Male Circumcision kits:

Preliminary options

Jessica Fast
Joanna Rosenblum
May 2009

1
The Clinton Foundation is exploring the feasibility of developing MC kits to
facilitate access to supplies

1. Develop • Are kits an appropriate option for supply procurement?

product • Can we reach a consensus on kit contents?
specifications

• Is demand sufficient enough to

2 F
2. Forecastt encourage supplier engagement?
demand

• Are
A suppliers
li iinterested
t t d iin entering
t i
3. Engage
suppliers the market for kits?

4. Negotiate
• Can we ensure access to high-quality,
prices low-cost kits for countries?

2
The Clinton Foundation is exploring the feasibility of developing MC kits to
facilitate access to supplies

1. Develop • Are kits an appropriate option for supply procurement?

product • Can we reach a consensus on kit contents?
specifications

• Is demand sufficient enough to

2 F
2. Forecastt encourage supplier engagement?
demand

• Are
A suppliers
li iinterested
t t d iin entering
t i
3. Engage
suppliers the market for kits?

4. Negotiate
• Can we ensure access to high-quality,
prices low-cost kits for countries?

3
We believe that kits are an appropriate option, but there are important
drawbacks to consider
Benefits
• Bundling eases ordering and
managing of supplies
• Packaging
P k i ensures
disposable and consumable
products are sterile
• Kits increase the efficiency
of service delivery
• Kits facilitate dissemination
of take-home educational
material
t i l
Drawbacks
• Kits may be more expensive
than buying supplies in bulk
• Kits
Kit lilimitit th
the flflexibility
ibilit off
clinicians to use their
preferred equipment
• Components may be pilfered
from kits, compromising
sterility of remaining contents
4
To develop kit options, we identified key factors that impact contents and
outlined kits to address each combination of those factors

3 key factors
• MC method
• Reusable vs. disposable instruments
• Use of electrocautery

6 kit options
p

Forceps-guided Dorsal slit or Sleeve

Disposable Kit 1A Kit 2A

instruments Kit 1B Kit 2B

Reusable Kit 3A
instruments Kit 3B

A = With electrocautery
B = No electrocautery
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We used the Orange Farm kit as our base kit (1A):
forceps-guided, disposable instruments, with electrocautery
Instruments
1 haemostatic clamp
1 needle holder
1 artery forceps
1 disposable scalpel
1 plastic forceps

Consumable supplies
10 sheets sterile gauze 10cm x 10cm
1 cohesive bandage 75mm x 75mm
3 sterile gloves
1 vaseline impregnated gauze 10cm x 10cm
1 suture material 75cm of 3.0 size absorbable
material (chromic/vicryl)
1 syringe 10mL
2 needle 22 gauge
g g
1 small roll adhesive tape, width app 1cm
1 alcohol swab
2 PVC apron

Pharmaceutical supplies
10 paracetamol tablets
10mL lignocaine
100mL betadine solution or alternative antiseptic
scrubbing solution

Operating room supplies

1 plastic tray to house instruments
1 absorbent sterile drape w/penis fenestration
app 750mm x 500cm
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We then determined how contents would change for each key factor

Instruments
If dorsal slit or sleeve 1 haemostatic clamp
1 needle holder
Remove: haemostatic clamp 1 artery forceps
1 disposable scalpel
Add: 1 surgical scissors, 1 1 plastic forceps 1 surgical scissors
marking pen
Consumable supplies
10 sheets sterile gauze 10cm x 10cm
1 cohesive bandage 75mm x 75mm
3 sterile gloves
1 vaseline impregnated gauze 10cm x 10cm
1 suture material 75cm of 3.0 size absorbable
material (chromic/vicryl)
1 syringe 10mL
2 needle 22 gauge
g g
1 small roll adhesive tape, width app 1cm
1 alcohol swab
2 PVC apron 1 marking pen

Pharmaceutical supplies
10 paracetamol tablets
10mL lignocaine
100mL betadine solution or alternative antiseptic
scrubbing solution

Operating room supplies

1 plastic tray to house instruments
1 absorbent sterile drape w/penis fenestration
app 750mm x 500cm
7
We then determined how contents would change for each key factor
If dorsal slit or sleeve
Remove: haemostatic clamp
Add: 1 surgical scissors, 1
marking pen
If reusable instruments
Remove: haemostatic clamp,
needle holder, artery forceps,
plastic forceps
If electrocautery not used
Add: 3 artery forceps, 5
sheets sterile gauze, 1
suture material
Instruments
1 haemostatic clamp
1 needle holder
4 1 artery forceps
1 disposable scalpel
1 plastic forceps 1 surgical scissors
Consumable supplies
15 10 sheets sterile gauze 10cm x 10cm
1 cohesive bandage 75mm x 75mm
3 sterile gloves
1 vaseline impregnated gauze 10cm x 10cm
2 1 suture material 75cm of 3.0 size absorbable
material (chromic/vicryl)
1 syringe 10mL
2 needle 22 g gauge
g
1 small roll adhesive tape, width app 1cm
1 alcohol swab
2 PVC apron 1 marking pen
Pharmaceutical supplies
10 paracetamol tablets
10mL lignocaine
100mL betadine solution or alternative antiseptic
scrubbing solution
Operating room supplies
1 plastic tray to house instruments
1 absorbent sterile drape w/penis fenestration
app 750mm x 500cm
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This resulted in draft contents for six preliminary kits (1A, 1B, 2A)

Kit 1A: Forceps-guided, disposable, Kit 1B: Forceps-guided, disposable, Kit 2A: Dorsal slit or Sleeve,
with electrocautery no electrocautery disposable, with electrocautery
1 haemostatic clamp 1 haemostatic clamp 1 surgical scissors
ments

1 needle holder 1 needle holder 1 needle holder

y forceps
1 artery p 4 artery
y forceps
p 1 artery
y forceps
p
Instrum

1 disposable scalpel 1 disposable scalpel 1 disposable scalpel

1 plastic forceps 1 plastic forceps 1 plastic forceps

10 sheets sterile gauze 10cm x 10cm 15 sheets sterile gauze 10cm x 10cm 10 sheets sterile gauze 10cm x 10cm
1 cohesive bandage 75mm x 75mm 1 cohesive bandage 75mm x 75mm 1 cohesive bandage 75mm x 75mm
3 sterile
il gloves
l 3 sterile
il gloves
l 3 sterile
il gloves
l
1 vaseline impregnated gauze 10cm x 1 vaseline impregnated gauze 10cm x 1 vaseline impregnated gauze 10cm x
Consumable

10cm 10cm 10cm

supplies

1 suture material 75cm of 3.0 size 2 suture material 75cm of 3.0 size 1 suture material 75cm of 3.0 size
absorbable material (chromic/vicryl) absorbable material (chromic/vicryl) absorbable material (chromic/vicryl)
1 syringe 10mL 1 syringe 10mL 1 syringe 10mL
s

2 needle 22 gauge 2 needle 22 gauge 2 needle 22 gauge

1 small roll adhesive tape, width 1 small roll adhesive tape, width 1 small roll adhesive tape, width
app 1cm app 1cm app 1cm
1 alcohol swab 1 alcohol swab 1 alcohol swab
2 PVC apron 2 PVC apron 2 PVC apron
1 marking gp pen
al
Pharmaceutica
supplies

10 paracetamol tablets 10 paracetamol tablets 10 paracetamol tablets

10mL lignocaine 10mL lignocaine 10mL lignocaine
100mL betadine solution or alternative 100mL betadine solution or alternative 100mL betadine solution or alternative
antiseptic scrubbing solution antiseptic scrubbing solution antiseptic scrubbing solution

1 plastic tray to house instruments 1 plastic tray to house instruments 1 plastic tray to house instruments
Operating

supplies

1 absorbent sterile drape w/penis 1 absorbent sterile drape w/penis 1 absorbent sterile drape w/penis
room

fenestration app 750mm x 500cm fenestration app 750mm x 500cm fenestration app 750mm x 500cm

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This resulted in draft contents for six preliminary kits (2B, 3A, 3B)

Kit 2B: Dorsal slit or Sleeve, Kit 3A: Any method, reusable, with Kit 3B: Any method, reusable, no
disposable, no electrocautery electrocautery electrocautery
1 surgical scissors 1 disposable scalpel 1 disposable scalpel
ments

1 needle holder
y forceps
4 artery p
Instrum

1 disposable scalpel
1 plastic forceps

15 sheets sterile gauze 10cm x 10cm 10 sheets sterile gauze 10cm x 10cm 15 sheets sterile gauze 10cm x 10cm
1 cohesive bandage 75mm x 75mm 1 cohesive bandage 75mm x 75mm 1 cohesive bandage 75mm x 75mm
3 sterile
il gloves
l 3 sterile
il gloves
l 3 sterile
il gloves
l
1 vaseline impregnated gauze 10cm x 1 vaseline impregnated gauze 10cm x 1 vaseline impregnated gauze 10cm x
Consumable

10cm 10cm 10cm

supplies

2 suture material 75cm of 3.0 size 1 suture material 75cm of 3.0 size 2 suture material 75cm of 3.0 size
absorbable material (chromic/vicryl) absorbable material (chromic/vicryl) absorbable material (chromic/vicryl)
1 syringe 10mL 1 syringe 10mL 1 syringe 10mL
s

2 needle 22 gauge 2 needle 22 gauge 2 needle 22 gauge

1 small roll adhesive tape, width 1 small roll adhesive tape, width 1 small roll adhesive tape, width
app 1cm app 1cm app 1cm
1 alcohol swab 1 alcohol swab 1 alcohol swab
2 PVC apron 2 PVC apron 2 PVC apron
1 marking gp pen
al
Pharmaceutica
supplies

10 paracetamol tablets 10 paracetamol tablets 10 paracetamol tablets

10mL lignocaine 10mL lignocaine 10mL lignocaine
100mL betadine solution or alternative 100mL betadine solution or alternative 100mL betadine solution or alternative
antiseptic scrubbing solution antiseptic scrubbing solution antiseptic scrubbing solution

1 plastic tray to house instruments 1 plastic tray to house instruments 1 plastic tray to house instruments
Operating

supplies

1 absorbent sterile drape w/penis 1 absorbent sterile drape w/penis 1 absorbent sterile drape w/penis
room

fenestration app 750mm x 500cm fenestration app 750mm x 500cm fenestration app 750mm x 500cm

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We collected feedback from 12 people, including program details to
determine which kit would be appropriate for their situation

Forceps-guided Dorsal slit or Sleeve

Kit 1A: South Africa1, Kit 2A: ---

Disposable
Zimbabwe2
instruments
Kit 1B: --- Kit 2B: Uganda3

Reusable Kit 3A: Botswana4, Swaziland2,5

instruments Kit 3B: Botswana4, Kenya6, Zambia7

A = With electrocautery
B = No electrocautery
1 Orange Farm; 2 PSI; 3 Rakai; 4 MOH; 5 FLAS; 6 MCC; 7 PSI/Jhpiego 11
 We also collected their feedback on contents of the six kits

Instruments
Need 3 more for dorsal slit / sleeve; 1 haemostatic clamp Add stitch cutter
Need 1 more for forceps-guided 1 needle holder
1 artery forceps
1 disposable scalpel
Better to have fine-toothed
1 plastic forceps
dissecting forceps; Better to have 10cm x 2cm strips;
Plastic not yet of sufficient
Consumable supplies Need 10 more if not using
quality to replace metal
10 sheets sterile gauze 10cm x 10cm electrocautery;
1 cohesive bandage 75mm x 75mm Don’t need more if not using
Only need 2 3 sterile gloves electrocautery
l t t
1 vaseline impregnated gauze 10cm x 10cm
1 suture material 75cm of 3.0 size absorbable
material (chromic/vicryl)
1 syringe 10mL Need 23 gauge
Too much
2 needle 22 g gauge
g needle for injection;
1 small roll adhesive tape, width app 1cm Need 18 gauge
Not needed 1 alcohol swab
Marking pen not
Prefer reusable 2 PVC apron
necessary (dorsal slit /
sleeve)
Pharmaceutical supplies
10 paracetamol tablets
Need more lignocaine; 10mL lignocaine Don’t’ include in kit
Prefer lignocaine / marcaine mix 100mL betadine solution or alternative antiseptic
scrubbing solution

Operating room supplies Add multi-use tray cover/

1 plastic tray to house instruments disposal bag with string
1 absorbent sterile drape w/penis fenestration
app 750mm x 500cm Add O-drape
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We are now ready to proceed with the next phase

• Collect additional feedback on contents of six

preliminary kits

• C
Consider suggested changes to the kits, and
make needed revisions

• Begin
B i d developing
l i d demand
d fforecastt ffor MC kit
kits

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Thank you

Bill & Melinda Gates Foundation

Strategy
gy development
p
Dino Rech
Steve Gesuale
Dai Ellis

Feedback on kits
Bob Bailey
Evans Chinkoyo
Ladislous Chonzi
Kristin Chrouser
Jessica Greene
Adam Groenveld
Karin Hatzold
Janet Tulibonywa Mwambona
Michael Stalker
Stephen Watya

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