E-DRUG: Injection Safety

----------------------------------------------------
Why the choice?
---------------

There is an ongoing debate within WHO's TECHNET on the strategy
to be followed and the choices to be made to ensure safety of
injections. This text outlines some of that debate.
                       
All parenteral procedures carry an element of risk. AutoDestruct
is the least risky, but it has limited application and costs a
lot more, conventional sterilisables lie in between.

The question is not which option to choose. It is how do we
develop strategies which will reduce the level of risk in any
given environment, (cultural, social and economic). If we start
from this point then for any particular situation we will have a
chance of developing a strategy which will give the best chance
of minimising the infection from dirty needles and syringes.

I fear that we become too concerned with the technology and that
effort will be dissipated in the search for a technical solution
to a managerial problem. Technology cannot make people behave
themselves. Technical fixes are useful when the managerial
context shows that they will succeed.

For example, Eritrea's stated problem -avoidance of AIDS- was
manifestly not solved by adopting disposables, on the contrary
disposables probably made the situation worse.

UNICEF's State of the World's Children 1997 lists 44 countries in
Africa of these only 10 spend more than $50-00 per capita on
health. With such levels of health expenditure should we not be
concentrating on the wider question -How can the quantity of all
drugs especially injectable drugs be reduced and what strategies
will ensure that the essential injections will be given safely?

- If UNICEF is going to opt for one or other of the available
technologies (assuming that a multi-purpose AD syringe becomes
available) then I do not see how UNICEF will be able to respond
with the optimal choice for any given situation.

The solution has to 'fit' the situation. There is no point in
adopting a solution which people will be instinctively resistant
to, which the budget cannot afford and for which the
infrastructure and management systems are deficient. If after
assessment sterilisables are the optimal choice for a given
situation then use them. If in another situation that choice is
for disposables then use those, but do not try to have a single
global answer. The world is a complex entity let us try to
understand it not just simplify it.

Within donor agencies and host countries there is a need to
prioritise, within an holistic approach, where effort and
resources are best spent.

The problem of injection safety needs to be given a much higher
priority both within the donor community and the recipient
countries. WHO/EPI has been addressing the problem of injection
safety for EPI for years. There is now a need to expand and
co-ordinate their initiative to encamps all providers of
parenteral procedures.

We have to prioritise and allocate tasks, for example do
injection reduction strategies take priority over new
technologies, how do we get political commitment? How do we get
compliance with procedures? Can we avoid collecting malaria
slides? what disposal and/or sterilising systems exist etc.

Deciding that means establishing a focus which will be
subscribed to by all those services -within a health service or
agency, which provide/advice on parenteral procedures. The task
may be set out as a matrix with services along the top and
elements down the side.

For example injection reduction will need different activities in
each service, combining vaccines for EPI, switching to oral for
curative and maybe FP, don't know for diagnostic, limiting
collection of malaria slides for malaria.

Immunisation
Curative
Diagnostic
Family Planning
Malaria (not just EPI)
Political commitment
Available technologies
Procedure reduction
Public perception
Existing problem quantified etc.

Such an approach helps to focus on the next steps:

who does what?
what are the expected outcomes?
how much is it worth investing in it ?
how long will it take ?
and so on.

With this approach we will avoid the problem of over investing
(time and money) in any one element. We will be able to
concentrate on the approach which we believe will give us the
greatest chance of success. The approach must be multi-faceted,
multi discipline and include all the technologies which we have
available. No one technology will meet the needs of all
situations.

Because parenteral procedures are used by almost all services of
health care they are not the responsibility of any one service.
All services have differing attitudes towards the ways of
achieving safety and compartmentalising in both health services
and health agencies means that trans-departmental activity is
always at a disadvantage compared to internal departmental
activity, sumarised as the -'don't interfere in my department'
syndrome.
        
We need to find countries which are willing to surmount the above
syndrome and to:
1. Analyse the situation, to identify the number of unavoidable
injections needed and how best to give them.
2. Draw up a plan of action which will address the problem of ALL
parenteral procedures and set out the level of investment each
component justifies, e.g. is new technology a higher priority
than transparent management systems.
3. Provide the necessary resources to establish a working system,
sustainably supplied and effectively managed
4. Invest in the managerial training and supervision to ensure
that the chosen solution works
5. Encourage the public to demand safety
6. Measure the improvements over time

This raises the issue - How do we measure success? For EPI we
have coverage, no such agreed yardstick exists for injection
safety.
At present we have no overall operational strategy, we need host
countries, money and resources. Would we not be better off using
the existing technologies? We have sterilisables, disposables
some AD and safety syringes -and concentrate on injection
reduction and getting injection equipment used correctly, that
means finding local strategies with the best social, professional
and economic' fit' and with the managerial infrastructure to
implement them.

There is one major omission in technologies, at present we have
no environmentally acceptable systems for incineration which are
affordable outside the 'developed' world.

Anthony Battersby,
FBA Health Systems Analysts.
Email: FBA@compuserve.com

--
Send mail for the `E-Drug' conference to `e-drug@usa.healthnet.org'.
Mail administrative requests to `majordomo@usa.healthnet.org'.
For additional assistance, send mail to: `owner-e-drug@usa.healthnet.org'.