may, for example, include a weak spot in the plunger that causes it to

break if the user attempts to pull back on the plunger after the injection. Others have a metal clip that blocks the plunger so it cannot be moved back, while in others the needle retracts

into the luer slip type syringe barrel at the end of the injection. Using these syringes in medical

settings will, according to WHO, protect millions of people from becoming infected with HIV, hepatitis and other diseases through the re-use of unsterile equipment by doctors and medical

staff, especially in the poorest health systems in the world. Their ambitious aim is that every country should have transitioned to these new syringes by 2020.

    However, these recommendations and this campaign explicitly do not apply to needle and syringe programmes for people who inject drugs (the population most impacted by HIV, hepatitis and

other diseases transmitted through contaminated injecting equipment). It has been demonstrated and proven on many occasions that these auto-disable syringes are unsuitable, ineffective and

undesirable in these programmes – clients simply do not like them, they are often harder to use, and they cost more. For example, drug preparation and injection amongst people who inject

drugs routinely involves more than one retraction or depression of the syringe plunger, making auto-disable syringes inappropriate. Several peer-reviewed studies have also documented the

inadequacy of auto-disable syringes for people who inject drugs – see this informative briefing from the USA's Harm Reduction Coalition for more information.

    As a result, and after intensive lobbying by the NNEF and other civil society partners around the world, the WHO guidelines (available here) include the clear exemption that health

systems must set "policies and standards for procurement, use and safe disposal of disposable [i.e. not auto-disable] syringes in situations where they remain necessary as described

above, including in syringe programmes for people who inject drugs". Similar disclaimers appear in the accompanying leaflet and press release – but this has not been picked up in the

media reporting, such as the recent BBC article.

    So in short, auto-disable or auto-retract syringes remain unsuitable for needle and syringe programmes. Of course, the message must continue to be that every syringe is intended to be

single use, and programmes should continue to use low dead space syringes as before. But these new guidelines from WHO should not change the way that we work.

    Injection is one of the important health care procedures used globally to administer drugs. Its unsafe use can transmit various blood borne pathogens. This article aims to review the

history and status of injection practices, its importance, interventions and the challenges for safe injection practice in developing countries. The history of injections started with the

discovery of syringe in the early nineteenth century. Safe injection practice in developed countries was initiated in the early twentieth century but has not received adequate attention in

developing countries. The establishment of “Safe Injection Global Network (SIGN)” was an milestone towards safe injection practice globally. In developing countries, people perceive

injection as a powerful healing tool and do not hesitate to pay more for injections. Unsafe disposal and reuse of contaminated luer lock type syringe is common. Ensuring safe injection practice is one of the greatest challenges for healthcare system in developing countries. To address

the problem, interventions with active involvement of a number of stakeholders is essential. A combination of educational, managerial and regulatory strategies is found to be effective and

economically viable. Rational and safe use of injections can save many lives but unsafe practice threatens life. Safe injection practice is crucial in developing countries. Evidence based

interventions, with honest commitment and participation from the service provider, recipient and community with aid of policy makers are required to ensure safe injection practice.

    Auto-disable syringe has a mechanism to immobilize the plunger or block the needle or cause the syringe to leak when a second injection is attempted hence it cannot be reused. The

needle is also fixed permanently in the syringe to prevent the reuse of the needle as well. Mandatory use of auto-disable syringes for vaccination is a good step for ensuring injection

safety. But associated cost and safe disposal is a serious limitation for developing countries. Although auto-disable syringe cannot be reused, the exposed needle can be risky. Moreover

disposal of auto-disable syringe is also a challenge in developing countries where the infrastructure for disposal is lacking. Despite the growing awareness about the need of safe health

care waste management (including disposal of injectable), compliance is lacking.[4] So, pros and cons of each

intervention, in context to the implementation region and resources should be analysed before implementation.

    The healthcare workers (front line workers) should be actively involved in the planning, implementation and evaluation of new technologies and other changes in the practice, for the

practical and successful implementation.[4]

    Injections have saved many lives but at the same time carry the risk of infections. So the current concern is how to make this practice more safe and beneficial in developing

nations? Various strategies such as educational, managerial and regulatory have been discussed but challenges have to be overcome for their successful implementation. Rational use of

injections, proper management and disposal of injectable products can lead to safe injection practice and for this honest commitment and participation is required from service provider,

recipient and community with support from policy makers. More research to understand the problem in individual countries and regions is required to develop evidence based interventions.

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