Cost of tetanus toxoid injection using a jet-injector (Imule) in collective immunization in Senegal: comparison with injection using a syringe and resterilizable needle

Needle-less jet injectors were developed by the US army after World War II. Their principal use, however, has been in the administration of lyophilized vaccines from multidose vials to at-risk populations in developing countries. In 1983, a hepatitis B epidemic occurred among customers of a beauty clinic in California (USA) following the use of jet-injectors, demonstrating a clear risk of cross-contamination associated with this technique. As a result, the WHO and Unicef stopped recommending jet-injectors for collective immunizations in developing countries. To eliminate the risk of contamination, Pasteur Mérieux Sérums et Vaccins (now Aventis Pasteur) developed, in 1990, jet-injectors for use with single-use vaccine cartridges. These injectors were tested for tetanus toxoid, DTP, influenza, hepatitis A and typhoid Vi vaccination. The immunogenic reaction was as strong and the injection as well tolerated as for injections using a standard needle and syringe. The additional cost of the Imule technique was evaluated in a district-wide (127,000 inhabitants) tetanus toxoid immunization program at Velingara, Senegal in 1993. The total cost was estimated to be 1.51 FF (76 F CSA, 0.32 US dollars) for one dose of tetanus vaccine given by needle and syringe and 2.41 FF (121 F CSA, 0.56 US dollars) for one dose given by Imule. Thus, the additional cost of injection by ImuleTM was 0.90 FF (45 F CSA, 0.21 US dollars). The cost of cross infection in sub-Saharan Africa has been estimated to be 2.37 FF (118 F CSA, 0.55 US dollars) per injection if injection practices are not supervised. Therefore, the Imule technique may be considered to be cost-effective. However, the technique is still not completely reliable, as shown by the total breakdown of four jet injectors during this vaccination session. Lyophilized vaccines have also not been tested in the field. Vaccinators prefer Imule, training is easy and immunization can be carried out on a day-to-day basis with no vaccine wastage. Imule is not yet in mass production, which would reduce costs. In the face of the ever-increasing risk of cross-contamination during vaccination sessions in sub-Saharan Africa, the Imule technique deserves considerable attention.