Factors associated with unsafe injections during the 2018–2020 Ebola virus disease outbreaks in the Democratic Republic of the Congo

Abstract

Context and objective. Unsafe injection practices can increase the spread of infections, including Ebola virus disease (EVD) during an outbreak. This study assessed high-risk injection practices and factors associated with unsafe injection practices during the 2018–2020 EVD outbreak in the Democratic Republic of the Congo. Methods. A cross-sectional study was conducted in the outbreak-affected area (ZeE), areas immediately adjacent (moderate-risk area or ZrM), and distant areas with significant exchanges (low-risk area or ZrF). Ten criteria from the World Health Organization (WHO) were applied to 572 injections selected through convenience sampling. Observations and interview data were analyzed using SPSS Version 27, which included descriptive statistics, the chi-square test, and binary logistic regression. An injection was considered safe when all criteria were successfully met. Results. The injections were administered by nurses (72.6%) for several purposes including curative care (60.5%), preventive care (14.9%), or to collect a sample (24.7%). Only 8.4% of injections were safe overall (14.9% in the ZeE, 4.3% in the ZrM, and 5.6% in the ZrF, p<0.001). Poor hand hygiene before and after the procedure, handling contaminated equipment, failure to disinfect the injection site, and inadequate waste management were the most risk practices. Being in the ZeE was associated with a lower risk of observing an unsafe injection compared to the ZrF area (adjusted odds ratio = 0.33; 95% CI: 0.16-0.69; p = 0.003). Conclusion. Although the EVD outbreak brought opportunities for improving injection safety, sustaining the progress achieved in ZeE and addressing less respected steps deserve special attention, such as provision of supplies and sanitation infrastructure, awareness raising, as well as further research on barriers to good practice. Received: August 17th, 2025 Accepted: November 5th, 2025 https://dx.doi.org/10.4314/aamed.v19i1.4