Best Infection Control Practices for ID, SC, and IM Injections Recommendations of the SIGN Working Group on Best Practices Geneva, October 2000 SIGN 2001

Injection Safety Standards: Background No prior agreement on what is a “safe injection”. Review of training materials showed many dangerous or questionable practices being promoted. Research does not exist to support many common practices (e.g. aspiration). This group focused on actions of the injector that could spread infection.

A “Best Practices” Document “Best” = pose minimum risk of disease transmission based on current evidence. Countries modify, or accept “best” practices based on risks and cost of adopting practices in their programs.

Process for Development of Best Practices for Infection Control Broke an injection into a series of steps Conducted a literature review Drafted and discussed the document Revised draft for public comments Availability of a final document

Categories of Evidence 1, 2 or 3 1 Strongly recommended and supported by research with appropriate study design and analysis. 2 Strongly recommended on the basis of strong theoretical rationale and suggestive, descriptive evidence. 3 Recommended on the basis of expert consensus and theoretical rationale.

Four Scientifically-Supported Practice Areas Use of sterile injection equipment for each injection Preventing contamination of equipment and medication Preventing needlesticks by disposal at point of use Preventing contact or access to used needles –reduces re-use –reduces needlesticks

Issues Where Firm Conclusions Could not Be Reached Use of engineered technology Hand hygiene Use of gloves for providing injections Swabbing vials or ampoules Skin preparation prior to injection

Use Simple Sheets to Help Discuss Practices Don’t expect guidelines or posters alone to change behavior People do things for a reason. Explore why. Knowledge is necessary but not sufficient to change practices.

Different Areas Have Different Problem Practices Decanting Aspiration Dosing Loading more than one dose in a syringe Placing syringes in disinfectant prior to re-use Storing syringes wet Placing a finger over the needle site

Use a Syringe and Needle with Proof of Sterility for Each Injection (1) Inspect packaging or sterilization monitors. Use syringes with quality controls that staff and parents can see.

If Single-Use Equipment is Unavailable… (1) Sterilize only equipment designed for steam- sterilization. Decontaminate syringes to make them safe to handle. Clean all visible dirt from syringes, remove plunger, flush needle, take apart. Use sterilization monitors. This critical task requires supervision and appropriate pay.

Prepare Injections in a Clean Area (2) Do not work in an area where blood, contaminated items or body fluids are or may be present. Water is available Soap is available Freshly prepared bleach and water or environmental disinfectant (not skin cleaner)

Use Single-Dose Vials if Possible (2) Single dose vials pose a lower risk for disease transmission. The risks of using single-dose vials will increase in programs where syringes are used more than once, and if reconstituted vaccine vials are not strictly discarded after 6 hours.

Use Tools or Barriers to Open Glass Vials (2) Staff frequently cut themselves opening glass vials. This is painful and contaminates the ampoule and work area. Purchase vials that do not need to be broken to open.

Follow Product-Specific Recommendations for Use, Storage and Handling (3) Discard reconstituted vaccines that do not contain preservatives within 6 to avoid sepsis or toxic shock Never use normal saline or water in place of diluent. Avoid freezing vaccines

Discard Needles that Have Touched Non- Sterile Surfaces (3) If if touched, discard.

Position Patients Prior to Injection (2) Anticipate and take measures to prevent sudden patient movement during and after injection. This may require making chairs available, revising clinic flow or reassigning staff.

Avoid Recapping and Manipulation of Needles (1) Reducing contact and manual handling of used syringes reduces needlesticks.

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