53655 Injection Safety at a glance Why tackle injection safety? What human and environmental health hazards are associated with unsafe injections? Injections are one of the most common health care procedures, with some 16 billion injections adminis- Syringes, needles and other sharps are often tered world-wide each year. Most injections (90 to reused without being sterilized. 95%) are given for therapeutic purposes, and only Dirty sharps (e.g. needles, syringes) are often 5 to 10% are given for immunization. handled in a way that exposes health care workers to needlestick injuries. Injections are often unnecessary and are frequently unsafe. Unsafe injections are responsible for millions Unsafe management and improper disposal of of cases of Hepatitis B and C, and an estimated one sharps waste can cause contamination. Sharps quarter of a million cases of HIV annually. Re-use of waste, e.g., is thrown in the environment where injection equipment without sterilization is frequently waste pickers and other people can be pricked a key problem. and infected. Unsafe injections are responsible for millions of cases of Hepatitis B and C, and an estimated one- What can be done to promote safe quarter of a million cases of HIV annually. and appropriate use of injections? Diseases that unsafe injections can cause: National governments, WHO, and others working with the Safe Injection Global Network (SIGN) continue to Hepatitis B virus--Hepatitis B (HBV) is well-known as collect compelling evidence of infections associated a highly infectious disease. Unsafe injections account with medical injections, and actively work to promote for about one-third of new HBV infections in develop- safe injection practices and policies. Introducing an ing countries, equal to an estimated total of nearly injection safety component at the design phase of rele- 21 million people infected each year. vant projects is a useful way to initiate a national safe Hepatitis C virus--Unsafe injections are the most injection plan in a systematic way. common cause of Hepatitis C (HCV) infection in the developing world, causing two million new infections The recommended core interventions and activities each year, over 40% of HCV cases. In some coun- are listed on pages 2 and 3. A key "Best Practice" is tries (e.g., Egypt and Pakistan), evidence suggests to deliver all supplies of injectables (e.g., vaccines, that HCV has reached high levels due to unsafe contraceptives, anti-TB drugs), with matching quanti- injection practices. ties of new disposable syringes--preferably auto- disable (AD) syringes, diluents and safety boxes. This HIV/AIDS--The World Health Organization (WHO) "bundling" of goods facilitates safe practice. estimates that unsafe injections cause an estimated 250,000 new HIV infections each year, about 5% The first step should be an assessment of the extent of of all new HIV infections. Research indicates that safe and unsafe injection practices and key problem most of the HIV infections that are caused by unsafe areas. WHO and the USAID-funded project BASICS, injections occur in South Asia and Africa. in cooperation with SIGN, have developed a rapid assessment and response guide. This tool allows Unnecessary injections are part of the problem practitioners to quickly assess the frequency and In certain regions of the world, use of injections has safety of injections through a sample survey of completely overtaken the real need, reaching propor- people who prescribe and administer injections and tions that go well beyond rational medical practice. of patients. The rapid assessment generates key injec- In some developing countries, over 90% of patients tion practice indicators, including: the annual number visiting a primary health care provider receive at of injections per person, and the proportion of injec- least one injection. In Indonesia and Tanzania, e.g., tions administered with injection equipment reused in studies show that well over 70% of the injections the absence of sterilization. A rapid assessment typi- given are considered unnecessary or could be given cally takes about three weeks of field work and costs instead through an oral formulation (e.g., a pill). about US$10,000­15,000. September 2003 Choosing Interventions: Research has shown that in most developing countries, sterilization of syringes is not systematic and is frequently unsafe. Auto-disable syringes should be used for immunization, and new disposable syringes should be used for therapeutic purposes. The table below offers the key interventions designed to change injection practices. Costs: A typical 5 litre safety box costs approximately 1 US$ and holds up to 100 syringes. The estimated international retail price for immunization auto-disable (AD) syringes is approximately 5 to 7 US cents. The international retail price for a disposable syringe ranges from 4 (2ml) to 8 (5ml) US cents. Objectives and Core Main Activities Beneficiaries/ Indicators Interventions Target Groups Assess the extent and type of unsafe injection practices as a basis for planning and budgeting Assess frequency and · Use rapid assessment surveys of health care people who give safety of injections and key providers and patients. injections areas of concern. · In health projects and HIV/AIDS interventions (such as Multi-country AIDS Projects), find out if patients number of injections per person per Integrate injection safety there is a comprehensive plan for safe injections, year (IS) into other health inter- or do a rapid assessment to determine what is ventions when designing needed. % of injection equipment reused in the relevant projects. · Determine what actions need to be taken, base- absence of sterilization line data, goals, funding needs. · Ensure that safe injection plans are adequately funded. Make sterile syringes and sharps collection boxes available in every health care facility Ensure access to safe injec- "Bundle" injectable medications with related essen- public and private health % of health care facilities with tion equipment and safety tial equipment and supplies. Make all injectable sub- care facilities (i.e.; adequate quantities of injection boxes. stances available with matching quantities of providers and patients); equipment, diluents and sharps boxes injection equipment and safety boxes. and procurement in stock · Bundle syringes, needles, diluents and safety officers boxes in essential drug programs. · Work with the national regulatory authority to healthcare providers, % of orders of injectable substances with ensure the quality of injection equipment by legal advocates, legal matching numbers of syringes (ADs for promoting standards and specifications, advisors, and the immunization, and disposable for and strong enforcement of regulations for national regulatory therapeutic injections), and with an safe injection equipment. adequate supply of safety boxes authorities Communicate about safe injection practices, and the risks of infection associated with poor injection practices Promote the use of dispos- Develop Communications for Behavioral Change injection providers % of health care facilities where able syringes (preferably (CBC) strategies to promote new, disposable, single- (e.g., nurses and doc- therapeutic injections are given with auto-disable for immuniza- use injection equipment and proper sterilization of tors), patients and the new, disposable, single use injection tion), promote the proper equipment equipment community at large use of injection equipment, · Build demand for AD syringes for immunization and promote safety issues · Support CBC to educate healthcare workers and % of health care facilities where used among health providers others about injection overuse and to promote the contaminated injection equipment can and patients elimination of unnecessary injections be observed in places where they · Offer pre-service and in-service training and con- expose health care workers and others to needlestick injuries duct spot checks Prevent injection overuse within the national drug policy Reduce injection Where appropriate, use CBC activities to promote % of patients expressing a preference patients overuse oral medication through: for injections in the case of fever · posters and leaflets · mass media Educate on the need to reduce prescriptions of health care workers who % of outpatient visits including at least injectable medications by using: prescribe injections one injection · posters and leaflets (e.g., physicians, nurses, · mass media medical assistants) · standard treatment guidelines · policy statements from national medical associa- tions and government · patient-provider interactive group discussions Reduce the number of Work with regulatory authorities to review, update pharmacies and depots; number of injectable medications on injectable medications used and improve the list of essential drugs to remove medical and pharmaceuti- the essential drugs list unnecessary injectable medications cal regulatory boards, authorities and distributors Do's and Don'ts Resources DO conduct an initial assessment. Injection practice The Safe Injection Global Network (SIGN) issues vary in each country. Simple rapid Secretariat, WHO Headquarters, Geneva, assessment tools are available to take stock of the Switzerland. Email: sign@who.int situation in countries. "First, do no harm" Introducing auto-disable syringes and ensuring injection safety in immunization systems of developing countries. DO promote auto-disable (AD) syringes for WHO/V&B/0.2.26 immunization, and educate the general public Aide-memoire for a national strategy for the safe about the importance of sterile injections and and appropriate use of injections, WHO, 2000: equipment. http://whqlibdoc.who.int/aide-memoire/ a71914.pdf DON'T implement safe and appropriate use of Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. injection policies as a separate program, but Unsafe injections in the developing world and incorporate these into existing programs in the transmission of blood-borne pathogens: a review. health system. Bulletin of the World Health Organization 1999; 77(10):789-800. DO engage all relevant programs and partners. Dicko M, Oni AQ, Ganivet S, Kone S, Pierre L, Involve nursing and professional associations, and Jacquet B. Safety of immunization injections in national medical associations, as well as those Africa: not simply a problem of logistics. Bulletin of the World Health Organization 2000; 78:163-9. involved in HIV/AIDS prevention and care, Kane A, Lloyd J, Zaffran M, Simonsen L, Kane M. essential drugs, immunization, family planning, TB Transmission of hepatitis B, hepatitis C and human and other programs in the health system. immuno-deficiency viruses through unsafe injections in the developing world: Model-based regional DO practice bundling of equipment. Safe injection estimates. Bulletin World Health Organization technologies can facilitate safer practices, particu- 1999, 77:801-807. larly when paired with other medical supplies. Best practices for intradermal, subcutaneous and intramuscular injections. WHO/BCT/DCT01.03 DO work with the national regulatory authority to WHO-UNICEF-UNFPA Joint Statement on Use of make regulations for injection equipment consistent Auto-Disable Syringes in Immunization Services with quality standards and specifications. Follow (1999) World Health Organization. (WHO/V&B/ WHO recommendations for sterilizing equipment. 99.25) http://www.who.int/vaccines-documents/ DocsPDF99/www9948.pdf DO create a system of accountability for the use of secure, safe and effective technologies to address Key web sites sharps waste. Work to prevent the unauthorized Safe Injection Global Network (SIGN) reuse or repackaging of syringes, and foster www.injectionsafety.org adequate waste care management using effective International Association for Safe Injection technologies. Technologies www.iasit.org WHO's Healthcare Waste web site DO ensure adequate financing of safe injection http://www.healthcarewaste.org plans, including of the Communications for Children's Vaccine Program at PATH: Behavioural Change (CBC) components. Likewise, www.childrensvaccine.org/html/safe_injection.htm ensure that waste management plans are adequately budgeted, monitored and staffed. Key Contacts at the World Bank Contact the Public Health Thematic Group: E-mail DON'T assume that injection safety is difficult to healthpop@worldbank.org achieve. The simple, inexpensive introduction of safe Contact: Jmercier@worldbank.org for World Bank injection practices is highly effective and can show Environmental and Health care Waste results quickly. Management Guidelines Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp