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

Table 1 Human development statistics for South Asia: Human development report 2015[18]

Indicators	Year	Sri Lanka	Maldives	India	Bhutan	Pakistan	Nepal	Bangladesh
Total population (millions)	2014	21.4	0.4	1267.4	0.8	185.1	28.1	158.5
GDP per capita (US$)	2011	9426	11283	5238	7167	4454	2173	2853
Population living below $1.25 a day (%)	2002-2012	-	1.5	23.6	2.4	12.7	23.7	43.3
Adult literacy rate (% ages ≥ 15)	2005-2013	91.2	98.4	62.8	52.8	54.7	57.4	58.8
Public health expenditure (% of GDP)	2013	3.2	10.8	4.0	3.6	2.8	6.0	3.7
Stunting (moderate or severe) (% under age 5)	2008-2013	14.7	20.3	47.9	33.6	45.0	40.5	41.4
Infant Mortality rate per 1000 live births	2008-2013	8.2	8.4	41.4	29.7	69.0	32.2	33.2
Overall human development index	2015	73.0	104	130	132	147	145	142

Table 2 Search and retrieval of information for injection use in South Asia 1995-2016

	Key words	India	Pakistan	Bangladesh	Nepal	Sri Lanka	Maldives
PubMed - Retrieved	Injection and country/state	189	51	12	14	13	5
PubMed - selected/relevant		25	25	5	8	0	0
Google Scholar1	Unsafe injections, injections, country	3		1 (419)	2 (329)	1 (242)	0 (40)
Google	Unsafe injections, injections, country	2	1	0	0
WHO website		0	0	0	0	0	0
PATH					2
In country assessments by MoH			1
Unpublished reports		1	2
Other circumstantial evidence2
Risk factors studies suggesting injection use	Risk factors, HBV (HCV), country			1
Hepatitis B/C	Hepatitis B, Hepatitis C, Country			19 (38)	13 (36)
Health care utilization	Health care seeking, Health care utilization, Private practice, Country			15 (32)		6 (16)
(retrieved)
Private practitioners health seeking (retrieved)	Health care seeking, Private practice, Country			5 (8)		3
Prescribing practices (retrieved)	Prescription practices, Country			5 (5)		1

¹Google scholar retrieved too many articles and most of them were not relevant: these were used mainly for countries for which information was not available through PubMed;

²Not used for countries for which data on injection use were available. Parenthesis represent retrieved and number represent the number that were relevant and reviewed. HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 3 Characteristic of injection use studies in South Asia 1995-2016

Ref.	Study type	Setting	Study base	City/province	n	Sampling	Year	Year
							conducted	published
India
Rajasekaran et al[37]	Population survey	Both	3 areas	Tamil Nadu	175	Convenience	2001	2003
IPEN study group[40]	Population survey	Both	Whole country	whole country	23997	Cluster sampling	2002-2003	2004
IPEN study group[40]	Patients exit interview and observations	Both	Whole country	whole country	6015	Cluster sampling	2002-2004	2004
Murhekar et al[36]	Population survey		Island	Nicobar Island	210	Cluster sampling	-	2004
Kotwal et al[34]	Population survey	Both	City	Delhi	150	Cluster sampling random	2003	2004
Anand et al[38]	Population survey	Rural	1 village	Haryana State	1280	Systematic sampling	-	2001
Lakshman et al[35]	Patients exit interview and observations	Both	15 miles around a town	Tamil Nadu	400	Consecutive patients	-	2000
Becker et al[66]	Population survey	Both	1 district	Karnataka	4949	Cluster sampling	2003	2005
Kermode et al[67]	Population survey	Urban	2 cities	New Delhi and Imphal	200	Convenience	2004	2006
Kermode et al[41]	Patients and relatives survey	Rural	2 hospitals	Bihar and Jharkhand	280 patients,	Systematic sampling, convenience	2004-2005	2006
					120 relatives
Pandit et al[42]	Population survey	Both	1 District	Anand	182 HF1	Stratified and simple random	2004	2008
					2080
Shah et al[68]	Providers interview	Both	1 district	Gujarat	251	Random sampling	2012-2013	2014
Bhargo et al[43]	Providers interview	Urban	1 district	Gwalior	30	Convenience	2012-2013	2014
Garapati et al[44]	Providers interview and observation	Both	1 district	Andhra Pradeh	300	Convenience	2010-2011	2014
Bendale et al[69]	Hospital survey	Urban	1 district	Maharashtra	20 sites	Random sampling		2015
Pakistan
Raglow et al[22]	Survey of OPD patients	Urban	Patients	Karachi	198	Consecutive patients	1995	2001
Janjua et al[23]	Population survey	Both	2 districts	Sindh	1150	Cluster sampling random	2001	2005
Janjua et al[29]	Population survey	Both	2 districts	Sindh	1150	Cluster sampling random	2001	2006
Janjua et al[26]	Patients exit interview and observations	Both	3 districts	Sindh	2124	Random sample of clinics	2004-2005	UP
Janjua et al[27]	Population survey	Both	Whole country	Whole country	10023	Cluster sampling	2006-2007	2014
Yousafzai et al[25]	Provider survey	Urban	City	Karachi	317	Convenience	2006	2013
Khan et al[6]	Patients exit interview and observations	Peri-urban	1 village	Sindh	203	consecutive patients	1995	2000
Mantel et al[70]2	Patients exit interview	Both	8 districts	3 provinces		Random sample of clinics	2002	UP
PDHS 2012-13[24]	Population survey 15-49 years of age	Both	National		F: 13558	Cluster sampling random	2012-2013	2014
					M: 3134
Bangladesh
Gibney et al[71]	Risk factor study	Urban	Truck stand	Dhaka	387	Cluster sampling random	1999	2001
Shill et al[51]	Provider interviews and facility records	Rural	Primary Health Care Centres	Dhaka	6	Convenience sample	2009	2011
Chowdhury et al[50]	Provider interviews, FGD, observations and prescription review		Primary Health Care Centres	National	Prescription: 4320	Cluster sampling	2008-09	2013
					Injection events: 480
Sri Lanka
Rannan-Eliya et al[59]	Patients exit interview	Both	National	Sri Lanka	2100	Random sample of clinics	2000	2003
Nepal
Gyawali et al[54]	Survey of pharmacies	Urban	City	Pokhara	54	Convenience sample	2012	2014
Gyawali et al[52]	Population survey	Both	1 district	Kaski	2470	Stratified sampling	2012	2014

¹Health Facilities;

²Included only public sector facilities. UP: Unpublished; F: Females; M: Males.

Table 4 Injection use and safety of injections in South Asia 1995-2016

Ref.	Annual ratio of injections per capita	Received an injection	Therapeutic	Injection reuse byinterview7	Injection reuse byobserving	Overall unsafe
India
Rajasekaran et al[37]	2.4	60.6%1	87%	64.6%
IPEN study group[40]	2.91-5.8	27.1%1/44.1%3	82.5%		31.6%	62.9%
Murhekar et al[36]	3	21.9%1	91%	6.5%
Kotwal et al[34]	5.1	45.6%1	71.2%	56.5%	77.5%
Anand et al[38]	2.45	35%4	40%-100%			45%
Lakshman et al[35]		89%3	100%		73%-99%	99%
Becker et al[66]	3.5	67.7%6
Kermode et al[67]	8.6	15%2	68%			31%
Kermode et al[41]		43%2 (Patients)	100%			7.6%
		13.3%1 (Relatives)
Pandit NB	0.2	21.6%6				77%
Shah et al[68]						64.1%
Bhargo et al[43]						76.7%
Garapati et al[44]	0.72				14.3%
Pakistan
Raglow et al[22]	8.4	51%5	100%	48%	16%
Janjua et al[23]	13.6	68%1	94%	46%
Janjua et al[26]		74%1
Janjua et al[23]		55%3			47%
Janjua et al[27]		51%6		4%
Yousafzai et al[25]						87%
Khan et al[6]		81%3		90%	94%
Mantel et al[70]					12%	65%
PDHS 2012-13[24]	F:5.4/M:4.9	F:61%/M: 53%6		F:15%/M:10%
Bangladesh
Gibney et al[71]		39.7%6	100%
Shill et al[51]	4.88
Chowdhury et al[50]		77.7%			15.5%
Sri Lanka
Rannan-Eliya et al[59]		3%3
Nepal
Gyawali et al[54]
Gyawali et al[52]	2.37	10.4%1	97.1%

¹During last 3 mo;

²During last 4 wk;

³Current visit from prescription review;

⁴Six months;

⁵Past one week;

⁶Past one year;

⁷Syringe that has been used on multiple patients, not opened in front of patient is considered unsafe; some studies performed direct observations while other relied on the patient recall; F: Females; M: Males.

Table 5 Prescribers, providers, and preference of patients and practitioners for injections in South Asia 1995-2016

Ref.	Prescribed by GP	Prescribed by unqualified practitioner	Provided at private clinic	Provider dispenser	Patient prefers Injection	Practitioner prefers injection	Practitioner says patient demand it
India
Rajasekaran et al[37]			59%	37.6%	40%		87.2%
IPEN study group[40]	42.6%	57.5%	77%1/34%2	93.5%	10.2%	70.6%3	88.6%
Murhekar et al[36]				50.8%	54.8%
Kotwal et al[34]					13.8%	58.8%	30%
Anand et al[38]					18%
Lakshman et al[35]					65%
Kermode et al[67]	8%	35%
Kermode et al[41]	55% (patients)		24.8% (patients)	7.7% (patients)	9.3% (relatives)
Pandit et al[42]	57%		55%		17%
Garapati et al[44]							48.7%
Bendale et al[69]	8.16%				35%	65%
Pakistan
Raglow et al[22]	94%		94%
Janjua et al[23]	63%	28%	69%	76%	16%
Janjua et al[26]	63%	28%	63%		32%
Janjua et al[23]
Janjua et al[27]			52%	16%
Yousafzai et al[25]	7.9%	8.8%		71%
Khan et al[6]					44%
Bangladesh
Gibney et al[71]
Shill et al[51]							50%
Sri Lanka
Rannan-Eliya et al[59]
Nepal
Gyawali et al[54]				92.6%
Gyawali et al[52]			12.6%	21.4%	5%

¹Therapeutic;

²Preventive injections;

³Physician took prescription decision/in 15% cases practitioner promoted injection prescription.