Giving

Safe Injections
 How to improve injection safety
in your institution
The World Health Organization (WHO) estimates that at least 50 percent of the world's 12 billion
injections administered each year are unsafeposing serious health risks to recipients, health
workers and the public. Most injections are given for therapeutic purposes, rather than for
immunizations and many of these "curative" injections may be unnecessary, ineffective or
inappropriate (Simonsen, 1999). Reducing unnecessary injections is one way to dramatically
improve the safety of injections in your institution.
The following pages describe how to make your institution a "safe injection zone.

Teach the health staff about the importance of injection safety

Irrespective or whether a health worker provides immunization or other services at the health
center, it's important that all staff members understand the importance of injection safety.
Following is a list of questions and answers to educate health workers about injection safety and
help them identify areas in which it can be improved.

Why is injection safety important?

The first rule of health care is "first, do no harm." Yet, every day, health workers around the world
give unsafe injections to patients. Poor injection technique and careless handling and disposal of
syringes and needles can also put patients, the health worker and the community at the risk of
contracting deadly diseases.

What is an unsafe injection?

An unsafe injection is an injection that can potentially harm the recipient, the provider or the
community. Health workers should assume that all used injection equipment is contaminated
and take the necessary precautions to ensure that no person or animal is potentially exposed to the
risk of infection or accidental needle stick injuries.

What are the risks associated with injections?

The most common, serious infections transmitted by unsafe injections are Hepatitis B, Hepatitis
C, and HIV, the virus that causes AIDS. WHO estimates that unsafe injections transmit 80,00,000
to 160,00,000 Hepatitis B virus infections, 23,00,000 to 47,00,000 Hepatitis C virus infections and
between 80,000 to 1,60,000 HIV infections each year. Unsafe injections can also transmit parasitic
(malaria), fungal, bacterial and other types of infections. Some infections, such as abscesses, may
appear relatively quickly; however, other infections spread by used syringes may not be obvious
for years or decades. Poorly administered injections can also cause injuries or drug toxicities
when the wrong injection site, drug, diluent or dosage is used.

What is the difference between safe and unsafe injection practices?

A safe injection does no harm to the recipient, does not expose the health worker to any risk, and
does not result in waste that is dangerous for the community. To achieve this, the injection needs to
be prepared with clean hands in a clean area, using medication drawn from a sterile
 vial. The injection must be administered using a sterile syringe and needle.
After administration, sharps must be discarded in a puncture-proof container for
appropriate disposal.
Any departure from this procedure represents a risk, rendering the injection
unsafe. Among unsafe practices, the re-use of a needle or syringe between
patients, without sterilization is the most dangerous.

Why is an 'unnecessary' injection unsafe?

The more injections that are given, the more people are exposed to needles and
syringes. Also, if the number of injections given exceeds the supplies of sterile
injection equipment, re-use of syringes and needles is likely to occur.
Therefore, the greater the use of injections, the higher the risk to the patient and
the community at large.

What are the reasons for injection overuse?

In health care settings in India, most injections are not necessary. Many
injections are given to satisfy the psychological needs of the patient, since the
patient (usually falsely) feels that injectable medication is more effective than
oral medication. Sometimes health workers add to the problem because they
feel they can make more money when prescribing injectable medication.
Giving any injection where a viable oral alternative is available has the
potential to do harm. It is the responsibility of service providers to consciously
address the problem of injection overuse by looking for alternatives.

Why aren't health professionals aware of the risks of unsafe injection practices?
Most health professionals understand that re-using syringes and needles can
cause cross-infection and put patients at risk. However, they are not fully aware
that unsafe injections have become an enormous public health problem. In many
cases, health workers have not been trained to problem-solve when supplies are
low, how to properly sterilize injection equipment, how to prevent needle stick
injury, and how to safely dispose off injection equipment. More importantly, they
may not understand the extent of the risk, not only to the patients, but also to
themselves, to waste handlers and to the community when they come in contact
with used and contaminated injection equipment.

What are some simple ways to improve

injection safety?
There are many ways to make a big difference in injection safety to your
institution. Some of the most neglected and most important changes you can make
are listed below.
Keep hands clean before giving injections
Wash or disinfect hands prior to preparing injection material. Avoid giving
injections if skin is infected or compromised by a local infection (such as a skin
lesion, cut, or weeping dermatitis). Cover any small cuts.
Always use sterile injection equipment
Always use a sterile syringe and needle for each injection and to reconstitute each
unit of medication. If auto disable or single-use syringes and needles are unavailable, use
equipment designed for steam sterilization. Document the quality of the sterilization
process using Time, Steam, and Temperature (TST) spot indicators or registers / records.

Prevent contamination of injection equipment and medication

n Prepare each injection in a clean designated area, where blood or body fluid
contamination is unlikely.
n Clean skin prior to injection with water and wait for it to dry. Do not use cotton balls
stored wet in a multi-use container.
n If multi-dose vials are used, always pierce the septum with a sterile needle. Avoid
leaving a needle in place of the stopper of the vial.
n Follow product-specific recommendations for use, storage and handling of a
medication or vaccine.
n Discard the syringe if the needle has touched any non-sterile surface.

Ensure safe containment of sharps immediately after use

It is important to make the health staff understand that sharps must be contained in a
sharps box immediately after use, without recapping or manually mutilating / handling
the sharps / needles. This is an important precaution and must be introduced through staff
training and supervision.

Practice safe disposal for all medical sharps waste

All health care providers should use safety boxes to dispose off used sharps. They should
safely dispose off these boxes, using facilities for treating, shredding /mutilation and
eventual burial of all medical waste in a safe location. These practices can be followed for
all sharps waste from your institution. You may also find alternative in efficient
incinerators or burning methods that make this process easier and even less damaging to
the community and the environment.

Prevent needle stick injuries to the provider

Anticipate and take measures to prevent sudden patient movement during and after
injection. Do not recap or touch needles. Collect used syringes and needles at the point of
use in a sharps container that is puncture-proof and leak-proof. The container should be
sealed when full.

Prevent public access to used needles

Seal sharps containers before carrying to a secure area in preparation for disposal. After
closing and sealing sharps containers, do not open, empty or reuse them. Manage sharps
waste in an efficient, safe and environment-friendly way to protect the community from
voluntary and accidental exposure to used injection equipment.

Determine whether unsafe practices are used in your institution

Following is a list of commonly observed unsafe injection practices. Which of these
practices are used in your institution? What can you do to correct them?
Some practices that can harm patients: Observed? Corrected?
Re-using any injection equipment without proper sterilization
Re-using disposable syringes or needles - even after sterilization
Changing the needle but re-using the syringe
Sterilizing glass syringes without supervision or without
monitoring time, steam and temperature indicators
Boiling and soaking injection materials in bleach for 30 minutes
prior to re-use
Boiling injection equipment in an open pan
Using only disinfectants on used syringes to prepare them for
re-use
Giving an injection when there are safer alternatives, such as oral
medication
Keeping freeze-dried vaccine more than 4 hours after reconstitution

Loading syringes with multiple doses and injecting multiple

persons
Applying pressure to bleeding sites with finger or with dirty
cotton
Immunizing infants in the buttocks
Leaving a needle in the vial to withdraw additional doses
Mixing (decanting) two partially opened vials of vaccine
Flaming needles
Mixing 10-dose vials of vaccine with a single-dose of diluent
Storing medication and vaccine in the same refrigerator
Touching the needle / swabbing the needle before injecting

Some practices that can harm health-care workers:

Recapping needles
Bending or removing needles with bare fingers
Placing needles on a surface or carrying exposed needles prior to
disposal
Sharpening blunt or blocked needles for re-use
Reaching into a mass of used syringes or needles (for any reason)

Some practices that can harm the community:

Leaving used syringes in areas where children can play with them
Dumping used syringes in areas accessible to the public
Dumping used syringes in municipal or other public waste piles
Giving or selling used syringes to vendors who will resell them
 Make your health center a
safe injection zone
To avoid further harm to the community, health-workers and patients, you may assign
an injection safety point-person to assess the safety of injections given in your health
center and take steps toward making your service area a safe injection zone.

Designate an injection safety point-person

The point-person can begin by using the checklist provided before to correct unsafe
practices.

Reduce the number of injections given in the curative sector by at least half.
Next, you can aim to reduce the number of injections given in the curative sector of
your institution by at least one half.

Educate the community about injection safety

Next, you can begin educating the community about injection safety. Give them tips on
how to make sure their health worker is taking adequate precautions when giving
injections.

Guidelines for disposal of bio-medical waste

generated during immunisation
1. The concerned Officer made responsible for the implementation of Immunization in
the respective area shall obtain authorization from the "Prescribed Authority" as
notified under the Bio-medical Waste (Management & Handling) Rules (i.e. State
Pollution Control Broad/Pollution Control Committee) for generating, collecting,
receiving, storing, transporting, treating, disposing, and/or handling bio-medical
waste in any other manner.
2. No untreated bio-medical waste shall be kept stored beyond a period of 48 hours..
3. Disposal of bio-medical waste generated within District Hospitals/ CHCs/ PHCs etc.;
Step 1 : Remove needles from AD syringe immediately after administering injection at
the site using a suitable syringe cutter that cuts plastic hub of syringe and not
the metal part of needle.
Step 2 : Segregate and store detached needles and broken vials, if any, separately in a
sturdy and puncture proof white translucent container.
Step 3: Segregate and store syringes and unbroken (but discarded) vials in red bag or
container. If a bag is used, its strength should be such that it can withstand the load
of waste inside.
Step 4: Label both the containers with Biohazard Symbol as stipulated in the Schedule
III of the BMW Rules.
Step 5: Send both the containers to the common Biomedical Waste Treatment Facilities
(CBWTF). In case, CBWTF does not exist, go to step 6.

Step 6: Treat both white translucent container and red container/bag in autoclave. The
autoclave shall comply with the standards stipulated in the Rules. Under
certain circumstances, if it is unable to impart autoclaving, boiling such waste
in water for at least 10 minutes/chemical treatment may be imparted. It shall
be ensured that these treatments ensure disinfection. However, such district
Hospital/CHC/PHC etc. shall ultimately make necessary arrangements to
impart autoclaving treatment on regular basis.
Step 7: Dispose the autoclaved waste as follows :
(i) Dispose the needles and broken vials in a pit/tank made as per the design
described in figure-1.
(ii) Send the syringes and unbroken vials for recycling or landfill.
Step 8: Wash properly both autoclaved containers for reuse (the material of the
containers shall be so selected that it withstands the pressure and temperature
during autoclaving).
Step 9: Make a proper record of generation, treatment and disposal of waste to enable
preparation of annual reports to be submitted to the "Prescribed Authority" by
31st January of every year.

Disposal of bio-medical waste generated at

Outreach Points/outside District Hospitals/
CHCs/PHCs etc.
Step 1: Remove needles from AD syringe immediately after administering injection at
the site using a suitable syringe cutter that cuts plastic hub of syringe and not
the metal part of needle. The removed needle having the detached plastic hub
of the syringe shall be made to fall in an attached white translucent, sturdy and
puncture proof container having a capacity to store at least 45 needles and
designed to ensure no spillage of stored needles while handling the syringe
cutter or carrying the same while traveling.
Step 2 : Store broken vials in a separate white translucent, sturdy and puncture proof
container or in the container mentioned at Step 1, in case its capacity is able to
accommodate broken vials also or,
Step 3 : Segregate and store the detached syringe and the discarded unbroken vials in the
red container.
Step 4 : Label the red and white translucent containers with Bio-hazard symbol.
Step 5 : Carry and handover these containers to the District Hospitals/ CHCs/ PHCs
etc. while unused remaining vaccines are carried to the District Hospitals/
CHCs/ PHCs etc. for cold storage and to do other documentation work. To
dispose these wastes at the District Hospitals/ CHCs/ PHCs etc., follow the step
5 onwards under "Guidelines for disposal of bio-medical waste generated during
immunization/'.
Step 6 : Maintain a proper record at the District Hospitals/ CHCs/ PHCs etc. in order to
assess that waste (needles/ syringes/ vials) reported back to District
Hospital/CHC/PHC matches with the stock issued. Such matching is to be done
by weighing, but not by counting in order to avoid occupational and safety
hazards.

Design of the Pit/Tank for Disposal of Treated

Needles and Broken Vials
The treated needles /broken vials should be disposed in a circular or rectangular pit as
shown in figure 1. Such rectangular circular pit can be dug and lined with brick,
masonry or concrete rings. The pit should be covered with a heavy concrete slab, which
is penetrated by a galvanized steel pipe projecting about 1.5 meters above the slab,
with an internal diameter of up to 50 millimeters or 1.5 the length of vials, whichever is
more. The top opening of the steel pipe shall have a provision of locking after the
treated waste sharps has been disposed in. When the pit is full, it can be sealed
completely, after another has been prepared.

For high water table regions where water table is less than 6 meters beneath bottom of
the pit, a tank with above mentioned arrangements shall be made above the ground.
 An introduction to the safety box
All used injection equipment should be placed in a safety box or a puncture-proof
sharps container immediately after use. Safety boxes will be provided to hospitals and
health centers for the immunization programme. If a safety box is not available, a
health worker can use locally available materials to create a functional and safe sharps
container.

How to assemble the safety box correctly

Manufactured safety boxes require-proper assembly before use. Each box comes with
pictorial instructions printed on the side of the box. The following instructions may also
help with initial assembly of boxes.

a) Push together long sides of flattened box to create box shape.

b) Punch in the four crescent shaped tabs on the back of the box.
c) Assemble the bottom of the box by folding straight-edged tab first, then pushing in
the perforated edges and folding the other tab over the first, tucking the corners into
the slots.
d) Assemble the top of the box by folding the straight-edged tab first, then pushing in
the perforated edges and folding the other tab over the first, tucking the corners into
the slots.
e) The tab at the front of the box may be folded into the box and used to seal the
circular opening while the box is not in use.
What to do if no safety box is available
If there is no safety box available, you can use an alternative container available in the
health center. Because we are recommending safe disposal of the sharps waste, we
recommend using a cardboard box with rigid sides and enough room to hold at least the
number of syringes used in one session. The box can be sealed and disposed after use or
sealed and stored in a safe place until the next session. Some potential sharps containers
include:
Shoeboxes
Vaccine boxes re-labeled "SHARPS"
Other empty boxes from tablet/cotton wool supplies, etc.

How to use the safety box

Step 1: Place the sharps container within arms reach
Step 2: After each injection, immediately place the syringe and needle in the safety box
or sharps container

Do not recap the needle

Do not bend the needle
Step 3: After the immunization session or when the safety box is full, close the
container and seal it with tape or string.
Step 4: Find a safe place to dispose the box.

If: Then

A local medical Arrange for the safety boxes to be .

waste facility / transported to the designated waste
transport system is disposal facility.
available.

No viable Find a secure area, preferably within the

transport/ health compound.
medical waste Ensure that no children or animals will
facility is available have access to the site.
Dig a small pit
Place the box or container inside the pit.
Cover the pit with dirt or sand
Auto Disable (AD) syringes are single-use, self-locking syringes that cannot be used more than
once. There are several varieties of AD syringes available, but they all operate on the same
principles. We will describe a typical syringe in this handbook. Other syringes may become
available, so it's important that health workers are comfortable switching between brands.
Following is a brief description of Auto Disable syringes and their proper use.

Using Auto Disable syringes

All Auto Disable syringes have a device that locks the plunger after a single use. Some
come with fixed needles and some do not. In this handbook, we will describe the KOJAK
SELINGE AD Syringes. This device comes with a fixed needle and is packaged with
plastic caps to keep the needle and plunger sterile before use.

HMD Syringes are 3-pc. syringes. A three piece syringe consist of three parts namely -
plunger, barrel & gasket, while a two piece syringe consists of only plunger and barrel

3 Piece Syringe 2 Piece Syringe

Advantages of 3-Piece Syringes over 2 Piece Syringes

3 Piece Syringe 2 Piece Syringe

A part from plunger & barrel there is
presence of Natural Rubber
chemically inert Piston which has
three lines of contact which minimize
chances of leakage over complete 5
year shelf life of the product.
No Gasket is present and hence chances of
leakages increase since the singular line of
contact of plastic plunger with barrel is very
thin. Quality may be OK in functioning but
shelf life not assured due to shrinkage
occurring on exposure to extreme
temperatures at the time of storage.

The siliconsized rubber piston allow
smooth motion during injection and
aspiration, there is no scratching of
the plastic barrel by the rubber gasket.
While using 2-pc. syringe one can observe
that the barrel tends to be pushed outward
by the hard plunger seal. The plastic
plunger scratches against the inside of the
barrel and this can cause very fine plastic
debris to move along with injection into the
body. This may cause harmful
 How to use Kojak Selinge AD Syringes

Step 1: Step 2:
Open the pack and take out Remove the needle cap.
syringe. Don't push plunger
forward, as otherwise
Syringe will get locked.

Step 3: Step 4:
Insert the needle into the Push the plunger for
vial and withdraw desired dosage and expel
medicament. air bubble.

Step 5: Step 6:
Inject the medicament Destroy the needle with
a needle cutter.

Step 7: Step 8:
Plunger breaks on Dispose off the syringe
withdrawal in a 'sharps' container.
 Questions and Answers about Auto Disable (AD) syringes

How is the KOJAK SELINGE syringe different from other AD syringes?

Standard AD syringes are designed for immunization with a fixed needle for only 0.5 ml or
1 ml dosages. KOJAK SELINGE can be used for any curative injection and is available in
the most commonly used sizes of 2 ml, 3ml, 5 ml & 10 ml. KOJAK SELINGE permits
aspiration and the blood collection which is not possible in most AD designs.

Will AD syringes create a waste problem?

The use of AD syringes should not significantly impact the already large medical waste
problem in India. However, all health programmes must responsibly manage waste and
minimize negative health impacts to the community and the environment. Currently, we
recommend that all AD syringes (and other disposable injection devices) are disposed in
the safest way, with very stringent control on the needles and syringes to ensure that there
are no leakages in the system to allow for harm to health workers, waste handlers or the
community at large. The needle bearing syringes should be immediately put in a
designated safety box or other available container and sealed after use. Their disposal
should be handled in an appropriate manner, using available local mechanisms for final
disposal of medical waste.

Advantages of using KOJAK AD Syringes

KOJAK permits Aspiration (critical for subcutaneous immunization injections)
KOJAK can be used for reconstitution and mixing of drugs

For more information on Auto Disable syringes please visit: www.hmdhealthcare.com

 Notes
..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................
 Injection safety is a major public health issue
Rational use of injections is needed
Technology and methods to achieve safe injections are feasible, available and
affordable
Potential for disease transmission threatens the public trust in health services
Each of us need to become advocates for safe injection practices

Where more information is available:

For Injection Safety:
www.injectionsafety.org
www.who.int
www.path.org
www.childrensvaccine.org
www.unicef.org
www.injectionsafety-india.org

On AD Syringes:
www.hmdhealthcare.com

Issued in public interest