E-drug: Cost effectiveness of injection safety
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[Crossposted from SIGNpost. Thanks. HH]
The final manuscript of WHO's cost effectiveness study on injection
safety was published in the Bulletin in April 2003. The pdf of this
article may be downloaded from the www.who.int/bulletin web site
(Dziekan et al). This work took place in the context of WHO's
CHOICE project (which was published in the World Health Report last
year), a label that provides a guarantee of objectivity and
standardization when looking at cost effectiveness of various health
interventions.
This study is an important milestone. As can be seen, policies for the
safe and appropriate use of injections are highly cost effective in all
WHO regions. This information is key for advocacy efforts at the
national level.
Regards,
Yvan Hutin
SIGN Secretariat
WHO Heardquarters, Geneva
Download the full article at:
http://www.who.int/bulletin/pdf/2003/bul-4-E-2003/81(4)277-285.pdf
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The cost-effectiveness of policies for the safe and appropriate use of
injection in healthcare settings
Gerald Dziekan,1 Daniel Chisholm,2 Benjamin Johns,2 Juan Rovira,3
& Yvan J.F. Hutin1
Objective
Poor injection practices transmit potentially life-threatening
pathogens. We modelled the cost-effectiveness of policies for the
safe and appropriate use of injections in ten epidemiological
subregions of the world in terms of cost per disability-adjusted life
year (DALY) averted.
Methods
The incidence of injection-associated hepatitis B virus (HBV),
hepatitis C virus (HCV), and human immunodeficiency virus (HIV)
infections was modelled for a year 2000 cohort over a 30-year time
horizon. The consequences of a ''do nothing'' scenario were
compared with a set of hypothetical scenarios that incorporated the
health gains of effective interventions. Resources needed to
implement effective interventions were costed for each subregion and
expressed in international dollars (I$).
Findings
Worldwide, the reuse of injection equipment in the year 2000
accounted for 32%, 40%, and 5% of new HBV, HCV and HIV
infections, respectively, leading to a burden of 9.18 million DALYs
between 2000 and 2030. Interventions implemented in the year 2000
for the safe (provision of single-use syringes, assumed effectiveness
95%) and appropriate (patients - providers interactional group
discussions, assumed effectiveness 30%) use of injections could
reduce the burden of injection-associated infections by as much as
96.5% (8.86 million DALYs) for an average yearly cost of I$ 905
million (average cost per DALY averted, 102; range by region, 14 -
2293). Attributable fractions and the number of syringes and needles
required represented the key sources of uncertainty.
Conclusion
In all subregions studied, each DALY averted through policies for the
safe and appropriate use of injections costs considerably less than
one year of average per capita income, which makes such policies a
sound investment for health care.
Discussion
The average cost of a policy by which single-use syringes and
needles are used for all injections amounts to less than I$ 0.50 per
person per year. This may seem an unaffordable gold standard where
sterilizable injection equipment is still in use, particularly because the
benefits of safe injections in terms of death and disability prevented
are far ahead in the future (32). However, in Burkina Faso, it was
estimated that purchasing injection equipment in quantities that
match injectable medicines increased essential drug expenditures by
only 2.2% (WHO, unpublished data). Supplying sufficient quantities of
single-use injection equipment is cost-effective. Implemented jointly
with interventions to reduce injection use, injection safety
interventions can prevent more death and disability while remaining a
sound investment in public health. In addition, policies for the safe
and appropriate use of injections can lead to savings in the cost of
injectable medicines. These savings could be redirected to finance
injection equipment for injectable medicines that are essential.
In all subregions analysed, the cost of each DALY averted through
national policies for the safe and appropriate use of injections is
considerably less than one year of average per capita income, which
is the threshold for an intervention being highly cost-effective
proposed recently by the WHO Commission on Macroeconomics and
Health (33). When recently compared with other strategies to reduce
leading risk factors for disease, the safe and appropriate use of
injections was found to cause a modest reduction in DALYs but was
one of the most cost-effective interventions (5). When compared with
other modes of preventing HIV infection in sub-Saharan Africa, the
cost- effectiveness ratio of policies for the safe and appropriate use of
injections remained under the threshold of I$ 50 per DALY averted,
which was in the range of the most cost-effective interventions for
preventing HIV infection (e.g. blood safety, targeted condom
distribution, and treatment of sexually transmitted diseases) (34).
A safe injection is defined as one that does not harm the recipient,
the provider and the members of the community (35). Therefore, the
costs of sharps waste collection and management were included as
part of programme costs. However, the effect of safe sharps waste
collection and management in terms of burden of disease secondary
to needlestick injuries among healthcare workers or the community
prevented could not be estimated. Thus, such a policy may be more
cost-effective than the present results indicate. The sensitivity
analysis indicates that the cost per DALY averted decreased by 36%
to 39% if the costs of safe sharps waste collection and management
were excluded to match costs and effects.
Policies for the safe and appropriate use of injections are natural
additions to universal infant vaccination against hepatitis B in a
national strategy to prevent HBV infection. Infant immunization
against hepatitis B is probably more costeffective than safe and
appropriate use of injections, with cost per life year saved ranging
from I$ 4 to I$ 36 (36). When global efforts for universal vaccination
of infants have reached adequate coverage for a sufficient period of
time, high levels of immunity against HBV infection will ultimately
protect populations from injection-associated HBV infection.
This study was not an attempt to compare various injection
technologies. The present model did not consider the use of
sterilizable injection equipment in any of the interventions because
there are no data available to indicate that it can lead to safe injection
practices. In fact, the use of sterilizable injection equipment has been
specifically associated with infections with bloodborne pathogens (37
- 41), and health systems using sterilizable syringes have poorer
practices than those using single-use equipment (42). No special
reference was made to the use of autodisable (AD) injection
equipment that inactivates itself after one use (43). AD syringes offer
the highest level of safety and are now considered to be the standard
for administering vaccines (44). However, immunization injections
account for fewer than 10% of all injections (1). Thus, introducing AD
syringes in immunization services will address only a small proportion
of the burden of disease associated with unsafe injections. With
respect to using AD syringes in curative services, although single-use
syringes can be reused, effectiveness data indicating that AD
syringes would be associated with safer injection practices compared
with standard single-use syringes made available in sufficient
quantities could not be identified. Nevertheless, AD syringes should
be considered for use in settings where unsafe practices are
common, particularly in the non-formal sector that is staffed with
unqualified health-care workers, specifically in South Asia (4, 45). In
such cases, the results of our analysis could be easily extrapolated to
AD syringes because they are now available at a cost that is very
close to the one of standard single-use syringes. In 2002, the
international retail price for an immunization AD syringe was five to
seven US cents, whereas international retail prices for single use
syringes ranged from four (2 ml) to eight (5 ml) US cents.
The present study presented several limitations. First, the model did
not take into account any longer-term dynamic effects that reducing
transmission of infection would have on the prevalence of infections
with bloodborne pathogens. This could be a problem in the case of
HCV infection because contaminated injections account for a high
proportion of new infections. This limitation could also lead to an
underestimation of the effect size, hence these interventions might be
described as being less cost-effective than they really are. Second,
the specific issues associated with working in the private sector were
not addressed. The provision of sufficient quantities of single-use
injection equipment and interactional group discussion might not be
sufficient where the informal private sector accounts for a high
proportion of healthcare services delivery. In such settings,
demonstration projects should identify effective strategies, some of
which might include the use of AD syringes in curative services or
addressing financial incentives to over-prescribing injections, or both.
Poor injection practice is not a leading cause of disability and death
worldwide. However, the safe and appropriate use of injection
equipment represents an opportunity to avert a substantial number of
DALYs at a relatively low cost. Improved injection practice can be
recommended for implementation worldwide, particularly in settings
where the reuse of injection equipment is common and where the HIV
prevalence in the general population exceeds 1%. Such policies can
be developed through a better coordination of already existing
programmes to facilitate implementation. Finally, in addition to being
cost-effective, the safe and appropriate use of injections is an
attainable way of applying the ''first do no harm'' principle as part of
the ethics of healthcare service delivery.
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