safe injection practices IAP

Guide Book on
Safe Injection Practices
Developed in Technical Collaboration with
Becton Dickinson, India
Indian Academy of Pediatrics

Editorial Board :
Advisors:
Editors: Dr. A Parthasarathy, Dr. T.U. Sukumaran, Dr. S.S. Kamath, Dr. Anil Mishra
First Edition: September, 2004
Second Edition: December 2006
Third (Current) Edition : May 2012
Publication:
The Indian Academy of Pediatrics
Kailas Darshan, Kennedy Bridge (Nana Chowk)
Mumbai 400007 (India)
Phone (022) 23887906, 23887922, 23889565
Fax: (022) 23851713
Email: iapcoff@bom5.vsnl.net.in
Website: www.iapindia.org
Society Regn.No.BOM 127/1963 GBBSD
Public Trust Regn.No. F-1166 (BOM)
Technical Collaboration and Educational Grant Support: Becton Dickinson, India
National Convenor’s Address:
Dr. S. Sachidananda Kamath, National Convenor
IAP National Task Force on Safe Injection Practices
Welcare Hospital, Vyttila, Cochin 682 019
Ph : 0484-2307897
Email : sskamath@vsnl.net
Published by:
IAP National Publication House, Gwalior, MP
Designed and Printed by:
PrintekWays:
149, DSIDC Complex, Okhla Industrial Area, Phase-I, New Delhi -110020
Dr. Rohit Agrawal, Dr. C.P. Bansal, Dr. Sailesh Gupta, Dr. Pravin J. Mehta
IAP Guide Book on Safe Injection Practices

IAP GUIDE BOOK ON
SAFE INJECTION PRACTICES
Advisors:
Dr. Rohit Agrawal
Dr. C.P. Bansal
Dr. Sailesh Gupta
Dr. Pravin J. Mehta
Editors:
Dr. A Parthasarathy
Dr. T.U. Sukumaran
Dr. S.S. Kamath
Dr. Anil Mishra
Editorial Board
Technical Collaboration and Educational Grant Support
From Becton Dickinson, India
Published by:
IAP Publication House,Gwalior,MP,
India

Dr. ROHIT AGRAWAL
MD, DCH
President IAP-2012
Consultant Pediatrician
Chandrajyoti Children's Hospital, Mumbai
Kohinoor Hospital, Mumbai
603/4 Vindyachalneelkanth Valley
th
7 Road,Rajawadi,Ghatkopar (East) Mumbai 400077
e-mail drrohitag@hotmail.com,
Mobile 9821096353
Dr. T.U. SUKUMARAN
President IAP-2011
Professor of Pediatrics
PIMS, Thiruvalla, Kerala
e-mail; rajakumaritus18252@gmail.com
Dr. C.P. BANSAL
MD, FIAP, PGDAP, FICMCH
Director, Shabd Pratap Hospital, Gwalior 474 012
President Elect- IAP-2013
e-mail; cpbansal@gmail.com
Dr. SAILESH GUPTA
MD, FIAP
Hon. Secretary General -2012
Ashna Children's Hospital, Uttara Apartments
Jan Kalyan Nagar, Malad West, Mumbai-400095
e-mail guptasailu@gmail.com
Mobile 9819042213
Dr. S.SACHIDANANDA KAMATH
MD,DCH, FIAP,DHHM,PGDAP
Convenor, National Task Force on
Safe Injection Practices,
Consultant Pediatrician, Welcare Hospital,
S A Road, Vyttila, Cochin - 682019
Dr. A. PARTHASARATHY
Distinguished Professor of Pediatrics,
The Tamil Nadu Dr. MGR University &
Retd. Professor of Pediatrics,
Madras Medical College &
Deputy Superintendent,
Institute of Child Health & Hospital for Children,
Chennai, TN.
Mobile 91 90422 60053,
email: apartha2020@gmail.com
Contributors' List
Dr. SHIVANANDA
Director
Professor and HOD Pediatrics
Indira Gandhi Institute of Child Health
South Hospital Complex, Bangalore - 560023
Mobile: 094484 66562
e-mail; sssiddhi@rediffmail.com
Dr. M.INDRA SHEKHAR RAO.
M.D.(Paed.)D.C.H.,NEO(USA)FIAP
Senior Pediatric Consultant,
Basant Sahney Children's Hospital, Secunderabad,
Former Medical Superintendent & HOD Pediatrics,
Institute of Child Health, Niloufer Hospital,
Hyderabad, A.P.
Residence:
"Indraprastha", 106, Abhinava Nagar,
Padmarao Nagar, Secunderabad, AP - 500 025.
e-mail; indramummulla@yahoo.co.in
Dr. RAJU C. SHAH
MD, D Ped, FIAP
Professor and HOD, Dept of Pediatrics,
GCS Medical college, Ahmedabad.
National President IAP (2005)
Chairman, Injection Safety Task Force, IAP(2004-7)
Ankur Institute of Child Health,
B/H Ciyu Gold Cinema, Ashram Road,
Ahmedabad 380009, Gujarat.
Phone: (079) 26583067.
e-mail; rajucshah@gmail.com
Dr. BALDEV S. PRAJAPATI
M.D.(PED.) GOLD MEDALIST
D. PED. FIAP, MNAMS, FICMCH.
Professor, GCS Medical College,
Hospital & Research Centre, AHMEDABAD.
EBM Central IAP (5 Terms)
Member& Trainer,
Safe Injection Practices(2005- 2007)
MEMBER, IAPCOI,2009-2011
Aakanksha Children Hospital,
Nava Vadaj Road, AHMEDABAD.
PHONES: (079) (H) 27559179, 27559667
(R) 27680256
(M) 09824039376
email: baldevprajapati55@gmail.com
IAP Guide Book on Safe Injection Practices i

Dr. ARUN SHAH
MD DCH FIAP FIAMS
Associate professor NMCH
Brahampura, Muzaffarpur, BIHAR
e-mail: drarunshah@hotmail.com
Dr. ALOK GUPTA MD
Pediatrician & Counselor
Jaipur, India.
+91 94140 62700
+91 94610 03070
e-mail; docalok@hotmail.com
Dr. M.A MATHEW
MD,DCH London FIAP
Professor Of Pediatrics
M.O.S.C Medical College
Kolenchery 682311
Kerala
State Coordinator for SAFE-I Program
office : 04843055262
Res:04846494556
Mobile:9447234554
e-mail; drmathew_11@yahoo.com
Dr. ANIL MISHRA
Regional Technical Advisor-Infection Control
BECTON DICKINSON, INDIA
Boomerang, A - Wing, Unit No- 310,
Third Floor, Chandivali Farm Road,
Chandivali, Near Powai,
Andheri - (E), MUMBAI - 400072
Telephone: 022- 32221318-19. 022- 28582430-32
Mobile: 09669696306
e-mail: anil_mishra@bd.com,
abbmishra@yahoo.com
DR. BHASKAR J SONOWAL
Technical Advisor- Infection Control and Patient
Safety
6th Floor, Signature Tower B, South City 1,
Gurgaon, Haryana 122001 India
tel: +91-124-3088333 cell: +91-9999501159
fax: +91-124-2383224/5/6
e-mail: bhaskar_sonowal@bd.com
Website: www.bd.com
Dr. OM PRAKASH KANSAL
Advisor-Injection Safety
tel: +91-124-3088333 cell: +919910555964
fax: +91-124-2383224/5/6
E-mail: op_kansal@bd.com
K. RAJESH NAIR
Senior ASM – Tender
South Regional Office - Kerala
e-mail: rajesh_nair@bd.com
Mobile:09745603110
Logistics
GANESH MEDHE
Boomerang,A-Wing,Unit No.310,
Chandivali Farm Road,Mumbai, India
Pin-400072
Tel- +91-22-33241600
e-mail: Ganesh_Medhe@bd.com
Mobile:08291135670
MANOJ CHAUBEY
Boomerang,A-Wing,
Unit No.310,Chandivali Farm Road,Mumbai, India
Pin-400072
Tel- +91-22-33241600
e-mail: manoj_chaubey@bd.com
Website: www.bd.com
ANU KHANNA
e-mail: Anu_Khanna@bd.com
IAP Guide Book on Safe Injection Practicesii

It is indeed a matter of pleasure and pride that IAP in partnership with BD India is making
sincere efforts to address the issue of unsafe injections in India, which remains an
important public health scourge, even in these times of technology advancements.
Out of the injections which are administered in day to day practice of medicine, a
significantly high percentage has been found to be unsafe. These unsafe injections will
continue to add to the disease burden and loss of life, if the problem is not addressed on
urgent basis. I am sure that our efforts will effectively address the issue of unsafe
injections, which is a major public health challenge.
This guidebook on injection safety will try to address the problem of unsafe injections by
serving as a treatise on injection safety. It has been ensured that the key issues which are
of relevance to different cadres of medical practitioners are addressed through this book
and the basic essential knowledge and skills do not become a hindrance in achieving
optimum standards of safety in its entirety. IAP and BD have planned state wise release
of this book and will work to address the state specific concerns of injection safety by
developing a contextual strategy in partnership with respective state governments.
I highly appreciate the efforts of all the experts from IAP and the technical team of BD
India, who have worked hard to ensure that the present edition of the guidebook
presents all facts and information which are of practical importance to a wide spectrum
of medical practitioners, undergraduates, post graduates and nursing cadre as well, in a
way that is simple and easy to understand.
Dr. Rohit Agrawal
National President-IAP, 2012
Foreword
IAP Guide Book on Safe Injection Practices iii

rd
I am immensely pleased to see that the revised and updated 3 edition of the guide book
on safe injection practices, which is a joint academic project of IAP and BD India is
available to all of us for use towards improving standards of injection safety. As you all
know, Safe Injection Practices has been a focus area of IAP and we continue to move
forward in this direction with valuable support from all of you.
Injection safety is of paramount importance in Indian context, if we wish to abide by the
ethical value of doing no harm to the patients. The concept of Safe Injection Practices in
India was conceived in 2004 during the Presidency of Dr. MKC Nair and has become an
important part of IAP's action plan. BD also works in different parts of the globe on
improving injection safety standards and has been partnering with IAP since the
inception of the project on Injection Safety. I am confident that this joint work of IAP and
BD will have the desired impact towards reducing unsafe injection practices in India.
This guide book will be helpful for the entire spectrum of healthcare staff, i.e. for
doctors, nurses, laboratory technicians, other categories of Health care workers and for
the registered medical practitioners. The structure, content and language have been
kept simplified so as to suit the needs of all categories of healthcare providers in various
settings. New chapters on 'Prevention of re-use of syringes 'and' Newer technologies in
injection delivery systems' in the present edition will be of immense practical utility to
the readers. Chapters on injection techniques, best practices, Healthcare worker safety,
Patient safety, waste disposal etc. have been extensively revised.
I sincerely thank Dr. SS Kamath for leading this initiative and to all the expert group
members from IAP and BD India who have contributed in developing this guide book. I
also thank BD India for providing the educational grant for this project.
Dr. T. U. Sukumaran
National President, 2011, IAP
Message
IAP Guide Book on Safe Injection Practicesiv

Dear IAP Colleague,
Injection Safety has been an area of high focus for the Indian Academy of Pediatrics. The
subject has been accorded priority in successive IAP Action plans, every year. Experts in
IAP have deliberated on ways to address the issue of unsafe injection practices in India.
One of the strategies in the multipronged approach is, to address the knowledge barrier
among the healthcare practitioners. As part of this strategy, IAP, in technical
collaboration with Becton Dickinson India has developed this guide book on Safe
Injection Practices. The objective while planning this book was to provide maximum
practical usefulness for healthcare professionals, therefore the structure of the contents
is simple and illustrative
We are confident that after the book is released and when trainings for the zonal level
and district level are rolled out, we will be able to impact the knowledge , skills and
practices of healthcare professional and the same would reflect through reduced
percentage of unsafe injections in India. It will help us abide by the ethical principle of
doing no harm to the patients.
We look forward to the stage when we will achieve the highest possible standards of
injection safety. I am confident that the joint efforts of IAP and BD will replace the unsafe
injections practices in India with safe and ethical practices.
Dr Sailesh Gupta,
Hon. Secretary General-2012
Message
IAP Guide Book on Safe Injection Practices v

Becton Dickinson Company (BD), in pursuance with its mission of Helping All People
Live Healthy Lives, besides producing high quality medical technology products, has
developed many initiatives across the globe to deliver direct benefits to the patients,
healthcare workers and to the people in general.
In India, BD's joint work with the Indian Academy of Pediatrics (IAP) to address the issue
of Injection safety is one of such initiatives. As a part of this strategy, IAP and BD jointly
worked to develop this training module on Injection safety as the first step.
Subsequently, this guidebook will be used as the basis of training of the healthcare
professional on Injection Safety.
A team of highly experienced experts from IAP and technical team members from BD
have carried out in-depth discussions to develop this guidebook which provides all
necessary information to the practitioners in a very simple but illustrative way.
I am confident that this joint effort of IAP and BD, India will work to effectively address
the problem of unsafe injections, a critical public health need in India.
Manoj Gopalakrishna,
Managing Director, BD India
Message
IAP Guide Book on Safe Injection Practicesvi

It is well known that prevention is always better than cure. Infections still form a major
part of under five mortality in a developing country like ours. Vaccines are the most cost
effective tools in the hands of pediatricians to prevent morbidity and mortality.
As more and more immunizations are being given, one has to bear in mind the rising
incidence of diseases transmitted by unsafe injection practices. On one hand we are
immunizing to prevent diseases and on the other hand if we do not follow the safe
injection practices we will also be instrumental in transmission of diseases. Hence it is
very important for all of us to be aware of what are safe injection practices and best
injection techniques so that we do not cause any harm while aiming to do good.
Injections are a must when we have to give injectable vaccines but are we justified in
giving so many injections in the curative section? We need to have rational prescription
habits and reduce the unnecessary injections. The lesser the injections we give, lesser
will be the risk of transmission due to unsafe practices.
One way of making the injections safer in the immunization sector is the use of AD
syringes as recommended by WHO. The Indian Academy of Pediatrics has always taken
the lead to come out with IAP recommendations in national issues related to child health
by conducting workshops which bring out a consensus document.
A workshop on safe injection practices was organized in New Delhi in June 2004 by Dr.
S.S. Kamath and Dr. Swati Bhave. There was representation of various stakeholders in
this meeting, including the Ministry of Health, UNICEF, WHO, IMA, TNAI etc. The
Secretary of Health and Family Welfare was kind enough to spend a lot of time to give
his comments during the two days. The recommendations brought out have been
published in the Indian Pediatrics, as well forwarded to all partners working in the field
of child health.
One of the recommendations of the workshop was that IAP should form a National Task
Force on Safe Injection Practices to propogate the message to the members and in the
community. In June 2004 Executive Board meeting, this task force was formed with Dr.
Raju C. Shah, the President Elect, as Chairperson, Dr. S.S. Kamath as the Convenor and
Dr. Swati Y. Bhave as Scientific Coordinator. It was decided to bring out the IAP Guide
Book on Safe Injection Practices and conduct workshops all over the country in the year
2005 with a set of slides and the Guide Book.This is a part of the Presidential Action Plan
of 2005.
Preface To The First Edition
IAP Guide Book on Safe Injection Practices vii

A master trainers' workshop was organized in March 2005 at Cochin.Here a peer
review was done of the scientific material and slides which were painstakingly prepared
by Dr. Swati Bhawe with a lot of technical inputs and help from Dr. Saurabh Sharma. We
are thankful to him and M/s Becton Dickinson India Pvt. Ltd. who have given an
educational grant for publication of the guide book and conduction of workshops.
All the members of the task force worked hard to give their inputs but special mention
must be made of Dr. Parthasarathy, Dr. Indra Shekhar Rao and Dr. Shivananda.
We thank Mr Narayanan of Pixel Studio, Cochin for designing and printing under able
guidance of Dr. S.S. Kamath.
We sincerely hope that this publication will be useful to all pediatricians who care for the
wellbeing of children.
Dr. S.S. Kamath
Dr. Swati Bhave
Dr. Raju C. Shah
IAP Guide Book on Safe Injection Practicesviii

This guide book on safe injection practices has been developed to strengthen the area
of injection safety in India, which remains a major public health concern and is
accountable for a significant share of deaths, morbidity and productivity losses. With
highly encouraging responses received about the usefulness of the earlier editions, form
practicing pediatricians and family physician from all over the country we decided to
extensively revise this book and make it of more practical utility for the practitioners. We
are immensely pleased to hand over this book to the medical and paramedical
community in India. We also urge all medical practitioners to accord highest priority to
safe injection practices.
This Guidebook is of significant value in helping all categories of Health Care Providers
to reduce the risk of spread of blood born infections which are transmitted through
unsafe injections including re-use of needles and syringes, needle stick injuries and
unsafe disposal of the used injection devices and sharps. The book has made sincere
efforts to address the issue of safety in its entirety, i.e. safety of patients, of healthcare
providers and of the community at large.
The content and structure of this Guide Book is so designed as to present the basic facts
related to injection safety in a manner which can be well understood by diverse target
groups like nurses, undergraduate medical students, interns, post-graduates, students
of laboratory technology, as well as practicing general physicians, specialists and super-
specialists, with equal degree of ease. This guide book will also serve as a ready reckoner
for all classes of professionals.
Special addition in this guidebook is the chapter on Re-use of syringes, which is posing a
major risk to the health of people in India. IAP and BD are jointly making efforts to
address this problem in India. We hope that orientation of health care providers
including Medical practitioners towards the need to put an effective check on the
problem of re-use and improving overall standards of injection safety will deliver lasting
benefits to the public health in India.
It is our fervent hope that this guide book will serve as an important aid to all cadres of
health workers in delivering safe injections.
Dr. A Parthasarathy
Dr. S.S. Kamath
Dr. Anil Mishra
Preface
IAP Guide Book on Safe Injection Practices ix

The current Guide Book on Injection Safety has been jointly developed by IAP and BD
India, with the objective of re-orienting the medical practitioners and other health care
providers towards this critical aspects of Injection Safety, which is an essential part of day
to day medical care. It has been observed that medics and paramedics, keeping their
focus on the expected outcome of medical care i.e. cure of the patient and his/her return
to normalcy, often overlook needed attention that is required to be paid to the minute
details of Injection safety, and this results in serious harm- either to the patient, or to the
care giver, and quite often to the community in general.
The Content and structure of this Guide Book has been so designed , as to be effective
for the larger community of medical practitioners, which includes specialists, general
practitioners, Registered Medical Practitioners (Including alternative streams of
medicine) , as well for the nursing , paramedical and laboratory staff who frequently
deliver injections either for diagnostic or for therapeutic purposes or for both. This
Guide Book will be of immense benefit to guide the graduating medical students and
nursing students also on issues related to Injection safety, and will help in creating a solid
understanding of the issue and also of the behavior and practices required to be
adopted for achieving highest levels of injection safety in medical practice, and thereby
abiding with the ethical principle of “ doing no harm to the patients”．
IAP and BD India , in order to maximize the utility of this Guide Book as an effective
training guide on Injection Safety, carried out multiple rounds of discussion on the
content and structure of the book. Current knowledge and key gaps amongst the
practitioners has been given due consideration in arriving at the final shape.
It is expected that this Guide Book will be the most comprehensive and informative
practical guide and will serve as 'Desk top reference' on matters of injection safety. The
book has given due emphasis on critical areas like, Healthcare worker safety from sharps
injury and other exposures, and patient safety from re-use of syringes and needles. It
also deals with the safety of the community at large, which faces disastrous effects of
improper disposal of bio-medical waste- specifically sharps and used syringes, which are
picked up for resale. As stated above, in order to have an understanding of the
prevailing knowledge, attitude and practices (KAP) of a small sample of injection
providers/medical practitioners on injection safety, a quick assessment was carried out.
It was later decided that for ensuring completeness of the information which is being
provided on injection safety in this Guide Book, each and every area needs mention,
Target Audience,
Expected Impact and Methodology
IAP Guide Book on Safe Injection Practicesx

IAP Guide Book on Safe Injection Practices xi
irrespective of the understanding of medical practitioners around that particular area.
This will also make the guidebook suitable for the practitioners who were not a part of
the sampling universe, and thus would make it replicable in true sense.
In the current scenario in medical practice and day to day medical care, re-use of syringes
and needles is a major threat for the patients in reference to spread of blood born
pathogens like HCV, HBV and HIV. The same risk is faced by the healthcare workers
through Needle Stick Injuries which they sustain in the process of providing care to the
patients, and consider it an unavoidable part of their profession. Expert members from
IAP and BD strongly felt that these two topics need special emphasis in the book, as they
contribute towards spread of blood born pathogens, the investigations and
management of which impose a financial burden on the health system, as well as these
infections contribute towards productivity losses which again have a financial bearing.
As mentioned above, IAP and BD constituted a Technical Expert group, comprising of
the members who have worked on specific aspects of the Injection safety, and have
taken help of their deep insight into the matter, for developing the structure and
content of this guide book. The Individual chapters have also been drafted by the
members of this expert team , which were subsequently reviewed by a smaller team of
experts.
The Technical Expert Group comprised of following experts from IAP and technical team
members from BD India:
1. Dr. Rohit Agrawal
2. Dr. T.U. Sukumaran
3． Dr. A. Parthasarathy
4. Dr. Sailesh Gupta
5． Dr. S.S. Kamath
6． Dr. Raju C Shah
7. Dr. C.P. Bansal
8. Dr. Arun Shah
9． Dr. Shivananda
10. Dr. Baldev S Prajapati
11. Dr. M Indra Shekhar Rao

IAP Guide Book on Safe Injection Practicesxii
12. Dr. Alok Gupta
13. Dr. M.A. Mathew
14． Dr. Anil Mishra ( BD India)
15. Dr. Bhaskar J. Sonowal ( BD India)
16. Dr. Om Prakash Kansal (BD India)
The Group of Experts got fully apprised to the recent advances and updates on given
topics and sub-topics, to ensure that updates on these areas are available for the
readers. However, the readers are recommended to continue updating their knowledge
on given topics and sub-topics as this is a dynamic field and the advances in technology
which can reinforce safety are necessary to be thoroughly understood.
Dr. A. Parthasarathy
Dr. S.S. Kamath
Dr. Anil Mishra

IAP Guide Book on Safe Injection Practices xiii
Table of Contents
Chapter - 1.1 Achieving Comprehensive Safety through a Safe Injection Environment 1-5
Chapter - 1.2 Importance of Injections and Injection Safety; Creating The Safe Environment 6-11
Chapter - 1.3 Rational Use of Injections 12-16
Chapter - 2 Best Practices to Ensure Injection Safety 17-25
Chapter - 3.1 Methods of Injection Delivery 26-35
Chapter - 3.2 Phlebotomy 36-47
Chapter - 3.3 IV Cannulation : A Process Oriented Approach 48-65
Chapter - 4.1 Injection Safety- Slicing The Problem of Reuse of Syringes 66-71
Chapter - 4.2 Healthcare Workers Safety 72-88
Chapter - 4.3 Injection Waste Disposal 89-97
Chapter - 5 Newer Technologies available in India to ensure Injection Safety 98-117
Chapter - 6 Surveillance mechanisms to understand Injection Safety 118-122
Chapter - 7 IAP Recommendations on Injection Safety 123-128
Evolution of Syringes-a pictorial journey 131
Resources and Links on Injection Safety 132
Points for Surveillance on Safe Injection Practices 133
IAP Plan of Action on Safe Injection Practices 134
Annexure - I WHO Fact Sheet on Injection Safety 129-130
Annexure - II
Annexure - III
Annexure - IV
Annexure - V
Chapter Page No.Title

Injection is one of the most common healthcare interventions globally. WHO estimates
that at least 16 billion (1600 crores) injections are delivered annually throughout
developing and transitional countries. It is also reported that 90-95% of all injections are
in the curative sector for routine care, not for immunization. The INCLEN (International
Clinical Epidemiology Network) report of Assessment of Injection Practices in India,
2004 found that approximately 6 billion injections are given in this country every year;
however it has also been reported by industries that only 3 billion syringes are actually
manufactured. This clearly spells out the huge magnitude of reuse of syringes in India.
This definitely needs to be addressed urgently to avoid incidents such as those of
Modasa (Gujarat) and Fatehabad (Haryana) where hundreds of people lost their lives
due to improper reuse of syringes. Reuse of syringes can easily be prevented by using
appropriate devices such as Reuse Prevention (RUP) syringes and following best clinical
practices for injection safety.
Sharps waste management is another area that should be considered as an important
area that needs urgent attention. Healthcare workers, housekeeping staff and the
general community are often at risk of infection due to accidental needlesticks when
sharps are not appropriately contained. Varied sharps management practices occur
throughout India, some of which have been scientifically proven as being potentially
harmful to human health. However, due to lack of understanding, awareness and will,
several such approaches are still being adopted. Needle burners, often used to blunt the
sharp tips of needles, have been shown to cause fumes, aerosol spread of infections,
blood and medicine splatter and have been discontinued in developed countries, but
their usage in India is still rampant posing a threat to the health of the healthcare
workers. Puncture-resistant sharps containers, which have been recommended by the
United States CDC (Center for Disease Control and Prevention) are not being universally
adopted due to the recurrent costs and inadequate infrastructure at the Combined
Waste Treatment Facility (CWTF) to deal with autoclaving and shredding these
containers. This lack of adoption helps propagate outdated practices like needle
burning.
Above all, injection Safety is compromised on several occasions in our healthcare
settings, due to the lack of awareness. Injection Safety is not a high focus component of
healthcare workers training (doctors, nurses paramedical workers etc) and most of the
understanding on injections is by the simple rule of on the job training. Therefore, if a
Chapter - 1.1
Achieving Comprehensive Safety through a
Safe Injection Environment
IAP Guide Book on Safe Injection Practices 1
1.1

wrong practice is adopted by the person who is followed by healthcare workers all the
healthcare workers learn the same mistakes and thus the effects are multiplied manifold
in actual practice. There is therefore a need for a training module that can help address
this most common intervention in healthcare – Injection Safety.
The concept of Injection safety can be easily understood if we consider the science
behind this. It can be thought of as an roadmap where different actions work in tandem,
all aligned to create a “Safe Injection Environment”.
Figure: The model on Safe Injection Environment (courtesy: Becton Dickinson)
Explaining the Safe Injection Environment (SIE):
The Safe Injection Environment aims to combat the spread of bloodborne pathogens
and avoid clinical complications associated with unsafe injection practices through
comprehensive solutions across the continuum of care. Injection safety is not only about
a syringe with a needle inserted into a human body to deliver a medication safely. It has
several components that go on to make a program in itself, a program that seeks to
improve not just the individual practice, but also the environment in which injections are
given.
The critical step towards ensuring a SIE is to ensure that the devices that are meant to be
used for injections are affordable (especially in resource constrained settings), that they
Safe Injection
Environment
Safe Disposal
Systems
Affordability, Accessibility and Availability
A
Safe Injection
Environment
Policy &
Compliance
Aspiration
Enablers:
Foundation:
IT & Info. Delivery
Capability
Optimized
Workflow
Risk Assess. /
Surveillance
Alternate / New
Technologies
Optimized
Product Array
On-going HCW
Education &
Training
Green Solutions /
Landfill Diversion
IAP Guide Book on Safe Injection Practices2
1.1

are accessible (it makes no sense if the affordable injection equipments are not
accessible to the provider) and available to the user
Box-1: Optimized Product Array
The foundation for the SIE happens to be that such devices that are affordable,
accessible and available have an optimized product array. For example, while
reconstituting medications, a standard injectable needle should not be used because –
1. Using an injectable needle can cause an accidental needlestick injury to the person
doing the reconstitution & 2. Such needles do not provide for glass particles to be
filtered out, which may then be injected to the recipient. In such situations using a blunt
filter needle may be helpful and more clinically appropriate. Another example is that
while drawing blood in an emergency situation it is highly possible that due to the rush
in patients, there could be inadvertent placement of sharps in places where there may
be high chances of accidental needlestick injuries. Moreover in such situations the HIV
status of the patients may not be known. To help the healthcare workers in such a
situation it is prudent to use safety devices (safety shielded needles) instead of
conventional. It is necessary to have an appropriate array of products to build a safer
injection environment.
Box - 2: Ongoing healthcare workers Education and Training
Healthcare workers are a respectable and sometimes limited resource that should be
protected while carrying out their healthcare delivery responsibilities. Moreover these
healthcare workers should be kept engaged and updated on the ways in which to treat
patients as well how to take care of themselves. The high turnover of such healthcare
resources, often leads to situations where training and education becomes paramount.
Through education and training programs, it can be ensured that Injection Safety can be
practiced – through processes that are safe to the patient, safe to the healthcare worker
and safe for the community.
Box - 3: Safe Disposal Systems
Biomedical waste is amongst the most dangerous of any waste that is generated,
primarily because of the numerous contaminants that could cause potentially life-
threatening illnesses if any person were to inadvertently get exposed to untreated
biomedical waste. Sharps waste, generated from needles and cannulae, are amongst
the most dangerous of the biomedical waste due to the risk of transmission of blood-
borne pathogens.
To ensure the safety of the community as well as the environment, it becomes necessary
to ensure that the right products and processes are adopted for collection, storage,
transportation, disinfection and treatment of such biomedical waste. Injection safety
1.1

can never be fully achieved if a modern, reliable and scientifically sound system of
handling biomedical waste is not available.
Box - 4: Green Solutions / Landfill diversions
With the growing importance being laid on developing a greener planet and reducing
the carbon footprint, some companies have been taking measures to help reduce the
environmental impact of healthcare delivery. International companies have invested
tremendous R&D resources in developing unique programs that reduce the amount of
plastic used to make injection devices, while retaining required performance attributes.
Moreover certain programs have been introduced to ensure that sharps disposal
containers and all contents therein can be appropriately shredded and recycled,
preventing plastic waste from accumulating in landfills.
Box - 5: Optimized workflow
It is important to ensure that the processes and protocols are available for healthcare
workers to optimize their workflow. Rational use of injections and standardization of
best practices for injection safety helps to limit clinical variability. When variability is
reduced and workflow is optimized, healthcare can be delivered more effectively and
efficiently, leading to higher healthcare worker and patient satisfaction.
Box - 6: Risk Assessment / Surveillance
A critical step towards an SIE, is to ensure that appropriate data is captured in a reliable
and consistent manner to monitor progress and improvement. Such data would help
the decision makers of the hospital or policy makers in taking the right steps to ensure
patient and healthcare workers safety. The data collected should be uniform and
complete, so that it is comparable and adequate correction measures in safety can be
taken.
A uniform software format like EPINet (Exposure Prevention Information Network)
developed by the University of Virginia, can help collect information on needlestick
injuries and blood and body fluid exposures. Data collected through this system helped
change the policy on sharps in the United States. In December 2000, President Bill
Clinton signed the historic act that mandates the use of Safety Engineered Devices in US
healthcare facilities. This was due in large part to data that demonstrated the high
incidence of needlestick injuries, the risks of bloodborne disease transmission and the
importance of protecting healthcare workers from such injuries.
Box - 7: Alternate / New Technologies
Companies are working continuously to develop products that cater to the unmet
needs of patients, healthcare workers and the community. Such new technologies are
being developed after prudent R&D to ensure that the technology is continuously
1.1

upgraded to meet the challenges of the new healthcare needs. Adopting such proven
technology is always a positive step towards ensuring comprehensive injection safety.
Box - 8: IT & Information delivery capability
IT has revolutionalized the world and has shortened distances. In healthcare, adoption
of IT and using IT to enhance patient & healthcare workers benefits is apt to keep pace
with the ever-changing medical world. Surveillance processes can get immediate
feedback, which can help decision makers to take the right steps on safety.
Benchmarking against industry standards and comparing available information helps
healthcare organizations know exactly where they stand. Outbreaks can easily be
identified and acted upon. Such steps only help healthcare get ready to meet newer
challenges.
Box - 9: Policy and Compliance
For any decision to be taken, it is prudent that the decision maker is armed with data-
driven information that can demonstrate the impact of certain healthcare interventions
on improving delivery of care. The SIE framework could help influence local, state or
even national policies on comprehensive injection safety by demonstrating wins and
positive measures that make a large public health impact. Adoption of this framework
would definitely help in ensuring Injection Safety across healthcare settings.
However, even after a policy is developed to adopt SIE, adherence to the protocols is
important so that there is no reversal of the gains made. Continuous monitoring of the
activities is important and so is the feedback that is provided. This leads to an
environment of continuous improvement. Behaviour change would only happen if
habits are concretely formulated. This would help healthcare organizations in reaching
the aspired goal of a Safe Injection Environment leading to comprehensive safety across
the continuum of care. The current initiative of IAP attempts to address all dimensions of
safety as stated above for achieving highest standards of injection safety for the benefit
of people, the patients and the healthcare professionals.
1.1

Injection is the commonest procedure carried out by the health care providers all over
the world. Over 22 billion (2200 crore) injections are given in the world, of which16
billion (1600 crore) injections are given every year across the developing countries.
Majority of these injections, over 95%, are given for therapeutic purpose. only 3% are
used for immunization activity and over 2% are used in laboratory work.
Rational use of injection is a highly important subject that is needed to be emphasized,
as nearly70% of injection that are being administered are actuary unnecessary.
WHY PEOPLE PREFER INJECTIONS?
People prefer injections because
• They believe injections act fast.
• Some Doctors regard injections as the best form of treatment
Doctors prescribe injections to satisfy the patients, even though by counseling they can
avoid giving these unnecessary injection. Some practitioners do it for commercial gains
which is not an ethical practice.
WHAT IS A SAFE INJECTION?
A safe injection does no harm to the patient, health care giver and to the community. If
injections are not delivered in a safe manner, it exposes people to dangerous and deadly
infections.
Millions are exposed to serious infections due to unsafe injection practices like re use of
syringes.Studies in many countries have shown that more often injections are given by
dipping the syringes in boiling water in the sterilizer. The study done by INCLEN in INDIA
has shown that 66% of injections are unsafe. Reuse of syringes is rampant to the extent
o f 40 -60%. Industry trends indicate that 5.8 injections are received by an individual on
an average annually.
Poor collection and disposal of injection waste practiced in many situations, in private
and public sector both, not only expose the health workers but also the community to
the hazard of needle stick injuries and thereby to the risk of contracting life threatening
infections.
Improper disposal of injection waste has other dimension of resale of used syringes and
needles and intravenous line tubings. These are rerouted to the health care settings for
mere commercial gains.
Chapter - 1.2
Importance of Injections and Injection Safety;
Creating The Safe Environment
1.2

DISEASES ASSOCIATED WITH UNSAFE INJECTION PRACTICES
It is estimated that each year 13 Lac new deaths are attributed to UNSAFE INJECTIONS.
and about 2700 million Rupees are spent as medical cost, to treat resulting infections.
Unsafe injections are known to transmit blood borne pathogens like bacteria, virus and
parasites, particularly, potentially lethal and dangerously morbid diseases like Heptitis B,
Hepatitis C, HIV, Malaria and other local and systemic bacterial infections.
Nearly 22 million people are infected each year representing 33% of new HBV infections
42% of new HCV infections and 2% of all new HIV infections that are attributable to
unsafe injections.
WHAT NEEDS TO BE DONE TO CHANGE THIS SCENARIO
Safe and appropriate use of infections is the only way and injection safety and basic
infection control practices are central to patient safety of saving the man kind from
deadly diseases which can be achieved by 3 ways:
• Behavioural change of health care providers.
• Availability and sustained supply of injection equipments.
• Safe and appropriate management of injection waste.
Of late it has been observed that in many countries consumers are demanding the safe
and quality injection equipments and and are concerned about safe disposable
methods.
There is an urgent need to ensure availability and sustained supply of safe injections
equipments like disposable syringes with safety features to prevent re-use, both at
curative and preventive settings to enable the health care workers to use them and to
meet the demand of consumers, The supply of disposables and waste disposable should
be available as bundle to facilitate the health care givers to practice appropriately.
Many countries are adopting the national policy on hospital waste management. Health
care providers at all level of care both in private and public settings are oriented in safe
injection practices however this is not happening in small care establishments.
A comprehensive system of implementation, creation of awareness and training of
health workers as per the local need to be developed.
WHO through safe injection global network, SIGN, provide technical advice through
policy guidelines, decision making, management and advocacy tools to help member
countries implement the system of safe injection practices by providing the affordable
equipments, capacity building of HCWs and materials to promote rationle use of
injections. SIGN also developed specific standard for AD syringes for use in
immunization and curative sector.
1.2

To ensure rational use of injections WHO urges its member countries to develop national
drug policy which is essential for appropriate use of drugs and injections. It will also help
in removal of unnecessary injectable medicines from essential drug list.
WHO developed guiding principles to ensure injection device security by emphasizing
the need of sustained supply chain of injection equipments to each health facility in the
public health system.
Center Of Disease Control and Prevention (CDC, Atlanta) has also emphasized the need
of safe injection practices through use of technology, trainings and appropriate policy
frameworks.
APIC RECOMMENDATIONS
The APIC (Association for Professionals in Infection Control and Epidemiology (APIC)
full) strongly supports adherence to the following safe injection, infusion and
medication vial practices .
• Perform hand hygiene (handwashing with soap and water or by application of a
60% or greater alcohol-hand sanitizer rub that is allowed to dry) before
accessing supplies, handling vials and IV solutions and preparing or administering
medications.
• Use aseptic technique in all aspects of parenteral medication administration,
medication vial use, injections and glucose monitoring procedures.
• Store and prepare medications and supplies in a clean area on a clean surface.
• Never store needles and syringes unwrapped because sterility cannot be ensured.
• Discard all opened vials, IV solutions and prepared or opened syringes that were
involved in an emergency situation.
• Avoid contacting sterile drugs and sterile areas of devices and containers with
non-sterile objects and/ or secretions and particles shed from personnel.
IV SOLUTIONS
• Never use IV solution containers (eg, bags, bottles) to obtain flush solutions or for
any other purpose for more than 1 patient.
• Never use infusion supplies, such as needles, syringes, flush solutions,
administration sets, or IV fluids, on more than one patient.
• Disinfect IV ports and vial stoppers by wiping with sterile 70% isopropyl alcohol.
FLUSHING
• Use single-dose containers for flush solutions, when ever possible.
1.2

• If a multi-dose vial must be used, use it for only one patient and then discard it.
Each entry into the multi-dose vial (dedicated to that patient) must be made with
a new, unused sterile needle and a new, unused sterile syringe.
SYRINGES
• Remove the sterile needle/cannulas and/or syringe from the package
immediately before use.
• Never use a syringe for more than one patient even if the needle has been
changed between patients. Changing the needle but not the syringe is
unacceptable.
• Use a new syringe and a new needle for each entry into a vial or IV bag.
• Utilize sharps safety devices whenever possible. Discard syringes, needles and
cannulas immediately after use.
• Dispose off used needles/syringes at the point of use in an approved sharps
container.
• Do not prepare medication in one syringe to transfer to another syringe.
• Never store or transport syringes in clothing or pockets.
• Prepare syringes as close to administration as possible.
VIALS
• Always follow the manufacturer's instructions for storage and use.
• Use single-use or single-dose vials whenever possible.
• Cleanse the access diaphragm of vials using sterile 70% isopropyl alcohol.
• Discard single-dose vials after use. Never use them again for another patient.
• Discard any vial that has been placed on a contaminated surface or a used
procedure tray or that has been used during an emergency procedure.
• Dedicate multi-dose medication vials for a single patient. Access all vials using a
new sterile syringe and new needle/cannula adhering to aseptic technique.
• Never store or transport vials in clothing or pockets.
• Never leave a needle, cannula, or spike device (even if it has a 1-way valve)
inserted into a medication vial rubber stopper because it leaves the vial vulnerable
to contamination.
• Do not use expired drugs.
1.2

• All vials used during an emergency should be discarded because sterility cannot
be guaranteed.
BLOOD GLUCOSE MONITORING DEVICES
• Assign a glucometer to each individual patient if possible. Clean and disinfect
glucometers if they must be shared between multiple patients.
• Use single-use lancets that permanently retract after puncture.
• Never reuse finger stick devices and lancets.
• Thoroughly clean all visible soil or organic material (eg, blood) from the
glucometer before disinfection.
SOME GENERAL POINTS
• Provide the HBV vaccination series to all previously unvaccinated health care
personnel whose activities involve contact with blood or body fluids.
• Immediately report body fluid exposures and needle-stick/sharps injuries.
• Ensure that staff preparing or administering injections or other parenteral
medications are competent to perform these tasks aseptically.
• Periodically assess compliance with safe injection practices by observing and
evaluating all personnel performing these procedures.
Phlebotomy, hepatic procedures, dialysis, endoscope settings are the risky areas for
Health Care Workers (HCW) and patients. Catastrophic outbreaks have been reported in
these settings due to unsafe injections practices and these areas are known for
unrecognized transmission
CONCLUSION
Health care providers everywhere need to spend time along with their colleagues to
review injection practices and other issues of care to ensure the safe injection practices
are understood and followed to save themselves, patients and community. Safe
injection practices are also critical to prevent microbial contamination of products
administered to patients.
Different reports of HBV and HCV transmission and outbreaks of bacterial infections
from different regions indicate that much more is needed to ensure that preventive
practices are being scrupulously followed in all health care settings.
HCWs and their managers must understand and practice these procedures safely.
Administrators of medical facilities must be aware of safe injection practices and ensure
that employees have the knowledge, training and equipment to safely implement these
procedures.
1.2

Continuing education efforts should be aimed at practicing safe injection practices. It is
critical that injectable medications, IV delivery systems and blood glucose monitoring
devices are used safely in all health care settings.
We have an obligation to reiterate and ensure that safe injection, infusion and
medication vial practices are the absolute standard of care throughout various health
care settings and across the continuum of care. We must take a lead in promoting
adherence to these safe Injection practices by Health care Providers to protect the health
and safety of the patients under our care.
POINTS TO REMEMBER
• Health care providers should prioritize improving their knowledge and skills on
injection safety.
• Ensuring injection safety as a preventive practice, should be followed in all health
care settings.
• Administrators of medical facilities should understand safe injection practices
and ensure skill building and compliance at the facility level.
• Continuing education efforts aimed at improving injection safety standards
should be accorded high priority.
References:
1. Safe injection practices to prevent transmission of infections to patients CDC2007 guidelines
2. AJIC Injection Practces Among Clinicians of United States Health Care settings 2010
3. WHO SIGN MEETING PROCEEDINGS 2010
4. WHO Injection Safety Guidelines
5. BD Safe Injection Practice Coalition FEB2009
6. CDC PREVENTION OF UNSAFE INJECTION PRACTICES
1.2

BACKGROUND
Medically inappropriate, ineffective and economically inefficient use of pharmaceuticals
is commonly observed in health care systems throughout the world, especially in
developing countries. However, various forms of inappropriate prescribing often remain
unnoticed by those who are involved in health sector decision making or delivery of
health services. This problem will usually come to the attention of health decision
makers or managers when there is an acute shortage of pharmaceutical budget that
requires action for cost-efficiency or there is a resistance to a particular drug.
Promoting appropriate use of drugs and Injections in the health care system is needed
because of
a) Financial reasons with which policy makers and managers are usually most
concerned.
b) An essential element in achieving quality of health and medical care for patients
and the community.
Actions or intervention programs to promote the appropriate use of drugs and
injections should, therefore, be continuously implemented and systematically
incorporated as an integral part of the health care system.
Defining Rational Use of Drugs (including injections)
People may have different perceptions and meanings regarding rational use of drugs, or
more specifically regarding rational prescribing. However, the Conference of Experts on
the Rational Use of Drugs, convened by the World Health Organization in Nairobi in
1985, defined rational use as follows:
Rational use of drugs requires that patients receive medicines appropriate to their
clinical needs, in doses that meet their own individual requirements, for an adequate
period of time and at the lowest cost to them and their community.
Injections are a form of drug administration and choosing this form of administration for
the patient needs utmost caution.
The requirements for rational use will be fulfilled if the process of prescribing is
appropriately followed. This process includes steps in defining a patient's problems (or
diagnosis); in defining effective and safe treatments (drugs and non drugs); in selecting
Chapter - 1.3
Rational Use of Injections
1.3

appropriate drugs, dosage and duration; in writing a prescription; in giving patients
adequate information; and in planning to evaluate treatment responses.
The definition implies that rational use of drugs and injections, especially rational
prescribing, should meet certain criteria as follows:
• Appropriate indication. The decision to prescribe drug(s) is entirely based on
medical rationale and the chosen therapy is an effective and safe treatment.
• Appropriate molecule. The selection of molecule for a patient is based on
efficacy, safety, suitability and cost considerations.
• Appropriate patient. No contraindications exist, the likelihood of adverse
reactions is minimal and the drug is acceptable to the patient.
• Appropriate patient information. Patients are provided with relevant, accurate,
important and clear information regarding their conditions and the medication(s)
that are prescribed.
• Appropriate evaluation. The anticipated and unexpected effects of medications
are appropriately monitored and interpreted.
Unfortunately, in the real world, prescribing patterns do not always conform to these
criteria and can be classified as inappropriate or irrational prescribing. Irrational
prescribing may be regarded as "pathological" prescribing when the above-mentioned
criteria are not fulfilled. Common patterns of irrational prescribing may, therefore, be
manifested in the following forms:
• The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral
upper respiratory infections.
• The use of correct drugs with incorrect administration, dosages and duration,
e.g., the use of IV metronidazole when suppositories or oral formulations would
be appropriate.
• The use of injections due to patient's request or commercial gains.
• The use of the wrong drug for a specific condition requiring drug therapy, e.g.,
tetracycline in childhood diarrhea requiring ORS.
• The use of drugs with doubtful or unproven efficacy, e.g., the use of antimotility
agents in acute diarrhea.
• The use of drugs of uncertain safety status, e.g., use of dipyrone (Baralgan, etc.).
• Failure to provide available, safe and effective drugs, e.g., failure to vaccinate
against measles or tetanus, or failure to prescribe ORS for acute diarrhea.
1.3

The use of unnecessarily expensive drugs, e.g. the use of a third generation,
broad-spectrum antimicrobial when a first-line, narrow spectrum agent is
indicated.
Some examples of commonly encountered inappropriate prescribing practices in many
health care settings include:-
• Overuse of antibiotics and antidiarrheals for nonspecific childhood diarrhea.
• Indiscriminate use of injections, e.g., in malaria treatment.
• Multiple or over-prescription.
• Excessive use of antibiotics for treating minor ARI.
• Multivitamins and tonics for malnutrition.
• Unnecessary use of expensive antihypertensives.
The drug use system is complex and varies from country to country. Drugs may be
imported or manufactured locally. The drugs may be used in hospitals or health centers,
by private practitioners and often in a pharmacy or drug shop where over the counter
preparations are sold. In some countries all drugs are available over the counter. Finally,
the public includes a very wide range of people with differing knowledge, beliefs and
attitudes about medicines. Consumers may have a very different perspective of what is
rational.
Factors Underlying Irrational Use of Drugs and Injections
Many different factors affect the irrational use of drugs. In addition, different cultures
view drugs in different ways and this can affect the way drugs are used.
The major forces can be categorized as those deriving from patients, prescribers, the
workplace, the supply system including industry influences, regulation, drug
information and misinformation and combinations of these factors.
Patients - Drug misinformation
－ Misleading beliefs
－ Patient demands/expectations
Prescribers - Lack of education and training
－ Inappropriate role models
－ Lack of objective drug information
•
1.3

－ Generalization of limited experience
－ Misleading beliefs about drugs efficacy
Workplace － Heavy patient load
－ Pressure to prescribe
－ Lack of adequate lab capacity
－ Insufficient staffing
Drug Supply System － Unreliable suppliers
－ Drug shortages
- Expired drugs supplied
Drug Regulation - Nonessential drugs available
－ Informal prescribers
－ Lack of regulation enforcement
Industry - Promotional activities
－ Misleading claims
All of these factors are affected by changes in national and global practices. For
example, the frequent use of injections is declining in many African countries because of
the fear of AIDS. In some countries, however, the use of injectables remains high due to
false assumption of prescribers that injections will improve patient satisfaction and that
they are always expected by the patients.
Impact of Inappropriate Use of Drugs
The impact of this irrational use of drugs can be seen in many ways:
• Reduction in the quality of drug therapy leading to increased morbidity and
mortality.
• Waste of resources leading to reduced availability of other vital drugs and
increased costs.
• Increased risk of unwanted effects such as adverse drug reactions and the
emergence of drug resistance, e.g., malaria or multiple drug resistant
tuberculosis.
1.3

Psychosocial impacts, such as when patients come to believe that there is “a pill
for every ill.” This may cause an apparent increased demand for drugs.
Hospital Problems
Drug use in hospitals has been a neglected area. However in both developed and
developing countries, the misuse of antibiotics, particularly for surgical prophylaxis, has
been widely reported. More so, the hospitals choose injectable form than oral
medications in such scenarios. Hospitals have been able to improve antibiotic use
through the use of formularies.
Points to Remember
• Never use injections due to patient's request or commercial gains.
• Appropriate indication. The decision to prescribe injections is entirely based on
medical rationale and the chosen therapy is an effective and safe treatment.
Analyze patients condition and then only prescribe injections if at all
required.Prefer oral medications if patients'scodition permits.
• Appropriate molecule. The selection of suitable molecule for a patient is based on
the disease condition, drug's efficacy, safety, suitability and cost considerations.
• Appropriate patient. No contraindications exist, the likelihood of adverse
reactions is minimal and the drug is acceptable to the patient.
• Appropriate patient information. Patients are provided with relevant, accurate,
important and clear information regarding their conditions and the medication(s)
that are prescribed. Discourage them to unnecessarily ask for injections.
• Appropriate evaluation. Monitor the patient for anticipated and unexpected
effects of medications given through injections.
References:
Laing RO. Rational drug use: an unsolved problem. Trop Doct. 1990; 20:101–3.
Avorn J, Harvey K, Soumerai, SB et al. Information and education as determinants of antibiotic use. Rev Infect Dis.
1987; 9(S3):S286–96.
Vance MA, Millington WR. Principles of irrational drug therapy. Int J Health Serv. 1986;16(3):355–61.
Quick JD, Foreman P, Ross-Degnan D, et al. Where Does the Tetracycline Go?: Health Center Prescribing and Child
Survival in East Java and West Kalimantan, Indonesia. Boston: Management Sciences for Health, October 1988.
Ross-Degnan, D, Laing RO, Quick, JD et al. A strategy for promoting improved pharmaceutical use: The International
Network for Rational Use of Drugs. Soc Sci and Med. 1992 35 (11) 1329–41.
．
•
1.3

Background
In transitional and developing countries where unnecessary injections are common, the
average number of health care injections per person was estimated to be 3.7 per year
(this includes all health care injections, including those given to diabetics for
administering insulin). Many injections, as well as being unnecessary, are also unsafe.
Each year, the reuse of injection equipment may cause 20 million infections with
hepatitis B virus (HBV), 2 million infections with hepatitis C virus (HCV) and 250 000
infections with human immunodeficiency virus (HIV) worldwide. These chronic
infections lead to a high burden of morbidity and mortality.
No evidence-based guidelines are available to guide injection providers through the
steps they should follow to prevent injection-associated infections. IAP with the
objective of addressing the issue in reference, have worked to develop guidelines and
recommendations which are based on the WHO framework. This chapter would throw
light on vital aspects of this.
Potentially Critical Issues
An injection is a procedure that introduces a substance into the body by piercing the skin
or a mucosal membrane and thus carries the risk of introducing disease causing agents
from outside to inside the body, Therefore some vitally important precautions should
always be practiced by the injection providers. The potentially critical issues which carry
a risk of causing infections amongst the recipient, the providers and the community in
general as well, are listed in the table below
Chapter - 2
Best Practices to Ensure Injection Safety
2

Potential Source of contamination and stages of occurrece
Use of sterile injection equipment
The most important infection control measures for preventing infection among
injection recipients is the use of a sterile syringe and needle for each injection and to
reconstitute each unit of medication (for medications that require a diluent). In many
countries, the practice of reusing injection equipment in the absence of sterilization is
common and such practices have been associated with infections.
Use of a new, single-use syringe and needle provides the highest level of safety to the
recipient. However, unreliable and insufficient supplies might lead to the equipment
being reused. Even though boiling injection equipment for 20 min does not sterilize it,
the use of pans to boil single-use injection equipment is common in developing and
transitional countries. In many instances these pans are used as containers of tepid
water where injection equipment is simply rinsed and soaked between injections Also, it
is necessary to use injection equipment that has been inspected for breaches in barrier
Potential source of Stage at which contamination Potentially critical issues
contamination or exposure or exposure might occur
Preventing infection among
a
injection recipients
Injection equipment Sterilization 1. Sterilization of injection equipment
Storage 2. Duration and conditions of storage
Handling 3. Handling of injection equipment
Injected substance Before opening 4. Type of medication
5. Medication and vial check
During opening 6. Swabbing of vial stopper/neck
7. Filing and breaking of ampoules and vials
After opening 8. Handling of multi-dose vials
Skin of the recipient Introduction of the needle 9. Site of injection administration
10. Skin preparation
Environment Injection preparation 11. Injection preparation area
12. Aseptic techniques
Hands of the provider Injection preparation and administration 13.Hand Hygiene
Preventing infection among
b
injection providers
Exposure to the injection recipient’s During injection administration 14. Preparation and/or restraint of patient
blood through needle-stick injury Handling of injection equipment 15. Needle recapping
after use 16. Needle removal
17. Needle cutting
18. Rising and dissembling sterilizable equipment
Collection of contaminated equipment 19. Use of sharps containers
20. Improper disposal of sharps
21. Quality of sharps containers
Sharps waste management 22. Removal of containers used to collect sharps
Preventing infection
b
in the community
Exposure to the injection recipient’s Sharps waste management 23. Storage of containers used to collect used Sharps
Blood through needle-stick injury 24. Terminal disposition of sharps waste
a
Contamination.
b
Exposure.
2

integrity and to discard it if it is punctured, torn, or damaged. By inspecting the
packaging of individual syringes,we can also have an idea about the completeness of
process of sterilization using Ethylene Oxide (ETO), which is carried out by the
manufacturers.. In the ribbon packs one should observe for presence of a paper strip
with perforations, which allow the ETO to enter and diffuse out. ETO sterilizes the
injection equipment and this effect is long lasting. Excess of residual ETO has
carcinogenic effects. If the packaging says that the syringe is ETO sterilized and the
paper used in not medical grade paper (flow wrap and blister packs) or there is no paper
strip with perforations (ribbon packs), then the quality of sterilization is doubtful.
Preventing contamination of injection equipment and medication
Work environment. It is important to prepare injections in a clean designated area,
where the risk of contamination by blood or body fluids is low. HBV persists for up to
seven days on surfaces, which can potentially lead to environmental contamination.
Environmental contamination is a potential source of HBV infection in settings where
chronic haemodialysis is performed.
Factors that might facilitate HBV transmission among patients receiving chronic
haemodialysis include a high prevalence of HBV infection among patients, an
environmental contamination with blood, a high frequency of percutaneous
procedures and the presence of patients with high levels of viraemia. These factors
might also be found in other health care settings because of following features:-
• High HBV endemicity
• Limited implementation of standard precautions
• Overuse of injections
• The presence of people in whom the HBV replicates actively (e.g. children)
In Romania, for example, where some of these conditions were present, HBV infection
was associated with injections in 1998. However, a review of injection practices in
Romania suggested that HBV transmission was probably related to the preparation of
injections in environments that were potentially contaminated with blood or body
fluids. The preparation of injections in contaminated environments might also lead to
bacterial infection.
Multi-dose vials. It is important to use single-dose vials rather than multi-dose vials
whenever possible. Although preservatives reduce the survival of bacteria, multi-dose
vials remain prone to bacterial contamination and the use of multi-dose vials has been
reported to be a potential source of infections in number of studies. Needles left in the
septum of multi-dose vials might encourage the use of the same syringe to repeatedly
draw medications for one patient, a practice that may lead to vial contamination and
2

infections among subsequent patient,. Thus, if multi-dose vials must be used, it is
essential that the person administering the injection pierces the septum with a separate
sterile needle and it is important not to leave any needle in place in the stopper.
A vial showing a needle in Septum
Breaking vials and ampoules. Injuries to injection providers can be another source of
infection. While opening glass ampoules, providers may lacerate their hands, which can
bleed and may cause infections. Thus, it is important to use pop-open ampoules and
vials rather than that need to be opened using a metal file. If a metal file is to be used, the
fingers should be protected using a clean barrier (e.g. small gauze pad).
Compromised packaging. Cracks and leaks in vials are a potential source of
contamination. Although it is not known how effective a visual examination of the vial is
in preventing infections, it is important to inspect the vial for and discard medications
with visible contamination or breaches of integrity (e.g. cracks or leaks) and to follow
product-specific recommendations for use, storage and handling.
Aseptic techniques. Medical devices might become contaminated with bacteria if
touched. Thus, a needle that has touched any non-sterile surface must be discarded.
Provider's hand hygiene and skin integrity. Washing or disinfecting hands is a
standard procedure that is carried out before preparing injection material. The need for
hand hygiene between each injection will vary depending on the setting and on
whether the health care worker has had contact with soil, blood, or body fluids.
Injections have been administered in the absence of hand-washing. Skin lesions and
skin irritation are associated with bacterial contamination. Thus, it is necessary to avoid
giving injections if skin integrity is compromised by local infection or other skin
conditions (e.g. weeping dermatitis) and to cover any small cut. This has been described
in details in the chapter on injection methods.
2

Swabbing vial tops Cotton balls and gauze stored wet in antiseptics might become
contaminated and have contributed to infections among patients, particularly when
benz-alkonium chloride was used. Thus, if swabbing with an antiseptic is selected for
use, an isopropyl alcohol swab must be used. Cotton balls stored wet in a multi-use
container must not be used.
Skin preparation of patient before injection. While the benefit of skin preparation is
unclear, unsafe skin preparation protocols may be harmful. Thus, if swabbing with an
antiseptic is selected for use, an isopropyl alcohol swab must be used. Cotton balls
stored wet in a multi-use container must not be used.
Prevention of needle-stick injuries to the provider
Best infection control practices for preventing infections among injection providers
address the prevention of movements of patients, the prevention of unsafe recapping of
needles and the collection of contaminated sharps in puncture-proof and liquid-proof
containers.
Movement of patients. Needle-stick injuries to providers when administering
injections are usually attributable to the abrupt movement of patients during the
procedure. Thus, it is important that providers anticipate and take measures to prevent
sudden patient movement during and after injection. In some instances, physical
assistance from other health care workers or family members might help to ensure that
the procedure is carried out under appropriate circumstances.
Recapping. Avoiding recapping of needles and other hand manipulations of used
needles is essential for preventing needle-stick injuries. A high proportion of needle-
stick injuries are attributable to recapping.
Sharps collection. It is important to collect and properly contain syringes and needles
at the point of use in a sharps container that is resistant and leak-proof and that is sealed
th
before it is full up to 3/4 level. Unsafe sharps waste collection causes between 5% and
28% of needle-stick injuries as per NIOSH. Puncture and liquid-proof containers
designed for the collection of contaminated sharps are associated with a lower risk of
needle-stick injuries than regular cardboard boxes. The presence of sharps containers
close to the point of use reduces the incidence of recapping and of recapping related
needle-stick injuries. Interventions that combine the provision of sharps containers and
risk communications reduce the total number of needle-stick injuries.
2

Other practice issues
Engineered technologies. Current hypodermic needles and syringes with safety
features for preventing needle-stick injuries require a provider-dependent activation
step. Their effectiveness is unclear. None are able to protect the provider when giving an
injection because the safety feature is only activated after use. Reports on the
effectiveness of other, safer needle-bearing devices (e.g. intravenous catheters,
phlebotomy needles) to protect health care personnel from needle-sticks are
encouraging. Thus, whenever possible, devices designed to prevent needle-stick injury
that have been shown to be effective for patients and providers are preferable.
Preventing infections in the community
Contaminated sharps are a potential source of biohazard to the community at large. To
prevent people being exposed to contaminated sharps, it is important to seal sharps
containers for transport to a secure area in preparation for disposal. After closing and
sealing, sharps containers must not be opened, emptied, reused, or sold.
In South Asia, used injection equipment is sought for recycling, mostly for the
plasticware industry Such practices might lead to needle-stick injuries among waste
pickers and can lead to illegal repackaging of syringes for reuse in hospitals and clinics.
Finally, it is important to manage sharps waste in an efficient, safe and environment-
friendly way. Contaminated sharps were observed in the immediate surroundings of a
high proportion of health care facilities in developing countries. Such unsafe sharps
waste management exposes the community to needle-stick injuries.
Use of new single use equipment
2

Summary of best infection control practices for intradermal, SC and IM needle
injections
• Eliminating unnecessary injections is the highest priority in preventing injection-
associated infections.
• When injections are medically indicated, they should be administered safely.
• These best practices are measures that have been determined through scientific
evidence or expert consensus most effectively to protect patients, providers and
communities.
1. Use sterile injection equipment
• Use a sterile syringe and needle for each injection and to reconstitute each unit of
medication.
• Use a new, single-use syringe and needle.
• Inspect packaging for breaches in barrier integrity.
• Discard a needle or syringe if the package has been punctured, torn, or damaged.
2. Prevent contamination of injection equipment and medication
• Prepare each injection in a clean designated area, where contamination from
blood or body fluid is unlikely.
• Use single-dose vials rather than multi-dose vials.
• If multi-dose vials must be used, always pierce the septum with a separate sterile
needle.
• Do not leave a needle in place in the stopper of the vial.
• Select pop-open ampoules rather than ampoules that need to be opened by
using a metal file. If an ampoule that requires a metal file is used, protect fingers
with a clean barrier (e.g. small gauze pad) when opening the ampoule.
• Inspect for and discard medications with visible contamination or breaches of
integrity (e.g. cracks, leaks).
• Follow product-specific recommendations for use, storage and handling.
• Discard a needle that has touched any non-sterile surfaces.
2

3. Prevent needle-stick injuries to the provider
• Anticipate and take measures to prevent sudden movement of patient during
and after injection.
• Do not recap needles and do not manipulate needles manually.
• Collect used syringes and needles at the point of use in an enclosed sharps
th
container that is puncture-proof and leak-proof and that is sealed before it is ¾
full.
4. Prevent access to used needles
• Seal sharps containers for transport to a secure area in preparation for disposal.
After closing and sealing sharps containers, do not open, empty, reuse, or sell
them.
• Manage sharps waste in an efficient, safe and environment-friendly way to
protect people from accidental exposure to used injection equipment.
5. Other practice issues
• Engineered technology. Whenever possible, use devices that have been
designed to prevent needle-stick injury and have been shown to be effective for
patients and providers. Auto-disable (AD) syringes are increasingly available to
prevent the reuse of injection equipment in selected settings, including
immunization services.
• Hand hygiene and skin integrity of provider. Perform hand hygiene (i.e.
wash or disinfect hands) before preparing injection material and giving
injections. The need for hand hygiene between each injection will vary
depending on the setting and whether there was contact with soil, blood, or
body fluids. Avoid giving injections if skin integrity is compromised by local
infection or other skin condition (e.g. weeping dermatitis). Cover any small cuts.
• Gloves. Single-use gloves may be indicated if excessive bleeding is anticipated.
• Swabbing vial tops or ampoules. If swabbing with an antiseptic is selected for
use, use a clean, single-use swab and maintain product-specific recommended
contact time. Do not use cotton balls stored wet in a multi-use container.
• Skin preparation of patient before injection. Wash skin that is visibly soiled
or dirty.. If swabbing with an antiseptic is selected for use, use a clean, single-use
swab and maintain product-specific recommended contact time. Do not use
cotton balls stored wet in a multi-use container.
2

References:
Hauri AM, Armstrong GL, Hutin YJF. Contaminated injections in health care settings. In: Ezzati M, Lopez AD, Rodgers
A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable
to selected major risk factors. Geneva: World Health Organization; 2003.
Best infection control practices for intradermal, subcutaneous,and intramuscular needle injections
Yvan Hutin,1 Anja Hauri,2 Linda Chiarello,3 Mary Catlin,4 Barbara Stilwell,2 Tesfamicael Ghebrehiwet,5
Julia Garner,2 & the Members of the Injection Safety Best Practices Development Group
Hauri AM, Armstrong GL, Hutin YJF. Contaminated injections in health care settings. In: Ezzati M, Lopez AD, Rodgers
A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable
to selected major risk factors. Geneva: World Health Organization; 2003.
Dicko M, Oni AQ, Ganivet S, Kone S, Pierre L, Jacquet B. Safety of immunization injections in Africa: not simply a
problem of logistics. Bulletin of the World Health Organization 2000;78:163-9.
Sopwith W, Hart T, Garner P. Preventing infection from reusable medical equipment: A systematic review.BMC
Infectious Diseases 2002;2:4. Available from:URL: http://www.biomedcentral.com
Centers for Disease Control. Recommendations for preventing transmission of infections among chronic
hemodialysis patients. Morbidity and Mortality Weekly Report 2001;50(RR05):1-43.
Hutin YJF, Craciun D, Ion-Neldelcu N, Mast EE, Alter MJ, Margolis HS. Using surveillance data to monitor key aspects
of the epidemiology of hepatitis B virus (HBV) infection in Romania. Abstract presented at the annual meeting of the
Infectious Diseases Society of America (IDSA). Denver (CO), November 1999.
　
Dentinger CM, Hutin YJF, Pasat L, Mihilescu I, Mast EE, Margolis HS. Knowledge and practices of nurses regarding
injection safety and use of universal precautions, Vilcea district, Romania. Abstract presented at the annual meeting
of the Society for Healthcare Epidemiology of America (SHEA). San Francisco (CA), April 1999 (Abstract S 42).
Centers for Disease Control. Recommendations for preventing transmission of infections among chronic
hemodialysis patients. Morbidity and Mortality Weekly Report 2001;50(RR05):1-43.
Simon PA, Chen RT, Elliot JA, Schwartz B. Outbreak of pyogenic abscesses after diphtheria and tetanus toxoids and
pertussis vaccination. Pediatric Infectious Disease 1993;12:368-71.
Phillips G, Fleming LW, Stewart WK. The potential hazard of using multipledose heparin and insulin vials in continuous
ambulatory peritoneal dialysis. Journal of Hospital Infection 1989;14:174-7.
Krause G, Whisenhunt S, Trepka M, Katz D, Nainan O, Wiersma S, et al. Patientto- patient transmission of hepatitis C
virus associated with use of multidose saline vials in a hospital. Presentation given at the 49th Annual Epidemic
Intelligence Service (EIS) Conference. Atlanta (GA), 2000.
Simon PA, Chen RT, Elliot JA, Schwartz B. Outbreak of pyogenic abscesses after diphtheria and tetanus toxoids and
pertussis vaccination. Pediatric Infectious Disease 1993;12:368-71.
Phillips G, Fleming LW, Stewart WK. The potential hazard of using multipledose heparin and insulin vials in continuous
ambulatory peritoneal dialysis. Journal of Hospital Infection 1989;14:174-7.
Sheth NK, Post GT, Wisniewski TR, Uttech BV. Multidose vials versus singledose vials: a study in sterility and cost-
effectiveness. Journal of Clinical Microbiology 1983;17:377-9.
Parker MR. The use of protective gloves, the incidence of ampoule injury and the prevalence of hand laceration
amongst anaesthetic personnel. Anaesthesia 1995;50:726-9. Bulletin
Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of hepatitis C virus from a patient to an
anesthesiology assistant to five patients. New England Journal of Medicine 2000;343:1851-4.
2

METHOS OF INJECTION DELIVERY
Commandments of Right Injection Delivery:
The right vaccine, right drug, to the right child, at the right age, at the right site, in the
right dose, in right dose, right interval, by the right procedure at the right age is the best
and cheapest investment a health-care system of any country can make for the positive
health of its people.
To make sure that the entire process of administering an injection is safe, the
equipments used, techniques applied and processes involved should be handled in an
utmost safe and hygienic manner.
It is also known that skin and the environment contain microorganisms which may be
commensals, but on the first opportunity can become pathogenic. Unsafe injections can
spread pathogens more easily than by inhalation, swallowing or sexual activity, as they
introduce them directly into the blood stream. As health care professionals, it is our
responsibility to ensure that all healthcare interventions are safe for beneficiaries, the
health care workers and the community at large.
HAND WASHING
Hands are the principal route by which cross-infection occurs.
Hand-washing is one of the most important standard precautions for preventing the
spread of diseases. Hand decontamination is a simple and effective way in which Health
Care Workers or Professionals (HCW/HCP) can prevent the transmission of infection
between patients and protect themselves leading to a reduction in patient morbidity &
mortality.
Hands must be decontaminated before and after every step of care that involves direct
contact with patients' skin, their food, invasive devices or dressings. Effective hand
decontamination can significantly reduce infection rates leading to a reduction in
patient morbidity and mortality. The current spread of antibiotic-resistant organisms can
be attributed, at least in part, to a failure of HCW/HCP to perform hand hygiene either as
often, or as efficiently as the situation requires.
Skin provides an environment that is acidic, arid, limited in nutrients and is constantly
shed and renewed. Micro-organisms present on the skin can be classified as “resident”
Methods of Injection Delivery
Chapter - 3.1
3.1

or “transient”. Resident microorganisms are commonly termed normal flora. They live
deeply seated within the epidermis – in skin crevices, hair follicles and sweat glands and
beneath fingernails. Their function is to protect the skin from invasion from more
harmful micro-organisms. These organisms do not readily cause infection and are not
easily removed. However, they may establish an infection following surgery or invasive
procedures. Transient microorganisms are located on the surface of the skin and
beneath the superficial cells of the stratum corneum. They are termed transient because
direct contact with other people, equipment and other body sites all result in the
transfer of these microorganisms to and from the hands.
Effective hand washing technique involves three stages; preparation, washing and
rinsing & drying. Preparation requires wetting hands under tepid running water before
applying liquid soap or an antimicrobial preparation. The hand-wash solution must
come in contact with all the surfaces of the hand. The hands must be rubbed together
vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the
fingers, the thumbs and the areas between the fingers. Hands should be rinsed
thoroughly prior to drying with pre-sterilized and clean towels or allowed to air dry.
Apply an emollient hand cream regularly to protect skin from the drying effects of
regular hand decontamination.
Picture demonstrating hand washing techniques
3.1

Six basic steps
SITE SELECTION
It varies according to the age of the recipient and the vaccine/drug effect may be
enhanced / diminished. All complications of injections viz nerve injury, muscle
contractures are also site dependant. The preferred sites for injections in pediatric
patients are antero-lateral aspect of thigh and the deltoid region. Vaccines should never
be given in the gluteal region, to prevent injury to the sciatic nerve and as gluteal fat
retards absorption, thus affecting antibody titers.
Antero-lateral Thigh
This is the preferred site for IM injection in children. The target muscle is Vastus Lateralis.
The injection is given on antero-lateral aspect of thigh, middle third portion between
greater trochanter and lateral femoral condyle. The rectus femoris muscle (which is
anterior on the thigh) should not be used.
Vastus Lateralis Relaxed Area
3.1

Deltoid Muscle
This is the alternate site for children above 2-3 years. The injection is given 3-5 cm below
the acromian process or midway between acromian process and deltoid insertion. The
muscle space is adequate for low volume injections. If not positioned properly there is a
potential for injury to axillary and radial nerves and posterior circumflex humeral vessels.
Triceps muscle should never be used since radial, brachial and ulnar nerves and profunda
brachii artery is under the muscle.
POSITIONING
This is important to ensure that the pain is minimum and also there is no injury to the
provider and the patient.
Thigh: Child may be laid supine or be held on adult's (mother's) lap & restrained.
Deltoid: Child may be held on adult's lap & restrained or may sit with little restrain, if
willing.
The part should be completely exposed and the child positioned & restrained such that
the target muscle is fully relaxed.
IM Injection deltoidDeltoid Muscle Area
IM Injection antero-lateral thighPositioning the child for IM injection
3.1

CLEANSING
Cleaning the injection site before giving injection is:
• Good Clinical Practice.
• Decreases number of microorganisms present in the skin.
• Reduce the risk of abscess.
If swabs are used to clean the skin they should be used in an inside out semicircular
movement, or, top to bottom without returning to the site. In most cases though the
recipient may be asked to wash the site prior to injecting. If Alcohol is used for cleaning,
it should be allowed to dry before injection is given.
Site cleaning
DO NOT TOUCH PARTS
Preventing contamination of injection equipment is as important as having a clean site.
Any part of the syringe that comes in contact with the Injectable drug and human
anatomy should NOT be touched. If accidentally any of these parts are touched, the
syringe and needle are NOT sterile and needs to be discarded immediately in the
appropriate container and new sterile syringe and a sterile needle should be used.
The site is cleaned/washed with clean water/soap and water/alcohol wipes and allowed
to dry. Routine disinfection of skin is not necessary for Immunization. Wipes
impregnated with medicated chemicals may interfere with live vaccines like measles.
Avoid pre-wetted cotton swabs (Kept in bottles/bowls) for fear of contamination.
Do Not Touch Parts
3.1

SIZE & BORE OF THE NEEDLE
Needle length depends upon the site, age of child and muscle mass.
Intra-Dermal Injection:
BCG: 26/27G x 16mm (2/3 inch)
Intra-Muscular Injection:
1) Most infants & children: 23G x 25mm (1 inch) needle.
2) Preterm/small babies (<2m): 26/27G x 16mm (2/3 inch)
3) Very obese children: 23G x 38mm (1½ inch)
SC Injection:
Measles, MMR etc vaccines: 26G x 16mm (2/3 inch) needle
Needle Bore (gauge): Wider the lumen of the needle, less injury will be caused by the
'jet effect' while injecting. 26/27 and 23 G needles are appropriate for most vaccines.
TECHNIQUE OF INJECTION ADMINISTRATION
1. WHO Recommended Techniques
Intra-dermal Injections
0
Needle inserted at an angle parallel to long axis (at approx.150 ) for about 2 mm, so that
entire needle bevel penetrates the skin and the injected solution raises a small bleb.
There is no need to aspirate before injecting in immunization. The vaccine should be
injected at a moderate rate of around 1ml/10 sec.
Intra-muscular Injections
0
Stretch the skin flat and push the needle down at 90
Subcutaneous Injections
Pinch up the skin between thumb and forefinger so as to lift the adipose tissue and then
0
push the needle in the pinched up tissue at a 45 .Posterior skin fold of the Triceps muscle
in the arm is the ideal site because of the loose skin available for pinching before
insertion of the needle, compared to thigh, though other sites are also recommended.
Illustration showing techniques of IM, SC and ID Injection
Sites on the Body Where
a Subcutaneous Injection
Can be Given
3.1

2. ACIP Recommended Techniques
Intra-dermal Injections
Intra-dermal injections are generally administered on the volar surface of the forearm,
except for human diploid cell rabies vaccine (HDCV) for which reactions are less severe
when administered in the deltoid area. With the bevel facing upwards, a 3/8 to 3/4 inch,
26 or 27gauge needle can be inserted into the epidermis at an angle parallel to the long
axis of the forearm. The needle should be inserted so the entire bevel penetrates the skin
and the injected solution raises a small bleb. Because of the small amounts of antigen
used in intra-dermal injections, care must be taken not to inject the vaccine
subcutaneously because it can result in a suboptimal immunologic response.
Subcutaneous Injections
Subcutaneous injections are usually administered into the posterior skin fold of the arm
/lateral aspect of thigh of infants and in the deltoid area of older children and adults. A
5/8- to 3/4”, 26/27- gauge needle should be inserted into the tissues below the dermal
layer of the skin.
Intramuscular Injections
• The preferred sites for intramuscular injections are the antero-lateral aspect of
the upper thigh and the deltoid muscle of the upper arm.
• Generally, gluteal area should not be used routinely for active vaccination of
infants, children or adults because of the potential risk of injury to the sciatic
nerve.
• In addition, injection into the gluteal area has been associated with decreased
immunogenicity of certain immunogens like Hepatitis B and Rabies vaccines,
presumably because of inadvertent subcutaneous injection or injection into deep
fat tissue.
• If the gluteal area is used for passive immunization when large volumes are to be
injected or multiple doses are necessary (e.g. large doses of immune globulin
[IG]), the central region should be avoided; only the upper, outer quadrant should
be used and the needle should be directed anteriorly (i.e. not inferiorly or
perpendicular to the skin) to minimize the possibility of involvement with the
sciatic nerve.
• For all intramuscular injections, the needle should be long enough to reach the
muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not
so long as to endanger underlying neurovascular structures or bone. Vaccinators
should be familiar with the structural anatomy of the area into which they are
injecting vaccine.
3.1

• An individual decision on needle size and site of injection must be made for each
person based on age, the volume of the material to be administered, the size of
the muscle and the depth below the muscle surface into which the material is to
be injected.
Infants (<12 months of age):
Among most infants, the antero-lateral aspect of the
thigh provides the largest muscle mass and is therefore
the recommended site. However, the deltoid can also be
used with the thigh; for example, when multiple
vaccines must be administered at the same visit. In most
cases, a 7/8- to 1inch, 22 to 24 gauge needle is sufficient
to penetrate muscle in the thigh of a 4-month-old
infant. The free hand should bunch the muscle and the
needle should be directed inferiorly along the long axis
of the leg at an angle appropriate to reach the muscle
while avoiding nearby neurovascular structures and
bone.
Toddlers and Older Children:
The deltoid may be used if the muscle mass is adequate. The needle size 22 to 24 gauges
and from 5/8 to 1¼ inches, based on the size of the muscle. As with infants, the antero-
lateral thigh may be used, but the needle should be longer—generally ranging from 7/8
to 1¼ inches.
Adolescents & Adults:
The deltoid is recommended for routine intramuscular vaccination
among adolescents & adults, particularly for Hepatitis B vaccine. The
suggested needle size is 23G x 1”. They are more prone to fainting
attacks and therefore injecting in a supine position will be a better
option in susceptible people.
Post Injection Precautions:
After emptying medication, wait for 10 seconds before withdrawing the syringe.
Withdraw the needle with a smooth and steady movement. Apply gentle pressure with
a gauze for a few seconds. Do not rub the area for site cleaning and post injection. Do
not use alcohol/spirit swab which may cause burning sensation.
IM Injection antero-lateral thigh
IM Injection in deltoid
3.1

Multiple Injections
Use separate syringe and needle for each injection: If more than one preparation is
administered or if vaccine and an immunoglobulin preparation are administered
simultaneously, it is preferable to administer each in two different limbs. It is also
preferable to avoid administering two intramuscular injections in the same limb,
especially if DPT is one of the products administered. However, if more than one
injection must be administered in a single limb, the antero-lateral aspect of thigh is
usually the preferred site because of the greater muscle mass; the injections should be
sufficiently separated (i.e. at least 2.5 cm or 1 inch apart) so that any local reactions are
unlikely to overlap & enough dendrite network is available for each vaccine to be carried
to the local lymph nodes.
POST INJECTION CARE & ANTICIPATORY GUIDANCE
The child should be observed for 15 minutes. The parents should be explained to look
out for adverse events: immediate and late,Instruct parents regarding management of
adverse events.
Always keep emergency and resuscitation equipment ready. Management of
anaphylaxis is to be done as per standard protocol.
EMERGENCY MANAGEMENT
1. Adverse events should be reported immediately to the concerned agencies.
2. Follow the standard procedures of ABC.
3. Shift the patient to emergency room for further appropriate management.
POINTS TO REMEMBER
1. Hand-washing before and after procedures including injections and examining
patients is a good clinical practice
2. Site selection is important. It is also age dependant. All immunization, except
BCG, should be given on the antero-lateral aspect of thigh or Deltoid
3. Different sites and/or limbs, as for as possible, should be used if more than one
injection is given at the same visit.
4. If the same site is used under extraordinary conditions the second injection
should be given at least one inch apart.
5. Cleaning of injection site reduces the risk of infection
6. Needle size and bore are dependent on the consistency of liquid to be injected
(viscous vaccines like DPT and Hepatitis B require longer needles with larger bore
3.1

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