The prescriber is required to inquire from the patients whether they have ever had skin itching, eruptions, or breathing problems following an injection. But this was in most instances omitted by the prescriber, though epinephrine was kept at the established facilities for use in case of anaphylatic shock. All providers deny witnessing any serious allergic reaction during their practice. It is difficult, however, to validate this information since the patients are normally discharged immediately after the administration of an injection, allowing no time for observation of reactions which are in most cases delayed. Meanwhile patients who experience reactions never report back to the provider; instead they would prefer consulting another provider.
None of the providers wash hands with soap prior to injecting. It should be noted that water and more so, soap, are not readily available in the semi-rural and remote facilities. The providers are aware of the importance of washing hands before injection administration.
Drug reconstitution often presents a problem in the semi-rural and remote provider facilities, Reconstitution would normally necessitate the use of sterile water to dissolve powder PPF or crystalline penicillin. Health units receiving drug kit supplies from UEDMP receive some limited supplies of injection water. Some of these supplies are illegally sold off to private and/or informal injection providers. In some informal units and private units water sterilized by boiling is utilized. But since this is mainly underground water, it contains many dissolved ions rendering it unsuitable for this purpose. Other, worse, practices which involve the use of chloroquine to reconstitute PPF or crystalline penicillin were also observed. Some patients request this mixture and indicate to the providers that their fever can only be cured by this kind of mixture. Some providers, especially the remote based facilities and home based ones, reconstitute drugs and kept them beyond the recommended duration because they injected too few patients to empty the vials within a day. The alteration in the chemical structures and solubility may precipitate some particles which form a nucleus for injection abscesses.
Prescriptions in urban and semi-rural facilities are in weights (mg) and these are converted to volume (ml) by the injection providers. This can be easily done in situations where the provider is biomedically trained. In remote and some of the semi-rural facilities prescriptions are in volume (ml); this allows for the non-biomedically trained providers to easily read off the calibrations on the syringes.
Cleaning of injection site
Cleaning of the injection site is done only at a few provider facilities. However, in some of the units, solutions used were not sterile - in most cases plain water is used, even in units provided with antiseptic solutions e.g. chlorhexidine by the UEDMP. This inappropriate cleaning of the injection site is especially problematic for rural children, who play outside, often naked, and who are likely to have dirt on their skins. Children form a considerable proportion of patients and are therefore at a high risk of contamination through the skin puncture.
Disinfection of drug vial neck
Disinfection of drug vial necks or rubber tops is not done at any of the provider facilities. In units using 500 ml bottles of injection water the bottles last for three to five weeks. Without disinfection this may serve as a source of contamination for many patients served from this bottle.
Some providers, especially the non-formal ones, are in the habit of moistening the needle before injection administration with the aid of a water soaked cotton wool. This provides a possibility of transferring germs from the unsterile water and fingers to the needle. Some of those providers who moisten needles before use claim that it assists to remove the dirt which the wrapping material from home may have imparted on the needle. A majority of providers, however, avoided touching the needle. While fixing the needle, they would touch the adapting receptacle of the syringe.