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Injection Practices Among Nurses --- Vâlcea, Romania, 1998

Please note: An erratum has been published for this article. To view the erratum, please click here.

In the early 1990s, human immunodeficiency virus (HIV) infection associated with possible reuse of syringes and needles was reported among children in Romanian orphanages (1). These findings led health-care workers to use new disposable syringes and needles for administering injections. By the late 1990s, reports suggested that new disposable syringes and needles had become standard for all injections. However, surveillance data collected by the Romanian Ministry of Health (MoH) during 1997--1998 indicated that acute hepatitis B virus (HBV) infection was associated with receiving injections among children aged <5 years (2). In Romania, injection frequently is used to administer medication, and nurses administer most injections (3). To identify the practices that might have resulted in injection-associated HBV transmission, selected clinic and hospital nurses were surveyed. This report summarizes the findings of the survey, which indicated that although nurses used new disposable syringes and needles, other inadequate infection-control practices might explain injection-associated HBV transmission. Results of the survey were used by the Romanian Coalition to Prevent Nosocomial Infections to prepare standards for injection safety to protect patients and health-care workers from HBV infection.

A systematic sample of every ninth nurse on the Vâlcea District nursing payroll was selected to be interviewed about knowledge and practice of infection control and bloodborne pathogen transmission during injection administration. Interviews were conducted during October 1998 using a standardized questionnaire. Information collected included demographics, work history, type of practice and injection administration knowledge, attitudes, and procedures.

Of the 1906 nurses on the payroll, 212 (11%) were included in the sample; 180 (85%) agreed to be interviewed. Of the 180, 164 (91%) were female; the mean age was 40 years (range: 23--61 years), and the mean number of years of practice was 20 (range: 1--42 years). Awareness of universal precautions to prevent bloodborne pathogen transmission was reported by 99% of respondents; 161 (91%; 95% confidence interval [CI]=86%--96%) of 177 respondents reported attending at least one training session on universal precautions. No respondent reported reusing syringes or needles on different patients; seven (4%; 95% CI=2%--8%) reported that they would reuse a syringe or needle on the same patient only in an emergency; 112 (62%; 95% CI=55%--69%) were unaware that HBV remains infectious in the environment for up to 1 week, and 78 (53%; 95% CI=44%--61%) of 148 reported that their work locations did not have an area for preparing injections that was separate from where blood and blood-contaminated objects might be handled. Seven (4%; 95% CI=2%--8%) were aware that following a needlestick the risk for transmission from an infected patient was greater for HBV infection than for HIV infection; 148 (82%; 95% CI=76%--87%) reported at least one incident of lacerating a finger while opening glass medication ampules to prepare injections. Shortages of infection-control supplies, including puncture-proof sharps containers, disinfecting solutions, and single-use gloves, were reported by 128 (72%; 95% CI=65%--79%) of 177, 95 (53%; 95% CI=45%--60%), and 84 (60%; 95% CI=51%--68%) of 141 respondents, respectively.

To validate the survey results, unannounced visits were made to four outpatient clinics and all wards of five hospitals to observe nurses' injection practices and adherence to universal precautions. In outpatient clinics, patients usually provided their own new disposable syringes and needles, and MoH provided clinics with new disposable syringes and needles for recommended vaccinations. However, this sterile equipment might have become contaminated with blood before use (e.g., blood specimens were collected in open wide-mouthed vials that were handled and placed on tables where injections were prepared, needles were placed in multidose vials to serve as access ports, and finger lacerations were left uncovered before preparing or administering injections).

Reported by: D Popesu Chisevescu, I Mihailescu, G Popaza Mihailescu, L Pasat, Vâlcea Public Health Direction, Vâlcea; N Ion-Nedelcu, Bucharest Public Health Direction, Bucharest; MI Popa, Ministry of Health, Romania. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

Editorial Note:

Overuse of injections and unsafe injection practices may lead to large-scale transmission of bloodborne pathogens (4). Although most injection-associated bloodborne pathogen transmission in health-care facilities can be attributed to reuse of unsterilized syringes and needles, results of this investigation suggest that this practice is likely to be rare in Romania. However, inadequate infection-control practices might explain injection-associated bloodborne pathogen transmission.

In 1998, almost all Romanian adults were aware of the risk for HIV infection associated with the reuse of syringes and needles (3). Patients either provided their own equipment or observed the opening of the package containing a new needle and syringe before receiving an injection (CDC, unpublished data, 1998). However, injections prepared in areas potentially contaminated with blood, multidose vial mishandling, and inadequate supplies were reported by nurses and validated by observation. In the United States, similar practices have been associated with HBV transmission in hemodialysis settings, in which frequent percutaneous exposures in a population with a high prevalence of chronic HBV infection may facilitate nosocomial HBV transmission (5,6). In Romania, where chronic HBV is endemic (7) and injections are often used to administer medication (4), these practices might explain injection-associated HBV transmission in the absence of syringe and needle reuse. Because most of the nurses interviewed were unaware that HBV persists in the environment for at least 1 week (8) and that the risk for transmitting HBV through injections can be up to 100 times greater than the risk for transmitting HIV (9), the nurses might not have perceived the risks for HBV transmission associated with these practices.

The findings in this report are subject to at least two limitations. First, logistic and resource constraints limited the survey to one district; however, reports suggested that nurses in Vâlcea had similar education and experience compared with nurses in other Romanian districts. Second, survey results were validated by observing nursing practice in clinics and hospitals. Because the nurses were aware they were being observed, behavior might have been modified.

In 1999, the Romanian Coalition to Prevent Nosocomial Infections held a multidisciplinary conference to define standards of injection safety. Recommendations included establishing dedicated areas for injection preparation, appropriately handling multidose vials, placing puncture-proof sharps containers in each room where injections are given, and covering lacerations. An integrated information, education, and communication campaign based on these recommendations and targeting patients and health-care workers was launched and an evaluation of the intervention is being planned. Activities conducted by government and nongovernment organizations aimed at achieving safe and appropriate use of injections are being facilitated by the Safe Injection Global Network (SIGN). Additional information is available from the SIGN secretariat, Department of Blood Safety and Clinical Technology, World Health Organization, 20 Avenue Appia, CH 1211, Geneva 27, Switzerland, or from the World-Wide Web,


  1. Hersch BS, Popovici F, Jezek Z, et al. Risk factors for HIV infection among abandoned Romanian children. AIDS 1993;7:1617--24.
  2. 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. Poster presented at the 36th annual meeting of the Infectious Disease Society of America, Denver, Colorado, November 1998.
  3. CDC. Frequency of vaccine-related and therapeutic injections---Romania, 1998. MMWR 1999;48:271--4.
  4. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bul Wrld Hlth Org 1999;77:789--800.
  5. Snydman DR, Bryan JA, Maon EJ, Gregg MB. Hemodialysis-associated hepatitis: report of an epidemic with further evidence on mechanisms of transmission. Am J Epidemiol 1976;104:563--70.
  6. Alter MJ, Ahtone J, Maynard JE. Hepatitis B virus transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Med 1983;99:330--3.
  7. Woodruff BA, Popovici F, Beldescu N, Shapiro CN, Hersh BS. Hepatitis B virus infection among pregnant women in northeastern Romania. Int J Epidemiol 1993;22:923--6.
  8. Bond WW, Favero MS, Peterson NJ, Gravelle CR, Ebert JE, Maynard JE. Survival of hepatitis B after drying and storage for one week. Lancet 1981;1:550--1.
  9. Gerberding JL. Incidence and prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and cytomegalovirus among health care personnel at risk for blood exposure: final report from a longitudinal study. J Infect Dis 1994;170:1410--7.

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