Will Covid-19 bring a return to single-use medical devices?

If healthcare were a country, it would be the fifth-largest emitter of greenhouse gases on the planet, with a carbon footprint equivalent to 514 coal-fired power plants. As such, it’s unsurprising that device makers have started to centre sustainability in product design, focusing on making reusable versions of devices like surgical forceps, instead of plastic ones that need to be disposed of straight away. The downside of reusables is that they become soiled after use and need to be reprocessed afterwards.

Now, the Covid-19 pandemic has caused people to become more apprehensive about touching surfaces and objects due to fears of surface-related disease transmission. This begs the question – will patients and practitioners turn away from reusable devices due to these same fears?

Such concerns are not necessarily grounded in reality. While some researchers have found that the SARS-CoV-2 virus can survive on surfaces for weeks in certain circumstances, The Lancet reports that many of these studies bear little resemblance to real-life scenarios. The studies have used concentrations of SARS-CoV-2 “a lot higher than those in droplets in real-life situations, with the amount of virus actually deposited on surfaces likely to be several orders of magnitude smaller”.

With millions of tonnes of waste plastic filling up landfills and spilling into oceans every year, it would take a fool to argue that single-use medical devices are the only path forward in healthcare. With 2020 still in the grip of the coronavirus pandemic, experts are expecting a sizeable setback in the global campaign to reduce plastic waste pollution, exacerbated by the huge volumes of single-use PPE that are being produced for use in the healthcare sector and beyond.

In the context of challenges like this, there’s an easy response to the ongoing discussion around reusable and single-use medical devices – single-use bad, reusable good, surely? Well, it’s a lot more complicated than that. The precautions being taken to prevent disease transmission in healthcare during Covid-19 – not to mention in the years before this novel coronavirus emerged – shine a spotlight on the nuances and grey areas here.

As SARS-CoV-2 has been shown to be transmissible via surfaces as well as in airborne particles, there are sensible precautions being taken to reduce the likelihood of the viral disease spreading via contaminated medical devices, including a preference for disposable instruments where possible.

Diagnostic devices such as bronchoscopes, flexible endoscopes and laryngoscopes are all useful in the context of Covid-19, and all require extensive cleaning and decontamination if single-use options aren’t available. A practice statement published in May in the journal Respiration by an international panel of pulmonary experts advised that single-use bronchoscopes should be used “if timely and validated reprocessing of the bronchoscopes is not ensured”.

And of course, the emergence of Covid-19 was hardly healthcare’s first exposure to contamination concerns. Some complex devices are simply very difficult to properly clean and sterilise, creating infection risks for patients.

Duodenoscopes, which are primarily reusable and guide clinicians to the bile duct and pancreatic duct, are an important example of this – the instruments’ many small parts are very difficult to clear of all potential pathogens, even with extensive hand-scrubbing, chemical disinfection and gas sterilisation.

The US Food and Drug Administration found 159 incidents of reported duodenoscope contamination in the six months between October 2018 and March 2019, causing 45 patient infections and three deaths, prompting the regulator to request more post-market safety studies from manufacturers, while other players have begun launching new disposable duodenoscopes on to the market.

Even on a purely environmental level, the picture isn’t necessarily as clear as it appears. While disposable devices are obviously more wasteful in terms of plastic and other materials, the high standards of sterilisation and reprocessing expected for safety-critical reusable devices creates an environmental of its own through the increased use of water, energy and chemicals.

A 2017 study published in the British Journal of Anaesthesia used lifecycle analysis to compare the performance of reusable and single-use anaesthetic equipment, and found that depending on the broader power mix, switching to reusables could result in a significant jump in CO₂ emission across the life of a device.

In Australia, for example, the researchers found that switching from single use to reusable equipment, while saving around A$18,000 a year, would also increase CO₂ emissions by almost 10%. Water use, an increasingly pressing issue for many countries, is also massively increased with reusable devices due to the regular cleaning cycles.

In between the single-use and reusable ends of the medical device spectrum, there are also semi-disposable devices, which are generally reusable but with disposable elements, as well as plastic recycling schemes to repurpose the materials used in disposable devices.

While there’s no doubt that waste reduction and resource efficiency should be an abiding concern for device makers, the safety-critical nature of the sector means that every case should be looked at individually on its merits and based on the best evidence. That might not create as fast a transition to sustainability as many would like, but pandemic or no, patient safety must always come first.

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