Don’t use used syringes

By Dr Arshad Altaf Published: July 28, 2013

According to the World Hepatitis Alliance, which is commemorating the World Hepatitis Day on July 28, there are 500 million people worldwide infected with hepatitis B or C, a number which is much higher than those suffering from HIV or any cancer. Pakistan is among those countries, which has one of the highest rates of hepatitis B and C infections. A national study in 2007 estimated that there are 12 million Pakistanis infected with these two life-threatening infections. The nationwide prevalence of hepatitis B is 2.5 per cent and that of hepatitis C is 4.9 per cent. Both these infections can be life-threatening and even if the treatment is provided free, it is a complicated and lengthy process with a varying success rate and has some very serious side-effects. While there are multiple causes of transmission of hepatitis B and C, ranging from unsafe blood transfusion, use of unsterilised surgical equipment, unsafe dental procedures, ear piercing or tattooing and shaving by barbers, the most established risk based on epidemiological research is unsafe injection practices by healthcare providers.

The World Health Organisation defines a safe injection as one that does not harm the recipient or the provider and does not result in waste that is dangerous to the community. Unfortunately in Pakistan, unsafe injection practices are very common and MBBS doctors, as well as untrained ones (quacks), prescribe unnecessary injections to patients. Another dangerous aspect is the reuse of single-use disposable syringe for economic reasons. Often the patient is so poor that she/he cannot afford to pay extra or the practitioner has a package deal in which some cheap medicines and an injection is part of the prescription. The reuse of disposable syringes still happens in Pakistan in this day and age, and is an intentional practice on part of the provider. The Safepoint Trust describes this practice in the following manner: “Syringe reuse is quite literally murder on a global scale.”

The Sindh government is sensitised on the issue and has been cognisant of this life-threatening practice. The Sindh cabinet approved the draft and the Sindh Assembly passed the Sindh Regulation and Control of Disposable Syringe Bill, 2010 on January 12, 2011. It has also become an Act of the Legislature of Sindh. The full Act is available at the official website of the Sindh Assembly. This action on part of the previous government must be appreciated as to the best of our knowledge, no other province has gone through this exercise.

The main clause of this Act under the heading of “Restriction” states that “no person shall manufacture, sell or use disposable syringes other that auto lock, auto destruct or auto break for injection, drawing of blood and other purposes.”  Under the heading of “Offence and Penalty”, it states that all directors, managers, secretaries or agents shall follow this Act, and those contravening will be punished with imprisonment for a term that may extend to two years or a fine which may extend to Rs500,000 or with both.

The key reason to pass this bill was to control the reuse of single-use disposable syringes, which as mentioned earlier, has been strongly associated with the spread of hepatitis B and C infections. Unfortunately, there are areas which still need improvement.

For the ease of readers, it should be clarified what an auto disable (AD) is. It is a type of syringe that was specifically developed to restrict the reuse on part of the providers. The syringe has a mechanism, which if used correctly, can make it difficult to reuse it after a single use. At the end of the procedure i.e., after administering an injection, a small force is applied on the plunger and there is a click sound, which practically locks the plunger, making the syringe hard to reuse. In many developed countries, the use of AD syringes is mandatory by law in healthcare settings.

Now coming to the gaps in the Act. The first major weakness is its lack of implementation. To the best of my knowledge, majority of public sector hospitals are still using and tendering conventional disposable syringes. It is safe to assume that medical superintendents or purchase departments are violating the law and can easily go to jail or be liable to huge fines. Most of these persons are probably not even aware of the Act.

The other problem in this Act pertains to the selling and manufacturing of AD syringes. Even though it states that no person shall manufacture or sell syringes other than AD, the Act has overlooked a very important condition, which is that the syringe has to conform to the standard set by the International Organisation for Standardisation Standard (ISO) 7886-4. Accordingly, the manufacturer of the syringe should also comply with the ISO Quality Systems Standards for Medical Devices Manufacturing ISO 13485. The language of this Act is such that at the moment, any supplier or manufacturer can provide any type of AD syringe and no one can legally question its quality or standard of manufacturing.

As an injection safety advocate and researcher, a major gap that I see in this Act is that it does not address the intentional reuse of syringes by healthcare providers. As mentioned earlier, this practice is still around and must be addressed in the form of a law. Prior to devolution, a team, of which I was a part, and other highly trained public health professionals, worked on several drafts of a similar kind of legislation. Even though it got stuck in the government’s bureaucratic system, it properly addressed this practice in detail. The poor and uneducated patient is often unaware of this kind of practice and rarely asks the provider if the syringe is new and opened from a sealed packet. No legislation is available in the province or at the national level, which addresses this issue.

In the end, to reiterate, it must be mentioned that this Act has some serious weaknesses in it. While it was being compiled, technical and public health experts should have been consulted. Making amendments in an existing legislation is a formidable task, knowing the political culture and wranglings that go around in the provincial legislature. Who will take the lead, who will revise it and who will improve it, remains a question for all concerned. One practical way is to form a provincial health promotion legislation committee, which should comprise relevant members of the provincial assembly, as well as public health professionals. They can work collectively to address weaknesses and gaps, and make improvement in this Act, which I am sure, was passed with all good intentions.

Published in The Express Tribune, July 28^th, 2013

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

Tropical Medicine & International Health

Early View (Online Version of Record published before inclusion in an issue)

Editorial

C. Gore¹, J. V. Lazarus^2,*, R. J. J. Peck¹, I. Sperle², K. Safreed-Harmon²

Article first published online: 23 JUL 2013

DOI: 10.1111/tmi.12151

© 2013 John Wiley & Sons Ltd

Keywords: hepatitis; injecting practices; public health; World Health Organization

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. 2009). 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. 2006).

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 injection-associated 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 1999). 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).

Respondents were given several possible reasons for the occurrence of unnecessary injections and were asked to choose ‘yes’, ‘no’ or ‘do not know’ for each one. All three countries indicated that healthcare workers believe injections to be more effective. Two indicated that patients prefer injections rather than oral medication. One indicated that oral equivalents are unavailable, although the other two indicated that this is not a reason for why unnecessary injections occur. Additionally, one country selected each of the following as a reason: healthcare workers believe that patients expect injections; healthcare workers are paid more for injections; and better adherence can be achieved through the use of injectable medicine as opposed to the oral equivalent. The survey also asked for examples of ‘a drug that is typically injected when a cheaper oral equivalent is also available’. Responses included antibiotics, diclofenac and vitamins.

It is our hope that the global hepatitis survey findings about unnecessary injection rates and follow-up survey findings will rekindle interest in a problem that may be causing widespread unnecessary suffering. In 2008, an estimated 14% of HIV infections were attributable to unsafe injections, as were 25% of hepatitis B infections, 8% of hepatitis C infections and 7% of infections with bacteraemia. These estimates collectively represented 28 million disability-adjusted life years (DALYs) (Safe Injection Global Network). Therefore, if even one tenth of unsafe injections globally in 2008 were cases in which the injection was not warranted, this would translate into a disease burden of 2.8 million DALYs attributable to unnecessary injections.

In actuality, it appears that estimating the global disease burden attributable to unnecessary injections would be a difficult task if at least 119 countries do not have national estimates for unnecessary injections. The lack of data gives rise to the first of four recommendations regarding how to reduce unnecessary injections. Tracking the incidence of unnecessary injections – understood as providing an injection when an oral equivalent is available – at the country level is essential for determining the magnitude of the problem and measuring progress on the response. Governments are urged to incorporate this metric into ongoing health system monitoring, including tracking it as a mode of transmission for all bloodborne viruses.

Our second recommendation calls for a more concerted global effort to reduce unnecessary injections. This issue is already on the agenda of the Safe Injection Global Network (SIGN), which since its inception in 1999 has provided leadership in the campaign to reduce unsafe injections. Given that SIGN and WHO now have a toolkit and other resources in place to help countries address the general problem of unsafe injections (Safe Injection Global Network), it is logical to focus more on increasing awareness of the contribution of unnecessary injections to disease transmission. Furthermore, the toolkit might be expanded with tools such as a global guidance document that informs decision-making around whether injections are warranted and identifies commonly injected medicines that should be replaced with oral equivalents. The latter might require WHO to carry out a review of the evidence regarding oral versus injectable drugs. Guidance is also needed on how to stage information, education and communication interventions to change perceptions among both health providers and the general public in regard to the role of injections in health care.

As for our two other recommendations, an informative body of evidence provides insight into the behavioural, economic and structural drivers of unnecessary injecting in healthcare settings, but the majority of these studies are more than a decade old. Health systems in many countries have undergone extensive changes in recent years, and research is needed to illuminate the dynamics behind current injecting practices. Finally, with the intensification of efforts to reduce unnecessary injections, research will also be needed to measure progress and to refine interventions, with particular attention given to how interventions should be adapted to address different drivers of the problem in different countries and cultures.

WHO research indicates that interventions to reduce unnecessary injections are cost-effective, as are interventions combining these activities with efforts to also reduce unsafe injections (World Health Organization 2003). WHO, SIGN and government authorities must work in collaboration with medical associations, nursing associations and civil society partners such as patient advocacy groups to take stock of this problem and develop country-specific strategies for its resolution. The WHO Director-General's upcoming injection safety initiative has the potential to serve as the backbone of this effort by increasing the global focus on unnecessary injections. Strong leadership on this issue is a moral imperative: it is simply unacceptable for the provision of medical treatment to be a pathway for large-scale disease transmission, suffering and death.

References

Altaf A, Janjua NZ & Hutin Y (2006) The cost of unsafe injections in Pakistan and challenges for prevention program. Journal of the College of Physicians and Surgeons Pakistan 16, 622–4.

Bodenschatz C, Talaat M, Kandeel A, Lohiniva AL, Radwan E & Mahoney F (2009) Injection prescribing patterns in public health care facilities in Egypt. East Mediterranean Health Journal 15, 1440–8.

Chowdhury AK, Roy T, Faroque AB et al. (2011) A comprehensive situation assessment of injection practices in primary health care hospitals in Bangladesh. BMC Public Health 11, 779. doi: 10.1186/1471-2458-11-779.

Kotwal A. (2005) Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices. Social Science and Medicine 60, 1133–47.

Safe Injection Global Network (2011) Advocacy Booklet. http://www.who.int/injection_safety/sign/sign_advocacy_booklet.pdf.

Safe Injection Global Network. Report of the SIGN2010 meeting. http://www.who.int/injection_safety/toolbox/sign2010_meeting.pdf.

Simonsen L, Kane A, Lloyd J, Zaffran M & Kane M (1999) Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bulletin of the World Health Organization 77, 789–800.

World Health Organization (2003) Managing an injection safety policy. http://www.who.int/injection_safety/toolbox/en/ManagingInjectionSafety.pdf

World Health Organization (2010) WHO best practices for injections and related procedures toolkit. http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf

World Health Organization (2013) Global Policy Report on the Prevention and Control of Viral Hepatitis in WHO Member States Geneva.

Yan Y, Zhang G, Chen Y, Zhang A, Guan Y & Ao H (2006) Study on the injection practices of health facilities in Jingzhou district, Hubei, China. Indian Journal of Medical Sciences 60, 407–16.

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