Evidence and information for national injection safety policies

The adverse consequences of poor injection practices have been reported for a few decades. However, key elements of evidence and information were lacking to allow decision-makers to formulate policies for the safe and appropriate use of injections. We conducted studies to (1) estimate the frequency of injection use and of poor injection practices, (2) estimate the consequences of poor injection practices in terms of death and disability, (3) formulate best infection control practices for intradermal, subcutaneous and intramuscular injections, (4) quantify the effectiveness of interventions to reduce unnecessary and unsafe use of injections and (5) estimate the cost-effectiveness of national policies for the safe and appropriate use of injections. WHO's Global Burden of Disease project defined 14 regions based on geography and mortality patterns. The analysis excluded four regions (predominantly affluent, developed nations) where reuse of injection equipment in the absence of sterilization was assumed to be negligible. To estimate the frequency of poor injection practices in the year 2000, data sources included published studies and unpublished WHO reports. Studies were reviewed using a standardized decision-making algorithm based upon the quality of the data to generate region-specific estimates of the annual number of injections per person and of the proportion of injections reused in the absence of sterilization. To estimate the consequences of unsafe injections in the year 2000 in terms of death and disability for 2000-2030 as part of the 2000 update of WHO’s Global Burden of Disease study, we modelled the fraction of new injection-associated HBV, HCV and HIV infections on the basis of the annual number of injections, the proportion of injections administered with reused equipment, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity and the total incidence. Infections in 2000 were converted into disability-adjusted life years (DALYs) in 2000-2030 using natural history parameters, background mortality, duration of disease, disability weights, age weights and a 3% discount rate. A guideline development group summarized evidence-based best practices to prevent injectionassociated infections in resource-limited settings. The development process included (1) a breakdown of the WHO reference injection safety definition into a list of potentially critical steps, (2) a review of the literature for each of these potentially critical steps, (3) the formulation of best practices and (4) the submission of the draft document to peer review. To estimate the effectiveness of interventions to reduce the unnecessary and unsafe use of injections, we searched electronic databases. In addition, we reviewed WHO reports and unpublished assessments made available to WHO. We selected studies that contained quantitative and qualitative information on the effect of interventions and that provided information on study design, type of interventions, targeted participants and targeted behaviours. To estimate the cost-effectiveness of national policies for the safe and appropriate use of injections, the consequences in 2000-2030 of a "do nothing" scenario for the year 2000 (as modelled for the Global Burden of Disease study) were compared to a set of counterfactual scenarios incorporating the health gains of effective interventions. Resources needed to implement effective interventions were costed for each sub-region and expressed in international dollars (I$). Four regions in the Global Burden of Disease study where reuse of injection equipment in the absence of sterilization was negligible were excluded from the analysis. In the 10 other regions, the annual ratio of injections per person was 3.4 (Range: 1.7 - 11.3) for a total of 16.7 thousand million injections received. Of these, 39.3 equipment reused in the absence of sterilization. Reuse was highest in the South East Asia region “D” (seven countries, mostly located in South Asia), the Eastern Mediterranean region “D” (nine countries, mostly located in the Middle East crescent) and the Western Pacific region “B” (22 countries) which together accounted for 88.4 year 2000 with equipment reused in the absence of sterilization. In 2000, contaminated injections caused an estimated 21 million HBV infections, two million HCV infections and 260 000 HIV infections, accounting for 32 9 177 679 DALYs between 2000 and 2030. Eliminating unnecessary injections is the highest priority to prevent injection-associated infections. However, when intradermal, subcutaneous or intramuscular injections are medically indicated, best infection control practices include (1) the use of sterile injection equipment, (2) the prevention of contamination of injection equipment and medication, (3) the prevention of needle-stick injuries to the provider and (4) the prevention of access to used needles. We identified twenty-one articles, abstracts, unpublished reports and assessments containing information on the effectiveness of interventions aiming at reducing injection use (n=19) and at decreasing the unsafe use of injections (n=5). Studies showed a reduction in injection use ranging from 1 of injection equipment in the absence of sterilization reported an absolute decrease of 30 in the intervention groups (relative decrease: 40-100 2000 for the safe (provision of single use syringes, assumed effectiveness: 95 use (patients-providers interactional group discussions, assumed effectiveness: 30 could reduce the burden of injection-associated infections by as much as 96.5 DALYs) for an average yearly cost of I$ million 905 (average cost-effectiveness per DALY averted: I$102, range by region: 14-2 293). In 2000, in developing and transitional countries, 16 thousand million injections were administered for a ratio of 3.4 injections per person. More than a third of all these injections were administered with injection equipment reused in the absence of sterilization, accounting for a substantial burden of infection with bloodborne pathogens. Best infection control practices could make injections safer for the recipient, the health care workers and the community, all the more as effective interventions are available to reduce injection use and to achieve a safe use of injections. These interventions can also be considered very cost-effective on the basis of a cost per DALY averted that is below one year of average per capita income. Remaining areas of uncertainty include (1) the formulation of routine methods to describe injection use and to quantify needs of injection equipment, (2) the description of unsafe practices in greater detail to prevent all opportunities of transmission, (3) the need to generate better estimates of the proportion of HIV infections that may be attributed to unsafe health care injections, (4) the identification of the role of engineered technologies in policies to achieve injection safety, (5) the recovery of experience in the scaling-up of successful interventions and (6) the assessment of the cost-effectiveness of scaled-up national interventions

A Fatal Waterborne Outbreak of Pesticide Poisoning Caused by Damaged Pipelines, Sindhikela, Bolangir, Orissa, India, 2008

Introduction. We investigated a cluster of pesticide poisoning in Orissa. Methods. We searched the village for cases of vomiting and sweating on 2 February 2008. We described the outbreak by time, place, and person. We compared cases with controls. Results. We identified 65 cases (two deaths; attack rate: 12 per 1000; case fatality: 3%). The epidemic curve suggested a point source outbreak, and cases clustered close to a roadside eatery. Consumption of water from a specific source (odds ratio [OR]: 35, confidence interval [CI]: 13–93) and eating in the eatery (OR: 2.3, CI: 1.1–4.7) was associated with illness. On 31 January 2008, villagers had used pesticides to kill street dogs and had discarded leftovers in the drains. Damaged pipelines located beneath and supplying water may have aspirated the pesticide during the nocturnal negative pressure phase and rinsed it off the next morning in the water supply. Conclusions. Innapropriate use of pesticides contaminated the water supply and caused this outbreak. Education programs and regulations need to be combined to ensure a safer use of pesticides in India

Injection use in two districts of Pakistan: implications for disease prevention

Objective. To estimate the annual number of injections per person in Sindh province of Pakistan and to describe their distribution with regard to prescribers, settings, and safety. Design. A population-based cross-sectional study in July-September 2001. Setting. Lyari, an urban town in Karachi district; and Digri, a rural subdistrict in Mirpur Khas district. Study participants. We selected a population-based cluster sample of 1150 individuals aged ≥3 months. We interviewed one person per household for the number of encounters they had with health care providers, number and types of injections received, safety circumstances, and cost of injections during the past 3 months. Main outcome measure. The number of injections per person per year. Results. After adjusting for age and sex, 68% of participants had received at least one injection in the previous 3 months (13.6 injections/person/year). The majority of the respondents received injections at the clinics of qualified general practitioners (n = 571, 67%) by dispensers (644, 76%). Most of the injections (n = 3446, 96%) were for curative purposes. A freshly opened syringe was used for only 454 (53%) of the injections. The average fee for receiving an injection was Rs. 51 (US$0.8). Conclusion. Injections are overused in Pakistan's Sindh province and the ratios of injection per capita that we found are among the highest ever reported. Interventions are needed to substantially reduce injection prescription among private health care providers who prescribe most of the injections received by the populatio

Risk factors for malaria deaths in Jalpaiguri district, West Bengal, India: evidence for further action

BACKGROUND: In 2006, a cluster of malaria deaths in the highly endemic Jalpaiguri district, West Bengal, India, led to assignment of additional resources. Malaria deaths decreased, but continued to occur. A study was conducted to identify the risk factors for residual malaria deaths. METHODS: Malaria death was defined as a death from fever with microscopically confirmed Plasmodium falciparum among residents of Jalpaiguri during 2007–2008. For each case, three age-, sex- and locality-matched controls were recruited among microscopically confirmed falciparum malaria patients cured during the same period. Clinical and treatment information was abstracted from records. Information about knowledge about malaria, presence of bed nets and DDT spraying was collected through interviews of the close relatives of study subjects. Odds ratio (OR) were calculated using multivariate methods. RESULTS: 51 malaria deaths were matched with 153 controls, which did not differ by age (median: 35 versus 36 years) and proportion of males (63% versus 63%). On multiple logistic regression analysis, compared with survivors, malaria deaths were more likely to have been admitted with already existing complications [OR = 4.1, 95% confidence interval (CI) = 1.6–10)], treated at a private facility (OR = 3.7, 95% CI = 1.2–12), received treatment after 48 hours of fever onset (OR = 14, 95% CI = 2.9–64), received chloroquine (OR = 13.3, 95% CI = 3.7–47). Households of the deceased were also more likely to miss bed nets (OR = 6.3, 95% CI = 1.9–24) and DDT spraying (OR = 9.2, 95% CI = 2.8–31). CONCLUSION: Elimination of malaria deaths will require education of providers for prompt referral before complications, engagement of the private sector, community awareness for early treatment as well as scaled-up use of bed nets use and DDT. Use of newer generation anti-malarials must to be generalized

Long-term improvement in unsafe injection practices following community intervention

Background: A study in 1994 identified frequent unsafe injections as the cause of widespread hepatitis C virus infection in Hafizabad, Pakistan. A simple low cost community education program was assessed to see if it improved injection safety.Methods: A local health organization developed educational materials on hepatitis C including advice on how to avoid unnecessary injections and, when injections were necessary, to use a new syringe and needle. Beginning in 1995, this advice was communicated through multiple channels including health education meetings, announcements in mosques, and via pamphlets. In 1998 study workers revisited controls from the 1994 case-control study (along with three of their neighbors of a similar age) to collect information on injection practices in the previous 12 months.Results: Thirty-three percent of the study\u27s participants in 1998 received \u3eor=5 injections in the preceding 12 months compared to 40% of the hepatitis C virus negative controls reported in the year prior to the 1994 study (p=0.85). In 1998 52 persons (34%) brought their own syringe for their most recent injection, a practice that was unreported in 1994. Overall, in 1998 59% of patients received their most recent injection with a new syringe and needle compared to 24% in 1994 (p=0.003).CONCLUSIONS: Following this low cost health communication effort, community members took steps to protect themselves from unsafe injections

Safer injections following a new national medicine policy in the public sector, Burkina Faso 1995 – 2000

BACKGROUND: The common failure of health systems to ensure adequate and sufficient supplies of injection devices may have a negative impact on injection safety. We conducted an assessment in April 2001 to determine to which extent an increase in safe injection practices between 1995 and 2000 was related to the increased access to injection devices because of a new essential medicine policy in Burkina Faso. METHODS: We reviewed outcomes of the new medicine policy implemented in1995. In April 2001, a retrospective programme review assessed the situation between 1995 and 2000. We visited 52 health care facilities where injections had been observed during a 2000 injection safety assessment and their adjacent operational public pharmaceutical depots. Data collection included structured observations of available injection devices and an estimation of the proportion of prescriptions including at least one injection. We interviewed wholesaler managers at national and regional levels on supply of injection devices to public health facilities. RESULTS: Fifty of 52 (96%) health care facilities were equipped with a pharmaceutical depot selling syringes and needles, 37 (74%) of which had been established between 1995 and 2000. Of 50 pharmaceutical depots, 96% had single-use 5 ml syringes available. At all facilities, patients were buying syringes and needles out of the depot for their injections prescribed at the dispensary. While injection devices were available in greater quantities, the proportion of prescriptions including at least one injection remained stable between 1995 (26.5 %) and 2000 (23.8 %). CONCLUSION: The implementation of pharmaceutical depots next to public health care facilities increased geographical access to essential medicines and basic supplies, among which syringes and needles, contributing substantially to safer injection practices in the absence of increased use of therapeutic injections

Recycling of Injection Equipment in Pakistan

The prevalence of hepatitis C virus (HCV) infection is high in the general population in Pakistan, ranging from 2% to 6%. Reuse of injection equipment in the absence of sterilization is common, particularly in healthcare facilities that serve low-income populations. Studies have identified unsafe injection practices as a major route of transmission of HCV in Pakistan. Changing the behavior of injection providers so that they would use new freshly opened disposable syringes would improve injection safety in Pakistan. However, frequent reports of recycling of injection equipment in the local media question the safety of apparently new syringes. Clinical laboratories are one of the major sources of production of used syringes. To evaluate the resale of used syringes, we followed the course of used syringes from their initial use to their final destinatio

A malaria outbreak in Naxalbari, Darjeeling district, West Bengal, India, 2005: weaknesses in disease control, important risk factors

An outbreak of malaria in Naxalbari, West Bengal, India, in 2005 was investigated to understand determinants and propose control measures. Malaria cases were slide-confirmed. Methods included calculation of annual blood examination rates (ABER, number of slides examined/population), collection of water specimens from potential vector-breeding sites, sorting of villages in categories depending on the number of abandoned wells within two kilometers radius and review of the DDT spray coverage. Cases were compared with matched neighbourhood controls in terms of personal protection using matched odds ratios (MOR). 7,303 cases and 17 deaths were reported between April 2005 and March 2006 with a peak during October rains (Attack rate: 50 per 1,000, case fatality: 0.2%). The attack rate increased according to the number of abandoned wells within 2 kilometres radius (P < 0.0001, Chi-square for trend). Abandoned wells were Anopheles breeding sites. Compared with controls, cases were more likely to sleep outdoors (MOR: 3.8) and less likely to use of mosquito nets and repellents (MOR: 0.3 and 0.1, respectively). DDT spray coverage and ABER were 39% and 3.5%, below the recommended 85% and 10%, respectively. Overall, this outbreak resulted from weaknesses in malaria control measures and a combination of factors, including vector breeding, low implementation of personal protection and weak case detection

An Outbreak of Cholera Associated with an Unprotected Well in Parbatia, Orissa, Eastern India

In November 2003, an outbreak (41 cases; attack rate–4.3%; no deaths) of severe diarrhoea was reported from a village in Orissa, eastern India. Thirteen of these cases were hospitalized. A matched case-control study was conducted to identify the possible exposure variables. Since all wells were heavily chlorinated immediately after the outbreak, water samples were not tested. The cases were managed symptomatically. Descriptive epidemiology suggested clustering of cases around one public well. Vibrio cholerae El Tor O1, serotype Ogawa was isolated from four of six rectal swabs. The water from the public well was associated with the outbreak (matched odds ratio: 12; 95% confidence interval 1.2–44.1). On the basis of these conclusions, access to the well was barred immediately, and it was protected. This investigation highlighted the broader use of field epidemiology methods to implement public-health actions guided by epidemiologic data to control a cholera epidemic