From Assessment to Planning

1
From Assessment to Planning

• Injection Safety Assessments
• coordinated by
• WHO/Vaccines and Biologicals
• in the Eastern Mediterranean Region
• Carsten Mantel, MD, MPH
• WHO STC

2
WHO/VB/VAM Assessment of Injection Safety

• WHO/VB Tool C
• Rationale, Objectives, Methods
• Experience from 22 country assessments 2000-2002
• WHO/EMR
• Regional Injection Safety Assessment
• Regional Injection Safety Strategy
• Regional Injection Safety Plan of Action

3
Injection Safety Critical Issues

• The risk to the recipient
• Re-use of syringes or needles
• Use of non-sterile equipment
• Risk to the health care worker
• Inappropriate waste collection
• Risk to the community
• Inappropriate waste disposal

4
Assessment of Injection Safety Tool C
Rationale

• Describes injection practices in a standardised
  and representative way
• Identifies detailed problems in injection
  practices
• Identifies local issues to design effective,
  efficient interventions
• Provides baseline information and indicators for
  monitoring progress

5
Assessment of Injection Safety Tool C
Objectives

• To determine if a facility meets necessary
  requirements for staff competence, equipment,
  supplies, and waste disposal.
• To assess if injections are administered
  according to recommended best practices.
• To identify the unsafe practices that may lead to
  infections and that should be targeted by
  interventions.
• To estimate the proportion of health-care
  facilities where injection practices are safe.

6
Assessment of Injection SafetyTool C Methods

• Standardized and representative method to allow
  for
• Measuring and documenting progress
• Comparison across countries
• Simple/structured and flexible (2-3 weeks)
• To be adjusted to country needs (other issues at
  health facility can be looked at simultaneously)
• Need to link with change ? plan of action.

7
Assessment of Injection Safety Tool C
Development

• Collaboration between SIGN, BASICS and WHO/VB
• Ohio State University
• Statistical advice on sampling strategy
• Computer simulation studies of sampling design

8
Assessment of Injection Safety Tool C Sampling

• Cross-sectional observational study
• Two-stage cluster sampling with probability
  proportional to size of population
• 8 districts randomly selected
• 10 health care facilities visited in each
  district
• Representative of the country
• With around 10 precision of the estimate

9
Assessment of Injection SafetyTool C Data
Collection

• Observation of supplies
• Type and number of syringes and needles
• Number of safety boxes, sharps containers
• Type of waste disposal
• Observation of injections
• Immunisation and curative departments
• Interview of healthcare workers
• With injection provider
• With the supervisor of the centre

10
Assessment of Injection Safety Tool C Data
Analysis

• Data Entry in Epi Info
• Data Analysis in Epi Info and e.g. Stata
• Calculation of means and proportions
• Calculation of 95 confidence intervals
  (binomial)
• Cluster sampling design taken into account

11
Tool C Injection Safety Assessments 2000-2002
Burkina Faso, Chad, Djibuti, Egypt, Eritrea,
Ethiopia, Gambia, Guinea, Honduras, Kyrgyzstan,
Morocco, Nepal, Niger, Oman, Pakistan, Paraguay,
Syria, Sudan, Tunesia, Yemen, Zambia, Zimbabwe
Assessments done
Assessments planned
12
Results Injection Equipment

• 20 country reports available as of June 2002
• Sterilizable equipment in majority of
  facilities 8/20
• AD-syringes for all immunizations 2/20
• Disposable equipment for curative injections
  20/20

13
Results Risk to Injection Recipients

• 100 use of sterile equipment for all observed
  injections 4/18 countries
• 100 use of sterile equipment for all observed
  immunization injections 9/17 countries

14
Results Risk to Injection Recipients

• Countries using disposable equipment (n12)
• In 9 countries 100 of immunizations are safe
• Countries using sterilizable equipment (n8)
• In 1 country 100 of immunizations are safe
• In all facilities leaking sterilizers, no regular
  use of time-steam-temperature spots

15
Results Risk to Injection Recipients

• Relative Risk for safe immunization injections
• for countries using disposable equipment
• v.s countries using sterilizable equipment
• OR 14.0 (95 CI 1.3 - 156)

16
Results Risk to the Health Care Worker

• Use of safety-boxes 0 - 89
• No sharps in open containers 5 - 66
• No two-hands recapping 29 - 84
• No needle-stick injuries in the last 12 month
  21 - 82
• Mean number of needle sticks
• per person and year 1 - 9

17
Results Risk to the Community

• No sharps in the surroundings 7 - 91
• Open burning or unsupervised dumping of sharps
  waste 18 - 64
• Health care waste policy 0 - 9

18
Discrepancy between IS policy and actual findings
(Country 1)

• Country policy Use of disposable injection
  equipment
• 84 of the injections are given with
  sterilizables
• Sterilizers without leaks only in 84, only in
  23 spare parts and in 7 TST spots available to
  register sterility

19
Discrepancy between IS policy and actual findings
(Country 2)

• Country policy Use of sterilizable injection
  equipment for immunizations
• Only 4 of health facilities in the country are
  using sterilizable equipment
• Clients are purchasing the injection material
  locally

20
WHO Eastern Mediterranean Region
23 countries with 482 Mio. total population
(2000)
21
WHO/EMR Injection Safety Situation

• Standardised assessments performed in 9/23
  countries representing 65 of EMR population
• Additional data used
• WHO/UNICEF Joint Reporting Forms on
  vaccine-preventable diseases
• SIGN reports
• ATT reports
• GAVI applications re injection safety
• Expert knowledge (Delphi estimates) of national
  EPI managers
• Published scientific papers (Egypt, Pakistan)

22
WHO/EMR Injection Safety Assessments
Palestine
Bahrain
Covering 65 of EMR population
23
WHO/EMR Risk to Injection Recipients
Proportions weighted by population figures
24
WHO/EMR Immunization Safety 2002
Palestine
Bahrain
gt 95 safe injections
91- 95 safe injections
81- 90 safe injections
71- 80 safe injections
? 70 safe injections
25
WHO/EMR Equipment and Supplies
Proportions weighted by population figures
26
WHO/EMR AD Injection Equipment
Palestine
Bahrain
At least partially available for 51 of EMR
population
27
WHO/EMR Risk to Health Care Workers
Data from 7 countries - weighted by population
figures
28
WHO/EMR Safety Boxes
Palestine
Bahrain
At least partially available for 93 of EMR
population
29
WHO/EMR Risk to Health Care Workers
Proportions weighted by population figures
30
WHO/EMR Risk to the Community
Proportion weighted by population figures
31
WHO/EMR Sharps Waste Disposal
Proportions weighted by population figures
32
WHO/EMR Summary Estimates

• Weighted
  Proportion
• Risk to Recipients (EPI and curative)
• Non-sterile injections 34
• Risk to Health Care Workers
• Sharps in open containers 71
• Two-hands re-capping 60
• Needle-stick injuries (admitted) 50
• Risk to the Community
• Unsafe sharps waste disposal 85

33
Pakistan Summary Estimates

• 95 CI
• Risk to Patients
• Non-sterile injections 64 (54 - 73)
• Risk to Health Care Workers
• Sharps in open containers 92 (85 - 96)
• Two-hands re-capping 83 (71 - 92)
• Needle-stick injuries (admitted) 46 (33 - 60)
• Risk to the Community
• Unsafe sharps waste disposal 94 (86 - 98)

34
Planning or Quality Cycle
Benchmarking
Assessment
Evaluation
Planning
Monitoring
Implementation
35
WHO/EMR Regional Injection Safety Goals

• Ensure the safety of all immunization injections
  in all member countries.
• Extend successful injection safety strategies and
  activities to other parts of health care services.

36
WHO/EMR Regional Injection Safety Targets

• All countries of the EMR will ...
• have reliable baseline data on injection safety
  by the end of 2003.
• have declared their political commitment to
  injection safety and have developed national
  policies, guidelines and plans of action on
  injection safety by the end of 2003.
• have sustained public information and
  communication activities and behaviour change
  strategies to increase injection safety by the
  end of 2005.

37
WHO/EMR Regional Injection Safety Targets

• All countries of the EMR will ...
• have strengthened their management capacity and
  improved human resources development in all
  issues related to injection safety by the end of
  2004.
• have assured that no reuse of injection equipment
  occurs at any time and that safe injection
  equipment and safety boxes are supplied bundled
  with all vaccines by the end of 2004.

38
WHO/EMRRegional Injection Safety Targets

• All countries of the EMR will ...
• have assured the safe collection, treatment and
  destruction of sharps waste by the end of 2005.
• have a regular reporting system and the capacity
  to supervise, monitor and evaluate injection
  safety programmes by the end of 2005.
• have extended successful injection safety
  strategies and activities from immunization
  services to other parts of the health care
  services by the end of 2005.

39
WHO/EMRRegional Injection Safety Plan of Action

• Eight main activities according to established
  targets
• Additional resource requirements 2002-2005
• for regional-level activities 655,000 USD
• for country-level activities 805,000 USD

40
WHO/EMR Regional Injection Safety Milestones
and Indicators

• Milestones set for 2003 - 2005
• Measurable indicators (input, process, outcome)
  suggested for regional and country level

41
Acknowledgements

• Dr. Julia Fitzner, WHO/VB/VAM
• Dr. Phillipe Duclos, WHO/VB/VAM
• Dr. Ezzedine Mohsnie, WHO/EMRO
• Dr. Yvan Hutin, WHO/BCT
• All collaborators, counterparts in Ministries of
  Health, field workers, health facility staff,
  patients and vaccinees