Contamination of medicine injection paraphernalia used by registered medical practitioners in south India: an ethnographic study

Abstract

While considerable attention has been directed at the important role of intravenous drug use in the spread of human immunodeficiency virus (HIV) and hepatitis B, little research to date has been conducted on the role of medicine injections in disease transmission. This is the case despite the fact that (a) the number of medicine injections is several orders of magnitude greater than injections of illegal drugs and (b) the networks of people potentially affected by contaminated medicine injection paraphernalia is far wider. In this article we examine the medicine injecting practices of a random sample of 40 registered medical practitioners (RMP) who have not had formal training in allopathic medicine (do not have MBBS or MD degrees) in Tamil Nadu, India. Attention is drawn to: (a) the lack of vigilance practitioners exercise in maintaining hygienic needles and syringes, (b) their perceptions of what constitutes acceptable hygienic procedure and (c) how patients respond in contexts where they are able to purchase disposable needles and syringes directly from practitioners or from the open market prior to visiting a practitioner. Study results are a cause for alarm and indicate widespread contamination of injection paraphernalia as well as common reuse of disposable needles. The study was confined to RMPs and the researchers strongly suggest that future studies of MBBS trained doctors practising in the public and private sectors be carried out. A structured observation instrument developed to record needle and syringe contamination during the process of injection administration is provided.

Introduction

The widespread popularity of injections in less developed countries has been well documented over the last two decades (Reeler, 1990, World Health Organization, 1992, Bloem and Wolffers, 1993, Hardon, 1993, van Staa and Hardon, 1996). Several reasons have been offered as to why local populations prefer injections to other forms of medication. These include: (a) beliefs about their efficacy, strength, and fast action, (b) dramatic demonstration effects experienced immediately at the site of the body, (c) economic factors which make injection-giving attractive for practitioners (enabling them to collect fees) and injection-receiving attractive for patients (in contexts where the cumulative costs of injections are less than oral medications), (d) the promotion of injections by medicine providers whose identity and status are closely tied to injection-giving, (e) the promotion of injections by practitioners as a means to reduce noncompliance, and (f) the aggressive marketing of injectables by pharmaceutical companies. Advocates of “rational drug use” have identified both practitioners' routine administration of injections and patients' routine demand for injections as practices requiring behavior change (Hadiyono et al., 1996). In many contexts, they have argued, an uncorrected feedback loop exists where: (1) practitioners think patients want far more injections than they actually desire to give (2) which prompts practitioners to administer far more injections than they actually deem necessary (in order to remain popular in a competitive health care market), (3) which practice leads patients to think that far more injections are required than are actually needed.

Whatever the case may be, the popularity of injections remains high in countries such as India, even at this time of rising awareness about acquired immunodeficiency syndrome (AIDS). In addition to targeting safe sex through condom use, AIDS messages in India have tied disease transmission to both contaminated needles (typically embedded in messages about illicit drugs) and contaminated razor blades. Curiously, more caution is exercised in some segments of the Indian population when one receives a shave (where the population demands and is willing to pay for fresh disposable razor blades), than when one receives an injection (where a disposable needle is not demanded). The cost of a disposable needle and razor blade are about the same (approximately five to ten cents US).

In this article, we take as a given widespread injection popularity in India (Greenhalgh, 1987, Prakash et al., 1989, Singhi and Singh, 1990, Wyatt and Mahadevan, 1993a, Wyatt and Mahadevan, 1993b, Wyatt and Mahadevan, 1993c, Nichter, 1996, Sathiyasekaran and Satyamoorthy, 1997)¹. We turn our attention to (a) the lack of vigilance practitioners exercise in maintaining hygienic needles and syringes, (b) their perceptions of what constitutes acceptable hygienic procedure and (c) how patients respond in contexts where they are able to purchase disposable needles and syringes directly from practitioners or from the open market prior to visiting a practitioner.

We present our findings recognizing that rather little is known about the role of injections (of medicine) in the transmission of HIV, hepatitis B (HBV) and parasitic diseases having a blood stage such as malaria². While considerable attention has been directed at the important role of intravenous drug (IVD) use in the spread of HIV and HBV, little research to date has been conducted on the role of medicine injections in disease transmission³. This is the case despite the fact that the number of medicine injections is several orders of magnitude greater than IVD injections and the networks of people potentially affected by contaminated medicine injection paraphernalia is far wider⁴.

What do existing studies of injection-related disease transmission suggest? Several studies have documented the commonality of bacterial abscesses following injections using improperly sterilized equipment (Bourgeade, 1975, Guyer, 1979, Soeters and Aus, 1989). The rapid proliferation of AIDS raised concern about the potential transmission of disease by injections and immunizations in endemic HIV areas. Berkley (1991) reviewed existing data from Africa, and suggested that while occasional cases of HIV may be transmitted by needles employed in the giving of medicine, this does not appear to be a major route of transmission. He based his opinion on both a biological assessment of HIV transmission and the observation that injections in the 5–14 year age group appear to be common, yet cases of HIV/AIDS are not⁵. The latter observation begs the question of whether children are injected with common needles, family needles, new sharp disposable needles, or needles reserved only for children by practitioners in different settings. Commenting on needle reuse without proper sterilization by nonqualified health care providers, Berkley speculated that such practitioners are likely to receive few patients per day, resulting in the exposure of injection equipment to sunlight which reduces the viability of the virus, thus lessening the chance of disease transmission after about half an hour. His assumptions may not hold true in places where such practitioners have a thriving business, especially during peak hours. In India, for example, many registered medical practitioners (RMP) who do not have formal training in allopathic medicine do a brisk injection business in town as well as in rural areas. They attend to fairly sick patients (TB, STD, and malaria patients, for example). As we shall see in this paper, they commonly reuse needles (including disposable needles) after following minimal cleaning procedures which do not insure sterilization.

In his conclusion, Berkley points to the difficulty in calculating the attributable risk of HIV transmission by injection and calls for prospective studies of disease transmission. He cautions against the dangers of injection use irrespective of HIV transmission. Citing the case of HBV transmission from unsterile injections, he points out that HBV requires far less volume of virus and the presence of far less blood in injection paraphernalia to transmit the disease than is the case with HIV⁶. HBV is estimated to be 100 times more infectious than HIV. In India, it is calculated that there are over 42 million HBV carriers (5% of India's population) with the number of cases in India being eclipsed only by China⁷.

A study by Narendranathan and Philip (1993) has looked into the possible transmission of HBV through contaminated needle use in a government hospital setting in India⁸. In this setting, injection administration is high, injection equipment is limited and sterilization procedures are suboptimal⁹. Investigating several possible routes of HBV transmission during the course of detailed patient histories, these clinical epidemiologists found evidence suggesting that exposure to reusable needles was correlated with HBV. A significant odds ratio for exposure to reusable needles (OR: 3.9 for single injection, OR: 9.8 for multiple injections) was documented when comparing a HBV group to a matched hospital control group¹⁰. Notably, 67% of exposures to reusable needles were found to have occurred in the hospital itself with tetanus prophylaxis being a common reason for receiving an injection (personal communication)¹¹. This study joins others (McCarthy et al., 1989, Ko et al., 1991, Singh et al., 1998, Hutin et al., 1999) in suggesting that unsterile injection equipment may be a more important contributor to disease transmission than has previously been recognized.