MISUSE AND OVERUSE OF INJECTION WORLDWIDE
Injection is one of the most common health care procedures. Each year at least 16 billion injections are administered in developing and transitional countries. The vast majority, around 95%, are given in curative care. Immunization accounts for around 3% of all injections, with the remainder for other indications, including use of injections for transfusion of blood and blood products and contraceptives.
In certain regions of the world, use of injections has completely overtaken the real need, reaching proportions no longer based on rational medical practice. In some situations, as many as nine out of ten patients presenting to a primary healthcare provider receive an injection, over 70% of which are unnecessary or could be given in an oral formulation.
Patients tend to prefer injections because they believe them to be stronger and faster medications. They also believe that doctors regard injections to be the best treatment. In turn, doctors over-prescribe injections because they believe that this best satisfies patients, even though patients are often open to alternatives. In addition, prescription of an injection sometimes allows the charging of a higher fee for service. Better communication between patients and providers can clarify these types of misunderstandings and help to reduce injection overuse.
UNSAFE INJECTION PRACTICES: A PLAGUE OF MANY HEALTH SYSTEMS
A safe injection does no harm. However, when safety control practices are not respected, severe infections can result, putting human lives at risk.
Reuse of syringes and needles in the absence of sterilization exposes millions of people to infections. Assessments carried out in numerous countries have revealed that syringes and needles are often just rinsed in a pot of tepid water between injections. Worldwide, up to 40% of injections are given with syringes and needles reused without sterilization and in some countries this proportion is as high as 70%.
Other unsafe practices, such as poor collection and disposal of dirty injection equipment, expose healthcare workers and the community to the risk of needle stick injuries. In some countries unsafe disposal can lead to re-sale of used equipment on the black market. The proportion of non industrialized countries still reporting that they use open burning of syringes (considered unacceptable by WHO) was 50% in 2004.
BURDEN OF DISEASE ASSOCIATED WITH UNSAFE INJECTION PRACTICES
The most recent study* indicates that each year unsafe injections cause an estimated 1.3 million early deaths, a loss of 26 million years of life, and an annual burden of USD 535 million in direct medical costs.
Unsafe injection practices are a powerful engine to transmit blood-borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Because infection with these viruses initially presents no symptoms, it is a silent epidemic. However, the consequences of this are increasingly recognized.
- Hepatitis B virus: HBV is highly infectious and causes the highest number of infections: in developing and transitional countries 21.7 million people become infected each year, representing 33% of new HBV infections worldwide
- Hepatitis C virus: Unsafe injections are the most common cause of HCV infection in developing and transitional countries, causing two million new infections each year and accounting for 42% of cases.
- Human immunodeficiency virus: Globally nearly 2% of all new HIV infections are caused by unsafe injections. In South Asia up to 9% of new cases may be caused in this way. Such proportions can no longer be ignored.
HBV, HCV, and HIV cause chronic infections that lead to disease, disability and death a number of years after the unsafe injection. Those infected with hepatitis B virus in childhood will typically present with chronic liver disease by the age of 30 years, at the prime of their life. This has a dramatic effect on national economies.
*The cost of unsafe injections by M.A. Miller & E. Pisani: Bulletin of the World Health Organization, Vol. 77, no 10, 808-811.
SAFE AND APPROPRIATE USE OF INJECTIONS IS WITHIN OUR GRASP
Unsafe injection practices are often viewed as a chronic problem with no easy solution. However, safe and appropriate use of injections can be achieved by adopting a three part strategy:
(1) Changing behaviour of health care workers and patients
Twenty years into the HIV pandemic, knowledge of HIV among patients and health care workers in some countries has driven consumer demand for safe injection equipment and irreversibly improved injection practices. With growing knowledge of HCV and HBV, similar patterns of consumer demand for safe injections should emerge. HIV prevention programmes can be expanded to include injection safety components.
(2) Ensuring availability of equipment and supplies
Simply increasing the availability of safe injection equipment can stimulate demand and improve practices. Because the cost of safe disposable syringes is low (less than 5 US cents per unit) when compared to the fee paid for receiving an injection (50 US cents on average), patients are usually willing to pay a little extra for safety once they personalize the risks.
(3) Managing waste safely and appropriately
As waste disposal is frequently not an integral part of health planning, unsafe waste management is common. However, when it is appropriately planned, significant results ensue. National health care waste management strategies require a national policy to manage health care waste, a comprehensive system for implementation, improved awareness and training of health workers at all levels, as well as the selection of appropriate options for the local solutions.
WHAT IS WHO DOING TO IMPROVE INJECTION SAFETY?
WHO hosts and coordinates the Safe Injection Global Network (SIGN), which assembles all major stakeholders to promote and sustain injection safety worldwide. Through the network, WHO provides advice and a series of policy, management and advocacy tools to help countries access safe, affordable equipment, promote the training of health staff and rational use of injections.
Guidance, policy and advocacy tools
WHO develops and updates a series of evidence-based resource materials on best practices for injection safety, waste management, health care worker protection and infection control. These resources are published online and distributed to countries. The SIGN secretariat also regularly provides data to assist countries for decision making, including tools to assess the state of injection safety in health care facilities, analyses of global burden of disease data resulting from unsafe injections, and cost effectiveness analyses for injection devices.
Support to achieve quality and safety of injection devices
In collaboration with the International Organization for Standardization and the International Association of Safe Injection Technologies (the umbrella organization of injection devices manufacturers), WHO has developed a specification standard for auto-disable syringes for immunization and curative purposes. The specification can be used by national regulatory authorities for product review or by national authorities for procurement.
To prevent injection overuse in the curative sector, WHO urges that countries’ national drug policies promote the rational use of therapeutic injections. This may include removing unnecessary injectable medicines from the national essential medicines list.
Support to increase access
In 2004, WHO developed "Guiding Principles to ensure injection device security", reaffirming the need to ensure bundled supply of injectable medicines, appropriate diluents, single use injection devices and safety boxes in sufficient quantities in each health care facility. This requires appropriate forecasting for financing, procurement and supply management.
To further assist countries, WHO has developed a procurement guide for single use syringes and safety boxes. WHO urges donors and lenders who finance injectable products to also finance appropriate quantities of items and the cost of sharps waste management.