Injections are a widely administered medical intervention. Every year, around 16 billion individual injections are administered worldwide. However, while intended to promote better health, sometimes injections can have the opposite outcome. This happens when injections are used unsafely -- reuse of injection equipment, accidental needle stick injuries, improper sharp biomedical waste management or the overuse of injections. Improper practices can lead to the transmission of life-threatening infections such as Hepatitis B, Hepatitis C and HIV.
Unsafe use and disposal of medical injections among others are estimated to have been responsible for up to 38% of Hepatitis C infections, 46% of Hepatitis B infections and 12% of HIV infections in India.
Of the nearly 3 billion injections administered annually in India, 1.89 billion are estimated to be unsafe due to inadequate sterilization, use of faulty techniques or unsatisfactory injection waste disposal. The large proportion of people put at risk cannot be ignored.
Unsafe injection practices not only expose patients to the risk of disease, disability and death but in fact pose a significant risk for healthcare service providers and the community as well, owing to the prevalence of occupational hazards such as needle stick injuries which occur due to the improper handling and disposal of biomedical waste.
As a case in point, a study on the prevalence of needle stick injuries (NSIs) among tertiary care staff nurses in a hospital in Nagpur revealed that among the 450 staff studied, 341 NSIs were reported with an estimated incidence rate of 2.39 NSIs per person per year. Such instances of unsafe use and disposal of medical injections among others are estimated to have been responsible for up to 38% of Hepatitis C infections, 46% of Hepatitis B infections and 12% of HIV infections in India.
There have been several efforts by professional bodies and institutes to highlight the issue and sensitize the stakeholders. The Indian Academy of Paediatrics (IAP) first published the Safe Injection Guidelines in 2004 and released an updated version in 2012. In 2014, the National Centre for Disease Control published a handbook on safe injection practices.
Most recently, in 2015, the WHO launched guidelines to provide global, evidence-based recommendations on the use of safety-engineered injection devices to prevent the reuse of syringes and NSIs in health-care workers. The ultimate aim is to make injection practices safer for healthcare workers, patients and the community, and to prevent injection-related transmission of viruses, particularly HIV, HBV and HCV by 2020. India, Uganda and Egypt have been enlisted as focus countries to upgrade the practices and technologies this year.
Wider acceptance of auto-disable, re-use preventable and sharp injury-protection syringes is required to stop transmission of blood-borne infections.
While these guidelines have been designed for use across countries, India faces unique challenges. The disease burden in India is concentrated in some high risk states. Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu account for 55% of all HIV infections in the country. On the other hand, West Bengal, Gujarat, Bihar and Uttar Pradesh account for another 22% of HIV infections in India. Similarly, many states in north India are facing the epidemic of Hepatitis B and Hepatitis C. This calls for the prioritization of these high-risk zones to implement safer technologies.
In April 2005, the Indian government introduced auto-disable syringes under the Universal Immunization Program (UIP) in all states. However, the impact of this decision is limited as about 95% of injections administered in India are for therapeutic reasons. Moreover, the private sector which provides more than 80% of outpatient care and 60% of inpatient care is not mandated to use this available and safer technology. The uptake of recommended safe injection technology has been gradual and piecemeal. Wider acceptance of auto-disable, re-use preventable and sharp injury-protection syringes is required to stop transmission of blood-borne infections.
The country needs a comprehensive strategy in accordance with the 2015 WHO Policy Guidelines to tackle the issue of unsafe injection practices. A strong monitoring and evaluation framework to measure quality together with a communication component that encourages the use of safety-engineered devices is critical to bring about behaviour change among prescribers and patients. Regular training for healthcare workers on the correct technique of administration and the rational use of injections is required as well. In addition, a strong surveillance system needs to be set up to generate appropriate data for evidence based decision making. More importantly, there is a need to build greater consensus and political will across stakeholders to ensure implementation.
Given the widespread use of injections in the country, it is essential to act quickly before the cost of unsafe injections begins to far overweigh the benefits associated with them.