A Systematic Review of the Literature on the Unsafe Injection Practices in the Health-Care Settings and the Associated Blood-Borne Disease Trend: Experiences from Selected South Asian Countries

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       
REVIEW ARTICLE
A Systematic Review of the Literature on the
Unsafe Injection Practices in the Health-Care
Settings and the Associated Blood-Borne Disease
Trend: Experiences from Selected South Asian
Countries
Wahida Kazi1,2, Shafi Bhuiyan3,4
1Toronto Public Health, ON, Canada, 2School of Public Health and Health Systems, University of Waterloo,
Waterloo, ON, Canada, 3Ryerson University, Toronto, ON, Canada, 4Dalla Lana School of Public Health,Clinical
Public Health, Social and Behavioural Health Sciences Division, University of Toronto, ON, Canada
ABSTRACT
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
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

© 2018 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.

      
         


INTRODUCTION
       
      
        

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       

       
        

        




        
     

UNSAFE INJECTION PRACTICE IS
A SIGNIFICANT PUBLIC HEALTH
ISSUE IN DEVELOPING COUNTRIES
 
            
      
      
      
       
        
         
     
     


    
      
         
      
  

     
       




      
       
      
       
        


      
      
      
          


       
      

      


CHALLENGES IN IMPLEMENTING
THE SAFE INJECTION PRACTICES
IN THE LOW RESOURCE
COUNTRIES



    

      





       
       
      
        
    

BIOHAZARDOUS WASTE DISPOSAL
IN SOUTH ASIAN COUNTRIES
      
      
       

       
          
       

       
       
      
        
       
       
   


         
       

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       


A SYSTEMATIC REVIEW OF THE
UNSAFE INJECTION PRACTICES IN
THE HEALTH-CARE SETTINGS
Literature search
        
       
   
       
    
        
      
      

      
       
      


     
        
      


         
  


   

        
           
         
    
       
          
 
     
         


Study objectives
         

        
        
        
         
        
        

METHODS
       

       

        
  
       

       
      
        



    

        
       
      
        

         


 

Inclusion criteria

  


        
      
      
        
 



Exclusion criteria
     
         
       
        
     
        
      


Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
      

RESULTS
Descriptive analysis of findings from the
systematic review
     
        
   

Pakistan
       

       


        
        
         
        
  
       
     
  
     
         
       
         

       
       
      
      

   
        
  
         
        
       


      
      
            
        



           
          


      
       
         



       
        
  

         
     
  
 


India
        
    
         
          
          
        
     

        
     

         
    

      
        
        

        

     
         



       
       
     


          
          
       



Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Bangladesh
        
        
      


         
     
       
        

        
        


        

    





        
     
      

  n

       


n
nn

      
       
     
         
    
        
 
        
         
       

         



Nepal
         
  
        

       
       
 

       

     

       


    

   
        


     
         




         


Sri Lanka
      
         
    
 
         
        
        
    
 
        
         

   
         
        
         
       

       
      


  



Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       


Meta-analysis [Tables 1-5 and Figures 1-10]
      
             
    


            

           







DISCUSSION
Health-care provider’s role


       
         
        
  


    
      
         
   

Shortage of resource
       

        
       


       


Inadequate training for the frontline healthcare
workers
       
       
          

        


       
      
         

Low-risk perception
        
         



        
       
       

         
      

          


    

Inadequate research

        




       
       

        
          
        

        
        

       


          
        
       

LESSONS LEARNED

      

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Table 1: The NSIs among the HCWs and the associated BBDs such as hepatitis B, hepatitis C, and HIV
Author and Year Study
design
Geography/
countries
Number of
participants
Event or NSI Outcome or
seroconversion with the
hepatitis B, C, or HIV
Cardo, 1997[28] CCS French, Italy, UK,
USA
HCWs
n=27 (case)
n=488 (control)
Large–gauge (<18)
hollow‑bore NSIs. NSIs
among cases=4 (15%)
and NSIs among
controls=6 (1.2%)
The seroconversion with
the BBDs (HIV) after the
needle‑related injuries
among the HCWs
Cardo, 1997[28] CCS French, Italy, UK,
USA
HCWs
n=33 (case)
n=675 (control)
NSIs from the procedure
involving needle in an
artery or a vein. NSIs
among cases=24 (73%)
and NSIs among
controls=7 (31%)
The seroconversion with
the BBDs (HIV) after the
needle‑related injuries
among the HCWs
Yazdanpanah, 2005[29] CCS 5 European
countries (France,
Italy, Spain,
Switzerland, and
UK)
HCWs
n=60 (case)
n=204 (control)
Percutaneous exposure
involving different kinds
of needles. NSIs among
cases=60 (100%)
and NSIs among
controls=171 (83.8%)
The seroconversion with
the BBDs (hepatitis C)
after the needle‑related
injuries among the HCWs
Yazdanpanah, 2005[29] CCS 5 European
countries (France,
Italy, Spain,
Switzerland, and
UK)
HCWs
n=60 (case)
n=204 (control)
Percutaneous exposure
involving Hollow bore
needle in a vein or an
artery. NSIs among
cases=48 (80%)
and NSIs among
controls=78 (38.2%)
The seroconversion with
the BBDs (hepatitis C)
after the needle‑related
injuries among the HCWs
Alemayehu, 2016[30] CCS Ethiopia HCWs
n=391 (case)
n=429 (control)
Percutaneous exposure
or sharp injury (include
needle stick, lancet, and
glass related). # of event
among cases=217 (26.5%)
and # of event among
controls=0% or 0
The seroconversion with
the BBDs (hepatitis C)
after the needle‑related
injuries among the HCWs
Canini, 2008[31] CCS Brazil HCWs
n=200 (case)
n=200 (control)
Percutaneous injury
associated risk factor
like recapping of used
needles (event). # of event
among cases=132 (66%)
and # of event among
control=29 (14.5%)
Case=HCWs who
reported the percutaneous
injury. Control=HCWs
who did not report any
percutaneous injury
Sohn, 2015[32] CCS Republic of
Korea (Busan,
Gyeongnam,
Jeonnam
Provinces in
Korea)
Patient
n=234 (case)
n=234 (patient
control)
Needlestick Injury is a risk
factor among the cases
and the controls. NSIs
among cases=18 (7.7%)
and NSIs among
controls=2 or 0.9%
Case=HCV positive
patient. Control=Hepatitis
C virus negative patient
Risk factors (e.g., NSIs)
Gorar, 2014[13] CCS Pakistan (Sindh
province and
Jamshoro District)
HCWs
n=81 (case)
n=83 (patient
control)
NSI is a risk factor among
case and control. NSIs
among cases=47 (58%)
and NSIs among
controls=24 (28.9%)
Case: HCWs with positive
hepatitis C antibody and
HBsAg. Control: Patient
who do not have hepatitis
C antibody or presence of
HBsAg
CCS: Case–control study, NSIs: Needlestick injuries, HCWs: Healthcare workers, BBDs: Blood‑borne diseases, HIV: Human
immunodeficiency virus, HBsAG: HBV surface antigen, HCV: Hepatitis C virus

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
(Contd...)
Identifying
number
Author, year of
publication
Study
design
Country Sample size=nNeedle recapping data Results of statistical analysis P value
1 Gyawali, 2015[3] CSS Nepal, Kaski
district
Sample # n=96 One handed recapping=21 (21.9%) Chi‑square=19.AQ59 P value <0.001
1 Gyawali, 2015[3] CSS Nepal, Kaski
district
Sample# n=96 Two‑handed recapping=26 (27.1)
2 Gorar, 2014[13] CCS Pakistan, Sindh
province
Sample # n=164 Not provided Unadjusted OR 1.2 95%
CI (0.36–4.4) for hepatitis B
positive HCWs
P=0.7
2 Gorar, 2014[13] CCS Pakistan, Sindh
province
Sample # n=164 Not provided Unadjusted OR=3. 95%
CI (0.92–9.9) for hepatitis C
positive HCWs
P=0.06
3 Zafar, 2009[17] CSS Pakistan, Sindh
province
Sample # n=1382
NSI
Mean of the NSIs due to recapping
between the year of 2002 and
2007=12.25%
4 Canini, 2008[31] CCS Brazil Case (HCWs
with PCIs) =200,
Control (HCWs
without PCIs)=200
Recapping among cases:
Yes=132 (66%)
No=68 (34.0%)
Recapping among controls:
Yes=29 (14.5%)
No=171 (85.5%)
Unadjusted OR for
recapping=11.44 95%
CI=(7.00–18.69)% and
unadjusted odd ratio for no
recapping=1
Not provided
5 Yao, 2012[33] CSS China Study
participant (nursing
student) n=246
Recapping associated NSIs
among nursing students: Before
intervention=230 (20.11%)
After intervention=4 (1.62%)
Chi‑square=3.9
6 Rais and Jamil,
2013[34]
CSS Pakistan, Sindh
province
HCWs n=100 Recapping of needle by HCWs;
Yes=88 (88%); No=12 (12.0%); Total
number of NSIs=76.92 (100%). # of
NSIs due to recapping=15 (19.5%)
7 Yoshikawa,
2013[35]
CSS Japan, 67 HIV
referral hospitals
Total NSIs n=5,463 Recapping as a cause of
NSI=476 (8.7%)
Mean=0.6. 95% CI=(0.5–0.7) P value=0.76
8 Vong, 2002[36] CSS Cambodia (Takeo
province and
Phnom province)
Participants=60 (30
prescribers and 30
injection providers)
Two‑handed recapping of used
needles=58%
Not provided Not provided
Table 2: The unsafe injection practices (the NSIs result from the recapping of the used needles by the HCWs)

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
      

    
       


         


           
    
       

       

    
        

      
   


         
   
      
        
      
         


   

        

CONCLUSION


        


          


   
       
        
     
  
         


Identifying
number
Author, year of
publication
Study
design
Country Sample size=nNeedle recapping data Results of statistical analysis P value
9 Alemayehu,
2016[30]
CCS Eastern Ethiopia Case=HCWs with a
history of NSI=391
and Control=HCWs
with no history of
NSIs=429
# of NSIs among cases=108 (27.62%)
and # of NSIs among control=0 (0%)
Total # of NSIs due to
recapping=18 (9.8%)
Not provided Not provided
10 Guo, 1999[37] CSS Taiwan 16
hospital
HCWs
n=8645 (82.4%)
# of NSIs due to
recapping=1809 (24.0%)
Not provided Not provided
CCS: Case–control study, NSIs: Needlestick injuries, HCWs: Healthcare workers, BBDs: Blood‑borne diseases, HIV: Human immunodeficiency virus, CI: Confidence interval, OR: Odds
ratio
Table 2: (Continued)

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Table 3: The reuse of needles and syringes in the South Asian countries
Study # Author’s name and
year of publication
Study design Geography Study sample
size=n
Reuse of needle and
syringes/unsterile
syringes
1 Chowdhury, 2011[10] CSS Bangladesh (6
divisions)
n=4230 The total # injection
administration events
were observed=480
# of the reuse of
the same syringe
or needle by
HCWs=74.4 (15.5%)
2 Janjua, 2016[38] Systematic
review
India Percentage
available
62.9% injections were
considered unsafe
3 Janjua, 2016[38] Systematic
review
Pakistan (Sindh
province survey)
49% of injections were
provided with reused
syringes (as per the
national HBV and HCV
survey)
4 Janjua, 2016[38] Systematic
review
Western Nepal n=2470 95% of injections were
provided with a new
single‑use syringe
5% of injections were
not provided with a
new syringe
5 Shill, 2011[39] CSS Bangladesh (at
6 upazilla Health
complex‑ Dhamrai,
Dohaar, Keranigonj,
Savar, Shaturia,
Singair)
n=1048 Reuse of syringe or
needle=0%
New syringe
used=100%
Unsafe injection
practices (such as
lack of hand washing
by staff or lack of
disinfection of the
injection field or
area)=50%
6 Khan, 2000[20] CSS Pakistan,
DarsanoChanno
n=203 17% of the participants
reported the reuse of
syringes
10% observed new
syringe being drawn
from the packet and
73% patient does not
know if the sterile
syringes were used
7 Janjua, 2005[14] CSS Pakistan, Lyari (an
urban town in
Karachi) and Digri (a
rural sub‑district in
Mirpur Khas district)
n=575 from an
urban and 575
from a rural
setting. total=1150
# of total injection
provided=848
450 (53%) of
injection were used
a freshly open
syringe. 398.56 (47%)
injections were not
open from the new
packages in front
of patients or at the
injection sites
(Contd...)

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Study # Author’s name and
year of publication
Study design Geography Study sample
size=n
Reuse of needle and
syringes/unsterile
syringes
8 Singh, 1998[23] CSS (hepatitis
B outbreak
investigation)
India, 3 affected
villages (Khata‑Amba,
Parsa, and Charadu)
# of cases=15
and # of healthy
person=31 Sample
size
n=46
89.13% of study
participants received
unsafe (reuse of
needle and syringes)
injection by informal
injection providers
9 Altaf, 2013[40] CSS Pakistan (Tando
Allahyar, Sindh)
n=300 (participant) 45 or 15% of
participants were
aware that the syringe
was new. 75% (n=219)
did not know if the
syringe was new or not
10 Gupta, 2013[22] CSS India, Sabarkantha
district, Modasa
Town, Gujarat
n=25 (100%)
of the admitted
patient
25 (100%) of study
participants reported
having an unsafe
injection
CCS: Case–control study, HCWs: Healthcare workers, HCV: Hepatitis C virus, HBV: Hepatitis B virus
Table 3: (Continued)
Table 4: The improper disposal of needle and syringes by the HCWs at the health‑care settings in the
developed and the developing countries
# Author and Year Study design Geography/
country
Subpopulation Sample
size
Number of Improper
needle disposal data
1 Gyawali et al.,
2015[3]
CSS Nepal, Kaski
district
HCWs n=53 Safety box was available
near to injection
site=41 (77.4%)
Safety box or needle/
sharp disposal box was
not available near to
injection site=12 (22.64%)
2Vong et al., 2002[36] CSS Cambodia,
Takeo
province,
and Phnom
Penh city
HCWs Injection
provider
n=60
Improper disposal of
needles and syringes by
13% of injection provider
3Wu et al., 2014[41] CSS China HCWs n=1783 Proper disposed of
sharps immediately after
injection=1435 (80.5%)
Improper disposed of
sharps=348 (19.51%)
4Yao et al., 2009[42] CSS China HCWs n=248 (#of
participants)
Used needles or sharp
instruments were not
timely places in a specific
container = 273 (23.91%)
Sharp containers
were properly
used = 845 (76.09%)
times
(Contd...)

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
# Author and Year Study design Geography/
country
Subpopulation Sample
size
Number of Improper
needle disposal data
5 Mohammadi et al.,
2011[43]
CSS Central Iran,
Qazvin
HCWs n=138 Correct approach
to discard
needles=49 (35.5%)
Incorrect approach
to discard
needle=89 (64.49%)
6 Wood et al.,
2001[44]
Prospective
Cohort study
Vancouver,
Canada
IDUs n=776 Number of safe needle
disposal=354 (45.6%)
Number
of unsafe needles
disposal=422 (54.38%)
7Yao et al., 2013[33] Intervention
Study (CSS)
China Nursing
students
n=246 Before providing
education to nursing
students: Appropriate use
of sharps containers=187
or 76.09% and no use
of sharps container
immediately after working
with needles=56.58 or
23.91%
Improper disposal rate
was reduced to 0% after
receiving the education
8Ersin et al., 2016[45] Semi‑experimental
study
Turkey HCWs n=144 38 (26.4%) HCWs
answered wrong
before training (e.g.,
change sharp box when
completely full) and
4 (2.8%) answered wrong
after receiving training
9 Sangeetha et al.,
2015[46]
Intervention
study (CSS)
India,
Bangalore
HCWs n=17 Inappropriate use of
sharps container is 38 or
24.21%
10 Chowdhury et al.,
2011[10]
CSS Dhaka,
Bangladesh
HCWs n=120
n=480
injection
provided by
120 HCWs
Used syringes and needle
disposed of Immediately
after injection into sharp
container=88.8 or 18.5%
Used needle and syringe
were not immediately
disposed of after
injection=391.2 or 81.5%
IDU: Intravenous drug users, CCS: Case–control study, HCWs: Healthcare workers
Table 4: (Continued)
       
  
       
      

      
 
     

    
Figure 1: The calculated effect size and 95% confidence interval,
p‑value, measures of (within and between) study variances of
selected studies (Table 1) both by random and fixed model
        


Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Table 5: The improper disposal of needles and syringes and the associated NSIs among the HCWs
Identifying # Author and
year of
publication
Study
design
Geography/
country
Study
population
Sample size (n) NSI related to
improper needle and
sharp disposal by
HCWs
Statistical
analysis results
1 Yoshikawa,
2013[35]
CSS Japan,
Kawasaki
HCWs n=5463 409 (7.5%) Mean=0.5 95%
confidence
interval is
0.4–0.5
2 Samargandy,
2016[52]
CSS Saudi
Arabia
HCWs n=302
percutaneous
exposure
49 (16.8%)
percutaneous
exposure due to
improper sharp
disposal
3 Alemayehu,
2016[30]
CCS Ethiopia HCWs n=820 HCWs n=217 sharp injury.
Average=19.53 or 9%.
Results from improper
disposal
4 Guo,
1999[37]
CSS Taiwan HCWs n=8645 A total number of
NSIs=5431
NSIs due to improper
sharp disposal=80.66
or 1.4%
5 Tomkins,
2010[47]
CCS Italy, Spain,
and Japan
HCWs n=626
Case=13
(seropositive
HCWS after NSIs)
and Control=503
(seronegative after
NSIs)
#of NSIs result during/
after needle/sharp
disposal among
cases=3 and # of NSIs
result during/after
needle/sharp disposal
among controls=121
Unadjusted
OR=1.1 (0.8–1.5)
6 Zafar,
2009 [17]
CSS Pakistan HCWs n=1382 (NSIs) 162 or 11.75% injuries
related to garbage
collection
7 Rais and
Jamil,
2013[34]
CSS Pakistan,
Karachi
HCWs n=77 (NSIs) 6 out of 77 total NSIs
are related to improper
needle and sharps
disposal
CCS: Case–control study, NSIs: Needlestick injuries, HCWs: Healthcare workers, OR: Odds ratio
Figure 2: This forest plot shows the crude odds ratio (OR)
for needlestick injuries and the associated risk of the blood‑
borne diseases in each study and the pooled crude OR of all
included studies (Table 1). P value is 0.000 which is <0.05.
Therefore, the finding is statistically significant


      
       
  
     
      
         
         
       


      

 
     



Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Figure 4: This forest plot shows the crude event rate for the
recapping of used needles by the healthcare workers in each
of the selected study and the pooled event rate of all included
studies (Table 2). By the fixed model, P value is 0.000 which
is <0.05 and therefore, the finding is statistically significant
Figure 3: The calculated effect size and 95% confidence interval.
P value, measures of (within and between) study variances of
selected studies (Table 2) both by random and fixed model
Figure 5: The calculated effect size and 95% confidence interval.
P value, measures of (within and between) study variances of
selected studies (Table 3) both by random and fixed model
Figure 6: This forest plot shows the crude event rate for the
reuse of needle and syringe in each the study and the pooled
event rate for the reuse of needles and syringes in all included
studies (Table 3). By the fixed model, P value is 0.000 which
is <0.05 and therefore, the finding is statistically significant
Figure 7: The calculated effect size and 95% confidence interval.
P value, measures of (within and between) study variances of
selected studies (Table 4) both by random and fixed model
Figure 8: This forest plot shows the crude event rate for the
improper disposal of needle and syringes by the healthcare
workers in the health‑care settings in each of the study and
the pooled event rate of all included studies (Table 4). By the
fixed model, P value is 0.000 which is <0.05, and the finding
is statistically significant.
Figure 9: 
P      

Figure 10: This forest plot shows the crude event rate for
the needlestick injuries related to the improper disposal of
used needle and syringes by healthcare workers in each of
the study and the pooled event rate of all included studies
(Table 5). By the fixed model, P value is 0.000 which is <0.05,
and the finding is statistically significant

   
        

REFERENCES
       
  

       
 
 

 

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
Figure 11: This flow chart shows the inclusion and exclusion process of potentially eligible articles
       


           
      

          

 


         
       
       

Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
        

 
   

         

        
   et al 
       

     

 
     
   

 


 


    
  

 
 


 
et al


       
    



       
       
       

   
et al.
         

      
  et al.       
   

           
       
        

 
et al.          
       

       
    


          
  et al.      
     

         
et al.
        

          
  et al.    


 
et al.  



   
et al.


   

         

 
        

 
          


 et al.
      
      

        
        

          
  


          et al.
       

         
       

          
       
 

 et al.
 
   


Kazi and Bhuiyan: A systematic literature review on the unsafe injection practices in the south asian countries and the blood-
borne disease trend
       
         
       

            
     
        
       

             et al
     

     
      

          



 


        


       

      

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
       
      

         
       

 
      
         


 
       

        
      

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        
        
       
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