Will there be enough syringes to deliver Covid-19 vaccines?

On Dec. 14, the first Americans received a Covid-19 vaccine, part of an initial group of healthcare workers and residents of long-term care facilities who are first in line. The broader vaccination process will unspool gradually over the next year or so—in the US, 100 million people could be have access to the vaccine by the end of February, Health and Human Services secretary Alex Azar recently told CBS.

The global pandemic response has been stymied by one supply shortfall after another, from yeast and toilet paper to N95 masks and virus tests—and vaccine deployment will be no exception. Meeting demand will likely be challenged by shortages of shot-giving equipment like glass vials and supplies to maintain cold storagechains, not to mention the raw vaccine materials themselves.

But governments and manufacturers appear to be ahead of the curve on one key piece of vaccination equipment: syringes.

Between existing stockpiles and orders on the books, there’s no sign of a looming shortage of syringes (the plastic tube with a piston that is attached to a needle and used to draw or inject fluids), experts told Quartz, either for Covid-19 vaccination or syringes’ myriad other medical uses. “For phase 1 distribution anywhere in the world, we shouldn’t face syringe shortages,” said Prashant Yadav, a senior fellow who studies global health supply chains at the Center for Global Development. “For that we have enough manufactured, stockpiled, or on order.”

That could change, though, once the vaccination effort widens beyond priority recipients to the general public. Governments will have to proactively place more orders, starting immediately, to meet demand months down the line.

The US has only averted a shortage now because of early orders. After a government whistleblower told Congress in May that the US had only 15 million syringes stockpiled, a number of large federal contracts went out to manufacturers, including an order for more than 280 million syringes from Becton Dickinson and Co, the world’s top needle producer, and a $600 million loan to ApiJect, a startup that produces disposable injection devices. Canada also placed a large order with BD.

“The contracts that were made ahead of time are really going to pay off,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.

China, India, and Brazil should be able to satisfy their syringe demand with supply from domestic production facilities, Yadav said, and developing countries in Latin America, Africa, and elsewhere will be able to tap the supply of 1 billion syringes the World Health Organization plans to make available over the next year.

But while the total supply of syringes shouldn’t be a problem, the timing could be: If more countries don’t start to place orders now for what they’ll need in the latter half of 2021, broader phases of the vaccine rollout could be gummed up. India, for example, doesn’t yet have sufficient syringe contracts placed to supply its 1.3 billion people, Yadav warned.

“It’s unclear if the pace at which they want to vaccinate and the pace at which syringes will become available will match,” he said. “If they are thinking of doing a US-style 100 million vaccine drive in a one-month period, they will have a crunch.”

One reason syringes are a relatively easy piece of the Covid-19 puzzle is that the world already produces a huge number of them. The production scale-up, while in need of advance planning, is manageable. The world uses about 16 billion disposable syringes every year, according to UNICEF, of which about 5% are for various immunizations (the rest are for administering drugs, drawing blood, and other uses).

This year, non-vaccine syringe demand will be below average, Yadav said, because fewer people are taking elective visits to hospitals. But again, timing is key: If a huge syringe order drops with little advance notice, that could potentially divert supply from other essential syringe needs, although there’s no evidence this has happened yet.

Matt Bernardo, executive director of Housing Works Community Healthcare, said groups like his that provide safe needle services to intravenous drug users are concerned about a shortfall, although they haven’t experienced one yet related to the Covid-19 vaccine. A bigger concern at this point, he said, is that New York state is cutting funding for HIV prevention programs, which the organization normally relies on to acquire syringes.

Could used syringes potentially be cleaned and put back into circulation in case of a shortage? Dan Vukelich, president of a trade group that represents medical device reprocessing companies, said that syringes are almost never recycled because it’s cheaper to just produce new ones. But there’s no legal or technical reason why they couldn’t be collected, sterilized, and refilled if needed, he said.

Whatever happens with syringes, other equipment also needs to be lined up to pull off vaccination drives without any delays. Makers of pharmaceutical glass are filling orders for billions of vaccine vials, and developing new, stronger kinds of glass. The likelihood of a vial shortage depends on how many governments and hospitals globally opt for the Pfizer or Moderna mRNA vaccines, which come packaged in 5-dose vials, versus the AstraZeneca or other non-mRNA vaccines that can be packaged in higher-dose vials.

The mRNA vaccines also make use of lipid nanoparticles to encase and protect strands of the genetic material; these have to be produced in a lab and were most likely the missing supply that caused Pfizer to announce on Dec. 3 that it would deliver 50 million fewer vaccines than anticipated this year.

“If the whole world says ‘We’re going to get Pfizer and Moderna mRNA vaccine,’ then we are facing a serious shortage of lipids,” Yadav said.

Hopefully world leaders will take some positive reinforcement from their success with syringes so far, and continue to plan ahead.