Hutin, Yvan. Evidence and information for national injection safety policies. 2003, Doctoral Thesis, University of Basel, Faculty of Science.
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Official URL: http://edoc.unibas.ch/diss/DissB_6912
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Abstract
The adverse consequences of poor injection practices have been reported for a few decades. However, key elements of evidence and information were lacking to allow decision-makers to formulate policies for the safe and appropriate use of injections. We conducted studies to (1) estimate the frequency of injection use and of poor injection practices, (2) estimate the consequences of poor injection practices in terms of death and disability, (3) formulate best infection control practices for intradermal, subcutaneous and intramuscular injections, (4) quantify the effectiveness of interventions to reduce unnecessary and unsafe use of injections and (5) estimate the cost-effectiveness of national policies for the safe and appropriate use of injections. WHO's Global Burden of Disease project defined 14 regions based on geography and mortality patterns. The analysis excluded four regions (predominantly affluent, developed nations) where reuse of injection equipment in the absence of sterilization was assumed to be negligible. To estimate the frequency of poor injection practices in the year 2000, data sources included published studies and unpublished WHO reports. Studies were reviewed using a standardized decision-making algorithm based upon the quality of the data to generate region-specific estimates of the annual number of injections per person and of the proportion of injections reused in the absence of sterilization. To estimate the consequences of unsafe injections in the year 2000 in terms of death and disability for 2000-2030 as part of the 2000 update of WHO’s Global Burden of Disease study, we modelled the fraction of new injection-associated HBV, HCV and HIV infections on the basis of the annual number of injections, the proportion of injections administered with reused equipment, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity and the total incidence. Infections in 2000 were converted into disability-adjusted life years (DALYs) in 2000-2030 using natural history parameters, background mortality, duration of disease, disability weights, age weights and a 3% discount rate. A guideline development group summarized evidence-based best practices to prevent injectionassociated
infections in resource-limited settings. The development process included (1) a
breakdown of the WHO reference injection safety definition into a list of potentially critical
steps, (2) a review of the literature for each of these potentially critical steps, (3) the formulation
of best practices and (4) the submission of the draft document to peer review.
To estimate the effectiveness of interventions to reduce the unnecessary and unsafe use of
injections, we searched electronic databases. In addition, we reviewed WHO reports and
unpublished assessments made available to WHO. We selected studies that contained
quantitative and qualitative information on the effect of interventions and that provided
information on study design, type of interventions, targeted participants and targeted behaviours.
To estimate the cost-effectiveness of national policies for the safe and appropriate use of
injections, the consequences in 2000-2030 of a "do nothing" scenario for the year 2000 (as
modelled for the Global Burden of Disease study) were compared to a set of counterfactual
scenarios incorporating the health gains of effective interventions. Resources needed to
implement effective interventions were costed for each sub-region and expressed in international
dollars (I).FourregionsintheGlobalBurdenofDiseasestudywherereuseofinjectionequipmentintheabsenceofsterilizationwasnegligiblewereexcludedfromtheanalysis.Inthe10otherregions,theannualratioofinjectionsperpersonwas3.4(Range:1.7−11.3)foratotalof16.7thousandmillioninjectionsreceived.Ofthese,39.3 million 905 (average cost-effectiveness per DALY
averted: I$102, range by region: 14-2 293). In 2000, in developing and transitional countries, 16 thousand million injections were
administered for a ratio of 3.4 injections per person. More than a third of all these injections were
administered with injection equipment reused in the absence of sterilization, accounting for a
substantial burden of infection with bloodborne pathogens. Best infection control practices could
make injections safer for the recipient, the health care workers and the community, all the more
as effective interventions are available to reduce injection use and to achieve a safe use of
injections. These interventions can also be considered very cost-effective on the basis of a cost
per DALY averted that is below one year of average per capita income. Remaining areas of
uncertainty include (1) the formulation of routine methods to describe injection use and to
quantify needs of injection equipment, (2) the description of unsafe practices in greater detail to
prevent all opportunities of transmission, (3) the need to generate better estimates of the
proportion of HIV infections that may be attributed to unsafe health care injections, (4) the
identification of the role of engineered technologies in policies to achieve injection safety, (5) the
recovery of experience in the scaling-up of successful interventions and (6) the assessment of the
cost-effectiveness of scaled-up national interventions.
infections in resource-limited settings. The development process included (1) a
breakdown of the WHO reference injection safety definition into a list of potentially critical
steps, (2) a review of the literature for each of these potentially critical steps, (3) the formulation
of best practices and (4) the submission of the draft document to peer review.
To estimate the effectiveness of interventions to reduce the unnecessary and unsafe use of
injections, we searched electronic databases. In addition, we reviewed WHO reports and
unpublished assessments made available to WHO. We selected studies that contained
quantitative and qualitative information on the effect of interventions and that provided
information on study design, type of interventions, targeted participants and targeted behaviours.
To estimate the cost-effectiveness of national policies for the safe and appropriate use of
injections, the consequences in 2000-2030 of a "do nothing" scenario for the year 2000 (as
modelled for the Global Burden of Disease study) were compared to a set of counterfactual
scenarios incorporating the health gains of effective interventions. Resources needed to
implement effective interventions were costed for each sub-region and expressed in international
dollars (I).FourregionsintheGlobalBurdenofDiseasestudywherereuseofinjectionequipmentintheabsenceofsterilizationwasnegligiblewereexcludedfromtheanalysis.Inthe10otherregions,theannualratioofinjectionsperpersonwas3.4(Range:1.7−11.3)foratotalof16.7thousandmillioninjectionsreceived.Ofthese,39.3 million 905 (average cost-effectiveness per DALY
averted: I$102, range by region: 14-2 293). In 2000, in developing and transitional countries, 16 thousand million injections were
administered for a ratio of 3.4 injections per person. More than a third of all these injections were
administered with injection equipment reused in the absence of sterilization, accounting for a
substantial burden of infection with bloodborne pathogens. Best infection control practices could
make injections safer for the recipient, the health care workers and the community, all the more
as effective interventions are available to reduce injection use and to achieve a safe use of
injections. These interventions can also be considered very cost-effective on the basis of a cost
per DALY averted that is below one year of average per capita income. Remaining areas of
uncertainty include (1) the formulation of routine methods to describe injection use and to
quantify needs of injection equipment, (2) the description of unsafe practices in greater detail to
prevent all opportunities of transmission, (3) the need to generate better estimates of the
proportion of HIV infections that may be attributed to unsafe health care injections, (4) the
identification of the role of engineered technologies in policies to achieve injection safety, (5) the
recovery of experience in the scaling-up of successful interventions and (6) the assessment of the
cost-effectiveness of scaled-up national interventions.
Advisors: | Tanner, Marcel |
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Committee Members: | Luby, S. |
Faculties and Departments: | 09 Associated Institutions > Swiss Tropical and Public Health Institute (Swiss TPH) > Former Units within Swiss TPH > Molecular Parasitology and Epidemiology (Beck) |
UniBasel Contributors: | Tanner, Marcel |
Item Type: | Thesis |
Thesis Subtype: | Doctoral Thesis |
Thesis no: | 6912 |
Thesis status: | Complete |
Number of Pages: | 60 |
Language: | English |
Identification Number: |
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edoc DOI: | |
Last Modified: | 02 Aug 2021 15:04 |
Deposited On: | 13 Feb 2009 14:55 |
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