Safe Injection Global Network Research Articles

ASSESSMENT OF SAFE INJECTION PRACTICES AND NEEDLESTICK INJURY AMONG NURSING STUDENTS AT MANSOURA UNIVERSITY

Injections are the most common health care procedure worldwide.Risk of unsafeinjection exposed health care providers to needle-stick injury that constitute a majorhazard for the transmission of bloodborne diseases.The establishment of Safe InjectionGlobal Network (SIGN) was a milestone towards safe injection practice globally. Safeinjection is a vital component of infection prevention process without which many patientsare at risk of being exposed to several non-curable and curable infectious diseases.Thisstudy aimed to assess nursingstudents' knowledge, practices, and attitude regarding safeinjection practices and needlestick injury.A cross sectional study design was utilized toaccomplish this study.Convenience sampling technique of community health nursingstudents were included in the sample.The study results revealed that the prevalence rate ofneedlestick injury (NSI)was 52.1% of among the studentsthrough last three levels of theiracademic study. The majority of the studied students had lack of knowledge andimproperpractice regarding safe injection practices and needlestick injury.Conclusion:needle stick injuries was prevalent among more than half of studied nursing students.Majority of the nursing students had a poor score level of knowledge and improper practiceregarding safe injection practices and needlestick injury.Finally, it is recommendedcontinuous health education program and training courses regarding safe injectionpractices prior to starting clinical practice.

Safety-Engineered Syringes: An Intervention to Decrease Hepatitis C Burden in Developing Countries—A Cost-Effectiveness Analysis From Egypt

IntroductionTo assess the cost-effectiveness of introducing the safety-engineered syringe (SES) to decrease hepatitis C burden resultant from unsafe injection practices in healthcare settings. MethodsA Markov process model for a hypothetical study cohort was developed over a 30-year time horizon to compare the adoption of SES use with the current strategy, conventional syringes (CS), in the Egyptian healthcare settings. The national treatment program was applied in both groups. Health benefits and total direct medical costs were estimated in both strategies. ResultsThe SES use demonstrated a reduction in the burden of injection-associated HCV infection because of unsafe practices in the Egyptian healthcare settings. The probability of HCV infection was 1.4% in the SES group and 40% in the CS group. Adoption of the SES use averted 177 hepatitis C cases and 157 hepatitis C–related deaths per 10 000 individuals. Introducing SES as a preventive strategy resulted in better quality-adjusted life-years (QALYs) (difference; 0.95 QALYs) and lower costs (difference; $−1712). ConclusionsAdoption of SES in the Egyptian healthcare settings is a more effective and cost-saving strategy. Our results are consistent with the WHO Injection Safety Program and Safe Injection Global Network initiatives, which call for adoption of smart syringes. The introduction of SES as one of the most urgently needed interventions is mostly encouraged to decrease hepatitis C burden in similar resource-limited settings. The use of SES as a prevention strategy may bring substantial population-level health gains and governmental cost savings in developing countries.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/-nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

ASSESSMENT OF HEALTH CARE PROVIDERS INJECTION PRACTICES IN DESSIE DISTRICT, NORTH-EASTERN ETHIOPIA: FACILITY BASED STUDY

According to the recent WHO report, it is estimated that injection cause an estimated 8-16 million cases of hepatitis B, 2.4-4.5 million cases of hepatitis C virus and 80,000 to 160,000 cases of Human Immunodeficiency Virus (HIV) infections annually worldwide. In Ethiopia, only a handful of studies have attempted to examine the safety of medical injections and vaccinations at health facilities. Besides, such efforts focused mainly at health facilities owned and operated by the government. The aim of this study was to assess injection practices and perception of the providers towards injections in Dessie and Dessie Zuria Woredas. Institutional based cross sectional study was conducted from March to October 2007. For this study the government owned health facilities were surveyed. All hospital and four health centers were selected by purposive sampling methods. Standard survey instruments were adapted from the WHO safe injection global Network (SIGN) for the purpose of this study. From the health facilities study the information generated through the use of different survey instruments and approaches revealed that an alarmingly high proportion of the injections provided at the health facilities were potentially unsafe. Although at the time of observation all the injections were provided using disposable or auto-disable injection equipment, the safety of injection practices was largely compromised due to unsafe practices of handling needles before and after injection, such as failure of proper collection, storage and disposal of syringe/needles, as well as, failure of proper reconstitution of medical injections or vaccines. As a result, the majority of the injections were provided in a manner that predisposes the patient, the health worker or the community to risk of accidental-needle stick injuries. The widespread misuse of puncture proof sharp collection boxes (safety boxes) and inappropriate use of incinerators were among the behavior of health workers that need to be targeted for intervention. There was an established perception among health workers that injection medications were more powerful and effective than oral medications, and thus they believe that most patients prefer injections to oral medications. It is concluded that an extremely high proportion of injections are administered in a potentially unsafe manner. Lack of essential supplies in the health facilities, such as safety boxes, as well as, inadequate skill and attitude among health workers and other personnel are the major obstacles against provision of safe injections. Accordingly, these gaps should be bridged through sustained provision of the necessary supplies coupled with training programs that promote appropriate behaviors and attitude among personnel working in health care facilities.

Assessment of the safety of injection practices and injection-related procedures in family health units and centers in Alexandria.

The Safe Injection Global Network (SIGN) developed an intervention strategy for reducing overuse of injections and promoting the administration of safe injections. Tool C--Revised is designed to assess the safety of the most common procedures that puncture the skin within health services. The aim of the study was to assess injection safety within the primary healthcare facilities in Alexandria using Tool C--Revised. A total of 45 family health units and centers in Alexandria were selected by proportional allocation from the eight regions of Alexandria. The Tool C--Revised of the WHO was used for observation of the entire facility, injection practices and injection-related procedures, and sterilization practices. Interview of different health providers and immediate supervisor of injections was carried out. Indicators that reflect risk included: deficiency of alcohol-based hand rub for cleansing hands (13.3%), compliance with hand wash before preparing a procedure (56.9% before injection practices, 61.3% before phlebotomy, and 67.6% before lancet puncture), and wearing a new pair of gloves before new procedures (48.6% before injection practices, 9.7% for phlebotomy, 11.8% for lancet puncture, and 80% for both intravenous injections and infusions). Enough disposable equipment in all facilities for at least 2 weeks dependent on the statement of the average numbers of procedures per week was shown. Only 38% of the providers had received training regarding injection safety in the last 2 years and 62.5% had completed their three doses of hepatitis B vaccine. Only 42.2% of staffs who handled healthcare waste had access to heavy gloves. Indicators related to injection and injection-related practices that reflect risk to patients include deficiency of alcohol-based hand rub tools, nonadherence to hand hygiene before preparing an injection, and inadequate adherence to using a clean barrier when opening a glass ampule and use of gloves. Indicators that may reflect risk to patients and providers include inadequate injection safety training and incomplete hepatitis B vaccination of healthcare providers. Indicators that may reflect risk to providers include nonadherence to safety precautions related to injection practices, such as inadequate access to heavy gloves by staff handling healthcare waste.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health's PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/-nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Evolution of the Global Use of Unsafe Medical Injections, 2000–2010

ObjectiveSince 1999, substantial efforts have been made by the international community to reduce the risks associated with unsafe injections, through ministries of health, international donors, the World Health Organization and the Safe Injection Global Network. The present study attempted to measure the progress, or lack thereof, made over the 2000–2010 decade in reducing unsafe injections in ten regions of the world corresponding to developing and transitional economies.MethodsData about the number of injections per person per year and the proportion of re-use of syringes and needles were obtained for 2010, mainly from population surveys, and compared with previous estimates for 2000 which had used various sources of information including injection safety assessments, population surveys and published studies on injection practices.ResultsFrom 2000 to 2010, in developing countries and transitional economies, the average number of injections per person per year decreased from 3.40 to 2.88, while the proportion of re-use of injection devices dropped from 39.8% to 5.5%. Combining both factors the number of unsafe injections per person per year decreased from 1.35 to 0.16. Even if substantial progress has been made, the Eastern Mediterranean region remains problematic, with 0.57 unsafe injections per person per year. In sub-Saharan Africa and Latin America, people now receive on average only 0.04–0.05 unsafe injections per year.ConclusionSubstantial progress has been made in reducing the number of unsafe injections in developing countries and transitional economies, essentially through a reduction in the re-use of injection devices. In some regions, elimination of unsafe injections might become a reasonable goal.

Unnecessary injecting of medicines is still a major public health challenge globally

In 2012, we sought responses from all 194 World Health Organization (WHO) Member States for the WHO/ World Hepatitis Alliance Global Hepatitis Survey (World Health Organization 2013). While the full survey results will be released on 28 July 2013, World Hepatitis Day, we feel that it is imperative to draw attention to one finding with potentially far-reaching public health implications. Only 7 of 126 Member States that responded to the survey were able to provide data for the following question: ‘What are your government’s official estimates of the number and percentage of unnecessary injections administered annually in healthcare settings?’ Another 6 respondents skipped the question, and 113 – almost 90% – answered ‘do not know’. It is dismaying to learn that such a large number of countries do not appear to have these data available in light of what has been documented regarding injection overuse in developing countries. Much of the evidence is from the 1980s and 1990s, but more recent studies in China and Egypt found unnecessary health facility injection rates of 57% and 95%, respectively (Yan et al. 2006; Bodenschatz et al. 2009). A 2006 Pakistani study estimated that 94% of therapeutic injections nationally are unnecessary (Altaf et al. 2006). A 1999 review article summarising earlier evidence noted levels of unnecessary injections ranging from 70% to 99% in various patient populations in India, Indonesia, the Russian Federation and Tanzania (Simonsen et al. 1999). The findings from the recent global hepatitis survey are a stark reminder of the persistence of this danger. In our survey, the three highest national estimates for the proportion of unnecessary injections were 68% (Mongolia), 50% (Cambodia) and 20% (Pakistan). These figures, coupled with the absence of data from many other countries, raise the question of whether progress is being made on reducing unnecessary injections, which WHO identifies as a key strategy for reducing injectionassociated disease transmission (World Health Organization 2010). Simonsen et al. (1999) define an unnecessary injection as ‘one where oral alternatives are available, where the injected substance is inappropriate or harmful or where the symptoms or diagnosis do not warrant treatment by injection’. The literature on this phenomenon indicates that a complex array of factors may influence the decision-making of both patients and healthcare providers. Providers may recommend injections and patients may welcome them because of widespread misconceptions about injected medications being stronger or more effective than other types of treatment (Safe Injection Global Network 2011). Even providers who know otherwise may feel pressured by patients to administer injections (Kotwal 2005; Safe Injection Global Network 2011) – and may be concerned that withholding injections will undermine their professional credibility (Kotwal 2005; Chowdhury et al. 2011). Furthermore, it has been suggested that some providers may be motivated to administer injections because of the profitability of this practice (Safe Injection Global Network 2011). We contacted the five Member States with national estimates of unnecessary injection levels of 5% or higher to obtain more information about why unnecessary injections occur. Three of them – Cuba, Mongolia and Pakistan – responded to this request, while two – Cambodia and Guyana – did not. (The two other Member States that reported national estimates of unnecessary injection levels were Denmark and Tonga, both of which indicated that no unnecessary injections take place).

Strategies and challenges for safe injection practice in developing countries

Injection is one of the important health care procedures used globally to administer drugs. Its unsafe use can transmit various blood borne pathogens. This article aims to review the history and status of injection practices, its importance, interventions and the challenges for safe injection practice in developing countries. The history of injections started with the discovery of syringe in the early nineteenth century. Safe injection practice in developed countries was initiated in the early twentieth century but has not received adequate attention in developing countries. The establishment of “Safe Injection Global Network (SIGN)” was an milestone towards safe injection practice globally. In developing countries, people perceive injection as a powerful healing tool and do not hesitate to pay more for injections. Unsafe disposal and reuse of contaminated syringe is common. Ensuring safe injection practice is one of the greatest challenges for healthcare system in developing countries. To address the problem, interventions with active involvement of a number of stakeholders is essential. A combination of educational, managerial and regulatory strategies is found to be effective and economically viable. Rational and safe use of injections can save many lives but unsafe practice threatens life. Safe injection practice is crucial in developing countries. Evidence based interventions, with honest commitment and participation from the service provider, recipient and community with aid of policy makers are required to ensure safe injection practice.

Assessment of injection-related practices in a tribal community of Andaman and Nicobar Islands, India

A survey to assess injection related practices carried out among the Nicobarese, a mongoloid tribe of Andaman and Nicobar Islands, India. The survey was carried out using the rapid assessment and response guide of Safe Injection Global Network of the World Health Organization and included review of randomly selected prescriptions of patients attending outpatient clinic of district hospital, interview and observation of injection providers in the district hospital and sub-centres and interview of the general population. The findings of the survey showed that 18.8% of prescriptions included at least one injection. The per capita injection rate was 3 per year. Majority of injections were administered with disposable syringe and needle and in hospital setting. All the injection providers were aware about possibility of HIV transmission through unsafe injections. However, the awareness among the general population was low. More than half of the individuals had preference to injections. It is suggested that remedial measures, such as education of prescribers to reduce the number of injections to a bare minimum, maintaining regular supply of disposable injection equipment, provision of adequate sharps containers with safe disposal facilities and community education be undertaken to avoid future spread of blood-borne pathogens.

Healthcare worker safety is a pre-requisite for injection safety in developing countries

Unsafe injection practices, including the re-use of unsterile needles and syringes, are commonplace in developing country health settings, and contribute substantially to the global burden of blood-borne viral disease. Unsafe injection practices place at risk not only patients, but also healthcare workers, who practice universal precautions inconsistently and are commonly exposed to blood in the course of their work. Global awareness of the link between unsafe injection practices and the burden of blood-borne viral disease was slow to emerge but has grown in the recent years. In 1999, the World Health Organization (WHO) established the Safe Injection Global Network (SIGN), which advocates a range of interventions for the promotion of injection safety. As well as exhorting healthcare workers to use a new needle and syringe for every injection, they should also be encouraged and supported to protect themselves from exposure to blood. It is argued here that promoting the occupational safety of healthcare workers in developing countries is an essential and currently under-valued component of the response to the problem of unsafe injection practices. Protecting healthcare workers from occupational infection with blood-borne viruses has a range of potential benefits, including safer injection practices for patients and less discrimination against people with HIV/AIDS. There is an urgent need for organisational commitment to the occupational safety of healthcare workers in developing countries, along with the provision of training in injection safety and universal precautions, adequate supplies of personal protective equipment, and hepatitis B vaccination.

Pre screening breast history in women participating in the prevalent screening round in the Norwegian Breast Cancer Screening Program

A survey to assess injection related practices carried out among the Nicobarese, a mongoloid tribe of Andaman and Nicobar Islands, India. The survey was carried out using the rapid assessment and response guide of Safe Injection Global Network of the World Health Organization and included review of randomly selected prescriptions of patients attending outpatient clinic of district hospital, interview and observation of injection providers in the district hospital and sub-centres and interview of the general population. The findings of the survey showed that 18.8% of prescriptions included at least one injection. The per capita injection rate was 3 per year. Majority of injections were administered with disposable syringe and needle and in hospital setting. All the injection providers were aware about possibility of HIV transmission through unsafe injections. However, the awareness among the general population was low. More than half of the individuals had preference to injections. It is suggested that remedial measures, such as education of prescribers to reduce the number of injections to a bare minimum, maintaining regular supply of disposable injection equipments, provision of adequate sharps containers with safe disposal facilities and community education be undertaken to avoid future spread of blood-borne pathogens.

Injection practices in Southern part of India

The World Health Organization defines ‘a safe injection’ as one that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in any waste that is dangerous to the community. Irrational and unsafe injection practices are rife in developing countries. The objective of the present study was to assess the injection practices in the state of Tamilnadu, India, using the Rapid assessment and response guide of the Safe Injection Global Network of the World Health Organization. Thirty-nine prescribers, 62 providers, and 175 members of the general public were interviewed. The areas were chosen out of convenience while at the same time adhering to the guidelines. The study was carried out between April and June 2001. The per capita injection rate was 2.4 per year. The ratio of therapeutic to immunization injections was 6.5:1, and the proportion of injections given with a disposable syringe and needle was 35.4%. Knowledge about diseases transmitted by unsafe injections, for example involving human immunodeficiency virus and hepatitis B virus, was greater among all the study groups. The annual incidence of needlestick injuries among providers was 23.6, which is extremely high. It is concluded that there are deficiencies in practice such as an excessive, unwarranted usage of injections, a sizeable prevalence of unsafe injection practices, the short supply of injection equipment leading to a high incidence of needlestick injuries, a low proportion of hepatitis B virus immunization among providers, and a lack of adequate sharps containers and disposal facilities in this part of India. It is suggested that immediate and long-term remedial measures, such as the education of prescribers to reduce the number of injections to a bare minimum, an adequate supply of injection equipment, provider protection with immunization for hepatitis B virus, the provision of adequate sharps containers with safe disposal facilities and, not least, community education, be undertaken to avoid the future epidemic of transmissible diseases.

Ensuring vaccine safety in immunization programmes — a WHO perspective

Ever since vaccines were firstly used against smallpox, adverse events following immunization have been reported. As immunization programmes expand to reach even the most remote communities in the poorest countries, it is likely that many more events will be temporally linked with vaccine administration. Furthermore, the profound shift in the general public and media interest in adverse events may lead to undue concerns and allegations which may ultimately jeopardize immunization programmes world-wide. While the health professional has understood this issue for some time, the public and the media have now also become all too aware of the significance of vaccine-related adverse events. The familiar vaccines, well-tested over decades, have not changed — but the perception regarding their safety has shifted. Claims outrageous or reasonable are being made against both the old and the newly-introduced vaccines. At the same time, the immunological and genetic revolution of the last decade may well bring to our notice some hypothetical risks that need to be addressed at pre-clinical level. WHO has been at the leading edge to guarantee vaccine safety for the last 30 years and will continue to do so. The Organization's plans for the next decade and beyond include the Safe Injection Global Network (SIGN), the development and introduction of safer technologies, and the prevention, early detection and management of AEFIs. The new technologies include needle-containing injection devices such as the autodisable syringe, as well as mucosal and transcutaneous immunization. Training will continue to be at the centre of WHO's efforts, limiting human error to a minimum. Mechanisms have been set in place to detect and respond to new and unforeseen events occurring. Above all, there is a willingness to respond to new climates and new technologies so that the Organization is in the best position to ensure safe immunization for all the world's children.

Immunization safety: A global priority – a major contribution of Canada's international immunization efforts

Immunization safety: A global priority – a major contribution of Canada's international immunization efforts