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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 Injections–A
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 ‘silent epidemic’, 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.
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News
in Brief |
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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 one’s 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
everybody’s 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 child’s 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).
Technology
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).
Genetics
What’s
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 sheep’s udder. The
miracle was that the cytoplasm transformed
the uder cell into it’s 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 Parkinson’s 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,
Consultant,
Department of Pediatrics,
Choithram Hospital and Research Center,
Indore 452 001, India.
E-mail:
passi@vsnl.com
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Pedscapes |
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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
CDC’s 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.
Children’s
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.
E-mail: vidyashankar@vsnl.com
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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