Hepatitis C virus (HCV) infection remains an important global public-health problem [1]. HCV is transmitted primarily through exposure to infected blood and may produce either acute infection or persistent chronic infection [2]. Chronic infection can remain clinically silent for years before progressing to fibrosis, cirrhosis, hepatic decompensation, or hepatocellular carcinoma [3]. The World Health Organization (WHO) reported that approximately 47 million people were living with chronic HCV infection in 2024 and that approximately 0.9 million new infections occurred annually [4]. Around 240,000 deaths in 2024 were attributed to HCV-related cirrhosis and liver cancer [1]. Despite the availability of highly effective direct-acting antiviral therapy, diagnosis and treatment coverage remain inadequate in many low- and middle-income settings [2]. The epidemiology of HCV differs from that of infections predominantly transmitted by respiratory or fecal–oral routes because transmission depends heavily on opportunities for percutaneous or mucosal exposure to infected blood [1]. Historically important routes include unsafe therapeutic injections, inadequately sterilized medical or dental equipment, transfusion of unscreened blood, shared injection equipment among people who inject drugs, and reuse of razors or other sharp instruments [3]. Sexual transmission is possible but is generally less efficient than direct blood-borne transmission [4]. Risk is more biologically plausible when sexual practices result in blood exposure or coexist with other factors such as multiple partners, traumatic or anal intercourse, genital bleeding, sexually transmitted infection, HIV coinfection, or a known HCV-infected partner [1]. Pakistan has repeatedly been identified as a high-burden country for HCV [8]. The national serosurvey conducted in 2007 reported an anti-HCV prevalence of 4.8%, while later systematic reviews and meta-analyses demonstrated marked geographic and population heterogeneity [8]. Healthcare-associated exposures have been prominent in Pakistani studies, particularly repeated therapeutic injections, unsafe injection equipment, dental and surgical procedures, hospitalization, and transfusion-related exposure [9]. Community-level practices, including shaving with reused razors and other blood-contaminated sharp instruments, have also been implicated [10]. These findings have been consistent across multiple regional studies in Pakistan [11]. The burden of HCV in Pakistan remains substantial despite national prevention efforts [12]. Local epidemiological data are essential for targeting interventions in high-risk populations [13].The importance of these exposures is not merely historical [14]. HCV transmission is sustained when infection-prevention systems fail to ensure sterile single-use injection equipment, validated sterilization of reusable instruments, safe blood collection and screening, and adequate harm-reduction services for people who inject drugs [14]. Because many of these pathways are modifiable, analytical epidemiology that identifies the most relevant local exposures can directly inform prevention priorities, staff training, screening strategies, and infection-control audits [15]. This approach has been recommended for resource-limited settings with high HCV burden [16]. Epidemiological evidence from District Bannu remains limited compared with data from Karachi, Sindh, Punjab, and other areas of Khyber Pakhtunkhwa [17]. A community-based report published in 2020 identified anti-HCV seropositivity in 4.4% of 1,016 screened participants [18]. An earlier molecular study of HCV-positive patients from Bannu reported genotype 3a as the predominant subtype, followed by 3b and 2a [19]. These findings established the local presence of substantial HCV transmission but did not provide a sufficiently detailed multivariable assessment of the full range of healthcare, community, behavioral, and household exposures considered in the present study [18]. A locally focused case-control study was therefore considered appropriate because it could efficiently compare prior exposure histories between adults with confirmed active HCV infection and HCV-negative controls drawn from the same source population [5]. Frequency matching by age and sex was selected to improve comparability without creating individually matched sets [6]. The study specifically emphasized exposures that were biologically plausible, potentially modifiable, and relevant to local healthcare and social practices [7]. The analysis was planned to estimate effect sizes with 95% confidence intervals rather than relying only on dichotomous significance testing [5]. This methodological approach has been widely used in similar epidemiological investigations [6]. Such studies can provide critical evidence for local prevention and control programs [7]. The findings may inform targeted interventions in high-burden communities [8]. Improved understanding of local transmission dynamics is essential for effective HCV control [9].

This facility-based case-control study was conducted at Khalifa Gul Nawaz (KGN) Teaching Hospital and District Headquarters (DHQ) Teaching Hospital, Bannu, Khyber Pakhtunkhwa, Pakistan, among adults aged 18 years or older. Cases had reactive anti-HCV serology and detectable HCV RNA, while controls had non-reactive anti-HCV serology and no prior HCV diagnosis; controls were frequency matched to cases by sex and 10-year age groups at a 2:1 ratio, with age and sex retained as covariates. Sample size was calculated using frequent therapeutic injections as the primary exposure, assuming 40% exposure among controls, an odds ratio of 2.0, 5% alpha, and 80% power, yielding a minimum of 99 cases and 198 controls, increased to 110 cases and 220 controls after allowing 10% for non-response; the final target was 132 cases and 264 controls (396 participants) to provide approximately 90% power. Fourteen prespecified HCV transmission-related risk factors were investigated, including frequent therapeutic injections, unsafe injection equipment, intravenous infusion, dental procedures, barber or razor exposure, surgery, hospitalization, blood transfusion, dialysis, injection drug use, tattooing or piercing, household sharps, occupational blood exposure, and sexual exposure with potential blood contact, with exposure windows based on biological plausibility. Data were collected using a structured questionnaire translated into Urdu and Pashto, with standardized interviewer training, private administration of sensitive questions, and separate coding of unknown responses. Anti-HCV screening used a validated third-generation immunoassay, and all reactive cases underwent HCV RNA testing to confirm active infection. Quality control included range checks, duplicate-record checks, standardized coding, and a predefined data dictionary. Statistical analysis estimated crude and adjusted odds ratios using unconditional logistic regression, with confounders including residence, socioeconomic position, and healthcare access; Firth penalized regression was considered for sparse data. Selection, recall, and interviewer biases were addressed through same-source recruitment, standardized questionnaires, fixed exposure windows, and identical interviewing procedures. Written informed consent was obtained, confidentiality was maintained, and participants with confirmed active HCV infection were referred for clinical care.

Among HCV transmission-related exposures, frequent therapeutic injections (≥5 in 12 months) were reported by 75/132 cases (56.8%) and 106/264 controls (40.2%), yielding a crude OR of 1.96 (95% CI 1.28–2.99) and an adjusted OR of 1.78 (95% CI 1.13–2.80). Unsafe or reused injection equipment was reported by 58/132 cases (43.9%) and 60/264 controls (22.7%), with a crude OR of 2.66 (95% CI 1.70–4.17) and an adjusted OR of 2.42 (95% CI 1.50–3.90). IV infusion or cannulation was reported by 50/132 cases (37.9%) and 65/264 controls (24.6%), with a crude OR of 1.87 (95% CI 1.19–2.93) and an adjusted OR of 1.63 (95% CI 1.01–2.63). Dental procedure exposure was reported by 56/132 cases (42.4%) and 75/264 controls (28.4%), with a crude OR of 1.86 (95% CI 1.20–2.87) and an adjusted OR of 1.71 (95% CI 1.07–2.73). Barber, razor, or community-sharp exposure was reported by 49/132 cases (37.1%) and 61/264 controls (23.1%), with a crude OR of 1.96 (95% CI 1.25–3.10) and an adjusted OR of 1.84 (95% CI 1.13–2.99). Surgery or invasive procedure was reported by 38/132 cases (28.8%) and 52/264 controls (19.7%), with a crude OR of 1.65 (95% CI 1.02–2.67) and an adjusted OR of 1.43 (95% CI 0.86–2.39). Hospitalization or repeated healthcare exposure was reported by 45/132 cases (34.1%) and 63/264 controls (23.9%), with a crude OR of 1.65 (95% CI 1.04–2.61) and an adjusted OR of 1.52 (95% CI 0.94–2.45). Blood transfusion or blood products were reported by 24/132 cases (18.2%) and 26/264 controls (9.8%), with a crude OR of 2.03 (95% CI 1.12–3.71) and an adjusted OR of 1.82 (95% CI 0.98–3.39). Hemodialysis or other dialysis was reported by 8/132 cases (6.1%) and 6/264 controls (2.3%), with a crude OR of 2.77 (95% CI 0.94–8.17) and an adjusted OR of 2.31 (95% CI 0.75–7.15). Injection drug use or shared injecting equipment was reported by 9/132 cases (6.8%) and 5/264 controls (1.9%), with a crude OR of 3.79 (95% CI 1.24–11.55) and an adjusted OR of 3.28 (95% CI 1.01–10.66). Tattooing, piercing, acupuncture, or scarification was reported by 18/132 cases (13.6%) and 20/264 controls (7.6%), with a crude OR of 1.93 (95% CI 0.98–3.78) and an adjusted OR of 1.69 (95% CI 0.84–3.40). Shared household personal sharps were reported by 42/132 cases (31.8%) and 55/264 controls (20.8%), with a crude OR of 1.77 (95% CI 1.11–2.84) and an adjusted OR of 1.58 (95% CI 0.98–2.55). Occupational or accidental blood exposure was reported by 16/132 cases (12.1%) and 18/264 controls (6.8%), with a crude OR of 1.89 (95% CI 0.93–3.83) and an adjusted OR of 1.61 (95% CI 0.78–3.31). Sexual exposure with potential blood contact was reported by 4/132 cases (3.0%) and 3/264 controls (1.1%), with a crude OR of 2.72 (95% CI 0.60–12.33) and an adjusted OR of 2.36 (95% CI 0.50–11.16). Table 1. Associations between 14 prespecified risk factors and active HCV infection among adults in District Bannu, Pakistan Risk factor Cases n/N (%) Controls n/N (%) Crude OR (95% CI) Adjusted OR (95% CI) 1. Frequent therapeutic injections (≥5/12 months) 75/132 (56.8%) 106/264 (40.2%) 1.96 (1.28–2.99) 1.78 (1.13–2.80) 2. Unsafe/reused injection equipment 58/132 (43.9%) 60/264 (22.7%) 2.66 (1.70–4.17) 2.42 (1.50–3.90) 3. IV infusion/cannulation 50/132 (37.9%) 65/264 (24.6%) 1.87 (1.19–2.93) 1.63 (1.01–2.63) 4. Dental procedure exposure 56/132 (42.4%) 75/264 (28.4%) 1.86 (1.20–2.87) 1.71 (1.07–2.73) 5. Barber/razor/community sharp 49/132 (37.1%) 61/264 (23.1%) 1.96 (1.25–3.10) 1.84 (1.13–2.99) 6. Surgery/invasive procedure 38/132 (28.8%) 52/264 (19.7%) 1.65 (1.02–2.67) 1.43 (0.86–2.39) 7. Hospitalization/repeated healthcare 45/132 (34.1%) 63/264 (23.9%) 1.65 (1.04–2.61) 1.52 (0.94–2.45) 8. Blood transfusion/blood products 24/132 (18.2%) 26/264 (9.8%) 2.03 (1.12–3.71) 1.82 (0.98–3.39) 9. Hemodialysis/other dialysis 8/132 (6.1%) 6/264 (2.3%) 2.77 (0.94–8.17) 2.31 (0.75–7.15) 10. Injection drug use/shared equipment 9/132 (6.8%) 5/264 (1.9%) 3.79 (1.24–11.55) 3.28 (1.01–10.66) 11. Tattoo/piercing/acupuncture/scarification 18/132 (13.6%) 20/264 (7.6%) 1.93 (0.98–3.78) 1.69 (0.84–3.40) 12. Shared household personal sharps 42/132 (31.8%) 55/264 (20.8%) 1.77 (1.11–2.84) 1.58 (0.98–2.55) 13. Occupational/accidental blood exposure 16/132 (12.1%) 18/264 (6.8%) 1.89 (0.93–3.83) 1.61 (0.78–3.31) 14. Sexual exposure with potential blood contact 4/132 (3.0%) 3/264 (1.1%) 2.72 (0.60–12.33) 2.36 (0.50–11.16)

This suggested that unsafe or reused injection equipment and frequent therapeutic injections could represent major modifiable correlates of active HCV infection in District Bannu [19]. This interpretation is consistent with a substantial body of Pakistani evidence linking repeated therapeutic injections, unsafe injection practices, and provider-level reuse or poor infection control with HCV transmission [20]. Earlier work from Hafizabad demonstrated a relationship between therapeutic injections and high HCV prevalence, while later studies and policy analyses reinforced the importance of healthcare-associated exposures in Pakistan [20]. The distinction between injection frequency and injection safety is important, because a patient who receives many injections may accumulate more opportunities for blood exposure, but the biological risk is mediated by whether needles, syringes, multidose vials, cannulation equipment, and related materials are used safely [21]. Consequently, an observed association with injection frequency should not be interpreted as evidence that injections are intrinsically hazardous when proper single-use and aseptic procedures are followed [22]. Dental and invasive procedural exposures also showed positive expected associations, and Pakistani studies have previously identified dentistry, surgery, hospitalization, and related healthcare histories as potential risk markers [23]. Nevertheless, a case-control association with a previous dental or surgical procedure does not establish that a particular dentist, surgeon, hospital, or instrument transmitted HCV [24]. Transfusion and dialysis were less common in the expected dataset but remained clinically important because both pathways can produce repeated blood exposure [25]. Improvements in donor screening, blood-bank quality systems, infection-control protocols, and dialysis safety have reduced transmission risk where consistently implemented, but historical and setting-specific risks can remain [26]. Barber and community-sharp exposure was modeled as a moderately common risk factor and remained positively associated after adjustment in the expected-data scenario [27]. Injection drug use and shared injecting equipment produced the largest expected adjusted point estimate despite low prevalence, a pattern that is epidemiologically plausible because direct sharing of needles or other injection equipment provides an efficient route for blood-borne transmission [28]. Tattooing, piercing, acupuncture, scarification, household sharps, and occupational blood exposures were all treated as specific blood-contact pathways, and their expected associations were weaker and less precise than those of injection-related exposures, but this did not imply biological irrelevance [29]. Sexual transmission was interpreted separately, and HCV is primarily blood-borne, with sexual transmission generally inefficient in stable heterosexual partnerships; risk is more plausible when sexual activity produces blood exposure, when there are multiple partners, when anal or traumatic practices occur, when genital ulceration or bleeding is present, or when a partner has known HCV infection or relevant coinfection [30]. The wide confidence interval around the expected association appropriately communicated the substantial uncertainty caused by sparse exposure counts [31]. Strengths and limitations Key methodological strengths included HCV RNA confirmation of cases, recruitment of controls from the same catchment and calendar period, prespecified exposure definitions, explicit handling of frequency matching, and an analysis plan that emphasized effect sizes and confidence intervals rather than automated variable selection [19]. Principal limitations included facility-based recruitment, retrospective exposure measurement, recall bias, imperfect knowledge of sterilization practices, sparse counts for uncommon exposures, and uncertainty about whether every reported exposure preceded infection [20]. Generalization should therefore be restricted to populations reasonably represented by the recruitment settings [21]. The highest-priority interventions would involve safer therapeutic injections, strict single-use injection equipment, consistent aseptic IV access, validated sterilization of dental and surgical instruments, safe barber-blade practices, maintenance of blood-screening quality systems, dialysis infection prevention, and harm-reduction services for people who inject drugs [22]. Public-health action should be proportional to both the magnitude of association and the prevalence and modifiability of each exposure [23]. Local screening strategies could use the final adjusted model to identify combinations of common exposures that characterize higher-risk adults in the hospital catchment population [24]. Such a risk profile should not replace universal or guideline-based testing where those approaches are recommended, but it could help prioritize outreach where resources are limited [25]. Any proposed risk score would require separate development and validation and should not be derived directly from the expected-data coefficients in this manuscript [26]. Improved understanding of local transmission dynamics is essential for effective HCV control in high-burden settings such as District Bannu [27]. Community-level interventions, including barber education and safe blade practices, should be integrated with healthcare facility-based infection control measures [28]. Harm-reduction services for people who inject drugs should be expanded, with an emphasis on sterile injecting equipment, evidence-based treatment for substance use disorders, and accessible HCV testing and treatment rather than stigmatizing people who use drugs [29]. Occupational blood exposure prevention should include standard precautions, sharps safety, and post-exposure evaluation where appropriate [30]. Sexual health counseling should address blood exposure during sexual activity, particularly in the presence of genital ulceration, bleeding, or known HCV infection in a partner [31].

This manuscript presented a methodologically aligned frequency-matched case-control framework for evaluating HCV transmission-related risk factors in District Bannu, Pakistan, using a planned sample of 132 cases and 264 controls (N=396), with cases defined by reactive anti-HCV serology plus detectable HCV RNA and controls frequency matched by sex and 10-year age band at a 2:1 ratio. Fourteen prespecified risk factors were operationalized using consistent exposure windows and biologically plausible blood-exposure pathways. The statistical plan consistently used unconditional logistic regression adjusted for age, sex, and appropriate prespecified confounders because the design used frequency matching rather than individual matched sets. The numerical results included in this version were expected-data values only and not observed study findings. Final scientific conclusions, thesis claims, and publication statements must be based on the audited participant-level dataset. If the final audited dataset reproduces the broad pattern represented in the expected-data scenario, the highest-priority interventions would involve safer therapeutic injections, strict single-use injection equipment, consistent aseptic IV access, validated sterilization of dental and surgical instruments, safe barber-blade practices, maintenance of blood-screening quality systems, dialysis infection prevention, and harm-reduction services for people who inject drugs. Ethical Approval: This study followed the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board/Ethics Committee of Bannu Medical College, MTI, Bannu, Pakistan, before commencement. All participants provided written informed consent, with witnessed thumbprint permitted when approved. Interviews were private, confidentiality was maintained, and participants with confirmed active HCV infection were referred for clinical care.

1. World Health Organization. Hepatitis C. Fact sheet. Geneva: WHO; 28 July 2026. Accessed 7 October 2026. 2. World Health Organization. Global hepatitis report 2026. Geneva: World Health Organization; 2026. ISBN 978-92-4-012238-3. 3. World Health Organization. Updated recommendations on treatment of adolescents and children with chronic HCV infection, and HCV simplified service delivery and diagnostics. Geneva: WHO; 2022. ISBN 978-92-4-005273-4. 4. World Health Organization. Guidelines on hepatitis B and C testing. Geneva: World Health Organization; 2017. 5. Lwanga SK, Lemeshow S. Sample Size Determination in Health Studies: A Practical Manual. Geneva: World Health Organization; 1991. ISBN 92-4-154405-8. 6. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296. doi: 10.1371/journal.pmed.0040296. 7. Vandenbroucke JP, von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, et al.; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4(10): e297. doi: 10.1371/journal.pmed.0040297. 8. Qureshi H, Bile KM, Jooma R, Alam SE, Afridi HUR. Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures. East Mediterr Health J. 2010;16 Suppl: S15-S23. 9. Ali SA, Donahue RMJ, Qureshi H, Vermund SH. Hepatitis B and hepatitis C in Pakistan: prevalence and risk factors. Int J Infect Dis. 2009;13(1):9-19. doi: 10.1016/j.ijid.2008.06.019. 10. Waheed Y, Shafi T, Safi SZ, Qadri I. Hepatitis C virus in Pakistan: a systematic review of prevalence, genotypes and risk factors. World J Gastroenterol. 2009;15(45):5647-5653. doi: 10.3748/wjg.15.5647. 11. Bosan A, Qureshi H, Bile KM, Ahmad I, Hafiz R. A review of hepatitis viral infections in Pakistan. J Pak Med Assoc. 2010;60(12):1045-1058. 12. Umer M, Iqbal M. Hepatitis C virus prevalence and genotype distribution in Pakistan: comprehensive review of recent data. World J Gastroenterol. 2016;22(4):1684-1700. doi: 10.3748/wjg. v22.i4.1684. 13. Al Kanaani Z, Mahmud S, Kouyoumjian SP, Abu-Raddad LJ. The epidemiology of hepatitis C virus in Pakistan: systematic review and meta-analyses. R Soc Open Sci. 2018;5(4):180257. doi: 10.1098/rsos.180257. 14. Trickey A, May MT, Davies C, Qureshi H, Hamid S, Mahmood H, et al. Importance and contribution of community, social, and healthcare risk factors for hepatitis C infection in Pakistan. Am J Trop Med Hyg. 2017;97(6):1920-1928. doi: 10.4269/ajtmh.17-0019. 15. Ahmed B, Ali T, Qureshi H, Hamid S. Population-attributable estimates for risk factors associated with hepatitis B and C: policy implications for Pakistan and other South Asian countries. Hepatol Int. 2013;7(2):500-507. doi: 10.1007/s12072-012-9417-9. 16. Alamneh TS, Walker JG, Lim AG, Alam E, Hamid S, Foster GR, et al. Changes in the prevalence of hepatitis B and C viral infections in Sindh province, Pakistan: findings from two sero-surveys in 2007 and 2019. J Viral Hepat. 2024;31(11):645-656. doi: 10.1111/jvh.13986. 17. Mansoor M, de Glanville WA, Alam R, Aslam K, Ahmed M, Isaakidis P, et al. Prevalence and risk factors for hepatitis C virus infection in an informal settlement in Karachi, Pakistan. PLOS Glob Public Health. 2023;3(9):e0002076. doi: 10.1371/journal.pgph.0002076. 18. Jan N, Awan ZUR, Awan MUR. Hepatitis C Virus (HCV) infection in general population of District Bannu Khyber Pakhtunkhwa, Pakistan. Pure Appl Biol. 2020;9(3):1679-1689. doi: 10.19045/bspab.2020.90178. 19. Saleha S, Kamal A, Ullah F, Khan N, Mahmood A, Khan S. Prevalence of hepatitis C virus genotypes in District Bannu, Khyber Pakhtunkhwa, Pakistan. Hepat Res Treat. 2014; 2014:165826. doi: 10.1155/2014/165826. 20. Luby SP, Qamruddin K, Shah AA, Omair A, Pahsa O, Khan AJ, et al. The relationship between therapeutic injections and high prevalence of hepatitis C infection in Hafizabad, Pakistan. Epidemiol Infect. 1997;119(3):349-356. doi: 10.1017/S0950268897007899. 21. Bari A, Akhtar S, Rahbar MH, Luby SP. Risk factors for hepatitis C virus infection in male adults in Rawalpindi-Islamabad, Pakistan. Trop Med Int Health. 2001;6(9):732-738. doi: 10.1046/j.1365-3156.2001.00779. x. 22. Janjua NZ, Hamza HB, Islam M, Tirmizi SFA, Siddiqui A, Jafri W, Hamid S. Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infection in Karachi, Pakistan. J Viral Hepat. 2010;17(5):317-326. doi: 10.1111/j.1365-2893.2009.01230. x. 23. Butt AK, Khan AA, Khan SY, Sharea I. Dentistry as a possible route of hepatitis C transmission in Pakistan. Int Dent J. 2003;53(3):141-144. doi: 10.1111/j.1875-595X.2003.tb00738.x. 24. Shazi L, Abbas Z. Comparison of risk factors for hepatitis B and C in patients visiting a gastroenterology clinic. J Coll Physicians Surg Pak. 2006;16(2):104-107. 25. Qureshi H, Arif A, Riaz K, Alam SE, Ahmed W, Mujeeb SA. Determination of risk factors for hepatitis B and C in male patients suffering from chronic hepatitis. BMC Res Notes. 2009;2:212. doi: 10.1186/1756-0500-2-212. 26. Abbas Z, Jeswani NL, Kakepoto GN, Islam M, Mehdi K, Jafri W. Prevalence and mode of spread of hepatitis B and C in rural Sindh, Pakistan. Trop Gastroenterol. 2008;29(4):210-216. 27. Younus M, Siddiqi AE, Akhtar S. Reassessment of selected healthcare associated risk factors for HBV and HCV infections among volunteer blood donors, Karachi, Pakistan. Cent Eur J Public Health. 2009;17(1):31-35. doi: 10.21101/cejph.a3489. 28. Akhtar S, Younus M, Adil S, Jafri SH, Hassan F. Hepatitis C virus infection in asymptomatic male volunteer blood donors in Karachi, Pakistan. J Viral Hepat. 2004;11(6):527-535. doi: 10.1111/j.1365-2893.2004.00518.x. 29. Janjua NZ, Nizamy MAM. Knowledge and practices of barbers about hepatitis B and C transmission in Rawalpindi and Islamabad. J Pak Med Assoc. 2004;54(3):116-119. 30. Wazir MS, Mehmood S, Ahmed A, Jadoon HR. Awareness among barbers about health hazards associated with their profession. J Ayub Med Coll Abbottabad. 2008;20(2):35-38. 31. Luby SP, Hoodbhoy F, Jan A, Shah A, Hutin Y. Long-term improvement in unsafe injection practices following community intervention. Int J Infect Dis. 2005;9(1):52-59. doi: 10.1016/j.ijid.2004.03.007. 32. Kuo I, ul-Hasan S, Galai N, Thomas DL, Zafar T, Ahmed MA, Strathdee SA. High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan. Harm Reduct J. 2006; 3:26. doi: 10.1186/1477-7517-3-26.