Nitrogen Dioxide Sterilization in Low-Resource Environments: A Feasibility Study

PLoS One. 2015 Jun 22;10(6):e0130043. doi: 10.1371/journal.pone.0130043. eCollection 2015.


Access to sterilization is a critical need for global healthcare, as it is one of the prerequisites for safe surgical care. Lack of sterilization capability has driven up healthcare infection rates as well as limited access to healthcare, especially in low-resource environments. Sterilization technology has for the most part been static and none of the established sterilization methods has been so far successfully adapted for use in low-resource environments on a large scale. It is evident that healthcare facilities in low-resource settings require reliable, deployable, durable, affordable, easily operable sterilization equipment that can operate independently of scarce resources. Recently commercialized nitrogen dioxide (NO2) sterilization technology was analyzed and adapted into a form factor suitable for use in low-resource environments. Lab testing was conducted in microbiological testing facilities simulating low-resource environments and in accordance with the requirements of the international sterilization standard ANSI/AAMI/ISO 14937 to assess effectiveness of the device and process. The feasibility of a portable sterilizer based on nitrogen dioxide has been demonstrated, showing that sterilization of medical instruments can occur in a form factor suitable for use in low-resource environments. If developed and deployed, NO2 sterilization technology will have the twin benefits of reducing healthcare acquired infections and limiting a major constraint for access to surgical care on a global scale. Additional benefits are achieved in reducing costs and biohazard waste generated by current health care initiatives that rely primarily on disposable kits, increasing the effectiveness and outreach of these initiatives.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Bacteria / drug effects
  • Feasibility Studies
  • Fungi / drug effects
  • Health Facilities
  • Health Resources / economics*
  • Health Services Accessibility
  • Nitrogen Dioxide / pharmacology*
  • Sterilization* / economics
  • Sterilization* / instrumentation
  • Sterilization* / methods
  • Viruses / drug effects


  • Nitrogen Dioxide

Grants and funding

Eniware, LLC provided funding for the study. As employees of Eniware LLC, Majdi Shomali, Trisha Avasthi and Ariel Trilling participated in the study design, analysis of data, preparation of the manuscript, and decision to publish. As an employee of Noxilizer Inc., David Opie participated in study design, analysis of data, and preparation of the manuscript. Eniware LLC and Noxilizer Inc. provided support in the form of salaries for these authors.