title: Towards safe injection practices for prevention of hepatitis C transmission in South Asia: Challenges and progress.
abstract: OBJECTIVE
  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  We searched published and unpublished literature on injection safety in South Asia published during 1995-2016 using the keywords "injection" "unsafe injection" and "immunization injection" and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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Naveed Zafar Janjua, Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada.
authors.forename: Naveed Zafar
authors.initials: NZ
authors.lastname: Janjua
authors.affiliation: Naveed Zafar Janjua, Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada.
authors.forename: Zahid Ahmad
authors.initials: ZA
authors.lastname: Butt
authors.affiliation: Naveed Zafar Janjua, Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada.
authors.forename: Bushra
authors.initials: B
authors.lastname: Mahmood
authors.affiliation: Naveed Zafar Janjua, Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada.
authors.forename: Arshad
authors.initials: A
authors.lastname: Altaf
mesh_terms: D001459:Bangladesh; D001631:Bhutan; D002983:Clinical Competence; D004866:Equipment Contamination / Q000517:prevention & control / Q000706:statistics & numerical data*; D006282:Health Personnel; D006509:Hepatitis B / Q000635:transmission*; D006526:Hepatitis C / Q000635:transmission*; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data; D007194:India; D007195:Indian Ocean Islands; D007267:Injections / Q000706:statistics & numerical data*; D016485:Needle Sharing / Q000706:statistics & numerical data; D009390:Nepal; D010154:Pakistan; D013188:Sri Lanka; D013242:Sterilization / Q000706:statistics & numerical data*
keywords: Hepatitis B; Hepatitis C; Prescription practices; South Asia; Unsafe injections