Dr Rajab Ali Khawaja, FCPS, MRCGP
Consultant Family Medicine

Correspondence:
Rajab Ali Khawaja, Consultant, Department of Family and Community Medicine, College of Medicine, King Khalid University Hospital, King Saud University, P.O. Box 7805. Riyadh 11472, Saudi Arabia.
Mob: +966-502704266. Fax: +9661-4691452.
Email: rajab99@hotmail.com rajabali999@yahoo.com

Injections are among the most common health care procedures throughout the world. There is a general reluctance among people to accept the injection without cleaning the site with alcohol swab. According to World Health Organization, there is a no need to routinely apply alcohol swab for skin preparation before subcutaneous, intradermal and intramuscular injection.

For the purpose of this survey, the term injection refers to intramuscular, intradermal and subcutaneous injections: it does not include intravenous or intra articular injections.

In medical care, an injection is the introduction of a drug, vaccine, contraceptive or other therapeutic agent into the body using a needle and syringe. Injections are among the most common health care procedures throughout the world and are frequently used nursing procedures with an estimated 16 billion administered on an annual basis among developing and transitional countries(1-3).

The skin is the largest organ of the body, covering its entire surface. It serves as a protective shield against heat, light, injury and infection. Other functions of skin include regulation of body temperature, storage of water and fat. Skin also acts as a sensory organ, prevents water loss and the entering of bacteria into the body. Normal human skin is colonized by large numbers of organisms that live harmlessly as commensals on its surface(4).

Alcohol swab is saturated with 70% isopropyl and thought to be the oldest topical antiseptic used for preoperative skin preparation and as a surgical scrub in the 19th century.

There is a very little evidence to support the need for disinfection of the skin prior to any intradermal, subcutaneous and intramuscular injection. Many studies reported that routine skin preparation by alcohol swab before intradermal, intramuscular and subcutaneous injection is unnecessary(5-11).

Yoshika Kazuaki and colleagues compared distillate water cotton with that of alcohol swab for skin preparation before a vaccination, and found no infection in both groups. Side effects of using swab were more frequent among alcohol swab users(12).

General practitioners, community practitioners and health visitors associations assessed the incidence of injection related infection as indicated by abscess in the injection site and concluded that one abscess occurs per 1 - 2 million injections(13). One study shows that among injecting drug users, skin cleaning may be associated with a lower risk of bacterial infections(14).

According to the recommendation of World Health Organization (WHO), swabbing of the clean skin before giving an injection is unnecessary. WHO further states wash skin that is visibly soiled or dirty. If swabbing with an antiseptic is selected for use, use a clean, single-use swab and maintain product-specific recommended contact time. Do not use cotton balls stored wet in a multi-use container. The recommendation for alcohol swab is to wipe the swab for 30 seconds over the site of injection and allow drying for a further 30 seconds to ensure bacteria are rendered inactive (otherwise there may be some increased injection pain)(15-16).

At present, according to policy guidelines in King Khalid University Hospital, use of alcohol swab for the preparation of skin before injection is necessary. We conducted this survey to assess the theoretical knowledge and attitude of the heath care providers and visiting patients towards the use of alcohol swabs and to have some awareness and a step towards WHO guidelines.

A cross sectional study was conducted among highly educated health care workers and their patients at King Khalid University Hospital, King Saud University Riyadh, Saudi Arabia during November 2008 to February 2009.

For this study, a stratified random sampling technique was used to present to both male and female physicians, nurses and patients. A pre-tested, pre-designed well-structured questionnaire, and containing open-ended and close-ended questions written in English with Arabic translation, was administered to participants during working hours i.e. 8:00 am - 4:00 pm. The covering letter of the questionnaire outlined the title and the purpose of the study and the identity of the researcher. Participants were informed about the importance of the study and were encouraged to participate.

A questionnaire was divided into various sections to learn the current general knowledge, attitude and practices of skin preparation (by 70% isopropyl alcohol swab) before subcutaneous, intradermal and intramuscular injections. Various steps were taken to increase the content validity of the questionnaire. Firstly, a comprehensive review of the relevant literature was carried out. Secondly, a pilot survey of 28 participants was conducted and on the basis of that a few questions were reformed, added or deleted. Lastly, all participants were informed on the issue of anonymity and no identifying information was included in the questionnaire.

Out of 200, one hundred and sixty three anonymously completed questionnaires were returned to the investigator.

Statistical Analysis: Data was entered into spreadsheet and processed on Statistical Package for Social Sciences-16 (SPSS-16). Demographic data and answers of questionnaire were analyzed in a descriptive fashion. Results were expressed as counts and percentages.

Out of 200 distributed questionnaires, 163 (85.5%) completed questionnaires were returned. Among 163 participants, 39 were physicians, 63 nurses and 61 were patients (Figure 1). Fifteen physicians were from Primary Care Clinics, 13 from Medicine and Allied, four from Pediatrics, five from surgery and two from Obstetric and Gynecology departments. Nineteen nurses participated from primary care clinics, ten from accident and emergency, eleven from medicine and allied, nine from paediatrics, two from general surgery and twelve from obstetrics/gynecology departments. Most of the physicians (69%) were board certified and 94% nurses were registered nurse (RN or BSN). Most of the attendants were surveyed when they came for the vaccination for their beloved. The majority of participating health care providers were Non-Saudis / expatriates (94%), whereas the majority of patients were Saudis (92%).

Figure 1: Questionnaire participants

Out of the 163 respondents, 94 (57.67%) were males and 69 (42.33%) were females; mean age of physicians, Nurses and attendants in years were 41, 33 and 39, respectively (Table 1).

Respondents' current knowledge:
Most of the participants derive their knowledge from various sources. More than three quarters of the respondents indicated that mass media and health care providers had contributed much to their knowledge about cleansing site of injection before subcutaneous, intradermal and intramuscular injection. Other identified sources were magazines, medical books, medical journals and family/friends (Table 2).

TABLE 2: Survey participants' source of knowledge (multiple sources were allowed)

The respondents' knowledge about swabbing before injection and injection related infections was poor. More than three quarters of all three participating groups wrongly answered and said "Routine skin preparation with alcohol swab before intradermal, subcutaneous and intramuscular injection will prevent infections".

Almost all health care providers and approximately half of the patients knew correctly that the swabbing before subcutaneous, intradermal and intramuscular injection will not minimize the pain before or after an injection.

Some of the physicians (15.38%) and nurses (15.87%) had a wrong belief and mentioned that, "Alcohol swab will minimize bleeding after injection", whereas the majority of them correctly replied to this question. Approximately half of the patients replied cortrectly to this question.

Unfortunately, about only half of the physicians, two thirds of nurses and two thirds of patients answered correctly that, "if swabbing is selected for use, wipe the swab for 30 seconds over the site of injection and allow drying for a further 30 seconds before giving injection".
Only 22% of the participants answered correctly that alcohol swab may affect the contents of injected medication and may affect the mode of action.

Attitude of respondents:
Almost all participants agreed that "Routine use of alcohol swab is time consuming and increases the cost of health budgets". Despite this view, more than two thirds of participants will refuse to receive an injection and will not allow anybody to inject them without skin preparation by alcohol swab before an injection. The main reason for refusal was the belief that, "Alcohol Swab will prevent the infection". Furthermore, 99% of participants stated that, "I or my Family had never received an injection without wiping the site of injection with alcohol swab" (Table 3).

TABLE 3: Participants' response related their Knowledge, Attitude and Practice of alcohol swab wiping before injection

Current Practice:
Currently due to the local policy, skin preparation with alcohol swab is in practice at King Khalid University Hospital, Riyadh. Nursing staff are supposed to routinely clean the skin at the site of injection before giving subcutaneous, intradermal and intramuscular injections.