Daily Times

In order to differentiate between safe and unsafeinjections it is of importance to understand the medically proven classification for safe injections. Safe injection is one which causes no harm to the provider, recipient or the community. With the ever-growing population in Pakistan along with its associated increase in health-related concerns it is required to talk on the root causes for such issues. As healthy population will be driving force for stable economic positioning for a developing country like Pakistan. Thus, there is need to talk about unsafe injections. They are the leading cause of HIV transmission in Pakistan and there is anominous need to eliminate their use.  Furthermore, we also need to carefully look at the details and figures showing widespread use of needless injections and intravenous therapy in the country. Lack of regulations and use of sub-standard products add to the problem.

According to Global Statistics, in 2019, approximately 38 million people including 1.8 million children under 15 years of age around the world have HIV/AIDS. The re-using needles, syringes and other injectable equipment puts others at risk of communicable diseases including HIV.Based on published report by World Health Organization, in developing countries up to 70% of injections are unsafe i.e., given with reused needle and syringe.Pakistan is one of the member state of the World Health Organization Eastern Mediterranean region, which has the highest number of unsafe injections in the world.On World AIDS day 2020, a statement released by World Health Organization stressed on the alarming situation for HIV in the region. There is significant increase in incidence and mortality from AIDS in the last decade.

Unsafe injections in Pakistan have been primarily linked to three HIV outbreaks so far. In 2008,JalalpurJattan in Gujrat Punjab, 88 HIV cases were identified.  The leading causes were the use of injection (96% cases), dental procedures (40% cases), barber shop use among maleparticipants and extramarital sex in 9.4% cases.  According to research published in Journal of Epidemiology and Global Health, HIV transmission in this population was thought to be endemic rather than an outbreak. Similarly, based on the data collected from KotImrana (Kotmomin) a village in Sargodha district (Punjab) in 2019, the re-used needles, re-used blades at barbers and unsafe sex practices were identified to associated with increased prevalence of HIV from 1.29% in June 2018 to 13.38% in Jan 2019. Besides this, a survey conducted in 2019 by United Nations organizations in RatoDero in Larkana district (Sindh) highlighted the unsterilized medical equipment (needles, syringes, IV drip sets) among many key factors identified 877 HIV patients with more than 80% children aged less than 15 years were found to be HIV positive.

Those in position of responsibility must show empathy. Focusing on offering rehabilitation services (lifelong) to those affected by HIV including adequate counselling

The above case scenarios clearly reflect injections are overused in Pakistan.Approximately 1.5 billion injections are used annually in Pakistan, of which 75 million is used for immunization whereas the larger remaining proportion is used as part of treatment. An average of 8.3 injection is used by one person in a year. According to World Health Organization, 93% of these therapeutic injections are unnecessary. Moreover, same syringe is used multiple times on multiple patients. Use of unsafe injections are associated with transmission of Hepatitis B & C as well. Patients who received more injections were more likely to acquire hepatitis C.

Therefore, the developing economy like Pakistan need to recognize that unsafe injection is a country wide problem. Safe injection practices and its related awareness and education must be encouraged. There is an urgent need for interventions on multiple levels to promote rationale use of injection.  It could be achieved through controlling quackery, patient education through awareness on how HIV is spread, proper disposal of sharps, banning recycling and repackaging of needles and syringes. These are some of the areas where intensive work and attention needs to be made. In addition, there should be a general public service message focusing on understanding and acknowledgement of the issue and clearly stating that use (unnecessary) and reuse of needles and syringes leads to transmission of HIV and viral hepatitis.

A project in TandoAllahyar (Sindh) used interventions like gatherings, television, radio & print media messages to address myths relating to transmission of Hepatitis B and C showed significant improvement from 9% at the beginning of study to 78% at the end of project in ameliorating awareness on association between re-used needles and viral hepatitis spread. Such practices at national level can bring change obviously it will not be overnight but a slow process. We as a human need to understand behaviour change takes time. In order to save vulnerable population particularly our children, we need to act fast and bad clinical practices should be terminated. The denialism related to re-use of sharps needs to be addressed. Indeed, we need to carefully, recognising and admit that a problem exist will lead us to the solution.  Not only the guidelines for disinfection and sterilization must be made available for both public and private sector healthcare facilities but it should be ensured that these are also implemented.

In order to conclude, the barriers to implementation must be identified and acted upon. There must be laws and regulations imposed in terms of heavy fines and cancellation of license to practice must be imposed. Furthermore, we need to closely assess our health care equity too. Those in position of responsibility must show empathy. Focusing on offering rehabilitation services (lifelong) to those affected by HIV including adequate counselling.  It is suggested to introduce and use of auto-disable AD (self-break, auto lock) syringes to minimize re-use is another way of dealing with the issue.  Almost half a decade ago, a proposal to manufacture 300 million AD syringes annually was discussed, however, unfortunately the speed through which this change should have happened has not occurred yet. Based on the learning from past experiences, very few measures have beenadopted by Pakistan to implement AD syringes.  Constitutionally, health related matters are provincial responsibility. There is always a solution to the problem, it’s the will that needs to exist. A strong commitment from the government, a clearly defined road map to deal with challenges and implementation of action plan is the key to success in controlling use of unnecessary and unsafe injections.

Dr. Hina Jawaid is Assistant Professor Family Medicine, University Health Sciences, Lahore, Pakistan.