Medicos campaign against unsafe injection practices

Rita Dutta - Mumbai

To combat the menace of unsafe injection practice among medicos, the Indian Medical Association (IMA) as well as the Indian Association of Paediatricians (IAP) would soon kickstart a national campaign.

What have rung alarm bells with the associations are studies conducted by IndiaClen Program Evaluation Network (IPEN) and Program for Appropriate Technology in Health (PATH), which indicate that about two-third of injection practices in India are irrational and unnecessary. Besides, reports of syringes being re-packed and re-sold in grey markets have raised concern, making the associations take some corrective steps.

Speaking to Express Healthcare Management, Kolkata-based Dr Sudipto Roy, president, IMA, said, “Improper handling and disposal of syringes expose the lives of the medicos, paramedical staff and nurses, along with patients, to risk associated with blood borne diseases like Hepatitis B, Hepatitis C and AIDS. Hence, IMA would impart training and awareness to its 1,70,000 members in 1600 branches across the country about the perils of unsafe injection practices, along with advocating rational use of injections and correct methods of administering them.”

A safe injection is one that is medically indicated, does not harm the recipient, the provider or the community at large. An unsafe injection practice includes injections administered with poor indication or when oral alternatives are available, improper methods of injection administration, faulty method of sterilising injections, re-use of syringes and incorrect disposal procedures.

The IMA has dedicated the April issue of its Journal of Indian Medical Association (JIMA) to safe injection practices. The gamut of topics include unsafe injection practices, correct methods of disposal of syringes, safer and newer injection practices and modern injection centres. According to Kolkata-based Dr Nemai Nath, associate editor, JIMA, “We felt JIMA was a potent tool to address this issue. Around 16 billion injections are being administered every year, out of which 4.2 billion are in India.”
Worldwide, over-use of injections and re-use of dirty syringes and needles combine to cause an estimated 8-16 million Hepatitis B virus infections, 2.3-4.7 million Hepatitis C virus infections, and 80 000-160 000 infections with HIV/AIDS, every year, WHO estimates state. As far as India is concerned, the estimate states that unsafe injections account for 53.6 percent of all Hepatitis B, 59.5 percent of Hepatitis C, and 24.3 percent of HIV/AIDS infections each year.

Acknowledging the danger of unsafe injection practices during immunisation, IAP has started an educational programme among its 15,000 members in 40 cities across India. Said Ahmedabad-based Dr Raju Shah, president, IAP, “Of all infections that medicos are exposed to, two to three per cent of are related to needle-stick .”

According to Dr Shah, the need to educate General Practitioners (GPs) is more important than consultants, as about 85 per cent of the therapeutic injections are prescribed by the GPs. “Around 90 per cent injections are given for therapeutic reasons, seven per cent for immunisation and the rest for transfusion of blood related products,” he adds.

Interestingly, the PATH study reveals that injections are administered even for mineral water, antibiotics and vitamins. Says Hyderabad-based Dr Satish B Kaipilyawar, project-co-ordinator, PATH, “Our study covering 10 wards, including 42 institutes, 63 prescribers and 72 administrators in Hyderabad found that 70 per cent injections had oral alternatives.”

The objective of the study, conducted in 2003-04 was to find the rationalisation of injection practices, administration practices, waste disposal practices and perceptions of the community about injections.
And if you thought that government hospitals are the only culprits, think again. Every third patient in government hospital and every second patient in private hospital receives injection and more than 42 per cent receive more than two injection in one month, the study revealed. “Children below five years received the maximum number of injection, which is 71 per cent, followed closely by the group of 25 to 59 at 70 per cent our study revealed,” Dr Kaipilyawar informed.

But why do medicos prefer injections over oral drugs? Corroborating the study, Dr Ketan Parikh, paediatric surgeon, Jaslok Hospital, Mumbai, says, “Doctors and patients believe injections are more effective and act faster than oral drugs.”

The World Bank-sponsored IPEN study endorsed that wrong injection habits were practiced in 50.7 per cent cases, about 23.8 per cent of the injections were unsafe due to questionable sterility, while re-use of injection syringes was practised in 16.2 per cent of the cases.

The study, covering 84 centres—69 medical colleges, nine NGOs and six public health institutes, further revealed that around 48.1 percent of all prescriptions recommend taking an injection. “Almost 33 percent of unsafe injections were associated with syringe reuse, putting patients at risk for blood-borne diseases like HIV/AIDS and Hepatitis. The rest of the injections were rendered unsafe due to wrong practices including faulty administration techniques,” informed Dr Nath.

While government hospitals contribute to 68.6 per cent, the private facilities also contribute to 59.7 per cent of unsafe injection practices. Recently, even union health minister Dr Anbumani Ramadoss had admitted in parliament that 69 per cent of injections given at government-run hospitals were unsafe.
If that was not shocking enough, take this: around 74 per cent of injections in immunisation campaigns are unsafe, IPEN study states. With around 210 million injections given for immunisations every year, the scary scenario moved WHO and several international associations worldwide to form Safe Injection Global Network (SIGN) in October 1999.

SIGN recommends a three-pronged strategy of changing behaviour among patients and healthcare workers to reduce injection over-use and achieve injection safety,  ensuring sufficient availability of sterile syringes and needles, and appropriately destroying sharps waste after use.
A signatory of SIGN, IAP had constituted a national task force in November 2004 to draft safe injection practice guidelines. “They deal with rationalisation of injections, along with correct methods of administering injections, disposal of syringes and methods of giving two types of injections: intramuscular and intravenous,” said Dr Shah, who is also the chairman of the national taskforce on safe injection practices of IAP. On parallel lines, IMA has formed Injection Safety Policy July, 2004 in association with PATH.

To give more teeth to the crusade against unsafe injection practice, IMA, IAP, WHO, PATH have jointly formed India Injection Safety Coalition (IJSC), secretariat of which is provided by PATH.

The various associations and NGOs had convinced the government to use Auto Disable (AD) syringes for immunisation from this year. Even our health minister confirmed this in his parliamentary speech, along with the promise of introducing a legislation on the same.

AD syringes are the best bet as they are rendered unusable automatically after having delivered a prescribed dose of medicine. “ADs are safer than glass syringes, which can be sterilised and reused or plastic syringes, which are supposed to be disposable, but are sometimes re-used,” says Dr Shah.

In December, last year, Hindustan Latex Ltd (HLL), a government of India enterprise, and BD (Becton Dickinson India Pvt Ltd) entered into an agreement, whereby HLL will market AD syringes for immunisation and curative purposes in the name ‘Autolok’, manufactured by BD, based on the BD SoloShot Technology.

According to Ram Sharma, managing director, BD, “It was brave on the current government’s part to admit that injection practice in India isunsafe. Now, things are improving with the government promising to introduce AD syringes for the immunisation programme.”

The Andhra Pradesh (AP) government has already taken a lead in using AD syringes for its immunisation programme. The AP government has another first to its credit in starting a Model Injection Centre (MIC) and a Model Demonstration Centre (MDC) at Niloufer Hospital for women and children run by PATH in Hyderabad.

“The centre is aimed at rationalising the number of injections, inculcating safe injection practices and safe disposal practices. Training is imparted to medical, nursing students, paramedical staff and doctors through weekly sessions,” said Dr Kaipilyawar. The success of the centre has encouraged the AP government to replicate the model at Guntur, added Dr Kaipilyawar.
With both the government and private sector joining hands to work towards this cause, strengthened with our health minister’s assurance, let us hope that the once possible instruments of death turn to life-savers.

rita@expresshealthcaremgmt.com