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Injection practices and medical waste disposal in EPI program in Riyadh and Eastern region, Saudi Arabia

Article Info

Authors
Volume: 11
Year: 2004
Month: July
Issue: 3
Reference: Al-johar H., Zamel M., Alsaleh S., Nooh R., Choudhry A., .Saudi Epidemiology Bulletin. 2004;11(3):.
In the kingdom of Saudi Arabia, vaccination of children began in 1964, with introduction of the BCG vaccine. The World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) in 1974.[1] This study was conducted by the Field Epidemiology Training Program to validate whether sterilizable injection equipment are still being used in EPI program in Saudi Arabia, and to evaluate injection practices of health workers and safe disposal of vaccination waste, by a cross sectional approach, in a sample of both governmental and private health facilities in Riyadh and Eastern province, limited to those providing vaccination services. Using multistage stratified random sampling technique we obtained a sample size of 60 health facilities.
In Riyadh, the study involved 22 governmental health workers (GHW) and 15 private (PHW). The median age of GHW was 29.5 years (IQR 25-36) and 38 years (IQR 34-39) for PHW. Saudis constituted 72.7% of GHW and non-Saudis represented 86.7% of PHW. All were females. A separate room designated for vaccination was found in 100% of governmental health facilities (GHF) compared to only 26.7% of private health facilities (PHF) where vaccination was provided along with other services. Two nurses or more were assigned to the vaccination clinic in 72.7% of GHF compared to 26.7% of PHF. Almost half the health workers had a work experience in vaccination between 1-5 years (45.5% of GHW and 53.3% of PHW). Vaccination practices are shown in Table 1.
MSF (Medecins Sans Frontieres) needle-remover sharp boxes were available in 54.5% of GHF and 53.3% of PHF. Needles only were discarded in the sharp boxes in 22.7% of GHF compared to 6.7% of PHF. In the rest, different materials were discarded along with the needles, such as used syringes, empty vials, cotton pads, needle packages, alcohol swabs and discarded gloves. Medical waste was segregated into two different boxes only in all the health institutes observed.
Cleaners were responsible for taking the closed sharp boxes outside the room in 100% of PHF, all manually removed (100%). In GHF, cleaners took the closed sharp box outside the room 95.5% of times, either manually (68.2%), or inside cardboard boxes (18.2%), or on a trolley (13.6%). The sharp boxes were kept for collection inside the health institute in 40.9% of GHF and 73.3% of PHF, then were taken away by municipality medical waste transportation from all GHF and by medical waste companies transportation from all PHF.
When asked about the correct procedure of final disposal of sharp waste, only 9.1% responded correctly "incineration", 31.8% burning, 27.3% burying, and 31.8% did not know. In PHF, 66.7% responded burning, 6.7% burying, and 26.6% did not know.
In the Eastern region, the study covered 15 GHW and 8 PHW. Median age of GHWs was 31 years (IQR 3035) and PHWs 30.5 years (IQR 28.533.5). Saudis accounted for 93.3% of GHW, and non-Saudis accounted for 100% of PHW. All were females.
All GHF had a designated room for vaccination compared to only 50% of PHF. Two nurses or more were assigned to vaccination clinic in 86.7% of GHF and 75% of PHF. Work experience varied among GHW, but 75% of PHW had experience between 1-5 years.
The MSF needle-remover sharp boxes were available in all GHF compared to only 62.5% of 1311F. Needles only were discarded in the sharp boxes in 20% of GHF. Medical waste were segregated into 4 boxes in 40% of GHF, 3 boxes in 6.7% and only two in 53.3%. All PHF segregated medical waste into two boxes only.
Cleaners were responsible for taking the closed sharp box outside the room in 66.7% of GHF and 100% of PHF; manually in 100% of 01-1F and 62.5% of PHF, or placed inside large cardboard boxes in 25% of PHF. All the health institutes kept the sharp boxes for collection inside, after which they were taken away from all GHF by municipality medical waste transportation, and from all PHF by medical waste companies transportation.
When asked about the correct procedure of final disposal of sharp waste, GHW responded "incineration" 26.7%, followed by burying 20%, and 53.3% did not know. PHW responded "incineration" 25%, burying 12.5%, and 37.5% did not know.
It was seen that Riyadh NW used a clean barrier to break the ampoule significantly more often than Eastern HW (OR=12.4, 95°/0C1=2.52-60.46; a0R-39.7, 95%C1= 4.78-333.3).
GHW kept a needle on top of multi-dose vials significantly more often than PHW (OR=18.7, 95% C1=2.28-153.6; aOR = 22.7, 95% CI = 1.77-294.12).
GHW recapped needles after injection significantly less often than PHW (OR=0.16, 95%CI=0.05-0.51), but the adjusted OR was not significant (a0R=0.21, 95%CI=0.03-1.36). Saudi health workers were less likely to practice needle recapping than non-Saudis (OR=0.13, 95%CI=0.04-0.42; aOR=0.36, 95%CI=0.06-2.21).
MSF needle-remover sharp boxes were significantly less available at Riyadh health institutes than Eastern (OR = 0.2, 95°/0C1 = 0.04-0.69: aOR=0.2, 95%CI=0.04-0.71). These boxes were found more often in GHF than PHF (OR = 2.1, 95%CI=0.69-6.23), but this was not significant.

Editorial note:

The WHO defines a "safe injection" as one that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in any dangerous waste to the community.[2] Unsafe use and disposal of injection equipment puts the health of patients, health care workers and the community at risk.[3]
Injections should be prepared in a clean designated area; the needle should not be left in the top of the multi-dose vaccine vial; safe procedures should be followed to reconstitute vaccines; and a new syringe and needle should be used for each child.[2]
In this study, while most practices were satisfied, some deviated from safe injection definition. Keeping a needle on top of a multi-dose vial could lead to contamination of the vaccine. Bacteria could survive in and have been transmitted to patients through contaminated multi-dose vials.[4] Using the same needle to draw the dose and then giving it to the child affects its sharpness after it has come in contact with the rubber material covering the vial, and can lead to local abscesses. In 1997-98, injection-associated abscesses were reported from 40% of health centers in Swaziland and 55% of health centers in Chad.[5] This could be avoided by using two separate needles, one to draw the dose and one to administer the injection to the child.
Recapping needles carries the risk of personal injury. The EPI manual clearly states not to recap needles after injection. Classically, injuries occur as the user either misses the sheath, or if the needle pierces the side and/or end of the cap.[4,6]
Removing needles from syringes after use should not be done manually but by needle cutter sharp boxes. All used injection equipment should be placed in a safety box immediately after use, which should be puncture-proof, water-proof, tamper-proof and fitted with covers. They should be rigid and impermeable to safely retain both the sharps and any residual liquids. They should be color-coded and marked "sharps only".[7] If a safety box is not available, a locally available material can be used to create a functional and safe sharps container, placed within reach of the health worker. Using needle cutter boxes is cost-effective, as only needles are discarded in the box.
Regulations of WHO on waste segregation and coding recommend that waste be segregated into four different color coded boxes. Only 40% of Eastern GHF segregated the medical waste into the recommended 4 boxes.
This study points to the need for more training on correct injection practices and 'safe injection' techniques. An effective needle stick injury prevention campaign is required. Special attention should be given to medical waste segregation, labeling of waste containers and proper disposal.
References
  1. Health curriculum from the UN CyberSchoolBus. Immunization, Unit 6€”main text: grades 7-11. http://www.vaccination Health Curriculum Unit 6--Main text. Gr. 7-11.htm (May20, 2004).
  2. Immunization in practice. Module 4: Ensuring safe injections; WHO/IVB/04.06.
  3. Aylward B, Lloyd J, Zaffran M, McNair-Scott R, Evans P. Reducing the risk of unsafe injections in immunization program: Financial and operational implications of various injections technologies. Bull wrld hlth org, 1995;73(4):531.
  4. CDC. Improper infection control practices during employee vaccination programs€”District of Columbia and Pennsylvania. MMWR, 1993; 42(50):969.
  5. Dico M, Oni A, Ganivet S, Kone S, Pierre L, Jacquit B. Safety of immunization injection in Africa: Not simply a problem of logistics. Bull wrld hlth org, 2000;78(2): 163.
  6. Safety and Environmental Protection Services. The avoidance of 'needle-stick' and similar sharp induced injuries. 1998.
  7. Handling, storage, and transportation of health-care waste. In: Pruss A, Giroult E, Rushbrook P, editors. Safe management of wastes from health-care activities. WHO, Geneva, 1999:61-76.
Table 1: Vaccination practices of health workers in Riyadh and Eastern region.
Vaccination practices
Riyadh
Eastern
GHF
(22)
PHF
(15)
GHF
(15)
PHF
(8)
Used new needle for each reconstitution
100%
100%
100%
100%
Used new syringe for each reconstitution
100%
100%
100%
100%
Kept powder between 2-8°c before use
95.5%
100%
100%
100%
Kelat diluent between 2-8°c before use
100%
100%
100%
100%
Shook multi-dose vial before withdrawing content
91%
93.3%
93.3%
100%
Kept a needle on top of multi-dose vial
45.5%
6.7%
46.7%