|Year : 2014 | Volume
| Issue : 1 | Page : 28-32
Unsafe injection practices: An occupational hazard for health care providers and a potential threat for community: A detailed study on injection practices of health care providers
Harsh D Shah1, Abha D Mangal2, Hiren R Solanki3, Dipesh V Parmar3
1 Department of Preventive and Social Medicine, Regional Child Survival Officer, Surat Region, Government of Gujarat, Jamnagar, Gujarat, India
2 Department of Preventive and Social Medicine, VMMC & Safdarjung Hospital, New Delhi, India
3 Department of Preventive and Social Medicine, Shree MP Shah Medical College, Jamnagar, Gujarat, India
|Date of Web Publication||15-Apr-2014|
Harsh D Shah
108, Dhanlaxmi Appartment, Rampark Society Areas, Modasa 383 315, Sabarkantha, Gujarat
Source of Support: None, Conflict of Interest: None
Background: In developing countries, unsafe injection practices are widely prevalent which invites potential risk to them and to the community also. Recent outbreaks of blood borne viruses (BBVs) in India were mainly due to unsafe injections use. Aims: This study was aimed to carry out detailed observation on injection practices and prevalence of needle stick injuries among the health care providers. Settings and Design: A cross-section observational study was conducted in Government Institutes by simple random sampling of a district of Gujarat. The sample size of study subject was 251 varying from female health workers, staff nurses, medical officers, internees, lab technicians and PG residents of Government Institutes. Materials and Methods: The study subjects were selected by simple random sampling as per their population proportion to the size. The criteria were set to stamp the unsafe injection practices and the consent was obtained from the respected authorities and detailed analysis was performed. Statistical Analysis: The frequency distribution, Chi-square and odds ratio analysis were done in SPSS 17 and Microsoft Excel 2007. Results: The study revealed, majority subjects were observed with the needle touching non-sterilized places accounted 64.14% unsafe injections. During the study, it was found that, out of 161 who were practicing unsafe injection methods had proportion of injuries was 65% (104/161) with significant association.(P < 0.05) Conclusions: There had been constant break in aseptic environment, which may harm health care providers and improper behavior may transmit BBVs infections to community. Hands on training, infection control measure, implementation of rational drug/injection policy, surveillance with immediate response system are the need to tackle this future threat.
Keywords: Health care providers, needle stick injuries, unsafe injections
|How to cite this article:|
Shah HD, Mangal AD, Solanki HR, Parmar DV. Unsafe injection practices: An occupational hazard for health care providers and a potential threat for community: A detailed study on injection practices of health care providers. Int J Health Allied Sci 2014;3:28-32
|How to cite this URL:|
Shah HD, Mangal AD, Solanki HR, Parmar DV. Unsafe injection practices: An occupational hazard for health care providers and a potential threat for community: A detailed study on injection practices of health care providers. Int J Health Allied Sci [serial online] 2014 [cited 2021 Jan 21];3:28-32. Available from: https://www.ijhas.in/text.asp?2014/3/1/28/130607
| Introduction|| |
Injections are the most common health care procedure world-wide. In developing countries alone, some 16,000 million injections are administered each year, among them; more than 90% are given for therapeutic purposes while 5-10% are given for preventive services, including immunization and family planning.  In India, this number is 83% and almost one out of every two patients (48.1%) attending outpatient clinics receives injections. The majority of therapeutic injections in developing countries are unnecessary.  A "safe injection" does not harm the recipient, does not expose the health care worker to any avoidable risk and does not result in waste that is dangerous for the community. When injections are medically indicated they should be administered safely. Safe injection practices involve use of sterile single-use needles and syringes for each procedure, prevention of any form of contamination to the medication or vaccine to be injected, safe practices to ensure that sharps injuries do not occur and appropriate waste disposal to prevent reuse of needle and syringes. 
Unsafe injections can place patients and community at risk of morbidity and may be at fatal mortality in a manner of outbreaks. A reuse of injection devices without sterilization is of particular concern as it may transmit hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV), accounting for 30%, 41% and 5% of new infections respectively.  In addition, inappropriate and unhygienic use of multi-dose vials, contaminated needles and syringes may transmit blood borne pathogens. Needle stick injury (NSI) that may look innocuous at first is a serious hazard as it carries the risk of transmission of infections such as HIV, HBV and HBC that cause serious and fatal illnesses.  These injuries can occur during minor as well as major indoor operative procedures, in the Outpatient departments during routine medical procedures and investigations, in immunization clinics etc., Globally, health care workers incur 2 million infections per year due to NSIs. However, majority of NSIs, 40-75% remain unreported because of lack of sensitization. , This study was carried out to determine the status of injection with objective to attain comprehensive data on injection practices conducted by health care workers, focusing on safety issues in their day-to-day procedures.
| Materials and Methods|| |
The study was an observational cross-sectional study conducted in facility health care workers from a district of Gujarat. A pre-designed and pre-tested profoma was used to obtain data for the study. Detailed observations on practices were taken to fill the profoma using the manual named; Model Injection Centers: A program to improve injection practices in the country, published by Central Coordinating Office, Clinical Epidemiology Unit, All India Institute of Medical Sciences, New Delhi.  The study duration was 8 months from September 2012 to April 2013. The observed health care providers were also asked about their NSIs occurrences.
| Study subjects|| |
The total health care provider of a district was counted 750 who were working in the district's government hospitals. In the sampling frame, all the 750 were included and then sample size was calculated by 4 pq/d 2 method for a cross-sectional observational study. In the calculation, P value from previous study was taken as 63% as per given in model injection center practical manual on sample size determination in health studies by IPEN study: An Assessment of injection practices in India.  At P = 0.63 (63%) and ε =10%, a sample size of 226 would be needed. In the design of the study, no response ration had been kept 10% of calculated sample size so derived study sample size came (248) 251 in the present cross-sectional observational study design. In the sampling frame out of 750 study population, 251 of medical officers, post graduate students, interns, nurses and laboratory technicians from the various clinical and para-clinical departments of a tertiary health center, six urban health centers (UHCs) and eight primary health center (PHC) units were selected based on the random sampling of the health care providers for detailed study to achieve 95% confidence interval. The each health care professional strata was included by simple random sampling and according to their proportion in the sampling frame. During the study, only one injection per health worker was taken into the consideration for better analysis. Out of the 251 study subjects, 33.3% (84) the PG students, 2% (5) medical officers, 5% (12) internees, 44% (110) of the Nurses, 3.7% (10) laboratory technicians, 12% (30) female health workers were included from tertiary level hospital, UHCs and PHCs of the study areas of the district respectively.
Ethical approval was taken from the Institutional Ethical Committee of Medical College and from the district health officials before the initiation of the study. After explaining the purpose of the study, consent for participation was taken from each of health care professionals. They were assured of confidentiality of their responses by the investigator and data was shared to the respected authority for better work management.
To start with, various methods of injection practices, health care professional who were included in the study conducting injection procedure was observed by the single investigator himself by pre tested checklist profoma. The details of the checklist contained their injection practices starts from the assembling of the injection materials to the final disposal of the bio-medical waste. The criteria were set to define the unsafe injection practices on the basis of observations without distracting them from their routine work.
The frequency analysis and association between variables by Chi-square test had been applied in Microsoft Excel 2007 and SPSS 17.
| Results|| |
The comprehensive data of injection practices was collected which showed that during assembling the injection materials, the widely used content was ampoule with 38.2%, then vial was used in 18.3%, as PG residents and nursing staff occupied majority part of the study population and hence intracath use was 23.9% which was widely used in tertiary level hospitals. Saline pint was used directly 15.5% times in tertiary level hospitals, UHCs and PHCs, whereas 4% for the blood withdrawal (venipuncture) for various laboratory tests. During the study, there were majority of the injections, were given via intravenous routes through the peripheral veins 67%, rest of the injections' route was intramuscular (37%). It was observed that purpose of giving injection were almost equal for curative and preventive/symptomatic aspects. However there was a difference between patients' responses and actual reasons. Nearly 44.6% patients responded that administered injections were for the curative purposes of underlined disease compared to 48.6% of actual reasons. While 19.1% patients knew that injections were given for the preventive/symptomatic relief compared to 51.4% of actual reason of same. On asking the patients, regarding prescribed injections, they were receiving; 36.3% patients did not know or were not informed.
The mean experience of employment of study population was 3.29 ± 2.4 years ranging from 1 to 13 years, varying from community health workers to post graduate residents. Nearly 6.8% subjects had used opened or used syringes and needles, which was considered unsafe to the patients or to the self-according to the set criteria. During the study, majority of the subjects (96.8%) were able to access plastic auto disable syringes, while 3.2% subjects used glass syringes, directly picked up from the boiler.
According to guidelines for safe injections practices, hub should be cut after every injection. However, it was observed that proportion of hub was cut after every injections was 90% out of 237 as proportion of hub cutter was around was 94.4%. So overall, 85% hubs of injections were cut after giving the injections. 82.5% observed injections had hub cutter emptied periodically and 82.5% subjects had disposed the injections related waste to the puncture proof plastic bags. Proportion of puncture proof bag was filled up more than three-fourth was 30% and the container of that waste was stored more than 48 h was 19.1% in observations.
The study had been set with defined minor criteria and major criteria for describing unsafe injection practices, which are listed in [Table 1] and [Table 2]. As per the criteria, majority subjects were observed with the needle touching non-sterilized places accounted 64.14% unsafe injections.
|Table 1: Major criteria (any 1 of below) for unsafe injection practices |
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|Table 2: Minor criteria (any 3 or more) for classification of unsafe injection practices (for each variable, there was different N) |
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During the study, it was found that those who did unsafe injection practices had association of getting the NSIs. The prevalence of needle sticks injury was 58.56%, amongst which majority injuries, 64% happened in nursing staffs, 60.7% injuries in PG residents of the tertiary care hospitals. Nearly 53.3% injuries were reported by health workers of UHCs and PHCs and internees with 50% proportion. Lab technicians were reported 40% with less amount and no medical officers of PHCs and UHCs had reported any needle sticks injuries within last 1 year of duration. Out of 161 who had practicing unsafe injection methods had proportion of injuries was 65% (104/161). The association between unsafe injection practices and getting NSIs was statistically significant [Table 3]. Odds ratio between those who practicing unsafe injection methods and NSIs within last 1 year was two. It means that those who were applying unsafe injection methods had 2 times risk of getting the NSI. Confidence interval was 1.18-3.37 at 95% confidence interval.
|Table 3: Association between unsafe injection practices and needle stick injury in last 1 year of the study (n=251) |
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| Discussion|| |
The Present study had documented potentially harmful injection practices 64.14% including improper handling and disposal of used injection equipment by health care providers of Government institutions. Annually more than 1.3 million deaths and US$ 535 million are estimated to be due to current unsafe injection practices.  Routine immunization programs account for approximately 750 million injections per year less than one-tenth of global total such injections are believe to be safer than many non-immunization injections in most countries. However, World Health Organization (WHO) recently estimated that up to one-third of immunization injections was unsafe in four out of six regions of the world. , In advent of new measles 2 nd dose vaccine had added few more injections in routine national immunization schedule. Earlier different studies had documented that unsafe injection practices are prevalent in India.  Previously, the outbreaks of blood borne viruses (BBVs), especially HBV, due to contaminated needles and syringes have been reported from India. ,
The issue of unsafe injection was complex in the study with multiple variables such as increased patients' workload in tertiary level hospitals, lack of sensitization and training, behavior and attitude toward the safety of injection procedure amongst health care providers. It was observed that there was constant break in the aseptic precautions during handling of the injection materials and disposing of the bio-medical waste.
In Gujarat, recent decades two blood borne outbreaks had been reported of HBV. The most probable reason was re-use multi dose vials and use of contaminated needles and syringes by health care providers. , Here, present study carried under the Government institutions which have higher proportion of unsafe practices according to the previous studies. 
The annual incidence of NSI among service providers was 58%, which was a nearly same than that observed in the South India study but much higher than the 2.2% observed in the developed world. ,
Previous study carried out in Gujarat had found 19% of proportion of NSIs that was lower compare to present study but that study was done in both private and government hospitals which could be the reason.  Over half (53%) of the service providers in Cambodia have reported NSIs in the last 12 months. One of the reasons for high NSIs was the practice of unsafe injection practices, a practice which was observed in 64% of service providers in the present study and 58% in the Cambodian study.  Recapping of the needle, inadequate injection material waste management, high patients load, inadequate supervision, lack of routine surveillance system could be the reasons might lead to NSIs this much prevalent.
The study region has not encountered any BBV outbreak but this study revealed the potential threats for the future probabilities amongst health fraternity and cannot deny spread into community. The health workers should be sensitized to the issues of importance and efficacy of safe practices as a mode of protecting themselves. The use of sterile auto disable syringes and needle for each and every injection is the standard practices with its proper disposal to reduce the risk of nosocomial infections among the health staff and its spread among the community. There is also need to develop infection control measures and a routine surveillance system to keep watch over and for making immediate correction on any hazards happened due to unsafe injection practices and its consequences. The problem of unsafe and unnecessary injections is complex and solutions will not be straight forward. Efforts could be made to teach the prescribers/providers to choose treatment wisely based on the evidence and provide all medication by safest and most appropriate route. The subject of safe injection practices (including use of newer technologies) should be part of nursing and medical curriculum. The stress should be on skill transfer through a mix of lectures and hands-on training. There is need to promote rational drug/injection therapy among all prescribers which can be achieved through defining effective and safe treatment protocols plus promoting minimal essential injection practices with standard operating procedures. A country wide IPEN study in 2003-2004 has revealed many observations on injection practices. Few years back WHO has published the injection safety policy in 2003 for uniformity in implementation of injection procedure, universal precautions and related bio-medical waste disposal in interest to achieve safe environment in hospitals.  There is an urgent need to evaluate details of injection safety on regular basis with definitive interventions. Based on that, the local health facilities should have uniform policy with organizational commitment in providing occupational safety to its health care providers. The policies should be disseminated to the staff and translated to the community.
| References|| |
|1.||World Health Organisation. Injection Safety. Geneva: World Health Organisation; Revised 2002 Apr. WHO Fact Sheet No. 231. Available from: http://www.who.int/mediacentre/factsheets/fs231/en/. [Last accessed on 2013 Apr 20]. |
|2.||India CLEN Programme Evaluation Network. Assessment of injection practices in India (2002-2003) Available from: http://www.inclentrust.org/uploadedbyfck/file/completed%20file/15_Main%20Report%20Book%20 (29-6-06).pdf. [Last accessed on 2013 Jul 20]. |
|3.||Hutin YJ, Chen RT. Injection safety: A global challenge. Bull World Health Organ 1999;77:787-8. |
|4.||Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004;15:7-16. |
|5.||Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: A review. Bull World Health Organ 1999;77:789-800. |
|6.||Kane A, Lloyd J, Zaffran M, Simonsen L, Kane M. Transmission of hepatitis B, hepatitis C and human immunodeficiency viruses through unsafe injections in the developing world: Model-based regional estimates. Bull World Health Organ 1999;77:801-7. |
|7.||Hutin YJ, Hauri AM, Armstrong GL. Use of injections in healthcare settings worldwide, 2000: Literature review and regional estimates. BMJ 2003;327:1075. |
|8.||Model Injection Centers (MIC): A Program to Improve Injection Practices in the Country (2005-2007). New Delhi, India: Published by Central Coordinating Office, Clinical Epidemiology Unit, All India Institute of Medical Sciences. Available from: http://www.ipen.org.in/stories/operationalmanual.pdf. [Last accessed on 2013 Jul 20]. |
|9.||Miller MA, Pisani E. The cost of unsafe injections. Bull World Health Organ 1999;77:808-11. |
|10.||State of the World′s Vaccines and Immunization. Geneva: World Health Organization; 1996 (Unpublished document WHO/GPV/96.04). Available upon request from vaccines and other biologicals. 1211 Geneva, 27 Switzerland: World Health Organization. |
|11.||Technical Network for Logistics in Health Manila Consultation ′96. Geneva: World Health Organization; 1996. (Unpublished Document WHO/EPI/LHIS/97.02). Available upon request vaccines and other biologicals. 1211 Geneva 27, Switzerland: World Health Organization. |
|12.||Singh J, Bhatia R, Patnaik SK, Khare S, Bora D, Jain DC, et al. Community studies on hepatitis B in Rajahmundry town of Andhra Pradesh, India, 1997-8: Unnecessary therapeutic injections are a major risk factor. Epidemiol Infect 2000;125:367-75. |
|13.||Singh J, Bhatia R, Gandhi JC, Kaswekar AP, Khare S, Patel SB, et al. Outbreak of viral hepatitis B in a rural community in India linked to inadequately sterilized needles and syringes. Bull World Health Organ 1998;76:93-8. |
|14.||Singh J, Gupta S, Khare S, Bhatia R, Jain DC, Sokhey J. A severe and explosive outbreak of hepatitis B in a rural population in Sirsa district, Haryana, India: Unnecessary therapeutic injections were a major risk factor. Epidemiol Infect 2000;125:693-9. |
|15.||Patel DA, Gupta PA, Kinariwala DM, Shah HS, Trivedi GR, Vegad MM. An investigation of an outbreak of viral hepatitis B in modasa town, gujarat, India. J Glob Infect Dis 2012;4:55-9. |
|16.||Gupta E, Bajpai M, Sharma P, Shah A, Sarin S. Unsafe injection practices: A potential weapon for the outbreak of blood borne viruses in the community. Ann Med Health Sci Res 2013;3:177-81. |
|17.||Pandit NB, Choudhary SK. Unsafe injection practices in Gujarat, India. Singapore Med J 2008;49:936-9. |
|18.||Rajasekaran M, Sivagnanam G, Thirumalaikolundusubramainan P, Namasivayam K, Ravindranath C. Injection practices in southern part of India. Public Health 2003;117:208-13. |
|19.||Luthi JC, Dubois-Arber F, Iten A, Maziero A, Colombo C, Jost J, et al. The occurrence of percutaneous injuries to health care workers: A cross sectional survey in seven Swiss hospitals. Schweiz Med Wochenschr 1998;128:536-43. |
|20.||Vong S, Perz JF, Sok S, Som S, Goldstein S, Hutin Y, et al. Rapid assessment of injection practices in Cambodia, 2002. BMC Public Health 2005;5:56. |
|21.||World Health Organisation. Managing an Injection Safety Policy. Geneva: World Health Organization; 2003 March. Report no: WHO/BCT/03.01. Available from: http://www.who.int/injection_safety/toolbox/en/ManagingInjectionSafety.pdf. [Last accessed 2013 Jul 20]. |
[Table 1], [Table 2], [Table 3]