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SIGNpost 00856

*SAFE INJECTION GLOBAL NETWORK* SIGNPOST

Post00856 SIGN Note + Field Notes + Abstracts + News 08 June 2016
CONTENTS
0. Moderators Note: SIGNpost via GoogleGroups
1. Notes from the Field: Investigation of Hepatitis C Virus Transmission
Associated with Injection Therapy for Chronic Pain — California, 2015
2. Abstract: Clinical epidemiology of acute hepatitis C in South America
3. Abstract: Knowledge and uptake of occupational post-exposure
prophylaxis amongst nurses caring for people living with HIV
4. Abstract: Healthcare waste management: an interpretive structural
modeling approach
5. Abstract: The Urban Emergency Department: A Potential Increased
Occupational Hazard for Sharps-related Injuries
6. Abstract: Status of HIV and hepatitis C virus infections among
prisoners in the Middle East and North Africa: review and synthesis
7. Abstract: Drug preparation, injection, and sharing practices in
Tajikistan: a qualitative study in Kulob and Khorog
8. Abstract: Beyond equipment distribution in Needle and Syringe
Programmes: an exploratory analysis of blood-borne virus risk and other
measures of client need
9. Abstract: Prevention and treatment produced large decreases in HIV
incidence in a model of people who inject drugs
10. Abstract: The ‘My five moments for hand hygiene’ concept for the
overcrowded setting in resource-limited healthcare systems
11. Abstract: Arteriovenous Fistula Formation After Intra-articular
Injection Following Total Joint Arthroplasty
12. Extract: Zika virus: a new challenge for blood transfusion
13. Abstract: Zika Virus Spreads to New Areas – Region of the Americas,
May 2015-January 2016
14. News
– Colorado USA: HIV-positive surgery tech has history of stealing drugs
– Colorado USA: Indicted medical technician tests HIV positive; thousands
of patients being tested

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SIGNpost 00856

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1. Notes from the Field: Investigation of Hepatitis C Virus Transmission
Associated with Injection Therapy for Chronic Pain — California, 2015
__________________________________________________________________

http://www.cdc.gov/mmwr/volumes/65/wr/mm6521a4.htm

MMWR Morb Mortal Wkly Rep 2016;65:547–549.
http://dx.doi.org/10.15585/mmwr/mm6521a4.
Notes from the Field: Investigation of Hepatitis C Virus Transmission
Associated with Injection Therapy for Chronic Pain — California, 2015

Monique A. Foster, MD1; Cheri Grigg, DVM2; Jaclyn Hagon, MSN3; Paige A.
Batson, MA3; Janice Kim, MD4; Mary Choi, MD2; Anne Moorman, MPH1; Charity
Dean, MD3

1National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
CDC; 2National Center for Emerging and Zoonotic Infectious Diseases, CDC;
3Santa Barbara County Public Health Department; 4California Department of
Public Health.

PDF [187 KB] http://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6521a4.pdf

On November 26, 2014, the California Department of Public Health (CDPH)
contacted CDC concerning a report from the Santa Barbara County Public
Health Department (SBPHD) regarding acute hepatitis C virus (HCV)
infection in a repeat blood donor. The patient, who was asymptomatic, was
first alerted of the infection by the blood bank and had no traditional
risk factors for HCV infection. The donor had a negative HCV nucleic acid
test (NAT) 56 days before the first positive NAT test, and an
investigation into the donor’s health care exposures and other potential
risk factors, including injection drug use, incarceration, and long-term
hemodialysis within this narrow exposure window, was conducted by SBPHD.

One such exposure occurred at a doctor’s office (clinic A) where the blood
donor received an injection procedure as part of prolotherapy.
Prolotherapy, also known as regenerative injection therapy, is an
increasingly popular, injection-based complementary and alternative
medical therapy used to treat chronic musculoskeletal pain (1). Common
substances injected include hypertonic dextrose, phenol-glycerine-glucose,
and morrhuate sodium, a mixture of saturated and unsaturated fatty acids
from cod liver oil (1). In addition, some patients also received platelet
rich plasma therapy, a method of prolotherapy that involves injection of
autologous blood with a high platelet-to-plasma ratio (2). No formal
practice guidelines have been established for prolotherapy treatment, and
no formal training is required to deliver this service. The initial
investigation into clinic A revealed infection control breaches that
included reentering multidose medication vials with a used syringe, use of
single-dose medication vials for multiple patients, poor hand hygiene and
inconsistent glove use, and lack of aseptic technique when handling
injection equipment and medication. Clinic A was advised to stop these
practices, and staff members were educated on bloodborne pathogen
transmission. A subsequent visit to clinic A revealed ongoing poor
infection control practices by staff members. After this visit, the county
health officer issued an order to close clinic A immediately. A joint
investigation into clinic A by SBPHD, CDPH, and CDC was initiated to
identify additional cases and determine the source of transmission.

Patients who visited clinic A during the preceding 10 months (n = 400)
were notified through mailed letters about their potential exposure to
HCV, hepatitis B virus (HBV), and human immunodeficiency virus (HIV).
SBPHD coordinated free testing through a local laboratory. Case-finding
activities included review of medical records for patients who visited
clinic A, review of state hepatitis surveillance records and crossmatching
with clinic A records, and serologic HCV and HBV testing of staff members.
Patients subsequently identified as having HCV infection were interviewed,
and a blood specimen was sent to CDC for HCV genotype and phylogenetic
testing.

In addition to the index patient, six other patients who received
injections at clinic A were determined to have HCV infection by serologic
testing. Among these six patients, five were unaware of their HCV
infection status. Four of the patients without a prior HCV diagnosis or
risk factors for HCV had injection procedures performed in clinic A on the
same day as the index patient. A common injected substance used in all the
infected patients was not identified through medical chart review,
although documentation of injected local anesthesia was inconsistent. No
new HBV or HIV infections were found.

Identification of a case of acute HCV infection in a frequent blood donor
without other risk factors should be considered a sentinel event and
should prompt public health investigation, because this could indicate a
possible health care–associated infection (3). HCV transmission from
health care exposures has been documented previously (Table) (4,5). Many
of these outbreaks are attributable to the same unsafe injection practices
observed in clinic A, namely reuse of syringes to access medications used
for multiple patients (5). Although hospitals have established infection
control education, resources, and oversight, health care settings where
complementary and alternative medical therapies are administered,
especially those that involve injections, might benefit from infection
control training and inclusion in health care–associated infection
surveillance networks, such as CDC’s National Healthcare Safety Network
(6). All health care settings, including complementary medical settings
where injections occur, should follow guidelines for safe injection
practices (7).

Corresponding author: Monique Foster, ydg9@cdc.gov, 404-718-8561.

1National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
CDC; 2National Center for Emerging and Zoonotic Infectious Diseases, CDC;
3Santa Barbara County Public Health Department; 4California Department of
Public Health.

References

Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care
practice. Prim Care 2010;37:65–80. CrossRef PubMed

Marx RE. Platelet-rich plasma (PRP): what is PRP and what is not PRP?
Implant Dent 2001;10:225–8. CrossRef PubMed

CDC. Reporting incident HBC and HCV infections meeting CSTE acute case
definition among repeat blood donors from blood collection centers to
public health departments. Atlanta, GA: US Department of Health and Human
Services, CDC; 2015.

http://www.cdc.gov/hepatitis/outbreaks/blooddonorinfections.htm
Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-
associated hepatitis B and C virus transmission: United States, 1998–2008.
Ann Intern Med 2009;150:33–9. CrossRef PubMed

CDC. Healthcare-associated hepatitis B and C outbreaks reported to the
Centers for Disease Control and Prevention (CDC) in 2008–2015. Atlanta,
GA: US Department of Health and Human Services, CDC; 2015.
http://www.cdc.gov/hepatitis/outbreaks/healthcarehepoutbreaktable.htm

CDC. Outpatient settings policy options for improving infection
prevention. Atlanta, GA: US Department of Health and Human Services, CDC;
2015.
http://www.cdc.gov/hai/pdfs/prevent/Outpatient-Settings-Policy-Options.pdf

CDC. Guideline for isolation precautions: preventing transmission of
infectious agents in healthcare settings. Atlanta, GA: US Department of
Health and Human Services, CDC; 2007.
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

TABLE. Health care–associated hepatitis C virus outbreaks reported to CDC,
by setting — 2008–2015
[ At The Link http://www.cdc.gov/mmwr/volumes/65/wr/mm6521a4.htm ]
__________________________________________________________________
________________________________*_________________________________

2. Abstract: Clinical epidemiology of acute hepatitis C in South America
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27253181

J Med Virol. 2016 Jun 2.
Clinical epidemiology of acute hepatitis C in South America.

Dirchwolf M1, Marciano S2, Mauro E2, Ruf A3, Rezzonico L4, Anders M5,
Chiodi D6, Petta NG7, Borzi S8, Tanno F9, Ridruejo E10, Barreyro F11,
Shulman C12, Plaza P13, Carbonetti R14, Tadey L15, Schroder T1, Fainboim
H1.

1Hepatopatías Infecciosas, Hospital F.J. Muñiz, Buenos Aires, C1282,
Argentina.
2Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, C1181,
Argentina.
3Fundación para la Docencia e Investigación de las Enfermedades del Hígado
(FUNDIEH), Buenos Aires, C1426, Argentina.
4Hepatología, Hospital de la Asociación Médica Dr. Felipe Glasman, Bahía
Blanca, Buenos Aires, 8000, Argentina.
5Unidad de Hepatología y Trasplante Hepático, Hospital Alemán, Buenos
Aires, C1118, Argentina.
6Hospital de Clínicas, Facultad de Medicina, UDELAR, Montevideo, 11600,
Uruguay.
7Servicio de Gastroenterología y Hepatología, Hospital Central del
Instituto de Previsión Social de Asunción, Asunción, 1209, Paraguay.
8Sección Hepatología, HIGA Prof. Dr. Rodolfo Rossi, La Plata Buenos Aires,
1900, Argentina.
9Servicio de Hepatología y Gastroenterología, Hospital Provincial del
Centenario de Rosario, Rosario, 2000, Argentina.
10Sección Hepatología, Centro de Educación Médica e Investigaciones
Clínicas Norberto Quirno “CEMIC”. Unidad de Hepatología y Trasplante
Hepático, Hospital Universitario Austral, Buenos Aires, C1431, Argentina.
11Laboratorio de Microbiología, Facultad de Química y Ciencias Naturales
Universidad de Misiones, Posadas, 3300, Argentina.
12Hepatología, Hospital Tornú, Buenos Aires, C1427, Argentina.
13Gastroenterología y Hepatología, Salta capital, 4400, Argentina.
14Gastroenterología y Hepatología, Hospital de Clínicas Nicolás
Avellaneda, Tucumán, 4000, Argentina.
15Unidad de Virología, Hospital F.J. Muñiz, Buenos Aires, C1282,
Argentina.

BACKGROUNDS: There is scarce data pertaining to acute hepatitis C (aHC)
infection in South America.

OBJECTIVES: To describe clinical characteristics and evolution of aHC in a
South American cohort.

METHODS: A retrospective survey was conducted at 13 hepatology units. All
patients =16 years old with aHC diagnosis were included. Demographic,
clinical and outcome information were registered in a standardized ad hoc
questionnaire.

RESULTS: Sixty-four patients were included. The majority were middle-aged
(median age: 46 years) and female (65.6%); most of them were symptomatic
at diagnosis (79.6%). HCV-1 was the most prevalent genotype (69.2%). Five
patients had liver failure: three cases of severe acute hepatitis, one
case of fulminant hepatitis and one case of acute-on-chronic liver
failure. Nosocomial exposure was the most prevalent risk factor. Evolution
was assessed in 46 patients. In the untreated cohort, spontaneous
resolution occurred in 45.8% and was associated with higher values of AST/
ALT and with the absence of intermittent HCV RNA viremia (p?=?0.01, p?=
0.05 and p?=?0.01, respectively). In the treated cohort, sustained
virological response was associated with nosocomial transmission and early
treatment initiation (p?=?0.04 each).

CONCLUSION: The prevalence of nosocomial transmission in this South-
American cohort of aHC stresses the importance of following universal
precautions to prevent HCV infection.

This article is protected by copyright. All rights reserved.

KEYWORDS: Latin America; epidemiology; hepatitis C virus; nosocomial
transmission
__________________________________________________________________
________________________________*_________________________________

3. Abstract: Knowledge and uptake of occupational post-exposure
prophylaxis amongst nurses caring for people living with HIV
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27246789

Curationis. 2016 Mar 29;39(1):e1-6.
Knowledge and uptake of occupational post-exposure prophylaxis amongst
nurses caring for people living with HIV.

Makhado L1, Davhana-Maselesele M.

1Department of Nursing Sciences, North-West University, Mmabatho.
22891935@nwu.ac.za.

BACKGROUND: Nurses caring for people living with HIV (PLWH) are at higher
risk of exposure to the human immunodeficiency virus (HIV) by needle
sticks, cuts, getting body fluids in their eyes or mouth and skin when
bruised or affected by dermatitis.

OBJECTIVES: To determine knowledge, insight and uptake of occupational
post-exposure prophylaxis (OPEP) amongst nurses caring for PLWH.

METHOD: A cross-sectional descriptive design was used in this study.
Stratified random sampling was used to sample 240 nurses. The study was
conducted in a regional hospital in Limpopo province. Both parametric and
non- parametric statistics were employed to analyse data.

RESULTS: A total of 233 nurses participated in the study. Sixty per cent
(n = 138) of all nurses had a situation at work when they thought that
they were infected by HIV and 100 (43%) nurses had experienced the
situation once or more in the past 12 month. Approximately 40% did not
know what PEP (post- exposure prophylaxis) is, and 22% did not know or
were not sure if it was available in the hospital. Only few participants
(n = 68, 29%) had sought PEP and most (n = 37, 54%) of them did not
receive PEP when they needed it. There was a significant association
between the knowledge and availability of PEP (r = 0.622).

CONCLUSION:
The study recommend an urgent need for policy makers in the health sector
to put in place policies, guidelines and programmes that will rapidly
scale up PEP services in health care settings, so that preventable
occupationally acquired HIV infection can be minimised amongst nurses.

KEYWORDS: Occupational Exposure; PLWH.; Post-Exposure Prophylaxis; Nurses;
HIV
__________________________________________________________________
________________________________*_________________________________

4. Abstract: Healthcare waste management: an interpretive structural
modeling approach
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/27256778

Int J Health Care Qual Assur. 2016 Jun 13;29(5):559-81.
Healthcare waste management: an interpretive structural modeling approach.

Thakur V1, Anbanandam R1.

1Department of Management Studies, Indian Institute of Technology,
Roorkee, India.

Purpose – The World Health Organization identified infectious healthcare
waste as a threat to the environment and human health. India’s current
medical waste management system has limitations, which lead to ineffective
and inefficient waste handling practices.

Hence, the purpose of this paper is to: first, identify the important
barriers that hinder India’s healthcare waste management (HCWM) systems;
second, classify operational, tactical and strategical issues to discuss
the managerial implications at different management levels; and third,
define all barriers into four quadrants depending upon their driving and
dependence power.

Design/methodology/approach – India’s HCWM system barriers were identified
through the literature, field surveys and brainstorming sessions.
Interrelationships among all the barriers were analyzed using interpretive
structural modeling (ISM). Fuzzy-Matrice d’Impacts Croisés Multiplication
Appliquée á un Classement (MICMAC) analysis was used to classify HCWM
barriers into four groups.

Findings – In total, 25 HCWM system barriers were identified and placed in
12 different ISM model hierarchy levels. Fuzzy-MICMAC analysis placed
eight barriers in the second quadrant, five in third and 12 in fourth
quadrant to define their relative ISM model importance. Research
limitations/implications –

The study’s main limitation is that all the barriers were identified
through a field survey and barnstorming sessions conducted only in
Uttarakhand, Northern State, India.

The problems in implementing HCWM practices may differ with the region,
hence, the current study needs to be replicated in different Indian states
to define the waste disposal strategies for hospitals.

Practical implications – The model will help hospital managers and
Pollution Control Boards, to plan their resources accordingly and make
policies, targeting key performance areas.

Originality/value – The study is the first attempt to identify India’s
HCWM system barriers and prioritize them.

KEYWORDS: Barriers; Fuzzy-MICMAC analysis; Healthcare waste; ISM;
Modelling; Waste management
__________________________________________________________________
________________________________*_________________________________

5. Abstract: The Urban Emergency Department: A Potential Increased
Occupational Hazard for Sharps-related Injuries
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/26468634
The Urban Emergency Department: A Potential Increased Occupational Hazard
for Sharps-related Injuries.

Wilson SP1, Miller J1, Mahan M2, Krupp S1.

1Department of Emergency Medicine, Henry Ford Hospital System, Detroit,
MI.
2Department of Statistics, Henry Ford Hospital System, Detroit, MI.

OBJECTIVES: Health care workers are at risk for sharps-related injuries
while working in the clinical arena. The authors sought to quantify and
compare the frequency of these injuries for all health care personnel
between the urban and community emergency department (ED).

METHODS: A retrospective review was performed on the institutional human
resources database of all self- or supervisor-reported sharps-related
injuries that occurred to ED personnel in a single health system from
January 2010 through September 2014. The health system was composed of a
single urban academic Level I trauma center and seven community EDs, two
of which were academic Level III trauma centers. Each sharps-related
injury was reviewed for site of injury, job class, and type of instrument
causing the injury.

RESULTS: There were 171 sharps-related injuries reported during 447,986
urban and 1,350,623 community patient visits. Of the 171 injuries, 44.4%
occurred to physicians, 39.2% to nurses, 12.9% to support staff, and 3.5%
to physician assistants. Injuries occurred more frequently at the urban
academic medical center when compared to the pooled community sites: 20.3
per 100,000 patient visits (n = 91) versus 5.9 per 100,000 patient visits
(n = 80), respectively (odds ratio = 3.43, 95% confidence interval = 2.54
to 4.63, p < 0.001). They also occurred more frequently at the urban site
when individually compared to each community site.

CONCLUSIONS: Physicians accounted for the largest proportion of health
care workers reporting sharps-related injuries. These injuries occurred
more frequently in the urban ED than in the community EDs.

© 2015 by the Society for Academic Emergency Medicine.
__________________________________________________________________
________________________________*_________________________________

6. Abstract: Status of HIV and hepatitis C virus infections among
prisoners in the Middle East and North Africa: review and synthesis
__________________________________________________________________

This Full Free article is available in: PDF HTML EPUB XML
http://www.jiasociety.org/index.php/jias/article/view/20873

J Int AIDS Soc. 2016 May 27;19(1):20873.
Status of HIV and hepatitis C virus infections among prisoners in the
Middle East and North Africa: review and synthesis.

Heijnen M1,2, Mumtaz GR1,3, Abu-Raddad LJ1,4,5.

1Infectious Disease Epidemiology Group, Weill Cornell Medicine – Qatar,
Cornell University, Qatar Foundation – Education City, Doha, Qatar.
2Department of Healthcare Policy and Research, Weill Cornell Medicine,
Cornell University, New York, NY, USA; amh3003@qatar-med.cornell.edu;
marieke.heijnen@gmail.com.
3Department of Infectious Disease Epidemiology, Faculty of Epidemiology
and Population Health, London School of Hygiene and Tropical Medicine,
London, UK.
4Department of Healthcare Policy and Research, Weill Cornell Medicine,
Cornell University, New York, NY, USA.
5College of Public Health, Hamad bin Khalifa University, Doha, Qatar.

INTRODUCTION: The status of HIV and hepatitis C virus (HCV) infections
among incarcerated populations in the Middle East and North Africa (MENA)
and the links between prisons and the HIV epidemic are poorly understood.
This review synthesized available HIV and HCV data in prisons in MENA and
highlighted opportunities for action.

METHODS: The review was based on data generated through the systematic
searches of the MENA HIV/AIDS Epidemiology Synthesis Project (2003 to
December 15, 2015) and the MENA HCV Epidemiology Synthesis Project (2011
to December 15, 2015). Sources of data included peer-reviewed publications
and country-level reports and databases.

RESULTS AND DISCUSSION: We estimated a population of 496,000 prisoners in
MENA, with drug-related offences being a major cause for incarceration.
Twenty countries had data on HIV among incarcerated populations with a
median prevalence of 0.6% in Afghanistan, 6.1% in Djibouti, 0.01% in
Egypt, 2.5% in Iran, 0% in Iraq, 0.1% in Jordan, 0.05% in Kuwait, 0.7% in
Lebanon, 18.0% in Libya, 0.7% in Morocco, 0.3% in Oman, 1.1% in Pakistan,
0% in Palestine, 1.2% in Saudi Arabia, 0% in Somalia, 5.3% in Sudan and
South Sudan, 0.04% in Syria, 0.05% in Tunisia, and 3.5% in Yemen. Seven
countries had data on HCV, with a median prevalence of 1.7% in
Afghanistan, 23.6% in Egypt, 28.1% in Lebanon, 15.6% in Pakistan, and
37.8% in Iran. Syria and Libya had only one HCV prevalence measure each at
1.5% and 23.7%, respectively. There was strong evidence for injecting drug
use and the use of non-sterile injecting-equipment in prisons.
Incarceration and injecting drugs, use of non-sterile injecting-equipment,
and tattooing in prisons were found to be independent risk factors for HIV
or HCV infections. High levels of sexual risk behaviour, tattooing and use
of non-sterile razors among prisoners were documented.

CONCLUSIONS: Prisons play an important role in HIV and HCV dynamics in
MENA and have facilitated the emergence of large HIV epidemics in at least
two countries, Iran and Pakistan. There is evidence for substantial but
variable HIV and HCV prevalence, as well as risk behaviour including
injecting drug use and unprotected sex among prisoners across countries.

These findings highlight the need for comprehensive harm-reduction
strategies in prisons.

KEYWORDS: HCV; HIV; Middle East and North Africa; PWID; incarceration;
prisons
__________________________________________________________________
________________________________*_________________________________

7. Abstract: Drug preparation, injection, and sharing practices in
Tajikistan: a qualitative study in Kulob and Khorog
__________________________________________________________________

https://tinyurl.com/h863ec7 Free Open Access Article

Subst Abuse Treat Prev Policy. 2016 Jun 2;11(1):21. doi: 10.1186/
s13011-016-0065-2.
Drug preparation, injection, and sharing practices in Tajikistan: a
qualitative study in Kulob and Khorog.

Otiashvili D1, Latypov A2,3, Kirtadze I4,5, Ibragimov U6, Zule W7.

1Addiction Research Center, Alternative Georgia, 14a Nutsubidze Str.,
Office 2, 0177, Tbilisi, Georgia. dato@altgeorgia.ge.
2Global Health Research Center of Central Asia, Columbia University, New
York, USA.
3The Central Asia Program, Institute for European, Russian, and Eurasian
Studies, The Eliott School of International Affairs, George Washington
University, Washington, DC, USA.
4Addiction Research Center, Alternative Georgia, 14a Nutsubidze Str.,
Office 2, 0177, Tbilisi, Georgia.
5Business School, Ilia State University, Tbilisi, Georgia.
6Rollins School of Public Health, Emory University, Atlanta, GA, USA.
7RTI International, Research Triangle Park, NC, USA.

BACKGROUND: Sharing injection equipment remains an important rout of
transmission of HIV and HCV infections in the region of Eastern Europe and
Central Asia. Tajikistan is one of the most affected countries with high
rates of injection drug use and related epidemics.The aim of this
qualitative study was to describe drug use practices and related behaviors
in two Tajik cities – Kulob and Khorog.

METHODS: Twelve focus group discussions (6 per city) with 100 people who
inject drugs recruited through needle and syringe program (NSP) outreach
in May 2014. Topics covered included specific drugs injected, drug prices
and purity, access to sterile equipment, safe injection practices and
types of syringes and needles used. Qualitative thematic analysis was
performed using NVivo 10 software.

RESULTS: All participants were male and ranged in age from 20 to 78 years.
Thematic analysis showed that cheap Afghan heroin, often adulterated by
dealers with other admixtures, was the only drug injected. Drug injectors
often added Dimedrol (Diphenhydramine) to increase the potency of “low
quality” heroin. NSPs were a major source of sterile equipment. Very few
participants report direct sharing of needles and syringes. Conversely,
many participants reported preparing drugs jointly and sharing injection
paraphernalia. Using drugs in an outdoor setting and experiencing
withdrawal were major contributors to sharing equipment, using non-sterile
water, not boiling and not filtering the drug solution.

CONCLUSION: Qualitative research can provide insights into risk behaviors
that may be missed in quantitative studies. These finding have important
implications for planning risk reduction interventions in Tajikistan.
Prevention should specifically focus on indirect sharing practices.

KEYWORDS: Indirect sharing; Infection risks; Injection drug use;
Tajikistan

Free Open Access Article
__________________________________________________________________
________________________________*_________________________________

8. Abstract: Beyond equipment distribution in Needle and Syringe
Programmes: an exploratory analysis of blood-borne virus risk and other
measures of client need
__________________________________________________________________

https://tinyurl.com/ju65aja

Harm Reduct J. 2016 May 31;13(1):18.

Beyond equipment distribution in Needle and Syringe Programmes: an
exploratory analysis of blood-borne virus risk and other measures of
client need.

Treloar C1, Mao L2, Wilson H2.

1Centre for Social Research in Health, UNSW, Sydney, 2052, NSW, Australia.
c.treloar@unsw.edu.au. 2Centre for Social Research in Health, UNSW,
Sydney, 2052, NSW, Australia.

BACKGROUND: Despite high levels of equipment distribution through Needle
and Syringe Programmes (NSPs) in Australia, the levels of reuse of
equipment among people who inject drugs remain concerning. This paper used
an exploratory analysis to examine the needs of NSP client that could be
addressed by NSPs to enhance service impact and blood-borne virus risk
practices.

METHODS: People who inject drugs were recruited from six NSP sites in
Sydney, Australia, to undertake a self-completed survey.

RESULTS: Using the responses of 236 NSP client participants, three factors
were identified in an exploratory factor analysis: recent risky injection
(Eigenvalue 3.63, 20.2 % of variance); disadvantage and disability
(Eigenvalue 2.26, 12.5 % of variance); and drug use milieu (Eigenvalue
1.50, 8.4 % of variance). To understand the distribution of these factors,
the standardised factor scores were dichotomised to explore those
participants with ‘above average’ vulnerability on each factor. A small
group of NSP clients reported a cluster of vulnerability measures. Most
participants (55.5 %) reported vulnerability on none or only one factor,
indicating that 45.5 % could be considered as having double (35.6 %) or
triple (8.9 %) vulnerability.

CONCLUSIONS: These results challenge NSPs to understand the heterogeneity
among their client group and develop programmes that respond to their
clients’ range of needs beyond those immediately associated with blood-
borne virus (BBV) risk. This paper contributes to the growing evidence
base regarding the need for BBV prevention efforts to examine strategies
beyond equipment distribution.

KEYWORDS: Blood-borne virus risk; Equipment reuse; Injecting drugs; Needle
and Syringe Programme

Free BMC Article
http://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-016-
0107-0
__________________________________________________________________
________________________________*_________________________________

9. Abstract: Prevention and treatment produced large decreases in HIV
incidence in a model of people who inject drugs
__________________________________________________________________

Free PMC Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469974/

Health Aff (Millwood). 2014 Mar;33(3):401-9.
Prevention and treatment produced large decreases in HIV incidence in a
model of people who inject drugs.

Marshall BD, Friedman SR, Monteiro JF, Paczkowski M, Tempalski B, Pouget
ER, Lurie MN, Galea S.

In the United States, people who inject drugs continue to be at greatly
increased risk of HIV infection. To estimate the effectiveness of various
prevention scenarios, we modeled HIV transmission in a dynamic network of
drug users and people who did not use drugs that was based on the New York
Metropolitan Statistical Area population.

We compared the projected HIV incidence in 2020 and 2040 if current
approaches continue to be used to the incidence if one or more of the
following hypothetical interventions were applied: increased HIV testing,
improved access to substance abuse treatment, increased use of needle and
syringe programs, scaled-up treatment as prevention, and a “high impact”
combination scenario, consisting of all of the strategies listed above.

No strategy completely eliminated HIV transmission. The high-impact
combination strategy produced the largest decrease in HIV incidence-a 62
percent reduction compared to the status quo.

Our results suggest that increased resources for and investments in
multiple HIV prevention approaches will be required to eliminate HIV
transmission among people who inject drugs.

KEYWORDS: AIDS/HIV; Epidemiology; Mental Health/Substance Abuse; Public
Health; Special Populations
__________________________________________________________________
________________________________*_________________________________

10. Abstract: The ‘My five moments for hand hygiene’ concept for the
overcrowded setting in resource-limited healthcare systems
__________________________________________________________________

https://www.ncbi.nlm.nih.gov/pubmed/25997803

J Hosp Infect. 2015 Oct;91(2):95-9.
The ‘My five moments for hand hygiene’ concept for the overcrowded setting
in resource-limited healthcare systems.

Salmon S1, Pittet D2, Sax H3, McLaws ML4.

1School of Public Health and Community Medicine, UNSW Medicine, UNSW,
Sydney, Australia.
2Infection Control Program and WHO Collaborating Centre on Patient Safety,
University of Geneva Hospitals and Faculty of Medicine, Geneva,
Switzerland.
3Division of Infectious Diseases and Infection Control, University and
University Hospital Zurich, Switzerland.
4School of Public Health and Community Medicine, UNSW Medicine, UNSW,
Sydney, Australia. Electronic address: m.mclaws@unsw.edu.au.

Hand hygiene is a core activity of patient safety for the prevention of
healthcare-associated infections (HCAIs). To standardize hand hygiene
practices globally the World Health Organization (WHO) released Guidelines
on Hand Hygiene in Health Care and introduced the ‘My five moments for
hand hygiene’ concept to define indications for hand hygiene rooted in an
evidence-based model for transmission of micro-organisms by healthcare
workers’ (HCWs) hands.

Central to the concept is the division of the healthcare environment into
two geographical care zones, the patient zone and the healthcare zone,
that requires the HCW to comply with specific hand hygiene moments.

In resource-limited, overcrowded healthcare settings inadequate or no
spatial separation between beds occurs frequently. These conditions
challenge the HCW’s ability to visualize and delineate patient zones.

The ‘My five moments for hand hygiene’ concept has been adapted for these
conditions with the aim of assisting hand hygiene educators, auditors, and
HCWs to minimize ambiguity regarding shared patient zones and achieve the
ultimate goal set by the WHO Guidelines–the reduction of infectious
risks.

Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.

KEYWORDS: Alcohol-based hand rub; Hand hygiene; Healthcare workers;
Healthcare- associated infections; My five moments for hand hygiene;
Overcrowding; Patient zone
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Arteriovenous Fistula Formation After Intra-articular
Injection Following Total Joint Arthroplasty
__________________________________________________________________

https://tinyurl.com/jz6thoz Free Full Article

Orthopedics. 2016 May 31:1-4.
Arteriovenous Fistula Formation After Intra-articular Injection Following
Total Joint Arthroplasty.

Kane I, Post Z, Ong A, Orozco F.

Intra-articular joint capsule injection is a common method used to control
postoperative pain as a result of primary total knee arthroplasty (TKA).

It is generally considered a safe practice and is highly effective in
reducing the need for postoperative opioid administration as well as
decreasing recovery time through early mobilization. However, any
injection into the posterior knee space has the potential to injure the
vascular structures surrounding the knee.

Iatrogenic formation of an arteriovenous fistula is a rare complication
after TKA, and there are no reported cases of arteriovenous fistula
formation as a direct result of intra-articular injection.

This case report describes this complication that occurred several days
after TKA. The patient had acute pain and swelling in the treated leg. An
arteriovenous fistula of the popliteal artery and vein was identified with
bilateral Doppler ultrasound and confirmed by angiogram.

The most likely inciting event for the formation of the arteriovenous
fistula was intra-articular injection of bupivacaine, which likely pierced
the popliteal artery and vein, allowing the formation of the patent
channel. The patient was treated successfully with stent placement through
interventional radiology.

Orthopedic surgeons performing intra-articular injections of the knee
should refamiliarize themselves with the anatomy and location of the
popliteal artery, use smaller-gauge needles, and aspirate the syringe
before the injection to decrease the risk of iatrogenic damage to the
vasculature or fistula formation.

[Orthopedics.]. Copyright 2016, SLACK Incorporated.
__________________________________________________________________
________________________________*_________________________________

12. Extract: Zika virus: a new challenge for blood transfusion
__________________________________________________________________

Free Full Text DOI: http://dx.doi.org/10.1016/S0140-6736(16)30428-7

Lancet. 2016 May 14;387(10032):1993-4.
Zika virus: a new challenge for blood transfusion.

Musso D1, Stramer SL2; AABB Transfusion-Transmitted Diseases Committee,
Busch MP3; International Society of Blood Transfusion Working Party on
Transfusion-Transmitted Infectious Diseases.

1Unit of Emerging Infectious Diseases, Institut Louis Malardé, Tahiti,
French Polynesia. Electronic address: dmusso@ilm.pf.
2American Red Cross, Gaithersburg, MD, USA.
3International Society of Blood Transfusions, Blood Systems Research
Institute, San Francisco, CA, USA.
__________________________________________________________________

Extract Extract Extract Extract Extract Extract Extract
Zika virus: a new challenge for blood transfusion

Zika virus is an emerging flavivirus initially described in 1947. The
first outbreak of Zika virus occurred in 2007 in the Pacific and the virus
has spread in this region since 2013, and in the Americas since 2015.
Concomitantly, severe neurological complications in adults, fetuses, and
neonates have been described. Zika virus is mainly mosquito borne, but
non-vector transmission (maternal–fetal, sexual, and blood transfusion) is
possible, with an unknown effect on the burden of the disease.1

Flavivirus transmission through blood transfusion has been reported for
dengue virus and West Nile virus.2, 3 The potential for transfusion-
transmitted Zika virus was shown in French Polynesia where 2·8% of
asymptomatic blood donors tested were positive for Zika virus RNA using an
in-house nucleic acid test (NAT),1 and in Brazil with two possible cases
of transfusion-transmitted Zika virus infections.1, 4 According to
criteria used by AABB (formerly the American Association of Blood Banks),
Zika virus should be classified as a high-risk agent that threatens the
safety of blood recipients.2

Continues at the link http://dx.doi.org/10.1016/S0140-6736(16)30428-7
__________________________________________________________________
________________________________*_________________________________

13. Abstract: Zika Virus Spreads to New Areas – Region of the Americas,
May 2015-January 2016
__________________________________________________________________

Free full text http://www.cdc.gov/mmwr/volumes/65/wr/mm6503e1.htm

MMWR Morb Mortal Wkly Rep. 2016 Jan 29;65(3):55-8.
Zika Virus Spreads to New Areas – Region of the Americas, May 2015-January
2016.

Hennessey M1, Fischer M, Staples JE.

1Division of Vector-Borne Diseases, National Center for Emerging and
Zoonotic Infectious Diseases, CDC.

Zika virus is a mosquito-borne flavivirus that was first identified in
Uganda in 1947 (1). Before 2007, only sporadic human disease cases were
reported from countries in Africa and Asia. In 2007, the first documented
outbreak of Zika virus disease was reported in Yap State, Federated States
of Micronesia; 73% of the population aged ≥3 years is estimated to have
been infected (2). Subsequent outbreaks occurred in Southeast Asia and the
Western Pacific (3).

In May 2015, the World Health Organization reported the first local
transmission of Zika virus in the Region of the Americas (Americas), with
autochthonous cases identified in Brazil (4). In December, the Ministry of
Health estimated that 440,000-1,300,000 suspected cases of Zika virus
disease had occurred in Brazil in 2015 (5).

By January 20, 2016, locally-transmitted cases had been reported to the
Pan American Health Organization from Puerto Rico and 19 other countries
or territories in the Americas* (Figure) (6). Further spread to other
countries in the region is being monitored closely.

Free full text http://www.cdc.gov/mmwr/volumes/65/wr/mm6503e1.htm
__________________________________________________________________
________________________________*_________________________________

14. News

– Colorado USA: HIV-positive surgery tech has history of stealing drugs

– Colorado USA: Indicted medical technician tests HIV positive; thousands
of patients being tested

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/h76hg3y
Colorado USA: HIV-positive surgery tech has history of stealing drugs

By Thomas Peipert, Associated Press, USA (03.06.16)

DENVER (AP) — Prosecutors in Colorado say that a former hospital surgery
technician who is accused of stealing painkiller syringes and found to be
HIV positive has a history of moving from hospital to hospital and lying
about his past to steal drugs.

After announcing his HIV status on Wednesday, officials urged patients who
may have possibly been infected by him to be tested.

The prosecutors allege that Rocky Allen was fired from at least three
hospitals in as many states, but that didn’t prevent him from landing a
job in August at Swedish Medical Center in suburban Denver, where he is
accused of taking a syringe of painkillers and replacing it with one
containing another substance.

A class-action lawsuit filed in March on behalf of three patients who had
surgery at Swedish claims hospital officials should have known about
Allen’s “suspicious employment history” and his alleged drug abuse before
they hired him.

“All the warning signs of what would later occur at SMC were present,” the
lawsuit states.

Allen had been fired from hospitals in Arizona, California and Washington
before he moved to Colorado. He also had drug problems when he served in
the Navy and was court-martialed in 2011 for stealing pain medication,
military records show.

According to the lawsuit, those records would have been released if
Swedish requested them as part of a background check or to inquire about
Allen’s military service.

It wasn’t immediately known what steps the hospitals took to investigate
Allen’s past, but prosecutors say he lied about his previous drug problems
when he applied for the job at Swedish.

Hospital spokeswoman Nicole Williams said Wednesday night she could not
comment about the lawsuit, but “our background checks are in line with
other (health care) organizations.”

Richard McCune, who is among the attorneys who filed the lawsuit, said
Wednesday that he and the plaintiffs are also frustrated it took so long
to find out that Allen is HIV positive — and that he first heard about it
through a news story forwarded to him by a friend.

“For it to come out in a public forum, it doesn’t endear a lot of
confidence in (Swedish Medical Center) handling this in an objective way,”
he said.

Before Wednesday, authorities had not described Allen’s health status, and
prosecutors previously only referred to him as having an undisclosed
“blood-borne pathogen.” Allen had tested negative for Hepatitis B and C, a
statement from the U.S. Attorney’s Office also said.

The fear is that Allen may have replaced the needles intended for patients
with syringes he previously used, making it possible for patients to be
infected. However, Allen’s public defender, Timothy O’Hara, has said that
while evidence showed Allen may have switched syringes, there was no
reason to believe he was re-using them.

Public health officials have said the risk of exposure to blood-borne
pathogens is low, and there have been no reported cases of patients
becoming infected because of Allen.

Authorities say someone saw Allen take a syringe filled with painkillers
from an operating room at Swedish on Jan. 22. The hospital fired him, and
three weeks later federal prosecutors charged him with tampering with a
consumer product and obtaining a controlled substance by deceit.

Swedish Medical Center officials attempted to notify about 3,000 patients
who underwent surgery in the hospital’s main operating room during Allen’s
employment.

Dr. Larry Wolk, chief medical officer and executive director of the
Colorado Department of Public Health and Environment, said Wednesday that
complete test results were not obtained for about 1,000 patients. While
the department said no evidence of transmission was found in those for
whom testing was completed, it could not confirm that no diseases were
passed on because testing was incomplete.
___

Associated Press writers Dan Elliott, Donna Bryson and Colleen Slevin
contributed to this report.
__________________________________________________________________
__________________________________________________________________

https://tinyurl.com/jc2jw78
Colorado USA: Indicted medical technician tests HIV positive; thousands of
patients being tested

By Shawn Price, UPI.com, USA (02.06.16)

Officials are hoping anyone who had surgery at Swedish Medical Center
between August 2015 and January 2016 will be tested for HIV and hepatitis.

Prosecutors say former medical technician Rocky Allen, who has HIV,
swapped syringes with unwitting patients to steal IV drugs. Screenshot via
Denver7

ENGLEWOOD, Colo., June 2 (UPI) — A former surgical tech charged with
swapping syringes at a Denver hospital so he could steal liquid pain
medication has tested positive for HIV, the U.S. Attorney’s office said.

Rocky Allen, 28, was indicted in February for tampering with a consumer
product and obtaining a controlled substance by deceit. Swedish Medical
Center, which fired him in January, has offered free testing to about
3,000 patients for HIV, and hepatitis C and B. So far 2,500 have tested
negative.

Colorado health officials want anyone who had surgery at the hospital
between Aug. 17, 2015, and Jan. 22, 2016, to be tested.

Officials said at least 1,000 former patients should be tested.

“The absence of such evidence is not proof that no disease transmission
occurred, because not all notified patients chose to be tested,” said Dr.
Larry Wolk, Colorado Department of Public Health’s chief medical officer.

Allen’s HIV test result were revealed on the same day public health
officials found serious problems with how Swedish Medical Center kept
track of medication, practiced infection control or surgical services. The
hospital has said it has a plan to correct the issues.
__________________________________________________________________
________________________________*_________________________________

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

The SIGN Forum welcomes new subscribers who are involved in injection
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
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We would like your help in building this archive. Please send your old
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Email mailto:sign.moderator@gmail.com
__________________________________________________________________
________________________________*_________________________________

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)
Health Systems and Innovation (HIS) at WHO HQ, Geneva Switzerland.

The SIGN Forum is moderated by Allan Bass and is hosted on GoogleGroups
__________________________________________________________________

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