THERE are three drivers of unsafe and unnecessary injections in Pakistan: prescriber, provider and patient. Prescribers (trained and untrained) often prescribe injections or IV drips even for minor ailments easily treated with oral medications. Private GPs are often intent on building a reputation of delivering quick results to increase their clientele and income. Providers (also trained and untrained) who work for these prescribers will reuse injection equipment in order to save their employers’ money, often on the latter’s instructions.

Patients, meanwhile, insist on getting injections or drips because they want quick relief. Many of the urban and rural poor cannot distinguish between a trained and untrained practitioner. They look for a health facility, inquire about its reputation, and seek treatment. Reuse of injection equipment such as needles, syringes or IV drip sets occurs at many private health facilities in order to save money — many of these patients cannot afford to pay for a new syringe.

Injection safety is complex and requires a multipronged approach.

Pakistan has one of the highest levels of unsafe injection practices in the world. Our patients also have one of the highest rates of number of injections per person annually (8.2 to 13.6). Unfortunately, the country also has one of the highest burdens of hepatitis C. Sound epidemiological studies, including the 2007 National Hepatitis Survey, have highlighted unsafe injection practices as one of the key reasons for transmission of HCV.

Unsafe injections have gained notoriety due to the recent HIV outbreak in Larkana and Ratodero. So far, more than 700 new HIV cases have been confirmed, the majority of them children. Preliminary findings suggest that reuse of injection and IV equipment may be the main cause of transmission, especially among children whose parents test negative for HIV.

Policymakers are aggressively propagating the introduction of reuse prevention (RUP) syringes, which have a built-in locking mechanism. The mechanism is only triggered when the plunger is pushed down fully – a ‘click’ can be heard indicating that the plunger has been locked and cannot be retracted. This type of syringe has been in use in the EPI programme for over a decade now and has helped significantly in curtailing the menace of reuse. But injection safety improvements in the programme were also attributed to improved supplies, training and monitoring of vaccinators in the field as well as at the static EPI centres.

In its 2015 injection safety guidelines, WHO recommend that all member states should switch to exclusive use of RUPs by 2020. It further recommends that conventional syringes should only be used in instances where multiple plunger movement is warranted, such as flushing an IV line or reconstituting medicines which require multiple plunger movements. This is an important point to note; health facility and procurement personnel have to go through complex calculations when ordering RUP syringes for a health facility. A new provider (health worker) must undergo a short training prior to using this type of syringe on patients, as pushing the plunger strongly while the needle is still in the patient’s muscle (in case of an intra-muscular injection) can cause moderate to severe pain. Without proper training, the healthcare worker might also waste a number of syringes. It is worth mentioning that the use of RUP syringes is not an absolute fail-safe — providers can intentionally avoid triggering the locking mechanism if they want to reuse the same syringe multiple times.

Moreover, some clauses in the Sindh Regulation and Control of Disposable Syringes Act, 2010, need amending. For example, clause 3 states, “No person shall manufacture, sell or use disposable syringes other than auto lock, auto destruct or auto break for injection, drawing of blood and other purposes.” As mentioned earlier, conventional syringes will still be required for some medical procedures. Clause 4 reads, “If the person contravening the provisions of the act, is a company, every director, manager, secretary or other officer or agent thereof shall, unless he proves that contravention is made without his knowledge and that he had exercised due diligence to prevent such contravention, be deemed to be guilty of such contravention.” If this clause also includes medical superintendents of hospitals, then this needs revision too.

Injection safety is complex. It requires a multipronged approach targeting the patients and healthcare providers. It also requires nationwide curtailment of prescription of unnecessary injections and IV drips. It is not only quacks but MBBS healthcare providers who also intentionally indulge in unsafe injection practices. The bottom line is: there is no quick fix or single measure that will help. A holistic approach must be adopted. At this time, an intensified nationwide injection safety awareness campaign is needed targeting at-risk communities and healthcare providers.

The writer is a physician and an expert on injection safety.

Published in Dawn, June 2nd, 2019