The Washington PostDemocracy Dies in Darkness

Opinion Want to end the pandemic? We’ll need to fix the global syringe shortage first.

Empty syringes are seen at a doctor's office in Berlin on Nov. 2. (Hannibal Hanschke/Reuters)
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Francis Kateh is the chief medical officer for Liberia. Edward Kelley is former director of integrated health services for the World Health Organization and head of global health for Apiject. Jimmy Kolker is the former U.S. ambassador to Burkina Faso and Uganda and former assistant secretary for global affairs for the U.S. Department of Health and Human Services.

The World Health Organization and UNICEF issued warnings last week that a lack of syringes would “paralyze progress” on vaccinations in low- and middle-income countries, putting the gap at 2.2 billion syringes.

That’s a conservative estimate. It’s likely the need for syringes will exceed projected supply by at least double those projections. And, as with vaccine doses, the shortage will hit poor countries in Africa and beyond the worst. If we want any hope of ending the pandemic, world leaders must address this shortfall — and fast.

Why is there such a massive shortage, even though organizations working on syringe availability previously forecast that the syringe supply would be “adequate in all scenarios”? The reason is simple, but long-standing: The world has manufactured vaccine syringes for two markets — high-income countries, and the rest of the world. Covid-19 has shown that in true emergencies, the needs of low-income countries for basic commodities such as vaccines or protective equipment cannot be shielded from the demands of the global north.

To ensure widespread vaccination for covid-19 in all countries by mid-2022, as the WHO intends, would require at least 14 billion injections. Add to that the need to treat the delta variant and evolving decisions on booster shots, and that number grows to more than 19 billion injections before the end of 2022.

Industry estimates are that 40 billion to 50 billion medical syringes are manufactured in a typical (non-pandemic) year globally. Yet most of these syringes are used for therapeutics such as insulin or cancer drugs, not vaccines. Only about 5 to 10 percent of all syringes are the smaller, specialty versions designed for vaccines. Vaccine syringe manufacturers have privately forecast collective production increases in vaccine syringes for 2022 that total nearly 5.5 billion annually, significantly increasing current capacity.

But as good as this response might be, it is still not enough. Not even close.

First, there are special needs. The Pfizer vaccine, which has benefited hundreds of millions of people worldwide, requires a 0.3-milliliter syringe — not a previously stockpiled size. In addition, a number of vaccines in production require mixing with an “adjuvant” or dilution fluid before being injected. This also requires an additional syringe for every multi-dose vial.

If expanded production and shifting production lines could add 5.5 billion syringes per year to the average annual total production, global syringe manufacturing capacity could reach about 9 billion vaccine syringes in 2022, still at least 5 billion short of what’s needed.

In normal times, supply should follow demand. But as with personal protective equipment early in the pandemic, covid-19 is exposing gaps in that thinking. Supply chains for syringes are fragile and liable to “syringe nationalism” as countries keep syringes local. The decision by India — the world’s second-largest syringe manufacturer behind China — to restrict syringe exports is already hurting the global vaccine effort.

Second, existing production lines cannot be shifted overnight. Less than half of syringe manufacturers surveyed by PATH appear to have taken actual steps to build new capacity and most producers state that they are operating at full capacity on existing lines. Even with a more robust and immediate response, creating new lines and building new factories will take at least 12 months, with regulatory approvals taking many additional months.

Manufacturers also worry that new capacity added for covid-19 will sit idle after the pandemic subsides. And they have good reason to think so. There is virtually no global “coordination effort” for syringes. Covax, the global collaborative platform for purchasing and distributing vaccines, is focused on doses. That leaves organizations such as UNICEF or the Pan American Health Organization to scramble whenever a vaccine donation is scheduled to land in a country, trying to ensure the right number of syringes arrives with the doses, often competing for supply with high-income countries or one another.

But most important, the world has taken the position that while obtaining and allocating vaccine doses might be a global goal (one that we are not fulfilling at present), ensuring vaccinations is not a collective responsibility.

So what's the solution? First, we need the kind of collective, major investment in injection devices that happened for vaccine production. We didn’t rely on the market alone for vaccine development and production, and we shouldn’t for syringes either. Second, we need to support countries and global organizations to preposition syringes so that when vaccine doses arrive, they do not expire sitting in warehouses unused. Finally, we must ensure that countries have the support needed to train and deploy the millions of health workers needed to vaccinate the world.

Vaccines don’t deliver themselves. What will end this pandemic is a full global vaccination program, complete with adequate syringes, trained health workers and strong public health messaging to overcome vaccine hesitancy and misinformation.