Towards safe injection practices for prevention of hepatitis C transmission in South Asia: Challenges and progress

Abstract

Aim: To summarize the available information about injection use and its determinants in the South Asian region.

Methods: We searched published and unpublished literature on injection safety in South Asia published during 1995-2016 using the keywords "injection" "unsafe injection" and "immunization injection" and combined these with each of the countries and/or their respective states or provinces in South Asia. We used a standardized questionnaire to abstract the following data from the articles: the annual number of injections per capita, the proportion of injections administered with a reused syringe or needle, the distribution of injections with respect to prescribers and providers and determinants of injection use.

Results: Although information is very limited for certain countries (i.e., Bhutan, Maldives and Sri Lanka), healthcare injection use is very common across South Asia, with cross-country rates ranging from 2.4 to 13.6 injections/person/year. Furthermore, recent studies show that 5% to 50% of these injections are provided with reused syringes, thus creating potential to transmission of blood-borne pathogens. Qualified and unqualified practitioners, especially in the private sector, are the major drivers behind injection use, but patients also prefer injections, especially among the rural, poor or uneducated in certain countries. According to available data, Pakistan and India have recently taken steps towards achieving safe injection. Potential interventions include the introduction of reuse prevention devices, and patient-, community- and patient/community and provider-centered interventions to change population and practitioner behavior.

Conclusion: Injection use is common in South Asian countries. Multilevel interventions aiming at patients, providers and the healthcare system are needed to reduce injection use and reuse.

Keywords: Hepatitis B; Hepatitis C; Prescription practices; South Asia; Unsafe injections.

Figure 1

Number of hepatitis C virus cases in India and Pakistan over time with viremia and cirrhosis[5].

Figure 2

Map of South Asian countries.

Figure 3

Annual ratio of injections per capita by education level in Pakistan, Pakistan Demographic and Health Survey 2012-2013.

Figure 4

Receipt of injection with newly opened syringes in Pakistan by wealth quintiles, Pakistan Demographic and Health Survey 2012-2013.

Figure 5

Social ecological model for reducing unsafe injection prescriptions.