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SIGNpost 00801

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00801 Hands + NSI + HAI + Abstracts + News 13 May 2015

CONTENTS
0. Moderators Note: UPDATES: Nepal earthquake 2015 – Grade 3 emergency
1. Hand hygiene in the control of Ebola and health system strengthening
Introduction
2. National Survey of Ethiopia’s Integrated Pharmaceutical Logistics
System Reveals Performance Improvements
3. Abstract: Nosocomial transmission of dengue fever via needlestick. An
occupational risk
4. Abstract: Needlestick prevention prior to Directive 2010/32/EU in a
sample of Italian hospitals
5. Abstract: A Review of the CDC Recommendations for Prevention of HAIs in
Outpatient Settings [+ Injection Safety Extract]
6. Abstract: A study on the factors affecting the prescription of
injection medicines in iran: a policy making approach
7. Abstract: Illicit drug use in acute care settings
8. Abstract: Increases in hepatitis C virus infection related to injection
drug use among persons aged =30 years – kentucky, tennessee, virginia,
and west virginia, 2006-2012
9. Abstract: Drug use, hepatitis C, and service availability: perspectives
of incarcerated rural women
10. Abstract: Compliance with hygiene procedures among medical faculty
students
11. Abstract: First reported case of transfusion-transmitted Ross River
virus infection
12. Abstract: Planning and response to Ebola virus disease: An integrated
approach
13. Abstract: Oral delivery of wafers made from HBsAg-expressing maize
germ induces long-term immunological systemic and mucosal responses
14. Abstract: Evaluation of Cellular Phones for Potential Risk of
Nosocomial Infection amongst Dental Operators and Auxiliary Staff
16. No Abstract: Blood-borne pathogens Q&A
17. News
– Kashmir India: Hepatitis C and preventive measures
– USA: Discarded Syringes Reveal Stigma’s Role in Growing Opiate and
Hepatitis Epidemics
– USA: Hepatitis C On the Rise in Appalachia
– Uganda: Fake Hepatitis B vaccine supplied to Lira schools
– Global: Fake AIDS, TB and malaria meds causing thousands of deaths

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__________________________________________________________________
________________________________*_________________________________

0. Moderators Note: UPDATES: Nepal earthquake 2015 – Grade 3 emergency
__________________________________________________________________
At the WHO website: Nepal earthquake 2015 Situation Updates

http://tinyurl.com/l23wtcb

Nepal earthquake 2015 – Grade 3 emergency
__________________________________________________________________
________________________________*_________________________________

1. Hand hygiene in the control of Ebola and health system strengthening
Introduction
__________________________________________________________________

http://tinyurl.com/qxsujdq
WHO Clean Care is Safer Care
Hand hygiene in the control of Ebola and health system strengthening
Introduction

For any infection that can be spread through touch, including those
carried in bodily fluids, hand hygiene is vital. It is the key action that
protects every individual. That is why WHO highlights a number of key
messages on hand hygiene in the prevention of Ebola Virus Disease, and how
improving hand hygiene action can positively affect whole communities, a
whole country, if the right systems and culture can be embedded.

Many of the WHO hand hygiene improvement tools have been relevant in the
situation of the Ebola outbreak but the local production of alcohol-based
handrub (ABHR) instructions have been promoted most in an attempt to
address the system change in the first instance as per the WHO
recommendation for a multimodal improvement strategy.

* Guide to local Production: WHO-recommended Handrub Formulations pdf,
312kb

http://who.int/entity/gpsc/5may/Guide_to_Local_Production.pdf?ua=1

Reports

* Local production of WHO-recommended alcohol-based handrubs: feasibility,
advantages, barriers and costs (WHO Bulletin) pdf, 856kb

http://who.int/entity/bulletin/volumes/91/12/12-117085.pdf?ua=1

Local production of alcohol based hand rub in African hospitals pdf, 259kb
http://tinyurl.com/q9wwovk
__________________________________________________________________
________________________________*_________________________________

2. National Survey of Ethiopia’s Integrated Pharmaceutical Logistics
System Reveals Performance Improvements
__________________________________________________________________
Anne Marie Hvid <anne_marie_hvid@jsi.com>
to: Sign Moderator <sign.moderator@gmail.com>
date: Sat, May 9, 2015
subject: National Survey of Ethiopia’s Integrated Pharmaceutical Logistics
System Reveals Performance Improvements

Since 2009, the Pharmaceuticals Fund and Supply Agency (PFSA) has used a
new supply chain system to manage essential health commodities in the
public sector—the Integrated Pharmaceutical Logistics System (IPLS).

A new report, Ethiopia: National Survey of the Integrated Pharmaceutical
Logistics System, shows that the system has generated significant
improvements, increasing the availability of medicines and other health
supplies.

For most products surveyed at facilities implementing IPLS, availability
was above 90 percent.

Learn more at http://bit.ly/1GU00UA


Anne Marie Hvid, PMP
Knowledge Management Advisor
USAID | DELIVER PROJECT
deliver.jsi.com
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Nosocomial transmission of dengue fever via needlestick. An
occupational risk
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25936825

Travel Med Infect Dis. 2015 Apr 16. pii: S1477-8939(15)00071-X.

Nosocomial transmission of dengue fever via needlestick. An occupational
risk.

Morgan C1, Paraskevopoulou SM2, Ashley EA3, Probst F3, Muir D3.

1Imperial College NHS Trust, Charing Cross Hospital, Fulham Palace Road,
London W6 8RF, UK. Electronic address: Caitlin.morgan@doctors.org.uk.
2Imperial College NHS Trust, Charing Cross Hospital, Fulham Palace Road,
London W6 8RF, UK. Electronic address:
maria.paraskevopoulou@imperial.nhs.uk.
3Imperial College NHS Trust, Charing Cross Hospital, Fulham Palace Road,
London W6 8RF, UK.

Dengue fever is currently considered to be the most important arboviral
cause of disease in humans, with a dramatic increase in incidence over the
last 30 years. The dengue virus is a flavivirus with four antigenically
distinct serotypes and is endemic in over 100 different countries in the
Americas, Africa, Eastern Mediterranean, Western Pacific and Southeast
Asia.

This is a case report of the first documented case of dengue transmission
via needlestick in the United Kingdom. Our case is of a 48 year old
healthcare worker who sustained a needlestick injury from a patient with
confirmed dengue fever and subsequently developed the illness himself.

Abbreviations: WHO (World Health Organisation), DHF (dengue heamorrhagic
fever), ICHNT (Imperial College Healthcare NHS Trust), RIPL (rare and
imported pathogens laboratory), PCR (polymerase chain reaction), ELISA
(enzyme-linked immunosorbent assay)

www.travelmedicinejournal.com/article/S1477-8939(15)00071-X/abstract
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Needlestick prevention prior to Directive 2010/32/EU in a
sample of Italian hospitals
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25951865

Med Lav. 2015 May 4;106(3):186-205.

Needlestick prevention prior to Directive 2010/32/EU in a sample of
Italian hospitals.

[Article in Italian]

Di Bari V1, De Carli G, Puro V, Da Hiv E Altri Patogeni A Trasmissione
Ematica Siroh GC.

1U.O.C. Infezioni Emergenti e Riemergenti e Centro di Riferimento AIDS,
Dipartimento di Epidemiologia e Ricerca Preclinica, Istituto Nazionale per
le Malattie Infettive “Lazzaro Spallanzani”- IRCCS, Roma, Italia..
virginia.dibari@inmi.it.

INTRODUCTION: Needlesticks and cuts are the most common occupational
injuries in healthcare workers (HCWs). Directive 2010/32/EU defines
principles and preventive interventions.

OBJECTIVES: To assess, in hospitals participating in the Italian Study on
Occupational Risk of HIV (SIROH) project, which are very active in
prevention, the degree of application of the measures provided for by the
Directive, prior to its incorporation into Italian law.

METHODS: An open questionnaire covering the 9 focal points of the
Directive, as a guide for a presentation at the SIROH meeting in 2013.

RESULTS: Of 100 SIROH hospitals, 97% and 96% respectively provide specific
information and education initiatives (54% and 73% of which expressly for
new employees). All centres reinforce the ban on recapping, and 30 monitor
its application by inspecting sharps containers; all hospitals place
containers on mobile trolleys and 78 provide operating procedures for
their replacement; all introduced at least one needlestick-prevention
device (NPD; 4 on average, range 1-11), most frequently intravenous
catheters (91%) and winged needles (87%), but 39% only in selected units;
14 centres implemented initiatives to eliminate unnecessary needles.
Regarding hepatitis B, all centres screen and vaccinate HCWs but only 78%
monitor their response: 89% of HCWs were immunized. Post-exposure
management protocols, although based on the same rationale, differ
significantly causing considerable differences in costs.

CONCLUSIONS: Most of the preventive interventions covered by the Directive
were implemented in SIROH hospitals. It is necessary to invest in NPD
availability and dissemination, elimination of unnecessary needles, and
streamline post-exposure protocols. The situation in the remaining Italian
facilities should be investigated.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: A Review of the CDC Recommendations for Prevention of HAIs in
Outpatient Settings [+ IS Extract]
__________________________________________________________________
Free Full Text
http://www.aornjournal.org/article/S0001-2092(15)00185-4/fulltext

AORN J. 2015 May;101(5):519-28.

A Review of the CDC Recommendations for Prevention of HAIs in Outpatient
Settings.

Garrett JH Jr.

According to the Centers for Disease Control and Prevention (CDC), most
health care-associated infections (HAIs) are caused by contamination from
the hands of health care providers or patients, contamination from the
environment, and contamination from the patient’s own skin.

To mitigate common sources of infection transmission, frontline health
care providers must be compliant with basic infection-prevention
interventions, including hand hygiene, environmental cleaning and
disinfection, safe injection practices, and designation of a trained
health care professional to be responsible for the infection prevention
and control program.

Integration of CDC recommendations should incorporate a bundled approach
to these interventions and should be part of a comprehensive approach to
infection prevention and control.

Effective infection-prevention practices in outpatient settings are
critical for reducing the risk of infection transmission, improving
patient safety and patient outcomes, and reducing costs associated with
health care delivery.

Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights
reserved.

KEYWORDS: IPC; ambulatory care; hand hygiene; infection prevention and
control; outpatient settings

Free Full Text
http://www.aornjournal.org/article/S0001-2092(15)00185-4/fulltext

__________________________________________________________________
Extract Extract Extract

Injection Safety

Health care providers must adhere strictly to injection safety practices
to prevent misuse of disposable items (eg, single-use needles and
syringes).

The risk for occupational exposure to bloodborne pathogens such as the
hepatitis B virus or human immunodeficiency virus (HIV) has dramatically
decreased since the Occupational Safety and Health Administration released
its Bloodborne Pathogens Standard;

however, in the past five years, outbreak investigations have suggested an
alarming pattern of inappropriate reuse of needles and syringes that are
labeled and indicated for single-patient use.13, 14, 15 Results of
investigations published in 2014 by the CDC have revealed a pattern of
poor injection safety practices, including

•use of a hypodermic needle with or without the syringe to administer
medication to multiple patients,

•reinsertion of a used syringe with or without the same hypodermic needle
into a medication vial or solution container to obtain additional
medication for a single patient and then using that vial or solution
container for subsequent patients, and

•preparation of medications in close proximity to contaminated supplies or
equipment.1
__________________________________________________________________
________________________________*_________________________________

6. Abstract: A study on the factors affecting the prescription of
injection medicines in iran: a policy making approach
__________________________________________________________________
Free Full Text
http://www.ccsenet.org/journal/index.php/gjhs/article/view/40562

Glob J Health Sci. 2015 Jan 13;7(3):40562.

A study on the factors affecting the prescription of injection medicines
in iran: a policy making approach.

Meskarpour-Amiri M, Dopeykar N, Mehdizadeh P1, Ayoubian A, Motaghed Z.
Author information

1. hmrc1391@gmail.com.

BACKGROUND & AIM: Inappropriate prescribing injection medicines can reduce
the quality of medical care, patient safety, and leads to a waste of
resources. Sufficient evidence is not available in developing countries to
persuade policy-makers to promote rational drug prescription. The
objective of this study is to assess some factors affecting the
prescription of the injection medicines in Iran.

METHODS: In this descriptive-analytic study, the data of 91,994,667
selected prescription letters were collected by the Ministry of the Health
and Medical Education (MOHME) throughout the country at the year 2011
which were analyzed through a logarithmic regression model.

RESULTS: Results of the study show that the percentage of the prescription
letters containing injection items varied from 27 percent (in Yazd) to 57
percent (in Ilam). Also the impact of price on the prescription of the
injection medicines was not significant (P=0.55). But the impact of the
prescription of antibiotics and corticosteroid on injections were
significant (P>0.05) and equal 0.44 and 0.65 respectively.

CONCLUSION: Increasing price of injection medicines as a policy towards
reducing consumptions cannot be a successful policy. But reducing the use
of antibiotics and corticosteroids can be a more effective policy to
reduce the use of injection medicines.

Free Full Text
http://www.ccsenet.org/journal/index.php/gjhs/article/view/40562
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Illicit drug use in acute care settings
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25944526

Drug Alcohol Rev. 2015 May 6.

Illicit drug use in acute care settings.

Grewal HK1, Ti L, Hayashi K, Dobrer S, Wood E, Kerr T.

1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, Canada.

INTRODUCTION AND AIMS: While persons with addiction are often
hospitalised, hospitals typically employ abstinence-based policies
specific to illicit drug use. Although illicit drug use is known to occur
within hospitals, this problem has not been well characterised. Therefore,
we sought to investigate the prevalence of and factors associated with
having ever used drugs in hospital among people who use drugs in
Vancouver, Canada.

DESIGN AND METHODS: Data were derived from prospective cohort studies of
people who use drugs between December 2012 and May 2013. Multivariable
logistic regression was used to identify demographic and behavioural
factors associated with having ever used illicit drugs in hospital.

RESULTS: Among 1028 participants who had experienced =1 hospitalisation,
43.9% reported having ever used drugs while hospitalised. In multivariable
analyses, factors positively associated with having ever used drugs in
hospital included daily cocaine injection and daily crack non-injection
(both P?<?0.05). Factors negatively associated with the outcome included
older age and male gender (both P?<?0.05). The most common reasons for
drug use in hospital were ‘wanting to use’ and ‘being in withdrawal’.
Drugs were most commonly used in patient washrooms.

DISCUSSION AND CONCLUSIONS: Our findings demonstrate that an abstinence-
based approach to drug use in hospitals may be ineffective at prohibiting
drug consumption. High-risk drug use behaviours arising from ongoing drug
use may pose risks for further harm and illness. Efforts to minimise the
harms associated with using drugs in hospital are urgently needed.

© 2015 Australasian Professional Society on Alcohol and other Drugs.

KEYWORDS: Canada; abstinence; harm reduction; hospitalisation; people who
use illicit drugs
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Increases in hepatitis C virus infection related to injection
drug use among persons aged =30 years – kentucky, tennessee, virginia,
and west virginia, 2006-2012
__________________________________________________________________
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm

MMWR Morb Mortal Wkly Rep. 2015 May 8;64(17):453-8.

Increases in hepatitis C virus infection related to injection drug use
among persons aged =30 years – kentucky, tennessee, virginia, and west
virginia, 2006-2012.

Zibbell JE, Iqbal K, Patel RC, Suryaprasad A, Sanders KJ, Moore-Moravian
L, Serrecchia J, Blankenship S, Ward JW, Holtzman D.

Hepatitis C virus (HCV) infection is the most common blood-borne infection
in the United States, with approximately three million persons living with
current infection.

Percutaneous exposure to contaminated blood is the most efficient mode of
transmission, and in the United States, injection drug use (IDU) is the
primary risk factor for infection.

State surveillance reports from the period 2006-2012 reveal a nationwide
increase in reported cases of acute HCV infection, with the largest
increases occurring east of the Mississippi River, particularly among
states in central Appalachia. Demographic and behavioral data accompanying
these reports show young persons (aged =30 years) from nonurban areas
contributed to the majority of cases, with about 73% citing IDU as a
principal risk factor.

To better understand the increase in acute cases of HCV infection and its
correlation to IDU, CDC examined surveillance data for acute case reports
in conjunction with analyzing drug treatment admissions data from the
Treatment Episode Data Set-Admissions (TEDS-A) among persons aged =30
years in four states (Kentucky, Tennessee, Virginia, and West Virginia)
for the period 2006-2012.

During this period, significant increases in cases of acute HCV infection
were found among persons in both urban and nonurban areas, with a
substantially higher incidence observed each year among persons residing
in nonurban areas. During the same period, the proportion of treatment
admissions for opioid dependency increased 21.1% in the four states, with
a significant increase in the proportion of persons admitted who
identified injecting as their main route of drug administration (an
increase of 12.6%).

Taken together, these increases indicate a geographic intersection among
opioid abuse, drug injecting, and HCV infection in central Appalachia and
underscore the need for integrated health services in substance abuse
treatment settings to prevent HCV infection and ensure that those who are
infected receive medical care.

Free full text

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Drug use, hepatitis C, and service availability: perspectives
of incarcerated rural women
__________________________________________________________________
Soc Work Public Health. 2015 Jul;30(4):385-96.

Drug use, hepatitis C, and service availability: perspectives of
incarcerated rural women.

Staton-Tindall M1, Webster JM, Oser CB, Havens JR, Leukefeld CG.

1a College of Social Work, University of Kentucky , Lexington , Kentucky ,
USA.

This study examined drug use, hepatitis C, and service availability and
use among a high-risk sample of rural women serving time in jails.

Data was collected from female offenders (N = 22) who participated in four
focus groups in three rural jail facilities located in Appalachia.

Findings indicated that drug misuse is prevalent in this impoverished area
of the country, and that the primary route of administration of drug use
is injection.

Findings also indicate that injection drug use is also commonly associated
with contracting hepatitis C (HCV), which is also perceived to be
prevalent in the area.

Despite knowledge associated with HCV risks, women in this sample were
seemingly apathetic about the increasing spread of HCV in the area and
unconcerned about the long-term consequences of the course of the
infection. Implications for future research and practice are discussed.

KEYWORDS: Drug use; HCV; women
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Compliance with hygiene procedures among medical faculty
students
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25812387

Med Pr. 2014;65(5):593-9.

[Compliance with hygiene procedures among medical faculty students].

[Article in Polish]

Kawalec A, Kawalec A, Pawlas K.

BACKGROUND:
Many of the healthcare associated infections (HCAIs) are transmitted by
healthcare workers’ hands, which actively contributes to transferring
pathogens from patient to patient and within the healthcare environment.
Hand hygiene is the easiest and cheapest method for preventing HCAIs. The
article presents the compliance with hygiene procedures in a group of
medical students of the Wroclaw Medical University.

MATERIAL AND METHODS:
The anonymous survey was conducted among 112 students. The survey included
questions about the frequency of disinfection of hands and stethoscopes,
changing clothes into clean ones, compliance with recommendations for
healthcare workers, as well as subjective assessment of the availability
of disinfectants in the hospital.

RESULTS: The results of the survey revealed that 35.7% of students did not
disinfect their hands before each patient’s examination, 90% of them
indicated limited access to disinfectants as the most important reason.
The majority (93.8%) of respondents were trained in hand hygiene. In
34.82% the availability of disinfectants in hospitals was assesed as good,
62.5% of respondents drew attention to the fact that the dispensers were
often empty. Compliance with recommendations for healthcare workers: 66.9%
posessed white coat with short sleeves, 52.68% wore wristwatch or jewelery
on their hands, 50% of students laundered white coat less frequently than
once a week, 9.82% did not disinfect their stethoscope at all, 15.18% did
that before each patient’s examination.

CONCLUSIONS: Students compliance with hand hygiene now and in their future
work as doctors is the easiest method for preventing HCAIs. Providing easy
access to disinfectants in the hospital environment and shaping hygiene
habits during clinical activities play an essential role.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: First reported case of transfusion-transmitted Ross River
virus infection
__________________________________________________________________
Free Full Text https://tinyurl.com/mst6mnc

Med J Aust. 2015 Mar 16;202(5):267-70.

First reported case of transfusion-transmitted Ross River virus infection.

Hoad VC1, Speers DJ2, Keller AJ3, Dowse GK4, Seed CR3, Lindsay MD4, Faddy
HM5, Pink J5.

1Australian Red Cross Blood Service, Perth, WA, Australia.
vhoad@redcrossblood.org.au.
2PathWest Laboratory Medicine WA, Perth, WA, Australia.
3Australian Red Cross Blood Service, Perth, WA, Australia.
4Department of Health Western Australia, Perth, WA, Australia.
5Australian Red Cross Blood Service, Brisbane, QLD, Australia.

We describe the first documented case of Ross River virus (RRV) infection
transmitted by blood transfusion. The recipient had a clinically
compatible illness, and RRV infection was confirmed by serological tests.
The implicated donation was positive for RRV RNA. We discuss the risk to
blood recipients and the implications for blood donation in Australia.

Free Full Text https://tinyurl.com/mst6mnc
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Planning and response to Ebola virus disease: An integrated
approach
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25952046

Am J Infect Control. 2015 May 1;43(5):441-6.

Planning and response to Ebola virus disease: An integrated approach.

Smith PW1, Boulter KC2, Hewlett AL3, Kratochvil CJ4, Beam EJ5, Gibbs SG6,
Lowe JM6, Schwedhelm MM2.

1Division of Infectious Diseases, College of Medicine, University of
Nebraska Medical Center, Omaha, NE; Department of Epidemiology, College of
Public Health, University of Nebraska Medical Center, Omaha, NE.
Electronic address: pwsmith@unmc.edu.
2Nebraska Medicine, Omaha, NE.
3Division of Infectious Diseases, College of Medicine, University of
Nebraska Medical Center, Omaha, NE; Department of Epidemiology, College of
Public Health, University of Nebraska Medical Center, Omaha, NE.
4Vice Chancellor for Clinical Research, University of Nebraska Medical
Center, Omaha, NE.
5College of Nursing, University of Nebraska Medical Center, Omaha, NE.
6Department of Environmental, Agricultural and Occupational Health,
College of Public Health, University of Nebraska Medical center, Omaha,
NE.

The care of patients with Ebola virus disease (EVD) requires the
application of critical care medicine principles under conditions of
stringent infection control precautions. The care of patients with EVD
requires a number of elements in terms of physical layout, personal
protective apparel, and other equipment.

Provision of care is demanding in terms of depth of staff and training.
The key to safely providing such care is a system that brings many
valuable skills to the table, and allows communication between these
individuals.

We present our approach to leadership structure and function-a variation
of incident command-in providing care to 3 patients with EVD.

Copyright © 2015 Association for Professionals in Infection Control and
Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

KEYWORDS: Biocontainment; Incident command; Leadership
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Oral delivery of wafers made from HBsAg-expressing maize
germ induces long-term immunological systemic and mucosal responses
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25944300

Vaccine. 2015 May 2. pii: S0264-410X(15)00566-6.

Oral delivery of wafers made from HBsAg-expressing maize germ induces
long-term immunological systemic and mucosal responses.

Hayden CA1, Fischer ME1, Andrews BL1, Chilton HC1, Turner DD2, Walker JH3,
Tizard IR2, Howard JA4.

1Applied Biotechnology Institute, Cal Poly Tech Park, San Luis Obispo, CA
93407, USA.
2Department of Veterinary Pathobiology, College of Veterinary Medicine,
Texas A&M University, College Station, TX 77843, USA.
3Department of Statistics, California Polytechnic State University, San
Luis Obispo, CA 93407, USA.
4Applied Biotechnology Institute, Cal Poly Tech Park, San Luis Obispo, CA
93407, USA. Electronic address: jhoward@appliedbiotech.org.

BACKGROUND: The hepatitis B surface antigen (HBsAg) has been administered
over the last 20 years as a parenteral vaccine against the hepatitis B
virus (HBV). Despite high seroconversion rates, chronic infection rates
are still high worldwide. Orally delivered vaccines provide a practical
alternative to injected vaccines, potentially helping poorly responding
populations and providing a viable alternative for populations in remote
locations. Anamnestic responses are vital to establishing the efficacy of
a given vaccine and have been assessed in this study using a plant-based
oral delivery platform expressing the hepatitis B surface antigen (HBsAg).

METHODS: Long-term immunological memory was assessed in mice injected with
a primary dose of Recombivax® and boosted with orally-delivered HBsAg
wafers, control wafers, or parenterally-delivered commercial vaccine
(Recombivax®).

RESULTS: Mice boosted with HBsAg orally-administered wafers displayed
sharp increases in mucosal IgA titers in fecal material and steep
increases in serum IgA, whereas mice boosted with Recombivax® showed no
detectable levels of IgA in either fecal or serum samples following four
boosting treatments. Long-term memory in the orally-treated mice was
evidenced by sustained fecal IgA, and serum IgA, IgG, and mIU/mL over one
year, while Recombivax®-treated mice displayed sustained serum IgG and
mIU/mL. Furthermore, sharp increases in these same antibodies were induced
after re-boosting at 47 and 50 weeks post-primary injection.

CONCLUSIONS: Orally-delivered vaccines can provide long-term immune
responses mucosally and systemically. For sexually-transmitted diseases
that can be acquired at mucosal surfaces, such as HBV, an oral delivery
platform may provide added protection over a conventional parenterally
administered vaccine.

Copyright © 2015 Elsevier Ltd. All rights reserved.

KEYWORDS: Anamnestic response; Bioencapsulation; Immunogenicity; Long-term
immune memory; Maize oral vaccine; Mucosal; Plant vaccine; Subunit
vaccine; Supercritical fluid extraction
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Evaluation of Cellular Phones for Potential Risk of
Nosocomial Infection amongst Dental Operators and Auxiliary Staff
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25954071

J Int Oral Health. 2015 Apr;7(4):51-3.

Evaluation of Cellular Phones for Potential Risk of Nosocomial Infection
amongst Dental Operators and Auxiliary Staff.

Nasim VS1, Al-Hakami A2, Bijle MN1, Al-Manea SA3, Al-Shehri MD3, Al-Malki
SM3.

1Assistant Professor, Department of Preventive Dental Sciences, Division
of Pedodontics, King Khalid University, College of Dentistry, Abha,
Kingdom of Saudi Arabia.
2Assistant Professor, Department of Microbiology, King Khalid University,
College of Medicine, Abha, Kingdom of Saudi Arabia.
3Intern, King Khalid University, College of Dentistry, Abha, Kingdom of
Saudi Arabia.

BACKGROUND: This study evaluates cellular phones for potential risk of
nosocomial infection amongst dental operators and auxiliary staff in a
dental school.

MATERIALS AND METHODS: Each participant’s mobile phone was first cleaned
with 70% isopropyl alcohol swab. Following the cleansing protocol, the
partakers were asked to make a short phone call. The mobile phones were
then washed aseptically by rotating damp cotton swabs with sterile normal
saline. Bacterial growth was identified on sheep blood agar and McConkey’s
agar plates. Sabouraud dextrose agar media was used for fungi species.
Descriptive statistics was established with the data statistically
explored with SPSS version 17.0.

RESULTS: About 50% of dental professionals had shown active bacterial and
fungal growth in which 35% (n=35) were dental operators and 15% (n=15)
were dental nurses. 53% Gram-positive organisms, 2% Gram-negative
organisms, and 3% fungi were identified growths on cellular phones.

CONCLUSION: Thus, it can be concluded that the cellular phones of dental
operators as compared to auxiliaries can act as a potential source of
nosocomial infection.

KEYWORDS: Dentists; dental auxiliary; infectious disease transmission;
nosocomial infection
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Risks to health care workers from nano-enabled medical
products
__________________________________________________________________
J Occup Environ Hyg. 2015 Jun;12(6):D75-85.

Risks to health care workers from nano-enabled medical products.

Murashov V1, Howard J.

1a Department of Health and Human Services, National Institute for
Occupational Safety and Health, Centers for Disease Control and
Prevention, Washington , DC.

Nanotechnology is rapidly expanding into the health care industry.

However, occupational safety and health risks of nano-enabled medical
products have not been thoroughly assessed.

This manuscript highlights occupational risk mitigation practices for
nano-enabled medical products throughout their life cycle for all major
workplace settings including (1) medical research laboratories, (2)
pharmaceutical manufacturing facilities, (3) clinical dispensing
pharmacies, (4) health care delivery facilities, (5) home health care, (6)
health care support, and (7) medical waste management.

It further identifies critical research needs for ensuring worker
protection in the health care industry.

KEYWORDS: health care; life cycle; medical products; nanomaterials;
nanotechnology; risk assessment; risk mitigation; workplace
__________________________________________________________________
________________________________*_________________________________

16. No Abstract: Blood-borne pathogens Q&A
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/25868226

J Calif Dent Assoc. 2015 Feb;43(2):105-6.

Blood-borne pathogens Q&A.

[No authors listed]
__________________________________________________________________
________________________________*_________________________________

17. News

– Kashmir India: Hepatitis C and preventive measures
– USA: Discarded Syringes Reveal Stigma’s Role in Growing Opiate and
Hepatitis Epidemics
– USA: Hepatitis C On the Rise in Appalachia
– Uganda: Fake Hepatitis B vaccine supplied to Lira schools
– Global: Fake AIDS, TB and malaria meds causing thousands of deaths

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
http://www.greaterkashmir.com/news/opinion/story/186152.html

Kashmir India: Hepatitis C and preventive measures

Only new and disposable syringes and needles taken from a sealed pack
should be used

By DR MUDASIR FIRDOSI, Srinagar, Kashmir, India (12.05.15)

Kashmir valley is witnessing another disaster in the form of Hepatitis C
epidemic. In some villages in Kokernag area, the number of cases is around
40% of the total population. In spite of media pressure, and demand from
local population, authorities are still contemplating curbing the further
spread of this infection. Similar scenario exists in other districts of
the valley like Shopian, Kupwara, and Srinagar.

Hepatitis C is not transmitted by routine personal contact and there needs
to be an actual transfer of the virus via blood, blood products and body
fluids, from one person to another. From the sociodemographic profile of
the rural population, one can easily exclude intravenous drug abuse or
sexual contact as the cause of the current epidemic in majority of cases.

The unsafe use of syringes and instruments by health professionals,
dentists, chemists and quacks does explain this explosive nature of the
problem. The situation is made worse by the lack of training and
accountability, unsafe sterilisation procedures or no sterilisation at
all. The reuse of disposable syringes is quite common and people are not
used to questioning the unsafe practice. Stitching of common injuries at
health centers is another common mode of infection. The practice of
circumcision in our community puts children at high risk if proper
precautions are not taken. Unsafe dental practices and mushrooming of
dental quacks is another worrying reason.

Use of injections is a common practice more so in villages. Even for minor
ailments, people prefer to get medication by injection than by oral route.
There is also a practice of using intravenous fluids in villages for no
apparent reason. The erroneous beliefs in the superiority of injections
compared to pills, or due to unscrupulous providers /quacks, who like to
inject people because of greed for extra money, the problem is
accentuated.

People should take extra precautions when seeking help for any medical
condition. When your doctor prescribes an injection, ask if you can get
along without any medicine, or if an oral alternative is available. Many
conditions, such as cold, flu, dry cough, and diarrhea are better treated
without injected medicines.

Most drugs, and other substances, can be taken orally, and should be
injected only in rare situations, like if someone is unconscious, or
vomits so much that oral medication will not stay down. Vitamins, glucose,
paracetamol and other drugs to reduce temperature, most pain-killers,
treatments to stop diarrhea or vomiting, medicines to treat asthma,
antibiotics (with a few exceptions, such as penicillin) should be taken
orally.

Only new and disposable syringes and needles taken from a sealed package
should be used. Syringes should not be kept at home for reuse even on the
same patient because it is potential source of infection. If for any
reason syringe or needle has to be reused, ask if it has been autoclaved
or boiled.

Single dose vial should be used as much as possible, which is a small
bottle with medicine for one injection only, so that there is no need to
reuse the medication on same or other patient. Multi-dose vials, with
medicine for many injections, are often used by dentists and anesthetists
when giving local anesthesia, like during removal of a tooth. This can
become a source of infection if both the needle and syringe is not changed
between the patients.

If no single dose vial is available, see that your doctor takes medicine
from a new multi-dose vial opened in front of you. This may not always be
possible and many doses are taken out from same bottle. Some people have
the bad habit to only change the needle (and not the whole syringe)
between two injections for a same patient, (and only change the whole
syringe in between patients), which contaminates the vials because of the
reflux mechanism, and you are placed at risk of getting contaminated with
the virus (HIV, Hepatitis B & C) or bacteria of the patients before you,
including drug resistant bacteria.

Recent investigations in the USA on nosocomial epidemics of Hepatitis C
showed that badly trained, unscrupulous care givers only changed the
needle and not the whole syringe to re-inject a same patient from multiple
dose drug vials. In the process of injection, when the needle is pulled
out, microscopic quantities of blood (not visible with the naked eye), get
back up into the syringe. Thus when only the needle is changed and syringe
is reused, multi-dose vial gets contaminated with the blood from the
syringe possibly containing the infection.

Then, when the vial is used for a new patient, even if a totally new
sterile syringe is used, the new patient is at risk of getting infected
with the virus/bacteria of the patient or patients who came before him for
treatment (and many microorganisms remain viable for days in microscopic
drop of blood). In 1996, even in North America, more than half of
anesthesiologists had those bad ‘dirty’ practices. Many health care givers
are not conscious of the danger of this practice. So both needle and
syringe should be changed with every withdrawal of medicine from the vial.

Another option is to take injections from pre-filled disposable syringes–
which are disposable syringes combined with single-dose vials, or single
dose cartridges. ‘Smart syringes’ which include a manufacturing system
which makes them definitively non-reusable, but they are unlikely
available due to cost issues.

Many people give injections – not only doctors and nurses, but also
pharmacists, traditional healers, family, and friends. No general
statements can be made about who gives safe injections. If a trained
provider respects your requests, uses a new syringe and needle, and takes
medicine from a single-dose vial, you are probably safer with the trained
provider. But if the trained provider will not do so, you may be safer
with an untrained provider who will listen to you.

Finally health care providers need training around infection control and
sterilisation so that this dangerous epidemic is put to a halt before it
is too late. Every new case is a potential source and the only way to
break the cycle of further transmission is to practice honestly and
safely. It is your right to demand safe health care and question where
ever you are in doubt. A five rupee syringe can save you money, can save
your health and ultimately your life.

mudasirfirdosi@gmail.com
__________________________________________________________________
__________________________________________________________________
https://tinyurl.com/kyr69ey

USA: Discarded Syringes Reveal Stigma’s Role in Growing Opiate and
Hepatitis Epidemics

By Rod McCullom, TheBody.com, USA (12.05.15)

Turners Falls is a picturesque unincorporated village in Western
Massachusetts near Springfield. The small, former mill town is nestled in
the Berkshire Mountains and has gained a reputation as a center for arts
and crafts. But now it’s garnering unwanted notoriety: The rural community
is experiencing an increase in heroin addiction. “Discarded syringes are
turning up everywhere,” reported New England Public Radio in a segment
broadcast April 28 on National Public Radio. Now that the long, hard
winter is over, Police Chief Chip Dodge has taken the unusual step of
asking residents to help locate discarded syringes.

“It’s gotten worse, Dodge says, since Massachusetts legalized possession
of hypodermic needles in 2006,” the report added without question. “That
meant less spread of disease through needle-sharing but more needles
around.”

Not exactly.

Massachusetts is one of at least 37 states and the District of Columbia
that allow some form of the sale of non-prescription, sterile syringes.
But it’s too simplistic and stigmatizing to blame those laws for an
increase in discarded syringes, according to policy and harm reduction
advocates. The discarded syringes are indicative of three public health
challenges: A surge in injection drug use across the state, the ongoing
challenge of safe and accessible syringe disposal and the rise in
infectious disease — namely hepatitis.

A public health emergency across the commonwealth was declared in March
2014 to address an increase in opiate use and fatal overdoses across the
state.

The statewide emergency was declared after 185 opioid overdoses were
recorded between December 2013 and February 2014. The 902 total confirmed
fatal opioid-related overdose deaths in 2013 was already a 27% increase
over the previous year, according to a December 2014 report from the
Massachusetts Department of Public Health.

“This is another example of a community that has to catch up with the
rates of injection drug use that are happening right in their backyard,”
said Daniel Raymond, policy director for the New York City-based Harm
Reduction Coalition. “The question should be, ‘How can we facilitate safe
syringe exchange disposal?’ We know from syringe exchange programs that
people who inject drugs want to be responsible in the disposal of their
syringes. But there usually are not places to dispose syringes.”

Stigma is also a considerable barrier to safe syringe disposal. “People
fear that they will be arrested if syringes are found on them or targeted
for other charges,” added Raymond.

In fact, Massachusetts adopted aggressive regulations to address syringe
disposal at the same time that over-the-counter syringe sales were
implemented in 2006. New regulations banned the disposal of syringes in
trash or recycling, and cities and towns were tasked with establishing
syringe disposal systems. The Massachusetts Department of Public Health
purchased disposal kiosks across the state, and a statewide directory
documents hundreds of these syringe and medical waste disposal locations
across the commonwealth.

But there is no listing for Turners Falls.

Nationwide, there has been an explosion of heroin and injectable opioid
drug use in rural areas. The trend began in the early 2000s with the
introduction of the powerful painkiller OxyContin. “Many of these people
eventually began injecting heroin because it is cheaper than painkillers
and more accessible,” explained Raymond.

The rural heroin epidemic has received national attention in recent weeks.
About 150 new HIV infections have been reported in a rural region in
Southern Indiana near the Kentucky border. Republican Gov. Mike Pence
authorized a syringe exchange program “but it’s not running according to
best practices,” reported the New York Times on May 5.

Syringe exchange programs have also been recently authorized in Kentucky
and Ohio. These “are not perfect programs but they are steps in the right
direction,” said Drug Policy Alliance Executive Director Bill Piper. “The
fact that conservative rural states are beginning to do this is a good
sign that the politics are shifting.”

About 15% of the 1.2 million Americas who are living with HIV infection
inject drugs, according to the U.S. Centers for Disease Control and
Prevention.

In Massachusetts, men who have sex with men and injection drug users are
the leading transmission categories for HIV infection. Those categories
accounted for 37% and 19% of all reported HIV cases in 2013, according to
the Massachusetts Department of Public Health’s Office of HIV/AIDS.

New HIV infections among injection drug users have steadily declined
across the state. But the rural opioid epidemic has also fueled a surge in
hepatitis C virus (HCV) infections, according to state health officials.
More than 2,000 new HCV cases have been identified in Massachusetts in the
past few years and most cases occur in people under the age of 30 who
inject drugs and share contaminated needles, according to Massachusetts
Department of Public Health data quoted in an April 15 article in the
Worcester Telegram.

There are only about five syringe exchange programs across Massachusetts.
Those are located in Boston, Cambridge, Holyoke, Northampton — around 20
miles from Turners Falls — and Provincetown.

Across the country, the surge in injection drug use has taxed the already
under-resourced small town and rural public health infrastructure. “Many
of these rural communities do not have many public health resources or
drug treatment facilities,” said Raymond. “They certainly do not have much
history with HIV and hepatitis.”

Rod McCullom has written and produced for ABC News and NBC, Scientific
American, The Atlantic, Ebony, Poz and many others. He will become a
Knight Science Journalism Fellow at the Massachusetts Institute of
Technology later this summer. His website is Rod20.com.

Copyright © 2015 Remedy Health Media, LLC. All rights reserved.
__________________________________________________________________
__________________________________________________________________
https://tinyurl.com/projx4b

USA: Hepatitis C On the Rise in Appalachia

Brian Wu, Science Times, UK (08.05.15)

The rates of hepatitis C infections have more than tripled in four
Appalachian states from 2006 to 2012, fueled by prescription drug abuse
among those who inject drugs, especially in rural areas, United States
health officials said.

National data show rising rates of hepatitis C infection across the
nation, with the biggest increases among people under the age of 30 living
in Kentucky, Tennessee, Virginia and West Virginia, according to a new
report issued by the U.S. Centers for Disease Control and Prevention.

In those four states along, hepatitis C infections rose 364 percent from
2006 to 2012 with nearly half of these new cases, or about 44.8 percent,
among people under the age of 30. Of the cases that have been reported
and researchers gathered data about potential risk factors, 73.1 percent
reported injecting drugs.

The report is the first CDC study to link the rise in hepatitis C to an
increase in injection drug use, said John Ward, director of viral
hepatitis prevention at the CDC, who called the rising infection rates
“staggering.”

“We’re in the midst of a national epidemic of hepatitis C,” Ward said.
Nationwide, more than 20,000 Americans die from hepatitis C a year, which
is more than the number who die from AIDS, he said. “The CDC views
hepatitis C as an urgent public health problem.”

The rate of new hepatitis C infections has also risen nationwide, more
than doubling from 0.3 cases per 100,000 people in 2010 to 0.7 cases in
2013. Kentucky had the highest rates that year, with 5.1 cases per
100,000, according to the CDC with Delaware and South Carolina reporting
no new cases that year.

The CDC also warned while the rates of HIV, the virus that causes AIDS,
are currently low in these four states, the increase in hepatitis C
infections raises concern that HIV infections could also begin to rise, as
HIV is also commonly spread by contaminated needles.

Several studies have found that needle exchange programs dramatically cut
the transmission of disease among injection drug users. Research shows
that needle exchanges have helped reduce HIV infections in New York. In
1992, 52 percent of new cases were injection drug users, but ten years
later, only 3 percent were injection drug users.

The USA needs to offer more needle exchanges in order to reduce hepatitis
and HIV infections, said Paul Samuels, president and director of the Legal
Action Center, which advocates on behalf of people with HIV or substance
abuse disorders.

“It is critically important that needle exchange programs like the
temporary one in Indiana be replicated across the country, and be
permanent,” Samuels said. “Studies have repeatedly proven that needle
exchange programs reduce HIV, hepatitis and other infections among people
who use intravenous drugs without increasing intravenous drug use, and
indeed they are a bridge to treatment for some participants. Substance
abuse prevention and treatment, including treatment with medications, and
harm reduction – including needle exchange – are all necessary components
of a comprehensive strategy for combatting the opioid epidemic and
addressing the many ways it can harm people with addictions.”
__________________________________________________________________
__________________________________________________________________
https://tinyurl.com/n2nzgk8

Uganda: Fake Hepatitis B vaccine supplied to Lira schools

Denis Ongeng, newvision, Kampala Uganda (07.05.15)

Lira assistant District Health officer has advised schools intending to
vaccinate their students against Hepatitis B to consult with their offices
before procuring vaccine.

Opio John Nelson said the vaccine is a delicate item that must be handled
with care and professionalism.

According to Opio, some suppliers have started supplying schools with fake
vaccine. He warned: “It can be very dangerous to peoples’ health.”

He added that children below the age of 14 should not be vaccinated
against Hepatitis B because it was included it routine vaccination for
children.

Opio cautioned the public to guard against getting in contact with body
fluids because it’s one way of contracting the virus.

Government needs at least shb40b to vaccinate all Ugandans against the
Hepatitis B, according the minister of primary health care Sarah Opendi.

Source: Radio Rupiny
__________________________________________________________________
__________________________________________________________________
https://tinyurl.com/qyl6tp2

Global: Fake AIDS, TB and malaria meds causing thousands of deaths

Kevin Grogan, .securingindustry.com (27.04.15)

Malaria mosquitoThe trade in fake malaria, HIV/AIDS, malaria and
tuberculosis drugs is again in the spotlight, amid fears that they are
responsible for tens of thousands of deaths in poor countries.

The “pandemic of falsified and substandard medicines is pervasive and
underestimated, particularly in low- and middle-income countries where
drug and regulatory systems are weak or non-existent”, according to Jim
Herrington of the University of North Carolina who co-edited a collection
of articles published in the American Journal of Tropical Medicine and
Hygiene.

One of the articles claims that falsified and poor quality malaria drugs
that contributed to the deaths of an estimated 122,350 African children in
2013 alone.

In another study, scientists examined nearly 17,000 samples of
antibiotics, antimalarial and anti-tuberculosis drugs and found that as
many as 41% failed to meet quality specifications.

In an essay accompanying the collection of articles, former US FDA
Commissioner Margaret Hamburg says that globalisation has added layers of
complexity to the drug supply chain that require greater oversight.

Dr Hamburg, who was recently named foreign secretary of the Institute of
Medicine, said that “today’s medical-product landscape blurs the line
between domestic and foreign production, drawing attention to the need for
global quality and safety oversight to prevent patient exposure to
falsified products”.

On a positive note, the authors of the articles said new methodologies to
test drug quality are emerging and scientists reported the results of four
investigations. They found that “simple paper-based test cards proved to
be an economical and portable method to identify very low quality anti-
malarials”.

More sophisticated approaches using fluorescent and luminescent techniques
can measure with greater precision, they note, “but may be difficult to
use in remote settings.” The authors believe that “all of these promising
tools require further testing to provide a greater evidence base to guide
policymakers”.

The scientists conclude that “an urgent and coordinated international
response is required to address the pandemic of poor quality drugs”.
Proposals include a global agreement, similar to the Framework Convention
on Tobacco Control External Web Site Policy, and stricter national laws to
prosecute those who knowingly sell counterfeit medicines.

The collection of articles were sponsored by the National Institute of
Health’s Fogarty International Center, the Bill and Melinda Gates
Foundation and the New Venture Fund.

© 2015 SecuringIndustry.com
__________________________________________________________________
________________________________*_________________________________

New WHO Injection Safety Guidelines

WHO is urging countries to transition, by 2020, to the exclusive use of
the new “smart” syringes, except in a few circumstances in which a syringe
that blocks after a single use would interfere with the procedure.

The new guideline is:

WHO Guideline on the use of Safety-Engineered Syringes for Intramuscular,
Intradermal and Subcutaneous Injections in Health Care

It is available for free download or viewing at this link:
www.who.int/injection_safety/global-campaign/injection-safety_guidline.pdf

PDF Requires Adobe Acrobat Reader [620 KB]
__________________________________________________________________
________________________________*_________________________________
Making all injections safe brochure

This is an illustrated summary brochure for the general public.

pdf, 554kb [6 pages]

www.who.int/injection_safety/global-campaign/injection-safety_brochure.pdf
__________________________________________________________________
________________________________*_________________________________

SIGN Meeting 2015

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

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

A report of the meeting will be posted ASAP
__________________________________________________________________
________________________________*_________________________________
* 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
__________________________________________________________________
________________________________*_________________________________
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
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The comments made in this forum are the sole responsibility of the writers
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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
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* Subscribe or un-subscribe by email to: sign.moderator@gmail.com, or to
sign@who.int

The SIGNpost Website is http://SIGNpostOnline.info

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We would like your help in building this archive. Please send your old
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The SIGN Internet Forum was established at the initiative of the World
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The SIGN Secretariat home is the Department of Health Systems Policies and
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The SIGN Forum is moderated by Allan Bass and is hosted on the University
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