Injections are one of the most often used health care interventions in clinical practice, and are used for preventive, curative and diagnostic interventions. They can be defined as “a skin-piercing event performed by a syringe and needle with the purpose of introducing a curative substance or vaccine into a patient by the IM/IV/SC/ID route”.

WHO defines safe injection as one, which (a) does no harm to the recipient (b) does not expose the health worker to any risk, and (c) does not result in waste that is dangerous for the community.

To achieve this, first, the injection should be prepared on a clean workspace that is free from any blood contamination. Second, the provider should wash his hands in an appropriate and technically correct manner. Third, a sterile syringe and needle should be used. Fourth, medication and diluents should be drawn from a sterile vial. Fifth, the skin should be cleaned before injection. Sixth, the used syringe and needle should be collected in a puncture and liquid-proof container. Finally, sharp waste should be managed appropriately. Failure to respect any of these steps exposes the recipient, the provider, or other people to unacceptable risks.

The most common danger of unsafe injections are infections, particularly infections with blood-borne pathogens, among which hepatitis B virus (HBV), Hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections represent the largest burden of death and chronic disease. Besides HBV, HCV, and HIV, selected outbreaks of viral hemorrhagic fevers have been associated with unsafe injection practices. Other injection-associated infections are of bacterial etiology and include abscesses and septicemia.

Injection therapy over the years has become widespread and popular in India. Of all the injections given majority are for curative purposes and only 15-20% are for immunization. Both the qualified and unqualified healthcare providers give these injections. Various studies done in India have over a period of time have found unsafe injections to be major risk factor in transmission of blood borne pathogens. Government of India with World Bank funding has instituted an assessment of injection practices in India, which was conducted by the INCLEN; the study found out that:

• Overall on an average 2.9 Injections per person per year are administered in the country based on a 3 month recall.
  
• At the country level, almost half (48.1%) of all clients coming out of health facilities had received injections during their visit.
  
• 51.1% of the curative injections at the all India level were prescribed for symptoms of fever/cough/diarrhea.
  
• 62.9% injections i.e., nearly 2/3rd Injections are unsafe and 31% of these carried a potential risk of transmitting blood borne viruses, and 53% were unsafe due to use of faulty techniques.
  

Other studies published over the years have put the number of injections given at 4 injections/person/year and proportion of unsafe injections at 50% of all injections given; these unsafe injections were also seen as a major risk factor in the spread of blood borne pathogens like Hepatitis B, C and HIV.

Many of the 12 billion injections that are administered annually world-wide are administered under unsafe conditions. In a review of published and unpublished studies, Adam Kane and his collaborators in the Bulletin of WHO estimated that in the developing world, the proportion of injections that are administered with a syringe and/or needle administered without sterilization ranges from 15% in former socialist economies of Eastern Europe and in the Middle East crescent to 50% in sub-Saharan Africa, China, India, and the rest of Asia.

When injections are overused and when breaks in infection control occur, blood-borne pathogen may be transmitted. Across the various regions of the world, the number of new persons infected with blood-borne pathogens due to unsafe injections ranges from 96000 for HIV, 2 million for Hepatitis C virus (HCV), and 21.7 million for Hepatitis B virus (HBV).


The transmission potential of HBV, HCV, and HIV is known from the studies for which healthcare workers have been followed for occurrence of infection with blood-borne pathogens after accidental needle-stick injuries. After an accidental needle-stick from an HBV infected source patient, the probability of infection for susceptible recipients averages 30%. After an accidental needle-stick from an HCV infected source patient, the probability of infection for susceptible recipients is 10 times smaller and averages 3%. For HIV, the probability of infection for susceptible recipients after an accidental needle-stick is 100 times smaller than HBV and averages 0.3%. Thus, while the transmission of HIV through unsafe injections is of particular concern because of its severity, it is less common than HBV and HCV transmission. Hepatitis B is the most likely pathogen transmitted through unsafe injections.

To achieve prevention, a multidisciplinary approach is needed to achieve safe and appropriate use of injections. First, behaviour of healthcare providers and patients must be changed to decrease injection overuse and achieve injection safety. Second, there should be provision of sufficient quantities of appropriate injection equipment and infection control supplies. Third, a sharp waste management system should be set up to ensure that disposable equipment is destroyed and not re-used.