I. Definition of Prevention Area
Addressing injection safety helps prevent the medical transmission of HIV and other blood-borne pathogens to patients and health care workers. Injection safety falls under the umbrella of health systems strengthening and encompasses safe medical injection, safe phlebotomy practices, safe disposal of health care waste, and the provision of post-exposure prophylaxis (PEP) following occupational exposure to HIV.
Many countries lack the policies and guidelines necessary to support injection safety practices. Health care workers without proper training and commodities for safe injection, infection control, and health care waste disposal practices may expose patients, providers, and communities to HIV.
In many countries, the problem of unsafe injections is further compounded by patients' and health care providers' perceptions, often culturally based, that injections are more effective than non-injection alternatives. Often, an economic incentive exists for health care providers to provide an injection because of higher fees for injection-based treatments. Further, health care providers are often not trained in injection safety or in counseling patients on non-injection treatment alternatives. Patients' high demand for injections and health workers' willingness to provide them results in a high volume of medically unnecessary injections. The number of phlebotomy and injection procedures performed has increased in recent years related to the rapid scale-up of prevention, testing, and treatment services provided by local governments and by programs funded through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). These factors create a greater need for new, sterile injection equipment and safe disposal strategies for the health care waste that is generated. Commodity procurement and distribution often reveal multiple, undocumented procurement mechanisms, insufficient planning, challenges with distribution, and lack of quality standards for injection equipment.
II. Epidemiological Justification for the Prevention Area
The World Health Organization (WHO) is currently engaged in an exercise to estimate the global burden of unsafe injection, the results of which are expected in 2011. Currently available data from WHO date to 2000. These data estimate that of the 16 billion injections administered annually in developing and transitional countries, at least 50 percent are unnecessary and unsafe; observations conducted between 1987 and 1998 found rates of unsafe injection higher than 50 percent in numerous countries. WHO estimates from 2000 indicate that unsafe injections are responsible for 5 percent of HIV infections, 32 percent of hepatitis B virus infections, and 40 percent of hepatitis C virus infections. Other data suggest a range of estimates with both higher and lower values; WHO's 2011 estimates are eagerly anticipated to resolve discrepant estimates and assess progress since 2000.
Over the last decade, evaluation data suggest that comprehensive injection safety programs have expanded the availability of guidelines, increased the use of new syringes and needles with every injection, improved health care waste management, and increased understanding of the importance of injection safety for patients, health care workers, and the wider community.
III. Core Programmatic Components
PEPFAR activities are based on the strategy recommended by WHO and the Safe Injection Global Network to reduce unsafe and unnecessary injections and limit the transmission of HIV, which has been expanded to include:
- Advocacy to make injection safety and health care waste management a priority among decision makers at the national level and health service providers at the facility level
- Building health worker capacity for safe injection through the development of preservice and in-service curricula and through strengthened systems of supportive supervision
- Behavior change communication among patients and health care workers to reduce unnecessary injections and achieve injection safety
- Advocacy for health worker safety through access to PEP and through the routine provision of the hepatitis B vaccination to all health practitioners
- Support for the procurement of necessary commodities for safe injection and health care waste management
- Support for safe and proper health care waste management practices
- Developing and updating standard, evidence-based treatment guidelines for common ailments to promote non-injection treatment alternatives.
IV. Current Status of Implementation Experience
Since 2004, PEPFAR has supported initiatives to prevent the medical transmission of HIV in Africa and the Caribbean by implementing comprehensive injection safety programs that include the elements previously delineated. Five-year follow-up assessments in 11 of the countries awarded PEPFAR funding for injection safety indicate that progress has been made; for example, almost all the countries developed a national injection safety policy and health care waste management plan. In addition, all countries have increased ownership of and sustained their injection safety initiatives through multidisciplinary participation in injection safety committees. Follow-up assessments conducted at intervention facilities also indicate a reduction in needle stick injury as reported by health workers, attributed to improved training in core practices such as not recapping used needles and properly disposing of used needles/syringes immediately in a sharps container.
Countries have developed tools for monitoring the use of safe injection and health care waste management supplies. These tools provide accurate data on the consumption of supplies and are used at the country level to advocate for resources for commodities. Logistics managers use the data to manage commodities proactively and ensure that commodities are available at service delivery points. Countries have been introduced to single-use safe injection technologies, and many countries have transitioned to self-procurement of these commodities.
The number of health care facilities that practice proper health care waste segregation in countries with injection safety programs has increased. Capacity building efforts have enabled national and local partners to develop health care waste management plans and advocate for resources. Health care workers have been increasingly sensitized to the critical role that everyone at a health facility--not just waste handlers--can play in health care waste management.
Advocacy efforts to government ministries have been effective in bringing necessary resources to support injection safety efforts. For example, some governments now vaccinate health care workers against hepatitis B and provide personal protective equipment. Injection safety projects and their partners have trained health care workers on PEP treatment guidelines and have advocated to assure the availability of PEP to health care workers.
Phlebotomy, which poses a recognized HIV risk for health care workers, was not initially included in PEPFAR's injection safety initiatives. Country-specific data assessing the burden of phlebotomy on HIV transmission are generally unavailable to inform development of a strategy for safe practices. While guidelines on safe phlebotomy practices were developed by WHO in 2010, work remains at the country level to assess current practices and develop a response.
Best injection safety practices developed under currently funded PEPFAR country programs could be modeled to improve injection safety in other countries. While injection safety efforts began following a vertical model, this issue is cross-cutting and there must be movement toward integration as a component of efforts to strengthen health systems.
This report on the impact of a Making Medical Injections Safer project compares the use of injections before and after an intervention to train health workers in rational injection use and to promote community-level behavior change. The study analyzes injection prescriptions by facility and patient characteristics. In four of the five districts studied, there was a significant reduction in the irrational use of injections, but the prevalence remains high, at approximately double the target of 15 percent. The authors recommend continued efforts to reinforce the promotion of non-injectable treatments.
Using data from a nationally representative, population-based behavioral survey, this study found that a quarter of the male respondents and a third of the female respondents had received at least three medical injections within the previous 12 months. HIV prevalence was significantly higher among those who had received five or more medical injections versus those who had received none, even after adjusting for a wide range of confounding factors. The authors acknowledge that their data was subject to some measurement constraints and possible selection bias but still conclude that their findings support the need for programs to encourage the rational use of injections.
This technical brief puts injection safety in the wider context of HIV transmission prevention in health care settings, as one of a range of primary prevention mechanisms that also includes blood safety, surgical care, waste disposal, and occupational health. It provides a summary of the global burden of HIV associated with medical injections, a checklist of operational considerations when developing HIV interventions for health care settings, and details of specific activities that can be implemented to promote safe injections. There is also a list of key World Health Organization resources on HIV in the health care setting.
This editorial describes some of the major developments in the last two decades' in reduction of occupational injuries due to contact with needles, other sharp devices, and blood. In the United States and other industrialized countries, the advent of antiretroviral drugs has enabled more effective post-exposure prophylaxis and dramatically reduced the number of inpatients living with HIV. There has also been a trend away from using needles wherever possible, substituting needles with a range of devices designed to protect the user from sharps injuries, a practice that needs to be extended beyond the industrialized world, the author writes. The article urges greater protection against injection-related injuries for health care workers worldwide.
This document emphasizes the key role that standard precautions play in the prevention of infection in health care settings. It summarizes the elements of the most basic level of infection control measures in health care--an infection control policy, hand hygiene, personal protective equipment, cough etiquette, environmental cleanliness, waste disposal, and prevention of sharps injuries. There is a checklist and a one-page summary of the key elements of standard precautions, with particular emphasis on hand and respiratory hygiene techniques. It is useful for developing strategies and interventions in infection prevention and control, including injection safety, in health care settings.
This fact sheet describes the extent of injection misuse and overuse in health care settings, fuelled by misguided demand from patients and irrational use by doctors. It explains how reuse of unsterilized needles and syringes, as well as inadequate disposal and black market resale of injecting equipment, all put lives at risk. There is also a summary of the burden of injection-related disease, notably HIV and hepatitis B and C. It highlights changing the behavior of patients and health care workers, ensuring adequate supplies of safe injection equipment, and proper waste management as key components of HIV prevention programs targeting injection safety.
National case surveillance data on occupationally acquired HIV infections shows that there is a fourfold higher incidence of such infections among female health care workers than their male counterparts. Nurses account for over two-fifths of all occupationally acquired cases of HIV. Hollow-bore needles used in phlebotomy caused almost all of the percutaneous exposures detected by surveillance. Safe use and disposal of needles, adoption of needleless procedures, and safety-engineered devices should be promoted as key components of a range of protective measures, the authors write. Employers are urged to continually monitor preventive measures and educate their employees about ways to reduce the risk of exposure to HIV.
This review brings together evidence from published studies and unpublished World Health Organization reports to show that the vast majority of injections in developing countries are therapeutic, most are unnecessary, and up to half are unsafe. Whereas the risk of needle-stick injuries in the general population has been almost eliminated in developed countries, it remains a significant threat to patients in developing countries. In some of the studies reviewed, unsafe injections were linked to blood-borne infections. Although injections account for a small proportion of HIV infections relative to sexual- and drug use-related transmission, they expose populations that would not have otherwise been at risk.
This article describes the results of a pilot program for safe disposal of insulin syringes and needles. The program gave diabetics in Guyana a month's supply of insulin syringes and one of four types of syringe disposal containers. It also initiated a disposal box return program at health facilities, trained pharmacists and diabetes clinic nurses in counseling skills, and trained waste handlers in safe disposal of the containers brought by patients back to clinics. The program dramatically reduced needle reuse, and patients returned syringes to clinics for disposal. Empty tablet containers and containers that clients had found themselves were the most popular choice because they incurred no cost.
These guidelines aim to promote best practices in phlebotomy to protect both health care workers and patients and improve the quality of blood samples. They provide practical guidance on phlebotomy, with chapters dedicated to different aspects--blood sampling systems, blood donation, arterial and capillary sampling, and drawing blood from children and infants. Implementation, monitoring, and evaluation are covered in detail. There are also line drawings to illustrate safe phlebotomy techniques, a table comparing blood drawing devices, checklists for infection prevention and control best practice, a description of content required when training phlebotomists, and a useful glossary.
This report highlights recent outbreaks of viral hepatitis at outpatient clinics, dialysis centers, and long-term care facilities in the United States to show that improper use of syringes, needles, and medication continues to happen even in developed countries. It refutes commonly held myths about injection safety (e.g., that changing the needle is sufficient to avoid contamination and that devices need only to be cleaned when there are visible contaminants). Boxes summarize injection safety information, recommendations for safe practices, and frequently asked questions. The authors conclude by calling on health care providers everywhere to review their injection safety procedures.
This workbook is divided into sections on the organizational steps and operational processes in implementing a sharps injury prevention program. The target audience includes health care administrators and program managers, helping them to assess their facility's injection safety program, to document planning and prevention activities, and to evaluate injection safety interventions. There is a detailed description of a sharps injury prevention program with tools such as forms and report templates for every step of the process. Once implemented, the program can help health care facilities gain accreditation and meet regulatory requirements. The workbook also provides guidance for calculating the cost of sharps injury and their prevention.
This report, in response to an HIV epidemic among children caused by poor infection control and contaminated blood, found that although there is strong awareness of infection control among hospital staff, there is a chronic shortage of resources to train and protect them. Gap analysis details shortcomings in many areas from hand hygiene, injections, and blood drawing to waste management, supply management, and worker supervision. There are detailed recommendations to strengthen the health care system, improve training, build capacity, and make infection prevention and control commodities more available. The report also provides several tools for the assessment of health facilities, policies, and training.
This report spells out the case for quality improvement in health care and the role of a structured improvement method known as an improvement collaborative, whereby different teams use the same indicators and work collaboratively to implement best practices and improve quality of care. The essential elements of this approach are shared objectives, adequate support for teams testing changes, a clear definition of changes to be made, regular performance measurement, shared learning, and a strategy to disseminate best practices. It outlines the key phases for implementing improvement collaborative--preparation, implementation, and dissemination, with detailed bullet points for each stage. This approach was adapted for quality improvement by the injection safety project in Zambia.
Drawing on experience gained during numerous technical assistance projects in the region, this manual provides tools for the assessment and planning of health care waste management that are specifically applicable to countries in sub-Saharan Africa. It offers guidance in four sections, starting with the fundamentals of health care waste management. Guidance sections for national assessment, as well as for the development and implementation of a national health care waste management plan, follow. Jointly developed by the World Health Organization and the Secretariat of the Basel Convention, the manual harmonizes both the waste management and public health dimensions of safe disposal of medical waste.
This manual is aimed at raising awareness of the risks of improper handling and disposal of sharps, to define the roles of staff involved in sharps waste management, and to provide staff with the information they need for proper disposal. Topics covered include health care worker safety, waste segregation, use of safety boxes, sharps disposal, and destruction of used supplies. Each chapter opens with a set of PowerPoint slides. More detailed information is presented in an accessible question-and-answer format with plenty of illustrations. There are also guidance notes for the trainer.
This joint statement reiterates the policy of the three U.N. organizations to supply vaccines bundled together with auto-disable syringes and safety disposal boxes for used syringes and needles. Partners in the financing of immunization programs are requested to finance only auto-disable syringes and incorporate safe waste management into their immunization projects. The statement reaffirms the U.N. Children's Fund policy of only allowing its funded projects to procure auto-disable and not standard disposable syringes. The human and financial costs of unsafe injections are covered, as well as the extent of vaccination in many countries and its increasing use in disease control and prevention.
This manual provides a framework for a national injection safety policy incorporating benchmarking, assessment, planning, implementation, and evaluation. It is targeted at national-level public health managers as well as their national and international partners. The document sets targets for indicators of injection practices and details the objectives, indicators, and cost elements of an injection safety action plan. Appendices include data on the burden of disease caused by unsafe injections, best practice guidelines, a template agenda for a national injection safety planning workshop, and cost-effectiveness data. A list of 10 key resources rounds out the guide.
This toolkit was designed to meet the training and daily practice needs of all health care workers, specifically those who give injections, draw blood, or manage medical waste, as well as administrators and infection control policymakers. It covers all types of needle injections, phlebotomy, and lancet procedures. The format, with many summary tables, step-by-step practice guides, checklists, and copious illustrations, makes the standard precautions information accessible and easy to follow. In addition to information on injection safety, there is a chapter on occupational risks and management of blood-borne pathogens, including guidance on the post-exposure management of HIV and hepatitis B and C. The content can be easily reproduced as posters, flash cards, and spreadsheets for use in training and education.
The 14 interrelated guidelines described in this guidance note are presented as a package and comprise national policies covering rights, legislation, and social protection; workplace policies, programs, and training; and policies covering budget, monitoring, and evaluation. They are aimed at policymakers in labor, health, and national HIV policy, and at health care workers in both the public and private sectors and their professional associations and unions. The workplace guidelines include education of health care workers on infection control and HIV prevention. Primary prevention of exposure to blood-borne pathogens is one of the main priorities of the guidelines.
This training participants' manual was developed for use in Tanzania and provides users with a detailed reference source for injection safety theory and practice. It was developed for training of health care workers to improve injection safety through behavior change, supply management, and safe handling of health care waste. There are chapters on communication about injection safety and preventing infection as well as the practicalities of safe injection. Although some of the information is specific to Tanzania, most of the contents of the manual have wider applicability. Training evaluation tools and a detailed glossary are included in the manual.
This report commissioned by the Global Alliance for Vaccines and Immunization (GAVI) examines its injection safety support program, which gave commodity and cash aid to 58 national immunization programs over a three-year period. The report found that once GAVI support for injection safety ended, all countries receiving commodities were able to replace and sustain the supply of auto-disable syringes and safety boxes, and those receiving cash also continued to use these safe injection tools. The GAVI project also had a broader positive impact on injection safety due to raised awareness of injection safety, but increased demand did not result in reduced prices for auto-disable syringes.
Written as a companion document to Do No Harm: Injection Safety in the Context of Infection Prevention and Control: Training of Trainers Facilitation Guide, this book brings together materials that have already been used in World Health Organization programs in Africa. It comprises injection safety training activities, lesson plans, teaching materials, and job aids. There are practical exercises for training activities aimed at changing behavior, such as practicing injection safety, encouraging patients to accept oral medication, and overcoming fear of reporting needle-stick injuries. There is an extensive collection of handouts for use on the job or in training sessions, as well as job aids such as checklists and posters.
Tool C is used for the assessment of injection safety, phlebotomy, lancet procedures, intravenous injections, and infusions. This tool is standardized, simple enough to be used by trained field workers, and flexible enough to be implemented in a range of different facilities including outpatient departments, immunization programs, laboratories, and blood transfusion services. Tool C provides procedural guidelines for sampling, data collection, data entry, and analysis and reporting. There are tables that can be used to record indicators of risk to patients, providers, and the community. The tool also includes a proposed schedule for facility assessments and a data collection instrument.
Written as a companion document to Do No Harm: Injection Safety in the Context of Infection Prevention and Control: Training Tools and Job Aids, this guide can be used by managers, policymakers, and health care workers responsible for injection safety to plan in-service training for operational level staff. There is a chapter on facilitation, which outlines the basic skills of effective adult training, as well as lesson planning and selection of teaching methods and materials. There are sample schedules for training modules on infection prevention, safe injection practices, and management of both supplies and waste. Case studies are used where appropriate to encourage group work and problem solving.
This guide can be used to conduct a study into the burden of disease associated with sharps injuries, notably infection with HIV and hepatitis B and C. The guide can help to specifically target protection measures by assessing the number of such infections attributable to sharps injuries and how many infections could be avoided with the use of post-exposure prophylaxis. There is a completed example of an assessment using the guide. Tables provide estimates of hepatitis and HIV prevalence, sharps injuries, and hepatitis B vaccination coverage in the World Health Organization (WHO) regions, but the latest data used are from 2001. The WHO aide-memoire for health care worker safety is also included.
Health care workers can use this set of Excel spreadsheets to observe injection practices and assess safety. There are six versions in all: four for use on a computer and two that can be used in hard copy. There are versions covering selected aspects of injection safety and versions using the full set of 36 questions and observations. All can be used as a checklist for hospitals and other health care facilities. There are questions designed to elicit information from health facility directors, injection providers, and medical waste handlers; recommended observations include storage, injection administration, and waste management facilities.
This two-page document from the World Health Organization (WHO) describes the background to injection safety, including the extent of unnecessary and unsafe injections worldwide, particularly in developing and transitional countries. It describes the range of sterile, single-use injection devices available and spells out WHO's policy on injection safety practices. WHO urges the phasing out of reusable injection devices and calls for single-use devices and safety boxes for disposal to be provided whenever injectable products are supplied. The document directs readers to the WHO's injection safety website, www.injectionsafety.org, where there are tools for assessment planning, implementation, and evaluation of injection safety policies.
The Centers for Disease Control and Prevention Injection Safety Page
This Centers for Disease Control and Prevention (CDC) website has information for both providers and patients, including educational materials, presentations, and frequently asked questions. There are guidelines on preventing unsafe injection practices and an introduction to The One & Only Campaign, led by the CDC and the Safe Injection Practices Coalition to promote safe injections. Recent publications related to injection safety are also available for download from the website.
Global Alliance for Vaccines and Immunization
This website has information about the Global Alliance for Vaccines and Immunization (GAVI) support for injection safety in immunization programs. There is information about GAVI funding toward the cost of adequate supplies of auto-disable syringes, reconstitution syringes, and safety boxes for national immunization programs. The site also contains a report produced in 2009 evaluating GAVI's injection safety support efforts.
Health Care Without Harm
Health Care Without Harm's website details the work done by this nongovernmental organization and its partners to promote health care practices that do not contribute to disease or ecological damage. Medical waste management is a key issue, and the site has information on waste minimization, alternatives to incineration, and a medical waste project in the Philippines that demonstrates how medical waste from a large-scale immunization campaign can be handled responsibly and safely without recourse. There are downloadable resources on a range of medical waste management issues including a global inventory of alternative medical waste treatment technologies and the health impact of incinerators.
Making Medical Injections Safer Project
John Snow, Inc.
This website comprises an overview of the Making Medical Injections Safer (MMIS) project and country program highlights with reports from 11 countries in Africa and the Caribbean. Project information includes an overview of technical information on sustainable approaches to injection safety supported by MMIS, program achievements, and lessons learned. There is a wide range of resources including training manuals, guidelines, reference materials, and materials for advocacy and behavior change communication.
U.S. President's Emergency Plan for AIDS Relief Issue Brief: Medical Injection Safety
This web page details the involvement of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in medical injection safety programs in 16 countries, including support for national safe injection policies, adoption of safe injection practices, purchase of safe injection equipment, and facilities for safe sharps waste disposal. The page cites examples of PEPFAR-supported projects to reduce excessive injections in Namibia and Uganda, sharps waste management training for health care workers in Tanzania, and safe sharps disposal in Kenya. The site also has links to useful resources from USAID and other organizations.
SAVE LIVES: Clean Your Hands: The World Health Organization's Global Annual Campaign
This section of the World Health Organization (WHO) website promotes its annual hand hygiene campaign, SAVE LIVES: Clean Your Hands, including resources to support national hand hygiene activities and advocacy resources for use in health care settings. Key documents on the site include the WHO guidelines on hand hygiene, and an implementation guide for WHO's multimodal hand hygiene improvement strategy. There are hand hygiene-related videos and tools for specific topics, including alcohol hand rub costing, evaluation and feedback, and workplace hand hygiene reminders. The information center contains locally adapted tools and media materials.
Safe Injection Global Network/World Health Organization.
The home page of the SIGNpost forum provides access to the Safe Injection Global Network (SIGN) Internet forum, where subscribers can post messages, comments, and requests for technical information relating to injection safety. Subscribers can receive a weekly email newsletter on safe and appropriate use of injections. The site also has a link to SIGNpost archives and files.
Technical Network for Strengthening Immunization Services
This website provides a forum for discussion, debate, and information sharing on the delivery of immunization services. There are reports from TechNet21's consultation meetings, operations, and surveys, and the website's e-forum enables professionals to share ideas via online forums and discussions. The tools and resources page includes a database of experts, job announcements, reference documents, and tools for resource planning and staff training. There is an extensive library of immunization-related books and research papers, as well as immunization fact sheets from 16 Asia-Pacific countries, a news page, and links to useful websites.
Injection Safety; The Dangers of Unnecessary Medical Injections and Mishandling of Medical Waste
U.S. Agency for International Development.
This website provides information about injection safety interventions supported by the U.S. Agency for International Development, including the Making Medical Injections Safer project, which runs injection safety program in 11 countries in Africa and the Caribbean. There is also a report on a health care waste management project in Uganda run by U.S. President's Emergency Plan for AIDS Relief partners.
World Health Organization Patient Safety
This section of the World Health Organization website gives access to a wealth of patient safety information and resources, from research to education and training. Much of the material is useful for health care workers, including introductory online courses, curriculum guides for teaching patient safety to medical students, and tools to support implementing change in patient safety practices. However, there are also resources for patients such as details of national patient safety workshops and events. An information center brings together a wide range of resources on patient safety, comprising both written materials and visual media.
World Health Organization/Safe Injection Global Network
This website introduces the Safe Injection Global Network (SIGN) and provides access to its meeting reports and weekly electronic newsletters. It is also a focal point for the World Health Organization's (WHO's) training tools and publications on injection safety, including the WHO best practices for injections and related procedures toolkit, the Tool C injection safety assessment tool, and related information.