online canadian pharmacy pharmacy ratings phentermine no prescription

SIGNpost 00687


Post00687 Challenge + Abstracts + Course + News 27 February 2013

1. Halting Unsafe Injection Practices Still a Challenge
2. Abstract: Psychiatric consequences of needlestick injury
3. Abstract: Ascertaining the 2004-2006 HIV type 1 CRF07_BC outbreak among
injecting drug users in Taiwan
4. Abstract: Insight and educational intervention concerning hepatitis
among roadside barbers and their clients in Karachi, Pakistan
5. Abstract: Oral versus intravenous steroids for treatment of relapses in
multiple sclerosis
6. Extract: “Greed, ignorance, and laziness” are behind medical injection
dangers in US, says official
7. No Abstract: Isopropyl alcohol skin antisepsis does not reduce incidence
of infection following insulin injection
8. WHO identifies main barriers to m-health
9. Post Graduate Certificate Harm Reduction
10. Publications: Hospital emergency response checklist
11. News
– USA: Infection outbreaks caused by cost-cutting clinics
– Toronto mulls licensing for workplaces with blood-borne disease risks
– Pakistan: Wipe it out: Number of new hepatitis cases on the rise
– India: WHO study to ‘prick’ doctors

The web edition of SIGNpost is online at:

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:

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

Subscribe or un-subscribe by email to: or to

Visit the WHO injection safety website and the SIGN Alliance Secretariat

Visit the SIGNpostOnline archives at:

Selected updates and breaking news items on the SIGN Moderator Facebook
page at:

Selected updates at:!/signmoderator

1. Halting Unsafe Injection Practices Still a Challenge
Halting Unsafe Injection Practices Still a Challenge
by George Ochoa, Infectious Disease Special Edition (FEBRUARY 2013)

An infection spread by unsafe injection practices can happen anywhere. In
2008, it happened at an endoscopy clinic in Las Vegas. When a patient
infected with hepatitis C was injected with propofol from a single-dose
vial, backflow contaminated the syringe. Nurses reused the syringe to draw
additional medication from the vial after replacing the needle. By placing
the reused syringe in contact with the vial, they contaminated the vial.
The routine reuse of single-dose vials for multiple patients resulted in an
outbreak of hepatitis C.

Joseph Perz, DrPH, a health care epidemiologist at the Centers for Disease
Control and Prevention (CDC) in Atlanta, recounted the story of the Las
Vegas outbreak in a Nov. 13 CDC webinar, “Unsafe Injection Practices in the
U.S. Healthcare System.” Since 2001, Dr. Perz said, at least 48 outbreaks
caused by unsafe injection practices have occurred in the United States,
with the majority (90%) in outpatient settings (10 in pain clinics and nine
in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or
hepatitis C; 27 were bacterial. More than 150,000 patients required
notification to recommend bloodborne pathogen testing following exposure to
unsafe injections.

Dr. Perz noted that contamination can occur with syringes as well as other
medication containers. For example, he noted that syringes can be reused
indirectly, as in the Las Vegas case, in which a reused syringe
contaminated a vial, or directly, in which a single syringe is used for
several patients. Insulin pens also can be reused mistakenly, causing
contamination. For example, it was reported in January that insulin pens
may have been reused unintentionally in more than 700 patients at the
Buffalo Veterans Affairs Medical Center, possibly exposing the patients to
HIV, hepatitis B and/or hepatitis C.

Another potential problem occurs when a single-dose vial is used for
multiple patients. Because the single-dose vials typically lack
preservatives, this practice carries risks for bacterial contamination. IV
bags also are often mistakenly used as a common source of supply for
multiple patients. “Another concern is that clinical staff may spike, or
prepare, batches of IV bags, or draw multiple syringes out of vials, and
hold them indefinitely although they are preservative-free,” Dr. Perz told
Pharmacy Practice News (sister publication to Infectious Disease Special

Darryl S. Rich, PharmD, MBA, FASHP, medication safety specialist, Institute
for Safe Medication Practices (ISMP), in Horsham, Pa., who was not
associated with the CDC webinar, said, “The most egregious [unsafe
injection practice] is the reuse of the same syringe. That is probably the
top in causing infections. Also egregious is using single-dose vials for
multiple patients.”

Multiple-dose vials also can be associated with contamination, Dr. Rich
said. “A CDC safe injection practice is that a multiple-dose vial should
not be opened and stored in the immediate patient treatment area,” said Dr.
Rich. “If it is, it should be used only for one patient and then discarded.
A lot of hospitals don’t agree with this particular guideline because of
the cost involved. CDC has evidence that these vials in close contact to
patients can cause cross-contamination, so I think it makes sense. It takes
a little creative thinking. See if there are areas to draw up doses from
multidose vials farther from the patient. Use single-dose vials instead of
multidose vials. The best approach is to use prefilled syringes drawn up
using automation in the pharmacy or prepared from an operating room

The Safe Injection Practices Coalition—a partnership of health care–related
organizations that includes the CDC and ISMP—is leading an effort to raise
awareness about safe injection practices. The slogan of the coalition’s One
& Only Campaign, is: “One needle, one syringe, only one time.” The message
is meant to be clear and to the point. “We do not want any health care
provider telling us they didn’t know better when it comes to syringe reuse
and other unsafe injection practices,” Dr. Perz noted.

Among the campaign’s resources is an injection safety checklist that
providers can use to assess adherence to safe injection practices (Figure).
“The injection safety checklist is meant for providers to stop [and] take a
moment to examine their practices, that of their staff and peers,” Dr. Perz
said. Campaign staff recently launched additional new materials, including
an animated video, a podcast, posters and a bloodborne pathogens training
activity (

Pharmacists Need To Be Part of Team Effort

Pharmacists have an important role to play in ensuring safe injection
practices, stressed Dr. Perz. “Pharmacists are in a good position to
understand how important it is to maintain sterility of injectable
medications. The pharmacists’ vigilance can extend to the point of care, to
ensure safe and appropriate use of dispensed medication products.”

“If there’s a shortage, the pharmacy should break the drug in large single-
dose vials down into individual units,” Dr. Rich said. “The pharmacist
needs to work with the infection control coordinator. It’s a team effort.”

Dr. Perz suggested three “E’s” for ensuring safe injections: “Epidemiologic
capacities and resources,” “Educational initiatives,” and “Enforcement and
oversight.” Pharmacists, he said, have a role in all three: recognizing
patterns and opportunities for prevention (epidemiology), educating
providers about appropriate practice (education), and participating in
walkthroughs and audits (enforcement).

A study published Dec. 10 online in American Health & Drug Benefits
delineated the effects of preventable adverse drug events (ADEs), such as
those caused by unsafe injection practices. The study, commissioned by BD,
showed that such ADEs affect more than 1 million hospitalized patients and
cost $2.7 billion to $5.1 billion annually.

—Additional reporting by Sarah Tilyou

Drs. Perz and Rich reported no relevant financial conflicts of interest.

Copyright © 2004 – 2013 McMahon Publishing. Infectious Disease Special
Edition and are part of McMahon

2. Abstract: Psychiatric consequences of needlestick injury

Occup Med (Lond). 2013 Feb 21.

Psychiatric consequences of needlestick injury.

Green B, Griffiths EC.

Faculty of Health and Social Care, University of Chester, Chester CH1 1SL,

Background: Needlestick injuries (NSIs) are a common occupational hazard
with potential physical health effects, including viral infections such as
hepatitis and HIV. Less appreciated are the psychiatric consequences of
NSIs, potentially including post-traumatic stress disorder (PTSD) and
adjustment disorder (AD).

Aims: To study psychiatric consequences of NSIs by diagnosis, duration and
severity of depressive symptoms.

MethodsCase control study from patients referred to a psychiatric trauma
clinic diagnosed according to ICD-10 diagnostic research criteria
guidelines. The Beck Depression Inventory (BDI) was administered to measure
depressive symptomatology and assess differences in depression severity
between psychiatric trauma patients who had or had not experienced an NSI,
and for relationships between the severity of depression and time since NSI
using linear models.

Results: There were 17 NSI cases and 125 controls. NSI patients had
moderately severe depressive symptoms (mean BDI score 22.7 15), which was
similar to 125 non-NSI trauma patients. 13 of these 17 cases had AD and
four had PTSD.

None contracted infections from their NSI, but most described secondary
effects of psychiatric illness on occupational, family and sexual
functioning. Severity of depressive symptoms declined with time after NSI,
but psychiatric illness lasted 1.78 months longer for every month a NSI
patient waited for seronegative test results (P < 0.05).

Conclusions: Enduring psychiatric illness can result from NSIs with a
severity similar to other psychiatric trauma. Swift delivery of test
results may reduce the duration of depression associated with NSI.

Occupational health professionals need to be aware of the psychiatric and
physical effects of NSIs.

3. Abstract: Ascertaining the 2004-2006 HIV type 1 CRF07_BC outbreak among
injecting drug users in Taiwan

Int J Infect Dis. 2013 Feb 12. pii: S1201-9712(13)00038-6.

Ascertaining the 2004-2006 HIV type 1 CRF07_BC outbreak among injecting
drug users in Taiwan.

Hsieh YH.

Department of Public Health, China Medical University, 91, Hsueh-Shih Road,
Taichung, Taiwan 40402; Center for Infectious Disease Education and
Research, China Medical University, Taichung, Taiwan. Electronic address:

OBJECTIVE: To ascertain the explosive 2004-2006 outbreak of HIV-1 CRF07_BC
among intravenous drug users (IDU) in Taiwan, which more than doubled the
total number of reported HIV cases in less than 3 years, resulting in a 45-
fold increase in cumulative IDU/HIV cases and a 40-fold increase in
previously seldom-reported female IDU/HIV cases.

METHODS: A mathematical model was utilized to fit the monthly case data, in
order to estimate the turning points (peak incidence) and the reproduction
number R of the outbreak. Furthermore, correlation analysis was carried out
to assess the correlation between infections among the male and female

RESULTS: Model fit revealed a two-wave epidemic during April 2004-March
2007. The larger second wave started shortly after May 2005 and peaked in
October 2005 before gradually subsiding. R was estimated to be 3.15
(3.14-3.16) and 27.21 (26.73-28.05) for the two respective waves. The time
series of monthly differences in male and female case data were found to be
most significantly correlated at lag 0 (i.e., r>0.7) with r=0.906 and
0.804, respectively in each direction. The Granger causality test indicated
that the male time series caused the corresponding female time series with
a lag of 2 months or less.

CONCLUSIONS: The modeling results revealed the presence of a small first
wave in 2004, before an explosion of cases after May 2005. Furthermore, a
harm reduction program implemented in August 2005 contributed to the
downturn in the epidemic after October. Correlation results also suggest
that the upsurge in male HIV cases led to the subsequent drastic surge in
female cases. Copyright © 2013. Published by Elsevier Ltd.

4. Abstract: Insight and educational intervention concerning hepatitis
among roadside barbers and their clients in Karachi, Pakistan

J Infect Dev Ctries. 2013 Feb 15;7(2):125-9.

Insight and educational intervention concerning hepatitis among roadside
barbers and their clients in Karachi, Pakistan.

Shahid A, Nasim S, Memon AA.

PMRC Specialized Research Centre on Child Health, National Institute of
Child Health, Karachi, Pakistan. PMRC_SRCCH@YAHOO.COM.

INTRODUCTION: This study aimed to determine perceptions of hepatitis and
make available an educational intervention session regarding the infection
among roadside barbers and their clients.

METHODOLOGY: A cross-sectional study using convenience random sampling
technique was conducted on all barbers and one each of their clients during
January to June, 2011, in Karachi, Pakistan. After informed consent was
taken and confidentiality ensured, respondents answered an anonymous
questionnaire of closed-ended questions regarding hepatitis. The interview
was followed by an educational intervention session. Data was analyzed
using SPSS version 17.

RESULTS: About 51% and 32% of the barbers and clients respectively had
knowledge regarding hepatitis. Razors were recognized as agents for
transmitting the infection by 12% and 42% of the barbers and clients
respectively. Most (96%) barbers disinfected the razor before use and 49%
of the clients confirmed that the razor was sterilized before shaving,
while 79% insisted on new blade. Though 50% and 30% of the barbers and
clients respectively knew that hepatitis is a preventable disease, only 2%
and 7% of the respective barbers and clients were vaccinated against
Hepatitis B. Reasons for not being vaccinated were non-awareness and cost
of the HBV vaccine. Only half of the barbers and clients considered
themselves to be at risk for hepatitis.

CONCLUSIONS: In Karachi, barbers and clients have poor knowledge of
hepatitis and the means of transmissions, as well as low vaccination rates
against HBV infection. Hence barbers and their clients must be educated
about hepatitis and its prevention.

Free full text

5. Abstract: Oral versus intravenous steroids for treatment of relapses in
multiple sclerosis

Cochrane Database Syst Rev. 2012 Dec 12;12:CD006921.

Oral versus intravenous steroids for treatment of relapses in multiple

Burton JM, O’Connor PW, Hohol M, Beyene J.

Department of Clinical Neurosciences, University of Calgary, Calgary,

BACKGROUND: This is an updated Cochrane review of the previous version
published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.:
CD006921. DOI: 10.1002/14651858.CD006921.pub2).Multiple sclerosis (MS), a
chronic inflammatory and neurodegenerative disease of the central nervous
system (CNS), is characterized by recurrent relapses of CNS inflammation
ranging from mild to severely disabling. Relapses have long been treated
with steroids to reduce inflammation and hasten recovery. However, the
commonly used intravenous methylprednisolone (IVMP) requires repeated
infusions with the added costs of homecare or hospitalization, and may
interfere with daily responsibilities. Oral steroids have been used in
place of intravenous steroids, with lower direct and indirect costs.

OBJECTIVES: The primary objective was to compare efficacy of oral versus
intravenous steroids in promoting disability recovery in MS relapses <= six
weeks. Secondary objectives included subsequent relapse rate, disability,
ambulation, hospitalization, immunological markers, radiological markers,
and quality of life.

SEARCH METHODS: A literature search was performed using Cochrane Multiple
Sclerosis and Rare Diseases of the Central Nervous System Group’s Trials
Register (January 2012), abstracts from meetings of the American Academy of
Neurology (2008-2012), the European Federation of Neurological Sciences
(2008-2012), the European Committee for Treatment and Research in Multiple
Sclerosis and American Committee for Treatment and Research in Multiple
Sclerosis (2008-2012) handsearching. No language restrictions were applied.

SELECTION CRITERIA: Randomized or quasi-randomized trials comparing oral
versus intravenous steroids for acute relapses (<= six weeks) in patients
with clinically definite MSover age 16 were eligible.

DATA COLLECTION AND ANALYSIS: Three review authors (JB, PO and MH)
participated in the independent assessment of all published articles as
potentially relevant to the review. Any disagreement was resolved by
discussion among review authors.We contacted study authors for additional
information.Methodological quality was assessed by the same three review
authors. Relevant data were extracted, and effect size was reported as mean
difference (MD), mean difference (MD), odds ratio (OR) and absolute risk
difference (ARD).

MAIN RESULTS: With this current update, a total of five eligible studies
(215 patients) were identified. Only one outcome, the proportion of
patients with Expanded Disability Status Scale (EDSS) improvement at four
weeks, was common to three trials, while two trials examined magnetic
resonance imaging (MRI) outcomes. The results of this review shows there is
no significant difference in relapse recovery at week four (MD -0.22, 95%
confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in
magnetic resonance imaging (MRI) gadolinium enhancement activity based on
oral versus intravenous steroid treatment. However, only two of the five
studies employed more current and rigorous methodological techniques, so
these results must be taken with some caution. The Oral Megadose
Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA)
trial and the “Efficacy and Safety of Methylprednisolone Per os Versus IV
for the Treatment of Multiple Sclerosis (MS) Relapses” (COPOUSEP) trial,
designed to address such limitations, are currently underway.

AUTHORS’ CONCLUSIONS: The analysis of the five included trials comparing
intravenous versus oral steroid therapy for MS relapses do not demonstrate
any significant differences in clinical (benefits and adverse events),
radiological or pharmacological outcomes.

Based on the evidence, oral steroid therapy may be a practical and
effective alternative to intravenous steroid therapy in the treatment of MS

Update of Cochrane Database Syst Rev. 2009;(3):CD006921.

6. Extract: “Greed, ignorance, and laziness” are behind medical injection
dangers in US, says official

BMJ. 2013 Jan 10;346:f176.

“Greed, ignorance, and laziness” are behind medical injection dangers in
US, says official

Lenzer J.

Dangerous injection practices by healthcare providers in the United States
have caused at least 49 infectious outbreaks since 2001, a new report has
found, putting 150?000 people at risk of diseases ranging from HIV to
hepatitis and drug resistant Staphylococcus aureus. Two thirds of the
dangerous injections were given in just the past four years, it says.

The findings, published by the newspaper USA Today,1 come on the heels of a
nationwide outbreak of more than 650 fungal infections related to tainted
drugs used across 19 states, resulting in 372 cases of meningitis and 39

Officials at the Centers for Disease Control and Prevention (CDC), which
provided the data to USA Today, said that the numbers in the …

Access to the full text of this article requires a subscription or payment.

7. No Abstract: Isopropyl alcohol skin antisepsis does not reduce incidence
of infection following insulin injection

Am J Infect Control. 2013 Feb 15. pii: S0196-6553(13)00023-0.

Isopropyl alcohol skin antisepsis does not reduce incidence of infection
following insulin injection.

O’Neill J, Grinager H, Smith SD, Sibley S, Harrison AR, Lee MS.

Department of Ophthalmology, University of Minnesota, Minneapolis,

8. WHO identifies main barriers to m-health

WHO identifies main barriers to m-health
By Issa Sikiti da Silva, Dakar, Senegal, BiztechAfrica (18.02.13)

Despite the successful pilot of m-health programmes in developing
countries, especially in Africa, the World Health Organisation (WHO) says
m-health implementation is still being hampered by competing health system
priorities, which it has identified as a top barrier globally across high,
upper-middle and lower-middle income countries.

WHO says that most health systems are severely overburdened, which means
they are constantly challenged by the need to make difficult decisions
about competing priorities.

Dakar-based industry watcher Leopold Camara agrees, saying that most
African governments already have ‘very little food’ on their plates to
share among ‘so many people’, which he said making a decision about who
will take what and who will get little or who won’t get nothing, becomes
very difficult.

“Concepts such as e-health and m-health can seriously change the face of a
country’s health system, but implementing such initiatives becomes
problematic if there is no adequate funding, especially in the face of
unknown cost-effectiveness of available m-health solutions,” Camara says,
adding that that is the reason why many m-health initiatives in developing
countries are privately-funded.

“Sometimes, I have the feeling that technology is putting too much pressure
on Africa, and forcing already-burdened African governments to bite more
than they can chew.”

The Geneva-based UN agency also says competing priorities generally
indicates that funding is allocated to other programmes ahead of m-health,
or can reflect a lack of general interest or understanding of the field.

Camara explains: “It becomes difficult when you have so little to spend to
solve your problems. Africa has too many health needs, from lack of drugs
to medical staff asking for a pay increase, no electricity at state
hospitals, not enough beds, no ambulances, replacing obsolete equipment,
building more clinics, and so on.

“African decision-makers firmly believe these needs must be taken care of,
first, before they think of investing in m-health, which they may think is
‘less important’. This lack of interest or knowledge continues to
constitute a dangerous obstacle to the development of e-health and m-health
in Africa.”

The Royal Tropical Institute, which says the majority of m-health
initiatives in resources-poor settings are pilots and few have been
identified for scaling up, lists about 50 Africa m-health programmes, most
of which have been implemented in countries such as Kenya, South Africa,
Ghana, Tanzania, Uganda, Mozambique, Ethiopia, Botswana, Malawi, Nigeria,
Rwanda, Gambia and Senegal.

Senegal’s well-known m-health initiative is called Djobi, which was
financed by the Fond Francophone des Inforoutes and set up by RAES (Réseau
Africain d’Educationpour la Santé), an NGO, in partnership with Orange,
PAMAS and Gaston Berger University.

Djobi, which is also implemented in Mali, aims to reduce child mortality by
30% among children of under five in both countries. Djobi was among the
eight m-health initiatives which received grants from the Norway-owned
Innovation Working Group (IWG) and mHealth Alliance in September 2012.

9. Online Post Graduate Certificate Harm Reduction

Post Graduate Certificate Harm Reduction

The Certificate in Harm Reduction consists of 117-hours of instruction
designed to introduce service providers, administrators and policy makers
to the principles, concepts and practices of harm reduction, to provide an
opportunity to critically examine examples of harm reduction work; and to
become familiar with strategies for mobilizing support for and developing
harm reduction programs in communities, families and institutions.

Participants who complete all evaluative components will receive a
Certificate in Harm Reduction from York University.

Course 1 – Introduction to Harm Reduction is approved for 39 Core CEU Hours
by the CACCF

Program Learning Objectives

The purpose of this initiative is to provide participants with:
•an understanding of the basic principles, philosophy and application of
harm reduction (as a strategy for working with individuals, families and
•provide students with the skills needed to critically analyze a broad
range of examples of harm reduction programs, policy and practice; and
•strategies for: mobilizing support for harm reduction in communities,
families and institutions;
developing programs; helping shape policy; coping with resistance;

Intended Audience

The intended audience for this initiative is a broad range of
practitioners, administrators and policy advisors/analysts interested in
better understanding and implementing Harm reduction policy/practice within
their organization and work setting, including health care professionals
(doctors, nurses, nurse practitioners), teachers and school administrators,
counselors / therapists, addiction workers, social workers, social service
workers, administrators and board members, policy analysts, politicians,
advocates, participants, criminal justice professionals, law enforcement
and others.

Details at:

York University Canada, Faculty of Liberal Arts & Professional Studies

10. Publications: Hospital emergency response checklist

WHO EURO Disaster preparedness and response

Hospital emergency response checklist

Available in:
English (PDF), 674.9 KB
Russian (PDF), 784.3 KB

Hospitals play a critical role in providing communities with essential
medical care during all types of disaster. Depending on their scope and
nature, disasters can lead to a rapidly increasing service demand that can
overwhelm the functional capacity and safety of hospitals and the health-
care system at large. The World Health Organization Regional Office for
Europe has developed the Hospital emergency response checklist to assist
hospital administrators and emergency managers in responding effectively to
the most likely disaster scenarios.

This tool comprises current hospital-based emergency management principles
and best practices and integrates priority action required for rapid,
effective response to a critical event based on an all-hazards approach.
The tool is structured according to nine key components, each with a list
of priority action to support hospital managers and emergency planners in

– continuity of essential services;
– well-coordinated implementation of hospital operations at every level;
– clear and accurate internal and external communication;
– swift adaptation to increased demands;
– the effective use of scarce resources; and
– a safe environment for health-care workers.

References to selected supplemental tools, guidelines and other applicable
resources are provided. The principles and recommendations included in this
tool may be used by hospitals at any level of emergency preparedness. The
checklist is intended to complement existing multisectoral hospital
emergency management plans and, when possible, augment standard operating
procedures during non-crisis situations.

11. News

– USA: Infection outbreaks caused by cost-cutting clinics
– Toronto mulls licensing for workplaces with blood-borne disease risks
– Pakistan: Wipe it out: Number of new hepatitis cases on the rise
– India: WHO study to ‘prick’ doctors

Selected news items reprinted under the fair use doctrine of international
copyright law:

USA: Infection outbreaks caused by cost-cutting clinics
14 News WFIE Evansville, USA (26.02.12)

The Centers for Disease Control is sounding the alarm about a dangerous
healthcare error responsible for at least 19 known infection outbreaks.

The practice of reusing single-dose vials is spreading life-threatening
bacterial, fungal and viral infections.

All of the outbreaks have involved outpatient settings like pain clinics,
but the risk is just as real about anywhere you receive an injection from a
single-dose vial.

The safe way to administer a single-dose vial of medication is by using the
needle or syringe on one patient only.

“The assumption is, you’re going to open it, pull out medicine and be
done,” says Michael Bell, deputy director of the Division of Healthcare
Quality Promotion at the Centers for Disease Control and Prevention in

Unlike multi-use vials which are intended for multiple patients, single-
dose vials do not contain antimicrobial preservatives.

Once a single-dose vial has been used on one patient, it should never be
used again.

“When you go in with a needle, you can actually push bacteria into the
sterile medication,” Bell explains.

This is how life-threatening infections like hepatitis B virus (HBV) and
hepatitis C virus (HCV), as well as bacterial infections including
Staphylococcus aureus, known as Staph, have spread to unsuspecting

This may cause you to wonder, why would a medication vial intended for use
on one person be reused?

America Now took this question to Steve Jarrett who is the medication
safety officer at Carolinas Healthcare System in Charlotte, NC.

Jarrett says one reason for reusing single-dose vials is due to
prescription drug shortages.

“As physician practices and hospitals try to stretch the medication they
have to treat their patients, there are times where a single-dose vial has
been used for more than one dose,” Jarrett says.

The practice of reusing a single-dose vial is also common when the size of
the patient, for example a small child, doesn’t require all of the
medication contained in a single-dose vial.

Discarding the leftovers may be expensive, but so are the costs associated
with outbreaks or lawsuits.

Combining or splitting medication must follow strict pharmacy guidelines,
and it must be done in a sterile setting.

So, how can a patient protect themselves and know they’re safe if they are
receiving medication via a needle or syringe?

Bell says every patient should ask questions about their doctor’s safety
practices before arriving at a healthcare facility and well before any
injection is administered.

“Your doctors and nurses want to do the right thing, but reminders never
hurt,” and Bell adds, “You can ask nicely and they won’t get upset. If they
do, you should probably find another doctor!”

Jarrett agrees that patients simply need to ask questions to the medical
staff like – What are you doing to keep me safe?

Experts say you shouldn’t be afraid to ask questions when it comes to your
medical care.

“It’s not wrong to say, upfront, I have a strong need to see you fill the
syringe in front of me and see you break open a fresh packet,” Bell says.

If you are too sick or shy to ask these questions, Bell recommends you ask
a family member or friend to go with you on your next appointment.

“It’s much easier for me to ask questions on behalf of my friend or family
member than to do it myself,” Bell says.

Tracking the source of an infection from a single-dose vial that was
inappropriately administered to multiple patients can be nearly impossible
for health officials to do weeks or months later.

This is why the CDC recommends if your injection site becomes unusually
inflamed, red or painful, you should seek medical care immediately.

An infection at the sight of an injection could indicate contamination
resulting from a vial that was inappropriately used on subsequent patients.
If this happens to you, be sure to report the incident to your local health

Ultimately, it is critical for you to add your own dose of precaution by
asking questions and taking charge of your care upfront.

Additional Information:

The following information is from Steve Jarrett, a medication safety
officer at Carolinas Healthcare System in Charlotte, NC.

He says the most important thing is to have a good relationship with your

Look for a provider who is well-respected in the community and who is
recommended by your insurance provider. Do your homework.

Michael Bell is the deputy director of the Division of Healthcare Quality
Promotion at the Centers for Disease Control in Atlanta.

He recommends that hospitals and clinics take any leftover single-dose vial
medication to their pharmacy, where under a hood and in a sterile
environment they can separate out doses.

He notes that while it’s been beneficial to patients to expand hospital
care into outpatient settings (easier access, home faster), there are
consequences involved in taking away the extra staff and layers of safety
practices commonly found in a hospital setting.

He says it would be nearly impossible for a patient to know that their
sickness came from an injection weeks or months ago.

If your injection site turns red, infected or painful, seek care

Let your Health Department know if you think your infection is due to an

He notes that since medications are not made in various vial sizes,
healthcare facilities often have leftovers.

In the case of drug shortages, healthcare providers may split doses to
provide the right amount for small patients when a drug is in limited
supply. (i.e. children)

He says the challenge in healthcare will be to rebuild the safety nets
found inside hospitals, into outpatient facilities, without the extra

Asking questions reminds your provider to double check their work.
Any situation where there are lots of injections, in small volumes, lends
itself to errors.

The following information is from the Centers for Disease Control and
Prevention in an online article entitled “Protect Patients Against
Preventable Harm from Improper Use of Single-Dose/Single-Use Vials”

Medications labeled as “single dose” or “single use” should be used for
only one patient to protect them from life-threatening infections that
occur when medications get contaminated from unsafe use.

Concerns over whether the CDC’s guidelines contribute to drug shortages and
increased medical costs.

CDC says shortages are due to manufacturing, shipping and other issues.
Single dose vials lack antimicrobial preservatives and can become

In critical need, medicines from UNOPENED single-dose vials can be
repackaged for multiple patients when done according to the United States
Pharmacopeia’s standards.

Reuse of syringes on multiple patients, sharing medications, medicine from
a single-dose vial to multiple patients and failure to use aseptic
technique when giving injections are all unsafe practices.

Since the CDC’s guidelines were published in 2007, the CDC has become aware
of at least 19 outbreaks associated with single-dose medications.

7 involved blood borne pathogen infections and 12 involved bacterial

All outbreaks involved outpatient settings with most occurring in pain
remediation clinics.

In a study published in the Journal of the American Medical Association,
two-thirds of the outpatient facilities inspected had lapses in basic
infection control practices. (Source:

Any potential savings from stretching medication would be quickly offset by
the costs associated with viral hepatitis, bloodstream infections,
meningitis, epidural abscesses . Legal costs and the loss of medical
licenses may also occur.

To prevent unnecessary waste or the temptation to use contents from single-
dose or single-use vials for more than one patient, clinicians and
purchasing personnel should select the smallest vial necessary for their
needs when making treatment and purchasing decisions.

There have been outbreaks resulting from pooling of contents of single-dose
or single-use vials and/or storage of contents for future use.

The following information is from the Centers for Disease Control and
Prevention website devoted to the “One Needle, One Syringe, Only One Time”
public health campaign (Source:

Since 2001, more than 130,000 patients in the US have been notified of
potential exposure to Hepatitis B, hepatitis C and HIV all due to lapses in
basic infection control practices (reusing syringes, contaminated vials,

Data from a survey of U.S. healthcare workers who provide medication
through injection indicate that 1% to 3% of healthcare providers reuse the
same needle and/or syringe on multiple patients.
Since 2007, at least 19 outbreaks associated with single-dose vials or IV
solutions have been reported.

7 outbreaks of hepatitis B and/or C
12 outbreaks of bacterial infections

What to ask your healthcare provider before receiving an injection:
– Will there be a new needle, new syringe and new vial?
– Can you tell me how you prevent the spread of infections in your
– What steps are you taking to keep me safe?

The following information is from the Centers for Disease Control and
Prevention in an online article entitled “FAQs for Patients” (Source:

Incorrect practices have been identified during the administration of
anesthetics, administration of IV medications (chemotherapy, cosmetic
procedures, etc), saline use to flush IV lines, administration of
intramuscular vaccines.

Incorrect practices can transmit bacterial, fungal and viral infections.

The following information is from the Centers for Disease Control and
Prevention in an online article entitled “Invasive Staphylococcus aureus
Infections Associated with Pain Injections and Reuse of Single-Dose Vials –
Arizona and Delaware, 2012” (Source:

The CDC released a report in July of 2012 on an investigation of two
outbreaks of invasive Staphylococcus aureus infection confirmed in 10
patients being treated in outpatient clinics.

Infection was associated with use of single-dose vials on more than one

Copyright 2013 America Now. All rights reserved.

Toronto mulls licensing for workplaces with blood-borne disease risks
OHS Canada, DAILY NEWS (25.02.13)

Toronto’s tattoo parlours and hair salons could be facing similar health
and safety criteria as restaurants if city council manages to introduce a
bylaw that will beef up their licensing standards for establishments where
exposure to blood is common.

On Feb. 20, the Board of Health presented Toronto councillors with stricter
regulations of Personal Services Settings (PSS), which includes tattoo
parlours, barber shops, acupuncture facilities, hair salons, body piercing
studios and anywhere where workers and their clients are at risk of blood-
borne diseases and infections, such as hepatitis B, hepatitis C and HIV.

“The risk is not only to folks who get the body piercings or tattoos, it is
also for the workers there,” explained Joe Mihevc, Ward 21 councillor and
chair of the health board. “Infection can pass to the operator as well, so
it’s also about wearing appropriate protective gear.

“The strategy is that you will have to get a license, and to get that
license you will have to have clearance from public health, and to get that
clearance, you will also have to be trained into how to make sure that your
place is kept clean.”

Under the new rules, PSS facilities would have to obtain licences after
regular inspections from the city, which would cost $319, plus $210

The system mimics Toronto’s DineSafe program that requires restaurants to
display either a green (pass), yellow (conditional pass) or red (fail) card
in the window to indicate the results of health inspections.

The proposed changes were met with a mixed response from the industry.
While some argue that the fees are too steep, others fear that inspectors
might not fully understand the true risks of their workplaces.

In an open letter from the Greater Toronto Tattoo Association, industry
officials expressed their concerns with the new licensing system, including
clarifying markers.

“A yellow, or conditional pass sign displayed would be a literal kiss of
death for any tattoo establishment. It has been our experience over the
past few years that health inspections have been conducted by individuals
who, by the nature of the questions they ask, often indicate that they know
little or nothing about the tattooing process,” the letter reads. “It is
our position, therefore, that inspection result postings be limited to
critical issues where the health and safety of the client is reasonably at
risk (improper sterilization, lack of barrier control, improper skin prep,
unsanitary conditions, etc).”

Toronto Health has already established a safe practice skeleton for workers
who face threats from blood-borne infections, which all city establishments
must abide by. That includes using sterile and single-use needles and
blades, always wearing gloves during invasive procedures, safely trashing
disposable material and always cleaning and disinfecting instruments and
equipment between clients.

Next, the proposal will be tabled at the Municipal Licensing and Standards
Committee meeting in the coming months.

Pakistan: Wipe it out: Number of new hepatitis cases on the rise
By Our Correspondent, The Express Tribune, Pakistan (19.02.13)

KARACHI: The Hepatitis Prevention and Control Programme has achieved
significant milestones and there are a number of solid statistics to back
it up. But according to Dr Ayaz Ali Memon, the manager of the programme, a
lot has yet to be done.

In recent times, the programme has stepped up its game to keep a check on
the disease. A total of 1,446 screening camps were established last year
alone. Just under one million people have been screened for the disease in
Sindh. About 6.7 million people living in the province have also been
inoculated against the disease.

Over the past three years, new molecular labs have been established at
Civil Hospital, Mirpurkhas, Chandka Medical College, Larkana, and Ghulam
Mohammad Mahar Medical College, Sukkur. While talking to The Express
Tribune, Dr Memon said, “These labs cover the most populated areas of the
province. Screening will help prevent the spread of the disease.”
Dr Memon added that despite all of this, greater effort is required to
prevent new cases. The programme he is working for is slated to end in
2014, but the incidence of hepatitis B and C is steadily rising across

Though there is no exact figure of the number of people infected, rough
estimates place the number of people in Sindh with hepatitis B at one
million and hepatitis C at two million. The number of infections is on the
rise across all age groups. Globally, around 600,000 people die every year
because of hepatitis B, while hepatitis C claims around 350,000 lives.

Dr Memon said that there is a need to improve the availability and storage
of vaccines across the province. A lack of cold storage can make it
difficult to store vaccines and subsequently drives to inoculate people. He
added that five cold storage chains have been established in the province –
three in Hyderabad and one each in Larkana and Khairpur.

How it spreads

Hepatitis A is usually seen in children and Hepatitis E in adolescents.
Both spread through contaminated food and water. Hepatitis A and E viruses
are self-limiting and settle within a few days to a few weeks.

Major risk factors include sharing of needles or blades, transfusion of
unscreened blood and unsafe sexual practices. The disease can also be
transferred from an infected mother to her newborn.

Published in The Express Tribune, February 19th, 2013.

India: WHO study to ‘prick’ doctors
Payal Gwalani, TNNm Times of India (12.02.13)

NAGPUR: A World Health Organisation ( WHO) report says around half the
injections used across the world are unsafe for administration, with a
worse ratio in developing countries. This has given rise to the Rapid
Assessment of Injection Safety ( RAIS) project at four state-run medical
colleges of Maharashtra to evaluate injection practices and suggest changes
on policy, educational and behavioural levels.

The city’s Indira Gandhi Government Medical College (IGGMCH), Pune’s BJ
Medical College, and the Government Medical Colleges at Akola and
Aurangabad are undertaking the study with technical assistance from medical
technology giant BD. Despite concerns about safety of injections, very few
states in India have guidelines for safe injection practices.

“Unsafe injection practices not only put patients at risk but also the
health care providers and the entire community at large. Increasing load of
blood-borne infections like HIV, Hepatitis B and C among others is reason
enough to take up this study,” said Dr Shilpa Lanjewar, coordinator for the
study at IGGMCH.

She said that the participating colleges are undertaking awareness
activities for staff, including nurses, class IV workers and sanitary
workers. They are prone to fall prey to infections because of improper
handling or disposal of injections, syringes or IV sets.

“BD is helping create a Safe Injection Environment (SIE) in many states
along with professional organizations such as IAP and states. We give
information and technical support to the four medical colleges also,” said
Dr Om Prakash Kansal, injection safety adviser of BD. He was in the city
during the annual national conference of Indian Preventive and Social
Medicine Association (IAPSM) hosted by Government Medical College and
Hospital’s PSM department.

The initial findings of the study were presented at this conference. The
assessment was that patients have the misconception that injections provide
quick relief, and so ask for it more often. The doctors surveyed said
resources were not adequate for them to practice safe injection practices.
* SAFETY OF INJECTIONS brief yourself at:

A fact sheet on injection safety is available at:

* Visit the WHO injection safety website and the SIGN Alliance Secretariat

* Download the WHO Best Practices for Injections and Related Procedures
Toolkit March 2010 [pdf 2.47Mb]:

Use the Toolbox at:

Get SIGN files on the web at:
get SIGNpost archives at:

Like on Facebook:

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 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:

The report is navigable using bookmarks and is searchable. Viewing
requires the free Adobe Acrobat Reader at:

Translation tools are available at:
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

* Subscribe or un-subscribe by email to:, or to

The SIGNpost Website is

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.


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.

Comments are closed.