Use of Injections in Healthcare Settings Worldwide, 2000: Literature Review and Regional Estimates

"Poor injection practices have been reported worldwide," the current study stated. "Many injections are unnecessary and unsafe. Of particular concern is the reuse of injection equipment in the absence of sterilization. The combination of injection overuse and unsafe practices results in a major route of transmission for hepatitis B and hepatitis C virus. Other complications of unsafe injections include infection with HIV, abscesses, septicemia, malaria and viral hemorrhagic fevers."

The authors estimated the global burden of disease attributable to contaminated injections in health care settings as part of the World Health Organization's 2000 update of its study of the global burden of disease. To describe worldwide injection practices in terms of frequency and safety, the researchers conducted a literature review of published studies and unpublished WHO reports. Using 10 of WHO's 14 regions defined on the basis of geography and mortality rates, they analyzed the annual ratio of injections per person and the proportion administered with equipment reused, unsterilized needles and syringes. Researchers excluded four WHO regions (European A, eastern Mediterranean B, American A, and Western Pacific A) because they contain mostly industrialized countries where the authors considered the proportion of needle reuse negligible. Injections of illicit drugs were not included.

In the other 10 regions, the investigators found the annual ratio of injections per person ranged from 1.7 to 11.3. The proportion of injections administered with reused, unsterilized needles ranged from 1.2 percent to 75 percent. The proportion of needle reuse was highest in Southeast Asia region D (including Bangladesh, Bhutan, North Korea, India, Maldives, Myanmar and Nepal -- 75 percent), eastern Mediterranean region D (Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, Somalia, Sudan and Yemen -- 70 percent) and the western Pacific region B (comprising Cambodia, China, Cook Islands, Fiji Kiribati, Laos, Malaysia, Marshall Islands, Federated States of Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Republic of Korea, Samoa, Solomon Islands, Tonga, Tuvalu, Vanautu and Vietnam -- 30 percent). The researchers did not include Latin America in the study due to a lack of data. European region B, consisting of former Soviet republics in central and eastern Europe, had the lowest proportion (1.2 percent) of needle reuse but the second-highest injection frequency (5.2 injections per person per year).

"Under the conservative assumption that the regions in Latin America for which no data were available would follow the pattern of reuse observed in eastern and central Europe, we estimated that 6.7 billion (39.3 percent of all [injections]) were given with reused equipment each year. These figures constitute a call for action since effective and affordable interventions are available," the study said.

The authors pointed out that health care providers give unsafe injections due to "the lack of single use injecting devices, the lack of awareness of the risk of HIV infection associated with unsafe injection, and the absence of sharps waste management."

The researchers recommended a number of policies to help ensure safe and effective injections and to eliminate unnecessary injections. HIV programs, they suggested, should communicate the risks of unsafe injections. Drug programs should build rational injection use into the national drug policy and ensure access to single use injection devices. Donors and lenders who supply injectable substances should also fund an adequate supply of single-use injection devices, health systems should manage sharps waste, injection practices should be monitored as technical quality indicators of health systems' performances, and specific targeted interventions should be developed for informal private providers, the authors concluded.

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