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SIGNpost 00727

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *

Post00727   GAVI IS China 2010 + Abstracts + Krokodil +News  08 January 2014

CONTENTS
0. Moderators Note 2014
1. Abstract: Evaluation of immunization injection safety in China, 2010:
Achievements, future sustainability
2. Abstract: Key outcomes and addressing remaining challenges-Perspectives
from a final evaluation of the China GAVI project
3. Abstract: Origins, design and implementation of the China GAVI project
4. Abstract: Helsinki declaration on patient safety in anaesthesiology –
part 10: infection control/hygiene
5. Abstract: Knowledge of nurses of the Family Health Strategy on health
services waste
6. Extract: New recommended practices for sharps safety released will be
available in the 2014 edition of Perioperative Standards and
Recommended Practices
7. Abstract: Needle stick injury and HIV risk among health care workers
in North India
8. Abstract: Assessment of hepatitis B vaccination and compliance with
infection control among dentists in Saudi Arabia
9. Abstract: Epidemiology of needlesticks at Landspítali University
Hospital during the years 1986-2011. A descriptive study
10. Abstract: Occupational exposures in healthcare workers in University
Hospital Dubrava–10 year follow-up study
11. Abstract: Alarming epidemics of human immunodeficiency virus and
hepatitis C virus among injection drug users in the northwestern
bordering state of Punjab, India: prevalence and correlates
12. Abstract: Safe havens and rough waters: Networks, place, and the
navigation of risk among injection drug-using Malaysian fishermen
13. Abstract: Vulnerability to HIV infection among female drug users in
Kathmandu Valley, Nepal: a cross-sectional study
14. Abstract: Are needle and syringe programmes associated with a
reduction in HIV transmission among people who inject drugs: a
systematic review and meta-analysis
15. Abstract: Evolution of the need and coverage of syringe exchange
programs in Spanish prisons, 1992-2009: A revised estimation
16. Abstract: Emergence of cocaine and methamphetamine injection among
HIV-positive injection drug users in Northern and Western India
17. Abstract: A brief history of hepatitis milestones
18. Abstract: Development of a novel transdermal delivery system of
Peptide and protein drugs using microneedle arrays
19. Abstract: Recent trends in hepatitis B virus infection in the general
Korean population
20. Abstract: Hepatitis B virus infection in South Korea: three decades
after universal vaccination
21. No Abstract: Global Fund pledges fall short of expectations
22. No Abstract: Occupational needlestick injuries in hospitals[Editorial]
23. No Abstract: Needlestick Injuries among Healthcare Workers of a
Tertiary Care Hospital in South India
24. No Abstract: Occupational Exposure to Bloodborne Pathogens in
Interventional Radiology-Risks, Prevention, and Recommendations: A
Joint Guideline of the Society of Interventional Radiology and
Cardiovascular and Interventional Radiological Society of Europe
25. No Abstract: Why use safety needle devices?
26. KROKODIL, ProMED-mail extract
27. News
– India: Blood banks cause of Hepatitis C in Kashmir: Experts ‘Unscreened
Donors Pose Risk To Patients’; Will Look Into Matter: Health Minister
– USA: HBV Vaccine Recommended for All Unvaccinated at Risk HCP
– USA: ND DOH reports investigation of Hepatitis C outbreak inconclusive
– Colorado USA: Poudre Valley Hospital recommends hepatitis C testing for
some ICU patients
– Philippines: 384 new HIV/AIDS cases in Nov bring 2013 tally to almost
5,000
– Canada: Hospitals take action to secure dirty needles

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________________________________*_________________________________

0. Moderators Note 2014
__________________________________________________________________
This is the first edition of SIGNpost for 2014.

There is a lot of work on injection safety and related infection
prevention and control going on around the world. Congratulations!

There still remains a lot to do.

Let us work together to make all injections safe in this new year

Very best wishes to all SIGN associates, partners, and friends for a safe
and effective year

allan
__________________________________________________________________
________________________________*_________________________________

1. Abstract: Evaluation of immunization injection safety in China, 2010:
Achievements, future sustainability
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24331020

Vaccine. 2013 Dec 27;31 Suppl 9:J43-8.

Evaluation of immunization injection safety in China, 2010: Achievements,
future sustainability.

Wu Z1, Cui F2, Chen Y1, Miao N1, Gong X1, Luo H1, Wang F1, Zheng H1, Kane
M3, Hadler SC4, Hutin YJ5, Liang X1, Yang W1.

OBJECTIVE: The study objectives were to evaluate injection practices in
China in the post GAVI project era and provide guidance for policy makers
to update national standards for injection practices and further improve
vaccination services.

METHODS: We conducted a national stratified, cross-sectional survey in
October 2010, according to WHO recommended sampling methods. First, we
stratified China into three regions (Eastern, Central and Western) based
on economic criteria. Second, in each region, we selected eight counties
with a probability proportional to population size. Third, in each
selected county, we selected (a) 10 townships at random among the list of
townships of the county and (b) the one county level hospital.

RESULTS: With respect to the risk to the patient, we never observed open
injection equipment lying around or needles left in the septum of multi-
dose vials. We never observed sterilizable injection devices syringes in
any of the facilities. The proportion of facilities using sharps
containers was highest in the East (85%), intermediate in the West (79%)
and lowest in the Central region (56%).

In 2009, auto-disable syringes and safety boxes were used in 78% and 79%
facilities in GAVI supported areas of the Western region, respectively.
Only one facility presented evidence of attempts to re-sterilize
disposable injection equipment in the Eastern region.

CONCLUSIONS: Use of AD syringe and sharps containers increased in
vaccination services in China, especially in GAVI supported areas, leading
to sustainable progress in terms of elimination of reuse of injection
devices. However, risk to patients still existed, including persisting use
of standard disposable syringes and attempts to re-use disposable devices.

Copyright © 2012 Elsevier Ltd. All rights reserved.

KEYWORDS: Evaluation, Immunization, Injection safety

Full Free Text:
http://www.sciencedirect.com/science/article/pii/S0264410X12016982
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Key outcomes and addressing remaining challenges-Perspectives
from a final evaluation of the China GAVI project
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24331024

Vaccine. 2013 Dec 27;31 Suppl 9:J73-8.

Key outcomes and addressing remaining challenges-Perspectives from a final
evaluation of the China GAVI project.

Yang W1, Liang X1, Cui F1, Li L1, Hadler SC2, Hutin YJ3, Kane M4, Wang Y5.

During the China GAVI project, implemented between 2002 and 2010, more
than 25 million children received hepatitis B vaccine with the support of
project, and the vaccine proved to be safe and effective. With careful
consideration for project savings, China and GAVI continually adjusted the
budget, additionally allowing the project to spend operational funds to
support demonstration projects to improve timely birth dose (TBD), conduct
training of EPI staff, and to monitor the project impact. Results from the
final evaluation indicated the achievement of key outcomes. As a result of
government co-investment, human resources at county level engaged in
hepatitis B vaccination increased from 29 per county on average in 2002 to
66 in 2009.

All project counties funded by the GAVI project use auto- disable syringes
for hepatitis B vaccination and other vaccines.

Surveyed hepatitis B vaccine coverage increased from 71% in 2002 to 93% in
2009 among infants. The HBsAg prevalence declined from 9.67% in 1992 to
0.96% in 2006 among children under 5 years of age. However, several
important issues remain: (1) China still accounts for the largest annual
number of perinatal HBV infections (estimated 84,121) in the WHO WPR
region; (2) China still lacks a clear national policy for safe injection
of vaccines; (3) vaccination of high risk adults and protection of health
care workers are still not implemented; (4) hepatitis B surveillance needs
to be refined to more accurately monitor acute hepatitis B; and (5) a
program for treatment of persons with chronic HBV infection is needed.

Recommendations for future hepatitis B control include: using the lessons
learned from the China GAVI project for future introductions of new
vaccines; addressing unmet needs with a second generation hepatitis B
program to reach every infant, including screening mothers, and providing
HBIG for infants born to HBsAg positive mothers; expanding vaccination to
high risk adults;

**** addressing remaining unsafe injection issues; and improving
monitoring of acute hepatitis B. This paper describes findings and
discusses perspectives from a final project evaluation, a national
stratified validated cross-sectional survey done in October 2010.

Copyright © 2012 Elsevier Ltd. All rights reserved.

KEYWORDS: Challenges, GAVI, Outcomes, Project

Full Free text:
http://www.sciencedirect.com/science/article/pii/S0264410X12013801
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Origins, design and implementation of the China GAVI project
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24331025

Vaccine. 2013 Dec 27;31 Suppl 9:J8-J14.

Origins, design and implementation of the China GAVI project.

Liang X1, Cui F1, Hadler S2, Wang X3, Luo H1, Chen Y1, Kane M4, Shapiro
C2, Yang W1, Wang Y5.

China received GAVI support for hepatitis B vaccination in 2001 because of
high disease burden and strong government will to protect infants at risk.

The China/GAVI project, implemented since 2002, was funded 50% by GAVI and
50% by the Government of China. The purpose of the project was to increase
coverage of hepatitis B vaccine through a pro-poor approach targeting all
counties of the 12 Western provinces and poverty counties of the 10
Central provinces, to accelerate integration of hepatitis B vaccine into
routine immunization, and assure immunization injection safety.

The mechanism of internal coordination among multiple government entities
and international cooperation was established and comprehensive strategies
were used to improve vaccine coverage and injection safety.

After 8 years of implementation, 193,000 health care workers in 118,316
health care facilities participated in the project, mostly at the township
hospitals level (55,051) and in community centres (104,547).

Through the China GAVI project, the 85% HepB3 coverage goal was reached in
98% of GAVI China project counties, the 75% timely birth dose (TBD)
coverage goal was reached in 80% of GAVI project counties, and AD syringes
were introduced into 100% of GAVI-supported areas.

Additionally, the GAVI project was instrumental in convincing the Chinese
Government to sustainably introduce and fully fund HepB vaccine for all
newborns in China.

The impact of hepB vaccination on HBsAg prevalence was observed throughout
China, as HBsAg prevalence (previously ~10%) is now less than 1% among
children under 5 years of age.

Copyright © 2012 Elsevier Ltd. All rights reserved.

KEYWORDS: Hepatitis B, Project, Vaccine

Free Full Text:
http://www.sciencedirect.com/science/article/pii/S0264410X12017884
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Helsinki declaration on patient safety in anaesthesiology –
part 10: infection control/hygiene
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24343142

Anasthesiol Intensivmed Notfallmed Schmerzther. 2013 Nov;48(11-12):703-5.

[Helsinki declaration on patient safety in anaesthesiology -part 10:
infection control/hygiene].

[Article in German]

Kerwat K, Wulf H.

There is a plethora of laws, regulations, guidelines and recommendations
relating to infection control and hygiene.

Major issues are the prevention of nosocomial infections, staff protection
and environmental protection. Of the highest relevance are the infection
control law [Infektionsschutzgesetz (IfSG)], the hygiene regulations of
the German federal states [Hygieneverordnungen der Bundesländer], the
German technical rules for biological materials [Technische Regel
Biologische Arbeitsstoffe 250 (TRBA 250)] – biological materials in
health-care and welfare work [Biologische Arbeitsstoffe im
Gesundheitswesen und in der Wohlfahrtspflege], the guidelines for hospital
hygiene and prevention of infection of the commission for hospital hygiene
and prevention of infection of the Robert-Koch Institute [Richtlinie für
Krankenhaushygiene und Infektionsprävention von der Kommission für
Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-
Institut], the recommendations of the commission on anti-infectives,
resistance and therapy of the Robert-Koch Institute [Empfehlungen der
Kommission Antiinfektiva, Resistenz und Therapie (ART) beim Robert Koch-
Institut].

Of subordinate importance are, e.g., the recommendations of the German
Society for Anesthesiology and Intensive Medicine (DGAI).

It is practically impossible for an anesthesiologist working in a hospital
to have knowledge of all laws, regulations, guidelines and
recommendations. And this is also not reasonable. Thus it is necessary to
distinguish the relevant from the irrelevant. Checklists can be useful
here.

The most important and effective individual action in hospital hygiene is
and remains hand hygiene as is propagated in the action “clean hands”,
irrespective of all laws, regulations, guidelines and recommendations.

© Georg Thieme Verlag Stuttgart · New York.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Knowledge of nurses of the Family Health Strategy on health
services waste
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23258685

Rev Bras Enferm. 2012 Jul-Aug;65(4):645-52.

[Knowledge of nurses of the Family Health Strategy on health services
waste].

[Article in Portuguese]

dos Santos MA, Souza Ade O.

The study addresses the problem involving the solid waste from health
service and the nurses attitude towards aspects related to the management
and environmental awareness.

Participants were ten professionals working in the Family Health Strategy,
from the municipalities of Araputanga, Mirassol D’west and São José dos
Quatro Marcos. Data were collected through questionnaires, and analyzed
using the software Origin®.

It was observed the level of knowledge regarding the current law,
management steps taken at the municipal and staff training, and also about
the ability of the professionals to diagnose situations and occupational
risk to public health.

Despite the existence of a significant knowledge on the subject, there is
still need to work on awareness and development of appropriate management
practices on the health services waste.

Free full text http://dx.doi.org/10.1590/S0034-71672012000400014
__________________________________________________________________
________________________________*_________________________________

6. Extract: New recommended practices for sharps safety released will be
available in the 2014 edition of Perioperative Standards and
Recommended Practices
__________________________________________________________________
AORN J. 2013 Jul;98(1):C5-6.

New recommended practices for sharps safety released.

Knudson L.

Free PDF at: http://tinyurl.com/lhjqsqb

________________________________________________________________________
Extract Extract Extract Extract Extract

New recommended practices for sharps safety released

Leslie Knudson
Managing Editor

The new “Recommended practices for sharps safety” was released
electronically in June 2013 and will be available in the 2014 edition of
Perioperative Standards and Recommended Practices.

The new recommended practices (RP) are an expansion of AORN’s “Guidance
statement: sharps injury prevention in the perioperative setting,” and
include best practices for preventing sharps injuries and reducing
bloodborne pathogen exposure to perioperative patients and personnel.

Following the requirements outlined in the Occupational Safety and Health
Administration’s (OSHA) Bloodborne Pathogens Standard,4 the RP is based on
a hierarchy of controls that include hazard elimination measures (e.g.,
exposure control plan); engineering controls (e.g., blunt suture needles,
safety scalpels); work practice controls (e.g., neutral zone, no-touch
technique); administrative controls (e.g., post-exposure evaluation and
follow-up); and personal protective equipment (PPE).

The recommendations for each topic reflect AORN’s critical evidence
review, appraisal, and rating process

continues at http://tinyurl.com/lhjqsqb
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Needle stick injury and HIV risk among health care workers
in North India
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23508479

Indian J Med Sci. 2011 Sep;65(9):371-8.

Needle stick injury and HIV risk among health care workers in North India.

Ashat M, Bhatia V, Puri S, Thakare M, Koushal V.

OBJECTIVES: To determine the occurrence of needle stick injuries among
various categories of health care workers (HCWs), the causal factors, and
the circumstances under which these occur. 2. To explore the possibilities
of measures to prevent these through improvement in knowledge, attitude,
and practice.

MATERIALS AND METHODS: The study was conducted in two government tertiary
level hospitals. Study sample comprised 107 HCWs, providing medical care
in two government tertiary level hospitals of Chandigarh. Subjects were
enquired about their exposure to needle prick injuries during patient
management in the last 6 months and also the action taken following
exposure. The statistical tools employed were: ratio, proportions, and
other basic methods of data interpretation.

RESULTS: The study among 107 HCWs included 27 doctors (25.2%), 68 nurses
(63.5%), and 12 paramedics (11.2%), with 87 (81.3%) being females. The
prevalence of needle stick injury and exposure to blood was reported by 73
(68.2%) participants. The main factor ascribed for this exposure was heavy
patient load (42.5%). The maximum accidents occurred during emergency care
(30.1%). Most common action following exposure was cleaning with spirit
(46.3%). Only 51 (47.7%) of HCWs admitted following universal precautions.
Among those exposed, only 10 (13.7%) persons had undergone HIV testing.

CONCLUSION: Two-thirds of HCWs were exposed to needle stick injuries. Lack
of awareness about post-exposure prophylaxis (PEP) was found.

Free full text http://tinyurl.com/kumorqv
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Assessment of hepatitis B vaccination and compliance with
infection control among dentists in Saudi Arabia
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23147878

Saudi Med J. 2012 Nov;33(11):1205-10.

Assessment of hepatitis B vaccination and compliance with infection
control among dentists in Saudi Arabia.

Al-Dharrab AA, Al-Samadani KH.

OBJECTIVE: To evaluate hepatitis B virus (HBV) vaccine coverage and the
use of infection control among dentists in Saudi Arabia.

METHODS: This cross-sectional study was carried out during the Third
International Conference at the King Abdulaziz University Faculty of
Dentistry, held on March 2012 in Jeddah, Saudi Arabia. Saudi or expatriate
dentists working in Saudi Arabia were included in the study. The
questionnaires were designed to meet the objective of the study.

RESULTS: A total of 402 dentists of whom 176 (44%) were male and 226 (56%)
female took part in this study. Their mean age was 37.4 years. In all, 246
(61%) were general dentists and 156 (39%) specialists. Four-fifths (80.5%)
of them had been vaccinated. Almost half (48.5%) had experience of needle
stick injury, but none reported having been infected with HBV. Among the
vaccinated dentists, 186 (57.5%) had not been screened for HBV antibodies.
Younger dentists were more particular about vaccination and more careful
in using protective wear. There was an association between protective
barriers and HBV vaccination, but there was no association between history
of needle stick injury and vaccination.

CONCLUSION: Dental healthcare workers have a high risk of infection with
HBV due to the nature of their work; so there should be a mandatory
program to vaccinate dentists against HBV and to ensure application of
protective measures during their practice.
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Epidemiology of needlesticks at Landspítali University
Hospital during the years 1986-2011. A descriptive study
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24345811

Laeknabladid. 2013 Dec;99(12):559-564.

[Epidemiology of needlesticks at Landspítali University Hospital during
the years 1986-2011. A descriptive study[Journal Article].]

[Article in Icelandic]

Jelle AE, Hafsteinsdottir EJ, Gudlaugsson O, Kristjansson M.

Introduction: Needlesticks, bodyfluid exposure and bites (incident) put
healthcare workers (HCWs) at risk of hepatitis B, C and HIV particularly
if patients are infected (high risk incident). The risk of infection is
greatest from bore-hollow needles.

The aim of the study was to describe the epidemiology of reported
incidents and evaluate underreporting by HCWs at Landspítali University
Hospital (LUH).

Methods: A retrospective descriptive study of reported incidents during
1986-2011. The ratio of incidents was calculated according to the HCWs age
and profession and distribution by source and wards. The ratio of high
risk incidents and vaccination status against HBV at time of incident was
determined as well as underreporting during 01.01.2005-31.12.2011.

Results: At least 4089 incidents occured during the study period but 3587
were reported and blood samples taken from 2578 patients. Approximately a
third of the incidents were associated with non-compliance with standard
precaution and 54,7% of needlesticks were associated with bore-hollow
needles.

Few reports came from physicians and medical students (17,9%).

During the study period 50,3% HCWs were vaccinated against HBV at time of
incident. High risk incidents were 94 (2.6%), mostly related to hepatitis
C (64,9%). Two HCWs became infected with HCV. During 2005-2011
underreporting was estimated to be 28,0%.

Conclusion: Improved education of standard precaution when handling
needles and sharps at LUH may reduce the number of incidents. Introduction
of safety-needles and safety-devices may greatly reduce needlesticks as a
large number of incidents were associated with hollow needles. Improved
HBV vaccination among HCWs and reporting incidents should be encouraged.

Key words: Sharps and needlestick injuries, blood and bodyfluid exposure,
health care worker, Bloodborne pathogens, HBV vaccination coverage,
occupational health.

Correspondence: Asdis Elfarsdottir Jelle, asdiself@landspitali.is.
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Occupational exposures in healthcare workers in University
Hospital Dubrava–10 year follow-up study
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24344541

Cent Eur J Public Health. 2013 Sep;21(3):150-4.

Occupational exposures in healthcare workers in University Hospital
Dubrava–10 year follow-up study.

Serdar T1, Derek L2, Unic A2, Marijancevic D2, Markovic D3, Primorac A4,
Petrovecki M5.

Occupational hazardous exposure in healthcare workers is any contact with
a material that carries the risk of acquiring an infection during their
working activities. Among the most frequent viral occupational infections
are those transmitted by blood such as hepatitis B virus (HBV), hepatitis
C virus (HCV) and human immunodeficiency virus (HIV). Therefore, they
represent a significant public health problem related to the majority of
documented cases of professionally acquired infections.

Reporting of occupational exposures in University Hospital Dubrava has
been implemented in connection with the activity of the Committee for
Hospital Infections since January 2002. During the period of occupational
exposures’ monitoring (from January 2002 to December 2011) 451 cases were
reported.

The majority of occupational exposures were reported by nurses and medical
technicians (55.4%).

The most common type of exposure was the needlestick injury (77.6%). 27.9%
of the accidents occurred during the blood sampling and 23.5% during the
surgical procedure. In 59.4% of the exposed workers aHBs-titer status was
assessed as satisfactory. Positive serology with respect to HBV was
confirmed in 1.6% of patients, HCV in 2.2% of patients and none for HIV.

Cases of professionally acquired infections were not recorded in the
registry. Consequences of the occupational exposure could include the
development of professional infection, ban or inability to work further in
health care services and last but not least a threat to healthcare workers
life.

It is therefore deemed necessary to prevent occupational exposure to
blood-borne infections. The most important preventive action in respect to
HBV, HCV and HIV infections is nonspecific pre-exposure prophylaxis.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Alarming epidemics of human immunodeficiency virus and
hepatitis C virus among injection drug users in the northwestern
bordering state of Punjab, India: prevalence and correlates
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24352120

Int J STD AIDS. 2013 Dec 18.

Alarming epidemics of human immunodeficiency virus and hepatitis C virus
among injection drug users in the northwestern bordering state of Punjab,
India: prevalence and correlates.

Panda S, Roy T, Pahari S, Mehraa J, Sharma N, Singh G, Singh J, Joseph F,
Singh S, Sharma NM.

In this study 1155 injection drug users receiving targeted intervention in
five cities of Punjab were surveyed; three cities (Amritsar, Taran-Taran,
Batala) were in districts sharing international border with Pakistan and
the rest two were Jalandhar and Ludhiana. Information on socio-demography,
substance use and sexual practices were collected; blood samples were
tested for biologic markers.

HIV and HCV antibody (HCVAb) prevalence in injection drug users were 29
and 49%, respectively. Of the HCVAb seroreactive injection drug users, 33%
had HIV as well. HIV prevalence in young injection drug users (=19 years),
estimated as surrogate for HIV incidence, was high at 12% and HCVAb in
this subgroup was 27%.

Herpes simplex virus 2 antibody (IgG) was detected in 10% injection drug
users; 2% had syphilis. Alcohol use prevalence was high and frequency of
use concerning.

In multivariate analyses, ‘city of residence closer to international
border’ and ‘>1 year duration of injecting drug’ were associated with HIV
and HCVAb.

Furthermore, ‘irregular supply of syringes and needles’ was associated
with HCVAb seroreactive status of injection drug users (adjusted odds
ratio 1.7; 95% CI 1.3-2.3; P?<?0.001), and ‘any genital disease symptom
within the last year’ (adjusted odds ratio 2; 95% CI 1.4-2.9; P?<?0.001)
was associated with HIV infection.

Alcohol and sexual risk reduction; strengthening of needle-syringe
exchange; reducing injecting duration and clinical management of HIV, HCV
and HIV/HCV co- infection appear as four core program needs.

KEYWORDS: AIDS, Indian subcontinent, Syphilis, epidemiology, human
immunodeficiency virus, sexually transmitted bacterial diseases, sexually
transmitted viral diseases
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Safe havens and rough waters: Networks, place, and the
navigation of risk among injection drug-using Malaysian fishermen
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24332971

Int J Drug Policy. 2013 Nov 22. pii: S0955-3959(13)00194-1.

Safe havens and rough waters: Networks, place, and the navigation of risk
among injection drug-using Malaysian fishermen.

West BS1, Choo M2, El-Bassel N3, Gilbert L3, Wu E3, Kamarulzaman A2.

BACKGROUND: HIV prevalence among Malaysian fishermen is ten times that of
the general population. Fishing boats are a key place where drug use
occurs, but we know little about how these environments shape HIV risk
behaviour. Utilizing Rhodes’ ‘risk environment’ framework, we assessed
drug use contexts and how characteristics of place associated with fishing
and fishermen’s social networks served as key axes along which drug use
and HIV risk behaviour occurred.

METHODS: Data were collected during 2009-2011 in Kuantan, a fishing port
on the eastern coast of Malaysia, and include 28 in-depth interviews and
398 surveys collected using RDS. Logistic regression was used to determine
the effect of occupational, network and risk environment characteristics
on unsafe injection behaviour and access to clean needles/syringes;
qualitative data were coded and analyzed thematically.

RESULTS: Drug injecting was common and occurred on boats, often with other
crewmembers. Captains and crewmembers were aware of drug use. Unsafe
injection practices were significantly associated with having a larger
proportion of drug injectors in network (OR=3.510, 95% CI=1.053-11.700)
and having a captain provide drugs for work (OR=2.777, 95% CI=
1.018-7.576). Size of fishermen network (OR=0.987, 95% CI=0.977-0.996),
crewmembers’ knowledge of drug use (OR=7.234, 95% CI=1.430-36.604), and
having a captain provide drugs for work (OR=0.134, 95% CI=0.025-0.720)
predicted access to clean needles/syringes. Qualitative analyses revealed
that occupational culture and social relationships on boats drove drug use
and HIV risk.

CONCLUSIONS: While marginalized in broader society, the acceptance of drug
use within the fishing community created occupational networks of risk.
Fishing boats were spaces of both risk and safety; where drug users
participated in the formal economy, but also where HIV risk behaviour
occurred. Understanding the interplay between social networks and place is
essential for developing HIV prevention and harm reduction policies
appropriate for the unique needs of this fishing population.

Copyright © 2013 Elsevier B.V. All rights reserved.

KEYWORDS: Fishermen, HIV, Injection drug use, Malaysia, Place, Risk
environment, Social networks
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Vulnerability to HIV infection among female drug users in
Kathmandu Valley, Nepal: a cross-sectional study
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24373529

BMC Public Health. 2013 Dec 28;13(1):1238.

Vulnerability to HIV infection among female drug users in Kathmandu
Valley, Nepal: a cross-sectional study.

Ghimire B, Suguimoto SP, Zamani S, Ono-Kihara M, Kihara M.

BACKGROUND: Women who use drugs are extremely vulnerable to HIV and
sexually transmitted infections (STIs), but studies on risk behaviours and
HIV infection among female drug users are limited in Nepal.

METHODS: In this cross-sectional study conducted between September 2010
and May 2011, HIV prevalence and risk factors for HIV infection were
investigated among female drug users recruited in drop-in centres, parks
and streets in the Kathmandu Valley. The participants completed face-to-
face interviews for a structured questionnaire, HIV pre-test counselling,
specimen collection for HIV test and they were provided with their results
at post- test counselling.

RESULTS: A total of 269 female drug users were recruited, of whom 28% (n =
77) were found HIV positive; the majority (78%, n = 211) being injecting
drug users and aged below 25 years (57%, n = 155). Nearly half (n = 137)
of the total participants had shared needles or syringes in the past
month, and 131 and 102 participants were involved in commercial or casual
sex respectively with only half or less of them having had used condoms in
the last 12 months. In multivariate analysis the variables associated with
HIV infection included: (a) older age; (b) history of school attendance;
(c) frequency of sharing of injection instruments; and (d) unsafe sex with
commercial or casual partners.

CONCLUSIONS: HIV was highly prevalent among female drug users in the
Kathmandu Valley, with its risk being strongly associated not only with
unsafe injection practice but also with unsafe sexual behaviours.
Awareness raising programmes and preventive measures such as condom
distribution, needle or syringe exchange or methadone maintenance therapy
should be urgently
introduced in this neglected subpopulation.

Free full text http://www.biomedcentral.com/1471-2458/13/1238/abstract
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Are needle and syringe programmes associated with a
reduction in HIV transmission among people who inject drugs: a
systematic review and meta-analysis
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24374889

Int J Epidemiol. 2013 Dec 27.

Are needle and syringe programmes associated with a reduction in HIV
transmission among people who inject drugs: a systematic review and meta-
analysis.

Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E,
Palmateer N, Doyle JS, Hellard ME, Hutchinson SJ.

BACKGROUND: Needle and syringe programmes (NSP) aim to reduce the risk of
HIV by providing people who inject drugs (PWID) with sterile injecting
equipment. A recent review of reviews (ROR) concluded that there was only
tentative evidence to support the effectiveness of NSP in reducing HIV. We
carried out a systematic review and meta-analysis to assess the
association between NSP and HIV transmission.

METHODS: Relevant primary articles presenting data on the risk of HIV
transmission associated with NSP were identified in two stages: (i) from
reviews identified in two published RORs (covering the period 1980-2008);
and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE
and PsychINFO for primary articles published since the most recent high
quality review (covering the period 2008-12). Study results were
synthesized using random-effects meta-analysis.

RESULTS: There were 12 studies comprising at least 12 000 person-years of
follow- up. Exposure to NSP was associated with a reduction in HIV
transmission: pooled effect size 0·66 [95% confidence interval (CI) 0·43,
1·01] across all studies, and 0·42 (95% CI 0·22, 0·81) across six higher
quality studies (according to the Newcastle-Ottawa tool).

CONCLUSIONS: There is evidence to support the effectiveness of NSP in
reducing the transmission of HIV among PWID, although it is likely that
other harm reduction interventions have also contributed to the observed
reduction in HIV risk. NSP should be considered as just one component of a
programme of interventions to reduce both injecting risk and other types
of HIV risk behaviour.

KEYWORDS: HIV, needle-exchange programmes, people who inject drugs
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Evolution of the need and coverage of syringe exchange
programs in Spanish prisons, 1992-2009: A revised estimation
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23165631

Rev Esp Sanid Penit. 2012 Feb;14(3):86-90.

[Evolution of the need and coverage of syringe exchange programs in
Spanish prisons, 1992-2009: A revised estimation].

[Article in Spanish]

de la Fuente L, Bravo MJ, Jiménez-Mejías E, Sordo L, Pulido J, Barrio G.

INTRODUCTION: The objective of this paper is to amend the bias included in
our previous work, presenting a corrected estimation of the need and
coverage of syringes/needles in Spanish prisons between 1992 and 2009.

METHODS: Data on the provision of the needles exchange programs (NEPs) in
prison is taken from official publications. The need was calculated by
applying multiplicative methods to secondary data from several sources.
Coverage was estimated as the quotient between provision and need and the
difference between these magnitudes. The detected need estimate bias has
been corrected.

RESULTS: NEP’s in prisons started in 1997. Their maximum coverage reached
36% in 2005, which is much higher than the initially estimated value.
However, it decreased by half in the next four years, reaching 17.4% in
2009.

CONCLUSION: The remarkable coverage reached by these programmes must be
valued, but more recent evolution leads us to emphasize the need to be
imaginative so that new epidemiological and economic circumstances do not
lead to their disappearance.

Comment in [In regard to the paper: Developments in the necessity and
coverage of the syringe exchange program in Spanish prisons, 1992-2009.
Estimation after correction].

Free full text at the linkout at:
http://www.ncbi.nlm.nih.gov/pubmed/23165631
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Emergence of cocaine and methamphetamine injection among
HIV-positive injection drug users in Northern and Western India
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24382362

Drug Alcohol Depend. 2013 Dec 17. pii: S0376-8716(13)00518-8.

Emergence of cocaine and methamphetamine injection among HIV-positive
injection drug users in Northern and Western India.

Mehta SH1, Srikrishnan AK2, Noble E3, Vasudevan CK2, Solomon S2, Kumar
MS2, Solomon SS4.

BACKGROUND: Little is known regarding the epidemiology of drug injection
and risk behaviors among injection drug users (IDUs) across India. In
particular, there is limited data on the prevalence of stimulant
injection.

METHODS: We sampled 801 HIV positive IDUs from 14 locations throughout
India to represent the geography of India as well as the diversity in IDU
epidemic stage (established epidemics, emerging epidemics and large
cities). All participants underwent a behavioral survey and blood draw.
Given prior associations with stimulant injection and HIV risk, we
compared stimulant injectors (cocaine and/or methamphetamine) to those who
injected opiates and/or pharmaceuticals only.

RESULTS: The median age was 33; 86% were male. The primary drugs injected
were heroin, buprenorphine and other pharmaceuticals. In all but four
sites, > 50% of those actively injecting reported needle sharing.
Stimulant injection was most common in emerging epidemics. Compared to
exclusive opiate injectors, stimulant injectors were significantly
younger, more likely to be educated and employed, more likely to report
non-injection use of heroin, crack/cocaine and amphetamines, heavy alcohol
use, recent needle sharing (71% vs. 57%), sex with a casual partner (57%
vs. 31%) and men having sex with other men (33% vs. 9%; p<0.01 for all).

CONCLUSIONS: Emerging IDU epidemics have a drug/sexual risk profile not
previously been observed in India. Given the high prevalence of stimulant
injection in these populations, HIV prevention/treatment programs may need
to be redesigned to maximize effectiveness. The high levels of injection
sharing overall reinforce the need to ensure access to harm-reduction
services for all.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

KEYWORDS: Amphetamine-type stimulants, Cocaine, HIV/AIDS, India, Injection
drug use
__________________________________________________________________
________________________________*_________________________________

17. Abstract: A brief history of hepatitis milestones
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24373076

Liver Int. 2014 Feb;34 Suppl 1:29-37.

A brief history of hepatitis milestones.

Trepo C.

Hepatitis has been a major plague of mankind. The history of the discovery
of causative viruses is one of the most fascinating scientific adventures
of this half century.

Individualization of several types of hepatitis only emerged after world
war two. Their identification has been associated with milestones which
revolutionized medicine and public health.

The discovery of HBV brought the first ever vaccine not prepared by tissue
culture but initially directly from plasma and soon the first vaccine
produced by genetic engineering. HBV vaccine proved to be the first “anti-
cancer” vaccine by preventing hepatocellular carcinoma and practically
eradicating it from childhood in Taiwan.

Successful vaccines became also available for HAV and more recently HEV.

The discovery of HCV in 1989 opened a new era since it was the first virus
was identified by a direct molecular approach. Two billion people are
infected with HBV and 350 million are chronic carriers of the virus. The
extraordinary effectiveness of HBV vaccination was best illustrated in
Taiwan and Singapore where in less than 2 decades HBs Ag carriers dropped
from 9,1% to 2,7% and HCC from 27% to 17%.

Successful development of nucleos(t)ides analogs make it now possible to
fully control disease progression with a daily pill long term therapy. The
progress in HCV therapy has been even more spectacular and successful
treatment jumped from 6 % with interferon alone in 1986 to more than 80%
in 2013 with triple combination therapies.

Remarkably chronic hepatitis C is the only chronic disease which is
curable. It will be soon possible to eradicate HCV infection with, an all
oral, daily single pill (containing several molecules) for 3 to 6 months
which will cure over 90% of patients.

This unprecedented therapeutic victory benefiting hundred millions of
people matches the triumphs over small pox, polio and tuberculosis. The
next 10 years should undoubtedly witness cure or full control over all
forms of acute and chronic hepatitis.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

KEYWORDS: Antivirals, HAV, HCV, HDV, Hepatitis B, Hepatitis C, History,
Interferon, Liver, Nucleoside analogs, Vaccine
__________________________________________________________________
________________________________*_________________________________

18. Abstract: Development of a novel transdermal delivery system of
Peptide and protein drugs using microneedle arrays
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24389619

Yakugaku Zasshi. 2014;134(1):63-7.

Development of a novel transdermal delivery system of Peptide and protein
drugs using microneedle arrays.

Katsumi H, Quan YS, Kamiyama F, Kusamori K, Sakane T, Yamamoto A.

Transdermal delivery of peptide and protein drugs may be limited by the
stratum corneum, which is a protective barrier against the entry of
microorganisms and water.

Many approaches have been utilized to promote peptide and protein drugs
delivery across the stratum corneum, including chemical enhancer
modification and physical disruption of barrier function. However, it has
been difficult to achieve therapeutic levels of peptide and protein drugs
via this route without any skin irritation. Recently, attention has been
paid to the possibility of using microneedle arrays in delivering peptide
and protein drugs into the skin.

As a novel and minimally invasive approach, microneedle arrays are capable
of creating superficial pathways across the skin for peptide and protein
drugs to achieve enhanced transdermal drug delivery. This method combines
the efficacy of conventional injection needles with the convenience of
transdermal patches, while minimizing the disadvantages of these
administration methods. Therefore, microneedle arrays are a very useful
alternative method for delivering peptide and protein drugs from the skin
into the systemic circulation without any serious damage to skin.

In this review, recent challenges in the developments of microneedle
arrays for the delivery of peptide and protein drugs are summarized.

Then, future developments of microneedle arrays for the delivery of
peptide and protein drugs are also discussed in order to improve their
therapeutic efficacy and safety.

Free full text
https://www.jstage.jst.go.jp/article/yakushi/134/1/134_13-00221-3/_article
__________________________________________________________________
________________________________*_________________________________

19. Abstract: Recent trends in hepatitis B virus infection in the general
Korean population
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/23864799

Korean J Intern Med. 2013 Jul;28(4):413-9.

Recent trends in hepatitis B virus infection in the general Korean
population.

Kim H, Shin AR, Chung HH, Kim MK, Lee JS, Shim JJ, Kim BH.

BACKGROUND/AIMS: Hepatitis B virus (HBV) is the major cause of chronic
liver disease in Korea, but viral prevalence has decreased because of
hepatitis B vaccination programs. In this study, we investigated
longitudinal changes in HBV in fection in the general Korean population.

METHODS: HBV surface antigen (hepatitis B surface antigen, HBsAg)
seropositivity was assessed from the Korea National Health and Nutrition
Examination Survey (I to V). In total, 50,140 subjects were tested for
serum HBsAg positivity over a period of 12 years (1998 to 2010).

RESULTS: The prevalence of HBsAg seropositivity decreased over the study
period. The rates of HBsAg carriers were 4.61% in 1998, 4.60% in 2001,
3.69% in 2005, 3.01% in 2008, and 2.98% in 2010 (p < 0.0001). The
reduction in HBV infection rates was more prominent in younger age groups.
Among teenagers (10 to 19 years), the percentage of HBsAg carriers
decreased from 2.2% in 1998 to 0.12% in 2010 (p < 0.0001). Among those
aged 10 to 39 years, the percentage of HBV infection decreased from 4.72%
in 1998 to 2.29% in 2010 (p < 0.0001). However, no decreasing trend in
HBsAg positivity was observed among those aged 50 or older (p > 0.05).
Neither gender nor socioeconomic status were associated with the decreased
prevalence of HBsAg carriers.

CONCLUSIONS: HBV infection has decreased in the Korean population since
the advent of vaccination programs. However, the decrease is limited to
the younger population, and viral persistence remains in the middle-aged
and older population.

KEYWORDS: Age groups, Hepatitis B surface antigens, Hepatitis B virus,
Korea, Prevalence

Comment in Hepatitis B virus infection in South Korea: three decades after
universal vaccination. [Korean J Intern Med. 2013]

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712149/

See editorial “Hepatitis B virus infection in South Korea: three decades
after universal vaccination” on page 408. [SIGN Mod: see below]
__________________________________________________________________
________________________________*_________________________________

20. Abstract: Hepatitis B virus infection in South Korea: three decades
after universal vaccination
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712147/

Korean J Intern Med. 2013 July; 28(4): 408–409.

Published online 2013 July 1.

Hepatitis B virus infection in South Korea: three decades after universal
vaccination

Jin-Wook Kimcorresponding author

In 1992, the World Health Assembly issued a resolution that recommend
universal hepatitis B vaccination in countries in which it is feasible
[1]. The rationale for the recommendation was that 1) hepatitis B virus
(HBV) is second only to smoking as a risk factor for cancer mortality [2],
and 2) the hepatitis B vaccine is among the safest and most efficient
vaccines available. Because the prevalence of HBV infection is highest in
Asian countries [3], excellent reports have been issued from Taiwan [4],
China [5], and Korea [6] regarding the efficacy of vaccination against
HBV, not only for the prevention of new infection, but also in terms of a
decrease in the incidence of hepatocellular carcinoma [4]. In South Korea,
the HBV vaccine was first available in 1982 and was generated from the
sera of patients. However, a decade passed until the universal vaccination
program was implemented. Since then, as show by Kim et al. [7] in this
issue, the prevalence of HBV infection has decreased continually (Fig. 1),
which is in line with reports from neighboring countries [4,5].

Figure 1 [Deleted]

Trend of hepatitis B surface antigen (HBsAg) seropositivity in South Korea
during the most recent two decades.

Of note, however, is the finding that the prevalence has not decreased
significantly in the population in their 50s. Several mechanisms might
underlie this finding: 1) as proposed by the authors, the risk of HBV-
related morbidity/mortality is relatively stable in this age group; and 2)
more importantly, this population has not had the opportunity to undergo
the new preventive measure (vaccination). Indeed, even if they were
vaccinated, the effect would be identical to the actual situation without
vaccination because new infection in patients in their thirties was
relatively rare during that era, because vertical transmission
predominated in Korea. In a mathematical model of vaccination and herd
immunity [8], the efficacy of the HBV vaccine was less certain than that
of vaccines against other infectious diseases-such as measles-because the
R0 (secondary cases produced by one primary case in a susceptible
population) is typically low [8]. Therefore, it is not surprising that the
impact of universal vaccination differs according to age.

More recent mathematical modeling has confirmed the benefit of HBV
vaccination in terms of overall HBV-related deaths [9], and older
generations should be proud of the benefit of their endeavors for the
younger generation.

Footnotes

No potential conflict of interest relevant to this article is reported.

References
1. World Health Assembly. Resolution WHA 45.17. Immunization and Vaccine
Quality. Geneva: World Health Assembly; 1992.
2. Maynard JE. Hepatitis B: global importance and need for control.
Vaccine. 1990;8(Suppl):S18–S20. [PubMed]
3. Safary A, Beck J. Vaccination against hepatitis B: current challenges
for Asian countries and future directions. J Gastroenterol Hepatol.
2000;15:396–401. [PubMed]
4. Chang MH, Chen CJ, Lai MS, et al. Universal hepatitis B vaccination in
Taiwan and the incidence of hepatocellular carcinoma in children: Taiwan
Childhood Hepatoma Study Group. N Engl J Med. 1997;336:1855–1859. [PubMed]
5. Wang WL, Shu ZJ, Zhou LX, Zhao YR. Clinical characteristics of
hepatitis B virus infection in middle school students born after the
universal infant vaccination program in Shanghai, China. Arch Virol.
2012;157:901–905. [PubMed]
6. Park NH, Chung YH, Lee HS. Impacts of vaccination on hepatitis B viral
infections in Korea over a 25-year period. Intervirology. 2010;53:20–28.
[PubMed]
7. Kim H, Shin AR, Chung HH, et al. Recent trends in hepatitis B virus
infection in the general Korean population. Korean J Intern Med.
2013;28:413–419.
8. Anderson RM, May RM. Vaccination and herd immunity to infectious
diseases. Nature. 1985;318:323–329. [PubMed]
9. Goldstein ST, Zhou F, Hadler SC, Bell BP, Mast EE, Margolis HS. A
mathematical model to estimate global hepatitis B disease burden and
vaccination impact. Int J Epidemiol. 2005;34:1329–1339. [PubMed]

Articles from The Korean Journal of Internal Medicine are provided here
courtesy of Korean Association of Internal Medicine
__________________________________________________________________
________________________________*_________________________________

21. No Abstract: Global Fund pledges fall short of expectations
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24367805

Lancet. 2013 Dec 21;382(9910):e50.

Global Fund pledges fall short of expectations.

Usher AD.
__________________________________________________________________
________________________________*_________________________________

22. No Abstract: Occupational needlestick injuries in hospitals[Editorial]
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24345810

Laeknabladid. 2013 Dec;99(12):557.

[Occupational needlestick injuries in hospitals[Editorial].]

[Article in Icelandic]

Gottfredsson M.
__________________________________________________________________
________________________________*_________________________________

23. No Abstract: Needlestick Injuries among Healthcare Workers of a
Tertiary Care Hospital in South India
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24334813

Infect Control Hosp Epidemiol. 2014 Jan;35(1):103-5.

Needlestick Injuries among Healthcare Workers of a Tertiary Care Hospital
in South India.

Joseph NM, Elan S, Vadivu S, Kanungo R.
__________________________________________________________________
________________________________*_________________________________

24. No Abstract: Occupational Exposure to Bloodborne Pathogens in
Interventional Radiology-Risks, Prevention, and Recommendations: A
Joint Guideline of the Society of Interventional Radiology and
Cardiovascular and Interventional Radiological Society of Europe
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24332714

J Vasc Interv Radiol. 2013 Dec 10. pii: S1051-0443(13)01510-8.

Occupational Exposure to Bloodborne Pathogens in Interventional Radiology-
Risks, Prevention, and Recommendations: A Joint Guideline of the Society
of Interventional Radiology and Cardiovascular and Interventional
Radiological Society of Europe.

Walser EM1, Dixon RG2, Silberzweig JE3, Bartal G4, Chao CP5, Gross K6,
Stecker MS7, Nikolic B8.

KEYWORDS: BBP, CDC, Centers for Disease Control and Prevention, HBV, HCV,
HCW, HIV, IR, NPA, NaSH, National Surveillance System for Healthcare
Workers, Needlestick Safety and Prevention Act, OSHA, Occupational Safety
and Health Administration, bloodborne pathogen, health care worker,
hepatitis B virus, hepatitis C virus, human immunodeficiency virus,
interventional radiology
__________________________________________________________________
________________________________*_________________________________

25. No Abstract: Why use safety needle devices?
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24261002

Br J Nurs. 2013 Jul 25-Aug 7;22(14):S14.

Why use safety needle devices?

McGowan D.
__________________________________________________________________
________________________________*_________________________________

26. KROKODIL, ProMED-mail extract

This is an extract of a longer running story on ProMED-mail and may be of
interest to SIGN readers.

Crossposted from PeoMED-mail with thanks.

ProMED-mail is a program of the International Society for Infectious
Diseases <http://www.isid.org>
__________________________________________________________________
KROKODIL, HOMEMADE OPIATE BLEND – USA: (TEXAS) SKIN NECROSIS
************************************************************

A ProMED-mail post <http://www.promedmail.org>
Communicated by: ProMED-mail from HealthMap Alerts <promed@promedmail.org>

[Desomorphine is an opioid analog with a chemical structure similar to
morphine. The structural differences produce a more rapid onset and
shorter duration of action than morphine.

Clandestine manufacture of desomorphine involves 2 steps: the
extraction of codeine from pharmaceutical products, followed by the
synthesis of desomorphine from the codeine. The extraction of codeine
involves mixing the codeine source (which often contains acetaminophen
and other substances) with organic solvents such as gasoline, adding a
strong base such as lye, and then adding an acidic solution such as
hydrochloric acid to produce water soluble codeine salts that will
reside in the aqueous layer. The codeine can be further extracted but
many will proceed directly with the next step. The extracted codeine
is mixed with iodine, hydrochloric acid, and red phosphorus to reduce
the codeine to desocodeine. Subsequently the desocodeine is
demethylated into desomorphine in a one-pot synthesis that may take 45
minutes. There are some reports of attempts at neutralization at the
end of the reaction using cigarette ash or sodium bicarbonate. Despite
these efforts the solution is often quite acidic with a pH less than 3
[1]. Analysis of Russian samples shows that what is purported to be
desomorphine is often a sloppy mixture of 4 synthetic analogues of
desomorphine, codeine, and other chemicals resulting from poor
synthesis procedures. The actual desomorphine content of krokodil
samples ranged from traces to 75 percent [2].

Desomorphine has been shown to have a greater addictive potential than
morphine [3]. The rapid onset of action produces an intense “rush”
that is both pleasurable and drives many users to compulsively use and
abuse the substance in a manner similar to heroin.

Repeated administration of any opiate can cause physical dependency,
which requires increasing doses to produce the desired effect and a
withdrawal syndrome if the substance is no longer taken.

Desomorphine, when produced in clandestine home labs is notoriously
impure and contaminated with toxic substances. Injection can cause
immediate damage and destruction of skin, blood vessels, muscles, and
bone. Iodine used in the synthesis process can cause thyroid and
muscle damage. Phosphorus, also a contaminant, is known to damage
cartilage. The damaged tissue is susceptible to infection, which may
lead to abscesses, inflammation, and destruction of the veins
(thrombophlebitis), and death of the soft tissue. The constellation of
related tissue damage has lead many media reports to refer to
desomorphine as a “flesh eating” or “flesh rotting” drug [5,6]. Pure
desomorphine itself is not known to cause these effects. Intravenous
injection of street krokodil is also well known to cause life
threatening blood stream infections, destruction of the heart valves,
and death. Because desomorphine is short acting compared to morphine
and heroin, the need for more frequent injection increases the risks
of infection from hepatitis C virus and HIV [4].

As with most opioids, death can occur at high doses because of
respiratory depression. Street desomorphine carries additional
potentially fatal risks associated with injecting impure chemicals
into the body.

This homemade concoction of fuel and narcotics literally eats the body
from the inside out. The lesions appear to have no cure and are
reported to be painful and devastating. The concoction is not pure and
may not be homogenous, and in some cases those choosing to use the
drug have injected straight fuel into the veins. Most people choosing
to use this drug are dead inside of 2 years. The warning here is for
people to know what they are doing and for parents to know about the
lethal effects of this combination and to warn children, teens, and
young adults.

Portions of this comment were extracted from
<https://www.erowid.org/chemicals/desomorphine/desomorphine_basics.shtml>.

References
———-
1. Grund JC, Latypov A, Harris M: Breaking worse: The emergence of
krokodil and excessive injuries among people who inject drugs in
Eurasia. Int J Drug Policy. 2013; 24(4): 265-74; available at
<http://www.ijdp.org/article/S0955-3959(13)00051-0/fulltext>.
2. Savchuk SA, et al: Chromatographic Study of Expert and Biological
Samples Containing Desomorphine. J Anal Chem. 2008; 63(4): 361-70;
available at
<http://link.springer.com/article/10.1134%2FS1061934808040096#page-1>.
3. Sargent LJ, May EL: Agonists-Antagonists Derived from Desomorphine
and Metopon. J Med Chem. 1970; 13(6): 1061-3; available from
<http://pubs.acs.org/doi/abs/10.1021/jm00300a009>.
4. Gahr M, Freudenmann RW, Hiemke C, et al: Desomorphine Goes
“Crocodile”. J Addict Dis. 2012; 31(4): 407-12; abstract available at
<http://www.tandfonline.com/doi/full/10.1080/10550887.2012.735570#>.
5. Winter M: Flesh-rotting ‘krokodil’ drug emerges in USA. USA Today.
27 Sep 2013.
<
http://www.usatoday.com/story/news/nation/2013/09/26/heroin-krokodil-
flesh-rotting-arrives-us-arizona/2879817/>.
6. Erowid E: 2500 results on google searching for “flesh eating” and
“desomorphine” on 29 Sep 2013.
<https://www.google.com/search?q=”flesh+eating”+desomorphine>
– Mod.TG

A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/r/276D>.]
__________________________________________________________________
________________________________*_________________________________

27. News

– India: Blood banks cause of Hepatitis C in Kashmir: Experts ‘Unscreened
Donors Pose Risk To Patients’; Will Look Into Matter: Health Minister
– USA: HBV Vaccine Recommended for All Unvaccinated at Risk HCP
– USA: ND DOH reports investigation of Hepatitis C outbreak inconclusive
– Colorado USA: Poudre Valley Hospital recommends hepatitis C testing for
some ICU patients
– Philippines: 384 new HIV/AIDS cases in Nov bring 2013 tally to almost
5,000
– Canada: Hospitals take action to secure dirty needles

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/osdrou2

India: Blood banks cause of Hepatitis C in Kashmir: Experts ‘Unscreened
Donors Pose Risk To Patients’; Will Look Into Matter: Health Minister

Mudasir Yaqoob, Greater Kashmir (06.01.14)

Srinagar Jan 6: In absence of proper screening of blood donated in blood
banks of hospitals in Kashmir, experts claim it has become main source of
increasing cases of Hepatitis C among patients.

According to guidelines of the World Health Organization (WHO), a donor
must be examined, asked specific questions about medical history and
undergo various tests to ensure that his or her blood is not infected.
President of Doctors Association of Kashmir , Dr Nisar-ul-Hassan, alleged
that Blood Banks are responsible for the “colossal Hepatitis C epidemic in
Kashmir.

“Blood Banks screen donated blood for Hepatitis C by enzyme immunoassay
which can give false negative results. Therefore donated blood is a huge
source of Hepatitis c virus transmission,” Dr Nisar said.
He said in developed countries, Blood Banks have switched from serological
tests to qualitative HCV RNA nucleic acid test (NAT) for screening donated
blood. “The introduction of NAT technology in developed countries for
screening blood bank pool has prevented transfusion related hepatitis c
infection,” he said.

“The burden of Hepatitis C has alarmingly increased by unhygienic chemist
shops, Dental clinics, diagnostic centers and nursing homes. The
callousness and insensitiveness on part of government has put whole
population at risk. Blood Banks should screen donated blood by NAT
technology to prevent any further transfusion related transmission of
virus,” Dr Nisar added. Doctors said Hepatitis C, HIV and Syphilis tests
of a donor are mandatory before donation of blood.

“Hepatitis C is a silent killer as it rarely presents with symptoms until
it leads to dreaded complications of cirrhosis and liver cancer. There is
neither any effective vaccine nor post exposure prophylaxis available
against Hepatitis C virus. So measures should be taken to prevent
Hepatitis C infection,” Dr Mirab said.

Abdul Hameed Rather of Bandipora who donated blood for his spouse at a
government hospital here said, “I was just verbally asked if I was
suffering from any disease and only my blood group was checked.”

“No other tests were carried out to rule out any infection in my blood,”
he claimed. Other blood donors also revealed that no tests were carried
out before they went for blood donation.

When contacted, the Minister of state for Health, Shabir Ahmad Khan said
he will look into the matter.
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http://tinyurl.com/p8uosp8

USA: HBV Vaccine Recommended for All Unvaccinated at Risk HCP

Healio Infectious Diseases, Healio.com USA (03.01.14)

Healio reported that CDC recommended all unvaccinated or incompletely
vaccinated healthcare personnel (HCP) who risk exposure to blood or body
fluids receive hepatitis B virus (HBV) vaccination. Vaccinated HCP should
have serologic testing one to two months after the final dose. HBV
antibody levels of 10 milli-International Units per milliliter (mIU/mL) or
more indicated immunity; HCPs with antibody levels lower than 10mIU/mL
should have an additional dose of HBV vaccine and another serologic test
in one to two months.

Although the number of acute HBV infections has declined in the United
States, HCPs still risked exposure from patients with chronic HBV. CDC
recommended testing newly hired and graduating HCPs and administering
additional doses of HBV vaccine, as necessary, to protect them from
exposure.

Initial post-exposure management included “washing wounds and skin sites
exposed with soap and water”; testing known HBV sources; referring the
patient for appropriate management; and reporting the HBV infection to
state or local authorities. When the exposure source was unknown, the
exposed person should receive treatment as if the source were HBV-
infected.

An exposed HCP who was unvaccinated, incompletely vaccinated, or had no
documented vaccination should have one dose of HBV immune globulin and a
vaccine dose as soon as possible after exposure to a confirmed source. The
HCP should complete the vaccine series and have antibody testing. Even if
the exposure source did not have HBV, the HCP should have the vaccine
series and antibody testing.

HCP with antibody levels of 10 mIU/mL or more at the time of testing did
not require post-exposure HBV management. Those with lower levels should
have one dose of HBV immune globulin and vaccination.

The full article, “CDC Guidance for Evaluating Health-Care Personnel for
Hepatitis B Virus Protection and for Administering Postexposure
Management” was published online in the Morbidity and Mortality Weekly
Report at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm.
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http://tinyurl.com/q7psq4w

USA: ND DOH reports investigation of Hepatitis C outbreak inconclusive

by Emma Rogers, Vaccine News Daily, USA (01.01.14)

north carolina department of health and human servicesThe North Dakota
Department of Health recently announced that the preliminary findings of
its investigation of a Hepatitis C outbreak in Minot are currently
inconclusive.

“The goal of this investigation was to identify modes of transmission or
risk factors associated with Hepatitis C in this population and stop
ongoing transmission,” State Epidemiologist for the N.D. Department of
Health Tracy Miller said. “At this time we still do not fully understand
how transmission occurred.”

All confirmed cases involve current or former residents of the ManorCare
Health Services center in Minot. While an epidemiologic analysis has been
conducted at the facility in search of breaches in infection control
procedures, none have yet been observed.

“Through observations and interviews, we further investigated these areas
looking for possible breaches in infection control procedures that would
explain the transmission of Hepatitis C,” Miller said. “However, we did
not observe any obvious breaches that would explain transmission.”

Hepatitis C is transmitted from blood-to-blood. The investigation is still
underway and specialists believe the outbreak may be a result of improper
podiatry, phlebotomy and nail care services at ManorCare.

“Even though we have not identified the exact method Hepatitis C was
transmitted in this outbreak, the health care providers have worked
proactively with us to review and reinforce policies and procedures to
strengthen infection control protocols,” Miller said.

The investigation will continue and the N.D. Department of Health
announced that it will bring a specialist in to help with the
investigation and help educate ManorCare staff on infection control
practices.

KEYS: Hepatitis, Medical Countermeasures
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http://tinyurl.com/ltw72vq

Colorado USA: Poudre Valley Hospital recommends hepatitis C testing for
some ICU patients

By Pat Ferrier,Fort Collins Coloradoan (30.12.13)

An employee at Poudre Valley Hospital’s intensive care unit suspected of
stealing intravenous painkillers may have put more than 200 patients at
risk of contracting hepatitis C, an infectious liver disease.

The hospital sent letters Saturday to 210 patients who received
intravenous painkillers in the ICU and some others who received the
painkillers in connection with the ICU care team between Sept. 2, 2011,
and Aug. 28, 2012, asking them to get tested immediately for hepatitis C.

Hospital officials stress there have been no reported cases of patients
acquiring the disease at the hospital and no evidence that any patients
were harmed. In an abundance of caution, they are asking patients to seek
free and confidential testing as soon as possible. As of Monday afternoon,
hospital officials said they had not heard from any patients, although
many may just be receiving the letter.

“We want patients to be assured at this time there are no reported cases
of patients acquiring hepatitis C and no evidence of harm to patients, but
we want to make sure they are absolutely safe and encourage them to get
tested,” said Ric Detlefsen, director of quality at Poudre Valley Hospital
and Medical Center of the Rockies.

In a conference call with reporters, hospital officials said the risk of
infection is low, “but patient safety is our No. 1 priority. We want to
make certain no patient was harmed and there is no risk whatsoever.”

Officials said Fort Collins police have been working with investigators
from the Colorado Department of Public Health and Environment since early
November when they learned the employee had been stealing leftover drugs
from patients. The hospital also learned the employee had hepatitis C but
was no longer infected after Aug. 28, 2012.

Fort Collins police spokeswoman Rita Davis said she could not find any
ongoing investigation in the department.

PVH officials would only identify the employee as a man but declined to
say what position he held. He was suspended during the initial
investigation and later fired.

Since it’s been 16 months since the employee was hepatitis free and no
other cases have been reported, “that speaks well to the risk being very
low,” said Dr. Stan Gunstream, chief quality officer.

The hospital’s investigation is still ongoing but officials could not say
how many times or how much of the painkillers were stolen.

See a sample version of the letter here.
http://pvhs.org/documents/News/Health_Alert_Letter_PVH.pdf

Hospital CEO Kevin Unger said in a press release: “We’re concerned. Some
of the diverted medications were injectable narcotics that we believe were
headed for the trash. We don’t have any evidence that patients were harmed
or infected with hepatitis C, but we want to be sure of that.”

Hepatitis C is an infectious liver disease that affects more than 3.2
million Americans, including about 85,000 Coloradans. Symptoms range in
severity from a mild illness that lasts a few weeks to a lifelong,
potentially fatal illness. Between 70 and 80 percent of people with acute
hepatitis C do not have any symptoms, according to the Centers for Disease
Control.

Some people, however, can have mild to severe symptoms soon after being
infected including: fever, fatigue, loss of appetite, nausea, vomiting,
abdominal pain, dark urine, clay-colored bowel movements, joint pain and
jaundice.

“That’s why we’re pushing so hard for people to come in and be tested,”
said Ric Detlefsen, director of quality at Poudre Valley Hospital and
Medical Center of the Rockies. Testing involves a blood draw and results
can typically be available the same day. Several effective treatments are
available including a injected protein type medicine and another oral
medication, said Dr. David Cobb, an infectious disease expert at PVH and
MCR.

In one of the most high profile cases of a health-care worker exposing
patients to hepatitis C, a traveling medical technician was sentenced in
New Hampshire to 39 years in prison earlier this month for causing an
outbreak throughout several states.

David Kwiatkowski, who had been diagnosed with hepatitis C, allegedly
stole narcotics-filled syringes, refilled them with saline and left the
contaminated needles to be used on other patients. Since his arrest in
2012, 46 people in four states have been diagnosed with the same strain of
hepatitis C he carried.

There is no evidence of similar behavior occurring at PVH, said Dan
Weaver, spokesman for Poudre Valley Hospital. “We are calling for this
test just as an extra precaution to make sure all patients are safe.”

USA Today contributed to this report.
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http://tinyurl.com/lllozya

Philippines: 384 new HIV/AIDS cases in Nov bring 2013 tally to almost
5,000

Business Mirror.Con Manila Philippines (28.12.13)

THE Department of Health (DOH) registered 384 new cases of HIV/AIDS in
November, bringing the year’s total thus far to 4,456, predominantly young
males—not necessarily gay—having sex with other males.

The Philippine HIV and AIDS Registry, which is maintained by the DOH,
showed that, of the newest cases, 379 were acquired through sexual
contact, with 96 percent of those infected males and 63 percent from the
20 to 29 age group.

Only five cases involved needle sharing among drug users.

The age range of those infected was from 17 to 59, with the median age
being 27 and 104 cases involving the youth from 15 to 24 years old.

MSMs, or men who have sex with men, accounted for 83 percent of the
infections.

November’s cases were 35 percent higher than the same period last year,
when 284 cases were registered.

Of these, 35 cases have progressed to AIDS.

Metro Manila accounted for 43 percent of cases, followed by Calabarzon
with 17 percent, Central Luzon and Davao with 9 percent each, and Western
Visayas with 5 percent.

Of this year’s total cases, 4,222 involved sexual contact, 1,250 involved
youth aged from 15 to 24 and three cases involved children younger than
15.

Another 231 cases involved needle sharing and three were mother-to-child
transmission.

Three hundred seven cases progressed to AIDS.

Of the 16,158 cases recorded since 1984, 861 patients have died and 307
have acquired full-blown AIDS.

The overwhelming number of infections—15,027, or 93 percent—involved
sexual contact, 4 percent (671) were through needle sharing, 20 through
blood transfusion and three from needle prick injuries.

Two percent, or 375 cases, were undetermined.

Almost half of all the cases – 7,485—were in the National Capital Region
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http://tinyurl.com/q4jv5dz

Canada: Hospitals take action to secure dirty needles

Global News, The Canadian Press, Canada (19.12.13)

Saskatchewan hospitals take action after toddler puts hands in pail with
dirty needles.

REGINA – Saskatchewan’s health minister says health regions across the
province have taken steps to make sure containers with used needles are
secure after a toddler put her hands into a pail of syringes at a
hospital.

Dustin Duncan asked the regions to do an audit in November to make sure
all facilities are following the rules for proper disposal.

An anxious wait for family after a toddler pricks herself after gaining
access to a container of used syringes at an Outlook, Sask. hospital.
Toddler pricks herself in pail of used syringes in Saskatchewan hospital
The audit was ordered after a toddler put her hands into a pail of used
syringes in the emergency room at the hospital in Outlook, south of
Saskatoon.

Duncan could not immediately say how many changes needed to be made, but
he says the fact that action was taken suggests used needle containers
were in the wrong spots, perhaps for convenience.

The minister says in those cases, containers were moved off the ground and
secured to a wall.

The little girl had to get Hepatitis B shots and drugs to prevent
infections, such as HIV, and she has to undergo regular blood tests for
several months to determine if she has caught anything.

© The Canadian Press, 2013
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