Transcript Poster presentation

Abstract
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Problem Statement: As in many former socialist economies, anecdotal reports suggested that injections
were overused to administer medications in Mongolia. Suspected explanations for injection overuse in the
country included a cultural preference for injections in the population and the persistence of outdated
standard treatment protocols that excessively recommended the use of injections.
Objectives: The Ministry of Health of Mongolia decided to conduct an assessment of injection practices to
make a step towards a safe and rational use injections policy.
Design: Descriptive cross sectional study.
Setting and Population: We used the WHO "Injection Practices: Rapid Assessment and Response Guide"
to collect information on injection practices, their determinants, and their consequences through
standardized interviews and observations of a small convenience sample of 21 prescribers, 28 injection
providers and 65 members of the population selected from twenty health care facilities in urban, semiurban, and rural areas in four districts and the capital city. Of the 65 persons from the population
interviewed, 21 (32%) were from urban areas, 19 (29%) from the semiurban areas and 25 (38%) from rural
areas.
Outcome Measures: Annual ratio of injections per capita; proportion of prescriptions that included at least
one injection; reported most common conditions for which injections were prescribed; proportion of
persons who preferred receiving an injection for the treatment of sickness with fever; proportion of
observed injections given safely.
Results: The 65 members of the population reported receiving an average of 13 injections per year.
Prescribers reported a total of 1,905 prescriptions per week on average; of these, 265 (14%) would include
at least one injection. Among the members of the population, 18 (28%) reported that they would prefer an
injection for the treatment of sickness with fever. Observed injection providers consistently used freshly
opened new disposable syringes and needles for all injections. However, there were breaks in infection
control practices while administering injections, eight of the 28 providers (28%) reporting occasional reuse
of disposable syringes with new needles for antibiotic administration to the same patient in hospital.
Injection providers reported 2.6 needle-stick injuries per year.
Conclusions: A multi-disciplinary initiative is necessary to achieve safe and rational use of injections in
Mongolia. To decrease injection overuse, approaches may include interactional group discussions between
patients and prescribers, revision of recommended treatment protocols, promotion of new standards of care
and promotion of oral drugs in the community. Following the survey, a communication campaign with
posters and radio spots was conducted to promote oral medicines and avoid unnecessary injections.
Rationale for an Assessment of
Injection Practices in Mongolia
• High prevalence of infection with HBV
and HCV
– 6.4% of children 0-15 years of age HBsAg
positive *
– 10.7% of children 0-15 years of age antiHCV positive *
• Anecdotal reports of poor injection
practices
– Injection overuse
– Unsafe practices
• Political will to engage in a safe and
appropriate use of injections policy
* 1998-1999 (Davaasuren at al.
National Medical University)
Study Aims
To make an initial step towards a safe
and appropriate use of injections
policy in Mongolia, the Ministry of
Health decided to conduct a rapid
assessment of injection practices.
Methods
Convenience Sample
• Selection of key national stakeholders
• Selection of 5 “Aimags” (district) to provide an overall
representation of the country
• Selection of 20 health-care facilities in the 5 “Aimags”
• Selection of one or more prescribers per facility (n= 21)
• Selection of one or more injection providers per facility (n=
28)
• Selection of 65 persons from the general population of all
ages and genders
Data collection
• National stakeholder interviews using open-ended
questionnaires
• Interview using a standardized questionnaire to:
– Injection prescribers
– Injection providers
– General population
• Standardized observation of injection practices
Injection Frequency, Mongolia, 2001
• 212 injections reported by 65 persons
in the last 3 months:
– 13 injections / person - year
– 8% of injections given for immunization
• Number of prescriptions including at
least an injection:
– Prescription review: 7% (n=420)
– Prescriber interview: 14% (265 reported
prescriptions out of 1905)
• Average number of injections per
prescription:
– Antibiotics: 20
– Vitamins: 10
Injection Use, Mongolia, 2001
• Top 3 diagnoses leading to the prescription of an
injection:
– Pneumonia, Genito-urinary infections, Cardio vascular
diseases and hypertension
• Top four injectable medications prescribed:
– Penicillin G, Vitamin B complex, Ampicillin, Dibazolum
Reported Determinants of Injection Overuse
• 86% (18/21) of prescribers do not perceive that
they over-prescribe injections
• Anecdotal reports from prescribers:
– Patients prefer injections, particularly elderly
– Pressure from patients causes overuse of injections
Awareness Regarding Pathogens Transmitted
through Unsafe Injections, Mongolia, 2001
HIV
HBV
Prescribers
Inj. Providers
Population
HCV
Jaundice
0%
20%
40%
60%
Proportion (%)
80%
100%
Reported Patients’ Preference for Injections,
Mongolia, 2001
80%
Proportion (%)
70%
60%
50%
40%
30%
20%
10%
0%
According to
prescribers (n=21)
According to the population,
in the case of fever (n=65)
Injection Safety (1):
Risk to the Patient, Mongolia, 2001
• Observation of 28 injection
providers
– No re-use of equipment in the
absence of sterilization
• 28% (8/28) injection
providers reported re-use of
syringes (with new needles)
on the same patient because
of shortages and overwork in
winter
• Unsafe handling of multidose vials
Injection Safety (2), Mongolia, 2001
Risk to the Injection Provider
• 68% (19/28) performed two-handed recapping
• 68% (19/28) reported needlestick injuries in the last
twelve months
– 2.6 needlesticks / injection provider-year
• No provider vaccinated against hepatitis B
• Hand sorting and counting of dirty sharps
Risk to the Community
• No dirty sharps observed around health-care facility
• 100% incineration with remarkable discipline (Open
sites, Drum incinerator, Stoves)
• Injection devices used at home by the population
discarded in the regular trash
Injection Practices in Mongolia,2001
Strengths
• Dramatic improvement of injection practices in Mongolia
over the last 10 years
– Large use of locally produced single use injection devices
– Good awareness of the risks associated with injections among
health-care workers
• Efficient health-care waste management despite a lack of
sophisticated waste treatment options
Weaknesses
• Ratio of injections per capita in Mongolia is the highest
ever reported
• Numerous breaks in infection control practices occur,
including possible re-use of single use injection devices in
the absence of sterilization
• Poor health care workers protection (high risk of needlestick
injuries)
Recommendations
The Ministry of Health is committed to
implement policy and plans to
institutionalize the safe and appropriate
use of injections
• To decrease injection overuse:
– interactional group discussions between patients and
prescribers
– Revision of treatment protocols and promotion of oral
medicines in the community.
• To improve injection safety:
– risk communication targeting patients and health care
workers
– provision of safety boxes in sufficient quantities and
repelling the requirement to count by hand used injection
devices
– procurement plan to increase access to waste treatment
options within a policy framework