Pilot-Testing the WHO Tools to Assess and Evaluate Injection Practices

WHO/BCT/03.10 DISTR.: GENERAL WORLD H EALTH O RGANIZATION P ILOT-TESTING THE WHO TOOLS TO A SSESS AND E VALUATE I NJECTION P RACTICES A Summary of 10 Assessments Coordinated by WHO in Seven Countries (2000-2001) 2 © World Health Organization 2003 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, quoted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. 3 TABLE OF CONTENTS Acknowledgements.....................................................................................................................................................4 Introduction..................................................................................................................................................................5 Section I: The rapid assessment and response guide .........................................................................................9 I.1. Injection practices in Albania: rapid assessment and proposed action plan 10 I.2. Injection practices in health care facilities of Shanghai, China 22 I. 3. Rapid assessment of injection practices in Mongolia, 2001 34 Section II: The tool to identify determinants of injection practices ........................................................... 41 II. 1. focus group discussions with the public in Sindh, Pakistan 42 II.2. In-depth interviews regarding injection practices in Sindh, Pakistan 47 Section III: The tool to estimate the frequency of injections and identify injection providers........... 53 III.1. Injection use in Mbarara District, Uganda: A population survey 54 III.2. Injection practices in Sindh, Pakistan: A population survey 62 Section IV: The tool to assess injection safety.................................................................................................. 75 VI.1. Survey of injection safety in Burkina Faso 76 VI.2. Survey of injection safety in Niger 82 Section V: The tool to assess the association between injections and infections.................................... 91 V.1. Risk factors for acute hepatitis B virus infection in Karachi, Pakistan 92 The WHO rapid assessment and response guide............................................................................................ 99 Injection Practices Indicators at a Glance 100 Introduction 101 Who Should Use This Guide? 102 Step 1- Engage Stakeholders 103 Step 2- Describe the Situation 104 Step 3- Make Assessment Plans 107 Step 4- Gather Evidence 108 Step 5- Develop Conclusions 112 Step 6- Ensure Use 118 Data Collection Instruments 121 Appendix 1: Template of a National Injection Safety Plan 127 References.................................................................................................................................................................129 4 A CKNOWLEDGEMENTS The Department of Blood Safety and Clinical Technology thanks the United States National Vaccine Program Office (NVPO), the United States Agency for International Development (USAID), the United States Centers for Disease Control and Prevention (CDC) and other donors whose financial support has made the production of this document possible. Funds to support the field work for all these assessments were provided through a grant from NVPO made available to WHO through USAID, apart from the study V.1. on the risk factors for acute hepatitis B virus infection in Karachi, Pakistan, that was funded through different donors. Edited by David Gisselquist Yvan J. F. Hutin 5 I NTRODUCTION OPENING AND SHUTTING THE DOOR TO IATROGENIC INFECTIONS The invention of the syringe in 1848 opened a new channel for pathogens to pass from one person to another.1 Over time, doctors found more medications to inject and more conditions to treat. The awareness regarding bloodborne pathogens and hygiene only came later. The first recorded outbreak of what was later identified as hepatitis B may have occurred in a Swedish factory in 1883, following smallpox vaccinations.2 Although it was widely recognized that jaundice followed injections to treat syphilis in the early decades of the 20th century, doctors blamed injected arsenic rather than a contaminating pathogen. In 1943, Bigger 3 and MacCallum 4 showed that non-sterile injections transmitted a pathogen that caused jaundice. Hence, the first safe injection initiative began almost 100 years after the first injection. Over the last 50 years, scientists have discovered new bloodborne pathogens. In 1967, the Australian antigen – currently known as HBV surface antigen (HBsAg) was first linked to viral hepatitis. In 1983, human immunodeficiency virus (HIV) was found in blood. In 1989, the hepatitis C virus (HCV) and antibodies were identified. The response in industrialized countries has been effective, if belated. After mid-century warnings about hepatitis from injections, doctors progressively shifted to a sterile syringe and needle for each injection. At the end of the 20th century, most injections are now given with new, single use injection equipment and episodes of transmission of bloodborne pathogens through injections are usually linked to the unsafe use of multi-dose vials or preparation of medications in areas potentially contaminated with blood or body fluids.5 However, in developing countries, the last half of the 20th century saw enormous increases in numbers of injections with insufficient care for sterile conditions. People in developing and transition countries received an estimated 16 thousand million injections in 2000, of which 6.6 thousand million were given with equipment reused in the absence of sterilization.6 Unsafe injections have contributed to high hepatitis B virus (HBV), HCV and HIV prevalence for decades. In parts of Africa and Asia, for example, 80%-90% of the population has been exposed to HBV and 5%-15% have active infections. HCV prevalence is estimated at 3.9%-5.3% in the Near East, African and Western Pacific regions, with much higher rates in some countries (e.g., 18% in Egypt, 13% in Cameroon, 11% in Mongolia).7 In too many countries, the door to iatrogenic infections through unsafe injections has been opened but not yet shut. THE NEED FOR ASSESSMENT TOOLS From the 1980s, spurred in part by concerns about HIV, public health experts expressed mounting concern about unsafe injections in developing countries. Early influential papers relied heavily on anecdotal information.8 During the early 1990s, WHO’s Action Programme on Essential Drugs sponsored well-designed and parallel studies of injection practices in Senegal, Uganda 9 and Indonesia. In 1999, the Bulletin of WHO published global estimates of annual unsafe injections and related HBV, HCV, and HIV infections. 10,11 In 1999, representatives from WHO, the United States Agency for International Development (USAID), the Program for Appropriate Technology in Health (PATH) and other international and national public and private organizations came together to create the Safe Injection Global Network 6 (SIGN). SIGN is a coalition of participants with a small secretariat in the WHO Department of Blood Safety and Clinical Technology (BCT). To facilitate the development of national programmes for the safe and the appropriate use of injections, WHO sponsored the development of tools to assess and evaluate injection practices. During 1999-2000, experts prepared drafts of protocols that were reviewed during a meeting of consultants. 12 In October 2000, this process led to the publication of five linked draft tools for pilot testing. The ten assessments in this volume come out of this process: each follows one of the draft protocols to examine injection practices in one of seven African and Asian countries. Each of these assessments has been carried out by, with or for a national organization or committee as part of a process to develop national policies for the safe and appropriate use of injections. THE WHO TOOLS TO ASSESS AND EVALUATE INJECTION PRACTICES The initial tools to assess and evaluate injection practices organized the investigations into four issues (Figure 1 and Table 1): (a) The determinants of injection practices, including knowledge, attitudes and institutions; (b) The frequency of injections; (c) The safety of injections; (d) The association between injections and adverse outcomes. Figure 1: Injection-associated adverse events are caused by poor injection practices that are a consequence of behavioural and system determinants Lack of equipment and supplies Lack of awareness Lack of sharps waste management Unsafe injection practices Injection overuse Injection adverse event The objective of interventions for the safe and appropriate use of injections is to prevent adverse outcomes so that people do not contract bloodborne viruses or otherwise suffer from injections or needle-stick injuries. This depends on injection practices, which depend in turn on knowledge and other factors that influence behaviours. ASSESSING DETERMINANTS OF INJECTION PRACTICES Qualitative determinants of poor and good injection practices may be identified through focus group discussions and in-depth interviews. Results of such assessment provide guidance to assess quantitatively the knowledge and attitudes regarding injection practices. 13 Section 2 in this book presents two assessments of the determinants of injection practices. 7 ASSESSING PRACTICES Risks with injections depend on how many injections each person receives,

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