Give Injections and Dispose of Waste Safely
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Immediately after giving the injection and without recapping the needle, a provider deposits the used syringe and needle in a conveniently located sharps disposal container. Safely disposing of used injection equipment prevents accidental needlesticks, which can lead to infection. Illustration: Rafael Avila/CCP
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As more providers give injectable contraceptives to more clients, injection safety remains crucial (208). The spread of infection from clients to other clients, health care providers, and the community can be avoided by:
- Ensuring an adequate continual supply of disposable injection equipment and sharps containers for safe disposal of needles and syringes,
- Following safe injection practices and universal precautions for infection prevention, and
- Establishing a safe waste management procedure.
Safety guidelines for contraceptive injections are the same guidelines that apply to all medical injections.
WHO defines a safe injection as one that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in waste that is dangerous to people (209). Of the 16 billion injections given for all purposes in developing countries each year, nearly two in every five are thought to be unsafe (81). WHO estimates that each year unsafe medical injections cause an estimated 21 million hepatitis B infections, 2 million hepatitis C infections, and 260,000 HIV infections (71). Every year these infections result in an estimated 1.3 million early deaths, 20 years of life lost per person, and US$535 million in medical costs (115). Injections remain an important delivery method for curative and preventive purposes, so improving injection safety is necessary.
In 2005 contraceptive injections accounted for an estimated 1% of all injections. No statistics are available on the percentage of contraceptive injections that are thought to be unsafe.
Auto-Disable Syringes Now Preferred
In the past it was common practice to use, sterilize, and reuse sterilizable injection equipment. More recently, single-use syringes, if disposed of as intended, have eliminated risk of client-to-client transmission of infection. The latest development is disposable auto-disable (AD) syringes. Unlike conventional disposable syringes, the AD syringe cannot be reused because it inactivates after a single use. Depending on the design, either the needle retracts or the plunger breaks or locks (149). WHO recommends AD syringes for all immunizations and recommends disposable syringes—ideally AD syringes—for all other medical injections, including contraceptive injections (210, 223). Purchased in bulk, AD syringes cost approximately US$0.06 each, about $0.02 apiece more than conventional disposable syringes (150, 195). USAID began including the AD syringes with all shipments of DMPA in 2002 (95, 128).
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A safe injection is one that does not harm the recipient, does not expose the provider to any unavoidable risk, and does not result in waste that is dangerous to people.
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Sterilizable needles and syringes should be considered only when disposable injection equipment is not available and if programs can ensure that sterilization conforms to WHO guidelines. Sterilization of reusable syringes and needles requires heating to 121°C (250°F) in high-pressure steam for at least 20 minutes (14, 206).
Universal Precautions Prevent Infection Transmission
Safe injections require not only the proper equipment but also that providers understand and follow the universal precautions for infection control and best practices for injections (160). Developed in 1987 by the U.S. Centers for Disease Control and Prevention, universal precautions are a simple set of practices designed to protect health care workers and their clients from infection in health care settings. Under the universal precautions principle, health care workers assume that all blood and body fluids are infectious, regardless of actual infectiousness (192, 218).
Rules for injections include:
- Prepare each injection in a clean designated area where contamination from blood or body fluid is unlikely.
- Wash hands with soap and water before and after giving an injection, if possible. Gloves are not needed unless there is a chance of direct contact with blood and other body fluids.
- Use a sterile syringe and needle for each injection. Use an AD syringe, if possible. If only sterilizable equipment is available, sterilize according to WHO guidelines.
- Discard used disposable needles and syringes in sharps containers immediately after use. Do not recap used needles.
- Safely dispose of sharps waste according to local or regional environmental regulations (80, 211, 218).
Proper Waste Disposal Keeps Clients, Staff, and Communities Safe
Disposable injectable equipment can generate a large amount of waste. Programs offering injectable contraceptives must have a procedure in place for collecting, storing, transporting, and disposing of sharps waste (207).
Used disposable needles and syringes should be placed in a sharps container immediately after use to prevent needlestick injuries and access to used needles. When a sharps container is three-fourths full, it should be destroyed. Overfilling the container can lead to needlestick injuries. WHO-approved sharps containers distributed by USAID are designed to hold 100 syringes (45). Donors promote injection safety by "bundling"—that is, shipping matching quantities of sharps containers with vials of contraceptive injectables and AD syringes.
Methods for destroying sharps containers and their contents include burial, burning, and incineration (burning at high temperature) (128). Unfortunately, there are no easy nonpolluting methods for destroying used injection equipment. Programs should choose the method that is most appropriate for their local conditions, taking into account cost, safety risks, and local and national environmental regulations (207, 213, 217).
Burying sharps waste in a protected pit at least two meters deep is a simple and inexpensive method of disposal. Some programs build special pits for sharps waste near the clinic. Pits must be fenced to prevent community members and scavengers from entering. Encapsulation—sealing sharps containers with concrete or other substances before burial—can ensure that buried waste is not unearthed.
Incineration, at temperatures above 800°C (1472°F), minimizes the volume of waste and reduces the pollutants produced. It requires special equipment and fuel, such as propane or natural gas. Programs with on-site incinerators should position incinerators in a convenient outdoor location, away from crops and homes, and far enough away so that smoke does not blow into the facility. Where an incinerator is not available on site, some programs transport waste to a central health facility or use incinerators at other facilities, such as cement factories (151).
Burning sharps waste in a metal container or a protected hearth at low temperatures is a commonly used option. Fuel such as kerosene is added to the container, and the waste is burned until the fire goes out. After burning, the ash and noncombustible material are buried in a protected pit at least one meter deep. This method is relatively inexpensive and can reduce the weight and volume of waste (151). Burning should be done only when no other options are available since it produces harmful substances. Some countries have banned this method of waste disposal.
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