1. SIGN Pakistan Dr. Arshad Altaf

2. Objectives of the Presentation zOverview of burden of disease in Pakistan because of unsafe injection practices zPresent activities of SIGN Pakistan zFuture plan

3. Burden of diseases in Pakistan zStudies in Pakistan have found hepatitis C : y60% hepatitis among liver cancer patients (Ahmed et al., 1995) y51% among beta thalassemia major patients (Ahmed et al., 1995) y46% among chronic liver disease patients (Mujeeb et al., 1998) y18% among cirrhotic patients (Mujeeb et al., 1998) y20% among commercial blood donors (Mujeeb et al., 1998)

4. Unsafe Injection Practices z1993: Luby et. al. y6.5% antibodies positive for hepatitis C in Hafizabad, Pakistan z1994: Luby et al. yFollow up case control study to identify risk factors yPositive individuals were 8.2 times more likely to receive > 5 injections per year

5. Unsafe Injections Practices z1995: Aamir Javed Khan et al., yInvestigated relationship between hep B & C and injections in peri urban Karachi y44% hepatitis C positive ythose who received more injections were more likely to be hepatitis C infected y94% of the needles/syringes were reused

6. Unsafe Injections Practices z1995: Reaglow et al., KAP study y49% received one or more injections at their last visit to health practitioner y35% received 10 or more injections in the last year y64% felt that injections are more powerful

7. Creation of SIGN Pakistan FIRST NATIONAL SYMPOSIUM zFirst national symposium on Safe Injection and Blood Practices in Pakistan on Feb 15, 2000 zObjectives: yProvide a forum to discuss ideas yIdentify persons and process to develop assessment protocol yCollect input for intervention from those who have conducted studies yFoster formation of Safe Injection working group

8. Formation of SIGN Pakistan zSIGN Pakistan Working Group formed zMaillist created (signpak@maillists.com) zFirst national meeting “Partners in Injection Safety” on June 17, 2000 zObjectives: yFormal announcement of SIGN Pakistan yTo identify national stakeholders

9. SIGNPAK Working Group zThe Aga Khan University zSindh AIDS Control Programme, Government of Sindh zHOPE

10. National Stakeholders zNational Institute of Health, Islamabad zWHO zUNAIDS zWorld Bank zBecton Dickinson zEPI (Expended Programme of Immunization) zUNICEF zCIET International zPPHF (Pakistan Public Health Foundation)

11. Development of Injection Assessment Tool zTraining workshop organized in Karachi (collaborating with SIGN-Geneva) zDr. Anne Reeler-Medical Anthropologist zDevelopment and assessment of tool in Karachi zCapacity building

12. Findings from Initial Assessment yTarget groups: Community & patients, health care providers, dispensers, vaccinators yFindings: xCommunities and patients knew about disposable syringes xPatients rely on doctor for prescription xThey want fast relief xCheaper to get injections xNot aware of hepatitis B or C, aware of pain/abscesses

13. Findings continued zGeneral practitioners: yInjections are important to stay in business yCost of prescription with and without injection is the same yNo consensus on who initiates injections y80-100% patients get at least one injection yNo health information given to patients

14. Action Plan yResearch yQualitative assessment in all four provinces yResources available for one province (SINDH) yQuantitative survey in an intervention area yDevelop appropriate health messages

15. Action Plan yAdvocacy ySensitize policy planners yDisposable medical devices ordinance 2000 yManufacturers-cheap technologies yAdvocacy seminars/workshops yNATIONAL COLLABORATORS

16. Action Plan zIntervention: zFour Ps yPhysicians yPatients yPopulation yPress