HomeAboutusEditorial BoardCurrent issuearchivesSearch articlesInstructions for authorsSubscription detailsAdvertise

  Login  | Users online: 817

   Ahead of print articles    Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size  


 
 Table of Contents    
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 37  |  Issue : 2  |  Page : 89-94
 

Estimating the burden of disease from unsafe injections in India: A cost-benefit assessment of the auto-disable syringe in a country with low blood-borne virus prevalence


School of Community Health Sciences, University of Nevada at Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, USA

Date of Submission04-Jan-2010
Date of Acceptance18-Sep-2011
Date of Web Publication12-May-2012

Correspondence Address:
Savanna Reid
431 Sunburst Dr. Henderson, NV 89002
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0218.96093

Rights and Permissions

 

   Abstract 

Background: Unsafe medical injections are a prevalent risk factor for viral hepatitis and HIV in India. Objectives: This review undertakes a cost-benefit assessment of the auto-disable syringe, now being introduced to prevent the spread of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV). Materials and Methods: The World Health Organization methods for modeling the global burden of disease from unsafe medical injections are reproduced, correcting for the concentrated structure of the HIV epidemic in India. A systematic review of risk factor analyses in India that investigate injection risks is used in the uncertainty analysis. Results: The median population attributable fraction for hepatitis B carriage associated with recent injections is 46%, the median fraction of hepatitis C infections attributed to unsafe medical injections is 38%, and the median fraction of incident HIV infections attributed to medical injections is 12% in India. The modeled incidence of blood-borne viruses suggests that introducing the auto-disable syringe will impose an incremental cost of $46-48 per disability adjusted life year (DALY) averted. The epidemiological evidence suggests that the incremental cost of introducing the auto-disable syringe for all medical injections is between $39 and $79 per DALY averted. Conclusions: The auto-disable syringe is a cost-effective alternative to the reuse of syringes in a country with low prevalence of blood-borne viruses.


Keywords: Cost-benefit, hepatitis B virus, hepatitis C virus, HIV, injections


How to cite this article:
Reid S. Estimating the burden of disease from unsafe injections in India: A cost-benefit assessment of the auto-disable syringe in a country with low blood-borne virus prevalence. Indian J Community Med 2012;37:89-94

How to cite this URL:
Reid S. Estimating the burden of disease from unsafe injections in India: A cost-benefit assessment of the auto-disable syringe in a country with low blood-borne virus prevalence. Indian J Community Med [serial online] 2012 [cited 2019 Mar 25];37:89-94. Available from: http://www.ijcm.org.in/text.asp?2012/37/2/89/96093



   Introduction Top


In India, transmission of blood-borne viruses in unsafe health care is endemic. [1] Poor sharps waste management and misconceptions about injection safety both contribute to injection equipment reuse in India. Recent outbreak investigations suggest that many injection providers believe it is safe to reuse a syringe after changing the needle, that it is safe to reuse injection equipment to access an IV line, or that it is safe to reuse injection equipment on the same patient when reconstituting from a multidose vial, without sterilization. [2] These misconceptions are still reported in high-income developed countries and are thought to be prevalent in the developing world. [3] Even more troubling, recycling of sharps waste for repackaging and resale is practiced on a large scale in India, uncovered recently in the investigation of a deadly hepatitis B outbreak. [4] The goal of this review is to evaluate the incremental cost-benefit of using the auto-disable syringe for all medical injections in India, in terms of prevented disability and mortality from hepatitis B, hepatitis C, and HIV infections. India's Ministry of Health issued an advisory to 24 Governors and State Health Ministers to introduce auto-disable syringes for all medical injections in 2008 to prevent injection equipment reuse in health care settings. Most states have not implemented this policy for curative injections, although auto-disable syringes are now used nationwide for immunization injections. Most injections in India are not immunization injections, as injectable drugs are widely preferred over oral formulations. [5] The benefit of using only auto-disable syringes in a country with a low prevalence of blood-borne viruses has not been previously assessed.


   Materials and Methods Top


The total number of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) infections that would result from unsafe medical injections in India in 2010, barring the introduction of auto-disable syringes for all medical injections, is estimated following the mass action model used to develop the World Health Organization global burden of disease estimates. [6] The incidence of each blood-borne virus I v is a product of the size of the susceptible population p s , the probability of transmission in an unsafe medical injection for each virus p tv , and the number of contaminated medical injections performed n c, as given in equation (1). Based on a systematic review of studies of needlestick accidents in health workers, the WHO estimates that the probability of HIV transmission in an unsafe medical injection is 1.2%, the probability of HBV transmission is 6% for HBeAg-negative source patients and 30% for HBeAg-positive patients, and the probability of HCV transmission is 1.8%. [6]



The number of contaminated injections n c is calculated from the unsafe reuse rate p r , the prevalence of each virus in the general population p v (or the adjusted probability that used injection equipment will be contaminated with the virus), and the number of injections per person-year n, as given in equation (2).



Because India's HIV epidemic is concentrated, the model for HIV is adjusted for associations between unsafe injection frequency and HIV prevalence across geographic and demographic segments of the population. The 2004 INCLEN injection safety report evaluated unsafe injection frequency in states and territories with varying HIV prevalence, and the National AIDS Control Organization of India reports HIV prevalence by state and territory. [7],[8] The 2005-2006 Demographic and Health Survey for India is used to relate unsterile injection frequency to HIV prevalence across age groups, gender and marital status, ethnic and religious groups, rural or urban residence, wealth and education level.

Risk factor analyses investigating an association between injections and hepatitis B, hepatitis C and incident HIV infections in India were identified in a systematic search using Pub Med. The population attributable fractions from these risk factor analyses are used to validate the model. The incremental cost per disability adjusted life year (DALY) from each prevented hepatitis B, hepatitis C and HIV infection is calculated in a cost-benefit assessment of the use of the auto-disable syringe, priced at $0.0425 in India.


   Results Top


In a nationwide survey in 2004, the estimated injection frequency varied by recall interval from 2.9 to 5.8 injections per person-year, of which 32% had the potential to transmit blood-borne viruses. [7] The Demographic and Health Survey for India indicates that 0.71% of unsafe injections given to adults were potentially contaminated with blood from an HIV-positive patient, before adjusting for associations between unsafe injection frequency and HIV prevalence. HIV prevalence in children under age 15 (29% of the population) is only 0.00028%. [9] In ecological regression, rural unsterile injection frequency is associated with HIV prevalence (P = 0.036, R 2 = 0.30, β = 1.4). The selected demographic predictors of HIV prevalence are also associated with unsafe injection frequency in adults (P = 0.010, R 2 = 0.23, β = 0.32). Equation (3) reports the adjustments for the probability of an unsafe injection given to a susceptible patient being contaminated with HIV, where β1 is the adjustment factor for geographic region, β2 is the adjustment factor for demographic group, p a is the probability the injection is being given in an adult patient care setting and p c is the probability that the injection is being given to a child. The estimated probability that an unsafe injection given to an HIV-negative patient will be contaminated with blood from an HIV-positive patient is 0.85%.



Three studies of sexually transmitted disease (STD) patients in India investigated an association between medical injections and incident HIV infections, with a median population attributable fraction of 12%. The modeled annual incidence of HIV from unsafe medical injections is 10-21 cases per 100,000. In South India, the adult incidence of HIV was 50 cases per 100,000 in 2008. [10] Thus, this mass action model attributes 20-42% of HIV transmission in India to unsafe medical injections, a far larger fraction than that supported by risk factor analyses in patients with competing risks. HIV incidence in these STD clinic attendees was far higher (5.1-8.2 per 100 person-years at risk) than the population average, suggesting that competing risks were greater in study participants than in the general population.

The median population attributable fraction for chronic hepatitis B across five risk factor analyses to look at injection risks is 46%. These studies are shown in [Table 1]. The modeled incidence of hepatitis B is 0.2-0.4%, or 10-20% of prevalent infections. This discrepancy suggests that either the modeled transmission efficiency of hepatitis B infections is a conservative estimate or the populations in which injections have been investigated as a risk factor for hepatitis B infection are at increased risk for unsafe injections.
Table 1: Population attributable fraction of hepatitis infections linked to injections in India

Click here to view


The median fraction of hepatitis C infections attributed to injections across five risk factor analyses, also shown in [Table 1], is 38%. The average annual incidence suggested by the age distribution of hepatitis C infection in India is 0.1%. [11] For hepatitis C, the modeled incidence is 0.03-0.05%, or 30-50% of prevalent infections.

Following the age-adjusted global burden of disease model for South Asia, these estimates predict that 352,000-646,000 DALYs from hepatitis B infection, 48,700-81,200 DALYs from hepatitis C infection and 2,605,000-5,210,000 DALYs from HIV infection would result which can be prevented by the use of the auto-disable syringe in 2010. These infections could be prevented at an incremental cost of $46-48 per DALY. Estimating HIV, HBV and HCV incidence from the median population attributable fractions in epidemiological investigations instead, the incremental cost may be higher or lower at $39-79 per DALY.


   Discussion Top


Unsafe medical injections carry a risk of blood-borne virus transmission (HIV, HBV, HCV) when the injection equipment is reused without sterilization. [22] This has been shown in case-control studies indicating an association between blood-borne virus infection and receipt of medical injections, [23],[24],[25] with many of these studies demonstrating a dose-response relationship [26],[27],[28] Corroborating evidence is available from blood-borne virus epidemics in populations of injection drug users [29],[30],[31] and from the outcomes of accidental needlesticks in health workers. [32],[33],[34] Phylogenetic analysis of outbreak strains of nosocomial HIV, HBV and HCV have further confirmed the biological plausibility of unsafe medical injections as a vehicle for transmission. [35],[36],[37] Continuing unsafe injection practices in India have been well documented and remain a serious threat to public health. [5],[38],[39]

The present model of blood-borne virus transmission in India through medical injection equipment reuse has several important limitations. Risk factor analyses investigating medical injection risks in India have not controlled for the full range of confounding variables thought to influence the association between medical injections and HIV, also likely to influence the association with HBV. Model-based cost-benefit assessments of the introduction of auto-disable syringes for all medical injections are as uncertain as the model parameters, and the modeled patient mixing patterns only indirectly capture differences in patient populations at facilities with high and low levels of injection equipment reuse. Taken together, however, model-based and empirical evidence of iatrogenic HIV, HBV and HCV transmission in India supports the introduction of auto-disable syringes as a cost-effective intervention. The estimated cost per DALY averted is a fraction of average earned annual income in India by either estimation method, indicating that the introduction of auto-disable syringes for all medical injections is a cost-effective national policy for a low-income country with low prevalence of blood-borne viruses. This is an improvement from the incremental cost per DALY averted estimated for South Asia in 2003. [40]

This review indicates that unsafe injections are associated with HIV at the individual level and at the population level in India. Unsterile injections may serve as a bridge for HIV transmission between high-risk groups and the general population, as has been documented on a tragic scale in the town of Jalal Pur in Pakistan. [41] Among patients at STD clinics, cyclic HIV transmission dynamics are possible, and high rates of hepatitis C infection in female sex workers are suggestive of a role for blood exposures in concentrated HIV epidemics. [42] Nevertheless, given the mismatch between modeled and epidemiological estimates of HIV transmission from unsafe medical injections, the true extent of iatrogenic HIV transmission remains unclear.

The most uncertain parameter in the model of blood-borne virus transmission is the transmission efficiency of each virus in a medical injection. The probability of HIV, HBV or HCV transmission in a contaminated medical injection may be similar to the risk from a needlestick accident. However, descriptive studies of needlestick accidents are few and the ranges of transmission efficiency estimates across these studies are wide. Recently, it has been argued that rinsing injection equipment eliminates the blood-borne virus transmission risk. [43] However, a comparison of the inoculum volume in a needlestick injury (in which the needle is inserted but the plunger of the syringe is not depressed) and in an injection shows that after adjustment for both rinsing the syringe and injecting the remaining contents of the syringe, the transmission efficiency in an unsafe injection is probably of the same order of magnitude as the transmission efficiency in a needlestick accident. [44]

Some other model parameter estimates are less uncertain. The 95% Confidence Intervals around the injection frequency estimates on 2 weeks and 3 months recall intervals were 5.3-6.3 injections and 2.8-3.2 injections per person per year. [7] The 95% Confidence Interval around the proportion of medical injections with the potential to transmit blood-borne viruses was 29-34%. [7] On the other hand, the adjustment for patient mixing patterns accounting for the association between HIV prevalence and exposure to unsafe medical injections was not empiric in the sense that demographic groups do not necessarily mix assortatively in clinical settings. Moreover, the adjustments did not account for the population distribution of the demographic characteristics that predict unsafe injection frequency and HIV prevalence.

The average registered medical practitioner reuses disposable syringes three times without sterilization, but this model assumes that blood-borne viruses are only transmitted from the first patient to the second. [1] Multidose vial contamination when an injection needle is used to reconstitute medication is also prevented by the introduction of auto-disable syringes, but this has not been modeled. In these respects, the model is a conservative one.

Finally, the model does not account for deaths from septicemia, a common complication of unsterile injecting among injection drug users that results from bacterial contamination. [45] Septicemia can result from injection equipment reuse irrespective of whether injection equipment has been used on a patient previously infected. In hospitalized patients with a bacterial culture positive intravenous catheter, 61% had a concomitant bacterial infection. [46] Injection equipment prepared for reuse by boiling is frequently culture positive (e.g., 33% contamination rate in one assay in Tanzania), and by implication injection equipment reused without sterilization is likely to be infectious. [47] In countries with a low prevalence of blood-borne viruses, the primary benefit of preventing injection equipment reuse may be the prevention of potentially serious bacterial infections. However, the burden of disease from nosocomial bacteremia has not previously been modeled.

Today, auto-disable syringes are required for all medical injections in India, Burkina Faso, the Democratic Republic of Congo, Nigeria, Tanzania, and Uganda, and the importation of syringes that are not auto-disable syringes is restricted in Burkina Faso and Tanzania. These national injection safety policies address a patient safety crisis recognized even in high-income developed countries - the widespread practice of injection equipment reuse without sterilization. [48],[49] The WHO recommends the use of auto-disable syringes for all immunization injections, and United Nations Children's Fund (UNICEF) recommends that auto-disable syringes also be used for reconstitution. More extensive use of auto-disable syringes may be needed in countries with generalized HIV epidemics to prevent these nosocomial infections.

In India, implementation of this policy still faces serious obstacles, as State Ministries of Health have not embraced the national government's advisory and the new Minister of Health has not pressed the issue. In Kerala, Karnataka and Madhya Pradesh, the policy has been opposed, although 25-47% of injections in government health facilities in these states carry a risk of blood-borne virus transmission from patient to patient. Only eight states and the central government owned hospitals have partially introduced auto-disable syringes for curative injections. HIV surveillance in India does not investigate iatrogenic risks, and awareness of medical injections as an important secondary HIV transmission route is not widespread. [50] As other developing countries move toward a zero-tolerance policy for iatrogenic HIV transmission, medical injection equipment reuse continues to contribute to widespread undetected blood-borne virus transmission in India. Implementation of the national advisory to use auto-disable syringes for all medical injections could radically improve patient safety and reduce the burden of disease from chronic and stigmatizing infections in the most vulnerable segments of society.

 
   References Top

1.Lakshman M, Nichter M. Contamination of medicine injection paraphernalia used by registered medical practitioners in south India: an ethnographic study. Soc Sci Med 2000;51:11-28.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak investigations highlight the need for safe injection practices and basic infection control. Clin Liver Dis 2010;14:137-51; x.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Okwen MP, Ngem BY, Alomba FA, Capo MV, Reid SR, Ewang EC. Uncovering high rates of unsafe injection equipment reuse in rural Cameroon: validation of a survey instrument that probes for specific misconceptions. Harm Reduct J 2011;8:4.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Rahman S. Recycling of medical waste causes deadly virus outbreak. Available from: http://www.thenational.ae/article/20090312/FOREIGN/97643596/1103/NEWSnone . [Last accessed on 2010 Jan 1].  Back to cited text no. 4
    
5.Kotwal A, Priya R, Thakur R, Gupta V, Kotwal J, Seth T. Injection practices in a metropolis of North India: perceptions, determinants and issues of safety. Indian J Med Sci 2004;58:334-44.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004;15:7-16.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Arora N. Assessment of injection practices in India. INCLEN Trust. Available from: http://www.ipen.org.in/images/stories/exec.%20summary.pdfnone . [Last accessed on 2010 Jan 3].  Back to cited text no. 7
    
8.Department of AIDS Control, Ministry of Health and Family Welfare. Annual Report 2009-2010.  Back to cited text no. 8
    
9.UNAIDS. 2008 Report on the global AIDS epidemic. Available from: http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/none . [Last accessed on 2010 Jul 29].  Back to cited text no. 9
    
10.Kumar Hn H, Jayaram S, Rao MR, Kumar S SG, Kotian M. Recent trends in HIV incidence in coastal South India: implications for prioritizing HIV control strategies. Open Med 2009;3:e26-30.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Marx MA, Murugavel KG, Tarwater PM, SriKrishnan AK, Thomas DL, Solomon S, et al. Association of hepatitis C virus infection with sexual exposure in southern India. Clin Infect Dis 2003;37:514-20.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Mehendale SM, Rodrigues JJ, Brookmeyer RS, Gangakhedkar RR, Divekar AD, Gokhale MR, et al. Incidence and predictors of human immunodeficiency virus type 1 seroconversion in patients attending sexually transmitted disease clinics in India. J Infect Dis 1995;172:1486-91.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Mehendale SM, Shepherd ME, Divekar AD, Gangakhedkar RR, Kamble SS, Menon PA, et al. Evidence for high prevalence and rapid transmission of HIV among individuals attending STD clinics in Pune, India. Indian J Med Res 1996;104:327-35.  Back to cited text no. 13
    
14.Reynolds SJ, Risbud AR, Shepherd ME, Zenilman JM, Brookmeyer RS, Paranjape RS, et al. Recent herpes simplex virus type 2 infection and the risk of human immunodeficiency virus type 1 acquisition in India. J Infect Dis 2003;187:1513-21.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Kurien T, Thyagarajan SP, Jeyaseelan L, Peedicayil A, Rajendran P, Sivaram S, et al. Community prevalence of hepatitis B infection and modes of transmission in Tamil Nadu, India. Indian J Med Res 2005;121:670-5.  Back to cited text no. 15
    
16.Risbud A, Mehendale S, Basu S, Kulkarni S, Walimbe A, Arankalle V, et al. Prevalence and incidence of hepatitis B virus infection in STD clinic attendees in Pune, India. Sex Transm Infect 2002;78:169-73.  Back to cited text no. 16
[PUBMED]  [FULLTEXT]  
17.Singh J, Bhatia R, Patnaik SK, Khare S, Bora D, Jain DC, et al. Community studies on hepatitis B in Rajahmundry town of Andhra Pradesh, India, 1997-1998: unnecessary therapeutic injections are a major risk factor. Epidemiol Infect 2000;125:367-75.  Back to cited text no. 17
[PUBMED]  [FULLTEXT]  
18.Singh S, Kumar J, Singh R, Dwivedi SN. Hepatitis B and C viral infection sin Indian kala-azar patients receiving injectable anti-leishmanial drugs: a community-based study. Int J Infect Dis 2000;4:203-8.  Back to cited text no. 18
[PUBMED]    
19.Singh S, Dwivedi S, Sood R, Wali JP. Hepatitis B, C and human immunodeficiency virus infections in multiply-injected kala-azar patients in Delhi. Scand J Infect Dis 2000;32:3-6.  Back to cited text no. 19
    
20.Marx MA, Murugavel KG, Sivaram S, Balakrishnan P, Steinhoff M, Anand S, et al. The association of health-care use and hepatitis C virus infection in a random sample of urban slum community residents in southern India. Am J Trop Med Hyg 2003;68:258-62.  Back to cited text no. 20
[PUBMED]  [FULLTEXT]  
21.Chowdhury A, Santra A, Chaudhuri S, Dhali GK, Chaudhuri S, Maity SG, et al. Hepatitis C virus infection in the general population: a community-based study in West Bengal, India. Hepatol 2003;37:802-9.  Back to cited text no. 21
    
22.Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bull World Health Organ 1999;77:789-800.  Back to cited text no. 22
[PUBMED]  [FULLTEXT]  
23.Ungchusak K, Rehle T, Thammapornpilap P, Spiegelman D, Brinkmann U, Siraprapasiri T. Determinants of HIV infection among female commercial sex workers in Northeastern Thailand: results from a longitudinal study. J Acquir Immune Defic Syndr Hum Retrovirol 1996;12:500-7.  Back to cited text no. 23
[PUBMED]    
24.Hutin YJ, Harpaz R, Drobeniuc J, Melnic A, Ray C, Favorov M, et al. Injections given in healthcare settings as a major source of acute hepatitis B in Moldova. Int J Epidemiol 1999;28:782-6.  Back to cited text no. 24
[PUBMED]  [FULLTEXT]  
25.Janjua NZ, Hamza HB, Islam M, Tirmizi SF, Siddiqui A, Jafri W, et al. Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infectino in Karachi, Pakistan. J Viral Hepat 2010;17:317-26.  Back to cited text no. 25
[PUBMED]  [FULLTEXT]  
26.Quigley MA, Morgan D, Malamba SS, Mayanja B, Okongo MJ, Carpenter LM, et al. Case-control study of risk factors for incidence HIV infection in rural Uganda. J Acquir Immune Defic Syndr 2000;23:418-25.  Back to cited text no. 26
    
27.Usman HR, Akhtar S, Rahbar MH, Hamid S, Moattar T, Luby SP. Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan. Epidemiol Infect 2003;130:293-300.  Back to cited text no. 27
[PUBMED]  [FULLTEXT]  
28.Khan AJ, Luby SP, Fikree F, Karim A, Obaid S, Dellawala S, et al. Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan. Bull World Health Organ 2000;78:956-63.  Back to cited text no. 28
[PUBMED]  [FULLTEXT]  
29.Williams ML, McCurdy SA, Bowen AM, Kilonzo GP, Atkinson JS, Ross MW, et al. HIV seroprevalence in a sample of Tanzanian intravenous drug users. AIDS Educ Prev 2009;21:474-83.  Back to cited text no. 29
[PUBMED]  [FULLTEXT]  
30.Quan VM, Go VF, Nam le V, Bergenstrom A, Thuoc NP, Zenilman J, et al. Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study. AIDS Care 2009;21:7-16.  Back to cited text no. 30
[PUBMED]  [FULLTEXT]  
31.Mahanta J, Borkakoty B, Das HK, Chelleng PK. The risk of HIV and HCV infections among injectino drug users in northeast India. AIDS Care 2009;21:1420-4.  Back to cited text no. 31
[PUBMED]  [FULLTEXT]  
32.Gibellini D, Borderi M, Bon I, Biagetti C, De Crignis E, Re MC. HIV-1 infection of a nurse from a newborn with an unknown HIV infection: a case report. J Clin Virol 2009;46:374-7.  Back to cited text no. 32
[PUBMED]  [FULLTEXT]  
33.Sugauchi F, Mizokami M, Orito E, Ohno T, Hayashi K, Kato T, et al. Molecular evolutionary analysis of the complete nucleotide sequence of hepatitis B virus (HBV) in a case fo HBV infection acquired through a needlestick accident. Clin Infect Dis 2000;31:1195-201.  Back to cited text no. 33
[PUBMED]  [FULLTEXT]  
34.Libois A, Fumero E, Castro P, Nomdedeu M, Cruceta A, Gatell JM, et al. Transmission of hepatitis C virus by discarded-needle injury. Clin Infect Dis 2005;41:129-30.  Back to cited text no. 34
    
35.Bobkov A, Garaev MM, Rzhaninova A, Kaleebu P, Pitman R, Weber JN, et al. Molecular epidemiology of HIV-1 in the former Soviet Union: analysis of env V3 sequences and their correlation with epidemiologic data. AIDS 1994;8:619-24.  Back to cited text no. 35
[PUBMED]    
36.Pourkarim MR, Verbeeck J, Rahman M, Amini-Bavil-Olyaee S, Forier AM, Lemey P, et al. Phylogenetic analysis of hepatitis B virus full-length genomes reveals evidence for a large nosocomial outbreak in Belgium. J Clin Virol 2009;46:61-8.  Back to cited text no. 36
[PUBMED]  [FULLTEXT]  
37.Centers for Disease Control and Prevention (CDC). Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic - Nevada, 2007. MMWR Morb Mortal Wky Rep 2008;57:513-7.  Back to cited text no. 37
    
38.Rajasekaran M, Sivagnanam G, Thirumalaikolundusubramainan P, Namasivayam K, Ravindranath C. Injection practices in southern part of India. Public Health 2003;117:208-13.  Back to cited text no. 38
[PUBMED]  [FULLTEXT]  
39.Bhave S, Kamath SS, Shah R. Injection safety and Indian Academy of Pediatrics. J Indian Med Assoc 2005;103:228-30, 232.  Back to cited text no. 39
[PUBMED]    
40.Dziekan G, Chisholm D, Johns B, Rovira J, Hutin YJ. The cost-effectiveness of policies for the safe and appropriate use of injection in healthcare settings. Bull World Health Organ 2003;81:277-85.  Back to cited text no. 40
[PUBMED]  [FULLTEXT]  
41.Emmanuel F. Outbreak Investigation, Mohalla JogiPura, Jalal Pur Jattan. HIV/AIDS Surveillance Project, 2010.  Back to cited text no. 41
    
42.Gisselquist D. How much do blood exposures contribute to HIV prevalence in female sex workers in sub-Saharan Africa, Thailand and India? Int J STD AIDS 2007;18:581-8.  Back to cited text no. 42
[PUBMED]  [FULLTEXT]  
43.Schmid GP, Buvé A, Mugyenyi P, Garnett GP, Hayes RJ, Williams BG, et al. Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet 2004;363:482-8.  Back to cited text no. 43
    
44.Reid S, Juma OA. Minimum infective dose of HIV for parenteral dosimetry. Int J STD AIDS 2009;20:828-33.  Back to cited text no. 44
[PUBMED]  [FULLTEXT]  
45.Rothman RE, Majmudar MD, Kelen GD, Madico G, Gaydos CA, Walker T, et al. Detection of bacteremia in emergency department patients at risk for infective endocarditis using universal 16S rRNA primers in a decontaminated polymerase chain reaction assay. J Infect Dis 2002;186:1677-81.  Back to cited text no. 45
[PUBMED]  [FULLTEXT]  
46.Park KH, Kim SH, Song EH, Jang EY, Lee EJ, Chong YP, et al. Development of bacteraemia of fungaemia after removal of colonized central venous catheters in patients with negative concomitant blood cultures. Clin Microbiol Infect 2009;16:742-6.  Back to cited text no. 46
[PUBMED]  [FULLTEXT]  
47.Hoelscher M, Riedner G, Hemed Y, Wagner HU, Korte R, von Sonnenburg F. Estimating the number of HIV transmission through reused syringes and needles in the Mbeya Region, Tanzania. AIDS 1994;8:1609-15.  Back to cited text no. 47
[PUBMED]    
48.Mortimer PP. Away with multi-use vials! AIDS 1999;13:1779-81.  Back to cited text no. 48
    
49.Plott RT, Wagner RF Jr, Tyring SK. Iatrogenic contamination of multidose vials in simulated use. A reassessment of current patient injection technique. Arch Dermatol 1990;126:1441-4.  Back to cited text no. 49
[PUBMED]  [FULLTEXT]  
50.Correa M, Gisselquist D. Routes of HIV transmission in India: assessing the reliability of information on AIDS case surveillance. Int J STD AIDS 2006;17:731-5.  Back to cited text no. 50
[PUBMED]  [FULLTEXT]  



 
 
    Tables

  [Table 1]


This article has been cited by
1 A path to eradication of hepatitis C in low- and middle-income countries
Camilla S. Graham,Tracy Swan
Antiviral Research. 2015;
[Pubmed] | [DOI]
2 Consensus Statement of HCV Task force of the Indian National Association for Study of the Liver (INASL). Part I: Status Report of HCV Infection in India
Pankaj Puri,Anil C. Anand,Vivek A. Saraswat,Subrat K. Acharya,Radha K. Dhiman,Rakesh Aggarwal,Shivram P. Singh,Deepak Amarapurkar,Anil Arora,Mohinish Chhabra,Kamal Chetri,Gourdas Choudhuri,Vinod K. Dixit,Ajay Duseja,A.K. Jain,Dharmesh Kapoorz,Premashis Kar,Abraham Koshy,Ashish Kumar,Kaushal Madan,Sri P. Misra,Mohan V.G. Prasad,Aabha Nagral,Amarendra S. Puri,R. Jeyamani,Sanjiv Saigal,Shiv K. Sarin,Samir Shah,P.K. Sharma,Ajit Sood,Sandeep Thareja,Manav Wadhawan
Journal of Clinical and Experimental Hepatology. 2014;
[Pubmed] | [DOI]
3 Treatment of chronic hepatitis C: What is new?
Anil C. Anand
Apollo Medicine. 2014;
[Pubmed] | [DOI]
4 Tackling the Hepatitis B disease burden in India
Pankaj Puri
Journal of Clinical and Experimental Hepatology. 2014;
[Pubmed] | [DOI]
5 Spending of HIV resources in Asia and Eastern Europe: Systematic review reveals the need to shift funding allocations towards priority populations
Craig, A.P., Thein, H.-H., Zhang, L., (...), Gorgens, M., Wilson, D.P.
Source of the Document Journal of the International AIDS Society. 2014;
[Pubmed]
6 Is There a Need for Cluster Hepatitis B and C Epidemiological Studies in the Region?: Yes
Jorge T. Insua
Current Hepatitis Reports. 2013; 12(4): 288
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
           

    

 
   Search
 
  
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Article in PDF (408 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
    References
    Article Tables

 Article Access Statistics
    Viewed3154    
    Printed102    
    Emailed0    
    PDF Downloaded367    
    Comments [Add]    
    Cited by others 6    

Recommend this journal

  Sitemap | What's New | Feedback | Copyright and Disclaimer
  2007 - Indian Journal of Community Medicine | Published by Wolters Kluwer - Medknow
  Online since 15th September, 2007