INTRODUCTION TO INJECTION SAFETY
Slide 1 – 4
IAP Plan of action, The National task force on safe injection practices and the sponsors of the workshop B.D. India Pvt. Ltd. .
Slide 5 - 8
These pictorials show the extent of misuse of injection devices and highlight the problem of injection safety. They tend to make us realize that one of the most commonly used medical device that is the syringe and one of the most common invasive procedure that is an injection has in the due course of time become one of the reasons of the spread of blood born pathogens
Slide 9 - 10
With the purpose of increasing awareness among program managers and health care professionals to the problem of unsafe injections a national network was created on the lines of the global SIGN alliance. This network has members from the government to the bilateral agencies/NGO / PVO, professional associations funding agencies and the industries. It is more of a virtual coalition with each member contributing towards making injections safer in India .IAP has played a leadership role in the coalition right from its inception.
Slide 11
This is a simple definition of injections, this definition also encompass injections used for recreational purposes.
Slide 12
WHO defines a safe injection as one which causes no harm to the recipient who is usually our patient and client, causes no harm to the health care professional who is delivering the injection and also to the community due to improper disposal.
Slide 13
Injections become unsafe when they transmit pathogens due any one or a combination of these reasons
1.      they are transferred from the fingers or objects to the needle a simple example of this is that a lot of     health care professionals swab the presterilized  prior to injecting or some even try to touch the needle tip to ascertain sharpness. Hand washing is also not rigorously followed even in high bio-burden areas like OPD and wards
2.      Pathogens present on the skin  and picked by the needle as the injection site has not been properly cleaned prior to injecting .
3.      pathogens are present in the medication to be injected. All injectibles  come in sterile multi dose vials or single dose ampules, but it is often observed that needles are left  patented in multi dose vials 
and in single dose ampules a cotton plug is used to close the opening.All these procedures expose the sterile contents of the vial / ampule to pathogens present in the environment.
4.      Pathogens are present inside the syringe or needle that has previously been used. This happens    while withdrawing the hollow bore needle from the patients bady a negative pressure is created in the needle and the biological fluids oozing out into the tract the needle had created are suckede into the needle and these can be a potential sources of pathogen transmission. If the needle is removed from the syringe the sane phenomena is repeated in the syringe.
Slide 14
WHO broadly defines four best practice areas which make the injections safe these are
1.      Using only sterile injection equipment meaning thereby that if reusable devices are being used they should have been properly sterilized using the correct equipment, temperature, pressure and time. If disposal devices are being used it should be ascertained that there has been no break or breach in the integrity of the pouches and they have been purchased from a reliable source and are well within the expiry limits of five years after the date of manufacture.
2.      Preventing contamination of equipment and medication. We have to insure that the sterility of the devices is not compromised in any way prior to the injection being given and it is also applicable for injectable medicines.
3.      Preventing Needle sticks abundant precautions should be taken to avoid injury to self while opening ampules or handling injection equipments after the injection has been given.
4.      Preventing access to used needles. This has to be achieved by practicing proper sharps disposal.
Slide 15
The global burden of disease study done in 2000 showed that South Asia accounted for one of the largest numbers of injections given per person per year which was close to 4.5. India is the largest country in south asia and contributes the maximum to this number. The other countries in the South Asian region are Pakistan, Maldives, Srilanka, Bangladesh, Bhutan and Nepal.
Slide 16
The same study also showed that in South Asia nearly four injections per person per year were given with equipment reused in the absence of sterilization. This is a clear cut indicator of the poor injection practises prevailing in the region.
Slide 17
A study published by Simonsen et al and data given in a WHO Fact sheet of 2002 indicated that unsafe injections may be responsible for approximately 33% of Hepatitis B 42% of Hepatitis C and 5% HIV, new infections per year world wide per year. This if mathematically extrapolated would mean that in India alone 30 to 60 lakh Hepatitis 4 to 8 lakh hepatitis C and 4 to 8 thousand HIV infections may have been caused by unsafe injections.
Slide 18 - 19
Simonsens study also indicated that in the Pediatric age group Unsafe immunization practices may be accounting for around 61% of new Hep B Infections every year and 70-90% of of the children who got infected early became chronic carriers and 20-28% of them died due to complications of Chronic HBV infection. This in a young country like India with 25 million children born every year is a frightening scenario.
The same study also gave a figure of 1.2 injections per person per year being given in India out of which 95% were for curative purposes and 5 % for immunization 33-50% of all OPD visits resulted in an injection 70-99% of these were not required and an astonishing 50% were unsafe.
Slide 20
Dr. Sneller Vishnu Priya from the US CDC conducted a field test of an injection safety assessment tool in Tamil Nadu  and found that awareness regarding HBV, HCV transmitted trough unsafe injections was variable in the population, providers and prescribers alike. The highest levels of awareness was for HIV and lowest is for HCV for all the three pathogens the awareness levels was highest amongst the prescribers and lowest among the general population.
Slide 21
A study conducted by Chengalpattu Medical College in Tamil Nadu found that nearly 2.4 injections person per year were being given the ratio of therapeutic to immunization injections was 6.5:1. 35.4 % of all injections were being given by disposable syringe and needles and nearly 35% of the service providers indicated that they had suffered from NSI.
Slide 22-24
A study done by India INCLEN for the GOI, funded by World Bank was conducted from 2002 to 2004. This study had two phases one qualitative and then quantitative nearly hundred institutions both public and private participated in the study. The results show that in India the number of injections per person per year is anything in between 3-5.8.
60% of these injections were unsafe and 3 reasons were ascribed to denote an injection to be unsafe. These were questionable sterility (22%) reuse of injection equipment (20%) and third wrong habits of injection givers.81 % of the glass syringes were estimate to be unsafe and 54% of plastic syringes were deemed to be unsafe. In government facilities 62% of the last injection given was a plastic syringe this was 80% for private facilities and 52% for immunization clinics, this showed a definite shift toward plastic disposable syringe though the government only procure and supplies glass syringes. It was estimated that nearly 204 crores injections are being given in the private sector and around 96 crores in the public sector of which 122 crore and 58 crore are unsafe respectively as fro immunization 36 crore injections are given in the public sector and 19 crores in the private out of which 22 crore and 11 crore respectively were unsafe.
Slide 25
The main gaps that lead to Unsafe injection practices can be surmised as
1. Uneven quality of sterilization & injection equipment compromising injection safety
2. Reuse of disposable syringes /needles caused by breaks in supply of adequate volume of equipment
3. Low awareness of risks from sharps / needle-stick injuries - health workers / waste handlers /   community
4. Need for appropriate equipment / strategy for safe disposal of sharps and infected waste