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SIGNpost 00831

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00831 Abstracts + World AIDS Day + News 02 December 2015

CONTENTS
0. Reminder: Key New Injection Safety Publications in 2015
1. Abstract: Reducing needlestick injuries through safety-engineered
devices: results of a Japanese multi-centre study
2. Abstract: Impacts of health education on knowledge and practice of
hospital staff with regard to Healthcare waste management at White Nile
State main hospitals, Sudan
3. Abstract: A cross-sectional observational study about media and
infection control practices: are photographic portrayals of healthcare
workers setting a bad example?
4. Abstract: The importance of needle gauge for pain during injection of
lidocaine
5. Abstract: Is epidural steroid injection effective for degenerative
lumbar spinal stenosis?
6. Abstract: Adverse Clinical Effects of Botulinum Toxin Intramuscular
Injections for Spasticity
7. Abstract: Retro or PeriBulbar Injection Techniques to Reverse Visual
Loss After Filler Injections
8. No Abstract: An Android app for recording hand hygiene observation data
9. News
– Indonesia: Harsh Drugs Laws, Rising HIV Rates, and Indonesia’s Battle
Over Both
– Russia: Russia HIV infection rate rising as World Aids Day marked
– Philippines: Special Report: Syringe scrimmage (When drugs and Aids
collide)
– California USA: Report Cites Fewer Needles On Sidwalks, But Complaints
About Them Rise
– California USA: Complaints skyrocket over syringes on streets in S.F.
– MA USA: Kindergartner stuck with needle in school garden
– End of daily injections for diabetes as scientists restore insulin
production

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__________________________________________________________________
________________________________*_________________________________

0. Reminder: Key New Injection Safety Publications in 2015

2015 Marks a turning point in Injection Safety with the publication of the
new Guidelines and the recommendations to countries. Encourage decision
makers in your countries to action the guidelines.
__________________________________________________________________
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
__________________________________________________________________
________________________________*_________________________________

1. Abstract: Reducing needlestick injuries through safety-engineered
devices: results of a Japanese multi-centre study
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26601603

J Hosp Infect. 2015 Oct 20. pii: S0195-6701(15)00395-3.
Reducing needlestick injuries through safety-engineered devices: results
of a Japanese multi-centre study.

Fukuda H1, Yamanaka N2.

1Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-
Ku, Fukuoka, Japan. Electronic address: h_fukuda@hcam.med.kyushu-u.ac.jp.
2Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-
Ku, Fukuoka, Japan; Kitakyushu General Hospital, Kitakyushu, Fukuoka,
Japan.

BACKGROUND: Quantitative information on the effectiveness of safety-
engineered devices (SEDs) is needed to support decisions regarding their
implementation. AIM: To elucidate the effects of SED use in winged steel
needles, intravenous (IV) catheter stylets and suture needles on
needlestick injury (NSI) incidence rates in Japan.

METHODS: Japan EPINet survey data and device utilization data for
conventional devices and SEDs were collected from 26 participating
hospitals between 1 April 2009 and 31 March 2014. The NSI incidence rate
for every 100,000 devices was calculated according to hospital, year and
SED use for winged steel needles, IV catheter stylets and suture needles.
Weighted means and 95% confidence intervals (CI) were used to calculate
overall NSI incidence rates.

FINDINGS: In total, there were 236 NSIs for winged steel needles, 152 NSIs
for IV catheter stylets and 180 NSIs for suture needles. The weighted NSI
incidence rates per 100,000 devices for SEDs and non-SEDs were as follows:
winged steel needles, 2.10 (95% CI 1.66-2.54) and 14.95 (95% CI
2.46-27.43), respectively; IV catheter stylets, 0.95 (95% CI 0.60-1.29)
and 6.39 (95% CI 3.56-9.23), respectively; and suture needles, 1.47 (95%
CI -1.14-4.09) and 16.50 (95% CI 4.15-28.86), respectively. All devices
showed a significant reduction in the NSI incidence rate with SED use (P <
0.001 for winged steel needles, P = 0.035 for IV catheter stylets and P =
0.044 for suture needles).

CONCLUSION: SED use substantially reduces the incidence of NSIs, and is
therefore recommended as a means to prevent occupational infections in
healthcare workers and improve healthcare safety.

Copyright © 2015 The Healthcare Infection Society. Published by Elsevier
Ltd. All rights reserved.

KEYWORDS: EPINet; Intravenous catheter stylets; Needlestick injury;
Safety- engineered device; Suture needles; Winged steel needles
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Impacts of health education on knowledge and practice of
hospital staff with regard to Healthcare waste management at White Nile
State main hospitals, Sudan
__________________________________________________________________

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633195/

Int J Health Sci (Qassim). 2015 Jul;9(3):315-331.
Impacts of health education on knowledge and practice of hospital staff
with regard to Healthcare waste management at White Nile State main
hospitals, Sudan.

Elnour AM1, Moussa MM2, El-Borgy MD2, Fadelella NE1, Mahmoud AH2.

1Faculty of Medicine and health sciences, University of El Imam El Mahdi,
Sudan.
2High Institute of Public Health, Alexandria University, Egypt.

OBJECTIVES: The present study aims at assessing nursing and sanitation
staff knowledge and practice regarding Healthcare Waste (HCW) management
before and after the implementation of an educational intervention program
at the main hospitals of the White Nile State in Sudan.

METHODOLOGY: Quasi-experimental study design was applied to assess the
impact of an intervention program on knowledge and practice regarding HCW
management. The same questionnaire used in the pre-test was used
immediately after the end of the intervention program and then again three
months later for a second post-test.

RESULTS: The results showed that the majority of nursing and sanitation
staff had fair knowledge regarding HCW management before the educational
intervention program (17% good, 58% fair, and 25% poor). After
implementation of the educational program, the majority had good knowledge
(56% good, 34% fair, and 10% poor) in the immediate post-test, and also in
the post-test three months later (59% good, 35% fair, and 6% poor). More
than half the nursing and sanitation staff had fair level of practice
before the educational intervention program (42% good, 55% fair, and 3%
poor). After the implementation of the intervention program, the immediate
post-test showed a similar result (45% good, 54% fair, and 1% poor), while
the post-test three months later showed that the majority demonstrated
good practice level (55% good, 42% fair, and 3% poor).

CONCLUSION: The nursing and sanitation staff at the main hospitals of the
White Nile State in Sudan recorded significant improvement in their
knowledge and practice with regard to HCW management immediately after the
educational intervention program and three months later.

Free PMC Article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633195/
__________________________________________________________________
________________________________*_________________________________

3. Abstract: A cross-sectional observational study about media and
infection control practices: are photographic portrayals of healthcare
workers setting a bad example?
__________________________________________________________________
Free Open Access http://www.aricjournal.com/content/4/1/53

Antimicrob Resist Infect Control. 2015 Nov 25;4:53.

A cross-sectional observational study about media and infection control
practices: are photographic portrayals of healthcare workers setting a bad
example?

Spierings EJ1, Spierings PT2, Nabuurs-Franssen M3, Hopman J4, Perencevich
E5, Voss A6.

1Radboud University of Nijmegen, Medical School, Platolaan 340, 6525 KD
Nijmegen, The Netherlands.
2Spierings Medische Techniek B.V., Nijmegen, The Netherlands.
3Department of Medical Microbiology and Infectious Diseases, Canisius-
Wilhelmina Hospital, Nijmegen, The Netherlands.
4Department of Medical Microbiology, Radboud University of Nijmegen,
Nijmegen, The Netherlands.
5Division of Infectious Diseases and Epidemiology, University of Iowa
Hospital and Clinics, Iowa City, IA USA.
6Department of Medical Microbiology and Infectious Diseases, Canisius-
Wilhelmina Hospital, Nijmegen, The Netherlands ; Department of Medical
Microbiology, Radboud University of Nijmegen, Nijmegen, The Netherlands.

BACKGROUND: Attempts to increase compliance with infection control
practices are complex and are – in part – based on attempts to change
behaviour. In particular, the behaviour of significant peers (role models)
has been shown to be a strong motivator. While role models within the
working environment are obviously the most important, some experts suggest
that media and public display cannot be ignored. The aim of this present
study was to examine the display of technique recommended by current
infection control guidelines including the “bare below the elbow”
principle, which is considered a basic requirement for good infection
control in many countries, in sets of professional stock photos.

FINDINGS: From 20 random photo-stock websites we selected pictures with
search terms “doctor and patient” and “nurse and patient”. In all selected
photos a doctor or nurse and a patient were presented, healthcare workers
(HCWs) were wearing white coats or uniforms, and their arms were visible.
Each photo was evaluated with regard to: closure of white coat, sleeve
length, personal clothing covered, hairstyle and presence of a wristwatch,
bracelet and/or ring. Overall, 1600 photos were evaluated. The most common
mistakes were with regard to HCWs’ white coats/uniforms. Eighty-nine
percent of the photos containing doctor’s images were considered incorrect
while 28 % of nurse-containing photos were incorrect.

CONCLUSIONS: The results seem to reflect the real world with only 40 %
displaying correct behaviour with doctors being worse than nurses. It
seems that the stereotypical image of a doctor does not agree with the
current infection control guidelines. If we aim for higher compliance
rates of HCWs, we need to change the social image of doctors and improve
production, selection and display of stock photo images.
__________________________________________________________________
________________________________*_________________________________

4. Abstract: The importance of needle gauge for pain during injection of
lidocaine
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26595751

J Plast Surg Hand Surg. 2015 Nov 23:1-4.
The importance of needle gauge for pain during injection of lidocaine.

Wågø KJ1, Skarsvåg TI1, Lundbom JS1, Tangen LF1, Ballo S1, Hjelseng T1,
Finsen V1,2.

1a Faculty of Medicine , NTNU , Trondheim , Norway and.
2b Department of Orthopaedic Surgery , St. Olav’s University Hospital ,
Trondheim , Norway.

BACKGROUND: Local anaesthetics such as lidocaine are used both in minor
and major surgical procedures, and can be painful. Different methods have
been investigated to reduce the discomfort of the injections. This study
investigated if different needle gauges can influence the pain experienced
during injection of lidocaine.

METHODS: A randomised study was performed on 36 healthy volunteers. Each
participant received three injections of 3?ml 1% lidocaine subcutaneously
on the abdomen using needles of different gauges. Following each
injection, the participants evaluated the pain experienced on a visual
analogue scale (VAS). After the session, they were asked to evaluate
verbally which injection they found least and most painful. The VAS and
verbal reports were used and compared to evaluate the difference between
the two types of clinically reported pain scales.

RESULTS: Twenty-one participants verbally reported the thinnest needle (27
gauge (G)) as least painful, compared to the intermediate (23 gauge;
p?=?0.013) and the thickest needle (21 gauge, p?=?0.004). The mean VAS
scores were 19 (SD?=?13) for the 21 gauge, 18 (SD?=?13) for the 23 gauge,
and 16 (SD?=?14) for the 27 gauge needles.

CONCLUSION: A significant preponderance of respondents stated that there
had been less pain using the thinnest needle. Mean VAS responses showed
the same trend, but the differences between them were not statistically
significant.

KEYWORDS: hand; injection; lidocaine; needle gauge; pain; plastic surgery
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Is epidural steroid injection effective for degenerative
lumbar spinal stenosis?
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26610278

Medwave. 2015 Nov 16;15(Suppl 3):e6315.
Is epidural steroid injection effective for degenerative lumbar spinal
stenosis?

[Article in English, Spanish]

Flores S1, Molina M2.

1Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
de Chile; Departamento de Traumatología y Ortopedia, Facultad de Medicina,
Pontificia Universidad Católica de Chile, Santiago de Chile; Proyecto
Epistemonikos, Santiago de Chile. Address: Facultad de Medicina,
Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
Email: mmolinas@med.puc.cl.
2Departamento de Traumatología y Ortopedia, Facultad de Medicina,
Pontificia Universidad Católica de Chile, Santiago de Chile; Proyecto
Epistemonikos, Santiago de Chile.

There are several nonsurgical alternatives to treat radicular pain in
degenerative lumbar spinal stenosis. Epidural steroid injections have been
used for several decades, but the different studies have shown variable
effects.

Searching in Epistemonikos database, which is maintained by screening 30
databases, we identified nine systematic reviews including seven pertinent
randomized controlled trials.

We concluded epidural steroid injection probably leads to little or no
effect on reducing radicular pain of spinal stenosis.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Adverse Clinical Effects of Botulinum Toxin Intramuscular
Injections for Spasticity
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26597813

Can J Neurol Sci. 2015 Nov 24:1-13.
Adverse Clinical Effects of Botulinum Toxin Intramuscular Injections for
Spasticity.

Phadke CP1, Balasubramanian CK2, Holz A1, Davidson C1, Ismail F1, Boulias
C1.

11Spasticity Research Program,West Park Healthcare Centre,University of
Toronto,Toronto,Ontario,Canada.
24Clinical & Applied Movement Sciences,Brooks College of Health,University
of North Florida,Florida,USA.

OBJECTIVE: The adverse events (AEs) with botulinum toxin type-A (BoNTA),
used for indications other than spasticity, are widely reported in the
literature. However, the site, dose, and frequency of injections are
different for spasticity when compared to the treatment for other
conditions and hence the AEs may be different as well. The objective of
this study was to summarize the AEs reported in Canada and systematically
review the AEs with intramuscular botulinum toxin injections to treat
focal spasticity.

METHODS: Data were gathered from Health Canada (2009-2013) and major
electronic databases.

RESULTS: In a 4 year period, 285 AEs were reported. OnabotulinumtoxinA (n=
272 events): 68% females, 53% serious, 18% hospitalization, and 8%
fatalities. The type of AEs reported were – muscle weakness (19%),
oropharyngeal (14%), respiratory (14%), eye related (8%), bowel/bladder
related (8%), and infection (5%). IncobotulinumtoxinA (n=13): 38% females,
62% serious, and 54% hospitalization.

The type of AEs reported were – muscle weakness (15%), oropharyngeal
(15%), respiratory (38%), eye related (23%), bowel/bladder related (15%),
and infection (15%).

Commonly reported AEs in the literature were muscle weakness, pain,
oropharyngeal, bowel/bladder, blood circulation, neurological, gait, and
respiratory problems.

CONCLUSION: While BoNTA is useful in managing spasticity, future studies
need to investigate the factors that can minimize AEs. A better
understanding of the underlying mechanisms of the AEs can also improve
guidelines for BoNTA administration and enhance outcomes.

KEYWORDS: adverse effects; botulinum toxin; dysphagia; muscle weakness;
pain; spasticity; systematic review
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Retro or PeriBulbar Injection Techniques to Reverse Visual
Loss After Filler Injections
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26618464

Dermatol Surg. 2015 Dec;41 Suppl 1:S354-S357.
Retro or PeriBulbar Injection Techniques to Reverse Visual Loss After
Filler Injections.

Carruthers J1, Fagien S, Dolman P.

1*University of British Columbia, Department of Ophthalmology, Vancouver,
Vancouver, British Columbia, Canada †Private Practice, Oculoplastic
Surgery, Boca Raton, Florida.

BACKGROUND: With the increasing popularity of three dimensional filler
treatments, the tip of the injecting needle or cannula is subdermal, often
adjacent to the facial vasculature. Inadvertent canalization of these
vessels can rarely result in vascular occlusion with consequent blindness
or stroke.

OBJECTIVE: The goal was to demonstrate a technique of retro or peribulbar
injection of hyaluronidase should such an emergency arise if no
ophthalmologist was immediately available. The treatment is needed
urgently because the retina can only withstand up to 90 minutes of
hypoxia.

MATERIALS AND METHODS: We present verbal and diagrammatic instructions for
this treatment and videos of both the retrobulbar technique (courtesy of
Dr. D. Maberley) and peribulbar technique (courtesy of Dr. S. Fagien).

RESULTS: None of us have yet used this technique to treat iatrogenic
filler induced blindness but we present the information for the benefit of
patient safety, given the limited time the retina can survive vascular
occlusion.

CONCLUSION: Inadvertent canalization of facial vessels can cause embolic
occlusion of retinal vasculature because of the anastomotic nature of the
facial vasculature and the end artery morphology of the retinal
circulation. Embolism from 3-dimensional hyaluronic acid filler use is
potentially reversible if hyaluronidase is injected into the adjacent
tissue.
__________________________________________________________________
________________________________*_________________________________

8. No Abstract: An Android app for recording hand hygiene observation data
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26601602

J Hosp Infect. 2015 Oct 26. pii: S0195-6701(15)00396-5.

An Android app for recording hand hygiene observation data.

Viswanath SK1, Jie L2, Meng QS2, Yuen C1, Tan TY3.

1Engineering Product Development, Singapore University of Technology and
Design, Singapore.
2Infection Control, Changi General Hospital, Singapore.
3Department of Laboratory Medicine, Changi General Hospital, Singapore.
Electronic address: thean_yen_tan@cgh.com.sg
__________________________________________________________________
________________________________*_________________________________

9. News

– Indonesia: Harsh Drugs Laws, Rising HIV Rates, and Indonesia’s Battle
Over Both

– Russia: Russia HIV infection rate rising as World Aids Day marked

– Philippines: Special Report: Syringe scrimmage (When drugs and Aids
collide)

– California USA: Report Cites Fewer Needles On Sidwalks, But Complaints
About Them Rise

– California USA: Complaints skyrocket over syringes on streets in S.F.

– MA USA: Kindergartner stuck with needle in school garden

– End of daily injections for diabetes as scientists restore insulin
production

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/ot8h4or
Indonesia: Harsh Drugs Laws, Rising HIV Rates, and Indonesia’s Battle Over
Both

By Jonathan Vit, VICE News (02.12.15)

This World AIDS Day, VICE is exploring the state of HIV around the globe.

Watch our special report, “Countdown to Zero,” tonight on HBO at 9pm ET,
and to get involved visit red.org and shop (RED).

Mira Febriyanti shoulders a backpack stuffed with needles as she steps
onto the soft ground of a trash-strewn lot. In the distance, white smoke
rises from a garbage fire smoldering in the afternoon rain.

The Indonesian capital of Jakarta is full of self-contained slum
communities cut off from the walled mansions, Western-style apartments,
and cavernous shopping malls built for the city’s moneyed upper class. In
some, homegrown industries are so pervasive that the slum takes on the air
of a factory town. In Muara Angke, it’s mussels harvested from the
polluted waters of Jakarta Bay. In Mayestik, it’s reams of colorful fabric
sold at the local market.

Here in Kampung Boncos, it’s heroin.

“I’ve met people from everywhere,” Febriyanti says of those lured to the
slum by the drug trade. “The dealers do not only sell drugs during the
day; this lasts until night, even until dawn sometimes. There is always
someone here who is ready to serve you.”

Febriyanti began working here more than a decade ago, handing out clean
needles for Kios Atma Jaya, an HIV/AIDS prevention organization. But she
first arrived in Kampung Boncos for the same reason most outsiders visit
the cramped West Jakarta slum — to buy heroin. That was in the late
nineties, when, Febriyanti explains, used needles sold for less than 10
cents and the bodies of addicts were abandoned in the dump.

“The situation in Boncos was not like it is today,” she says.

She approaches a small crowd of heroin users waiting out the rain beneath
a sagging blue tarp. A young man holds an energetic but dirty kitten in
his lap, while a woman named Anastasya listens to Febriyanti speak.

“It was really bad,” Anastasya says after Febriyanti describes the slum in
years past. “Needles used to be available for rent.”

Febriyanti opens her backpack and begins handing out fresh packages of
sterile needles and rubbing alcohol. Anastasya takes a seat next to an
older woman struggling to find a usable vein in her neck with the help of
a circular pocket mirror decorated with glittery blue hearts.

Anastasya leans over and takes the needle.

“Right here?” she asks, gently tapping the woman’s neck before sticking
the needle in. The woman flinches as Anastasya moves the syringe, but she
eventually pulls the needle out without pushing the plunger, unable to
find a vein.

Neighborhoods like Kampung Boncos form the front lines of Indonesia’s
fight to curb the spread of HIV in a country where new infections continue
to grow at an alarming rate. An estimated 54.4 percent of Jakarta’s
injecting drug users are HIV positive, according to figures released by
the country’s National AIDS Commission.

Nationwide, that figure drops to 36.4 percent, and for years it’s remained
stable — one of Indonesia’s few successes in its battle to curb HIV’s
spread. But the results of an unpublished 2013 survey revealed an apparent
spike in new infections among drug users in three of the country’s
provincial cities — Tangerang, Pontianak, and Yogyakarta — raising
concerns that Indonesia’s HIV prevention programs are starting to crack
under the pressure of the country’s increasingly harsh drug laws.

“This is a worrying trend,” says Kah Sin Cho, Indonesia country director
for UNAIDS. “For a long time, we have thought that the prevalence of HIV
among drug users had started to decline, so this came as a bit of a
surprise.”

Experts cite a variety of factors to explain the spike, including the
central government’s decision sometime around 2007 to begin centralizing
the distribution of clean needles at public health centers known as
puskesmas. It was an attempt to reduce the nation’s dependence on foreign
funding for harm reduction programs, but drug users want little to do with
the health centers.

“[They have] very good intentions,” Cho says. “But part of the problem
with distributing needles in the puskesmas is that drug users have to go
to puskesmas… and health personnel are not necessarily seen as very
friendly or very sympathetic toward drug users.”

Organizations like Kios are attempting to fill the gap by collecting clean
needles from the centers and distributing them. But in some cities, that
can get you thrown in jail.

“Here we have a really effective tool for reducing HIV transmission among
drug users,” Cho says, “but at the same time, people hesitate to carry
them around because they know they will be subject to arrest if they are
found with needles.”

Indonesia suffered a 427 percent increase in reported AIDS-related deaths
between 2005 and 2013, according to UNAIDS. (For comparison, during the
same years, AIDS-related deaths dropped 56 percent in Thailand.) In 2014,
UNAIDS warned the Indonesian government that the country was being “left
behind” in the fight to contain the virus after researchers discovered a
48 percent increase in new infections. Indonesia’s then–health minister
Nafsiah Mboi responded by saying UNAIDS lacked an understanding of the
country.

Today, the Ministry of Health is expanding HIV testing programs, a
herculean task in a country of 250 million people living on 13,000 islands
spread across an area roughly as wide as the United States. As HIV testing
facilities open their doors, health officials routinely discover new
populations beset by the virus. In the remote region of Papua, for
instance, the government has struggled to contain an isolated epidemic
where infection rates have climbed to 200 times the national average,
affecting an estimated 86,000, according to UNAIDS.

The country’s current health minister, Nila Moeloek, is now promoting
abstinence and condom use as effective barriers to HIV transmission — but
she has yet to directly address the rise in new infections among drug
users. President Joko Widodo has doubled down on the country’s already
harsh drug laws since taking office last year, declaring that the nation
was facing a “drug emergency” before resuming executions for convicted
drug traffickers. In his first year in office, Widodo ordered the
execution of 14 people, most of them foreigners, over drug trafficking
offenses. The country’s drug executions have now been put on hold as the
government focuses on boosting Indonesia’s sluggish economic growth.

Widodo claims about 50 people die of drug use in Indonesia every day and
has warned that as many as 18,000 people may die by the year’s end. Those
figures have been repeatedly reported as fact by domestic media, despite
evidence presented by academics that Widodo’s numbers are exaggerations.

The president also ordered the National Narcotics Agency (BNN) to
dramatically increase the number of users in the country’s rehabilitation
programs. The agency wants to be placing 400,000 drug users a year into
rehab by 2017, and ultimately, in effect, the BNN wants to force every
drug user in Indonesia, from recreational marijuana smokers to long-term
heroin addicts, into treatment.

“In Indonesia, there are 4 million drug addicts,” the BNN’s spokesman said
earlier this year. “So if we rehabilitate 400,000 addicts a year, then in
10 years our work will be done.”

The BNN has been conducting sweeps in open-air drug markets, private
homes, hotel rooms, and even entire apartment buildings, forcing residents
to submit urine samples in a push to meet a presidential quota of 100,000
new patients in drug treatment facilities by the end of 2015. Meanwhile,
the BNN’s new chief continues to float controversial ideas, like a plan to
build an island prison for drug traffickers that is surrounded by
crocodiles, tigers, and piranha.

Harm reduction organizations warn that the kind of aggressive policing
that’s become the norm under Widodo may further undermine the country’s
fight against HIV — something already happening in the city of Tangerang.

The Greater Jakarta area is a geographical grouping of five cities and
their associated districts that is home to some 30 million people.
Indonesians call the metro area “Jabodetabek,” a portmanteau of city names
that grows longer as the capital’s suburbs expand. Tangerang, one of those
cities, is the manufacturing hub of Java, home to more than 1,000
factories that make everything from yarn to Toyotas.

About 2 million people live in Tangerang, where HIV rates among
intravenous drug users are on the rise. The city lacks the open-air drug
markets of Jakarta because, locals say, the city’s conservative residents
and strict police force won’t allow it. So heroin users cop in
neighborhoods like Kampung Boncos, a 30-minute bus ride away.

Kios runs a branch office in Tangerang in a quiet residential neighborhood
off one of the main roads. A white sign hangs above the front gate,
informing visitors in pink letters that the modest stucco house is an
“HIV-AIDS Information and Service Center.” A man named Afriano greets
visitors in jeans and a dark gray t-shirt. In his office, I ask if it’s
safe for the drug users who seek access to clean needles.

“Is it safe? Of course it’s not — they still have to deal with the
police,” Afriano says. “Even at the several clinics that offer methadone,
drug users are still detained by the police to be interrogated.”

Law enforcement in Tangerang is less tolerant than police in the capital,
he says, so the fear of getting caught with drugs or a needle is quite
high. Still, in Tangerang, the government allows Kios to operate in the
open. A few miles away, in the city of South Tangerang, the needle
exchange program is banned outright.

“These policies are one of the reasons why HIV increased here,” Afriano
says. “If there are difficulties finding needles, [heroin users] will
share the needles instead. They don’t care what type of disease they might
catch. What they know is, ‘I need to get high. I have the package. I want
to inject drugs.'”

TOPICS: indonesia, health, drugs, aids, hiv, heroin, kampung boncos, kios
atma jaya, unaids, jakarta, asia & pacific, nila moeloek, joko widodo
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https://tinyurl.com/ja9aye6
Russia: Russia HIV infection rate rising as World Aids Day marked

By Tribune wire reports, Chicago Tribune, Chicago IL USA (01.12.15)

World AIDS Day is observed every December 1st with calls from
international health and advocacy organizations for the public to get
involved in programs for awareness, prevention and treatment of HIV/AIDS.
The number of HIV-positive people with access to AIDS medicines has jumped
to 41 percent in the past five years, the United Nations said.

On a frigid evening on the outskirts of Moscow, two HIV-prevention
activists unzip backpacks, pull out packs of hypodermic needles and start
discretely approaching people leaving a nearby pharmacy with an offer that
could save their lives.

One man, cheeks sunken and behavior jittery, takes a plastic bag full of
needles, a tube of ointment for sores and a pamphlet of material about
disease prevention. “Thank you,” he says, quickly making eye contact
before hurrying away.

While the rate of HIV infection is on a global decline as World AIDS Day
is marked Tuesday, the number of new infections in Russia continues to
rise. By 2016, the country’s Federal AIDS Center estimates the total
number of those diagnosed with HIV will reach 1 million. The majority of
new infections occur among injecting drug users when dirty needles are
shared.

So-called harm reduction programs — which distribute clean needles and
condoms as well as provide methadone substitution therapy — are shown to
reduce the spread of diseases such as HIV. But the Russian government has
refused to fund such initiatives, saying this approach to treatment
enables addicts to continue living their dangerous lifestyle.

Activists have tried to bridge the gap.

“We know we can’t reach everyone and you can’t force anyone to stop using,
but at least this provides the tools people need to reduce the spread of
diseases,” said Lena Groznova, who has been participating in the Andrey
Rylkov Foundation’s outreach program for the past three years. The
foundation’s activists are out nearly every day in Moscow, waiting around
pharmacies that sell non-prescription eye drops used to enhance the effect
of opiates.

Though such clean needle distribution programs are allowed to operate, a
decline in international funding severely limits the scope of their
activity.

In 2009, Russia was supposed to take over the work of one of the major HIV
prevention and treatment donors, the Global Fund to Fight AIDS
Tuberculosis and Malaria, which operates exclusively in low-income
countries and no longer considers Russia eligible based on this criterion.

“We assumed that the government was picking up all the pieces and taking
over the treatment component for all of the people in need. However, the
treatment that was being done by the community was not being supported by
the government,” Nicolas Cantau, the Global Fund project manager for
Eastern Europe and Central Asia, told The Associated Press. “We were all
taken by surprise.”

After learning Russia would no longer fund grassroots outreach
organizations, the Global Fund decided to continue its work within Russia,
but with a fraction of the previous budget. As a result, only 4,300 people
have received anti-retroviral drugs this year, compared to 66,000 people
in 2009 who had access to the HIV medication with the help of Global Fund
aid money. The Fund has again made plans to leave Russia by the end of
2017.

Approximately 30 percent of Russians in need of anti-retroviral drugs
currently do not have access to them, according to the Health Ministry.

The U.S. Agency for International Development and the Open Society
Foundation, which collectively sponsored over 200 organizations working
with HIV, were both forced out of Russia in 2012.

Methadone substitution therapy is widely used globally to wean addicts off
intravenous drugs. In Russia, however, the outdated “cold turkey” method
is the only available rehabilitation route for addicts; distributing
methadone can bring a prison sentence of up to 20 years.

In neighboring Ukraine, whose HIV epidemic has mirrored Russia’s,
methadone therapy is legal and increasingly prevalent. After years of
rapid growth in infection rates, the number of new HIV infections among
drug injectors was down in 2013 by 33 percent, according to the HIV/ AIDS
Alliance of Ukraine, a decline that has largely been attributed to the
introduction of methadone therapy.

Crimea is frequently cited as an example of what happens when methadone
therapy is suddenly made unavailable. After the Ukrainian peninsula was
annexed by Russia in March 2014 and methadone became illegal, an estimated
80 to 100 of its 12,000 HIV-positive residents died from suicide and
overdose, according to UNAIDS.

“Russia decided to come up with its own plan to deal with its drug
problem, but 15 years have passed and there is no alternative plan,” said
Vadim Pokrovsky, the head of the Federal AIDS Center in Moscow, who
diagnosed the first HIV case in the Soviet Union in 1987.

In October, Russia announced it would double spending on HIV care and
prevention next year to $600 million.

Maxim Malyshev, who runs a clean needle distribution program with the
Rylkov Foundation, is skeptical that the increase in government funding
will have much positive effect.

“Look at what they are currently doing with their budget. Will we get more
signs on the metro telling us HIV doesn’t occur in monogamous
relationships?” Malyshev said, referring to a current public information
campaign on the Moscow subway. The signs read: “Love and loyalty to your
partner is your protection from AIDS” and “HIV isn’t transferred through
friendship.”

Bishop Methodius runs purity education programs at Russian Orthodox
Churches, advocating a wholesome life to protect against HIV infection.
“For us, the lessons of chastity are more important than sexual
education,” he said.

Sexual education programs in schools, also widely believed to slow the
spread of HIV, have also been shot down by conservative government
officials who say they promote sexual activity among children.

“I am often asked: When will you have sex education? I say never,” Pavel
Astakhov, the president’s children’s rights commissioner, said at a press
conference last year. Astakhov has also famously remarked that the best
sex education is Russian literature.

“For the last 20 years of the HIV epidemic that I’ve been involved in the
Russian Federation, there was this sense that the epidemic doesn’t affect
me. It doesn’t affect the average Russian. It only affects marginalized
groups like injecting drug users and therefore is not something that is
relevant or of concern for Russian society, or the average Russian
person,” Vinay Saldanha, the director of the UNAIDS Regional Support Team
for Eastern Europe and Central Asia, told the AP.

Saldanha, however, is hopeful that Prime Minister Dmitry Medvedev’s recent
remarks on the scale of the HIV epidemic in Russia could signal a change
in the way the illness is perceived at the upper levels of the Russian
government.

Malyshev was a bit more cautious about what the future might have in store
for HIV activists.

“I’ve stopped making predictions,” he said. “There have been too many
surprises in the past 20 years.”

Associated Press

Copyright © 2015, Chicago Tribune
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https://tinyurl.com/og6ucb2
Philippines: Special Report: Syringe scrimmage (When drugs and Aids
collide)

By Cherry Ann T. Lim, Sun.Star, Philippines (01.12.15)

Giving syringes to drug users to stop spread of HIV prickly issue

[Photo] CEBU. Dr. Alice Utlang, executive director of the Cebu City Office
for Substance Abuse Prevention, gestures as she criticizes the Cebu City
Health Department’s program to give syringes and needles to injecting drug
users to prevent the spread of the human immunodeficiency virus (HIV). “My
office is here preventing drug use, while it’s as if the other office is
encouraging drug use.” (Sun.Star Foto/Arni Aclao)

[Photo] CEBU. This message on a wall in Cebu City encourages people who
inject drugs not to share needles. It was part of a campaign under the
“HIV/Aids Prevention in the Philippines: Reaching Out to Most-at-Risk
Populations” project to stop the spread of the human immunodeficiency
virus (HIV) among injecting drug users. Other messages on posters, like
“<i>Kung adunay HIV, ang tambal libre. Pa-test na!</i> (If you have HIV,
medicine is free. Get tested now!)” were not as subtle. (Sun.Star
Foto/Arni Aclao)

IN EARLY 2014, Dr. Alice Utlang started work at the Cebu City Office for
Substance Abuse Prevention (Cosap) at the Cebu City Health Department
building.

A curious sight immediately met Cosap’s new executive director: the long
line of people outside the CebuPlus Association Inc. office close by.
CebuPlus works with the City Health Department to prevent the spread of
the human immunodeficiency virus (HIV).

“Since 2010, the City Health Department has been giving syringes to drug
users. I knew some of those lining up, private butchers from Barangay
Lorega,” said Utlang, a former city veterinarian. “I asked them, ‘You have
no plan to stop (using drugs)?’ I interviewed them one by one. Some of
those lining up were not even users. They would just sell the syringes for
P20 to drug users.”

She raised her complaint to the Cebu City Anti-Drug Abuse Council (Cadac).
“Di ko kampante. (I’m concerned.) My office is here preventing drug use,
while it’s as if the other office is encouraging drug use,” Utlang said of
the Cebu City Health Department’s (CHD) program to give clean needles and
syringes to injecting drug users for free to prevent the spread of HIV.
HIV is transmitted through sexual contact, needle sharing among injecting
drug users, transfusion of infected blood products, and mother-to-child
transmission.

In 2010, more than half of Cebu City’s injecting drug users (IDUs) were
found to be infected with HIV, the virus that causes Acquired
Immunodeficiency Syndrome (Aids).

This, amid the high rate of syringe- needle sharing, with up to 10 people
sharing a syringe to save on costs.

Following Cadac’s objection, “City Health temporarily stopped the
distribution—but only because they transferred it. They opened a
distribution center in Kamagayan. It was in the barangay hall,” Utlang
said.

Haven

Barangay Kamagayan is a haven for drug users. In Cebu Province, 81 percent
of male IDUs used a shooting gallery in Kamagayan as their usual venue for
injection. Ten percent used their own house; five percent, a hangout in
Mandaue City; three percent, another IDU’s house, the Department of
Health’s (DOH) 2013 Integrated HIV Behavioral and Serologic Surveillance
(IHBSS) found.

For Cebu City residents, 85 percent of male IDUs and 73 percent of female
IDUs frequented the Kamagayan shooting gallery.

Research

The Kamagayan project was to have been a two-year operations research of
the DOH, Philippine National Aids Council, the Cebu City government and
Population Services International. Among the aims of the free syringe
distribution program in Kamagayan was to reduce the number of blood-borne
diseases like hepatitis C and HIV.

On Oct. 8, 2014, the Dangerous Drugs Board (DDB), through Board Resolution
298, approved the “scientific and medical study” funded by the World Bank
and Asian Development Bank. Aside from needle and syringe distribution,
the study components included counseling on HIV, counseling on drug abuse,
medical services and psycho-social care.

But on hearing of the project, Sen. Vicente Sotto III in a privilege
speech last May 11 said the DDB resolution was in conflict with Section 12
of Republic Act 9165, the Comprehensive Dangerous Drugs Act of 2002, that
prohibits possession of paraphernalia for dangerous drugs.

The DDB had declared the village a safe zone from arrests in relation to
Section 12 insofar as IDU participants and village health personnel in the
needle-syringe exchange program were concerned.

Sotto said the DDB also could not allow any agency to conduct studies for
HIV/Aids prevention, as it is empowered to conduct or support studies for
“drug prevention and control” only, which the DOH’s research was not, as
it even “sabotages the government’s campaign for drug prevention.”
Senior Supt. Pablo Labra II, Police Regional Office 7 intelligence
division chief, agreed that syringe distribution could worsen the drug
problem and opposed it as well.

“We stopped the needle and syringe distribution in the Kamagayan barangay
hall last May,” said Dr. Ilya Tac-an, head of the CHD’s Social Hygiene
Clinic. “But HIV and drug counseling continue there.”

On non-drug users getting the syringes, she said the stigma of being a
drug user prevented some from showing up to get the free needles, so
“there’s a chance that in the early days we arranged with those living
there so we could have access (to the drug users). But we discourage
selling of the needles.”

“When we gave needles, we got blood samples also when we registered them,
so we know that some of those resellers were also users,” she added.

Rehab better

Cosap’s Utlang said the money spent for the syringes should have been used
to rehabilitate the addicts instead.

She said rehab at a government facility costs just P6,000 a month. Or it
could be just P3,000, as the other P3,000 is just “a deposit at the
canteen if you buy something there.”

CebuPlus executive director Jerson See said some P6 million worth of
syringes was bought for the program.

The DOH undertook the harm reduction program after the Cebu City HIV/Aids
Registry showed that the main mode of HIV transmission in Cebu City had
shifted from sexual contact in 2008 to injecting drug use in 2010.
From January 1984 to August 2015, 99 percent of the 1,247 people who got
HIV through injecting drug use in the country were from Central Visayas,
the bulk of them from Cebu City.

Many users

There are an estimated 2,500 injecting drug users in Cebu City.
After testing 2,000 IDUs, the CHD found 1,050 positive for HIV.
“But some of these are from outside Cebu City. They just came to Cebu City
because in the past, there was no testing in their cities,” said Tac-an.
Only recently has HIV testing been made available in Talisay, Danao,
Mandaue and Lapu-Lapu cities.

Metro Cebu (Mandaue, Lapu-Lapu, Talisay, Cebu cities and Consolacion town)
is estimated to have 5,000 IDUs, she said.

For the entire Cebu province, See said the estimate was 6,000 IDUs in
2013.

Asked why practically all who got HIV by injecting drugs were from Central
Visayas, Tac-an said, “Other sites in the country did not access their
IDUs.”

She said Cebu and Quezon cities started surveillance of IDUs in 1993.
Thereafter, only three sites consistently reached the 300 target sample
size needed.

“Only Cebu, General Santos and Zamboanga continued their surveillance of
IDUs,” she said.

More than 90 percent of IDUs in Cebu City use Nalbuphine (generic name of
Nubain).

Mobile

Recognizing that clients are mobile, the DOH supported a tri-city program
targeted at IDUs in Cebu and males having sex with males (MSM) in Quezon
City.

The “HIV/Aids Prevention in the Philippines: Reaching Out to Most-at-Risk
Populations,” a three-year project of the United States Agency for
International Development, ended in September. It aimed to provide
services for IDUs in the social hygiene clinics of Cebu, Lapu-Lapu and
Mandaue cities, and to reach 80 percent of the key MSM and IDU
populations.

It strengthened peer education to motivate HIV counseling and testing, and
the use of prevention commodities (meaning it distributed
syringes/needles, condoms and lubricants). It also improved case
management to increase treatment initiation, retention and adherence.
The goal was to maintain national HIV prevalence in the general population
at less than one percent, in accordance with the 2011-2016 Aids Medium-
Term Plan, and to keep the HIV prevalence among IDUs in the tri-city area
below 58 percent in 2015.

The target was met, its March 2015 report said. HIV prevalence was at 51.5
percent among male IDUs in Cebu City, 32.4 percent among female IDUs in
Cebu City, and 35 percent for male IDUs in Mandaue City, using the 2013
IHBSS figure as the accomplishment figure.
The 2011 IHBSS figures were 53.8 percent for Cebu City and 3.6 percent for
Mandaue, meaning the cases in Mandaue grew. No figures were given for
Lapu-Lapu.

The report said “needle-syringe distribution was halted periodically
because of legal issues,” and that the Mandaue City Health Office had had
“reservations about implementing a needle-syringe program.”

Even the innocent

Harm reduction helps not just the IDUs.

“Some females have partners who are HIV-positive IDUs, so they were
infected by their IDU partners,” said See of CebuPlus. “Their babies may
be HIV positive.”

“In Cebu City, there’s already a two-year-old and a nine-year-old born
with HIV. If we don’t respond to this, more women and children will become
HIV positive,” he said.

“The problem is more of the sex partners of the IDUs since we don’t see
them,” Tac-an said. “Most likely, the other IDUs already have HIV, so we
have been able to reach them. But the sex partners appear only when they
are pregnant because there is a pre-natal checkup. That’s the time we
encourage them to go for testing for HIV, hepatitis B and syphilis. This
is free.”

But logistical limitations hamper testing. “We have satellite laboratories
in only six barangays. We encourage that at the first pre-natal they get
tested for HIV. But if there is no lab, they are referred to another
barangay for the blood test,” she said.

Long before

Unknown to many, syringe distribution in Cebu City began not in 2010 but
in 1993.

“Since the 1990s, one non-government organization had been giving syringes
to IDUs in partnership with the Cebu City Health Department. All the
projects ended in 2009,” Tac-an said. “In late 2009, the CHD saw a spike
in HIV cases among IDUs. That’s why the department stepped in to continue
syringe distribution in 2010.”

From 1996 to 2009, the HIV prevalence among Cebu City IDUs was less than
one percent. This jumped to 53 percent in 2010, then 53.3 percent in 2011.
She said the low HIV prevalence in the years syringes were distributed
shows that harm reduction prevents the spread of HIV.

Malaria outbreak

What first alerted health officials to the risks injecting drug use posed
on public health was a 1992 malaria outbreak among IDUs in Cebu, a non-
malarial area, Tac-an said in an interview with the World Health
Organization (WHO) Representative Office-Philippines. They later
discovered that it was not mosquitoes, but needle sharing by drug users,
that spread the malaria.

Another blood-borne disease, hepatitis C, was also rampant in the IDUs,
showing the risks needle sharing posed on the spread of other blood-borne
diseases like HIV.

Tac-an told the WHO that almost 95 percent of Cebu City’s IDUs have
hepatitis C, not a surprise considering “needle-sharing is so common but
safe needle exchange is not widely practiced, plus it is criminalized.”

To show how widespread HIV is among the city’s IDUs, she told Sun.Star:

“The Kamagayan study was approved by the DDB in October 2014. The research
required a sample size of 400 HIV negative people so we could see if with
intervention, we could maintain their negative status. But it took us a
long time to find 400 HIV negative IDUs because so many of the IDUs were
positive. We got the 400 in January 2015 only. Because so many were HIV
positive, we had to test a lot of people.”

Rehab blues

In Kamagayan, part of the study was to give six slots for free for
rehabilitation at the New Horizon Treatment and Rehabilitation Center in
Argao town.

“In less than a year, we already got six people to agree to go to rehab,”
Tac-an said. “There is also counseling on the harmful effects of drugs.”
Cosap’s Utlang was not impressed. She said, “Since the (drug users) were
already there, they should have rehabilitated them.”

Tac-an, however, said: “Some (IDUs) say, ‘We have no money’ for rehab.
Others say they’ve gone to rehab three times already—meaning rehab won’t
work, especially if you did not go there voluntarily.”

While there have been cases of successful rehabilitation, she said some
people would also say “there is no cure for drug addiction. You just say
you have been drug-free for (this number of) days or years.”

Most of the time, those who succeeded were those who left the place they
lived, the place that enabled their addiction, she said.

A long-time volunteer in Kamagayan’s efforts to rid itself of the drug
haven tag, who asked not to be named, said many parents of the more well-
off drug addicts had sent the police to Kamagayan multiple times to arrest
their children when they went there to buy drugs. But six months later,
after their stint in rehab, the addicts usually returned to Kamagayan to
get their fix again.

Not free

“The problem with drug rehabilitation is that Cebu doesn’t have free
treatment,” See of CebuPlus said. “It will cost more than P50,000 per
person. And all rehab centers are already full. There are 2,500 IDUs in
Cebu City alone. How will you (accommodate) all these in the facilities?
We need a multi-sectoral solution.”

Utlang admitted that 60 addicts are still waiting to get into the
government-run Argao facility. She also said treatment in a private drug
rehabilitation center will cost P18,000 to P45,000 a month. “It’s
expensive because it includes accommodation and aircon. And depending on
the assessment of your case, they might give you (medication to help you
withdraw from your addiction).”

Education

CebuPlus does not condone drug abuse.

“It’s not like we’re tolerating drug use. But if we don’t give it
(syringe) to them, they will still buy it. The cost of syringes is (only)
P10-P15. The drug is P20-P30. It’s like giving condoms. Whether you give
these or not, people will still have sex,” See said.

He said there is also more to the Kamagayan project than needle and
syringe distribution. “Education includes disposal of needles. They should
bring their (used needles) to the center” for proper disposal.

He said this way drug users would not just throw their needles anywhere,
where children could pick them up and get pricked.

The 2013 IHBSS found that half of Cebu and Mandaue IDUs threw their
needles and syringes in public trash bins, where in theory they could be
found and reused by others.

From January 2016, CebuPlus will sustain the Kamagayan Comprehensive Care
Center on the fourth and fifth floors of the Kamagayan Barangay Hall.
“The center provides testing, education, counseling and health services,
even for regular diseases, even wound care only, not only HIV,” See said.
It is focused on IDUs.

The long-time volunteer said village officials also did not support drug
use.

In fact, he said, some drug users got angry on going to the barangay hall
for the free syringes when they were arrested for carrying ampules or
syringes that still had small amounts of illegal drugs inside. The
syringes should have been empty because possession of dangerous drugs is
illegal. The users are checked before they go up to the center.

Global state

According to the 2014 Global State of Harm Reduction (GSHR), 90 countries
and territories had needle and syringe exchange programs (NSP), among them
Brazil, Australia, Germany, China, Indonesia, Malaysia, Thailand and
Vietnam. It said NSP was available in prisons in eight countries.

In its 2007 “Guide to starting and managing needle and syringe programs,”
the WHO said a punitive approach “based overly on criminal justice
measures succeeds only in driving underground those people most in need of
prevention and care services.”

Last year, the WHO recommended “decriminalizing drug use to enable a
supportive environment for key (at-risk) populations,” the GSHR said.
To allay fears that harm reduction will encourage intravenous drug use,
the 2012 policy brief “Unsafe injecting drug use, a growing source of HIV
transmission in the Philippines: Implications to policy” cited studies in
the United States in 2002, Asia in 2007, and Europe in 2012 showing that
making clean syringes and needles available to IDUs “does not lead to an
increase in drug use in general, nor to intravenous injection, in
particular.”

The programs also brought drug dependents into contact with helping
agencies, “often resulting in better monitoring, care and treatment,” it
said.

The Kamagayan volunteer confirmed that the giving of syringes did not
result in the drug users shooting drugs more often than their usual five
to eight times a day. But he said that sometimes, after using the clean
needles, the poorer drug users, like jeepney dispatchers, passed these on
to others. The educated and more affluent addicts, however, kept their
needles to themselves.

Out of reach

CHD’s Tac-an showed the difficulty of reaching and maintaining contact
with IDUs. For instance, only half of male IDUs tested for HIV in Cebu
City got their results, the 2013 IHBSS showed.

“Most IDUs don’t give their contact numbers because they don’t have a cell
phone,” Tac-an said. “If they had a cell phone, they had already pawned it
(to buy drugs). They changed their number, so we just try to look for the
peer educator (fellow IDU) who referred them to us.”

Results are available the day after testing, but she said due to the
distance or lack of fare money, some people don’t return until months
later. This means in the interim, those with HIV and didn’t know it could
have infected others.

In the past, since the distribution of the needles and syringes was
weekly, the drug addicts came often. “We gave them an incentive to come,
plete (fare money), snacks, tag (just) P10 ra gud,” she said. “Then we
could monitor whether they had already started on their medication.”

In the end, the fate of the needle and syringe exchange program will hinge
on whether drug users should be considered criminals or medical patients.
Tac-an told the WHO, “The health of all citizens must be a priority,” and
that public officials would not be working at cross-purposes if health
officials focused on harm reduction for drug users while law enforcers
addressed drug trafficking.

(Second of three parts)
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http://sfist.com/2015/11/30/report_streets_cleaned_up_their_act.php
California USA: Report Cites Fewer Needles On Sidwalks, But Complaints
About Them Rise Anyway

By Caleb Pershan, SFist, SAn Francisco CA USA (30.11.15)

A report evaluating 184 routes through San Francisco between July 1, 2014
and June 30, 2015 shared with the Examiner shows more streets free from
debris and detritus “which pose the greatest risk to safety and
wellbeing.” Now, to what could that possibly refer? Did you have to ask?
Do you want to know?

The big three are feces, needles, and condoms, and residential streets
free from them in San Francisco are up 11 percent. Clean commercial
streets are also up by 7 percent in the annual Street and Sidewalk
Maintenance Standards report, which isn’t yet available online. The
document historically maintains that “there is zero tolerance for feces,
needles, and condoms — 100 percent of sidewalks need to be free of these
to pass the standard,” and while the current 69 percent residential street
pass rate and 62 percent rate for commercial streets isn’t perfect, it’s a
marked improvement.

But it’s not enough to satisfy San Franciscans who are registering more
complaints and disgust than ever with the City. Specifically, the
Chronicle points to a drastic uptick in such grievances in the recent
past, particularly during the past year. While complaints regarding
needles numbered 440 in 2012, so far this year there have been at least
2,565.

What gives? Are we finally fed up? Are we clutching our pearls a bit too
tightly? The movements of gentrification could be responsible for the
disconnect, in part, with both needle users and San Franciscans new to
certain locations. Put another way, the theory goes that gentrification
has pushed needle users and non-needle users, perhaps some new to the city
and city life altogether, into contact in different places, resulting in
alarm and complaint.

Another factor the Chronicle cites is the shift in the city’s needle
policy. We’ve gone, in title and practice, from “needle exchange” to
“syringe access.” What was once a one-for-one program that encouraged
users to turn in dirty needles has, for health reasons, been eliminated.

Says Public Health Department spokeswoman Rachael Kagan, “you don’t need a
needle to get a needle.” That’s because, in order to reduce transmission
rates, addicts shouldn’t be sharing needles. Needle-sharing, the
Department claims, is a behavior bolstered by one-for-one supply
limitations.

In terms of neighborhoods, the Tenderloin and Chinatown were found to have
the greatest quantity of the big three. Broken glass, another hazard, was
down across the city by a bit less than syringes, condoms, and feces.
There were 3 percent fewer incidents of glass on commercial streets and 8
percent fewer on residential sidewalks.
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https://tinyurl.com/jpv5gqb
SF California USA: Complaints skyrocket over syringes on streets in S.F.

By Debra J.Saunders & Kevin Fagan, San Francisco Chronicle USA (30.11.15)

[Photo] Department of Public Works labor worker, Tai Auimatagi, collects a
dirty needle from a fountain, at UN Plaza, in San Francisco, California on
Friday, November 20, 2015. He says when he arrives at work, the first
thing he does is get rid of the used needles. Photo: Gabrielle Lurie,
Special To The Chronicle

There’s little in life that Amos Howard resents more than used needles in
the street.

He’s 60, and the street is where he sleeps in San Francisco. So he spends
a good portion of each day picking up dirty syringes with thick gloves so
he doesn’t get pricked when he sits or lies down.

THE LITTERED STREETS OF S.F.

Bernard Sices (left), an employee of the San Francisco Public Works
Department’s “alley crew”, helps homeless people move their belongings so
his crew can clean the sidewalk at an encampment at 8th and Brannan
Streets in San Francisco, California, on Wednesday, July 1, 2015.

The alley crew visits homeless encampments on a daily basis to disinfect
the ground and haul away refuse. S.F. faces increasing pressure to clean
sidewalks as city grows Pharmacist Gantt Galloway shows patients and staff
members the a syringe kits filled with needles and Naloxone, Friday
February 21, 2014, in Lafayette, Calif.

A Bay Area lawmaker is proposing to extend the state’s syringe access
program by allowing pharmacists to sell an unlimited number of clean
needles without prescriptions.

Program’s end reopens debate on clean needles for drug users Activity on
Duboce Avenue behind the Safeway store in the Duboce Triangle neighborhood
in San Francisco, Calif. on Thursday, August 21, 2014. Duboce Triangle
neighborhood getting scary with drugs, violence

He says he’s seen more needles lately. So do a lot of people. The number
of complaints to the city about discarded needles has skyrocketed in the
past couple of years — and although San Francisco has the largest program
in the nation for handing out free, clean needles to drug addicts, a quiet
policy change has evolved over the past decade that may be contributing to
that rise in complaints.

San Francisco no longer requires that addicts turn in a dirty needle for
every clean needle they receive at city programs. In fact, since 2008, the
practice has been termed “syringe access” rather than “needle exchange” —
the same change that has occurred at handout programs across the country.

Now, said San Francisco’s Public Health Department spokeswoman, Rachael
Kagan, “you don’t need a needle to get a needle.”

More addicts

If they can get a clean needle without having to make a one-for-one trade,
addicts are far less likely to share syringes, thereby reducing the
transmission of HIV, hepatitis C and deadly staph infections, program
managers say. Encouraging clean-needle use has become especially urgent in
San Francisco, where health department figures show the number of
intravenous drug addicts has ballooned 46 percent since 2007, to 22,000.
Officials attribute at least part of the increase to a growing use here
and nationwide of methamphetamine and heroin.

A side-effect of the policy shift, however, is that addicts have less
reason to bundle up their dirty needles to tote them in for exchange. San
Francisco has tried to compensate by making needle-disposal “sharps” boxes
more readily available in pharmacies and restrooms and on street-cleaning
trucks, and by conducting aggressive cleanup sweeps.

But by some people’s accounts, it’s not working. According to the city’s
311 portal, which records citizen complaints, reports of used needles
littering the streets and parks soared from 440 in all of 2012 to 2,565
this year through Nov. 19.

City workers say much of this can be explained by gentrification pushing
street addicts into neighborhoods that didn’t see them as much before —
particularly in the Mission District. But not all of it.

More on the street

Mario Montoya, a longtime Public Works Department supervisor, picked up
100 or so discarded needles the other day at United Nations Plaza — what
he called a normal haul.

“Just in the last few years, I’d say it’s gone up 30 percent,” Montoya
said. Homeless displacement and touchy newcomers doubtless account for
part of the rise, he added, “but I’d have to say, that could be from a lot
more folks out here doing drugs. Because I also see that.”

Assessing the causes of needle litter is difficult because statistical
examination of the subject is thin.

The San Francisco AIDS Foundation is paid $1.7 million by the city to
distribute about 2.4 million clean needles each year, and there is no
tally of how many are turned back in to the city or the sharps boxes.
Although the city health department is working on a way to count dirty
syringes, for now it’s guesswork.

Meanwhile, even homeless people like Howard are concerned enough about the
proliferation of dirty needles to pitch in.

“I despise anyone who throws their needles in the street, and I let them
know it,” Howard said one recent afternoon, glaring at a pair of
methamphetamine addicts lying on the sidewalk at South Van Ness Avenue and
16th Street. “I do not want to sleep on them, I don’t want a child
stepping on them. And fortunately, the DPW (Department of Public Works)
guys are very good about working with us.”

Addicts’ arrangement

As he spoke, city street cleaner Juan Venegas was scouring the gutter for
syringes. Like most of his colleagues in needle-heavy areas such as the
Mission, he has agreements with addicts in the street camps that they will
leave used syringes at certain spots for him — in his case, at the base of
a tree and at the foot of a wall.

“Junkies are regular human beings,” Venegas said, poking the dirt with a
pair of pickup tongs. “They don’t want to be around used needles, but some
get neglectful. So we pick them up. I tell them where to leave them, and
they do. Most of them, anyway.”

One of the meth addicts Howard glared at, Orelia Slinky, 43, said leaving
dirty needles lying around was “not cool. It would be nice if they took
all the dirty ones back when we got clean ones.”

She and her boyfriend said they try to bundle their used syringes into
water bottles or sacks and leave them for street cleaners or take them to
drop boxes.

Such diligence is not universal. Take, for example, a young man who
identified himself only as “Junkie Jim.”

Jim sat on a box at on Folsom Street south of 17th Street the other
afternoon, shot a load of methamphetamine into his well-tracked arm and
tossed the syringe into the gutter. Another half-dozen needles lay
scattered nearby.

“Hey man, I didn’t sleep last night, and I’ve been sick,” he said when
asked why he didn’t stow the needle. “I usually try to turn ’em in, but
today …” He shrugged.

Photo: Santiago Mejia, Special To The Chronicle Photo: Santiago Mejia,
Special To The Chronicle A man passes the San Francisco AIDS Foundation’s
needle exchange program. More than 2 million clean needles are distributed
in the city through what are now called syringe access programs, but there
is no tally of how many are turned back in to the city.

Changing the rules

San Francisco has funded a needle-exchange program to prevent the spread
of disease among drug users since 1993. But gradually, with little or no
public debate — none was required — the organizations that run the syringe
dispensaries ended the exchange requirement.

Some officials acted after a landmark study by the National Institutes of
Health in 2007 found that most addicts properly disposed of syringes even
if they weren’t required to trade one-for-one. But many agencies, from New
Jersey to Los Angeles, were evolving toward the change anyway based on
experience.

Locally, Alameda County still aims for a one-for-one trade, but doesn’t
require it. Contra Costa County still demands a one-for-one exchange, but
that’s because it is not as densely populated with intravenous drug
abusers, officials said.

“San Francisco’s technique is good for that city, and the fact is that
every location examines and adapts their practices for what works for
them,” said Obiel Leyva, a needle exchange and education manager for
Contra Costa County. “Not requiring one-for-one exchange is probably more
prevalent in the heavily impacted urban areas.”

Dirty needles are strewn across the ground at United Nations Plaza in San
Francisco, where the Department of Public Works finds at least 100 needles
a day. Photo: Gabrielle Lurie, Special To The Chronicle Photo: Gabrielle
Lurie, Special To The Chronicle Dirty needles are strewn across the ground
at United Nations Plaza in San Francisco, where the Department of Public
Works finds at least 100 needles a day.
Making it easy

San Francisco makes it as easy as possible for users to get a clean needle
without turning in a used one.

For instance, a handout flyer at a city syringe access center at Sixth and
Mission streets directs people to a nearby facility on Market Street if
the office is closed. “Just say hello to the folks at the desk and let
them know what size — longs, shorts, micros, 29’s or bee stingers & they
will bring syringes & all the supplies to you in a discreet plain brown
bag,” the flyer reads.

At the Market Street facility, users can obtain a “starter kit” — 20
needles, alcohol swabs, cotton balls and other items. A staffer also hands
out a small biohazard bin for safe needle disposal. No swap of dirty
needles is required.

In fact, the Market Street outlet won’t even accept used needles. “We
don’t take returns at this location — please visit an exchange for safe
disposal,” the flyer says.

“Not requiring used syringes in exchange for clean ones is completely more
effective in preventing disease — people are less likely to share, because
they have more clean needles available,” said Eileen Loughran, a community
liaison for San Francisco’s syringe programs. “But to be clear — if
someone approaches one of our syringe sites, you get more clean ones if
you turn old ones in. If you have no used needles to trade, all you can
get is a starter pack of 20.”

Lower HIV rates

Advocates have long credited San Francisco’s syringe programs for the
city’s significantly lower rates of HIV infection among drug injectors. A
1997 study in the medical journal the Lancet found that San Francisco and
other cities with needle-exchange programs had an 11 percent lower HIV
rate than cities without exchanges. And a 1994 study sponsored by the
National Institute on Drug Abuse, also of San Francisco and other cities,
found “no support for the hypothesis that syringe and needle exchange
contributes to drug abuse.”

Loughran recalled that some San Francisco dispensaries began to go from
“needle exchange” to “syringe access” as far back as 15 years ago. The
Public Health Department, needing no state or city approval, made the
official change in 2008.

“At least half of the programs (in the nation) now operate with a more
flexible distribution model. Probably over half,” said Daniel Raymond,
policy director for the national Harm Reduction Coalition in New York, one
of the leading needle outfits in the U.S.

Raymond said that even without the swap requirement, many users still
bring in used needles. In most cities with syringe access programs, the
return rate is 80 to 90 percent, he said. Raymond said syringe access
rather than needle exchange has become recognized as “a best practice.”

[Photo] Kenneth C. Hanks Sr., a labor worker for the Department of Public
Works, collects an abundance of needles every day in the Civic Center
neighborhood, in San Francisco, California on Friday, November 20, 2015.
Photo: Gabrielle Lurie, Special To The Chronicle Photo: Gabrielle Lurie,

Drop-off boxes

However, although used needles have dotted the city for decades, there is
clearly an impression that more are littering San Francisco’s streets and
parks today. City Hall, said Loughran, is aware of the spike in complaints
and is having “multiple conversations” about what to do, including
establishing “rapid response teams.”

The city has placed syringe disposal boxes in seven hot spots, and
Walgreens has added dirty-needle boxes in its stores throughout the city.
“We do a lot of emphasis on disposal,” Loughran said.

The Public Works agency also plays a major role in the cleanup. According
to spokeswoman Rachel Gordon, street crews have stepped up their efforts
in recent years and carry 421 syringe disposal boxes on the job. The
department’s nine public Pit Stop toilets have syringe disposal boxes.

Gordon said an average of two Public Works employees are pricked each
year, but that there have been no reported disease transmissions.

Public Works employees aren’t the only ones — police officers also suffer
needle sticks from time to time, said Lt. Mike Nevin.

“There needs to be a reasonable approach to this,” Nevin said. “There
needs to be responsibility on the user’s end.”

Mario Montoya Jr., a supervisor with the Department of Public Works, makes
his way to UN Plaza where he supervises the clean up of dirty needles, in
San Francisco, California on Friday, November 20, 2015. Photo: Gabrielle
Lurie, Special To The Chronicle Photo: Gabrielle Lurie, Special To The
Chronicle Mario Montoya Jr., a supervisor with the Department of Public
Works, makes his way to UN Plaza where he supervises the clean up of dirty
needles, in San Francisco, California on Friday, November 20, 2015.
For some, it’s tough

Some drug users say being responsible — tracking, storing and swapping
needles — is a tall order amid the chaotic environment of the street.

“I’m trying to quit meth, but it’s a job just to get your next fix, your
food, keep from getting raped,” said Ariel Young, 30, as she sat in her
tent at Folsom and 17th streets. “I put my needles in plastic bottles and
take them to the Capp Street needle center, and they don’t ask for them
there, but I leave them anyway.

“It’s nasty having them around. Most of us out here try to do something
instead of just throw them in the street. But yeah, sometimes you slip
up.”

Another homeless woman standing next to Young’s tent, who merely snarled
when asked her name, spat on the ground.

“I hate slammers,” she said, using the street term for meth injectors.
“Slammers are slobs. Leave their needles everywhere, and I have to walk on
them. Slobs.”

Young grimaced and stared at her sleeping bag, silently.

Chronicle staff writer Joaquin Palomino contributed to this report.

Debra J. Saunders and Kevin Fagan are San Francisco Chronicle staff
writers.
__________________________________________________________________
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https://tinyurl.com/pj3jzmr

MA USA: Kindergartner stuck with needle in school garden
My Fox Boston, Boston MA USA (26.11.15)

BOSTON (MyFoxBoston.com) — A little boy was tested for serious diseases
after being stuck with a needle on school grounds.

It’s a parent’s worst nightmare and Kristin Torres wants the city to take
action.

Her son, Charlie, was collecting leaves in the David Ellis Elementary
School Garden in Roxbury Monday when the 6-year-old was stuck twice with a
hypodermic needle.

Torres said she was contacted by the school nurse and then she rushed her
kindergartner to the emergency room, where he was tested for HIV,
Hepatitis C and Hepatitis B.

“They did state that it was a low chance. But to me, low chance, high
risk, low risk. There should be no risk at all,” she said.

Boston Public Schools said that the school has contacted the Public Health
Commission and the needle was found and disposed of. “The school will do
everything it can to educate its students about the dangers of needles and
prevent such an incident from reoccurring,” said a statement.

FOX25 cameras were rolling as a leaf clean-up crew worked on and around
the Ellis School grounds Wednesday and they showed us what they found – at
least a half dozen needles.

Boston Police said they have stepped up patrols in the area.

Torres is so shaken up due to the incident that she is working on moving
to another area.
__________________________________________________________________
________________________________*_________________________________
https://tinyurl.com/pb6fty2
End of daily injections for diabetes as scientists restore insulin
production

By Sarah Knapton, Science Editor, (25.1.15)
Injecting billions of immune cells back into the body boosts insulin
production, preventing the need for daily injections

The end of daily injections for diabetes sufferers could be in sight after
scientists showed it is possible to restore insulin production for up to a
year by boosting the immune system.

Hundreds of thousands of people in Britain suffer from Type 1 diabetes and
need to inject themselves daily to keep blood sugar levels under control.

The disease attacks insulin-secreting cells in the pancreas. Healthy
people have billions of ‘peacekeeping’ cells called ‘T-regs’ which protect
insulin-making cells from the immune system but people suffering Type 1
diabetes do not have enough.

“The T-reg intervention frees people like me from the daily grind of
insulin therapy and lifelong fear of complication”
Mary Rooney, Type 1 diabetes patient

Now researchers at the University of California and Yale have shown that
the ‘T-regs’ can be removed from the body, increased by 1,500x in the
laboratory and infused back into the bloodstream to restore normal
function.

An initial trial of 14 people has shown that the therapy is safe, and can
last up to a year.

“This could be a game-changer,” said Dr Jeffrey Bluestone, Professor in
Metabolism and Endocrinology at the University of California, San
Francisco (UCSF).

“By using T-regs to ‘re-educate’ the immune system, we may be able to
really change the course of this disease. “We expect T-regs to be an
important part of diabetes therapy in the future.”

Sufferers of type 1 and type 2 diabetes may have to inject insulin
dailySufferes of type 1 and type 2 diabetes may have to inject insulin
daily Photo: Alamy

Not only does the treatment stop the need for regular insulin injections,
but it prevents the disease progressing which could save sufferers from
blindness and amputation in later life.

Diabetes is an autoimmune disease. The immune system usually defends
against infections, but in Type 1 diabetes the process goes awry and as
well as fighting foreign invaders, it also targets the body’s own cells.

In the new procedure, doctors removed around two cups of blood containing
around two to four million ‘T-reg’ cells from 14 patients aged between 18
and 43 who had been recently diagnosed with diabetes. Their ‘T-reg’ cells
were separated from other cells and replicated in a growth medium, before
being infused back into the blood.

Child psychologist Mary Rooney, 39, who was diagnosed with type diabetes
in 2011, was the first trial participant, and said the therapy had ‘freed
her from the daily grind’ of injections.

Speaking of her diagnosis she said: “After weeks of losing weight, always
being thirsty, having blurry vision that would come and go, and generally
feeling run-down, I knew something wasn’t right. Type 1 diabetes was the
furthest from my mind, though.

“Initially, I was in a state of shock. I didn’t realize that you could be
diagnosed with Type 1 diabetes as an adult

“My first thoughts were “This sucks” and “This can’t possibly be
happening,” but I knew I couldn’t just stay in a state of denial and
disappointment forever.”

Miss Rooney, who worked as a researcher at the University of California
soon learned that the institution was looking for patients for the T-reg
trial, and asked to be enrolled.

“By being that first patient, I knew I was taking a chance. And I have to
be honest: I was scared,” she told Healthline.

“But I liked the fact that this experimental treatment involved using my
own regulatory T-cells, which would be expanded in a lab and then re-
infused. The theory behind this study really made sense to me.

“The T-reg intervention frees people like me from the daily grind of
insulin therapy and lifelong fear of complication.”

The team say that T-Reg treatments also hold promise as treatments for
other autoimmune diseases such as rheumatoid arthritis and lupus, and even
as therapies for cardiovascular disease, neurological diseases and
obesity.

The research was published in the journal Science Translational Medicine.
__________________________________________________________________
________________________________*_________________________________

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
relation to injection safety.

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

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

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

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

The SIGNpost Website is http://SIGNpostOnline.info

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

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

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

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

The SIGN Secretariat home is the Service Delivery and Safety (SDS)
Health Systems and Innovation (HIS) at WHO HQ, Geneva Switzerland.

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

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