Jet injector

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A health worker using a jet injector on a child

A jet injector is a type of medical injecting syringe that uses a high-pressure narrow jet of the injection liquid instead of a hypodermic needle to penetrate the epidermis. It is powered by compressed air or gas, either from a pressure hose from a large cylinder, or from a built-in gas cartridge, small cylinder, or spring (as in the MadaJet, Medijector Vision, Vitajet, Injex 23 and 30, or Insujet).

Jet injectors were used for mass vaccination, and as an alternative to needle syringes for diabetics to inject insulin. As well as health uses, similar devices are used in other industries to inject grease or other fluid.

The term "hypospray," although better known within science-fiction, originates from an actual jet injector known as the Hypospray and has been cited within several scientific articles.[1][2][3]

Types[edit]

A Med-E-Jet vaccination gun from 1980

A jet injector, also known as a jet gun injector, air gun, or pneumatic injector, is a medical instrument that uses a high-pressure jet of liquid medicament to penetrate the skin and deliver and deposit medicament under the skin, without a needle. Jet injectors can be single-dose or multi-dose jet injectors.

Throughout the years jet injectors have been redesigned to overcome the risk of carrying contamination to subsequent subjects.

To try to stop the risk, researchers placed a single-use protective cap over the reusable nozzle. The protective cap was intended to act as a shield between the reusable nozzle and the patient's skin. After each injection the cap would be discarded and replaced with a sterile one. These devices were known as protector cap needle-free injectors or PCNFI.[4]

However, a safety-test by Kelly and colleagues (2008)[5] found a PCNFI device failed to prevent contamination. After administering injections to Hepatitis B patients, researchers found Hepatitis B had penetrated the protective cap and contaminated the internal components of the jet injector, showing that the internal fluid pathway and patient contacting parts cannot safely be reused.

Researchers developed a new jet injection design by combining the drug reservoir, plunger and nozzle into a single-use disposable cartridge. The cartridge is placed onto the tip of the jet injector and when activated a rod pushes the plunger forward. These devices are known as disposable-cartridge jet injectors or DCJI.[4]

The International Standards Organization recommended abandoning the use of the name "jet injector" which is associated with carrying a risk of cross-contamination and rather refer to newer devices as "needle-free injectors."[6]

Modern needle-free injector brands[edit]

The Biojector 2000 is a make of gas-cartridge-powered jet injector. It is claimed by its manufacturer that it can deliver intramuscular injections and subcutaneous injections up to 1 milliliter. The part which touches the patient's skin is single-use and can be replaced easily. It can be powered from a big compressed gas cylinder instead of gas cartridges. It is made by Bioject.[7]

The Vision (MJ7) is a compact, spring-powered jet injector. It can deliver up to 1.6ml in 0.03ml increments, and is designed to last 3000 injections. The medication travels through a hole in the needle-free syringe that is about half the diameter of a 30 gauge syringe. The part which touches the patient's skin can be used for a week. The device was designed by Antares Pharma (formerly Medi-Jector).[8]

The PharmaJet Needle-Free Injector delivers vaccines either intramuscularly or subcutaneously by means of a narrow, precise fluid stream syringe that delivers the medicine or vaccine through the skin in one-tenth of a second.[9]

Diabetics have been using jet injectors in the United States for at least 20 years. These devices have all been spring loaded. At their peak, jet injectors accounted for only 7% of the injector market. Currently, the only model available in the United States is the Injex 23. In the United Kingdom, the Insujet has recently entered the market. As of June 2015, the Insujet is available in the UK and a few select countries.

Concerns[edit]

Since the jet injector breaks the barrier of the skin, there is a risk of blood and biological material being transferred from one user to the next. Research on the risks of cross-contamination arose immediately after the invention of jet injection technology.

There are three types of inherent problems with jet injectors:

Splash-back[edit]

Splash-back refers to the undesirable phenomenon after a jet stream initiates penetration of the outer skin at a high velocity causing the jet stream to ricochet backwards and contaminate the nozzle.[10]

Instances of splash-back have been published by several researchers. Samir Mitragrotri visually captured splash-back after discharging a multi-use nozzle jet injector using high-speed microcinematography.[11] Hoffman and colleagues (2001) also observed the nozzle and internal fluid pathway of the jet injector becoming contaminated.[12]

Fluid suck-back[edit]

Fluid suck-back is the undesirable phenomenon when blood, present upon the nozzle of the jet injector, is sucked back into the injector orifice, contaminating the next dose to be fired.[13]

The CDC has acknowledged that the most widely used jet injector in the world, the Ped-O-Jet, sucked fluid back into the gun. "After injections, they [CDC] observed fluid remaining on the Ped-O-Jet nozzle being sucked back into the device upon its cocking and refilling for the next injection (beyond the reach of alcohol swabbing or acetone swabbing)," stated Dr. Bruce Weniger.[14]

Retrograde flow[edit]

Retrograde flow is the undesirable phenomenon in which after the jet stream penetrates the skin and creates a hole, the pressure of the jet stream causes a backwards flow in which the jet spray, after mixing with tissue fluids and blood, shoots out of the hole, against the incoming jet stream and back into the nozzle orifice.[15]

As shocking as this phenomenon sounds, numerous researchers have documented retrograde flow.[16][17][12][18][19]

Hepatitis B can be transmitted by less than one millionth of a millilitre[20] so makers of injectors need to ensure there is no cross-contamination between applications. The World Health Organization no longer recommends jet injectors for vaccination due to risks of disease transmission.[21]

Numerous studies have found cross-contamination of diseases from jet injections. An experiment using mice, published in 1985, showed that jet injectors would frequently transmit the viral infection LDV from one mouse to another.[22] Another study used the device on a calf, then tested the fluid remaining in the injector for blood. Every injector they tested had detectable blood in a quantity sufficient to pass on a virus such as hepatitis B.[20]

From 1984–1985 a weight-loss clinic in Los Angeles, California administered human chorionic gonadotropin with a Med-E-Jet injector. CDC investigation found 57 out of 239 people who had received the jet injection tested positive for hepatitis B.[23]

In addition to transmission between patients, jet injectors have been found to inoculate bacteria from the environment into users. In 1988 a podiatry clinic used a jet injector to deliver local anaesthetic into patients' toes. Eight of these patients developed infections caused by Mycobacterium chelonae. The injector was stored in a container of water and disinfectant between use, but the organism grew in the container.[24] This species of bacteria is sometimes found in tap water, and had been previously associated with infections from jet injectors.[25]

History[edit]

  • December 18, 1866: Jules-Auguste Béclard presents Dr. Jean Sales-Girons invention, Appareil pour l'aquapuncture to l'Académie Impériale de Médecine in Paris. This is the earliest documented jet injector to administer water or medicine under enough pressure to penetrate the skin without the use of a needle.[26]
  • 1920s: Diesel engines begin to be made in large quantities: thus the start of serious risk of accidental jet-injection by their fuel injectors in workshop accidents.
  • 1935: Arnold K. Sutermeister, a mechanical engineer, witnessed a worker injure his hand from a high pressure jet stream and theorizes of using the concept to administer medicine. Sutermeister collaborates with Dr. John Roberts in creating a prototype jet injector.[27]
  • 1937: First published accidental jet injection by a diesel engine's fuel injector.[28]
  • 1936: Marshall Lockhart, an engineer, files a patent for his idea of a jet injector after learning of Sutermeister's invention.[29]
  • 1947: Lockhart's jet injector, known as the Hypospray, was introduced for clinical evaluation by Dr. Robert Hingson and Dr. James Hughes.[30]
  • 1951: The Commission on Immunization of the Armed Forces Epidemiological Board requested the Army Medical Service Graduate School to develop "jet injection equipment specifically intended for rapid semiautomatic operation in large-scale immunization programs." [31] This device would become known as the multi-use nozzle jet injector (MUNJI).
  • 1954-1967: Dr. Robert Hingson partook in numerous health expeditions with his charity Brother's Brother Foundation. Hingson stated he vaccinated upwards of 2 million people across the globe using various multi-use nozzle jet injectors.[32]
  • 1955: Warren and colleagues (1955) reported on the introduction of a prototype multi-dose jet injector, known as the Press-O-Jet, which had successfully undergone clinical testing upon 1,685 soldiers within the U.S. Army.[31]
  • 1959: Abram Benenson, the Lieutenant Colonel for the Division of Immunology at Walter Reed Army Institute of Research reports on the development of what became widely known as the Ped-O-Jet. The invention was the collaboration of Dr. Benenson and a civilian scientist working for the US Army Medical Equipment and Research Development Laboratory, named Aaron Ismach.[33]
  • 1961: The Department of the Army made multi-use nozzle jet injectors the standard for administering immunizations.[34]
  • 1961: The CDC implemented mass vaccination programs across the United States called Babies and Breadwinners to combat polio. These vaccination events used multi-use nozzle jet injectors.[35]
  • 1964: Aaron Ismach invents an intradermal nozzle for the Ped-O-Jet injector, which allowed to deliver the shallower smallpox vaccinations.[36]
  • 1964: Aaron Ismach was awadred the Exceptional Civilian Service Award at the Eighth Annual Secretary of the Army Awards ceremonies for his invention of the intradermal nozzle.[37]
  • 1966: Oscar Banker, an engineer, patents his invention of a portable multi-use nozzle jet injector that utilizes CO2 as its energy source. This would become known as the Med-E-Jet.[38]
  • September 1966: The Star Trek series used its own jet injector device under the name "hypospray".
  • 1967: Nicaraguans undergoing smallpox vaccinations nicknamed the gun-like jet injectors (Ped-O-Jet and Med-E-Jet) as "la pistola de la paz," meaning "the pistol of peace." The name "Peace Guns" stuck.[39]
  • 1976: The United States Agency for International Development (USAID) published a book called War on Hunger which detailed the War Against Smallpox which Ismach's Jet Injector gun was used to eradicate the disease in Africa and Asia. The US government spent $150 million a year to prevent its recurrence in North America.
  • 1986: A Hepatitis B outbreak occurs amongst 57 patients at a Los Angeles clinic due to a Med-E-Jet injector.[23]
  • 1997: The USA Department of Defense, the jet injector's biggest user, announced that it would stop using it for mass vaccinations due to concerns about infection.[40][41]
  • 2003: Department of Veterans Affairs recognizes for the first-time ever a veteran acquired Hepatitis C from his military jet injections and awards service-connection for his disability.[42]
  • February 13, 2013: The PharmaJet Stratis Needle-Free Injector received WHO PQS Certification.[43]
  • August 14, 2014: The U.S. Food and Drug Administration (FDA) approved use the PharmaJet Stratis 0.5ml Needle-free Jet Injector for delivery of one particular flu vaccine (AFLURIA® by bioCSL Inc.) in people 18 through 64 years of age.[44]

Accidental jet injection[edit]

Accidents have happened in vehicle repair garages and elsewhere where one of the following has unintentionally acted as a hypodermic jet injector:

Accidental injection of oil or paint by such high-pressure sprays can cause very serious injuries which may require amputation, and can induce fatal sepsis.

References[edit]

  1. ^ Clarke AK, Woodland J (February 1975). "Comparison of two steroid preparations used to treat tennis elbow, using the hypospray". Rheumatol Rehabil. 14 (1): 47–9. PMID 1091959. doi:10.1093/rheumatology/14.1.47. 
  2. ^ Hughes GR (June 1969). "The use of the hypospray in the treatment of minor orthopaedic conditions". Proc. R. Soc. Med. 62 (6): 577. PMC 1811070Freely accessible. PMID 5802730. 
  3. ^ Baum J, Ziff M (March 1967). "Use of the hypospray jet injector for intra-articular injection". Ann. Rheum. Dis. 26 (2): 143–5. PMC 1031030Freely accessible. PMID 6023696. doi:10.1136/ard.26.2.143. 
  4. ^ a b Jet Infectors. "What Is A Jet Injector?". jetinfectors.com. Retrieved October 23, 2016. 
  5. ^ Kelly, K (March 4, 2008). "Preventing contamination between injections with multiple-use nozzle needle-free injectors: a safety trial.". Vaccine. 26 (10): 1344–1352. PMID 18272265. doi:10.1016/j.vaccine.2007.12.041. 
  6. ^ International Standards Organization (June 3, 1999). "Needle-free injectors for medical use [draft report]" (PDF). 
  7. ^ http://www.bioject.com/
  8. ^ http://www.wikinvest.com/stock/Antares_Pharma_%28AIS%29/Antares_Medi-jector_Series_Needle-free_Injectors
  9. ^ "PharmaJet Product Page". 
  10. ^ Jet Infectors. "Inherent Problems With Jet Injectors" (PDF). Jet Infectors. Retrieved July 31, 2017. 
  11. ^ Mitragotri, Samir (July 2006). "Current status and future prospects of needle-free liquid jet injectors". Nat Rev Drug Discov. 5 (7): 543–548. PMID 16816837. doi:10.1038/nrd2076. 
  12. ^ a b Hoffman, Peter; Abuknesha, RA; Andrews, NJ; Samuel, D; Lloyd, JS (2001). "A model to assess the infection potential of jet injectors used in mass immunization". Vaccine. 19: 4020–4027. PMID 11427278. 
  13. ^ Jet Infectors. "Inherent Problems With Jet Injectors" (PDF). Jet Infectors. Retrieved July 31, 2017. 
  14. ^ Weniger, BG; Jones, TS; Chen, RT. "The Unintended Consequences of Vaccine Delivery Devices Used to Eradicate Smallpox: Lessons for Future Vaccination Methods" (PDF). Jet Infectors. Jet Infectors. Retrieved October 23, 2016. 
  15. ^ Jet Infectors. "Inherent Problems With Jet Injectors" (PDF). Jet Infectors. Retrieved July 31, 2017. 
  16. ^ Kale, TR; Momin, M (2014). "Needle free injection technology – An overview". Innovations. 5 (1). Retrieved October 23, 2016. 
  17. ^ Suria, H; Van Enk, R; Gordon, R; Mattano, LA Jr. (1999). "Risk of cross-patient infection with clinical use of a needleless injector device". American Journal Infect Control. 27 (5): 444–7. PMID 10511493. doi:10.1016/s0196-6553(99)70012-x. 
  18. ^ World Health Organization. "STEERING GROUP ON THE DEVELOPMENT OF JET INJECTION FOR IMMUNIZATION" (PDF). asknod.org. Retrieved October 23, 2016. 
  19. ^ Kelly, K; Loskutov, A; Zehrung, D; Puaa, K; LaBarre, P; Muller, N; Guiqiang, W; Ding, H; Hu, D; Blackwelder, WC (2008). "Preventing contamination between injections with multi-use nozzle needle-free injectors: a safety trial". Vaccine. 26: 1344–1352. doi:10.1016/j.vaccine.2007.12.041. Retrieved July 31, 2017. 
  20. ^ a b Hoffman, P.N; R.A Abuknesha; N.J Andrews; D Samuel; J.S Lloyd (2001-07-16). "A model to assess the infection potential of jet injectors used in mass immunisation. Population risk (Veterans and children) for another deadly virus, previously known as "non A- non B" or Chronic Hepatitis C "CHC or HCV".". Vaccine. 19 (28–29): 4020–7. PMID 11427278. doi:10.1016/S0264-410X(01)00106-2. 
  21. ^ World Health Organization (2005-07-13). "Solutions: Choosing Technologies for Safe Injections". Archived from the original on 21 September 2012. Retrieved 2011-05-06. 
  22. ^ Brink, P.R.G.; Van Loon, M.; Trommelen, J.C.M.; Gribnau, W.J.; Smale-Novakova, I.R.O. (1985-12-01). "Virus Transmission by Subcutaneous Jet Injection". J Med Microbiol. 20 (3): 393–7. PMID 4068027. doi:10.1099/00222615-20-3-393. 
  23. ^ a b Canter, Jeffrey; Katherine Mackey; Loraine S. Good; Ronald R. Roberto; James Chin; Walter W. Bond; Miriam J. Alter; John M. Horan (1990-09-01). "An Outbreak of Hepatitis B Associated With Jet Injections in a Weight Reduction Clinic". Arch Intern Med. 150 (9): 1923–1927. PMID 2393323. doi:10.1001/archinte.1990.00390200105020. Retrieved 2011-05-06. 
  24. ^ Wenger, Jay D.; John S. Spika; Ronald W. Smithwick; Vickie Pryor; David W. Dodson; G. Alexander Carden; Karl C. Klontz (1990-07-18). "Outbreak of Mycobacterium chelonae Infection Associated With Use of Jet Injectors". JAMA. 264 (3): 373–6. PMID 2362334. doi:10.1001/jama.1990.03450030097040. 
  25. ^ Inman, P.M.; Beck, A.; Brown, A.E.; Stanford, J.L. (August 1969). "Outbreak of injection abscesses due to Mycobacterium abscessus". Archives of Dermatology. 100 (2): 141–7. PMID 5797954. doi:10.1001/archderm.100.2.141. 
  26. ^ Béclard, F (1866). "Présentation de l'injecteur de Galante, Séance du 18 décembre 1866, Présidence de M. Bouchardat [Presentation of Jet Injector of Galante, H., meeting of 18 December 1866, Monsieur Bouchardat presiding].". Bulletin de l'Académie Impériale de Médecine (France). 32: 321–327. 
  27. ^ Roberts, JF (1935). "Local infiltration of tissues from a machine designed to deliver high pressure, high velocity jets of fluid [Doctoral Thesis].". Columbia University. College of Physicians and Surgeons. 
  28. ^ Rees CE (11 September 1937). "Penetration of tissue by fuel oil under high pressure from diesel engine". JAMA. 109 (11): 866–7. doi:10.1001/jama.1937.92780370004012c. 
  29. ^ Lockhart, Marshall (June 22, 1943). "Hypodermic Injector. Patent Number US 2322244". 
  30. ^ Hingson, RA; Hughes, JG (1947). "Clinical studies with jet injection. A new method of drug administration". Current Researches in Anesthesia and Analgesia. 26 (6): 221–230. PMID 18917536. 
  31. ^ a b Warren, J; Ziherl, FA; Kish, AW; Ziherl, LA (1955). "Large-scale administration of vaccines by means of an automatic jet injection syringe.". JAMA. 157 (8): 633–637. doi:10.1001/jama.1955.02950250007003. Retrieved July 31, 2017. 
  32. ^ Rosenberg, Henry; Axelrod, Jean (July 1998). ""Robert Andrew Hingson: His Unique Contributions to World Health as Well as to Anesthesiology."". Bulletin of Anesthesia History. 16 (3): 10–12. 
  33. ^ Benenson, AS (1959). "Mass immunization by jet injection. In: Proceedings of the International Symposium of Immunology, Opatija, Yugoslavia, 28 September – 1 October 1959": 393–399. 
  34. ^ Department of the Army. "Annual Report of the Surgeon General United States Army Fiscal Year 1961.". U.S. Army. Retrieved July 31, 2017. 
  35. ^ Jet Infectors. "Babies and Breadwinners: 1961 Mass Polio Vaccination Campaign". Jet Infectors. Retrieved July 31, 2017. 
  36. ^ Ismach, A (July 14, 1964). "Intradermal nozzle for jet injection devices. Patent Number US 3140713". 
  37. ^ Army Research and Development (June 1968). "1968 R&D Achievement Awards Won By 18 Individuals, 5 Teams". Army Research and Development Magazine. 9 (6): 3. 
  38. ^ Banker, Oscar (December 20, 1966). "Jet Type Portable Inoculator. Patent Number US 3292621A". Retrieved July 31, 2017. 
  39. ^ Lord, A. "The Peace Gun". Smithsonian. Retrieved July 31, 2017. 
  40. ^ The DoD order
  41. ^ Veterans info page
  42. ^ Cleveland Veterans Affairs Regional Office. "There is Hope for Hepatitis C". Yahoo. Retrieved July 31, 2017. 
  43. ^ "PharmaJet's Stratis® Needle-free Injector Receives WHO PQS Certification as a Pre-qualified Delivery Device for Vaccine Administration". FierceVaccines. 
  44. ^ https://www.cdc.gov/flu/protect/vaccine/jet-injector.htm

External links[edit]