1. Introduction of Auto-Disable (AD) Syringes Program for Appropriate Technology in Health Cairo, Egypt October 2000

2. The Common Sense Approach  Troubleshoot early on to correct unintended consequences.  Supervise injection technique.  Monitor satisfaction with products.

3. In Other Words  Monitor the system, the user, and the product.

4. Know Which Syringes You Are Using  UNICEF should track what they ship.  Programs should track what they receive: –brand and type –fixed or detached needle, length and gauge of needle, dose lines –save a sample, if necessary

5. Prepare Users for Multiple Types of AD Syringes  UNICEF provides several brands.  Brands and models change from year to year.  If 1 syringe is shipped for every 1 dose of vaccine, syringes will be left over.

6. Bundling 1:1 :

7.  Vaccine wastage rates may be 10-60%.  AD syringe wastage rates are more typically <10%.  Over time, different types of AD syringes may accumulate.

8. Training Manual Available  PATH and partners prepared a Training Manual to introduce AD syringes. –English copies are available. –PDF copy available in November. –Contact info@path.org to discuss translation.

9. Contents of Manual  1 page instructions for 4 types of AD syringes  Background information for trainers or supervisors  Sample lessons  Safe injection techniques

10. We Know Current Injections are Unsafe  Use the introduction of AD syringes to review: –Dose accuracy with all syringes –Reuse in curative sectors –Recapping –Keeping syringes from the public

11. Dose Accuracy  Surprising variability in doses given by nurses with standard syringes  Re-train and supervise

12. Dose Volumes Using Standard 21G 2 ml Syringe Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 Number of Attempts Dose Volume (ml) -0.05 0.15 0.35 0.55 0.75 0.95 1.15 12345678910

13. Dose Volumes Using an AD 23G 1 ml Syringe Without Instructions Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 -0.05 0.15 0.35 0.55 0.75 0.95 1.15 12345678910 Number of Attempts Dose Volume (ml)

14. Dose Volumes Using an AD 23G 1 ml Syringe After Reading Instructions Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 -0.05 0.15 0.35 0.55 0.75 0.95 1.15 12345678910 Number of Attempts Dose Volume (ml)

15. Look for Unexpected, Unsafe Consequences  Old BCG syringe has a 0.05 and 0.1 ml dose line.  New AD syringe has only 0.05 ml?  What are people doing to compensate?

16. Unintended Consequences  Do they give two injections?  Do they use one syringe and guess the volume?  Do they change the dose?  Do they use the syringe twice?  Do they use another sterilizable syringe with a 0.1 ml dose?

17. Preventing Reuse with AD Syringes  Depends on How You Manage Stock-Outs: –When mothers come with their syringe will it be used? –When stock runs out will the family be sent to purchase any syringe available? –Do clinics revert to sterilizable syringes?

18. Policy Changes for Equity and Safety  Argue for facilities to improve management and provide syringes and supplies.  Facilities can purchase at lower costs than consumers.

19. Post Marketing Surveillance  Settle safety disagreements with data. –Can WHO prepare a statistically sound framework with the correct unit of analysis that controls for user, facility, and injection order biases?

20. Remember, If You Change a Familiar Object  AND look for problems (adverse events surveillance), people may assume existing, but previously unnoticed problems, are caused by the change.

21. Prepare for that Change  Troubleshoot early on and correct for unanticipated, system-related impacts.  Monitor practice: train and supervise.  Monitor products.