Community-Based Safe Injection Initiatives - Nepal

Advocacy efforts will involve the development of a close working relationship with a wide variety of local partners to increase understanding of injection safety issues and to facilitate their active involvement in problem-solving and action related to those issues. There will be a special focus on creation of local policies and social norms conducive to increased injection safety.

In addition, there will be behaviour change interventions for injection providers and consumers. Specifically, educational outreach and service provider training initiatives will build on already high levels of awareness of injection safety problems (as documented in GWP studies), but with a special focus on ways in which relatively simple changes in behavior can dramatically reduce risk to providers, consumers, and the general community.

Finally, local solutions for safe disposal of contaminated sharps and other medical waste will be developed through the building of sustainable systems for distribution of locally procured (or produced) "safety boxes" (sharps containers) and safe collection and disposal of the boxes. When possible, those systems will result in complete destruction of the boxes and their contents in hospital incinerators. The project team anticipates close collaboration with the needle exchange efforts of the "Nepal Initiative" to fight HIV/AIDS.

As the project progresses, the team will document all phases of the process to the end of accomplishing the global dissemination of lessons learned. These will be disseminated through electronic and print publications and in international meetings.

Health, Environment, Immunisations & Vaccines.

Recent data (Wittet and Bhattarai 2000, Bhattarai et al. 2001, Nygard and Fitzner 2002) indicate that injection safety and environmental pollution with contaminated sharps constitute a serious problem in Nepal. Some of the key issues documented in those studies include:

• Injections commonly are given in Nepal by individuals with little or no formal medical training;
• injections commonly are given for health problems better addressed through improved nutrition ("women's weakness"), through use of oral medications (certain infections, muscle pain), or for which medications are not effective (colds and flu);
• injections, minor surgeries (lancing boils, dental procedures, etc.), and unnecessary intravenous infusions commonly are given in an unsafe manner, i.e. without use of sterile equipment or without checking for allergies to medications;
• injection providers and consumers report having observed adverse consequences following injection including abscesses, amputation, and death;
• unsafe handling of injection equipment and other sharps and needle prick incidents among injection providers are common;
• contaminated injection equipment is typically found in the environment, where it is easily accessible by children, people working in the fields, and others;
• injection equipment often is collected by junk dealers, most likely for repackaging without sterilization;
• generally there are no systems in place for safe disposal and destruction of contaminated medical waste, especially outside of large hospitals;
• injection providers in both public and private sectors contribute to this public health and environmental crisis; and
• many injection providers and consumers understand the dangers of cross-infection and what should be done to avoid it, but their behaviors are inconsistent with their knowledge.

Data from other countries show that these problems are not unique to Nepal. However, the project team reported finding little documentation of successful injection safety initiatives, and fewer descriptions of effective and practical interventions. A recent call for "clever local solutions" to injection safety and sharps disposal problems, communicated worldwide through online fora such as SIGNpost and Technet, resulted in very few responses. Hence the need to experiment with, document, and disseminate community-based solutions to injection safety problems. The project team suspects that successful local solutions from Nepal may be effective in other countries as well.

GWP has a long history working with communities in Nepal's Central Region to reduce HIV infection, including promoting injection safety.