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India's Vaccines Come With Risk

Dirty Needles Used for Immunization Can Spread Other Diseases

By Rama Lakshmi
Special to The Washington Post
Wednesday, February 9, 2005; Page A18

GUDAMB, India -- As soon as a rural health worker, Jayalakshmi Nair, walked into this village on a recent visit, she began encouraging women to bring their children to receive immunizations against such life-threatening diseases as tuberculosis and leprosy.

But as she set up a makeshift office with a table and chair in the courtyard of an elementary school, she knew that she could be spreading other illnesses.

Jayalakshmi Nair, an Indian health worker, administers a vaccine against leprosy and tuberculosis to a 3-month-old at a village immunization clinic. (Rama Lakshmi For The Washington Post)

By the time the mothers reluctantly lined up with wailing children in their arms, Nair had begun using a pot of water that had been heated over a wood fire to clean her reusable syringe. For two hours, Nair dipped used needles in the lukewarm water for a few seconds with her bare hands before re-using them.

"There is no power in the village most of the day. For sterilization we are supposed to carry kerosene and cooking stove with us to the villages," Nair said, capping the needles before she prepared to use them again.

"But for six months there has been no kerosene supply. So I have to make do with whatever I have," she said, acknowledging the risks associated with unsterilized equipment. "For me, immunizing the children is a bigger priority."

For shots against tuberculosis and leprosy, she used the same needle and glass syringe for each child, pausing between patients by briefly dipping the needle in the steel pot. For diphtheria shots, she changed the needle but used the same glass syringe for each injection without any attempt to sterilize the equipment.

Government-run immunization sites such as Nair's in the northern Indian state of Uttar Pradesh are a major danger zone for the spread of blood-borne infections such as Hepatitis B, Hepatitis C and HIV, according to a study funded by the World Bank last year. Nair is a government nurse in the state's Saharanpur district, where only 38 percent of the population has received immunizations, officials said. They have reported outbreaks of measles in the region almost yearly.

Officials said they expected a significant change with the decision to begin introducing auto-disable syringes in all of their immunization programs, starting this year.

The AD syringes, as they are known, are single-use injection devices that work by locking the plunger of the syringe after a dosage has been administered, making re-use impossible.

About 250 million to 300 million immunization injections are given in India every year and the switch from glass to AD syringes is being made despite a significant cost increase in India's immunization program, officials said.

"Protecting children by the right immunization device is central to increasing child survival rates in India," said Marzio Babille of UNICEF, which has used AD syringes in trial programs in India. "Introduction of AD syringes boosted demand for immunization by 20 percent in the villages we work in, because parents see that the shots are painless and safe," Babille said.

According to the World Bank-funded study conducted by a nongovernmental consortium, the Indian Clinical Epidemiology Network, or IndiaCLEN, about 65 percent of all injections in India are unsafe due to improper sterilization, syringe re-use or incorrect injection practices. And 69 percent of injections administered in government-run facilities were found to be unsafe.

Beset with the problems of irregular and inadequate supply of equipment, India's race to increase immunization coverage has often meant taking shortcuts on safety procedures.

"India has one of the largest immunization programs in the world," with tens of thousands of sites, many of which use glass syringes, said Pradeep Haldar, a Health Ministry official. "Monitoring each site is impossible. Injection safety has been compromised because sterilization is a cumbersome, time-consuming process."

The World Health Organization estimates that at least 50 percent of the world's 16 billion injections administered each year are unsafe, posing serious health risks.

"Irrational injections and wrong injection practices are rampant," said Narendra Arora, the team leader of the IndiaCLEN study. "Many give injections over the patient's shirt, touch the injection with their hands or wipe it with a swab." He said training programs against such practices would soon be introduced in medical colleges.

A recent study by a New Delhi-based environment group, Vatavaran, found that about 40,000 plastic syringes were used daily in the capital's hospitals, but only 40 percent were disinfected and destroyed after use. The remainder were picked up from dumping sites, washed, repacked and resold, the report said.

The case of Khursheed Mustaqeem demonstrates the dangers of improper needle use. Mustaqeem, 26, said that her son, Faizan, 5, was diagnosed with HIV two years ago, even though she and her husband tested negative for the virus, which causes AIDS.

"I was shocked when the doctor told me Faizan got it through unsafe needles," she said, patting Faizan to sleep in her tiny one-room home in New Delhi.

Her son has been receiving antiretroviral drugs for a year.

"My son cannot play marbles on the street like other boys. He just watches them from the window," she sighed. "Now I dread all hospitals and all needles. God knows what dangerous disease I will bring back home."

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