(1996; 157 pages)
6.2.1 Hygienic practices in Uganda
A serious problem with regard to hygienic practices in Uganda is the home possession of personal injection equipment which is either used at home or carried to provider facilities when seeking injection treatment. Private practitioners encourage this practice not only to keep the cost of injection use as low as possible, but also to avoid any blame that may arise regarding the unhygienic administration of injections. As a consequence of the popular concern with the spread of HIV through communally shared needles and syringes in public health facilities, and the distribution of injection equipment to the users by private and non-formal providers, personal appropriation of needles and syringes is now very common in Uganda (Figure 16). In Busoga, 63% of the households (227/360) visited kept needles and syringes at home. The figure for Ankole was significantly higher, 82% of the households (297/360) owned needles and syringes (**p=0.001). Only a limited number of households were in possession of injectables at home, as a 'first aid medication': in Busoga 21% (77/360) and in Ankole 34% (121/360) (**p=0.001).
Figure 16. Home possession of injection equipment and injectables (Household survey - Uganda)
N = all households
Busoga n=360; Ankole n=360
Experience with complications of injections
Administration of injections without proper sterilization procedures would lead to increased risks of transmitting a range of potentially serious pathogens, including hepatitis B, the occurrence of abscesses and the provocation of poliomyelitis. The prevalence of hepatitis B is difficult to establish in household studies, but incidence of injection abscesses may serve as an important indicator of hygienic conditions in health facilities (Soeters & Aus 1989). In Uganda it was revealed that a significant number of households had experienced complications from injections31. Of the 360 households visited in Busoga, 155 (43%) indicate that they experienced injection complications at some time. Of these, 133 households (37%) had experiences with injection abscesses, 14 (4%) reported cases of allergy, while 8 households (2%) reported lameness. Some of the popular ideas about cause of complications seem to diverge from the biomedical explanatory models which emphasize hygiene or inappropriate injections. If complications occur, respondents relate these not to lack of hygiene or inappropriate injectable solutions, but to personal qualities of the provider. Complications are thought to be the result of the 'bad hand' of a provider (Birungi 1994a/b).
31Data is only available for Busoga, not for Ankole.
All providers in the Ugandan study denied 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. The major fear about injection use, however, is the contraction of AIDS. Most of the users (and providers) are not scared, or even bothered, about infections arising out of poor methods of injection, handling, storage or the contraction of other diseases such as hepatitis.
Injection equipment in health facilities
The Ugandan government recommends the use of reusable equipment only. With the co-sponsorship of large donors such as the Danish Red Cross and UNICEF, the Ministry of Health now provides only reusable injection equipment to its units for both curative and immunization services. These are provided together with paraffin, sterilizers, training and logistics for supervision by senior health care managers. Private pharmacies and drugshops act as the significant sources of disposable injection equipment to providers and users.
The reusable equipment observed was mainly plastic. A few glass syringes were also identified both in provider facilities and in users' possession. However, the distinction between reusable and disposable equipment was not made by the majority of providers and users who treat all equipment as reusable. Some providers maintained that some disposable equipment, especially syringes, may outlive reusables. This removes the boundary between reusable and disposable.
The mistrust in the effectiveness of 'communal sterilization' is evident in both patients and health providers. It is common practice, particularly in the semi-rural and remote communities, for patients to contact the provider for the injectable and then arrange for the injection to be administered at home. In other cases, patients bring along their used equipment on an index visit to the provider. Based on observations at provider facilities, an estimated sixty percent of the patients brought their own personal equipment with them to the clinic. Nearly all provider facilities sell equipment to patients with injection prescriptions at the index visit. In one of the urban private clinics, needles were sold to patients at each subsequent visit; these would then be applied to an old syringe which the patient brought along. The rationale to this practice was that the syringe offered little chance of transferring contamination as compared to the needles. This contrasted with the semi-rural and remote government health centres which offered only needles for sale to the patient while syringes were provided by the health centre. Government health centres are sometimes provided with more needles than syringes.
In Ankole, out of the 14 provider facilities visited which administered injections at the time of the visit32, 72% did not observe minimum hygienic conditions before injection administration, while 50% and 64% respectively did not observe minimum hygienic conditions during and after injection administration (Figure 17).
32In Ankole, sixteen providers were included in the providers study. Two did not administer injections at all during the visit of the researchers. Here, they are excluded because their hygienic practices could not be assessed. The remaining 14 provider facilities in Ankole were: 2 government hospitals; 10 private clinics and 2 drug shops (informal providers). See Table 12, Appendix 2.B.
The poor hygienic practices include the use of saucepans instead of sterilizers, picking up the boiled needles and syringes with bare hands, the improper disposal of needles and syringes or giving the equipment to the patient to carry home. The providers who fall below standards in the category 'before injecting' are those who use saucepans as sterilizers and encourage patients to keep and sterilize their own equipment at home. Those who fall under the category 'during injecting' pick up the needles and syringes with their hands from the sterilizers/saucepans and/or use unsterilized swabbing material to clean the injection site. Those in the 'after injecting' category did not flush needles and syringes with water after use or took a long time before putting them back into the sterilizer/saucepan and/or reused disposable equipment.
In Busoga, the observations at 21 provider facilities33 show that 62% of the providers did not meet minimum hygienic standards before injecting, 48% did not meet minimum hygienic standards during injecting, and 81% did not meet minimum hygienic standards after injection (Figure 18).
33In Busoga, hygienic practices were assessed in 21 provider facilities, being 1 government hospital, 4 government health centres, 3 NGO health centres, 6 private clinics, 3 informal providers (drug shops) and 4 home providers of injections. See Table 12, Appendix 2.B.
Figure 17. Injection administration & hygiene (Percentage of providers NOT observing hygiene - Observation - Ankole, Uganda)
N = all providers who provided injection
Using WHO standards (Appendix 2A)
Figure 18. Injection administration & hygiene (Percentage of providers NOT observing hygiene - Observation - Busoga, Uganda)
N = all providers who provided injection
Using WHO and MOH standards (Appendix 2A)
All providers flush the injection equipment before sterilization using sterile or non sterile water. Sterilization through boiling was used by all providers. In the semi-rural and remote provider facilities, and in households, cooking pans were used for boiling the equipment. Providers instruct patients to boil the equipment prior to visiting their facilities. However, interviews with patients at the provider facilities indicate that boiling was not actually done by many patients. This fact was known to the providers but they continued using the equipment. Reusable injection equipment should be boiling for at least 20 minutes. Often, this time period is not observed. One itinerant injectionist in a remote community did not even allow the equipment to remain in boiling water for more than one minute before he reused it.
The frequency of boiling of equipment varies from facility to facility. However, the majority of established provider facilities boil their instruments once a day before patients start reporting in the morning. The same equipment is used on multiple patients, especially in the remote provider facilities. In the urban and semi-rural provider facilities where over 60% of the patients bring their own syringes and needles, quite a lot of equipment remains unused. These are sterilized again for use the following day. The busy provider facilities such as the hospital, NGO facilities and urban private clinics keep their boilers on throughout the busy hours (10 am - 2 pm). The used needles and syringes are flushed and immersed in the boiling water. Here, it is difficult to distinguish between the equipment that had just been immersed in the water and that which had been boiling for the last 20 minutes.
Steam sterilization is employed only in those provider facilities offering immunization services. Portable steam sterilizers issued by UNICEF are utilized. The method is properly applied by the responsible units. From the users' point of view this sterilizing procedure is more acceptable than other methods employed in public health services - they witness the opening of the sterilizer.
Chemical sterilization was observed in one private clinic in an urban area. Hypochlorite 10% solution was used. The provider learnt from a medical review that it is effective against HIV and this was the major reason for applying it. Patient-owned equipment is flushed with the solution before washing with water. The facility-owned equipment is immersed in the solution for hours before boiling. This double sterilization, he says, has not failed the unit in preventing injection abscesses.
Although providers are often aware of the importance of washing their hands before administering an injection, none of the providers actually did so. Water and soap are not readily available in many facilities.
Drug reconstitution often presents a problem in the semi-rural and remote provider facilities. Sterile injection water needed for dissolving powder PPF or crystalline penicillin is in short supply. In some informal units and private units water sterilized by boiling is utilized. Since this is mainly underground water, it contains many dissolved ions rendering it unsuitable for this purpose. Another practice which was already mentioned involves the use of chloroquine to reconstitute PPF or crystalline penicillin. Some providers keep the reconstituted drugs beyond the recommended duration because they inject too few patients to empty the vials within a day. The alteration in the chemical structures and solubility may precipitate some particles which when injected form a nucleus for injection abscesses.
Cleaning of the injection site is done only at a few provider facilities. In the units where the injection site is cleaned, solutions used were not sterile - in most cases plain water is used, even in units provided with antiseptic solutions such as chlorhexidine. Patients are therefore at a high risk of contamination through the skin punctured wound. 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 informal ones, are in the habit of moistening the needle before injection administration with the aid of 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.
Biomedically trained providers do not apply their fingers to guide the needle into the skin, but this practice is very common among the non-biomedically trained providers who claim that many of the needles are blunt and could easily break if not guided with the assistance of their index finger. Since most of the needles used are brought along by patients, providers could only discover that the equipment is blocked during injection or when adjusting the volume of drug prescribed.
Use of the same equipment on multiple patients was observed in over 50% of the health facilities. The practice is most common among providers in government health units, informal facilities and home providers, especially in the semi-rural and remote communities. Here, the number of patients sometimes overwhelms the available syringes, needles, and fuel for sterilization. One of the aid posts in a remote community had only three syringes to treat an average of 15 patients daily and sterilization was carried out once daily only.
After withdrawal of the needle the injection site is always massaged with a cotton swab or by using bare fingers. In some of the established facilities the equipment is dismantled and placed in water in a kidney dish. In facilities where multidosing prevails, the piston and syringe are put in a separate container from that of the needles. The majority of needles presented by patients at provider facilities are uncapped. In all provider facilities visited used needles and syringes are left littered on the floors and tables of the injection rooms. Only a few health units have waste bins. The urban provider facilities dump this waste into communal skips where rubbish is scavenged by town destitutes. Since the needles are usually disposed uncapped, they pose a potential health hazard. In the semi-rural and remote provider facilities, final dumping was in the banana garden or a placenta pit where available. But in most instances used needles and syringes are never disposed; instead the providers give them to the users to carry home.
It is rather impossible to meet optimum hygienic standards in Uganda, due mainly to the personalization of injection equipment. This process fundamentally breaks the sterile chain as patients often present their personal, reused, disposable sets of needles and syringes at the provider facilities. There are also indications of use of the same equipment on multiple patients, poor disposal and inadequate sterilization both at home and at provider facilities. As a consequence, a high percentage of provider facilities in both regions do not meet the required minimum standards of hygiene at each stage of injection administration.
Following hygienic standards in injecting is not related to the level of training or to the discipline of the health worker. On the whole, NGO health facilities meet the highest hygienic standards. These units have cleaner environments than other provider facilities. Although drug and other supply inputs are essentially the same for the NGO and government facilities, the equipment, including fuel for sterilization, is better managed at NGO facilities.