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SIGNpost 00784

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00784    Cambodia HIV + Videos + Abstracts + News     14 January 2015

CONTENTS
1. Commentary: Cambodian HIV Inquiry Reportage Continues to Mislead Public
About Healthcare Risks
2. New Videos help check Injection Practices
3. Journal of Viral Hepatitis: Special Issue: Hepatitis C Disease Burden &
Strategies to Manage the Burden – Volume 2
4. Abstract: Occupational risk towards blood-borne infections among
ambulance personnel in a provincial hospital network in Thailand
5. Abstract: Occupational exposure to blood in multiple trauma care
6. Abstract: Epidemiology of exposure to HIV/AIDS risky conditions in
healthcare settings: the case of health facilities in Gondar City,
North West Ethiopia
7. Abstract: Biomedical waste management: Study on the awareness and
practice among healthcare workers in a tertiary teaching hospital
8. Abstract: Healthcare waste management: qualitative and quantitative
appraisal of nurses in a tertiary care hospital of India
9. Abstract: Historical epidemiology of hepatitis C virus (HCV) in select
countries – volume 2
10. Abstract: A Multi-Center Randomized Controlled Trial of Adding Brief
Skill-Based Psychoeducation to Primary Needle and Syringe Programs to
prevent Human Immunodeficiency Virus: Study Protocol
11. Abstract: Vial washers for the compounding pharmacy: ensuring
preparation safety
12. Abstract: Impact of the International Nosocomial Infection Control
Consortium (INICC) multidimensional hand hygiene approach in 3 cities
in Brazil
13. Abstract: Comparison of hand hygiene monitoring using the 5 Moments
for Hand Hygiene method versus a wash in-wash out method
15. Abstract: Evaluation of voriconazole oral dosage in Japan
16. News
– Cambodia: Tainted needles blamed
– Cambodia: HIV Outbreak Linked to Infected NeedlesCambodia: Cambodia
finds 212 with HIV where unlicensed medic operated
– Norway: Oslo heroin user contracts botulismUK: Scotland reports 3
additional botulism cases in heroin users
– Health Care-Associated Hepatitis C Infections Reviewed
– Ebola: Ebola death toll goes past 8,000: WHO – Unconfirmed case in
Berlin
– Cambodia: Government Targets Unlicensed Medics Amid HIV Outbreak
– Cambodia: Man Charged for Causing HIV Outbreak in Patients

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1. Commentary: Cambodian HIV Inquiry Reportage Continues to Mislead Public
About Healthcare Risks

Crossposted from dontgetstuck.org with thanks.

See the News section below for a sample of the news reports on the
Cambodia HIV cluster.
__________________________________________________________________
http://tinyurl.com/klnm3b2

Don’t Get Stuck With HIV

Cambodian HIV Inquiry Reportage Continues to Mislead Public About
Healthcare Risks

Posted by Simon Collery on January 12, 2015

One of the remarks that many articles about the Cambodian HIV outbreak are
mentioning now, almost as if every journalist is tweaking the same press
release and putting their name on it, is about needlestick injuries and
the CDC’s estimate that “99.7% of needlestick occurrences involving HIV
infected blood do not result in transmission“.

This figure is irrelevant and entirely misleading: receiving an injection
or an infusion is nothing like a needlestick injury when some or all of
the equipment, or the substance being administered, are contaminated.
Needlestick injuries are typically slight and shallow and the inoculant is
likely to be very small.

Some of the titles also mention ‘tainted needles‘, but this may give the
incorrect impression that reused syringes are not also a likely factor in
this outbreak, along with contaminated multi-dose vials of medicines,
vaccines, distilled water and other substances.

An injection involves the needle going below the skin, into muscle or into
a vein, depending on what kind of injection it is. Most of the contents of
the syringe and needle, along with anything remaining in them from
previous uses, goes into the patient’s body. Some estimates of risks are
given on this Don’t Get Stuck With HIV webpage.

Most of the contents of the syringe and needle enter the patient’s body.
Some remains in the syringe and needle. In addition, it is possible for a
vacuum to form in the syringe, allowing a small amount of blood from the
patient to enter the syringe. To repeat, this is nothing like a
needlestick injury.

Someone from the World Health Organization is reported as saying
“different types of injection procedures carry different levels of risk“,
which is a major improvement on the CDC quotes, but the WHO remark needs
to be explained further, while the CDC one needs to be removed altogether.

Similar remarks apply to infusions, intravenous drips, etc. The risk of
transmission from some common procedures can be very high indeed. Visitors
to Cambodia may have noticed how popular intravenous drips are, with
passengers on the back of motorbike taxis holding up the bag as they ride,
and small ‘medical’ practices opening on to streets in Phnom Penh
(although I doubt if many visitors have used such clinics because they
tend to be aware of the risks of infection with HIV and other viruses
through unsafe healthcare).

It is also very disturbing that the single practitioner said to have been
involved in the outbreak has been arrested, imprisoned and even accused of
murder (though little mention has been made of any murder victims). This
is not going to encourage other practitioners, or professionals of any
kind, political, administrative, ancillary, etc, to come forward and
assist with the inquiry.

Members of the public may be careful what they say to police if they think
others may be arrested and accused of murder. But even employees of CDC,
WHO, UNAIDS and the like may be reluctant to find evidence that the risk
of healthcare associated HIV transmission is very high, because they have
been insisting for several decades that it hardly ever occurs.

To ensure the cooperation of as many health practitioners as possible the
Cambodian authorities need to consider a ‘no blame’ investigation. Every
article so far suggests confusion, professionals not recognizing HIV risks
from unsafe healthcare, politicians appearing to know nothing about it
and, more importantly, members of the public not knowing about the risks
they face, or how to avoid them (there is some useful advice here).

It is especially important that members of the public are involved and
that they understand a ‘no blame’ investigation. While some people may be
angry about the single unlicensed practitioner identified so far, the
entire health service, department of health, and even the global health
community must share some of the responsibility.

Local human rights NGO Licadho stresses this point. The government of
Cambodia (and governments of every developing country) have been claiming
to have implemented ‘universal precautions’ to prevent healthcare
associated HIV transmission. But is this a mere tick in a box marked
‘universal precautions’?

In the light of this and numerous other outbreaks, declarations about
universal precautions may need to be questioned to establish if there is
any mechanism for ensuring that these precautions are being followed, and
even if it is possible to follow them in seriously under-resourced health
services.
__________________________________________________________________
________________________________*_________________________________

2. New Videos help check Injection Practices
__________________________________________________________________
New Videos help check Injection Practices

Copied with thanks from the One and Only Campaign

https://www.youtube.com/user/OneandOnlyCampaign
__________________________________________________________________
________________________________*_________________________________

3. Journal of Viral Hepatitis: Special Issue: Hepatitis C Disease Burden &
Strategies to Manage the Burden – Volume 2
__________________________________________________________________
Journal of Viral Hepatitis

Special Issue: Hepatitis C Disease Burden & Strategies to Manage the
Burden – Volume 2

January 2015

Volume 22, Issue Supplement s1
Pages 1–73

© John Wiley & Sons Ltd

Free Full Text – Link from the Table of Contents
http://onlinelibrary.wiley.com/doi/10.1111/jvh.2014.22.issue-s1/issuetoc
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Occupational risk towards blood-borne infections among
ambulance personnel in a provincial hospital network in Thailand
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25427363

Southeast Asian J Trop Med Public Health. 2014 Jul;45(4):940-8.

Occupational risk towards blood-borne infections among ambulance personnel
in a provincial hospital network in Thailand.

Luksamijarulkul P, Pipitsangjan S, Vatanasomboon P.

Health-care personnel working in an ambulance may be at risk for work-
related infections, especially blood-borne infections. This cross-
sectional study was conducted to assess occupational risks and their
preventive practices for blood-borne infections among ambulance personnel
working in a provincial hospital network.

One hundred sixty-one personnel who voluntarily participated were
interviewed using a structured questionnaire. The one-month history of
risk exposures to blood-borne infections was collected. In order to cover
the real situation of patient care practices among ambulance personnel
during working, 30 ambulance runs were observed. Data from the
questionnaire and field observation were analyzed and presented by
descriptive statistics.

The results indicated that 82% had a history of contact with jaundiced
patients, and 95% had a history of contact with AIDS patients.

Approximately, 63.4% had a history of contact with patients’ blood through
injuries; of these, 64.7% had needle stick injuries, and 24.5% had sharp
injuries. Data for blood-borne preventive practices from interviews
reported 82.6% wore disposaiole gloves when doing a blood puncture or
giving intravenous fluid/blood.

Only 54% broke off drug vials with a clean cloth or cotton wool to
protect from an injury, in contradiction to recommended procedure.

The mean score of preventive practices was 7.6±2.2; a score classified at
a moderate level. However, data from field observations demonstrated only
30.3% of observed personnel (3/9) used aprons and goggles when contacting
a large amount of blood, and only 11.1% (1/9) broke off drug vials with a
clean cloths to protect from an injury.

Continuous education and training, as well as the improvement of safety
equipment are needed to better protect ambulance personnel from
occupational risks.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Occupational exposure to blood in multiple trauma care
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25566692

Anaesthesist. 2015 Jan 9.

[Occupational exposure to blood in multiple trauma care.]

[Article in German]
Wicker S1, Wutzler S, Schachtrupp A, Zacharowski K, Scheller B.

1Betriebsärztlicher Dienst, Universitätsklinikum Frankfurt, Theodor-Stern-
Kai 7, 60590, Frankfurt a. M., Deutschland, Sabine.Wicker@kgu.de.

BACKGROUND: Trauma care personnel are at risk of occupational exposure to
blood-borne pathogens. Little is known regarding compliance with standard
precautions or occupational exposure to blood and body fluids among
multiple trauma care personnel in Germany.

AIM: Compliance rates of multiple trauma care personnel in applying
standard precautions, knowledge about transmission risks of blood-borne
pathogens, perceived risks of acquiring hepatitis B, hepatitis C and human
immunodeficiency virus (HIV) and the personal attitude towards testing of
the index patient for blood-borne pathogens after a needlestick injury
were evaluated.

MATERIAL AND METHODS: In the context of an advanced multiple trauma
training an anonymous questionnaire was administered to the participants.

RESULTS: Almost half of the interviewees had sustained a needlestick
injury within the last 12 months. Approximately three quarters of the
participants were concerned about the risk of HIV and hepatitis. Trauma
care personnel had insufficient knowledge of the risk of blood-borne
pathogens, overestimated the risk of hepatitis C infection and underused
standard precautionary measures. Although there was excellent compliance
for using gloves, there was poor compliance in using double gloves
(26.4?%), eye protectors (19.7?%) and face masks (15.8?%). The
overwhelming majority of multiple trauma care personnel believed it is
appropriate to test an index patient for blood-borne pathogens following a
needlestick injury.

CONCLUSION: The process of treatment in prehospital settings is less
predictable than in other settings in which invasive procedures are
performed. Periodic training and awareness programs for trauma care
personnel are required to increase the knowledge of occupational
infections and the compliance with standard precautions.

The legal and ethical aspects of testing an index patient for blood-borne
pathogens after a needlestick injury of a healthcare worker have to be
clarified in Germany.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Epidemiology of exposure to HIV/AIDS risky conditions in
healthcare settings: the case of health facilities in Gondar City,
North West Ethiopia
__________________________________________________________________
http://www.biomedcentral.com/1471-2458/14/1283 Free Full Text

BMC Public Health. 2014 Dec 16;14:1283.

Epidemiology of exposure to HIV/AIDS risky conditions in healthcare
settings: the case of health facilities in Gondar City, North West
Ethiopia.

Beyera GK1, Beyen TK.

1Department of Environmental and Occupational Health and Safety, Institute
of Public Health, College of Medicine and Health Sciences, University of
Gondar, Gondar, Ethiopia. getkoo@yahoo.com.

BACKGROUND: It has been estimated that every year more than quarter a
million health care workers exposed to HIV risky conditions in health care
settings, more so in developing countries, with high incidence of HIV/AIDS
and unsafe practices. Particularly, Sub-Saharan African countries share at
least half of these occupational exposures to HIV risky conditions among
health care workers. The aim of this study was to determine the
epidemiology of health care workers’ exposure to HIV/AIDS risky conditions
and associated factors in the healthcare settings in Gondar city.

METHODS: Institution based quantitative cross sectional study was
conducted from April 1-20, 2014. The study included 401 health care
workers who were selected from the source population by simple random
sampling technique. Data were collected by interviewing health care
workers using structured and pretested questionnaire. After the collected
data entered to EPI INFO version 3.5.3 statistical software and exported
to SPSS version 20.0 for analysis, both binary and multivariable logistic
regressions were done to identify factors associated with exposure to
HIV/AIDS risky conditions.

RESULTS: From a total of 401 health care workers involved in this study,
162(40.4%) reported at least one history of occupational exposure to
HIV/AIDS risky conditions in the last one year. More than half (52.31%) of
physicians and 47.62% of anesthetists were exposed to HIV/AIDS risky
conditions within one year. Lack of training on infection prevention, 5-10
years work experience, long working hours per week, absence of work
guidelines, and dissatisfaction with current job were significantly
associated with accidental occupational exposure to HIV/AIDS risky
conditions.

CONCLUSION: This study found quite high prevalence of health care workers
exposure to HIV/AIDS risky conditions in the health care settings in
Gondar city. Therefore, effective and goal oriented educational programmes
targeting at health care workers and establishment of surveillance systems
for registering, reporting and management of occupational exposures in
health care settings are quite important.

Free full text http://www.biomedcentral.com/1471-2458/14/1283
__________________________________________________________________
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7. Abstract: Biomedical waste management: Study on the awareness and
practice among healthcare workers in a tertiary teaching hospital
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25560016

Indian J Med Microbiol. 2015 Jan-Mar;33(1):129-31.

Biomedical waste management: Study on the awareness and practice among
healthcare workers in a tertiary teaching hospital.

Joseph L, Paul H, Premkumar J; Rabindranath, Paul R, Michael JS1.

1Department of Clinical Microbiology , Christian Medical College and
Hospital, Vellore, Tamil Nadu, India.

Bio-medical waste has a higher potential of infection and injury to the
healthcare worker, patient and the surrounding community.

Awareness programmes on their proper handling and management to healthcare
workers can prevent the spread of infectious diseases and epidemics.

This study was conducted in a tertiary care hospital to assess the impact
of training, audits and education/implementations from 2009 to 2012 on
awareness and practice of biomedical waste segregation.

Our study reveals focused training, strict supervision, daily
surveillance, audits inspections, involvement of hospital administrators
and regular appraisals are essential to optimise the segregation of
biomedical waste.

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

8. Abstract: Healthcare waste management: qualitative and quantitative
appraisal of nurses in a tertiary care hospital of India
__________________________________________________________________
http://www.hindawi.com/journals/tswj/2014/935101/

ScientificWorldJournal. 2014;2014:935101.

Healthcare waste management: qualitative and quantitative appraisal of
nurses in a tertiary care hospital of India.

Shivalli S1, Sanklapur V2.

1Community Medicine, Yenepoya Medical College, Yenepoya University,
Deralakatte, Mangalore, Karnataka 575018, India.
2Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka
575018, India.

Background. The nurse’s role in healthcare waste management is crucial.
Objectives. (1) To appraise nurses quantitatively and qualitatively
regarding healthcare waste management; (2) to elicit the determinants of
knowledge and attitudes of healthcare waste management.

Method. A cross-sectional study was undertaken at a tertiary care hospital
of Mangalore, India. Self-administered pretested questionnaire and
“nonparticipatory observation” were used for quantitative and qualitative
appraisals. Percentage knowledge score was calculated based on their total
knowledge score. Nurses’ knowledge was categorized as excellent (>70%),
good (50-70%), and poor (<50%). Chi square test was applied to judge the
association of study variables with their attitudes and knowledge.

Results. Out of 100 nurses 47 had excellent knowledge (>70% score). Most
(86%) expressed the need of refresher training. No study variable
displayed significant association (P > 0.05) with knowledge. Apt
segregation practices were followed except in casualty. Patients and
entourages misinterpreted the colored containers.

Conclusion. Nurses’ knowledge and healthcare waste management practices
were not satisfactory.

There is a need of refresher trainings at optimum intervals to ensure
sustainability and further improvement.

Educating patients and their entourages and display of segregation
information board in local language are recommended.

Free Full Article http://www.hindawi.com/journals/tswj/2014/935101/
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Historical epidemiology of hepatitis C virus (HCV) in select
countries – volume 2
__________________________________________________________________
J Viral Hepat. 2015 Jan;22 Suppl 1:6-25.

Historical epidemiology of hepatitis C virus (HCV) in select countries –
volume 2.

Saraswat V1, Norris S, de Knegt RJ, Sanchez Avila JF, Sonderup M,
Zuckerman E, Arkkila P, Stedman C, Acharya S, Aho I, Anand AC, Andersson
MI, Arendt V, Baatarkhuu O, Barclay K, Ben-Ari Z, Bergin C, Bessone F,
Blach S, Blokhina N, Brunton CR, Choudhuri G, Chulanov V, Cisneros L,
Croes EA, Dahgwahdorj YA, Dalgard O, Daruich JR, Dashdorj NR, Davaadorj D,
de Vree M, Estes C, Flisiak R, Gadano AC, Gane E, Halota W, Hatzakis A,
Henderson C, Hoffmann P, Hornell J, Houlihan D, Hrusovsky S, Jarcuška P,
Kershenobich D, Kostrzewska K, Kristian P, Leshno M, Lurie Y, Mahomed A,
Mamonova N, Mendez-Sanchez N, Mossong J, Nurmukhametova E, Nymadawa P,
Oltman M, Oyunbileg J, Oyunsuren Ts, Papatheodoridis G, Pimenov N,
Prabdial-Sing N, Prins M, Puri P, Radke S, Rakhmanova A, Razavi H, Razavi-
Shearer K, Reesink HW, Ridruejo E, Safadi R, Sagalova O, Sanduijav R,
Schréter I, Seguin-Devaux C, Shah SR, Shestakova I, Shevaldin A, Shibolet
O, Sokolov S, Souliotis K, Spearman CW, Staub T, Strebkova EA, Struck D,
Tomasiewicz K, Undram L, van der Meer AJ, van Santen D, Veldhuijzen I,
Villamil FG, Willemse S, Zuure FR, Silva MO, Sypsa V, Gower E.

1Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow,
India.

Chronic hepatitis C virus (HCV) infection is a leading cause of liver
related morbidity and mortality. In many countries, there is a lack of
comprehensive epidemiological data that are crucial in implementing
disease control measures as new treatment options become available.

Published literature, unpublished data and expert consensus were used to
determine key parameters, including prevalence, viremia, genotype and the
number of patients diagnosed and treated. In this study of 15 countries,
viremic prevalence ranged from 0.13% in the Netherlands to 2.91% in
Russia.

The largest viremic populations were in India (8 666 000 cases)
and Russia (4 162 000 cases). In most countries, males had a higher rate
of infections, likely due to higher rates of injection drug use (IDU).
Estimates characterizing the infected population are critical to focus
screening and treatment efforts as new therapeutic options become
available.

© 2014 John Wiley & Sons Ltd.

KEYWORDS: HCV; diagnosis; disease burden; epidemiology; hepatitis C;
incidence; mortality; prevalence; treatment

Full Free Text:
http://onlinelibrary.wiley.com/doi/10.1111/jvh.12350/full
__________________________________________________________________
________________________________*_________________________________

10. Abstract: A Multi-Center Randomized Controlled Trial of Adding Brief
Skill-Based Psychoeducation to Primary Needle and Syringe Programs to
prevent Human Immunodeficiency Virus: Study Protocol
__________________________________________________________________

Iran J Psychiatry. 2014 Jul;9(3):175-80.

A Multi-Center Randomized Controlled Trial of Adding Brief Skill-Based
Psychoeducation to Primary Needle and Syringe Programs to prevent Human
Immunodeficiency Virus: Study Protocol.

Naserbakht M1, Noroozi A2, Hajebi A1.

1Mental Health Research Center, Tehran Institute of Psychiatry, School of
Behavioral Sciences and Mental Health, Iran University of Medical
Sciences, Tehran, Iran.
2Iranian National center for Addiction Studies, Tehran University of
Medical Sciences, Tehran, Iran.

OBJECTIVES: Our objective was to design an RCT in order to assess the
effects of adding a brief skill-based psychoeducation (PE) to routine
Needle and Syringe Programs to reduce injection and high risk sexual
behaviors associated with Human Immunodeficiency Virus (HIV) infection
among referrals of Drop-in Centers (DICs).

METHOD/DESIGN: This was a randomized control trial with the primary
hypothesis that adding skill-based PE to the routine needle syringe
program (NSP) provided in the DICs would be more effective in reducing
injection and high risk sexual behaviors associated with HIV infection
compared to the routine programs. We intended to randomly allocate 60
patients per group after obtaining informed written consent,. The
intervention group receive a combination of brief psychoeducation
consisting two individual sessions of skill-based education concerning
blood borne viral infection, specifically HIV. The control group received
the routine primary NSP services provided in DIC. Study assessments were
undertaken by a psychologist at baseline, 1 and 3 months after
recruitment. The primary outcome measure was the comparison of the trend
of alterations in high risk sexual and injection behaviors associated with
HIV infection during 3 months after the initiation of the intervention
between the two groups. Secondary outcome measures included the comparison
of HIV/AIDS related knowledge and client satisfaction in the participants.

DISCUSSION: This paper presents a protocol for an RCT of brief skill-based
PE by a trained psychologist to reduce the sexual and injection related
high risk behaviors among drug users who received primary NSP services in
DIC. This trial tried to investigate the efficacy of the intervention on
increasing HIV/AIDS related knowledge and client satisfaction. The results
of different indicators of high risk behaviors will be discussed.

KEYWORDS: Drop-in Center; HIV; High risk behavior; Needle and Syringe
Programs (NSPs); Psychoeducation

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277809/
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Vial washers for the compounding pharmacy: ensuring
preparation safety
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25508634

Int J Pharm Compd. 2014 Jul-Aug;18(4):270-6.

Vial washers for the compounding pharmacy: ensuring preparation safety.

Johnson K, Sully A, Anthenat B.

The safety and effectiveness of customized formulations have always been
priorities for compounding pharmacists, perhaps even more so since a
tragic outbreak of meningitis in 2012 was traced to preparations from the
New England Compounding Center in Framingham, Massachusetts.

Since that time, pharmaceutical compounding in the U.S. has been the focus
of renewed interest from the public and from government organizations and
regulatory bodies created to ensure patient safety. As a result,
responsible compounders have responded to ensure–to even greater levels–
the purity and safety of the formulations they prepare.

One tool useful in doing so is the mechanical vial washer, which can
produce cleaner vials (and/or ampules, syringes, and cartridges, depending
on the washer model) more consistently than does washing vessels by hand.
In this article, several such washers appropriate for use in a compounding
pharmacy are profiled, and a pharmacist’s experience in using one of those
models is described.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Impact of the International Nosocomial Infection Control
Consortium (INICC) multidimensional hand hygiene approach in 3 cities
in Brazil
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25564118

Am J Infect Control. 2015 Jan 1;43(1):10-5.

Impact of the International Nosocomial Infection Control Consortium
(INICC) multidimensional hand hygiene approach in 3 cities in Brazil.

Medeiros EA1, Grinberg G2, Rosenthal VD3, Bicudo Angelieri D1, Buchner
Ferreira I4, Bauer Cechinel R4, Zanandrea BB5, Rohnkohl C5, Regalin M5,
Spessatto JL6, Scopel Pasini R6, Ferla S6.

1Hospital São Paulo, São Paulo, Brazil.
2Hospital General Porto Alegre, Porto Alegre, Brazil; Hospital Sao Miguel,
Joaçaba, Brazil; Hospital Universitario Santa Terezinha, Joaçaba, Brazil.
3International Nosocomial Infection Control Consortium, Buenos Aires,
Argentina. Electronic address: victor_rosenthal@inicc.org.
4Hospital General Porto Alegre, Porto Alegre, Brazil.
5Hospital Sao Miguel, Joaçaba, Brazil.
6Hospital Universitario Santa Terezinha, Joaçaba, Brazil.

BACKGROUND: Hand hygiene (HH) is the main tool for cross-infection
prevention, but adherence to guidelines is low in limited-resource
countries, and there are not available published data from Brazil.

METHODS: This is an observational, prospective, interventional, before-
and-after study conducted in 4 intensive care units in 4 hospitals, which
are members of the International Nosocomial Infection Control Consortium
(INICC), from June 2006-April 2008. The study was divided into a 3-month
baseline period and a follow-up period. A multidimensional HH approach was
introduced, which included administrative support, supplies availability,
education and training, reminders in the workplace, process surveillance,
and performance feedback. Health care workers were observed for HH
practices in each intensive care unit during randomly selected 30-minute
periods.

RESULTS: We recorded 4,837 opportunities for HH, with an overall HH
compliance that increased from 27%-58% (P < .01). Multivariate analysis
showed that some variables were associated with poor HH compliance: men
versus women (49% vs 38%, P < .001), nurses versus doctors (55% vs 48%, P
< .02), among others.

CONCLUSIONS: With the implementation of the INICC approach, adherence to
HH was significantly increased. Programs should be aimed at improving HH
in variables found to be predictors of poor HH compliance. Copyright ©
2015 Association for Professionals in Infection Control and Epidemiology,
Inc. Published by Elsevier Inc. All rights reserved.

KEYWORDS: Developing countries; Hand hygiene; Hand washing; Intensive care
unit; Multidimensional approach
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Comparison of hand hygiene monitoring using the 5 Moments
for Hand Hygiene method versus a wash in-wash out method
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25564119

Am J Infect Control. 2015 Jan 1;43(1):16-9.

Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene
method versus a wash in-wash out method.

Sunkesula VC1, Meranda D2, Kundrapu S3, Zabarsky TF4, McKee M4, Macinga
DR5, Donskey CJ6.

1Infectious Diseases Division, Department of Medicine, Case Western
Reserve University School of Medicine, Cleveland, OH; Center for
Proteomics and Bioinformatics, Case Western Reserve University School of
Medicine, Cleveland, OH.
2Geriatric Research, Education, and Clinical Center, Cleveland VA Medical
Center, Cleveland, OH.
3Infectious Diseases Division, Department of Medicine, Case Western
Reserve University School of Medicine, Cleveland, OH.
4Infection Control Department, Cleveland VA Medical Center, Cleveland, OH.
5Microbiology, GOJO Industries, Inc, Akron, OH; Department of Integrative
Medical Sciences, Northeastern Ohio Medical University, Rootstown, OH.
6Infectious Diseases Division, Department of Medicine, Case Western
Reserve University School of Medicine, Cleveland, OH; Geriatric Research,
Education, and Clinical Center, Cleveland VA Medical Center, Cleveland,
OH. Electronic address: curtisd123@yahoo.com.

BACKGROUND: One strategy to promote improved hand hygiene is to monitor
health care workers’ adherence to recommended practices and give feedback.
For feasibility of monitoring, many health care facilities assess hand
hygiene practices on room entry and exit (wash in-wash out). It is not
known if the wash in-wash out method is comparable with a more
comprehensive approach, such as the World Health Organization’s My 5
Moments for Hand Hygiene method.

METHODS: During a 1-month period, a surreptitious observer monitored hand
hygiene compliance simultaneously using the wash in-wash out and My 5
Moments for Hand Hygiene methods.

RESULTS: For 283 health care worker room entries, the methods resulted in
similar rates of hand hygiene compliance (70% vs 72%, respectively). The
wash in- wash out method required 148 hand hygiene events not required by
the My 5 Moments for Hand Hygiene method (ie, before and after room entry
with no patient or environmental contact) while not providing monitoring
for 89 hand hygiene opportunities in patient rooms.

CONCLUSION: The monitoring methods resulted in similar overall rates of
hand hygiene compliance. Use of the wash in-wash out method should include
ongoing education and intermittent assessment of hand hygiene before clean
procedures and after body fluid exposure in patient rooms. Published by
Elsevier Inc.

KEYWORDS: Compliance; Hand hygiene; My 5 Moments for Hand Hygiene
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Sublingual or subcutaneous immunotherapy for seasonal
allergic rhinitis: an indirect analysis of efficacy, safety and cost
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24444390

J Eval Clin Pract. 2014 Jun;20(3):225-38. doi: 10.1111/jep.12112. Epub
2014 Jan 21.

Sublingual or subcutaneous immunotherapy for seasonal allergic rhinitis:
an indirect analysis of efficacy, safety and cost.

Dranitsaris G1, Ellis AK.

1Augmentium Pharma Consulting, Toronto, Ontario, Canada.

RATIONALE, AIMS AND OBJECTIVES: The standard of preventive care for poorly
controlled seasonal allergic rhinitis (AR) is subcutaneous immunotherapy
(SCIT) with allergen extracts, administered in a physician’s office. As an
alternative to SCIT, sublingual immunotherapy (SLIT) is now an option for
patients with seasonal AR. Oralair, a SLIT tablet containing freeze-dried
allergen extracts of five grasses [cocksfoot (Dactylis glomerata), meadow
grass (Poa pratensis), rye grass (Lolium perenne), sweet vernal grass
(Anthoxanthum odoratum) and timothy grass (Phleum pratense)], and Grazax,
a SLIT tablet containing a standardized extract of grass pollen allergen
from timothy grass (P?pratenase), are two such agents currently available
in many countries. However, head-to-head comparative data are not
available. In this study, an indirect comparison on efficacy, safety and
cost was undertaken between Oralair, Grazax and SCIT.

METHODS: A systematic review was conducted for double-blind placebo-
controlled randomized trials evaluating Oralair, Grazax or SCIT in
patients with grass-induced seasonal AR. Using placebo as the common
control, an indirect statistical comparison between treatments was
performed using meta regression analysis with active drug as the primary
independent variable. An economic analysis, which included both direct and
indirect costs for the Canadian setting, was also undertaken.

RESULTS: Overall, 20 placebo-controlled trials met the study inclusion
criteria. The indirect analysis suggested improved efficacy with Oralair
over SCIT [standardized mean difference (SMD) in AR symptom
control?=?-0.21; P?=?0.007] and Grazax (SMD?=?-0.18; P?=?0.018). In
addition, there were no significant differences in the risk of
discontinuation due to adverse events between therapies. Oralair was
associated with cost savings against year-round SCIT ($2471), seasonal
SCIT ($948) and Grazax ($1168) during the first year of therapy.

CONCLUSIONS: Oralair has at least non-inferior efficacy and comparable
safety against SCIT and Grazax at a lower annual cost.

© 2014 The Authors. Journal of Evaluation in Clinical Practice published
by John Wiley & Sons, Ltd.

KEYWORDS: Grazax™; Oralair™; allergic rhinitis; immunotherapy;
subcutaneous; sublingual
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Evaluation of voriconazole oral dosage in Japan
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25566590

Jpn J Antibiot. 2014 Oct;67(5):279-84.

[Evaluation of voriconazole oral dosage in Japan].

[Article in Japanese]
Hamada Y1, Kawasumi N, Hirai J, Yamagishi Y, Mikamo H.

1Department of Infection Control and Prevention, Aichi Medical University
Hospital.

Voriconazole (VRCZ), a broad-spectrum triazole, is served in two dosage
forms-injection and oral. VRCZ is difference dosage of oral and
intravenous administration writing a medical package insert in Japan. 6
mg/kg intravenous injection (IV) twice daily for first day as initial
loading dose, followed by 3-4 mg/kg IV twice daily between meals is
recommended. 300 mg orally twice daily for first day as initial loading
dose, followed by 150-200 mg orally twice daily between meals is
recommended. Patients weighing over 40 kg, 200 mg orally twice daily
between meals is recommended. Patients weighing under 40 kg, 100 mg orally
twice daily between meals is recommended, increase to 150 mg twice daily
if inadequate response.

This study evaluated VRCZ trough concentration and oral dosage in the 23
cases which administered VRCZ to analysis for TDM in Aichi University
Hospital. Spearman rank correlation coefficient was calculated to examine
relationships among variables. The level of statistical significance was
set at p=0.05. All data were analyzed and processed on JMP 8 (SAS
Institute Japan). There was a significant positive correlation between
VRCZ trough concentration and dose/weight (r=0.47 p<0.05).

In this result, VRCZ oral dosage is appropriate to administer dose/weight
(mg/kg) twice a day as same as IV.
__________________________________________________________________
________________________________*_________________________________

16. News

– Cambodia: Tainted needles blamed
– Cambodia: HIV Outbreak Linked to Infected NeedlesCambodia: Cambodia
finds 212 with HIV where unlicensed medic operated
– Norway: Oslo heroin user contracts botulismUK: Scotland reports 3
additional botulism cases in heroin users
– Health Care-Associated Hepatitis C Infections Reviewed
– Ebola: Ebola death toll goes past 8,000: WHO – Unconfirmed case in
Berlin
– Cambodia: Government Targets Unlicensed Medics Amid HIV Outbreak
– Cambodia: Man Charged for Causing HIV Outbreak in Patients

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
http://www.phnompenhpost.com/national/tainted-needles-blamed

Cambodia: Tainted needles blamed

May Titthara, Phnom Penh Post, Cambodia (12.01.15)

The Ministry of Health, the World Health Organization and UNAIDS have
released an update on their ongoing investigation into an HIV outbreak in
Battambang’s Roka commune, saying that a preliminary enquiry does indeed
point to tainted injections as the main source of transmission.

According to a joint statement dated January 9, UNAIDS, the WHO and the
National Center for HIV/AIDS Dermatology and STDs (NCHADS) said that based
on interviews conducted in the area, the percentage of people who reported
having received intravenous injections as a part of medical treatment was
“significantly higher” among those who had tested positive for HIV.

The statement also largely ruled out other modes of transmission, such as
unprotected sex and intravenous drug use, as well as mother-to-child
transmission. Most of the children who tested positive for HIV, the groups
said, had HIV-negative mothers.

In the statement, Minister of Health Mam Bunheng said that steps were
being taken to ensure that unsafe medical practices do not continue to
result in HIV transmission.

“The Ministry of Health is ensuring health facilities follow universal
precautions and use clean and sterile equipment, as well as working on
raising awareness of safe injection practices and overall HIV prevention
among the general public,” he said. “We have reinforced implementation of
the MOH policy to stop unlicensed informal medical practices.”

While the medical investigation of the outbreak is still ongoing, criminal
liability for the cluster of HIV cases has been laid at the feet of local
unlicensed medical practitioner Yem Chroeum.

In late December, Chroeum was charged with murder, “intentionally”
infecting his patients with HIV and operating an unlicensed clinic, though
it remains unclear whether any of his patients actually died as a result
of his treatment.

If found guilty, Chroeum could face life imprisonment.

Police singled out Chroeum early on as an inordinate amount of positive
HIV infections began cropping up in the commune following the positive
testing of an elderly man in November. Many of those who tested positive
reported receiving injections from Chroeum, who reportedly confessed to
reusing needles.

NCHADS director Mean Chhivun also said in an interview yesterday that most
forms of transmission had been ruled out, “so that we said the major
source causing people to be infected with HIV was injection and
intravenous injection”.

“We are also waiting on results from the USA and South Korea too,” he
added.

According to Friday’s release, the number of people found to be infected
in the area has risen to 212, with 82 per cent of cases hailing from Roka.

Just under 20 per cent of those infected are 14 years old or younger, and
22 per cent are over 60.

In the same statement, Dr Dong-Il Anh, the WHO’s representative in
Cambodia, praised the Ministry of Health for stopping the spread of
infections when it did, but said that there is still much work to be done
to reform the informal health sector.

“There is a pressing need to strengthen the regulatory framework for the
private and informal health sector in order to ensure that health care is
responsive, safe and of high quality,” he said.

Friday’s statement says all HIV-positive persons in Cambodia are offered
free treatment, and that 78 people started anti-retroviral therapy in
Battambang between December 22 and 31.

Some have expressed scepticism that a single doctor could have infected
more than 200 people with HIV, even if he was reusing needles.

According to the US Centers for Disease Control and Prevention, about one
in 300 needle-stick or cut exposures to HIV-infected blood results in
infection.

However, Dr Masami Fujita, HIV team leader at the WHO, said in an
interview yesterday that different types of injection procedures carry
different levels of risk, and investigators were still trying to learn
what types of services those infected in Roka had received. Given what
investigators know so far, he said, injections are currently a “major
suspect”.

“But exactly how it happened among this community, exactly what kind of
procedure caused these infections, we still don’t know the details,” he
added.

Whatever the cause, the government must shoulder some of the blame for its
lax handling of the informal medical sector, said Am Sam Ath, senior
investigator at the rights group Licadho.

“The ministry itself and the government are responsible,” he said
yesterday, adding that “we do not know how many unlicensed doctors are
treating people in this way”.

In a statement dated December 18, the Ministry of Health advised all
municipal and provincial health institutions to crack down on “illegal
health services”, and drafted a similar letter to provincial authorities.

“All directors of the health departments have to take serious measures
against illegal health services defying the law and previous directives
and send them to court,” reads the December 18 statement, signed by Dr Te
Kuyseang, a secretary of state at the Ministry of Health.

Additional Reporting By Stuart White
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/locy9le

Cambodia: HIV Outbreak Linked to Infected Needles

Kong Sothanarith, VOA Khmer, (12.01.15)

Video at: http://tinyurl.com/qdonuhy

PHNOM PENH— A government-led investigation into the widespread HIV
outbreak in Battambang province has concluded, finding that the spread of
the virus came from multiple injections with infected needles.

In total, 1,940 people in Roka commune had their blood tested in the last
month; 212 tested positive for the virus, health officials said Monday.

“The study showed that the percentage of people that reported receiving an
injection or intravenous infusion as part of their health treatment was
significantly higher among the people who tested positive for HIV than the
people who were HIV negative,” the Cambodian Health Ministry’s National
Center for HIV/AIDS said in a joint statement with the World Health
Organization and UNAIDS. “Thi difference is statistically significant.”

Of the 212 Roka commune residents who tested positive for HIV, 18 percent
were under 14, and 22 percent were over the age of 60; 82 percent came
from the commune’s Roka village.

“There are test to detect HIV transmission through the sexual
relationship, injections, intravenous infusions, and blood infusions,” Ly
Penh Sun, deputy director of the Center for HIV/AIDS said. “And the
factors found are the intravenous injections and infusions.”

An unlicensed doctor in Roka village, Yem Chrin, has been charged with
murder and faces life in prison for allegedly spreading the disease. He
has admitted to regularly re-using needles for injections. In a Dec. 18
police raid authorities seized dozens of used syringes and needles.
__________________________________________________________________
__________________________________________________________________

www.reuters.com/article/2015/01/10/us-cambodia-hiv-idUSKBN0KJ0DS20150110

Cambodia: Cambodia finds 212 with HIV where unlicensed medic operated

By Prak Chan Thul, Phnom Penh, Reuters (10.01.15)

(Reuters) – Cambodian health authorities have found 212 villagers infected
with HIV in a district where an unlicensed medic has been charged with
murder on suspicion of spreading the virus with contaminated equipment.

Prosecutors charged the medic with murder last month after the spread of
the virus that causes AIDS among scores of people came to light.

The 212 people with HIV were discovered after authorities tested a total
of 1,940 people in the district in Battambang province in the northwest
where the medic treated people.

The government and international health agencies including the World
Health Organization and UN AIDS released their findings in a statement on
Saturday but they did not mention the medic.

However, Health Minister Mam Bunheng urged health authorities to strictly
follow protocols on the use of clean equipment and he vowed to eliminate
new HIV infections by 2020.

“The Ministry of Health is ensuring health facilities to follow
universal precautions and use clean and sterile equipment,” Mam Bunheng
said.

The medic, Yem Chrin, provided cheap health services to the poor and was
believed to have possessed healing powers, police said.

The government and health organizations said there appeared to be a link
between injections and HIV among the people they tested.

“The study showed that the percentage of people that reported receiving an
injection or intravenous infusion as part of their health treatment was
significantly higher among the people who tested positive for HIV than the
people who were HIV negative,” they said in their statement.

The case has been a blow to Cambodia’s largely successful efforts against
HIV infection after the virus first spread quickly through the
impoverished country in the 1990s.

(Editing by Robert Birsel)
__________________________________________________________________
__________________________________________________________________
http://outbreaknewstoday.com/oslo-heroin-user-contracts-botulism-63489/

Norway: Oslo heroin user contracts botulism

Posted by Robert Herriman, Outbreak News Today (10.01.15)

An injecting heroin user from Oslo, Norway contracted botulism, according
to a Norwegian Institute of Public Health (NIPH) report last week
(computer translated).

Health officials say the patient developed symptoms on 12/26/2014 and is
hospitalized. They warn that heroin in the Oslo area may be contaminated,
and if true, one can expect that more become ill.

There are no reports of additional suspected cases so far.

This reported case actually took place before the five cases being
reported out of Scotland this year.

The NIPH says substance abusers and healthcare professionals who are in
contact with abusers must be aware of the possibility that heroin
circulating in the Oslo area may be contaminated with botulism spores. It
is thus necessary to have attention on botulism symptoms in injecting drug
users.

Oslo has informed OOH and relevant institutions which are in contact with
abusers to inform users about the danger of botulism heroin injection, and
to be aware of symptoms in users.

In the Fall of 2013, an outbreak with four confirmed and three probable
cases of wound botulism among drug users in Oslo and Vestfold was
reported. It has previously been reported clusters of cases of wound
botulism in Norway and other European countries, including England,
Germany, Switzerland and Ireland
__________________________________________________________________
__________________________________________________________________
UK: Scotland reports 3 additional botulism cases in heroin users

OutbreakNewsToday (09.01.15)

NHS Greater Glasgow and Clyde, NHS Ayrshire & Arran, Police Scotland and
Health Protection Scotland are investigating three new probable cases of
Botulism in drug injecting heroin users.

Two of the new patients are from the Greater Glasgow and Clyde area whilst
one is from the NHS Ayrshire & Arran area. All three are receiving
treatment in hospital and are in a serious condition.

This takes the total number of probable cases to five. The initial two
patients, one critical and one stable, are still in hospital.

The cause of these infections continues being investigated with the focus
on injecting drug use.

Dr Catriona Milocevi, NHS Greater Glasgow Consultant in Public Heath
Medicine, said: “I urge all drug injecting heroin users to be extremely
alert and to seek urgent medical attention from Accident and Emergency if
they experience any early symptoms such as blurred or double vision,
difficulty in swallowing and speaking and/or inflammation at the injection
site.

“It is important for injecting drug users to engage with the wide range of
services we offer designed to help them tackle their addictions. However
for those who continue to inject it is extremely important that they seek
urgent medical help if they show these early symptoms.
“Heroin users should avoid injecting heroin into their muscles. Injecting
heroin into a vein or smoking can reduce the risk of botulism, although
not using heroin at all is by far the best course of action.”
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/nwpr9tl

Health Care-Associated Hepatitis C Infections Reviewed

By Catherine Kolonko, HCPLive (09.01.15)

As a new year begins, the spread of hepatitis C infection through the
health care system continues to be a public health concern and is the
subject of a review study that appeared in the December 14 issue of World
Journal of Gastroenterology.

The blood-borne virus is considered a major public health threat because
chronic infection can go years without detection and can result in severe
damage to the liver. Recent advancements in newly developed drugs to treat
the hepatitis C virus (HCV) have fueled hope of a cure for the more than
100 million people across the globe believed to be infected.

There is no vaccine for the virus, which has 11 recognized genotypes and
several subtypes. It is this variability of the viral genome along with a
poor understanding of the pathophysiology of chronic HCV infection that
hinders progress on the vaccine development front, according to the
article.

Medical settings such as hospitals, clinics, surgery departments, and
transplantation wards have been implicated in the dissemination of HCV,
the article states. Care that exposes HCV-infected blood to others poses a
risk of infection that is shared among patients and health care workers
alike.

To reach a goal of eradicating HCV in the coming decades, it is important
to halt transmission of the virus particularly in the field of care-
associated infection, according to the review article. It identifies and
discusses the following three situations in which the virus can be
acquired:
From infected patient to non-infected patient
From infected patient to a health care worker
From infected health care worker to non-infected patient

In previous decades before the virus was discovered in 1989, blood
transfusions were a common vehicle of HCV transmission. Infected blood
donors could not be identified to prevent them from donating because there
was no test to screen for the virus.

“In the past, many people have been contaminated via blood products and
unsafe injections because the risk was unknown, the virus was unidentified
and the hygienic practices were not well established,” states the article.
“Before the era of HIV/AIDS, blood was considered as a safe matrix and
blood-borne pathogens were not identified as serious health care
problems.”

Currently in developed countries the risk of HCV transmission via the
administration of blood products has been dramatically reduced since
regular testing of blood supplies began after discovery of the virus.
However the conditions are “alarmingly” different in 39 developing
countries where as recent as 2012 there was no routine screening for the
virus in blood supplies.

Other concerns are unsafe injection practices such as reuse of syringes,
vials or saline bags that help the virus spread from the infected to the
uninfected in various clinics and other nonhospital health care settings.
In 2007 after an HCV outbreak in a Nevada endoscopy clinic, eight other
clusters of HCV infections were identified retrospectively in different
American medical settings. Between 1998 and 2008 there were 275 patients
found to be infected by one of the above mentioned means, according to the
article.

The article authors support an increase in efforts to inform and educate
health care workers on the risks inherent in blood-borne infections. It
also stresses the importance of wide spread adoption of standard
precautions among health care workers such as regular hand washing and
wearing of protective gloves, masks and gowns, as well as work practices
and safe injection practices with single-use disposable needles and
syringes.

“Despite the absence of a prophylactic vaccine, most of the conditions are
met for controlling the HCV risk in health care settings,” state the
authors. “With the conviction that where there is will there is a way,
this goal can and must be achieved in the next years.”
__________________________________________________________________
__________________________________________________________________
http://www.dw.de/ebola-death-toll-goes-past-8000-who/a-18172023

Ebola: Ebola death toll goes past 8,000: WHO – Unconfirmed case in Berlin

Deutsche Welle, Germany (05.01.15) [Edited]

Doctors in the German capital, Berlin, meanwhile said on Monday that a
suspected Ebola infection in a patient from South Korea remains
unconfirmed.

The person, whose sex and age have not been named, was injured by a
hypodermic needle while treating an Ebola patient in Sierra Leone and
brought to Berlin for treatment on Saturday.

Three people infected with Ebola have so far been flown to Germany for
treatment. Two recovered, but a UN employee from Africa died in hospital
in the eastern city of Leipzig.
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/nup7es7

Cambodia: Government Targets Unlicensed Medics Amid HIV Outbreak

By Alex Consiglio And Hay Pisey, Cambodia Daily (05.01.15)

As the number of villagers testing positive for HIV continues to climb in
Battambang province’s Roka commune, the Health Ministry is scrambling to
rein in the illegal medical practices that may have led to the outbreak
and are widespread throughout the country.

Two hundred and twenty-six villagers in Sangke district’s Roka commune
have now tested positive for HIV since the commune health center began
preliminary tests on December 8, deputy commune chief Soeum Chhom said
Sunday.

Yem Chrin, an unlicensed doctor who often made house calls and treated his
patients using injections, admitted to police that he reused syringes on
multiple occasions, and was jailed on murder charges on December 22.

The cause of the outbreak remains unknown, but a government-led task
force, which includes the U.S. Centers for Disease Control, is
investigating possible sources of the epidemic and has sent blood samples
abroad to determine whether the villagers’ infections share the same viral
subtype, which can help narrow down the mode of transmission.

Medical experts say the reuse of syringes is unlikely to be the sole cause
of the HIV outbreak, but that it is plausible a lone medical practitioner
single-handedly spread the virus to hundreds of people if infection
prevention protocols were not followed.

“This can happen anywhere,” said Ung Prahors, acting director of the
Cambodian Health Committee, an NGO that provides assistance to villagers
in poor communes suffering from AIDS and tuberculosis.

“We have seen through our work…that there are a lot of unlicensed health
workers who go around injecting people,” Dr. Prahors said. “If they do not
practice infection prevention control, they will also spread HIV in the
villages.”

Last week, the Health Ministry issued a directive to provincial health
department officials, as well as provincial police and prosecutors, urging
them to stop unlicensed health care workers from operating in their
jurisdictions.

“Please take the most serious measures against unlicensed health services
that do not comply with the law…by filing cases of unlicensed health
services to the court,” says the document, which is signed by Health
Minister Mam Bunheng.

Oum Sopheap, the director of Khana, a local HIV prevention and support NGO
that has been aiding Roka commune residents who have tested positive for
the virus, said Mr. Chrin was able to operate in the commune for many
years because health officials do not proactively seek out unlicensed
health-care workers.

“It’s not until something like this happens that there is a response from
the government,” he said. “It’s [Mr. Chrin’s] responsibility for using
dirty needles—he needs to be held responsible—but it’s also the
authorities’ responsibility. It seems he was able to operate a long time
without any proper checks.”

Srun Sok, director of the Health Ministry’s hospital services department,
which oversees the licensing of doctors and clinics, said in a recent
interview that his ministry was unaware of Mr. Chrin’s practice.

“We didn’t know, because there were no reports on this person,” he said.
“It must be the commune chief or chief of the commune health center that
reports it to the district level,” which then informs the provincial
health department.

However, By Beng Sor, who took over as director of the Roka health center
about a year ago, said he was not aware that he was meant to be
responsible for reporting on health-care workers operating without a
license.

“I have never reported any,” said Mr. Beng Sor, noting that Mr. Chrin had
been working in the commune for more than a decade. “If they had asked me
to, I would have.”

Seth Savuth, the former director of the commune health center, claimed
that in 2012 he reported at least two unlicensed health-care workers in
Roka commune—including Mr. Chrin—to district health officials.

But the director of the Sangke operational district’s health department,
Im Chetra, who oversees the Roka health center, said he never received any
reports with Mr. Chrin’s name on them.

“I have not seen his name on the reports,” Mr. Chetra said, adding that
while it is easy to crack down on unlicensed clinics, tracking down
unlicensed doctors who make house calls is far more difficult.

According to the Health Ministry, the number of unlicensed clinics dropped
from 87 in 2010 to zero in 2011, a figure maintained in 2012 and 2013.

The Health Ministry’s Mr. Sok stressed that these statistics only reflect
unlicensed practices being run out of a building.

“Currently, we are worried about mobile health workers working illegally,”
he said.

Spreading the Virus

Whenever Yuom Nary had a headache or fever, she would ask Mr. Chrin to
visit her home and administer an injection or intravenous drip.

Ms. Nary, 25, said she cannot recall what the doctor injected her with,
but that his treatments helped and were offered pro bono when she did not
have enough money to pay for them.

“I usually had injections and IV drips from him when I had a headache and
fever,” she said.

“I got injections not only from him, but also from other doctors who are
in my village,” she added. “I had injections with other doctors when he
was busy with other patients.”

Chris Grundmann, country director for the University Research Co., which
implements programs funded by the U.S. Agency for International
Development?to improve health care services, said Cambodians often do not
feel that they are getting treated properly unless an injection is
administered.

“What most people want when they go to a village doctor is an injection of
some sort or an IV drip,” he said. “A lot of times, it is a vitamin
injection, which is not particularly useful, but [it] is what people
want.”

Mr. Sok said Roka commune residents likely choose to be treated by
private, unlicensed doctors because the commune health center only
administers injections in emergency situations, or as part of a
vaccination program.

“The people working at [commune] health centers do not have the
knowledge,” he said. “We believe that their capacity, knowledge and skills
are not sufficient to provide injections [on demand].”

Sten Vermund, an HIV expert at the Vanderbilt University School of
Medicine in Nashville, Tennessee, whose research focuses on developing
countries, said it would probably take a long period of time to infect
hundreds of people with HIV simply by reusing syringes.

“I think it’s improbable that 200 people would get infected in a single
episode of needle-syringe contamination because there is a diluting
effect,” Dr. Vermund said. “But it might have been repetitive behavior on
the part of the doctor.”

Roka commune residents who have tested positive for HIV include a 4-month-
old and a man in his 80s, and migrant workers who had been out of the
country for a year.

Considering the range of villagers testing positive for the virus, Dr.
Vermund said other possible sources of the infection, via medical
practices by so-called “injectionists,” could be the improper use of
multi-dose vials.

He said that if Mr. Chrin had been using multi-dose vials—– common in
developing countries because they are less expensive—he might have
injected an HIV-positive patient and then dipped the needle back into the
vials to draw up another dose.

“People can make that mistake, where they’ve inoculated the bottle of
medicine so now the next nine doses coming out of that bottle are
contaminated, even if they do use a new needle and syringe,” he said. “So
you can make the mistake once, and everyone down the line pays the price,
even if subsequent needles and syringes are sterile.”

Dr. Vermund added that if Mr. Chrin had been using a saline solution to
prepare medications for injection, he might also have contaminated a large
supply of the solution by double-dipping a contaminated needle.

“It has to be an absolutely strict protocol [for infection prevention],”
he said. “You can’t make one mistake out of ten—you have to make zero
mistakes.”

A foreign doctor working in Cambodia, speaking on the condition of
anonymity in order not to jeopardize his frequent work with the Health
Ministry, said the dangerous practices mentioned by Dr. Vermund were
common in the country.

“These bad practices exist in Cambodia because there often isn’t the right
supplies,” the doctor said. “In Cambodia, they don’t have single-dose
vials for all medications; they often have multi-dose vials.”

Dr. Vermund said that if authorities have confiscated medical tools used
by Mr. Chrin that have HIV on them, the virus could be compared to that in
villagers’ blood.

“You can do a molecular evaluation to see whether the doctor’s needles
have the same viral subtype,” he said. “That would increase the evidence
immensely. If they want to definitively evaluate this, it can be done.”

© 2015, The Cambodia Daily.
__________________________________________________________________
__________________________________________________________________
http://tinyurl.com/pclgyo3

Cambodia: Man Charged for Causing HIV Outbreak in Patients

Kong Sothanarith, VOA Khmer, Cambodia (22.12.14)

PHNOM PENH — A man in Battambang province as been arrested and charged
with spreading HIV, infecting at least 140 people in what authorities
Monday called “cruel murder.”

Yem Chrin, 55, had been detained and questioned since last Wednesday and
was charged Monday, following an investigation into the outbreak, in Rokar
commune.

Police say Yem Chrin was operating an unlicensed clinic and was not
licensed as a doctor.

“He confessed to using the same syringe and sometimes the same needle,”
Sar Thet, Battambang police chief, said.

The 140 cases have been confirmed HIV positive by the Pasteur Institute in
Phnom Penh.

Mean Chhivun, director of the National AIDS Authority, said many elderly
are among those infected and an investigation continues to learn the
extent of the outbreak.
__________________________________________________________________
________________________________*_________________________________

SIGN Meeting 2015

The Safe Injection Global Network SIGN meeting is 23-24 February 2015 at
WHO Headquarters in Geneva Switzerland

The main topic of the meeting will be the new injection safety policy
recommendation and developing the appropriate strategies for
implementation in countries worldwide.

The Keynote speaker will be Dr Margaret Chan, the Director-General of WHO.

Dr. Chan will launch the new IS policy which recommends the use of safety
engineered injection devices for reuse prevention and sharps injury
protection.
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________________________________*_________________________________
* SAFETY OF INJECTIONS brief yourself at: www.injectionsafety.org

A fact sheet on injection safety is available at:
http://www.who.int/mediacentre/factsheets/fs231/en/index.html

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

* Download the WHO Best Practices for Injections and Related Procedures
Toolkit March 2010 [pdf 2.47Mb]:
http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf

Use the Toolbox at: http://www.who.int/injection_safety/toolbox/en/

Get SIGN files on the web at: http://signpostonline.info/signfiles-2
get SIGNpost archives at: http://signpostonline.info/archives-by-year

Like on Facebook: http://facebook.com/SIGN.Moderator

The SIGN Secretariat, the Department of Health Systems Policies and
Workforce, WHO, Avenue Appia 20, CH-1211 Geneva 27, Switzerland.
Facsimile: +41 22 791 4836 E- mail: sign@who.int
__________________________________________________________________
________________________________*_________________________________

The 2010 annual Safe Injection Global Network meeting to aid collaboration
and synergy among SIGN network participants worldwide was held from 9
to 11 November 2010 in Dubai, The United Arab Emirates.

The SIGN 2010 meeting report pdf, 1.36Mb is available on line at:
http://www.who.int/injection_safety/toolbox/sign2010_meeting.pdf

The report is navigable using bookmarks and is searchable. Viewing
requires the free Adobe Acrobat Reader at: http://get.adobe.com/reader/

Translation tools are available at: http://www.google.com/language_tools
or http://www.freetranslation.com
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________________________________*_________________________________
All members of the SIGN Forum are invited to submit messages, comment on
any posting, or to use the forum to request technical information in
relation to injection safety.

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

Use of trade names and commercial sources is for identification only and
does not imply endorsement.

The SIGN Forum welcomes new subscribers who are involved in injection
safety.

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

The SIGNpost Website is http://SIGNpostOnline.info

The SIGNpost website provides an archive of all SIGNposts, meeting
reports, field reports, documents, images such as photographs, posters,
signs and symbols, and video.

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

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

The SIGN Internet Forum was established at the initiative of the World
Health Organization’s Department of Essential Health Technologies.

The SIGN Secretariat home is the Department of Health Systems Policies and
Workforce, Geneva Switzerland.

The SIGN Forum is moderated by Allan Bass and is hosted on the University
of Queensland computer network. http://www.uq.edu.au
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