Disposal of syringes, needles, used bandages, broken equipment and many other items of medical waste remains a challenge in most countries.· The first priority is to dispose of the used equipment where it will do no harm¹ to anyone who happens to come into contact with it.· Throwing out used syringes without being enclosed in a secure safety box and proper disposal of the safety boxes (which is not easy), means that they often end up on an open dump.· Here, there is often someone with a significant incentive to look for anything that can be re-sold – including used syringes.· One study in India showed that rag pickers (people who scavenge rubbish dumps for anything that can be re-sold) receive on average five needle sticks each day from syringes and needles that they are collecting to recycle.· Auto-disable syringes can’t of course be re-used and therefore have no re-sale value back into the medical services either formal or informal.· What about the health rag pickers however?· They are exposed to hepatitis B, HIV, and tetanus infections and who know what else from the needle sticks.

The latest WHO policy (1999) is that all syringes need to be disposed of properly² but in practice this has yet to be fully implemented, particularly in urban areas where burying waste can be a challenge.  Remember roughly half the world’s population now live in cities.

While the WHO policy on safe disposal continues to develop is there a way to protect these poorest-of-the-poor rag pickers by removing the needle from the syringe before it is discarded?  Needle cutters, also called hub cutters, specially designed for removing needles from used syringes have been on the market for at least seven years but there is no official recommendation that they be used in immunization programmes. 
It is true that cutting the needle off a used syringe adds a new step in the collection of sharps waste could increase the risk for needle-stick injuries among health care workers.

However, a needle-free syringe in a rubbish dump will surely result in fewer needle-stick injuries among waste handlers and in the community at large.  Also, removing the needle from the syringe:
(a) decreases the volume of infectious sharps waste
(b) allows the syringe alone to be disposed of with fewer precautions than sharps waste and
(b) the needles alone can be handled as infectious sharps waste.

Many studies have been made on the additional risk of using needle cutters and so far not a single additional needed stick has been recorded. The additional risk therefore seems to be very small; the benefit to the communities, and to the rag pickers in particularly, seems to be very large.

However in 2005 WHO recommended that additional studies are needed “ … on [the] risk associated with this device before introducing needle remover/cutter in immunization settings.” ³, ⁴.

Do you think someone should also be doing studies on rate of infections in the communities associated with NOT using needle cutters?

We welcome your views and comments.

¹ Note: contrary to popular opinion this text does not appear in the Hippocratic oath in the original or the several recognized translated versions:  http://en.wikipedia.org/wiki/Hippocratic_Oath
² The WHO-UNICEF-UNFPA joint statement on the use of auto-disable syringes in immunization
services (1999) says: “Used auto-disable syringes should be deposited in safety boxes without re-capping, burned locally and the remains buried underground - until improved disposal methods are developed. Urgent attention should be given to develop improved means for effective, safe and environmentally-acceptable waste processing and final disposal of auto-disable syringes.”
³ http://www.searo.who.int/en/Section23/Section1108/Section1835/Section1864_8338.htm
⁴ Management of Solid Health-Care Waste at Primary Health-Care Centres. A Decision-Making Guide, Immunization, Vaccines and Biologicals (IVB), Protection of the Human Environment Water, Sanitation and Health (WSH), World Health Organization, Geneva, 2005