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SIGNpost 00855

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00855    Intradermal Vax + Abstracts + News     01 June 2016

CONTENTS
0. Moderators Note
1. Blog: When less is more: why intradermal vaccine delivery matters to
global health
2. Global: Nearly 1000 Healthcare Workers Killed Since 2014, WHO Says
3. Abstract: Transmission of blood-borne pathogens in US dental health
care settings: 2016 Update
4. Abstract: Cost-Effectiveness Analysis of Safety-Engineered Devices
5. Abstract: Fungal Infections Associated with Contaminated Steroid
Injections
6. Abstract: Preoperative Hip Injections Increase the Rate of
Periprosthetic Infection After Total Hip Arthroplasty
7. Abstract: Needle-free jet injector intradermal delivery of fractional
dose inactivated poliovirus vaccine: Association between injection
quality and immunogenicity
8. Abstract: Assessment and selection of the best treatment alternative
for infectious waste by modified Sustainability Assessment of
Technologies methodology
9. Abstract: Academic physicians’ and medical students’ perceived barriers
toward bystander administered naloxone as an overdose prevention
strategy
10. Abstract: Can HIV and Hepatitis C Virus Infection be Eliminated Among
Persons Who Inject Drugs?
11. Abstract: A cross-national analysis of the effects of methadone
maintenance and needle and syringe program implementation on incidence
rates of HIV in Europe from 1995 to 2011
13. Abstract: Digital Subtraction Angiography Use During Epidural Steroid
Injections Does Not Reliably Distinguish Artery from Vein
14. Abstract: Mycobacterium abscessus Infection After Facial Injection
With Autologous Fat: A Case Report
15. No Abstract: Nurses should insist trusts obey sharp safety law
16. News
– India: 2234 Get HIV Due to Contaminated Blood, UP Tops the List: RTI
– Michigan USA: Free needle drop off will take place June 10

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1. Blog: When less is more: why intradermal vaccine delivery matters to
global health

Crossposted with thanks from the PATHblog… Stories of Innovation and
Impact http://blog.path.org/
__________________________________________________________________
https://tinyurl.com/jxchkeh Article and photos at the link
When less is more: why intradermal vaccine delivery matters to global
health

By Darin Zehrung, PATH, USA (27.05.16) [Edited]

Novel delivery solutions can help overcome shortages of polio vaccine,
ensuring children receive the protection they need.

Sustaining high-immunization coverage is critical to eliminating polio and
ultimately global eradication. As countries continue to introduce
inactivated poliovirus vaccine (IPV) into routine immunization schedules,
strategies for delivering IPV are shifting to better accommodate increases
in demand and unanticipated shortages. One approach recently recommended
by the World Health Organization (WHO) is the use of a fractional dose of
IPV (fIPV), which can be achieved by delivering the vaccine intradermally
(i.e., into the upper layers of the skin). However, fractional dosing can
be challenging in the settings common to developing countries—that is,
until now.

A promising, underutilized delivery route

The skin is an active player in the human immune system, and delivering
vaccines or pharmaceuticals directly to it can be more immunologically
efficient than injection into the muscle or subcutaneous tissues. So, why
is delivery efficiency important?

Hint: it can help vaccinators do more with less.

Research shows that intradermal delivery can, in some instances, achieve
the same immunological results as intramuscular or subcutaneous delivery
but with 80 percent less vaccine. When supply shortages occur, this could
mean the difference between stretching supplies across more patients, or
risking that a percentage of those same patients go unprotected from
vaccine-preventable disease.

Nevertheless, fractional dosing remains inconsistently used because the
injection procedure for achieving it requires considerable training and
experience to master with a conventional needle and syringe. Consequently,
its impacts have historically been too varied to make it standard
practice.

The role of innovation

PATH accelerates the development, delivery, and introduction of vaccines
that protect children and communities from disease. Part of this work
includes a long history of collaborating with product developers, device
manufacturers, and country ministries of health to design, develop, and
assess technologies that better enable intradermal delivery. Throughout,
our focus has been on vaccines of importance to developing-country
immunization programs where fractional dosing has been effective and could
help bridge coverage gaps in low-resource settings.

Recently, in close collaboration with the WHO’s Global Polio Eradication
Initiative (GPEI), we helped build the clinical evidence base for two
fIPV-capable delivery technology solutions, the PharmaJet Tropis
disposable-syringe jet injector and West Pharmaceutical Services ID
Adapter, which PATH originally developed in partnership with SID
Technologies, LLC, then transferred to West in 2013.

Disposable-syringe jet injector.

Disposable-syringe jet injectors, like the PharmaJet Tropis device, use a
sterile single-dose syringe and a pressurized liquid stream rather than a
needle to administer a fractional dose of inactivated poliovirus vaccine
to patients.

[Photo A close up of an intradermal adapter used in vaccination.]

[The PATH-developed West Pharmaceutical Services Intradermal Adapter fits
over a traditional needle and syringe like a sleeve, standardizing the
injection depth and angle so health care workers can more easily and
precisely deliver an intradermal injection. Photo: PATH.]

With strong data underscoring the value and effectiveness of each device,
the GPEI plans for both to be available by early 2017 to support country
use of fIPV—helping ensure supply shortages neither threaten the
protection of children and families nor disrupt progress in the global
fight against polio.

More delivery solutions on the horizon

PATH and our partners are also helping to advance microarray patches
(MAPs) designed to adhere like Band-Aids as they deliver vaccines through
the skin. Overall, MAPs hold considerable promise as a thermostable,
compact, and integrated (i.e., prefilled) intradermal delivery technology
that might even be simple enough for house-to-house volunteers with
minimal training to use for vaccinations. Such outreach strategies could
be game-changing for polio eradication efforts.

The need for these and other novel delivery technologies are uniquely
relevant and important to achieving coverage targets and accelerating
progress in public health. After all, a vaccine can mean the difference
between a family’s grief and a child’s healthy future.

Darin Zehrung leads the Vaccine and Pharmaceutical Delivery Technologies
portfolio at PATH. With Birgitte Giersing from the WHO Division of Vaccine
Research, he recently co-delivered the keynote address at the 4th
International Conference on Microneedles in London.

Posted in: Featured posts, Impact, Innovation, Vaccines and immunization
__________________________________________________________________
________________________________*_________________________________

2. Global: Nearly 1000 Healthcare Workers Killed Since 2014, WHO Says
__________________________________________________________________

http://www.medscape.com/viewarticle/863967
Global: Nearly 1000 Healthcare Workers Killed Since 2014, WHO Says

Megan Brooks, Medscape Medical News (27.05.16)

Between January 2014 and December 2015, there were 594 reported attacks on
healthcare that led to 959 deaths and 1561 injuries in 19 countries,
according to a report from the World Health Organization (WHO).

“Even one attack on health care is one too many. Therefore, the number of
reported attacks reflected in this report is tragic. The high tolls of
death and injury to our health colleagues and the inevitable impact on
health service delivery call for greater action,” WHO says.

The report is a first attempt to consolidate and analyze available data on
the situation, and the findings shed light on the “severity and frequency”
of the problem, the agency adds.

More than half of the attacks were against healthcare facilities (63%) and
more than a quarter were against healthcare providers (26%). Sixty-two
percent of the attacks were reported to have intentionally targeted
healthcare.

Unprecedented Need

The Syrian Arab Republic had the most reported attacks on healthcare each
year — more than twice as many as any other country or territory in 2014
and nearly four times as many in 2015.

WHO notes that in some countries a single attack resulted in a significant
proportion of the total deaths and injuries for that year.

For example:

In the Central African Republic, 16 of the 26 deaths attributed to attacks
on healthcare in 2014 occurred in a single attack, on April 28, during an
armed robbery on a Médecins Sans Frontières hospital in the northern town
of Boguila.

In Iraq, 18 of the 71 reported deaths in 2014 occurred when the obstetrics
section of the Hawija Hospital was bombed on September 6.

Thirty-one of the 43 deaths in Iraq in 2015 occurred during a bombing on
Fallujah’s maternity hospital on August 13.

In Libya, 34 of the 39 deaths in 2015 occurred on August 14, when 12 care
providers and 22 patients were executed.

“The most disturbing challenge for health care providers during
emergencies is when they themselves are the victims of attacks — real or
threatened, targeted or indiscriminate. Yet we witness with alarming
frequency a lack of respect for the sanctity of health care, for the right
to health care, and for international humanitarian law: patients are shot
in their hospital beds, medical personnel are threatened, intimidated or
attacked, hospitals are bombed,” WHO notes.

“Health needs in emergencies are often urgent and service delivery is
complex. Meeting these life-saving health needs is increasingly
challenging,” WHO notes. “In the current global context, the needs are
unprecedented. In 2015, an estimated 125 million people affected by
emergencies were in need of assistance — the largest number ever on
record,” they point out.

The findings in the report underscore the need for “intensified action
from a broad spectrum of actors to ensure that health care is provided
universally during emergencies to all those who need it, unhindered by any
form of violence or obstruction,” WHO says.

They also point to a need for more and better data collection on the
problem. “The lack of information on the impact of attacks on health
service delivery and the health of affected populations is a significant
knowledge gap and a priority for information collection moving forward,”
the agency says.

WHO. Report on Attacks on Health Care in Emergencies. Published May 26,
2016. Full text http://www.who.int/hac/techguidance/attacksreport.pdf
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Transmission of blood-borne pathogens in US dental health
care settings: 2016 Update
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27233680

J Am Dent Assoc. 2016 May 24. pii: S0002-8177(16)30307-5.
Transmission of blood-borne pathogens in US dental health care settings:
2016 Update.

Cleveland JL, Gray SK, Harte JA, Robison VA, Moorman AC, Gooch BF.

BACKGROUND: During the past decade, investigators have reported
transmissions of blood-borne pathogens (BBPs) in dental settings. In this
article, the authors describe these transmissions and examine the lapses
in infection prevention on the basis of available information.

METHODS: The authors reviewed the literature from 2003 through 2015 to
identify reports of the transmission of BBPs in dental settings and
related lapses in infection prevention efforts, as well as to identify
reports of known or suspected health care-associated BBP infections
submitted by state health departments to the Centers for Disease Control
and Prevention.

RESULTS: The authors identified 3 published reports whose investigators
described the transmission of hepatitis B virus and hepatitis C virus. In
2 of these reports, the investigators described single-transmission events
(from 1 patient to another) in outpatient oral surgery practices. The
authors of the third report described the possible transmission of
hepatitis B virus to 3 patients and 2 dental health care personnel in a
large temporary dental clinic.

The authors identified lapses in infection prevention practices that
occurred during 2 of the investigations; however, the investigators were
not always able to link a specific lapse to a transmission event.

Examples of lapses included the failure to heat- sterilize handpieces
between patients, a lack of training for volunteers on BBPs, and the use
of a combination of unsafe injection practices.

CONCLUSIONS: The authors found that reports describing the transmission of
BBPs in dental settings since 2003 were rare. Failure to adhere to Centers
for Disease Control and Prevention recommendations for infection control
in dental settings likely led to disease transmission in these cases.

PRACTICAL IMPLICATIONS: The existence of these reports emphasizes the need
to improve dental health care personnel’s understanding of the basic
principles and implementation of standard precautions through the use of
checklists, policies, and practices.

Published by Elsevier Inc.

KEYWORDS: Infection control; blood-borne pathogens; dentistry; health
care– associated infection; hepatitis B virus; hepatitis C virus; human
immunodeficiency virus; infection prevention; standard precautions
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Cost-Effectiveness Analysis of Safety-Engineered Devices
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27226284

Infect Control Hosp Epidemiol. 2016 May 26:1-10.
Cost-Effectiveness Analysis of Safety-Engineered Devices.

Fukuda H1, Moriwaki K2.

11Department of Health Care Administration and Management,Graduate School
of Medical Sciences,Kyushu University,Fukuoka,Japan.
22Department of Medical Statistics,Kobe Pharmaceutical
University,Higashinada-ku,Kobe-shi,Hyogo,Japan.

OBJECTIVE To estimate the cost-effectiveness of safety-engineered devices
(SEDs) relative to non-SEDs for winged steel needles, intravenous catheter
stylets, suture needles, and insulin pen needles. DESIGN Decision analysis
modeling.

PARTICIPANTS Hypothetical cohort of healthcare workers who utilized needle
devices.

METHODS We developed a decision-analytic model to estimate and compare the
life-cycle costs and benefits for SED and non-SED needle devices. For this
cost-effectiveness analysis, we quantified the total direct medical cost
per needlestick injury, number of needlestick injuries avoided, and
incremental cost-effectiveness ratio. Sensitivity analyses were performed
to examine the robustness of the base-case analysis.

RESULTS In the base-case analysis, we calculated the incremental cost-
effectiveness ratios of SED winged steel needles, intravenous catheter
stylets, suture needles, and insulin pen needles to be $2,633, $13,943,
$1,792, and $1,269 per needlestick injury avoided, respectively.
Sensitivity analyses showed that the calculated incremental cost-
effectiveness ratio values for using SEDs did not fall below zero even
after adjusting the values of each parameter.

CONCLUSION The use of SED needle devices would not produce cost savings
for hospitals. Government intervention may be needed to systematically
protect healthcare workers in Japan from the risk of bloodborne pathogen
infections.

Infect Control Hosp Epidemiol 2016;1-10.
__________________________________________________________________
________________________________*_________________________________

5. Abstract: Fungal Infections Associated with Contaminated Steroid
Injections
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27227303
Microbiol Spectr. 2016 Apr;4(2).

Fungal Infections Associated with Contaminated Steroid Injections.

Kauffman CA, Malani AN.

In mid-September 2012, the largest healthcare-associated outbreak in U.S.
history began. Before it was over, 751 patients were reported with fungal
meningitis, stroke, spinal or paraspinal infection, or peripheral
osteoarticular infection, and 64 (8.5%) died.

Most patients had undergone epidural injection, and a few osteoarticular
injection, of methylprednisolone acetate that had been manufactured at the
New England Compounding Center (NECC).

The offending pathogen in most cases was Exserohilum rostratum, a brown-
black soil organism that previously was a rare cause of human infection.

Three lots of methylprednisolone were contaminated with mold at NECC; the
mold from unopened bottles of methylprednisolone was identical by whole-
genome sequencing to the mold that was isolated from ill patients.

Early cases manifested as meningitis, some patients suffered posterior
circulation strokes, and later cases were more likely to present with
localized infection at the injection site, including epidural abscess or
phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with
intradural involvement of nerve roots. Many patients with spinal or
paraspinal infection required surgical intervention.

Recommendations for treatment evolved over the first few weeks of the
outbreak. Initially, combination therapy with liposomal amphotericin B and
voriconazole was recommended for all patients; later, combination therapy
was recommended only for those who were most ill, and voriconazole
monotherapy was recommended for most patients. Among those patients who
continued antifungal therapy for at least 6 months, outcomes for most
appeared to be successful, although a few patients remain on therapy.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Preoperative Hip Injections Increase the Rate of
Periprosthetic Infection After Total Hip Arthroplasty
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27221820

J Arthroplasty. 2016 Apr 22. pii: S0883-5403(16)30073-0.
Preoperative Hip Injections Increase the Rate of Periprosthetic Infection
After Total Hip Arthroplasty.

Schairer WW1, Nwachukwu BU1, Mayman DJ1, Lyman S1, Jerabek SA1.

1Hospital for Special Surgery, New York, New York.

BACKGROUND: Intraarticular injections are both diagnostic and therapeutic
for patients with osteoarthritis. A potential risk of periprosthetic joint
infection (PJI) after total hip arthroplasty (THA) may occur from direct
inoculation and/or immune suppression by corticosteroids. Large
population-level databases were used to evaluate hip injection on the 1-
year rate of PJI in patients undergoing primary THA.

METHODS: State-level ambulatory surgery and inpatient databases for
Florida and California (2005-2012) were used to identify primary THA
patients with 1- year preoperative and postoperative windows to evaluate
possible injections or PJI, respectively. Patients were grouped as no
injection or as THA performed 6-12 months, 3-6 months, or 0-3 months after
injection. Risk adjustment was performed with multivariable regression.

RESULTS: A total of 173,958 patients were included; 5421 (3.1%) underwent
THA after an injection: 1395 (1.1%) of patients after 6-12 months, 1863
patients after 3-6 months, and 2163 (1.2%) after 0-3 months. In the 0-3
month group, PJI was significantly increased at 3 months (1.58%, P =
.015), 6 months (1.76%, P = .022), and 1 year (2.04%, P = .031) compared
with the noninjection control group (1.04%, 1.21%, and 1.47%,
respectively). There were no differences in the 3- to 6-month and 6- to
12-month injection groups.

CONCLUSION: There is an increased risk of PJI when THA is performed within
3 months of hip injection. We recommend that patients and their surgeons
consider delaying elective THA until 3 months after an injection to avoid
this elevated risk of infection.

Copyright © 2016 Elsevier Inc. All rights reserved.

KEYWORDS: complications; epidemiology; injection; periprosthetic joint
infection; total hip arthroplasty
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Needle-free jet injector intradermal delivery of fractional
dose inactivated poliovirus vaccine: Association between injection
quality and immunogenicity
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26192350

Vaccine. 2015 Oct 26;33(43):5873-7.
Needle-free jet injector intradermal delivery of fractional dose
inactivated poliovirus vaccine: Association between injection quality and
immunogenicity.

Resik S1, Tejeda A2, Mach O3, Sein C4, Molodecky N4, Jarrahian C5, Saganic
L5, Zehrung D5, Fonseca M1, Diaz M1, Alemany N2, Garcia G2, Hung LH1,
Martinez Y1, Sutter RW4.

1Pedro Kouri Institute of Tropical Medicine, Havana, Cuba.
2Centro Provincial de Higiene, Epidemiologia y Microbilogia, Camaguey,
Cuba.
3The World Health Organization, Geneva, Switzerland. Electronic address:
macho@who.int.
4The World Health Organization, Geneva, Switzerland.
5PATH, Seattle, WA, USA.

INTRODUCTION: The World Health Organization recommends that as part of the
polio end-game strategy a dose of inactivated poliovirus vaccine (IPV) be
introduced by the end of 2015 in all countries currently using only oral
poliovirus vaccine (OPV). Administration of fractional dose (1/5 of full
dose) IPV (fIPV) by intradermal (ID) injection may reduce costs, but its
conventional administration is with Bacillus Calmette-Guerin (BCG) needle
and syringe (NS), which is time consuming and technically challenging. We
compared injection quality achieved with BCG NS and three needle-free jet
injectors and assessed ergonomic features of the injectors.

METHODS: Children between 12 and 20 months of age who had previously
received OPV were enrolled in the Camaguey, Cuba study. Subjects received
a single fIPV dose administered intradermally with BCG NS or one of three
needle-free injector devices: Bioject Biojector 2000® (B2000), Bioject ID
Pen® (ID Pen), or PharmaJet Tropis® (Tropis). We measured bleb diameter
and vaccine loss as indicators of ID injection quality, with desirable
injection quality defined as bleb diameter ≥5mm and vaccine loss <10%. We
surveyed vaccinators to evaluate ergonomic features of the injectors. We
further assessed the injection quality indicators as predictors of immune
response, measured by increase in poliovirus neutralizing antibodies in
blood between day 0 (pre-IPV) and 21 (post-vaccination).

RESULTS: Delivery by BCG NS and Tropis resulted in the highest proportion
of subjects with desirable injection quality; health workers ranked
Biojector2000 and Tropis highest for ergonomic features. We observed that
vaccine loss and desirable injection quality were associated with an
immune response for poliovirus type 2 (P=0.02, P=0.01, respectively).

CONCLUSIONS: Our study demonstrated the feasibility of fIPV delivery using
needle-free injector devices with high acceptability among health workers.
We did not observe the indicators of injection quality to be uniformly
associated with immune response.

Copyright © 2015. Published by Elsevier Ltd.

KEYWORDS: Cuba; Needle-free injector; Poliomyelitis
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Assessment and selection of the best treatment alternative
for infectious waste by modified Sustainability Assessment of
Technologies methodology
__________________________________________________________________

http://jehse.biomedcentral.com/articles/10.1186/s40201-016-0251-1

J Environ Health Sci Eng. 2016 May 27;14:10.
Assessment and selection of the best treatment alternative for infectious
waste by modified Sustainability Assessment of Technologies methodology.

Rafiee A1, Yaghmaeian K1, Hoseini M2, Parmy S3, Mahvi A1, Yunesian M4,
Khaefi M5, Nabizadeh R4.

1Center for Solid Waste Research (CSWR), Institute for Environmental
Research (IER), Tehran University of Medical Sciences, Tehran, Iran ;
Department of Environmental Health Engineering, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran.
2Department of Environmental Health Engineering, School of Public Health,
Shiraz University of Medical Sciences, Shiraz, Iran.
3Department of Environmental Health Engineering, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran.
4Department of Environmental Health Engineering, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran ; Center for Air
Pollution Research (CAPR), Institute for Environmental Research (IER),
Tehran University of Medical Sciences, Tehran, Iran.
5Environmental and occupational health center, Ministry of health medical
education, Tehran, Iran.

BACKGROUND: Improper treatment of infectious waste can cause numerous
adverse environmental and health effects such as transmission of diseases
through health personnel and other susceptible groups,who come in contact
with such wastes. On the other hand, selection of appropriate treatment
alternatives in infectious waste management has become a challenging task
for public health authorities especially in developing countries. The
objective of this paper is to select the best infectious waste treatment
alternative by the modified Sustainability Assessment of Technologies
(SAT) methodology, developed by the International Environmental Technology
Center of the United Nations Environment Program (IETC-UNEP).

METHODS: SAT methodology consists of three main components, including
screening, scoping and detailed assessment. In screening, different
infectious waste treatment alternatives undergo screening using the
finalized environmental and technical criteria. Short-listed treatment
options from the previous step, then go through the comprehensive scoping
and detailed assessment (2nd and 3rd components) which is more qualitative
and quantitative in nature. An empirical case in Tehran, the largest city
in Iran, is provided to illustrate the potential of the proposed
methodology.

RESULTS: According to the final score, “Hydroclave”, was the most suitable
infectious treatment technology. The ranking order of the treatment
alternatives were “Autoclave with a shredder”, “Autoclave”, “Central
Incineration” and “chemical treatment” on the basis of technical,
economical, social and environmental aspects and their related criteria.

CONCLUSIONS: According to the results it could be concluded that the top
ranking technologies basically have higher scores in all the aspects.
Hence it is easier to arrive at a decision for the final technology
selection based on the principles of sustainability.

KEYWORDS: Health-care waste; Hospital; Infectious waste treatment; SAT
methodology; Tehran

Free full text
http://jehse.biomedcentral.com/articles/10.1186/s40201-016-0251-1
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Academic physicians’ and medical students’ perceived barriers
toward bystander administered naloxone as an overdose prevention
strategy
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27235991

Addict Behav. 2016 May 17;61:40-46.
Academic physicians’ and medical students’ perceived barriers toward
bystander administered naloxone as an overdose prevention strategy.

Gatewood AK1, Van Wert MJ2, Andrada AP2, Surkan PJ2.

1Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street,
Baltimore, MD 21205, United States. Electronic address:
akgatewood@jhu.edu.
2Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street,
Baltimore, MD 21205, United States.

AIMS: To identify perceived barriers to the prescription of naloxone to
third-party contacts of opiate users.

DESIGN: Qualitative descriptive study.

SETTING: Two academic hospitals in Baltimore, MD, USA.

PARTICIPANTS: Thirty medical providers, including both physicians and
medical students.

MEASUREMENTS: Qualitative; in-depth interviews and focus groups analyzed
using line-by-line, focused, and axial coding based on methods adapted
from grounded theory.

FINDINGS: Academic physicians and medical students cited three categories
of barriers to naloxone prescription related to drug, provider, and
patient characteristics. Concerns about naloxone itself included inability
to prevent addictive behaviors, duration of action, medical risks,
expiration date, and route of administration. Concerns about medical
providers included lack of knowledge or experience, medical community
common practices and norms, insufficient provision of third-party
education, physician and clinic scheduling practices, worry about
insulting patients, and fear of being viewed as enabling drug abuse.
Concerns about patients included increased risk-taking behaviors, opiate
withdrawal symptoms, potential repeat overdose related to withdrawal-
discomfort, decreased contact with medical providers, and stigma.

CONCLUSIONS: Minimizing barriers to naloxone provision may increase
acceptability and prescription practice in the medical community.
Addressing these barriers from multiple provider perspectives is critical
to advance naloxone prescription as a harm reduction strategy, which has
the potential to prevent opiate overdoses.

Copyright © 2016 Elsevier Ltd. All rights reserved.

KEYWORDS: Harm reduction; Naloxone; Naloxone prescription; Opioid
overdose; Overdose prevention
__________________________________________________________________
________________________________*_________________________________

10. Abstract: Can HIV and Hepatitis C Virus Infection be Eliminated Among
Persons Who Inject Drugs?
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550554/

J Addict Dis. 2015;34(2-3):198-205.
Can HIV and Hepatitis C Virus Infection be Eliminated Among Persons Who
Inject Drugs?

Perlman DC1, Des Jarlais DC, Feelemyer J.

1a Department of Medicine , Mount Sinai Beth Israel , New York , New York,
USA.

HIV and hepatitis C virus (HCV) infection are readily transmitted among
persons who inject drugs. The HIV and HCV epidemics have expanded rapidly,
becoming global health issues.

Combined prevention has been implemented to reduce injection and sexual
transmission of HIV and HCV among persons who inject drugs.

Reductions in risky injection and sexual behavior have led to dramatic
reductions in HIV in many countries. Whether comparable reductions in HCV
transmission can be achieved has yet to be determined.

Eliminating HIV and HCV among persons who inject drugs will require
considerable resources and commitment, particularly in low and middle
income countries.

KEYWORDS:
HIV; combined prevention; drug injection; hepatitis C virus; persons who
inject drugs

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550554/
__________________________________________________________________
________________________________*_________________________________

11. Abstract: A cross-national analysis of the effects of methadone
maintenance and needle and syringe program implementation on incidence
rates of HIV in Europe from 1995 to 2011
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/27212656

Int J Drug Policy. 2016 Feb 26. pii: S0955-3959(16)30015-9.
A cross-national analysis of the effects of methadone maintenance and
needle and syringe program implementation on incidence rates of HIV in
Europe from 1995 to 2011.

Marotta PL1, McCullagh CA2.

1Columbia University, United States; School of Social Work, United States;
Social Intervention Group, United States; Global Research Center of
Central Asia, 1255 Amsterdam Avenue, 8th Floor, New York, NY, United
States. Electronic address: Plm2113@columbia.edu.
2Columbia University, United States; School of Social Work, United States;
Social Intervention Group, United States.

Although many studies have found an association between harm reduction
interventions and reductions in incidence rates of Human Immunodeficiency
Virus (HIV) infection, scant research explores the effects of harm
reduction cross-nationally.

This study used a year- and country-level fixed effects model to estimate
the potential effects of needle-and- syringe programs (NSPs) and methadone
maintenance therapy (MMT) on incidence rates of HIV in the general
population and among people who inject drugs (PWID), in a sample of 28
European nations.

After adjusting for Gross Domestic Product (GDP) and total expenditures on
healthcare, we identified significant associations between years of MMT
and NSP implementation and lower incidence rates of HIV among PWID and the
general population.

In addition to years of implementation of NSP and MMT, the greater
proportion of GDP spent on healthcare was associated with a decrease in
logged incidence rates of HIV.

The findings of this study suggest that MMT and NSP may reduce incidence
rates of HIV among PWID cross-nationally. The current study opens a new
avenue of exploration, which allows for a focus on countrywide policies
and economic drivers of the epidemic.

Moreover, it highlights the immense importance of the adoption of harm
reduction programs as empirically-based health policy as well as the
direct benefits that are accrued from public spending on healthcare on
incidence rates of HIV within the general population and among
subpopulations of PWID.

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

KEYWORDS: HIV prevention; Harm reduction; Health policy; Methadone
maintenance therapy; Needle and syringe programs; People who inject drugs
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Digital Subtraction Angiography Use During Epidural Steroid
Injections Does Not Reliably Distinguish Artery from Vein
__________________________________________________________________

http://www.painphysicianjournal.com/linkout?issn=1533-3159&vol=19&page=255

Pain Physician. 2016 May;19(4):255-66. Free PDF at the link
Digital Subtraction Angiography Use During Epidural Steroid Injections
Does Not Reliably Distinguish Artery from Vein.

Nagpal AS, Chang-Chien GC, Benfield JA1, Candido KD, Rana MV, Eckmann M.

1Department of Physical Medicine & Rehabilitation, University of Texas
Health Science Center San Antonio.

BACKGROUND: Epidural steroid injections (ESIs) are among the most common
procedures performed in an interventional pain management practice. It is
well known that tragic complications may arise from ESIs, most commonly
those performed using a transforaminal approach. Digital subtraction
angiography (DSA) has been hailed as a fluoroscopic technique that can be
used to detect arterial placement of the injection needle, and therefore
as a safety measure that can decrease the incidence of catastrophic
sequelae of these procedures.

OBJECTIVE: The objective of this article was to review existing scientific
pain literature to determine if DSA can distinguish arterial vs. venous
uptake.

STUDY DESIGN: Narrative review.

METHODS: The current narrative review of DSA in interventional spine was
completed with a PUBMED search using the key words: digital subtraction
angiography, epidural, fluoroscopy, intravascular injection, paraplegia,
and quadriplegia in accordance with Preferred Reporting Items for
Systematic Reviews and Meta- Analyses (PRISMA) guidelines.

RESULTS: After identification of duplicate articles, 383 articles were
screened by title, abstract, and/or full article review. Ten of these
articles were deemed appropriate, after applying inclusion and exclusion
criteria, as they specifically looked at the use of digital subtraction
angiography in interventional spine epidural injections. This included 4
case reports, 3 prospective studies, one retrospective analysis, one
prospective cohort study, and one meta-analysis. All of the available
studies claiming that DSA was capable of detecting vascular spread are
likely accurate, but no significant detection of specifically arterial
spread has been reported. The known catastrophic complications related to
ESIs are purported to be due to arterial injection of insoluble steroids
or local anesthetic and detection of arterial spread of contrast during
fluoroscopy would be of obvious benefit to the interventionalist.

LIMITATIONS: Small study size, non-randomized studies between DSA and real
time fluoroscopy.

CONCLUSION: Existing studies do not support that DSA can predict arterial
spread. In fact, DSA exposes the practitioner and the patient to higher
levels of radiation without objective evidence of any safety parameters.

KEY WORDS: Digital subtraction angiography, real-time fluoroscopy,
transforaminal epidural injection, particulate steroids, cervical
radicular artery, lumbar radicular artery, spinal cord injury.

Free full text
http://www.painphysicianjournal.com/linkout?issn=1533-3159&vol=19&page=255
__________________________________________________________________
________________________________*_________________________________

14. Abstract: Mycobacterium abscessus Infection After Facial Injection
With Autologous Fat: A Case Report
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27220017

Ann Plast Surg. 2016 May 23.
Mycobacterium abscessus Infection After Facial Injection With Autologous
Fat: A Case Report.

Yang P1, Lu Y, Liu T, Zhou Y, Guo Y, Zhu J, Jia C, Chen L, Yang Q.

1From the Department of Plastic and Reconstructive Surgery, Hua Dong
Hospital, Fu Dan University, Shanghai, China.

We report a case of Mycobacterium abscessus infection in a 29-year-old
woman after facial injection with autologous fat. Nineteen months
previously, she received a facial surgery of autologous fat injection with
the fat harvested from her inner thigh.

On examination, she had multiple painful and fluctuant abscesses
associated with local pyrexia in her bilateral temporal and lower orbital
regions. A B ultrasound revealed multiple fat liquefaction in her
bilateral temporal and lower orbital regions. The acid-fast bacilli
culture and polymerase chain reaction sequencing confirmed M. abscessus
infection.

She was treated with moxifloxacin, clarithromycin, and ethambutol for 12
months, and finally the symptoms subsided.

To avoid infection after fat graft, aseptic technique as well as standard
operation of the fat harvest and process should be strictly enforced. In
cases of persistent infection, or invalid cases treated with conventional
antibiotic therapy, nontuberculous mycobacteria should be suspected, and a
polymerase chain reaction sequencing as well as a drug sensitivity test
should be carried out.
__________________________________________________________________
________________________________*_________________________________

15. No Abstract: Nurses should insist trusts obey sharp safety law
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27071225

Nurs Times. 2016 Feb 24-Mar 1;112(8):2-3.
Nurses should insist trusts obey sharp safety law.

Stephenson J.
__________________________________________________________________
________________________________*_________________________________

16. News

– India: 2234 Get HIV Due to Contaminated Blood, UP Tops the List: RTI

– Michigan USA: Free needle drop off will take place June 10

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/hfpxaam
India: 2234 Get HIV Due to Contaminated Blood, UP Tops the List: RTI

News18.com, India (31.05.16)

2234 Get HIV Due to Contaminated Blood, UP Tops the List:

An RTI enquiry has revealed that 2234 cases of HIV transmission due to
transfusion of contaminated blood have been registered in India between
October 2014 and March 2016.

The National Aids Control Organisation (NACO) has released the details of
blood contamination figures in response to an RTI query filed by activist
Chetan Kothari.

The details reveal that many blood banks are flouting norms resulting in
people contracting deadly diseases, a report in The Hindu says.

According to its latest annual report, NACO’s total blood collection was
around 30 lakh units till September 2014. Nearly 84% of the donated blood
units came from voluntary blood donation, which seem to be the source of
the problem, according to Naresh Goyal, Deputy Director General, NACO.
NACO also claims that Uttar Pradesh has the highest number of HIV
transmission cases at 361 followed by Gujarat which is second with 292
cases.

The law mandates that donors/donated blood should be screened for
transmissible infections of HIV, HBV and Hepatitis C, malaria and
syphilis.

NACO’s 2015 annual report had stated that the total number of people
living with HIV/AIDS (PLHIVs) in India was estimated at around 20.9 lakh
in 2011. Nearly 86% of these patients are in the 15-49 age-group.
__________________________________________________________________
__________________________________________________________________
Michigan USA: Free needle drop off will take place June 10

By Judy Wagley, Petoskey News-Review, Michigan USA (26.05.16)

GAYLORD — Members of the community who use needles to self-administer
their medication will soon have a place to dispose of used “sharps” safely
and securely.

McLaren Northern Michigan will host a free needle drop off from 9 a.m. to
1 p.m. Friday, June 10 at the Karmanos Cancer Institute of McLaren
Northern Michigan Gaylord office, 918 N. Center Ave.

The program will continue the second Friday of every other month with
future dates of Aug. 12, Oct. 14, and Dec. 9.

Sarah Zeilinger, RN, OCN, clinical supervisor of Gaylord hematology/
oncology, said proper needle disposal is an important public safety
concern.

“We want to keep these needles out of the environment, out of our
landfills and out of our trash.” she said. “We don’t know what they may be
contaminated with; we need to dispose of them responsibly.”

Many self-injectors may not be aware of safe disposal methods and simply
throw their used needles in the trash or flush them down the toilet,
posing a risk of injury or potential infection to anyone who encounters
them. A person who is accidentally gets a needle stick will likely face
many weeks of medication and testing to prevent and check for potential
infection and life-threatening diseases including HIV/AIDS and hepatitis B
or C.

Zeilinger said needles to be dropped off must be sealed in a hard,
impermeable plastic container such as a laundry soap bottle or coffee
canister.

“Part of the service here is that people will then leave with an approved
sharps container,” she said. “Then every two months, we will make an
exchange.”

Joy Shannon of Gaylord assists a diabetic friend who uses 30 to 40 needles
each month. She adamantly does not want to put them in the trash.

“If you have even 50 people doing that and putting needles into a landfill
— could you imagine?” Shannon said. “Even if they are sealed, someone
could open them up. Kids and animals could get at them.”

Shannon said she and her friend have been looking for a safe place to
dispose of the used needles.

Zeilinger said while McLaren currently offers a regular drop-off program
in Emmet County, June 10 marks the first in Otsego County. She added that
needles only will be accepted. They will be put into a special container
and taken to a location that handles bio-hazard material.

Other medications may be taken any time during business hours to the
Otsego County Sheriff’s Office, 124 S. Court Ave. or to the Michigan State
Police Gaylord Post, 563 S. Otsego Ave.

For information about the drop off event, call (800) 248-6777.
__________________________________________________________________
________________________________*_________________________________

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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