1. Abstract Problem Statement: As in many former socialist economies, anecdotal reports suggested that injections were overused to administer medications in Mongolia. Suspected explanations for injection overuse in the country included a cultural preference for injections in the population and the persistence of outdated standard treatment protocols that excessively recommended the use of injections. Objectives: The Ministry of Health of Mongolia decided to conduct an assessment of injection practices to make a step towards a safe and rational use injections policy. Design: Descriptive cross sectional study. Setting and Population: We used the WHO "Injection Practices: Rapid Assessment and Response Guide" to collect information on injection practices, their determinants, and their consequences through standardized interviews and observations of a small convenience sample of 21 prescribers, 28 injection providers and 65 members of the population selected from twenty health care facilities in urban, semi- urban, and rural areas in four districts and the capital city. Of the 65 persons from the population interviewed, 21 (32%) were from urban areas, 19 (29%) from the semiurban areas and 25 (38%) from rural areas. Outcome Measures: Annual ratio of injections per capita; proportion of prescriptions that included at least one injection; reported most common conditions for which injections were prescribed; proportion of persons who preferred receiving an injection for the treatment of sickness with fever; proportion of observed injections given safely. Results: The 65 members of the population reported receiving an average of 13 injections per year. Prescribers reported a total of 1,905 prescriptions per week on average; of these, 265 (14%) would include at least one injection. Among the members of the population, 18 (28%) reported that they would prefer an injection for the treatment of sickness with fever. Observed injection providers consistently used freshly opened new disposable syringes and needles for all injections. However, there were breaks in infection control practices while administering injections, eight of the 28 providers (28%) reporting occasional reuse of disposable syringes with new needles for antibiotic administration to the same patient in hospital. Injection providers reported 2.6 needle-stick injuries per year. Conclusions: A multi-disciplinary initiative is necessary to achieve safe and rational use of injections in Mongolia. To decrease injection overuse, approaches may include interactional group discussions between patients and prescribers, revision of recommended treatment protocols, promotion of new standards of care and promotion of oral drugs in the community. Following the survey, a communication campaign with posters and radio spots was conducted to promote oral medicines and avoid unnecessary injections.

2. Rationale for an Assessment of Injection Practices in Mongolia High prevalence of infection with HBV and HCV –6.4% of children 0-15 years of age HBsAg positive * –10.7% of children 0-15 years of age anti- HCV positive * Anecdotal reports of poor injection practices –Injection overuse –Unsafe practices Political will to engage in a safe and appropriate use of injections policy * 1998-1999 (Davaasuren at al. National Medical University)

3. Study Aims To make an initial step towards a safe and appropriate use of injections policy in Mongolia, the Ministry of Health decided to conduct a rapid assessment of injection practices.

4. Methods Convenience Sample Selection of key national stakeholders Selection of 5 “Aimags” (district) to provide an overall representation of the country Selection of 20 health-care facilities in the 5 “Aimags” Selection of one or more prescribers per facility (n= 21) Selection of one or more injection providers per facility (n= 28) Selection of 65 persons from the general population of all ages and genders Data collection National stakeholder interviews using open-ended questionnaires Interview using a standardized questionnaire to: –Injection prescribers –Injection providers –General population Standardized observation of injection practices

5. Injection Frequency, Mongolia, 2001 212 injections reported by 65 persons in the last 3 months: –13 injections / person - year –8% of injections given for immunization Number of prescriptions including at least an injection: –Prescription review: 7% (n=420) –Prescriber interview: 14% (265 reported prescriptions out of 1905) Average number of injections per prescription: –Antibiotics: 20 –Vitamins: 10

6. Injection Use, Mongolia, 2001 Top 3 diagnoses leading to the prescription of an injection: –Pneumonia, Genito-urinary infections, Cardio vascular diseases and hypertension Top four injectable medications prescribed: –Penicillin G, Vitamin B complex, Ampicillin, Dibazolum Reported Determinants of Injection Overuse 86% (18/21) of prescribers do not perceive that they over-prescribe injections Anecdotal reports from prescribers: –Patients prefer injections, particularly elderly –Pressure from patients causes overuse of injections

7. 0%20%40%60%80%100% Jaundice HCV HBV HIV Prescribers Inj. Providers Population Awareness Regarding Pathogens Transmitted through Unsafe Injections, Mongolia, 2001 Proportion (%)

8. Reported Patients’ Preference for Injections, Mongolia, 2001 0% 10% 20% 30% 40% 50% 60% 70% 80% According to prescribers (n=21) According to the population, in the case of fever (n=65) Proportion (%)

9. Injection Safety (1): Risk to the Patient, Mongolia, 2001 Observation of 28 injection providers –No re-use of equipment in the absence of sterilization 28% (8/28) injection providers reported re-use of syringes (with new needles) on the same patient because of shortages and overwork in winter Unsafe handling of multi- dose vials

10. Injection Safety (2), Mongolia, 2001 Risk to the Injection Provider 68% (19/28) performed two-handed recapping 68% (19/28) reported needlestick injuries in the last twelve months –2.6 needlesticks / injection provider-year No provider vaccinated against hepatitis B Hand sorting and counting of dirty sharps Risk to the Community No dirty sharps observed around health-care facility 100% incineration with remarkable discipline (Open sites, Drum incinerator, Stoves) Injection devices used at home by the population discarded in the regular trash

11. Injection Practices in Mongolia,2001 Strengths Dramatic improvement of injection practices in Mongolia over the last 10 years –Large use of locally produced single use injection devices –Good awareness of the risks associated with injections among health-care workers Efficient health-care waste management despite a lack of sophisticated waste treatment options Weaknesses Ratio of injections per capita in Mongolia is the highest ever reported Numerous breaks in infection control practices occur, including possible re-use of single use injection devices in the absence of sterilization Poor health care workers protection (high risk of needlestick injuries)

12. Recommendations The Ministry of Health is committed to implement policy and plans to institutionalize the safe and appropriate use of injections To decrease injection overuse: –interactional group discussions between patients and prescribers –Revision of treatment protocols and promotion of oral medicines in the community. To improve injection safety: –risk communication targeting patients and health care workers –provision of safety boxes in sufficient quantities and repelling the requirement to count by hand used injection devices –procurement plan to increase access to waste treatment options within a policy framework