ANNEXURE IV
Universal Precautions WHO Guidelines

What it is
Universal precautions are simple infection control measures that reduce the risk of transmission of blood borne pathogens through exposure to blood or body fluids among patients and health care workers. Under the "universal precaution" principle, blood and body fluids from all persons should be considered as infected with HIV, regardless of the known or supposed status of the person. Improving the safety of injections is an important component of universal precautions.

Why it is Important
i. Any percutaneous or per mucosal exposure to blood or body fluids represent a potential source of HIV infection. These include skin-piercing procedures with contaminated objects and exposures of broken skin, open wounds, cuts and mucosal membranes (mouth or eyes) to the blood or body fluid of an infected person.
ii. Although they account for a minority of HIV infections, health care procedures represent a highly preventable source of HIV infection. Among health care associated sources of infection, unsafe injections are of particular concern, accounting for an estimated 3.9% to 7.0% of new infections worldwide. In addition, unsafe practices in hemodialysis and plasmapheresis centers have been associated with HIV transmission.
iii. Health care worker protection is an essential component of any strategy to prevent discrimination against HIV infected patients by health care workers.
iv. If health care workers feel they can protect themselves from HIV infection, they can provide better care.

How it is Done
1. Ensure Universal Precautions
i. Sterilizable injection should only be considered if single use equipment is not available and if the sterility can be documented with Time, Steam and Temperature indicators.
ii. Discard contaminated sharps immediately and without recapping in puncture and liquid proof containers that are closed, sealed and destroyed before completely full.
iii. Document the quality of the sterilization for all medical equipment used for per cutaneous procedures.
iv. Wash hands with soap and water before and after procedures; use of protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body fluids.
v. Disinfect instruments and other contaminated equipment.
vi. Handle properly soiled linen. (Soiled linen should be handled as little as possible. Gloves and leak proof bags should be used if necessary. Cleaning should occur outside patient areas, using detergent and hot water.)

2. Ensure Adherence to Universal Precautions
i. Staff understanding of universal precautions
Health care workers should be educated about occupational risks and should understand the need to use universal precautions with all patients, at all times, regardless of diagnosis. Regular in-service training should be provided for all medical and non-medical personnel in health care settings. In addition, pre-service training for all health care workers should address universal precautions.
ii. Reduce unnecessary procedures
Reduce the supply of unnecessary procedures: Health care workers need to be trained to avoid unnecessary blood transfusions (e.g., using volume replacement solutions), injections (e.g., prescribing oral equivalents), suturing (e.g. episiotomies) and other invasive procedures. Standard treatment guidelines should include the use of oral medications whenever possible. Injectable medications should be removed from the national Essential Drug List where there is an appropriate oral alternative.
Reduce the demand for unnecessary procedures: Create consumer demand for new, disposable, single-use injection equipment as well as increased demand for oral medications.
iii. Make adequate supplies available
Adequate supplies should be made available to comply with basic infection control standards, even in resource constrained settings. Provision of single use, disposable injection equipment matching deliveries of injectable substances, disinfectants and "sharps" containers should be the norm in all health care settings. Attention should also be paid to protective equipment and water supplies. (While running water may not be universally available, access to sufficient water supplies should be ensured.)
iv. Adopt locally appropriate policies and guidelines
Use of sterilizable injection equipment should be discouraged, as evidence shows that the adequacy of the sterilization is difficult to ensure. National health care waste management plans should be developed. The proper use of supplies, staff education and supervision needs should be outlined clearly in institutional policies and guidelines. Regular supervision in health care settings can help to deter or reduce risk of occupational hazards in the workplace. If injury or contamination result in exposure to HIV infected material, post exposure counseling, treatment, follow-up and care should be provided.

Human Resources, Infrastructure and Supplies Needed
Institutional guidelines for universal precautions should be in place. The necessary supplies (e.g., oral medications, needles and syringes, sharps containers, disinfectant, antiretroviral) must be made available. Health care waste management may require the construction of adapted waste treatment options (e.g. incinerators and alternatives to incineration).
An infection control specialist is beneficial to ensuring that universal precautions are followed in all institutions. Universal precautions should be a part of all health care worker training, which should be provided on a regular basis in health care worker in-service education. Specific efforts should be made to train health care workers in reducing unnecessary invasive procedures. In addition, professional associations, including the national nursing association and the national medical association, should be engaged in health care worker protection and support the "First do no harm principle" principle.

Cost Information
The cost of the equipment needed to make injections sterile (i.e., new, single-use disposable syringes and sharps boxes) should be covered by those who supply injectable substances. The average international retail price for disposable syringes ranges from 4 US cents (2 ml) to 8 US cents (5 ml). A typical five litre safety box costs US$ 1 and holds 100 syringes and needles. In practice, in the case of essential drugs, these costs should not lead to an increase of the drug expenditure of more than 5% and can be compensated by an elimination of unnecessary injectable medications from the national list of essential medicines.