By Adrian Brune (New York), with Chris Messina (Boston)
There is an old folk tale passed from generation to generation among the people of Mali – not too unlike the one from the Old Testament – that Gary Cohen likes to repeat when he talks about his visit there last year. Seven days after a baby is born, a bird passes over the infant’s house and may or may not take the infant’s life; thus, newborns are not given a name until the eighth day of their life.
To the people of Mali, that bird represents the gods, karma, or just simple misfortune. To Gary Cohen, that bird is disease and that disease bears the name of tetanus. To the people of Mali, not much above the mystical can be done to prevent the bird from coming and taking the baby and sometimes, its mother to the heavens. To Gary Cohen, President of Medical Systems at BD (Becton, Dickinson and Company, Franklin Lakes, NJ), one of the largest manufacturers of vaccination devices in the United States, almost everything can.
Gary Cohen of BD passionately argues that investing a small amount in inexpensive locking syringes will dramatically reduce AIDS and tetanus in the developing world.
“Mali presented all the mass-immunization challenges – it is a very poor country with a high prevalence of tetanus and a population dispersed into very remote, difficult-to-reach locations,” Cohen said. “These are the things I knew about Mali before making the trip. The things I learned during the trip deepened my knowledge of what it will take to eliminate maternal and neonatal tetanus.”
And doing that is an uphill battle in itself. It could also be a gamble for the nongovernmental organizations that Cohen traveled to Mali with, such as the World Health Organization (WHO) and UNICEF. Vaccinating against tetanus is risky, even for the local clinics that are located in Mali. It’s a gamble in the sense that administering the vaccinations that could save the lives of these women and children ironically also could make them sick with HIV, Hepatitis B, or another blood-borne disease because of the reuse of dirty syringes.
Approximately 16 billion injections are given worldwide every year and 40 percent of those are given with reused syringes in the developing world, according to a World Health Organization report. Sometimes that reuse is intentional, due to economics or the lack of education; but often, used syringes are repackaged and resold appearing brand-new to the unsuspecting health care worker.
Conservative estimates suggest that in the year 2000 alone, contaminated injections caused about 260,000 new HIV infections, 21 million Hepatitis B infections and 2 million Hepatitis C infections - and recent research published in the International Journal of STD and AIDS argued that up to half of all new HIV infections may be a result of unsafe injections. Many experts agree that this problem can be solved inexpensively. For an estimated annual cost of less than one percent of the total $15 billion HIV/AIDS package recently approved by U.S. President Bush, the entire continent of Africa could be supplied with safe injection devices. Doing so would effectively eliminate this entire category of disease spread, according to another WHO report.
“New financial resources are vital if there is to be a significant impact to reduce the global HIV/AIDS pandemic,” the WHO’s Director General Dr. Gro Harlem Brundtland has said of Bush’s pledge. “Such new money provides a challenge to build capacity within local and national health systems so that they are better able to respond to people’s needs – particularly in poor communities that are affected -”.
There is a solution to the problem of re-used syringes, however, and that is auto-disable injection devices. These have locking features that physically prevent re-use. Working with WHO and concerned health care providers, BD and other medical supply manufacturers have developed new, safer variants of the one hundred year old basic syringe technology. These developments include reliable, low-cost, non-reusable syringes such as BD’s SoloShot, a device that locks once the injection is given and the needle is retracted. Another innovation is a pre-filled syringe called a Uniject – a small, prefilled device that injects medication or vaccines and then cannot be reused. See: Figure 2:
Both SoloShot and Uniject were initially developed by the Program for Appropriate Technology (PATH), a non-profit, non-governmental organization (NGO) based in (Seattle, WA). PATH, which is funded by both the US Agency for International Development (USAID) and the Gates Foundation, is leader in creating appropriate technologies to meet the health care needs of women and children in developing countries. PATH invented these new variants of an old medical device. However, it took the resources of private industry, such as PATH’s licensee BD, the world’s largest syringe manufacturer, to produce this innovation in large quantities with high quality.
On left, used Uniject syringe (BD). On right, autodisabled SoloShot syringe (BD), with plunger locked into the barrel after use.
While clever technology is necessary, it is not sufficient in the notoriously poor developing world, where over a billion people live on less than $1/day. The price has to be right, too. In this regard, the scale built up by BD and other large syringe manufacturers such as Tyco Healthcare(Mansfield, MA) a Star Syringe Limited (East Sussex, UK) licensee, helps. High speed, massive volume manufacturing technology allows each "auto-disable" syringe to be sold for less than a dime. The BD SoloShot(TM) IX syringe, for example, sells for about five cents a piece.
Dr. Michael Free, VP/ Senior Advisor for Technology at PATH, says that one of the challenges for auto-disable syringes was “not only to develop them, but to get them adopted”. To support adoption, PATH works closely with both developing-world-based syringe manufacturers and large firms including BD and Star Syringe. The next evolution of technology that Dr. Free sees is “the adoption of retractable technology, which offers additional value by protecting against auto-stick”. These syringes have needles that automatically retract into the barrel. (See Figure 3) Thus they not only eliminate re-use, they also protect health care workers against accidental sticks with a used and possibly- contaminated syringe. These syringes are twice as expensive, however. Dr. Free projects that retractable syringes will cost twice as much as standard auto-disable syringes.
Image on left Courtesy of BD, Franklin Lakes, NJ, Image on right: Body1
On left, retractable syringe prior to use. On right, retractable syringe after use. Needle is pulled into and discarded inside the barrel.
So for now, global health organizations are focusing their syringe adoption efforts. Even though many world studies say that unsafe sexual practice is Africa’s biggest issue when it comes HIV/AIDS spread, syringe reuse still constitutes a major problem. Until syringe reuse is stopped, a baby in Mali might avoid tetanus, only to contract HIV or hepatitis from a vaccination injection. That’s Africa’s new “Catch-22”.
But Gary Cohen still believes.
“We can stop the deadly bird from passing over the homes of newborns in under-developed countries,” he said. “We can put an end to their suffering.”
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