1. SIGN Rapid Assessment Survey Northern Areas, Pakistan Lubna Samad, MRCS, FCPS Pediatric Surgeon National Institute of Child Health

2. Objectives provide information on existing injection practices among –prescribers –providers –general population

4. Demographic & Health Indicators District Gilgit and Ghizar, Northern Areas IndicatorsTotal Population310,139 IMR37 DPT3 Coverage82-88% Govt employed doctors~45 Source: Based on 2000 Annual Report Aga Khan Health Service, Pakistan Projected at 2.2% population growth rate

5. Methods Northern Areas Rapid Assessment, 2001 Urdu translation of Instruments 2, 4, 5 13 physician prescribers 14 injection providers 26 general population

6. Physician Prescribers ( n= 13) Northern Areas Rapid Assessment, 2001 Ave number of patients per week318 Proportion to whom injections are prescribed 14% Ave total injections in treatment4 Injections preferred31% Oral preferred46% Either23%

7. Physician Prescriptions ( n= 280) Northern Areas Rapid Assessment, 2001 15% (43/280) of all prescriptions sampled included at least one injection Most common illness for which injections prescribed: pneumonia, acute severe abdominal pain, gastroenteritis, enteric fever

8. Injection Provider Observations ( n= 14) Northern Areas Rapid Assessment, 2001 Use of new disposable syringes14 Immediate discarding in sharp box2 Two handed recapping8 Appropriate destruction/ disposal of sharps 2

9. Injection Providers ( n= 14) Northern Areas Rapid Assessment, 2001 Ave number of injections given per week64 Ave number of needle sticks in 12 months2 Proportion never received HBV vaccine79% Insufficient quantities of injection equipment available 57% Insufficient quantities of sharp boxes available 86% No access to waste disposal facility79%

10. General Population ( n= 26) Northern Areas Rapid Assessment, 2001 Proportion received an injection/ infusion in past 3 months 19% How many on average?3 Needle and syringe came from plastic pack 67% Proportion of injection cost paid for syringe/needle 6% Proportion who prefer oral treatment77%

11. Reported Associations Between Injection Reuse and Infections Northern Areas Rapid Assessment, 2001 Prescribers N= 13Providers N= 14 General Population N= 26 HIV100%43%12% HCV77%7%0 HBV92%36%0 others076%46% don't know 07%50%

12. Summary Frequent prescription and administration of injections (est. 2-3 per person per year) Lack of awareness regarding the transmissibility of hepatitis viruses and HIV Lack of safe injection equipment, waste disposal facilities

13. Progress Since Rapid Assessment District Hospital, Gilgit –Improved monitoring of injection equipment supplies –Improved health facility waste management –HCV screening introduced Market survey Market survey of syringes planned for early 2003 –Healthy Minute –Expert interviews –Dramatization/serials