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Syed MA, Khan A, Chaudhry A, Baig MA, Memon NM, Kumar S, Bhurt SA, Qadri M, Vighio A, Baig ZI, Rabold EM, Ali H, Blanton C, Asghar RJ, Ikram A, Rahim M, Solangi M, Mahipala P, Fontaine RE. An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan. J Acquir Immune Defic Syndr 2022; 89:121-128. [PMID: 34723928 DOI: 10.1097/qai.0000000000002845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019. METHODS For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression. RESULTS The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400). DISCUSSION Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.
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Affiliation(s)
- Muhammad Asif Syed
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Adnan Khan
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Ambreen Chaudhry
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Mirza Amir Baig
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Naveed Masood Memon
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Santosh Kumar
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Saeed Ahmed Bhurt
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Munaza Qadri
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Anum Vighio
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Zeeshan Iqbal Baig
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Elizabeth M Rabold
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and Tuberculosis
| | - Hammad Ali
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and Tuberculosis
| | - Curtis Blanton
- Centers For Disease Control and Prevention, Division of Global Health Protection
| | | | | | - Musa Rahim
- WHO Health Emergencies, WHO Country Office, Islamabad, Pakistan; and
| | | | - Palitha Mahipala
- WHO Health Emergencies, WHO Country Office, Islamabad, Pakistan; and
| | - Robert E Fontaine
- Centers For Disease Control and Prevention, Division of Global Health Protection
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Ali Khan A, Munir M, Miraj F, Imran S, Arif Siddiqi D, Altaf A, Khan AJ, Chandir S. Examining unsafe injection practices associated with auto-disable (AD) syringes: a systematic review. Hum Vaccin Immunother 2021; 17:3247-3258. [PMID: 33989509 PMCID: PMC8381785 DOI: 10.1080/21645515.2021.1911514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/09/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022] Open
Abstract
Auto-disable (AD) syringes are specifically designed to prevent syringe reuse. However, the notion that specific AD syringe designs may be unsafe due to reuse concerns related to the syringe's activation point has surfaced. We conducted a systematic review for evidence on the association between AD syringe design and syringe reuse, adverse events following immunization (AEFI), or blood borne virus (BBV) transmission. We found no evidence of an association between AD syringe design and unsafe injection practices including syringe reuse, AEFIs, or BBVs. Authors of three records speculated about the possibility of AD syringe reuse through intentionally defeating the disabling mechanism, and one hinted at the possibility of reuse of larger-than-required syringes, but none reported any actual reuse instance. In contrast to AD syringes, standard disposable syringes continue to be reused; therefore, the global health community should expand the use of AD syringes in both immunization and therapeutic context as an essential strategy for curbing BBV transmission.
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Affiliation(s)
| | | | | | | | | | | | | | - Subhash Chandir
- IRD Global, Singapore, Singapore
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Samo AA, Laghari ZA, Baig NM, Khoso GM. Prevalence and Risk Factors Associated with Hepatitis B and C in Nawabshah, Sindh, Pakistan. Am J Trop Med Hyg 2020; 104:1101-1105. [PMID: 33350368 DOI: 10.4269/ajtmh.20-1228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022] Open
Abstract
In Pakistan, viral hepatitis is a serious public health problem affecting millions of people. Both hepatitis B and hepatitis C infections are spreading rapidly in all provinces of Pakistan, including Sindh, because of lack of knowledge about routes of transmission, low literacy rate, reuse of syringes, piercing, and other factors. However, information about the prevalence and risk factors is inadequate. So, a general population-based study was conducted to determine the prevalence rate and risk factors of hepatitis B and hepatitis C in Nawabshah. Healthy individuals were screened for hepatitis B and hepatitis C using an immunochromatographic rapid test followed by confirmation through ELISA and PCR. Information about sociodemographic and risk factors was obtained through a pretested questionnaire. Descriptive frequencies, odds ratio, and CI were calculated using SPSS software version 23. In total, 523 participants were screened for hepatitis B and hepatitis C, among whom 232 were females and 291 were males. The overall prevalence of hepatitis C and hepatitis B was 14.3% and 6.7%, respectively. In a bivariate analysis, hepatitis B infection was significantly associated with risk factors such as hospitalization, blood transfusion, needle injury, multiple sex partners, reused syringe, dental extraction, surgery, injectable drug abuse, and shaving at barbershops. Hepatitis C infection was associated with factors including surgery, needle injury, blood transfusion, reused syringes, dental extraction, and shaving at barbershops. The increasing prevalence of hepatitis B surface antigen and hepatitis C virus in Nawabshah is a public health concern. There is dire need to implement preventive measures.
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Affiliation(s)
- Ayaz Ali Samo
- Department of Physiology, University of Sindh, Jamshoro, Pakistan
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La-Rotta EIG, Garcia CS, Pertuz CM, Miquilin IDOC, Camisão AR, Trevisan DD, Aoki FH, Correa-Filho HR. Conhecimento e adesão como fatores associados a acidentes com agulhas contaminadas com material biológico: Brasil e Colômbia. CIENCIA & SAUDE COLETIVA 2020; 25:715-727. [DOI: 10.1590/1413-81232020252.04812018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/03/2018] [Indexed: 11/21/2022] Open
Abstract
Resumo Fizemos estudo transversal para iniciar coorte em dois Hospitais Universitários de dois países - Brasil e Colômbia - para avaliar a prevalência de acidentes com material biológico (AT-MB), o nível de adesão às Precauções Padrão (PP) e o conhecimento sobre patógenos transmissíveis pelo sangue e fatores associados entre trabalhadores e estudantes da saúde, no marco da implementação da norma NR-32. Criamos escalas para estimar conhecimento e adesão baseadas em 12 e 11 perguntas respectivamente. Utilizamos Regressão de Poisson-Tweedie para avaliar a associação do conhecimento e da adesão às PP com sofrer AT-MB. Avaliamos 965 indivíduos (348 estudantes e 617 profissionais). O conhecimento teve média de 10,98 com mediana de 11 (10, 12) e α-Cr de 0,625. A média de adesão foi de 30,74 com mediana de 31 (28, 34) e α-Cr de 0,745, associando-se a País, grupo (estudantes) e percepção de risco. Entre os fatores associadas ao relato de AT-MB encontraram-se o conhecimento, a adesão às PP, País de origem e ter tomado o esquema completo de vacinação contra Hepatites B. Concluímos que o nível de conhecimento e adesão foram adequados, ainda melhores entre os participantes do Brasil e associaram-se ao relato AT-MB.
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Clustering of hepatitis C virus antibody positivity within households and communities in Punjab, India. Epidemiol Infect 2019; 147:e283. [PMID: 31587676 PMCID: PMC6805795 DOI: 10.1017/s0950268819001705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To better understand hepatitis C virus (HCV) epidemiology in Punjab state, India, we estimated the distribution of HCV antibody positivity (anti-HCV+) using a 2013-2014 HCV household seroprevalence survey. Household anti-HCV+ clustering was investigated (a) by individual-level multivariable logistic regression, and (b) comparing the observed frequency of households with multiple anti-HCV+ persons against the expected, simulated frequency assuming anti-HCV+ persons are randomly distributed. Village/ward-level clustering was investigated similarly. We estimated household-level associations between exposures and the number of anti-HCV+ members in a household (N = 1593 households) using multivariable ordered logistic regression. Anti-HCV+ prevalence was 3.6% (95% confidence interval 3.0-4.2%). Individual-level regression (N = 5543 participants) found an odds ratio of 3.19 (2.25-4.50) for someone being anti-HCV+ if another household member was anti-HCV+. Thirty households surveyed had ⩾2 anti-HCV+ members, whereas 0/1000 (P < 0.001) simulations had ⩾30 such households. Excess village-level clustering was evident: 10 villages had ⩾6 anti-HCV+ members, occurring in 31/1000 simulations (P = 0.031). The household-level model indicated the number of household members, living in southern Punjab, lower socio-economic score, and a higher proportion having ever used opium/bhuki were associated with a household's number of anti-HCV+ members. Anti-HCV+ clusters within households and villages in Punjab, India. These data should be used to inform screening efforts.
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Mumtaz GR, Hilmi N, Majed EZ, Abu-Raddad LJ. Characterising HIV/AIDS knowledge and attitudes in the Middle East and North Africa: Systematic review and data synthesis. Glob Public Health 2019; 15:275-298. [PMID: 31558094 DOI: 10.1080/17441692.2019.1668452] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article reviews HIV/AIDS knowledge and attitudes in various population groups in the Middle East and North Africa (MENA), and highlights their relevance to HIV epidemiology and the design and implementation of preventions and treatment efforts. PubMed and the MENA HIV/AIDS Epidemiology Synthesis Project database of grey/unpublished literature were searched. Levels of knowledge were categorised based on presence of basic knowledge, comprehensive knowledge, and misconceptions and misinformation. Attitudes towards people living with HIV/AIDS (PLHIV) were classified into positive or negative. Basic knowledge was overall high among key populations at higher risk of infection (KPAR), and bridging and general population groups, but still a few population pockets had low basic knowledge. Level of comprehensive knowledge was overall low, and misinformation and misconceptions were prevalent. Some KPAR, including people who inject drugs, men who have sex with men, and female sex workers, were unaware of some modes of HIV transmission. Perception of risk of infection was low even among KPAR. We found differentials in knowledge putting women, rural populations, refugees, and other marginalised minorities at a disadvantage. Attitudes towards PLHIV tended to be negative. These findings are of concern, particularly for KPAR currently experiencing emerging HIV epidemics.
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Affiliation(s)
- Ghina R Mumtaz
- Department of Epidemiology and population Health, American University of Beirut, Beirut, Lebanon.,Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Nahla Hilmi
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - El Zahraa Majed
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar.,Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, USA.,College of Health and Life Sciences, Hamad bin Khalifa University, Doha, Qatar
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Hayashi T, Hutin YJF, Bulterys M, Altaf A, Allegranzi B. Injection practices in 2011-2015: a review using data from the demographic and health surveys (DHS). BMC Health Serv Res 2019; 19:600. [PMID: 31455315 PMCID: PMC6712605 DOI: 10.1186/s12913-019-4366-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015. Methods We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004–2010 and 2011–2015. Results Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004–2010 and 2011–2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012. Conclusions Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.
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Affiliation(s)
- Tomoyuki Hayashi
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland. .,Department of Gastroenterology, Kanazawa University and WHO Collaborating Center for Chronic Hepatitis and Liver Cancer, Kanazawa, Ishikawa, Japan.
| | - Yvan J-F Hutin
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Marc Bulterys
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Arshad Altaf
- Integrated Service Delivery, World Health Organization, Western Pacific Region, Manila, Philippines
| | - Benedetta Allegranzi
- Infection Prevention and Control, World Health Organization, Geneva, Switzerland
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Trickey A, May MT, Davies C, Qureshi H, Hamid S, Mahmood H, Saeed Q, Hickman M, Glass N, Averhoff F, Vickerman P. Importance and Contribution of Community, Social, and Healthcare Risk Factors for Hepatitis C Infection in Pakistan. Am J Trop Med Hyg 2017; 97:1920-1928. [PMID: 29141707 DOI: 10.4269/ajtmh.17-0019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pakistan has a high prevalence of hepatitis C virus (HCV) infection, estimated at 4.9% (2,290/46,843) in the 2007 national HCV seroprevalence survey. We used data from this survey to assess the importance of risk factor associations with HCV prevalence in Pakistan. Exposures were grouped as community (going to the barbers, sharing smoking equipment, having an ear/nose piercing, tattoo, or acupuncture), healthcare (ever having hemodialysis, blood transfusion, or ≥ 5 injections in the last year), demographic (marital status and age), and socio-economic (illiterate or laborer). We used mutually adjusted multivariable regression analysis, stratified by sex, to determine associations with HCV infection, their population attributable fraction, and how risk of infection accumulates with multiple exposures. Strength of associations was assessed using adjusted odds ratios (aOR). Community [aOR females 1.5 (95% confidence interval [CI]: 1.2, 1.8); males 1.2 (1.1, 1.4)] and healthcare [females 1.4 (1.2, 1.6); males 1.2 (1.1, 1.4)] exposures, low socio-economic status [females 1.6 (1.3, 1.80); males 1.3 (1.2, 1.5)], and marriage [females 1.5 (1.2, 1.9); males 1.4 (1.1, 1.8)] were associated with increased HCV infection. Among married women, the number of children was associated with an increase in HCV infection; linear trend aOR per child 1.06 (1.01, 1.11). Fewer infections could be attributed to healthcare exposures (females 13%; males 6%) than to community exposures (females 25%; males 9%). Prevalence increased from 3% to 10% when cumulative exposures increased from 1 to ≥ 4 [aOR per additional exposure for females 1.5 (1.4, 1.6); males 1.2 (1.2, 1.3)]. A combination of community, healthcare, and other factors appear to drive the Pakistan HCV epidemic, highlighting the need for a comprehensive array of prevention strategies.
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Affiliation(s)
- Adam Trickey
- Bristol Medical School, University of Bristol, Bristol, United Kingdom.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom
| | - Margaret T May
- National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom.,Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Charlotte Davies
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Huma Qureshi
- Pakistan Medical Research Council (PMRC), Islamabad, Pakistan
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Hassan Mahmood
- Pakistan Medical Research Council (PMRC), Islamabad, Pakistan
| | - Quaid Saeed
- National AIDS Control Programme, Islamabad, Pakistan
| | - Matthew Hickman
- National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom.,Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nancy Glass
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Peter Vickerman
- National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom.,Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Janjua NZ, Butt ZA, Mahmood B, Altaf A. Towards safe injection practices for prevention of hepatitis C transmission in South Asia: Challenges and progress. World J Gastroenterol 2016; 22:5837-5852. [PMID: 27433097 PMCID: PMC4932219 DOI: 10.3748/wjg.v22.i25.5837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/05/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
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.
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