www.injectionsafety.org safe immunization practices and prevention of hepatitis b and c susan mackay...

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


NGO UN

Governments

IndustryAssociations WHO SIGN Secretariat

SIGN participants and SIGN secretariat


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

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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


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


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


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


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


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


Assisting countries in implementing policies and plans

Assess

PlanImplement

Evaluate

The Quality Cycle

Benchmarking



Benchmarking


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



Assess

Benchmarking


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)



Assess

Plan

Benchmarking


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



Assess

PlanImplement

Benchmarking


Assisting in the implementation of policies for the safe and appropriate

use of injections• 1. Behaviour change

– Toolbox project in progress



use of injections• 2. Provision of supplies

– Purchasing guide to ensure quality and safety– Inclusion in the essential drug list to ensure access



use of injections• 3. Sharps waste management

– Integrated approach:• Policy• Streamlining waste management• Training• Choice of disposal options

– www.healthcarewaste.org



Assess

PlanImplement

Evaluate

Benchmarking


Monitoring impact

Outcomes Incidence of infections

ProcessesInjection frequency

Injection safety

Inputs Resources and activities


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


Poor injection practices …

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