Hazards of injectable therapy

Development of microparticles for oral administration of Periplaneta americana extract to treat ulcerative colitis

Ulcerative colitis (UC) is a chronic disease, which can result the inflammation of the rectum, mucosa of the colon, and submucosa. The active component such as polypeptide in Periplaneta americana, which is one of the most common insects in the nature, can be extracted to treat UC. However, the active components in Periplaneta americana extract (PAE) can be degraded in the stomach due to its extreme acidic environment and enzyme. In this study, we developed a pH-dependent drug delivery method using polymer cellulose acetate (Eudragit S100) as a carrier to deliver high concentration PAE to inflamed colon. Both in vitro and in vivo results showed the PAE-Eudragit-S100 could treat UC through delivering active drug components to colon without degradation.

The Arabidopsis defensin gene, AtPDF1.1, mediates defence against Pectobacterium carotovorum subsp. carotovorum via an iron-withholding defence system

Plant defensins (PDFs) are cysteine-rich peptides that have a range of biological functions, including defence against fungal pathogens. However, little is known about their role in defence against bacteria. In this study, we showed that the protein encoded by ARABIDOPSIS THALIANA PLANT DEFENSIN TYPE 1.1 (AtPDF1.1) is a secreted protein that can chelate apoplastic iron. Transcripts of AtPDF1.1 were induced in both systemic non-infected leaves of Arabidopsis thaliana plants and those infected with the necrotrophic bacterium Pectobacterium carotovorum subsp. carotovorum (Pcc). The expression levels of AtPDF1.1 with correct subcellular localization in transgenic A. thaliana plants were positively correlated with tolerance to Pcc, suggesting its involvement in the defence against this bacterium. Expression analysis of genes associated with iron homeostasis/deficiency and hormone signalling indicated that the increased sequestration of iron by apoplastic AtPDF1.1 overexpression perturbs iron homeostasis in leaves and consequently activates an iron-deficiency-mediated response in roots via the ethylene signalling pathway. This in turn triggers ethylene-mediated signalling in systemic leaves, which is involved in suppressing the infection of necrotrophic pathogens. These findings provide new insight into the key functions of plant defensins in limiting the infection by the necrotrophic bacterium Pcc via an iron-deficiency-mediated defence response.

Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices

The rapid uptake of the hypodermic syringe as a medical technology by physicians in Europe and America since its introduction in the middle of the 19th century has led to a level of medical and public acceptance seldom reached by other therapeutic techniques. Presently, the developed world has clear guidelines regarding injection use and safety; in contrast, developing countries are facing the brunt of risks associated with the use of this technology, which was introduced into their societies during the early 20th century. There is now a popular demand for injections, and an alarming number of unnecessary and unsafe injections are being administered. The problem of unsafe injections is not restricted to curative injections, but includes immunizations too. The association of unsafe injections and infection transmission is quite clear, and there is an urgent need to reduce the number of required injections and make them safe. An understanding of the determinants of current injection practices in the socio-cultural-economic context is necessary in order to plan relevant and effective interventions.

Long-term improvement in unsafe injection practices following community intervention

BACKGROUND

A study in 1994 identified frequent unsafe injections as the cause of widespread hepatitis C virus infection in Hafizabad, Pakistan. A simple low cost community education program was assessed to see if it improved injection safety.

METHODS

A local health organization developed educational materials on hepatitis C including advice on how to avoid unnecessary injections and, when injections were necessary, to use a new syringe and needle. Beginning in 1995, this advice was communicated through multiple channels including health education meetings, announcements in mosques, and via pamphlets. In 1998 study workers revisited controls from the 1994 case-control study (along with three of their neighbors of a similar age) to collect information on injection practices in the previous 12 months.

RESULTS

Thirty-three percent of the study's participants in 1998 received >or=5 injections in the preceding 12 months compared to 40% of the hepatitis C virus negative controls reported in the year prior to the 1994 study (p=0.85). In 1998 52 persons (34%) brought their own syringe for their most recent injection, a practice that was unreported in 1994. Overall, in 1998 59% of patients received their most recent injection with a new syringe and needle compared to 24% in 1994 (p=0.003).

CONCLUSIONS

Following this low cost health communication effort, community members took steps to protect themselves from unsafe injections.

Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates

OBJECTIVE

To describe injection practices worldwide in terms of frequency and safety.

DESIGN

Literature review. The global burden of disease project of the World Health Organization defined 14 regions on the basis of geography and mortality patterns. Data sources included published studies and unpublished WHO reports. Studies were reviewed by using a standardised decision making algorithm to generate region specific estimates.

SETTING

Healthcare facilities, both formal and informal.

DATA SOURCES

General population and users of healthcare facilities.

MAIN OUTCOME MEASURE

Annual number of injections per person and proportion of injections administered with syringes or needles, or both, reused in the absence of sterilisation.

RESULTS

The analysis excluded four regions (predominantly affluent, developed nations) where reuse of injection equipment in the absence of sterilisation was assumed to be negligible. In the 10 other regions, the annual ratio of injections per person ranged from 1.7 to 11.3. Of these, the proportion administered with equipment reused in the absence of sterilisation ranged from 1.2% to 75.0%. Reuse was highest in the South East Asia region "D" (seven countries, mostly located in South Asia), the eastern Mediterranean region "D" (nine countries, mostly located in the Middle East crescent), and the western Pacific region "B" (22 countries). No information regarding injection safety was available for Latin America.

CONCLUSIONS

Overuse of injections and unsafe practices are still common in developing and transitional countries. An urgent need exists to use injections safely and appropriately, to prevent healthcare associated infections with HIV and other bloodborne pathogens.

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

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.

Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania

OBJECTIVE

To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes.

METHODS

In 1991, 66 randomly selected health units in Mwanza Region, Tanzania, were visited and factors were determined that might contribute to HIV transmission by injections. In a workshop with all senior health workers from the region, findings were presented and treatment and sterilization guidelines developed. Thereafter, seminars were held at each health centre of the region. Four months after the intervention, data were collected at the same health facilities in order to assess changes in prescribing practices, sterilization procedures, and sterility of needles and syringes.

RESULTS

The knowledge on indications for injections improved markedly for paramedical staff. The proportion of outpatients receiving an injection dropped from 23% to 10% and the proportion of patients receiving an avoidable injection dropped from 16% to 6%. Procedures for sterilization, keeping sterilized equipment, and administration of injections improved. A smaller proportion of sterilized needles and syringes tended to be contaminated in dispensaries, but this reduction from 44% to 22% was not significant.

CONCLUSION

Considerable improvement in knowledge, prescription practices and sterility procedures was observed at dispensary level after carrying out a training programme.

Injection practices in Mwanza Region, Tanzania: prescriptions, patient demand and sterility

This paper describes prescription and sterilization practices in Mwanza Region, Tanzania, before the introduction of interventions aiming at reducing HIV transmission by injections. Sixty-six health facilities from Mwanza Region were included in the study. Data were collected in interviews and questionnaires, through structured observation, bacteriological culture and record analysis. Criteria for avoidable injections were based on recommendations of the Essential Drugs Programme and on a regional consensus workshop. One in 4 out-patients received an injection 70% of which were avoidable. Most were given for acute respiratory infections, skin diseases and urinary tract infections. Forty per cent of cultures taken from sterilized needles and syringes yielded growth of microorganisms. Of 120 patients interviewed most preferred to be treated with injections for almost any complaint. Patient demand for injections was felt to be a problem in 85% of the health facilities and may have contributed to overprescription of injectables. Consensus treatment and sterilization guidelines as well as a health education programme were developed and introduced to all health workers through seminars.

Acquired immunodeficiency syndrome in Romania

After the initial description of acquired immunodeficiency syndrome (AIDS) in Romania in late 1989, national AIDS case surveillance was established with a modified version of the World Health Organisation (WHO) clinical case definition. This modified case definition requires that AIDS cases have both clinical and serological evidence of human immunodeficiency virus (HIV) infection. Before December, 1989, Romania had reported 13 AIDS cases to WHO. By Dec 31, 1990, 1168 AIDS cases were reported to Romania's Ministry of Health, of which 1094 (93.7%) occurred in children less than 13 years of age at diagnosis. Of these, 1086 (99.3%) were in infants and children less than 4 years of age, and 683 (62.4%) in abandoned children living in public institutions at the time of diagnosis. By Dec 31, 1990, 493 (45.1%) mothers of children with AIDS had been located and tested, and 37 (7.5%) were positive for HIV; 423 (38.7%) cases were in children who had received transfusions of unscreened blood, and 6 (0.5%) were in children with clotting disorders. HIV transmission through the improper use of needles and syringes is strongly suspected in most of the remaining 628 (57.4%) children with AIDS, most of whom had received multiple therapeutic injections. This outbreak demonstrates the serious potential for HIV transmission in medical facilities that intensively and improperly use parenteral therapy and have poor sterilisation technique.