Unsafe injection practices and the reselling of sharps waste are the major causes of periodic Hepatitis B and C epidemics

Drugs and tattoos are fads among today’s youth who seem to have absolutely no idea of the resultant risks involved in contracting a life-threatening disease such as hepatitis. The situation could be especially galling for those who contract hepatitis accidentally. Ask Mr. Amitabh Bachchan. Seriously injured on the sets of the film “Coolie” in 1982, the actor only pulled through after weeks of care and dozens of blood transfusions.

Almost 28 years later, in April 2010, tests revealed that Mr. Bachchan had liver cirrhosis caused by Hepatitis B (HPB). For nearly three decades, the deadly disease had silently wasted away almost 25 per cent of his liver. When the HPB virus causes prolonged infection and damages the liver over the years, it is called chronic Hepatitis B. Most persons with chronic HPB may remain symptom-free for years. During this time, blood tests are usually normal or mildly abnormal. Only when the liver is seriously damaged may there be signs of severe disease such as cirrhosis or liver failure. By then, it may be too late.

The viruses

That’s why awareness and preventive measures are essential. Hepatitis, which is an inflammation of the liver, is usually caused by a viral infection. Among hepatitis viruses — A, B, C, D and E — HPB and Hepatitis C (HPC) present the greatest danger through periodic outbreaks. Moreover, HPB and HPC cause chronic disease in millions worldwide, constituting the most common causes of liver cirrhosis and cancer.

Modes of transmission

Both are usually contracted via parenteral contact with infected body fluids. Common transmission modes include infected blood or blood products and invasive medical procedures with contaminated equipment. But hepatitis cannot be contracted via casual contact or by sharing food and drinks. Both disorders can also be transmitted by sharing needles with an infected person during drug sessions, tattooing or piercing with infected tools, and sharing razors or toothbrushes with the infected person. Drugs, tattoos and casual unprotected sex are therefore best avoided.

But the greatest danger arises from unsafe injection practices. According to the World Health Organisation (WHO), 12 billion injections are administered annually globally — five per cent during immunisations and 95 per cent for curative reasons. With needle and syringe reuse and other unsafe injection practices common in low-income countries, both health-care personnel and patients are vulnerable to blood-borne viruses. As per estimates, unsafe injection practices may be responsible for up to 160,000 HIV cases, 16 million HPB and 4.7 million HPC infections globally.

Such transmissions are also endemic in India. In February this year, at Ratia town, Fatehabad district, Haryana, more than 1,600 confirmed cases of HPC were reported in an outbreak caused by doctors and dentists reusing syringes and needles. In February 2009, at Modasa, Sabarkantha district, Gujarat, one of India’s deadliest outbreaks of HPB — 593 confirmed cases and 94 deaths — was triggered by the ignorance and greed of private practitioners reusing infected syringes. Investigations after recent outbreaks have revealed that many health-care personnel consider it safe to reuse a syringe just by changing the needle. It is also considered safe to reuse injection equipment to access an intravenous line as well as reuse this on the same patient when reconstituting from a multi-dose vial, even without sterilisation.

Advisory not implemented

Moreover, apart from doctors and nurses, injections are administered by a variety of health-care workers, including peons, cleaners and scavengers, as recent exposés on news channels have shown. The problems of unsafe injection habits are further compounded by the large-scale practice of repackaging and reselling sharps waste in India.

These practices also jeopardise the likely health gains from children’s immunisation programmes. With unsafe injection practices, children can be particularly endangered during immunisations. This is why the WHO recommends that auto-disable syringes be used in all immunisation projects.

The policy faces great hurdles in India as State governments have not implemented the Central government’s 2008 advisory to Governors and State Health Ministries about introducing auto-disable syringes for all injections to prevent the reuse of injection equipment. Although auto-disable syringes are being used for national immunisation programmes, most States have not implemented the policy for curative injections.

India has been prone to periodic outbreaks of Hepatitis B and C. To break this vicious cycle, mandatory safety norms are needed in all public and private health-care facilities. Stringent prevention of unsafe injection practices is the best way to ensure India stops periodic outbreaks of hepatitis epidemics. In the ultimate analysis, safe injection practices could immensely improve patient safety and minimise the disease burden from chronic infections that regularly afflict India’s most vulnerable sections.

(Dr. Sailesh G. Gupta is Secretary General, Indian Academy of Pediatrics. The views expressed are personal.)

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