Safety of Immunization Injections in Africa: Not Simply a Problem of Logistics

Excerpt from beginning of report

"In 1995, the WHO Regional Office for Africa launched a logistics project to address the four main areas of immunization logistics: the cold chain, transport, vaccine supply and quality, and the safety of injections in the countries of the region. The impact of this logistical approach on immunization injection safety was evaluated through surveys of injection procedures and an analysis of the injection materials (e.g. sterilizable or disposable syringes) chosen by the Expanded Programme on Immunization (EPI) and those actually seen to be used. Re-use of injection materials without sterilization, accidental needle-stick injuries among health care workers, and injection-related abscesses in patients were common in countries in the WHO African Region. Few health centres used time-steam saturation-temperature (TST) indicators to check the quality of sterilization and, in many centres, the injection equipment was boiled instead of being steam sterilized. Facilities for the proper disposal of used materials were rarely present. Although the official EPI choice was to use sterilizable equipment, use of a combination of sterilizable and disposable equipment was observed in the field. Unsafe injection practices in these countries were generally due to a failure to integrate nursing practices and public awareness with injection safety issues, and an absence of the influence of EPI managers on health care service delivery. Holistic rather than logistic approaches should be adopted to achieve safe injections in immunization, in the broader context of promoting safe vaccines and safety of all injections."

Results of immunization injection safety surveys indicate that "injection equipment was being re-used without sterilization, and that there were accidental needle-stick injuries among health care workers and injection-related abscesses both in Senegal (in 1995), where sterilizable syringes were used and in Côte d'Ivoire (in 1996) , where disposable syringes were used. A substantial proportion (20-80%) of health centres lacked sufficient supplies of injection equipment. Used syringes and needles were observed lying in and around the health centres."

Under the report section entitled "Discussion" the authors assert that "study countries have not made any progress with regard to safety over the last 10 years." They describe the reasons for re-use of syringes and needles without sterilization include "shortage of injection equipment, lack of awareness about the risks of bloodbourne pathogen transmission, and improper disposal of sharps leading to recycling and re-sale after repackaging." The authors also indicate that the survey showed "inconsistencies between the injection equipment recommended by EPI for each country and the practices observed in the health centres. They go on to state these reasons: "the impact of acquired immunodeficiency syndrome (AIDS) control programme messages, which promote disposable syringes; the time needed for the overworked health care workers to clean and sterilize the injection equipment; the fear of accidental needle-stick injury during this process of cleaning; and the absence of confidence in the safety of sterilizable syringes in the population and among health care workers."

In conclusion, the authors suggest that to achieve injection safety within immunization programmes, "immunization should be considered as a medical act, treated as such, and be subject to the "First do not harm" principle. This consideration should bring safe injection practices to the attention of WHO country and intercountry team leaders in the African Region." Additionally, the authors recommend that "injection safety should be approached holistically together with nursing practices, social mobilization, and logistics."

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