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Overview of injection practices in two governorates in Egypt Maha Talaat1, Said El-Oun2, Amr Kandeel2, Wafa Abu-Rabei2, Caroline Bodenschatz1, Anna-Lena Lohiniva1, Zoheir Hallaj3 and Frank J. Mahoney1,4 1 2 3 4
US Naval Medical Research Unit, Cairo, Egypt Ministry of Health and Population, Cairo, Egypt Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt US Centers for Disease Control and Prevention, Atlanta, USA
Summary
objective To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood-borne pathogen transmission. methods Household surveys of a population-based sample of residents in the Nile Delta and in Upper Egypt; focus group discussions and in-depth interviews with community target groups, formal and informal medical providers. results Of 4197 persons interviewed, 26.2% reported receiving an injection in the past 3 months. Of these, 77% reported it was for therapeutic indications. The age-sex specific prevalence of injections was highest among children 0–2 years of age and among older adults. Women were more likely to report having an injection than men, particularly at the age above 20 years. Overall, respondents reported receiving on average 4.2 injections per year, indicating that up to 281 million injections are provided per year in Egypt. Injection administrators were public and private sector physicians, pharmacists, barbers, doctor assistants, housekeepers, relatives and friends. Injection prescribers were mostly private and public sector physicians. Of the 1101 respondents who received an injection in the past 3 months, 92 (8.4%) reported that the provider did not use a syringe taken from a closed sealed packet. conclusion The frequency of therapeutic injection use is high in Egypt and may contribute to bloodborne pathogen transmission. The Ministry of Health and Population (MOHP) is developing interventions targeted towards promotion of injection safety and reduction of injection overuse on community basis as part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt. keywords hepatitis C, Egypt, injections, safety
Introduction Numerous studies indicate that unsafe injections contribute to the transmission of blood-borne pathogens throughout the world (Hersh et al. 1991; Luby et al. 1997; Singh et al. 1998; Vos et al. 1998; Frank et al. 2000). Several epidemiologic investigations suggest that unsafe injections are a significant risk factor for hepatitis C virus (HCV) infection in Egypt (Darwish et al. 1993; Mohamed et al. 1996; Habib et al. 2001). Additional studies have reported that unsafe medical, surgical, dental and transfusion procedures, as well as poor sterilization of medical equipment, also contribute to the transmission of HCV infection in Egypt (Tibbs 1997; El-Zayadi et al. 1999). As part of a comprehensive strategy to prevent bloodborne pathogen transmission in Egypt, the Ministry of Health and Population (MOHP) has implemented a national programme to promote infection control, safe 234
transfusion practices, and safe injection practices. This report provides results from a survey to evaluate the frequency and safety of injections in two governorates. The objectives of the survey were to determine the frequency and type of injections in a population-based sample of the community; identify persons who prescribe and administer injections; evaluate the safety of injections; and to explore socio-cultural beliefs of the population and health providers to injections and gain deep insight into the role of injection administrators in the society. This is the first study that describes the extent and characteristics of injection use and injection providers in Egypt. The data is being used to design and evaluate interventions to promote safe injections in Egypt. Methods The study used both quantitative and qualitative data collection methods.
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Study governorates and target populations Egypt is classified administratively into 27 governorates. The study was conducted in one governorate in the Nile Delta (Lower Egypt) and one in Upper Egypt. The Lower Egypt governorate, located about 80 km north of Cairo, has a population of 4 million. It has 13 administrative districts, each with 11–36 villages and an urban district capital. Most inhabitants live in rural areas. The governorate in Upper Egypt is located 640 km south of Cairo and has a population of 2.5 million. It includes 11 administrative districts with four to 33 villages per district. The economy in the community of Upper Egypt is less well developed than the governorate in Lower Egypt. Most residents in both governorates are involved in agriculture. The study included residents from eight randomly selected study sites including four villages and one urban area in Lower Egypt governorate and two villages and one urban area in Upper Egypt governorate. All households were enumerated in each of the eight selected sites to serve as the sampling frame for each site. Household prevalence rate of injections was determined by any household who included at least one member who received an injection within the period of 3 months prior to the survey. Sample size calculations on the number of households to include in each study site were based on an estimated 30% household injection prevalence rate with confidence limits of 22–38%. All individuals in the selected households were invited to participate in the survey. Survey methods Persons participating in the survey were invited for interview using a structured questionnaire. For children younger than 10 years, the head of the household was interviewed. Information was collected on age, sex, education, occupation and detailed history of injections over the past 3 months, including the number and type of injections received, the provider and prescriber of the last injection, and the safety of the last injection including data on type and source of syringe used. Injections were defined as any skin puncturing procedure performed with a syringe and needle to introduce a substance. Safety of injections was assessed by asking about the source of syringe used for the last injection. Injections were classified as ÔsafeÕ if respondents replied the injection was provided by means of a plastic syringe obtained from a closed sealed packet. Injections were classified as unsafe if the respondent indicated the injection was provided by a previously opened plastic syringe. It was assumed that injections provided by opened plastic syringes were reused syringes. Nobody reported receiving injections from a glass syringe
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that is designed for reprocessing. Participants were also questioned regarding their lifetime history of having an injection-associated abscess. Providers of injections were classified as formal and informal medical providers. Formal medical providers include health care professionals with formal medical training to administer injections. Persons who have not received training on providing injections and who are not licensed or officially recognized as injection providers were classified as informal providers. Survey teams included Ministry of Health and local public health workers trained to standardize data collection methods. Qualitative research methods and tools The qualitative study was undertaken in the same villages and cities where the quantitative assessment has been undertaken. It started after completion of the quantitative assessment for further intensive investigations to explore reasons behind certain findings. We conducted 18 focus group discussions in each governorate. Community target groups were adult men and women, and four focus group discussions were held for each target group. In each governorate five focus group discussions were held with doctors and five with nurses. Twenty in-depth interviews were conducted with informal injection administrators in each governorate. Focus group discussions with community members were conducted to ascertain the perception of community members regarding their preference of injections and reasons behind that, reuse of syringes, health-seeking behaviour and the use of formal and informal injection providers. For doctors and nurses, measuring their beliefs in injections and understanding their motives for prescribing injections were explored. We interviewed 20 informal injection administrators in each governorate. Perception on injection preference and risks associated with injections were measured. Data collected in the focus group discussions were tape recorded and notes were taken during the sessions. Content analysis was performed by coding of segments of text related to various topics and categories. Segments of the same topics were sorted and compared across all the interviews. Data analysis Survey questionnaires were entered into a computerized database. Household and individual based prevalence rates of injections in the past 3 months were calculated as indicators to describe the extent of injection use in the population. Estimates on the annual number of injections a person received was estimated by multiplying the number 235
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of injections a person received by four in the past 3 months. The total number of injections provided each year in Egypt was calculated by multiplying the mean number of injections per person per year by the census data for the year 2001. Data was presented for type of injections, injection administrators, prescribers and their characteristics, and socio-cultural beliefs on injections. Cluster analysis was used to adjust for the effect of household clustering on injection practices. It was performed with software that uses the Taylor Linearized Deviation approach (Sullivan et al. 1994). Each household was assigned a unique number that served as a field to identify households as the primary sampling unit.
Results Injection prevalence rate Based on sample size calculations, a total of 470 and 250 households were included in the survey from Lower and Upper Egypt, respectively. Although all households participated in the study, individuals absent at the time of the survey were not included in the survey. Of 4813 eligible household members, 87% completed the interview (n ¼ 4197), including 85% of residents in Lower Egypt and 91% of residents in Upper Egypt. The male to female ratio in the sample was 1:1. Overall, 72% of households in both governorates had at least one member who received an injection in the past 3 months. Individual based prevalence rate of injections was significantly higher among residents of Lower Egypt governorate than those of Upper Egypt governorate
(P ¼ 0.005). No consistency in the pattern of household prevalence rate of injections was observed in rural and urban areas in both governorates. For the Lower Egypt governorate, the household prevalence rate of injections was significantly higher in rural than urban areas (Prevalence ratio 1.2, P ¼ 0.02). For the Upper Egypt governorate, the household prevalence rate of injections did not vary among residents in rural areas compared with residents in the urban community (P > 0.05) (Table 1). Among the 4197 household residents who completed the interview, 1101 (26.2%) reported receiving an injection in the past 3 months. The design effect of household clustering on the individual prevalence of injections was minimal (0.9). The age–sex specific injection prevalence of persons receiving an injection over the past 3 months peaked in the 0–2-year-old age group, where most compulsory vaccines are provided. When analysed by gender, women were more likely to receive injections than men at most age groups, but statistical significance was only observed above the age of 50 years (Prevalence ratio 1.6, P ¼ 0.03) (Figure 1). Types of injections When questioned about the indications for their most recent injection, the majority of participants (77.2%) reported receiving a therapeutic injection vs. immunizations (15.7%) or other injections (7.1%) such as infusions or contraceptive injections. Residents of the Lower Egypt governorate were more likely to receive therapeutic injections compared with residents of Upper Egypt (80.3% and 71.3%, respectively, Figure 2).
Table 1 Household and Individual-based prevalence rate of injections in Lower and Upper Egypt governorates in the past 3 months Households with members receiving injections in the past 3 months
Total no. of house holds Lower Egypt Rural 369 Urban 101 Total 470 Upper Egypt Rural 158 Urban 92 Total 250
No. of households with at least one member receiving an injection
Household prevalence rate of injections
275 63 338 106 74 180
Individuals receiving injections in the past 3 months
Total no. of persons interviewed
No. of persons who received injections
Individualbased prevalence rate of injections
95% confidence intervals
Estimated annual no. of injections per person
74.5 62.4 71.9
2058 541 2599
592 128 720
28.8 23.7 27.7
27.7–29.8 20.1–27 26.6–28.8
4.8 4 4.8
67.1 80.4 72.0
1034 564 1598
257 124 381
24.8 21.9 23.8
24.8–24.9 21.9–21.9 23.8–23.8
3.2 4.8 3.6
Estimated annual number of injections per person was calculated based on multiplying by 4 the number of injections a person received in the past 3 months.
236
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Lower Egypt 80
80.3
Upper Egypt
71.3
60 40
22.9
20
11.9
7.8
5.8
s er th O
Im m un iz at io n
Th er ap eu tic
0
Figure 2 Types of injections in Lower and Upper Egypt governorates. Others include intravenous infusions and contraceptive injections.
Of the 1101 persons who had had an injection in the last 3 months, 1009 (91.6%) received a safe one (i.e. from a syringe that was opened from a new packet), against 92 (8.4%) participants who had been injected with a previously opened plastic syringe. Of the 92 unsafe injections, 52 (56.5%) were administered by a governmental source, 25 (27.2%) by informal practitioners and 15 (16.3%) by other providers. When asked about adverse events associated with injections, 69 (1.6%) respondents reported a lifetime history of having an abscess caused by an injection. Injection administrators and their characteristics There was remarkable variability in the characteristics of persons providing injections: 475 (43.1%) people received it from the governmental health workers, 375 (34.1%) from informal medical providers, 164 (14.9%) from private sector physicians or nurses, 48 (4.4%) from pharmacists, and 39 (3.5%) were not able to identify the
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41 31.7
21
18.8 7.6
2.6 5.2
N ot kn ow n
m
ac
y
6 1.3
ar
G ov er nm en t
51 +
0 –5 41
11 –2
3– 11
31 –4 0
0 21 –3 0
0
0
20
Figure 1 Age–sex specific prevalence rate of injections in Lower and Upper Egypt.
Per cent
40
20
Age groups
64.8
60
Ph
40
Upper Egypt
In fo rm al s
Per cent
80
60
0– 2
Per cent
80
100
Lower Egypt
100
e
Total
at
Females
iv
Males
Pr
100
Figure 3 Injection administrators in Lower and Upper Egypt governorates.
source. Residents in Upper Egypt were given injections more frequently in governmental facilities, while participants in Lower Egypt received most of theirs from both informal and governmental providers (Figure 3). Informal injection providers included relatives, housekeepers of local governmental clinics, tamargi (assistants of private medical doctors) and so-called health barbers (Table 2). Almost half (48.3%) of the 375 injections administered by informal practitioners were provided by relatives, neighbours and friends; 43.9% were administered by housekeepers and tamargi. A very small proportion (5.9%) was administered by barbers. Residents in the Lower Egypt governorate were more likely to use housekeepers and tamargi than residents in Upper Egypt who reported receiving injections from their household relatives. Health barbers exist only in Lower Egypt. Injection prescribers Of the 1101 persons who received an injection in the past 3 months, 947 (86%) reported that either a public or private sector clinician prescribed it. In both governorates private sector clinicians prescribed injections slightly more often than government health workers; there was little difference between urban and rural areas (Table 3). Socio-cultural beliefs on injections The quantitative assessment revealed high injection rates among the general population. Most men and women explained that they prefer injections as a way of treatment, because they are powerful and cure faster, circumvent the problems of having to swallow bad tasting tablets and stomach upsets caused by pills, and because they are particularly useful for children who are always reluctant to swallow medicine. The efficacy of injections in cases 237
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Health Barber
Lower Egypt Rural Urban Total Upper Egypt Rural Urban Total
Relatives/ friends
Housekeepers/ tamargi
Total
No.
%
No.
%
No.
%
244 51 295
11 11 22
4.5 21.6 7.5
104 23 127
42.6 45.1 43.1
129 17 146
52.9 33.4 49.5
59 21 80
0 0 0
0 0 0
36 18 54
61.0 85.7 67.5
23 3 26
39.0 14.3 32.5
Table 2 Characteristics of the group of informal injection administrators
Table 3 Prescribers of injections in Lower and Upper Egypt governorates Prescribers of last injection
Lower Egypt Rural Urban Total Upper Egypt Rural Urban Total
Selfmedication
Public doctor
Private doctor
Total
No.
%
No.
%
No.
592 128 712
28 10 38
4.7 7.8 5.3
249 38 287
42.1 29.7 39.3
257 124 381
10 4 14
3.9 3.2 3.7
102 38 140
39.7 30.6 36.7
Pharmacist
Relatives
Others
%
No.
%
No.
%
No.
%
274 60 334
46.3 46.9 46.4
31 16 47
5.2 12.5 6.5
10 1 11
1.7 0.8 1.5
3 3
2.3 0.4
115 71 186
44.7 57.3 48.8
6
2.3
1
0.4
6
1.6
1
0.3
23 11 34
8.9 8.9 8.9
Others include doctors in their working sites as factories or military hospitals.
of serious illness was especially stressed. Few respondents recognized adverse events and difficulty in the administration of injections. These included pain of the prick of the needle, the need to store ampoules in the refrigerator and lack of access to an injection provider. By discussing with community members the criteria upon which they choose injection administrators, the majority explained that an injection is not a sophisticated process and it just needs a trustful experienced person who does not require special skills or training. Using formal providers is appreciated as they are more trained, however, they are not readily accessible to all the population. The alternative is the informal group of injection administrators who are more accessible, move from house to house and provide their services in an easy, comfortable way. Also, domestic providers who are friends, relatives and neighbours are important providers as they may be available day and night without any expected cost. The most important criteria identified for an injection provider is ÔtrustÕ. Using 238
health barbers as injection providers in Lower Egypt governorate was very much appreciated as residents consider that they are experienced in providing injections and other medical services. In addition, barbers have a good reputation for administering injections without visible side-effects and they provide injections for a lower cost than formal providers. Payment is according to the patient’s financial capability. Interviews with medical staff indicated that doctors and nurses had similar perceptions of the strong effect of injections vs. oral medications, particularly for treatment of serious diseases. Physicians also reported that part of the motivation to prescribe injections was a desire to please their patients who often request injections, particularly elderly women. They also reported that if they refuse to prescribe injections, many patients return for further treatment that is considered a burden or seek care in other facility. Interviews with informal health providers revealed similar perceptions regarding the effectiveness of injections
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as the population and the formal group. They believed in the rapid effect of injections and the efficacy in case of serious disease. They did not recognize any risks related to injections, whether self risk or consumer risk. Rarely, exposure to needle sticks was expressed as a risk for transmission of diseases. However, risk to the recipient of the injection was only mentioned if syringes were reused. Discussion Findings in this study indicate that there is a high frequency of therapeutic injections among the general population, that many injections are prescribed and administered by untrained medical providers and that reuse of syringes occurs which is likely to contribute to blood-borne pathogen transmission in Egypt. Numerous epidemiologic investigations demonstrate that an increased number of injections is associated with blood-borne pathogen infection (Hyams et al. 1987; Anonymous 1997; Luby et al. 1997; Hutin et al. 1999). The frequency of exposure to injections in Egypt (4.2 injections/person/year) is higher than those reported from Tanzania, Uganda, Indonesia, and Thailand (Reeler & Hematorn 1994; Gumodoka et al. 1996; Van Staa & Hardon 1996) but lower than what has been reported in Pakistan where it is estimated that residents receive 8.5 injections a year (Raglow et al. 2001). Using current estimates for the population of Egypt (67 000 000), and assuming that the figure of 4.2 injections per person per year is representative of the country as a whole, this study indicates approximately 281 million injections are administered yearly. Similar to studies in other countries, qualitative findings in the study indicate that consumers prefer injections because of strong belief that injections cure faster and provide Ôstronger medicineÕ. Clinicians, particularly private sector providers, may contribute to this increased frequency of injections by meeting patients’ demand for injections and receiving indirect financial benefit for prescribing injections by keeping their patients. Focus group discussions among clinicians and in-depth interviews with informal providers also suggest that providers believe that injections are more effective than oral medications in treating many different diseases similar to what is reported in other countries (Staa & Hardon 1996). The finding that the bulk of injections provided in Egypt are therapeutic and administered by a diverse group of trained and untrained providers presents a challenge for behaviour change strategies to reduce overuse of injections and promote injection safety. Developing a behaviour change strategy will be challenging, particularly when targeting informal medical
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providers who administer injections at the community level in diverse locations and times. The motivation for using informal providers seems to include trust, convenience and cultural factors. Health barbers, who traditionally were a primary source of medical care in the past, provided a minority of injections in the Lower Egypt governorate but at a much lower cost than formal medical providers. Overall, the survey indicates that injection practices are embedded in diverse ways in Upper and Lower Egypt and emphasizes the importance of quantitative assessments of injection practices in different populations to better target behaviour change strategies. One of the limitations of this study is that the administration and safety of the injections was not directly observed and information on injection safety was obtained through patient recall. It may be difficult for a consumer to determine whether a syringe has been previously used on another patient, thus using a previously opened plastic syringe was the only indicator for unsafe injections, although in some cases, the provider might have opened the packet out of the patient’s sight. The finding that health barbers offered injections at much lower cost, sometimes even lower than the cost of a new syringe, also suggests that reuse of syringes does occur, although precise measures of the extent of reuse is difficult to measure. A second limitation of the study is the inability to extrapolate the findings of this study to all of Egypt. In particular, the study did not include residents from large urban areas who represent a considerable proportion of the population. In Egypt, prevention of blood-borne pathogen transmission is a leading public health priority because of the high prevalence of HCV infection in the general population. HCV infection is a leading cause of chronic liver disease and hepatocellular carcinoma in Egypt (Mohamed et al. 1996). The epidemiology of HCV transmission in Egypt is complex. It is hypothesized that parenteral exposure to schistosomiasis treatment through mass campaigns before the 1980s was responsible for widespread HCV transmission and the creation of a large reservoir of persons with chronic HCV infection (Frank et al. 2000). Epidemiologic studies have reported additional diverse risk factors including unsafe injections and poor infection control practices (Darwish et al. 1993; El-Sayed et al. 1996; Mohamed et al. 1996; Angelico et al. 1997; Habib et al. 2001). It is apparent that a comprehensive programme to address all aspects of blood-borne pathogen transmission is urgently needed. Promoting safe injections is part of strategy that also includes efforts to promote infection control in the health care setting and improve the safety of transfusion practices. Promotion of injection safety is challenging because the adverse outcome associated with unsafe injections, such as acute hepatitis, may occur several months 239
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later or may be clinically inapparent. Thus, providers may not associate behaviours that promote blood-borne pathogen transmission with adverse events. A communication strategy targeting providers to promote safe injections must include both knowledge base and behaviour change components. The finding that persons can receive injections from practically anyone emphasizes the importance of educating the community as well as the formal medical sector. At the community level, reducing consumer demand for injections and creating public demand for safe injections and safe medical procedures is essential. Acknowledgements The authors thank the support of all health officials in Lower Egypt and Upper Egypt governorates, particularly Dr Mohamed Khairy, Undersecretary General, Dr AbdelRaouf Zoheiri, Undersecretary General, Dr Abdel-Hamid Youssef, Director General, Dr Hosni Youssef, Director General and Dr Mohamed Rabei. This work was supported by USAID, Work Unit no. 80000.000.000.E0022. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, the U.S. Government, nor the Egyptian Ministry of Health and Population. References Angelico M, Renganathan E, Gandin C et al. (1997) Chronic liver disease in the Alexandria governorate: Egypt: contribution of schistosomiasis and hepatitis virus infections. Journal of Hepatology 26, 236–243. Anonymous (1997) Centers for Disease Control and Prevention. Recommendations for follow-up of health care workers after occupational exposure to hepatitis C virus. Morbidity and Mortality Weekly Report 46, 603–606. Darwish MA, Raouf TA, Rushdy P et al. (1993) Risk factors associate with a high seroprevalence of hepatitis C virus infection in Egyptian blood donors. American Journal of Tropical Medicine and Hygiene 49, 440–447. El-Sayed NM, Gomatos PJ, Rodier GR et al. (1996) Seroprevalence survey of Egyptian tourism workers for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and Treponema pallidum infections: association of hepatitis C virus infections with specific regions of Egypt. American Journal of Tropical Medicine and Hygiene 55, 179–184. El-Zayadi AR, Abe K, Selim O et al. (1999) Prevalence of GBV-C/ hepatitis G virus viraemia among blood donors, health care personnel, chronic non-B non-C hepatitis, chronic hepatitis C
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and hemodialysis patients in Egypt. Journal of Virology Methods 80, 53–58. Frank C, Mohamed MK, Strickland GT et al. (2000) The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet 11, 887–891. Gumodoka B et al. (1996) Injection practices in Mwanza Region, Tanzania: prescriptions, patient demand and sterility. Tropical Medicine and International Health 1, 884–880. Habib M, Mohamed MK, Abdel-Aziz F et al. (2001) Hepatitis C virus infection in a community in the Nile Delta: risk factors for seropositivity. Hepatology 33, 248–253. Hersh BS, Popovici F, Apetrei RC et al. (1991) Acquired immunodeficiency syndrome in Romania. Lancet 338, 645–649. Hutin YJ, Harpaz R, Drobeniuc J et al. (1999) Injections given in healthcare settings as a major source of acute hepatitis B in Moldova. International Journal of Epidemiology 28, 782–786. Hyams KC, Mansour MM, Massoud A et al. (1987) Parenteral antischistosomal therapy: a potential risk factor for hepatitis B infection. Journal of Medicine and Virology 23, 09–114. Luby SP, Qamruddin K, Shah AA et al. (1997) The relationship between therapeutic injections and high prevalence of hepatitis C infection in Hafizabad, Pakistan. Epidemiology and Infection 119, 349–356. Mohamed MK et al. (1996) Viral hepatitis C infection among Egyptians. The magnitude of the problem: epidemiological and laboratory approach. Journal of Egyptian Public Health Association 71, 80–111. Raglow G, Luby S & Nabi N (2001) Therapeutic injections in Pakistan: from the patients’ perspective. Tropical Medicine and International Health 6, 69–75. Reeler AV & Hematorn C (1994) Injection Practices in the Third World. A Case Study of Thailand. Geneva: World Health Organization (WHO/DAP/94.8). Singh J, Bhatia R, Gandhi JC et al. (1998) Outbreak of viral hepatitis B in a rural community in India linked to inadequately sterilized needles and syringes. Bulletin of the World Health Organization 76, 93–98. Sullivan K, Kalsbeek W, Chen M et al. (1994) Csample: Analyzing Data from Complex Survey Samples. EPI-Info, Version 6. Atlanta: Centers for Disease Control and Prevention, pp. 157–184. Tibbs CJ (1997) Tropical aspects of viral hepatitis. Hepatitis C. Transactions of the Royal Society of Tropical Medicine and Hygiene 91, 121–124. Van Staa AL & Hardon A (1996) Injection Practices in the Developing World: a Comparative Review of Field Studies in Uganda and Indonesia. Geneva: World Health Organization (WHO/DAP/96.4). Vos J, Gumodoka B, can Asten HA, Berege ZA et al. (1998) Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania. Tropical Medicine and International Health 3, 291–292.
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Authors Wafa Abu-Rabei, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail:
[email protected] Caroline Bodenschatz, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail:
[email protected] Said El-Oun, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail:
[email protected] Zoheir Hallaj, Eastern Mediterranean Regional Office, World Health Organization, Nasr City, 7608, Egypt. E-mail:
[email protected] Amr Kandeel, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail:
[email protected] Anna-Lena Lohiniva, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail:
[email protected] Frank J. Mahoney, US Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA. E-mail:
[email protected]. navy.mil Dr Maha Talaat, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail:
[email protected] or
[email protected] (corresponding author).
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