Saturday, July 3, 2010

Even WHO Admits Unsafe Injections are Ubiquitous

The dental unit of a hospital in Missouri has realised that 1,800 of its clients may have been exposed to diseases such as HIV and hepatitis B and C as a result of poor hygiene. All the people, apparently all war veterans, who may have been exposed, are being contacted and an investigation has been called for to find out how such an incident could occur. A political spokesperson has said that this is unacceptable for veterans. Whether he thinks it would be equally unacceptable for people who have spent no time in military service is unclear.

Still, it’s good to hear that there is a protocol, there is sterilization equipment and that someone is checking to see that the protocol is adhered to. It’s also reassuring that there are people who know that lack of care in using such equipment can give rise to infection risks and that if there is any possibility that clients are at risk, they can be and will be contacted and given a full check-up. Presumably, the staff involved will be retrained and those found to be responsible will be disciplined appropriately.

A similar occurrence in California resulted in 3,400 patients being contacted because they underwent a colonoscopy and it was found that correct hygiene precautions may not have been followed. And in the UK, 519 people have been contacted because a healthcare worker who may have treated them was found to be HIV positive. The worker, who has worked in a number of hospitals, has been moved to a role where there is no risk of blood contact.

The two American incidents are probably more worrying than the UK incident because patients are unlikely to be infected by HIV positive healthcare workers, in practice. But infections from unsafe medical procedures are thought to be common, especially in countries where there are low levels of training, staffing, safety and funding. The World Health Organisation (WHO) estimates that in some regions, up to 70% of the 16 billion injections given in transitional and developing countries are unnecessary. They estimate that up to 40% of injections worldwide are given with syringes or needles reused without sterilization and this could be as high as 70% in some countries.

One doctor in Kenya relates how he has stuck himself with needles on several occasions. He also says this is common among healthcare workers. However, the likelihood of a healthcare worker becoming infected is quite low, in practice. The biggest worry is of patients being infected by contaminated equipment. And this doctor says that they don’t always have enough needles, for children in particular. He describes how they improvise to get around this problem but also admits that this means the patient can be infected with hepatitis. He doesn’t mention HIV but presumably they are at risk from any blood borne disease.

This one medic can see up to 100 patients a day, as can many practicing healthcare workers in other facilities all over Kenya and East Africa. Doctors and other healthcare practitioners receive a lot of training but if they don’t have the equipment, they either need to ‘improvise’ or refuse to treat people. But what of all the other people who give injections and carry out other procedures that involve potential blood exposure? The risks may be lower but some of them only receive a few weeks training. And there are those with no training at all who also give injections, informal practitioners and the like.

UNAIDS ‘estimate’ that unsafe healthcare results in around 0.6% to 2.5% of HIV infections in Kenya. Yet the WHO estimate that globally, 2% of HIV infections are caused by unsafe injections. Is it really credible that countries with high prevalence of blood borne diseases and low levels of safety in healthcare settings could have such low transmission rates through unsafe medical procedures? WHO estimates that up to 9% of HIV infections may come from unsafe injections in South Asia. How could the figure be so much lower in African countries, where healthcare is known to be of a very low standard and prevalence of HIV is so much higher than it is anywhere in Asia?

In the US and the UK, where there is a relatively small risk that people will be infected with HIV as a result of medical procedures, hundreds, even thousands of people are screened to make sure that they were not infected. But in developing countries, where HIV prevalence is high, we are told that most HIV transmission is through heterosexual sex and therefore transmission through unsafe medical procedures cannot be high. Where there is doubt, people are not recalled and screened. Potential nosocomial cases (ones that occurred in healthcare settings) are not investigated. There is overwhelming evidence that heterosexual behaviour in African countries does not explain high levels of HIV, but because they are African countries, it is accepted that they have lots of sex, that they should stop doing so and when they do, everything will be ok.

Health facilities in African countries lack adequate drug supplies, have chronic shortages of trained personnel and do not even have enough condoms at a time when they are faced with rising HIV prevalence. It is not credible that, at the same time, there is a very low risk of HIV infection through unsafe medical practices. Global HIV policy is obsessed with sexual HIV transmission to the extent that non-sexual transmission is being completely ignored, especially in developing countries. Informing people of the non-sexual risks of HIV transmission, and how to avoid them, is just as important as informing them of the sexual risks. People have a right to the information they need to protect themselves.


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