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SIGNpost 00717

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *

Post00717    -33% new HIV + Dental + Abstracts + News 25 September 2013

CONTENTS
0. Moderators Note
1. UNAIDS reports a 52% reduction in new HIV infections among children and
a combined 33% reduction among adults and children since 2001
2. UK: Needle and syringe programmes (update): guideline consultation
3. USA: OSAP Dental Practice Hepatitis C Prevention Informational Toolkit
4. Blog: Misinformation from UNAIDS’ flawed Modes of Transmission model
5. Abstract: A tool to assess knowledge, attitude and behavior of
indonesian health care workers regarding infection control
6. Abstract: Knowledge and Perceptions of HIV/AIDS among Cameroonian
Nursing Students
7. Abstract: Assessment of health-care waste disposal methods using a
VIKOR-based fuzzy multi-criteria decision making method
8. Abstract: Effect of infection control strategy on knowledge, attitude
and practice towards hepatitis B transmission and prevention in
vulnerable populations
9. Abstract: Burden of infectious diseases, substance use disorders, and
mental illness among Ukrainian prisoners transitioning to the community
10. Abstract: Pharmacy syringe purchase test of nonprescription syringe
sales in San Francisco and Los Angeles in 2010
11. Abstract: Estimates of the size of key populations at risk for HIV
infection: men who have sex with men, female sex workers and injecting
drug users in Nairobi, Kenya
12. Abstract: Health and safety risks associated with public injecting
among people who inject drugs in Bangkok, Thailand
13. Abstract: Seroprevalence of hepatitis B and C infection among the
HIV-positive population in Abuja, Nigeria
14. Abstract: Injecting drug use among gay and bisexual men in Sydney:
prevalence and associations with sexual risk practices and HIV and
hepatitis C infection
15. Abstract: The prevalence and trends of transfusion-transmissible
infectious pathogens among first-time, voluntary blood donors in
Xi’an, China between 1999 and 2009
16. Abstract: Management of an incident of failed sterilization of
surgical instruments in a dental clinic in Hong Kong
18. Abstract: Global implementation of WHO’s multimodal strategy for
improvement of hand hygiene: a quasi-experimental study
19. Abstract: Modified World Health Organization hand rub formulations
comply with European efficacy requirements for preoperative surgical
hand preparations
20. Abstract: Hand hygiene and the use of personal protective equipment
21. Abstract: Disinfectants in health care: finding an alternative to
chlorine dioxide
22. Abstract: Safety and immunogenicity of revaccination with reduced dose
intradermal and standard dose intramuscular influenza vaccines in
adults 18-64 years of age
23. Abstract: Comparative pharmacokinetics of subcutaneous trastuzumab
administered via handheld syringe or proprietary single-use injection
device in healthy males
24. Abstract: Tolerability of intramuscular and intradermal delivery by
CELLECTRA® adaptive constant current electroporation device in healthy
volunteers
25. Abstract: Higher lung accumulation of intravenously injected organic
nanotubes
26. No Abstract: Injuries to health workers are common but safety checks
are rare, report finds
27. No Abstract: Global Fund needs $15bn to fight HIV, tuberculosis, and
malaria
28. News
– UK: Dirty needles’ concern over beauty treatments
– UK: Revealed: Glasgow’s Victoria Infirmary slammed by health inspectors
over filthy wards and dirty needle disposal procedures
– UK: NICE To Update Guidance on “Needle Risk”
– Imaging Technique Detects Pediatric Liver Disease Without Need For
Needle Biopsy
– USA: Tulsa Dentist Spread Hepatitis C, Health Officials Say

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0. Moderators Note
__________________________________________________________________
SIGNpost, SIGNpostOnline.info, SIGN on Twitter, and the SIGN Moderator on
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SIGNpost will maintain limited posting for this period.

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__________________________________________________________________
________________________________*_________________________________

1. UNAIDS reports a 52% reduction in new HIV infections among children and
a combined 33% reduction among adults and children since 2001
__________________________________________________________________
http://tinyurl.com/UNAIDS-23092013

UNAIDS reports a 52% reduction in new HIV infections among children and a
combined 33% reduction among adults and children since 2001

World closing in on Millennium Development Goal 6, globally the AIDS
epidemic has been halted and reversed—race is on to reach universal access
to HIV treatment.

GENEVA, 23 September 2013—As world leaders prepare to meet at the United
Nations General Assembly to review progress towards the Millennium
Development Goals—a new report from the Joint United Nations Programme on
HIV/AIDS (UNAIDS) shows dramatic acceleration towards reaching 2015 global
targets on HIV.

New HIV infections among adults and children were estimated at 2.3 million
in 2012, a 33% reduction since 2001. New HIV infections among children
have been reduced to 260 000 in 2012, a reduction of 52% since 2001. AIDS-
related deaths have also dropped by 30% since the peak in 2005 as access
to antiretroviral treatment expands.

By the end of 2012, some 9.7 million people in low- and middle-income
countries were accessing antiretroviral therapy, an increase of nearly 20%
in just one year. In 2011, UN Member States agreed to a 2015 target of
reaching 15 million people with HIV treatment. However, as countries
scaled up their treatment coverage and as new evidence emerged showing the
HIV prevention benefits of antiretroviral therapy, the World Health
Organization set new HIV treatment guidelines, expanding the total number
of people estimated to be in need of treatment by more than 10 million.

“Not only can we meet the 2015 target of 15 million people on HIV
treatment—we must also go beyond and have the vision and commitment to
ensure no one is left behind,” said Michel Sidibé, Executive Director of
UNAIDS.

Significant results have also been achieved towards meeting the needs of
tuberculosis (TB) patients living with HIV, as TB-related deaths among
people living with HIV have declined by 36% since 2004.

Despite a flattening in donor funding for HIV, which has remained around
the same as 2008 levels, domestic spending on HIV has increased,
accounting for 53% of global HIV resources in 2012. The total global
resources available for HIV in 2012 was estimated at US$ 18.9 billion, US$
3-5 billion short of the US$ 22-24 billion estimated to be needed annually
by 2015.

As well as outlining new global HIV estimates, the 2013 UNAIDS Report on
the global AIDS epidemic reviews progress on ten specific targets which
were set by United Nations Member States in the 2011 UN Political
Declaration on HIV and AIDS.

The report finds that progress has been slow in ensuring the respect of
human rights, securing access to HIV services for people most at risk of
HIV infection, particularly people who use drugs, and in preventing
violence against women and girls––a key factor in vulnerability to HIV.
Gender inequality, punitive laws and discriminatory actions are continuing
to hamper national responses to HIV and concerted efforts are needed to
address these persistent obstacles to the scale up of HIV services for
people most in need.

The 2013 UNAIDS Report on the global AIDS epidemic is available on line at
unaids.org

http://tinyurl.com/UNAIDS-23092013

www.unaids.org/en/resources/campaigns/globalreport2013/globalreport/

2013 Report on the Global AIDS Epidemic (PDF, 2.4MB)
http://tinyurl.com/UNAIDS-2013-Report
__________________________________________________________________
________________________________*_________________________________

2. UK: Needle and syringe programmes (update): guideline consultation
__________________________________________________________________
http://www.nice.org.uk/guidance/index.jsp?action=folder&o=65286

UK: Needle and syringe programmes (update): guideline consultation

NICE is conducting an update of NICE public health guidance 18 (2009).
The updated guidance has been extended to focus on providing needle and
syringe programmes (NSPs) for young people aged under 16 who inject drugs
and users of performance and image-enhancing drugs.

All registered stakeholders for this update are invited to comment on the
provisional recommendations via this website during a 6 week consultation
with stakeholders.

Organisations not registered as stakeholders are not able to comment. Find
out how your organisation can become a stakeholder.

Please note – the provisional recommendations presented here do not
constitute NICE formal guidance on this topic. The recommendations are
provisional and may change after consultation.

This consultation will take place between 24 September and 5 November
2013.

The draft guidance sets out the provisional recommendations that have been
developed.

Please note – Comments forms with attachments such as research articles,
letters or leaflets will not be accepted. If comments forms do have
attachments they will be returned without being read. If the stakeholder
resubmits the form without attachments, it must be by the consultation
deadline.

Consultation Documents

Needle and syringe programmes (update): draft guidance
http://www.nice.org.uk/_gs/link/?id=4ADA85DB-E904-CCB3-08EA136CEBDA95E7

Needle and syringe programmes (update): stakeholder comments form
http://www.nice.org.uk/_gs/link/?id=4AD7201A-0677-4201-2C7416E5AF3CF05F

Points to consider in the consultation

Points or areas that are not covered, but which appear to fall within the
scope of the guidance.

Potential inconsistencies or any disagreement with the Public Health
Advisory Committee’s interpretation of the evidence and its applicability.

The practical value of the provisional recommendations.

Issues of presentation and style, including how the provisional
recommendations have been grouped and ordered.

Whether the right organisations and individuals have been identified under
‘Who should take action’ for each recommendation.

Do you think this guidance could be improved to better promote equality of
opportunity relating to age, disability, gender, gender identity,
ethnicity, religion and belief, sexual orientation or socio-economic
status? If so, please include details of:
– Which particular parts of the guidance you think affect equality of
opportunity.
– Why and how you think equality of opportunity is affected.

In addition are there reasons why any of the recommendations in the
guidance may result in an increase in inequality of opportunity relating
to age, disability, gender, gender identity, ethnicity, religion and
belief, sexual orientation or socio-economic status?

How to submit your comments

Please provide all responses to this draft guidance using the Stakeholder
Comments Form (ensuring all relevant fields are completed, including your
organisation’s name). Please forward the form by 5pm on 5 November 2013 at
the very latest to nspupdate@nice.org.uk

NICE is unable to accept:

More than one response per stakeholder organisation

Comments received after the consultation deadline

Comments that are not complete on a stakeholder comments form

Confidential information or other material that you would not wish to be
made public

Comments forms with attachments such as research articles, letters or
leaflets. If comments forms do have attachments they will be returned
without being read. If the stakeholder resubmits the form without
attachments, it must be by the consultation deadline.

What will happen to your comments?

All comments (with the exception of personal, individual comments and late
comments) will be sent to the project team at the end of the consultation

Comments from registered stakeholders will be formally responded to by the
project team and posted on the NICE website after the final guidance is
published.

No action will be taken upon receipt of personal, individual comments and
late comments.

Please note: NICE reserves the right to summarise and edit comments
received during consultations, or not to publish them at all, where in the
reasonable opinion of NICE, the comments are voluminous, publication would
be unlawful or publication would be otherwise inappropriate.

Supporting evidence

The following evidence was used by the Public Health Advisory Committee in
developing the provisional recommendations. Please see the supporting
evidence section of the draft guidance for further details.

Review 1: ‘Update of NICE guidance PH18 on needle and syringe programmes:
qualitative and quantitative review updates’

Review 2: ‘Update of NICE guidance PH18 on needle and syringe programmes:
PIEDs review’

Review 3: ‘Injecting drug use among young people – risk, harm and factors
affecting access to services: a systematic review of the evidence’
Policy review and consensus development exercise: ‘Analysis of national
and local policy and protocols on the delivery of needle and syringe
programme services to young people under 18: policy review and consensus
development exercise’

Reviews 1 and 2 were conducted by Liverpool John Moores University.

Review 3 and the ‘Policy review and consensus development exercise’ were
conducted by the London School of Hygiene and Tropical Medicine.

View the evidence revies and economic modelling used to develop the
original guidance.

Needle and syringe programmes (update): draft guideline
http://guidance.nice.org.uk/PHG/72/Consultation/DraftGuidance/pdf/English

Needle and syringe programmes (update): guideline consultation comments
proforma
http://guidance.nice.org.uk/PHG/72/Consultation/DraftGuidance/doc/English

Needle and syringe programmes (update): supporting evidence
http://tinyurl.com/m8ooem6
__________________________________________________________________
________________________________*_________________________________

3. USA: OSAP Dental Practice Hepatitis C Prevention Informational Toolkit
__________________________________________________________________
http://tinyurl.com/HepC-Dentist-toolkit

OSAP Offers Hepatitis C Prevention Informational Toolkit

Infection Control Today (24,09.13)

In light of last week’s announcement of the first documented patient-to-
patient transmission of hepatitis C virus (HCV) in a dental practice, the
Organization for Safety, Asepsis and Prevention (OSAP) is offering some
members-only resources to the broader dental community to help support
compliance efforts for safe infection prevention practices.

The HCV case stems from the public health investigation of a Tulsa,
Oklahoma oral surgical clinic in which current and former patients of the
practice may have been exposed to bloodborne viruses. The Oklahoma State
Department of Health and Tulsa Health Department released an interim
status report on Sept. 18 on the results of their public health
investigation.

“This is the first documented report of patient-to-patient transmission of
hepatitis C virus associated with a dental setting in the United States,”
says Dr. Kristy Bradley, Oklahoma state epidemiologist. Bradley spoke at
OSAP’s 2013 Infection Prevention Symposium in June. “While dental
procedures are generally safe, this reinforces the importance of adhering
to strict infection control procedures in dental settings.”

With the amount of media coverage this case is receiving, OSAP believes
the time is right for the dental team to have a conversation about
infection control and bloodborne pathogens, especially hepatitis C. OSAP
has developed a free downloadable hepatitis C toolkit featuring relevant
regulations and guidelines, best practices, instructional resources and
patient resources available to its members. It can now be accessed by
every dental professional at www.osap.org/?page=Issues_HepC.
Also available are videos in English and Spanish, fact sheets, online
training and many other resources.

A summary of Bradley’s June lecture describing the investigative process
in this case that includes key takeaways, implementation steps and
hyperlinked resources can be found on pages 2-3 of the 2013 OSAP Symposium
Proceedings, is available at: http://tinyurl.com/HepC-Centist-1

The Oklahoma State Department of Health’s announcement can be found at:
http://tinyurl.com/HepC-Dentist-Statement

Additional resources are available through OSAP’s website, www.OSAP.org,
the Centers for Disease Control and Prevention (CDC) at www.CDC.gov and
the American Dental Association at www.ADA.org.
__________________________________________________________________
________________________________*_________________________________

4. Blog: Misinformation from UNAIDS’ flawed Modes of Transmission model

Crossposted from the Blog ‘Dont Get Stuck’
http://dontgetstuck.wordpress.com
__________________________________________________________________
http://dontgetstuck.wordpress.com

Misinformation from UNAIDS’ flawed Modes of Transmission model

by David Qisselquist on September 14, 2013

To defeat HIV/AIDS in Africa, UNAIDS recommends: “Know your epidemic.” The
best way to do so is to investigate to trace the source of infections –
especially in children with HIV-negative mothers, virgins, and married
people with HIV-negative spouses and no outside partners.

But that’s not what UNAIDS urges African governments to do. Instead,
UNAIDS urges governments to use its Modes of Transmission (MOT) model to
estimate numbers of infections from various risks.

But the MOT model contains a glaring error. Because of this error, whoever
uses the model ends up estimating far too many infections coming from
spouse-to-spouse transmission.

In Uganda, for example, the MOT model estimates that 60,948 married adults
got HIV from their spouses during 2008. This is two-thirds of the model’s
estimated total new infections from all risks in Uganda in 2008.

The MOT model got this number by supposing that 5.9% of married adults
(421,000 adults) were HIV-negative with HIV-positive spouses, and that
14.5% of these spouses at risk got HIV from husbands or wives in 2008
(60,948 = 14.5% x 421,000).

But the number of spouses at risk is far, far less. Uganda’s 2004/5
HIV/AIDS Sero-behavioral Survey reports that 6.2% of husbands and 5.2% of
wives were HIV-positive. But – and this is the important fact the MOT
model ignored – most HIV-positive husbands and wives were married to each
other. Only 2.8% of wives and 1.8% of husbands were HIV-negative with HIV-
positive spouses.

Overall only about 2.3% of married adults (averaging 2.8% of wives and
1.8% of husbands) were HIV-negative with HIV-positive spouses – only
222,000 vs. the 421,000 estimated in the MOT model. If 14.5% of these
222,000 adults got HIV from their spouses in a year, that would account
for 32,100 new infections (14.5% x 222,000), far less than the 60,948
estimated in the MOT model.

Why is this important? Because if fewer infections are coming from
spouses, how did so many Ugandans get HIV in 2008? In other words, the MOT
not only over-estimates HIV from spouses, but also underestimates
infections from other risks.

What risks are underestimated? Hold on now! Don’t run away with sexual
fantasies about young people and some married adults having too much fun
with non-spousal partners. Indulging in racist and stigmatizing sexual
fantasies is something too many official AIDS experts like to do. But the
evidence does not support such fantasies. The best information on sexual
behavior does not come close to explaining Uganda’s epidemic.

Setting aside sexual fantasies, the underestimated risks are more likely
to be those that UNAIDS’ staff and other health professionals want to
ignore – skin-piercing procedures with unsterile instruments, such as
injections, dental care, manicures, etc. This is true not only in Uganda
but also in more than 15 other African countries that have used the MOT
model to get ridiculous figures on numbers of HIV infections from spouses.

Remember how we began: The best way to “know your epidemic” is to trace
infections. Let’s challenge HIV/AIDS researchers – finally — to do their
job. Although it’s decades too late, tracing is still needed to find all
the important risks and to stop Africa’s generalized HIV/AIDS epidemics.

[Note: This blog summarizes evidence and arguments in: Gisselquist D.
UNAIDS’ Modes of Transmission model misinforms HIV prevention efforts in
Africa’s generalized epidemics, available at:
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2315554. ]
__________________________________________________________________
________________________________*_________________________________

5. Abstract: A tool to assess knowledge, attitude and behavior of
indonesian health care workers regarding infection control
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24045391

Acta Med Indones. 2013 Jul;45(3):206-15.

A tool to assess knowledge, attitude and behavior of indonesian health
care workers regarding infection control.

Duerink DO, Hadi U, Lestari ES, Roeshadi D, Wahyono H, Nagelkerke NJ,
Meulen RG, Broek PJ.

Department of Infectious Diseases, Leiden University Medical Centre,
Leiden, The Netherlands.

Aim: to investigate knowledge, attitude and behaviour toward infection
control in two teaching hospitals on the island of Java by means of a
questionnaire and to evaluate the use of the questionnaire as a tool.

Methods: we investigated knowledge, attitude and behaviour toward
infection control in two teaching hospitals on the island of Java by means
of a questionnaire to identify problem areas, barriers and facilitators.
The target was to include at least 50% of all health care workers
(physicians, nurses, assistant nurses and infection control nurses) in
each hospital, department and profession.

Differences between demographic variables and scores for individual
questions and groups of questions were compared using the chi-square
statistic and analysis of variance and Spearman’s rho was used to test for
correlations between knowledge, attitude, self-reported behaviour and
perceived obstacles.

Results: more than half of the health care workers of the participating
departments completed the questionnaire. Of the 1036 respondents (44%
nurses, 37% physicians and 19% assistant nurses), 34% were vaccinated
against hepatitis B, 77% had experienced needle stick accidents and 93%
had been instructed about infection control. The mean of the correct
answers to the knowledge questions was 44%; of the answers to the attitude
questions 67% were in agreement with the correct attitude; obstacles to
compliance with infection control guidelines were perceived in 30% of the
questions and the mean self-reported compliance was 63%.

Safe handling of sharps, hand hygiene and the use of personal protective
equipment were identified as the most important aspects for interventions.
Significant positive correlations were found between knowledge, attitude,
self-reported behaviour and perceived obstacles.

Conclusion: the questionnaire in conjunction with site visits and
interviews was a valuable strategy to identify trouble spots in the
hospitals and to determine barriers to facilitators of change that should
be taken into account when planning interventions. Successful
interventions should cover hospital management, the infection control
team, as well as the health care workers on the wards.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Knowledge and Perceptions of HIV/AIDS among Cameroonian
Nursing Students
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24047598

Int J Nurs Educ Scholarsh. 2013 Sep 18;10(1).

pii: /j/ijnes.2013.10.issue-1/ijnes-2012-0036/ijnes-2012-0036.xml.

Knowledge and Perceptions of HIV/AIDS among Cameroonian Nursing Students.

Diesel H, Ercole P, Taliaferro D.

The HIV/AIDS pandemic impacts people throughout the world and is
complicated by fear, prejudice, and stigma. Nurses play a major role in
the health care delivery systems, yet in many parts of the world with high
HIV sero-prevalence rates, nurses lack sufficient training and education
to provide care to patients with HIV/AIDS.

In an effort to build capacity and improve knowledge, attitudes and
beliefs regarding care of patients with HIV/AIDS, a 4-day workshop was
provided by American nursing students for Cameroonian nursing students.
The training program included HIV epidemiology, disease management, and
natural course of the disease, testing, legal and ethical issues, and
infection control practices.

Pre- and post-test scores were calculated using a series of surveys that
measured HIV-related knowledge, attitudes, and beliefs.

Results indicated that these measures of HIV-related perceptions improved
due to the train- the-trainer workshop.
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Assessment of health-care waste disposal methods using a
VIKOR-based fuzzy multi-criteria decision making method
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24011433

Waste Manag. 2013 Sep 4. pii: S0956-053X(13)00379-6.

Assessment of health-care waste disposal methods using a VIKOR-based fuzzy
multi-criteria decision making method.

Liu HC, Wu J, Li P.

School of Management, Hefei University of Technology, Hefei 230009, PR
China; Department of Industrial Engineering and Management, Tokyo
Institute of Technology, Tokyo 152-8552, Japan.

Nowadays selection of the appropriate treatment method in health-care
waste (HCW) management has become a challenge task for the municipal
authorities especially in developing countries. Assessment of HCW disposal
alternatives can be regarded as a complicated multi-criteria decision
making (MCDM) problem which requires consideration of multiple alternative
solutions and conflicting tangible and intangible criteria.

The objective of this paper is to present a new MCDM technique based on
fuzzy set theory and VIKOR method for evaluating HCW disposal methods.
Linguistic variables are used by decision makers to assess the ratings and
weights for the established criteria. The ordered weighted averaging (OWA)
operator is utilized to aggregate individual opinions of decision makers
into a group assessment.

The computational procedure of the proposed framework is illustrated
through a case study in Shanghai, one of the largest cities of China.

The HCW treatment alternatives considered in this study include
“incineration”, “steam sterilization”, “microwave” and “landfill”.

The results obtained using the proposed approach are analyzed in a
comparative way.

Copyright © 2013. Published by Elsevier Ltd.

KEYWORDS: Fuzzy sets, Health-care waste management, OWA operator, VIKOR
method
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Effect of infection control strategy on knowledge, attitude
and practice towards hepatitis B transmission and prevention in
vulnerable populations
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24047685

Int J Risk Saf Med. 2013 Jan 1;25(3):135-43.

Effect of infection control strategy on knowledge, attitude and practice
towards hepatitis B transmission and prevention in vulnerable populations.

Al-Tawil MM, El-Gohary EE, El-Sayed MH.

Haematology Oncology Department, Children Hospital, Faculty of Medicine,
Ain Shams University, Cairo, Egypt.

BACKGROUND: Health care workers (HCWs) and hematological patients needing
blood/ blood product transfusion are particularly vulnerable to blood born
infections (BBI) including viral hepatitis.

OBJECTIVE: To evaluate knowledge, attitude and practice (KAP) of these
target groups regarding viral hepatitis B (HBV) transmission and its
change with implementing infection control policy and procedures.

METHODS: An anonymous questionnaire with closed questions was used to
evaluate KAP including vaccination status in 2 target groups, in Children
Hospital, Ain Shams University, Cairo, Egypt: 184 nurses and 210 children
and adolescents with blood diseases. One year after instituting infection
control as a part of hospital procedures, the same questionnaire was
reused to evaluate KAP towards HBV.

RESULTS: Baseline knowledge regarding HBV transmission, sequelae and
preventive measures, was poor in both groups. Among nurses, only 62% wore
gloves on withdrawing or giving blood to patients, 43.5% routinely washed
hands between patients and 37.5% reported exposure after sharp injury.
Only 38% of patients and 40% of nurses received HBV vaccination. Targeted
infection control policy and procedures significantly improved KAP
regarding HBV in both groups. Vaccination coverage significantly increased
and reached 88.7% for nurses and 72% for patients.

CONCLUSIONS: Hospital based infection control units with established
policy and procedures against BBI significantly improved KAP towards HBV
including a significant increase in vaccination intake.
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Burden of infectious diseases, substance use disorders, and
mental illness among Ukrainian prisoners transitioning to the community
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23527238

PLoS One. 2013;8(3):e59643.

Burden of infectious diseases, substance use disorders, and mental illness
among Ukrainian prisoners transitioning to the community.

Azbel L, Wickersham JA, Grishaev Y, Dvoryak S, Altice FL.

Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.

BACKGROUND: The epidemics of incarceration, substance use disorders
(SUDs), and infectious diseases are inextricably intertwined, especially
in the Former Soviet Union (FSU). Few objective data documenting this
relationship regionally are available. We therefore conducted a
comprehensive, representative country-wide prison health survey in
Ukraine, where one of the world’s most volatile HIV epidemics persists, in
order to address HIV prevention and treatment needs.

METHODS: A nation-wide, multi-site randomly sampled biobehavioral health
survey was conducted in four Ukrainian regions in 13 prisons among
individuals being released within six months. After consent, participants
underwent standardized health assessment surveys and serological testing
for HIV, viral hepatitis, and syphilis.

RESULTS: Of the 402 participants (mean age = 31.9 years), 20.1% were
female. Prevalence of HIV, HCV, HBV, and syphilis was 19.4% (95% CI =
15.5%-23.3%), 60.2% (95% CI = 55.1%-65.4%), 5.2% (95% CI = 3.3%-7.2%), and
10% (95% CI = 7.4%-13.2%), respectively, with regional differences
observed; HIV prevalence in the south was 28.6%. Among the 78 HIV-infected
inmates, 50.7% were unaware of their HIV status and 44 (56.4%) had CD4<350
cells/mL, of which only five (11%) antiretroviral-eligible inmates were
receiving it. Nearly half of the participants (48.7%) reported pre-
incarcertion drug injection, primarily of opioids, yet multiple substance
use (31.6%) and alcohol use disorders (56.6%) were common and 40.3% met
screening criteria for depression.

CONCLUSIONS: This is the only such representative health study of
prisoners in the FSU. This study has important implications for regional
prevention and treatment because, unlike elsewhere, there is no recent
evidence for reduction in HIV incidence and mortality in the region. The
prevalence of infectious diseases and SUDs is high among this sample of
prisoners transitioning to the community. It is critical to address pre-
and post- release prevention and treatment needs with the development of
linkage programs for the continuity of care in the community after
release.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602355/
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Pharmacy syringe purchase test of nonprescription syringe
sales in San Francisco and Los Angeles in 2010
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/22718357

J Urban Health. 2013 Apr;90(2):276-83. doi:

Pharmacy syringe purchase test of nonprescription syringe sales in San
Francisco and Los Angeles in 2010.

Lutnick A, Cooper E, Dodson C, Bluthenthal R, Kral AH.

Urban Health Program, RTI International, San Francisco, CA, USA.
alutnick@rti.org

The two main legal sources of clean needles for illicit injection drug
users (IDUs) in California are syringe exchange programs (SEPs) and
nonprescription syringe sales (NPSS) at pharmacies. In 2004, California
became one of the last states to allow NPSS.

To evaluate the implementation of NPSS and the California Disease
Prevention Demonstration Project (DPDP), we conducted syringe purchase
tests in San Francisco (SF) and Los Angeles (LA) between March and July of
2010.

Large differences in implementation were observed in the two cities. In
LA, less than one-quarter of the enrolled pharmacies sold syringes to our
research assistant (RA), and none sold a single syringe. The rate of
successful purchase in LA is the lowest reported in any syringe purchase
test. In both sites, there was notable variation among the gauge size
available, and price and quantity of syringes required for a purchase.

None of the DPDP pharmacies in LA or SF provided the requisite health
information.

The findings suggest that more outreach needs to be conducted with
pharmacists and pharmacy staff. The pharmacies’ failure to disseminate the
educational materials may result in missed opportunities to provide needed
harm reduction information to IDUs. The varied prices and required
quantities may serve as a barrier to syringe access among IDUs.

Future research needs to examine reasons why pharmacies do not provide the
mandated information, whether the omission of disposal options is
indicative of pharmacies’ reluctance to serve as disposal sites, and if
the dual opt-in approach of NPSS/DPDP is a barrier to pharmacy enrollment.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Estimates of the size of key populations at risk for HIV
infection: men who have sex with men, female sex workers and injecting
drug users in Nairobi, Kenya
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23761166

Sex Transm Infect. 2013 Aug;89(5):366-71.

Estimates of the size of key populations at risk for HIV infection: men
who have sex with men, female sex workers and injecting drug users in
Nairobi, Kenya.

Okal J, Geibel S, Muraguri N, Musyoki H, Tun W, Broz D, Kuria D, Kim A,
Oluoch T, Raymond HF.

Population Council, Nairobi, Kenya.

OBJECTIVES: Size estimates of populations at higher risk for HIV infection
are needed to help policy makers understand the scope of the epidemic and
allocate appropriate resources. Population size estimates of men who have
sex with men (MSM), female sex workers(FSW) and intravenous drug users
(IDU) are few or non-existent in Nairobi, Kenya.

METHODS: We integrated three population size estimation methods into a
behavioural surveillance survey among MSM, FSW and IDU in Nairobi during
2010–2011. These methods included the multiplier method, ‘Wisdom of the
Crowds’ and an approach that drew on published literature. The median of
the three estimates was hypothesised to be the most plausible size
estimate with the other results forming the upper and lower plausible
bounds. Data were shared with community representatives and stakeholders
to finalise ‘best’ point estimates and plausible bounds based on the data
collected in Nairobi, a priori expectations from the global literature and
stakeholder input.

RESULTS: We estimate there are approximately 11 042 MSM with a plausible
range of 10 000–22 222, 29 494 FSW with a plausible range of 10 000–54 467
FSW and approximately 6107 IDU and plausibly 5031–10 937 IDU living in
Nairobi.

CONCLUSIONS: We employed multiple methods and used a wide range of data
sources to estimate the size of three hidden populations in Nairobi,
Kenya. These estimates may be useful to advocate for and to plan,
implement and evaluate HIV prevention and care programmes for MSM, FSW and
IDU. Surveillance activities should consider integrating population size
estimation in their protocols.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Health and safety risks associated with public injecting
among people who inject drugs in Bangkok, Thailand
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24033410

Drug Alcohol Rev. 2013 Aug 28.

Health and safety risks associated with public injecting among people who
inject drugs in Bangkok, Thailand.

Leung LT, Ti L, Hayashi K, Suwannawong P, Kaplan K, Wood E, Kerr T.

British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, Canada; Faculty of Medicine, University of British Columbia,
Vancouver, Canada.

INTRODUCTION AND AIMS: The injection of illicit drugs in public spaces is
known to pose significant health risks to people who inject drugs (IDU).
However, to our knowledge this practice has not been explored in the Asian
context. Therefore, we sought to characterise the prevalence of and
factors associated with public injecting among a community-recruited
sample of IDU in Bangkok, Thailand.

DESIGN AND METHODS: Data were derived from the Mitsampan Community
Research Project between July and October 2011. Using multivariate
logistic regression, this cross- sectional study examined the prevalence
and correlates of public injecting within the past six months among 437
IDU participants.

RESULTS: In total, 121 (27.7%) participants reported injecting drugs in a
public space within the past six months. In multivariate analyses, public
drug injection was independently associated with male gender [adjusted
odds ratio (AOR) 2.51, 95% confidence interval (CI)) 1.29-5.22], weekly
heroin injection (AOR 2.19, 95% CI 1.27-3.77), assisted injection (AOR
1.93, 95% CI 1.06-3.49), rushed injection (AOR 4.36, 95% CI 2.65-7.24),
incarceration (AOR 2.27, 95% CI 1.01-5.04) and noticing police presence
where drugs are bought or used (AOR 1.83, 95% CI 1.06-3.19).

DISCUSSION AND CONCLUSION: A substantial proportion of Thai IDU in our
sample reported recent public drug injection. This behaviour was
independently associated with a wide range of individual and contextual
factors that pose significant health and safety risks to the IDU. These
findings highlight the importance of addressing the broader social and
physical risk environment surrounding IDU as a means of preventing
negative health outcomes among this population. [Leung LTF, Ti L, Hayashi
K, Suwannawong P, Kaplan K, Wood E, Kerr T. Health and safety risks
associated with public injecting among people who inject drugs in Bangkok,
Thailand. Drug Alcohol Rev 2013].

© 2013 Australasian Professional Society on Alcohol and other Drugs.

KEYWORDS: Thailand, assisted injection, injection drug use, law
enforcement, public injecting
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Seroprevalence of hepatitis B and C infection among the
HIV-positive population in Abuja, Nigeria
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23382745

Afr Health Sci. 2012 Sep;12(3):312-7.

Seroprevalence of hepatitis B and C infection among the HIV-positive
population in Abuja, Nigeria.

Tremeau-Bravard A, Ogbukagu IC, Ticao CJ, Abubakar JJ.

Gede Foundation, 13 Danube Street, Abuja, Nigeria.
a_tremeau_bravard@hotmail.com

BACKGROUND: In Nigeria, it is estimated that 3.6% of the population were
living with Human immunodeficiency virus in 2009, and the country had the
world’s second highest number of HIV/AIDS related deaths after South
Africa. Viral hepatitis is also a major public health concern as hepatitis
B virus (HBV) afflicts an estimated 350 million people, and hepatitis C
virus (HCV) affects 150 million people worldwide.

OBJECTIVES: We conducted a retrospective study of HBV and HCV
seroprevalence among Nigerian population coming to our clinic in Abuja and
receiving HIV/AIDS treatment.

METHODS: In this cohort study, we collected medical data from 443 HIV-
positive patients between September 2010 and May 2011. Standard enzyme
immunoassays were used to determine the serological prevalence of
hepatitis B (HBsAg) and C (anti-HCV antibody) among HIV-positive
individuals.

RESULTS: Among the HIV/AIDS positive individuals, we found that 35
patients were infected with hepatitis B virus (7.9%), 10 with hepatitis C
virus (2.3%) and 3 with both hepatitis B and C viruses (0.7%). The overall
hepatitis- HIV prevalence is 10.8%. The majority of the population
infected was under 39 years of age (55%) and the same proportion of males
and females was observed in all the studied categories (HIV, HIV +
hepatitis B and/or C). Remarkably, an overall lower CD4 count was seen in
the co-infected population (205 cells/µl versus 243 cells/µl), with the
lowest seen for the triply infected individuals (97 cells/µl).

CONCLUSIONS: Our findings underscore the importance of screening for
hepatitis B and hepatitis C viruses in the HIV-infected population in
developing countries, and particularly in sub-Saharan Africa, where the
epidemics are still growing.

KEYWORDS: Hepatitis B virus, Hepatitis C virus, Human Immunodeficiency
Virus, Nigeria, cohort study

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557671/
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Injecting drug use among gay and bisexual men in Sydney:
prevalence and associations with sexual risk practices and HIV and
hepatitis C infection
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23321949

AIDS Behav. 2013 May;17(4):1344-51.

Injecting drug use among gay and bisexual men in Sydney: prevalence and
associations with sexual risk practices and HIV and hepatitis C infection.

Lea T, Mao L, Bath N, Prestage G, Zablotska I, de Wit J, Holt M.

National Centre in HIV Social Research, The University of New South Wales,
Sydney, NSW 2052, Australia. toby.lea@unsw.edu.au

Injecting drug use is commonly reported among gay and bisexual men in
Australia. We examined the prevalence and covariates of injecting drug use
among men participating in the Sydney Gay Community Periodic Survey
between 2004-06 and 2011. In 2004-06, data was collected about which drugs
were injected, while in 2011, data was collected about hepatitis C (HCV)
and esoteric sexual practices.

In 2004-06, 5.6 % of men reported injecting drugs in the previous 6
months; 3.4 % reported methamphetamine injection and 0.4 % heroin
injection. In 2011, men who injected drugs were less likely to be employed
full-time, and more likely to be HCV-positive, HIV- positive, to have used
party drugs for sex, and to have engaged in esoteric sexual practices.

The strong associations between injecting drug use, sexual risk practices
and blood-borne virus infection suggests the need for combined sexual
health and harm reduction services for gay and bisexual men who inject
drugs.
__________________________________________________________________
________________________________*_________________________________

15. Abstract: The prevalence and trends of transfusion-transmissible
infectious pathogens among first-time, voluntary blood donors in
Xi’an, China between 1999 and 2009
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23195637

Int J Infect Dis. 2013 Apr;17(4):e259-62.

The prevalence and trends of transfusion-transmissible infectious
pathogens among first-time, voluntary blood donors in Xi’an, China between
1999 and 2009.

Ji ZH, Li CY, Lv YG, Cao W, Chen YZ, Chen XP, Tian M, Li JH, An QX, Shao
ZJ.

Department of Epidemiology, School of Public Health, The Fourth Military
Medical University, No. 17, Changle West Road, Xi’an, China 710032.

OBJECTIVES: The prevalence of infectious diseases is increasing in
developing countries, and this may threaten the biological safety of
donated blood. This study analyzed trends in the prevalence of
transfusion-transmissible infectious pathogens among Chinese, first-time,
voluntary blood donors from 1999 to 2009 to evaluate the potential for
disease transmission.

METHODS: From 1999 to 2009, all first-time donors at the Xi’an Blood
Service (XBS) were screened for hepatitis B virus (HBV), hepatitis C virus
(HCV), human immunodeficiency virus (HIV), and syphilis infections using
enzyme-linked immunosorbent assays (ELISA); results were confirmed using
alternative commercial kits. The prevalence and temporal trends were
analyzed using the Cochran-Armitage trend test and other appropriate
methods.

RESULTS: From 1999 to 2009, 263 299 first-time blood donors were analyzed.
The overall prevalence rates were 1.16% for HBV, 0.51% for HCV, 0.02% for
HIV, and 0.31% for syphilis. There was a significant decrease in the trend
for HBV and HCV infections, while a significant increase was found for
syphilis. The prevalence of HIV infection remained low and stable during
the study period.

CONCLUSIONS: These findings suggest that HBV infection is the primary
threat to blood safety, while the increasing prevalence of syphilis might
also be a potential threat.

Copyright © 2012 International Society for Infectious Diseases. Published
by Elsevier Ltd. All rights reserved.
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Management of an incident of failed sterilization of
surgical instruments in a dental clinic in Hong Kong
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24034908

J Formos Med Assoc. 2013 Sep 10. pii: S0929-6646(13)00267-2.

Management of an incident of failed sterilization of surgical instruments
in a dental clinic in Hong Kong.

Cheng VC, Wong SC, Sridhar S, Chan JF, Ng ML, Lau SK, Woo PC, Lo EC, Chan
KK, Yuen KY.

Department of Microbiology, Queen Mary Hospital, Hong Kong Special
Administrative Region, China; Infection Control Team, Queen Mary Hospital,
Hong Kong Special Administrative Region, China; Carol Yu Centre for
Infection, The University of Hong Kong, Hong Kong Special Administrative
Region, China.

BACKGROUND/PURPOSE: We describe an investigation of an incident of failed
sterilization procedure in a dental clinic. We aim to illustrate the
principles in performing such investigations and to highlight some of the
important checkpoints in sterilization procedures.

METHODS: In response to this incident, proper sterilization of all
equipment was performed immediately. On-site investigation was conducted
by the investigation panel, to identify the cause and risks, to coordinate
post- exposure management in affected patients, and to make
recommendations to prevent similar happenings.

RESULTS: The incident was due to a rare lapse of monitoring during the
autoclaving cycle. A total of 127 sources and 250 exposed patients were
identified within 24 hours of the discovery of the incident for risk
assessment and testing for blood borne viruses, including hepatitis B
virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus
(HIV). A protocol was devised to manage the exposed patients against HBV,
HCV, and HIV.

Immunization and hyperimmune globulin for hepatitis B, and tetanus toxoids
were given to the exposed patients where indicated. Exposed patients were
followed-up for 6 months.

We came to the decision that dating of instrument packages and signed
documentation of each autoclave printout, color change of chemical
indicators of each load, and the daily autoclave performance should be
made mandatory with immediate effect.

CONCLUSION: Rapid response is extremely crucial in minimizing the impact
of this incident and relieving the anxiety of the affected patients.
Proper recording and documentation of autoclave cycles and regular
auditing should be enforced to prevent similar incidents.

Copyright © 2013. Published by Elsevier B.V.
__________________________________________________________________
________________________________*_________________________________

18. Abstract: Global implementation of WHO’s multimodal strategy for
improvement of hand hygiene: a quasi-experimental study
__________________________________________________________________
http://tinyurl.com/leqcudk

The Lancet Infectious Diseases, Volume 13, Issue 10, Pages 843 – 851,
October 2013

Global implementation of WHO’s multimodal strategy for improvement of hand
hygiene: a quasi-experimental study

Benedetta Allegranzi MD a, Angèle Gayet-Ageron MD b, Nizam Damani MD c,
Loséni Bengaly PhD d, Prof Mary-Louise McLaws PhD e, Maria-Luisa Moro MD
f, Ziad Memish MD g, Orlando Urroz MD h, Prof Hervé Richet MD i, Julie
Storr MBA j, Liam Donaldson MD j, Prof Didier Pittet MD b Corresponding
AuthorEmail Address

Background Health-care-associated infections are a major threat to patient
safety worldwide. Transmission is mainly via the hands of health-care
workers, but compliance with recommendations is usually low and effective
improvement strategies are needed. We assessed the effect of WHO’s
strategy for improvement of hand hygiene in five countries.

Methods We did a quasi-experimental study between December, 2006, and
December, 2008, at six pilot sites (55 departments in 43 hospitals) in
Costa Rica, Italy, Mali, Pakistan, and Saudi Arabia. A step-wise approach
in four 3—6 month phases was used to implement WHO’s strategy and we
assessed the hand-hygiene compliance of health-care workers and their
knowledge, by questionnaire, of microbial transmission and hand-hygiene
principles. We expressed compliance as the proportion of predefined
opportunities met by hand-hygiene actions (ie, handwashing or hand
rubbing). We assessed long- term sustainability of core strategy
activities in April, 2010.

Findings We noted 21 884 hand-hygiene opportunities during 1423 sessions
before the intervention and 23 746 opportunities during 1784 sessions
after. Overall compliance increased from 51·0% before the intervention
(95% CI 45·1—56·9) to 67·2% after (61·8—72·2). Compliance was
independently associated with gross national income per head, with a
greater effect of the intervention in low-income and middle-income
countries (odds ratio [OR] 4·67, 95% CI 3·16—6·89; p<0·0001) than in high-
income countries (2·19, 2·03—2·37; p<0·0001).

Implementation had a major effect on compliance of health-care workers
across all sites after adjustment for main confounders (OR 2·15,
1·99—2·32). Health-care-workers’ knowledge improved at all sites with an
increase in the average score from 18·7 (95% CI 17·8—19·7) to 24·7
(23·7—25·6) after educational sessions. 2 years after the intervention,
all sites reported ongoing hand-hygiene activities with sustained or
further improvement, including national scale-up.

Interpretation Implementation of WHO’s hand-hygiene strategy is feasible
and sustainable across a range of settings in different countries and
leads to significant compliance and knowledge improvement in health-care
workers, supporting recommendation for use worldwide.

Funding WHO, University of Geneva Hospitals, the Swiss National Science
Foundation, Swiss Society of Public Health Administration and Hospital
Pharmacists.

Copyright © 2013 World Health Organization. Published by Elsevier
Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd. All rights
reserved.
__________________________________________________________________
________________________________*_________________________________

19. Abstract: Modified World Health Organization hand rub formulations
comply with European efficacy requirements for preoperative surgical
hand preparations
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23388358

Infect Control Hosp Epidemiol. 2013 Mar;34(3):245-50.

Modified World Health Organization hand rub formulations comply with
European efficacy requirements for preoperative surgical hand
preparations.

Suchomel M, Kundi M, Pittet D, Rotter ML.

Institute of Hygiene and Applied Immunology, Medical University of Vienna,
Vienna, Austria. miranda.suchomel@meduniwien.ac.at

BACKGROUND: The World Health Organization (WHO) has published “Guidelines
on Hand Hygiene in Health Care” recommending 2 hand rub formulations based
on 80% vol/vol ethanol or 75% vol/vol isopropanol for local production in
healthcare settings where commercial products are not available or are too
expensive. Previous investigations have shown that neither formulation
meets the efficacy requirements of European norm (EN) 12791, which is the
most stringent available norm for surgical hand rub preparations. Even
when modified with approximately 5% higher alcohol content, the
formulations proved to be inferior to the reference of the norm when
measured after 3 hours.

OBJECTIVE: Because the high glycerol content of the formulations was
suspected to negatively influence their efficacy, additional
investigations were performed with varying glycerol content.

METHODS: Modified formulations with higher alcohol concentration (mass
instead of volume percentage) and lower glycerol concentration (0.725%
instead of 1.45%) or without the addition of glycerol were evaluated for
their conformity with the efficacy requirements of EN 12791, which demands
noninferiority in comparison with a reference hand antisepsis procedure
immediately and 3 hours after treatment on volunteers’ hands.

DESIGN: Randomized Latin-square design.

SETTING: Microbiology laboratory of the Medical University of Vienna,
Vienna, Austria.

PARTICIPANTS: Twenty-five healthy volunteers.

RESULTS: Reducing the concentration of glycerol or omitting it completely
rendered both WHO formulations noninferior to the reference, both
immediately and 3 hours after surgical hand antisepsis.

CONCLUSIONS: Both WHO-recommended formulations meet the efficacy
requirements of EN 12791 by increasing their alcohol concentrations by 5%,
prolonging their application to 5 minutes and reducing the glycerol
concentration to 0.725%.
__________________________________________________________________
________________________________*_________________________________

20. Abstract: Hand hygiene and the use of personal protective equipment
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24037392

Br J Nurs. 2013 Sep 12;22(16):920-5.

Hand hygiene and the use of personal protective equipment.

Wyeth J.

Lead Nurse for Infection Prevention and Control at the Royal Berkshire NHS
Foundation Trust, Reading.

Infection prevention and control nurses (IPCNs) have an extremely wide
remit in relation to the facilitation of appropriate infection prevention
and control practice within healthcare environments. In order to be
effective IPCNs need to be involved at all stages of healthcare service
delivery and need to form close working relationships with staff at all
levels and in all departments within their organisation.

The provision of the necessary facilities within the clinical environment,
along with the ongoing training and support of staff are essential
prerequisites to changing the behaviour of staff in order to consistently
deliver effective hand hygiene and other infection prevention and control
practices.

Auditing of practice and the investigation of incidents enable the
identification of areas of practice requiring improvement, which
subsequently informs the continual development of training programmes and
initiatives with a view to improving patient and staff safety.

IPCNs need to be able to react swiftly to the emergence of new infectious
organisms and/or evidence to identify what is required in order to ensure
that staff are compliant with anticipated practice to maintain the safety
of the patients in their care, themselves and their colleagues.
__________________________________________________________________
________________________________*_________________________________

21. Abstract: Disinfectants in health care: finding an alternative to
chlorine dioxide
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24037393

Br J Nurs. 2013 Sep 12;22(16):926-32.

Disinfectants in health care: finding an alternative to chlorine dioxide.

Keward J.

CNS Infection Prevention & Control at Alder Hey Children?s NHS Foundation
Trust, Eaton Road, West Derby, Liverpool.

Cleanliness of the clinical environment has a direct impact on healthcare-
associated infection (HCAI) incidence and there is increasing evidence of
its importance with regard to infection prevention and control. While
traditional high-level disinfectants have excellent antimicrobial
properties, these are typically offset against issues such as
corrosiveness, toxicity, cost and user acceptance.

Recent years have seen several user-friendly sporicidal disinfectants
emerge onto the market. Antimicrobial profile and user acceptance
determine the clinical success of any disinfectant. Therefore, product
adoption is often a two-stage process with a tabletop evaluation of the
appropriate technical data, including efficacy claims, followed by an in-
use product evaluation.

The first part of this article demonstrates the importance of the clinical
environment with respect to HCAI and examines some of the issues around
disinfectants used in health care and considerations when selecting a new
disinfectant for use.

The second part reports the experiences of the Infection Prevention and
Control team at Alder Hey Children’s Hospital in their assessment and
subsequent adoption of a new user-friendly sporicidal disinfectant into
clinical practice.
__________________________________________________________________
________________________________*_________________________________

22. Abstract: Safety and immunogenicity of revaccination with reduced dose
intradermal and standard dose intramuscular influenza vaccines in
adults 18-64 years of age
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24055306

Vaccine. 2013 Sep 19. pii: S0264-410X(13)01239-5.

Safety and immunogenicity of revaccination with reduced dose intradermal
and standard dose intramuscular influenza vaccines in adults 18-64 years
of age.

Gorse GJ, Falsey AR, Johnson CM, Morrison D, Fried DL, Ervin JE, Greenberg
DP, Ozol-Godfrey A, Landolfi V, Tsang PH.

Division of Infectious Diseases, Allergy and Immunology, Saint Louis
University School of Medicine, 1100 S. Grand Boulevard, St. Louis, MO
63104, USA. Electronic address: gorsegj@slu.edu.

BACKGROUND: This clinical trial examined the safety and immunogenicity of
annual revaccination with Fluzone® Intradermal (Sanofi Pasteur,
Swiftwater, PA) vaccine compared to a standard intramuscular (IM) split-
virion trivalent influenza vaccine (Fluzone®, Sanofi Pasteur).

METHODS: This phase II, active-controlled, multi-centre, open-label trial
was conducted in 2009 and 2010, and enrolled 1250 adults 18-64 years of
age who were randomly selected from participants in a phase III influenza
vaccine trial the previous year (NCT00772109). Subjects who had previously
received the ID vaccine were randomized 2:1 to be revaccinated with the ID
or IM vaccine and those who previously received the IM vaccine were
randomized 1:1. Solicited reactions were recorded on the day of
vaccination and continuing for the next 7 days, non-serious adverse events
for 28 days, and serious adverse events for 6 months after vaccination.
Hemagglutination inhibition antibody titres were assessed pre-vaccination
and at day 28.

RESULTS: Reactions were well-tolerated and resolved in the first 7 days,
but erythema, induration, swelling, pruritus and ecchymosis were reported
by more subjects receiving the ID vaccine than the IM vaccine. Compared to
receipt of IM vaccine in the previous year, ID vaccine in the previous
year led to statistically higher rates of erythema, swelling and
induration after IM vaccine in the second year. Injection-site pain and
systemic reactions did not differ between ID and IM vaccines. No
treatment-related serious adverse events were reported. Geometric mean
antibody titres, seroprotection rates, and seroconversion rates were non-
inferior for the ID and IM vaccines for all three viral strains.

CONCLUSIONS: The ID vaccine was as immunogenic as the IM vaccine, and
raised no safety concerns. It can be used interchangeably with the IM
vaccine for annual revaccination in adults 18-64 years of age in
consecutive years without safety concerns.

Copyright © 2013. Published by Elsevier Ltd.

KEYWORDS: AE, CI, GMT, HAI, ID, IM, Immunogenicity, Intradermal,
Intramuscular, LLOQ, SAE, Safety, Trivalent influenza vaccine, adverse
event, confidence interval, geometric mean titre, hemagglutination
inhibition, intradermal, intramuscular, lower limit of quantitation,
serious adverse event
__________________________________________________________________
________________________________*_________________________________

23. Abstract: Comparative pharmacokinetics of subcutaneous trastuzumab
administered via handheld syringe or proprietary single-use injection
device in healthy males
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24057039

Cancer Chemother Pharmacol. 2013 Sep 22.

Comparative pharmacokinetics of subcutaneous trastuzumab administered via
handheld syringe or proprietary single-use injection device in healthy
males.

Wynne CJ, Ellis-Pegler RB, Waaka DS, Schwabe C, Lehle M, Heinzmann D,
Mangat R, Li C, Dick AE, Cranshaw NA, Lum BL.

Christchurch Clinical Studies Trust, 31 Tuam Street, Christchurch, New
Zealand, chris@ccst.co.nz.

PURPOSE: To demonstrate pharmacokinetic (PK) comparability for a single
dose of 600 mg subcutaneous (SC) trastuzumab, administered via a novel
single-use injection device (SID) or handheld syringe in 119 randomized
healthy male subjects.

METHODS: The co-primary PK endpoints area under the time-concentration
curve from the start of dosing to day 22 (AUC0-21 days) and maximum
observed trastuzumab serum concentration (C max) were dose-normalized and
body- weight-adjusted, and compared using geometric mean ratios (GMRs).
SID performance, injection site pain, adverse events, and antidrug
antibodies (ADAs) were assessed.

RESULTS: GMRs and 90 % confidence intervals (CIs) were 1.01 (0.96-1.07)
for AUC0-21 days and 1.02 (0.96-1.10) for C max, which fell within the
prespecified bioequivalence range (0.80-1.25). No SID quality issues or
failures occurred. Adverse events were mostly mild, with no deaths,
adverse event- related withdrawals, or life-threatening, cardiac, or
serious events reported. The ADA rate was low, and no neutralizing
antibodies were detected.

CONCLUSIONS: Trastuzumab SC via SID demonstrated comparable PK and safety
to handheld syringe administration. SID performance was very satisfactory.
__________________________________________________________________
________________________________*_________________________________

24. Abstract: Tolerability of intramuscular and intradermal delivery by
CELLECTRA® adaptive constant current electroporation device in healthy
volunteers
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24051434

Hum Vaccin Immunother. 2013 Jun 4;9(10).

Tolerability of intramuscular and intradermal delivery by CELLECTRA®
adaptive constant current electroporation device in healthy volunteers.

Diehl MC, Lee JC, Daniels SE, Tebas P, Khan AS, Giffear M, Sardesai NY,
Bagarazzi ML.

Inovio Pharmaceuticals; Blue Bell, PA USA.

DNA vaccines are being developed as a potentially safe and effective
immunization platform. However, translation of DNA vaccines into a
clinical setting has produced results that have fallen short of those
generated in a preclinical setting. Various strategies are being developed
to address this lack of potency, including improvements in delivery
methods. Electroporation (EP) creates transient increases in cell membrane
permeability, thus enhancing DNA uptake and leading to a more robust
immune response.

Here, we report on the safety and tolerability of delivering sterile
saline via intramuscular (IM) or intradermal (ID) injection followed by in
vivo electroporation using the CELLECTRA® adaptive constant current device
in healthy adults from two open-label studies. Pain, as assessed by VAS,
was highest immediately after EP but diminishes by about 50% within 5 min.
Mean VAS scores appear to correlate with the amount of energy delivered
and depth of needle insertion, especially for intramuscular EP. Mean
scores did not exceed 7 out of 10 or 3 out of 10 for IM and ID EP,
respectively.

The majority of adverse events included mild to moderate injection site
reactions that resolved within one day. No deaths or serious adverse
events were reported during the course of either study. Overall, injection
followed by EP with the CELLECTRA® device was well-tolerated and no
significant safety concerns were identified.

These studies support the further development of electroporation as a
vaccine delivery method to enhance immunogenicity, particularly for
diseases in which traditional vaccination approaches are ineffective.

KEYWORDS: electroporation, intradermal, intramuscular, vaccination, visual
analog scale
__________________________________________________________________
________________________________*_________________________________

25. Abstract: Higher lung accumulation of intravenously injected organic
nanotubes
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23345977

Int J Nanomedicine. 2013;8:315-23.

Higher lung accumulation of intravenously injected organic nanotubes.

Maitani Y, Nakamura Y, Kon M, Sanada E, Sumiyoshi K, Fujine N, Asakawa M,
Kogiso M, Shimizu T.

Institute of Medicinal Chemistry, Hoshi University, Tokyo, Japan.
yoshie@hoshi.ac.jp

The size and shape of intravenously injected particles can affect their
biodistribution and is of importance for the development of particulated
drug carrier systems. In this study, organic nanotubes (ONTs) with a
carboxyl group at the surface, a length of approximately 2 µm and outer
diameter of 70-90 nm, were injected intravenously into tumor-bearing mice.

To use ONTs as drug carriers, the biodistribution in selected organs of
ONTs postinjection was examined using irinotecan, as an entrapped water-
soluble marker inside ONTs, and gadolinium-chelated ONT, as an ONT marker,
and compared with that of a 3 µm fluorescently labeled spherical
microparticle which was similar size to the length of ONTs.

It was found that for irinotecan, its active metabolite and gadolinium-
chelated ONTs were highly accumulated in the lung, but to a lower level in
the liver and spleen. On the other hand, microparticles deposited less in
the lung and more highly in the liver. Moreover, histologic examination
showed ONTs distributed more in lung tissues in part, whereas
microparticles were present in blood vessels postinjection.

These preliminary results support the notion of using negatively charged
ONTs as intravascular carriers to maximize accumulation in the lung whilst
reducing sequestration by the liver and spleen. This finding suggested
that ONTs are potential carriers for lung-targeting drug delivery.

KEYWORDS: biodistribution, lung, microparticle, organic nanotube, particle
shape

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551461/
__________________________________________________________________
________________________________*_________________________________

26. No Abstract: Injuries to health workers are common but safety checks
are rare, report finds
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23881950

BMJ. 2013 Jul 23;347:f4701.

Injuries to health workers are common but safety checks are rare, report
finds.

McCarthy M.
__________________________________________________________________
________________________________*_________________________________

27. No Abstract: Global Fund needs $15bn to fight HIV, tuberculosis, and
malaria
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24037858

BMJ. 2013 Sep 13;347:f5601.

Global Fund needs $15bn to fight HIV, tuberculosis, and malaria.

Gulland A.

London.
__________________________________________________________________
________________________________*_________________________________

28. News

– UK: Dirty needles’ concern over beauty treatments
– UK: Revealed: Glasgow’s Victoria Infirmary slammed by health inspectors
over filthy wards and dirty needle disposal procedures
– UK: NICE To Update Guidance on “Needle Risk”
– Imaging Technique Detects Pediatric Liver Disease Without Need For
Needle Biopsy
– USA: Tulsa Dentist Spread Hepatitis C, Health Officials Say

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
http://tinyurl.com/k9ojz4q
UK: Dirty needles’ concern over beauty treatments

By Peter Russell, WebMD UK Health News (24.09.13)

Medically Reviewed by Dr Keith David Barnard

People using image and performance enhancing drugs need to as be aware as
recreational drug users of how to protect themselves from the health risks
of contaminated needles, a health watchdog is warning.

The National Institute for Health and Care Excellence (NICE) says nearly
93,500 people inject opiates such as heroin in England each year and
another 70,000 people in England and Wales are thought to have injected
anabolic steroids in the last 12 months. However, people who inject so-
called ‘legal highs’, tanning agents, dermal fillers such as collagen, or
Botox also need help to avoid infection, it says.

Blood-borne diseases

Anyone injecting themselves with dirty needles is at risk of risk getting
blood-borne diseases like HIV and hepatitis.

Dr Vivian Hope, a Public Health England expert in infections among people
who inject drugs, says in a statement: “Our recent research suggests that
levels of HIV and hepatitis infection among men using image and
performance enhancing drugs have increased since the 1990s.”

NICE has issued draft guidance covering England and Wales aimed at
reducing the risk for those undergoing treatments at home or in salons
where hygiene standards may be poor.

Needle and syringe programmes

NICE recommends that people should get access to sterile needles and
syringes to help prevent the risk of infections.

Professor Mike Kelly, Director of the NICE Centre for Public Health
Excellence, says in a statement: “Since we last published our guidance on
needle and syringe programmes in 2009, we’ve seen an increase in the use
of performance and image enhancing drugs such as anabolic steroids, Botox,
tanning agents and the use of dermal fillers like collagen. We’ve also
heard anecdotal evidence that more teenagers are injecting these
performance and image enhancing drugs too.

“We’re updating our guidance – and our public consultation on the draft
update is an important part of this process – to make sure all of these
groups of people are considered in the planning and delivery of needle and
syringe programmes.”

One proposed recommendation suggests that areas could consider providing
drop boxes (also known as public sharps boxes) to dispose of used needles
and syringes. Additionally, people who use needle and syringe programmes
should be provided with individual sharps boxes and advice on how to
dispose of needles and syringes safely. The aim is to reduce the number of
used needles and drug equipment in parks, public places and the user’s
neighbourhood. This would benefit not just the users, but the wider
community.

Another suggestion is to enable people who need injecting equipment to
obtain it when they need it, by the use of out of hours vending machines
or late night pharmacies.

Reaction

Commenting in a statement on the draft guidance, Rajiv Grover, consultant
plastic surgeon and president of the British Association of Aesthetic
Plastic Surgeons (BAAPS) says: “Due to the lack of regulation in the
cosmetic sector it is impossible to know how many patients could be at
risk of blood borne diseases from needle sharing with either Botox or
fillers.

“These should be considered medical procedures and BAAPS has campaigned
for over a decade to have this field of non-surgical cosmetic treatments
tightly regulated.

“The dangers of sharing needles in cosmetic injectables are so great that
any practitioner who does this should be considered guilty of a criminal
offence and nothing less.”

The consultation will close on Tuesday 5th November 2013, with updated
guidance expected to be published next year.

© 2013 WebMD, LLC. All rights reserved.
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/m8qrogt

UK: Revealed: Glasgow’s Victoria Infirmary slammed by health inspectors
over filthy wards and dirty needle disposal procedures

By Janice Burns, Scottish Daily Record, Scotland UK (24.09.13)

NHS Greater Glasgow and Clyde have been given one month to resolve the six
“high priority” problems at the city’s Victoria Infirmary

ONE of Scotland’s top hospitals has been slammed by health inspectors for
having filthy wards and bins overflowing with dirty needles.

NHS Greater Glasgow and Clyde have been given a month to meet six “high
priority” problems at the city’s Victoria Infirmary, which last year was
hit by an infestation of rats.

A report by the Healthcare Environment Inspectorate said dirty bed frames,
bed control panels and intravenous drip stands were found in the
hospital’s elderly assessment ward south 2.

Patient hoists on the ward were “contaminated and dusty” and a chair
weighing scale was unclean.

A bin with protruding sharp implements was also discovered on the same
ward.

The HEI said: “We found there were recurring issues with cleanliness of
patient equipment, sharps and waste management.

“We were not assured a managed environment could be consistently
demonstrated to minimise the risk of infection.

“We observed poor compliance in some standard infection control
precautions, in particular, sharps management in ward 17 and ward south 2.

“For example, a sharps bin in a clinical preparation area with protruding
sharps and temporary closure mechanisms not used on sharps bins.”

Eight out of 17 commodes in the hospital were found to be unclean.

Stained mattresses were also uncovered in the inspection on July 23 and
24.

HEI chief inspector Susan Brimelow said: “We’ve identified six high
priority requirements that we expect NHS Greater Glasgow and Clyde to
address within the month.

“These include a requirement that staff follow the correct procedure for
cleaning patient equipment.

“We will return to ensure action has been taken to improve standards of
infection control, cleanliness and hygiene for patients using the Victoria
Infirmary.”

The Victoria infirmary in GlasgowThe Victoria infirmary in Glasgow
Ben Curtis/PA

Rory Farrelly, NHS Greater Glasgow and Clyde’s acute director of nursing,
said: “We are extremely disappointed and concerned that some areas fell
short of the standards expected in all our hospitals.

“Clearly we need to reinforce some of our policies with both clinical and
facility teams.”

Last July, horrified patients and visitors at the Victoria spotted rats
near the A&E department and pest control experts along with environmental
health were called.

In February this year, more than 200 operations had to be cancelled at
Glasgow’s Gartnavel Hospital because surgical equipment was dirty and
“unsafe” for use.

Last November, figures showed there had been 6562 vermin and bug-related
incidents at Scottish hospitals since 2010 – seven a day.

Patients reported finding rats, cockroaches, fleas, bats, maggots, ants,
silverfish bugs and dead animals in wards.
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/kdqpb4l

UK: NICE To Update Guidance on “Needle Risk”

Environmental Health News and Updates rhenvironmental.co.uk (24.09.13)

The National Institute for Health and Care Excellence (NICE) is updating
its guidance on needle and syringe exchanges in response to a change in
the profile of drug users.

Previously the scheme was aimed primarily at intravenous drug users but a
sharp increase in the number of people using needles for so called ‘vanity
treatments’ which include Botox, tanning agents and dermal fillers have
caused a rethink.

Rajiv Grover president of the British Association of Aesthetic Plastic
Surgeons admits that it’s difficult to quantify the size of the problem;
“Due to the lack of regulation in the cosmetic sector it is impossible to
know how many patients could be at risk of blood borne diseases from
needle sharing with either Botox or fillers.”

Earlier this month a study by Public Health England (PHE) suggested that
men who inject anabolic steroids and tanning agents are at higher risk of
contracting HIV and viral hepatitis.

Whilst cases of HIV and hepatitis B have slowly declined over the years,
hepatitis C continues to be of concern with 43% of those injecting drugs
testing positive for the virus in 2011.

One of the recommendations proposed in the new guidance is that local
authorities consider providing sharps boxes for the disposal of used
needles. As Andy Dudley who co-ordinates Sheffield’s needle and syringe
programme pointed out, boxes can also have a positive influence on the
local environment; “Sharps bins and drop boxes don’t only make the
situation safer for the individual who is using the needle and syringe but
also for their community. It ends where you don’t find needles and dirty
works in parks, in public places and the user’s neighbourhood.”

The new guidelines are open for public consultation until November 5th.
http://www.nice.org.uk
__________________________________________________________________
__________________________________________________________________
Imaging Technique Detects Pediatric Liver Disease Without Need For Needle
Biopsy

RedOrbit (20.09.13)

Source: Cincinnati Children’s Hospital Medical Center

A new, non-invasive imaging technique, magnetic resonance elastography
(MRE), can now help physicians accurately detect fibrosis (scarring) in
children with chronic liver disease – a growing problem due in part to
increasing obesity rates.

A new study shows that MRE detects such chronic diseases as non-alcoholic
fatty liver disease (NAFLD), which is increasingly common in children and
teens, affecting an estimated 13 percent of adolescents. NAFLD can lead to
progressive liver disease and liver failure. Obesity is a major risk
factor.

“Because many pediatrics patients in the United States with NAFLD are
severely obese, MRE is likely to be superior to ultrasound-based
elastography in this population, as ultrasound-based methods are less
reliable in severely obese patients,” says Stavra Xanthakos, MD, a
gastroenterologist at Cincinnati Children’s Hospital Medical Center and
lead author of the study.

The study is published online in the Journal of Pediatrics. If the
findings are validated in larger studies, MRE could reduce dependence on
costly and invasive liver biopsies to detect fibrosis.

In 2011 and 2012, the researchers evaluated 35 children and teens between
the ages of 4 and 20 for chronic liver disease using both MRE and liver
biopsy. The study demonstrated that MRE was highly accurate in detecting
more advanced fibrosis in children with chronic liver disease, including
severely obese patients.

A needle biopsy is standard practice for evaluating liver fibrosis. This
not only has risks for the patient and high expense, but it is often
frightening for children and teens. MRE is a way to measure tissue
stiffness that uses low frequency sound waves in combination with magnetic
resonance, which involves the combination of magnetic fields and radio
frequency waves to produce diagnostic images. MRE can be accomplished in
just a few minutes using the MR scanner.

“Having the ability to easily and non-invasively assess the degree of
fibrosis in a child’s liver could help us identify the issue early and
being the right course of treatment in a timely and effective manner,”
says Daniel Podberesky, MD, chief of thoracoabdominal imaging at
Cincinnati Children’s and a co-author of the study. “An added strength of
magnetic resonance technology is the ability to more precisely measure
liver fat, which allows us to non-invasively determine changes in liver
fat quantity after clinical interventions.”

“Our results show the exciting potential of MRE to improve clinical care
and reduce dependence on liver biopsies, but it is not yet ready for
primetime clinical use,” adds Dr. Xanthakos. “In addition to validation in
larger pediatric cohorts, we still need to determine whether MRE can
predict changes in liver disease over time. We hope to study MRE in
patients to test how well changes in imaging correlate with changes in
liver stiffness after treatment or lifestyle changes.”

Dr. Xanthakos co-directs the Cincinnati Children’s Steatohepatitis Center.
Steatohepatitis is an advanced stage of fatty liver disease.

In all, physicians at Cincinnati Children’s have successfully evaluated
more than 200 children using liver MRE with no adverse events.
__________________________________________________________________
__________________________________________________________________
USA: Tulsa Dentist Spread Hepatitis C, Health Officials Say

By Katie Moisse, Health Editor, ABC WORLD NEWS, USA (18.09.13)

A Tulsa-area dentist accused of using rusty equipment and dirty needles is
responsible for the country’s first known outbreak of hepatitis C among
dental patients, health officials said today.

Dr. W. Scott Harrington’s practice was shut down in March 2013 after a
surprise inspection revealed major lapses in sterility practices. At least
89 of Harrington’s patients have since tested positive for hepatitis C.

“This is the first documented report of patient-to-patient transmission of
hepatitis C virus associated with a dental setting in the United States,”
state epidemiologist Dr. Kristy Bradley said in a statement. “While dental
procedures are generally safe, this reinforces the importance of adhering
to strict infection control procedures in dental settings.”

Read more about the investigation into W. Scott Harrington’s practice.

Harrington allegedly re-used needles, a practice that can contaminate
drugs with disease-causing pathogens. The dentist of 36 years kept a
separate set of tools for patients known to carry an infectious disease,
according to a complaint filed by the Oklahoma Board of Dentistry. But the
tools had red-brown rust spots, indicating that they were “porous and
cannot be properly sterilized.”

“The basic things that everyone knows — follow CDC guidelines, use clean
syringes, don’t reuse multi-dose vials in multiple patients, don’t use
rusted equipment — those are things even non-physicians know,” board
president Susan Rogers told ABC News in March. “Those are basic things.
That part makes it egregious.”

More than 7,000 patients from Harrington’s Tulsa and Owasso clinics were
sent letters in late March outlining the risk of infection and steps to
obtain free blood testing. Of 4,202 people tested at state clinics, 89
tested positive for hepatitis C, five for hepatitis B and four for HIV. An
unknown number of patients also sought testing through private clinics,
according to the state health department.

“While our investigation documents the transmission of hepatitis C, we
have no reason to believe the hepatitis B cases resulted from exposure in
this dental practice,” said Bradley, who in March explained that the
investigation into the outbreak was “complex” and involved in-depth
interviews to determine the likelihood that an exposure was linked to
Harrington’s practice.

Genetic testing for HIV is ongoing, according to the state department of
health. A final report will be issued when the testing is complete.

The March inspection by the Oklahoma Board of Dentistry was prompted by a
patient testing positive for hepatitis C and HIV with no known risk
factors. In its report, the board called Harrington a “menace to the
public health,” describing how he would pour bleach on patients’ wounds
until they “turned white.”

The investigation into Harrington’s practice and the infectious disease
testing has cost more than $710,000 in federal, state and local funds,
according to the state department of health.
__________________________________________________________________
________________________________*_________________________________
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