Injections that kill: nosocomial bacteraemia and degedege in Tanzania

Abstract

In Tanzania and some other African rural settings, a traditional proscription of injections for the treatment of cerebral malaria (degedege) stems from parents' fear that injections will kill a child with fever and convulsions. The re-use of injection equipment in rural clinics is associated with bacterial contamination even where sterilization is practiced to prevent HIV transmission. A secondary infection with bacterial sepsis is indistinguishable from non-responsive malaria on clinical examination, and may be a significantly under-reported adverse event in rural Tanzania. In a prospective survey of patients whose venous catheter was culture positive on removal, 61% developed bloodstream infections. Parents report having witnessed a child's death following an injection for the treatment of fever and convulsions in rural Tanzania, and some traditional healers who would refer a child with uncomplicated malaria for Western biomedical treatment are convinced that injections are fatal for a child with convulsions. Injection drug users learn aseptic technique to avoid what is called a 'dirty hit', a systemic infection that is felt immediately after injecting, indicating sudden deterioration is likely in a sick child if an IV injection is unsafe. Community mistrust of injection providers has been too casually attributed to superstition; to address parents' concerns, injection safety should be a priority in rural health services. Intravenous injections carry a 0.2% risk of acute bacteremia when given with unsterile equipment, while unsafe infusions carry a 3.7% risk of infection, much greater than the risk from intramuscular injections of vaccine. Sepsis should be considered an important adverse event in the management of severe malaria, but the diagnosis of nosocomial bloodstream infections is a challenge in hospitals that cannot culture for bacteria. When the auto-disable syringe was introduced, patient safety improved at a Tanzanian district hospital; a reduction in the burden of serious secondary infections large enough to reduce the average inpatient length of stay was observed. Nosocomial bloodstream infections are a common cause of fever in Tanzanian hospitals. In Tanzania, bacteremia is sometimes associated with more deaths in hospitals than malaria. Although other obstacles to appropriate treatment for malaria may be more important in rural Tanzania, the belief that injections will kill a child is suggestive of avoidable adverse events. The intensity of malaria treatment in rural areas and frequent recourse to informal sector health care presented a significant challenge for the prevention of adverse events including sepsis and HIV transmission. A household survey in rural Tanzania found that 27% of malaria treatment occurs at drug stores, and 30% of patients seek treatment at a general shop. A majority of rural patients evaluated for malaria in the formal sector have taken chloroquine before coming to the clinic. A new national injection safety policy banning the import of non-auto-disable syringes prevents injection equipment re-use in the informal sector. Improving injection safety in rural Tanzania through the introduction of auto-disable syringes will ensure that parents have nothing to fear from quinine injections and infusions that are usually life saving.