1. FIRST EXPERIENCE OF AD SYRINGES IN INDIA A CASE STUDY Dr. K.Suresh, UNICEF, Delhi MD, DIH, DF, FIAP, FIPHA, FISCD

2. BACKGROUND Before 1985: –Syringes & needles for vaccination/ other uses were state responsibility –Sterilization process was boiling in saucepan Electric sterilizer & autoclave –Syringes & needles supply Inadequate

3. BACKGROUND 1985- Inception of UIP –GOI supplied Glass syringes and needles (UNICEF- Sup) –Norm - 1 syringes @ 40 injection 1 needle @ 10 injection 1 BCG needle @ 5 injection –Autoclave & Drum sterilizers for PHCs & institutions 1986-87 –Double rack pressure cooker sterilizer provided for SC for outreach sessions

4. BACKGROUND 1987-88: –Plastic reusable syringes were supplied and tried –Experience not encouraging, so banned –Reverted back to glass syringes –UNICEF continued to supply all Glass Syringes and replacement of gas kit & other spare parts 1995-96 onwards –GOI supplies glass syringes from GOI/ WB fund 1998-99 –AD syringes tried for the first time

5. INTRODUCTION OF AD SYRINGES The existing mechanisms of sterilizing reusable glass /plastic disposable syringes were a matter of concern For injection safety, UNICEF India procured offshore AD syringes and supplied to all the districts (NNT)/cities (measles) since 1998. –8.5 m women have been immunized with TT –Around 3.3 million children in age group 9-59 months urban urban measles campaign

6. 0.5ml AD Syringes

7. METHOD OF TRAINING THE VACCINATORS

8. USER FRIENDLINESS Observers from UNICEF Delhi and Jaipur and state Government officers were involved 64 sites were visited during NNT campaigns in Rajasthan and MP and over 200 workers were interviewed using a structured protocol. During urban measles campaigns assessment was carried out in 8 and at least 600 workers were interviewed and their opinion were recorded.

9. REASONS FOR USERS’ CHOICE %

10. WITHDRAWL OF VACCINE ADS Vs. CONVENTIONAL Rest were non- responders

11. RESIDUAL VACCINE IN SYRINGE

12. WASTAGE OF ADS

13. One piece Two piece

14. EXPERIENCE WITH ONE PIECE Vs. TWO PIECE Observation- Disadvantage of using two piece ADS –Sterilization of needle is compromised in field situation while fixing the needle –Leakage of vaccine when needle is not fixed well –Air bubble get in due to loose fitting of needle –Proportion of vaccine wastage was more –Overall time per injection is more for two piece Based on this, ICO requested Copenhagen not to supply two piece ADS to India Programme

15. USER FRIENDLINESS STUDY OF USER FRIENDLINESS STUDY OF MONOJECT BCG ADS AND NEEDLES Around 8500 protocol of around 280 users were received and analyzed Observations –Instruction given on the packet of syringe - 4.54 pt. –Plunger rod in terms of easy to break - 4.42 (this lead to higher wastage rate ~14%) –Sharpness of needle - 4.58 –Comfortability of intradermal injection - 4.41 –Preference for Monoject - 4.51

17. DISPOSAL OF ADS Disposal of AD Syringes continued to be the main concern Several methods were tried during the campaign – First Method -syringes and needles were burnt in the open space on the ground using dry twigs, leaves and paper. – Second Method - needles and syringes were burnt in a pit using dry wings, leaves and papers. The burnt syringes and needles formed an ugly lump of molten plastic in both the methods.

20. DISPOSAL OF ADS – Third method - digging of pits around 9-12” deep. Used needles and syringes were kept in cardboard or shoeboxes with a hole of about 2 inches radius on the top of the box. These boxes were then kept inside the pit and cotton swaps soaked with spirit/ kerosene were slipped inside the boxes through these holes. The boxes then were lit with fire. It burnt them completely, even without raking. In the end only the burnt needles remained. Finally the pits were closed with the excavated earth.

26. STUDY ON FUME & RESIDUAL Carried by Shri-ram Institute for Industrial Research Purpose –To ascertain the air quality on burning in enclosed area –Outdoor exercise  dispersal of smoke formed

27. STUDY ON FUME & RESIDUAL –Characterisation The burnt material of disposable syringes does not show any reactive nature. –ADS is not self combustible. –The pH of the water leachate of the sample is 6.9. The sample does not reveal the chance of corrosive nature. –The water leachate of the sample is free from acute toxicity.

28. STUDY ON FUME & RESIDUAL Observations & Recommendations –Burning in enclosed area  high concentration of pollutants  strictly prohibited –Burning in open area Addition of 5-8% pollution Dioxins were not detected. –Needs - Clearance from Environmental Authorities Burning in open area could be done

29. STUDY ON FUME & RESIDUAL Suggestions for Open Area Burning –area with sufficient assimilative capacity –Not more than 100 syringes are burnt at one time –Kerosene/spirit use very less quantity to start ignition –Ensure sufficient wind speed –Ash disposal: ash not hazardous nature and is safe for disposal in the pit pit should be immediately covered after complete burning and further cooling to avoid the scatting of waste

30. CONCLUSION Injection Safety is a major concern NO Monitoring of injection Practices Replenishment & Ensuring use of injection safety equipment-NOT EASY AD syringe is the best option Management of sharps and plastics-a challenge Environmental safety Reduce injection over use