Safe Observer

INJECTION SAFETY ABSOLUTELY REQUIRED TO COMBAT HEPATITIS

How many of the 2000 million cases of viral hepatitis B have taken a dirty needle as a preferred route of travel?

No one knows for sure.

Studies on nosocomial viral hepatitis B are lacking in poor and even middle income countries.

But what we do know is cause for concern.

The hepatitis B virus (HBV) travels fast and wide via blood contact, riding on a re-used syringe, from patient to patient, from one user to the next, whenever disinfection is lacking.

Even if HBV also spreads via the oral fecal route, blood contact is a sure winner.

This year a large scale epidemic of HBV in Gujarat, India, was traced to illegal dirty recycling of 'single use' syringes on a grand scale. Certainly Gujarat is but the very tip of the iceberg.

Unsafe injection is directly responsible for many millions today living with hepatitis B, 40% of all new cases, at least 21 million new cases per year!^[1]

Hepatitis B can be prevented with a vaccine, but the means to vaccinate are lacking.

And dirty needles is the main route for Hepatitis C for which there is no vaccine.

130–170 million people are chronically infected with hepatitis C virus (HCV)[2]

At least two million new people get infected with hepatitis C every year through unsafe injections during health care.

In the old days, hepatitis C epidemics anywhere were commonly called 'Syringe Epidemics', since HCV does not transmit via water or food and has not been established to transmit well through sex.

 

Today in the world, up to 60% of Intravenous Drug Users (IVDU) are infected with HCV simply because they shared 'dirty' needles. If Egypt today has up to 20% of its adult population carrying HCV, it is the direct proven consequence of a massive treatment campaign against schistosomiasis in the 60s and the 70s with injectables, a campaign done with the best of intentions by the Ministry of Health with support from the United Nations organizations, and in which unsafe injection practices were widespread.

57% of cases of liver cirrhosis and 78% of primary liver cancer result from hepatitis B or C virus infection[3]

Just from these facts about Hepatitis B and Hepatitis C alone, implementing SAFE INJECTION in all health and related settings would save several hundred million people from sickness or death.

At a time when the WHO has initiated the drive for Primary Health Care for all, we can no longer afford to wait: universal health coverage, equity in health, means people have a right to clean and safe injection wherever they may live.

What are the facts we know and don't know today?

- Injecting drug use represents the highest risk for hepatitis C virus infection, with prevalence rates in people reporting this behavior ranging between 30% and 60%.^[4]

What does that mean for patients whenever health care workers re-use single use injection devices or use them improperly?

Research is very much needed since a given patient population may run a risk of nosocomial hepatitis that is close to the risk in an IVDU population.

The special attention paid to the problem of needle sharing among IVDU has not been matched with similar attention to patient populations.

However the high concentration of hepatitis among in-patients, and the increased viremia for HIV-HCV co-infected patients, means that patients unwittingly subjected to 'needle sharing' are placed at a risk of HCV infection which may be quite high.

Coordinating programmes for the prevention and control of hepatitis with other related programmes will contribute to the strengthening of health systems in all countries. To date, prevention and control efforts have been successful but fragmented. The WHO does not have a comprehensive strategy for viral hepatitis. Thus, the time is right to create new opportunities for prevention, including establishing goals and strategies for disease control, increasing education and promoting screening and treatment of the 500 million people or so already infected with hepatitis B and C viruses.^[5]

Adopted use of auto-disabled syringes, large scale vaccination against Hepatitis B, efforts at treatment, have all been agreed upon goals and adopted strategies by the WHO and other United Nations organizations or partnerships such as GAVI.

The simple goal of SAFE INJECTION in health care remains the most important and self evident objective to prevent several hundred million people from unnecessary suffering and even death.

 

SAFE INJECTION is a priority in the HIV era.

While there is significant variation between countries, WHO estimates that in sub-Saharan Africa, approximately 18% of injections are given with reused syringes or needles that have not been sterilized [6]

A wheel of misfortune is attached to unsafe injections in so many poor communities: patient checks into health care for one disease and may come out with another disease because of unsafe injections. The WHO AFRO focal point for Patient Safety estimates that in Sub Saharan Africa 20% to 70% of patients may contracts a nosocomial infection[7].

Continued unsafe practices on these populations is a clear and absolute violation of patient rights.

Attention has been paid, and rightly so, to safer immunization, but injections for immunization only constitute 3% of all injections, and unfortunately it is still the case today that, in poor countries, local immunization campaigns can still be undertaken with old glass syringes and without prior attention to safe use of injection equipment.

Attention has been rightly paid to IVDU's human right not to be exposed to infection – hence the harm reduction campaigns to provide clean injection equipment.

But poor patients are unwittingly placed at same level of risk as intra-venous drug users from HIV, HBV, HCV whenever there is unsafe sharing of injection equipment.

Time has come to lift the veil on the dangerous practice of unsafe injections. Today, in 2009, industry estimates at 30 billion the number of therapeutic injections given every year, or which- if we based ourselves on the studies done in 2000, up to 40% may be unsafe in some settings.

In Nevada, USA, in 2008, 63,000 people were notified of their possible risk of hepatitis C due to re-use of syringes and contamination of multi dose medication vials at an endoscopy center. We learn daily of unsafe practices even in advanced industrialized countries.

Judging on the 2000-2009 outbreak investigations for Hepatitis C and B and HIV in the United States, 35

disease outbreaks - and the outbreak of HIV among children in Kyrgyzstan and Kazakhstan 250 children contaminated with HIV in 2006-2007 - indirect contamination is still common globally. Even in well to do countries health care staff - who should know better - contaminate product vials with the very unsafe practice of only changing the needle.

Ignorance in many parts of the world, poverty in others – when health care workers wages are below subsistence level which is an incentive for trafficking in injection devices, - lack of resolve for strong safe health care systems nationally and globally are responsible for this sad state of affair.

It took a century for Ignac Semmelweis' lesson on the way to prevent death of women during childbirth to become understood, and, still around the world, dirty hands still touch women.

Will it take another century for the scientifically established lesson of blood exposure via soiled sharps and needles to become understood?

 

Why so much denial to this day?

Why tolerate so much stigma to ill patients contaminated in health care?

Why denial, when as late as 1996 studies found that nearly 50% of anesthesiologists in the USA (60% in Canada) had unsafe practices that could contaminate vials of anesthesia products.[8]

Information and training is made all the more important by the decision for "Task Shifting"[9]

There is a tendency for silence on loose infection control and prevention and its terrible consequences,

But recent years have seen significant progress to redress this situation:

• The history making document of the National Institute of Health was entitled: “To Err is Human” and it is through facing error that science and wellbeing progress in every field of human endeavor.
• PEPFAR included funding for safe injections, and PEPFAR new 2009 edition admitted to the need for investigations of suspected nosocomial HIV in LMIC countries, an essential tool to identify and stop unsafe injections today.
• The Global Fund on AIDS, Tuberculosis and Malaria has agreed to fund safer health care and strengthening of health services.
• CDC investigations of hepatitis outbreak in the US and Eastern Europe have shown the way.
• The Association for Professionals in Infection Control and Epidemiology in the USA announced its commitment to support for adherence to safe injection practices in clinical settings throughout the U.S.; network of African professionals for infection control have picked up on the issue (IPCAN and RIPAQS).
• The Council of Europe has voted in May 2006 a resolution on patient safety as the core of a strengthened health care system based on a strong well trained and well paid workforce in which the need for universal and equitable coverage overrides all other interests.
• Ever since the late Director General of the WHO, Dr J.W. Lee introduced the issue, all have agreed that no vertical system of disease control can work without strengthened health system.
• The WHO adopted the Primary Health Care strategy in 2008, and injection safety is among the central component of PHC implementation.
• The WHO will in 2010 undertake a major effort in Health System Strengthening Research, and certainly all aspects of injection devices elaboration function and use will be part of that.

With the 2008 WHO report on Primary Health Care for All, now is the time to apply the Primary Health Care principles to injection safety programs to ensure universal coverage.

Brazil has called for world attention to Hepatitis in 2010, the WHO secretariat is introducing a resolution.

NOW is the time! No patient in the world should be subjected to a filthy injection procedure, to injection contaminated products and catheters. This is clear violation of basic human right.

Today, NGOs, the WHO, other United Nations organizations, the private sector, primary health care actors, all have a shared interest in making sure that each and every person giving an injection in health care applies a safe procedure.

Injection Safety will demand the coalition of all concerned.

http://www.who.int/injection_safety/en/.

 

[1] World Health Assembly 2009, 62nd Session 18 May 2009 – discussion reported. Background paper for EB 2010

[2] Same as above.

[3] Same as above.

[4] WHO 2009 Background paper for EB 2010

[5]  World Health Assembly 2009, 62nd Session 18 May 2009 – discussion reported. Background paper for EB 2010

[6] WHO/Joint Commission/JCI Patient Safety Solution Vol 1,Nb8, 2007. Single use of Injection device- ref web.

7- Dr Jean-Bosco Ndihokubwayo, Coordinator, Patient Safety, WHO/AFRO Brazzaville, presentation to March 2009 Dakar, Sénégal, Regional Forum Francophone States: Forum sous-régional sur l’implication des patients et associations d’usagers dans la promotion de la sécurité des soins en Afrique

[8] http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution8-LowRes.pdf

[9] Task Shifting to Tackle Health Workers Shortages, WHO

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