Medical injections and HIV
The Safe Injection Global Network defines a safe injection to be:
"Safe for the patient, the health worker and the environment"72
Medical injections are injections received as treatment, or for the prevention of ill-health (for example immunisation).
Once a person receives an injection a small amount of their blood can remain on the needle or syringe. If the person was infected with HIV and the same needle or syringe is used on another person, without correct sterilization there is a risk they may become infected with HIV. HIV infected blood on needles, syringes and other medical equipment can survive for up to two hours outside of the body73 and it has been found that syringes containing HIV infected blood can still transmit HIV, even after being rinsed, for up to 4 weeks.74 Studies have illustrated the parallel between the re-use of equipment and infection with blood borne viruses.75 76
Receiving injections in healthcare settings is very safe in developed countries. Health workers in these countries have easy access to new equipment and have undertaken training in safe practice. However, access to training, new equipment and resources to sterilize equipment is often lacking in developing countries and generally it is in these countries where the transmission of HIV infection, in healthcare settings, occurs.77 Gross re-use of medical equipment, including syringes, was reported in three of Kazakhstan's Hospitals in 2007.78 Furthermore, in Romania, more than 10,000 new babies and young children were infected with HIV from contaminated injections and unscreened blood transfusions between 1987 and 1991.79
Health systems must be strengthened to provide healthcare workers with training and resources if injections are to be made safer.80 81 Similarly, patients must be made aware that medical equipment should be new or sterilised before use.
Only estimates of the probability of becoming infected with HIV through an unsafe medical injection are available and whereas WHO estimates it to be 1.2 percent, other estimates vary from 0.1 percent and 6.9 percent.82 Some have identified medical injections in sub-Saharan Africa as a major cause of new HIV infections and claim 20-40% of infections are from medical injections.83 84 85 86 87 88 However, WHO estimates for sub-Saharan Africa are far more conservative at 2.5 percent.89 90 They uphold that although HIV transmission in healthcare settings, notably medical injections, is an area of concern, most infections are sexually transmitted.91
Controversy aside it is evident that unsafe procedures when administering medical injections have serious repercussions for the spread of HIV and despite the risks, un-sterilized needles and syringes continue to be re-used. As WHO figures show, across the world up to 39 percent of injections are administered with equipment that has previously been used and un-sterilized.92
The Safe Injection Global Network (SIGN)93 and the Presidents Emergency Plan For AIDS Relief (PEPFAR) are examples of governments and organisations working to promote safe injection and healthcare practices to eliminate the risks to patients and healthcare workers.94 'Making Medical Injections Safer' (MMIS)95, funded by PEPFAR, works in 11 countries alongside host governments to promote the safe use and disposal of unsafe injections through initiatives such as the training and education of healthcare providers.96 For example an MMIS project in Tanzania during December 2006 resulted in the training of more than 8,000 healthcare workers in safe injection practices.97
Technology such as single dose, pre-filled Auto-Disable (AD) injection devices (used for vaccinations) and AD syringes98, which have a one-way valve making the syringe useless after one use, have the potential to make injections in developing countries safer.99 100 101 Currently, AD syringes are used mainly for immunisation programmes where the potential for the reuse of injection equipment is high. A 2003 joint statement from WHO, UNICEF and UNFPA stated that AD syringes should be used for immunisations, particularly during immunising campaigns.102 However, vaccinations only account for 10 percent of injections whereas 90 percent are for curative (or treatment) purposes.103
The Indian government issued a mandate in 2008 for the use of AD syringes in all government health facilities, for both curative and immunising purposes.104 Despite the phasing out of sterilizable and disposable syringes by some international organizations and governments, both continue to be used instead of AD syringes.105 The most recent study found the percentage of non-industrialised countries using AD syringes for routine immunisation had increased since the previous study to 62 percent. However, exclusive use of AD syringes was still low at 38 percent.106 Sterilizable syringes rely on the safe practice of the user, which can fluctuate in response to other factors. For example, sterilization may be overlooked during busy periods, such as mass vaccination campaigns, or when access to resources is limited, such as fuel to boil water.
Unsafe practices such as only rinsing needles between vaccinations have been recorded. For example in Gudamb, India, a rural health worker who carried out such a procedure stated, "for sterilization we are supposed to carry kerosene and a cooking stove with us... but for six months there has been no kerosene supply... for me, immunizing the children is a bigger priority".107 Disposable syringes can also be reused and generate large amounts of waste, which often fuels the demand for cheap injection equipment and can be associated with the transmission of HIV.
However, AD syringes are safe irrespective of the environment they are being used in and only cost 2 cents more than traditional syringes (since they were first introduced, the cost of AD syringes has declined from US15 cents to US6 cents).108 109 UNICEF mass vaccination campaigns can vaccinate an estimated 10 million children in one week and they use only AD syringes.110
Waste disposal is a problem if correct facilities are not in place (incinerators) - but AD syringes cannot be collected and sold for reuse. Access to AD devices in remote areas may be problematic. However, if governments accept the need for injection safety and AD syringes become readily available, it is likely that the disposal of and access to AD syringes will cease to be a problem - as will HIV transmission through injections.
Whereas the reuse of medical equipment occurs predominantly in developing countries, healthcare facilities in developed countries are still not 100 percent risk averse, despite the overall high level of conformity to safety guidelines. In 2008, a health clinic in Las Vegas in the United States was closed following evidence that syringes were being reused and equipment used for colonoscopies was not being cleaned between patients. 111 112 This resulted in 40,000 people requiring tests for HIV, hepatitis C and B.113 The CDC campaign slogan "One Needle, One Syringe, Only One Time" is aimed at health workers in America to raise awareness of the importance of new equipment.114
Is an injection the only answer?
In some countries the risk of HIV infection through medical injection can be limited by keeping the number of injections received to a minimum. Studies in sub-Saharan Africa indicate that individuals who receive 5 or more medical injections are 2.3 times more at risk of being infected with HIV than those who do not.115 In Uganda, a correlation between HIV prevalence and having more than 5 medical injections was found. Of those who received 5 or more injections 10.8 percent of men and 11.4 percent of women were infected with HIV, whereas 4.0 percent of men and 6.3 percent of women, of those who had not received an injection, were infected with HIV.116
WHO estimates that up to 70 percent of injections in some countries, were 'medically unnecessary'.117 118 For example, in some countries injections are given unnecessarily to administer antibiotics or vitamins.119 120 Oral medication is an alternative to injections and this treatment should be used wherever possible. To reinforce efforts to minimize the use of injections and therefore reduce the HIV risk in healthcare settings, patients in low and middle-income countries, where injection safety is often low and HIV prevalence high, need to question whether they really need the injections.
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