AFRO-NETS> The Drum Beat - 78 - Safe Injections through Communication Activities

[Warren Feek <wfeek@comminit.com>]

The Drum Beat - 78 - Safe Injections through Communication Activities
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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. 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 work-
ers to inject excessively include the desire to respond to a per-
ceived 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 ac-
count 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 vi-
rus, 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 mil-
lion years of life lost, and lead to US$ 535 million in direct medi-
cal costs.


3. POOR INJECTION PRACTICES CAN BE ELIMINATED

To reduce overuse of injections and to assure safe injection prac-
tices, 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 fa-
cility. Third, mechanisms should be in place so that "sharps" (i.e. 
needles, syringes) are so disposed of as to ensure that dirty injec-
tion 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 responsi-
ble 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, immu-
nization services and family planning should increase the availabil-
ity of clean injection equipment. It is recommended that responsibil-
ity 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 injec-
tions worldwide. SIGN is made of 2 components. First, the SIGN asso-
ciates 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 com-
mon 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 inno-
vators and opinion leaders in developing countries through the use of 
electronic communication mechanisms, including a weekly, moderated e-
mail forum. Subscription at:
http://www.injectionsafety.org/html/joining.html
and 
http://www.injectionsafety.org


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PRACTICAL EXPERIENCE


6. INDONESIA - Overuse of therapeutic injections is often attributed 
to patients' demand. However, in Indonesia, the proportion of pa-
tients who actually prefer injections does not exceed 5 to 20%. This 
minority who prefers injections pressures providers to demand injec-
tions. 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 injec-
tions 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 in-
tervention 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 over-
use of injections was achieved. 


7. ROMANIA - In the early 1990's in Romania, the scandal due to pub-
licity given to injection-associated HIV injections drove a tremen-
dous 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 sug-
gests that when patients and providers are aware of the risks associ-
ated with unsafe injections, they will modify their behaviour and en-
gage in safer injection practices. In 1998, UNICEF led additional 
communication activities to address residual poor injection prac-
tices, 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 trans-
mission. 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 profession-
als and institutions from the public, private, and associative sec-
tors. SIGN Pakistan has been actively brainstorming potential na-
tional 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 coun-
try. In response to this situation, Egyptian stakeholders have cre-
ated 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 Ser-
vice Trust and WHO conducted a campaign to increase the safety of im-
munization injections. This campaign was designed in collaboration 
with Tanzanian communication specialists and artists. Posters, maga-
zines, 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 injec-
tion 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. 

***

Material provided by 
Dr Yvan Hutin
Medical Officer, SIGN secretariat
Blood Safety and Clinical Technology (BCT), WHO
mailto:hutiny@who.int 
http://www.injectionsafety.org 

***
Please send items for The Drum Beat to 
The Editor
Deborah Heimann 
mailto:dheimann@comminit.com

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