Uniject as a delivery system for the once-a-month injectable contraceptive Cyclofem in Brazil

Integrating plant molecular farming and materials research for next-generation vaccines

Biologics - medications derived from a biological source - are increasingly used as pharmaceuticals, for example, as vaccines. Biologics are usually produced in bacterial, mammalian or insect cells. Alternatively, plant molecular farming, that is, the manufacture of biologics in plant cells, transgenic plants and algae, offers a cheaper and easily adaptable strategy for the production of biologics, in particular, in low-resource settings. In this Review, we discuss current vaccination challenges, such as cold chain requirements, and highlight how plant molecular farming in combination with advanced materials can be applied to address these challenges. The production of plant viruses and virus-based nanotechnologies in plants enables low-cost and regional fabrication of thermostable vaccines. We also highlight key new vaccine delivery technologies, including microneedle patches and material platforms for intranasal and oral delivery. Finally, we provide an outlook of future possibilities for plant molecular farming of next-generation vaccines and biologics.

Integrating plant molecular farming and materials research for next-generation vaccines

Biologics - medications derived from a biological source - are increasingly used as pharmaceuticals, for example, as vaccines. Biologics are usually produced in bacterial, mammalian or insect cells. Alternatively, plant molecular farming, that is, the manufacture of biologics in plant cells, transgenic plants and algae, offers a cheaper and easily adaptable strategy for the production of biologics, in particular, in low-resource settings. In this Review, we discuss current vaccination challenges, such as cold chain requirements, and highlight how plant molecular farming in combination with advanced materials can be applied to address these challenges. The production of plant viruses and virus-based nanotechnologies in plants enables low-cost and regional fabrication of thermostable vaccines. We also highlight key new vaccine delivery technologies, including microneedle patches and material platforms for intranasal and oral delivery. Finally, we provide an outlook of future possibilities for plant molecular farming of next-generation vaccines and biologics.

Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa

BACKGROUND

Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming.

METHODS

We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression.

RESULTS

We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter.

CONCLUSIONS

Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.

Can a Compact Pre-Filled Auto-Disable Injection System (cPAD) Save Costs for DTP-HepB-Hib Vaccine as Compared with Single-Dose (SDV) and Multi-Dose Vials (MDV)? Evidence from Cambodia, Ghana, and Peru

Background

A compact pre-filled auto-disable injection (cPAD) presentation is being developed for the fully liquid pentavalent DTP-HepB-Hib vaccine. A cost analysis (CA) to compare this presentation with the presently used single-dose vial (SDV) and multi-dose vial (MDV) was conducted in Cambodia, Ghana, and Peru.

Methodology

The CA included the development of an excel-based costing model and considered the costs of vaccine, safe injection equipment, procurement, storage, transport and distribution, vaccine administration by health staff, medical waste management, start-up activities, as well as coverage, birth cohort, vaccine, and safe injection equipment wastage rates. The outcome was the change in cost per pentavalent fully immunized child (PFIC) for a switch to cPAD. Field visits to health facilities, and interviews with key informants from immunization services and regulatory authorities, were conducted to collect data and to test the costing model in country context. Cost data were also obtained from manufacturers, published price lists, and author estimates. A sensitivity analysis (SA) was conducted to explore possible variations in values of data collected.

Results

Based on vaccine price trends estimated for 2016, cPAD is less costly in Ghana [incremental cost per PFIC: $US−0.59 (−6.46 %)] than the current presentation (ten-dose MDV) and in Peru (SDV): $US−0.89 (−7.14 %). In Cambodia, cPAD is more costly than SDV: $US+0.33 (+3.90 %).

Discussion and Conclusion

The most significant cost item per PFIC is the vaccine (reflecting wastage rates) in all presentations. The dominance of the vaccine price per dose and, to a lesser extent, the wastage rates in the incremental cost per PFIC show potential to simplify future analyses. Other relevant considerations at country level for a change of presentation include the potential for improved safety with cPAD, planned introduction of other vaccines, environmental and safety issues, and financial sustainability.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0010-0) contains supplementary material, which is available to authorized users.

Operational assessments of Sayana® Press provision in Senegal and Uganda

OBJECTIVE

Sayana® Press (SP) is a unique injectable contraceptive (depot medroxyprogesterone acetate, or DMPA) administered subcutaneously in the Uniject(TM) injection system.(1) SP simplifies the injection process; it requires no assembly of components and is easily disposable. This new technology appears to be well suited for community-based delivery of injectable contraception. The study objective was to evaluate SP management and administration in low-resource settings, focusing on how the delivery logistics, administration time, storage and waste-management requirements compare to the traditional intramuscular DMPA injectable (DMPA IM).

STUDY DESIGN

We conducted 58 semistructured interviews with clinic providers and community health workers in Senegal and Uganda to identify the merits, challenges and appeal of SP relative to DMPA IM.

RESULTS

Providers identified logistical challenges with the management and administration of DMPA IM, including stock outs, transportation, storage constraints, and, in a few instances, waste disposal. Most providers (between 63% and 88%, depending on the logistics issue) do not expect SP to either aggravate or solve those problems. Some envisioned that SP could facilitate supply management (5%), storage (11%) and waste disposal (22%). The all-in-one packaging of SP was perceived to reduce the incidence of mismatched supplies (syringes and vials), and its smaller size was expected to ease space constraints and reduce the frequency of safety box incineration.

CONCLUSION

Adding SP to the method mix is unlikely to have a profound impact on clinic operations but may lessen logistical problems related to supply, storage and waste management.

IMPLICATIONS

Community health workers and clinic providers who administer SP may see some modest improvements in service delivery logistics. Particularly in settings where service delivery logistical challenges are more pronounced, offering SP may facilitate injectable contraceptive delivery.

Feasibility and acceptability of gentamicin in the Uniject prefilled injection system for community-based treatment of possible neonatal sepsis: the experience of female community health volunteers in Nepal

OBJECTIVE

Explore feasibility and acceptability of gentamicin in the Uniject prefilled injection system, in combination with oral cotrimoxazole-p and an appropriate newborn weighing scale, for treatment of possible neonatal sepsis when administered in the community by female community health volunteers.

STUDY DESIGN

In a community-based program in Nepal, 45 volunteers recorded 422 live births. Among these, 82 infants were identified as having possible severe bacterial infection. In all, 67 of these infants were treated with gentamicin in Uniject and 15 were referred to the health facility. Mixed methods were used to collect data about Uniject performance, acceptability and safety.

RESULT

Volunteers successfully treated 67 infants with gentamicin in Uniject. Gentamicin in Uniject performed well and was acceptable.

CONCLUSION

Gentamicin in Uniject, in combination with cotrimoxazole-p and an appropriate newborn weighing scale, is a feasible and acceptable option for treatment of possible neonatal sepsis in the community by female community health volunteers.

Self-administration of subcutaneous depot medroxyprogesterone acetate for contraception: feasibility and acceptability

BACKGROUND

The objectives of the study were to assess feasibility, continuation rates and patient satisfaction with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC).

MATERIALS AND METHODS

The study included 50 DMPA-seeking women between the ages of 18 and 49 years enrolled at two Florida Planned Parenthood health centers. Participants were taught self-injection during their initial study visit and, upon proficiency, self-injected one dose in clinic. Participants then injected a series of three more doses outside the health center over 9 months. Continuation rates, feasibility and acceptability were determined by analysis of four postinjection surveys.

RESULTS

Continuation of DMPA-SC at injection 4 was 74% (95% confidence interval 62%-86%). Overall, survey responses from the three at-home injections indicated the method to be convenient (95%), easy (87%) and recommendable to others (94%). Twenty percent of injections were met with difficulty, most commonly cited as plunger resistance. No pregnancies occurred in study.

CONCLUSIONS

Continuation was high with DMPA-SC self-injection. Participants reported injection to be easy and convenient and are likely to recommend self-administration to other women. Device issues are one potential deterrent.

CEU: Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Postpartum hemorrhage: a prospective, comparative study in Angola using a new disposable device for oxytocin administration

BACKGROUND

Postpartum hemorrhage (PPH) is the single most common cause of maternal death in the world, and oxytocin is known to be effective for its prevention and treatment. The use of syringes can be problematic in areas affected by HIV. The aim of this study was to introduce Uniject (a new disposable device for administration of 10 IU oxytocin) as part of active management of the third stage of labor (AMTL) and try to reduce PPH.

METHODS

A prospective, comparative study was performed between March 1998 and May 2000 in Luanda. Seven hundred and eighty-two parturient women with physiological management were compared to 814 with AMTL. Postpartum lost blood was collected using a plastic sheet during labor and a bucket placed under a cholera bed for 2 h postpartum. Student's t-test and chi(2) test were used.

RESULT

PPH was reduced from 40.4 to 8.2% and severe PPH (> or =1000 ml) from 7.5 to 1% in the AMTL group (P < 0.001).

CONCLUSIONS

Uniject was well tolerated and offers an alternative for oxytocin administration. AMTL should be implemented also in resource-poor settings as a routine management to reduce PPH.

Oxytocin in prefilled Uniject™ injection devices for managing third-stage labor in Indonesia

We assessed the use and acceptability of an injection device (Uniject) prefilled with oxytocin, as part of active management of third-stage labor (AMTL) by Indonesian midwives attending home births. We interviewed 140 village midwives (bidan di desa) and 2220 mothers whose deliveries they attended during the intervention period. We completed baseline and post-intervention assessments to determine their experiences and views of oxytocin Uniject use. Delivery logs and supervisory reports were reviewed. The assessment was done in three rural districts and one municipality in Lombok. Injection practices and oxytocin availability did not change dramatically, although dose accuracy, use of sterile injection equipment, and proper disposal improved when the Uniject device was used. Midwives had little difficulty using the Uniject device properly; they overwhelmingly preferred it to standard needles and syringes. Postpartum hemorrhage rates did not change substantially. Oxytocin via Uniject holds promise for safer, more convenient use of oxytocin by trained midwives attending home deliveries, thereby potentially reducing the incidence of postpartum hemorrhage.

Injectable contraception. New and existing options

DMPA and MPA/E2C contraception offer women safe, effective, convenient, and reversible birth control choices. The use of DMPA, a 3-month injectable, is characteristically associated with amenorrhea. Lactating women and women in whom contraceptive doses of estrogen are contraindicated can use this progestin-only birth control method. Return of fertility can be delayed in women discontinuing DMPA to become pregnant. In some cases, the use of DMPA also confers important noncontraceptive and therapeutic benefits. A monthly estrogen/progestin injectable contraceptive, MPA/E2C should appeal to women who are concerned about daily pill taking, who prefer regular cycles to amenorrhea, and who find monthly injections acceptable and accessible. As is true for oral contraceptives, MPA/E2C represents an appropriate choice for women who prefer a rapidly reversible contraceptive. Currently, the proposed contraindications for MPA/E2C parallel those for combined oral contraceptives. As MPA/E2C contraception becomes available for American women, clinicians will learn how to best include this new method among the array of contraceptive choices. By individualizing contraceptive selection, counseling, and management approaches based on the relevant behavioral and medical considerations reviewed herein, clinicians can maximize their patients' success with injectable contraceptives. The more innovative that clinicians, family planning agencies, and insurers are in facilitating access to care (including reinjections), the more women will be able to avail themselves of safe, effective, and reversible methods of contraception. In addition to the physician's office or health clinic, other sites at which women might receive contraceptive injections include employee health clinics, college health clinics, or perhaps the pharmacy where the prescription is filled. Self-administration may become an appropriate option for some users of injectable contraception.

New once-a-month injectable contraceptives, with particular reference to Cyclofem/Cyclo-Provera

Once-a-month injectable contraceptives containing a progestogen and an estrogen have been developed that disrupt vaginal bleeding patterns less than the widely used progestogen-only preparations. Pharmacokinetic studies were undertaken of dosages and ratios of the progestogens and the respective estrogens. In Phase III clinical trials, annual pregnancy rates were below 0.4% for Mesigyna (norethisterone enanthate/estradiol valerate, Schering AG, Berlin, Germany) and below 0.2% for Cyclofem (MPA/E2C) (medroxyprogesterone acetate/estradiol cypionate, Aplicaciones Farmaceuticas, SA, Mexico and PT Tunggal, Indonesia). More than two-thirds of women had predictable, regular cycles, and discontinuation due to bleeding-related problems occurred less than half as often as with progestogen-only injectables. With MPA/E2C, return to fertility is similar to that observed with other hormonal or intrauterine methods, and both products have little effect on lipids or hemostasis. Introductory trials of MPA/E2C in 12000 women with 100000 woman-months of experience confirmed the high efficacy of the product in routine use. The use of MPA/E2C in a non-reusable injection device, Uniject (Becton Dickinson, Franklin Lakes, NJ) is discussed. Once-a-month hormonal contraceptives have been shown to provide a safe contraceptive option for all women and an alternative for women who wish to use injectable formulations that cause less disruption in vaginal bleeding and minimal side effects.

Self-administration with UniJect of the once-a-month injectable contraceptive Cyclofem

The objective of this study was to evaluate women's acceptance of and ability to self-administrate the injectable contraceptive Cyclofem using prefilled UniJect devices. A total of 102 women were invited to participate in the study. Fourteen women (13.7%) refused to participate. Of the remaining 88 women, 32 women (31.4%) consented to participate and were trained using oranges but were still afraid of the procedure and ultimately refused to self-administer the injections. Only 56 women (55%) ultimately self-injected Cyclofem with UniJect. They performed a total of 144 injections, all of them on the ventral side of the thigh. When nurses evaluated women's ability to activate the devices, they found that more than 80% were successful in both the group of women that later self-administered the injections and the group that did not. The evaluation of the self-administered injection technique showed that more than 90% of the women correctly self-administered the contraceptive using UniJect. With respect to the opinion of the women about the self-administration of the contraceptive, more than 50% (32 of 56) of women who self-injected preferred to self-administer the injection and said that they wished to continue with the self-administration, one-third (17) reported that they were afraid, and seven women (12.5%) expressed the opinion that the injection in the thigh was more painful than the administration in the buttocks or arm. In conclusion, our study showed that women can be trained to successfully self-administer the monthly injectable contraceptive Cyclofem and generally respond positively to UniJect.