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SIGNpost 00836

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00836 Abstracts Abstracts New Year Catch-up Part 1    20 January 2016

CONTENTS
1. Abstract: Safe injections and waste management among healthcare workers
at a regional hospital in northern Tanzania
2. Abstract: Notes from the Field: Injection Safety and Vaccine
Administration Errors at an Employee Influenza Vaccination Clinic – New
Jersey, 2015
3. Abstract: Factors influencing nurse compliance with Standard
Precautions
4. Abstract: Investigating the impact of clinical anaesthetic practice on
bacterial contamination of intravenous fluids and drugs
5. Abstract: Occupational exposure to blood borne pathogens among
healthcare workers: a cross-sectional study of a registry in Colombia
6. Abstract: Influencing factors for needlestick injuries in student
nurses
7. Abstract: Understanding sharps injuries in home healthcare: The Safe
Home Care qualitative methods study to identify pathways for injury
prevention
8. Abstract: Incident reporting by acute pain service at a tertiary care
university hospital
9. Abstract: Medical waste in mobile prehospital care
10. Abstract: London Trusts proud to describe their work
11. Abstract: New England Compounding Center Indictment
12. Abstract: Novel interventions to prevent HIV and HCV among persons who
inject drugs
13. Abstract: The effect of on-site and outreach-based needle and syringe
programs in people who inject drugs in Kermanshah, Iran
14. Abstract:Hepatitis C and HIV in injecting drug users in Armenia,
Colombia
15. Abstract: Not in the vein: ‘missed hits’, subcutaneous and
intramuscular injections and associated harms among people who inject
psychoactive drugs in Bristol, United Kingdom
16. Abstract: Impact of implementation of the World Health Organization
multimodal hand hygiene improvement strategy in a teaching hospital in
Taiwan
17. Abstract: Steroid Injection and Nonsteroidal Anti-inflammatory Agents
for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of
Randomized Controlled Trials
18. Abstract: Safety and efficacy of alternative antibiotic regimens
compared with 7 day injectable procaine benzylpenicillin and
gentamicin for outpatient treatment of neonates and young infants with
clinical signs of severe infection when referral is not possible: a
randomised, open-label, equivalence trial
19. Abstract: Currently Approved And Emerging Oral Therapies In Multiple
Sclerosis: An Update For The Ophthalmologist
20. Abstract: Modes of vaccine administration at a glance
21. Abstract: Inverse micellar sugar glass (IMSG) nanoparticles for
transfollicular vaccination
22. No Abstract: Hepatitis B outbreaks in home healthcare
23. No Abstract: Sharps injuries in the community: lower risk than in
healthcare settings
24. No Abstract: Managing risk of hepatitis B after sharps injuries
25. No Abstract: Nurses at risk of injuries
26. No Abstract: Epidemiology of sharps injury and splash exposure in an
oncology care center in eastern India
27. News
– USA: Medical waste dumped near Sudderth Drive and U.S, 70
– Australia: Mother steps on needle at south-east Queensland beach
– California USA: Report: 4 Year Old Has Corralitos Needle Stick Injury –
Take Back Santa Cruz’s Needles Solutions Team says an eighth person – the
fourth child – has been stuck with a needle left in public
– Australia: At least six inmates infected with hepatitis C as slow
progress on needle exchange continues
– Pakistan: Sindh has 3m hepatitis carriers, CM told
– Egypt: Curing Hepatitis C, in an Experiment the Size of Egypt

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__________________________________________________________________
________________________________*_________________________________

1. Abstract: Safe injections and waste management among healthcare workers
at a regional hospital in northern Tanzania
__________________________________________________________________

Tanzan J Health Res. 2013 Jan;15(1):64-70.

https://www.ncbi.nlm.nih.gov/pubmed/26591675
Safe injections and waste management among healthcare workers at a
regional hospital in northern Tanzania.

Nilsson J1, Pembe AB, Urasa M, Darj E.

1Department of Women’s and Children’s Health, International Maternal and
Child Health, Uppsala University, Uppsala, Sweden.

Unsafe injections and substandard waste management are public health
issues exposing healthcare workers and the community to the risk of
infections.

The objective of this study was to assess the knowledge and practice of
safe injections and health care waste management among healthcare workers
at a regional hospital in northern Tanzania.

This cross sectional descriptive study was conducted in a regional
hospital in northern Tanzania. Data was collected through a self-
administered questionnaire with additional observations of the
incinerator, injections, waste practices, and the availability of medical
supplies. Data was analysed in SPSS descriptive statistics and chi-square
tests were performed.

A total of 223 of 305 (73%) healthcare workers from different cadres were
included in the study. The majority of healthcare workers had adequate
knowledge and practice of safe injections, but inadequate knowledge about
waste management.

The majority of the staff reported knowledge of HIV as a risk factor,
however, had less knowledge about other blood-borne infections.

Guidelines and posters on post exposure prophylaxes and waste management –
were present at the hospital, however, the incinerator had no fence or
temperature gauge.

In conclusion, healthcare workers reported good knowledge and practice of
injections, and high knowledge of HIV transmission routes. However, the
hospital is in need of a well functioning incinerator and healthcare
workers require sufficient medical supplies.

There was a need for continual training about health care waste management
and avoidance of blood-borne pathogens that may be transmitted through
unsafe injections or poor health care waste management.
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Notes from the Field: Injection Safety and Vaccine
Administration Errors at an Employee Influenza Vaccination Clinic – New
Jersey, 2015
__________________________________________________________________

Free full text http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6449a3.htm

MMWR Morb Mortal Wkly Rep. 2015 Dec 18;64(49):1363-4.
Notes from the Field: Injection Safety and Vaccine Administration Errors
at an Employee Influenza Vaccination Clinic – New Jersey, 2015.

Taylor L, Greeley R, Dinitz-Sklar J, Mazur N, Swanson J, Wolicki J, Perz
J, Tan C, Montana B.

On September 30, 2015, the New Jersey Department of Health (NJDOH) was
notified by an out-of-state health services company that an experienced
nurse had reused syringes for multiple persons earlier that day.

This occurred at an employee influenza vaccination clinic on the premises
of a New Jersey business that had contracted with the health services
company to provide influenza vaccinations to its employees.

The employees were to receive vaccine from manufacturer-prefilled, single-
dose syringes.

However, the nurse contracted by the health services company brought three
multiple-dose vials of vaccine that were intended for another event.

The nurse reported using two syringes she found among her supplies to
administer vaccine to 67 employees of the New Jersey business. She
reported wiping the syringes with alcohol and using a new needle for each
of the 67 persons.

One of the vaccine recipients witnessed and questioned the syringe reuse,
and brought it to the attention of managers at the business who, in turn,
reported the practice to the health services company contracted to provide
the influenza vaccinations.

Free full text http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6449a3.htm
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Factors influencing nurse compliance with Standard
Precautions
__________________________________________________________________

Free Full Text Article
http://www.ajicjournal.org/article/S0196-6553(15)01035-4/fulltext

Am J Infect Control. 2016 Jan 1;44(1):4-7.
Factors influencing nurse compliance with Standard Precautions.

Powers D1, Armellino D2, Dolansky M3, Fitzpatrick J3.

1Kransoff Quality Management Institute, North Shore Long Island Jewish
Health System, New York, NY. Electronic address: avpdnp@gmail.com.
2Infection Prevention, North Shore Long Island Jewish Health System, New
York, NY.
3Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.

BACKGROUND: Exposure to blood and bodily fluids represents a significant
occupational risk for nurses. The most effective means of preventing
bloodborne pathogen transmission is through adherence to Standard
Precautions (SP).

Despite published guidelines on infection control and negative health
consequences of noncompliance, significant issues remain around compliance
with SP to protect nurses from bloodborne infectious diseases, including
hepatitis B virus, hepatitis C virus (HCV), and HIV.

METHODS: A descriptive correlational study was conducted that measured
self-reported compliance with SP, knowledge of HCV, and perceived
susceptibility and severity of HCV plus perceived benefits and barriers to
SP use. Relationships between the variables were examined. Registered
nurses (N = 231) working in ambulatory settings were surveyed.

RESULTS: Fewer than one-fifth (17.4%) of respondents reported compliance
with all 9 SP items. Mean score for correct responses to the HCV knowledge
test was 81%. There was a significant relationship between susceptibility
of HCV and compliance and between barriers to SP use and compliance.

CONCLUSIONS: This study explored reasons why nurses fail to adopt
behaviors that protect them and used the Health Belief Model for the
theoretical framework. It concentrated on SP and HCV because more than 5
million people in the United States and 200 million worldwide are infected
with HCV, making it 1 of the greatest public health threats faced in this
century.

Understanding reasons for noncompliance will help determine a strategy for
improving behavior and programs that target the aspects that were less
than satisfactory to improve overall compliance. It is critical to examine
factors that influence compliance to encourage those that will lead to
total compliance and eliminate those that prevent it.

Copyright © 2016 Association for Professionals in Infection Control and
Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

KEYWORDS: Bloodborne pathogens; Health Belief Model; Hepatitis C virus
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Investigating the impact of clinical anaesthetic practice on
bacterial contamination of intravenous fluids and drugs
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25648939

J Hosp Infect. 2015 May;90(1):70-4.
Investigating the impact of clinical anaesthetic practice on bacterial
contamination of intravenous fluids and drugs.

Mahida N1, Levi K2, Kearns A3, Snape S2, Moppett I4.

1Department of Clinical Microbiology, Nottingham University Hospitals NHS
Trust, Nottingham, UK. Electronic address: nikunj.mahida@nuh.nhs.uk.
2Department of Clinical Microbiology, Nottingham University Hospitals NHS
Trust, Nottingham, UK.
3Antimicrobial Resistance and Healthcare Associated Infection Reference
Unit, Public Health England, London, UK.
4Anaesthesia and Critical Care, Division of Clinical Neuroscience,
University of Nottingham, Nottingham, UK.

Syringes (N = 426), ventilator machine swabs (N = 202) and intravenous
(IV) fluid administration sets (N = 47) from 101 surgical cases were
evaluated for bacterial contamination.

Cultures from the external surface of syringe tips and syringe contents
were positive in 46% and 15% of cases, respectively.

The same bacterial species was cultured from both ventilator and syringe
in 13% of cases, and was also detected in the IV fluid administration set
in two cases.

A significant association was found between emergency cases and
contaminated syringes (odds ratio 4.5, 95% confidence interval 1.37-14.8;
P = 0.01).

Other risk factors included not using gloves and failure to cap syringes.

Copyright © 2015 The Healthcare Infection Society. Published by Elsevier
Ltd. All rights reserved.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Occupational exposure to blood borne pathogens among
healthcare workers: a cross-sectional study of a registry in Colombia
__________________________________________________________________

http://www.occup-med.com/content/10/1/45 Open access Free Full Text

J Occup Med Toxicol. 2015 Dec 16;10:45.
Occupational exposure to blood borne pathogens among healthcare workers: a
cross-sectional study of a registry in Colombia.

Pérez-Diaz C1, Calixto OJ2, Faccini-Martínez ÁA3, Bravo-Ojeda JS2, Botero-
García CA4, Uribe-Pardo E2, Mantilla-Florez YF2, Benitez F2, Duran A2,
Osorio J5.

1Infectious Diseases Department, Clinica Marly, Bogotá, Colombia ;
Infectious Diseases Department, Hospital de la Samaritana, Bogotá,
Colombia ; Servicios y asesorías en infectología (SAI), Calle 50 # 13-62,
110231420, Bogotá, Colombia.
2Servicios y asesorías en infectología (SAI), Calle 50 # 13-62, 110231420,
Bogotá, Colombia.
3Servicios y asesorías en infectología (SAI), Calle 50 # 13-62, 110231420,
Bogotá, Colombia ; School of Medicine, Universidad de la Sabana, Chia,
Colombia.
4School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia.
5School of Medicine, Fundación Universitaria Navarra, Neiva, Colombia.

BACKGROUND: Occupational exposure to blood borne pathogens caused by
percutaneous injuries or mucosal contamination is frequent among
Healthcare Workers (HCW).

METHODS: A cross-sectional analysis of HCW with an occupational exposure
to blood reported to professional risk insurance agencies between 2009 and
2014 was performed. Comparisons between groups according to exposure level
(mild, moderate, and severe) were evaluated.

RESULTS: Two thousand, four hundred three reports were classified
according exposure as mild 2.7 %, moderate 74.8 %, severe 21.9 %. Factors
related: health sciences student with mild exposure events [adjusted odds
ratio (AOR) 11.91, 95 % CI 5.13-27.61, p?<?0.00001], and physician with
moderate exposure events (AOR 1.90, 95 % CI 1.17-3.07, p?=?0.009).

Factors inversely related: physician with severe exposure events (AOR
0.54, 95 % CI 0.32-0.91, p?=?0.02) and health sciences student with
moderate exposure events (AOR 0.08, 95 % CI 0.04-0.15, p?<?0.00001). It
was found an important relationship between severe events with infectious
diseases specialist assessment, and follow-up adherence. Additionally, a
case of Human Immunodeficiency Virus seroconversion was presented (0.0004
%), no other seroconversions were observed.

CONCLUSIONS: Occupational exposure events must be managed according to
established protocols, but adherence failure was evident with the
exception of severe exposure cases. Thus, interventions to enhance
occupational safety are required. Occupation must be considered as a risk
factor during initial assessment of events.

KEYWORDS: Blood borne pathogen; Health care worker; Occupational exposure
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Influencing factors for needlestick injuries in student
nurses
__________________________________________________________________

Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2015 Jul;33(7):528-31.

https://www.ncbi.nlm.nih.gov/pubmed/26653653
[Influencing factors for needlestick injuries in student nurses].

[Article in Chinese]

Liu C1, Liu X, Zhu Y, Liu Y2.

1Nursing department, Qilu Hospital of Shandong University, Jina 250012,
China.
2E-mail: liu-yx@sdu.edu.cn.

OBJECTIVE: To investigate the needlestick injuries in student nurses
during nine months of in-ternship in our hospital, and reveal the high-
risk periods, risk procedures, and influencing factors for needlestick
injuries, and explore the prevention approaches.

METHODS: Three hundred and fifty student nurses who interned at our
hospital from April to December 2014 and from July 2014 to March 2015 were
surveyed using self-de-signed questionnaires. Three hundred and forty
questionnaires were recovered and 334 out of them were valid. Data were
collected and questionnaires were analyzed.

RESULTS: The incidence of needlestick injuries was 60.8%; the incidence of
needlestick injuries was substantially higher at the early stage than at
the late stage of the internship, and higher in the day shift than in the
night shift.

Moreover, the incidence of needlestick injuries was the highest during the
removal of a syringe or infusion needle, accounting for 24.3% of the total
incidence.

Some other significant factors for needlestick injuries in student nurses
included education level, reports on oc-cupational exposure, constant
update of nursing knowledge, regular hematological examination, and
relevant training experiences.

According to 61.7% of student nurses, clinical operations were affected
due to underlying concern about needlestick injuries.

CONCLUSION: More attention should be paid to high incidence of needlestick
injuries in student nurses, especially at the early stage of their
internship. To reduce the incidence of needlestick injuries, education on
occupational protection should be given to student nurses in advance, and
the pre-job training should be enhanced.
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Understanding sharps injuries in home healthcare: The Safe
Home Care qualitative methods study to identify pathways for injury
prevention
__________________________________________________________________

https://tinyurl.com/jhwenln

BMC Public Health. 2015 Apr 11;15:359.

Understanding sharps injuries in home healthcare: The Safe Home Care
qualitative methods study to identify pathways for injury prevention.

Markkanen P1, Galligan C2, Laramie A3, Fisher J4, Sama S5, Quinn M6.
Author information
1Department of Work Environment, College of Health Sciences, University of
Massachusetts Lowell, Lowell, (MA), USA. Pia_Markkanen@uml.edu.
2Department of Work Environment, College of Health Sciences, University of
Massachusetts Lowell, Lowell, (MA), USA. Catherine_Galligan@uml.edu.
3Occupational Health Surveillance Program, Massachusetts Department of
Public Health, Boston, (MA), USA. Angela.Laramie@state.ma.us.
4Training for Development of Innovative Control Technology Project, San
Francisco, (CA), USA. tdictproj@aol.com.
5Department of Work Environment, College of Health Sciences, University of
Massachusetts Lowell, Lowell, (MA), USA. Susan_Sama@uml.edu.
6Department of Work Environment, College of Health Sciences, University of
Massachusetts Lowell, Lowell, (MA), USA. Margaret_Quinn@uml.edu.

BACKGROUND: Home healthcare is one of the fastest growing sectors in the
United States. Percutaneous injuries from sharp medical devices (sharps)
are a source of bloodborne pathogen infections among home healthcare
workers and community members.

Sharps use and disposal practices in the home are highly variable and
there is no comprehensive analysis of the system of sharps procurement,
use and disposal in home healthcare. This gap is a barrier to effective
public health interventions. The objectives of this study were to i)
identify the full range of pathways by which sharps enter and exit the
home, stakeholders involved, and barriers for using sharps with injury
prevention features; and ii) assess the leverage points for preventive
interventions.

METHODS: This study employed qualitative research methods to develop two
systems maps of the use of sharps and prevention of sharps injuries in
home healthcare. Twenty-six in-depth interview sessions were conducted
including home healthcare agency clinicians, public health practitioners,
sharps device manufacturers, injury prevention advocates, pharmacists and
others. Interview transcripts were audio-recorded and analyzed
thematically using NVIVO qualitative research analysis software. Analysis
of supporting archival material also was conducted. All findings guided
development of the two maps.

RESULTS: Sharps enter the home via multiple complex pathways involving
home healthcare providers and home users. The providers reported using
sharps with injury prevention features. However, home users’ sharps seldom
had injury prevention features and sharps were commonly re-used for
convenience and cost-savings.

Improperly discarded sharps present hazards to caregivers, waste handlers,
and community members. The most effective intervention potential exists at
the beginning of the sharps systems maps where interventions can eliminate
or minimize sharps injuries, in particular with needleless treatment
methods and sharps with injury prevention features.

Manufacturers and insurance providers can improve safety with more
affordable and accessible sharps with injury prevention features for home
users. Sharps disposal campaigns, free-of-charge disposal containers, and
convenient disposal options remain essential.

CONCLUSIONS: Sharps injuries are preventable through public health actions
that promote needleless treatment methods, sharps with injury prevention
features, and safe disposal practices. Communication about hazards
regarding sharps is needed for all home healthcare stakeholders.

Free Open Access Article https://tinyurl.com/jhwenln
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Incident reporting by acute pain service at a tertiary care
university hospital
__________________________________________________________________

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676240/

J Anaesthesiol Clin Pharmacol. 2015 Oct-Dec;31(4):501-4.
Incident reporting by acute pain service at a tertiary care university
hospital.

Ahmed A1, Yasir M1.

1Department of Anesthesiology, Aga Khan University, Karachi, Pakistan.

BACKGROUND AND AIMS: Provision of effective and safe postoperative pain
management is the principal responsibility of acute pain services (APSs).
Continuous quality assurance is essential for high-quality patient care.
We initiated anonymous reporting of critical incidents by APS to ensure
continuous quality improvement and here present prospectively collected
data on the reported incidents. Our objective was to analyze the frequency
and nature of incidents and to see if any harm was caused to patients.

MATERIAL AND METHODS: Data were collected from January 1, 2012 to
September 30, 2013. An incident related to pain management was defined as
An incident that occurs in a patient receiving pain management supervised
by APS, and causes or has the potential to cause harm or affects patient
safety. A form was filled including incident type, personnel involved, any
harm caused, and steps taken to rectify it. Frequencies and percentages
were computed for categorical variables.

RESULTS: A total of 2042 patients were seen and 442 (21.64%) incidents
reported during the study period, including documentation errors
(136/31%), noncompliance with protocols (113/25.56%), wrong combination of
drugs (56/12.66%), premature discontinuation (74/16.72%), prolonged delays
in change of syringes (27/6.10%), loss to follow-up (19/4.29%),
administration of contraindicated drugs (9/2.03%), catheter pull-outs
(6/1.35%), and faulty equipment (2/0.45%). Steps were taken to rectify the
errors accordingly. No harm was caused to any patient.

CONCLUSION: Reporting of untoward incidents and their regular analysis by
APS is recommended to ensure high-quality patient care and to provide
guidance in making teaching strategies and guidelines to improve patient
safety.

KEYWORDS: Pain management; patient safety; postoperative pain; quality
improvement

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676240/
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Medical waste in mobile prehospital care
__________________________________________________________________

https://tinyurl.com/h3soecj Free Full Text Article

Rev Bras Enferm. 2015 Dec;68(6):1122-1129.
Medical waste in mobile prehospital care.

[Article in English, Portuguese]

Mendes AA1, Veiga TB1, Ribeiro TM1, André SC1, Macedo JI2, Penatti JT1,
Takayanagui AM3.

1Programa de Pós-Graduação Enfermagem em Saúde Pública, Escola de
Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto,
SP, Brasil.
2Centro de Material e Esterilização, Universidade Estadual do Norte do
Paraná, Bandeirantes, PR, Brasil.
3Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo,
Ribeirão Preto, SP, Brasil.

OBJECTIVE: the objective of this study is to identify how Medical Waste
(MW) is managed in Mobile Prehospital Care (MPC) services in the state of
São Paulo as well as characterize and quantify this waste.

METHOD: exploratory and descriptive field study with data collection based
on the methodology proposed by the Pan American Health Organization
(PAHO), which was conducted over eight consecutive days to identify the
production and characteristics of generated waste.

RESULTS: it was found that the MW management of the MPC is not yet in line
with the requirements of RDC 306/04, which could affect the occupational
safety of workers, patients, the community, and the environment.

CONCLUSION: it is recommended for the health managers to focus on this
issue. The lack of studies with regard to MPC also indicates the need for
further studies on the waste management.
__________________________________________________________________
________________________________*_________________________________

10. Abstract: London Trusts proud to describe their work
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26685637

Health Estate. 2015 Nov;69(10):27-32.
London Trusts proud to describe their work.

Baillie J.

‘Waste not, Want not’ was the title of a recent IHEEM seminar which
examined some of the key issues for those responsible for dealing with
healthcare waste–from regulatory compliance and correct segregation of
waste streams, to the opportunities for more on-site processing.

HEJ editor, Jonathan Baillie, reports on the joint presentations given by
key environmental and sustainability personnel at two of London’s largest
NHS Trusts, and their private sector waste management partners. These
discussed some of the key initiatives that each Trust and its ‘partner’
have taken to not only significantly reduce the amount of waste generated
on their estate, but also to dispose of it in an environmentally
responsible way.

These initiatives, the speakers explained, were all part of their
organisations’ journey on the road to achieving ‘Deep Green’, a ‘nirvana’-
like state where their activities have a zero net impact on the
environment.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: New England Compounding Center Indictment
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26685489

Int J Pharm Compd. 2015 Mar-Apr;19(2):94-102.
New England Compounding Center Indictment.

Cabaleiro J.

This article is a review of the lapses in compliance with United States
Pharmacopeia standards and pharmacy law as alleged by the New England
Compounding Center indictment.

This indictment was a result of an outbreak of fungal meningitis traced to
fungal contamination of compounded methylprednisolone suspension for
epidural steroid injections.

This article is also intended as a gap analysis for compounders to review
compliance at their own facility, and, if necessary, take the appropriate
steps to implement best practices.
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Novel interventions to prevent HIV and HCV among persons who
inject drugs
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25589380

Curr HIV/AIDS Rep. 2015 Mar;12(1):145-63.
Novel interventions to prevent HIV and HCV among persons who inject drugs.

Coffin PO1, Rowe C, Santos GM.
Author information
1San Francisco Department of Public Health, 25 Van Ness Ave Suite 500, San
Francisco, CA, 94102, USA, pcoffin@gmail.com.

Persons who inject drugs (PWID) are at high risk for infection with and
poor outcomes from HIV and hepatitis C virus (HCV). Well-established
interventions for HIV/HCV prevention among PWID include syringe access,
opioid agonist maintenance treatment, and supervised injection facilities,
yet these interventions remain unavailable or inadequately resourced in
much of the world.

We review recent literature on biomedical and behavioral interventions to
reduce the burden of HIV/HCV among PWID, with an emphasis on randomized
controlled trials and quasi-experimental studies.

Since 2013, there have been significant advancements in utilizing
antiviral therapy and behavioral interventions for prevention among PWID,
including approaches that address the unique needs of couples and sex
workers. In addition, there have been significant developments in
pharmacotherapies for substance use and the implementation of naloxone for
opioid overdose prevention.

Notwithstanding multiple ongoing structural challenges in delivering
HIV/HCV prevention interventions to PWID, these emerging and rigorously
evaluated interventions expand possibilities for prevention among PWID.
__________________________________________________________________
________________________________*_________________________________

13. Abstract: The effect of on-site and outreach-based needle and syringe
programs in people who inject drugs in Kermanshah, Iran
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26764125

Int J Drug Policy. 2016 Jan;27:127-31.
The effect of on-site and outreach-based needle and syringe programs in
people who inject drugs in Kermanshah, Iran.

Nazari SS1, Noroozi M2, Soori H3, Noroozi A4, Mehrabi Y3, Hajebi A5,
Sharifi H6, Higgs P7, Mirzazadeh A8.

1Safety Promotion and Injury Prevention Research Center, Department of
Epidemiology, School of Public Health, Shahid Beheshti University of
Medical Sciences, Tehran, Iran.
2Department of Psychiatry, University of Social Welfare and Rehabilitation
Sciences, Tehran, Iran.
3Department of Epidemiology, School of Public Health, Shahid Beheshti
University of Medical Sciences, Tehran, Iran.
4School of Advanced Technologies in Medicine (SATM), Tehran University of
Medical Sciences (TUMS), Tehran, Iran; Iranian National Center for
Addiction Studies (INCAS), Iranian Institute for Reduction of High-Risk
Behaviors, Tehran University of Medical Sciences (TUMS), Tehran, Iran.
5Mental Health Research Center, Tehran Institute of Psychiatry, School of
Behavioral Sciences and Mental Health, Iran University of Medical
Sciences, Tehran, Iran.
6Regional Knowledge Hub, and WHO Collaborating Centre for HIV
Surveillance, Institute for Futures Studies in Health, Kerman University
of Medical Sciences, Kerman, Iran.
7National Drug Research Institute, Faculty of Health Sciences, Curtin
University, Australia.
8Regional Knowledge Hub, and WHO Collaborating Centre for HIV
Surveillance, Institute for Futures Studies in Health, Kerman University
of Medical Sciences, Kerman, Iran; Global Health Sciences, University of
California, San Francisco, CA, USA. Electronic address:
ali.mirzazadeh@ucsf.edu.

BACKGROUND: Needle and syringe programs (NSPs) are widely used to reduce
harms associated with drug injecting. This study assessed the effect of
facility-based (on-site services at drop-in centre) and outreach models of
NSP on injection risk behaviours.

METHODS: Self-reported data from 455 people who injected drugs (PWID)
during 2014 in Kermanshah, Iran, were examined to measure demographic
characteristics and risk behaviors. Self-reported and program data were
also assessed to identify their main source of injection equipment.
Participants were divided into three sub-groups: facility-based NSP users,
outreach NSP users and non-users (comparison group). Coarsened exact
matching was used to make the three groups statistically equivalent based
on age, place of residence, education and income, and groups were compared
regarding the proportion of borrowing or lending of syringes/cookers,
reusing syringes and recent HIV testing.

RESULTS: Overall, 76% of participants reported any NSP service use during
the two months prior to interview. Only 23% (95%CI: 17-27) reported
outreach NSP as their main source of syringes. Using facility-based NSP
significantly decreased recent syringe borrowing (OR: 0.27, 95%CI:
0.10-0.70), recent syringe reuse (OR: 0.38, 95%CI: 0.23-0.68) and
increased recent HIV testing (OR: 2.60, 95%CI: 1.48-4.56). Similar effects
were observed among outreach NSP users; in addition, the outreach NSP
model significantly reduced the chance of lending syringes (OR: 0.31,
95%CI: 0.15-0.60), compared to facility-based NSP (OR: 1.25, 95%CI:
0.74-2.17).

CONCLUSION: These findings suggest that the outreach NSP model is as
effective as facility-based NSP in reducing injection risk behaviours and
increasing the rate of HIV testing. Outreach NSP was even more effective
than facility-based in reducing the lending of syringes to others. Scaling
up outreach NSP is an effective intervention to further reduce
transmission of HIV via needle sharing.

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

KEYWORDS: Injection risk behaviours; Matching; Needle and syringe
programs; People who inject drugs
__________________________________________________________________
________________________________*_________________________________

14. Abstract:Hepatitis C and HIV in injecting drug users in Armenia,
Colombia
__________________________________________________________________

Free full text
http://www.adicciones.es/index.php/adicciones/article/view/749

Adicciones. 2015 Dec 15;27(4):246-252.
Hepatitis C and HIV in injecting drug users in Armenia, Colombia.

[Article in English, Spanish]

Berbesi-Fernández D1, Segura-Cardona Á, Montoya-Vélez L, Castaño-Perez GA.

1Universidad CES. dberbesi@ces.edu.co.

Abstract in English, Spanish

A constant and progressive increase in the availability of heroin in
Colombia in recent decades and the intravenous use of this drug have
established the need to prevent a possible epidemic of HIV and hepatitis
C.

This research determined the sero-prevalence of hepatitis C and HIV
according to sociodemographic characteristics and risk behaviors in people
who inject drugs in Armenia, Colombia. This is a cross-sectional study on
265 users captured through respondent-driven sampling after informed
consent.

Sero-prevalence of hepatitis C was 22.3 % [95% CI 12.3 % -23.5 %]; for HIV
infection, it was 2.6 % [95% CI 0.4 to 6.0]; 67.5% reported injecting for
more than two years, 35 % shared needles and syringes, and 12.4 % had used
a condom during their last sexual intercourse.

Users who did not purchase syringes in drugstores in the last six months
are 2.7 times [95% CI 1.32 to 5.48] more likely to contract hepatitis C;
daily injection frequency was higher in HIV- positive cases [OR 2.87; 95%
CI 0.55 to 15.9] but nonsignificant.

One fourth of respondents are infected with HIV or hepatitis C, either as
a single infection or co-infection.

This study identified risk practices such as sharing needles and low
condom use in the last six months, worldwide documented and discussed risk
factors.

This research is a first step in the search for strategies to prevent the
spread of HIV infection and hepatitis C in networks of injecting drug
users.

Free full text
http://www.adicciones.es/index.php/adicciones/article/view/749
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Not in the vein: ‘missed hits’, subcutaneous and
intramuscular injections and associated harms among people who inject
psychoactive drugs in Bristol, United Kingdom
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26689890

Int J Drug Policy. 2015 Nov 17. pii: S0955-3959(15)00345-X.
Not in the vein: ‘missed hits’, subcutaneous and intramuscular injections
and associated harms among people who inject psychoactive drugs in
Bristol, United Kingdom.

Hope VD1, Parry JV2, Ncube F3, Hickman M4.

1National Infection service, Public Health England, London, UK; Centre for
Research on Drugs & Health Behaviour, Department of Social and
Environmental Health Research, London School of Hygiene & Tropical
Medicine, London, UK. Electronic address: vivian.hope@phe.gov.uk.
2National Infection service, Public Health England, London, UK; Centre for
Research on Drugs & Health Behaviour, Department of Social and
Environmental Health Research, London School of Hygiene & Tropical
Medicine, London, UK.
3National Infection service, Public Health England, London, UK.
4School of Social and Community Medicine, University of Bristol, Bristol,
UK.

BACKGROUND: The extent of intentional or accidental subcutaneous and
intramuscular injections and the factors associated with these have rarely
been studied among people who inject drugs, yet these may play an
important role in the acquisition bacterial infections. This study
describes the extent of these, and in particular the factors and harms
associated with accidental subcutaneous and intramuscular injections (i.e.
‘missed hits’).

METHODS: People who inject drugs were recruited using respondent driven
sampling. Weighted data was examined using bivariate analyses and logistic
regression.

RESULTS: The participants mean age was 33 years (31% aged under 30-years),
28% were women, and the mean time since first injection was 12 years (N=
329). During the preceding three months, 97% had injected heroin, 71%
crack- cocaine, and 16% amphetamines; 36% injected daily. Overall, 99%
(325) reported that they aimed to inject intravenously; only three aimed
to inject subcutaneously and one intramuscularly. Of those that aimed to
inject intravenously, 56% (181) reported ever missing a vein (for 51 this
occurred more than four times month on average). Factors associated with
‘missed hits’ suggested that these were the consequence of poor vascular
access, injection technique and/or hygiene. ‘Missed hits’ were twice as
common among those reporting sores/open wounds, abscesses, or redness,
swelling and tenderness at injection sites.

CONCLUSION: Intentional subcutaneous and intramuscular injections are rare
in this sample. ‘Missed hits’ are common and appear to be associated with
poor injection practice. Interventions are required to reduce risk through
improving injecting practice and hygiene.

Crown Copyright © 2015. Published by Elsevier B.V. All rights reserved.

KEYWORDS: Infections; Intramuscular; People who inject drugs; Risk
behaviours; Subcutaneous
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Impact of implementation of the World Health Organization
multimodal hand hygiene improvement strategy in a teaching hospital in
Taiwan
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26694582

Am J Infect Control. 2015 Dec 13. pii: S0196-6553(15)01038-X.

Impact of implementation of the World Health Organization multimodal hand
hygiene improvement strategy in a teaching hospital in Taiwan.

Chen JK1, Wu KS1, Lee SS2, Lin HS3, Tsai HC4, Li CH5, Chao HL5, Chou HC6,
Chen YJ5, Huang YH5, Ke CM5, Sy CL1, Tseng YT1, Chen YS7.

1Division of Infectious Diseases, Department of Internal Medicine,
Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
2Division of Infectious Diseases, Department of Internal Medicine,
Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of
Medicine, National Yang-Ming University, Taipei, Taiwan.
3School of Nursing, Fooyin University, Kaohsiung, Taiwan; Department of
Health Services Policy and Management, University of South Carolina,
Columbia, SC.
4Division of Infectious Diseases, Department of Internal Medicine,
Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Graduate Institute
of Environmental Education, National Kaohsiung Normal University,
Kaohsiung, Taiwan.
5Infection Control Unit, Kaohsiung Veterans General Hospital, Kaohsiung,
Taiwan.
6Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung,
Taiwan.
7Division of Infectious Diseases, Department of Internal Medicine,
Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. Electronic
address: yschen@vghks.gov.tw.

BACKGROUND: Hand hygiene (HH) is considered to be the most simple, rapid,
and economic way to prevent health care-associated infection (HAI).
However, poor HH compliance has been repeatedly reported. Our objective
was to evaluate the impact of implementing the updated World Health
Organization (WHO) multimodal HH guidelines on HH compliance and HAI in a
tertiary hospital in Taiwan.

METHODS: We conducted a before-and-after interventional study during
2010-2011. A multimodal HH promotion campaign was initiated. Key
strategies included providing alcohol-based handrub dispensers at points
of care, designing educational programs tailored to the needs of different
health care workers, placement of general and individual reminders in the
workplace, and establishment of evaluation and feedback for HH compliance
and infection rates.

RESULTS: Overall HH compliance increased from 62.3% to 73.3% after 1 year
of intervention (P < .001). The rate of overall HAI decreased from 3.7% to
3.1% (P < .05), urinary tract infection rate decreased from 1.5% to 1.2%
(P < .05), and respiratory tract infection rate decreased from 0.53% to
0.35% (P < .05). This campaign saved an estimated $940,000 and 3,564
admission patient days per year.

CONCLUSION: The WHO multimodal HH guidelines are feasible and effective
for the promotion of HH compliance and are associated with the reduction
of HAIs.

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

KEYWORDS: Cost-savings; Health care–associated infection; Multimodal hand
hygiene promotion
__________________________________________________________________
________________________________*_________________________________

17. Abstract: Steroid Injection and Nonsteroidal Anti-inflammatory Agents
for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of
Randomized Controlled Trials
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26683932

Medicine (Baltimore). 2015 Dec;94(50):e2216.
Steroid Injection and Nonsteroidal Anti-inflammatory Agents for Shoulder
Pain: A PRISMA Systematic Review and Meta-Analysis of Randomized
Controlled Trials.

Sun Y1, Chen J, Li H, Jiang J, Chen S.

1Department of Sports Medicine and Arthroscopy, Huashan Hospital, Fudan
University, Shanghai 200040, People’s Republic of China.

Advantages and possible risks associated with steroid injection compared
with nonsteroidal anti-inflammatory drugs (NSAIDs) for shoulder pain are
not fully understood.To compare the efficiency and safety of steroid
injection versus NSAIDs for patients with shoulder pain.PubMed, Embase,
and the Cochrane Library were searched through July 2015.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: randomized
controlled trials (RCTs) that assessed steroid injection versus NSAIDs for
patients with shoulder pain.

STUDY APPRAISAL AND SYNTHESIS METHODS: predefined primary efficacy outcome
was functional improvement; and secondary efficacy outcomes included pain
relief and complications. Relative risks (RRs) and standardized mean
differences (SMDs) with 95% confidence intervals (CIs) were calculated
using a random-effects model accounting for clinical heterogeneity.Eight
RCTs involving 465 participants were included in the meta-analysis.

Five trials compared steroid injection with oral NSAIDs, and 3 compared
steroids injection with NSAIDs injection. Compared with steroid injection,
oral NSAIDs were less effective in 4 or 6 weeks for functional improvement
(SMD 0.61; 95% CI, 0.08-1.14; P?=?0.01), while there was no significant
difference in pain relief (SMD 0.45; 95% CI, -0.50-1.40; P?<?0.00001) or
complication rate (RR 1.10; 95% CI, 0.26-4.58; P?=?0.29).

Meta-analysis was not performed for NSAIDs injection due to considerable
heterogeneity.

Conflicting results were observed in favor of either steroid or NSAIDs
injection.

Not all diseases that can lead to shoulder pain were included, detailed
intervention protocols were inconsistent across studies, and some
estimated data were input into comparison while some data were lost, which
could exert an influence on pooled results.

Steroid injection, compared with oral NSAIDs, provides slightly more
improvement in shoulder function without superiority in pain relief or
risk of complications at 4 to 6 weeks.

Treatment decision should be made based on diseases. NSAIDs injection
might be a treatment method for shoulder pain.
__________________________________________________________________
________________________________*_________________________________

18. Abstract: Safety and efficacy of alternative antibiotic regimens
compared with 7 day injectable procaine benzylpenicillin and
gentamicin for outpatient treatment of neonates and young infants with
clinical signs of severe infection when referral is not possible: a
randomised, open-label, equivalence trial
__________________________________________________________________

https://tinyurl.com/hrscjex Free Full Text

Lancet Glob Health. 2015 May;3(5):e279-87.
Safety and efficacy of alternative antibiotic regimens compared with 7 day
injectable procaine benzylpenicillin and gentamicin for outpatient
treatment of neonates and young infants with clinical signs of severe
infection when referral is not possible: a randomised, open-label,
equivalence trial.

Baqui AH1, Saha SK2, Ahmed AS2, Shahidullah M3, Quasem I2, Roth DE4,
Samsuzzaman AK5, Ahmed W6, Tabib SM7, Mitra DK8, Begum N8, Islam M2,
Mahmud A8, Rahman MH8, Moin MI8, Mullany LC8, Cousens S9, El Arifeen S10,
Wall S11, Brandes N12, Santosham M8, Black RE8; Projahnmo Study Group in
Bangladesh.

1International Center for Maternal and Newborn Health, Department of
International Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD, USA. Electronic address: abaqui@jhu.edu.
2Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka,
Bangladesh.
3Bangabandhu Shaikh Mujib Medical University, Dhaka, Bangladesh.
4Department of Paediatrics, Hospital for Sick Children and University of
Toronto, Toronto, ON, Canada.
5Shishu Sasthya Foundation, Dhaka, Bangladesh.
6Chittagong Ma O’ Shishu Hospital, Chittagong, Bangladesh.
7Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh.
8International Center for Maternal and Newborn Health, Department of
International Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD, USA.
9Faculty of Epidemiology and Population Health, London School of Hygiene &
Tropical Medicine, London, UK.
10icddr,b, Dhaka, Bangladesh.
11Saving Newborn Lives, Save the Children Federation, Washington, DC, USA.
12United States Agency for International Development, Washington, DC, USA.

BACKGROUND: Severe infections remain one of the main causes of neonatal
deaths worldwide. Possible severe infection is diagnosed in young infants
(aged 0-59 days) according to the presence of one or more clinical signs.
The recommended treatment is hospital admission with 7-10 days of
injectable antibiotic therapy.

In low-income and middle-income countries, barriers to hospital care lead
to delayed, inadequate, or no treatment for many young infants.

We aimed to identify effective alternative antibiotic regimens to expand
treatment options for situations where hospital admission is not possible.

METHODS: We did this randomised, open-label, equivalence trial in four
urban hospitals and one rural field site in Bangladesh to determine
whether two alternative antibiotic regimens with reduced numbers of
injectable antibiotics combined with oral antibiotics had similar efficacy
and safety to the standard regimen, which was also used as outpatient
treatment.

We randomly assigned infants who showed at least one clinical sign of
severe, but not critical, infection (except fast breathing alone), whose
parents refused hospital admission, to one of the three treatment
regimens. We stratified randomisation by study site and age (<7 days or
7-59 days) using computer-generated randomisation sequences.

The standard treatment was intramuscular procaine benzylpenicillin and
gentamicin once per day for 7 days (group A). The alternative regimens
were intramuscular gentamicin once per day and oral amoxicillin twice per
day for 7 days (group B) or intramuscular procaine benzylpenicillin and
gentamicin once per day for 2 days, then oral amoxicillin twice per day
for 5 days (group C).

The primary outcome was treatment failure within 7 days after enrolment.
Assessors of treatment failure were masked to treatment allocation.
Primary analysis was per protocol. We used a prespecified similarity
margin of 5% to assess equivalence between regimens.

This study is registered with ClinicalTrials.gov, number NCT00844337.

FINDINGS: Between July 1, 2009, and June 30, 2013, we recruited 2490 young
infants into the trial. We assigned 830 infants to group A, 831 infants to
group B, and 829 infants to group C. 2367 (95%) infants fulfilled per-
protocol criteria.

78 (10%) of 795 per-protocol infants had treatment failure in group A
compared with 65 (8%) of 782 infants in group B (risk difference -1.5%,
95% CI -4.3 to 1.3) and 64 (8%) of 790 infants in group C (-1.7%, -4.5 to
1.1).

In group A, 14 (2%) infants died before day 15, compared with 12 (2%)
infants in group B and 12 (2%) infants in group C.

Non-fatal relapse rates were similar in all three groups (12 [2%] infants
in group A vs 13 [2%] infants in group B and 10 [1%] infants in group C).

INTERPRETATION: Our results suggest that the two alternative antibiotic
regimens for outpatient treatment of clinical signs of severe infection in
young infants whose parents refused hospital admission are as efficacious
as the standard regimen.

This finding could increase treatment options in resource-poor settings
when referral care is not available or acceptable.

Copyright © 2015 Baqui et al. Open Access article distributed under the
terms of CC BY. Published by .. All rights reserved.

Comment in
Outpatient treatment for neonates and young infants with clinically
suspected severe infection. [Lancet Glob Health. 2015]

Free full text https://tinyurl.com/hrscjex or
www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70347-
X/fulltext

Registration may be required
__________________________________________________________________
________________________________*_________________________________

19. Abstract: Currently Approved And Emerging Oral Therapies In Multiple
Sclerosis: An Update For The Ophthalmologist
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26703886

Surv Ophthalmol. 2015 Dec 15. pii: S0039-6257(15)30048-5. d
Currently Approved And Emerging Oral Therapies In Multiple Sclerosis: An
Update For The Ophthalmologist.

Eckstein C1, Bhatti MT2.

1Department of Neurology, Duke University Medical Center, Durham, NC.
2Department of Neurology, Duke University Medical Center, Durham, NC;
Department of Ophthalmology, Duke Eye Center, Durham, NC. Electronic
address: tariq.bhatti@duke.edu.

Although our understanding of multiple sclerosis (MS) has grown
substantially, its cause remains unknown. Nonetheless, in the past three
decades there have been tremendous advancements in the development of
disease-modifying drugs (DMDs). In July, 1993, the US FDA approved the
first DMD–interferon ß, and there are currently thirteen medications
approved for use in relapsing MS. All the early medications are
administered either as a subcutaneous or intramuscular injection, and
despite the clinical efficacy and safety of these medications, many
patients were hampered by the inconvenience of injections and injection-
related side effects.

In September, 2010, the first oral DMD — fingolimod– was approved. Since
then, two additional oral DMDs (teriflunomide and dimethyl fumarate) have
been approved, and several other oral medications are being evaluated in
extensive MS development programs.

Because of frequent ocular involvement, ophthalmologists are often
involved in the care of MS patients and therefore need to be aware of the
current treatment regimens prescribed by neurologists, some of which can
have significant ophthalmic adverse events.

We update the current advancements in the treatment of MS and discuss the
published clinical data on the efficacy and safety of the currently
approved and emerging oral therapies in MS.

Copyright © 2015 Elsevier Inc. All rights reserved.

KEYWORDS: Central Nervous System; Dimethyl Fumarate; Disability; Disease
Modifying Drugs; Fingolimod; Magnetic Resonance Imaging; Multiple
Sclerosis; Relapses; Teriflunomide
__________________________________________________________________
________________________________*_________________________________

20. Abstract: Modes of vaccine administration at a glance
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26697711

Berl Munch Tierarztl Wochenschr. 2015 Nov-Dec;128(11-12):451-5.
Modes of vaccine administration at a glance.

Makoschey B.

A number of different vaccination techniques are applied in farm animals.
The intramuscular, subcutaneous and intradermal injection of vaccines are
parenteral application methods that are currently used for different
attenuated and inactivated vaccines. The injection may be performed by
needle or pressure.

Depending on the method of application, the mucosal immunization can be
performed intraocular, intranasal and/or oral. In general, the vaccine
follows the natural route of infection of the respective pathogen.
Attenuated vaccines usually replicate in the primary target organs.

Mucosal application of attenuated vaccines via drinking water or spray are
routinely applied in poultry. Both techniques offer advantages for mass
application.

The administration route and the method of vaccination have a great
influence on the efficacy and safety of a vaccine. The instructions of the
manufacturers must therefore be strictly respected.

Unfortunately, there is no ideal administration method applicable for any
vaccine in all species.
________________________________________________________________
________________________________*_________________________________

21. Abstract: Inverse micellar sugar glass (IMSG) nanoparticles for
transfollicular vaccination
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25795506

J Control Release. 2015 May 28;206:140-52.

Inverse micellar sugar glass (IMSG) nanoparticles for transfollicular
vaccination.

Mittal A1, Schulze K2, Ebensen T2, Weissmann S2, Hansen S3, Guzmán CA4,
Lehr CM5.

1Saarland University, Biopharmaceutics and Pharmaceutical Technology,
Saarbruecken, Germany.
2Helmholtz Center for Infection Research (HZI), Department of Vaccinology
and Applied Microbiology, Braunschweig, Germany.
3Saarland University, Biopharmaceutics and Pharmaceutical Technology,
Saarbruecken, Germany; Helmholtz Institute for Pharmaceutical Research
Saarland (HIPS), Department of Drug Delivery, Helmholtz Centre for
Infection Research (HZI), Saarland University, Saarbruecken, Germany.
4Helmholtz Center for Infection Research (HZI), Department of Vaccinology
and Applied Microbiology, Braunschweig, Germany. Electronic address:
cag@helmholtz-hzi.de.
5Saarland University, Biopharmaceutics and Pharmaceutical Technology,
Saarbruecken, Germany; Helmholtz Institute for Pharmaceutical Research
Saarland (HIPS), Department of Drug Delivery, Helmholtz Centre for
Infection Research (HZI), Saarland University, Saarbruecken, Germany.
Electronic address: claus-michael.lehr@helmholtz-hzi.de.

Transfollicular antigen delivery through the intact skin is an interesting
new avenue for needle-free vaccination.

The aim of this work was to evaluate the potential of surfactant based
inverse micellar sugar glass nanoparticles (IMSG NPs) as a delivery system
for such purpose.

To this end, we evaluated the strength and type of immune response
elicited after administration of IMSG NPs containing the model antigen
ovalbumin (OVA) by intranasal, transfollicular or intradermal route.

Furthermore, we explored the possibility of improving the immune response
elicited by co- encapsulating the adjuvant bis-(3′,5′)-cyclic dimeric
adenosine monophosphate (c-di-AMP) and OVA within one particulate carrier
system. The study showed enhanced stability and encapsulation efficacy of
the antigen when encapsulated in IMSG NPs in comparison to polylactic-co-
glycolic acid (PLGA) and chitosan-PLGA NPs. Moreover, by transfollicular
delivery, IMSG NPs showed enhanced follicular uptake in comparison to OVA
solution or OVA-loaded chitosan-PLGA NPs.

While the immune response stimulated after intranasal administration was
negligible, significant humoral and cellular responses were observed after
immunization via transfollicular and intradermal route. This holds
particularly true when OVA and c-di-AMP were co-encapsulated in IMSG NPs,
as compared to OVA±c- di-AMP solution or OVA-loaded IMSG NPs without
adjuvantation.

The results of this study underscore not only the potential of
transfollicular vaccination, but also the need for optimized nanocarriers
and adjuvants.

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

KEYWORDS: Inverse micellar sugar glass nanoparticles; Ovalbumin;
Transfollicular; Vaccination
__________________________________________________________________
________________________________*_________________________________

22. No Abstract: Hepatitis B outbreaks in home healthcare
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25171244

Home Healthc Nurse. 2014 Sep;32(8):500-1.
Hepatitis B outbreaks in home healthcare.

McGoldrick M1.

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

23. No Abstract: Sharps injuries in the community: lower risk than in
healthcare settings
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26350382

BMJ. 2015 Sep 8;351:h4766.

Sharps injuries in the community: lower risk than in healthcare settings.

Osowicki J1, Curtis N2.

1Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
joshua.osowicki@rch.org.au.
2Department of Paediatrics, University of Melbourne, Parkville.
__________________________________________________________________
________________________________*_________________________________

24. No Abstract: Managing risk of hepatitis B after sharps injuries
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26490050

BMJ. 2015 Oct 21;351:h5568.
Managing risk of hepatitis B after sharps injuries.

De Schryver AA1, Van Hooste W1, Van Acker H1, Claessens B1, Haenen R1, Van
Crombrugge K1, Godderis L1.

1IDEWE Occupational Health Services, Interleuvenlaan 58, B 3001 Leuven,
Belgium.

Comment in
Authors’ reply to De Schryver and colleagues. [BMJ. 2015]
https://www.ncbi.nlm.nih.gov/pubmed/26490160

Comment on
Management of sharps injuries in the healthcare setting. [BMJ. 2015]
https://www.ncbi.nlm.nih.gov/pubmed/26223519
__________________________________________________________________
________________________________*_________________________________

25. No Abstract: Nurses at risk of injuries
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26460423

Aust Nurs Midwifery J. 2015 Aug;23(2):26-8.
Nurses at risk of injuries.

[No authors listed]
__________________________________________________________________
________________________________*_________________________________

26. No Abstract: Epidemiology of sharps injury and splash exposure in an
oncology care center in eastern India
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25111936

Infect Control Hosp Epidemiol. 2014 Sep;35(9):1201-3.
Epidemiology of sharps injury and splash exposure in an oncology care
center in eastern India.

Bhattacharya S1, Chatterjee S, Goel G, Mahajan A, Ramanan VR, Chandy M.

1Microbiology Department, Tata Medical Center, Kolkata, India.

Erratum in
Infect Control Hosp Epidemiol. 2014 Dec;35(12):1552.
__________________________________________________________________
________________________________*_________________________________

27. News

– USA: Medical waste dumped near Sudderth Drive and U.S, 70

– Australia: Mother steps on needle at south-east Queensland beach

– California USA: Report: 4 Year Old Has Corralitos Needle Stick Injury –
Take Back Santa Cruz’s Needles Solutions Team says an eighth person – the
fourth child – has been stuck with a needle left in public

– Australia: At least six inmates infected with hepatitis C as slow
progress on needle exchange continues

– Pakistan: Sindh has 3m hepatitis carriers, CM told

– Egypt: Curing Hepatitis C, in an Experiment the Size of Egypt

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/gnntou4
USA: Medical waste dumped near Sudderth Drive and U.S, 70

Dianne L Stallings, Ruidoso News, New Mexico USA (19.01.16)

Illegally dumped medical waste can spread infectous diseases, contaminate
water supplies and injured unsuspecting workers cleaning up debris

Solid waste officials report new illegal dumping of medical waste,
hypodermic needles or “sharps,” in blue cardboard recycling containers in
the lower Sudderth Drive area near the Lincoln County Medical Center and
the intersection with U.S. 70.

Handling medical waste places material processing employees and truck
drivers at Greentree Solid Waste in jeopardy, officials with the garbage-
collection coalition said. Medical waste, particularly needles or sharps,
can spread infectious disease and can injure workers. The contaminated
load, appearing to be used diabetes sharps, was reloaded at the Greentree
Recycling Center and transported the same day to the Otero-Greentree
Regional landfill, the officials reported.

Medical waste consists of sharps, medicines and controlled substances and
it is considered a “special waste.”

Handling medical waste carefully is very important to prevent someone from
getting pricked or sick, to ensure medicines and controlled substances do
not contaminate the drinking water supply and to prevent the spread of
infectious viral diseases. The Presbyterian Healthcare system that
operates the hospital in Ruidoso and the health clinics in rural Lincoln
County uses an approved medical waste disposal company, Stericycle Inc. of
Albuquerque, to pick up and dispose of medical waste in a designated
landfill in Bernalillo County.

Hypodermic needles or “sharps” can go in the trash, but they must be in a
puncture proof container with a cap and be properly labeled. Try using a
detergent bottle with a screw-on cap and label the bottle with “sharps” or
“needles,” officials advised. Once the bottle is full and the cap secured,
place it in a household trash can. Do not put the bottle in a blue
recycling bin.

Or, properly dispose of sharps or hypodermic needles through your
healthcare provider. Medicines such as pills, vitamins, prescription
drugs, and any liquids, including cough syrup and eye drops, should not be
put or poured down the drain or toilet. It is very difficult for a septic
tank or waste water treatment plant to remove many of the chemicals that
are in pharmaceutical drugs. The contaminated water can make its way into
creeks, rivers, surface and ground water supplies. Medicine should be
crushed, wetted, bagged, and disposed of in the trash so it cannot be
used.
Heavily regulated prescription or non-prescription drugs, including
controlled substances, should be treated like medicine and never put down
the drain or in the trash.
Controlled substances should be crushed, wetted, bagged, and disposed of
in the trash so it cannot be used. A local pharmacy or healthcare provider
may take back old prescriptions.

For more information on proper medical waste disposal, contact the Solid
Waste Authority office at 378-4697, toll free at 1-877-548-8772, via email
at gswa@greentreeswa.org. General recycling information is available on
the Authority website at www.greentreeswa.org.
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https://tinyurl.com/jqzy3hy
Australia: Mother steps on needle at south-east Queensland beach

AAP, Brisbane Times, Australia (18.01.16)

A woman will have an anxious wait for test results after stepping on a
needle at Burleigh Beach.
A woman will have an anxious wait for test results after stepping on a
needle at Burleigh Beach. Photo: Fairfax Media

A mother faces an anxious wait for the results of medical tests after
stepping on a discarded hypodermic needle at a southeast Queensland beach.

The woman, aged in her 40s, stood on the needle on Sunday afternoon while
at Burleigh Heads beach with her husband and children, who were working as
volunteer lifesavers.

She was taken to hospital for blood tests but may not know the results for
months.

It is the second needle-related accident in the area in three weeks after
a four-year-old girl trod on one at nearby Currumbin beach late last year.

“There is no place for the sort of activity on Gold Coast beaches,” Gold
Coast Lifesaving Coordinator Nathan Fife said.

“Fortunately lifesavers were able to find the needle, package it up and
send it off to hospital for testing.”

It can take up to three months for traces of needle-transmitted virus
hepatitis C to be detected.

Gold Coast City Council regularly uses tractors to remove rubbish from
sand but Mr Fife said a completely clean beach cannot be guaranteed.

“Unfortunately it (a needle) is something so small,” he said.

“If anyone does step on something, we recommend letting the nearest
lifesaver know straight away.”
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https://tinyurl.com/zdevhh7
California USA: Report: 4 Year Old Has Corralitos Needle Stick Injury –
Take Back Santa Cruz’s Needles Solutions Team says an eighth person – the
fourth child – has been stuck with a needle left in public

By Dave Colby (Patch Staff), Santa Cruz Patch, California USA (17.01.16)

SANTA CRUZ – A vigilant civic group intent on alerting the public to the
dangers of local hypodermic waste said Saturday a 4 year old girl has been
stuck with a needle left in a public place in Santa Cruz County.

Take Back Santa Cruz says the girl was poked with an old syringe she found
while playing in Aldridge Park in Corralitos.

According the group’s Needles Solutions Team, this is the eighth confirmed
needle stick injury, and fourth to a child, in Santa Cruz County since
their reporting records began 37 months ago.

The group says when the girl’s mother realized what had happened, the girl
told her “Mom, it didn’t hurt.”

After some time in the emergency room, doctors apparently determined the
needle appeared “old”, the injury was not deep, and the girl was at “less
than 0.01 % risk.”

Take Back Santa Cruz says Aldridge Park is located approximately 5.3 miles
from the County’s Syringe Services Program (SSP) located in Watsonville.
The SSP dispenses free, clean syringes to drug users in an effort to
prevent the transmission of diseases such as HIV and Hepatitis via the
sharing of dirty drug needles.

In letters sent to the Santa Cruz County Board of Supervisors and the
Santa Cruz City Council last week, the Needles Solutions Team says it
found 242 needles in the most recent monthly reporting period.

Among the significant finds:

A man who lives on Market Street found a needle in his driveway, and
another in a jacket in a tree on his property.

8 needles were found outside Safeway on Morrissey.

A nine year old found a needle in her front yard at her home in the
Morrissey neighborhood.

City workers found two needles in the Rose Garden at City Hall.

There were numerous reports of needles found on Seabright Beach. This
includes a find by a mother and her two children while they were making a
drift wood fort on the beach.

Many of the photographs associated with these reports show that SSP water
capsules were also found along with the needles.

Hot Spot NIPS Locations for Reporting Periods 37:

Seabright Beach was hands-down the “hottest” spot for citizen needle finds
this month.
Depot Park
Harvey West Park
Levee
San Lorenzo Park restrooms
Beach Street restrooms
Cowell Beach
Rivermouth

Overview of Last 37 Months:

Total Number of Needles Reported Found: 9,694

Average Number of Needles Found Per Month: 262

Source of needles: Again, based on the frequent presence of other items
from the SSP such as water capsules, cookers, and alcohol wipes, we
conclude that a significant number of needles found in public spaces
likely originated from the SSP (and obviously were not returned for
exchange.)

However, there are other needles being found that do not match those given
out by the SSP, so there are presumably other sources of discarded
needles.
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https://tinyurl.com/j9yusvv
Australia: At least six inmates infected with hepatitis C as slow progress
on needle exchange continues

By Christopher Knaus, The Canberra Times, Australia (21.12.15)

Corrections Minister Shane Rattenbury said he was concerned about every
new hepatitis C case, but said the working group needed time to develop a
needle exchange model that could address the concerns of guards. Photo:
Rohan Thomson

At least six more inmates have been infected with hepatitis C inside the
ACT’s prison, as progress on the much-delayed needle exchange proposal
continues.

Health authorities received 30 notifications for hepatitis C infections
involving prisoners at the Alexander Maconochie Centre from the year to
September, figures released to Fairfax Media show.

Six were confirmed as “in-custody transmissions”. Authorities were unable
to determine whether a further 12 hepatitis C cases were caused by
transmission behind bars or in the community.

[Hepatitis ACT executive officer John Didlick said the reality at the AMC
was an unregulated needle exchange, which was “the very worst possible”
model. Photo: Emma Kelly]

The remaining 12 were confirmed as in-community transmissions.

News of the new infections came as guards, their union, and the government
continued to hammer out a needle exchange model that would win the support
of custodial officers at the Alexander Maconochie Centre.

The proposal for a prison-based needle and syringe program was announced
in 2012 by then chief minister Katy Gallagher, who said she hoped to have
it operating in 2013.

But prison guards immediately voiced concerns, fearing the program could
not be managed in a way that guaranteed their safety.

Under their union’s enterprise agreement, a prison-based needle exchange
could not be introduced without the support of guards.

The dispute between government and guards led to a two-year stalemate,
eventually broken by the formation of a working group to come up with a
more suitable model that could be taken back to the guards.

It was given a year to find a model that worked but that model would still
need the support of a majority of custodial officers before it could
become operational.

Both CPSU regional director Vince McDevitt and Corrections Minister Shane
Rattenbury said the working group was progressing well.

Mr Rattenbury said he was always concerned about new hepatitis C
notifications emerging from the prison, but said the working group needed
time to develop a model that could be taken to custodial officers.

“Will we get to a point where everyone agrees? I don’t know yet,” he said.

“But what we have done is we’ve created a space and an opportunity for
people to get together to get to a place where we could agree. We were in
a circumstance 18 months ago where that was not going to happen.”

Hepatitis ACT, a not-for-profit organisation funded by ACT Health, said
news of the six in-custody transmissions was concerning but hardly
surprising, given there had been some 81 cases of hepatitis C since the
jail’s opening.

Executive officer John Didlick said the current situation at the jail
amounted to an “unregulated needle and syringe program”, which he
described as the “very worst possible” model.

“The AMC is either going to have a sterile and regulated harm reduction
program, or it is going to maintain an unsterile unregulated harm
production program,” he said.

“The only thing that is impossible at this point is a prison without drugs
and injecting equipment.”

Public Health Association of Australia chief executive officer Michael
Moore said the continued emergence of hepatitis C cases in the prison
could only amount to a “failure of duty of care” by the ACT government.

Mr Moore said it was only a matter of time before an infected prisoner
took the government to court, potentially forcing authorities to introduce
a system that complied with their duty of care.

“When we know what to do, when we can see the system working elsewhere
(without needles being used as weapons) it can only be seen as a failure
of duty of care that such programs are not operating in the ACT prison and
people are getting infected when it simply is not necessary,” he said.
__________________________________________________________________
__________________________________________________________________

http://epaper.dawn.com/DetailImage.php?StoryImage=15_01_2016_118_006
Pakistan: Sindh has 3m hepatitis carriers, CM told

By Our Staff Reporter, Dawn.com, Karachi Pakistan (15.12.15)

KARACHI: A recent official survey shows that around three million
hepatitis carriers are in the province who include over two million people
with hepatitis C and around a million with hepatitis B, said officials in
a meeting held at Chief Minister House.

Chief Minister Syed Qaim Ali Shah presided over the meeting with Finance
Minister Syed Murad Ali Shah, Health Minister Jam Mehtab Dahar,
information adviser to the CM Maula Bux Chandio and senior officials to
review the progress on the vertical programme on hepatitis.

The officials informed the CM that the figures of hepatitis patients
almost remained unchanged since the programme was launched in 2009 at the
cost of Rs2.7 billion, with the objective to take preventive and curative
measures and create public awareness.

In 2009, said an official statementciting the briefing, there were over
three million hepatitis patients in Sindh.

In 2011 the programme was extended further for another three years, 2011
2014, at a cost of Rs3.315 billion.

Secretary health Saeed Mangnejo said around 8,608,400 people in the
province had been given hepatitis-B vaccine so far which included 2.9
million general public,1.9 million high risk population, 170,001 newborns
as first dose, 87,538 jail inmates,3,488,708 school children, 194,000
people in flood-hit areas, 6,540 haemophilic dialysis patients and 10,201
drug injecting users.

Programme manager Dr Khaliq Shaikh said under the programme 462,365
patients had received treatment and 154,405 of them were hepatitis-C
patients, 14,636 hepatitis-B and 3,638 hepatitis-D patients.

Apart from it, he added, 26,418 patients were under treatment, including
17,890 of hepatitis-C, 88,347 of hep-atitis-B and 181 of hepatitis-D.

He said that under the programme 300,000 schoolchildren were vaccinated in
September and October last year while their third doze was due in
February. He said they had also vaccinated 2,165 jail inmates recently.

The health minister said under the programme 20.7 million auto-
destructible (ADs) syringes had been provided to districts to promote the
use of AD syringes and discourage the recyclables. `To create public
awareness, 154 awareness sessions have been conducted in jails and sub-
jails.

He said he had worked out a plan to establish a molecular lab at
Benazirabad district, while more such centres would be set up at the
taluka hospitals of different districts.

The CM asked the health department to increase screening provision and
mobilise teams at grass-roots level for arranging hepatitis screening and
vaccination camps, particularly in the high risk areas.
__________________________________________________________________
__________________________________________________________________

Free full text at the link – Read in Arabic or English
www.nytimes.com/2015/12/16/health/hepatitis-c-treatment-egypt.html
Egypt: Curing Hepatitis C, in an Experiment the Size of Egypt

By Donald G. Mcneil Jr., New York Times, New York USA (15.12.15)

A new approach tested in Egypt could become the blueprint for providing
cutting-edge medicines to the poor.

SHABAS EL SHUHADA, Egypt — Abdel Gawad Ellabbad knows exactly how he was
infected with hepatitis C.

As a schoolboy in this Nile Delta rice-farming village, his class marched
to the local clinic every month for injections against schistosomiasis, a
parasitic disease spread by water snails.

A nurse would boil the syringes, fill each with five doses and then jab
five boys in a row with a single needle.

“I didn’t want that hot needle touching me, so I thought I’d be smart,”
Mr. Ellabbad, 52, said. “I let the other guys go first.”

Six million Egyptians were infected with hepatitis C by unsterile needles
during the country’s decades-long fight against schistosomiasis. The virus
spread insidiously; today, at least 10 percent of Egyptians, nearly nine
million people, are chronically infected, the highest rate in the world.

But a grand experiment unfolding across the country may change all that.

Once demonized for withholding lifesaving AIDS drugs from poor countries
in Africa, chastened pharmaceutical companies are testing an alternative
strategy: a complicated deal to sell hepatitis drugs at a fraction of
their usual cost while imposing tight restrictions intended to protect
lucrative markets in the West.

The strategy has raised howls of outrage from public health advocates in
some quarters. If it succeeds, though, the arrangement in Egypt may serve
as a blueprint not just for curing hepatitis around the world, but also
for providing other cutting-edge medicines to citizens in poor countries
who could never afford them.

[Photo… continues at the link
www.nytimes.com/2015/12/16/health/hepatitis-c-treatment-egypt.html
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________________________________*_________________________________

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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