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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Safe Injection - Vital to Health

The Underlying Causes

Safe "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.

Lack of Awareness in the general population

Patient 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.

Many 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.

It is hoped that the information and discussion occurring through the Forum (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, USAID, CDC, and other agencies , will help to provide a more realistic view of the threat to health arising from unsafe injections.


Constraints on policy makers

No 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 every injection.

On 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 injections.

In 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 training.

Lack of standards and guidelines

Clear, 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.

Professional training tends to cover sterile technique for invasive procedures, but contiminated waste handling and disposal is neither taught, nor supervised nor provided for.


Inadequate Training and Motivation of Health Care Workers

Even 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 safety boxes

These 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.

In 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.

Training 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.

Inadequate supervision and monitoring of injection practices

Disposable 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.

Abscesses 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.

Inadequate supplies and facilities to provide a safe injection

Sometimes, 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.

 Disposable 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 needles.

In 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.

Unsafe disposal of used equipment

Even 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.

In 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.

Subsequently, 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 prohibitive.