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SIGNpost 00846

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00846 Ebola Needle Stick Standard + Abstracts + News 30 March 2016

CONTENTS
1. Adopting a global safety standard for the prevention of Ebola
needle-stick exposures
2. Abstract: Needle Stick Injuries and their Related Safety Measures among
Nurses in a University Hospital, Shiraz, Iran
3. Abstract: Underreporting of blood exposure incidents: a worrying
situation among nursing students
4. Abstract: Hepatitis B Virus infection and its modes of prevention among
clinical students of Obafemi Awolowo University (OAU), Ile-Ife, Nigeria
5. Abstract: Optimising health and safety of people who inject drugs
during transition from acute to outpatient care: narrative review with
clinical checklist
6. Abstract: The state of harm reduction in the Middle East and North
Africa: A focus on Iran and Morocco
7. Abstract: Drug Abuse, HIV, and HCV in Asian Countries
8. Abstract: Taking care of themselves: how long-term injection drug users
remain HIV and Hepatitis C free
9. Abstract: Enhanced surveillance of tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis (Tdap) vaccines in pregnancy in the
Vaccine Adverse Event Reporting System (VAERS), 2011-2015
10. Abstract: Sterile Product Packaging and Delivery Systems
11. Abstract: Patients’ ability to treat anaphylaxis using adrenaline
autoinjectors: a randomized controlled trial
12. Abstract: Aerosolized Antibiotics
13. Abstract: Gloves Reprocessing: Does It Really Save Money?
14. Abstract: Occult Hepatitis B Virus Infection in Nigerian Blood Donors
and Hepatitis B Virus Transmission Risks
15. Abstract: Pre-Donation Screening of Volunteer Prisoner Blood Donors
for Hepatitis B And C in Prisons of Punjab, Pakistan
16. Abstract: Knowledge, Attitudes and Practices of Hepatitis B and C
Among Barbers of Urban and Rural Areas of Rawalpindi and Islamabad
17. No Abstract: Nosocomial transmission of dengue fever via needlestick.
An occupational risk
18. No Abstract: Policy change towards implementing harm reduction in Sub-
Saharan Africa
19. News
– China: China Arrests 37 For Selling Fake Vaccines

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1. Adopting a global safety standard for the prevention of Ebola needle-stick exposures

Crossposted with thanks from: Infect Control Hosp Epidemiol. 2015
Jun;36(6):745-6.
__________________________________________________________________
Open Access http://dx.doi.org/10.1017/ice.2015.62 Free Full Text

Infect Control Hosp Epidemiol. 2015 Jun;36(6):745-6.
Adopting a global safety standard for the prevention of Ebola needle-stick exposures.
Letter to the Editor

Adopting a Global Safety Standard for the Prevention of Ebola Needle-Stick Exposures

Gabriella De Carlia1 c1, Francesco M. Fuscoa1, Vincenzo Puroa1, Giuseppe
Ippolitoa1 and the EuroNHID Working Group

a1 Department of Epidemiology and Pre-Clinical Research, National
Institute for Infectious Diseases L. Spallanzani-IRCCS, Rome, Italy.
Members of the EuroNHID Working Group: Brodt RH, Schilling S, Gottschalk
R, Maltezou HC, Bannister B, Vetter N, Kojouharova M, Parmakova K,
Skinhoej P, Kronborg G, Siikamaki H, Brouqui P, Perronne C, Lambert J,
Hemmer R, Borg M, Azzopardi CM, Brantsæter AB, Fjellet AL, Horban A, Strle
F, Trilla A, De Iaco G.

(Online publication April 01 2015)

Correspondence

c1 Address correspondence to Gabriella De Carli, Infezioni Emergenti e
Riemergenti e Centro di Riferimento AIDS, National Institute for
Infectious Diseases, L. Spallanzani-IRCCS, Via Portuense 292, 00149, Rome,
Italy. (gabriella.decarli@inmi.it).
To the Editor — As of February 2, 2015, 13 healthcare workers (HCWs)
working for international organizations or volunteers who acquired Ebola
Virus Disease (EVD) in West Africa have been medically evacuated, and
another 12 were repatriated after sustaining a significant exposure
(frequently a contaminated needle stick)1,2 to specialized isolation
facilities in Europe with high-level isolation units.

These isolation facilities were identified early in the course of the
current epidemic as those better equipped and prepared to safely manage
EVD cases, being able to minimize the occupational risk for HCWs.

Actually, in 2009 the European Network for Highly Infectious Diseases
project,3 aiming to enhance and maintain preparedness and response,
cooperation, and exchange of information and experiences between isolation
facilities identified by the national health authorities as referral
centers in Europe, already recognized that HCWs had not only been
extensively trained in adopting high isolation precautions but had also
been adequately resourced with safety-engineered devices integrating a
protective mechanism for needle-stick prevention.

Adoption of safety- engineered devices at that time was not required by
European regulation, being implemented on a voluntary basis by hospitals
and facilities. All 48 isolation facilities visited had in place a written
procedure for needle- stick prevention and post-exposure management as
well as standardized systems for injury recording. All had adopted at
least 1 safety-engineered device (Table 1), all hollow-bore devices,
mainly for blood collection or central and peripheral vascular access. In
23 facilities, 7 or more of these devices were routinely in use, 3–6 were
in use in 22 facilities, and <3 were in use in the remaining 3 facilities.
In 46 facilities, some strategies were in place for the promotion and
implementation of safe practices for needle-stick prevention, with 25
performing specific practical exercises. Actions to monitor the correct
application of preventive procedures were specified by 18 facilities: 11
performed specific audits on this issue; HCWs were monitored by an expert
in 4 facilities; practical test after training and examination of sharp
containers were performed in 1 facility each.

Finally, in 3 facilities the only monitoring strategy was represented by
the analysis of accidents. Safety-Engineered Devices in Use in 48
Isolation Facilities Designated for the Referral and Management of Highly
Infectious Diseases in 16 European Countries (EuroNHID), 2009–2010

TABLE 1 Safety-Engineered Devices in Use in 48 Isolation Facilities
Designated for the Referral and Management of Highly Infectious Diseases
in 16 European Countries (EuroNHID), 2009–2010 https://tinyurl.com/j2sejgb

This extensive preparation and training is necessary because performing an
invasive procedure normally represents a risk and this risk is higher when
wearing a full gear with goggles and facial respirators. Among specific
factors possibly increasing the risk of contaminated sharps injuries,
visibility, communication, and range of motion were found to affect this
risk. High-efficiency particulate air respirators have a negative impact
on each of these variables,4 and wearing personal protective equipment for
highly infectious diseases may, to a degree, hinder a healthcare worker’s
ability to perform routine tasks.

Recent debate among medical experts is sharply divided over whether most
patients in West Africa should, or can, be given intravenous hydration.
Some have argued that more aggressive treatment with IV fluids is
medically possible and a moral obligation, and others have counseled
caution, saying that pushing too hard would put overworked doctors and
nurses in danger. It is difficult to insert needles while wearing three
pairs of gloves and foggy goggles: IVs must be monitored; drawing virus-
laden blood for tests is dangerous; and patients sometimes yank needles
out.5 Indeed, needle-stick injuries have been responsible for transmitting
Ebola and other hemorrhagic fever viruses in past outbreaks,6 and needle
sticks are considered a ‘high risk’ epidemiologic factor when evaluating a
person for exposure to Ebola virus.

Among the HCWs repatriated from Sierra Leone, a South Korean doctor was
evacuated to Germany after sustaining a needle stick while using a
hypodermic needle to draw blood from a patient with a very high viral load
who died the next day from EVD. After sustaining a needle stick with a
needle left in a bottle because the sharps container was too full, a US
doctor was medically evacuated, transported in isolation to the National
Institutes of Health in Bethesda, Maryland, and treated with an
experimental drug to prevent EVD; eventually it was determined that he was
uninfected. For the management of HCWs returning from Ebola-affected
areas, the European Centre for Disease Prevention and Control has
recommended active monitoring and restricted movement, social
interactions, and engagement in clinical activities for those HCWs who
sustain needle sticks.7

The first recommendation by the Emergency Care Research Institute (ECRI)
regarding equipment-related preparedness for Ebola is to use needle-stick
prevention devices, to ensure that all areas likely to be used for
treating Ebola patients have a full complement of those devices, and to
try out available devices to make sure their protective features can be
safely engaged when staff are double- or triple-gloved.8

HCW health and safety are of great concern in Europe and in the United
States, and they should be even more a priority in epidemic areas. Where
safety devices were introduced, with the help and support of international
programs for patient and HCW safety, no further needle-stick injuries were
reported in relation to the specific at-risk procedure.9 International
health organizations and authorities should support the provision of
protected needles to all those who are working in the worst affected West
African countries. Decreasing HCW risk should also be a moral obligation
to help create a “safe working environment to foster the development of
local expertise,”10 as well as to protect foreign HCWs seeking to stem the
Ebola epidemic. Such measures include more safely performing invasive
procedures such as intravenous rehydration and constant measuring of blood
chemistry, which hopefully increase patient survival, and avoiding
preventable injuries.

Acknowledgments

Financial support: This study was supported by grants from the European
Commission of the European Network for Highly Infectious Diseases (no.
2006205) and from the Italian Ministry of Health: Ricerca Corrente IRCCS,
and Ricerca Finalizzata 2009 (grant no. 1530527).
Potential conflict of interest: GDC and VP have developed educational
material for Becton Dickinson; FMF and GI report no conflicts related to
this article.

References

1. Epidemiological update: Outbreak of Ebola virus disease in West Africa
30/01/2015. European Centre for Disease Prevention and Control website.
http://www.ecdc.europa.eu/en/press/news/_layouts/forms/News_DispForm.aspx?
List=8db7286c-fe2d-476c-9133-18ff4cb1b568&ID=1160. Published 2015.
Accessed January 31, 2015.

2. Public Health England. Second healthcare worker transported to UK for
Ebola monitoring. Precautionary action taken, 2 similar incidents are
unrelated. United Kingdom government website.
https://www.gov.uk/government/news/second-healthcare-worker-transported-
to-uk-for-ebola-monitoring. Published 2015. Accessed February 13, 2015.

3. Ippolito, G, Puro, V, Brouqui, P, Lauria, F, Fusco, F; EuroNHID
Consortium. Letter to the editor: Management of patients with Ebola virus
disease in Europe: high-level isolation units should have a key role. Euro
Surveill 2014;19:20993. [PubMed] [Google Scholar]

4. Eck, EK, Vannier, A. The effect of high-efficiency particulate air
respirator design on occupational health: a pilot study balancing risks in
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5. McNeil, DG Jr. Ebola doctors are divided on IV therapy in Africa. The
New York Times, January 1, 2015.
http://www.nytimes.com/2015/01/02/health/ebola-doctors-are-divided-on-iv-
therapy-in-africa.html?_r=0#story-continues-1. Published 2015. Accessed
February 13, 2015.

6. Tarantola, A, Abiteboul, D, Rachline, A. Infection risks following
accidental exposure to blood or body fluids in health care workers: a
review of pathogens transmitted in published cases. Am J Infect Control
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7. Technical report: Infection prevention and control measures for Ebola
virus disease. Management of healthcare workers returning from Ebola-
affected areas. European Centre for Disease Prevention and Control
website.
www.ecdc.europa.eu/en/publications/Publications/Management-HCW-return-
Ebola-affected-areas.pdf. Published 2015. Accessed January 31, 2015.

8. Guidance. Checklist: equipment-related preparedness for Ebola.
Emergency Care Research Institute website.
https://www.ecri.org/components/HDJournal/Pages/Checklist-Equipment-
Related-Preparedness-for-Ebola.aspx. Published 2014. Accessed January 31,
2015.

9. Rouveix, E, Madougou, B, Pellissier, G, et al. Promoting the safety of
healthcare workers in Africa: from HIV pandemic to Ebola epidemic. Infect
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On the front lines of Lassa fever. Emerg Infect Dis 2004;1:1889–1890.
[Google Scholar]
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Needle Stick Injuries and their Related Safety Measures among
Nurses in a University Hospital, Shiraz, Iran
__________________________________________________________________

Open Access http://www.e-shaw.net/article/S2093-7911(15)00062-1/abstract

Saf Health Work. 2016 Mar;7(1):72-7.
Needle Stick Injuries and their Related Safety Measures among Nurses in a
University Hospital, Shiraz, Iran.

Jahangiri M1, Rostamabadi A2, Hoboubi N3, Tadayon N3, Soleimani A3.
Author information
1Department of Occupational Health, School of Health, Shiraz University of
Medical Sciences, Shiraz, Iran.
2Department of Occupational Health, Ashtian Health Care Center, Arak
University of Medical Sciences, Arak, Iran; Student Research Committee,
Shiraz University of Medical Sciences, Shiraz, Iran.
3Student Research Committee, Shiraz University of Medical Sciences,
Shiraz, Iran.

BACKGROUND: This study aimed to determine the prevalence and factors
related to needle stick injuries (NSIs) and to assess related safety
measures among a sample of Iranian nurses.

METHODS: In this cross-sectional study, a random sample of 168 registered
active nurses was selected from different wards of one of the hospitals of
Shiraz University of Medical Sciences (SUMS). Data were collected by an
anonymous questionnaire and a checklist based observational method among
the 168 registered active nurses.

RESULTS: The prevalence of NSIs in the total of work experience and the
last year was 76% and 54%, respectively. Hollow-bore needles were the most
common devices involved in the injuries (85.5%).

The majority of NSIs occurred in the morning shift (57.8%) and the most
common activity leading to NSIs was recapping needles (41.4%).

The rate of underreporting NSIs was 60.2% and the major reasons for not
reporting the NSIs were heavy clinical schedule (46.7%) and perception of
low risk of infection (37.7%).

A statistically significant relationship was found between the occurrence
of NSIs and sex, hours worked/week, and frequency of shifts/month.

CONCLUSION: The study showed a high prevalence of NSIs among nurses.
Supportive measures such as improving injection practices, modification of
working schedule, planning training programs targeted at using personal
protective equipment, and providing an adequate number of safety
facilities such as puncture resistant disposal containers and engineered
safe devices are essential for the effective prevention of NSI incidents
among the studied nurses.

KEYWORDS: needle stick injuries (NSIs); nurses; safety injection index
(SII)

Free Article http://dx.doi.org/10.1016/j.shaw.2015.07.006
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Underreporting of blood exposure incidents: a worrying
situation among nursing students
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26946805

Rech Soins Infirm. 2015 Dec;(123):49-65.
[Underreporting of blood exposure incidents: a worrying situation among
nursing students].

[Article in French]

Noé C.

Accidental blood exposure incidents require immediate medical evaluation,
permitting early treatment, if needed, for a possible infection and enable
identification of the work accident in case of HIV infectivity status.

A study wax [was] conducted with nursing students in two different years
of study in order to formalize the rate of underreporting of blood
exposure incidents and to determine the reasons.

The results highlight that, over a period of three years of training, 52 %
of blood exposure incidents have not been declared as occupational
accidents.

The reasons for nursing students underreporting of blood exposure
incidents are related on the one hand to the negative perceptions and
feelings that students have (personal fault 55 % and awkwardness 82 %) and
to the fear of negatives consequences (31 %) on the evaluation of their
internship in particular and on their nursing training in general.

On the other hand, students tend to conform to other caregivers who
themselves underestimate the risk of blood exposure incidents (22 %).

The identification of these elements will help to initiate a discussion
and to prepare direct actions in order to encourage reporting of blood
exposure incidents by nursing students and their colleagues during
internships.
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Hepatitis B Virus infection and its modes of prevention among
clinical students of Obafemi Awolowo University (OAU), Ile-Ife, Nigeria
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26949778

Afr J Med Med Sci. 2014 Dec;43 Suppl:31-7.
Hepatitis B Virus infection and its modes of prevention among clinical
students of Obafemi Awolowo University (OAU), Ile-Ife, Nigeria.

Atiba BP, Ajao KO, Babalola RN, Awosusi AE, Ayeni OO, Ijadunola KT.

BACKGROUND: Hepatitis B is a major global health problem and is a major
infectious and occupational hazard for health workers, especially doctors,
nurses, dentists and laboratory staff, including those who are under
training, because of exposure to patients’ body fluids during clinical
activities. Clinical students are also at risk of HBV infection during
their training in medical school. HBV vaccination status is very low among
medical students in Nigeria

AIM: This study assessed the knowledge of clinical students of the Obafemi
Awolowo University (OAU), Ile-Ife about hepatitis B virus infection and
its modes of prevention.

METHODS: A descriptive cross-sectional study was conducted among all 594
clinical students of OAU using a pretested, self-administered, semi-
structured questionnaire. Data were analysed and summarized using
descriptive and inferential statistics (logistic regression).

RESULTS: Four hundred and thirty (72.4%) respondents correctly identified
four modes of transmission, while 470 (79%) respondents reported
vaccination as a mode of prevention of HBV infection. Of all the
respondents, 61.6% had ever received Hepatitis B virus vaccine, while only
39.2% of the respondents had received at least three doses of HBV vaccine.
At bivariate level, gender (?2 = 23.685, p < 0.001) and level of study (?2
= 7.383, p < 0.05) were significantly associated with HBV vaccine uptake.
At multivariate level, gender (OR = 2.58, 95% CI = 1.80-3.7 1) and level
of study (OR = 1.71, 95% CI =1.14-2.54) remained significantly associated
with HBV vaccine uptake.

CONCLUSION: The study concluded that clinical students had poor knowledge
of safe sexual practices and post-exposure prophylaxis as preventive
measures. The uptake of HBV vaccine was also poor. The significant
correlates of vaccine uptake were gender and level of study.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Optimising health and safety of people who inject drugs
during transition from acute to outpatient care: narrative review with
clinical checklist
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27004476
Postgrad Med J. 2016 Mar 22. pii: postgradmedj-2015-133720.

Optimising health and safety of people who inject drugs during transition
from acute to outpatient care: narrative review with clinical checklist.

Thakarar K1, Weinstein ZM2, Walley AY2.

1Department of Medicine/Infectious Diseases, Maine Medical Center,
Portland, Maine, USA.
2Clinical Addiction Research and Education Unit, Section of General
Internal Medicine, Department of Medicine, Boston University School of
Medicine/Boston Medical Center, Boston, Massachusetts, USA.

The opioid epidemic in the USA continues to worsen. Medical providers are
faced with the challenge of addressing complications from opioid use
disorders and associated injection drug use.

Unsafe injection practices among people who inject drugs (PWID) can lead
to several complications requiring acute care encounters in the emergency
department and inpatient hospital.

Our objective is to provide a narrative review to help medical providers
recognise and address key health issues in PWID, who are being released
from the emergency department and inpatient hospital. In the midst of
rises in overdose deaths and infections such as hepatitis C, we highlight
several health issues for PWID, including overdose and infection
prevention.

We provide a clinical checklist of actions to help guide providers in the
care of these complex patients. The clinical checklist includes strategies
also applicable to low-resource settings, which may lack addiction
treatment options.

Our review and clinical checklist highlight key aspects of optimising the
health and safety of PWID.

Published by the BMJ Publishing Group Limited.

KEYWORDS: VIROLOGY
__________________________________________________________________
________________________________*_________________________________

6. Abstract: The state of harm reduction in the Middle East and North
Africa: A focus on Iran and Morocco
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27012581

Int J Drug Policy. 2016 Feb 19. pii: S0955-3959(16)30022-6.
The state of harm reduction in the Middle East and North Africa: A focus
on Iran and Morocco.

Himmich H1, Madani N2.

1Association de Lutte contre le Sida, Casablanca, Morocco. Electronic
address: h.himmich@gmail.com.
2Dana-Farber Cancer Institute, Boston, MA, United States. Electronic
address: navid_madani@dfci.harvard.edu.

HIV/AIDS and hepatitis C among people who inject drugs are on the rise in
the Middle East and North Africa (MENA) region. But the regional response
to the epidemic falls short both in terms of the quality and scale of
response.

From the threat of the death sentence for drug offenses to the burden of
refugees fleeing conflict, there are many legal, political and social
barriers that hinder the introduction and expansion of harm reduction in
the region.

However Iran and Morocco are two pioneering countries and over the last
decade they have been providing evidence that harm reduction is feasible
and acceptable in MENA.

Using different approaches, these two countries have overcome various
obstacles and encouraged discussion and collaboration among stakeholders,
including government, health professionals, civil society and community-
based organizations. In so doing they have created an enabling environment
to endorse a national harm strategy.

Copyright © 2016 Elsevier B.V. All rights reserved.

KEYWORDS: Drug policy; Harm reduction; Iran; MENA; Morocco
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Drug Abuse, HIV, and HCV in Asian Countries
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27000123

J Neuroimmune Pharmacol. 2016 Mar 21.
Drug Abuse, HIV, and HCV in Asian Countries.

Hser YI1,2, Liang D3, Lan YC4, Vicknasingam BK5, Chakrabarti A6.

1University of California, Los Angeles, Los Angeles, CA, USA.
yhser@ucla.edu.
2China Medical University, Taichung City, Taiwan. yhser@ucla.edu.
3University of California, Los Angeles, Los Angeles, CA, USA.
4China Medical University, Taichung City, Taiwan.
5Centre for Drug Research, Universiti Sains Malaysia, Gelugor, Penang,
Malaysia.
6Regional Occupational Health Centre (ROHC), Eastern, National Institute
of Occupational Health, Ahmedabad, Gujarat, India.

Drug abuse and co-occurring infections are associated with significant
morbidity and mortality. Asian countries are particularly vulnerable to
the deleterious consequences of these risks/problems, as they have some of
the highest rates of these diseases.

This review describes drug abuse, HIV, and hepatitis C (HCV) in Asian
countries. The most commonly used illicit drugs include opioids,
amphetamine-type stimulants (ATS), cannabis, and ketamine.

Among people who inject drugs, HIV rates range from 6.3 % in China to 19 %
in Malaysia, and HCV ranges from 41 % in India and Taiwan to 74 % in
Vietnam.

In the face of the HIV epidemics, drug policies in these countries are
slowly changing from the traditional punitive approach (e.g.,
incarcerating drug users or requiring registration as a drug user) to
embrace public health approaches, including, for example, community-based
treatment options as well as harm reduction approaches to reduce needle
sharing and thus HIV transmission. HIV and HCV molecular epidemiology
indicates limited geographic diffusion.

While the HIV prevalence is declining in all five countries, use of new
drugs (e.g., ATS, ketamine) continues to increase, as well as high-risk
sexual behaviors associated with drug use-increasing the risk of sexual
transmission of HIV, particularly among men who have sex with men.

Screening, early intervention, and continued scaling up of therapeutic
options (drug treatment and recovery support, ART, long-term HIV and HCV
care for drug users) are critical for effective control or continued
reduction of drug abuse and co-infections.

KEYWORDS: Asia; China; Drug abuse; HCV; HIV; India; Malaysia; Taiwan;
Vietnam
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Taking care of themselves: how long-term injection drug users
remain HIV and Hepatitis C free
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25688570

Sociol Health Illn. 2015 May;37(4):626-41.
Taking care of themselves: how long-term injection drug users remain HIV
and Hepatitis C free.

Meylakhs P1, Friedman SR2, Mateu-Gelabert P2, Sandoval M2, Meylakhs N3.

1Laboratory for Comparative Social Research, National Research University
Higher School of Economics, St. Petersburg, Russia.
2National Development and Research Institutes, New York, USA.
3International Center for AIDS Research and Training, Botkin Hospital for
Infectious Diseases, St. Petersburg, Russia and Centre for Independent
Social Research, St. Petersburg, Russia.

Though prevalence of HIV and especially Hepatitis C is high among people
who inject drugs (PWID) in New York, about a third of those who have
injected for 8-15 years have avoided infection by either virus despite
their long-term drug use. Based on life history interviews with 35 long-
term PWID in New York, this article seeks to show how successful
integration and performance of various drug using and non-drug using roles
may have contributed to some of these PWID’s staying uninfected with
either virus.

We argue that analysis of non-risk related aspects of the lives of the
risk-takers (PWID) is very important in understanding their risk-taking
behaviour and its outcomes (infection statuses). Drawing on work-related,
social and institutional resources, our double-negative informants
underwent both periods of stability and turmoil without getting infected.

© 2015 The Authors. Sociology of Health & Illness © 2015 Foundation for
the Sociology of Health & Illness/John Wiley & Sons Ltd.

KEYWORDS: HIV and HCV prevention; New York City; injection drug users;
qualitative study; role theory
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Enhanced surveillance of tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis (Tdap) vaccines in pregnancy in the
Vaccine Adverse Event Reporting System (VAERS), 2011-2015
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27013434

Vaccine. 2016 Mar 21. pii: S0264-410X(16)30032-9.

Enhanced surveillance of tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis (Tdap) vaccines in pregnancy in the Vaccine Adverse
Event Reporting System (VAERS), 2011-2015.

Moro PL1, Cragan J2, Tepper N3, Zheteyeva Y4, Museru O5, Lewis P5, Broder
K5.

1Immunization Safety Office, Division of Healthcare Quality Promotion,
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID),
Centers for Disease Control and Prevention (CDC), <add>1600 Clifton Road,
MS D26</add>, Atlanta, GA 30333, USA. Electronic address: pmoro@cdc.gov.
2Birth Defects Branch, Division of Birth Defects and Developmental
Disabilities, National Center on Birth Defects and Developmental
Disabilities (NCBDDD), CDC, Atlanta, GA 30333, USA.
3Women’s Health and Fertility Branch, Division of Reproductive Health,
National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP), CDC, Atlanta, GA 30333, USA.
4Community Interventions for Infection Control Unit, Division of Global
Migration and Quarantine, CDC, Atlanta, GA 30333, USA.
5Immunization Safety Office, Division of Healthcare Quality Promotion,
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID),
Centers for Disease Control and Prevention (CDC), <add>1600 Clifton Road,
MS D26, Atlanta, GA 30333, USA.

BACKGROUND: In October 2011, the Advisory Committee on Immunization
Practices (ACIP) issued updated recommendations that all pregnant women
routinely receive a dose of tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis (Tdap) vaccine.

OBJECTIVES: We characterized reports to the Vaccine Adverse Event
Reporting System (VAERS) in pregnant women who received Tdap after this
updated recommendation (2011-2015) and compared the pattern of adverse
events (AEs) with the period before the updated recommendation
(2005-2010).

METHODS: We searched the VAERS database for reports of AEs in pregnant
women who received Tdap vaccine after the routine recommendation
(11/01/2011-6/30/2015) and compared it to published data before the
routine Tdap recommendation (01/01/2005-06/30/2010). We conducted clinical
review of reports and available medical records. The clinical pattern of
reports in the post-recommendation period was compared with the pattern
before the routine Tdap recommendation.

RESULTS: We found 392 reports of Tdap vaccination after the routine
recommendation. One neonatal death but no maternal deaths were reported.
No maternal or neonatal deaths were reported before the recommendation. We
observed an increase in proportion of reports for stillbirths (1.5-2.8%)
and injection site reactions/arm pain (4.5-11.9%) after the recommendation
compared to the period before the routine recommendation for Tdap during
pregnancy. We noted a decrease in reports of spontaneous abortion
(16.7-1%). After the 2011 Tdap recommendation, in most reports,
vaccination (79%) occurred during the third trimester compared to 4%
before the 2011 Tdap recommendation. Twenty-six reports of repeat Tdap
were received in VAERS; 13 did not report an AE. One medical facility
accounted for 27% of all submitted reports.

CONCLUSIONS: No new or unexpected vaccine AEs were noted among pregnant
women who received Tdap after routine recommendations for maternal Tdap
vaccination. Changes in reporting patterns would be expected, given the
broader use of Tdap in pregnant women in the third trimester.

Copyright © 2016. Published by Elsevier Ltd.

KEYWORDS: Adverse events; Epidemiology; Pregnancy; Surveillance; Tdap;
Vaccine safety
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Sterile Product Packaging and Delivery Systems
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26891564

Int J Pharm Compd. 2015 Nov-Dec;19(6):491-500.
Sterile Product Packaging and Delivery Systems.

Akers MJ.

Both conventional and more advanced product container and delivery systems
are the focus of this brief article. Six different product container
systems will be discussed, plus advances in primary packaging for special
delivery systems and needle technology.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Patients’ ability to treat anaphylaxis using adrenaline
autoinjectors: a randomized controlled trial
__________________________________________________________________

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654245/

Allergy. 2015 Jul;70(7):855-63.
Patients’ ability to treat anaphylaxis using adrenaline autoinjectors: a
randomized controlled trial.

Umasunthar T1,2, Procktor A1,2, Hodes M2,3, Smith JG4, Gore C1,2, Cox
HE1,2, Marrs T5, Hanna H1,2, Phillips K1,2, Pinto C1,2, Turner PJ1, Warner
JO1,2, Boyle RJ1,2.

1Section of Paediatrics, Imperial College London, London, UK.
2Imperial College Healthcare NHS Trust, St. Mary’s Hospital, London, UK.
3Academic Unit of Child and Adolescent Psychiatry, Imperial College
London, London, UK.
4Population Health Research Institute, St. George’s, University of London,
London, UK.
5Department of Paediatric Allergy, Division of Asthma, Allergy and Lung
Biology, King’s College London, London, UK.

BACKGROUND: Previous work has shown patients commonly misuse adrenaline
autoinjectors (AAI). It is unclear whether this is due to inadequate
training, or poor device design. We undertook a prospective randomized
controlled trial to evaluate ability to administer adrenaline using
different AAI devices.

METHODS: We allocated mothers of food-allergic children prescribed an AAI
for the first time to Anapen or EpiPen using a computer-generated
randomization list, with optimal training according to manufacturer’s
instructions. After one year, participants were randomly allocated a new
device (EpiPen, Anapen, new EpiPen, JEXT or Auvi-Q), without device-
specific training. We assessed ability to deliver adrenaline using their
AAI in a simulated anaphylaxis scenario six weeks and one year after
initial training, and following device switch.

Primary outcome was successful adrenaline administration at six weeks,
assessed by an independent expert. Secondary outcomes were success at one
year, success after switching device, and adverse events.

RESULTS: We randomized 158 participants. At six weeks, 30 of 71 (42%)
participants allocated to Anapen and 31 of 73 (43%) participants allocated
to EpiPen were successful – RR 1.00 (95% CI 0.68-1.46).

uccess rates at one year were also similar, but digital injection was more
common at one year with EpiPen (8/59, 14%) than Anapen (0/51, 0%, P =
0.007). When switched to a new device without specific training, success
rates were higher with Auvi- Q (26/28, 93%) than other devices (39/80,
49%; P < 0.001).

CONCLUSIONS: AAI device design is a major determinant of successful
adrenaline administration. Success rates were low with several devices,
but were high using the audio-prompt device Auvi-Q.

© 2015 The Authors Allergy Published by John Wiley & Sons Ltd.

KEYWORDS: adrenaline; anaphylaxis; autoinjector; food allergy; human
factors research

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654245/
__________________________________________________________________
________________________________*_________________________________

12. Abstract: Aerosolized Antibiotics
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26070573

Respir Care. 2015 Jun;60(6):762-1; discussion 771-3. d
Aerosolized Antibiotics.

Restrepo MI1, Keyt H2, Reyes LF3.

1University of Texas Health Science Center at San Antonio, San Antonio,
Texas. South Texas Veterans Health Care System, San Antonio, Texas.
restrepom@uthscsa.edu.
2University of Texas Health Science Center at San Antonio, San Antonio,
Texas.
3University of Texas Health Science Center at San Antonio, San Antonio,
Texas. Universidad de La Sabana, Bogota, Colombia.

Administration of medications via aerosolization is potentially an ideal
strategy to treat airway diseases. This delivery method ensures high
concentrations of the medication in the targeted tissues, the airways,
with generally lower systemic absorption and systemic adverse effects.

Aerosolized antibiotics have been tested as treatment for bacterial
infections in patients with cystic fibrosis (CF), non-CF bronchiectasis
(NCFB), and ventilator-associated pneumonia (VAP).

The most successful application of this to date is treatment of infections
in patients with CF.

It has been hypothesized that similar success would be seen in NCFB and in
difficult-to-treat hospital-acquired infections such as VAP.

This review summarizes the available evidence supporting the use of
aerosolized antibiotics and addresses the specific considerations that
clinicians should recognize when prescribing an aerosolized antibiotic for
patients with CF, NCFB, and VAP.

Copyright © 2015 by Daedalus Enterprises.

KEYWORDS: aerosols; antibacterial agents; bronchiectasis; cystic fibrosis
(CF); ventilator-associated pneumonia (VAP)
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Gloves Reprocessing: Does It Really Save Money?
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27011553

Indian J Surg. 2015 Dec;77(Suppl 3):1291-4.
Gloves Reprocessing: Does It Really Save Money?

Arora P1, Kumari S2, Sodhi J1, Talati S1, Gupta AK1.

1Department of Hospital Administration, Postgraduate Institute of Medical
Education and Research, Chandigarh, India.
2Central Sterile Supply Department, Postgraduate Institute of Medical
Education and Research, Chandigarh, India.

Gloves are reprocessed and reused in health-care facilities in resource-
limited settings to reduce the cost of availability of gloves.

The study was done with the aim to compute the cost of reprocessing of
gloves so that an economically rationale decision can be taken.

A retrospective record-based cross-sectional study was undertaken in a
central sterile supply department where different steps during
reprocessing of gloves were identified and the cost involved in
reprocessing per pair of gloves was calculated. The cost of material and
manpower was calculated to arrive at the cost of reprocessing per pair of
gloves.

The cost of a reprocessed pair of surgical gloves was calculated to be
Indian Rupee (INR) 14.33 which was greater than the cost of a new pair of
disposable surgical gloves (INR 9.90) as the cost of sterilization of one
pair of gloves itself came out to be INR 10.97.

The current study showed that the purchase of sterile disposable single-
use gloves is cheaper than the process of recycling.

Reprocessing of gloves is not economical on tangible terms even in
resource-limited settings, and from the perspective of better infection
control as well as health-care worker safety, it further justifies the use
of disposable gloves.

KEYWORDS: Cost; Gloves; Health-care worker safety; Reprocessing
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Occult Hepatitis B Virus Infection in Nigerian Blood Donors
and Hepatitis B Virus Transmission Risks
__________________________________________________________________

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0131912
Free PLOS Article

PLoS One. 2015 Jul 6;10(7):e0131912.
Occult Hepatitis B Virus Infection in Nigerian Blood Donors and Hepatitis
B Virus Transmission Risks.

Oluyinka OO1, Tong HV2, Bui Tien S3, Fagbami AH4, Adekanle O5, Ojurongbe
O1, Bock CT6, Kremsner PG2, Velavan TP7.

1Institute of Tropical Medicine, University of Tübingen, Tübingen,
Germany; Deparment of Medical Microbiology and Parasitology, Ladoke
Akintola University of Technology, Ogbomosho, Nigeria.
2Institute of Tropical Medicine, University of Tübingen, Tübingen,
Germany.
3Department of Infectious Diseases, Robert Koch Institute, Berlin,
Germany; Department of Molecular Biology, 108 Military Central Hospital,
Hanoi, Vietnam.
4Deparment of Medical Microbiology and Parasitology, Ladoke Akintola
University of Technology, Ogbomosho, Nigeria.
5Obafemi Awolowo University, Ile Ife, Nigeria.
6Department of Infectious Diseases, Robert Koch Institute, Berlin,
Germany; Department of Molecular Pathology, University of Tübingen,
Tübingen, Germany.
7Institute of Tropical Medicine, University of Tübingen, Tübingen,
Germany; Fondation Congolaise pour la Recherche Medicale, Brazzaville,
Republic of Congo.

BACKGROUND: Occult hepatitis B virus infection (OBI) characterized by the
absence of detectable HBsAg remains a potential threat in blood safety. We
investigated the actual prevalence, viral factors and genotype of OBI
infections in Nigerian blood donors.

METHODS: Serum collected from two blood banks were reconfirmed as HBsAg
seronegative by ELISA. Forty HBsAg positive samples were employed as
controls. HBV-DNA was amplified from all donors and viral loads were
determined using quantitative real-time PCR. Antibodies to the HBV core,
surface and HBe antigen (anti-HBc,anti-HBs,HBeAg) were measured. The
PreS/S and PreC/C regions of the HBV genome were sequenced.

RESULTS: Of the 429 blood donors, 72(17%) were confirmed as OBI by DNA
detection in different reference labs and excluded the concern of possible
contamination. Of the 72 OBI samples, 48(67%) were positive for anti-HBc,
25(35%) positive for anti-HBs, and 2(3%) positive for HBeAg. Of the 72 OBI
samples, 31(43%) were seropositive for either anti-HBc, anti-HBs or HBeAg,
21 (30%) positive for both anti-HBc and anti-HBs,one positive for both
anti-HBc and HBeAg. None of the OBI samples were positive for all three
serological markers. The viral load was <50copies/ml in the OBI samples
and genotype E was predominant. The L217R polymorphism in the reverse
transcriptase domain of the HBV polymerase gene was observed significantly
higher in OBI compared with HBsAg positive individuals (P<0.0001).

CONCLUSION: High incidence of OBI is relevant in high endemic areas
worldwide and is a general burden in blood safety. This study signifies
the high prevalence of OBI and proposes blood donor samples in Nigeria
should be pre-tested for OBI by nucleic acid testing (NAT) and/or anti-HBc
prior to transfusion to minimize the HBV infection risk.

Free PLOS Article
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0131912
__________________________________________________________________
________________________________*_________________________________

15. Abstract: Pre-Donation Screening of Volunteer Prisoner Blood Donors
for Hepatitis B And C in Prisons of Punjab, Pakistan
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27004325

J Ayub Med Coll Abbottabad. 2015 Oct-Dec;27(4):794-7.
Pre-Donation Screening of Volunteer Prisoner Blood Donors for Hepatitis B
And C in Prisons of Punjab, Pakistan.

Pervaiz A, Sipra FS, Rana TH, Qadeer I.

BACKGROUND: Prisoners as a high risk group are never recommended for blood
donations. In Pakistan, prisoners are legally allowed to donate blood and
get thirty days extra remission. Inspectorate of prisons allowed Alizaib
Foundation for blood donation camps subject to predonation screening of
volunteer prisoner blood donor against infectious diseases. This study was
conducted to identify the potential benefits of pre-donation screening.

METHODS: This cross sectional study was conducted in October, 2009 in
Punjab. Intending volunteer prisoner blood donors from January, 2007 to
September, 2009 from prisons of Punjab were included. Physically fit were
tested for Hepatitis C Virus (HCV) and B Virus (HBV) by Rapid test kit
before bleeding. Data was analysed by Epi-Info.

RESULTS: A total of 5894 male volunteer prisoner donors were screened and
1038 (17.6%) were rejected. The mean age was 28 years (range: 17-70
years). Of 5894, 857 (14.5%) were HCV positive and 222 (3.8%) were HBV
positive. HCV & HBV co-infection was present among 41 (0.7%). Being
convicted prisoner blood donor is significantly associated with higher
seroprevalence for HCV (OR 1.35, 95% C.I. 1.17-1.57) and being under trial
prisoner is significantly associated with higher seroprevalence for HBV
(OR 1.40, 95% C.I. 1.06-1.85).

CONCLUSION: Hepatitis B & C viruses were responsible for almost 18%
prisoner blood donor rejection. Pre-donation screening of blood donors is
an effective intervention to improve the safety and limit the cost of
blood. Treatment of identified cases may contribute to public health. In
the international scenario this study findings necessitate the amendments
in the relevant prison rules.
__________________________________________________________________
________________________________*_________________________________

16. Abstract: Knowledge, Attitudes and Practices of Hepatitis B and C
Among Barbers of Urban and Rural Areas of Rawalpindi and Islamabad
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27004334

J Ayub Med Coll Abbottabad. 2015 Oct-Dec;27(4):832-6.
Knowledge, Attitudes and Practices of Hepatitis B and C Among Barbers of
Urban and Rural Areas of Rawalpindi and Islamabad.

Shah HB, Dar MK, Jamil AA, Atif I, Ali RJ, Sindhu AS, Usmani AQ.

BACKGROUND: Hepatitis B and Hepatitis C are serious global public health
problems with a prevalence of 10-15% with majority of the cases seen in
the developing countries including Pakistan. It is a blood borne infection
transmitted by infected blood and blood products through transfusions,
contaminated needles, vertical transmission, unsafe sex and reuse of
razors by barbers.

The literature search so far did not reveal any study comparing knowledge,
attitude and practices of hepatitis B & C in barbers working in Urban and
rural areas.

METHODS: A comparative cross sectional survey was carried out among
barbers of urban and rural areas of Rawalpindi and Islamabad. A structured
close ended questionnaire was filled from total of 202 barbers by non-
probability convenience sampling technique. Comparative data analysis was
done including variables like age, education, knowledge about hepatitis B
& C, mode of transmission, role of the blades and media etc.

RESULTS: Knowledge about hepatitis B & C was good in urban areas (92%) as
compared to those working in the rural areas (68%). Using new blade for
every customer was seen in urban (100%) and rural (93%) area. However
barbers knowledge about symptoms of the disease (urban 81% & rural 93%)
and vaccination trend of Hepatitis B was low.

CONCLUSION: This study showed a marked difference in the knowledge,
attitude and practices of the barbers working in the urban and the rural
areas. Main focus should be on launching Health education programs and
behaviour change communication campaigns for the barbers. Strict
regulatory monitoring must be done against unlicensed street barbers.

https://www.ncbi.nlm.nih.gov/pubmed/27004334
__________________________________________________________________
________________________________*_________________________________

17. No Abstract: Nosocomial transmission of dengue fever via needlestick.
An occupational risk
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25936825

Travel Med Infect Dis. 2015 May-Jun;13(3):271-3.
Nosocomial transmission of dengue fever via needlestick. An occupational
risk.

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

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

18. No Abstract: Policy change towards implementing harm reduction in Sub-
Saharan Africa
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27017377

Int J Drug Policy. 2016 Mar 9. pii: S0955-3959(16)30061-5.
Policy change towards implementing harm reduction in Sub-Saharan Africa.

Abdool R1.

1Consultant HIV Expert, Formerly United Nations Office of Drugs and Crime,
Nairobi, Kenya. Electronic address: reychad.abdool@gmail.com.
__________________________________________________________________
________________________________*_________________________________

19. News

– China: China Arrests 37 For Selling Fake Vaccines

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/jkqvhee
China: China Arrests 37 For Selling Fake Vaccines

By Catherine Cabral-Isabedra, Tech Times (23.03.16)

Arrest: Chinese officials arrest 37 over their suspected involvement in
the fake vaccine scandal. The poorly stored vaccines were distributed to
about 24 provinces, including Beijing, Guangdong and Chongqing.
(Photo : Keith Allison | Flickr)

Chinese officials detained 37 people involved in the manufacture and sale
of fake vaccines, state media reports.

About a month ago, a mother and daughter made headlines as they were
detained in relation to the fake vaccines scandal. The duo is thought to
have sold almost $100 million worth of suspected counterfeit vaccines
since 2011. The food and drug office in the province of Shandong province
is now on the lookout for the suspected buyers and sellers of the fake
vaccines.

Officials estimate that at least 300 persons are involved in the criminal
vaccine network that spans 24 provinces and cities that include Guangdong,
Beijing and Chongqing. A thorough investigation is now in place as about
nine suspected pharmaceutical wholesalers are thought to have distributed
the vaccines.

On Monday, the Food and Drug Administration started an investigation to
find out how the vaccines were manufactured, distributed and used.

The list of vaccines that were improperly refrigerated and deemed
ineffective include vaccinations for Japanese encephalitis, polio, mumps,
rabies and hepatitis B.

The World Health Organization’s (WHO) office in China declared support to
Chinese health officials in the crackdown of fake vaccines. It also
advised that vaccines should be properly managed and stored in order to
keep its potency. Improperly stored vaccines may become ineffective in
providing protection for vaccinated children.

As residents of involved provinces blame ineffective vaccines for serious
illnesses of their children, WHO clarifies that poorly stored vaccines may
not confer immunity to the illness but it cannot cause severe illnesses,
as previously contested.

The scandal made Chinese Premier Li Keqiang issue a standing order for
government institutions to work collectively in investigating the matter.
He also vowed to prosecute the involved criminals and negligent government
officials.

“This vaccine safety incident has created a deep concern among the public
and laid bare numerous regulatory loopholes,” said Li.

This is not the first time that China was involved in a fake vaccine
scandal. There were prior reports of ineffective vaccines sold in the
market.

Photo: Keith Allison | Flickr
__________________________________________________________________
________________________________*_________________________________

New WHO Injection Safety Guidelines

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

The new guideline is:

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

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

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

This is an illustrated summary brochure for the general public.

pdf, 554kb [6 pages]

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

SIGN Meeting 2015

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

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

A report of the meeting will be posted ASAP
__________________________________________________________________
________________________________*_________________________________
* SAFETY OF INJECTIONS brief yourself at: www.injectionsafety.org

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

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

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

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

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

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The SIGN Secretariat, the Department of Health Systems Policies and
Workforce, WHO, Avenue Appia 20, CH-1211 Geneva 27, Switzerland.
Facsimile: +41 22 791 4836 E- mail: sign@who.int
__________________________________________________________________
________________________________*_________________________________
All members of the SIGN Forum are invited to submit messages, comment on
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The SIGN Forum welcomes new subscribers who are involved in injection
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We would like your help in building this archive. Please send your old
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________________________________*_________________________________

The SIGN Internet Forum was established at the initiative of the World
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The SIGN Secretariat home is the Service Delivery and Safety (SDS)
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The SIGN Forum is moderated by Allan Bass and is hosted on the University
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__________________________________________________________________

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