What blood borne virus can be prevented by vaccination?

HIV, Hepatitis B virus (HBV) and hepatitis C virus (HCV) are blood- borne infections (BBIs) readily spread by injection equipment  contaminated with blood and other body fluids. Exposures to unsafe injections during health–care are the leading cause of new HCV infections globally. Improvements in infection control by clinical care systems and use of auto-disable (AD) syringes by pediatric immunization programs reduced the risk of HCV infection and other BBIs. However, the rapid introduction and scale-up of COVID-19 vaccination in low-and middle-income countries (LMICs), while a welcomed addition to the pandemic response, pose new risks for exposures to blood contaminated injection equipment and the resurgence of BBIs. Leading public health officials recently raised concerns regarding injection safety of COVID-19 vaccination programs (1).

At least three factors increase the potential for unsafe injections during mass COVID-19 vaccination particularly in low and middle income countries (LMICs). First, the supply of auto-disposable syringes might not meet the demand for COVID-19 vaccination. Over the remainder of 2021 and through 2022, an estimated 15 b-19 b doses of COVID-19 are expected to be delivered.  This number of vaccinations will require massive increases in syringe supply, distribution with ready availability at the site of vaccination.  

While models estimate existing supplies of AD syringes are sufficient in the short term, more production of AD syringes is needed to meet demands for COVID-19 vaccination in 2022.  UNICEF Executive Director Henrietta Fore has expressed concern regarding the coming shortage of COVID-19 vaccine syringes particularly for LMICs where auto-disposable syringes are critical for injection safety (2). Dr. Matshidiso Moeti, director of the WHO regional office in Africa recently raised this alarm: “Unless drastic measures are taken to boost syringe production, Africa faces a crisis." (3)  

Secondly, syringe production is complex for COVID-19 vaccines. Different syringes are needed to deliver vaccine doses which vary by type of COVID-19 vaccine.  The Pfizer-BioNTech vaccine requires 0.3-mL dose. This syringe is made by a limited number of manufacturers with no reserve in a global stockpile. The Oxford-AstraZeneca vaccine and others require 0.5-mL doses. As AD syringes are typically designed to provide a preset 0.5-ml dosage only, additional manufacture of a 0.3 mL dose is needed to meet the demand for this type of syringe while avoiding declines in production of 0.5 mL syringes.

Thirdly, the rapid scale-up of COVID-19 vaccination can exceed the capacity of current pediatric and adolescent vaccination programs; most countries do not have adult vaccination programs. Governments will seek to rapidly achieve high immunization coverage among adults. In most countries, public demand for vaccination is high. To achieve high COVID-19 vaccination coverage will often require recruitment of adult care providers and other clinical staff who have not previously participated in vaccination programs.  These staff must receive training in injection of vaccinations.  The demands on governments and their vaccination programs can also place pressure to use available vaccines even if injection safety is compromised. Dr. Sabin Nsanzimana, director-general at the Rwanda Biomedical Centre, recently reported some vaccines are received less than a month before expiration (3).

To mitigate the transmission risks of BBIs, COVID-19 immunization campaigns must assure a reliable supply of safe injection equipment, and the program management and clinical training to assure COVID-19 vaccines are safe.  

Necessary steps to assure safe injections of COVID-19 vaccines include:  

1. COVID-19 vaccination programs must develop a budget-based COVID-19 vaccination plan with procurement and distribution systems in place to match the supply of injection equipment with the scale up of COVID-19 vaccination.
2. COVID-19 vaccination programs must have the expertise to develop appropriate injection safety policies with technical assistance available upon request.  
3. COVID-19 vaccination programs must have oversight to assure safe injection practices.
4. COVID-19 vaccinators must be trained in safe injection practices and waste management.
5. COVID-19 vaccination programs must collect data to monitor injection safety practices, identify lapses in practices, investigate potential exposures to BBI and implement corrective actions.  
6. Unicef, Gavi and other key stakeholders should assist COVID-19 vaccine programs in development and evaluations of safe injection programs.
7. COVID-19 vaccination programs should participate in a community of practice to disseminate information regarding injection safety protocols and to share lessons learned.

The Task Force for Global Health can create a community of practice for national COVID-19 vaccination programs to share their injections safety plans, procedures and evaluations.  

1)    Chan  M,  Dzau  V,  Jha  A,  Hunt  J,  Kelley  E,  Zeltner  T.    The  global  vaccine  effort  will be  a hollow  victory  if it  leads  to  unsafe  injection  practices.    Washington  Post.  July  19,  2021 https://www.washingtonpost.com/opinions/2021/07/19/global-vaccine-effort-would-be-hollow-victoryif-it-leads-unsafe-injection-practices/   accessed   October  28,2021

2)  Urgent  action  needed  now  to  ensure  sufficient  COVID  vaccine  syringe  supply  to  meet  2022 vaccination  targets.  Unicef   https://www.unicef.org/press-releases/urgent-action-needed-now-ensuresufficient-covid-vaccine-syringe-supply-meet-2022 accessed  October  28,  2021  

3) Jerving J.  Looming  syringe  crisis  threatens  COVID-19  vaccine  efforts  in  Africa,  Devex. https://www.devex.com/news/looming-syringe-crisis-threatens-covid-19-vaccine-efforts-in-africa101948?access_key=&utm_source=nl_newswire&utm_term=article&utm_content=cta&mkt_tok=Njg1L UtCTC03NjUAAAGAarIOICftu4p4DMHzRQ2mZKHx-DfvbcSzWConANB1EBcoaDakMnVvmHPS8pzqo2Oe_9HPSLXTwqV3onH4lVn27mFNx86Rldq9f898fLH8PHLNuY  accessed October  28,2021

Hepatitis B, Hepatitis C and HIV are the 3 main blood borne viruses (BBVs). They are transmitted through:

• Exposure (of broken skin, mucous membranes or blood) to infected blood and body fluids, for example during:
  • treatment using reused or non sterile medical, dental or surgical equipment
  • blood or blood product transfusion
  • body piercings and tattoos performed with non-sterile equipment
  • sharing of drug injecting equipment
• Sex: oral, vaginal or anal

The risk of being exposed to a BBV infection is increased by:

• having unprotected sex with a new or casual partner or sex worker in any country.

You can also be exposed to BBVs through medical treatment, particularly in countries with limited medical facilities or less strict infection control and hygiene practices. Types of travel that can increase your risk of requiring medical treatment might include:

Recommendations for Travellers

All BBVs are transmitted in the same way. Even if you are vaccinated against Hepatitis B, you should still take preventative steps to reduce your risk of exposure to Hepatitis C and HIV:

• Practice safe sex during travel.
• Purchase comprehensive travel insurance that includes medical repatriation.
  • Ensuring that you can access a high standard of medical care, or return to the UK for treatment reduces your chance of exposure to BBVs.
• Consider carrying a comprehensive medical/first aid travel kit if you are travelling to a resource poor setting to avoid exposure to reused or unsterile medical supplies.
  • Travel kits are available from large pharmacies, travel shops, clinics and online retailers. Depending on the kit, they may contain sterile injecting equipment, wound suture needles and intravenous drip set.
  • For customs clearance these kits must be supplied with a certificate showing the contents and the reason for its purchase.
• Avoid procedures such as ear piercing, tattooing, acupuncture, manicures and shaving with open razors unless you know the equipment being used has been adequately sterilised or is single use.
• Avoid using, reusing or sharing any recreational drug taking equipment.
  • The penalties for use of recreational drugs are severe in many countries.
• If hiring vehicles abroad make sure they are road worthy and that you are familiar with the local road rules.
  • Use the same amount of caution and protection (helmets, seat belts, protective clothing) as you would in the UK.
• If travelling for cosmetic, dental, medical or surgical procedures, research the clinic or hospital beforehand and ensure they use sterile, single use equipment and have a high standard of infection control.
  • For further information see the Medical Tourism page.
• If travelling to work or volunteer in a medical setting ensure you are fully familiar with the risks of blood borne viruses in an occupational setting.

Blood transfusion
In Western Europe, North America, Japan and Australasia all donated blood is now screened for blood borne viruses. Blood transfusion services in many resource poor countries are basic, and much of the donated blood may be unscreened. The risks from receiving a blood transfusion in such circumstances are high.

• Accidents are the commonest reason for needing a blood transfusion.
• Consider joining the Blood Care Foundation (see below).

Vaccination

Hepatitis B vaccine should be considered if you may be at risk of exposure. This should be discussed with your travel health advisor.

There is no vaccine against Hepatitis C or HIV.

The Illness

Initial infection with a BBV may cause no symptoms or can produce an initial severe illness. Although initial infection with Hepatitis B and C may spontaneously clear, all 3 BBVs can cause life-long infection.

Hepatitis C infection can be cured with oral treatment.

Chronic Hepatitis B infection and HIV infection cannot be cured but the life-long infection can be controlled with treatment.

Further Information

The Blood Care Foundation is an organisation which aims to make reliably screened blood, blood products and sterile equipment available to its members in case of emergency.

The Foundation uses a network of internationally recognised sources, from where screened blood can be dispatched to members anywhere in the world in an emergency. However this does not usually help with an immediate need for blood transfusion, for example, after massive blood loss in an accident.

• Blood Care Foundation Website

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