Safe Injection - Vital to Health
"sharps" practices require a well functioning system
of management, supervision, training, logistics,
infrastructure, and support. Any breakdown in the system will
result in increased risk of disease transmission from
contaminated sharps. In general, the more procedures involving
injections or other skin penetration, the higher the risk. The
causes of unsafe sharps practices all have to do with failures
in one or more parts of the system.
of Awareness in the general population
awareness of the risks of injections varies widely. Demand for
injections is very high due to the perceived curative benefit.
In some countries where patients are aware of the need for
new, sterile syringes, they often bring their own purchased
syringes with which to vaccinate their children [WHO/DAP, Uganda
1994]. In areas where patient awareness is low,
patients accept shots from used syringes they see rinsed in
dirty water. Experience has shown that patient awareness can
stimulate health worker awareness.
syringes are sold directly to consumers or used in the
informal health system. Only when consumers are made aware of
the risks of unsterile injections, will the risks associated
with injections outside the formal health system be brought
under greater control.
is hoped that the information and discussion occurring through
(Technet Mailing List, send message with SUBSCRIBE in the
message body to join the list), and as a result of the current
awareness-raising activities of WHO,
and other agencies , will help to provide a more realistic
view of the threat to health arising from unsafe injections.
on policy makers
public health official or health care manager wants to be an
agent of disease transmission. Yet, these decision makers must
make judgments about how their health care resources should be
spent. Whether determined by competitive markets or public
budgets, all their decisions are trade-offs between perceived
cost and benefit. For safe injection, the up-front cost should
be apparent, and includes costs of education, training, and
supervision, as well as logistical and other support systems,
and a premium for safety equipment such as autodestruct or
anti-stick technologies. In addition, as programs become more
successful at curbing reuse of disposable syringes, costs will
include the additional expense of providing one syringe for
the other hand, the benefit side of the equation is
often clouded by the "time gap" between the
injection or accidental-stick injury and the onset of disease.
This factor probably contributes more than any other to the
lack of awareness of unsafe injections among decision makers.
The "time gap" phenomenon is due to the natural
history of the blood borne diseases that are transmitted due
to contaminated syringes and needles. Most infections caused
by unsafe injections go unnoticed, because they usually begin
without symptoms and have a long incubation period to the
clinical disease—making it unlikely that the disease will be
attributed to an injection months or even years earlier.
Because infrastructure and systems for tracking, recording,
and follow-up are limited in developing countries, patterns of
iatrogenic infection are much less likely to come to the
notice of busy health workers, let alone, be associated with
injection practices. In the absence of routine serological
testing, even active disease surveillance systems would not
pick up an increase in HBV infections due to unsafe
order for training of health workers to be effective,
management, supervision, and infrastructure must all be
supportive of the changed behavior. If, following training,
health workers return to an environment that is more conducive
to noncompliant practices, then the gap between knowledge and
practice will remain regardless of the quality and quantity of
of standards and guidelines
consistent standards, guidelines, and protocols are often
absent or unknown at the level of health care service
delivery, particularly in developing countries. International
guidelines exist but are often contradicatory or they specify
procedures requiring equipment or supplies which are not
available in many countries. At national level in developing
countries, even guidelines on hospital infection control are
rarely available and virtually unknown in the thousands of
health centres where injections are performed.
training tends to cover sterile technique for invasive
procedures, but contiminated waste handling and disposal is
neither taught, nor supervised nor provided for.
Training and Motivation of Health Care Workers
when safe injection programs are in place and in-service
training sessions have taken place, health workers may
continue to take risks including:
- recapping needles;
- vaccinating large numbers of people in the
course of just 1-2 hours per day;
- handling contaminated sharps;
- failing to burn or bury sharps so they overflow
behaviors suggest that individuals may not see a connection
between a theoretical risk and their own actions; or may
maintain alternative belief systems that govern their conduct.
populations where many essential resources are scarce, people
are understandably reluctant to throw away
"functional" items. In the formal health care
system, training of providers or use of autodestruct
technologies can help overcome this cultural resistance to
disposal of single-use syringes and needles.
and motivation play an integral role in efforts to control and
prevent the health risks caused by unsafe injection practices.
Although technologies can help to overcome unsafe injection
practices, they cannot provide the ultimate solution.
supervision and monitoring of injection practices
single-use syringes intended for one-time use are widely
reused in developing countries because of scarcity, resale
value, and a cultural resistance to throwing away valuable
items that still appear functional. Additionally, over 50% of
injections for immunization are given with sterilizable
syringes which are intended for re-use. These must be
individually handled, cleaned, and sterilized before reuse. In
some country programs, (e.g., Bangladesh and Eritrea
immunization programs), an effective training and supervision
has led to the successful management of reusable syringes.
However, in many countries, fuel for sterilization is often in
short supply, sterilizers in disrepair or lacking spare parts,
and training reinforcement and supervision not sufficient to
assure a high level of quality control over cleaning and
sterilization practices. Boiling is still used as a means of
disinfection of reusable injection equipment in some areas and
is unable to destroy some bacterial spores, such as Tetanus.
Although the cost of reusable syringes on a per-use basis
appears much lower than disposable single-use syringes, in the
absence of proper training, supervision, and equipment
maintenance, the hidden costs of disease transmission may be
very high. The extent of disease transmission is hidden
because the diseases are often asymtomatic for many months or
years. Whether syringes are disposable or reusable, the costs
of safe, effective disposal are also hidden.
occurring at the site of injection are an indication of severe
breakdown in quality of sharps practices. These indicators
should be aggressively followed up in monitoring programs.
supplies and facilities to provide a safe injection
injection equipment is in short supply. This may be because
syringes and needles are shipped separately from the vaccines
or other medicaments which they are meant to deliver.
equipment may also be pilfered for use by individuals or in
the private health care sector. Syringes, needles, and doses
of medicament may all end up in disproportion to one another.
In crowded clinics, where no alternative injection systems are
available and where levels of training and supervision are
inadequate, this situation can lead to reuse of syringes and
the USA, it is estimated that approximately 8,700 cases of HBV
from percutaneous exposures—mostly needle-sticks—occurred
every year before widespread HB immunization, and in 1995, 200
US health workers died of needle-stick-related infections. It
seems likely that many more such incidents occur in the
developing world, although those due to illicit reuse of used
needles are likely to greatly exceed those due to accidental
needle stick. In many cases of needle stick—even among well
trained health care workers—contributory factors can be
performance pressure due to the urgency of their mission,
fatigue, or lack of adequate assistance. One option for
reducing accidental needle stick injuries is through the use
of anti-stick technologies.
disposal of used equipment
if dried at room temperature, hepatitis B virus can remain
infectious for at least a week. Hypodermic needles and other
contaminated sharps represent a particularly hazardous form of
medical waste, since they can easily penetrate the skin.
Injection of infectious material through the skin is much more
likely to trigger an infection than if intact skin comes into
contact with infectious material. Thus, disposal of used
syringes and needles requires special consideration and cannot
be treated in the same way as other medical waste that does
not contain sharps.
many developing countries, there exists a strong economic
incentive—and even an organized "scavenging"
system—for collection and "recycling" of syringes
and needles. Waste disposal policies, infrastructure,
medical-waste audits, training, and political and financial
support are needed to shut down and prevent this dangerous
practice. Point-of-use needle destruction technologies may
help to reduce this problem, although health service providers
must be trained and motivated to use them.
the waste must be protected from pilfering and accidental
handling until it can be destroyed with minimum impact on the
environment using effective disposal technologies. In
developing countries, the cost of proper medical waste
disposal, if it is known, is often viewed as unnecessary or