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Frequency of Vaccine-Related and Therapeutic Injections -- Romania, 1998

In Romania and other countries, therapeutic injections have been associated with transmission of hepatitis B and C viruses, human immunodeficiency virus type 1 (HIV-1), and other bloodborne pathogens (1-6). During 1997-1998, acute hepatitis B was associated with recent injections in Romanian children aged less than 5 years (3). Injection-associated bloodborne pathogen transmission occurs when infection-control practices are inadequate, and overuse of injections to administer medications might increase opportunities for transmission. To estimate the frequency of therapeutic injections and to describe the attitudes and practices of adults about injections to administer medications, local health departments in Romania surveyed the general population of four districts (Hunedoara, Iasi, Mures, and Prahova {1997 combined population: 2.8 million}) in June 1998. This report summarizes results from these surveys, which indicate that injections are used frequently to administer medications in Romania.

A cluster sample of 300 households in each of the four viral hepatitis sentinel surveillance districts was surveyed, totaling 1200 households (7). All household members, or adult guardians for children aged less than 15 years, were interviewed in person to collect information about age, sex, and number of vaccine-related or therapeutic injections received during June 1, 1997-May 31, 1998. To evaluate attitudes and practices regarding therapeutic injections among adults, one randomly selected person aged greater than or equal to 18 years in each household was interviewed. Therapeutic injections were defined as injections or infusions administered through intradermal, subcutaneous, intramuscular, or intravenous routes and not given for vaccination or recreational drug use.

Of the 3676 survey participants (mean age: 38 years; range: 0-98 years; 48% male), 365 (10%) reported receiving at least one vaccine-related injection (median: two injections; range: one-15 injections) for a total of 988 injections; this proportion was inversely related to age, with 60% of children aged less than 5 years and 2% of persons aged greater than or equal to 45 years receiving vaccine-related injections (Table_1). At least one therapeutic injection (median: eight injections; range: one-735 injections) was reported by 1334 (36%) participants for a total of 19,630 injections. The proportion of participants who reported receiving a therapeutic injection did not vary significantly across all age groups but was lower for males than for females (prevalence ratio=0.8; 95% CI=0.7-0.9) (Table_1). Of the 19,630 therapeutic injections, 643 (3%) were intravenous infusions, and 18,987 (97%) were other injections. Most (18,249 {96%}) of these other injections were administered by health-care workers; of these, 11,020 (56%) were administered in outpatient clinics or in homes, 6236 (32%) in hospitals, and 993 (5%) in dental settings.

Of the 1197 persons aged greater than or equal to 18 years (mean age: 49 years; range: 18-95 years; 45% male) interviewed about attitudes and practices regarding therapeutic injections, 891 (74%) believed injectable medications were "stronger" than oral medications. A smaller proportion preferred injected over noninjected medications to treat fever (28%), "common cold" (29%), diarrhea (17%), and for vitamin supplementation (42%) (Table_2). In addition, 32% of the participants indicated they would ask their physician for an oral medication if an injection were prescribed, and 10% stated they would ask their physician for an injectable medication if an oral medication were prescribed (Table_2). Syringes were reported in 46% (95% Confidence interval {CI}=42%-51%) of households, of which 96% (95% CI=94%-98%) were new disposable syringes.

Reported by: O Sfetcu, D Cremenasiu, S Circiumaru, Hunedoara Health District; M Barhala, R Florescu, E Duca, Iasi Health District; A Cojan, E Marialaky, MM Yanku, Mures Health District; M Irimia, A Dobrescu, Prahova Health District; M Popa, N Ion-Nedelcu, D Craciun, Dept of Preventive Medicine, Ministry of Health, Romania. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

Editorial Note

Editorial Note: By extrapolating the findings in this survey to the population of Romania (1997 population: 22.5 million), an estimated average of 5.3 therapeutic injections are administered annually per capita, and approximately 120 million therapeutic injections are administered each year. For each vaccine-related injection, survey respondents received 20 therapeutic injections.

In Romania, a substantial proportion of adults preferred injected medication for treatment of conditions for which injections generally are not indicated, including fever, acute upper respiratory tract infection, vitamin supplementation, and diarrhea. However, this proportion did not exceed 42% and suggests that Romanians may not insist on injectable medications for common illnesses. In other countries, reasons reported for demand for therapeutic injections include beliefs that the pain of the injection is a marker of efficacy, that medications are more effective when entering the body percutaneously, and that injections represent advanced technology (8).

In addition to patient preference for injections, physicians' prescribing practices also might affect the observed high use of therapeutic injections. In other countries, reported reasons for overuse of injections by health-care providers include a desire to observe therapy, belief that efficacy is greater when medications are injected, and occasionally, financial incentives to use injections (8). Population focus groups conducted in 1998 in Romania indicate that patients trust their physicians' advice about medical treatments and would not seek a second opinion if an injection were not prescribed (CDC, unpublished data, 1998). Additional information is needed on the determinants of physicians' prescribing practices in Romania to promote the use of alternatives to injected medications.

The findings in this report are subject to at least two limitations. First, review of survey participants' medical records could not be used to validate self-reports of injections. Participants' inability to recall accurately the number of injections received during the 12-month referent period, particularly participants who had been hospitalized, may have led to underestimation of the total number of injections received. Second, data are from only four districts in Romania and may not be representative of the entire country.

Because knowledge about and sufficient resources for proper infection-control practices for safe injections are limited in Romania (CDC, unpublished data, 1998), overuse of therapeutic injections increases opportunities for bloodborne pathogen transmission among patients. Accordingly, programs to improve injection safety should focus on reducing the number of therapeutic injections administered. Such programs might be developed more effectively if initial studies are conducted to estimate the frequency of injections in the population and identify determinants of injection use among patients and health-care providers.


  1. Kane M. Unsafe injections. Bull World Health Organ 1998;76:99-100.

  2. Hutin YJF, Harpaz R, Drobeniuc J, Favorov M, Shapiro CN, Woodruff BA. Transmission of hepatitis B virus in Moldova: association with injections given in different health care settings. Presented at the 37th meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. Toronto, Ontario, Canada, September 1997.

  3. Hutin YJF, Craciun D, Ion-Nedelcu N, Mast EE, Alter MJ, Margolis HS. Using surveillance data to monitor key aspects of the epidemiology of hepatitis B virus (HBV) infection in Romania. Presented at the 36th annual meeting of the Infectious Disease Society of America. Denver, Colorado, November 1998.

  4. Hyams KC, Mansour MM, Massoud A, Dunn MA. Parenteral antischistosomal therapy: a potential risk factor for hepatitis B infection. J Med Virol 1987;23:109-14.

  5. Mohamed MK, Hussein MH, Massoud AA, et al. Study of the risk factors for viral hepatitis C infection among Egyptians applying for work abroad. J Egypt Public Health Assoc 1996;71:113-42.

  6. Hersh BS, Popovici F, Jezek Z, et al. Risk factors for HIV infection among abandoned Romanian children. AIDS 1993;7:1617-24.

  7. Bennett S, Woods T, Liyanage W, Smith D. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat Q 1991;44:98-106.

  8. Reeler AV. Injections: a fatal attraction? Soc Sci Med 1990;31:1119-25.

    Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
    TABLE 1. Number and percentage of survey participants who reported receiving an
    injection during June 1, 1997-May 31, 1998, by sex, age, and type of injection --
    Hunedoara, Iasi, Mures, and Prahova districts, Romania
                                              Vaccination               Therapeutic
                             No.       -----------------------    --------------------                                    c
    Characteristic      participants   No.    (%)    (95% CI*)    No.   (%)   (95% CI)
     Male                  1755        167   ( 9)    ( 8%-11%)    571   (32)  (29%-36%)
     Female                1911        196   (10)    ( 8%-12%)    762   (40)  (37%-43%)
    Age group (yrs)+
     0- 4                   202        123   (60)    (53%-67%)     78   (38)  (30%-46%)
     5-14                   442        119   (27)    (22%-32%)    111   (25)  (19%-31%)
    15-44                  1589         88   ( 5)    ( 4%- 7%)    582   (37)  (33%-40%)
     >=45                  1441         35   ( 2)    ( 1%- 3%)    563   (39)  (36%-42%)
    Total                  3676        365   (10)    ( 8%-11%)   1334   (36)  (33%-39%)
    * Confidence interval.
    + Because of missing data, numbers may not add up to total.

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    Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
    TABLE 2. Demographic characteristics and preference for injectable medications for
    common illnesses among persons aged >=18 years -- Hunedorara, Iasi, Mures, and
    Prahova districts, Romania, 1998*
    Characteristic                          No.     (%)   (95% CI+)
     Men                                    534    (45)      --
     Women                                  662    (55)      --
    Age group (yrs)
     18-34                                  309    (26)      --
     35-49                                  338    (28)      --
     50-64                                  292    (24)      --
       >=65                                 258    (22)      --
    Preferred injectable medications for
     Fever                                  340    (28)   (25%-33%)
     Common cold                            348    (29)   (25%-33%)
     Diarrhea                               210    (17)   (15%-20%)
     Vitamin supplementation                504    (42)   (37%-47%)
    Would request oral medications
     from physician if injectable
     medications were prescribed            381    (32)   (28%-35%)
    Would request injecting medications
     from physician if oral medications
     were prescribed                        125    (10)   ( 8%-13%)
    * n=1197.
    + Confidence interval.
    & Because of missing data, numbers may not add to total.

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