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W.H.O. guidelines on injection safety

W.H.O. guidelines on injection safety

Injections are one of the most common health-care procedures. Every year at least 16 billion injections are administered worldwide. The vast majority – around 90% – are given in curative care. Immunization injections account for around 5% of all injections, with the remaining covering other indications, including transfusion of blood and blood products, intravenous administration of drugs and fluids and the administration of injectable contraceptives. Injection practices worldwide and especially in low- and middle-income countries (LMICs) include multiple, avoidable unsafe practices that ultimately lead to large scale transmission of blood-borne viruses among patients, health-care providers and the community at large. While data are not available on the associated burden of all possible diseases, unsafe injection practices would logically impact on other blood borne diseases transmitted through the reuse of injection equipment e.g. haemorrhagic fevers such as Ebola and Marburg viruses, malaria, and others. Reuse and unsafe practices also risk bacterial infections and abscesses at the injection site, which can cause long term damage.

Unsafe practices include, but are not limited to the following prevalent and high risk practices:

  1. Reuse of injection equipment to administer injections on more than one patient including reintroduction of injection equipment into multi-dose vials, reuse of syringes barrels or of the whole syringe, informal cleaning with reuse and other practices. These practices are often ingrained and believed to be safe, but in reality lead to transmission of blood-borne viruses such as HIV, HBV, and HCV as well as bacterial infections and abscesses at the injection site. In 2000, WHO estimated that 40% of the 16 billion injections were given with reused injection equipment leading to 21 million new HBV cases (32% of all new cases), 2 million new HCV cases (40% of all new cases) and around 260 000 HIV cases (5% of all new HIV cases). Other diseases can also be transmitted through the reuse of injection equipment e.g. viral haemorrhagic fevers such as Ebola and Marburg.

  2. Accidental needle-stick injuries (NSIs) in health-care workers (HCWs) which occur while giving an injection or after the injection, including handling infected sharps before and after disposal. Certain practices that are considered high risk for HCWs, such as recapping contaminated needles, are associated with NSIs and have frequently been observed during surveys on injection practices using WHO’s injection safety assessment Tool. In 2003, WHO showed that there were 3 million accidental needle-stick injuries leading to 37% of all new HBV cases in HCWs, 39% of new HCV cases and around 5.5% of new HIV cases.

  3. Overuse of injections for health conditions where oral formulations are available and recommended as the first line treatment. Demand for and prescriptions of injectable medicines that are inappropriate include overuse of antibiotics, use of unnecessary injectable products such as certain vitamins,etc. WHO will embark on an injection safety global campaign targeting both healthcare workers and communities as a means of decreasing demand for and over prescription on injections.

  4. Unsafe sharps waste management putting health-care workers, waste management workers and the community at large at risk of needle-stick injuries and subsequent blood borne infections. Unsafe management of sharps waste includes incomplete incineration, disposal in open pits or dumping sites, leaving used injection equipment in hospital laundry and other practices that fail to secure infected sharps waste. Reuse prevention and needle-stick injury protection syringes, especially in curative services, are the focus of the recommendations contained in this document, along with provision of sharps waste management equipment.

WHO has analysed the potential contribution of safety-engineered syringes in reducing the problem of reuse and preventing needle-stick injuries. Safety syringes are well-established and available in global markets. Official performance requirements and definitions have been added and developed over time, beginning with auto-disable syringes for immunization in 1990 and progressing to models with reuse prevention in 2006 and needle-stick protection features in 2012. The ISO definitions also provide guidance for procurers in determining the specifications and minimum standards for performance of safety engineered devices for selection of appropriate devices.

“Sterile Hypodermic syringes for single use with a reuse prevention· feature (RUP).” This definition includes syringes that can measure flexible dosing amounts, have removable needles and a feature that blocks the syringe from being used a second time. The reuse prevention feature is activated following a single aspiration and injection in reuse prevention syringes Type A while in syringes Type B the mechanism allows multiple plunger aspirations if reconstitution of the medication or the vaccine is required , or if multiple drugs needs to be mixed in the same syringe before being injected to the patient. This definition is provided for syringes used in curative services where a broad range of injection procedures are performed and are typically 2.0 – 10.0 ml in size.  ISO 23908: “Sterile hypodermic syringes with a sharps injury protection feature (SIPs)”.· Some SIPs can also have a built-in reuse prevention feature. SIPs cover AD and RUP syringes that have an additional feature to prevent sharps injury, such as a means to contain the infected sharp after use.

The 1999 policy recommends the exclusive use of AD syringes for all immunization injections.  “Guiding principles to ensure injection device security”  issued by SIGN in 2003, which· states: “Syringes with a reuse prevention feature offer the highest level of safety for injection recipients. They should be considered for use for therapeutic injections where local data indicate that unsafe practices are particularly common.”  WHO best practices for injections and related procedures toolkit, published by WHO in 2010, which notes the importance of sufficient supply of quality-assured syringes and matching quantities of safety boxes. It is expected that the evidence-based policy guidance in this document will additionally contribute to preventing the reuse of syringes on patients and to a decrease in the rate of needle-stick injuries in health-care workers related to injection procedures, thus contributing to the prevention of injection transmitted infections.

“We recommend the use of injection devices with a reuse prevention feature (RUPs), as opposed to devices without reuse prevention features, by health-care workers delivering intramuscular, subcutaneous or intradermal injectable medications to patients”.


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