Systematic Reviews
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 7, 2016; 22(25): 5837-5852
Published online Jul 7, 2016. doi: 10.3748/wjg.v22.i25.5837
Towards safe injection practices for prevention of hepatitis C transmission in South Asia: Challenges and progress
Naveed Zafar Janjua, Zahid Ahmad Butt, Bushra Mahmood, Arshad Altaf
Naveed Zafar Janjua, Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
Naveed Zafar Janjua, Zahid Ahmad Butt, Bushra Mahmood, School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
Arshad Altaf, Service Delivery and Safety, World Health Organization, Geneva 27, Switzerland
Author contributions: Janjua NZ conceived the idea, designed the study and wrote first draft; all authors contributed to the literature review, critical revision and editing, and approval of the final version.
Conflict-of-interest statement: None to declare.
Data sharing statement: All data presented in this paper are available in the cited references.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Naveed Zafar Janjua, MBBS, MSc, DrPH, Senior Scientist, Clinical Associate Professor, Clinical Prevention Services, British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Telephone: +1-604-7072514 Fax: +1-604-7072690
Received: March 27, 2016
Peer-review started: March 28, 2016
First decision: May 12, 2016
Revised: June 5, 2016
Accepted: June 15, 2016
Article in press: June 15, 2016
Published online: July 7, 2016

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METHODS: We searched published and unpublished literature on injection safety in South Asia published during 1995-2016 using the keywords “injection”“unsafe injection” and “immunization injection” and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: Unsafe injections, Hepatitis C, Hepatitis B, South Asia, Prescription practices

Core tip: The reuse of syringes in healthcare has been consistently identified as major route of hepatitis B and C transmission in Pakistan and India. Injection use and reuse is common in Pakistan, India and other South Asian countries. This paper synthesizes literature on injection use, re-use and potential interventions to reduce injection use and reuse to prevent hepatitis C transmission and hence overall disease burden. We also propose a multi-level model to guide further research, interventions and programs to prevent unnecessary injection use and reuse.