Unsafe injections in the developing world and transmission of bloodborne pathogens: a review

Unsafe injections are suspected to occur routinely in developing countries. We carried out a literature review to quantify the prevalence of unsafe in jections and to assess the disease burden of bloodborne infections attribut able to this practice. Quantitative information on injection use and unsafe injections (defined as the reuse of syringe or needle between patients wit hout sterilization) was obtained by reviewing the published literature and unpublished WHO reports. The transmissibility of hepatitis B and C viruses and human immunodeficiency virus (HIV) was estimated using data from studie s of needle-stick injuries. Finally, all epidemiological studies that linke d unsafe injections and bloodborne infections were evaluated to assess the attributable burden of bloodborne infections. It was estimated that each pe rson in the developing world receives 1.5 injections per year on average. H owever, institutionalized children, and children and adults who are ill or hospitalized, including those infected with HIV, are often exposed to 10-10 0 times as many injections. An average of 95% of all injections are therape utic, the majority of which were judged to be unnecessary. At least 50% of injections were unsafe in 14 of 19 countries (representing five developing world regions) for which data were available. Eighteen studies reported a c onvincing link between unsafe injections and the transmission of hepatitis B and C, HIV, Ebola and Lassa virus infections and malaria. Five studies at tributed 20-80% of all new hepatitis B infections to unsafe injections, whi le three implicated unsafe injections as a major mode of transmission of he patitis C. In conclusion, unsafe injections occur routinely in most developing world r egions, implying a significant potential for the transmission of any bloodb orne pathogen. Unsafe injections currently account for a significant propor tion of all new hepatitis B and C infections. This situation needs to be ad dressed immediately, as a political and policy issue, with responsibilities clearly defined at the global, country and community levels.