The Great Syringe Switch

THE time is not far off when only auto-destruct syringes will be available in Pakistan. Actually, Nov 30, 2021, is the official deadline for switching from the conventional plastic disposable and potentially reusable injection syringe to the AD syringe. Why?

The first hypodermic syringe switch took place in 1955 from glass to plastic syringe. Glass syringes and needles had to be sterilised in boiling water over and over again, they could break and they were expensive. The invention of the plastic syringe was a mini revolution — one syringe for single-use and then thrown away!

However, since the emergence and spread of blood-borne infections especially AIDS and hepatitis C and B in the 1980s, the reuse of contaminated syringes and needles has emerged as a serious public health issue. The syringe used in an injection administered to a patient of a blood-borne disease if not sterilised properly and used again on another patient can introduce the virus of the previous patient in the new one. It has been found again and again in various settings especially in low- and middle-income countries that the reuse of contaminated syringes triggers outbreaks of blood-borne diseases.

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The latest such example was the Larkana outbreak of AIDS in 2019. HIV spread among hundreds of very young children of a local community in a short period of time. When investigated it was found that almost all the children had received injections at the hands of local GPs. It was established unequivocally that the reuse of contaminated syringes among children was the main culprit. One such outbreak was witnessed in 2009 in a village near Gujrat.

Medical practitioners have wrongly promoted the idea that injections are needed for even minor ailments.

The practice of the reuse of disposable syringes was and is very common in the private healthcare sector. In order to save the cost of the syringe, medical practitioners continue to use the same syringe on gullible patients. I visited Larkana during the outbreak, along with the Sindh health minister, and seeing poor and miserable mothers running from pillar to post for the testing and treatment of their children was a heartbreaking sight. Realising that reusing syringes is not an uncommon practice elsewhere in Pakistan too, I set up a National Taskforce on Injection Safety in November 2019 to which I invited all the stakeholders. After thorough deliberations the taskforce developed a comprehensive National Action Plan for Injection Safety and recommended an important regulatory intervention to ban the import, manufacture, sale and use of conventional disposable plastic syringes which was causing the spread of hepatitis C and HIV AIDS.

Pakistan has one of the highest prevalence rates of hepatitis C (nine per cent) in the world and UNAIDS estimates that Pakistan has the fastest-growing number of AIDS cases in Asia.

Unsafe injections are not the only factor responsible for the spread of these blood-borne diseases but these are definitely among the major causes. Given the largely unregulated medical practice in the country, the irrational use of medicines including injections is rampant. Medical practitioners have inculcated the wrong belief among people that injections are needed for any minor ailment and that they are more effective. Hence the demand for injections is high. The statistics are mind-boggling. The highest number of injections in the world are administered in Pakistan — eight to 10 injections per person per year. Ninety-four per cent of these injections are not needed at all.

The AD syringe cannot be reused after single use because its plunger gets locked once the medicine is pushed into the body of the patient. Once locked, any attempt to get the plunger out will destroy the syringe. Such an intervention will remove the possibility of the spread of blood-borne diseases through the reuse of contaminated syringes.

The Sindh government tried to introduce the same measure a decade ago through The Sindh Regulation and Control of Disposable Syringe Act, 2010, whereby “no person shall manufacture, sell or use disposable syringes other than auto-lock, auto-destruct or auto-break for injection….” But the government failed to implement this legislation.

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Once the national taskforce recommended this replacement the manufacturers and importers were resistant as this would negatively affect their businesses and especially in the case of manufacturers they would have to make new investments to change their moulds for manufacturing AD syringes. They also argued that reuse of syringes is not the only or main problem responsible for the spread of diseases but that improper medical waste disposal was the real culprit. After three meetings and realising the government’s commitment, however, they asked for time in order to make changes in their businesses and eventually a deadline was set for switching to AD syringes.

The government has facilitated both manufacturers and importers by waiving custom duties and sales tax on AD syringes. This is to offset the effect of any increase in price for consumers, although given the economies of scale the price difference between the conventional and AD syringe will diminish as has already happened in some provincial bulk procurements. Suppliers also wanted fast-track registration of AD syringes with the Drug Regulatory Authority of Pakistan to which the government responded positively.

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Despite difficulties in trade due to Covid-19, the federal government set the deadline of March 31, 2021, as the last day for importers to clear stocks from customs and July 31, 2021, for manufacturers. The good news is that out of the currently 16 manufacturers of syringes in Pakistan, nine have converted to AD syringes or have obtained the mould for it. The rest are in the process. Now a new deadline of Nov 30, 2021, has been set.

There is now an urgent need for running strong and sustained educational and training campaigns on the use of AD syringes, the rational use of injections and the proper disposal of medical waste.

Through consultative, collective and collaborative national efforts Pakistan is set to eliminate a major cause of the spread of blood-borne diseases in Pakistan. We are also setting an example for other countries. Of course, there will be slips along the way but the ultimate objective is clear and will be achieved in the near future.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.

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