Does the world have the tools to inoculate billions?

Update: PATH's Market Dynamics and Medical Devices and Health Technologies teams are developing a model that is anticipating a shortage of upwards of 1 billion auto-disable syringes into 2021, additional data will be available in mid-November. Read about the global effort to close the gap here.

Article originally posted May 11, 2021:

As more countries join in the largest vaccination campaign in human history, one thing has become clear: a vaccine is only effective if health systems have the tools to safely roll it out.

Are there enough syringes to go around for COVID-19 vaccines? Are there enough safety boxes for sharps? And how do countries manage different syringe requirements for different vaccines?

It’s important to understand that not all vaccination equipment is created equal. Safe-injection practices include the use of specific vaccination equipment such as autodisable syringes and reuse prevention syringes (both of which contain mechanisms that prevent reuse) and safety boxes, which ensure the syringes are disposed of properly.

Over the last few decades, these indispensable tools have reduced the risk of bloodborne disease transmission of hepatitis B, hepatitis C, and HIV while protecting health care workers from needlestick injuries.

“In partnership with UNICEF and several other global organizations, PATH helped to pioneer the first autodisable syringes in the 1980s and 1990s, advocated for their routine use across the world, and played an integral role in their global-level procurement,” says Courtney Jarrahian, portfolio leader of packaging and delivery technologies at PATH. “Today, many countries have adopted them as a standard for immunization.”

The world has come a long way in making vaccinations safer, but now more than ever, leaders must remain committed to safe-injection practices—even in the face of vaccine distribution and delivery challenges. The World Health Organization and UNICEF recently reaffirmed this policy by issuing a joint announcement promoting the exclusive use of injection safety devices for all immunization activities.

Although the world’s COVID-19 vaccines are proving effective, new challenges to streamlined vaccine deployment are emerging.

When the COVID-19 vaccine candidates made their debut late last year, countries were surprised to discover differences in the doses: the Pfizer-BioNTech vaccine requires 0.3-ml doses while the Oxford-AstraZeneca vaccine and others require 0.5-ml doses. Autodisable syringes are typically designed to provide a preset 0.5-ml dosage only—a common dose size across many vaccines.

“The Pfizer COVID-19 vaccine is an outlier when it comes to its syringe requirements. The autodisable syringe needed is not the standard size the world has used in the past for intramuscular injections,” says Courtney.

Adding to that complication are issues with “dead space” inside syringes—the tiny drop of vaccine left inside the syringe after the full dose has been delivered. Specialty syringes designed to have low dead space must be used to obtain all doses from Pfizer-BioNTech vaccine vials. To prevent large-scale complications earlier this year, PATH worked rapidly with the World Health Organization, UNICEF, and manufacturers to supply 0.3-ml, low dead space autodisable syringes to countries supported by UNICEF.

While preliminary analysis from PATH’s Global COVID-19 Vaccine Syringe Supply Assessment shows there are enough autodisable syringes (both 0.5 ml and 0.3 ml) and safety boxes for 2021, logistics will still need to be sorted out, including how to manage vaccines being shipped faster than their respective syringes. PATH continues to track and model the global COVID-19 syringe supply as this unprecedented vaccine rollout continues.

Another potential challenge? Because syringes are bulky in such large quantities, they are typically transported around the world by ship. This alone can take about ten weeks. Like so many other supply chains disrupted during the pandemic, safe-injection devices are at the mercy of fluctuating shipping times—and that can make it difficult for health systems to predict availability.

The implications are clear for Courtney: “A mismatch in syringe availability could delay giving vaccines or compel countries to use non-autodisable syringes, which would be a major step backward.”

Since the World Health Organization and UNICEF first began requiring autodisable syringes for immunization in 1999, the rate of unsafe injections has dropped by more than 86 percent, preventing millions of infections of HIV, hepatitis B, and hepatitis C. If countries fall back on non-autodisable syringes now, it will not only go against training and recommendations that have been in place for two decades but it could also erase much of the progress that has been made in safe-injection practices.

Manufacturers have responded by increasing the production of autodisable syringes to meet anticipated global needs—more than doubling total output. UNICEF secured autodisable syringe supplies for the low- and lower-middle-income countries receiving COVID-19 vaccines under COVAX, and in 2021, expects to supply up to 1 billion autodisable syringes and 10 million safety boxes.

While the most immediate obstacles have been cleared, many logistical considerations remain. What else can countries do to streamline the ongoing rollout? Courtney provides a few considerations:

• Do no harm: ensure injection safety is a focus of the COVID-19 vaccine rollout to continue decades of progress in safe-injection learning.
• Follow the recommendation of global health entities to use autodisable syringes during all immunization campaigns to protect health care workers and the health of the public.
• Check the syringe type required for a specific vaccine and confirm that the syringes being procured meet the specifications for dose and dead space, if applicable.
• Consider the logistics of how syringes, safety boxes, and other vaccine equipment will be stored and distributed. Plan for warehouse space if syringes arrive in advance of vaccines.
• Anticipate longer shipping times for syringes than for vaccines, and plan accordingly. As a backup, consider using syringes already stored for routine immunizations during the initial COVID-19 vaccine rollout until syringes can be resupplied.

Great strides have been made in vaccine injection safety these last few decades. As countries work to roll out their COVID-19 vaccination campaigns, this safe-injection progress should remain at the forefront of global health priorities.