www.injectionsafety.org safe immunization practices and prevention of hepatitis b and c susan mackay...
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www.injectionsafety.org
Safe Immunization Practices and Prevention of Hepatitis B and C
Susan MackayBehaviour Change Project
Safe Injection Global Network (SIGN) SecretariatWHO, Geneva, Switzerland
www.injectionsafety.org
NGO UN
Governments
IndustryAssociations WHO SIGN Secretariat
SIGN participants and SIGN secretariat
www.injectionsafety.org
Injection Safety: Definition
• No harm to the recipient• No harm to the health-care worker• No harm to the community
Challenges
Reuse of equipmentUnsafe collection
Unsafe disposal
Injections given with sterile and unsafe equipment worldwide
0 2 4 6 8 10 12
Middle East Crescent
South Asia
Eastern Europe andCentral Asia
East and Southern Africa
South East Asia
China and Pacific
West Africa
Central Europe
South America
Number of injections per person and per year
Injections given withequipment re-used in theabsence of sterilization
Injections given with sterileequipment
Glo
bal B
urd
en
of D
i sea
se, 2
00
0
www.injectionsafety.org
Determinants of unsafe injection practices in immunization services
• System incentive to achieving high coverage– Vaccine usually funded through donors or lenders
• No system incentive to achieve safe injections – Injection equipment is not costed, budgeted, or
funded– “The sterilizable policy” smoke screen– Perception of injection safety as a “logistics” issue
rather than a prevention policy issue
www.injectionsafety.orgInjection preparation table, Pakistan, 1995
Reuse of disposable injection equipment
www.injectionsafety.orgInjection preparation table, Romania, 1998
No reuse of disposable injection equipment,other breaks in safety
www.injectionsafety.org
Injection safety beyond the use of new, disposable injection equipment
• Theoretical rationale– Experience from the dialysis environment – Persistence of HBV in the environment
• Ecological evidence – HBV and HCV infection among injection drug users
participating in needle exchange programmes – Association between injection and HBV infection in 1998
in Romania despite the absence of reuse of equipment
• Analytical studies– Association between “indirect sharing” and HBV
infection among injection drug users ** Bialek S. et al. US CDC EIS conference, 2001
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Proposed model for the transmission of HBV in various healthcare setting
Dialysis setting
Outpatient setting in low prevalence
area
? Prevalence of infection
? Exposure to blood
? Percutaneous exposures
? Prevalence of patients with high viremia
High risk Low risk
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Proportion of new HBV Infections attributable to unsafe injections, 2000
0% 20% 40% 60% 80%
AMR B
EUR B
AFR D
AMR D
SEAR B
WPR B
AFR E
EUR C
SEAR D
EMR D
World: 35%, N= 22.5 million
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Hepatitis B virus infection prevention
• Two prevention axis– Immunization of infants
(child cohorts) – Prevention of exposure to the virus,
including injection safety(older age groups)
• One common goal for GAVI– Protecting the adult
who is in every child
Patient with cirrhosis in Africa
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Proportion of new HCV infections attributable to unsafe injections, 2000
0% 20% 40% 60% 80% 100%
AMR B
AFR D
AMR D
EUR B
AFR E
SEAR B
WPR B
EUR C
SEAR D
EMR D
World: 55%, N= 2.7 million
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Assisting countries in implementing policies and plans
Assess
PlanImplement
Evaluate
The Quality Cycle
Benchmarking
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Assisting countries in implementing policies and plans
Benchmarking
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Outline of best practices
1. Use sterile injection equipment
2. Prevent contamination of injection equipment and medication
3. Prevent needlestick injuries to the provider
4. Prevent access to used needles
5. Other practice issues
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Assisting countries in implementing policies and plans
Assess
Benchmarking
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Rapid Assessment and Response Guide
Injection AdverseEvent
Injection Overuse
Unsafe InjectionPractices
Providers
System
Tool A available (focus group guide)
Tool B available(injection frequency survey)
Tool D available(Template for
epidemiological studies)
Tool C available(Based upon best practices)
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Assisting countries in implementing policies and plans
Assess
Plan
Benchmarking
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Safe and appropriate use of injections:proposed national strategy
• Initial assessment• National coalition• Three-element approach
1- Behaviour change2- Equipment and supplies3- Sharps waste management
• Monitoring and evaluation
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Assisting countries in implementing policies and plans
Assess
PlanImplement
Benchmarking
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Assisting in the implementation of policies for the safe and appropriate
use of injections• 1. Behaviour change
– Toolbox project in progress
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Assisting in the implementation of policies for the safe and appropriate
use of injections• 2. Provision of supplies
– Purchasing guide to ensure quality and safety– Inclusion in the essential drug list to ensure access
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Assisting in the implementation of policies for the safe and appropriate
use of injections• 3. Sharps waste management
– Integrated approach:• Policy• Streamlining waste management• Training• Choice of disposal options
– www.healthcarewaste.org
www.injectionsafety.org
Assisting countries in implementing policies and plans
Assess
PlanImplement
Evaluate
Benchmarking
www.injectionsafety.org
Monitoring impact
Outcomes Incidence of infections
ProcessesInjection frequency
Injection safety
Inputs Resources and activities
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Injection safety in immunization services
Challenges– Unsuccessful past efforts– History of narrow, technology oriented approach – Costs of injection safety initiatives – Conflict between the safety and coverage objectives– EPI cannot be responsible for the safety of all injections
Opportunities – Successful comprehensive approaches– Increasing recognition of holistic strategies– Promotion of responsible budgeting for EPI– Documentation of safe immunization coverage– EPI can spearhead and catalyse injection safety efforts
www.injectionsafety.org
Poor injection practices …
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