Written by Karan Deep Singh

In late November, an urgent email popped up in the inbox of Hindustan Syringes & Medical Devices, one of the world’s largest syringe makers.

It was from UNICEF, the United Nations agency for children, and it was desperately seeking syringes. Not just any would do. These syringes must be smaller than usual. They had to break if used a second time, to prevent spreading disease through accidental recycling.

Most important, UNICEF needed them in vast quantities. Now.

“I thought, ‘No issues,’” said Rajiv Nath, the company’s managing director, who has sunk millions of dollars into preparing his syringe factories for the vaccination onslaught. “We could deliver it possibly faster than anybody else.”

As countries jostle to secure enough vaccine doses to put an end to the COVID-19 outbreak, a second scramble is unfolding for syringes. Vaccines aren’t all that useful if health care professionals lack a way to inject them into people.

Rajiv Nath, managing director of Hindustan Syringes & Medical Devices, at the company’s factory in Ballabgarh. (Rebecca Conway/The New York Times)

Officials in the United States and the European Union have said they don’t have enough vaccine syringes. In January, Brazil restricted exports of syringes and needles when its vaccination effort fell short.

Further complicating the rush, the syringes have to be the right type. Japan revealed last month that it might have to discard millions of doses of the Pfizer-BioNTech vaccine if it couldn’t secure enough special syringes that could draw out a sixth dose from its vials. In January, the Food and Drug Administration advised health care providers in the United States that they could extract more doses from the Pfizer vials after hospitals there discovered that some contained enough for a sixth — or even a seventh — person.

“A lot of countries were caught flat-footed,” said Ingrid Katz, the associate director of the Harvard Global Health Institute. “It seems like a fundamental irony that countries around the world have not been fully prepared to get these types of syringes.”

The world needs between 8 billion and 10 billion syringes for COVID-19 vaccinations alone, experts say. In previous years, only 5% to 10% of the estimated 16 billion syringes used worldwide were meant for vaccination and immunization, said Prashant Yadav, a senior fellow at the Center for Global Development, a think tank in Washington, and an expert on health care supply chains.

Wealthier nations like the United States, Britain, France and Germany pumped billions of dollars of taxpayer money into developing the vaccines, but little public investment has gone to expand manufacturing for syringes, Yadav said.

“I worry not just about the overall syringe manufacturing capacity but capacity for the specific types of syringes,” he said, “and whether syringes would already be in locations where they are needed.”

Cartons of syringes wait to be sterilized at the Hindustan Syringes & Medical Devices factory in Ballabgarh. (Rebecca Conway/The New York Times)

Not all of the world’s syringes are suited to the task.

To maximize the output from a vial of the Pfizer vaccine, for example, a syringe must carry an exact dose of 0.3 milliliters. The syringes also must have low dead space — the infinitesimal distance between the plunger and the needle after the dose is fully injected — to minimize waste.

The industry has ramped up to meet demand. Becton Dickinson, which is based in New Jersey and a major syringe manufacturer, said it will spend $1.2 billion over four years to expand capacity in part to deal with pandemics.

The United States is the world’s largest syringe supplier by sales, according to Fitch Solutions, a research firm. The United States and China are neck and neck in exports, with combined annual shipments worth $1.7 billion. While India is a small player globally, with only $32 million in exports in 2019, Nath of Hindustan Syringes sees a big opportunity.

Each of his syringes sells for only three cents, but his total investment is considerable. He invested nearly $15 million to mass-produce specialty syringes, equal to roughly one-sixth of his annual sales, before purchase orders were even in sight. In May, he ordered new molds from suppliers in Italy, Germany and Japan to make a variety of barrels and plungers for his syringes.

Nath added 500 workers to his production lines, which crank out more than 5,900 syringes per minute at factories spread over 11 acres in a dusty industrial district outside New Delhi. With Sundays and public holidays off, the company churns out nearly 2.5 billion a year, though it plans to scale up to 3 billion by July.

Hindustan Syringes has a long history of supplying UNICEF immunization programs in some of the poorest countries, where syringe reuse is common and one of the main sources of deadly infections, including HIV and hepatitis.

In late December, when the World Health Organization cleared Pfizer’s vaccine for emergency use, Robert Matthews, a UNICEF contract manager in Copenhagen, and his team needed to find a manufacturer that could produce millions of syringes.

“We went, ‘Oh, dear!’” said Matthews, as they looked for a syringe that would meet WHO specifications and was compact for shipping. Hindustan Syringes’ product, he said, was the first.

The company is set to begin shipping 3.2 million of those syringes soon, UNICEF said, provided they clear another quality check.

Nath has sold 15 million syringes to the Japanese government, he said, and over 400 million to India for its COVID-19 inoculation drive, one of the largest in the world. More are in line, including UNICEF, for which he has offered to produce about 240 million more, and Brazil, he said.

Syringes sealed in blister-packs are boxed up at Hindustan Syringes & Medical Devices at the company’s factory in Ballabgarh. (Rebecca Conway/The New York Times)

Inside the company’s Plant No. 6, machines coated in yellow paint hum as they squirt out plastic barrels and plungers. Other machines, from Bergamo, Italy, assemble each component, including needles, monitored by sensors and cameras. Workers in blue protective suits inspect trays full of syringes before unloading them into crates that they hand carry to a packaging area next door.

To increase efficiency, Nath relies on a syringe design by Marc Koska, a British inventor of safety injections, and its ability to produce all of the components in-house. Hindustan Syringes makes its needles from stainless steel strips imported from Japan. The strips are curled into cylinders and welded at the seam, then stretched and cut into fine capillary tubes, which machines glue to plastic hubs. To make the jabs less painful, they are dipped in a silicone solution.

The syringe business is a “bloodsucker,” Nath said, where upfront costs are astronomical and profits marginal. If demand for his syringes drops by even half in the next few years, he will lose almost all of the $15 million he invested.

It’s clearly a frugal operation. The blue carpet in Nath’s office looks just as old as his desk or the glass chandelier by the stairs, fixtures his father put in place in 1984, before he handed over the company to Nath and his family.

A family business is exactly how he likes it. No shareholders, no interference, no worries. In 1995, when Nath needed money to increase production and buy lots of new machines, he sought private capital for the first time. Had that been the case today, he said, he wouldn’t be able to follow his gut and produce his syringes at this enormous scale.

“You have a good night’s sleep,” Nath said. “It’s better to be a big fish in a small pond.”