Training must address common mistakes that providers make—for example, giving several clients injections with the same needle and syringe without sterilizing or disinfecting the equipment (see sidebar, Five Basic Steps of Infection Prevention: Do's and Don'ts). EPI has estimated the risk of infection if all providers reused each needle and syringe one time for immunizations without sterilizing or disinfecting them. (EPI recommends that infants and women of childbearing age each receive five immunizations.) In areas such as sub-Saharan Africa, where the prevalence of hepatitis B is about 10%, 260 per 100,000 fully immunized infants would be infected with hepatitis B. In areas with an intermediate prevalence of HIV infection of 1% among pregnant women, three infants and 12 women per 100,000 would be infected with HIV (16).

Both donors and family planning clients prefer disposable needles and syringes to reusable equipment. Clients may be reassured when providers use a new needle and syringe for an injection. In Kenya, for example, family planning clients feared that some providers were reusing needles and syringes without sterilizing them. In response, the Family Planning Association of Kenya (FPAK) sells disposable needles and syringes to clients, who then hand them to the FPAK provider giving the injection (144).

The choice of reusable or disposable equipment may depend on cost. EPI estimates that at low volume—five injections per day, for example—costs are about equal. As volume increases, reusable equipment becomes cheaper. In clinics giving 50 injections per day, for example, disposable equipment costs $0.05 per injection and reusable equipment, $0.01 per injection. In addition to the workload, costs depend on procurement costs, the cost of fuel for sterilization and disposal, and the lifespan of the equipment (344). USAID and UNFPA, which provide supplies free of charge, ship injectables with disposable equipment (55, 118).

Infections may be transmitted through improper storage of vials containing several doses of injectable. For example, clinics operating once a week may store partially used vials for one or two weeks. To avoid this problem, use of one-dose vials is recommended.

Both motivation and supervision are essential to infection prevention. Understanding their own risk of infection and the risk to clients can motivate providers to follow safe procedures. In one study of immunizations, for example, providers suffered one needlestick for every 500 injections (294). If stuck with a needle used on a client infected with hepatitis B, 5% to 27% of providers become infected (96). Also, supervisors need to ensure a steady supply of equipment, enforce procedures for infection prevention, and account for disposable equipment after its use (305).