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SIGNpost 00675

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *

Post00675 Some Success + India + IDUs + Abstracts + News 14 November 2012

CONTENTS
1. Summaries of injection safety country success stories
2. Safe Injection Global Network: Advocacy booklet
3. EDITORIAL: Patient safety in India: Time to speed up our efforts to
reduce avoidable harm
4. Summary: Recommendations and Reports – Integrated Prevention Services
for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and
Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from
CDC and the U.S. Department of Health and Human Services
5. Abstract: Hazards Analysis, within Departments and Occupations, for
Hepatitis B Virus among Health Care Workers in Public Teaching Hospitals
in Khartoum State; Sudan
6. Abstract: Inadvertent epidural injection of drugs for intravenous use. A
review
7. Abstract: Fungal Infections Associated with Contaminated
Methylprednisolone in Tennessee
8. Abstract:Epidural Corticosteroid Injections in the Management of
Sciatica: A Systematic Review and Meta-analysis
9. Abstract: Risks of acupuncture range from stray needles to pneumothorax,
finds study
10. Abstract: Transmission of Hepatitis C virus among people who inject
drugs: viral stability and association with drug preparation equipment
11. Abstract: Hand hygiene compliance: is there a theory-practice-ethics
gap?
12. Abstract: Social and moral norm differences among Portuguese 1st and
6th year medical students towards their intention to comply with hand
hygiene
13. Abstract: Skin decontamination by low-temperature atmospheric pressure
plasma jet and dielectric barrier discharge plasma
14. Abstract: U.S. Postlicensure safety surveillance for adolescent and
adult tetanus, diphtheria and acellular pertussis vaccines: 2005-2007
15. Abstract: Enfuvirtide and cutaneous injection-site reactions
16. Abstract: Application of copper to prevent and control infection. Where
are we now?
17. USA: Case Counts – Multistate Fungal Meningitis Outbreak
18. The 11th International Congress on AIDS in Asia and the Pacific
(ICAAP11)
10. News
– Spinal steroid shots may have little effect on sciatica
– UK: HIV blood products inquiry to view new evidence
– Solar Power: An Alternative Device to Sterilize Surgical Instruments in
Rural Areas
– Australia: Hepatitis C-Infected Doctor Pleads Guilty to 55 Charges of
Negligently Causing Serious Injury
– USA: US CDC Offers Grand Rounds on Unsafe Injection Practices
– USA: Massachusetts pharmacy board head fired after meningitis outbreak
– Global: Polio program seeks expert approval for changes to crucial
endgame

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__________________________________________________________________
________________________________*_________________________________

1. Summaries of injection safety country success stories
__________________________________________________________________

Summaries of injection safety country success stories

Safe Injection Global Network

Introduction

This publication demonstrates intervention success stories that have
improved injection safety in both developed and developing countries,
proving that positive results are viable in different country settings.
Intervention strategies that target all these three core components
simultaneously have been shown to have the greatest positive effect on
improved injection safety:

behaviour change among patients and healthcare workers to decrease
injection overuse and achieve injection safety, availability of necessary
and of good quality injection devices and supplies, management of sharps
waste.

Download English, pdf, 2.47Mb
www.who.int/injection_safety/sign/success_story_summaries_regions.pdf
http://www.who.int/injection_safety/sign/country_success/en/index.html
__________________________________________________________________
________________________________*_________________________________

2. Safe Injection Global Network: Advocacy booklet
__________________________________________________________________

http://www.who.int/injection_safety/sign/advocacy_booklet/en/index.html

Safe Injection Global Network: Advocacy booklet

Introduction

Unsafe injection practices are an international issue. With an estimated 16
thousand million injections administered annually in developing and
transitional countries alone, the importance of promoting safe injection
practices is unprecedented. Over the past few decades failures to follow
safe injection practices have burdened many developing as well as developed
countries with outbreaks of infectious diseases.

Although the exact global burden of disease resulting from unsafe
injections is difficult to measure, 40% of all injections are believed to
be unsafe while in some countries the proportion is as high as 70%.
Globally, approximately 3-4 injections per person per year are
administered. As such, the danger of contaminated needles and syringes put
thousands of millions of people at risk of contracting bloodborne pathogens
including hepatitis B virus (HBV), hepatitis C virus (HCV), and human
immunodeficiency virus (HIV).

Download English, pdf, 1.75Mb
http://www.who.int/entity/injection_safety/sign/sign_advocacy_booklet.pdf
__________________________________________________________________
________________________________*_________________________________

3. EDITORIAL: Patient safety in India: Time to speed up our efforts to
reduce avoidable harm

This article asks for more attention to medical errors in India, noting
problems exposed by the INCLEN survey of injection practices.

Open Access http://www.nmji.in/archives/Volume-25/Issue-3/Editorial.pdf
__________________________________________________________________
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 25, NO. 3, 2012 p129-131

EDITORIAL

Patient safety in India: Time to speed up our efforts to reduce avoidable
harm

RAJAN MADHOK, NOBHOJIT ROY, SUKHMEET PANESAR

http://www.nmji.in/archives/Volume-25/Issue-3/Editorial.pdf
[PDF] 129

Patient Safety in India: Time to speed up our efforts to reduce avoidable
harm

The 1995 Supreme Court declaration bringing hospitals under the purview of
the Consumers Protection Act (CPA) of 1986 was possibly the start of the
movement for the safety of the patient in India. Even though the phrase
‘patient safety’ did not become a part of common medical vocabulary until
the late 1990s, the CPA made the members of the profession realize that
they would be held accountable for shortfalls in care. Since then, there
have been several high-profile incidents in which the safety of patients
was grossly neglected. These include the deaths of 14 patients in the J.J.
Group of Hospitals following the administration of contaminated glycerol,
an incident that was probed by the 1997 Lentin Commission,1 the report of
which held the physicians liable; the Hepatitis B epidemic in the district
of Sabarkantha, Gujarat in which 94 persons died;2 the deaths of 18
pregnant women at Umaid Hospital in Jodhpur;3 and most recently, the fire
at the AMRI hospital in Kolkata.4 While there have been such large
incidents, as well as regular newspaper reports of individual cases, there
is little scientific data on the extent of the problem of patient safety in
India. The one major study by the International Clinical Epidemiology
Network (INCLEN) on injection safety showed that nearly two-thirds of the
injections given were potentially unsafe (personal communication, Professor
N.K. Arora). Elsewhere in the world, it has been reported that the risk of
acquiring a healthcare-associated infection or neonatal infection is
estimated to be 2–20 times higher in developing countries than in
industrialized ones
www.who.int/features/factfiles/patient_safety/en/ndex.html. A recent study
in 26 hospitals in eight developing countries in the Eastern Mediterranean
and Africa showed that there was an adverse event in 2.5%–18.5% of
hospitalized patients.5 So, patient safety is clearly a major public health
issue in India, and some would argue that the problem is likely to be much
more serious, given the concerns about counterfeit drugs, faulty medical
equipment, unsafe blood banks or unregulated organ donation, for example.

Are we doing enough to tackle the problem and ensure safer care? And what
else should we be doing to speed up progress? Since the publication of the
Institute of Medicine’s seminal report6 in 1999, which showed that
healthcare itself was the eighth leading cause of death, after AIDS, breast
cancer and motor vehicle accidents, in the USA, there has been a growing
interest in patient safety internationally. The WHO launched the World
Alliance on Patient Safety (WAPS) to help stimulate further research to
ascertain the extent and root causes of the problem and, more importantly,
develop innovative solutions to reduce the burden of harm due to unsafe
healthcare. Much progress has since been made, in the past decade, but it
is equally clear from some high-profile instances, for example, in the
National Health Service (NHS) in the UK that a lot more needs to be done (
http://www.midstaffsinquiry.com/).

In India, while the CPA was a stimulus that made doctors aware of the
problem and encouraged safe practice, it also led to ‘defensive’ medicine,
causing an overall rise in litigation, though with few doctors being
penalized. Further, it led to an increase in healthcare costs. The tendency
to resort to litigation, and harsher sanctions, received 130 THE NATIONAL
MEDICAL JOURNAL OF INDIA VOL. 25, NO. 3, 2012 another impetus in 2003 with
the Mashelkar Committee on Spurious and Counterfeit Drugs, which suggested
the death penalty for offenders.7 However, such measures are not enough and
given the slow judicial system, they cannot bring about the sea change that
is necessary in medical practice. For the moment, they have only set in
motion a negative trend of blaming and shaming individuals, which is seldom
appropriate, given that most inquiries into adverse incidents show that
there are systemic problems. The current approach has also made it
difficult, nay impossible, for doctors to report adverse incidents and thus
learn from errors. There is a vicious cycle whereby the lack of reporting
makes it difficult to understand the root causes and fix the systemic
problems, which, in turn, perpetuates the situation and causes it to
worsen. All this is further compounded by our society’s general ‘laissez
faire’ approach to safety, whereby in almost all spheres of our daily
lives, we accept that things go wrong and attribute them to ‘divine
intention’.

On the other hand, though it is not right to blame a single person, we
should resist the temptation of glossing over the problem by proclaiming
that the ‘system is rotten’ or there are ‘no resources’. We can, and
should, fix things by formulating standard operating protocols for
treatment and procedures, introducing physical barriers and training for
the use of technology, for example. Atul Gawande’s work on a surgical
safety checklist is a good example of a simple and low-cost intervention.8
Of course, not all complex medical practices can be oversimplified into
checklists, but the evidence shows that most errors are fairly elementary.
The final collapse is usually a result of glitches in communication, over-
reliance on human memory, inadequate access to information, not knowing
whom to ask and non-standardized operating guidelines. None of these gaps
requires the investment of too many resources, and money is not the
concrete that can fill the cracks in the patient care pathway.

Bringing about the changes mentioned above is easier said than done.
History shows that medical practice does not change fast: it was in 1847
that Semmelweiss emphasized the importance of hand-washing to save pregnant
mothers, yet hand hygiene remains the first global priority for patient
safety in the 21st century. So, we need to avoid gimmicks and quick fixes,
and while we can learn a lot from the developed world, we should recognize
that the Indian context is different and create appropriate solutions.

Healthcare is a burgeoning industry in India. The early experience with the
‘kneereplacement- with-a-free-trip-to-the-Taj’ medical tourism model shows
that patients are not easily seduced by glossy interiors and good catering.
They would like to see more attention being paid to the important but
invisible interventions of the committees for hospital infection control,
as well as to operation theatre safety standards. While private hospital
patients may be more educated and discerning and may help create the
necessary pressure for change, patients in the public hospital system are
unlikely to be either demanding or effective. The recent proposal to
introduce universal healthcare coverage under the 12th Five-Year Plan will
mean a massive growth, given the huge unmet need for healthcare in India.
When the floodgates open, the provision of more care, without the creation
of systems for safer care, will result in more harm and the policy may turn
out to be a lose–lose proposition.

We, therefore, need to take stock and develop a longer term strategy. India
is a signatory to the WAPS and institutions such as the Quality Council of
India have been set up. There are also other initiatives, such as the
National Initiative on Patient Safety at the All India Institute of Medical
Sciences and the Indian Confederation for Healthcare Accreditation, to
promote action. We need to build on these developments.

We could start with a five-pronged approach:

1. Lobbying and assisting institutions and the government with the creation
of systems for recording, learning and reporting on the quality of services
and adverse events in a ‘balanced’ manner (neither too heavy-handed, nor
too light), and making it possible to set up such systems given the
concerns of such documentation.

2. Accelerating the implementation of proven patient safety interventions,
such as the Global Patient Safety Challenges work on hand hygiene and
surgical checklist, by the introduction of mandatory compliance with ‘Never
Events’ (http://
www.telegraph.co.uk/health/healthnews/4933949/List-of-eight-blunders-the-
NHSmust-never-commit-released-by-watchdog.html).

3. Empowering patients to question and work with professionals, for example
through the Patient Safety Alliance (www.patientsafetyalliance.in), which
also draws on the work being done by the Health Education Library for
Patients (www.healthlibrary.com).

4. Capacity-building through education and training at the undergraduate
level by using the WHO curriculum on patient safety and for established
professionals through distance learning, for example through the People’s
Open Access Education Initiative (www.peoples-uni.org).

5. Undertaking further research by building on the work started by the
INCLEN.

The healthcare profession’s ability to remain unmoved, despite well-known
examples, such as the incidents mentioned earlier, is no longer acceptable.
Such incidents prompt newspaper headlines for a few days, and business
resumes as usual soon after. We should give patient safety a higher
priority. Of course, we will need time, but this should not induce
complacency; the need is urgent.

While divisive, the Lokpal Bill and the recent television series, ‘Satyamev
Jayate’, show that the tide may be turning and the public is getting ready
to discuss and tackle difficult issues. Soon they will want to hear from
us, the doctors, about what we are going to do to protect them and their
dear ones from healthcare-related harm. Hiding behind the excuses of
general corruption, limited resources or the lack of any serious
governmental directive will not endear us to the general public; nor should
we attempt this for the sake of our professional pride. We should be true
to our Hippocratic Oath, which tells us, ‘First, do no harm’.
REFERENCES
1 Visvanthan S. The Great Indian Novel: The Lentin Report, Econ Pol Wkly
1999;34:39–48.
2 Gandhi SJ. Hepatitis B outbreak investigation report in Sabarkantha
District, Gujarat State, February 2009. Available
at www.academicjournals.org/ijmms/PDF/Pdf2011/May/Gandhi.pdf (accessed on 2
Jun 2012).
3 Gupta N, Srinivasan S. Serial maternal deaths in a tertiary care
hospital: Some questions. Available at http://
www.issuesinmedicalethics.org/192ed70.html. (accessed on 2 Jun 2012).
4 Nagral S. Fire in a hospital. Indian J Med Ethics 2012;9:76–7.
5 Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El-Assady R, et al;
WHO Patient Safety EMRO/AFRO
Working Group. Patient safety in developing countries: Retrospective
estimation of scale and nature of harm to patients
in hospital. BMJ 2012;344:e832.
6 Institute of Medicine. To err is human: Building a safer health system.
Available at http://www.nap.edu/openbook.php?
isbn=0309068371 (accessed on 2 Jun 2012).
7 Mashelkar Committee Report. Ministry of Health and Family Welfare,
Government of India. August 2003
8 WHO. WHO guidelines for safe surgery. Available at
http://whqlibdoc.who.int/publications/2009/
9789241598552_eng.pdf (accessed on 2 Jun 2012).

RAJAN MADHOK
Formerly, Medical Director, NHS Manchester, UK
and Adjunct Professor, INCLEN, India
rajan.madhok@btinternet.com

NOBHOJIT ROY
Department of Surgery, Bhabha Atomic Research Centre Hospital
Mumbai, Maharasthra
n.roy@tiss.edu

SUKHMEET PANESAR
Centre for Population Health Sciences, The Medical School, Edinburgh, UK
and National Patient Safety Agency, London, UK
sukhmeet.panesar@surgicalmatrix.com
__________________________________________________________________
________________________________*_________________________________

4. Summary: Recommendations and Reports – Integrated Prevention Services
for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and
Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from
CDC and the U.S. Department of Health and Human Services
__________________________________________________________________
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w

Morbidity and Mortality Weekly Report (MMWR)
November 9, 2012 / 61(rr05);1-40

Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually
Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly:
Summary Guidance from CDC and the U.S. Department of Health and Human
Services

Recommendations and Reports

This report originated in the National Center for HIV/AIDS, Viral
Hepatitis, STD, and TB Prevention, Kevin Fenton, MD, PhD, Director.

Corresponding preparer: Salaam Semaan, DrPH, National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention, CDC, 1600 Clifton Road, MS E-07,
Atlanta, GA 30333; Telephone: 404-639-8870; Fax: 404-639-3125; E-
mail:SSemaan@cdc.gov.

Summary

This report summarizes current (as of 2011) guidelines or recommendations
published by multiple agencies of the U.S. Department of Health and Human
Services (DHHS) for prevention and control of human immunodeficiency virus
(HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and
tuberculosis (TB) for persons who use drugs illicitly. It also summarizes
existing evidence of effectiveness for practices to support delivery of
integrated prevention services. Implementing integrated services for
prevention of HIV infection, viral hepatitis, STDs, and TB is intended to
provide persons who use drugs illicitly with increased access to services,
to improve timeliness of service delivery, and to increase effectiveness of
efforts to prevent infectious diseases that share common risk factors,
behaviors, and social determinants. This guidance is intended for use by
decision makers (e.g., local and federal agencies and leaders and managers
of prevention and treatment services), health-care providers, social
service providers, and prevention and treatment support groups.
Consolidated guidance can strengthen efforts of health-care providers and
public health providers to prevent and treat infectious diseases and
substance use and mental disorders, use resources efficiently, and improve
health-care services and outcomes in persons who use drugs illicitly.

An integrated approach to service delivery for persons who use drugs
incorporates recommended science-based public health strategies, including
1) prevention and treatment of substance use and mental disorders; 2)
outreach programs; 3) risk assessment for illicit use of drugs; 4) risk
assessment for infectious diseases; 5) screening, diagnosis, and counseling
for infectious diseases; 6) vaccination; 7) prevention of mother-to-child
transmission of infectious diseases; 8) interventions for reduction of risk
behaviors; 9) partner services and contact follow-up; 10) referrals and
linkage to care; 11) medical treatment for infectious diseases; and 12)
delivery of integrated prevention services. These strategies are science-
based, public health strategies to prevent and treat infectious diseases,
substance use disorders, and mental disorders. Treatment of infectious
diseases and treatment of substance use and mental disorders contribute to
prevention of transmission of infectious diseases. Integrating prevention
services can increase access to and timeliness of prevention and treatment.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Hazards Analysis, within Departments and Occupations, for
Hepatitis B Virus among Health Care Workers in Public Teaching Hospitals
in Khartoum State; Sudan
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23121743

Glob J Health Sci. 2012 Aug 26;4(6):51-9.

Hazards Analysis, within Departments and Occupations, for Hepatitis B Virus
among Health Care Workers in Public Teaching Hospitals in Khartoum State;
Sudan.

Elmukashfi TA, Ibrahim OA, Elkhidir IM, Bashir AA, Elkarim MA.

Sudan, University of Khartoum, Faculty of Medicine, Department of Community
Medicine.. tahamukashfi@hotmail.com.

BACKGROUND: Infection with hepatitis B virus (HBV) can lead to a range of
clinical illnesses.

OBJECTIVES: To examine hazards of hepatitis B virus associated with
clinical departments and occupations; among health care workers in Public
Teaching Hospitals in Khartoum State, Sudan.

METHODS: The study was a cross sectional, facility-based study. It was
conducted on stratified two-stage cluster random sample of 843 subjects of
whom 324 were at high-hazard, 445 at moderate hazard, and 74 at low hazard;
depending on degree of exposure to blood and body fluids of patients. To
assess hazards of HBV among departments and occupations of HCWs, non-
parametric Methods of Chi-square test, was used.

RESULTS: For Anti-HBc vulnerable departments was Renal Dialysis (100%);
while for occupations was midwives (73.3%). For carrier rate (+ve HBsAg),
highest rate found in department of Management (6.8%); while for
occupations was Midwives (6.7%). Regarding immunity (+ve Anti-HBs), the
highest percentage found in the department of Dentistry (25.9%); while for
occupations was associated with Doctors (14.8%). For a profile of high
infectivity (+ve HBeAg), the most vulnerable department in terms of HBV
hazards was the Surgery (1.4%); while for occupations was nurses (0.9%).

CONCLUSION: There was a significant association for infection rate of HBV
with occupation and type of department. The most hazardous departments, was
Surgery with a profile of high infectivity rate, followed by other
departments (medicine, pediatrics, psychiatry & ophthalmology). As for
occupations, the most hazardous group was nurses group with a profile of
high infectivity rate.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Inadvertent epidural injection of drugs for intravenous use. A
review
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23136808

Acta Anaesthesiol Belg. 2012;63(2):75-9.

Inadvertent epidural injection of drugs for intravenous use. A review.

Beckers A, Verelst P, van Zundert A.

Catharina Hospital – Department of Anesthesiology, Eindhoven, The
Netherlands.

INTRODUCTION: The frequency of inadvertent injection of drugs in the
epidural space is probably underestimated and underreported, but it can
cause serious morbidity and possibly mortality.

OBJECTIVE: The aim of this review is to collate reported incidents of this
type, to describe the potential mechanisms of occurrence and to identify
possible therapeutic solutions.

METHODS: We searched into medical databases and reviewed reference lists of
papers retrieved.

RESULTS: A list is reported of more than 50 drugs that were inadvertently
injected into the epidural space. This list includes drugs which produce
no, little or short-lasting neurological deficits, but also includes drugs
that may be more etching and can result in temporary or even permanent
neurological deficit.

DISCUSSION: Most drugs do not lead to sequelae other than pain during
injection or transient neurological complaints. Other drugs may have more
deleterious consequences, such as paraplegia. Both the dose of the
inadvertent injected drug and the time frame play an important role in the
patient’s outcome.

“Syringe swap”, “ampoule error”, and epidural/intravenous line confusion
due to inaccurate or absent colour coding of epidural catheters were the
main sources of error.

Preventive strategies, including non Luer-lock epidural injection ports,
might increase safety.
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Fungal Infections Associated with Contaminated
Methylprednisolone in Tennessee
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23131029

N Engl J Med. 2012 Nov 6.

Fungal Infections Associated with Contaminated Methylprednisolone in
Tennessee.

Kainer MA, Reagan DR, Nguyen DB, Wiese AD, Wise ME, Ward J, Park BJ, Kanago
ML, Baumblatt J, Schaefer MK, Berger BE, Marder EP, Min JY, Dunn JR, Smith
RM, Dreyzehner J, Jones TF; the Tennessee Fungal Meningitis Investigation
Team.

From the Tennessee Department of Health, Nashville (M.A.K., D.R.R., A.D.W.,
J.W., M.L.K., J.B., B.E.B., J.R.D., E.P.M, J.Y.M., J.D., T.F.J.); and the
Division of Healthcare Quality Promotion (D.B.N., M.E.W., M.K.S.), Epidemic
Intelligence Service, Scientific Education and Professional Development
Program Office (D.B.N., J.B., R.M.S.), and the Division of Foodborne,
Waterborne, and Environmental Diseases (B.J.P., R.M.S.), Centers for
Disease Control and Prevention, Atlanta. Supported by the Tennessee
Department of Health, by an appointment to the Applied Epidemiology
Fellowship Program administered by the Council of State and Territorial
Epidemiologists and funded by the Centers for Disease Control and
Prevention Cooperative Agreement 5U38HM000414-5, and by the Prevention and
Public Health Fund 2012: Epidemiology and Laboratory Capacity for
Infectious Diseases (ELC) Building and Strengthening Epidemiology,
Laboratory and Health Information Systems Capacity in State and Local
Health Departments Cooperative Agreement 3U5OCI000929-02S5; the
Epidemiology and Laboratory Capacity for Infectious Diseases-Program
Components Cooperative Agreement 1U5OCK000211-01; and the Emerging
Infections Program Cooperative Agreement 1U5OCK000198-01 (all, Centers for
Disease Control and Prevention).

Background We investigated an outbreak of fungal infections of the central
nervous system that occurred among patients who received epidural or
paraspinal glucocorticoid injections of preservative-free
methylprednisolone acetate prepared by a single compounding pharmacy.

Methods Case patients were defined as patients with fungal meningitis,
posterior circulation stroke, spinal osteomyelitis, or epidural abscess
that developed after epidural or paraspinal glucocorticoid injections.
Clinical and procedure data were abstracted. A cohort analysis was
performed.

Results The median age of the 66 case patients was 69 years (range, 23 to
91). The median time from the last epidural glucocorticoid injection to
symptom onset was 18 days (range, 0 to 56). Patients presented with
meningitis alone (73%), the cauda equina syndrome or focal infection (15%),
or posterior circulation stroke with or without meningitis (12%). Symptoms
and signs included headache (in 73% of the patients), new or worsening back
pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff
neck (in 29%). The median cerebrospinal fluid white-cell count on the first
lumbar puncture among patients who presented with meningitis, with or
without stroke or focal infection, was 648 per cubic millimeter (range, 6
to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was
114 mg per deciliter (range, 29 to 440); and the glucose concentration was
44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to
6.7]).

A total of 22 patients had laboratory confirmation of Exserohilum rostratum
infection (21 patients) or Aspergillus fumigatus infection (1 patient). The
risk of infection increased with exposure to lot 06292012@26, older vials,
higher doses, multiple procedures, and translaminar approach to epidural
glucocorticoid injection. Voriconazole was used to treat 61 patients (92%);
35 patients (53%) were also treated with liposomal amphotericin B. Eight
patients (12%) died, seven of whom had stroke.

Conclusions We describe an outbreak of fungal meningitis after epidural or
paraspinal glucocorticoid injection with methylprednisolone from a single
compounding pharmacy. Rapid recognition of illness and prompt initiation of
therapy are important to prevent complications. (Funded by the Tennessee
Department of Health and the Centers for Disease Control and Prevention.).

Free full text http://www.nejm.org/doi/full/10.1056/NEJMoa1212972
__________________________________________________________________
________________________________*_________________________________

8. Abstract:Epidural Corticosteroid Injections in the Management of
Sciatica: A Systematic Review and Meta-analysis
__________________________________________________________________
http://annals.org/article.aspx?articleid=1390546

Ann Intern Med. 13 November 2012

Epidural Corticosteroid Injections in the Management of Sciatica: A
Systematic Review and Meta-analysis

Rafael Zambelli Pinto, MSc; Chris G. Maher, PhD; Manuela L. Ferreira, PhD;
Mark Hancock, PhD; Vinicius C. Oliveira, MSc; Andrew J. McLachlan, PhD;
Bart Koes, PhD; and Paulo H. Ferreira, PhD

Background: Existing guidelines and systematic reviews provide inconsistent
recommendations on epidural corticosteroid injections for sciatica. Key
limitations of existing reviews are the inclusion of trials with active
controls of unknown efficacy and failure to provide an estimate of the size
of the treatment effect.

Purpose: To determine the efficacy of epidural corticosteroid injections
for sciatica compared with placebo.

Data Sources: International Pharmaceutical Abstracts, PsycINFO, MEDLINE,
EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL.

Study Selection: Randomized, placebo-controlled trials assessing the
efficacy of epidural corticosteroid injections in participants with
sciatica.

Data Extraction: Two independent reviewers extracted data and assessed risk
of bias. Leg pain, back pain, and disability were converted to common
scales from 0 (no pain or disability) to 100 (worst possible pain or
disability). Thresholds for clinically important change in the range of 10
to 30 have been proposed for these outcomes. Effects were calculated for
short-term (>2 weeks but =3 months) and long-term (=12 months) follow-up.

Data Synthesis: Data were pooled with a random-effects model, and the GRADE
(Grading of Recommendations Assessment, Development and Evaluation)
approach was used in summary conclusions. Twenty-five published reports (23
trials) were included. The pooled results showed a significant, although
small, effect of epidural corticosteroid injections compared with placebo
for leg pain in the short term (mean difference, -6.2 [95% CI, -9.4 to
-3.0]) and also for disability in the short term (mean difference, -3.1
[CI, -5.0 to -1.2]). The long-term pooled effects were smaller and not
statistically significant. The overall quality of evidence according to the
GRADE classification was rated as high quality.

Limitation: The review included only English-language trials and could not
incorporate dichotomous outcome measures into the analysis.

Conclusion: The available evidence suggests that epidural corticosteroid
injections offer only short-term relief of leg pain and disability for
patients with sciatica. The small size of the treatment effects, however,
raises questions about the clinical utility of this procedure in the target
population.

Primary Funding Source: None.
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Risks of acupuncture range from stray needles to pneumothorax,
finds study
__________________________________________________________________

BMJ 2012;345:e6060

Risks of acupuncture range from stray needles to pneumothorax, finds study

Zosia Kmietowicz

About 100 patients a year in England and Wales experience adverse events
after acupuncture delivered by the NHS, ranging from having needles left on
their body to pneumothorax, a study has found.1

Although most incidents aren’t harmful, it is likely that the total figure
is an underestimate because of under-reporting, say the researchers. They
recommend a number of practices that can improve the safety of acupuncture.

The researchers searched the database of the national reporting and
learning system run …

Access to the full text of this article requires a subscription or payment.
Please log in or subscribe.

http://www.bmj.com/content/345/bmj.e6060?view=long&pmid=22960463
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Transmission of Hepatitis C virus among people who inject
drugs: viral stability and association with drug preparation equipment
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23129759

J Infect Dis. 2012 Nov 5. [Epub ahead of print]

Transmission of Hepatitis C virus among people who inject drugs: viral
stability and association with drug preparation equipment.

Doerrbecker J, Behrendt P, Mateu-Gelabert P, Ciesek S, Riebesehl N, Wilhelm
C, Steinmann J, Pietschmann T, Steinmann E.

Institute of Experimental Virology, Twincore, Centre for Experimental and
Clinical Infection Research; a joint venture between the Medical School
Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI).

Background. HCV transmission among people who inject drugs remains a
challenging public health problem. We investigated the risk of HCV
transmission by analyzing the direct association of HCV with filters, water
to dilute drugs and water containers.

Methods. Experiments were designed to replicate practices and include
equipment routinely used by injecting drug users. HCV stability in water
was assessed by inoculation of bottled water with HCV. Viral association
with containers was investigated by inoculation of water with subsequent
emptying and refilling of containers. Transmission risk associated with
drug preparation filters was analyzed by drawing virus through a filter
following incubation to release infectivity.

Results. HCV can survive for up to three weeks in bottled water. Water
containers present a risk for HCV transmission as infectious virions
remained associated with water containers after washing. Physical
properties of the water containers determined the degree of HCV
contamination after re- filling with water. HCV also associated with filter
material, with around 10% of the viral inoculum.

Conclusions. This study demonstrates the potential risk of HCV transmission
among people who inject drugs who share water, filter and water containers
and will help to define public health interventions to reduce HCV
transmission.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Hand hygiene compliance: is there a theory-practice-ethics
gap?
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23123746

Br J Nurs. 2012 Sep 27-Oct 10;21(17):1011-4.

Hand hygiene compliance: is there a theory-practice-ethics gap?

Mortell M.

Practice is usually based on tradition, rituals and outdated information;
there is often an additional gap between theoretical knowledge and its
application in practice. This theory-practice gap has long existed
(Allmark, 1995; Hewison et al, 1996). It often arises when theory is
ignored because it is seen as idealistic and impractical, even if it is
practical and beneficial.

Most research relating to the lack of integration between theory and
practice has concluded that environmental factors are responsible and will
affect learning and practice outcomes. The author believes an additional
dimension of ethics is required to bridge the gap between theory and
practice. This would be a moral obligation to ensure theory and practice
are integrated.

To implement new practices effectively, healthcare practitioners must deem
these practices worthwhile and relevant to their role. This introduces a
new concept that the author calls the theory-practice-ethics gap. This
theory-practice-ethics gap must be considered when examining some of the
unacceptable outcomes in healthcare practice (Mortell, 2009). The
literature suggests that there is a crisis of ethics where theory and
practice integrate, and practitioners are failing to fulfil their duty as
providers of healthcare and as patient advocates.

This article examines the theory-practice-ethics gap when applied to hand
hygiene. Non-compliance exists in hand hygiene among practitioners, which
may increase patient mortality and morbidity rates, and raise healthcare
costs. Infection prevention and control programmes to improve hand hygiene
among staff include: ongoing education and training; easy access to
facilities such as wash basins; antiseptic/alcohol handgels that are
convenient, effective, and skin- and user-friendly; and organisational
recognition and support for clinicians in hand washing and handgel
practices. Yet these all appear to have failed to achieve the required and
desired compliance in hand hygiene.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Social and moral norm differences among Portuguese 1st and
6th year medical students towards their intention to comply with hand
hygiene
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/22111788

Psychol Health Med. 2012;17(4):408-16.

Social and moral norm differences among Portuguese 1st and 6th year medical
students towards their intention to comply with hand hygiene.

Roberto MS, Mearns K, Silva SA.

Department of Social and Organisational Psychology, ISCTE-IUL, Lisbon
University Institute, Lisbon, Portugal. magda.sofia.roberto@gmail.com

This study examines social and moral norms towards the intention to comply
with hand hygiene among Portuguese medical students from 1st and 6th years
(N = 175; 121 from the 1st year, 54 from the 6th year). The study extended
the theory of planned behaviour theoretical principles and hypothesised
that both subjective and moral norms will be the best predictors of 1st and
6th year medical students’ intention to comply with hand hygiene; however,
these predictors ability to explain intention variance will change
according to medical students’ school year. Results indicated that the
subjective norm, whose referent focuses on professors, is a relevant
predictor of 1st year medical students’ intention, while the subjective
norm that emphasises the relevance of colleagues predicts the intentions of
medical students from the 6th year. In terms of the moral norm, 6th year
students’ intention is better predicted by a norm that interferes with
compliance; whereas intentions from 1st year students are better predicted
by a norm that favours compliance. Implications of the findings highlight
the importance of role models and mentors as key factors in teaching hand
hygiene in medical undergraduate curricula.
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Skin decontamination by low-temperature atmospheric pressure
plasma jet and dielectric barrier discharge plasma
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/22682918

J Hosp Infect. 2012 Jul;81(3):177-83.

Skin decontamination by low-temperature atmospheric pressure plasma jet and
dielectric barrier discharge plasma.

Daeschlein G, Scholz S, Ahmed R, von Woedtke T, Haase H, Niggemeier M,
Kindel E, Brandenburg R, Weltmann KD, Juenger M.

Department of Dermatology of the Ernst Moritz Arndt University, Greifswald,
Germany. georg.daeschlein@uni-greifswald.de

BACKGROUND: Over the past few years, plasma medicine has become an
important field in medical science. Cold plasma has proven anti-
inflammatory, antimicrobial and antineoplastic effects.

AIM: To test the decontamination power of two cold plasma sources [low-
temperature atmospheric pressure plasma jet (APPJ) and dielectric barrier
discharge plasma (DBD)] in vivo on human fingertips.

METHODS: After 3, 15, 30, 60, 90, 120, 150, 180, 210 and 240 s of spot
treatment with the APPJ and DBD, the log reduction factors (RFs) of
physiological (PF) and artificially (AF) contaminated flora (Staphylococcus
epidermidis and Micrococcus luteus) were calculated. The bacterial load was
determined after counting. Tolerance (paresthesia, pain and heat) was
measured using a numerical rating scale.

FINDINGS: Both plasma devices led to a significant reduction in PF and AF.
The maximum log reduction factors for PF were 1.3 for the DBD at 210 s and
0.8 for the APPJ at 60 s. For AF, the maximum log reduction factors were
1.7 for the DBD at 90 s and 1.4 for the APPJ at 120 s. Treatment with both
devices was well tolerated.

CONCLUSION: Both the APPJ and DBD were highly effective in eradicating PF
and AF from the fingertips of healthy volunteers. No plasma-resistant
isolates were observed. Cold plasma appears to have potential for skin
disinfection. For hand hygiene purposes, plasma exposure times would need
to be reduced significantly by technical means.

Copyright © 2012 The Healthcare Infection Society. Published by Elsevier
Ltd. All rights reserved.
__________________________________________________________________
________________________________*_________________________________

14. Abstract: U.S. Postlicensure safety surveillance for adolescent and
adult tetanus, diphtheria and acellular pertussis vaccines: 2005-2007
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23142308

Vaccine. 2012 Nov 7. pii: S0264-410X(12)01570-8.

U.S. Postlicensure safety surveillance for adolescent and adult tetanus,
diphtheria and acellular pertussis vaccines: 2005-2007.

Chang S, O’Connor PM, Slade BA, Woo EJ.

Office of Biostatistics and Epidemiology, Center for Biologics Evaluation
and Research, U.S. Food and Drug Administration (FDA), Rockville, MD,
United States. Electronic address: soju.chang@nih.hhs.gov.

BACKGROUND: Pre-licensure clinical trials for two U.S. licensed tetanus
toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccinees
did not reveal any major safety concerns. However, routine use in large
adolescent and adult populations could reveal rare and potentially serious
adverse events (AEs).

METHODS: To characterize reported AEs following Tdap vaccination and
identify potential safety concerns warranting further evaluation, we
analyzed data from the Vaccine Adverse Event Reporting System (VAERS) and
assessed the frequency and proportions of AEs and reporting rates (reports
per 100,000 vaccine doses distributed).

RESULTS: A total of 2090 reports (7% were serious; 55% listed Tdap alone)
involving Tdap vaccinees were submitted to VAERS May 2005-June 2007. The
crude reporting rate was 10.2 per 100,000 vaccine doses distributed. The
median age of vaccinees was 22 years, and the female to male ratio was
about 2 to 1. The majority of reports described common local and systemic
signs and symptoms, such as injection site reactions, fever, and headache.
Rarely reported adverse events included myopericarditis, demyelinating
diseases of the central nervous system, Guillain-Barré Syndrome, syncope,
encephalopathy/encephalitis, seizure, Bell’s palsy, anaphylaxis, and
thrombocytopenia.

CONCLUSIONS: Because adolescents and adults were not routinely vaccinated
against pertussis in the past, this surveillance summary provides important
– and reassuring – information about the use of Tdap in these age groups.
Although subject to the limitations of passive surveillance, the findings
of this VAERS review support the pre-licensure clinical trial data with
regard to the safety of the U.S. licensed Tdap vaccines. Continued
monitoring of clinically significant adverse events that are temporally
associated with Tdap vaccination and further assessment of such events
using controlled observational studies may provide additional information
about the safety of these vaccines.

Copyright © 2012. Published by Elsevier Ltd.
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Enfuvirtide and cutaneous injection-site reactions
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23134996

J Drugs Dermatol. 2012 Oct 1;11(10):e35-8.

Enfuvirtide and cutaneous injection-site reactions.

Mirza RA, Turiansky GW.

Enfuvirtide belongs to a newer class of antiretroviral (ARV) agents called
fusion inhibitors for the treatment of human immunodeficiency virus type 1
(HIV-1) infection. Enfuvirtide blocks attachment, binding, and entry of the
viral capsid into the host CD4+ cell.

Administration is only available subcutaneously in a twice-daily regimen
particularly for those patients who have previously failed more than one
ARV regimen.

Common side effects of enfuvirtide administration include fatigue,
insomnia, nausea, and diarrhea; however, injection-site reactions are the
most common side effect and present in nearly all individuals undergoing
treatment.

The spectrum of cutaneous manifestations ranges from little to no reaction
to cysts, nodules, induration, or sclerodermalike lesions. These reactions
are mostly variants of iatrogenically induced hypersensitivity and are
self-limited.
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Application of copper to prevent and control infection. Where
are we now?
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/22738611

J Hosp Infect. 2012 Aug;81(4):217-23.

Application of copper to prevent and control infection. Where are we now?

O’Gorman J, Humphreys H.

Department of Microbiology, Beaumont Hospital, Dublin, Ireland.
joanneogorman@gmail.com

BACKGROUND: The antimicrobial effect of copper has long been recognized and
has a potential application in the healthcare setting as a mechanism to
reduce environmental contamination and thus prevent healthcare-associated
infection (HCAI).

AIM: To review the rationale for copper use, the mechanism of its
antimicrobial effect, and the evidence for its efficacy.

METHODS: A PubMed search of the published literature was performed.

FINDINGS: Extensive laboratory investigations have been carried out to
investigate the biocidal activity of copper incorporated into contact
surfaces and when impregnated into textiles and liquids. A limited number
of clinical trials have been performed, which, although promising, leave
significant questions unanswered. In particular there is a lack of
consensus on minimum percentage copper alloys required for effectiveness,
the impact of organic soiling on the biocidal effect of copper, and the
best approach to routine cleaning of such surfaces. Limited information is
available on the ability of copper surfaces to eradicate spores of
Clostridium difficile.

CONCLUSION: Additional studies to demonstrate that installing copper
surfaces reduces the incidence of HCAI are required and the cost-
effectiveness of such intervention needs to be assessed. Further research
in a number of key areas is required before the potential benefits of using
copper routinely in the clinical setting to prevent and control infection
can be confirmed and recommended.

Copyright © 2012 The Healthcare Infection Society. Published by Elsevier
Ltd. All rights reserved.
__________________________________________________________________
________________________________*_________________________________

17. USA: Case Counts – Multistate Fungal Meningitis Outbreak

[From contaminated injections]

Crossposted from ProMED-mail [edited] with thanks
<promed@promed.isid.harvard.edu>
__________________________________________________________________

Current CDC statistics

Case Counts – Multistate Fungal Meningitis Outbreak

Date: Fri 9 Nov 2012
Source: CDC [edited]
http://www.cdc.gov/HAI/outbreaks/meningitis.html

At-A-Glance
– ———-
Status: Ongoing Investigation
Infection: Fungal
Facility Type: Outpatient Setting
Case Count: 438
States: 19
Deaths: 32

State / Total Case Counts / Peripheral Joint Infections / Deaths
– —————————————-
Florida / 23 / 0 / 3
Georgia / 1 / 0 / 0
Idaho / 1 / 0 / 0
Illinois / 2 / 0 / 0
Indiana / 52 / 0 / 4
Maryland / 23 / 0 / 1
Michigan / 128 / 6 / 8
Minnesota / 11 / 0 / 0
New Hampshire / 13 / 4 / 0
New Jersey / 27/ 0 / 0
New York / 1 / 0 / 0
North Carolina / 3 / 0 / 1
Ohio** / 15 / 0 / 0
Pennsylvania / 1 / 0 / 0
Rhode Island / 3 / 0 / 0
South Carolina / 1 / 0 / 0
Tennessee / 81 / 0 / 13
Texas / 2 / 0 / 0
Virginia / 50 / 0 / 2
– ———————–
Totals 438* / 10 / 32

428* cases of fungal meningitis, stroke due to presumed fungal meningitis,
or other central nervous system-related infection meeting the outbreak case
definition, plus 10* peripheral joint infections (e.g., knee, hip,
shoulder, elbow). No deaths have been associated with peripheral joint
infections.

**Ohio previously reported 16 cases. Ohio has corrected their case count to
15 cases.

Case counts by state are based on the state where the procedure was
performed, not the state of residence.
__________________________________________________________________
________________________________*_________________________________

18. The 11th International Congress on AIDS in Asia and the Pacific
(ICAAP11)
__________________________________________________________________
http://www.icaap11.org

The 11th International Congress on AIDS in Asia and the Pacific (ICAAP11)

Theme: “Asia/Pacific Reaching Triple Zero: Investing in Innovation”
18-22 November 2013
Bangkok, Thailand

Bangkok – Thailand: ICAAP 11 which will be held from 18 to 22 November,
2013 in Bangkok, Thailand, is expected to be attended by 4,000 participants
from countries in Asia and the Pacific. The return of the ICAAP to
Thailand after 17 years represents a unique opportunity to reflect upon
the journey of the fight against HIV/AIDS in the region; and more
importantly to set a new trajectory in responding to the changing
needs of people infected and affected by the HIV/AIDS epidemics.

The theme of the conference “Asia/Pacific Reaching Triple Zero: Investing
in Innovation” presents a regional response to a global call in
reaching the goal of zero new HIV infections, zero discrimination and
zero AIDS-related deaths. ICAAP 11 programme will be focusing on
innovative ways of combating HIV/AIDS , and building practical
knowledge and technology that does not need to be new, but will work best
for targeted populations in specific environments and settings; and on
revolutionizing socio-political responses to AIDS by enhancing
political commitment, increasing capacity of local governments and
engaging key affected populations.

Community involvement is being considered as an indispensable wheel
for running ICAAP 11. Efforts were made to ensure participation of
HIV/AIDS affected people from the beginning of the congress preparation.
The Local Organizing Committee (LOC) has recently met with regional
HIV/AIDS community to plan activities for engaging communities at
the local and grassroots levels in different countries for their
inputs, which will form a significant part of ICAAP11 programme.

The ICAAP 11 LOC is working full steam ahead to craft the congress
programme. Since the establishment of LOC and appointments of the four core
committees i.e. Scientific Programme Committee; Community Programme
Committee; Leadership Programme Committee; and Fund Raising and
Sponsorship Committee to work hand in hand with the ICAAP 11 Secretariat
Office, more than 14 meetings were convened to brainstorm ideas and
synergies to create a more inclusive congress where innovative ideas will
be shared among key affected populations, international agencies, NGOs,
academia.

About ICAAP:

The ICAAP is the largest HIV/AIDS Forum in Asia and the Pacific region, and
the second largest one in the world. It is a biennial gathering
for the release and discussion of scientific, programmatic and policy
developments in the global response to the issues of HIV/AIDS. ICAAP
promotes opportunities for greater regional collaboration, sharing of
ideas amongst people infected and affected by the HIV/AIDS epidemics from
across the Asia/Pacific region.

Conference Organization: The organization of ICAAP 11 will be led by the
Population and Community Development Association (PDA), the leading and
most diversified NGO in Thailand, which is widely 1known for its
pioneering programmes in family planning and HIV/AIDS prevention. The AIDS
Society of Asia and the Pacific (ASAP) and UNAIDS are the co-conveners of
ICAAP 11.

Local Supporters of the ICAAP 11 include the Ministry of Public
Health; Ministry of Tourism and Sports; Ministry of Foreign
Affairs; Faculty of Public Health; Research Centre for Health
Economics and Evaluation (ReCHEE), Mahidol University; Thai Red
Cross AIDS Research Centre; AIDS TB and STIs Control Division;
Thailand MOPH-US CDC Collaboration; Empower Foundation; Raks Thai
Foundation; Thai National AIDS Foundation; The Planned Parenthood
Association of Thailand; PSI Thailand Foundation; Social Health Development
Foundation; Violet Home, Health and Opportunity Network; Thailand
Convention and Exhibition Bureau; The Association of Domestic
Travel; Thailand Incentive and Convention Association

For more information about ICAAP 11, please contact:

ICAAP11 Local Organizing Committee (LOC) Secretariat
Population and Community Development Association (PDA)
6 th Floor, 6, Sukhumvit 12, Klongtoey, Bangkok 10110

E-mail: secretariat@icaap11.org
Tel: + 66 2 229 4825
Fax: + 66 2 2229 4632
__________________________________________________________________
________________________________*_________________________________

10. News

– Spinal steroid shots may have little effect on sciatica
– UK: HIV blood products inquiry to view new evidence
– Solar Power: An Alternative Device to Sterilize Surgical Instruments in
Rural Areas
– Australia: Hepatitis C-Infected Doctor Pleads Guilty to 55 Charges of
Negligently Causing Serious Injury
– USA: US CDC Offers Grand Rounds on Unsafe Injection Practices
– USA: Massachusetts pharmacy board head fired after meningitis outbreak
– Global: Polio program seeks expert approval for changes to crucial
endgame

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
Spinal steroid shots may have little effect on sciatica
By Andrew M. Seaman, Reuters (12.11.12)

NEW YORK (Reuters Health) – Despite the growing popularity of steroid
injections to treat various kinds of back pain in recent years, a new
review of past research finds the shots do little to alleviate sciatica, a
common condition that causes leg and back pain.

Analyzing results from nearly two dozen clinical trials on thousands of
patients, Australian researchers found that epidural injections (into the
spine) of corticosteroids had no long- or short-term effect on sciatica
back pain, and such a small short-term effect on leg pain it would make no
difference to the patient.

“I think it’s pretty clear that this treatment is not good to do,” said
Chris Maher, of The George Institute for Global Health in Sydney,
Australia, who worked on the study.

Nonetheless, the use of epidural steroid injections to treat back pain of
all sorts among Medicare patients nearly doubled from 741,000 in 2000 to
about 1,438,000 in 2004, according to the researchers.

In the U.S., the cost of one shot can be several hundred dollars.

And a tainted supply of one of the steroids included in the trials under
analysis – methylprednisolone – recently caused a nationwide outbreak of
fungal meningitis that infected 400 people and led to 31 deaths, according
to the Centers for Disease Control and Prevention.

For sciatica, which is thought to be caused by nerve damage, past studies
have already questioned the effectiveness of spinal steroid shots.

In April, for instance, a study of 81 people found that whether they
received steroids or a placebo for sciatica, their condition ended up
improving about the same amount. (see Reuters Health article of April 16,
2012.)

Maher and his colleagues set out to see whether past studies supported the
use of epidural corticosteroid injections to help manage sciatica, and
collected results from “gold standard” randomized controlled trials.

Overall, 23 trials were included in the final analysis, which represented
about 2,300 patients, whose pain was ranked on a scale from zero to 100 –
with higher scores representing worse pain.

For the back pain component of sciatica, the researchers found that the
injections didn’t seem to make a difference over short or long periods of
time.

When it came to leg pain, there was no difference a year or so after the
injection, but there was a statistically significant six-point drop in pain
scores over the short term – about 2 weeks to 3 months.

But that, according to Maher, is not enough to mean anything to a doctor or
patient.

“You can appreciate that six points on a hundred-point scale is a tiny
difference, and in our view that is probably not clinically important,” he
said.

‘QUESTION IS CLOSED’

“We really think the question is closed,” said Maher. “So in terms of our
research agenda, we’re moving on to other treatments for sciatica.”

Maher told Reuters Health that, instead of steroid injections, people
suffering with sciatica should consult their doctor, but other options
include simple pain relievers, such as acetaminophen, drugs that treat pain
by working throughout a person’s nervous system and, as a last resort,
surgery.

Not everyone agrees that steroid injections should be excluded from the
hierarchy of treatments for sciatica.

“In general, I think we’ve learned over the years that the epidural
injections are turning out to be less and less successful… but there are
times when they should be considered,” said Dr. Kirkham B. Wood, chief of
the orthopedic spine service at Boston’s Massachusetts General Hospital.

He told Reuters Health that he believes an injection should be considered,
for example, in someone with sciatica resulting from a relatively recent
herniated disc, “who time and medication has not helped.”

Wood does believe, however, that the injections are overused, and said
there was a time when the injections were the go-to treatment for simple
back pain.

“I think the pendulum is certainly swinging away from their broad use,” he
said.

The meningitis outbreak in the U.S. will also likely dampen enthusiasm for
the shots, researchers acknowledged.

“If this was a treatment that worked, then you’d have to weigh the benefits
and the harm,” Maher said, but it doesn’t work (for sciatica), he
emphasized.

Maher and his team, who published their results in the Annals of Internal
Medicine on Monday, hope doctors will pick up on their findings.

But Maher told Reuters Health that it may take some time to change how
doctors see the injections.

“It’s been around for decades and it will take a while to stop,” he said.

SOURCE: bit.ly/SQRXAa Annals of Internal Medicine, online November 12,
2012.
__________________________________________________________________
__________________________________________________________________
http://www.bbc.co.uk/news/uk-scotland-20299302

UK: HIV blood products inquiry to view new evidence
BBC News, UK (12.11.12)

The judge chairing the investigation into contaminated NHS blood products
in the 1980s will take further written evidence at his inquiry.

Lord Penrose refused an application from the Haemophilia Society to reopen
the oral hearings stage to call expert witnesses on the topic of
statistics.

However, he inquiry will now take further written evidence from witnesses
named at the procedural hearing.

Hundreds of patients were infected before screening was introduced.

The Penrose Inquiry is the Scottish public inquiry into Hepatitis C/HIV
acquired infection from NHS treatment in Scotland with blood and blood-
related products.

It is examining whether enough was done to protect patients at staff at the
time.

Lord Penrose had considered a written application from Thompsons
Solicitors, who represent the patients, relatives and the Haemophilia
Society during a procedural hearing on 29 October 2012 which was open to
the public.

The application requested the reopening of the oral hearings stage of the
inquiry to call or recall five expert witnesses, but Lord Penrose has now
published his written decision refusing the request.

Thompsons Solicitors partner Patrick McGuire expressed disappointment at
Lord Penrose’s refusal to hear additional oral evidence and questioned the
purpose of the inquiry.

“This decision will serve as a terrible body blow to the many victims,
campaigners and legal representatives who are seeking answers and
transparency around this devastating scandal,” said Mr McGuire.

“The inquiry can’t possibly fulfil its remit without giving a definitive
figure in regards to numbers infected and that is what the additional oral
evidence on statistics would have examined.

“To conclude without this detail could be viewed by some as casting doubt
over the entire process.”

Lord Penrose is chairing the probe into how Eileen O’Hara and Rev David
Black contracted the virus while in NHS care.

The oral hearings began in March 2011 and concluded in March 2012 and were
held to examine the topics identified for further investigation in Lord
Penrose’s Preliminary Report, which was published in September 2010.

Over a total of 89 days of hearings, the inquiry heard from 60 witnesses,
including during a number of closed sessions where patients and relatives
gave evidence to the inquiry anonymously.

The final report will be published in 2013.
__________________________________________________________________
__________________________________________________________________
Solar Power: An Alternative Device to Sterilize Surgical Instruments in
Rural Areas
By DONALD G. McNEIL Jr., The New York Times, USA (12.11.12)

Solar power can steam-sterilize surgical instruments, according to a new
study — but the contraption needed to do so is not pocket-size.

Sterilizing instruments needed in surgical emergencies like Caesarean
births or appendectomies can be a problem in rural clinics in Africa: There
may be no electricity, jugs of bleach or tanks of propane.

So a Rice University team recently modified a prototype of an old solar
stove to power a simple autoclave, which is a pressure-cooker for
instruments, and tested it in the Texas sun.

On all 27 attempts, it reached United States government sterilization
standards.

How practical it is awaits African trials; it is nearly 12 feet long and 6
feet tall and has bright curved mirrors to focus sunlight on a water-filled
pipe. On sunny days, it can make steam at 150 degrees Celsius (302 degrees
Fahrenheit) from about 9 a.m. to 3 p.m.

Douglas A. Schuler, above, a Rice business professor and lead author of the
study, published in The American Journal of Tropical Medicine and Hygiene,
said he “married into the project.” His French father-in-law designed the
solar stove years ago after a student trip to West Africa. But women in
Haiti, where they tested it, “just hated cooking on it,” Dr. Schuler said,
so they found a different use for it.

The initial setup costs about $2,100. But sunlight costs nothing, making
five years of operation about $2,000 cheaper than using propane.

A version of this article appeared in print on November 13, 2012, on page
D6 of the New York edition with the headline: Solar Power: An Alternative
Device to Sterilize Surgical Instruments in Rural Areas.
__________________________________________________________________
__________________________________________________________________
Australia: Hepatitis C-Infected Doctor Pleads Guilty to 55 Charges of
Negligently Causing Serious Injury
Emily Portelli, Herald Sun, Australia (09.11.12)

James Latham Peters, 63, a former abortion clinic doctor at a clinic in
Melbourne’s eastern suburbs, has pleaded guilty to infecting more than 50
patients with hepatitis C. The victims, 20 of whom were present in the
courtroom of the Australian Supreme Court, wept as Peters replied “guilty”
to each of the 55 charges of causing serious injury by negligence.

In previous court proceedings, the former anesthetist was alleged to have
infected patients between 2008 and 2009 at the Croydon Day Surgery by using
needles to inject himself before using them on his patients.

Since 1996, Peters had been attempting to hide his drug addiction to the
drug fentanyl, an opioid used in general anesthesia; he knew of his
hepatitis C status since 1997, according to a previous court hearing.
Justice Paul Coghlan, the trial judge, declared his sympathy for the women
suffering as a result of Peters’ actions. “The victims in this case are a
group of the most highly innocent people you could ever come across,”
declared Justice Coghlan. Peters will appear before the Supreme Court for a
plea on February 11, 2013.
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USA: US CDC Offers Grand Rounds on Unsafe Injection Practices
Infection Control Today, USA (09.11.12)

Grand Rounds at the Centers for Disease Control and Prevention (CDC) are a
forum in which experts present a series of lectures and bring ideas from
diverse perspectives on a public health issue.

The Grand Rounds, “Unsafe Injection Practices in the U.S. Healthcare
System” will be held on Tuesday, Nov. 13, 2012 from 1 p.m. to 2 p.m. ET.

The Public Health Grand Rounds is a monthly webcast created to foster
discussion on major public health issues. Each session focuses on key
challenges related to a specific health topic, and explores cutting-edge
scientific evidence and potential impact of different interventions. The
Grand Rounds sessions also highlight how CDC and its partners are already
addressing these challenges and discuss the recommendations for future
research and practice.

Injectable medicines are commonly used in healthcare settings for the
prevention, diagnosis, and treatment of various illnesses. This session of
Grand Rounds will explore how unsafe injection practices that put patients
at risk of infection have been associated with a wide variety of procedures
and settings.

Unsafe injections also increase the burden on patients, healthcare
providers, and medical care and public health systems. These harms are
preventable through renewed attention to infection control and injection
safety practices, which will be a focus of the presentations at this Grand
Rounds.

CLICK HERE for a copy of the injection safety checklist that will be
discussed at the upcoming Grand Rounds.
http://www.cdc.gov/injectionsafety/PDF/SIPC_Checklist.pdf

For more information, CLICK HERE.
http://www.cdc.gov/features/grandrounds/index.html
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USA: Massachusetts pharmacy board head fired after meningitis outbreak
By Tim McLaughlin, Reuters (07.11.12)

BOSTON | (Reuters) – Authorities fired the director of the Massachusetts
Board of Pharmacy after he failed to investigate a complaint against New
England Compounding Center, the company at the center of a deadly U.S.
meningitis outbreak, state officials said on Wednesday.

NECC is linked to a meningitis outbreak that has infected more than 400
people and caused 31 deaths.

Massachusetts officials said they uncovered a complaint against NECC by
Colorado pharmacy regulators just months before the outbreak. The
complaint, which said NECC was distributing drugs without patient-specific
prescriptions, was forwarded on July 26 to James Coffey, director of the
Massachusetts pharmacy board.

Coffey failed to order an investigation or take any other action on the
Colorado complaint, the Massachusetts Department of Public Health’s interim
commissioner, Dr. Lauren Smith, said in a statement.

In the years before the outbreak, NECC escaped harsh punishment from the
Massachusetts pharmacy board, raising questions about oversight of the
customized drug mixing industry, state records released last month show.

Smith said Coffey has been terminated and the pharmacy board’s counsel,
Susan Manning, has been placed on administrative leave pending the final
conclusions of the investigation.

“It is incomprehensible that Mr. Coffey and Ms. Manning did not act on the
Colorado complaint given NECC’s past, and their responsibility to
investigate complaints,” Smith said in a statement. “Following the
outbreak, staff also failed to disclose the existence of Colorado’s
complaint to leadership at” the Department of Public Health.

Coffey was not immediately available for comment.

The Colorado State Board of Pharmacy shared information that showed NECC
had distributed many drugs to many hospitals in Colorado between 2010 and
2012, but without patient-specific prescriptions. That was a violation of
NECC’s Colorado and Massachusetts licenses, according to Smith’s statement.
NECC was not immediately available for comment.

In 2011, during a routine inspection, Colorado inspectors found that NECC
had participated in the unregistered/unlicensed distribution of
prescription drugs in Colorado. As a result, Colorado issued a cease-and-
desist order against NECC in April 2011.

“I find the actions of NECC reprehensible,” Smith said in the statement.
“We have the right to expect that all companies producing medication for
use in delivering health care to comply with laws designed to protect
patient safety. But I also expect the staff charged with oversight to
perform their duties to the highest standards. That failed to happen here.”

(Reporting by Tim McLaughlin; Editing by Gary Hill and Leslie Adler)
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http://tinyurl.com/bsf7367

Global: Polio program seeks expert approval for changes to crucial endgame
By Helen Branswell, The Canadian Press, Canada (06.11.12)

Public health officials plotting the strategy behind the effort to rid the
world of polio are seeking approval for fundamental changes to the
blueprint for the way the eradication program will eventually come to a
stop.

The Global Polio Eradication Initiative is asking for endorsement of
changes it wants to make to the polio endgame, the tricky manoeuvring that
will be needed to safely stop vaccinating against polio once it appears the
viruses are no longer spreading and causing disease.

The initiative hopes the options it is proposing will speed up the end of
polio transmission and make the final moves in this lengthy battle safer.
At a meeting in Geneva today, it is asking the World Health Organization’s
vaccine experts — the Strategic Advisory Group of Experts on Immunization —
to approve recommendations aimed at making **injectable polio vaccine a
more crucial component of the endgame strategy.

Getting a green light from the committee, which goes by the acronym the
SAGE, is only the first step in an approval process that would require
countries to sign on as well. And the WHO’s point person for polio knows
all countries aren’t there yet when it comes to agreeing to a role for
injectable vaccine, or IPV as it is known.

“I think we have to accept that we are not at a point yet where every
country has concurred to introduce this universally. Not at all,” Dr. Bruce
Aylward, the assistant director-general for polio, emergencies and country
collaboration said in a recent interview.

Since the polio eradication program was launched in 1988 it has relied on
oral polio vaccine. OPV, in polio shorthand, costs pennies a dose and is
easy to administer. Anyone can be trained to give the vaccine, two drops of
which are squeezed from a eye dropper into an open mouth. It is given to
millions of children in scores of countries every year.

By comparison, the injectable vaccine is substantially more expensive,
currently running at around $2.75 a dose when procured through UNICEF,
which buys in bulk for developing countries. (Children immunized with
injectable vaccine need three or four doses each.)

And the $2.75 is just the cost of the vaccine. Factor in the syringes and
the medical professionals needed to wield them, and it becomes clear why
for many years IPV was only used by well-to-do countries. Of late, though,
an increasing number of middle-income countries have been using it as well.
That’s because despite its higher price, IPV is safer than the oral
vaccine, which is made from live but weakened polio viruses.

OPV causes polio in a small portion of children who get the vaccine or
encounter the viruses used in the serum. It is estimated that one out of
every 750,000 children will develop polio after getting their first dose of
OPV. That is called vaccine-associated paralytic polio or VAPP.

And the vaccine viruses, which inoculated children shed in their stools,
can spread in an environment where sanitation is poor, moving from
vaccinated child to unvaccinated child in tainted water or tiny bits of
fecal matter picked up on a finger that finds its way into a mouth. If
those vaccine viruses spread long enough, they regain their power to
paralyze, acting like regular polio viruses. Polio cases caused by
spreading vaccine viruses are called VDPVs — vaccine-derived polio viruses.
When wild polio viruses paralyzed scores of thousands of children a year,
the benefits of oral vaccine over rode the risks of VAPP and VDPV cases.
But so far this year there have only been 177 cases of paralytic polio, in
four countries. When the world gets down to a few dozen of cases of polio a
year, the continued heavy reliance on OPV will risk seeding the world with
vaccine viruses that could spread and trigger outbreaks of VDPV cases.

In essence, the question is: When is it no longer safe to fight fire with
fire? Some experts have been saying for years that injectable vaccine has
to play a role in the phasing out of oral vaccine. And for years the polio
campaign leadership resisted those calls, saying the scientific evidence
was not there to support the move.

These days, though, they are IPV converts. And they are asking the SAGE to
urge that all countries vaccinate all vulnerable children with at least one
dose of injectable vaccine as part of the endgame strategy. The thinking is
that if vaccine viruses start spreading more broadly in the phasing out of
the oral vaccine, children will have some protection from the dose of IPV.
Aylward suggested an outbreak of vaccine-derived polio in Nigeria that
started in 2005 has shaped thinking about the risk vaccine viruses pose. So
far there have been 381 cases of paralytic polio in that outbreak, which
has not yet been extinguished.

“There’s increasing evidence that these things are real. They can persist
and take some time to knock out. And Africa may be at the greatest risk due
to the gaps in immunization coverage there,” he said. It’s know that
vaccine viruses spread best in areas where the percentage of children who
are fully immunized is low.

But 24 years into the eradication effort, many countries are eager to stop
spending money on polio vaccination entirely. Earlier this year, in fact,
Bangladesh debated whether it could cut its national immunization day, a
cornerstone of polio control efforts. (The government was urged not to and
it followed the advice.)

Aylward said the polio campaign partners are working hard to find a way to
get the price of injectable vaccine below $1 a dose and ideally closer to
50 cents a shot. At that rate, more countries would buy into the IPV plan,
he said.

Options on the table include using a smaller dose but injecting it into the
skin, rather than the muscle, because that triggers a better immune
response, or using a boosting compound called an adjuvant with the vaccine
to allow for smaller doses.

“The issue now is making sure that there are affordable products available
but then also that countries will accept to do that,” Aylward said.
“Because there are a lot of countries that wish they could just stop OPV
cold.”

The polio eradication campaign is a partnership of Rotary International,
the WHO, UNICEF, the U.S. Centers for Disease Control and the Bill and
Melinda Gates Foundation.

It currently hopes to halt the spread of polio in the three countries which
have never stopped transmission — Nigeria, Pakistan and Afghanistan — by
2014-15. (The fourth country to report cases this year is Chad, which has
seen sporadic importations of polio from Nigeria.) If that goal is reached,
the world would be declared polio free three years after the last case
occurred.
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* SAFETY OF INJECTIONS brief yourself at: www.injectionsafety.org

A fact sheet on injection safety is available at:
http://www.who.int/mediacentre/factsheets/fs231/en/index.html

* Visit the WHO injection safety website and the SIGN Alliance Secretariat
at: http://www.who.int/injection_safety/en/

* Download the WHO Best Practices for Injections and Related Procedures
Toolkit March 2010 [pdf 2.47Mb]:
http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf

Use the Toolbox at: http://www.who.int/injection_safety/toolbox/en/

Get SIGN files on the web at: http://signpostonline.info/signfiles-2
get SIGNpost archives at: http://signpostonline.info/archives-by-year

Like on Facebook: http://facebook.com/SIGN.Moderator

The SIGN Secretariat, the Department of Health Systems Policies and
Workforce, WHO, Avenue Appia 20, CH-1211 Geneva 27, Switzerland.
Facsimile: +41 22 791 4836 E- mail: sign@who.int
__________________________________________________________________
________________________________*_________________________________

SIGN meets annually to aid collaboration and synergy among SIGN network
participants worldwide.

The 2010 annual Safe Injection Global Network meeting was held from 9
to 11 November 2010 in Dubai, The United Arab Emirates.

The SIGN 2010 meeting report pdf, 1.36Mb is available on line at:
http://www.who.int/entity/injection_safety/toolbox/sign2010_meeting.pdf

The report is navigable using bookmarks and is searchable. Viewing
requires the free Adobe Acrobat Reader at: http://get.adobe.com/reader/

Translation tools are available at: http://www.google.com/language_tools
or http://www.freetranslation.com
__________________________________________________________________
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The comments made in this forum are the sole responsibility of the writers
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Use of trade names and commercial sources is for identification only and
does not imply endorsement.

The SIGN Forum welcomes new subscribers who are involved in injection
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* Subscribe or un-subscribe by email to: sign.moderator@gmail.com, or to
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The SIGNpost Website is http://SIGNpostOnline.info

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We would like your help in building this archive. Please send your old
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The SIGN Internet Forum was established at the initiative of the World
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SIGN Forum is moderated by Allan Bass and is hosted on the University of
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