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Post00732       2 Letters + Abstracts + News    12 February 2014

1. Letter: Incidence of needlestick and other sharp object injuries in a
Chinese hospital
2. Abstract: Medical waste management training for healthcare managers – a
4. Abstract: Incidence of hepatitis C virus infection among Egyptian
healthcare workers at high risk of infection
5. Abstract: Occupational exposures to blood and body fluids among health
care workers at university hospitals
6. Abstract: Organizational influence on the occurrence of work accidents
involving exposure to biological material
8. Abstract: Knowledge and practice of post-exposure prophylaxis (PEP)
against HIV infection among health care providers in a tertiary
hospital in Nigeria
9. Abstract: Biological contamination of insulin pens in a hospital
10. Abstract: HCV, HBV, and HIV seroprevalence, coinfections, and related
behaviors among male injection drug users in Arak, Iran
11. Abstract: Exploring stakeholder perceptions of facilitators and
barriers to using needle exchange programs in yunnan province, china
12. Abstract: A connectivity model for assessment of HIV transmission risk
in injection drug users (IDUs
13. Abstract: A survey of infection control teaching in u.s. Dental
14. Abstract:Intradermal delivery for vaccine dose sparing: overview of
current issues
15. Abstract: Dose sparing and enhanced immunogenicity of inactivated
rotavirus vaccine
16. Abstract: EMLA(R) cream: A pain-relieving strategy for childhood
17. Letter: Hand-held hazards by health-care workers
18. No Abstract: Moving the agenda forward: the prevention and management
of hepatitis C virus infection among people who inject drugs
19. Krokodil, Homemade Opiate Blend – Mexico (Sonora): Skin Necrosis
20. News
– USA: Ohio: Local Alcohol, Drug, and Mental Health Board Seeks Home for
Needle Disposal Boxes
– Nepal: Eco-friendly medical waste disposal in Nepal
– USA: Md. Senate approves needle exchange expansion
– Iran: French company reveals involvement in HIV scandal in 1980s
– USA: Baltimore wants to give out thousands more needles to drug users
– Ukraine: Methadone Clinics Help Ukraine Succeed Where Russia Fails on

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1. Letter: Incidence of needlestick and other sharp object injuries in a
Chinese hospital

Crossposted from the American Journal of Infection Control with thanks.

AJIC: American Journal of Infection Control

Volume 42, Issue 2 , Pages 213-214, February 2014

Incidence of needlestick and other sharp object injuries in a Chinese

Peiwen Zhang, BS
Li Wang, PhD, Hongqin Bao, BS, Zhongyu Gao, MDemail address, Xiaoping
Chen, BS
Denghai Zhang, PhD, MD
Ning Jiang, BS

To the Editor:

Health care workers (HCWs) are among those at highest risk of occupational
infection from biologic factors because they are exposed to human body
fluids daily. Every year, hundreds of thousands of HCWs are at risk of
occupationally acquired bloodborne diseases as the result of
needlestick/sharps injuries (NSI).1, 2 In 2009, an online network
reporting system for NSI among medical personnel was established in
Shanghai, China.

The study analyzed the data provided by Shanghai International Forum on
Infection Control. All NSI events were reported from the Gongli hospital
from July 2009 to August 2013. Gongli is a teaching hospital located in
Shanghai, China. This is a 600-bed hospital serving a population of
800,000 inhabitants. The average number of HCWs in the past 4 years is
1,208, including doctors, nurses, diagnostic technicians, and health care
staff such as cleaners/housekeepers. A total of 122 NSI have been

Nursing personnel, including nurses and nurse students, were most likely
to experience NSI. Of 122 NSI, 72.73% were nurses, and 18.04% were
doctors, This phenomenon is consistent with the findings from other
countries concerning NSI.3 This can be explained by the fact that nurses
administer most of the injections and are responsible for venipunctures,
intravenous fluid administration, and other procedures that require the
use of needles and the greater amount of time nurses spend in direct
patient contact.4

In China, most of the patients go to a third-grade hospital for medical
treatment because of the lack of family doctors. HCWs in China work under
great pressure. By analysis of NSI by circumstances, we found that about
73.77% of the cases happened between needles/sharps after use and before
disposal (Table 1). These values were higher than the data found in other
studies.3, 5 This is due to Chinese HCWs’ heavy workload, especially for
nurses. They have no time to concentrate on the proper disposal of the
needles or sharp instruments after use.

The situation reveals “management shortcoming” in the hospital, and this
special period should be considered in the design of biosafety strategies.
In addition, the cleaners are also vulnerable, and 9 incidents of NSI were
reported. Furthermore, 97.54% of these incidents are preventable by
modifying practices such as recapping or preoccupational/occupational
training programs.

Table 1.
Analysis of needlestick/sharp injuries by circumstances
Incidents, n Percentage

By needles or sharp instruments before use 1 0.82

By needles or sharp instruments in used 14 11.48

By needles or sharp instruments in used 1 0.82

Recapping needles 1 0.82

Pulling out the needle from the rubber or other resistance body 1 0.82

By needles or sharp instruments after use, before disposed 90 73.77

Injured by needles or sharp instruments left untreated or beside a
container 1 0.82

During the disposal of instruments in container 3 2.46

After disposal, injured by needles or sharp instruments outstretching from
the garbage bags or other container 3 2.46

Injured by needles or sharp instruments that was left on the floor,
tables, beds, or others 1 0.82

Others 6 4.92

Total 122 100

The finding of this study can increase awareness and reduce the
occupational risks from NSI. Because the online network reporting system
for sharp injuries among medical personnel in China has just been
established in some cities in recent years, further investigations are
needed to reduce incidence of NSI in Chinese hospitals.

Stein DD, Makarawo TP, Ahmad MF. A survey of doctors’ and nurses’
knowledge, attitudes and compliance with infection control guidelines in
Birmingham teaching hospitals. J Hosp Infect. 2003;54:68–73

Nagao Y, Baba H, Torii K, Nagao M, Hatakeyama K, Iinuma Y, et al. A long-
term study of sharps injuries among health care workers in Japan. Am J
Infect Control. 2007;35:407–411

Jahan S. Epidemiology of needlestick injuries among health care workers in
a secondary care hospital in Saudi Arabia. Ann Saudi Med. 2005;25:233–238

Rampal L, Zakaria R, Sook L. Needle stick and sharps injuries and factors
associated among health care workers in a Malaysian Hospital. Eur J Soc
Sci. 2010;13:354–362

Shiao JS, Mclaws ML, Huang KY, Guo YL. Student nurses in Taiwan at high
risk for needlestick injuries. Ann Epidemiol. 2002;12:197–201
II: S0196-6553(13)01292-3


© 2014 Association for Professionals in Infection Control and
Epidemiology, Inc. Published by Elsevier Inc All rights reserved.

2. Abstract: Medical waste management training for healthcare managers – a

J Environ Health Sci Eng. 2013 Jul 16;11(1):20.

Medical waste management training for healthcare managers – a necessity?

Ozder A, Teker B, Eker HH, Altindis S, Kocaakman M, Karabay O.

BACKGROUND: This is an interventional study, since a training has been
given, performed in order to investigate whether training has significant
impact on knowledge levels of healthcare managers (head-nurses, assistant
head nurses, hospital managers and deputy managers) regarding bio-medical
waste management.

METHODS: The study was conducted on 240 volunteers during June – August
2010 in 12 hospitals serving in Istanbul (private, public, university,
training- research hospitals and other healthcare institutions). A survey
form prepared by the project guidance team was applied to the participants
through the internet before and after the training courses. The training
program was composed of 40 hours of theory and 16 hours of practice
sessions taught by persons known to have expertise in their fields.
Methods used in the analysis of the data chi-square and t-tests in
dependent groups.

RESULTS: 67.5% (162) of participants were female. 42.5% (102) are working
in private, and 21.7% in state-owned hospitals. 50.4% are head-nurses, and
18.3% are hospital managers.A statistically significant difference was
found among those who had received medical waste management training
(preliminary test and final test) and others who had not (p<0.01). It was
observed that information levels of all healthcare managers who had
received training on waste management had risen at the completion of that
training session.

CONCLUSION: On the subject of waste management, to have trained healthcare
employees who are responsible for the safe disposal of wastes in hospitals
is both a necessity for the safety of patients and important for its
contribution to the economy of the country.

Free Open Access Article

4. Abstract: Incidence of hepatitis C virus infection among Egyptian
healthcare workers at high risk of infection

J Clin Virol. 2013 May;57(1):24-8.

Incidence of hepatitis C virus infection among Egyptian healthcare workers
at high risk of infection.

Abdelwahab SF, Hashem M, Galal I, Sobhy M, Abdel-Ghaffar TS, Galal G,
Mikhail N, El-Kamary SS, Waked I, Strickland GT.

Department of Microbiology and Immunology, Faculty of Medicine, Minia
University, Minia, Egypt.

BACKGROUND: Hepatitis C virus (HCV) is a global health threat with Egypt
having the highest worldwide prevalence. Evaluation of the efficacy of a
preventive HCV vaccine, such as those currently in Phase I/II trials,
requires a cohort with a high-risk exposure to HCV.

OBJECTIVE: To identify a reliable cohort for evaluating preventive HCV
vaccines, we studied HCV incidence among HCW in a hospital where almost
85% of patients are HCV-infected.

STUDY DESIGN: Of 717 HCW negative for HCV-antibodies (anti-HCV) at
baseline, 651 were followed up and tested for seroconversion twice
annually for an average of 504 ± 154 days. Those reporting a needle-stick
injury were additionally tested for both HCV antibodies and RNA monthly
for a total of four months.

RESULTS: Two subjects (0.31%) had anti-HCV and HCV-RNA seroconversion with
an overall incidence of 2.04/1000 person-years and a 4.8% incidence among
the 21 subjects who reported a needle-stick injury. Two additional
subjects had viremia without detectable anti-HCV. Two of the four subjects
were among 21 with reported needle-stick injuries (9.5%) and another had
surgery. All four were nurses providing direct patient care.

CONCLUSIONS: Our results show that both transient and persistent viremia
were detectable in this high-risk cohort of HCW and suggest that absence
of anti-HCV in two of the subjects may be due to low-dose viral exposures.

These data indicate that HCV infections acquired from documented injuries
during direct patient care are frequent in Egypt and can guide selection
of eligible HCW suitable for preventive HCV vaccine trials.

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

Full free text:

5. Abstract: Occupational exposures to blood and body fluids among health
care workers at university hospitals

Srp Arh Celok Lek. 2013 Nov-Dec;141(11-12):789-93.

Occupational exposures to blood and body fluids among health care workers
at university hospitals.

Markovic-Denic L1, Brankovic M2, Maksimovic N2, Jovanovic B3, Petrovic I4,
Simic M5, Lesic A5.

1Insitute of Epidemiology, School of Medicine, University of Belgrade,
Belgrade, Serbia.
2Insitute of Epidemiology, School of Medicine, University of Belgrade,
Belgrade, Serbia.
3Department of Anesthesiology, Clinical Center of Serbia, Belgrade,
4Department of Otorhinolaryngology with Maxillofacial Surgery, Clinical
Hospital Center Zemun, Belgrade, Serbia.
5Clinic of Orthopedic Surgery and Traumatology, Clinical Center of Serbia,
Belgrade, Serbia.

INTRODUCTION: Occupational exposure to blood and body fluids is a serious
concern of health care workers and presents a major risk of transmission
of infections such as human immuno-deficiency virus (HIV), hepatitis B
virus (HBV), and hepatitis C virus (HCV).

OBJECTIVE: The aim of this study was to determine the frequency and
circumstances of occupational blood and body fluid exposures among health
care workers.

METHODS: Cross-sectional study was conducted in three university hospitals
in Belgrade. Anonymous questionnaire was used containing data about
demographic characteristics, self-reported blood and body fluid exposures
and circumstances of percutaneous injuries.

RESULTS: Questionnaire was filled in and returned by 216 health care
workers (78.2% of nurses and 21.8% of doctors). 60.6% of participants-
health care workers had sustained at least one needlestick injury during
their professional practice; 25.9% of them in the last 12 months. Of
occupational groups, nurses had higher risk to experience needlestick
injuries than doctors (p = 0.05). The majority of the exposures occurred
in the operating theatre (p = 0.001). Among factors contributing to the
occurrence of needlestick injuries, recapping needles (p = 0.003) and
decontamination/cleaning instruments after surgery (p = 0.001) were more
frequent among nurses, while use of a needle before intervention was
common among doctors (p = 0.004). Only 41.2% of health care workers had
reported their injuries to a supervisor in order to obtain medical
attention. 50.2% of health care workers were vaccinated with three doses
of hepatitis B vaccine.

CONCLUSION: There is a high rate of needlestick injuries in the daily
hospital routine. Implementation of safety devices would lead to
improvement in health and safety of medical staff.

Full free text

6. Abstract: Organizational influence on the occurrence of work accidents
involving exposure to biological material

Rev Lat Am Enfermagem. 2013 Jan-Feb;21 Spec No:199-206.

Organizational influence on the occurrence of work accidents involving
exposure to biological material.

[Article in English, Portuguese]

Marziale MH, Rocha FL, Robazzi ML, Cenzi CM, dos Santos HE, Trovó ME.

Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, SP,

OBJECTIVES: to analyze work accidents involving exposure to biological
materials which took place among personnel working in nursing and to
evaluate the influence of the organizational culture on the occurrence of
these accidents.

METHOD: a retrospective, analytical study, carried out in two stages in a
hospital that was part of the Network for the Prevention of Work
Accidents. The first stage involved the analysis of the characteristics of
the work accidents involving exposure to biological materials as recorded
over a seven-year period by the nursing staff in the hospital studied, and
registered in the Network databank. The second stage involved the analysis
of 122 nursing staff members’ perception of the institutional culture, who
were allocated to the control group (workers who had not had an accident)
and the case group (workers who had had an accident).

RESULTS: 386 accidents had been recorded: percutaneous lesions occurred in
79% of the cases, needles were the materials involved in 69.7% of the
accidents, and in 81.9% of the accident there was contact with blood.

Regarding the influence of the organizational culture on the occurrence of
accidents, the results obtained through the analysis of the two groups did
not demonstrate significant differences between the average scores
attributed by the workers in each organizational value or practice

It is concluded that accidents involving exposure to biological material
need to be avoided, however, it was not possible to confirm the influence
of organizational values or practices on workers’ behavior concerning the
occurrence of these accidents.

Free full text

8. Abstract: Knowledge and practice of post-exposure prophylaxis (PEP)
against HIV infection among health care providers in a tertiary
hospital in Nigeria

J Int Assoc Physicians AIDS Care (Chic). 2012 May-Jun;11(3):179-83.

Knowledge and practice of post-exposure prophylaxis (PEP) against HIV
infection among health care providers in a tertiary hospital in Nigeria.

Owolabi RS, Alabi P, Ajayi S, Daniel O, Ogundiran A, Akande TM, Onafowokan

OBJECTIVE: To assess the knowledge and practice of post exposure
prophylaxis (PEP) against HIV infection among health care providers in
University of Abuja Teaching Hospital (UATH).

METHODS: A cross-sectional survey conducted on 230 health care providers
in UATH.

RESULTS: Majority (97.0%) of the respondents have heard about PEP, but
only a few (30.9%) of them could correctly identify the drugs used and
duration of PEP. A third of respondents have had one form of accidental
exposure or the other. HIV test was carried out in about two-thirds
(64.8%) of the source patients. Thirteen (28.3%) of the source patients
were HIV- positive. Of the 13 respondents that were exposed to HIV-
positive patients, only 3 (23.1%) received PEP, and these three completed
PEP, while majority, 10/13 (76.9%) did not receive PEP in spite of their
exposure to HIV-positive sources.

CONCLUSION: The study shows that the knowledge and practice of PEP among
health care providers are very poor.

9. Abstract: Biological contamination of insulin pens in a hospital

Am J Health Syst Pharm. 2013 Jul 15;70(14):1244-8.

Biological contamination of insulin pens in a hospital setting.

Herdman ML, Larck C, Schliesser SH, Jelic TM.

Department of Pharmaceutical and Administrative Sciences, School of
Pharmacy, University of Charleston, Charleston, WV 25304, USA.

PURPOSE: Biological contamination of insulin pens in a hospital setting
was studied.

METHODS: This prospective study, conducted at two hospitals within a
multihospital system, examined 125 insulin pens that had been returned to
the inpatient pharmacies after patient discharge and were refrigerated for
up to 48 hours before laboratory testing. Insulin was removed from the 125
pens and examined microscopically for the presence of nucleated cells and
red blood cells (RBCs). Positive samples were examined by a pathologist to
determine the cell types present. An immunochromatographic assay was used
to determine the presence of free hemoglobin in the insulin. The 10
control samples were negative on microscopic examination.

RESULTS: Out of 125 insulin pens, 7 (5.6%) tested positive for cells or
hemoglobin. Microscopic examination revealed six positive samples
containing a total of nine cells, including macrophages, squamous cells,
and an RBC. The sample containing the RBC was not the same sample that
tested positive for hemoglobin. Based on findings of intact cells and
hemoglobin in insulin pens after administration, the potential exists for
transmission of infectious agents from patient to patient if a single pen
cartridge is used to administer insulin to multiple patients, even if a
new needle is used for each individual.

CONCLUSION: Examination of 125 insulin pens used in hospitals revealed
hemoglobin in 1 pen and at least one cell in another 6 pens. The nine
detected cells consisted of four squamous epithelial cells, four
macrophages, and one RBC.

Full text:

10. Abstract: HCV, HBV, and HIV seroprevalence, coinfections, and related
behaviors among male injection drug users in Arak, Iran

AIDS Care. 2014 Feb 6.

HCV, HBV, and HIV seroprevalence, coinfections, and related behaviors
among male injection drug users in Arak, Iran.

Ramezani A, Amirmoezi R, Volk JE, Aghakhani A, Zarinfar N, McFarland W,
Banifazl M, Mostafavi E, Eslamifar A, Sofian M.

a Clinical Research Department , Pasteur Institute of Iran , Tehran ,

This study explored the prevalence and related risk behaviors for
hepatitis C (HCV), hepatitis B (HBV), and human immunodeficiency virus
(HIV) among a sample of male injection drug users (IDUs) in Arak, Iran.

One hundred male IDUs attending methadone maintenance clinics between
April and September 2012 were enrolled and evaluated for HCV, HBV, and HIV

The majority of study participants (56%) had evidence of HCV exposure, 6%
had evidence of HBV, and 19% were HIV-infected. Coinfections were
frequent; 15% had evidence of HIV and HCV, 6% had evidence of HBV and HCV,
and 5% had serologic markers for all three infections. Most (84%) were
susceptible to HBV infection.

A history of any syringe sharing (54%) and syringe sharing in prison (25%)
were common. In bivariate analyses, a history of any syringe sharing and
syringe sharing in prison were both associated with all three viral

The high prevalence of HCV, HBV, HIV, and coinfections among IDU in Arak
is concerning and indicates rapid disease spread outside of Iran’s main
urban centers.

Prevention efforts should expand vaccination for IDUs who are nonimmune to
HBV and continue to target syringe sharing with efforts such as needle
exchange programs, including inside prisons.

11. Abstract: Exploring stakeholder perceptions of facilitators and
barriers to using needle exchange programs in yunnan province, china

PLoS One. 2014 Feb 3;9(2):e86873.

Exploring stakeholder perceptions of facilitators and barriers to using
needle exchange programs in yunnan province, china.

Philbin MM1, Fujie Z2.

1HIV Center for Clinical & Behavioral Studies Columbia University and the
NY State Psychiatric Institute, New York City, New York, United States of
2Treatment and Care Division, National Center for AIDS/STD Control and
Prevention, Chinese Center for Disease Control and Prevention, Beijing,

Injection drug use is an ongoing urban health crisis in China and one of
the largest drivers of the transmission of HIV/AIDS. Sentinel surveillance
sites in Yunnan province show upwards of 20% of injection drug users
(IDUs) are HIV positive. Though the Ministry of Health has scaled-up
needle exchange programs (NEPs), they have not received official
government recognition nor have they been extensively evaluated to explore
factors influencing their acceptability and feasibility.

Using in-depth qualitative interviews conducted from February to July 2008
with 35 participants consisting of IDUs and other key stakeholders, we
explored facilitators and barriers to accessing needle exchange programs
in Kunming, the capital of Yunnan province. Content analysis was conducted
to identify themes including attitudes toward NEPs and harm reduction,
barriers to access, and suggestions for improvement.

Themes that emerged included fears of breached confidentiality and police
interference at the exchange sites and tensions between the public health
and law enforcement perspective. Low levels of NEP-related knowledge and
awareness were uniformly reported among interviewees. Suggestions to
facilitate an increase in NEP acceptance included raising awareness of
harm reduction and HIV more generally, offering services such as
psychological counseling, job training and behavioral therapy at NEPs, and
increasing communication between police, government, and public health
officials. High rates of HIV infection among injection drug users in China
have prompted rapid scale up of NEPs. Additional adaptations are
necessary, however, to increase needle exchange use among injection drug

This study finds that an urgent need to raise awareness of NEPs among
policy makers and IDUs and act upon identified steps for developing
social- structural interventions to create enabling environments that
facilitate increased access to NEPs among injection drug users in Kunming.

Free full text

12. Abstract: A connectivity model for assessment of HIV transmission risk
in injection drug users (IDUs

Eval Program Plann. 2013 Aug;39:23-7.

A connectivity model for assessment of HIV transmission risk in injection
drug users (IDUs).

Flaer PJ, Cistone PJ, Younis MZ, Parkash J.

Diagnosis and Treatment Planning Section, AEGD Residency Program of
Community Smiles, Dade County Dental Research Clinic, Miami, FL, USA

The purpose of this study was to produce models composed of mapping of
connectivity networks of HIV transmission risk in injection drug users

This methodology provided a novel approach and diagnostic tool for
understanding HIV infection transmission risk and drug use in the typical
niche of IDUs, i.e., a “shooting gallery” (a gathering site for injection
drug activity). Furthermore, component IDUs may have memberships in
multiple “shooting galleries” revealing subsequent interconnectivities.

Charting of IDU connectivity diagrams illustrated the relationships of
peripheral sites to the critical central core of high HIV transmission
risk. Members of this highly interlinked and infectious central core of
IDUs had high HIV transmission risk and severe drug use-producing high
morbidity and mortality that resulted in great public health concern. In
addition, connectivity diagrams reveal very high HIV transmission risk in
component IDUs in “dual memberships”, i.e., membership in more than one
central core (with the highest number of partners). Therefore, IDUs with
“dual memberships” were the most infectious members of the “shooting

In summation, network mapping of HIV transmission risk in IDUs allows for
subsequent socio-behavioral analysis and the development of focused
individual and programmatic interventions.

Copyright © 2013 Elsevier Ltd. All rights reserved.

13. Abstract: A survey of infection control teaching in u.s. Dental

J Dent Educ. 2014 Feb;78(2):187-94.

A survey of infection control teaching in u.s. Dental schools.

Porteous NB, Bizra E, Cothron A, Yeh CK.

San Antonio Dental School, 7703 Floyd Curl Drive, San Antonio, TX


This study was conducted to determine the content of infection control
(IC) curricula, the extent of IC monitoring and compliance, and the number
of bloodborne pathogen (BBP) exposures/year in U.S. dental schools.

A questionnaire was emailed to persons responsible for predoctoral IC
programs. The response rate was 60 percent.

Most schools did not have an independent course and used classroom
lectures and clinic demonstrations to teach IC. Schools with an IC
committee were more likely to use online learning (p<0.05), utilize
multiple teaching methods (p<0.05), issue written warnings for IC
violations (p<0.0001), and use multiple disciplinary actions (p<0.005)
than schools without an IC committee.

Schools with an IC coordinator were less likely to issue grade reductions
for IC violations than schools with no IC coordinator (p<0.05). Thirty-
eight percent reported =16 BBP exposures/year, and 18 percent reported <5.

There was significant correlation between BBP exposure incidents and large
class size (p<0.005).

Respondents were satisfied with their IC curriculum and perceived that
dental students had a high level of IC compliance and satisfaction, along
with staff IC promotion and compliance.

The findings suggest that schools without an IC committee should consider
its benefits.

Further investigation of schools with high numbers of BBP exposures is

KEYWORDS: bloodborne pathogen, clinic management, clinical education,
dental education, dental schools, infection control, infection control
compliance in dental schools, infection control teaching

14. Abstract:Intradermal delivery for vaccine dose sparing: overview of
current issues

Vaccine. 2013 Jul 25;31(34):3392-5.

Intradermal delivery for vaccine dose sparing: overview of current issues.

Zehrung D, Jarrahian C, Wales A.

PATH, 2201 Westlake Avenue, Suite 200, Seattle, WA 98121, USA.

There is a wide range of methods and technologies aimed at improving human
vaccine products and the way they are delivered. Some of these have the
potential to increase vaccine effectiveness in specific populations and
may furthermore help to increase vaccine access, reduce costs, and ease
the logistical burdens of immunization programs, especially in low-
resource settings.

One strategy under evaluation is the use of intradermal (ID) delivery of
vaccines, which has been shown to result in dose sparing with some
vaccines. Novel ID delivery devices could enable needle-free and therefore
safer and more reliable ID administration than current ID injection
methods, facilitating ID delivery and dose sparing with existing or new

There are promising clinical data with some vaccines that highlight the
potential of reduced-dose immunization via the ID route. And more studies
are under way.

However, a number of clinical and technical research as well as
operational challenges exist, including establishing the optimal doses for
different vaccines, reformulating to adjust antigen concentration or add
preservatives, matching vaccine vial volume to session size, working with
vaccine manufacturers to achieve regulatory clearance for ID delivery, and
developing ID delivery devices suitable for the varying scenarios of use
of different vaccines. These will need to be addressed before the benefits
of ID delivery and the impact of novel ID delivery technologies on human
health are fully realized.

Copyright © 2012 Elsevier Ltd. All rights reserved.

KEYWORDS: Delivery devices, Dose sparing, Intradermal delivery, Reduced-
dose vaccination, Vaccine delivery

15. Abstract: Dose sparing and enhanced immunogenicity of inactivated
rotavirus vaccine

Vaccine. 2013 Jul 25;31(34):3396-402.

Dose sparing and enhanced immunogenicity of inactivated rotavirus vaccine

administered by skin vaccination using a microneedle patch. Moon S, Wang
Y, Edens C, Gentsch JR, Prausnitz MR, Jiang B.

Skin immunization is effective against a number of infectious diseases,
including smallpox and tuberculosis, but is difficult to administer. Here,
we assessed the use of an easy-to-administer microneedle (MN) patch for
skin vaccination using an inactivated rotavirus vaccine (IRV) in mice.
Female inbred BALB/c mice in groups of six were immunized once in the skin
using MN coated with 5 µg or 0.5 µg of inactivated rotavirus antigen or by
intramuscular (IM) injection with 5 µg or 0.5 µg of the same antigen, bled
at 0 and 10 days, and exsanguinated at 28 days.

Rotavirus-specific IgG titers increased over time in sera of mice
immunized with IRV using MN or IM injection. However, titers of IgG and
neutralizing activity were generally higher in MN immunized mice than in
IM immunized mice; the titers in mice that received 0.5 µg of antigen with
MN were comparable or higher than those that received 5 µg of antigen IM,
indicating dose sparing.

None of the mice receiving negative-control, antigen-free MN had any IgG
titers. In addition, MN immunization was at least as effective as IM
administration in inducing a memory response of dendritic cells in the

Our findings demonstrate that MN delivery can reduce the IRV dose needed
to mount a robust immune response compared to IM injection and holds
promise as a strategy for developing a safer and more effective rotavirus
vaccine for use among children throughout the world.

Published by Elsevier Ltd.

KEYWORDS: IRV, Microneedle, Rotavirus, Skin immunization

16. Abstract: EMLA(R) cream: A pain-relieving strategy for childhood

J Int Med Res. 2014 Feb 5.

EMLA(R) cream: A pain-relieving strategy for childhood vaccination.

Abuelkheir M, Alsourani D, Al-Eyadhy A, Temsah MH, Meo SA, Alzamil F.

Department of Clinical Pharmacy, King Khalid University Hospital, King
Saud University, Riyadh, Saudi Arabia.

OBJECTIVES: To evaluate the effectiveness of topical eutectic mixture of
local anaesthetics (EMLA®) cream in reducing the pain associated with
vaccination injections.

METHODS: This was a randomized, double-blind, placebo-controlled study
that included children who presented for routine immunization. Eligible
children were randomly assigned to receive either EMLA® or placebo cream.
The Modified Behavioural Pain Scale (MBPS) was used to assess baseline and
postvaccination pain scores, while a visual analogue scale (VAS) was used
to assess pain at the time of the needle prick and at the end of the

RESULTS: A total of 107 children were enrolled in the EMLA® group and 109
children in the placebo group. The difference between the pre- and
postvaccination MBPS scores was significantly lower in the EMLA group than
in the placebo group (2.56?±?1.96 versus 3.95?±?2.20, respectively). The
VAS scores at the time of the needle prick and after the injection were
significantly lower in the EMLA® group compared with the placebo group
(1.60?±?1.67 versus 3.24?±?2.01; 3.29?±?2.27 versus 4.86?±?2.20;

CONCLUSIONS: Application of EMLA® cream can be effectively incorporated as
a routine pain-relieving intervention within routine vaccination

KEYWORDS: Eutectic mixture of local anaesthetics (EMLA®), childhood
vaccination, pain assessment, vaccination pain

17. Letter: Hand-held hazards by health-care workers

Crossposted from the Indian Journal of Medical Microbiology with thanks.
Indian J Med Microbiol [serial online] 2013 [cited 2014 Feb 11];31:320-1.

Hand-held hazards by health-care workers.

Datta P, Bansal N, Chander J.

Available from:

Dear Editor,

Health-care workers (HCWs) accessories like stethoscope, mobile and pen
have become important fomites in spread of health-care infections (HAI).
Personal equipment used at patient’s point of care may be responsible for
cross-transmission and these represent an important risk for hospitalized
patients. Over 30 years back, stethoscopes had being identified as
potential vector for HAI as they come onto direct contact with patient’s
skin. [1] To further increase this complexity, mobiles of HCWs showed
9-25% contamination with pathogenic bacteria, methicillin resistant
Staphylococcus aureus (MRSA) and Acinetobacter spp. being the most common.

We designed a preliminary study aimed to determine the microbial
contamination rates of randomly selected stethoscopes. Also, the
relationship between stethoscope contamination, stethoscope cleaning
practices and mobile contamination was assessed.

This prospective surveillance study was carried out at a tertiary care
centre with randomly selected HCWs including physicians, interns and
nursing staff from various areas of the hospital. The surface of the
diaphragm of each participant’s stethoscope and their respective mobiles
were swabbed with sterile cotton tipped swab sticks, moistened in sterile
normal saline. The swabs were then transported to Department of
Microbiology and the isolates were identified according to standard
microbiological criteria. Isolates identified as S. aureus were further
tested for MRSA using 30 µg cefoxitin as per Clinical Standards Laboratory
Institute guidelines.

A total of 80 HCWs were enrolled in the study. A total of 21 stethoscopes
and 19 mobiles were found colonized. All positive samples yielded S.
aureus (n = 40), out of which 50% were MRSA. No Gram-negative bacilli or
coagulase-negative Staphylococci were isolated. Cleaning practices of
stethoscope correlated with contamination on stethoscope as shown in
[Table 1].

Table 1: Rate of colonization of stethoscope, mobile and cleaning

Uneke et al., and Pandey et al., found S. aureus to be the most common
pathogen (54% and 27.5%, respectively) as compared to other bacteria
isolated from stethoscope and other accessories of the doctor. [3],[4]
Additionally, 16 out of 80 HCWs (20%) who had stethoscope colonization
also had colonization on their MRSA. This important fact could be linked
to presence of MRSA on the hands of these workers thereby spreading to
both mobiles and stethoscope. The absence of Gram-negative bacteria, from
mobiles of our health-care setup, has been previously documented. [5]

Eradication of bacteria from equipment is considered a vital part of
infection control practices. Simple steps of hand washing (My 5 moments of
hand hygiene, World Health Organization) before, after and in between
patients are pivotal for good hospital infection practices. The importance
of cleaning stethoscope and mobile daily cannot be re-emphasized.

1. Whittington AM, Whitlow G, Hewson D, Thomas C, Brett SJ. Bacterial
contamination of stethoscopes on the intensive care unit. Anaesthesia
2. Tacconelli E. When did the doctors become fomites? Clin Microbiol
Infect 2011;17:794-6.
3. Uneke CJ, Ogbonna A, Oyibo PG, Onu CM. Bacterial contamination of
stethoscopes used by health workers: Public health implications. J Infect
Dev Ctries 2010;4:436-41.
4. Pandey A, Asthana AK, Tiwari R, Kumar L, Das A, Madan M. Physician
accessories: Doctor, what you carry is every patient’s worry? Indian J
Pathol Microbiol 2010;53:711-3.
5. Datta P, Rani H, Chander J, Gupta V. Bacterial contamination of
mobile phones of health care workers. Indian J Med Microbiol

18. No Abstract: Moving the agenda forward: the prevention and management
of hepatitis C virus infection among people who inject drugs

Clin Infect Dis. 2013 Aug;57 Suppl 2:S29-31.

Moving the agenda forward: the prevention and management of hepatitis C
virus infection among people who inject drugs.

Grebely J, Bruggmann P, Backmund M, Dore GJ.

19. Krokodil, Homemade Opiate Blend – Mexico (Sonora): Skin Necrosis

Crossposted with thanks from ProMED-mail <>
ProMED-mail is a program of the International Society for Infectious
Diseases <>
Krokodil, Homemade Opiate Blend – Mexico (Sonora): Skin Necrosis

Source: Latino [edited] Date: 6 Feb 2014

Health authorities around the world are on alert as registered cases
of krokodil use rise. Krokodil is a low-cost drug whose effects are
similar to those of heroin, but its use leads to a long and painful
death. After the 1st cases of addiction to krokodil were detected in
October 2013 in Illinois and Arizona, health authorities of the state
of Sonora in Mexico have confirmed the 1st case of addiction to the
“drug of the living dead” on Mexican soil.

According to information published by Proceso, the 1st officially
confirmed case of krokodil use has been registered in Nogales, a city
on the border with Arizona in the United States.

According to Proceso, state authorities reported that an older man
showed up at a Residential Mutual Help Center. When he received
medical attention, it was confirmed that he had all the symptoms
associated with krokodil, one of the most lethal drugs nowadays. The
injuries it generates cause the skin to die and rot.

The director of the Mental Health Service of Sonora, Leticia Amparano
Gamez, told the Mexican media that the man, who is also addicted to
meth, cocaine and heroin, has received medical help and is under
observation: “We’re treating him and working, hoping it won’t branch
out and more consumers show up,” Gamez said, quoted by Proceso.

The new report comes days after another case of krokodil addiction was
detected in a 17 year old girl from Houston, Texas. According to The
Latin Times, the girl was visiting the tourist city of Puerto Vallarta
in Mexico to visit her family last November [2013]. Later, the girl
was interned at a hospital where she received treatment due to
injuries in her genitals. The doctors treating the girl thought it was
an advanced cased of an STD due to the “serious lacerations” she
presented. However, shortly after, the girl admitted to injecting
krokodil into her genitals.

In early 2005, the drug became popular among Russian addicts to due to
its low cost and similar effects to heroin. According to Time, in
2005, Russia’s drug enforcement agency sporadically reported seizing
the drug; however, by 2011, Russia had seized 65 million doses, and
Russia’s government estimates that at least a million people are
addicted to krokodil. Prolonged used of Krokodil produces necrosis
wherever it is injected. The skin rots and falls off, exposing bones.

[byline: Jorge Calvillo]

communicated by: ProMED-mail from HealthMap Alerts

[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 per cent [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

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

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
2. Savchuk SA, et al. Chromatographic study of expert and biological
samples containing desomorphine. J Anal Chem. 2008; 63(4): 361-70;
available at
3. Sargent LJ, May EL. Agonists-antagonists derived from desomorphine
and metopon. J Med Chem. 1970; 13(6): 1061-3; available from
4. Gahr M, Freudenmann RW, Hiemke C, et al. Desomorphine goes
“crocodile”. J Addict Dis. 2012; 31(4): 407-12; abstract available at
5. Winter M. Flesh-rotting ‘krokodil’ drug emerges in USA. USA Today.
27 Sep 2013.
6. Erowid E. 2500 results on Google searching for “flesh eating” and
“desomorphine” on 29 Sep 2013
<”flesh+eating”+desomorphine>. –

Sonora, Mexico may be located on the HealthMap/ProMED-mail interactive
map at <>.]

20. News

– USA: Ohio: Local Alcohol, Drug, and Mental Health Board Seeks Home for
Needle Disposal Boxes
– Nepal: Eco-friendly medical waste disposal in Nepal
– USA: Md. Senate approves needle exchange expansion
– Iran: French company reveals involvement in HIV scandal in 1980s
– USA: Baltimore wants to give out thousands more needles to drug users
– Ukraine: Methadone Clinics Help Ukraine Succeed Where Russia Fails on

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

USA: Ohio: Local Alcohol, Drug, and Mental Health Board Seeks Home for
Needle Disposal Boxes

CDC National Prevention Information Network, USA (07.02.14)

This article was reported by Chillicothe Gazette.

The Chillicothe Gazette reported that Ohio’s Paint Valley Alcohol, Drug,
and Mental Health (ADAMH) board soon would post a pole-mounted, metal
collection box specifically for discarded needles. Executive Director Juni
Frey stated that ADAMH had not yet selected a location for the box,
purchased in response to residents’ complaints about finding discarded
needles in the organization’s five-county service area. Chillicothe Police
Public Information Officer Bud Lytle confirmed that police received an
average of two complaints each week and attributed the increase in
discarded needles to rising heroin use after a crackdown on prescription
pain pills.

Ross County Health Commissioner Dr. Timothy Angel confirmed the need to
provide a means for drug users to dispose of syringes and needles safely.
Angel reported no new HIV cases in the county since 2008, but noted
increasing hepatitis C incidence and a rise in confirmed hepatitis B from
10 cases in 2006 to 41 in 2013. Angel noted that removing discarded
needles from the community would help prevent hepatitis transmission and
protect citizens from accidental exposure through needle sticks. Lytle
advised citizens not to touch any discarded needle and to call the police
or sheriff’s office for safe disposal.

Although needle exchange programs were not part of the effort to remove
dirty needles from the community, Angel did not rule out establishment of
a service. The Ross County Health Commission currently was starting two
other drug programs. “Project DAWN” provided education and a nasal
treatment, Naloxone, that could block the uptake of opioids and prevent
fatal overdose. The health district also was initiating a drug treatment
program based on use of naltrexone (Vivitrol), a prescription-only
injection that could prevent a drug user from relapsing to opioid use
after detoxification.

Nepal: Eco-friendly medical waste disposal in Nepal (06.02.14)

KATHMANDU, 6 February 2014 (IRIN) – Managing waste is one of the most
complicated and risky tasks among the many challenges of running a
hospital in Nepal. Few health facilities comply with the applicable waste
disposal laws, which can jeopardize patient and practitioner health. But
one government hospital is using eco-friendly methods to reduce its waste.

“When I first came to Bir Hospital [in Kathmandu, the capital] it was a
complete mess,” said Mahesh Nakarmi, director of the Health Care Waste
Management Programme at Health Care Foundation-Nepal (HECAF), an NGO
promoting affordable, safe healthcare. He found that waste was stored in
buckets under the patient’s bed, and there were no procedures in place to
safely dispose of infected materials, including syringes.

The UN World Health Organization (WHO) defines healthcare waste as
including needles, chemicals, pharmaceuticals, medical devices,
radioactive materials blood and body parts. “Poor management of healthcare
waste exposes healthcare workers, waste handlers and the community to
infections, toxic effects and injuries,” warns the agency.

Since HECAF started working with the facility two years ago to improve its
waste disposal, the 121-year-old Bir Hospital in central Kathmandu has
nearly halved the amount of waste it dumps into municipal systems, is
routinely separating hazardous materials from non-hazardous garbage, and
has begun experimenting with new disposal procedures, such as
vermicomposting, in which waste is fed to various types of earthworms.

“It is generally accepted that 70 percent is about the maximum recyclable
amount,” Ruth Stringer, international science and policy coordinator at
Health Care Without Harm, an international organization advocating
environmentally friendly healthcare systems, told IRIN during a field
visit to HECAF’s programme. “Bir’s figure of 55 percent is remarkable. Few
low-income country hospitals have systems as efficient and effective as

The waste management campaign has also enhanced safety. “Before this
programme started we went shopping in the pharmacies near the hospital and
found several types of fake syringes that were made from used syringes…
from this hospital,” Nakarmi said. Bir Hospital now uses both electronic
and manual needle-cutting devices in all inpatient wards so medical staff
can destroy syringes properly, immediately after use.

“This way we can keep the plastic pieces, put them in the autoclave, then
recycle the parts,” said Saraswoti Thakuri, a nurse and project
coordinator with HECAF. An autoclave uses pressurized steam to sterilize
medical items. Bir purchased a pair of autoclaves to sterilize waste and
to ensure a backup would be available in case one unit had a technical

“Autoclaving is essential for safety when it comes to hazardous materials,
but it also means we’re not just burning waste and creating more air
pollution,” Nakarmi said. “Burning plastic creates carcinogens. We’re a
healthcare facility, how could we do that?”

HECAF also is trying out other organic options. “We have ongoing
experiments with worms eating contaminated gauze that hasn’t been
autoclaved,” said Nakarmi. It will take several rounds of testing to
determine whether the worms’ digestive process sterilizes the material or
not. A 2006 study in India suggested that worm digestion could sterilize
infectious waste, but no large-scale trials have been conducted.

Nakarmi is also experimenting with the hospital’s first biogas system to
dispose of tumours and severed body parts for bio-degradation alongside
food waste. Biogas is a mixture of methane and carbon dioxide produced by
fermenting organic matter like animal or human waste, biodegradable waste,
and municipal solid waste.

Nepal’s 2011 Solid Waste Management Act mandates each hospital to
sterilize its hazardous waste before handing it over to the municipality,
in line with the WHO “polluter pays” guidelines, but compliance is still

Sumitra Amatya, executive director of the government’s Solid Waste
Management Technical Support Centre (SWMTSC), which monitors healthcare
waste management and refers violations to municipalities, said several
institutions have been fined up to US$1,000 per violation for poor waste
management in recent years.

Some facilities are warming to Nakarmi’s recycling philosophy. Paropakar
Maternity and Women’s Hospital in Kathmandu has recently begun
experimenting with composting placentas.

Changing the minds of staff to follow new procedures has been one of
biggest challenges at
Bir, the city’s oldest hospital, which operates at 10 times its 460-bed

“I thought if I can change waste management in the worst place, then
everyone else can follow,” said Nakarmi.


USA: Md. Senate approves needle exchange expansion

By Associated Press, USA (06.02.14)

ANNAPOLIS, Md. — The Maryland Senate on Thursday approved a measure to
allow drug users to get more than one clean needle at one time in
Baltimore’s exchange program.

The measure, approved with no debate on a 39-5 vote, repeals a requirement
that needles be exchanged on a one-for-one basis.

The bill does not spell out a specific number of needles people could get
at once. Sen. Verna Jones-Rodwell, D-Baltimore, said supporters have a
limit of about 50 in mind, and a change in the legislation may be needed
to reflect that. A similar bill is pending in the House of Delegates.

Other cities have expanded such programs to cut down on diseases like AIDS
that spread by intravenous drug use among other factors. Baltimore’s
program was established in 1994 despite opposition, but health officials
have credited it with reducing the transmission of disease.

“I think it’s proven to be very effective with decreasing the transmission
of intravenous disease and to really deal with the public health issue
that we have been trying to deal with for years with drug use in the
population,” Jones-Rodwell said.

The bill was sponsored by Baltimore senators.

The program serves about 2,500 people annually in the city and exchanges
about 200 needles for each of them each year. It also educates
participants about the dangers of contracting HIV infections through
needle-sharing practices and refers them to substance abuse programs.

The city’s health department estimates that when the program changes to a
needs-based model, it will give each participant an additional 60 syringes
annually. A state analysis estimates costs to the city’s health department
would rise by $19,500 in the next fiscal year with the change in the
program. Each syringe costs 13 cents.

Copyright 2014 The Associated Press. All rights reserved.

Iran: French company reveals involvement in HIV scandal in 1980s

Anustup Roy, Press TV, Paris (01.02.14)

The French company Sanofi Pasteur now says it is willing to talk about the
blood contamination cases which led to hundreds of deaths in Iran. During
the 1980s, the company exported HIV-contaminated blood to many countries
including Iran. Our correspondent Anustup Roy has this report from Paris.

The Sanofi Pasteur Company in France says it is willing to talk about its
past activities, which cost the lives of 250 Iranians.

In early 1980s, the company was called the Marion Institute and supplied
HIV contaminated blood for the treatment of haemophiliacs in France.
Although it had stopped selling such blood by 1986 in France, reports in
the French press show that the company continued to export contaminated
blood to Iran, West Germany, Iraq, Argentina, Saudi Arabia and Italy. When
the first cases of contaminated blood emerged in France in 1985, Laurent
Fabius was the Prime Minister.

After years of legal battles, charges were brought against him in 1999 but
he was acquitted.Now the same politician is the minister of Foreign
Affairs.Similarly, almost all other officials and ministers were freed of
all charges.

And Sanofi Pasteur company In recent years, the French pharmaceutical and
health care industry has seen a rise in conflicts of interest like the
Mediator pill case, which caused deaths. And often, it can take patients
and their families, over years, if not months, to obtain justice.Such long
waits and such repetition of pharmaceutical and medical blunders are a
sign that a lot remains to be done.
USA: Baltimore wants to give out thousands more needles to drug users

Effort to curb HIV is one of mayor’s top bills in General Assembly this

By Luke Broadwater, The Baltimore Sun, Baltimore MS USA (17.01.14)

Hoping to curb the spread of HIV, Baltimore officials want to hand out
thousands more needles to drug addicts than Maryland law now allows.

Since 1994, city Health Department vans that work with addicts have traded
clean syringes for used ones in a one-for-one exchange, currently
distributing 500,000 needles a year. City officials say that system hasn’t
stopped enough heroin addicts from sharing or reusing needles and
spreading disease.

So the Rawlings-Blake administration is asking the General Assembly to
pass legislation allowing the city to distribute as many syringes as an
addict needs — no strings attached — as is done in New York, Chicago, San
Francisco and Vancouver. That means 500,000 to 1 million more needles a
year would be given out.

“Baltimore continues to have a problem with HIV infection,” said
Baltimore’s health commissioner, Dr. Oxiris Barbot. “We’re concerned about
hepatitis C infections. This is an opportunity to decrease those rates.”

There are about 14,000 people in Baltimore with a diagnosis of HIV or
AIDS, about 2 percent of the population. The city’s Needle Exchange
Program, now in its 20th year, provides syringes to about 2,500 people

City officials say the program has been successful. In 1992, 53 percent of
Baltimore’s HIV-positive population contracted the virus through
intravenous drug use, according to the Health Department. That dropped to
17 percent by 2009 and 12 percent by 2012.

Barbot said Baltimore’s one-for-one needle exchange program results in
addicts using clean syringes about 42 percent of the time. But she said
programs in cities that distribute needles “as needed” get them to use
clean syringes about 61 percent of the time.

Mayor Stephanie Rawlings-Blake calls the requested legislation “common
sense” and says it’s one of the most important bills she’s pushing in
Annapolis this year.

“There will be less exposure to dirty needles,” the mayor said. “Cities
that have gone to a needs-based exchange have seen AIDS reduced.”

If the legislation is approved, the budget for distributing needles would
need to be increased from about $35,000 to $55,000, officials said.

Not everyone sees the move as a good idea. Mike Gimbel, an independent
consultant who formerly headed Baltimore County’s Office of Substance
Abuse, said he believes that having more clean needles would encourage
addicts to keep using drugs. He said used syringes could be sold or
proliferate as litter on city streets.

“I don’t want to see more needles on the street,” Gimbel said. “The needle
to a heroin addict is gold, especially a new needle that’s sharp. They’ll
sell them to other addicts.”

Gimbel said he contracted hepatitis C from injecting heroin as a teenager
40 years ago and is undergoing treatment for the infection.
“I’ve never been a fan of needle exchange,” he said. “I don’t believe that
harm-reduction programs convince addicts to get help. Addicts don’t
usually stop until they reach a level of pain. The reason I stopped is I
was afraid I was going to die.”

State Sen. Verna Jones, who heads the city’s Senate delegation, said she
won’t support the bill without changes. She says the number of needles
distributed should be capped. “It shouldn’t be a syringe on demand,” she
said. “There should be a ceiling on it.”

But Del. Curt Anderson, chairman of the city’s House delegation, supports
the mayor’s proposal, pointing to evidence that the city’s needle-exchange
program has been successful.

“One of the reasons why it was initially set at one-to-one is we wanted to
get the bill passed, and we were going to face conservative opposition if
we were just giving out a ton of free needles,” he said. “We won’t face as
much opposition now because the program works.”

Anderson recalled how Dr. Maxie T. Collier, a former city health
commissioner and early supporter of needle exchanges, “predicted an
epidemic of the AIDS virus hitting Baltimore, like a Third World country.”

“That never happened,” Anderson said. “The fact that it didn’t makes me
think we’ve done well.”

Barbot said addicts in Baltimore say they now use needles two to four
times before turning them in to the Health Department. She said city
officials would still require addicts to turn in the old needles in their
possession and that it’s highly unlikely that offering more clean needles
would create drug users.

“The reality is, we don’t get clients who come in starting to look at
using drugs,” she said. “While Baltimore was one of the first cities to
institute a syringe exchange, it’s one of the last major cities to change
to a needs-based exchange.”

The mayor’s legislative initiatives for the 2014 General Assembly include
several bills she says will help fight crime and encourage development.

She wants the Assembly to prevent individuals with outstanding criminal
arrest warrants — there are 38,000 such outstanding warrants in Baltimore
— from receiving a state income tax refund. Rawlings-Blake wants
legislation empowering judges to track “gang-related” crimes in hopes of
helping prosecutors gain tougher sentences for repeat, violent criminals.

She is also asking that the state consider increased penalties for illegal
dumping and for assaults on traffic enforcement officers — there were 19
such assaults last year — and extend tax credits that she believes help
attract and retain city residents.

“We’ve got a good track record of getting bills passed, and we’re pretty
judicious in deciding what bills we put forward,” Rawlings-Blake said.

Ukraine: Methadone Clinics Help Ukraine Succeed Where Russia Fails on HIV

By Simeon Bennett, Bloomberg News, USA (14.01.14)

Ukraine is checking the spread of HIV for the first time in more than a
decade by handing out methadone and clean needles to drug users, measures
long embraced in the U.S. yet still opposed in neighboring Russia.

More than 8,300 people were receiving substitution therapy to keep them
off injected drugs as of Dec. 1, more than all the other nations of the
former Soviet Union combined, according to the International HIV/AIDS
Alliance in Ukraine, which supports many of the nation’s clinics with
money from the Geneva-based Global Fund to Fight AIDS, Tuberculosis and

The approach is working. New HIV infections, which had been rising since
1999, fell in 2012 to 20,743 from 21,777 in 2011, according to the
nation’s health ministry. In Russia, where the government bans opioid
substitutes such as methadone and refuses to fund clean-needle programs,
new infections jumped 13 percent to 70,453 in 2012.

“Ukraine is important because it’s an emerging policy contrast to Russia,”
said Chris Beyrer, a professor at the Johns Hopkins Center for Global
Health in Baltimore, and the president-elect of the International AIDS
Society. “They have been making more progress on harm reduction and they
have been making more progress, albeit painfully slowly, on methadone.”

Ukraine, along with Russia, suffered through a ballooning HIV epidemic
among drug users after the collapse of the Soviet Union in 1991 eased
access to opiates such as heroin. About 230,000 people are living with the
virus in Ukraine, more than any country in Europe or Central Asia except
Russia, according to the Joint United Nations Programme on HIV/AIDS, or

Recovering Addicts

Alexander Tsukrenko is one of about 400 recovering drug users who attend a
clinic in western Kiev, trekking an hour each way for handful of pills
that are keeping him off illicit drugs. Some travel as much as three hours
each way for treatment.

“This program gives me life,” said Tsukrenko, 46, who signs his name in
the clinic’s register alongside the number 1,491 — the number of days he
has been performing the ritual.

Edward Ovcharuk, who used drugs for 17 years, has been on methadone for
two months. The treatment has already changed his life, he said.

“I used to steal money from my family,” Ovcharuk, 33, said outside the
clinic in Kiev. “I don’t need to steal anymore. I’m not waking up in the
morning thinking about drugs.”

The International HIV/AIDS Alliance aims to expand the number of people
receiving such therapy to 9,600 this year, Andrey Klepikov, the
organization’s director, said in an e-mail.

Krokodil Shots

Still, while Ukraine has made progress on HIV, the drug scourge that has
fueled it rages on. The alliance estimates that more than 250,000 people
in the country are injecting opiates. Increasingly Ukrainian drug users
are adopting a deadly concoction called krokodil, named for the gaping
wounds it creates.

Users such as a 33-year-old woman who gives her name as Oxsana present a
daunting challenge for HIV prevention.

Oxsana prepares krokodil in the basement of a decaying Soviet-era
apartment block behind a strip club in the eastern city of Donetsk. She
tips a mixture of crushed codeine pills, gasoline and citric acid into a
small dish over a gas burner. She sprinkles phosphorous — the flammable
chemical used on the end of matchsticks — over the liquid, reducing it to
a brown paste that she scrapes off with a razor blade and taps into a
small glass bottle. Oxsana adds a scoop of iodine, then a few drops of
water, filling the room with acrid gray smoke.

Clean Needles

She draws the fluid into a syringe and sits under a bare light bulb
searching for a vein on her left thigh. Her first effort fails, so she
tries again, this time on the sole of her right foot. Then she turns to
inject a friend, Marina, in her right arm with a clean needle provided by
a charity worker.

The effects of krokodil only last about half an hour, requiring Oxsana to
repeat the process as many as 20 times a day. She said the habit costs
about 400 hryvnia ($48) a day for the two of them. Oxsana and Marina sell
sex to fund their addiction, charging 150 hryvnia for oral sex and 250
hryvnia for intercourse. Both women say they have HIV, and both have been
in and out of prison.

While the number of people on methadone is relatively small and doesn’t
entirely account for the reduction in new cases, it’s part of a broader
approach to preventing infections among risk groups that is bearing fruit,
said Charles Vitek, the country director for Ukraine and Russia in the
U.S. Centers for Disease Control and Prevention’s AIDS division.

“The provision of clean needles and information about the importance of
clean needles and increased access to testing, all of those things work
together to have a prevention effect,” Vitek said in a telephone interview
from Kiev. “As long as continued prevention efforts go on and treatment
expansion keeps going up, we should see a continued drop-off in cases.”
* SAFETY OF INJECTIONS brief yourself at:

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The 2010 annual Safe Injection Global Network meeting to aid collaboration
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