Academic journal article Bulletin of the World Health Organization

Unsafe Injections in the Developing World and Transmission of Bloodborne Pathogens: A Review

Academic journal article Bulletin of the World Health Organization

Unsafe Injections in the Developing World and Transmission of Bloodborne Pathogens: A Review

Article excerpt

Voir page 797 le resume en francais. En la pagina 798 figura un resumen en espanol.


WHO estimates that at least 12 billion (12 thousand million) syringes are sold each year for injection purposes and that approximately 1 billion injections are given yearly in the course of childhood vaccination programmes (1).

In industrialized countries, it became clear early this century that unsafe injections can lead to transmission of bloodborne infections. For example, in Britain in 1917, an outbreak of malaria among soldiers was linked to injection treatments for syphilis (2). In a 1945 memorandum from the United Kingdom Ministry of Health, it was concluded that viral hepatitis following injection treatment was "communicated by traces of blood transferred on syringes and needles from patient to patient" (3). Outbreaks of jaundice following injection campaigns in the 1940s and 1960s among Royal Air Force servicemen who received multiple immunizations clearly linked infection with injections for which syringes were reused after changing the needle only (4). This observation has been supported by laboratory studies demonstrating that syringes become contaminated because negative pressure is generated when the needle is removed (5, 6). After decades of awareness of the risks related to unsafe injections, the policy of "one sterile syringe and needle for each patient" was eventually adopted widely by the medical community in industrialized countries (4). The subsequent introduction of disposable syringes largely reduced the problem in industrialized countries to needle-stick injuries among health care workers and needle-sharing among injecting drug users, with a residual risk for the public through medical and dental procedures (7).

In contrast, the general population in developing countries continues to be at risk of acquiring bloodborne diseases from unsafe injections (1, 8). Several studies have identified unsafe injections as a major risk factor in outbreaks of bloodborne infectious diseases (9-12). However, the problem is not limited to occasional outbreaks; unsafe injections cause a steady number of unrecognized transmissions of bloodborne infections in developing countries on a daily basis.


We undertook a systematic search for literature published in English and French as well as English abstracts of foreign-language literature available via MEDLINE for the years 1966 through 1998. Other relevant articles were identified from the bibliographies of these papers. We also abstracted observations on injection use and safety from all WHO country reports and consultations since 1980 from the WHO Expanded Programme on Immunization (EPI); all of these are unpublished as of 1999. Each country report was based on visits to several health centres that delivered vaccines as a part of their services. The country names were coded, since the content of these reports cannot be used without permission from the countries concerned.

The definitions shown below were adopted for the purposes of this study.

* An injection is a skin-piercing event performed with a syringe and needle with the purpose of introducing a curative substance or a vaccine into a patient by the intramuscular, intravenous or subcutaneous route. This excludes all other skin-piercing procedures, such as blood transfusions, surgery, tattoos and body-piercing.

* An unsafe injection is one in which the syringe, needle, or both, have been reused without sterilization. This conservative definition was chosen to facilitate a quantitative comparison of injection safety information. It does not include other unclean handling of sterile equipment.

* An unnecessary injection is one where oral alternatives are available, where the injected substance is inappropriate or harmful, or where the symptoms or diagnosis do not warrant treatment by injection.

Potential for transmission of bloodborne infections via unsafe injections

Injection use

History. …

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