Injection practices in 2011-2015: A rapid review using data from the Demographic and Health Surveys (DHS)

BackgroundReuse of injection devices to give healthcare injections decreased from 39.8% to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015.MethodsWe searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004- 2010 and 2011-2015.ResultsSince 2011, 40 of 92 countries (43%) that had DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data up to 2010 and since 2011, 69% improved in terms of safety. The annual number of unsafe injections was reduced in 81% of countries, with the notable exception of Pakistan where the number of unsafe injections was the highest and did not decrease between 2006 and 2012.ConclusionInjection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular is facing residual unsafe practices that are not improving. Further efforts are needed to completely eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

Knowledge and practice of injection safety among healthcare workers in a Nigerian secondary healthcare facility

Injection safety is important in today’s healthcare delivery particularly in settings with a high burden of blood-borne viruses. A safe injection protects the patient, the healthcare worker and the community from avoidable infections. In Nigeria, the national policy on injection safety and healthcare waste management were developed in 2007. The development of the policy was followed by series of training on safe injection and behavioural change. Despite this, high burden of unsafe injections was reported in many parts of the country. This study assessed the level of knowledge and practice of injection safety among healthcare workers in a secondary healthcare facility in north-western Nigeria. The study targeted all the healthcare workers employed in the hospital. A self-administered questionnaire was distributed to all the available healthcare workers. A total of 80/88 questionnaires were returned and analysed. Majority of the respondents were male in their early career who were within the age range of 31-40years. The results showed that 88.75% of the healthcare workers correctly described injection safety as defined by the WHO. However, only 18.75% and 40.0% had good knowledge of risks associated with, and diseases that can be transmitted through unsafe injections respectively. In addition, only 25.0% reported safe injection practices. Reuse of syringe was reported by 37.50% of the respondents and over 88% recap used needles. Majority of the healthcare workers reported a previous history of needlestick injury which was not associated with their professional cadre p-value = 0.146. Despite injection safety training, inadequate knowledge with poor injection practice was found among the surveyed healthcare workers. The reuse of syringes and needles underscores the need for adequate and safe injection commodities at all levels of healthcare delivery. Keywords: healthcare workers, injection safety, knowledge, practice

862. Spatial Distribution of HIV Transmission in Ethiopia and Characteristics of HIV Clusters

Background HIV prevalence in Ethiopia has decreased by nearly 75% in the past 20 years with the implementation of antiretroviral therapy, but HIV transmission continues in certain high-risk regions around the country. Identification of the spatial and temporal trends of these transmission clusters, as well as their epidemiologic correlates, can lead to refinement of targeted interventions. Methods We used data from the 2005, 2011, and 2016 Ethiopia Demographic and Health Survey program (DHS). The spatial-temporal distribution of HIV was estimated using the Kuldorff spatial scan statistic, which determines the likelihood ratio of HIV within possible circular clusters across the country. Significant clusters (P < 0.05) were identified and compared based on known HIV risk factors using descriptive statistics to compare them to the noncluster area of the country. All analyses were conducted in SaTScan and R. Results Data from 11,383, 29,812, and 26,753 individuals with HIV were included in the 2005, 2011, and 2016 DHS, respectively. Four HIV clusters were identified consistently over the 3 time points, with the clusters representing 17% of the total population and 47% of all HIV cases. The 4 clusters were centered on the Addis Ababa, Afar, Dire Dawa/Harare, and Gambella regions, respectively. Cluster 1 is characterized by higher levels of unsafe injections (4.9% vs. 2.2%, P < 0.001) and high-risk occupations, such as truck drivers (5.7% vs. 1.7%, P < 0.001), when compared with noncluster regions, but by lower levels of transactional sex (18.6% vs. 23.0%, P < 0.001). Cluster 2 is also characterized by higher levels of high-risk occupations (2.8% vs. 1.7%, P < 0.01), whereas cluster 4 is characterized by a lower prevalence of circumcised men (59.1% vs. 91.3%, P < 0.01). No cluster had significantly higher levels of having more than one sexual partner in the last 12 months, although cluster 3 had a significantly lower level (0% vs. 1.7%, P < 0.001). Conclusion HIV in Ethiopia is composed of heterogeneous clusters of HIV transmission that appear to be driven by different risk factors. Further decreasing the HIV burden will likely require targeted and prioritized interventions in specific regions rather than uniform national policies. Disclosures All authors: No reported disclosures.

Massive Iatrogenic Outbreak of Human Immunodeficiency Virus Type 1 in Rural Cambodia, 2014–2015

Background In 2014–2015, 242 individuals aged 2–89 years were newly diagnosed with human immunodeficiency virus type 1 (HIV-1) in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak. Methods We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C virus (HCV) and hepatitis B virus (HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV. We performed amplification, sequencing, and evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed healthcare practitioner were obtained from 193 cases and 1499 controls during interviews. Results Cases were coinfected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV env C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012–July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P = .04). Fifty-nine of 153 (38.6%) tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed 3 main clades, 1 containing 34 subtypes 1b with tMRCA in 2012, and 2 with 51 subtypes 6e and tMRCAs in 2002–2003. Conclusions Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically diverse HCV propagation.

HIV transmission efficiency through contaminated injections in Roka, Cambodia

A nosocomial HIV outbreak recognized in late 2014 in Roka commune, Cambodia, demonstrates the potential for rapid transmission through skin-piercing healthcare procedures. Information reported from the investigation of the Roka commune outbreak is sufficient to estimate the transmission efficiency of HIV through contaminated injection equipment. With conservative assumptions, two estimates are 4.6% and 9.2%. These estimates are much greater than widely disseminated and influential low estimates of risk from unsafe injections, estimates which have encouraged low estimates of the contribution of unsafe healthcare to Africa’s generalized HIV epidemics. More information about nosocomial risks in Roka commune could improve the estimates in this paper and advise HIV prevention programs, particularly in countries with unreliably sterile healthcare and high HIV prevalence.

Unnecessary & Unsafe Injections Replace Disposable by Auto-Disable Syringes

Injections are a skin procedure performed with a syringe and needle to introduce a substance for prophylactic, curative, or recreational purpose. Injections can be given intevenously, intramuscularly, intradermally, or subcutaneously. Injections are among the most frequently used medical procedures, with an estimated 12 billion injections administered worldwide. A large majority (more than 90%) of these injections are administered for curative purpose (for every vaccination, 20 curative injections are administered). Injections have been used effectively for many years in preventive and curative healthcare. In preventive healthcare, injections have been used to administer vaccinations that have had major impact in reducing childhood mortality due to measles and other vaccine preventable diseases. While injections are still necessary today to administer most vaccination, the number of vaccination injections could be reduced through the use of combination vaccines. In curative healthcare, injections have been used to administer such antibiotics as Penicillin, Streptomycin, as well as many other life saving medications. Today, safe and effective alternatives to injected medications are available and most medications used in primary care can be administered orally. Injections are predominantly needed for treatment of severe diseases, mostly in hospital settings. Nevertheless, injections are overused to administer medications in many countries because of an ingrained preference for injections among health workers and patients. A safe injection does no harm to the recipient, does not expose the healthcare worker to any risk, and does not result in waste that is dangerous for the community. To achieve this, an injection needs to be prepared with clean hands in a clean area, using a syringe and a sterile needle. After administration, sharp equipments such as needle need to be discarded in a puncture proof container for appropriate disposal. When these rules are not followed, injections are unsafe and may expose recipients, healthcare workers, or the community to infections. Among unsafe practices, syringe or needle reuse between patients without sterilization is associated with a high risk of blood-borne pathogen transmission. Unsafe injections occur in many parts of the world and more particularly in developing countries where up to 50% of injections are administered with reused syringes and needles. To reduce the overuse of injections, and to assure safe injection practice, multidisciplinary strategies comprising of various elements have been discussed in this article. DOI: http://dx.doi.org/10.3126/jucms.v1i3.8770 Journal of Universal College of Medical Sciences Vol.1(3) 2013: 67-70