Safe Immunization Practices and Prevention of Hepatitis B and C Susan Mackay Behaviour Change Project Safe Injection Global Network (SIGN) Secretariat WHO, Geneva, Switzerland

NGOUN Governments Industry Associations WHO SIGN Secretariat SIGN participants and SIGN secretariat

Injection Safety: Definition No harm to the recipient No harm to the health-care worker No harm to the community Challenges Reuse of equipment Unsafe collection Unsafe disposal

Injections given with sterile and unsafe equipment worldwide Global Burden of Disease, 2000

Determinants of unsafe injection practices in immunization services System incentive to achieving high coverage –Vaccine usually funded through donors or lenders No system incentive to achieve safe injections –Injection equipment is not costed, budgeted, or funded –“The sterilizable policy” smoke screen –Perception of injection safety as a “logistics” issue rather than a prevention policy issue

Injection preparation table, Pakistan, 1995 Reuse of disposable injection equipment

Injection preparation table, Romania, 1998 No reuse of disposable injection equipment, other breaks in safety

Injection safety beyond the use of new, disposable injection equipment Theoretical rationale –Experience from the dialysis environment –Persistence of HBV in the environment Ecological evidence –HBV and HCV infection among injection drug users participating in needle exchange programmes –Association between injection and HBV infection in 1998 in Romania despite the absence of reuse of equipment Analytical studies –Association between “indirect sharing” and HBV infection among injection drug users * * Bialek S. et al. US CDC EIS conference, 2001

Proposed model for the transmission of HBV in various healthcare setting Dialysis setting Outpatient setting in low prevalence area ? Prevalence of infection ? Exposure to blood ? Percutaneous exposures ? Prevalence of patients with high viremia High risk Low risk

Proportion of new HBV Infections attributable to unsafe injections, 2000 World: 35%, N= 22.5 million

Hepatitis B virus infection prevention Two prevention axis –Immunization of infants (child cohorts) –Prevention of exposure to the virus, including injection safety (older age groups) One common goal for GAVI –Protecting the adult who is in every child Patient with cirrhosis in Africa

Proportion of new HCV infections attributable to unsafe injections, 2000 World: 55%, N= 2.7 million

Assisting countries in implementing policies and plans Assess Plan Implement Evaluate The Quality Cycle Benchmarking

Assisting countries in implementing policies and plans Benchmarking

Outline of best practices 1. Use sterile injection equipment 2. Prevent contamination of injection equipment and medication 3. Prevent needlestick injuries to the provider 4. Prevent access to used needles 5. Other practice issues

Assisting countries in implementing policies and plans Assess Benchmarking

Rapid Assessment and Response Guide Injection Adverse Event Injection Overuse Unsafe Injection Practices Providers System Tool A available (focus group guide) Tool B available (injection frequency survey) Tool D available (Template for epidemiological studies) Tool C available (Based upon best practices)

Assisting countries in implementing policies and plans Assess Plan Benchmarking

Safe and appropriate use of injections: proposed national strategy Initial assessment National coalition Three-element approach 1- Behaviour change 2- Equipment and supplies 3- Sharps waste management Monitoring and evaluation

Assisting countries in implementing policies and plans Assess Plan Implement Benchmarking

Assisting in the implementation of policies for the safe and appropriate use of injections 1. Behaviour change –Toolbox project in progress

Assisting in the implementation of policies for the safe and appropriate use of injections 2. Provision of supplies –Purchasing guide to ensure quality and safety –Inclusion in the essential drug list to ensure access

Assisting in the implementation of policies for the safe and appropriate use of injections 3. Sharps waste management –Integrated approach: Policy Streamlining waste management Training Choice of disposal options –

Assisting countries in implementing policies and plans Assess Plan Implement Evaluate Benchmarking

Monitoring impact Outcomes Incidence of infections Processes Injection frequency Injection safety Inputs Resources and activities

Injection safety in immunization services  Challenges –Unsuccessful past efforts –History of narrow, technology oriented approach –Costs of injection safety initiatives –Conflict between the safety and coverage objectives –EPI cannot be responsible for the safety of all injections Opportunities –Successful comprehensive approaches –Increasing recognition of holistic strategies –Promotion of responsible budgeting for EPI –Documentation of safe immunization coverage –EPI can spearhead and catalyse injection safety efforts

Poor injection practices …