online canadian pharmacy http://www.canadianpharmacy365.net/ pharmacy ratings phentermine no prescription

SIGNpost 00681

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *

Post00681 Catchup on Abstracts Case Reports Course + News 9 January 2013

CONTENTS
0. Moderators Note
1. Abstract: Study of status of safe injection practice and knowledge
regarding injection safety among primary health care workers in Baglung
district, western Nepal
2. Abstract: Fungal Infections Associated with Contaminated
Methylprednisolone Injections – Preliminary Report
3. Abstract: Social representations of needlestick injuries
4. Abstract: Chronic hepatitis C virus (HCV) disease burden and cost in the
United States
5. Abstract: Antiviral agents and hepatitis C
6. Abstract: Validation of the efficacy of a solar-thermal powered
autoclave system for off-grid medical instrument wet sterilization
7. Abstract: Local Anesthetics Injection Therapy for Musculoskeletal
Disorders: A Systematic Review and Meta-Analysis
8. Abstract: Review article: Improving drug safety for patients undergoing
anesthesia and surgery
9. Abstract: Injection Anthrax-a New Outbreak in Heroin Users
10. Abstract: Hepatitis B Infection among high risk population: a
seroepidemiological survey in Southwest of Iran
11. Abstract: Global geographical overlap of aflatoxin and hepatitis C:
controlling risk factors for liver cancer worldwide
12. Abstract: Oral and injectable contraception use and risk of HIV
acquisition among women in the methods for improving reproductive
health in Africa (MIRA) study
13. Abstract: Multidrug-Resistant Acinetobacter baumannii Infection
Following Para-Articular Steroid Injection in the Knee – A Case Report
14. Abstract: Necrotizing fasciitis after spinal anesthesia
15. Abstract: Fatal Nosocomial Spread of Crimean-Congo Hemorrhagic Fever
with Very Short Incubation Period
16. Abstract: Chemotherapeutically Induced Cutaneous Tuberculosis after BCG
Injection in a Patient with Pelvic Osteosarcoma
17. Abstract: An unexpected needlestick injury
18. No Abstract: Acute hepatitis B virus (HBV) infection in a repeat blood
donor during anti-HBV vaccination
19. No Abstract: No excuse for unsafe injection practice
20. No Abstract: Talking dirty on healthcare waste. Interview by Claire
Read
21. No Abstract: Unsafe injection practices plague US outpatient
facilities, harm patients
22. No Abstract: Penalties don’t show effect. Study: infection rates not
altered by nonpayment
23. No Abstract: Reducing nurse burnout might reduce hospital-acquired
infections
24. Harvard School of Public Health’s new online course, “Health in
Numbers: Quantitative Methods in Clinical and Public Health Research”
25. News
– USA: Doc Infects Patients with Hep B in Surgery
– Naloxone reverses overdoses without hefty price tag
– India: Hepatitis outbreak is traced to contaminated needles and barber
shop razors, study shows
– USA: Dirty medical needles infect thousands in U.S. – Outbreaks show not
all clinicians follow rules

The web edition of SIGNpost is online at:
http://signpostonline.info/archives/***

More information follows at the end of this SIGNpost!

Please send your requests, notes on progress and activities, articles,
news, and other items for posting to: sign.moderator@gmail.com

Normally, items received by Tuesday will be posted in the Wednesday
edition.

Subscribe or un-subscribe by email to: sign.moderator@gmail.com, or to
sign@who.int

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

Visit the SIGNpostOnline archives at: http://signpostonline.info

Selected updates and breaking news items on the SIGN Moderator Facebook
page at: http://facebook.com/SIGN.Moderator

Selected updates at: http://twitter.com/#!/signmoderator
__________________________________________________________________
________________________________*_________________________________

0. Moderators Note
__________________________________________________________________

This is the first edition of SIGNpost for 2013.

Please send your requests, notes on progress and activities, articles,
news, and other items for posting to: sign.moderator@gmail.com

Let us make injections safe!
__________________________________________________________________
________________________________*_________________________________

1. Abstract: Study of status of safe injection practice and knowledge
regarding injection safety among primary health care workers in Baglung
district, western Nepal
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23286907

BMC Int Health Hum Rights. 2013 Jan 3;13(1):3.

Study of status of safe injection practice and knowledge regarding
injection safety among primary health care workers in Baglung district,
western Nepal.

Gyawali S, Rathore DS, Kc B, Shankar RP.

BACKGROUND: Unsafe injection practices and injection overuse are widespread
in developing countries harming the patient and inviting risks to the
health care workers. In Nepal, there is a dearth of documented information
about injection practices so the present study was carried out: a) to
determine whether the selected government health facilities satisfy the
conditions for safe injections in terms of staff training, availability of
sterile injectable equipment and their proper disposal after use and b) to
assess knowledge and attitudes of healthcare workers in these health care
facilities with regard to injection safety.

Methodology: A descriptive cross-sectional mixed type (qualitative and
quantitative) survey was carried out from 18th May to 16th June 2012. In-
depth interviews with the in-charges were conducted using a semi-structured
questionnaire. Observation of the health facilities using a structured
observation tool was done. The data were analysed manually by summarizing,
tabulating and presenting in various formats.

RESULTS: The in-charges (eight males, two females) who participated in the
study ranged in age from 30 to 50 years with a mean age of 37.8 years.
Severe infection followed by pain was the most important cause for
injection use with injection Gentamicin being most commonly prescribed. New
single use (disposable) injections and auto-disable syringes were used to
inject curative drugs and vaccines respectively. Sufficient safety boxes
were also supplied to dispose the used syringe. All health care workers had
received full course of Hepatitis B vaccine and were knowledgeable about at
least one pathogen transmitted through unsafe injection practices.

Injection safety management policy and waste disposal guideline was not
available for viewing in any of the facilities. The office staff who
disposed the bio-medical wastes did so without taking any safety measures.
Moreover, none of these staff had received any formal training in waste
management.

CONCLUSIONS: Certain safe injection practices were noticed in the studied
health care facilities but there remain a number of grey areas where unsafe
practices still persists placing patient and health workers at risk of
associated hazards.

Training concentrating on injection safety, guidelines to dispose
biomedical waste and monitoring of the activity is needed.

Free full text http://www.biomedcentral.com/1472-698X/13/3/abstract
http://www.biomedcentral.com/content/pdf/1472-698X-13-3.pdf
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Fungal Infections Associated with Contaminated
Methylprednisolone Injections – Preliminary Report
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/23252499

Free full Text http://www.nejm.org/doi/full/10.1056/NEJMoa1213978

N Engl J Med. 2012 Dec 19.

Fungal Infections Associated with Contaminated Methylprednisolone
Injections – Preliminary Report.

Smith RM, Schaefer MK, Kainer MA, Wise M, Finks J, Duwve J, Fontaine E, Chu
A, Carothers B, Reilly A, Fiedler J, Wiese AD, Feaster C, Gibson L, Griese
S, Purfield A, Cleveland AA, Benedict K, Harris JR, Brandt ME, Blau D,
Jernigan J, Weber JT, Park BJ; the Multistate Fungal Infection Outbreak
Response Team.

From the Epidemic Intelligence Service, Scientific Education and
Professional Development Program Office (R.M.S., S.G., A.P.), Division of
Foodborne, Waterborne, and Environmental Diseases (R.M.S., A.P., A.A.C.,
K.B., J.R.H., M.E.B., B.J.P.), Division of Healthcare Quality Promotion
(M.K.S., M.W., J.J., J.T.W.), and Division of High-Consequence Pathogens
and Pathology (D.B.), Centers for Disease Control and Prevention, Atlanta;
the Tennessee Department of Health, Nashville (M.A.K., A.D.W.); the
Michigan Department of Community Health, Bureau of Epidemiology, Lansing
(J. Finks, J. Fielder); the Indiana State Department of Health,
Indianapolis (J.D., C.F.); the Virginia Department of Health, Richmond
(E.F., L.G.); the Maryland Department of Health and Mental Hygiene,
Baltimore (A.C.); the New Jersey Department of Health, Trenton (B.C.); the
Florida Department of Health, Tallahassee (A.R.); and the North Carolina
Division of Public Health, Raleigh (S.G.).

Background Fungal infections are rare complications of injections for
treatment of chronic pain. In September 2012, we initiated an investigation
into fungal infections associated with injections of preservative-free
methylprednisolone acetate that was purchased from a single compounding
pharmacy.

Methods Three lots of methylprednisolone acetate were recalled by the
pharmacy; examination of unopened vials later revealed fungus. Notification
of all persons potentially exposed to implicated methylprednisolone acetate
was conducted by federal, state, and local public health officials and by
staff at clinical facilities that administered the drug. We collected
clinical data on standardized case- report forms, and we tested for the
presence of fungi in isolates and specimens by examining cultures and
performing polymerase-chain-reaction assays and histopathological and
immunohistochemical testing.

Results As of October 19, 2012, more than 99% of 13,534 potentially exposed
persons had been contacted. As of December 10, there were 590 reported
cases of infection in 19 states, with 37 deaths (6%). As of November 26,
laboratory evidence of Exserohilum rostratum was present in specimens from
100 case patients (17%). Additional data were available for 386 case
patients (65%); 300 of these patients (78%) had meningitis. Case patients
had received a median of 1 injection (range, 1 to 6) of implicated
methylprednisolone acetate. The median age of the patients was 64 years
(range, 16 to 92), and the median incubation period was 20 days (range, 0
to 120); 33 patients (9%) had a stroke.

Conclusions Analysis of preliminary data from a large multistate outbreak
of fungal infections showed substantial morbidity and mortality. The
infections were associated with injection of a contaminated glucocorticoid
medication from a single compounding pharmacy. Rapid public health actions
included prompt recall of the implicated product, notification of exposed
persons, and early outreach to clinicians.

Free full text http://www.nejm.org/doi/full/10.1056/NEJMoa1213978
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Social representations of needlestick injuries
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23258732

Rev Lat Am Enfermagem. 2012 Dec;20(6):1176-85.

Social representations of needlestick injuries.

[Article in English, Portuguese, Spanish]

Lubenow JA, Moura ME, Nunes BM, Figueiredo Mdo L, Sales LC.

Universidade Federal da Paraíba, Brazil.

OBJECTIVES: understand the Social Representations about needlestick
injuries elaborated by Nursing Technicians and analyze how these
representations influence their conducts.

METHOD: the data, obtained by interviews, were processed using ALCESTE
software and their analysis was based on Serge Moscovici’s Social
Representations Theory.

RESULTS: it was evidenced that, after the accident, these professionals
take care of the affected area. Then, they report the accident, motivated
by the fear of catching HIV and hepatitis. The different feelings
experienced are due to this fear and the way they were forwarded by the
institution, reflecting in the cause they attribute to their accident.

CONCLUSIONS: it was verified that knowledge about the accident as a whole
is very incipient in this professional group, demanding continuing
education and greater emphasis on this subject in professional training. It
is expected that this study draws public authorities and health
institutions’ attention to the problem and that it modifies Nursing
Technicians’ Social Representations about percutaneous exposure.

Free full text via link at http://www.ncbi.nlm.nih.gov/pubmed/23258732
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Chronic hepatitis C virus (HCV) disease burden and cost in the
United States
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23280550

Hepatology. 2012 Dec 22.

Chronic hepatitis C virus (HCV) disease burden and cost in the United
States.

Razavi H, El Khoury A, Elbasha E, Estes C, Pasini K, Poynard T, Kumar R.

Center for Disease Analysis, Louisville, Colorado, USA.
homie.razavi@c4da.com.

Background: Hepatitis C virus (HCV) infection is a leading cause of
cirrhosis, hepatocellular carcinoma, and liver transplantation. A better
understanding of HCV disease progression and the associate cost can help
the medical community manage HCV and develop treatment strategies in light
of the emergence of several potent anti-HCV therapies.

Methods: A system dynamic model with 36 cohorts was used to provide maximum
flexibility and improved forecasting.

Results: New infections incidence of 16,020 (95% confidence interval of
13,510-19,510) was estimated in 2010. HCV viremic prevalence peaked in 1994
at 3.3 (2.8-4.0) million, but it is expected to decline by two thirds by
2030. The prevalence of more advanced liver disease, however, is expected
to increase, as well as the total cost associated with chronic HCV
infection. Today, the total cost is estimated at $6.5 ($4.3-$8.4) billion
and it will peak in 2024 at $9.1 ($6.4-$13.3) billion. The lifetime cost of
an individual infected with HCV in 2011 was estimated at $64,490. However,
this cost is significantly higher among individuals with a longer life
expectancy.

Conclusions: This analysis demonstrated that US HCV prevalence is in
decline due to lower incidence of infections. However, the prevalence of
advanced liver disease will continue to increase as well as the
corresponding healthcare costs.

Lifetime healthcare costs for an HCV infected person are significantly
higher than for non-infected persons. In addition, it is possible to
substantially reduce HCV infection through active management.

Copyright © 2012 American Association for the Study of Liver Diseases.

http://www.ncbi.nlm.nih.gov/pubmed/23280550
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Antiviral agents and hepatitis C
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23252194

N Y State Dent J. 2012 Jun-Jul;78(4):42-5.

Antiviral agents and hepatitis C.

Archer-Festa M, Nilsen-Kupsch S.

Marcher@citytech.cuny.edu

Hepatitis C is the leading cause of chronic hepatitis, cirrhosis, liver
cancer and liver transplantation. In 70% to 80% of the people infected, the
virus creates a chronic carrier state and the patient will be clinically
asymptomatic or have mild symptoms.

Two new direct-acting antiviral agents, boceprevir and telaprivir, both
protease inhibitors, have been approved by the FDA for treatment of
Hepatitis C genotype 1.

The current hepatitis C post-exposure protocol is that no immediate post-
exposure therapy is advised, but the dental healthcare worker should be
tested periodically and offered antiviral therapy if a chronic carrier
state exists.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Validation of the efficacy of a solar-thermal powered
autoclave system for off-grid medical instrument wet sterilization
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/22848098

Am J Trop Med Hyg. 2012 Oct;87(4):602-7.

Validation of the efficacy of a solar-thermal powered autoclave system for
off-grid medical instrument wet sterilization.

Kaseman T, Boubour J, Schuler DA.

Brown School of Engineering, Rice University, Houston, TX 77005, USA.
tremayne.kaseman@gmail.com

This work describes the efficacy of a solar-thermal powered autoclave used
for the wet sterilization of medical instruments in off-grid settings where
electrical power is not readily available.

Twenty-seven trials of the solar-thermal powered system were run using an
unmodified non-electric autoclave loaded with a simulated bundle of medical
instruments and biological test agents.

Results showed that in 100% of the trials the autoclave achieved
temperatures in excess of 121°C for 30 minutes, indicator tape displayed
visible reactions to steam sterilization, and biological tests showed that
microbial agents had been eliminated, in compliance with the Centers for
Disease Control and Prevention requirements for efficacious wet
sterilization.
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Local Anesthetics Injection Therapy for Musculoskeletal
Disorders: A Systematic Review and Meta-Analysis
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23247004

Clin J Pain. 2012 Dec 14.

Local Anesthetics Injection Therapy for Musculoskeletal Disorders: A
Systematic Review and Meta-Analysis.

Mohammer D, Mayer B, Joos S.

*Division of General Practice/Family Medicine, University Hospital of
Tübingen, Österbergstraße, Tübingen §Department of General Practice and
Health Services Research †Competence Centre General Practice Baden-
Württemberg, University Hospital Heidelberg, Voßstraße, Heidelberg
‡Institute of Epidemiology and Medical Biometry, University of Ulm,
Schwabstraße, Ulm, Germany.

OBJECTIVES:: Therapeutic injections with local anesthetics (TLA) are
widespread and are used for various symptoms of the musculoskeletal system.
The aim of the present project was to evaluate the efficacy and safety of
TLA in the treatment of musculoskeletal disorders.

METHODS:: Systematic literature search for controlled clinical trials
(Medline, Cochrane, CAMbase, hand search of references) without language
limitation; independent screening of the search results (n=3200 hits),
abstract reading, and full-text analysis by 2 reviewers. Two authors
independently extracted the data and assessed study quality. Meta-analysis
was calculated for studies using a continuous scale for pain assessment.

RESULTS:: Twenty- four controlled trials were included in this review. In
almost all studies no primary outcome measure was defined and the overall
study quality was low. The qualitative data analysis revealed no clear
trend for or against TLA. The meta-analysis of 12 studies showed no
significant difference in pain reduction for TLA compared with control
treatments consisting of saline injections or other substances, oral
analgesics, or nonpharmacological interventions (standardized mean
difference -0.31, 95% confidence interval, -0.75 to 0.14). Minor adverse
side effects were reported in 7 studies in both the TLA and the control
groups with no trend for one of the groups to be safer.

DISCUSSION:: Despite the widespread use of TLA for musculoskeletal
disorders in daily practice, available data are sparse and of low quality
and, therefore, do not allow a final recommendation. High-quality studies
are needed to close the gap between common practice and research.
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Review article: Improving drug safety for patients undergoing
anesthesia and surgery
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23264011

Can J Anaesth. 2012 Dec 22.

Review article: Improving drug safety for patients undergoing anesthesia
and surgery.

Orser BA, Hyland S, U D, Sheppard I, Wilson CR.

Department of Anesthesia, Sunnybrook Health Science Centre, University of
Toronto, Toronto, ON, Canada, beverley.orser@utoronto.ca.

PURPOSE: This article presents a summary of recent advances, including
tools and interventions, that are designed to improve drug safety for
patients in critical care settings, particularly those undergoing
anesthesia and surgery.

PRINCIPAL FINDINGS: Medication error remains a leading cause of adverse
events among patients undergoing anesthesia.

Misidentification of ampoules, vials, and syringes is a common source of
error. Systems are now being engineered to reduce the likelihood of
medication misidentification through approaches such as revision of
standards for labelling of drug ampoules and vials and the development of
bar code systems that allow “double checking” or drug verification in the
operating room.

Also, efforts are being made to improve medication reconciliation, a
process for accurately communicating a patient’s medication information
during transitions from one healthcare setting to another.

Finally, the opportunity exists for anesthesiologists to increase awareness
about the rising problem of opioid addiction in patients for whom typical
doses are initially prescribed for appropriate indications such as
postoperative pain.

CONCLUSIONS: There is a need to improve drug delivery systems in complex
critical care environments, particularly the operating room.
Anesthesiologists must continue to play a leading role in promoting drug
safety in these environments.
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Injection Anthrax-a New Outbreak in Heroin Users
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23267409

Dtsch Arztebl Int. 2012 Dec;109(49):843-8.

Injection Anthrax-a New Outbreak in Heroin Users.

Grunow R, Verbeek L, Jacob D, Holzmann T, Birkenfeld G, Wiens D, von
Eichel-Streiber L, Grass G, Reischl U.

Robert Koch Institute (RKI), Berlin.

BACKGROUND: Injection anthrax is a rare disease that affects heroin users
and is caused by Bacillus anthracis. In 2012, there were four cases in
Germany, one of which was fatal, as well as a small number of cases in
other European countries, including Denmark, France, and the United
Kingdom. Three cases among drug users occurred in Germany in 2009/2010, in
the setting of a larger outbreak centered on Scotland, where there were 119
cases.

CASE PRESENTATION AND CLINICAL COURSE: We present three cases of injection
anthrax, two of which were treated in Regensburg and one in Berlin. One
patient died of multi-organ-system failure on the day of admission to the
hospital. The others were treated with antibiotics, one of them also with
surgical wound debridement. The laboratory diagnosis of injection anthrax
is based on the demonstration of the pathogen, generally by culture and/or
by polymerase chain reaction, in material removed directly from the
patient’s wound. The diagnosis is additionally supported by the detection
of specific antibodies.

CONCLUSION: Injection anthrax may be viewed either as an independent
disease entity or as a special type of cutaneous anthrax with massive
edema, necrotizing fasciitis in many cases, and about 30% mortality. It has
appeared in recent years among heroin users in various European countries.
In patients with suggestive clinical presentation and a history of heroin
use, anthrax infection must be suspected early, so that the appropriate
diagnostic tests can be performed without delay. Timely treatment can be
life-saving. It is therefore important that physicians-and the individuals
at risk-should be well-informed about this disease.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528063/
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Hepatitis B Infection among high risk population: a
seroepidemiological survey in Southwest of Iran
__________________________________________________________________
BMC Infect Dis. 2012 Dec 27;12(1):378.

Hepatitis B Infection among high risk population: a seroepidemiological
survey in Southwest of Iran.

Khosravani A, Sarkari B, Negahban H, Sharifi A, Tori MA, Eilami O.

BACKGROUND: Hepatitis B virus (HBV) infection remains a major global health
problem. This study aimed to assess the prevalence and risk behaviors for
HBV infection among high risk groups in Kohgiloyeh and Boyerahmad province,
in Southwest of Iran.

METHODS: Blood samples were collected from 2009 subjects, between 2009 and
2010 in Kohgiloyeh and Boyerahmad province, in southwest of Iran. Recruited
subjects were the high risk groups for HBV infection, including inmates,
injecting drug users, health care workers, patients on maintenance
haemodialysis, hemophilic patients and patients with a history of blood
transfusion. Their serum samples were tested for the presence of antibodies
to hepatitis B core antigen (HBC IgM, IgG) by enzyme-linked immunosorbent
assay (ELISA). Seropositive specimens were tested for HBsAg. Demographic
features of participants were recorded during sample collecting.

RESULTS: HBsAg was detected in 24 of the 2009 subjects, giving an overall
prevalence of 1.2%. All HBsAg positive cases were males. The prevalence of
HBsAg among injection drug users was 3.2%. Significant correlation was
found between HBV infection and drug abuse, level of education and place of
residence (p<0.05), while no significant correlation was found between HBV
infection and previous history of blood transfusion, unprotected sexual
behavior, and thalassemia.

CONCLUSION: Based on the findings of this study, incarceration and drug
abuse are the most important risk factors for acquiring HBV infection in
this region. Modifying behavior, improving the individual education and
expanding the HBV vaccination coverage may reduce the rate of infection in
the region.

Free full text http://www.biomedcentral.com/1471-2334/12/378/abstract
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Global geographical overlap of aflatoxin and hepatitis C:
controlling risk factors for liver cancer worldwide
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23281740

Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2013 Jan 2.

Global geographical overlap of aflatoxin and hepatitis C: controlling risk
factors for liver cancer worldwide.

Palliyaguru DL, Wu F.

a Department of Environmental and Occupational Health , University of
Pittsburgh, 100 Technology Drive , Pittsburgh , PA 15219 , USA.

About 85% of hepatocellular carcinoma (HCC, liver cancer) cases occur in
low-income countries, where the risk factors of dietary aflatoxin exposure
and chronic hepatitis B and C (HBV and HCV) viral infection are common.
While studies have shown synergism between aflatoxin and HBV in causing
HCC, much less is known about whether aflatoxin and HCV synergise
similarly.

From an exposure perspective, it was examined whether there is a
geographical overlap in populations worldwide exposed to high dietary
aflatoxin levels and with high HCV prevalence.

While HCV is one of the most important risk factors for HCC in high-income
nations (where aflatoxin exposure is low), it is found that HCV prevalence
is much higher in Africa and Asia, where aflatoxin exposure is also high.
However, within a given world region, there are some inconsistencies
regarding exposure and cancer risk.

Therefore, there is a need to control risk factors such as aflatoxin and
hepatitis viruses in a cost-effective manner to prevent global HCC, while
continuing to evaluate biological mechanisms by which these risk factors
interact to increase HCC risk.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Oral and injectable contraception use and risk of HIV
acquisition among women in the methods for improving reproductive
health in Africa (MIRA) study
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23262502

AIDS. 2012 Dec 19.

Oral and injectable contraception use and risk of HIV acquisition among
women in the methods for improving reproductive health in Africa (MIRA)
study.

McCoy SI, Zheng W, Montgomery E, Blanchard K, van Der Straten A, de Bryn G,
Padian NS.

aUniversity of California, Berkeley, California, USA bWomen’s Global Health
Imperative, RTI International, San Francisco, California, USA cIbis
Reproductive Health, Cambridge, Massachusetts, USA dUniversity of
California San Francisco, San Francisco, California, USA eUniversity of the
Witwatersrand, Johannesburg, South Africa fU.S. Department of State,
Washington, D.C., USA.

OBJECTIVE:: Evaluate the effect of oral and injectable hormonal
contraception (HC) on the risk of HIV acquisition among women in South
Africa and Zimbabwe.

DESIGN:: Secondary data analysis of 4913 sexually active women aged 18-49
years followed for up to 24 months in the MIRA phase III effectiveness
trial of the diaphragm and lubricant gel for HIV prevention.

METHODS:: Participants were interviewed quarterly about contraception and
sexual behavior and were tested for pregnancy, HIV, and other sexually
transmitted infections. We used a Cox proportional hazards marginal
structural model, weighted by the inverse probability of HC use, to compare
the risk of HIV acquisition among non-pregnant women reporting use of
combined oral contraceptive pills (COC), progestin-only pills (POP), and/or
injectable HC to women not using these methods.

RESULTS:: During the study, 283 participants seroconverted. Use of oral
contraceptives (POP or COC) was not associated with HIV risk (adjusted
hazard ratio (HRa)?=?0.86, 95% confidence interval (CI): 0.32, 1.78).
Injectable HC was associated with a small non-significant risk of HIV
infection (HRa?=?1.34, 95% CI: 0.75, 2.37). The effect of injectable HC was
similar in the unweighted site-adjusted only (HRa?=?1.32, 95% CI: 1.00,
1.74) and baseline factor adjusted models (HRa?=?1.27, 95% CI: 0.94, 1.72).

CONCLUSIONS:: In this study, oral contraceptives were not associated with
HIV acquisition. There is substantial uncertainty in the effect of
injectable HC on HIV risk. These findings underscore the importance of dual
protection with condoms and the need for diverse contraceptive options for
women at risk of HIV infection.
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Multidrug-Resistant Acinetobacter baumannii Infection
Following Para-Articular Steroid Injection in the Knee – A Case Report
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23267456

Bull NYU Hosp Jt Dis. 2012;70(4):276-8.

Multidrug-Resistant Acinetobacter baumannii Infection Following Para-
Articular Steroid Injection in the Knee – A Case Report.

Artiaco S, Cicero G, Bellomo F, Bianchi P.

Acinetobacter baumanniiis an emerging gram-negative nosocomial pathogen
that rarely causes infections in orthopaedic patients.

We report a case of imipenem-resistant Acinetobacter baumanniiparaarticular
infection of the knee occurring in a healthy patient following one
ambulatory ste-roid injection for the treatment of quadriceps tendinopathy.

The infection was reduced by early surgical debridement of infected
tissues, abscess drainage, and prolonged antibiotic therapy with colistin.

To our knowledge, this is the first case in the literature reporting such
an infection following single steroid injection in orthopaedic patients.
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Necrotizing fasciitis after spinal anesthesia
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23240648

Acta Anaesthesiol Scand. 2012 Dec 14.

Necrotizing fasciitis after spinal anesthesia.

Kundra S, Singh RM, Grewal A, Gupta V, Chaudhary AK.

Department of Anesthesia, Dayanand Medical College and Hospital, Ludhiana,
India.

Regional anesthesia is the preferred technique for Cesarean delivery.
Strict aseptic precautions should be taken; otherwise, infectious
complications including abscess formation, meningitis and necrotizing
fasciitis may result.

We report a case of a 26-year-old post-partum female who presented with
necrosis of the skin of back following spinal anesthesia, which was
administered for Cesarean delivery 5 days prior at a private nursing home.
On presentation, she was drowsy, appeared dehydrated and febrile.
Examination of her back revealed necrosis of skin extending from just below
the scapula to the gluteal region. Debridement of skin over the back was
performed, and intravenous antibiotics started. After three debridements
following which skin grafting was performed, she made complete recovery.

Infectious complications following regional anesthesia are rare, and most
of the literature focuses on colonization of epidural catheters or epidural
abscess. There is no report of necrotizing fasciitis following spinal
anesthesia so far.

Sources of infection that are suspected in our case include: local
anesthetic solution used for subcutaneous infiltration, nonadherence to
aseptic precautions, skin flora of patient, endogenous source and
nasopharyngeal flora of anesthesiologist.

We considered each possibility, and the most likely cause in our case
appears to be infection from an ** already-used vial of a local anesthetic
agent. Local anesthetics have bacteriostatic properties, but infection may
still be transmitted through contaminated solutions.

The present case highlights the importance of maintaining strict aseptic
precautions, avoiding reusing multidose vials and early recognition of this
complication as timely intervention can be lifesaving.

© 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta
Anaesthesiologica Scandinavica Foundation.
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Fatal Nosocomial Spread of Crimean-Congo Hemorrhagic Fever
with Very Short Incubation Period
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23269658

Am J Trop Med Hyg. 2012 Dec 26.

Fatal Nosocomial Spread of Crimean-Congo Hemorrhagic Fever with Very Short
Incubation Period.

Naderi H, Sheybani F, Bojdi A, Khosravi N, Mostafavi I.

Department of Infectious Diseases, Faculty of Medicine, Mashhad University
of Medical Sciences, Mashhad, Iran; Registered nurses, Imam Reza Hospital,
Mashhad, Iran.

Crimean-Congo hemorrhagic fever is a tick-borne viral zoonosis with the
potential of human-to-human transmission with case fatality rates from 3%
to 50%. The incubation period depends on host, route of infection, and
viral dose.

Herein, we report a nosocomial spread of the disease in a hospital at
Mashhad, northeastern Iran, with a very short incubation period for one of
the secondary cases. The patient was a medical student who had a negligible
contact with a Crimean-Congo hemorrhagic fever patient during his admission
to the hospital.

The time interval between the contact and the onset of symptoms was merely
20 hours. Unfortunately, he died within 1 week of exposure.
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Chemotherapeutically Induced Cutaneous Tuberculosis after BCG
Injection in a Patient with Pelvic Osteosarcoma
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23240721

Surg Infect (Larchmt). 2012 Dec;13(6):406-8.

Chemotherapeutically Induced Cutaneous Tuberculosis after BCG Injection in
a Patient with Pelvic Osteosarcoma.

Zoccali G, Cota C, Marolda G, Ferraresi V, Giuliani M, Zoccali C.

1 Plastic and Reconstructive Section, Department of Health Sciences,
University of L’Aquila , L’Aquila, Italy .

Background: Tuberculosis (TB) is a serious infection afflicting a multitude
of people worldwide. Recently, its prevalence has increased. The incidence
of skin involvement generally is low. Bacillus Calmette-Guérin (BCG) is a
live attenuated strain of Mycobacterium bovis that typically is
administered as a vaccine to stimulate the immune system when treating some
early neoplasms or to guard against tuberculosis.

Methods: Case report and literature review. Case Report: The authors
describe a young man with osteosarcoma of the left hemipelvis who received
intradermal BCG injection for immune stimulation prior to surgery. In the
course of neoadjuvant chemotherapy, he developed cutaneous tuberculosis.

Conclusion: It is our opinion that BCG injection should be avoided in all
patients requiring surgery, especially in oncologic patients, where the
immunodeficiency brought on by chemotherapy predisposes to active
opportunistic infection.
__________________________________________________________________
________________________________*_________________________________

17. Abstract: An unexpected needlestick injury
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23265043

Middle East J Anesthesiol. 2012 Jun;21(5):751-2.

An unexpected needlestick injury.

Blasius KR, Neustein SM.

Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY,
USA.

Needle stick injuries occur at a significant rate. According to the
National Institute for Occupational Safety and Health, there are
approximately 600,000 to 800,000 needlestick and other percutaneous
injuries every year among healthcare workers.

Not only do the needlestick injuries put workers at risk for blood borne
pathogens, but they cause a significant psychological and emotional burden
for those involved.

This is a report of an anesthesia resident who sustained a needlestick
injury through the sterile drapes by a surgical resident.
__________________________________________________________________
________________________________*_________________________________

18. No Abstract: Acute hepatitis B virus (HBV) infection in a repeat blood
donor during anti-HBV vaccination
__________________________________________________________________
Blood Transfus. 2012 Jul;10(3):384-6.

Acute hepatitis B virus (HBV) infection in a repeat blood donor during
anti-HBV vaccination.

Gessoni G, Barin P, Salvadego MM, Favarato M, Valverde S, Marchiori G.

Department of Transfusion Medicine, Venetian Area, Venice, Italy.
ggessoni@asl14chioggia.veneto.it

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417739/
__________________________________________________________________
________________________________*_________________________________

19. No Abstract: No excuse for unsafe injection practice
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23265655

AORN J. 2013 Jan;97(1):132-5.

No excuse for unsafe injection practices.

McCrea MK.
__________________________________________________________________
________________________________*_________________________________

20. No Abstract: Talking dirty on healthcare waste. Interview by Claire
Read
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23155872

Health Serv J. 2012 Sep 13;122(6320):16-7.

Talking dirty on healthcare waste. Interview by Claire Read.

Cohen G.
__________________________________________________________________
________________________________*_________________________________

21. No Abstract: Unsafe injection practices plague US outpatient
facilities, harm patients
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23268495

JAMA. 2012 Dec 26;308(24):2551-2.

Unsafe injection practices plague US outpatient facilities, harm patients.

Kuehn BM.
__________________________________________________________________
________________________________*_________________________________

22. No Abstract: Penalties don’t show effect. Study: infection rates not
altered by nonpayment
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23163085

Mod Healthc. 2012 Oct 15;42(42):8-9.

Penalties don’t show effect. Study: infection rates not altered by
nonpayment.

McKinney M.
__________________________________________________________________
________________________________*_________________________________

23. No Abstract: Reducing nurse burnout might reduce hospital-acquired
infections
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23099574

Am J Nurs. 2012 Nov;112(11):15.

Reducing nurse burnout might reduce hospital-acquired infections.

Potera C.
__________________________________________________________________
________________________________*_________________________________

24. Harvard School of Public Health’s new online course, “Health in
Numbers: Quantitative Methods in Clinical and Public Health Research”
__________________________________________________________________
HSPH to Launch Second Public Health Course on edX

January 2, 2013

Harvard School of Public Health’s new online course, “Health in Numbers:
Quantitative Methods in Clinical and Public Health Research,” an
introduction to biostatistics and epidemiology, has drawn 53,857 students
from all over the world.

The three-month course, which began in October 2012, was one of the first
two courses offered by Harvard through edX, the online education platform
launched last May by Harvard University and the Massachusetts Institute of
Technology. Since May, four other institutions—the University of California
Berkeley, the University of Texas System, Wellesley College, and Georgetown
University—have joined Harvard and MIT in edX.

New HarvardX courses being offered in spring 2013 include HSPH’s second
public health course, Human Health and Global Environmental Change, co-
taught by Aaron Bernstein, associate director of the Center for Health and
the Global Environment at HSPH, and John Spengler, director of the Center
and Akira Yamaguchi Professor of Environmental Health and Human Habitation
in the Department of Environmental Health. In addition, HarvardX will offer
courses on Greek literature, justice, computer science.

Visit the main edX site http://www.edx.org/
__________________________________________________________________
________________________________*_________________________________

25. News

– USA: Doc Infects Patients with Hep B in Surgery
– Naloxone reverses overdoses without hefty price tag
– India: Hepatitis outbreak is traced to contaminated needles and barber
shop razors, study shows
– USA: Dirty medical needles infect thousands in U.S. – Outbreaks show not
all clinicians follow rules

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
USA: Doc Infects Patients with Hep B in Surgery
Rachael Rettner, NBCNews.com (03.01.13)

According to a report by researchers at the University of Virginia Health
System, a surgeon with hepatitis B infection passed the virus to at least
two patients during surgery. The report states that the doctor learned that
he had hepatitis B infection when he received a routine test for blood-
borne diseases after he stuck himself with a needle. He had emigrated from
a country with a high prevalence of hepatitis B, and it is believed he had
the virus for a while without experiencing symptoms.

The Centers for Disease Control and Prevention and the hospital where the
surgeon practiced began an investigation to find and test all the patients
the surgeon had treated for the nine months he had worked at the hospital.
Of 232 patients tested, two were found to be infected with a strain of
hepatitis B virus that was genetically identical to that of the surgeon.
The patients were treated with drugs. Six additional patients had been
infected with hepatitis B. These patients no longer had the virus in their
blood; therefore researchers were unable to determine if it had been
transmitted by the surgeon. Since the patients had no known risk factors
for developing hepatitis B, it is considered possible that they also got
the virus from the surgeon.

Dr. Costi Sifri, an infectious disease researcher and hospital
epidemiologist at the University of Virginia Health System, stated that it
is not clear how the surgeon passed the virus to the patients. The surgeon
said he wore two sets of gloves during surgery. The researchers suggest
that tiny tears in the gloves that occurred during surgery may have caused
the virus to pass to the patients. Sifri noted that the surgeon would have
had to have a cut on his hands as well.

The report, “Transmission of Hepatitis B Virus from an Orthopedic Surgeon
with a High Viral Load,” was published in the journal Clinical Infectious
Diseases (2013; 56(2): 218-224).
__________________________________________________________________
__________________________________________________________________
Naloxone reverses overdoses without hefty price tag
By Andrew M. Seaman, Reuters (31.12.12)

NEW YORK (Reuters Health) – Distributing a drug that reverses drug
overdoses in heroin users would save lives and be cost-effective, according
to a new analysis.

U.S. researchers, who published their findings in the Annals of Internal
Medicine on Monday, calculated that one death may be prevented for every
164 naloxone injection kits they distribute to heroin users.

That, the researchers say, works out to be a few hundred dollars for every
year of healthy life gained.

“The great news here is these overdose deaths can be prevented, it’s cost
effective to do so, and may even be cost saving,” said Dr. Phillip Coffin,
the study’s lead author from the San Francisco Department of Public Health.

Naloxone is a drug that stops opioids such as heroin from reaching
receptors in the brain, which may reverse an overdose. The drug is
currently only approved by the U.S. Food and Drug Administration (FDA) to
be injected into a person, but there are promising trials for an inhaled
version of it.

The general idea, according to Coffin, is that giving heroin or opioid
users naloxone injection kits gives them the chance to reverse another
person’s overdose.

“Typically when someone has an overdose, they’re unconscious and they fall
asleep quite quickly… So the idea that you would reverse your own overdose
is not practical,” said Dr. Wilson Compton from the National Institute on
Drug Abuse (NIDA) in Bethesda, Maryland.

Currently, an estimated 213,000 people in the U.S. use heroin each year.
Over that population’s lifetime, more than one in 10 users may die of an
overdose.

Compton, who co-authored an editorial accompanying the study, said naloxone
has few side effects, except that high doses may send someone into
withdrawal.

For the new study, Coffin and a colleague created a computer simulation
that predicted what would happen if they distributed naloxone injection
kits to 20 percent of U.S. heroin users, and compared the resulting deaths
and costs to a simulation of users without kits.

In that scenario, the model found that in a population of 200,000 heroin
users 6.5 percent of deaths that would have occurred could be prevented
with distribution of the kits.

The simulation also found that almost 2 percent of heroin users eventually
quit when the kits were distributed. That, however, also led to about a 1
percent increase in overdoses, because high-risk users were living longer.

The researchers calculated that the kits would cost about $400 for every
year of healthy life gained.

That’s well below the $50,000 per healthy year of life gained threshold
that policymakers typically think is worth paying for, the authors note.

Coffin told Reuters Health that distributing the kits may end up saving
money because it might prevent aggressive attempts to revive a person who
overdoses, which can be costly.

“This study helps us understand that providing naloxone is not only
effective, but can also be a very cost effective approach to preventing
overdose deaths in heroin addicts,” Compton said.

Coffin added that there may be additional benefits from distributing the
kits based on real-world experiences in places such as New York City,
Chicago, San Francisco and Scotland, where overdose deaths fell between 37
percent and 90 percent with naloxone distribution programs.

“It may be influencing behavior,” said Coffin. “That rides on the
assumption that talking to people about overdoes and providing them with a
tool to prevent overdoses makes them a little bit more careful.”

But Compton said these kits may only be part of an approach to curb the
growing epidemic of opioid overdose deaths.

“Providing this intervention to address the overdose epidemic is one piece
of it, but we think it must be part of a larger approach to prevent the
abuse and misuse of prescription drugs,” he said.

According to Compton and his editorial co-authors, which include NIDA
Director Dr. Nora Volkow and representatives from the FDA, total U.S. drug
overdose deaths in 2010 reached almost 40,000 and outpaced deaths from
motor vehicle accidents.

Overall, Coffin told Reuters Health he thinks the results are “fantastic,”
because it shows “it’s a really excellent benefit for a modest amount of
dollars.”

SOURCE: http://bit.ly/Ms1ZbQ Annals of Internal Medicine, online December
31, 2012.
__________________________________________________________________
__________________________________________________________________
BMJ 2012;345 28 December 2012

India: Hepatitis outbreak is traced to contaminated needles and barber shop
razors, study shows

Meera Kay

A village in the Ernakulam district in Kerala, India, has experienced a
serious outbreak of hepatitis B virus, which has been traced to injections
with contaminated needles and transmission in barber shops.

The origins of the outbreak were discovered after the local government
commissioned a private firm, the Manipal Centre for Virus Research (MCVR),
to carry out a disease mapping and risk factor study.

The centre’s head, G Arunkumar, said that the hepatitis B virus infection
was possibly introduced into the population before 2011, …

Access to the full text of this article requires a subscription or payment.
http://dx.doi.org/10.1136/bmj.e8700
USA: Dirty Needles: How Some Clinics Endanger Patients
by Candy Sagon, AARP News (blog) (28.12.12)

Since 2001, 150,000 patients have been given unsafe shots that in many
cases resulted in life-threatening diseases, thanks to non-sterile needles
and other unsafe injection practices, according to an investigation by USA
Today.

Many of these bad shots took place at smaller outpatient clinics and
doctor’s offices that are not subject to inspection by the U.S. Centers for
Medicare & Medicaid Services. Two-thirds of these risky injections were
given in the past four years.

Although the majority of injections are administered safely, a significant
number — some studies estimate 5 percent — don’t follow safety standards,
USA Today reported. One University of Pennsylvania infectious disease
specialist called it “a hidden epidemic” because there’s so little
oversight of these smaller facilities. Michael Bell, the associate director
for infection control at the Centers for Disease Control and Prevention
(CDC), called it “a huge issue [that] really comes down to a matter of
greed, ignorance or laziness.”

The newspaper, which examined CDC records of injection-related disease
outbreaks, found that “at least 80 percent occur in doctors’ offices and
outpatient clinics, from pain management and endoscopy centers to
alternative medicine operations that provide services such as vitamin
injections.”

Many of these smaller facilities are not inspected or certified by
Medicare, which oversees large hospitals and surgical centers that
participate in the federal insurance program for the elderly, poor and
disabled, reporter Peter Eisler wrote. Instead, they fall under the purview
of state health boards that generally lack the authority and resources to
investigate such places.

By not following longstanding CDC guidelines for safe use of sterile
injections, USA Today found that errors led to at least 49 disease
outbreaks and victims infected with potentially life-threatening bacterial
infections, such as MRSA, and sometimes fatal viruses, such as hepatitis.
In many cases, doctors or nurses were reusing syringes, or injecting
multiple patients from a single-use vial, often to save money.

The newspaper profiled a 57-year-old Nebraska woman who contracted
hepatitis C while being treated for cancer at an oncology clinic, and a 64-
year-old Nevada man who was infected with hepatitis C at an endoscopy
clinic that reused syringes. That clinic endangered tens of thousands of
patients in one of the country’s largest injection-related health scares,
investigators in 2008 discovered.

How can patients protect themselves? Here are a few suggestions:

Ask if a facility is certified by Medicare, which would indicate there’s
more oversight of their medical procedures.

Ask your health providers what infection control measures they follow.

Ask to watch the syringe being filled and make sure everything is securely
packaged before being opened to administer your medicine.

According to CDC safety guidelines, syringes and needles are meant to be
sterile and single-use. The syringe should be filled from a vial of
medicine with an intact seal that indicates it’s sterile and has not been
previously used.
__________________________________________________________________
__________________________________________________________________

http://tinyurl.com/ade7ljv

USA: Dirty medical needles infect thousands in U.S. – Outbreaks show not
all clinicians follow rules
Written by Peter Eisler, USA Today, USA (27.12.12)

[Photo Caption] ‘It’s a huge issue. It makes us crazy,’ says Michael Bell,
associate director for infection control at the Centers for Disease Control
and Prevention. Lesley Webster/Centers for Disease Control and Prevention

[Photo Caption] Health officials still face a quiet threat that was
supposed to die with the advent of the disposable syringe 150 years ago:
dirty needles. Lesley Webster/Centers for Disease Control and Prevention

States pass legislation on training

Several states have responded to injection-related disease outbreaks by
passing laws that require better training on injection-safety measures:

• North Carolina began requiring all health care facilities to have
designated staff trained in safe injection practices in 2009, after seven
hepatitis cases were tied to unsafe injections at a cardiology clinic where
as many as 1,200 patients were put at risk.

• New York passed a law in 2008 requiring the health department to issue
new injection safety rules for all health care facilities after several
hepatitis outbreaks were linked to bad injections, including the infection
of 19 patients at an endoscopy clinic.

• Nevada in 2011 began requiring all health care professionals to certify
their knowledge of safe injection practices as a condition of licensure
after a huge hepatitis outbreak.

Victims push for criminal penalties

After a dermatologist in Grand Rapids, Mich., was found in 2008 to have put
13,000 patients at risk of hepatitis and other illnesses by reusing
syringes, victims raised concerns because no criminal penalties were
available for the practice. Lawmakers responded in 2010 with a law that
imposes felony penalties for health care providers who “knowingly
reuse/recycle a single-use device” for any sort of injection.

• The penalty: up to 10 years in prison, a fine of up to $50,000 — or both.

As drug-resistant superbugs and increasingly virulent viruses menace the
medical community, health officials still face a quiet threat that was
supposed to die with the advent of the disposable syringe 150 years ago:
dirty needles.

Since 2001, more than 150,000 patients nationwide have been victims of
unsafe injection practices, and two-thirds of those risky shots were
administered in just the past four years, according to data from the U.S.
Centers for Disease Control and Prevention. The errors led to at least 49
disease outbreaks, a USA Today examination shows.

Evelyn McKnight, 57, contracted hepatitis C a decade ago while being
treated for cancer at a Nebraska oncology clinic. The virus required six
months of debilitating drug treatment on top of her chemotherapy, and it
could re-emerge at any time.

“People think, ‘This can’t happen in the United States; this is a Third
World thing,’ ” said McKnight, who heads HONOReform, a foundation that
advocates safe injection practices. “Unfortunately, it happens on a regular
basis, and it affects a lot of people, families, communities.”

Without question, the overwhelming majority of the hundreds of millions of
injections administered annually in hospitals, nursing homes, clinics and
doctors offices are done safely and without incident. But a significant
percentage of clinicians — some studies suggest more than 5 percent — don’t
follow accepted safety standards.

That translates into a lot of bad shots.

“It’s a huge issue. It makes us crazy,” said Michael Bell, the CDC’s
associate director for infection control. “We’re trying to eliminate a
range of harms in health care — high-level, complex challenges — and we
look behind us and these basic, obvious, completely preventable problems
are still occurring. … It really comes down to a matter of greed, ignorance
or laziness.”

USA Today reviewed state and federal outbreak reports, regulatory records
and court documents to gauge the scope and effect of unsafe injection
practices. The newspaper also interviewed public health officials, doctors
and nurses — and victims. Key findings:

• The CDC’s official tally of 150,000 people who were affected by unsafe
injections likely represents a fraction of all cases. Although that figure
comprises all the patients who got bad shots — including those who weren’t
sickened — it’s based only on incidents that are reported, and many are
not. Symptoms from injection-related illnesses, such as hepatitis, can take
years to emerge, so many cases are not traced back to their true cause.

• Federal and state data show that unsafe injections are more common in
clinics, smaller outpatient facilities and long-term care centers than in
acute care hospitals. Some of the biggest illness outbreaks linked to reuse
of syringes or the injection of multiple patients from single-use vials
have occurred at stand-alone clinics, such as oncology and endoscopy
facilities, or outpatient surgical settings.

• Many clinics and other outpatient facilities with suspect injection
records operate in a regulatory gray area with little oversight. Concerns
about injection practices in those settings often are the purview of state
medical boards, which generally lack the regulatory authority or
investigative resources of health departments. Few states have passed laws
to address concerns about injection practices in such facilities.

Henry Chanin and his wife waited a lifetime to see the ruins of ancient
Greece, but when they finally got there in the summer of 2006, the ever-fit
headmaster of a private school couldn’t muster the energy to climb the
Acropolis of Athens. Days later, they cut short their trip and went home.

On the flight back, Chanin’s wife looked at him and gasped. “My God,” she
said, “you’re yellow.”

Chanin, 64, had felt increasingly lousy in the weeks after a routine
colonoscopy at the Endoscopy Center of Southern Nevada. Within 24 hours of
returning from Europe, he was diagnosed with hepatitis C.

Investigators concluded that the endoscopy center reused syringes to draw
anesthetic from vials that were used for multiple patients. In early 2008,
the state notified 50,000 patients who had visited the clinic over several
years that they should be tested for hepatitis and other ills. Warnings
also went to 13,000 patients from a sister clinic.

Chanin’s hepatitis is in remission, but he still suffers joint pain and
can’t handle strenuous activity — he has given up morning dog walks and
sometimes needs a golf cart to get around his school’s campus.

“I’m not cured, but the virus is inactive, so I’m not in danger of having
my liver eaten up,” he said. “I’m actually lucky — there are others whose
lives have been smashed, who went through the treatment, twice, and it
didn’t work. … They’re in need of a liver transplant; it’s not treatable.”

In all, the state identified 115 patients with hepatitis, but the official
toll is just nine — those whose infections were tied absolutely to the bad
injections through genetic testing. The other 106 cases are listed by the
state as “possibly linked.”

The endoscopy center and its sister clinic were closed in the wake of the
outbreak; many patients, including Chanin, won lawsuits seeking damages.

It’s hard to quantify the effect of unsafe injections.

Given the challenges in linking hepatitis and other ills to injections that
might have occurred years before a patient shows symptoms, there’s little
hope of pinning down the true number of victims.

“We think the outbreaks we’ve seen are the proverbial tip of the iceberg,”
said Joseph Perz, an epidemiologist who heads the CDC’s injection safety
program. “Unless there are two or three cases, a cluster of patients who
all have had the same health care exposure,” illnesses linked to bad
injections are “easy to miss.”

So public health experts are focusing more on the front end: figuring out
how many people are administering bad shots.

In an anonymous 2010 survey of 5,446 clinical personnel who administer
injections, 6 percent said they “sometimes or always” use single-use
medication vials to draw shots for more than one patient — a practice that
violates CDC infection safety protocols barring repeated shots from a
single-use vial once its sterile seal is broken.

In the same survey, published in the American Journal of Infection Control,
1 percent of respondents reported reusing syringes on multiple patients.

The big problem — drawing multiple doses of medication from single-use
vials — often stems from misunderstandings about infections and a desire
among clinicians to avoid wasting drugs, said Gina Pugliese, an infection
control specialist who led the survey for the Premier Safety Institute.

Often, a drug might come in vials no smaller than, say, 10 milliliters,
Pugliese said, but certain procedures require no more than 2 to 3
milliliters.

Some clinicians believe it is safe to draw multiple doses from such a vial,
either using the same syringe for the same patient, or using different
syringes for different patients, she adds. But both practices violate
infection control protocols.

The fact that 1 percent of clinicians re-use syringes, often after swapping
out the needle, is “more surprising,” Pugliese said, noting that the
practice, which some clinicians see as a way to save time or money, has
long been identified as an infection risk.

The pharmaceutical industry could help by manufacturing drugs in vial sizes
that better suit doctors’ requirements, Pugliese said. But the most
immediate need is better education of clinicians.

The physician-owned oncology clinic where Evelyn McKnight got hepatitis
typifies the sort of facility where injection problems are most common.

A USA Today analysis of CDC records on injection-related disease outbreaks
shows that at least 80 percent occur in doctors’ offices and outpatient
clinics, from pain management and endoscopy centers to alternative medicine
operations that provide services such as vitamin injections.

Many of those facilities are not subject to inspection by the U.S. Centers
for Medicare & Medicaid Services (CMS), which oversees hospitals and
surgical centers that participate in the federal insurance programs for the
elderly, poor and disabled. And they generally don’t seek the independent
accreditation obtained by larger health care facilities.

“The lack of oversight in nonhospital settings is a big gap in the
regulatory environment,” McKnight said. “I think the American public would
be surprised that pharmacies and restaurants, which have inspections of
their facilities, are more closely regulated than a lot of these clinics.”
__________________________________________________________________
________________________________*_________________________________
* 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
__________________________________________________________________
________________________________*_________________________________
All members of the SIGN Forum are invited to submit messages, comment on
any posting, or to use the forum to request technical information in
relation to injection safety.

The comments made in this forum are the sole responsibility of the writers
and does not in any way mean that they are endorsed by any of the
organizations and agencies to which the authors may belong.

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
safety.

* Subscribe or un-subscribe by email to: sign.moderator@gmail.com, or to
sign@who.int

The SIGNpost Website is http://SIGNpostOnline.info

The new website is a work in progress and will grow to provide an archive
of all SIGNposts, meeting reports, field reports, documents, images such as
photographs, posters, signs and symbols, and video.

We would like your help in building this archive. Please send your old
reports, studies, articles, photographs, tools, and resources for posting.

Email mailto:sign.moderator@gmail.com
__________________________________________________________________
________________________________*_________________________________

The SIGN Internet Forum was established at the initiative of the World
Health Organization’s Department of Essential Health Technologies. The
SIGN Forum is moderated by Allan Bass and is hosted on the University of
Queensland computer network. http://www.uq.edu.au
__________________________________________________________________

Comments are closed.