|POST for injections
|1. Avoid skin-piercing procedures
||(a) When your doctor prescribes an injection, ask if you can get along without any medicine, or if an oral alternative is available. Many conditions, such as colds, flu, dry cough, and diarrhoea are often better treated without injected medicines.(b) The following drugs and other substances can be taken orally, and should be injected only in rare situations (especially if someone is unconscious, or vomits so much that oral medication will not stay down):
- paracetamol and other drugs to reduce temperature
- most pain-killers
- treatments to stop diarrhea or vomiting
- medicines to treat asthma
- antibiotics (with a few exceptions, such as penicillin)
(c) Most sexually transmitted disease (STD) can be treated with oral drugs. The most common exception is syphilis, which is often treated with injected penicillin. If your provider wants to inject penicillin for syphilis, ask for one injection of long-acting penicillin, which is safer than 7-10 daily injections of short-acting penicillin. (Old syphilis infections are harder to treat, and may require repeated injections of long-acting penicillin.)
|2. Use new disposable instruments
||(a) Use a new disposable syringe and needle taken from a sealed package.(b) Ask your provider to take medication to inject from a single-dose vial (a small bottle with medicine for one injection only).
Single dose vial with distilled water
Many providers stock only multi-dose vials (with medicine for many injections). You can ask your provider to write a prescription for a single-dose vial, which you can buy at a pharmacy. If no single-dose vial is available, ask your provider to take medicine from a new multi-dose vial opened in front of you. This is especially important for local anaesthetics. (Exception: If your provider uses a new syringe and needle every time he or she takes medicine from a multi-dose vial, there is no chance for blood or HIV to get into the vial. Can you be sure?)(c) Another option is to take injections from pre-filled disposable syringes– which are disposable syringes combined with single-dose vials, or single dose cartidges.
Single dose cartidge
|3. You sterilize the instruments
||It’s safer not to do this. If you keep reused syringes and needles at home, even if you boil them after use, it’s easy for them to pick up germs from hands, cloth, and air. This can lead to infections and abscesses. So: use new disposables.
|4. Ask providers how they sterilize instruments
||Your provider will have to use special reusable syringes and needles in some situations, such as to inject rabies vaccine. If the syringe or needle are reused, ask if they have been autoclaved or boiled.
Additional information on injections
Too many injections: Many injections are unnecessary, given for conditions (fever, cough, diarrhoea) that are almost always better treated with oral or even no medicines. In Tanzania in 1991-92, 70% of injections were unnecessary.[i] In six African countries during 1989-90, adults reported an average of 1.7 to 2.7 injections per year.[ii] In 2002, a WHO team used information from new studies to estimate that Africans received an average of 2.0-2.2 injections per person per year.[iii]
Reused syringes are dangerous, even with new needles: When someone receives an injection, some of their blood can get into the needle and syringe through back pressure from their muscle and through suction when the needle is withdrawn from their flesh at the end of an injection.
Disposable syringe and needle
If a provider then changes the needle to reuse the syringe with a new needle, blood in the old needle can get to the tip of the syringe through suction when the needle is removed from the nozzle of the syringe. There is good evidence for this: In an experiment more than 50 years ago, researchers filled syringes with sterile solution, injected some of the solution into mice with a deadly infection, changed the needles, and then with the same syringes injected the remaining fluid into healthy mice. Within two days, infections from these injections killed more than 70% of the formerly healthy mice.[iv]
Glass syringe and needle
Many providers do not know this is dangerous. For example, 91% of health care staff in Ethiopia[v] in 2003-04 thought an injection was safe if the provider changed the needle but reused the syringe. A study of immunization injections in Swaziland in 1997 found that health staff in 8 of 26 clinics changed needles while reusing syringes.[vi] In 1987 WHO warned, “A dangerous practice has slipped into common use…: changing needles but using the same syringe for several consecutive injections.”[vii]
Syringe and/or needle reuse in Africa: Reuse of syringes and/or needles has been a long-standing problem, going back to colonial times. During 1995-98, WHO surveyed injection practices in 13 African countries. A summary of findings from these surveys concluded that “the study countries have not made any progress with regard to safety over the last 10 years.” [viii] In 1999 WHO estimated that 50% of injections in Africa reused syringes and/or needles without sterilization.[ix] Despite improvements over the last 10-15 years, unsafe injections remain all too common. In 2002, WHO estimated that 17-19 percent of injections in Africa reused syringes and/or needles without sterilization.[x]
Multi-dose vials: Most injected vaccines and drugs come from multi-dose vials (small bottles that contain doses for many injections). Medicines in multi-dose vials may be contaminated with HIV or other pathogens. This can happen if a provider reuses a syringe – even with a new needle – to withdraw medicine from a vial. If HIV gets into the vial, it could survive for weeks, waiting to get into other patients. Multi-dose vials of local anaesthetic are especially dangerous. After an initial injection of local anaesthetic, some patients continue to feel pain. In such cases, providers might re-use the same syringe to withdraw another dose of anaesthetic for a second injection; this could contaminate the vial.
Multi-dose vials have spread hepatitis B and C viruses in the US. In Australia, a multi-dose vial of local anaesthetic is suspected to have passed HIV from one HIV-positive patient to four others visiting a doctor’s clinic in one day.[xi]
Depending on the drug and vaccine, you can often but not always find single-dose vials available in your country. But for some medicines or vaccines, it may be difficult or impossible for you to avoid multi-dose vials.
Some injection providers routinely leave a needle embedded in the cap of a multi-dose vial. This is an added risk, because the needle provides a pathway for pathogens from the air or from hands or anything else that touches the needle to get into the vial.
Some medicines come in dried or concentrated form, and must be mixed with distilled water before injecting. The distilled water usually comes from a large bottle used to mix other medicines. Think of this large bottle as a multi-dose vial that can be contaminated; you can ask the provider to take saline water from a small or new bottle.
Are untrained providers a risk? Many people give injections – not only doctors and nurses, but also pharmacists, traditional healers, family, and friends. No general statements can be made about who gives safe injections. If a trained provider respects your requests, uses a new syringe and needle, and takes medicine from a single-dose vial, you are probably safer with the trained provider. But if the trained provider will not do so, you may be safer with an untrained provider who will listen to you.
Late and limited progress toward injection safety: In 1999, WHO established a Steering Committee on Immunization Safety. The Committee’s first report recognized that “up to one-third of immunization injections are not carried out in a way that guarantees sterility.”[xii] To solve this problem, WHO proposed to shift immunization injections to auto-disable syringes – which cannot be reused, because they break after one use. Most African governments have shifted all immunization injections to auto-disable syringes. However, reuse continues to be a problem for curative injections, which account for more than 90% of injections. As of early 2011, governments of only a handful of African countries, including DRC, Uganda,[xiii] and Nigeria, promote auto-disable syringes for curative injections.
Risks to get HIV from injections
If the previous patient was HIV-positive, and the provider reuses the needle and syringe, or even just the syringe, with no effort to clean, your chance to get HIV from an intramuscular or sub-cutaneous injection may be estimated at 0.5%-3% (see Table on Estimated risks in Blood-borne Risks section). For an intravenous injection, the risk may be estimated at 3%-10%. Your risk may be much less if the syringe or needle are wiped or rinsed after use. Your risk may be greater if what is injected comes from a multi-dose vial.
If the syringe and needle are new or sterilized, and if the medicine comes from a single- or multi-dose vial opened for you, you have no risk to get HIV from the injections.
Evidence that medical injections have infected people with HIV
One of the best ways to estimate risks to get HIV from injections is to follow people who are HIV-negative, testing them from time to time to see who gets HIV, and then asking everyone about risks (such as skin-piercing procedures and number of sex partners). Information on injections is available from 9 studies in Africa during 1984-2005 that tested and followed people in the general population (such as villagers or women at antenatal clinics, but not sex workers).
Taking all of these studies together, 11 of 12 results show that men and/or women who reported injections were more likely, often many times more likely, to show up with a new HIV infection compared to those who reported no injections (see the column on the right in the Table, below). In only one study were people who received injections less likely to have new HIV infections.
Table: Evidence that people got HIV from medical injections
|Country, year of study
||Relative risk to get HIV in people with recent injections vs. people with no recent injections
* This result is based on reported hormone injections for birth control.
[i] Gumodoka B, Vos J, Berege ZA, van Asten HA, Dolmans WM, Borgdorff MW. Injection practices in Mwanza region,Tanzania: prescriptions, patient demand and sterility. Trop Med Int Health 1996;1:874–880.
[ii] Ferry B. Risk factors related to HIV transmission: Sexually transmitted diseases, alcohol consumption and medically-related injections. In Cleland J, Ferry B (eds). Sexual Behaviour and AIDS in the Developing World. Geneva: WHO, 1995. pp. 193-207.
[iii] Hauri AM, Armstrong GL, Hutin YJF. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004; 15: 7-16.
[iv] Evans RJ, Spooner ETC. A possible mode of transfer of infection by syringes used for mass inoculation. Brit Med J 1950; 2: 185-188.
[v] W/Gebriel Y. Assessment of the safety of injections and related medical practices in health institutions at Sidama Zone, SNNPRS, Thesis for the degree of Master of Public Health. Addis Abbaba: Addis Ababa University, 2004.
[vi] Daly AD, Nxumalo MP, Biellik RJ. An assessment of safe injection practices in health facilities in Swaziland. S Afr Med J 2004; 94: 194-7.
[vii] Expanded programme on immunization: changing needles but not the syringe: an unsafe practice. Wkly Epidemiol Rec 1987; 62: 345-346.
[viii Quoted from p.166 in: Dicko M, Oni A-QO, Ganivet S, et al. Safety of immunization injections in Africa: Not simply a problem of logistics. Bull WHO 2000; 78: 163-9. p.166.
[ix] Kane A, Lloyd J, Zaffran M, Kane M, Simonsen L. Transmission of hepatitis B, hepatitis C, and human immunodeficiency viruses through unsafe injections in the developing world: model-based regional estimates. WHO Bull 1999;77:810–817.
[x] Hauri AM, Armstrong GL, Hutin YJF. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004; 15: 7-16.
[xi] Shields JW. Patient-to-patient transmission of HIV. Lancet 1994; 343: 415.
[xii] WHO. Report of the first meeting of the Steering Committee on Immunization Safety, Geneva, 25-26 October 1999. Doc. no.: WHO/V&B/00.17. Geneva: WHO, 2000.
[xiv] N’Galy B, Ryder RW, Bila K, et al. Human immunodeficiency virus infection among employees in an African hospital. N Eng J Med 1988; 319: 1123-7.
[xv] Wawer MJ, Sewankambo NK, Berkley S, et al. Incidence of HIV-1 infection in a rural region of Uganda. BMJ 1994; 308: 171-3.
[xvi] Bulterys M, Chao A, Habimana P, et al. Incident HIV-1 infection in a cohort of young women in Butare, Rwanda. AIDS 1994; 8: 1585-91.
[xvii] Quigley MA, Morgan D, Malamba SS, et al. Case-control study of risk factors for incident HIV infection in rural Uganda. J Acquir Immune Defic Syndrome 2000; 23: 418-25.
[xviii] Whitworth JA, Birao S, Shafer LA, et al. HIV incidence and recent injections among adults in rural southwestern Uganda. AIDS 2007; 21: 1056-8.
[xix] Todd J, Grosskurth H, Changalucha J, et al. Risk factors influencing HIV infection incidence in a rural African population: A nested case-control study. J Infect Dis 2006; 193: 458-66.
[xx] Gisselquist D. New information on the risks of HIV transmission in Mwanza, Tanzania [letter]. J Infect Dis 2006; 194: 536-7.
[xxi] Kiwanuka N, Gray RH, Serwadda D, et al. The incidence of HIV-1 associated with injections and transfusions in a prospective cohort, Rakai, Uganda. AIDS 2004; 18: 342-4.
[xxii] Lopman BA, Garnett GP, Mason PR, et al. Individual level injection history: A lack of association with HIV incidence in rural Zimbabwe. PLoS Med 2005; 2: 142-6.
[xxiii] Kumwenda NI, Kumwenda J, Kafuafula G, et al. HIV-1 incidence among women of reproductive age in Malawi. Int J STD AIDS 2008; 19: 339-341.
[xxiv] Kumwenda JJ, Makanani B, Taulo F, et al. Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008; 46: 1913-1920.