Post00338 EPI WASTE

Post00338 EPI WASTE 1 May 2001 CONTENTS 1. DISPOSAL OF UNUSED VACCINE VIALS 2. GAVI DONATIONS - INJECTION WASTE DISPOSAL Continued 3. HEALTH-CARE WASTE MANAGEMENT DRAFT RAPID ASSESSMENT TOOL 4. FROM GAVI IMMUNIZATION FOCUS: FIRST, DO NO HARM 1. DISPOSAL OF UNUSED VACCINE VIALS This discussion took place in March between James Patterson, UNICEF/Timor, Allan Bass, Technet, and Umit Kartoglu, WHO/ATT. Our thanks to James for leading us to revisit this problem. WHO Fact Sheet October 2000, Wastes From Health-Care Activities, is reproduced below. Opinion, comments and additions please: [log in to unmask] or use your reply button ___________________________________________________________________________ Date: Mon, 5 Mar 2001 From: [log in to unmask] (James Patterson) Subject: Disposal of UNUSED vaccine vials To: Technet Moderator Dear Allan, After a review of WHO guidelines for waste disposal, we remain confused as to the best practice for disposal of UNUSED vaccine vials/ampoules. (To be destroyed either because of expiry or cold chain failure.) The vaccines in question are: freeze-dried BCG & Measles, OPV, DPT, DT, and TT. Should such sealed vials be incinerated (>1400C) or encapsulated? best regards, EPI East Timor --- From: [log in to unmask] To: [log in to unmask] CC: [log in to unmask] Subject: RE: Disposal of UNUSED vaccine vials Date: Fri, 9 Mar 2001 Dear James, I've forwarded your message on EPI waste disposal to Umit Kartoglu at WHO/V&B/ATT in Geneva for a response. Incineration at 800'C is the recommendation as I recall - but as you know - the vials will explode and do present a hazard - either to the incinerator or the operators. Lower temp burning - if it is complete and long enough duration - is probably just as effective. Let us see what Umit answers. Immunization waste management is a real problem without really good solutions at this point in time. regards, allan Technet Moderator --- From: [log in to unmask] To: [log in to unmask] CC: [log in to unmask] Subject: RE: Disposal of UNUSED vaccine vials Date: Fri, 9 Mar 2001 Dear James, Thank you for raising this issue. I am not aware of any specific WHO recommendation regarding disposal of unused/used vaccine vials/ampoules. I also cross checked this with some colleagues in WHO Geneva and it seems that there is not any. The only document I found mentioning of disposal of used vaccine vials is the "Immunization in Practice" Module 9 "After a session" page 5, reads as follows: "Wrap empty vials, other vials and rubbish in newspaper or other paper. Then either burry or burn them if the local government does not collect them." In East Timor situation (assuming that you do not have high temperature incineration facility) the best way of disposal would be burying them. I would also like to inform you that this issue would be addressed in a group work to put together an aide-memoire for planners and managers on management of wastes from immunization activities. I will keep you posted on developments. Regards, Umit Dr. Umit Kartoglu Technical Officer V&B/ATT, HTP Room M230 World Health Organization Avenue Appia 20, CH-1211 Geneva 27 Switzerland Tel: +41 22 791 4972; Fax: +41 22 791 4384 e-mail: [log in to unmask] ___________________________________________________________________________ WHO Fact Sheet October 2000 WASTES FROM HEALTH-CARE ACTIVITIES Health-care activities - for instance, immunizations, diagnostic tests, medical treatments, and laboratory examinations - protect and restore health and save lives. But what about the wastes and by-products they generate? From the total of wastes generated by health-care activities, almost 80% are general waste comparable to domestic waste. The remaining approximate 20% of wastes are considered hazardous materials that may be infectious, toxic or radioactive. The wastes and by-products cover a diverse range of materials, as the following list illustrates (percentages are approximate values): Infectious wastes cultures and stocks of infectious agents, wastes from infected patients, wastes contaminated with blood and its derivatives, discarded diagnostic samples, infected animals from laboratories, and contaminated materials (swabs, bandages) and equipment (disposable medical devices etc.); and Anatomic - recognizable body parts and animal carcasses. Infectious and anatomic wastes together represent the majority of the hazardous waste, up to 15% of the total waste from health-care activities. Sharps: syringes, disposable scalpels and blades etc. Sharps represent about 1% of the total waste from health-care activities. Chemicals for example solvents and disinfectants; and Pharmaceuticals: expired, unused, and contaminated; whether the drugs themselves (sometimes toxic and powerful chemicals) or their metabolites, vaccines and sera. Chemicals and pharmaceuticals amount to about 3% of waste from health-care activities. Genotoxic waste: highly hazardous, mutagenic, teratogenic1 or carcinogenic, such as cytotoxic drugs used in cancer treatment and their metabolites; and Radioactive matter, such as glassware contaminated with radioactive diagnostic material or radiotherapeutic materials; Wastes with high heavy metal content, such as broken mercury thermometers. Genotoxic waste, radioactive matter and heavy metal content represent about 1% of the total waste from health-care activities. The major sources of health-care waste are hospitals and other health-care establishments, laboratories and research centres, mortuary and autopsy centres, animal research and testing laboratories, blood banks and collection services, and nursing homes for the elderly. High-income countries can generate up to 6 kg of hazardous waste per person per year. In the majority of low-income countries, health-care waste is usually not separated into hazardous or non-hazardous waste. In these countries, the total health-care waste per person per year is anywhere from 0.5 to 3 kg. HEALTH IMPACTS Health-care waste is a reservoir of potentially harmful micro-organisms which can infect hospital patients, health-care workers and the general public. Other potential infectious risks include the spread of, sometimes resistant, micro-organisms from health-care establishments into the environment. These risks have so far been only poorly investigated. Wastes and by-products can also cause injuries, for example radiation burns or sharps-inflicted injuries; poisoning and pollution, whether through the release of pharmaceutical products, in particular, antibiotics and cytotoxic drugs, through the waste water or by toxic elements or compounds such as mercury or dioxins. Sharps Throughout the world every year an estimated 12 000 million injections are administered. And not all needles and syringes are properly disposed of, generating a considerable risk for injury and infection and opportunities for re-use. Worldwide, 8-16 million hepatitis B, 2.3 to 4.7 million hepatitis C and 80 000 to 160 000 HIV infections are estimated to occur yearly from re-use of syringe needles without sterilization2. Many of these infections could be avoided if syringes were disposed of safely. The re-use of disposable syringes and needles for injections is particularly common in certain African, Asian and Central and Eastern European countries. Regarding injection practices, public health authorities in West Bengal, India, have recommended a shift to re-usable glass syringes, as the disposal requirements for disposable syringes could not be enforced. In developing countries, additional hazards occur from scavenging on waste disposal sites and manual sorting of the waste recuperated at the back doors of health-care establishments. These practices are common in many regions of the world. The waste handlers are at immediate risk of needle-stick injuries and other exposures to toxic or infectious materials. Vaccine waste In June 2000, six children were diagnosed with a mild form of smallpox (vaccinia virus) after having played with glass ampoules containing expired smallpox vaccine at a garbage dump in Vladivostok (Russia). Although the infections were not life-threatening, the vaccine ampoules should have been treated before being discarded. Radioactive wastes The use of radiation sources in medical and other applications is widespread throughout the world. Occasionally, the public is exposed to radioactive waste, usually originating from radiotherapy treatments, that has not been properly disposed of. Serious accidents have been documented in GOINIA Brazil in 1988 in which four people died from acute radiation syndrome and 28 suffered serious radiation burns. Similar accidents happened in Mexico City in 1962, Algeria in 1978, Morocco in 1983 and Ciudad in Mexico in 1983. Risks associated with other fractions of health-care wastes, in particular blood waste and chemicals, have been relatively poorly assessed, and need to be strengthened. In the meantime, precautionary measures need to be taken. RISKS ASSOCIATED WITH WASTE DISPOSAL Although treatment and disposal of health-care wastes aim at reducing risks, indirect health risks may occur through the release of toxic pollutants into the environment through treatment or disposal. Landfilling can potentially result in contamination of drinking water. Occupational risks may be associated with the operation of certain disposal facilities. Inadequate incineration, or incineration of materials unsuitable for incineration can result in the release of pollutants into the air. The incineration of materials containing chlorine can generate dioxins and furans3, which are classified as possible human carcinogens and have been associated with a range of adverse effects. Incineration of heavy metals or materials with high metal contents (in particular lead, mercury and cadmium) can lead to the spread of heavy metals in the environment. Dioxins, furans and metals are persistent and accumulate in the environment. Materials containing chlorine or metal should therefore not be incinerated. Only modern incinerators are able to work at 800-1000 degree C, with special emission-cleaning equipment, can ensure that no dioxins and furans (or only insignificant amounts) are produced. Smaller devices built with local materials and capable of operating at these high temperatures are currently being field-tested and implemented in a number of countries. At present, there are practically no environmentally-friendly, low-cost options for safe disposal of infectious wastes. Incineration of wastes has been widely practised, but alternatives are becoming available, such as autoclaving, chemical treatment and microwaving, and may be preferable under certain circumstances. Landfilling may also be a viable solution for parts of the waste stream if practised safely. However, action is necessary to prevent the important disease burden currently created by these wastes. In addition, perceived risks related to health-care waste management may be significant. In most cultures, disposal of health-care wastes is a sensitive issue and also has ethical dimensions. WASTE MANAGEMENT: REASONS FOR FAILURE The absence of waste management, lack of awareness about the health hazards, insufficient financial and human resources and poor control of waste disposal are the most common problems connected with health-care wastes. Many countries do not have appropriate regulations, or do not enforce them. An essential issue is the clear attribution of responsibility of appropriate handling and disposal of waste. According to the "polluter pays" principle, this responsibility lies with the waste producer, usually being the health- care provider, or the establishment involved in related activities. STEPS TOWARDS IMPROVEMENT Improvements in health-care waste management rely on the following key elements: The build-up of a comprehensive system, addressing responsibilities, resource allocation, handling and disposal. This is a long-term process, sustained by gradual improvements; Awareness raising and training about risks related to health-care waste, and safe and sound practices; Selection of safe and environmentally-friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste. Government commitment and support is needed to reach an overall and long- term improvement of the situation, although immediate action can be taken locally. Health-care waste management is an integral part of health-care, and creating harm through inadequate waste management reduces the overall benefits of health-care. WHO'S RESPONSE The first global and comprehensive guidance document, Safe Management of Wastes from Health-Care Activities, released by WHO in 1999, addresses aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training. It is aimed at managers of hospitals and other health-care establishments, policy makers, public health professionals and managers involved in waste management. It is accompanied by a Teacher's Guide, which contains material for a three-day workshop aimed at the same audience. The Interagency Guidelines for the Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies provide practical guidance on the disposal of drugs in difficult situations in or after emergencies are also available. The full text of these publications is available on the WHO web site: http://www.who.int/water_sanitation_health under "health-care wastes". Planned WHO products and activities include: - The publication of a decision-maker's guide for health-care waste management in primary health care centres; - The implementation of health-care waste systems at country level; - The development of a database on practical options for health-care waste management, mainly targeted at developing country situations (soon on http://www.healthcarewaste.org/); - Testing of low-cost options for health-care waste management; -The development of guidance for the disposal of blood and blood bags; - An approach for promoting the use of products in health-care activities leading to reduced production of wastes or less harmful wastes. Publications can be ordered from WHO, MDI/EIP (Marketing and Dissemination). CH-1211 Geneva 27 (e-mail: [log in to unmask]) All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be obtained on Internet on the WHO home page http://www.who.int __________________________________*______________________________________ 2. GAVI DONATIONS - INJECTION WASTE DISPOSAL Continued In Technet Post00334, GAVI DONATIONS - INJECTION WASTE DISPOSAL, on 10 April 2001, John Lloyd, PATH/CVP, Ticky Raubenheimer, CCCCM/SA/CSIRO, and Anthony Battersby, FBA Analysts, have kindly posted an interesting discussion on the GAVI/CVP supported addition of new vaccines and immunization system strengthening - WHICH ADDS a lot of hazardous materials to the volume of injection waste in immunization programs. Data from many countries indicate that the management of immunization and other injection waste is inadequate and dangerous to health workers and to the public. The key issue is that in the next year or so 7,661 cubic meters of immunization injection waste is being added to health systems where the current management of health care waste in inadequate to non-existent. * Mikko Lainejoki, UNICEF, volunteers to join in a working group and reminds us that GAVI partners should not work in isolation to address this priority problem. Opinion, comments and additions please: [log in to unmask] or use your reply button ___________________________________________________________________________ From: [log in to unmask] Date: Tue, 10 Apr 2001 07:54:43 +0200 To: Technet Moderator , Subject: Re:Post00334 GAVI DONATIONS - INJECTION WASTE DISPOSAL Dear John, Ticky and Anthony, If and when you plan to start a small working group on waste management issues we would like to be part of that work. We have prioritized waste management as one of our key areas and try to avoid working in isolation (only involving UNICEF Country Offices). In his work plan Stephane Guichard has allocated a good portion of his time for waste management issues and is ready to join a dynamic network and get things moving. Please kindly advise what/when/how we could be of assistance or partners in this important work. Best regards, mikko ____________________________________*______________________________________ 3. HEALTH-CARE WASTE MANAGEMENT DRAFT RAPID ASSESSMENT TOOL Annette Pruess, WHO/WSE/PHE, points us to a draft rapid assessment tool to assist countries assessing health care waste management. The tool is available on the SIGN website: www.injectionsafety.org * Comments and suggestions to: [log in to unmask], [log in to unmask] ___________________________________________________________________________ From: [log in to unmask] To: [log in to unmask] Subject: Health-care waste management Date: Tue, 20 Mar 2001 Dear Allan, We have prepared a tool for assessing the situation in a country regarding health-care waste management. This "Rapid Assessment Tool" is available on the SIGN web site www.injectionsafety.org. It is still in draft form, and will remain so for about another year. It has already been field tested in Albania and Ivory Coste, but we would like to benefit from further experience from the field with that tool, so please send us your comments (to [log in to unmask]). This tool assists in drawing a picture of current practices, understanding the level of awareness regarding risks associated with unsafe health-care waste management, and evaluating the existing regulatory framework. It not only assists in assessing the situation, but in addition provides the necessary information to design an action plan on the basis of the information collected. It is composed of a brief introduction to the area, various questionnaires to use with several key actors in the country (Ministries of Health and of Environment, managers of health-care facilities, staff responsible for waste management in those facilities etc.). It also assists in choosing a sample of health-care facilities to visit during the assessment, and in the planning phase of the assessment. A simple rating system assists in evaluating the overall situation of the country regarding the safety of health-care waste management. Finally, a glossary outlines basic terms used in health-care waste management. An assessment would take an estimated 3 person-weeks, including preparation and reporting. A more thorough assessment, or assessment of a large country, may require additional work. Annette Pruess Annette Pruess, Scientist World Health Organization Water, Sanitation and Health (WSH) Protection of the Human Environment (PHE) 20, avenue Appia, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 41 59 Tel: +41 22 791 35 84 e-mail: [log in to unmask] Visit our web sites: www.who.int/water_sanitation_health/ _____________________________________*_____________________________________ 4. FROM GAVI IMMUNIZATION FOCUS: FIRST, DO NO HARM This set of articles, Contributed by Lisa Jacobs, GAVI/UNICEF, were originally published in: GAVI Immunization Focus March 2001 Immunization Focus A quarterly publication of the Global Alliance for Vaccines and Immunization http://www.VaccineAlliance.org GAVI is a partnership of public and private organizations dedicated to increasing children's access worldwide to immunization against killer diseases. ___________________________________________________________________________ Date: Mon, 26 Mar 2001 From: [log in to unmask] (Lisa Jacobs) To: Technet Moderator Subject: GAVI AND INJECTION SAFETY Allan- Perhaps you might consider posting the text of the articles on safety that were just published in Immunization Focus. There is a main article, two 'country reports', from Egypt and Pakistan, and a checklist of 10 behaviours that promote safety. Thanks, Lisa Lisa Jacobs, Communication Officer GAVI Secretariat [log in to unmask] phone: +41 22 909 5042 fax: +41 22 909 5931 mobile: +41 79 447 1935 http://www.vaccinealliance.org ___________________________________________________________________________ FIRST, DO NO HARM Lisa Jacobs examines the road to injection safety - from recognition of the problem to action YOU may already know: unsafe injection practices spread disease. In a tragic twist of irony, health workers who aim to improve people's health may be unintentionally spreading harm with every prick of an unsterile needle, every time they toss a used disposable syringe in a vat of warm water for eventual re-use, or drop it in a trash can. The result? From 8 million to 16 million new hepatitis B infections, 2.3 million to 4.7 million new hepatitis C infections and 80,000 to 160,000 new HIV infections every year. These chronic infections are responsible for an estimated 1.3 million early deaths and lead to US$ 535 million in direct medical costs every year. Injections are prescribed for a wide variety of reasons. While they are essential for delivery of vaccines and many treatments, they are also given for other, questionable reasons. The belief that an injection is the most powerful and quick way to deliver medicine - even if the syringe contains nothing but vitamins - contributes to over-demand for, and over-prescribing of, injections. In fact, the majority of injections given for curative reasons in developing countries are thought to be unnecessary. Why are unsafe injections tolerated - by health workers, patients, caretakers, government officials? The answers are complex and include economic imperatives and cultural attitudes about waste. But perhaps the most important reason is that the people with decision-making power - including patients and caretakers of children - do not understand the risks, the extent of the problem, or that solutions (Box 1) are well within reach. According to Dr Yvan Hutin, an epidemiologist and hepatitis B expert who runs the Safe Injection Global Network (SIGN), understanding the problem is the first and most crucial step. In fact, in many cases, as soon as people see the evidence of what is occurring, they are convinced they must do something about it, says Dr Hutin. "The problem of unsafe injections will not solve itself. But when safety is included in health sector plans and budgets, it will improve." A PROBLEM WITH CLEAR SOLUTIONS In 1995, a study in Burkina Faso found that only one in ten injections in rural health centres was performed with sterile equipment. A new system was then introduced that made essential drugs - including disposable, sterile syringes - readily available at every health centre through a cost recovery scheme. Five years later, the impact on safety was astounding: by 2000 nearly 100% of injections in the centres surveyed were given with a sterile syringe. In this instance, increased supply of syringes led to increased demand - a demand for which people were willing to pay. "The Burkina Faso experience shows how incredibly amendable this problem is," said Dr Hutin. "Sometimes it is just a matter of making clean needles available." The supply, or logistics, approach that worked in Burkina Faso will not be the answer for all countries. Demand led to supply in Romania, where a highly publicised outbreak of HIV infections occurred among orphans in the early nineties. Children had been infected through blood transfusions and injections conducted in orphanages. With the vivid images of medically-induced HIV infection, concern about contracting diseases from syringes built among the general public. People demanded new syringes, in sealed packages, for every injection, and the system responded. "Every time an intervention has been funded and attempted, regardless as to whether it was behaviour change, provision of supplies or sharps waste management, it showed some impact," says Dr Hutin. "So if we have a sector wide approach that combines all these low-cost interventions, we should be able to eliminate unsafe injection practices." EPI: A SMALL PART OF THE PROBLEM, A BIG PART OF THE SOLUTION Even though immunization injections account for fewer than 10% of the 12 billion injections given annually, most health systems have considered injection safety the responsiblity of the immunization programme, or EPI. Unfortunately, that responsibility has not been supported with appropriate budgets. And even though it is essential that immunization programmes have safe practices, EPI managers have no control over the use and over-use of injections in the greater health system. "We can't solve the problem," says Dr Caroline Akim, EPI Manager in Tanzania. "But we can act as advocates, and push the health system to address it." In fact, advocating for safe injection policies and practices is an opportunity for immunization programmes to have a profound, system- wide impact. The first priority, according to many, is to adopt a policy on safe injection and disposal. "Having a system-wide policy is necessary to extend responsibility for injection safety to the whole health sector, instead of just in EPI," says Dr Akim. A national policy also gives programmes the authority to seek out and put an end to actions that are unsafe. However, a policy is only as good as its implementation. Without buy-in by all stakeholders, a safe injection and disposal policy will just be another rule on the books - one that may be considered a nuisance, adding costs to programmes and perhaps even depriving people of much needed income. "A policy that is not followed is just like having no policy at all," said Dr. B. Wabudeya, Minister of State for Health in Uganda. And the danger is that those in roles of responsibility may think that once a policy is drafted and adopted, the situation has been addressed. MEASURING THE PROBLEM If discovery is the first step toward solving the problem, the first step has just been made easier. A simple, focused methodology for tracking injection and disposal practices, and documenting knowledge and understanding among health workers and patients, has just been developed jointly by SIGN, the World Health Organization and BASICS, a programme funded by the US Agency for International Development. Referred to as 'Tool C' (as in, third of a series of four), this new methodology has been tested in Burkina Faso, Niger, Ethiopia, Mali, Mauritania, Zimbabwe and Egypt(1). The aim is to make it as easy for governments to monitor injection safety as to monitor the percentage of all children immunized, or coverage. "What is the good of increasing coverage if you also increase exposure to hepatitis B and C, or HIV?" asks Hutin. The methods behind Tool C are simple. In each country, a team of 12 monitors activities in 80 health centres in 10 districts over 2 weeks. Importantly, the data collected are practical, so countries can quickly identify solutions. For example, the team finds out how many health centres have dedicated areas for the preparation of injections, and whether they have at least a week's supply of disposable/AD equipment in stock. The measures are standardized, so, as more countries undertake the process, common problems can be highlighted and appropriate actions designed. DANGEROUS WASTE Tool C identified a serious problem in Burkina Faso, one that has caught many communities unprepared. Investigators found needles discarded in open containers in 66 health centres, putting health workers at risk of accidental needle-stick injuries. At most of the centres, used needles and syringes were found in the surrounding environment, putting the larger community at risk - a situation that has been identified in a number of countries. "In many developing countries, collection and removal of waste is considered to be a municipal responsibility - not that of the hospitals and health system," says Annette, from the environmental safety division at WHO. "The concept of 'polluter pays' is a very Western concept." Not only do children find syringes to be effective squirt toys; in many countries, scavengers also scour refuse for saleable items. Conventional disposable syringes can be rinsed, re-packaged and re-sold as new, when they are not in fact sterile. According to environmental experts, some health workers actually collect used syringes to sell to recyclers, providing income for both. And risk for many. Now, having learned of their waste disposal problem, health officials in Burkina Faso have developed plans to address it. Their chances for success are high; a recent assessment in Ivory Coste found that facilities which took responsibility for healthcare waste as part of their duty of care successfully eliminated dirty sharps from their environment. "What is needed above all is the will to take care of the problem," says Dr Hutin. TECHNOLOGY TO THE RESCUE? Many countries are addressing injection safety by making the switch to AD syringes for immunizations. AD syringes have a mechanism designed to lock the syringe once it is used, so that it cannot be re-used. Countries that have been approved to receive vaccines from GAVI and the Global Fund will also receive the requisite number of AD syringes. GAVI is now weighing a policy to further help countries with the transition from sterilizable and/or disposable syringes to AD syringes for all vaccines, in order to support countries to comply with the policy of WHO, UNICEF and UNFPA to use AD syringes for all immunizations by 2003. But when it comes to safety, technology is not the entire solution. "If you want to learn how to re-use an 'auto-disable' syringe, come to Pakistan," says Johnny Thaneoke Kyaw-Myint, Senior Project Officer for Health and Nutrition with UNICEF Pakistan. He was, of course, not serious. "People have learned how to manipulate the syringe so that the safety mechanism doesn't catch. So it can be re-used, or sold and re-used, again." The lesson? People must be educated, motivated and supported to insist upon a sterile syringe with every injection. Provision of safe injection equipment should be part of a broader strategy that also includes encouraging behaviour change and the management of sharps waste. At present, 500 million AD syringes are produced annually for use in developing countries. Within two years, as more and more countries follow, that number is expected to rise to 2 billion. The disposal issue becomes more critical each day. Simple actions can be taken immediately, says Dr Annete. Supplies of sharps boxes should be available in all health centres - not just in time for immunization campaigns. Small incinerators can be built; local oven-builders can be employed to build incinerators. The costs are affordable; a small incinerator to serve a district can be built for under US$700, according to Dr John Lloyd, an immunization expert with the Bill and Melinda Gates Children's Vaccine Program at PATH. Until recently, the problem of unsafe injections seemed insurmountable, says Dr Hutin. "But in fact, when one looks at the experience acquired, we now know that safety is an area that is easy to address - if the health system decides to address it. We know some simple strategies to follow, and results are visible and quick." Reference (1) Full series and available summary results at: http://www.injectionsafety.org/html/resources.html ___________________________________________________________________________ Country file 1: Pakistan - a country ready for change SOME would be daunted by the scale of the challenges facing Pakistan's newly formed injection safety network. But Dr Arshad Altaf, one of the key organisers of the network, does not sound like the daunted type. "There are no short cuts; we need education and training, and we need injection safety to get the attention and priority that it deserves," says Dr Altaf, a medical doctor and behavioural epidemiologist from the Aga Khan University in Karachi. The burden of bloodborne infections in Pakistan is heavy. As many as one in ten of the general population is a chronic carrier for hepatitis B virus (HBV). And, in the past few years, hepatitis C virus (HCV) has spread rapidly; in some parts of Pakistan, more than one in 20 people are chronic carriers. Researchers have concluded that unsafe injections are the most likely cause of this growing HCV epidemic. And since HCV is even more likely than HBV to cause chronic liver disease, the burden of long-term illness is rising. UNNECESSARY INJECTIONS Studies in Hafizabad, southwest of Lahore, and Darsano Channo, near Karachi, both found that exposure to injections was the strongest risk factor for being infected with hepatitis; the more injections, the greater the probability of being infected(1). "Painkillers, antibiotics, antimalarials, steroids and multivitamins are all given by injection," says Dr Altaf. All at a price: patients often pay 30 Pakistan rupees (about US $0.50) for an injection when the whole household's income is often as low as US$1.60 a day. "When the supply of syringes runs out, the clinics just dip the syringe in water and re-use it," says Dr Altaf. In a study at Aga Khan University Hospital, Dr Naheed Nabi and others(2) found that most patients believed injections were more effective than oral medications, and were willing to pay more for them. But when told that oral medications are equally effective, four-fifths of patients said they would prefer to avoid an injection. Interestingly, 91 per cent of the patients who received injectable treatments said that their doctors recommended them, disputing the claim that health workers are merely responding to demand. Only 9 per cent of patients had requested injections. RECYCLED SYRINGES A further problem is waste disposal. "There is no proper management or disposal system for waste," says Dr Altaf. His team have tracked the final destinations of syringes from hospitals and clinical laboratories in Karachi. Many are dumped at community waste sites where scavenger boys collect them and sell them to dealers. Some are also sold to scavengers by cleaners at the clinics and labs. "The used syringes with needles are sold by the kilogram at up to 10 Pakistan rupees [17 US cents]," says Dr Altaf. Needles are removed by the dealers and are re-moulded. The syringe plastic is washed, crushed and made into granules, which are sold on to the plastic ware industry. A minority of syringes are also repackaged and sold for repeat medical use. The earnings from the hazardous trade of recycling used syringes might seem small to comfortable outsiders sitting in the industrialized countries. But to people on low incomes, they are significant, says Dr Altaf. "With the financial incentive and the culture of re-use being so ingrained in the country, we expect that recycling will continue," he says. EDUCATE THE SCAVENGERS Pakistan must develop a proper system(3) for clinical waste disposal, Dr Altaf believes. This, together with the eventual use of autodisable (AD) syringes in the country's immunization clinics, may reduce the risks of bloodborne infections. But until doctors and patients gain a greater understanding of the risks of infection, and the number of unnecessary therapeutic injections falls, large numbers of conventional disposable syringes will continue to enter community waste dumps. Dr Altaf believes that it may be pragmatic to educate those involved in the recycling trade about the risks of infection and create a reliable system for the safe removal and incineration of needles before the syringes are put in the trash. If the recycling of syringes for remoulded plastic cannot realistically be stopped yet, at least the risks to everyone can be reduced. In the short year since Pakistan formed its national network for the Safe Injection Global Network, no time has been wasted. Today, the network's activities are beginning to bear fruit: the country has recognized the scale of its problem and - crucially - most stakeholders in the health system are now keen to do something about it. REFERENCES (1) Presentation at SIGN Pakistan symposium, February 2000, by Dr Stephen Luby, CDC, Atlanta USA. (2) Presentation at SIGN Pakistan symposium, February 2000, by Dr Naheed Nabi, Aga Khan University, Karachi, Pakistan. (3) For an update on current WHO policies and activities on healthcare waste disposal, see http://www.who.int/inf-fs/en/fact253.html and http://www.injectionsafety.org/documents/Aide-Memoire-HCWM.pdf Phyllida Brown ___________________________________________________________________________ Country file 2: Egypt: 'We need to decrease the demand for injections' EGYPT knows better than most countries the human cost of re-using needles. An astonishingly high proportion of the population - about one in eight people - is infected with hepatitis C virus (HCV), and hepatitis B is also widespread(1). Much of this disease burden is attributed to unsafe injections. The problem is not new, but today there is a new and powerful commitment to overcoming it. "Injection safety and infection control have become high priorities of the Ministry of Health and Population," says Dr Maha Talaat, a public health specialist and executive manager for a new programme in the ministry. The programme's goal is to prevent the transmission of bloodborne pathogens in the health service. Dr Talaat is also a member of a new national coalition of health workers that is striving to increase awareness of injection safety issues. Part of Egypt's problem can be traced back to a mass treatment for schistosomiasis before the 1980s. The treatment required multiple injections and is believed to have spread HCV widely(2). But new cases of HCV infection have continued to appear today, even though the schistosomiasis treatment has long been replaced. Researchers believe that re-used needles are still to blame. Today, studies suggest HCV continues to be spread by unsafe injections and other healthcare practices. Most of the injections are unnecessary. "People prefer injections to oral medications because they think that injections will cure them faster," says Dr Talaat. "We need to decrease the demand for injections." The government has planned its response carefully. This year, the new programme is gathering essential baseline data so that it can measure the impact of interventions that will start next year, including training for healthworkers, education and mass media campaigns for the public, and action to ensure that supplies of sterile injection equipment are available at all times. The top priority, Dr Talaat believes, is to educate those who deliver the injections. The first step is to identify who they are. The team has already discovered, from a study in one governorate, that more than 40% of injections in this setting are given not by trained healthworkers but by lay people including relatives, friends and "health barbers", whose services are cheaper than those of doctors. These findings, and further studies to find out healthworkers' practices across the country, will be crucial in the design and targeting of training material. Another key priority is safer disposal systems for clinical waste, says Dr Talaat. "The Ministry of Environmental Affairs, together with the Ministry of Health and Population, are working to try to solve this problem," says Dr Talaat. Because there is no proper system for the transport and incineration of clinical waste, all syringes - whether or not they are in safety boxes - are a hazard once they leave the healthcare facility. Some find their way to municipal rubbish dumps where children play with them. If the final disposal system is not properly managed, says Dr Talaat, no type of equipment, including safety boxes or autodisable (AD) syringes, can be regarded as safe. No one doubts the scale of the challenge facing Egypt. But now it is recognized. And, with a new government programme and an active coalition of healthworkers determined to achieve change, the battle has begun. REFERENCES (1) WHO press release: http://www.who.int/inf-pr-2000/en/pr2000-14.html (2) Frank et al. The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. The Lancet, 2000, 355: 887-891. Phyllida Brown ___________________________________________________________________________ Box 1: Ten actions that will improve injection safety Patients: 1. State a preference for oral medications when visiting healthcare facilities 2. Demand a sterile syringe for every injection Health workers: 3. Avoid prescribing injectable medication whenever possible 4. Use a sterile syringe for every injection and dispose of it properly Immunization services: 5. Deliver vaccines with matching quantities of auto-disable (AD) syringes and sharps boxes Essential drugs programme: 6. Make sterile syringes and sharps boxes available in every healthcare facility HIV/AIDS prevention programmes: 7. Include awareness regarding the risks of unsafe injections within all education and behaviour-change activities Health care system: 8. Ensure sharps waste management as part of the system's duty of care 9. Monitor safety of injections as a critical quality indicator of healthcare service delivery Ministry of Health: 10. Coordinate safe and appropriate national policies, with appropriate costing, budgeting, and financing ____________________________________*______________________________________