EtO is estimated to be used to sterilize of half of all medical devices, or about 20 billion units per year. It’s primarily used for new, single-use and reusable devices and equipment. For example EtO is used to sterilize an estimated 95% of all surgical kits.
There are currently no EtO alternatives for some products. Of all sterilization methods, EtO is least likely to harm a medical device’s materials or components. Other sterilization methods have limitations on material compatibility and scalability or lack accepted validation measures for sterility assurance.
“The absence of EtO for use on medical devices and equipment would cause widespread disruption to the availability of sterile medical devices including feeding tubes used in neonatal intensive care units, drug-eluting cardiac stents, catheters, shunts, and other implantable devices,” the EPA said in its 2023 proposal for new EtO regulation.
But there are some EtO alternatives available for a wide range of medical devices, and more may be on the way as the FDA works with the medtech industry to ensure the safety of patients, sterilization workers and neighbors of sterilization facilities.
Radiation sterilization: gamma ray and electron beam (e-beam)
The next most common methods of medical device sterilization after EtO are two forms of radiation sterilization: gamma irradiation and electron beam (e-beam) Irradiation. Like EtO, these methods can penetrate product packaging, and can even go further into airtight compartments where EtO can’t reach.
But radiation sterilization methods can damage semiconductors and degrade other electronics in medical devices. Radiation sterilization can also damage or otherwise change the properties of certain polymers and plastics, and discolors clear glass.
What about heat sterilization?
Heat sterilization is the least expensive method of sterilization for medical devices, and that means any device that can be sterilized with heat instead of EtO probably already is. The high temperature of heat sterilization — whether dry heat or steam — makes it suitable only for heat-resistant materials, and the moisture from steam is a deal-breaker for electronics.
Potential ethylene oxide alternatives in development
The FDA is working with four companies to identify new sterilization methods and technologies through its FDA Innovation Challenge, which is also seeking ways to reduce emissions from continued EtO sterilization.
The four companies working directly with the FDA on new sterilization methods and technologies are focusing on five technologies:
- Supercritical carbon dioxide sterilization (NovaSterilis)
- Nitrogen dioxide sterilization (Noxilizer)
- Accelerator-based radiation sterilization (STERIS)
- Vaporized hydrogen peroxide sterilization (STERIS)
- Vaporized hydrogen peroxide-ozone sterilization (TSO3, a Stryker subsidiary)
The new sterilization methods that don’t use EtO would not only need to be safe and effective, but also meet certain criteria for compatibility, scalability and high throughput.
The new approaches would need to be compatible with a large cross-section of materials used for medical devices, packaging and sterile barriers, particularly materials that are compatible with EtO sterilization.
The FDA also wants the new approaches to have the potential for scale and effective sterilization of large volumes of devices in order to fulfill some or all of the demand for EtO sterilization.
Another potential alternative is chlorine dioxide gas, developed by Johnson & Johnson. The FDA approved the sterilant for contract sterilization of medical devices in 2021, and it’s been used for implantable contact lenses, artificial joints, suture products, surgical kits, vial stoppers, endoscopes and electronic devices.
But EtO has so far held one or more advantages over chlorine dioxide, hydrogen peroxide and other options, so the search continues.