Injection safety work in countries
In 2015, WHO initiated an ongoing pilot intervention campaign on injection safety in three countries including India, Egypt and Uganda, to provide successful examples and lessons learned, to other countries. The purpose of the pilot is:
- to demonstrate feasibility of the campaign and policy at national/local level;
- to provide impact data on key indicators, for example the number of injections per person per year, the percentage of unsafe injections etc.; and
- to evaluate some of the success factors and barriers to technology and behavioural change.
The key components of the intervention are:
- rapid review of available information
- political commitment and stakeholder engagement-leading to a local policy
- baseline assessment of injection practices
- procurement and continuous availability of products
- device introduction, industry engagement
- health care waste management
- awareness campaign for patients and communities
- monitoring and evaluation.
Between the 1950s and 1980s, injections were one of the main mode of mass scale treatment of schistosomiasis in Egypt. Since needles and syringes were reused, injection safety was compromised and this was cited as one of the key causes of spread of hepatitis C in the country. Injections have always been in popular demand for minor ailments at primary and first level treatment facilities, in public and private settings. However, the country has recognized that injection safety is an urgent priority that needs special attention. The injection safety pilot project in Egypt has resulted in significant progress and achieved success in a number of areas.
The first step was to carry out a desk review of available literature, from 2000 to 2015, which provided useful findings. The findings of the desk review revealed that reuse of needles and syringes was between 20-23% , while the number of injections per person per year was estimated to be 6.8. Unsafe disposal, after bending the needle, took place following 23% of injections. A national assessment on injection safety in 2016 was completed in eight governorates of the country covering health care facilities in the public and private sector, as well as informal providers within the community. A total of 85 facilities were assessed, including 16 Ministry of Health (MoHP) hospitals, 15 private hospitals, six university hospitals, 48 primary health centres and 48 community (private) pharmacies. Reuse of injection equipment was not found in any of the facilities. In all assessed facilities 98% of syringes and needles were taken from new packaging every time. 90% of facilities had no overflowing sharps containers. The number of injections per person per year was found to be 5.9 (while it was 6.8 based on the findings of the desk review). 35% of facilities prepared injections on a clean surface.
MoHP and the WHO Country Office are progressing on developing a national policy on injection safety which will include country-wide use of RUP (re-use prevention) syringes for injections. In addition, Egypt will conduct an economic modelling study on the impact of reducing unnecessary and unsafe injections, develop a communication strategy and provide standardized training to health workers on injection safety.
Uganda was among the four African countries besides Ethiopia, Mozambique and Nigeria, to have been part of the Making Medical Injection Safer (MMIS) project led by USAID between 2004-2009. Uganda had introduced a national policy of using RUP syringes in 2004. WHO included Uganda as the injection safety pilot country after a scoping mission identified gaps. The strategy involved sustaining the switch by addressing gaps in injection safety in the country. The sequence of events was similar to Egypt, since as a first step, a desk review was also performed which provided useful information in progressing to next steps such as getting a baseline assessment. Under the leadership of Uganda’s Ministry of Health and the WHO Country Office, a baseline assessment for Uganda was conducted in early 2017, to assess the extent of unsafe injection practices, that may lead to infections, and to estimate the proportion of health facilities where procedures were unsafe.
One hundred and ninety two facilities (100 public, 92 private) were randomly selected in 31 districts out of 112. The findings of the assessment showed no evidence of sterilization of disposable syringes and no loose disposable injection equipment was found in 77% of the facilities. The average number of injections per person per year was 3.3. Disposal of sharps for procedures varied. For example, waste generated from phlebotomies and lancets was disposed of appropriately 90-97% of the time, while waste from intravenous injections was disposed of in 60% of cases, and the figure for intravenous infusion was 78%. Supervisors at 47% of public facilities reported stock-outs in the past six months, while it was as high as 77% across private facilities. The procurement and supply management assessment study showed that there are limited suppliers available of RUPs and stock-outs at public facilities are therefore common. There is awareness about devices but there is also a lack of skills on proper use of RUPs. There were issues with the quality of the product found in the assessment. Uganda will progress towards developing a comprehensive training manual on infection control and injection safety which will be implemented in all districts of the country.
Injection safety in the health care sector in India has remained a problem and multiple outbreaks of hepatitis B, in particular, have been reported and investigations have attributed a strong role to the widespread reuse of injection equipment. High-level advocacy by the WHO Country Office with the Central Ministry of Health and Family Welfare (MoHFW) has brought more attention to injection safety. A technical advisory group on injection safety was notified by MoHFW, which after consultations identified the State of Punjab as the site for an injection safety pilot. An extensive desk review was performed which provided the basis to move to next steps. In April 2017, the Punjab Health Department decided to establish 40 model injection safety centres in district hospitals, as well as medical and nursing institutes throughout Punjab. These will serve as resource and training centres for RUPs, for health workers. The Health Department of Punjab is moving forward with introducing RUPs in their health system. There are six RUP manufacturers in India who have been asked to provide specifications of their products to the technical committee who will review them prior to publishing the tender. A baseline assessment has been planned for August 2017, as well as an economic modelling study and a knowledge, attitudes and perceptions study on injections in Punjab.