May 23, 2019
Opinion: A safety-first approach to keeping patients and practitioners safe

By Gary Cohen, Renuka Gadde and Janine Jagger

At a time when universal health coverage (UHC) is an overriding goal for sustainable development, the well-being of health care workers must be prioritized. They are the indispensable life-savers in the health care equation. Without a sufficiently staffed, healthy, and protected workforce, can UHC be achieved?

For as long as we can trace, it has been the place of the medical provider to assume responsibility for the safety of patients in their care. Despite the peril inherent in providing care to the ill, there was no view that providers were entitled to protection of their own health and lives.

The change that finally occurred in the late 1980s was not a timid one. The advent of the HIV/AIDS pandemic and the first reports that identified caring for HIV/AIDS patients as a risk factor for contracting HIV led to palpable panic and pressure, applied by professional associations and unions, to engage policymakers with influence in health care settings.

Nothing short of a revolution swept through the medical device industry, resulting in the replacement of the most common and frequently used medical devices with an array of products reengineered for the single purpose of protecting health care personnel from injury and transmission of infectious pathogens.

In 2000, influential agencies, such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration, among others, were key actors in achieving change by introducing policies to protect health care workers from blood exposure.

A movement that came out of a tragedy

The top transmission route was identified to be injuries from needles or sharp instruments contaminated with blood from HIV positive patients, hence the focus on injury reduction from sharp medical devices as a primary prevention strategy. There were numerous factors that needed to be in sync to bring about this revolution.

The first of these, which everything else depended upon, was the engagement of the medical device manufacturers and their willingness to reengineer a host of the most commonly used devices, such as syringes and sharp surgical instruments, with safety features including protective shields for needles, and even eliminating the use of needles when possible.

Companies were being asked to “cannibalize” their own products, which in many cases was their core business. But instead of pushback from the manufacturers, there was a push forward.

Based on the mobilization to address sharp object injuries, and policy changes that facilitated adoption of safety designs in the United States and Western Europe, transition to these devices has occurred at a large scale. However, these achievements have fallen short in places where they are most needed: in low- and middle-income countries (LMICs) such as those in sub-Saharan Africa where the prevalence of HIV/AIDS and other bloodborne infections remains high.

Moving the needle in LMICs

Efforts are continuing to prompt larger scale transition to safety devices in LMICs. However, several factors have inhibited the transition to safety devices in these countries, despite substantial efforts to mobilize the same type of changes that have occurred in other regions.

Significant change is only likely to be seen when governments in LMICs enact the types of laws, regulations and guidelines that are needed to achieve transition at large scale. The following key factors will help drive transition and change with the ultimate goal of policy alignment:

Tackle stigma. Despite efforts to deploy surveillance systems to collect data on the incidence of sharp object injuries in LMICs, there is still significant stigma associated with reporting needlestick injuries in some countries, and so underreporting is a major challenge. What data is collected often has not been widely communicated or shared. It is necessary to reduce stigma in order to ensure sharps injuries are no longer overlooked.

Promote advocacy. Increase the opportunity for health workers, particularly nurses, to influence change. Some of the most vocal advocates for policy change in the U.S. were affected health care workers telling their stories.

Reframe the cost conversation. Safety-engineered needle devices cost more to manufacture than conventional needle devices, and therefore are more expensive to procure, though the gap between conventional and safety devices has reduced over time. However, the costs of complications, treatment, and loss of productivity due to needlestick injuries are not fully contemplated in this type of procurement decision.

The road ahead

The Ebola epidemic in West Africa in 2014 and the more recent resurgence of the disease underscores how important health care worker safety remains. It is estimated that two-thirds of health care workers who contracted Ebola due to exposure to infected patients in the three affected countries in 2014 — Liberia, Guinea, Sierra Leone — died as a result.

Safety-engineered needle devices for blood drawing and IV infusions were needed to protect health care workers from exposure to Ebola. In fact, BD donated devices valued at over $1 million in order to help protect health care workers.

In 2015, the World Health Organization issued new guidelines on injection safety. While WHO guidelines are taken very seriously in LMICs, movement to concrete policy and practice change at country level has been slow. Additionally, these guidelines only covered syringe and needle usage and did not cover devices such as blood drawing needles that are more likely to transmit infectious diseases from patient to health care worker.

Despite these additional barriers, efforts are continuing to achieve broader transition to safety devices in LMICs. Manufacturers are collaborating with leading public health agencies such as CDC to train health care workers in LMICs on safer sharps practices; new lower cost safety devices have been developed; and there is an ongoing effort to raise awareness of the need to protect health care workers from sharp object injuries.

Having a strong and vibrant health workforce is critical to keeping patients and communities safe and is essential to achieving UHC and fulfilling the UN Sustainable Development Goals tools and examples to promote health care worker safety are available, and we can no longer tolerate a trade-off of health care worker risk for the sake of patient care.

We should instead focus on driving a “safety first” approach for patients and practitioners.

For more coverage on patient and health care worker safety, visit the Safety First series here.

About the authors

Gary Cohen is executive vice president of global health and president of the BD Foundation at BD (Becton, Dickinson and Company), a medical technology company with 65,000 employees worldwide. He is also a board director of the CDC Foundation and UNICEF USA, board co-chair of GBCHealth, and board chair and founder of Together for Girls. He previously served on the UN Commission on Life Saving Commodities for Women and Children, and presently serves as chair of the CDC/Corporate Roundtable on Global Health Threats and on the Scientific Advisory Board of Grand Challenges Canada.

Renuka Gadde is vice president for global health at BD (Becton, Dickinson and Company). She provides leadership for BD’s global health initiatives primarily focusing on emerging and developing countries. Her responsibilities include extensive external engagement with ministries of health, international agencies, and nongovernment organizations, and significant internal engagement across BD's units, geographies, and functions in support of strategies, products, and programs that advance equitable access to health for all people.

Janine Jagger is an epidemiologist, professor of medicine, and Becton Dickinson professor of health care worker safety at the University of Virginia School of Medicine. She founded and directed the International Health Care Worker Safety Center at the University of Virginia. She informed a new generation of safety-engineered medical devices to reduce occupational transmission of bloodborne pathogens and was awarded U.S. patents for seven medical devices.


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