The Drum Beat 78 - Safe Injections through Communication Activities

1. INJECTIONS WASTE PRECIOUS HEALTHCARE RESOURCES - A literature review published in 1999 indicated that, of all medical procedures, injections are probably the most common. About 12 billion injections are administered each year throughout the world. Less than 10% are for immunizations. Many of the therapeutic injections, the widest application, could be avoided. In many countries, both patients and health care workers prefer medicines to be administered by injection. Reportedly, patients ask for injections because they believe that medication is more efficacious by that route and that the pain of the injection is a marker of that efficacy. Reasons for health care workers to inject excessively include the desire to respond to a perceived patient preference, the wish to monitor compliance directly and, in some instances, the possibility of charging a higher fee for service. Overall, unnecessary injections lead to high out-of-pocket health care expenses for patients and their families.

2. UNSAFE INJECTIONS TRANSMIT BLOODBORNE PATHOGENS ON A LARGE SCALE - Many injections administered in the world are unsafe. Of particular concern is the reuse of injection equipment without sterilization - a frequent practice in developing countries and those in transition, where it is common to rinse syringes and needles in containers of tepid water between injections. In these countries, injections account for a high proportion of new infections due to hepatitis B and C viruses. Each year, globally, reuse of dirty injection equipment causes an estimated 8 to 16 million infections with hepatitis B virus, 2.3 to 4.7 million infections with hepatitis C virus, and 80 000 to 160 000 infections with HIV. Together, these chronic infections are responsible for an estimated 1.3 million early deaths and 26 million years of life lost, and lead to US$ 535 million in direct medical costs.

3. POOR INJECTION PRACTICES CAN BE ELIMINATED - To reduce overuse of injections and to assure safe injection practices, multidisciplinary strategies comprising 3 elements should be implemented. First, there needs to be a change in behaviour: patients and health care workers should be encouraged to adopt safe practices and to avoid unnecessary injections. Second, sufficient quantities of clean injection equipment should be available in each health care facility. Third, mechanisms should be in place so that "sharps" (i.e. needles, syringes) are so disposed of as to ensure that dirty injection equipment is not reused and the risk of accidental needle-stick injuries is minimized.

4. SAFE & APPROPRIATE USE OF INJECTIONS SHOULD NOT BE A NEW "PROGRAMME" - Globally, efforts to ensure safe and appropriate use of injections require collaboration between all partners. Because multidisciplinary interventions are needed, the basis of preventive activities should be careful coordination of already existing initiatives rather than the creation of new programmes. National health authorities responsible for health promotion, HIV prevention, integrated management of childhood illnesses and blood transfusion services should promote safer behaviour among patients and health care workers. Similarly, national authorities responsible for access to essential drugs, immunization services and family planning should increase the availability of clean injection equipment. It is recommended that responsibility for safe management of health care waste should be assigned to health care services.

5. USE THE SAFE INJECTION GLOBAL NETWORK (SIGN) TO DIFFUSE THE INNOVATION OF SAFE & APPROPRIATE USE OF INJECTIONS - The Safe Injection Global Network (SIGN) is a voluntary association of stakeholders who strive for the safe and appropriate use of injections worldwide. SIGN is made of 2 components. First, the SIGN associates include the institutions, organizations, and individuals who share a common goal in preventing poor injection practices. Second, a secretariat based at WHO coordinates the network. SIGN associates agree to collaborate within SIGN to exchange information, coordinate their advocacy strategies, and conduct activities according to a common strategic framework. SIGN was organized as a network to make use of weak ties between different institutions and professionals of various disciplines. In its activities, SIGN attempts to reach innovators and opinion leaders in developing countries through the use of electronic communication mechanisms, including a weekly, moderated e-mail forum (Subscribe) and the Internet.

 

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6. INDONESIA - Overuse of therapeutic injections is often attributed to patients' demand. However, in Indonesia, the proportion of patients who actually prefer injections does not exceed 5 to 20%. This minority who prefers injections pressures providers to demand injections. Because of strong pressure from that minority, providers tend to believe that all patients prefer injections. Then, they over-prescribe injections to all patients, including to the 80% to 95% who do not prefer injections. This majority, who does not prefer injections but is given injections by providers, deducts that providers prefer injections. This curious discrepancy between the respective perceptions of the patient and the provider was addressed in an intervention study aiming at restoring a good quality of communication between patients and health care providers. Following "interactional group discussions" a substantial and sustained decrease in the overuse of injections was achieved.

7. ROMANIA - In the early 1990's in Romania, the scandal due to publicity given to injection-associated HIV injections drove a tremendous consumer demand for new, disposable injection equipment. Between 1990 and 1998, the country virtually eliminated the practice of re-using injection equipment in the absence of sterilization. This suggests that when patients and providers are aware of the risks associated with unsafe injections, they will modify their behaviour and engage in safer injection practices. In 1998, UNICEF led additional communication activities to address residual poor injection practices, including the preparation of injections in contaminated area, the inappropriate use of multi-dose vials, the failure to collect sharps in safety boxes, and the failure to appropriately dispose of sharps waste.

8. PAKISTAN - In Pakistan, the frequency of unnecessary injections is high and many injections are given with dirty equipment. Such poor injection practices drive high levels of bloodborne pathogen transmission. Despite this concerning situation, Pakistani stakeholders have engaged in creating a national chapter of the Safe Injection Global Network. National members of SIGN Pakistan include professionals and institutions from the public, private, and associative sectors. SIGN Pakistan has been actively brainstorming potential national plans for the safe and appropriate use of injections and is still investigating funding mechanisms to carry out such plans.

9. EGYPT - In Egypt, unsafe injection practices, including during past mass treatment campaigns for schistosomiasis, have contributed to the large-scale spread of hepatitis C virus infection in the country. In response to this situation, Egyptian stakeholders have created a national coalition called "Developing Infection Control in Egypt" (DICE). DICE Egypt is also elaborating a joint plan of action to achieve safe and appropriate use of injections.

10. TANZANIA - In Tanzania, immunization services were plagued by poor injection practices. In a joint initiative, the BBC World Service Trust and WHO conducted a campaign to increase the safety of immunization injections. This campaign was designed in collaboration with Tanzanian communication specialists and artists. Posters, magazines, and other communication material were pre-tested and adapted to healthcare workers and the population, the proposed audience of the campaign. The effectiveness of this campaign will be evaluated on the basis of an injection safety assessment.

11. ALBANIA - In Albania, a mass measles campaign was scheduled for Nov. 2000. However, initial assessment indicated that unsafe injection practices were occurring and that a mass campaign could lead to adverse effects. In addition to the provision of safer auto-disable (AD) syringes and safety sharps collection boxes, the task force for the mass measles campaign in Albania decided on a special injection safety plan. This plan included (1) an initial rapid assessment of the situation and (2) the implementation of a communication campaign with pamphlets and videos for healthcare workers. An evaluation of the effectiveness of this injection safety plan is in progress.

 

Material provided by Dr Yvan Hutin, Medical Officer, SIGN secretariat, Blood Safety and Clinical Technology (BCT), WHO - hutiny@who.int.
SIGN website.
 

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