UNDER the Expanded Programme on Immunisation, injections are administered to nearly eight million Pakistani children every year. According to the programme’s policy, all injections are administered using auto-disable syringes.

The immunisation coverage of children under two years of age (according to the last Pakistan Health and Demographic Survey, 2017-18) stands at around 66 per cent. Despite being free of cost, more than a third of Pakistani parents do not get their children vaccinated against 10 vaccine-preventable childhood diseases. Among the excuses that are offered are that injections cause pain to their children and that the latter fall sick after they are administered the vaccine.

On the other hand, when it comes to injections mostly intended for curative purposes and administered to the adult population, there is overuse. With an annual average of eight to 10 injections per person, Pakistan has the highest number of per capita injections anywhere in the world. What is of even more concern is that around 95pc of these injections are completely unnecessary, as per experts.

The major reason for this love for the shot is that patients believe it provides them with quick relief. Absolving themselves, the health providers claim that patients demand an injection or a drip. However, the reality is that patients are at the mercy of the health providers and trust them blindly, never questioning the ‘need’ for an injection. Not only that, they don’t even ask about safe injection practices, and are oblivious to the risks associated with the reuse of injectable equipment whether syringes or intravenous drips.

Safe injection practices are an alien concept in Pakistan.

Unsafe injections have also contributed significantly to the increase in the burden of Hepatitis C, with Pakistan now having among the highest prevalence levels anywhere. A common denominator of blood-borne infections is the use of unsafe injections.

The HIV/AIDS outbreak in parts of the country has also been attributed to the reuse of syringes and intravenous drip sets. One such case was in Ratodero in Larkana district where, as of November 2019, a total of 1,189 people out of the 36,736 screened for the virus were confirmed HIV positive. Over 80pc of the HIV-affected population was in the under-18 category.

Most unnecessary and unsafe injection practices happen at private clinics or dispensaries. In Pakistan, there are estimates that about 70pc of the patients go to private ‘healthcare facilities’. Sometimes the health providers there, mostly quacks, have no or limited knowledge about injection safety. They prescribe unnecessary injections to provide quick relief and increase their clientele and thus income.

Intravenous drips are also prescribed for conditions which can be dealt with through oral medications. The charges for an intravenous drip literally depend on how much a patient can pay and can range from Rs250 to over Rs1,000. Syringes and drip sets at these clinics are reused because of the inability of the patient to pay extra, the patient’s own lack of knowledge of the risks associated with reuse and the medical staff’s intention to save money.

Awareness is needed for both the prescriber as well as the consumer. The public first needs to know that if a cure is available through tablets, capsules or syrup, they must avoid injections. And secondly, if a shot is necessary, they must ensure that the syringe is new and not reused.

In order to promote the rational use of injectable medicines it is important to enable the patients and community to go beyond patient-doctor trust and question the doctor regarding the need for an injection in the first place to avoid the irrational use of syringes and needles. They need to differentiate between cure and prevention.

On the other hand, the provider needs to be trained regarding syringe safety as well as the appropriate prescription of injections.

The WHO Injection Safety guidelines of 2015 recommend that all states should switch to Reuse Prevention (RUP) syringes. A 2019 WHO-Unicef joint policy statement strongly recommended the systematic and exclusive use of auto-disable syringes for immunisation and RUP syringes for therapeutic injections. It urges countries to switch to RUP by 2020.

This may help bring down the incidence of reuse especially by private practitioners. The reuse of syringes will decrease when RUP syringes (auto-lock, auto-disable, auto-destruct syringes that get locked and cannot be reused) gain prevalence in medical settings.

However, while imposing a ban on conventional disposal syringes, it is equally essential to ensure the uninterrupted availability of auto-disable syringes across the country. The joint statement also urges manufacturers to develop and improve the affordability of auto-disable and RUP syringe technologies.

The writer is a freelance journalist.

Published in Dawn, February 17th, 2020