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SIGNpost 00807

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00807 Waste Position + GBD + Abstracts + Extract + News 08 July 2015

CONTENTS
1. WHO Recruiting for Health Care Waste Position
2. Abstract: Global, regional, and national incidence, prevalence, and
years lived with disability for 301 acute and chronic diseases and
injuries in 188 countries, 1990-2013: a systematic analysis for the
Global Burden of Disease Study 2013
3. Abstract: Quantification of Dental Health Care Waste Generated among
Private Dental Practices in Bengaluru City
4. Abstract: A description of HIV prevalence trends in Nigeria from 2001
to 2010: what is the progress, where is the problem?
5. Abstract: Best Practices for Managing Medical Equipment and Supplies
Stored in a Vehicle
6. Abstract: Use of a medically supervised injection facility among street
youth
7. Abstract: Community attitudes towards harm reduction services and a
newly established needle and syringe automatic dispensing machine in an
inner-city area of Sydney, Australia
8. Abstract: Laws prohibiting peer distribution of injecting equipment in
Australia: A critical analysis of their effects
9. Abstract: Hepatitis C associated to substance abuse: ever closer to a
treatment without Interferon
10. Extract: Blood safety system reforms in Pakistan
11. Abstract: Skin preparation with alcohol versus alcohol followed by any
antiseptic for preventing bacteraemia or contamination of blood for
transfusion
12. Abstract: Investigation of a Novel Intravenous Catheter “Safe Wing
Cath”
13. Abstract: Hepatitis D Virus: Introduction and Epidemiology
14. Abstract: Laundering habits of student nurses and correlation with the
presence of Staphylococcus aureus on nursing scrub tops pre- and
postlaundering
15. Abstract: Variation in health care worker removal of personal
protective equipment
16. Abstract: Nanozyme-strip for rapid local diagnosis of Ebola
17. News
– USA: Amid ‘incredible epidemic,’ needle exchange programs gain momentum
As needle exchange clinics gain acceptance across the US, politics and
bureaucracy may be curbing their spread
– Australia: 40,000 Sydney dental patients face anxious wait after HIV
scare

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1. WHO Recruiting for Health Care Waste Position

Replies and the full terms of Reference please email hhwater@who.int

Applicants are asked to submit a CV, a short cover letter highlighting
experience and motivation for the work and a proposed daily rate, no later
than 15 July 2015.
__________________________________________________________________

Ute Pieper

Jul 6 2015

Dear All,

Good news: After over 4 years finally Yve’s post will be filled again!

Before the announcement of the permanent position, WHO wants to get
someone on board immediately who will start with a consultancy and then
advertise the post this fall for start 1 Jan.

Maybe interesting for some of you or share.

Best regards from Kuala Lumpur,

ute

Dr. Ute Pieper
Environmental Health Consultant

2A Persiaran Hampshire B-3A-3
50450 Kuala Lumpur I Malaysia
Skype username: utepieper
Mobile: +60 11 2827 9035
__________________________________________________________________
WHO Recruiting for Health Care Waste Position

WHO is seeking expressions of interest from professionals interested in
undertaking a full-time consultancy (1 August-30 December 2015) to advance
WHO’s work on health care waste.

The consultant will also support monitoring of WASH in health care
facilities and WASH in emergencies. The work requires close interactions
with colleagues in vaccines, infection prevention and control and
emergencies. The consultant will be based in Geneva with approximately 30%
travel to support implementation efforts.

The work requires a strong technical background in health care waste,
familiarity with WHO standards and guidelines, field experience in
developing countries and experience in organizing and managing multi-
sectoral efforts.

For the full ToR please email hhwater@who.int. Applicants are asked to
submit a CV, a short cover letter highlighting experience and motivation
for the work and a proposed daily rate, no later than 15 July 2015.
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Global, regional, and national incidence, prevalence, and
years lived with disability for 301 acute and chronic diseases and
injuries in 188 countries, 1990-2013: a systematic analysis for the
Global Burden of Disease Study 2013
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26063472

Free Full Text: https://tinyurl.com/pe4q7xz registration may be required

Lancet. 2015 Jun 5. pii: S0140-6736(15)60692-4.

Global, regional, and national incidence, prevalence, and years lived with
disability for 301 acute and chronic diseases and injuries in 188
countries, 1990-2013: a systematic analysis for the Global Burden of
Disease Study 2013.

Global Burden of Disease Study 2013 Collaborators.

BACKGROUND: Up-to-date evidence about levels and trends in disease and
injury incidence, prevalence, and years lived with disability (YLDs) is an
essential input into global, regional, and national health policies. In
the Global Burden of Disease Study 2013 (GBD 2013), we estimated these
quantities for acute and chronic diseases and injuries for 188 countries
between 1990 and 2013.

METHODS: Estimates were calculated for disease and injury incidence,
prevalence, and YLDs using GBD 2010 methods with some important
refinements. Results for incidence of acute disorders and prevalence of
chronic disorders are new additions to the analysis. Key improvements
include expansion to the cause and sequelae list, updated systematic
reviews, use of detailed injury codes, improvements to the Bayesian meta-
regression method (DisMod-MR), and use of severity splits for various
causes. An index of data representativeness, showing data availability,
was calculated for each cause and impairment during three periods globally
and at the country level for 2013. In total, 35?620 distinct sources of
data were used and documented to calculated estimates for 301 diseases and
injuries and 2337 sequelae. The comorbidity simulation provides estimates
for the number of sequelae, concurrently, by individuals by country, year,
age, and sex. Disability weights were updated with the addition of new
population-based survey data from four countries.

FINDINGS: Disease and injury were highly prevalent; only a small fraction
of individuals had no sequelae. Comorbidity rose substantially with age
and in absolute terms from 1990 to 2013. Incidence of acute sequelae were
predominantly infectious diseases and short-term injuries, with over 2
billion cases of upper respiratory infections and diarrhoeal disease
episodes in 2013, with the notable exception of tooth pain due to
permanent caries with more than 200 million incident cases in 2013.
Conversely, leading chronic sequelae were largely attributable to non-
communicable diseases, with prevalence estimates for asymptomatic
permanent caries and tension-type headache of 2·4 billion and 1·6 billion,
respectively. The distribution of the number of sequelae in populations
varied widely across regions, with an expected relation between age and
disease prevalence. YLDs for both sexes increased from 537·6 million in
1990 to 764·8 million in 2013 due to population growth and ageing, whereas
the age-standardised rate decreased little from 114·87 per 1000 people to
110·31 per 1000 people between 1990 and 2013. Leading causes of YLDs
included low back pain and major depressive disorder among the top ten
causes of YLDs in every country. YLD rates per person, by major cause
groups, indicated the main drivers of increases were due to
musculoskeletal, mental, and substance use disorders, neurological
disorders, and chronic respiratory diseases; however HIV/AIDS was a
notable driver of increasing YLDs in sub-Saharan Africa. Also, the
proportion of disability-adjusted life years due to YLDs increased
globally from 21·1% in 1990 to 31·2% in 2013.

INTERPRETATION: Ageing of the world’s population is leading to a
substantial increase in the numbers of individuals with sequelae of
diseases and injuries. Rates of YLDs are declining much more slowly than
mortality rates. The non-fatal dimensions of disease and injury will
require more and more attention from health systems. The transition to
non-fatal outcomes as the dominant source of burden of disease is
occurring rapidly outside of sub-Saharan Africa. Our results can guide
future health initiatives through examination of epidemiological trends
and a better understanding of variation across countries.

FUNDING: Bill & Melinda Gates Foundation. Copyright © 2015 Elsevier Ltd.
All rights reserved.

Free Full Text: https://tinyurl.com/pe4q7xz registration may be required

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60692-4.pdf
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Quantification of Dental Health Care Waste Generated among
Private Dental Practices in Bengaluru City
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26124606

J Int Oral Health. 2015 Jun;7(6):84-7.

Quantification of Dental Health Care Waste Generated among Private Dental
Practices in Bengaluru City.

Krishnappa P1, Sreekantaiah P2, Hiremath SS3, Thapsey H4, Shivraj NS5,
Murthy NS6.

1Professor and Head, Department of Public Health Dentistry, Faculty of
Dental Sciences, MS Ramaiah University of Applied Sciences, Bengaluru,
Karnataka, India.
2Senior Professor, Department of Community Medicine, MS Ramaiah Medical
College and Hospitals, Bengaluru, Karnataka, India.
3Professor and Head, Department of Public Health Dentistry, Oxford Dental
College and Research Centre, Bengaluru, Karnataka, India.
4Professor, Department of Community Medicine, MS Ramaiah Medical College
and Hospitals, Bengaluru, Karnataka, India.
5Assistant Professor, Department of Community Medicine, MS Ramaiah Medical
College and Hospitals, Bengaluru, Karnataka, India.
6Professor and Research Coordinator, Department of Community Medicine, MS
Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India.

BACKGROUND: Bengaluru, in India has more than 1148 practicing dentists for
a population of 8.42 million. The amount and type of dental health care
waste (DHCW) generated by the dental practitioners has to be assessed
prior to chalking out and implementation of an effective DCHW management
plan. Currently, there is no evidence available regarding the quantity,
type, and method of disposal adopted by these practitioners. Hence, this
study was conducted with the objective of estimating the quantity of DHCW
by the private dental practitioners in Bengaluru city.

MATERIALS AND METHODS: The sample size was estimated to be 110. The
sampling frame was constituted from the registered dental practitioners in
Bengaluru with the Department of Health and Family Welfare, Govt. of
Karnataka. Sampling strategy employed included a probability proportional
sampling strategy for the four zones in Bengaluru followed by a simple
random sampling of clinics from each zone. Standardized weight method was
followed to estimate the quantity of different category of waste. Three
data collectors who were trained and calibrated collected the information
regarding the type and quantity of waste generated, the nature of practice
and years of establishment.

RESULTS: Total quantity of waste generated was 0.161 kg/clinic/day with
0.130 kg and 0.026 kg of infectious and recyclables, respectively. The
projected data for the actual number of private practices in Bengaluru
city showed alarming figures of 41,535 kg and 8307 kg of infectious and
recyclable waste being generated every year. Data also showed poor
management practices of lead foil and plaster of paris and alarming
figures projected annual quantity.

CONCLUSION: The data demonstrated large quantities of hazardous waste
generation and poor segregation practices of the practitioners. This
warrants the immediate need for collective, voluntary measures to be
initiated for appropriate and effective management of DHCW.

KEYWORDS: Dental health care waste; private dental practitioners;
quantification
__________________________________________________________________
________________________________*_________________________________

4. Abstract: A description of HIV prevalence trends in Nigeria from 2001
to 2010: what is the progress, where is the problem?
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4199354/

Pan Afr Med J. 2014 Jul 21;18 Suppl 1:3.

A description of HIV prevalence trends in Nigeria from 2001 to 2010: what
is the progress, where is the problem?

Bashorun A1, Nguku P2, Kawu I3, Ngige E3, Ogundiran A4, Sabitu K5, Nasidi
A6, Nsubuga P7.

1Nigeria Field Epidemiology and Laboratory Training Program (N-FELTP),
Abuja, Nigeria ; HIV/AIDS Division, Department of Public Health, Federal
Ministry of Health, Nigeria.
2Nigeria Field Epidemiology and Laboratory Training Program (N-FELTP),
Abuja, Nigeria.
3HIV/AIDS Division, Department of Public Health, Federal Ministry of
Health, Nigeria.
4World Health Organization, Nigeria Office.
5Nigeria Field Epidemiology and Laboratory Training Program (N-FELTP),
Abuja, Nigeria ; Department of Community Medicine, Ahmadu Bello University
Zaria, Nigeria.
6Nigeria Center for Disease Control and Prevention (NCDC), Abuja, Nigeria.
7Global Public Health Solutions, Decatur, GA, USA.

INTRODUCTION: Nigeria’s population of 160 million and estimated HIV
prevalence of 3.34% (2011) makes Nigeria the second highest HIV burden
worldwide, with 3.2 million people living with HIV (PLHIV). In 2010, US
government spent about US$456.5 million on the Nigerian epidemic.
Antenatal clinic (ANC) HIV sero-prevalence sentinel survey has been
conducted biennially in Nigeria since 1991 to track the epidemic. This
study looked at the trends of HIV

in Nigeria over the last decade to identify progress and needs. METHODS:
We conducted description of HIV sero-prevalence sentinel cross-sectional
surveys conducted among pregnant women attending ANC from 2001 to 2010,
which uses consecutive sampling and unlinked-anonymous HIV testing (UAT)
in 160 sentinel facilities. 36,000 blood samples were collected and
tested. We used Epi-Info to determine national and state HIV prevalence
and trends. The Estimation and Projection Package with Spectrum were used
to estimate/project the burden of infection.

RESULTS: National ANC HIV prevalence rose from 1.8% (1991) to 5.8% (2001)
and dropped to 4.1% (2010). Since 2001, states in the center, and south of
Nigeria had higher prevalence than the rest, with Benue and Cross Rivers
notable. Benue was highest in 2001 (14%), 2005 (10%), and 2010 (12.7%).
Overall, eight states (21.6%) showed increased HIV prevalence while six
states (16.2%) had an absolute reduction of at least 2% from 2001 to 2010.
In 2010, Nigeria was estimated to have 3.19 million PLHIV, with the
general population prevalence projected to drop from 3.34% in 2011 to
3.27% in 2012.

CONCLUSION: Examining a decade of HIV ANC surveillance in Nigeria revealed
important differences in the epidemic in states that need to be examined
further to reveal key drivers that can be used to target future
interventions.

KEYWORDS: HIV; Nigeria; Pregnant; Sentinel; antenatal; clinic; estimates;
prevalence; projection; testing

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4199354/
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Best Practices for Managing Medical Equipment and Supplies
Stored in a Vehicle
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26121507

Home Healthc Now. 2015 Jul-Aug;33(7):368-72.

Best Practices for Managing Medical Equipment and Supplies Stored in a
Vehicle.

McGoldrick M1.

1Mary McGoldrick, MS, RN, CRNI, is a Home Care and Hospice Consultant,
Home Health Systems, Inc., Saint Simons Island, Georgia.

Home care clinicians often have to transport supplies to patients’ homes,
and remove and transport items from the home after care is provided.

This article will provide guidelines and best practices for the proper
methods of managing and storing infection prevention and control supplies
and regulated medical waste in a home care clinician’s personal vehicle.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Use of a medically supervised injection facility among street
youth
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/24925493

J Adolesc Health. 2014 Nov;55(5):684-9.

Use of a medically supervised injection facility among street youth.

Hadland SE1, DeBeck K2, Kerr T3, Nguyen P4, Simo A4, Montaner JS3, Wood
E5.

1Division of Adolescent and Young Adult Medicine, Department of Medicine,
Boston Children’s Hospital, Boston, Massachusetts; Department of
Pediatrics, Harvard Medical School, Boston, Massachusetts.
2British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, British Columbia, Canada; School of Public Policy, SFU Harbour
Centre, Simon Fraser University, Vancouver, British Columbia, Canada.
3British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, British Columbia, Canada; Faculty of Medicine, University of
British Columbia, Vancouver, British Columbia, Canada.
4British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, British Columbia, Canada.
5British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,
Vancouver, British Columbia, Canada; Faculty of Medicine, University of
British Columbia, Vancouver, British Columbia, Canada. Electronic address:
uhri-ew@cfenet.ubc.ca.

PURPOSE: Supervised injecting facilities (SIFs) provide a sanctioned space
for injection drug users and are associated with decreased overdose
mortality and HIV risk behaviors among adults. Little is known about SIF
use among youth. We identified factors associated with use of the
Vancouver SIF, the only such facility in North America, among street
youth.

METHODS: From September 2005 to May 2012, we collected data from the At-
Risk Youth Study, a prospective cohort of street youth in Vancouver, BC,
Canada. Eligible youth were aged 14-26 years. Participants reporting
injection completed questionnaires at baseline and semiannually. We used
generalized estimating equation logistic regression to identify factors
associated with SIF use.

RESULTS: During the study period, 42.3% of 414 injecting youth reported
use of the SIF at least once. Of all SIF-using youth, 51.4% went to the
facility at least weekly, and 44.5% used it for at least one-quarter of
all injections. SIF-using youth were more likely to live or spend time in
the neighborhood surrounding the SIF (adjusted odds ratio [AOR], 3.29; 95%
confidence interval [CI], 2.38-4.54), to inject in public (AOR, 2.08; 95%
CI, 1.53-2.84), or to engage in daily injection of heroin (AOR, 2.36; 95%
CI, 1.72-3.24), cocaine (AOR, 2.44; 95% CI, 1.34-4.45), or crystal
methamphetamine (AOR, 1.62; 95% CI, 1.13-2.31).

CONCLUSIONS: This study, the first to examine SIF use among street youth
in North America, demonstrated that the facility attracted high-frequency
young drug users most at risk of blood-borne infection and overdose and
those who otherwise inject in public spaces.

Copyright © 2014 Society for Adolescent Health and Medicine. Published by
Elsevier Inc. All rights reserved.

KEYWORDS: Adolescent; Drug abuse; HIV; Hepatitis C; Needle sharing
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Community attitudes towards harm reduction services and a
newly established needle and syringe automatic dispensing machine in an
inner-city area of Sydney, Australia
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26118798

Int J Drug Policy. 2015 Jun 2. pii: S0955-3959(15)00163-2.

Community attitudes towards harm reduction services and a newly
established needle and syringe automatic dispensing machine in an inner-
city area of Sydney, Australia.

White B1, Haber PS2, Day CA2.

1Discipline of Addiction Medicine, Central Clinical School, The University
of Sydney, NSW 2006, Australia. Electronic address:
bethany.white@sydney.edu.au.
2Discipline of Addiction Medicine, Central Clinical School, The University
of Sydney, NSW 2006, Australia.

BACKGROUND: Automatic dispensing machines (ADMs) are an inexpensive method
of increasing needle and syringe distribution to people who inject drugs
but widespread implementation has been limited. The operation of ADMs in
Australia has been met with apparent community opposition despite national
data indicating support for harm reduction. Key community concerns include
perceived increases in crime and drug use. This study aimed to examine
community-level support for a newly implemented ADM in an inner-city
Sydney area known for high levels of drug use.

METHODS: Attitudes to harm reduction and ADMs were assessed via a brief
face-to- face survey of local residents (n=118) and businesses (n=35)
located within the vicinity of needle and syringe program (NSP) services
including the ADM. Participation was voluntary and no reimbursement was
provided. Univariate analysis assessed statistically significant
differences between residents’ and businesses’ knowledge of, and support
for, a range of harm reduction initiatives, both generally and in the
local area. Univariate logistic regression models were used to determine
factors associated with indicating support for an ADM locally.

RESULTS: The response rate was higher among businesses (60%) compared to
residents living in street-accessible dwellings (42%). Participants
indicated support for fixed-site NSPs in general (83%) and locally (77%).
Support for ADMs was slightly lower – 67% indicated support for ADMs
generally and 60% locally. Negative opinions regarding ADMs (believing
that they encourage drug use, attract drug users to the area and increase
drug- related crime) were found to be significantly associated with a
lower likelihood of indicating support for ADMs locally.

CONCLUSION: Despite media reports suggesting widespread community concern,
there was general community support for harm reduction, including ADMs.
While it is important that harm reduction services are aware of community
concerns and respond appropriately, such responses should be considered
and interpreted against a broader backdrop of support.

Copyright © 2015 Elsevier B.V. All rights reserved.

KEYWORDS: Automatic dispensing machines; Community opinion; Harm
reduction; Household survey; Needle and syringe programs
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Laws prohibiting peer distribution of injecting equipment in
Australia: A critical analysis of their effects
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26118796

Int J Drug Policy. 2015 Jun 6. pii: S0955-3959(15)00167-X.

Laws prohibiting peer distribution of injecting equipment in Australia: A
critical analysis of their effects.

Lancaster K1, Seear K2, Treloar C3.

1Drug Policy Modelling Program, National Drug and Alcohol Research Centre,
UNSW, Australia. Electronic address: k.lancaster@unsw.edu.au.
2Faculty of Law, Monash University, Australia.
3Centre for Social Research in Health, UNSW, Australia.

The law is a key site for the production of meanings around the ‘problem’
of drugs in public discourse. In this article, we critically consider the
material-discursive ‘effects’ of laws prohibiting peer distribution of
needles and syringes in Australia.

Taking the laws and regulations governing possession and distribution of
injecting equipment in one jurisdiction (New South Wales, Australia) as a
case study, we use Carol Bacchi’s poststructuralist approach to policy
analysis to critically consider the assumptions and presuppositions
underpinning this legislative and regulatory framework, with a particular
focus on examining the discursive, subjectification and lived effects of
these laws.

We argue that legislative prohibitions on the distribution of injecting
equipment except by ‘authorised persons’ within ‘approved programs’
constitute people who inject drugs as irresponsible, irrational, and
untrustworthy and re-inscribe a familiar stereotype of the drug ‘addict’.
These constructions of people who inject drugs fundamentally constrain how
the provision of injecting equipment may be thought about in policy and
practice.

We suggest that prohibitions on the distribution of injecting equipment
among peers may also have other, material, effects and may be
counterproductive to various public health aims and objectives. However,
the actions undertaken by some people who inject drugs to distribute
equipment to their peers may disrupt and challenge these constructions,
through a counter-discourse in which people who inject drugs are
constituted as active agents with a vital role to play in blood-borne
virus prevention in the community. Such activity continues to bring with
it the risk of criminal prosecution, and so it remains a vexed issue.

These insights have implications of relevance beyond Australia,
particularly for other countries around the world that prohibit peer
distribution, but also for other legislative practices with material-
discursive effects in association with injecting drug use.

Copyright © 2015 Elsevier B.V. All rights reserved.

KEYWORDS: Australia; Carol Bacchi; Law; Needle and syringe program; Peer
distribution; Problematisation
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Hepatitis C associated to substance abuse: ever closer to a
treatment without Interferon
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26132303

Adicciones. 2015 Jun 17;27(2):141-149.

Hepatitis C associated to substance abuse: ever closer to a treatment
without Interferon.

[Article in English, Spanish]

Muga R1, Zuluaga P, Sanvisens A, Rivas I, Fuster D, Bolao F, Tor J, Red de
Trastornos Adictivos-Rta -.

1Servei de Medicina Interna. Hospital Universitari Germans Trias i Pujol,
Universitat Autònoma de Barcelona, Badalona..
rmuga.germanstrias@gencat.cat.

With 3-4 million of new infections occurring annually, hepatitis C virus
(HCV) infection is a global Public Health problem. In fact, hepatitis C
virus infection is one of the leading causes of liver disease in the
world; in Western countries, two thirds of the new HCV infections are
associated with injection drug use.

The treatment of hepatitis C will change in the coming years with the
irruption of new anti-HCV drugs, the so called Direct Antiviral Agents
(DAA) that attack key proteins of the HCV life cycle. The new antiviral
drugs are effective, safer and better tolerated. The 2014 WHO HCV
treatment guidelines include some of them.

The new DAA are used in combination and it is expected that Interferon
will be not necessary in future treatment regimens against HCV
infection.The irruption of new and potent antivirals mandate the review of
the current standards of care in the HCV infected population. More
inclusive and proactive treatment policies will be necessary in those
individuals with substance use disorders.
__________________________________________________________________
________________________________*_________________________________

10. Extract: Blood safety system reforms in Pakistan
__________________________________________________________________
Free Full Text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212023/

Blood Transfus. 2014 Oct;12(4):452-7.

Blood safety system reforms in Pakistan.

Zaheer HA1, Waheed U1.

1Safe Blood Transfusion Programme, Government of Pakistan, Islamabad,
Pakistan.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212023/
__________________________________________________________________

Extract Extract Extract Extract Extract Extract
__________________________________________________________________

Blood Transfus. 2014 Oct;12(4):452-7.

Blood safety system reforms in Pakistan.

The Islamic Republic of Pakistan is the sixth most populous country in the
world with a population of 180 million1. Literacy rate is 49.5% and the
population growth rate is 2.03%. Urdu is the national language but English
is also widely spoken and understood. Islamabad is the federal capital and
the total country area is 796,095 km2. The health care system in Pakistan
faces numerous challenges and operates through a three-tier delivery
structure and a variety of public health interventions. The role of
private sector is growing and according to an estimate its share has
reached 75%2. The overall health regulatory framework is weak and
inadequate3. The total expenditure on health is 2.5 % of the GDP4.
Following the implementation of the 18th amendment of the constitution in
June 2011, all the functions related to health were devolved to the
provincial/state health departments5. The public health system is
deficient in terms of human and physical infrastructure to match the needs
of the growing population and the challenges faced by natural and man-made
disasters including terrorism occurring with increasing frequency in the
recent past.

Blood transfusion system

The blood transfusion system (BTS) in Pakistan reflects the dynamics of a
country in development. After independence in 1947, the system had to
cater for the needs of some 33 million inhabitants while now the
population is estimated to be 180 million. The rapid growth of the BT
system in a country building up its post-independence structures was not
guided by national blood transfusion standards or overseen by blood
transfusion authorities or a national blood transfusion programme. The
back-bone of the system was “multifunctional” hospital blood banks,
complemented by an ever increasing number of private blood bank
laboratories. From the 1970s until today there has been a steady growth of
the sector especially through non-governmental organizations (NGOs)/blood
donor organizations (BDOs), which are only remotely acquainted with
existing policies, standards and guidelines and which in their majority
are not licensed for the services they are providing, mostly under
humanitarian principles.

…… Continues
Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212023/
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Skin preparation with alcohol versus alcohol followed by any
antiseptic for preventing bacteraemia or contamination of blood for
transfusion
__________________________________________________________________
Free Full Text
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007948.pub3/full

Cochrane Database Syst Rev. 2015 Feb 12;2:CD007948.

Skin preparation with alcohol versus alcohol followed by any antiseptic
for preventing bacteraemia or contamination of blood for transfusion.

Webster J1, Bell-Syer SE, Foxlee R.

1Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Level
2, Building 34, Butterfield Street, Brisbane, Queensland, Australia, 4029.
joan_webster@health.qld.gov.au. wigan1943@bigpond.com.

BACKGROUND: Blood for transfusion may become contaminated at any point
between collection and transfusion and may result in bacteraemia (the
presence of bacteria in the blood), severe illness or even death for the
blood recipient. Donor arm skin is one potential source of blood
contamination, so it is usual to cleanse the skin with an antiseptic
before blood donation. One-step and two-step alcohol based antiseptic
regimens are both commonly advocated but there is uncertainty as to which
is most effective.

OBJECTIVES: To assess the effects of cleansing the skin of blood donors
with alcohol in a one-step compared with alcohol in a two-step procedure
to prevent contamination of collected blood or bacteraemia in the
recipient.

SEARCH METHODS: In December 2014, for this third update, we searched the
Cochrane Wounds Group Specialised Register; The Cochrane Central Register
of Controlled Trials (CENTRAL), The Cochrane Library; Ovid MEDLINE; Ovid
MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO
CINAHL.

SELECTION CRITERIA: All randomised trials (RCTs) comparing alcohol based
donor skin cleansing in a one-step versus a two-step process that includes
alcohol and any other antiseptic for pre-venepuncture skin cleansing were
considered. Quasi randomised trials were to have been considered in the
absence of RCTs.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed
studies for inclusion.

MAIN RESULTS: No studies (RCTs or quasi RCTs) met the inclusion criteria.

AUTHORS’ CONCLUSIONS: We did not identify any eligible studies for
inclusion in this review. It is therefore unclear whether a two-step,
alcohol followed by antiseptic skin cleansing process prior to blood
donation confers any reduction in the risk of blood contamination or
bacteraemia in blood recipients, or conversely whether a one-step process
increases risk above that associated with a two-step process.

Update of Skin preparation with alcohol versus alcohol followed by any
antiseptic for preventing bacteraemia or contamination of blood for
transfusion. [Cochrane Database Syst Rev. 2013]

Free Full Text
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007948.pub3/full
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Investigation of a Novel Intravenous Catheter “Safe Wing
Cath”
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26121821

Masui. 2015 Feb;64(2):212-7.

[Investigation of a Novel Intravenous Catheter “Safe Wing Cath”].

[Article in Japanese]

Nakamura R, Fukuda H, Miyoshi H, Matsunami K, Hamada H, Kawamoto M.

BACKGROUND: A Safe Wing Cath (SWC) is a novel intravenous catheter which
has a unique needlestick injury safety mechanism.

METHODS: We investigated the success rate of intravenous catheterization
using SWC by questionnaire. Anesthesiologists were recruited who had no
previous experience of using SWC. Two or three consecutive trials were
subjected for investigation.

RESULTS: During four months in 2012, 8 anesthesiologists were asked to do
the job 23 times. The success rate was 62.5% at first use by each
anesthesiologist 87.5% at second use, and 100% at third use.

CONCLUSIONS: Experienced anesthesiologists can learn the technique of SWC
on its second or third use.
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Hepatitis D Virus: Introduction and Epidemiology
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26134842

Cold Spring Harb Perspect Med. 2015 Jul 1;5(7). pii: a021576.

Hepatitis D Virus: Introduction and Epidemiology.

Rizzetto M1.

1Division of Gastroenterology, University of Torino, 10126 Torino, Italy.

Hepatitis D is caused by the hepatitis D virus (HDV), a unique RNA
pathogen that requires the hepatitis B surface antigen (HBsAg) to infect.
Hepatitis D is transmitted by the parenteral route.

The main susceptible group is patients with chronic HBsAg infection who
become superinfected with the virus. Hepatitis D occurs throughout the
globe, but control of hepatitis B virus (HBV) in the last two decades has
consistently diminished the circulation of HDV in industrialized
countries.

However, hepatitis D remains a medical issue for injecting drug users
(IDUs), as well as immigrants from endemic HDV areas, who are
reintroducing the infection in Europe.

Copyright © 2015 Cold Spring Harbor Laboratory Press; all rights reserved.
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Laundering habits of student nurses and correlation with the
presence of Staphylococcus aureus on nursing scrub tops pre- and
postlaundering
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26143576

Am J Infect Control. 2015 Jul 1. pii: S0196-6553(15)00530-1.

Laundering habits of student nurses and correlation with the presence of
Staphylococcus aureus on nursing scrub tops pre- and postlaundering.

Scott E1, Goodyear N2, Nicoloro JM2, Marika DJ3, Killion E3, Duty SM3.

1Department of Biology, Simmons College, Boston, MA; Center for Hygiene
and Health in the Home and Community, Simmons College, Boston, MA.
Electronic address: scotte2@simmons.edu.
2Department of Clinical Laboratory and Nutritional Sciences, University of
Massachusetts Lowell, Lowell, MA.
3School of Nursing and Health Sciences, Simmons College, Boston, MA.
Little is known about student nurse laundering practices. Student nurses
swabbed their scrub tops after clinical and after laundering, and they
completed a laundry survey; 13.5% of students wore the same scrub more
than once, and few followed recommended guidelines by using hot water
(20%) or bleach (5.6%) when laundering scrubs.

After clinical shifts, 17% of swabs tested positive for Staphylococcus
aureus; however, laundering eradicated it from 64.3% of positive samples.
This was not statistically significant.

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

KEYWORDS:Infection control; Laundry; Scrubs; Staphylococcus aureus;
Student nurse
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Variation in health care worker removal of personal
protective equipment
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26138659

Am J Infect Control. 2015 Jul 1;43(7):750-1.

Variation in health care worker removal of personal protective equipment.

Zellmer C1, Van Hoof S1, Safdar N2.

1William S. Middleton Veterans Hospital and Section of Infectious
Diseases, Department of Medicine, University of Wisconsin, Madison, WI.
2William S. Middleton Veterans Hospital and Section of Infectious
Diseases, Department of Medicine, University of Wisconsin, Madison, WI.
Electronic address: ns2@medicine.wisc.edu.

In the current era of emerging pathogens such as Ebola virus, removal of
personal protective equipment (PPE) is crucial to reduce contamination of
health care workers. However, current removal practices are not well
described.

We undertook a systematic evaluation of health care worker removal of PPE
for contact isolation to examine variation in removal procedures.

Findings indicate that under usual conditions, only about half of health
care workers correctly remove their PPE, and very few remove their PPE in
the correct order and dispose of it in the proper location.

Published by Elsevier Inc.

KEYWORDS:Emerging pathogens; Healthcare associated infection
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Nanozyme-strip for rapid local diagnosis of Ebola
__________________________________________________________________
http://www.ncbi.nlm.nih.gov/pubmed/26134291

Biosens Bioelectron. 2015 May 11;74:134-141.

Nanozyme-strip for rapid local diagnosis of Ebola.

Duan D1, Fan K1, Zhang D1, Tan S2, Liang M3, Liu Y3, Zhang J1, Zhang P4,
Liu W4, Qiu X5, Kobinger GP5, Fu Gao G6, Yan X7.

1Key Laboratory of Protein and Peptide Pharmaceuticals, CAS-University of
Tokyo Joint Laboratory of Structural Virology and Immunology, Institute of
Biophysics, Chinese Academy of Sciences, Beijing 100101, China.
2CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute
of Microbiology, Chinese Academy of Sciences, Beijing 100101, China.
3National Institute for Viral Disease Control and Prevention, Chinese
Center for Disease Control and Prevention, Beijing 100052, China.
4State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of
Microbiology and Epidemiology, Beijing 100071, China.
5National Laboratory for Zoonotic Diseases and Special Pathogens, Public
Health Agency of Canada, Winnipeg, Manitoba R3E 3R2, Canada.
6CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute
of Microbiology, Chinese Academy of Sciences, Beijing 100101, China;
Office of Director-General, Chinese Center for Disease Control and
Prevention, Beijing 102206, China.
7Key Laboratory of Protein and Peptide Pharmaceuticals, CAS-University of
Tokyo Joint Laboratory of Structural Virology and Immunology, Institute of
Biophysics, Chinese Academy of Sciences, Beijing 100101, China. Electronic
address: yanxy@ibp.ac.cn.

Ebola continues to rage in West Africa. In the absence of an approved
vaccine or treatment, the priority in controlling this epidemic is to
promptly identify and isolate infected individuals. To this end, a rapid,
highly sensitive, and easy-to-use test for Ebola diagnosis is urgently
needed.

Here, by using Fe3O4 magnetic nanoparticle (MNP) as a nanozyme
probe, we developed a MNP-based immunochromatographic strip (Nanozyme-
strip), which detects the glycoprotein of Ebola virus (EBOV) as low as
1ng/mL, which is 100-fold more sensitive than the standard strip method.

The sensitivity of the Nanozyme-strip for EBOV detection and diagnostic
accuracy for New Bunyavirus clinical samples is comparable with ELISA, but
is much faster (within 30min) and simpler (without need of specialist
facilities).

The results demonstrate that the Nanozyme-strip test can
rapidly and sensitively detect EBOV, providing a valuable simple screening
tool for diagnosis of infection in Ebola-stricken areas.

Copyright © 2015 Elsevier B.V. All rights reserved.

KEYWORDS: Ebola detection; Immunochromatographic strip; Nanozyme
__________________________________________________________________
________________________________*_________________________________

17. News

– USA: Amid ‘incredible epidemic,’ needle exchange programs gain momentum
As needle exchange clinics gain acceptance across the US, politics and
bureaucracy may be curbing their spread
– Australia: 40,000 Sydney dental patients face anxious wait after HIV
scare

Selected news items reprinted under the fair use doctrine of international
copyright law: http://www4.law.cornell.edu/uscode/17/107.html
__________________________________________________________________
https://tinyurl.com/nrfhm4l

USA: Amid ‘incredible epidemic,’ needle exchange programs gain momentum
As needle exchange clinics gain acceptance across the US, politics and
bureaucracy may be curbing their spread

by Lisa De Bode, Al Jazeera America (07.07.15)

A spike in intravenous drug use in a growing number of U.S. counties has
led to soaring infection rates of hepatitis C and HIV in communities
across the country. Increasingly these counties are pushing for the
creation of needle exchange programs, but politics and bureaucracy appears
to be slowing the spread of such harm reduction programs.

By enabling access to health care, rehab facilities and addressing social
inequalities that exacerbate substance abuse, advocates say harm reduction
programs, like needle exchanges, help to reduce the negative health
effects of drug injection.

“There has been a big change in how state legislators view overdose and
view drug-related harm in general,” said Corey Davis, the deputy director
of the National Health Law Program.

But despite renewed interest in clinics where people can receive treatment
and drop off contaminated wares in exchange for clean ones, political and
bureaucratic hurdles are preventing widespread implementation — even after
epidemics in Indiana, Ohio, Kentucky and elsewhere raised national alarm.

In April, an HIV outbreak in Scott County, Indiana grabbed headlines when
health officials there recorded more than 100 cases in a month. The number
grew to 169 by June — more than 30 times the county’s yearly average. Most
infections occurred from injecting Opana, a popular painkiller containing
oxymorphone, with contaminated needles.

Following the outbreak, Indiana Gov. Mike Pence waived the state’s anti-
needle ban that criminalized the possession of a syringe without a medical
reason and signed a law allowing county officials to request permission to
establish their own needle exchange programs — though these clinics were
not eligible for state funding.

While some saw this as opening the door for harm reduction clinics across
the state, the reaction so far has been muted. Only two counties have made
use of the new rules, though a third county is considering establishing an
exchange, according to local reports.

Health officials in Scott County, Indiana, declared a health emergency and
established a needle exchange program in April to slow the spread of HIV.

In June, health officials in Madison County, just northeast of
Indianapolis, successfully petitioned the state for a needle exchange
program after health officials discovered 130 individuals with hepatitis
C. Again, intravenous drug use was the primary mode of transmission,
according to the Madison County Health Department.

Madison County has the third-highest prescription drug overdose rate in
Indiana, after Starke County and Scott County, where the state’s first
needle exchange program was established, the department added.

Still, despite the evidence of an ongoing statewide opioid epidemic, Davis
said the dearth of counties making use of the new rules likely means their
implementation is being “tied up in politics.”

The new laws are “a step in the right direction, but they are still pretty
restrictive,” Davis said. “There are all these hoops that have to be
jumped through.”

The Indiana legislation requires law enforcement, county and state
officials to collaborate on the syringe exchange programs and mandates
that municipal officials adopt a local health officer’s request to declare
a medical emergency at a public hearing, allowing for public testimony,
after which the state health commissioner must endorse the declaration.

“If it was truly a public health decision, it would just be a decision of
the public health department,” Davis said. “It’s telling that there are
only two counties that have initiated these programs, even though we have
this clear evidence that there is an epidemic of HIV.”

“Epidemics don’t follow county lines,” he added.

Lawmakers from Indiana’s southern neighbor Kentucky signed a bill in March
legalizing needle exchanges amid increasing rates of hepatitis C and HIV .
More than 1,300 syringes were distributed in the first week of the state’s
first needle exchange program in June, WLKY Louisville News reported.

But as in Indiana, a needle exchange clinic in Louisville required the
approval of the local health department and city and county
administrators, according to state guidelines for local health
departments. And the president of the Kentucky’s state senate, Robert
Stivers, says the needle exchange program is not keeping the public safe
and may be violating state law by sometimes handing out clean needles
without receiving a contaminated one in return.

Communities in Indiana and Kentucky aren’t the only ones in the region
mulling changes to how they deal with injection drug use and the spread of
infectious disease.

In Franklin County, Ohio, where Columbus is located, health officials
recorded 1,369 cases of hepatitis C in 2014, nearly double that statistic
from five years prior, according to data from the Columbus Health
Department.

That evidence is leading local Ohio officials to consider opening a needle
exchange clinic in the county. Exchange programs are legal in the state,
but there are only a handful.

“We are looking at harm reduction plans that have been put in place in the
state and throughout the country,” said Jose Rodriguez, a spokesman for
the Columbus Public Health Department, “so that we can learn about best
practices.”

Rodriguez was unable to confirm the cause of the surge in infections, but
Judith Feinberg, a professor of clinical medicine at the University of
Cincinnati, who spearheaded the opening of one of Ohio’s few needle
exchange clinics last year, said the increase in infections almost
certainly came from the intravenous drug user community.

“It’s the only thing that makes sense,” she said. “The primary way for
people to get hepatitis C is through blood,” she added. “This isn’t
something you get from food. It has to be drug use.”

Hepatitis C, in contrast to HIV, can live on for days on contaminated
equipment. About 80 percent of intravenous drug users generally will
eventually contract the disease, according to Feinberg.

“There is a massive need,” she said. “This is an incredible epidemic [of
hepatitis C]. This is the only way to have an impact from a public health
perspective.”

Feinberg said the traditional method of detaining and imprisoning drug
users to take them off the street had failed.

“This isn’t something you’ll arrest your way out of. It’s a chronic brain
disease, and it needs to be treated as such,” she said.

SHARE THIS: https://tinyurl.com/nrfhm4l
__________________________________________________________________
__________________________________________________________________
https://tinyurl.com/nh78dsy

Australia: 40,000 Sydney dental patients face anxious wait after HIV scare

By Amy Corderoy, Sydney Morning Herald, Australia (02.07.15)

Patients who may be at risk should talk to their GP, or they can call a
public information line on 1800 610 344. As the line has been receiving a
high volume of calls, an alternative number and email have also been set
up: 1300 066 055 or CDB@doh.health.nsw.gov.au

Tens of thousands of Sydney dental patients face an anxious wait after
discovering they could be at risk of infection with HIV and hepatitis.

Health authorities say 40,000 people have visited The Gentle Dentist,
which has operated at Campsie since 2005 and Sussex Street in the city
since 2008, and has been found to have had serious deficiencies in its
cleaning and sterilisation practices that have put its patients at risk of
infection.

However, of that group only the 11,251 who had an invasive procedure who
should be tested for the infectious diseases, NSW Health told a press
conference this morning.

On Wednesday Fairfax Media revealed that the owner of the clinics, dentist
Samson Chan, has had his dental registration suspended over the breaches,
along with four other dentists working at the practice. A further six have
had conditions placed on their registration.

NSW Health’s director of health protection, Jeremy McAnulty, said all
patients who had procedures at the clinic, not just those patients of the
suspended or disciplined doctors, should be tested if they had any
invasive procedures that involved things such as instruments in their gums
or complex surgery.

“We are hopeful that there will not have been any transmission but there
is a risk to some people,” he said. “[But] the risk is low and people
should bear that in mind”.

Patients at another two clinics, run by another unrelated dentist, Robert
Starkenburg, have also been warned to see their GP.

Dr Starkenburg, who was known to be an HIV-friendly doctor, is thought to
have seen about 800 patients in the period he was not complying with
infection control rules. NSW Health said all those people could be at risk
of infection because “due to inadequate patient records at Dr
Starkenburg’s surgeries, it is not possible to determine which patients
had invasive procedures”.

But Dr McAnulty said despite the work Dr Starkenburg did with HIV
patients, who can have compromised immune systems and can be at risk not
only of transmitting HIV but catching other conditions, there was no extra
risk to patients at his clinic.

“Taking into account the type of patients and treatment for the practice
we believe the risk to patients is low,” he said. He said infection
control procedures had a number of steps and all would need to be
compromised for an infection to spread.

Dr Starkenburg on Wednesday told Fairfax Media that he was “very sorry”
about what had happened, and his older age had made it difficult to keep
up with changing rules around infection control, but he did not believe
any of his patients would be infected.

At the press conference in the NSW Health headquarters in North Sydney
this morning, Dr McAnulty also defended the delays in announcing the
infection risks at both clinics, despite Dr Starkenburg being suspended in
December and serious problems at The Gentle Dentist being discovered in
February.

He said all 40,000 patient records needed to be assessed in that time,
contacts made through Medicare and repeat assessments of the clinic done.

Shane Fryer, a member of the Dental Council of NSW that assessed the
dental clinics, said the majority of dental practitioners did the right
thing and the public should not be scared of infection at their dentist.

He said while The Gentle Dentist was continuing to operate at the moment,
he was confident that the remaining practioners were practicing
appropriate hygiene control – so much so that he would be willing to
undergo a root canal surgery there.

The Dental Council has referred Dr Starkenburg and The Gentle Dentist
practitioners who have had action taken against them to the Health Care
Complaints Commission for further investigation.
__________________________________________________________________
________________________________*_________________________________

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

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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
and does not in any way mean that they are endorsed by any of the
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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

The SIGNpost website provides an archive of all SIGNposts, meeting
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We would like your help in building this archive. Please send your old
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Email mailto:sign.moderator@gmail.com
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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
Workforce, Geneva Switzerland.

The SIGN Forum is moderated by Allan Bass and is hosted on the University
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