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Global Update

Indian Pediatrics 2000;37: 345-347

Safety of Injections


Injections are a skin puncturing procedure performed with a syringe and needle to intro-duce a substance for prophylactic, curative, or recreational purposes. Injections can be given intravenously, intramuscularly, intradermally, or subcutaneously. Injections are among the most frequently used medical procedures, with an estimated 12 billion injections administered each year world-wide. A large majority (more than 90%) of these injections are administered for curative purposes (for every vaccina- tion injection, 20 curative injections are administered).

Injections have been used effectively for many years in preventive and curative healthcare. In preventive healthcare, injections have been used to administer vaccinations that have had a major impact in reducing childhood mortality due to measles and other vaccine-preventable diseases. While injections are still necessary today to administer most vaccina-tions, the number of vaccination injections could be reduced through the use of combination vaccines.

In curative healthcare, injections have been used to administer such antibiotics as penicillin, streptomycin as well as many other life-saving medications. Today, safe and effective alter-natives to injected medications are available and most medications used in primary care can be administered orally. Injections are predomi-nantly needed for the treatment of severe diseases, mostly in hospital settings. Never-theless, injections are overused to administer medications in many countries because of an ingrained preference for injections among healthcare workers and patients.

Unsafe Injection Practice Causes Cross-Infection

A safe injection does no harm to the recipient, does not expose the healthcare worker to any risk, and does not result in waste that is dangerous for the community. To achieve this, an injection needs to be prepared with clean hands in a clean area, using medication drawn from a sterile vial. The injection must be administered using a sterile syringe and needle. After administration, sharp equipment such as needles needs to be discarded in a puncture-proof container for appropriate disposal. When these rules are not followed, injections are unsafe and may expose recipients, healthcare workers, or the community to infections. Among unsafe practices, syringe or needle re-use between patients without sterilization is associated with a high risk of bloodborne pathogen transmission (see below). Unsafe injections occur in many parts of the world, and more particularly in developing countries where up to 50% of injections are administered with re-used syringes and needles.

The transmission of bloodborne pathogens through unsafe injections was documented as early as 1917, when an outbreak of malaria among British soldiers was linked to injection treatment for syphilis. Since then, unsafe injection practices have been linked to the transmission of many pathogens between patients (cross infection), including the hepatitis viruses, HIV, Ebola virus, dengue fever virus, and the malaria parasite. In addition, unsafe injections may cause abscesses, septicemia, or increase the risk of paralysis when patients are infected with the polio virus. Of all the adverse effects of unsafe injections, the hepatitis B and hepatitis C viruses, which are transmitted respectively a hundred times and ten times more effectively through unsafe injections than HIV/AIDS, cause the heaviest burden of disease.

Cross Infection Associated with InjectionsĖA Complex Problem

When breaks in safe injection practices occur, overuse of injections increases opportuni-ties for bloodborne pathogen transmission. Reasons for popular demand for injections include beliefs that injections are stronger medications (Pakistan), that injections work faster (Romania), that the pain of the injection is a marker of efficacy (some African countries), that a drug is more efficient when entering the body directly (Colombia, Thailand), and that injections represent a more advanced techno-logy (many developing countries). Among healthcare workers, motivations for overuse of injections include belief of a better efficacy of injected drugs (Romania), ability to directly observe therapy, and thus compliance with treatment regimens, and, sometimes, financial incentives. In some healthcare systems (e.g., Pakistan), healthcare providers can charge a higher fee if they administer an injection.

Reasons that explain unsafe injection practices include lack of awareness regarding the risks associated with unsafe injections, lack of injection supplies, and lack of disposal infrastructure for injection equipment. Injection technology has developed considerably since its beginnings in the eighteenth century, moving from glass syringes that require sterilization after each use to plastic disposable syringes designed to be discarded after one single use. More recently, auto-disable disposable syringes modified to disable themselves automatically by the plunger blocking after one single use have been developed. Nevertheless, many countries cannot afford these more advanced techno-logies, which may cost twice as much as standard injection equipment. In some countries, such as India, syringes are scavenged for resale. On other continents, such as Africa, syringes and needles are reused until they break, as culturally, waste is not acceptable. For health budgets with limited resources purchasing policies can only address the most immediate concerns and thus cannot ensure safe equipment and increased supplies.

A Heavy Burden of Disease

In many countries where hepatitis B and hepatitis C are highly endemic, unsafe injection practices account for a large proportion of infections. The proportion of new cases of hepatitis B that are attributable to unsafe injections was 60% in Taiwan in 1977 and 52% in Moldova in 1994. In Egypt, the proportion of new cases of hepatitis C that are attributable to unsafe injections exceeded 40% in 1996. The burden of disease associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) has been likened to a Ďsilent epidemicí, as these diseases typically take twenty years to evolve from infection to symptomatic chronic liver disease (cirrhosis and liver cancer).

Depending on the age at which infection occurs, 10% to 70% of persons infected with HBV develop a chronic infection. The younger the age at which infection occurs, the higher the risk of chronic disease. Of the 370 million people chronically infected with hepatitis B virus world-wide, more than one million die each year because of their infection; overall, 25% will eventually die of chronic liver disease. Hepatitis B is the fifth leading cause of death from infectious diseases in the world.

The proportion of individuals contracting HCV who develop chronic infection is even higher than for HBV. With 170 million people infected with HCV throughout the world, the burden of chronic liver disease and death associated with HCV infection is increasingly recognized, although no estimate is yet available.

Taken together, hepatitis B and C account for 75% of all cases of chronic liver disease world-wide and, while no estimate is available for the whole world, the annual cost of hepatitis B and hepatitis C in the United States alone has been estimated at $ 1.3 billion (medical and work loss). As the diseases progress and symtpoms become more acute, loss of health incurs absence from work, inability to support family, and loss of social position. Every carrier of the disease, whether symptomatic or asymptomatic, is a potential sourceof infection to others.

In addition to hepatitis B and hepatitis C, unsafe injections may cause HIV infection. However, because HIV is less efficiently transmitted through injections than the hepatitis viruses, unsafe injections account for far less infections than unprotected sexual intercourse in countries where HIV infection is highly endemic.

Improving Public Health Through Safe and Appropriate Injection Practice

To prevent the transmission of bloodborne pathogens that results from unsafe injections, injection use must be reduced and injection safety must be achieved. To move populations away from injection overuse and toward oral medications, behavioral change of patients and healthcare workers should be encouraged through the combination of a supportive environment and Information, Education, and Communication (IEC) activities. Health infrastructures must be adapted and the issue of negative incentive (e.g., higher fee for services when an injection is prescribed) must be addressed, bearing in mind that oral treatment is less labor-intensive (requiring less health workers) and often more cost-effective (cheaper drugs, less staff involved). In addition, to achieve injection safety, a combined strategy to improve awareness and healthcare worker performance, provide injection supplies, and strengthen disposal infrastructure must be developed. The medical device industry should also be encouraged to develop safer technology that is adapted to national public health requirements and government budget capabilities.

To prevent the adverse effects of unsafe injection practices, United Nations organiza-tions, non-governmental organizations, govern-ments, donors, and universities sharing a common interest in a safe and appropriate use of injections joined their forces in a Safe Injection Global Network (SIGN). Because of the complexity of the problem, assistance from different types of professionals will be needed (e.g. public health officers, infection control practitioners, epidemiologists, anthropologists, specialists in behavior development, researchers in administration technology, environmen-talists). Because little experience is available regarding integrated programs that link the community with the health system to aim at safe and appropriate use of injections, the Safe Injection Global Network plans to co-ordinate the launch of pilot projects in five countries. Results of the evaluation of these pilot projects should be available by 2002, and will enable the Safe Injection Global Network to identify strategies that work to develop a large-scale initiative to ensure that safe and appropriate use of injections is a priority for all.

News in Brief


Disease Watch

Net dependent: The most contemporary diagnosis to be made today is internet addiction. Psychiatrists are divided in opinion as to whether this entity is real or being loosely used. But a recent careful survey of 809 internet users found that 20 fit the ICD-10 criteria for addiction. Withdrawal symptoms, increasing tolerance and loss of control identify compulsive users. Neurochemical changes which herald addictive behaviors such as increased dopamine in the nucleus accumbens have also been documented. Predisposing conditions include attention deficit, depression, social phobia and impulse control disorder. It becomes especially serious when proper functioning in daily life is hampered including loss of jobs due to failure to reach oneís workplace, or misuse of office computer facilities (Lancet 19 Jan 2000).

China panics: The last case of polio in China had been reported in March 1997. Hence the documentation of acute flaccid paralysis in a 16 month old boy in Qinhai province in China sent shivers of alarm down everybodyís spine. Gene sequencing data has proven that it was probably imported from India. A festival of 30,000 Sala people, an ethnic minority with strong trading links with India held 10 days before the childís paralysis may explain the import of the virus. Seven million children in surrounding areas have been immunized and 2 more rounds are planned for March and April. In the fight against polio there is no room for complacency (Lancet 12 Feb 2000).


Early warning systems: A British general practitioner was recently convicted of 15 murders and is probably guilty of a 100 more. He has been labeled the worst serial killer in British history. But though his nefarious activities had been going on for years it was mere chance which finally brought him to book. Similarly, there are many cases where unexplained increase in a disease or mortality in a localized geographical area may help us pinpoint the cause. Executives of the British Medical Association are clamoring for the introduction of technology called GIS (geographical information systems) which will serve as an early warning signal for unexplained discrepancies in morbidity and mortality in different areas. Basically health statistics are linked to geographic data and analyzed to yield useful data. But The prerequisites are wide-spread computerization and regular feeding in of accurate data which may be the limiting steps. On a small scale Britain already has a group called SAHSU (Small Area Health Statistics Unit) which has investigated many disease clusters such as the links between nuclear installations and childhood leukemia as well as the abnormal mortality rates of the Pediatric Cardiac Surgery Unit at Bristol. Widespread use of GIS will give us many more potential insights into the origins of deaths related to various environmental hazards and epidemics which are still picked up by chance or by the time it is too late (New Scientist 12 Feb 2000).


Whatís new in cloning: Dolly the sheep was created in Roslin Institute when an unfertilized egg was enucleated and the cytoplasm was fused with a mature cell from the sheepís udder. The miracle was that the cytoplasm transformed the uder cell into itís embryonic state and it started dividing. One of the major objections of opponents of cloning has been the use of valuable eggs. Recent trials in Roslin University may overcome these. They are now trying to fuse the mature cell with embryonic stem cells and not the egg. Since stem cells are being cultured in vitro it does away with the need for ova. Once the technique is mastered, therapeutic cloning may be possible where the patients cell are cloned to produce tissue or organs which he needs such as neurons in Parkinsonís or heart muscle for cardiac transplant without fear of rejection (New Scientist 29 Jan 2000).

Lab Watch

Growing brains: For years scientists were convinced that while many other cells in the body continue to muliply, this was not true in the human brain. To safeguard memories and learning this was considered a small price to pay. But a brilliant study by a neuroscientist called Gage from the Salk Institute of Biological Sciences in California has overturned this theory. Terminally ill cancer patients who were injected with a Bromodeoxyuridine tracer to monitor the production of new cancer cells were studied after their death. Finding the tracer in non cancerous cells in the dentate gyrus where new memories are formed helped prove that new cells continue to be formed in our brain. This will open the floodgates into research about how memories form, what induces neuro-nogenesis and how to improve recovery after brain damage. Animal experiments have shown that enriched environments which include learning, exercise and also freedom are major promoters of neuronal growth while the stress hormones cause neuronal stunting (New Scientist 12 Feb 2000).

Gouri Rao Passi,
Department of Pediatrics,
Choithram Hospital and Research Center,
Indore 452 001, India.

-mail: passi@vsnl.com



Emerging Infectious Diseases - www.cdc.gov/ncidod/EID/index.htm Emerging Infectious Diseases is published 6 times a year by the National Center for Infectious Diseases, Centers for Disease Control and Prevention. It is indexed in index Medicus/Medline, Current Contents, Excerpta Medica, and other databases. It is a part of CDCís plan for combating emerging infectious diseases. The full text of articles from 1995 are available online.

Children with Diabetes - www.childrenwithdiabetes.com This is an on-line magazine for children with insulin-dependent diabetes and their families. This site carries information about the disease, dietary advice, recent advances in treatment, a chat room and links to resources on the internet.

Magic Foundation - www.magicfoundation.org MAGIC (Major Aspects of Growth in Children) foundation as the name suggests is a national non-profit organization providing support and education regarding growth disorders in children and related adult disorders. MAGIC covers over 100 different types of growth disorders and educational/supportive services worldwide. Information brochures on the various disorders and a quarterly newsletter, the magic touch are available online.

Childrenís Vaccine program - www.childrensvaccine.org This large scale program on vaccination coverage in developing countries was started by Bill Gates, of Microsoft. The website gives details of the program, vaccina-tion links and other useful information on immunization.

Pneumococcal Website - www.pneumo.com/home.html As the name suggests, this site, sponsored by a drug company is aimed at disseminating information on various aspects of pneumococcal infection in children. The bibliography on the disease and vaccines is extensive.

Learning Disabilties Online - www.idonline.org/ccldinfo This website, funded by a private organization, the Emily Hall Tremaine Foundation, provides a wealth of information on various learning disabilities including clinical information, addresses of various support organ-izations and places where these patients can get help. Links to internet resources on learning disabilities are also provided here.

Neonatology and Genetics Links from Karolinska Institute - www.mic.ki.se/diseases/c16.html An exhaustive collection of links to internet resources on various genetic disorders and on neonatology are available in this site from Karolinska Institute Library, Sweden.

Action for Autism - www.autism-india.org This is the webpage of Action for Autism (AFA) - A national, charitable organization providing support and services to persons with autism and those who work with them in South Asia. The organization provides assessments, counselling, information, distribution and referral, home-based management programs, and networking between parents. This website contains, information about autism, activities of the organization, autism in India, facilities for patients and autism links. The autism network, the journal published by the organization is available online.

C. Vidyashankar,
Department of Pediatrics,
Base Hospital, Delhi Cantonment,Delhi 110 010, Delhi.

Note: These websites have been verified on February 20, 2000. In case of any difficulty in accessing the URLs readers are requested to check the electronic version of the journal or contact the author.


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