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SIGNpost 00594


Post00594 SIGN2010 Report + Calls4Action + Abstracts + News 13 April 2011

1. New: SIGN 2010 meeting report
2. The Lancet Editorial: HIV and injecting drug use: a global call for
3. Abstract: Prevalence of hepatitis C virus infection among health-care
workers: A 10-year survey
4. Abstract: Needlestick and sharps injuries in the nursing student
5. Abstract: Practical techniques to enhance the safety of health care
workers in office-based surgery
6. Abstract: Should blood-borne virus testing be part of operative
consent? When the doctor becomes the patient
7. Abstract: Drug administration error related to computerized prescribing
8. Abstract: A survey of environmental safety issues at 20 medical clinics
9. Abstract: Prevalence and trend of hepatitis C virus infection among
blood donors in Chinese mainland: a systematic review and meta-
10. Abstract: Hand disinfection in hospitals – benefits and risks
11. Abstract: Efficacy of decontaminants and disinfectants against
Clostridium difficile
12. Abstract: Prevention of hepatitis B virus and hepatitis C virus
transmission in hemodialysis centers: review of current international
13. Abstract: Performance of medical residents in sterile techniques
during    central vein catheterization: randomized trial of efficacy
of simulation-based training
14. No Abstract: Study of attitude regarding health care waste management
among health care providers of a tertiary care hospital in Kolkata
15. No Abstract: Prevent needlestick injuries: at all cost
16. No Abstract: Medical Equipment and Infection Control: It’s All About
17. No Abstract:Hand hygiene: a different look
18. No Abstract:The Intertwined Epidemics of HIV Infection, Incarceration,
and Substance Abuse: A Call to Action
19. Global: Health-Systems Strengthening: Current and Future Activities
20. News
– Philippines: DOH: Tainted blood recipients have died
– Philippines: PNRC enforces policy on ‘no paid blood donor’
– Nevada USA: Proposal Makes Syringes Legal Without Prescription
– USA: DC’s treatment in fed budget angers local leaders
– Australia: Family face nervous wait after needle stick injury
– USA: Germy Faucet Fingered In Outbreak Of Blood Infections From Alabama
– Africa: World Health Day: WHO AFRO boss tasks Africa on drug resistance
– USA: Tainted IV Lawsuits Filed Over Deaths At Alabama Hospital
– MDGs Still In Reach, But 2015 Deadline Will Be Missed, Bill Gates Says
– Afghanistan: New Therapy Attacks Soaring Drug Addiction

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Visit the WHO injection safety website and the SIGN Alliance Secretariat

1. New: SIGN 2010 meeting report

The 2010 annual Safe Injection Global Network meeting was held from 9
to 11 November 2010 in Dubai, The United Arab Emirates.

The SIGN 2010 meeting report pdf, 1.36Mb is available on line at:

The report is navigable using bookmarks and searchable. Requires the free
Adobe Acrobat Reader at:

2. The Lancet Editorial: HIV and injecting drug use: a global call for

The Lancet Editorial: HIV and injecting drug use: a global call for action

The Lancet, Volume 377, Issue 9773, Page 1212, 9 April 2011 <

When world leaders meet in New York at the UN High-Level Meeting on AIDS
(June 8-10, 2011), they will review the past decade’s progress and chart
the future course of the global HIV response. There are some advances to
celebrate, with global HIV incidence falling and access to treatment
improving. But there are also unmitigated failures to be addressed moving
forward. As a LancetSeries emphasised last year, people who inject drugs
have been left behind in global efforts to scale up access to HIV
prevention, treatment, care, and support. Their needs have been neglected,
and their rights have been ignored, and, in many cases, horribly violated
as governments have chosen to pursue punitive, disproportionate drug laws
instead of evidence-based health strategies to address drug-related harm.

The June meeting represents a unique opportunity to correct these
injustices. A new document-the Beirut Declaration on HIV and Injecting
Drug Use: A Global Call for Action-released at the 22nd International Harm
Reduction Conference, Beirut, Lebanon (April 3-7, 2011), sets out how the
international community has failed people who inject drugs and the actions
now required by governments. Crucially, evidence-based programmes (needle
and syringe exchange programmes, opioid substitution, and antiretroviral
treatment) targeting the 16 million people who inject drugs worldwide need
to be financed, implemented, and scaled up across all settings to prevent
and treat HIV infection. Ineffective drug policies also need to end,
funding for harm reduction needs to be vastly increased, and vulnerable
groups who inject drugs (including women, young people, and people in
prison) need access to integrated health and harm-reduction services.
These actions should be explicitly included in the new global declaration
on HIV/AIDS that will be drafted at the June meeting with measurable
targets to hold governments accountable.

Misplaced moral judgments have underpinned the neglect of people who
inject drugs in the global HIV response. Yet it is wholly immoral to let
people become infected with HIV or die when evidence-based interventions
exist to prevent these outcomes. A bold and humane response is needed from
governments at the June meeting and beyond. Millions of lives are at

3. Abstract: Prevalence of hepatitis C virus infection among health-care
workers: A 10-year survey

Mol Med Report. 2010 Jul-Aug;3(4):561-4.

Prevalence of hepatitis C virus infection among health-care workers: A 10-
year survey.

Marconi A, Candido S, Talamini R, Libra M, Nicoletti F, Spandidos DA,
Stivala F, Proietti L.

Department of Biomedical Sciences, University of Catania, Catania, Italy.

Hepatitis C virus (HCV) is one of the most common blood-borne pathogens
transmitted from patients to health-care workers (HCWs).

HCV infection status among HCWs and occupational blood exposure accidents
were monitored to assess the risk of HCV infection among 403 HCWs from a
single institution between 1999 and 2009. Additionally, HCV-related
malignancies were evaluated in the HCV-positive HCWs.

HCV infection was detected in 3% of the subjects at the first survey. The
HCWs that initially tested negative for HCV remained negative during the
10 years of the survey. Of note, a statistically significant decrease was
observed in the number of HCWs that experienced occupational blood
exposure accidents, from 116 in 1999 to 72 in 2009 (p=0.0002). One HCV-
infected HCW developed B-cell non- Hodgkin lymphoma (NHL) of the liver.
The heavy chain gene combinations detected in the DNA from the NHL tissue
were of the type usually found in HCV-associated lymphomas, supporting the
role of HCV infection in the lymphomagenesis of this patient.

The set of universal precautions recommended by the US Center for Disease
Control and Prevention aided in the prevention of HCV transmission from
patients to HCWs, as all 390 HCV- negative HCWs remained negative for the
duration of the survey.

Consequently, these recommendations also serve to prevent the development
of HCV-associated malignancies such as hepatocellular carcinoma or B-cell

4. Abstract: Needlestick and sharps injuries in the nursing student

Nurs Stand. 2011 Mar 9-15;25(27):38-45.

Needlestick and sharps injuries in the nursing student population.

Hambridge K.

Faculty of Health, University of Plymouth, Devon.

Needlestick injuries (NSIs) and sharps injuries are a potential source of
harm. Such injuries can cause considerable distress and have an economic
effect on both the person who is injured and the healthcare organisation.

Although data regarding trained nurses are more plentiful, there is a
dearth of published information and research on the incidence and causes
of NSIs and sharps injuries in the nursing student population, especially
in the UK.

This article provides an overview of the available evidence.
There is a need for better education of nursing students and more
effective supervision in relation to NSIs and sharps injuries.

5. Abstract: Practical techniques to enhance the safety of health care
workers in office-based surgery

J Cutan Med Surg. 2011 Jan-Feb;15(1):48-54.

Practical techniques to enhance the safety of health care workers in
office-based surgery.

Alghamdi KM, Alkhodair RA.

Dermatology Department, College of Medicine, King Saud University, Riyadh,
Saudi Arabia.

BACKGROUND: Office-based surgery is commonly practiced in different
specialties for a variety of procedures. During these procedures, the
health care worker (HCW) is exposed to a large number of pathogens that
can be bloodborne, including the hepatitis B virus (HBV), hepatitis C
virus (HCV), and human immunodeficiency virus (HIV).

These pathogens can be transmitted through needlesticks or sharp injuries
to intact skin or by backsplash of contaminated body fluids onto mucous
membranes or injured skin.

OBJECTIVES AND CONCLUSIONS: This article reviews the published techniques
designed to protect the HCW from such hazards.

These techniques are classified into preoperative, intraoperative, and
postoperative. Preoperative measures include general protective measures,
organization of the surgical field, and consideration of alternative
treatments in high- risk patients. Intraoperative techniques deal with
safe handling and transferring of sharp instruments, working without using
sharps, and protection from backspray injuries. Postoperative measures
address proper disposal of used sharps.

6. Abstract: Should blood-borne virus testing be part of operative
consent? When the doctor becomes the patient

J Med Ethics. 2011 Apr 8.

Should blood-borne virus testing be part of operative consent? When the
doctor becomes the patient.

Adams ST, Leveson SH.

Department of General Surgery, York Hospital, York, UK.

Point-of-care testing (POCT) is a sensitive, specific and rapid form of
testing for the presence of HIV antibodies. Post-exposure prophylaxis for
HIV infection can reduce seroconversion rates by up to 80%.

Needlestick injuries are the second commonest cause of occupational injury
in the NHS and 20% of these occur during operations. In the NHS, in order
to protect staff and patients from the risk of bloodborne viruses such as
HIV, it is mandatory to report such injuries; however, numerous studies
have shown that many groups, particularly doctors, are reluctant to do so.

This article outlines the arguments for and against the introduction of
preoperatively seeking consent from patients to have their blood tested
for HIV via POCT in order to improve the reporting rates of needlestick
injuries incurred during surgery and to protect staff from infection.

7. Abstract: Drug administration error related to computerized prescribing

J Oncol Pharm Pract. 2010 Dec;16(4):273-6.

Drug administration error related to computerized prescribing.

Le Garlantezec P, Aupée O, Alméras D, Lefeuvre L, Souleau B, Sgarioto A,
Bohand X.

Hôpital d’instruction des armées du Val de Grâce, Pharmacy Department,
Paris, France.

INTRODUCTION: One of the main reasons for the implementation of computer-
based prescribing was to reduce medication errors. However, the risk has
not fallen to zero and new kinds of errors have been detected.

SETTING: the following case relates one of these medication errors
involving a preparation of vincristine. This antineoplastic drug was
injected to a patient via a subcutaneous route of administration instead
of an intravenous bolus injection.

RESULTS: consequently, a cutaneous erythema appeared. This incident
resulted from an error in the programming of the administration route of
the protocol operated by a pharmacist and a physician. The pharmacist, who
was responsible for the validation of the computerized medical order and
then for the compounding and the dispensing of the drug, did not detect
the error.

CONCLUSION: this case highlights the need of improved and irreproachable
therapeutic protocols. Recorded in a database, they must be validated
pharmaceutically and medicinally to secure computer-based prescribing,
drug handling, dispensing, and administering of the antineoplastic drugs.
Even if the pharmaceutical analysis of prescriptions is made easier with
computerization, we encourage the training of nurses and the evaluation of
their knowledge as well as the necessity for pharmacists to learn to
detect new kinds of errors and to verify periodically protocols.

8. Abstract: A survey of environmental safety issues at 20 medical clinics

J Environ Health. 2011 Jan-Feb;73(6):86-94.

A survey of environmental safety issues at 20 medical clinics.

Savely SM, Hamilton WJ, Degani F, Weinberg AD, Muraca P.

Chronic Disease Prevention and Control Research Center, Baylor College of
Medicine, Houston, TX 77030-3411, USA.

In the study described in this article, the authors performed safety walk-
throughs or inspections for 20 clinics located both inside a major medical
center clinic (onsite) and away from the main clinic site (offsite). A
checklist was used to evaluate compliance with institutional, local,
state, and federal guidelines and regulations.

The results obtained at onsite clinics were compared with the results from
offsite clinics.

Findings suggested no overall difference in the number of yes (desirable)
answers. A marginally significant difference, however, was observed
between the onsite and offsite clinics with regard to knowledge of
infection control and waste/infection control questions.

The walk-throughs helped create an improved working relationship between
clinic personnel and environmental safety personnel, allowed for
correction of safety issues, enabled an informal training opportunity, and
increased institutional compliance with guidelines and regulations.

9. Abstract: Prevalence and trend of hepatitis C virus infection among
blood donors in Chinese mainland: a systematic review and meta-

BMC Infect Dis. 2011 Apr 9;11(1):88.

Prevalence and trend of hepatitis C virus infection among blood donors in
Chinese mainland: a systematic review and meta-analysis.

Gao X, Cui Q, Su J, Shi X, Peng Z, Chen X, Lei N, Ding K, Wang L, Yu R,
Wang N.

BACKGROUND: Blood transfusion is one of the most common transmission
pathways of hepatitis C virus (HCV). This paper aims to provide a
comprehensive and reliable tabulation of available data on the
epidemiological characteristics and risk factors for HCV infection among
blood donors in Chinese mainland, so as to help make prevention strategies
and guide further research.

METHODS: A systematic review was constructed based on the computerized
literature database. Infection rates and 95% confidence intervals (95% CI)
were calculated using the approximate normal distribution model. Odds
ratios and 95% CI were calculated by fixed or random effects models. Data
manipulation and statistical analyses were performed using STATA 10.0 and
ArcGIS 9.3 was used for map construction.

RESULTS: Two hundred and sixty-five studies met our inclusion criteria.
The pooled prevalence of HCV infection among blood donors in Chinese
mainland was 8.68% (95% CI: 8.01%-9.39%), and the epidemic was severer in
North and Central China, especially in Henan and Hebei. While a
significant lower rate was found in Yunnan. Notably, before 1998 the
pooled prevalence of HCV infection was 12.87% (95%CI: 11.25%-14.56%) among
blood donors, but decreased to 1.71% (95%CI: 1.43%-1.99%) after 1998. No
significant difference was found in HCV infection rates between male and
female blood donors, or among different blood type donors. The prevalence
of HCV infection was found to increase with age. During 1994-1995, the
prevalence rate reached the highest with a percentage of 15.78% (95%CI:
12.21%-19.75%), and showed a decreasing trend in the following years. A
significant difference was found among groups with different blood
donation types, Plasma donors had a relatively higher prevalence than
whole blood donors of HCV infection (33.95% vs 7.9%).

CONCLUSIONS: The prevalence of HCV infection has rapidly decreased since
1998 and kept a low level in recent years, but some provinces showed
relatively higher prevalence than the general population. It is urgent to
make efficient measures to prevent HCV secondary transmission and control
chronic progress, and the key to reduce the HCV incidence among blood
donors is to encourage true voluntary blood donors, strictly implement
blood donation law, and avoid cross-infection.

Free Article

10. Abstract: Hand disinfection in hospitals – benefits and risks

J Dtsch Dermatol Ges. 2010 Dec;8(12):978-83.

Hand disinfection in hospitals – benefits and risks.

[Article in English, German]

Kampf G, Löffler H.

Bode Chemie GmbH, Scientific Affairs, Hamburg, Germany Institute for
Hygiene and Environmental Medicine, University of Greifswald, Germany.

The WHO regards hand hygiene as an essential tool for the prevention of
noso-comial infections. The hygienic hand disinfection has a superior
antimicrobial efficacy compared to hand washing and should be performed as
the treatment of choice before and after a variety of activities at the
point of patient care.

Washing hands should be preferred when the hands are visibly soiled. Skin
irritation is quite common among healthcare workers and is mainly caused
by water, soap and long lasting occlusion.

Compliance with hand disinfection in clinical practice is often low.
Measures to improve compliance include training, provision of hand rubs
where they are needed, and the responsibility of doctors to set a good

Improved compliance in hand hygiene and targeted use of alcohol- based
hand rubs can reduce the nosocomial infection rate by up to 40 %.

The benefit of hand disinfection is therefore much larger than possible

© The Authors * Journal compilation © Blackwell Verlag GmbH, Berlin.

11. Abstract: Efficacy of decontaminants and disinfectants against
Clostridium difficile

J Med Microbiol. 2011 Apr 7.

Efficacy of decontaminants and disinfectants against Clostridium

Vohra P, Poxton IR.

University of Edinburgh.

Clostridium difficile is a common nosocomial pathogen transmitted mainly
via its spores. These spores can remain viable on contaminated surfaces
for several months and are resistant to most commonly used cleaning
agents. Thus, effective decontamination of the environment is essential in
preventing the transmission of C. difficile in healthcare establishments.

However, this emphasis on decontamination must also be extended to
laboratories due to risk of exposure of staff to potentially virulent
strains. Though few cases of laboratory-acquired infection have been
reported, the threat of infection by C. difficile in the laboratory is

Our aim was to test the efficacy of four disinfectants, Actichlor,
MicroSol 3+, TriGene Advance and Virkon, and one laboratory decontaminant,
Decon 90, against vegetative cells and spores of C. difficile. Five
strains were selected for the study: the three most commonly encountered
epidemic strains in Scotland, PCR ribotypes 106, 001 and 027, and control
strains 630 and VPI 10463.  MICs were determined by agar dilution and
broth microdilution.

All the agents tested inhibited the growth of vegetative cells of the
selected strains at concentrations below the recommended working
concentrations. Additionally, their effect on spores was determined by
exposing the spores of these strains to different concentrations of the
agents for different periods of time. For some of the agents, an exposure
of ten minutes was required for sporicidal activity. Further, only
Actichlor was able to bring about a 3 log10 reduction in spore numbers
under clean and dirty conditions. It was also the only agent that
decontaminated different hard, non-porous surfaces artificially
contaminated with C. difficile spores. However, this too required an
exposure time of more than 2 min and up to 10 min.

In conclusion, only the chlorine-releasing agent Actichlor was found to be
suitable for the elimination of C. difficile spores from the environment
making it the agent of choice for the decontamination of laboratory

12. Abstract: Prevention of hepatitis B virus and hepatitis C virus
transmission in hemodialysis centers: review of current international

Arab J Nephrol Transplant. 2011 Jan;4(1):35-47.

Prevention of hepatitis B virus and hepatitis C virus transmission in
hemodialysis centers: review of current international recommendations.

Elamin S, Abu-Aisha H.

Ahmed Gasim Kidney Transplant Center and Sudan Peritoneal Dialysis
Program, Sudan.
INTRODUCTION: Hepatitis B virus (HBV) and hepatitis C virus (HCV)
infections in hemodialysis (HD) patients are associated with adverse
outcomes, especially after kidney transplantation.

REVIEW: In the HD setting, cross-contamination to patients via
environmental surfaces, supplies, equipment, multiple-dose medication
vials and staff members is mainly responsible for both HBV and HCV
transmission. The incidence and prevalence of HBV in HD centers have
dropped markedly as a result of isolation strategy for HBsAg positive
patients, the implementation of infection control measures and the
introduction of HBV vaccine. The incidence and prevalence of HCV infection
among HD patients remain higher than the corresponding general population.
There is ongoing debate as to whether isolation of HCV infected patients
is needed to combat high anti-HCV seroconversion rates. The current
guidelines do not recommend isolation or the use of dedicated machines for
HCV infected patients, and rely on strict adherence to infection control
measures for the prevention of HCV transmission in the HD setting.
Investigations of dialysis associated outbreaks of HCV infection indicate
that transmission most likely occurs because of inadequate infection
control practices. Routine screening of anti-HCV negative patients, with
HCV-antibody testing, and monthly monitoring of ALT levels is recommended
to monitor transmission within centers.

CONCLUSION: Prevention of transmission of HBV and HCV in the HD setting
warrants a multi-faceted approach. Not enough stress can be placed on the
importance of adequate infection control practices for the prevention of
both infections. Prevention of HBV transmission is augmented by correct
implementation of isolation strategies and the universal vaccination of
susceptible patients.

13. Abstract: Performance of medical residents in sterile techniques
during    central vein catheterization: randomized trial of efficacy
of simulation-based training

Chest. 2011 Jan;139(1):80-7.

Performance of medical residents in sterile techniques during central vein
catheterization: randomized trial of efficacy of simulation-based

Khouli H, Jahnes K, Shapiro J, Rose K, Mathew J, Gohil A, Han Q, Sotelo A,
Jones J, Aqeel A, Eden E, Fried E.

Department of Medicine, St Luke’s-Roosevelt Hospital Center, New York, NY
10019, USA.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a
preventable cause of a potentially lethal ICU infection. The optimal
method to teach health-care providers correct sterile techniques during
central vein catheterization (CVC) remains unclear.

METHODS: We randomly assigned second- and third-year internal medicine
residents trained by a traditional apprenticeship model to simulation-
based plus video training or video training alone from December 2007 to
January 2008, with a follow-up period to examine CRBSI ending in July
2009. During the follow-up period, a simulation-based training program in
sterile techniques during CVC was implemented in the medical ICU (MICU). A
surgical ICU (SICU) where no residents received study interventions was
used for comparison. The primary outcome measures were median residents’
scores in sterile techniques and rates of CRBSI per 1,000 catheter-days.

RESULTS: Of the 47 enrolled residents, 24 were randomly assigned to the
simulation-based plus video training group and 23 to the video training
group. Median baseline scores in both groups were equally poor: 12.5 to 13
(52%-54%) out of maximum score of 24 (P = .95; median difference, 0; 95%
CI, 0.2-2.0). After training, median score was significantly higher for
the simulation-based plus video training group: 22 (92%) vs 18 (75%) for
the video training group (P < .001; median difference, 4; 95% CI, 3-6).
During the follow-up period, there was a significantly lower rate of CRBSI
in the MICU (1.0 per 1,000 catheter-days) compared with the SICU (3.4 per
1,000 catheter-days) (P = .03). The incidence rate ratio derived from the
Poisson regression (0.30; 95% CI, 0.10-0.91) indicated there was a 70%
reduction in the incidence of CRBSI in the postintervention MICU compared
with the preintervention MICU and the postintervention SICU.

CONCLUSIONS: Simulation-based training in sterile techniques during CVC is
superior to traditional training or video training alone and is associated
with decreased rate of CRBSI. Simulation-based training in CVC should be
routinely used to reduce iatrogenic risk. TRIAL REGISTRY:; No.: NCT00612131; URL:

14. No Abstract: Study of attitude regarding health care waste management
among health care providers of a tertiary care hospital in Kolkata

Indian J Public Health. 2010 Apr-Jun;54(2):104-5.

Study of attitude regarding health care waste management among health care
providers of a tertiary care hospital in Kolkata.

Chattopadhyay D, Bisoi S, Biswas B, Chattopadhyay S.

Free Article

15. No Abstract: Prevent needlestick injuries: at all cost

Aust Nurs J. 2011 Feb;18(7):3.

Prevent needlestick injuries: at all cost.

Beavis W.

16. No Abstract: Medical Equipment and Infection Control: It’s All About

Biomed Instrum Technol. 2011 Mar-Apr;45(2):151-3.

Medical Equipment and Infection Control: It’s All About Cooperation.

Stiefel RH.

17. No Abstract:Hand hygiene: a different look

Arch Argent Pediatr. 2010 Oct;108(5):389-90.

[Hand hygiene: a different look].

[Article in Spanish]

Fernández Jonusas S.

Hospital Italiano de Buenos Aires, Argentina.

Free Article

18. No Abstract:The Intertwined Epidemics of HIV Infection, Incarceration,
and Substance Abuse: A Call to Action

J Infect Dis. 2011 May;203(9):1201-3.

The Intertwined Epidemics of HIV Infection, Incarceration, and Substance
Abuse: A Call to Action.

Flanigan TP, Beckwith CG.

Department of Medicine, Alpert Medical School of Brown University and The
Miriam Hospital, Providence, Rhode Island.

19. Global: Health-Systems Strengthening: Current and Future Activities

Crossposted from The Lancet with thanks

The Lancet, Volume 377, Issue 9773, Pages 1222 – 1223, 9 April 2011

Health-systems strengthening: current and future activities

Jesper Sundewall a, R Chad Swanson b, Arvind Betigeri c, David Sanders d,
Téa E Collins e, George Shakarishvili f, Ruairi Brugha g h

There is strong consensus in the global health community, among donors,
recipient countries, and policy makers, about the need for health-system
strengthening in low-income and middle-income countries.1, 2 Traditional
donors and new disease-specific aid initiatives, such as the GAVI
Alliance, the US President’s Emergency Plan for AIDS Relief (PEPFAR), and
the Global Fund to Fight AIDS, Tuberculosis and Malaria, are directly or
indirectly funding health-system strengthening. The need for greater
capacity to produce a better evidence-base for health-system strengthening
has resulted in the first global symposium on health-systems research, to
be held in Montreux, Switzerland, in November, 2010.3 The consensus on the
importance of strong health systems is welcomed. However, without clarity
on future directions, focus and energy could dissipate. The following
areas in health-system strengthening require more attention and better

First, there is lack of consensus on what health-system strengthening
means, and consequently on how it should be done and evaluated.4 As a
result, efforts in health-system strengthening are fragmented. Some
commentators are enthusiastic about WHO’s building-blocks model.4, 5
Others have proposed to identify synergies for converging multiple
frameworks.6 Donors have differing priorities and constraints on how they
can channel funds, which limit their adoption of a prescriptive model of
health-system strengthening.7 The efforts of PEPFAR and the Global Fund,
and to a lesser extent those of the GAVI Alliance, for health-system
strengthening are generally restricted to activities related to specific
target diseases, which can distort national priorities and staff
allocation.4 Consensus on health-system strengthening requires recognition
of the constraints on major donors-accountability to domestic taxpayers,
domestic media, and legal frameworks-which lead them to establish parallel
systems from priority setting through to monitoring and evaluation.

However, donors need to explicitly acknowledge the pre-eminent principles
of equity, universal coverage, and the stewardship responsibilities and
accountability of recipient countries to their citizens.
Second, health systems are highly contextual.8 Health problems and needs
vary across countries and regions, as do the systems to respond to these
problems. Anglophone sub-Saharan African countries have seen 30 years of
undermining of their health systems by structural adjustment and
successive fiscal crises, contributing to wholesale emigration of trained
health workers.9 Many Asian and Latin-American health systems are tiered
and fragmented because of the unregulated growth of private health care
and successive externally-driven initiatives. Public health systems in the
countries of the former Soviet Union, previously universally
accessible-albeit often inefficient-have been disrupted by reductions in
funding and rapid privatisation, resulting in large inequities. There is
no magic bullet, no one size fits all. Health-system strengthening must be
a long-term iterative process in which local stakeholders, not donors or
external experts, take the lead in adapting evidence-based solutions to
local political and cultural contexts, enhancing community capacities and
enabling community-based responses.

Robust, responsive, and efficient health systems are needed to reach the
Millennium Development Goals. The current surge in activities around
health-system strengthening is encouraging, but focus and clarity are
critical. Some important initiatives and resources for health-system
strengthening that address the challenges described include the following.

First, inter-agency consultations to jointly define the scope of health-
system strengthening and to develop a common approach to tracking
investments in such strengthening are in progress.10 Second, WHO and the
World Bank have developed a toolkit for assessing health-system
strengthening.11 Third, there is the Alliance for Health Policy and
Systems Research.12 Fourth, the Taskforce on Innovative International
Financing for Health Systems has recommended increased funding for health-
system strengthening.8 Fifth, there is a consensus statement for health-
system strengthening to which a growing number of global health
professionals and practitioners are contributing.13 Sixth, at the Montreux
symposium, stakeholders will “share evidence, identify significant
knowledge gaps, and set a research agenda that reflects the needs of low
and middle-income countries”.3

The panel proposes areas where better evidence and capacity is needed to
advance the agenda for health-system strengthening. The propositions
encourage involvement and interactions between all levels, from local
communities to global policy makers and funders. A joint understanding of
health-system strengthening and an agenda for action with broad support
across a wide spectrum of stakeholders will be central tools to improve
efforts. The period leading up to the November symposium is an opportunity
to improve and refine the agenda for research and action.


Future research and evaluation focus areas for health-system

Focal health-system strengthening areas:

Role of civil society and community-based organisations in health-system

Retention and optimum use of human resources for health as a function of
health-system strengthening

Approaches to strengthening health-systems governance

Optimum approaches to intersectoral collaborations for health-system

Assessments of health-systems performance at different levels of health

Operational research to test capacity of district health-information
systems to provide evidence on health-systems performance

Capacity of health systems to respond to demographic change, ageing
populations, chronic diseases, and emerging infections

Measuring and improving health-service quality

Cross-country comparative health-systems analyses to understand how health
interventions and contexts interact

Future activities in health-system strengthening might include:

Formation of high-level task force involving policy makers and other
stakeholders from low-income and middle-income countries to review
evidence-base for health-system strengthening

Training in implementation and evaluation of strategies for health-system
strengthening for senior health-systems stewards in ministries of health

Developing tools for assessments of health-systems impacts to test effects
of new global programmes and initiatives on health systems14

Supporting countries to develop menus of priorities for health-system
strengthening for donors to fund

Developing efficient funding mechanisms for donors to coordinate, channel,
and minimise duplication in support for health-system strengthening to

Encouraging broad adoption of the ten steps to systems thinking as
formulated by WHO in efforts on health-system strengthening12

Engaging civil society in efforts for health-system strengthening for
stronger community-based responses

We declare that we have no conflicts of interest.


1 Travis P, Bennett S, Haines A, et al. Overcoming health-systems
constraints to achieve the Millennium Development Goals. Lancet 2004; 364:

2 WHO. The world health report 2000-health systems: improving performance. (accessed April 12, 2010).

3 First Global Symposium on Health Systems Research. (accessed April 18, 2010).
4 Samb B, Evans T, Dybul M, et al. An assessment of interactions between
global health initiatives and country health systems. Lancet 2009; 373:

5 WHO. Everybody’s business: strengthening health systems to improve
health outcomes: WHO’s framework for action.
(accessed April 12, 2010).

6 Shakarishvili G, Atun R, Berman P, Hsiao W, Burgess C, Lansang MA.
Converging health systems framework: towards a concepts-to-actions roadmap
for health systems strengthening in low- and middle-income countries.
Global Health Gov 2010; III: 1-16.

7 Taskforce on Health Systems Research. Informed choices for attaining the
Millennium Development Goals: towards an international cooperative agenda
for health-systems research. Lancet 2004; 364: 997-1003.

8 Fryatt R, Mills A, Nordstrom A. Financing of health systems to achieve
the health Millennium Development Goals in low-income countries. Lancet
2010; 375: 419-426.

9 Sanders DM, Todd C, Chopra M. Confronting Africa’s health crisis: more
of the same will not be enough. BMJ 2005; 331: 755-758.

10 World Bank. Moving towards a health systems funding platform. (accessed Feb 17, 2010).

11 WHO. Toolkit for monitoring health systems strengthening.
(accessed May 26, 2010).

12 De Savigny D, Adam T. Systems thinking for health systems
(accessed April 20, 2010).

13 Strengthening Health Systems. Health systems strengthening consensus
(accessed April 20, 2010).

14 Swanson RC, Mosley H, Sanders D, et al. Call for global health-systems
impact assessments. Lancet 2009; 374: 433-435.

a Division of Global Health (IHCAR), Stockholm SE-171 77, Sweden
b Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
c Health Systems Action Network, New Delhi, India
d School of Public Health, University of Western Cape, Bellville, Cape
Town, Western Cape, South Africa
e Global Forum for Health Research, Geneva, Switzerland
f Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
g Royal College of Surgeons, Dublin, Ireland
h London School of Hygiene and Tropical Medicine, London, UK

20. News

– Philippines: DOH: Tainted blood recipients have died
– Philippines: PNRC enforces policy on ‘no paid blood donor’
– Nevada USA: Proposal Makes Syringes Legal Without Prescription
– USA: DC’s treatment in fed budget angers local leaders
– Australia: Family face nervous wait after needle stick injury
– USA: Germy Faucet Fingered In Outbreak Of Blood Infections From Alabama
– Africa: World Health Day: WHO AFRO boss tasks Africa on drug resistance
– USA: Tainted IV Lawsuits Filed Over Deaths At Alabama Hospital
– MDGs Still In Reach, But 2015 Deadline Will Be Missed, Bill Gates Says
– Afghanistan: New Therapy Attacks Soaring Drug Addiction

Selected news items reprinted under the fair use doctrine of international
copyright law:

Philippines: DOH: Tainted blood recipients have died
By Mayen Jaymalin,The Philippine Star, Manila, Philippines (13.04.11)

The Department of Health (DOH) reported yesterday that the two recipients
of HIV-contaminated blood donation have died.

Dr. Eric Tayag, chief of the DOH National Epidemiology Center, however,
stressed that the transfusion of contaminated blood was not the cause of
death of the two victims.

“The two recipients died not because of contamination, but because of
serious illness, which is the main reason why they needed blood
transfusion,” Tayag said.

Tayag merely said the recipients were a child and an adult female, but he
declined to divulge other details.

One of the recipients was among the new HIV cases recorded by the DOH last

Philippines: PNRC enforces policy on ‘no paid blood donor’
BY Maricar Aranas, Star, Manila, Philippines (12.04.11)

Provincial Administrator Louella Bael of the Philippine National Red Cross
said they are strictly enforcing the “no paid blood donor” policy in line
with the Department of Health and the World Health Organization
regulations for a safe and clean blood campaign.

Red Cross Negros Oriental now uses the machine blood screening which is
more accurate than the rapid blood screening to help prevent incidents of
collecting contaminated blood from infected donors.

Bael said all blood-letting activities are done with strict precautions,
like asking the donor to fill up a questionnaire with complete date
including confidential information that will be kept confidential.

She added all blood collected suspected to be contaminated with any
disease, will be sent to the PNRC laboratory in Manila for further tests.
All blood found positive of contamination will be automatically rejected.

Bael said precautionary measures are taken being taken by PNRC in Negros
Oriental to ensure the safety of patients.

The precautionary measures include checking of medical history and
physical check up. PNRC local chapters are reminded to carefully practice
stringent checking of blood donors against transfusion-transmitted
infections such as HIV, malaria, Hepatitis B and C and syphilis.

The PNRC issued the warning because of the reported HIV contaminated blood
is now under investigation by the DOH. The report clarified that the blood
believed to be HIV contaminated blood is not from the Red Cross.*MA

Nevada USA: Proposal Makes Syringes Legal Without Prescription
Associated Press. USA  (12.04.11)

The Senate Health and Human Services Committee voted Tuesday in favor of a
bill that would make it legal to possess and distribute hypodermic
syringes without a prescription. The committee amended the measure to
specify where syringes could be distributed, and by whom. Jennifer Hadayia
of the Washoe County Health District said 10 percent, or 60, of the new
HIV/AIDS cases logged in 2009 were the result of needle sharing among
intravenous drug users. SB 335 now advances to the Senate floor.

USA: DC’s treatment in fed budget angers local leaders
By JESSICA GRESKO, The Associated Press, USA (11.04.11)

WASHINGTON – The budget deal lawmakers struck to avoid a government
shutdown was greeted by some with relief, but it has one city already
reeling: the capital itself.

City officials say Washington was used as a pawn last week’s budget
bargaining, with new restrictions part of the price of a deal. Under the
budget agreement reached Friday, the details of which are still uncertain,
the city will likely be unable to spend city dollars on abortions for low
income women. It may also be banned from spending city money on needle
exchange programs believed vital to curbing the spread of HIV in the city,
where the disease is considered an epidemic. Also back, a school voucher
program favored by Republicans.

Angry that Congress appears ready to take away autonomy granted to the
city in the last several years, city officials and residents plan to rally
Monday outside the Capitol to oppose the changes, but they may be

The news is considered a setback for the city, which is in the unique
position of having its own city government but its budget and laws
overseen by Congress. The city had enjoyed more freedom in the past four
years when both the House and Senate were controlled by Democrats, the
party traditionally more friendly to pleas of autonomy from the heavily
Democratic city. When Republicans took control of the House in January,
the city readied for changes. Still, city leaders said they are outraged
that Washington appears to have been used as a bargaining chip.

The city’s mayor, Vincent Gray, said in a statement Saturday after the
deal was announced that he was “angry and terribly disappointed that the
District of Columbia suffered collateral damage amidst partisan

Ilir Zherka, the executive director of D.C. Vote, a nonpartisan group that
lobbies for more independence for the District, said his group doesn’t
intend to let the budget pass this week without a fight.

“We’re not going to accept that they decided to throw the District of
Columbia under the bus,” said Zherka, whose group is planning a rally
Monday evening on Capitol Hill.

But while the news is considered a setback for the capital city and its
600,000 residents, the restrictions wouldn’t be new.

The city’s ability to spend money on abortions for low-income women has
seesawed back and forth over the last two decades. When Democrats have
controlled both houses of Congress and the presidency, in 1993 and 1994
and again in 2009 and 2010, the city has been able to spend its own money
to pay for abortions for women on Medicaid. When Republicans have
controlled at least one branch of government that ability has been taken

The fact that Congress will likely re-impose the ban on abortion funding
wasn’t a shock to Tiffany Reed, the president of D.C. Abortion Fund, a
non-profit organization that makes grants to poor women to pay for
abortions, which can cost $300 to $500 or more. Reed said her group, which
helped pay for more than 300 abortions a year, had expected the ban to be
re-imposed, but she was angry Congress had stepped in again to local
affairs just as the lifting of the ban was beginning to take effect.

“It gives me a lot of rage quite frankly,” she said. “I’m really
disappointed in our pro-choice president that he allowed this to happen.”

As for a possible reintroduction of a ban on city money for needle
exchanges, it would be a step back. Congress prohibited the city from
using its own money for needle exchange programs for two decades beginning
in the late 1980s. Other groups stepped in to provide the service with
private dollars, but it is a widely held belief that the city’s inability
to pay for needle exchange programs led to an increase in the number of
residents contracting HIV. Approximately 3 percent of city residents are
currently living with HIV or AIDS, a level considered by health officials
to be an epidemic.

When the ban was lifted in 2007 the city invested money in community
programs that collected 300,000 used syringes in the last year. People who
work at the city’s three needle exchange programs say they aren’t sure how
they will cope if the city is again unable to provide money.

“It would be nothing short of disastrous,” said Cyndee Clay the executive
director of at HIPS, an organization that works with sex workers and drug
users and is currently exchanging about 8,000 needles a month. “I don’t
understand why they’re doing this to us.”

In the past year the city has given HIPS $125,000 to buy syringes and pay
for staff. If city funding is cut the organization may not have money to
buy syringes, Clay said, calling a potential ban infuriating.

Eleanor Holmes Norton, the city’s representative in Congress, said she has
not yet seen the actual language in the budget but has been told that the
abortion rider and school vouchers are in. Norton, a Democrat who is not
allowed to vote on the House floor, said she doesn’t believe needle
exchange is part of the deal, but she said she won’t be sure until she
sees final language.

“We got bargained away,” Norton said of the budget deal. “I don’t know for

Australia: Family face nervous wait after needle stick injury
BY Alecia Pinner, Frankston Weekly, Mornington, Australia (12.04.11)

NINE-year-old Benjamin was happily running along Carrum Beach three weeks
ago when his foot was punctured by a discarded syringe.

Yesterday, Benjamin received the second of a series of four blood tests to
determine whether he had contracted any blood-borne viruses, such as
hepatitis or HIV [human immunodeficiency virus].

His worried family, who did not want to be identified, will not be able to
sleep easily until final tests in six months are able to rule out all

Benjamin was visiting the beach with a friend’s parents, who heard him cry
out and saw the syringe, which he had kicked, floating through the air.

They quickly rushed Benjamin to the water, rinsed his foot and squeezed
flowing blood from his wound.

Benjamin’s father Aaron said it was “unbelievable” to receive the phone
call saying Benjamin was in an emergency ward – “it was an absolute

Benjamin’s parents were relieved when they checked their son’s medical
records and saw he had been previously immunised against hepatitis B.

Aaron said this was not the first time the Narre Warren family had
unexpectedly come across syringes.

The father of three said that when he recently took his daughter to the
bathroom at a Frankston fast food restaurant, they found blood and a
discarded syringe in a basin.

“The heartache and stress makes you not want to take your kids to the
beach,” he said.

“If they stop the sale of syringes altogether and made them only available
from methadone clinics, that could stop this problem.”

USA: Germy Faucet Fingered In Outbreak Of Blood Infections From Alabama
by SCOTT HENSLEY, National Public Radio, USA (08.04.11)

Serratia marcescens bacteria were found in pharmacy that made IV fluids
for hospitalized patients.

* Don’t drink the water, or use it to mix intravenous fluids for hospital

An investigation into microbial contamination that led to blood infections
of 19 hospitalized patients in Alabama has found a genetic match between
bacteria cultured from a dozen infected patients and water samples from a
faucet in a pharmacy that prepared IV nutrition products.

The bacteria were also found on a mixing container, stirrer and inside a
bag of amino acids at the pharmacy. The Alabama Department of Public
Health says “a failure in a step of the sterilization process… was most
likely the cause of the contamination.”

The bacterial culprit was Serratia marcescens. And the source was Meds IV
Pharmacy in Birmingham, Ala.

Nine people who developed blood infections died, though all were already
ill enough to require intravenous nutrition. The Alabama Department of
Public Health said it first learned of the problem on March 16, when two
hospitals in the state notified officials of patients with bloodstream

All the IV products made by the pharmacy were recalled in late March.

Alabama State Health Officer Donald Williamson said in a Thursday media
briefing that it wasn’t clear if a filter used in sterilization process
was defective or if there was a more systematic breakdown of procedures,
Reuters reported. The investigation will continue, he said.

As Shots recently reported, bacteria can live quite happily in some
faucets. Johns Hopkins Hospital has found the germs that cause
Legionnaire’s disease can thrive in hands-free faucets. As a result,
Hopkins will be using old-fashioned faucets in a new hospital that is
nearing completion.
[ See report of the study at: ]

Africa: World Health Day: WHO AFRO boss tasks Africa on drug resistance
Afrique en ligne (07.04.11)

Brazzaville, Congo – The WHO Regional Director for Africa, Dr. Luis Sambo,
Thursday urged African nations to take advantage of this year’s World
Health Day theme to ‘awaken to the real threat of drug resistance in our
region, consolidate our efforts to combat it and raise the required
resources’. The theme of this year’s World Health Day, marked around the
world 7 April, is ‘Combat Drug Resistance: “No action today, No cure
tomorrow”. In his message on the observance of the Day, Dr. Sambo said
governments should develop and implement medicine policies and strategies
that take into consideration the threat of drug resistance so as to limit
the evolution and possible spread of resistant germs.

He said since surveillance is the primary strategy for tracking emerging
drug resistance in the population, thus allowing for early and appropriate
action, countries should therefore strengthen their capacity for early
detection and identification of resistant germs that cause
diseases of public health importance.

‘In addition, national laboratories responsible for monitoring drug
resistance must be suitably staffed and fully equipped for them to produce
meaningful data in support of this surveillance. The information generated
should be regularly shared between stakeholders for informed
action by national authorities,’ the WHO Afro boss said.

He warned that left unchecked, the uncontrolled rise in resistant germs
threatens lives and wastes limited resources, saying: ‘Urgent and
coordinated action is required at all levels to ensure the preservation of
these life-saving drugs for future generations.’

Antibiotics have been in use for over 70 years with positive outcomes in
patients, but due to prolonged and at times suboptimal use of these drugs,
targeted germs have developed resistance.

The other reasons for drug resistance include the use of fake and
counterfeit medicines, poor prescribing habits and non compliance to
prescribed treatment.

‘If not properly managed, resistant germs may spread and cause severe
diseases. However, attempts have been made to overcome drug resistance
through the development of newer medicines and combining multiple drugs in
the treatment of single germs,’ Dr. Sambo said.

He said the WHO African Region, drug resistance surveillance is limited to
a few countries resulting in incomplete data on the true extent of this

‘Despite limited laboratory capacity to monitor this resistance; available
data suggest that the African Region shares the worldwide trend of
increasing drug resistance. Significant resistance has for example been
reported for diseases such as bloody diarrhoea due to dysentery,
tuberculosis, Malaria and AIDS,’ he said.

USA: Tainted IV Lawsuits Filed Over Deaths At Alabama Hospital (06.04.11)

At least two wrongful death lawsuits have been filed against Meds IV, an
Alabama compounding pharmacy, which is believed to have provided Alabama
hospitals with contaminated intravenous nutritional supplements that have
been linked to nine deaths and at least 19 illnesses.

The Meds IV lawsuits have been filed on behalf of Mary Ellen Kise and
Lavonne Mottern, both of whom died after receiving the company’s total
parenteral nutrition (TPN) intravenous supplement. A third product
liability lawsuit was also filed on behalf of Todd Hammond, who was
allegedly injured after being injected with TPN.

Last month, the company shut down in the wake of a TPN recall issued after
an outbreak of Serratia marcescens infections hit a number of Alabama

Meds IV was a compounding pharmacy that made medications that are not
premixed by drug companies. U.S. Centers for Disease Control and
Prevention (CDC) officials say that the pharmacy made the decision to
close its doors during the course of the investigation into the outbreak
and it is not likely that the business will re-open.

TPN is a liquid nutritional supplement given to patients who have
gastrointestinal problems via IV or catheter. It is supposed to be shipped
in a sterile container to hospitals and used within a short span of time.
CDC officials and investigators from the Alabama health department say it
is likely that the contamination occurred during the mixing process by
Meds IV.

The Alabama hospitals that are known to have received tainted Meds IV TPN
include Baptist Princeton, Baptist Shelby, Baptist Prattville, Medical
West, Cooper Green Mercy and Select Specialty Hospital in Birmingham. Kise
died at Baptist Prattville and Mottern died at Baptist Princeton. Hammond
was in Select Specialty Hospital when he was diagnosed with an infection.

The outbreak is still under investigation by Alabama health officials, the
CDC and the FDA; which seized the company’s records last week. A report on
the investigation could be released later this week.

MDGs Still In Reach, But 2015 Deadline Will Be Missed, Bill Gates Says
Kaiser Daily Global Health Policy Report, USA (06.04.11)

The U.N. Millennium Development Goals (MDGs) can still be attained if
developed nations meet their aid pledges, but the 2015 deadline likely
will be missed, Bill Gates, co-founder of the Bill & Melinda Gates
Foundation, said in remarks to the European Parliament’s development
committee in Strasbourg, France, on Tuesday, EUobserver reports. Gates is
traveling in Europe this week. &

In May 2005, EU-15 member states reaffirmed a previous aid commitment to
give 0.7 percent of their gross national income (GNI) to poorer countries
by 2015, also settling on an intermediary commitment of 0.51 percent by

“The increase, if we got to this 0.7 percent, would be 20 billion euros in
addition to what is being given today. Given what we now know on how to
spend that money well, it would make a huge difference,” Gates said,
adding, “That would give you the money to achieve the MDGs, not by 2015,
but within 10 years.”

Gates also noted the large role government funding plays in development
aid. “If you take international aid, private philanthropy, even with our
foundation and others, is less than two percent of what’s given to poor
countries,” he said. “I think we can grow it [philanthropy], and I think
it has a special role … but in terms of the big things, really helping
poor countries with health and agriculture, it’s government foreign aid,”
according to Gates . He also called for more involvement from the private
sector, the Guardian reports. “We need more philanthropists – drug
companies, banks, mobile phone, mineral companies,” he said.

Afghanistan: New Therapy Attacks Soaring Drug Addiction
Pavol Stracansky, Inter Press Service  (05.04.11)

A methadone program for heroin addicts in Afghanistan is proving to be a
success, according to local doctors and international health
organizations. Until last year, detoxification was the only option for
injection drug users (IDUs) seeking addiction treatment in the country.

“In a setting like Afghanistan, where there are no referrals possible to a
social worker or a psychosocial counselor, and where you need to integrate
everything in the same program, the results are quite impressive,” said
Dr. Zemaray Amin of Doctors of the World (DOTW), which heads the Kabul-
based project. Amin is “completely optimistic” the program’s success will
lead to a wider local acceptance of substitution therapy.

DOTW estimates the number of heroin users in Afghanistan has increased by
140 percent, from 50,000 in 2005 to 120,000 in 2009. HIV prevalence among
IDUs in three Afghanistan cities has grown from 3 percent in 2006 to 7
percent in 2009, the group estimates. Hepatitis C prevalence has risen
too, from 36.6 percent in 2006 to 40.3 percent in 2009.

Six months into the trial, the client retention rate was 83 percent,
compared to just over 75 percent for similar trials elsewhere. Crime and
mental health outcomes among clients have also improved, researchers told
the recent International Harm Reduction Association’s annual conference in

This first major Afghan trial of the intervention is backed by
Afghanistan’s health ministry and funded by the World Bank. Nonetheless,
the program ran into problems importing methadone – though it had secured
permission from Afghanistan’s counter-narcotics ministry – months into the
trial. The counter-narcotics ministry now is calling for an independent
review, while a freeze has been placed on enrolling new patients.
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