Safe Immunization Practices and Prevention of Hepatitis B and C

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

2. WHO SIGN Secretariat SIGN participants and SIGN secretariat NGO UN Associations Industry Governments

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

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

5. 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

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

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

8. 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

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

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

11. Patient with cirrhosis in Africa 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

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

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

14. Benchmarking Assisting countries in implementing policies and plans

15. 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

16. Assess Benchmarking Assisting countries in implementing policies and plans

17. Tool A available (focus group guide) Tool B available(injection frequency survey) RapidAssessmentandResponseGuide System Tool C available(Based upon best practices) Providers Tool D available(Template for epidemiological studies) Injection Overuse Unsafe Injection Practices Injection Adverse Event

18. Assess Benchmarking Plan Assisting countries in implementing policies and plans

19. 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

20. Assess Benchmarking Plan Implement Assisting countries in implementing policies and plans

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

22. 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

23. 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 • www.healthcarewaste.org

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

25. InputsResources and activities Processes Injection frequency Injection safety Monitoring impact OutcomesIncidence of infections

26. 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

27. Poor injection practices …