Academic journal article Bulletin of the World Health Organization

The Cost-Effectiveness of Policies for the Safe and Appropriate Use of Injection in Healthcare Settings. (Research)

Academic journal article Bulletin of the World Health Organization

The Cost-Effectiveness of Policies for the Safe and Appropriate Use of Injection in Healthcare Settings. (Research)

Article excerpt

Introduction

Poor injection practices lead to infections with hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) (1). In addition, unsafe injections have been important vectors for the introduction of HCV to patients in some countries, including Egypt and Pakistan (2-4). However, the burden of cirrhosis, hepatocellular carcinoma, and acquired immunodeficiency syndrome (AIDS) associated with unsafe injections is delayed and may not be directly apparent.

Although injection-associated infections constitute a silent epidemic, effective interventions are available to reduce injection use and unsafe practices (G. Dziekan & Y.J.F. Hutin, unpublished data, 2002). First, information, education and communication (IEC) targeting prescribers, including patient-prescribers interactional group discussions, reduces injection use. Second, the provision of single-use injection equipment improves safety.

For national stakeholders faced with competing priorities, the availability of effective interventions to prevent a hidden epidemic might not be sufficient to justify investing in a policy for the safe and appropriate use of injections. Economic considerations also enter the debate. Accordingly, we set out to estimate the sectoral cost-effectiveness of policies for the safe and appropriate use of injections in terms of cost per disability-adjusted life year (DALY) averted.

Methods

Study populations

The six regions of WHO were separated into subgroups of countries on the basis of having similar rates of child and adult mortality. This resulted in 14 Global Burden of Disease 2000 epidemiological subregions characterized by the WHO region acronyms (AFR (African Region); AMR (Region of the Americas); EMR (Eastern Mediterranean Region); EUR (European Region); SEAR (South-East Asia Region); and WPR (Western Pacific Region)) and a letter for the mortality stratum (Table 1) (5). Four subregions in which the reuse of injection equipment in the absence of sterilization is negligible were excluded from the analysis (AMR A, EMR B, EUR A and WPR A).

Effectiveness model

We considered a theoretical cohort of the population living in the year 2000 in subregions where reuse of injection equipment has been reported (figures provided by the Global Burden of Disease study group). We first applied a current, "do nothing" scenario where persons were injected using contaminated needles and consequently acquired infections. Second, we applied a series of hypothetical intervention scenarios for the year 2000, taking into account the effect of these interventions on the incidence of infections.

DALYs attributable to poor injection practices

We modelled the fraction of incident HBV, HCV, and HIV infections attributable to contaminated injections on the basis of the annual number of injections per person, the proportion of injections administered with equipment reused in the absence of sterilization, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity, and the incidence (6). The burden in DALYs for the years 2000-30 due to infections in the year 2000 was estimated on the basis of the natural history of viral infections (6), background mortality, Global Burden of Disease life tables (7), and the average duration and disability weights of acute hepatitis, cirrhosis, hepatocellular carcinoma, and AIDS--the four sequelae of interest (8). DALYs were age-weighted and 3% discounted (7).

Effectiveness of interventions

We examined interventions for reducing the unsafe use of injections, interventions for reducing injection use, and the effect of these two interventions when implemented jointly (G. Dziekan & Y.J.F. Hutin, unpublished data, 2002). For interventions to reduce the unsafe use of injections, we considered the effectiveness of interventions on the basis of provision of single-use injection equipment (9, 10). …

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