online canadian pharmacy pharmacy ratings phentermine no prescription

SIGNpost 00595


Post00595  Investigation? + Waste + Harm + Abstracts + News  20 April 2011

1. Grand Jury report – suspect transmission of bloodborne viruses: Who can
help to get an outbreak investigation underway?
2. Solutions to the waste management conundrum
3. UNAIDS: Middle East and North Africa ready to scale up harm reduction
services in its response to AIDS
4. Abstract: Vaccination, consent and multidose vials
5. Abstract: Health care waste management of potentially infectious
medical waste by healthcare professionals in a private medical
practice: a study of practices
6. Abstract: Hepatitis B, hepatitis C and HIV transfusion-transmitted
infections in the 21st century
7. Abstract: Haemovigilance: an effective tool for improving transfusion
8. Abstract: The effectiveness of harm reduction in preventing HIV among
injecting drug users
9. Abstract: Female sexual partners of injection drug users in Vietnam: an
at-risk population in urgent need of HIV prevention services
10. Abstract: The economics of HIV prevention strategies in NSW
11. Abstract: Guarding against an HIV epidemic within an Aboriginal
community and cultural framework; lessons from NSW
12. Abstract: Hospital cleaning in the 21st century
13. Abstract: Evaluation of the effects of the VibraJect attachment on
pain in children receiving local anesthesia
14. Abstract: Patients’ perceptions of doctors’ clothing: should we really
be ‘bare below the elbow’?
15. No Abstract: A managed care organization’s initiative to improve
patient safety in the use of concentrated insulin16. Award: Scientific
Articles that Impact Latin America and/or the
16. Award: Scientific Articles that Impact Latin America and/or the
17. Project Optimize Newsletter
18. News
– Global: Medical errors in top 10 killers: WHO
– Canada: Public Open to Drug Injection Site
– India: Fake IV & Glucose Fluids Seized at Jodhpur City Hospital
– Canada: Spring melt reveals needle problem in Prince Albert
– USA: Children at Risk for Disease After Medical Mistake
– Colorado USA: Parents’ horror as they are told to test their infants
for HIV after flu vaccine mix-up
– Nevada USA: Doctor who reused medical devices gets license back but
musthave monitor

This edition of SIGNpost is located at:
and is printer friendly.

If your email reader truncates your SIGNpost – click on the link above to
download the complete posting.

Please send your requests, notes on progress and activities, articles,
news, and other items for posting to:

Normally, items received by Tuesday will be posted in the Wednesday

Subscribe or un-subscribe by email to:

More information follows at the end of this SIGNpost!

Visit the WHO injection safety website and the SIGN Alliance Secretariat

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:

1. Grand Jury report – suspect transmission of bloodborne viruses: Who can
help to get an outbreak investigation underway?

To: SIGNpost <>
From: David Gisselquist <david_gisselquist[at]>


A 14 January 2011 Grand Jury report (PDF 2.04KB available at: )
focuses on late-term abortions and a woman’s death immediately following
a procedure at an abortion clinic in Philadelphia that served primarily
poor African-American women.

However, the report also notes unsterile conditions, providing evidence to
suspect transmission of bloodborne viruses through reused instruments.
Yet, almost 3 months later, there is no indication that any health agency
at the city, state, or national level has taken any initiative to invite
women who attended the clinic in the past several years, and who may have
been exposed to bloodborne viruses, including HIV, to come for tests.

African-American women in the US have a risk for HIV infection almost 20
times greater than for White, non-Hispanic women. Contrary to a lot of
stigmatizing fantasy and boilerplate prose, only a minority of African-
American women with AIDS have well-identified risks. The last available
raw data from CDC (later data is adjusted before publication) report that
16% of African-American women with new AIDS cases in 2005 were IDUs, 1%
received blood or tissue, and 7% were heterosexuals with HIV-positive
partners who were IDUs or MSMs. That’s a total of 24% with well-
identified risks. What about the other 76%? Thirty-seven percent were
classified as having HIV-positive heterosexual partners, but with the
partners’ risk not specified; and 39% were classified as having other or
unknown risk.see:

An investigation of bloodborne transmission through sub-standard health
care serving poor women, such as the Philadelphia abortion clinic, might
help to answer the question – why do African-American womenn have such
high risk for HIV?

* Who can help to get an outbreak investigation underway in Philadelphia?

David Gisselquist, Lucy Hancock, John J Potterat, Devon Brewer

2. Solutions to the waste management conundrum

Crossposted from the new Technet21 website with thanks.

Article and comment at:

Solutions to the waste management conundrum
Yves Chartier, WHO, and Olga Popova, Crucell

Worldwide immunization programs have had an enormously positive impact on
health and health care since 1974 when the World Health Assembly launched
the Expanded Programme on Immunization. However, like all great
achievements the effort has unveiled new challenges. One of the most
serious has been the re-use of syringes without adequate sterilization. As
this issue came to light in the 1950s, disposable syringes were developed
to resolve the problem. Unfortunately, they did not, and the rise of
HIV/AIDS and hepatitis B and C transmission raised the issue into an even
greater sphere of concern. The late 1980s brought the successful
development and deployment of autodisable syringes, which are now in
widespread use in immunization programs. And while autodisable syringes
have considerably reduced re-use and contamination issues – at least
within the relatively narrow confines of immunization programs – their use
has given rise to an associated concern, how to manage injection-related

Improper management of injection-related waste can have both direct and
indirect health consequences for health personnel, community members, and
the environment. Direct consequences of improper waste management arise
when disposable materials (especially syringes) are intentionally re-used.
The transmission of hepatitis B and C and HIV represent the main disease
burden caused by inadequate management of injection-related waste.
Unintentional injuries may also occur when people mishandle or are exposed
to inadequately disposed waste, for example through scavenging on waste

Indirect health effects can arise from environmental pollution in the form
of toxic emissions from inadequate burning of medical waste or in the
sheer volume of waste generated in a short period of time. For instance, a
countrywide mass immunization campaign will produce millions of used
syringes in a period of three to four weeks. This requires appropriate
options and a well-prepared strategy defined months before the campaign

A variety of technologies have been developed to aid in the safe storage,
collection, treatment, and disposal of health care wastes. Several types
of treatment and disposal processes, such as incineration, microwave or
chemical treatment, and melting have been applied in health care settings
with varying degrees of safety, cost, and impact on the environment.

However most are geared toward industrialized country settings. None of
the available low-cost treatment devices (i.e., below US$500) on the
market are both safe and environmentally friendly. In developing
countries, a trade-off has to be made between direct health risks
resulting from the absence of a waste management strategy, and indirect
health risks created by environmental pollution (e.g., by production of
dioxins from inadequate incineration).

Despite the difficult tradeoffs in waste management approaches, countries
are better off with a waste management strategy than without one. Some
countries have made significant improvements by adopting purchase policies
that consider the waste stream and/or by isolating and treating the most
harmful segments of the waste.

At the global level, vaccine manufacturers and injection equipment
suppliers are also seeking solutions. Crucell, for example, is adopting a
holistic approach to its pentavalent vaccine, looking for solutions that
can meet the needs of complex, developing-country environments. First, it
changed its formulation from lyophilized to liquid, thus reducing
opportunities for reconstitution errors, eliminating multiple procedural
steps, shortening the vaccination session, shrinking storage needs, and
minimizing waste. Next, it offered the vaccine in single-dose vials, thus
reducing vaccine wastage, eliminating the need for preservatives, and
minimizing the possibility of contamination. Recently it has begun to
explore the feasibility of offering liquid pentavalent vaccine in the
UnijectTM  injection system, a plastic, compact prefilled autodisable
system. Belying its big name, Uniject is nothing more than a small bubble
of plastic attached to a needle. It is precisely prefilled with a single
dose by manufacturers, thus eliminating vaccine wastage or improper
dosing. It is so easy to use that health workers need a scant two hours of
training before successfully using it. From a waste-management
perspective, Uniject cannot be reused, thus minimizing the threat of
disease transmission. It contains only about 35 percent of the plastic of
a standard disposable syringe, and the type of plastic used in Uniject can
be incinerated without generating toxic fumes (unlike those produced by
with a rubber piston).

By testing and seeking solutions such as these, pharmaceutical companies
like Crucell can ameliorate some of the health care waste management
problem countries face. Ultimately, the waste management conundrum must be
addressed at all levels, from upstream technology development to
downstream waste minimization and management, to ensure that health care
can be delivered without side effects on health care workers, communities,
or the environment.

3. UNAIDS: Middle East and North Africa ready to scale up harm reduction
services in its response to AIDS

Crossposted from UNAIDS with thanks.

Middle East and North Africa ready to scale up harm reduction services in
its response to AIDS

UNAIDS, 13 April 2011

A man receiving opioid substitution therapy as part of a harm reduction
programme in the Islamic Republic of Iran. Credit: UNAIDS/P.Virot
Injecting drug use and the growing HIV epidemic in the Middle East and
North Africa were the focus of the Harm Reduction 2011 conference that
took place in Beirut, Lebanon from 3-7 April 2011

Some 1000 scientists, researchers, drug users, doctors and politicians
from 80 countries participated in the first international drugs-related
conference to be held in the Middle East and North African (MENA) region.

Discussions during the conference centred around the existence of
legislation in the region that hinders the implementation of harm
reduction programmes. Nearly one million people in the Middle East and
North Africa (MENA) inject drugs. Injecting drug use is already the major
mode of HIV transmission in Afghanistan, Pakistan, the Islamic Republic of
Iran (more than 67% of registered cases) and Libya (up to 90% of cases).
It is also significant in Oman and Bahrain and has growing incidence in
Morocco and Egypt.

The region is slowly increasing availability of harm reduction programmes
although countries are at different stages of introducing the different
components of the harm reduction package. The Islamic Republic of Iran is
a model-with a rapidly scaled-up plan to make available needles and
syringes, opioid substitution therapy (OST), HIV testing and counseling,
and sexually transmitted infection services. Morocco also has integrated
harm reduction policies into its national AIDS strategic plan. Pilot drop-
in centres with needle and syringe exchange are in place, and preparations
for introducing OST are underway.

The Lebanese Minister of Health announced during the conference the launch
of a pilot programme consisting of the first ever legal sale of
Buprenorphine in government hospitals for people who inject drugs. “The
government’s support for harm reduction measures such as the provision of
Buprenorphine is based on our belief that the evidence for such a public
health measure is irrefutable-its implementation has helped to contain HIV
and Hepatitis infections amongst injecting drug use communities in every
country it has been introduced,” said Dr Walid Ammar, Director General of
the Lebanese Ministry of Public Health.

Despite positive changes occurring in some countries, repressive measures
and criminalization of drug users are still predominant in the region.
This discourages people at higher risk of transmission from accessing HIV

Funding harm reduction

The uptake of harm reduction in most of the region has been slow mainly
due to governments and civil society organizations lack of awareness as
well as capacity to implement effective harm reduction activities.

To try reverse this situation, the Global Fund to fight AIDS, Tuberculosis
and Malaria has granted $US 8.3 million to a multi-country project. Its
aim is to raise awareness, advocate and build capacity of civil society
organizations to scale up the provision of harm reduction services in 12
countries over the next three years. The 12 countries included in the
project are Iran, Pakistan, Libya, Lebanon, Syria, Jordan, Bahrain,
Morocco, Egypt, Afghanistan, Oman and West Bank and Gaza.

The project will begin in July 2011 and will be coordinated by the Middle
East and North Africa Harm Reduction Association (MENAHRA), based in

UNAIDS strategy goal by 2015:

All new HIV infections prevented among people who use drugs.

Globally, there are an estimated three million people who inject drugs
also living with HIV-with nearly 13 million more at risk of HIV infection.
Access to HIV prevention services, including harm-reduction programmes has
increased but not at the required levels. In 2009 the median coverage of
HIV prevention services was 32%.

It is estimated that on average globally fewer than two clean needles are
provided per month per person who injects drugs, there are about eight
people in opioid substitution treatment for every 100 people who inject
drugs. According to WHO, UNODC and UNAIDS target-setting guidelines, the
availability of fewer than 100 syringes per person who injects drugs per
year is considered low.

Few countries have data on HIV treatment coverage for people living with
HIV who inject drugs, 14 countries treat 5% or fewer and in only nine
countries does treatment reach more than 10% of people living with HIV who
inject drugs.

UNAIDS calls for scaling up comprehensive, evidence informed and human-
rights-based programmes accessible to all people who inject drugs (i.e.
attending to harm reduction alongside demand reduction), including
programmes to reduce hepatitis co-infection, increasing access to HIV
treatment, and ensuring legal and policy frameworks serve HIV prevention

4. Abstract: Vaccination, consent and multidose vials

Med J Aust. 2011 Apr 18;194(8):414-6.

Vaccination, consent and multidose vials.

Diamond MR, O’Brien-Malone A.

School of Psychology, University of Tasmania, Hobart, TAS, Australia.

Multidose vials (MDVs) for injectable therapeutic agents, including
vaccines, pose a risk of infection to injected patients as a result of
contamination of the vials. The Australian Government Department of Health
and Ageing (DoHA) distributed the vaccine against pandemic (H1N1) 2009
influenza in MDVs. The distribution was accompanied by consent forms. The
consent forms provided an inadequate basis for a discussion with patients
about the risks associated with the use of MDVs.

The High Court of Australia has previously held that medical practitioners
who fail to explain the material risks of medical procedures to their
patients might be held liable in negligence for any adverse sequelae of
the procedures, even if the risks are very low.

Medical practitioners, nurses, medical indemnity insurers and the DoHA
should prepare now for the probable future use of MDVs by developing a
consent form that would provide a solid foundation for a discussion of
material risks with patients seeking vaccination.

5. Abstract: Health care waste management of potentially infectious
medical waste by healthcare professionals in a private medical
practice: a study of practices

Sante Publique. 2010 Nov-Dec;22(6):605-15.

[Health care waste management of potentially infectious medical waste by
healthcare professionals in a private medical practice: a study of

[Article in French]

Brunot A, Thompson C.

ARS d’Ile-de-France, délégation territoriale Paris, 35, rue de la gare,
75019 Paris.

A cross-sectional study was conducted with a sample of 278 health
professionals (GPs and specialists, dentists, physical therapists and
nurses) in a private medical practice in Paris to study the medical waste
management practices related to the production and disposal of potentially
hazardous health care waste.

With the exception of physical therapists, most professionals produced
medical waste (72% to 96,2% according to occupation), with a monthly
median of 3 liters (inter-quartile range 1-15 liters). All sharp objects
and needles were separated and 91% of them eliminated via a specific
process for that sector. These percentages were respectively 84% and 69%
concerning contaminated waste that was neither needles or used for
cutting. 48% of the professionals reported the existence of documents that
could track the disposal of their medical waste.

To improve practice, professionals cited collection on-site at the office
(74%) and reliability of the contracted service provider to collect the
waste (59%).

The study showed that health professionals need information on the
regulations regarding potentially infectious medical waste, in particular
on the traceability of its elimination. They also noted the lack of
clarity and precision with regard to the definition of risk of infection:
31,7% of professionals only declare the production of sharp or cutting
waste without having specified criteria for risk of infection.

6. Abstract: Hepatitis B, hepatitis C and HIV transfusion-transmitted
infections in the 21st century

Vox Sang. 2011 Jan;100(1):92-8.

Hepatitis B, hepatitis C and HIV transfusion-transmitted infections in the
21st century.

Dwyre DM, Fernando LP, Holland PV.

Department of Pathology, University of California Davis Medical Center,
Sacramento, CA 95817, USA.

In the past, transfusion-transmitted virus (TTV) infections were not
uncommon. In recent years with advanced technologies and improved donor
screening, the risk of viral transfusion transmission has been markedly
reduced. Hepatitis B virus (HBV), hepatitis C virus (HCV) and human
immunodeficiency virus (HIV) have all shown marked reduction in
transmission rates.

However, the newer technologies, including nucleic acid technology (NAT)
testing, have affected the residual rates differently for these virally
transmitted diseases.

Zero risk, which has been the goal, has yet to be achieved. False
negatives still persist, and transmissions of these viruses still occur,
although rarely. It is known that HBV serological testing misses some
infected units; likewise, HBV NAT-negative units have also been known to
transmit the virus. Similarly, HIV minipool NAT-negative units have
transmitted HIV, as recently as 2007; likely, these transmissions would
have been prevented with single-unit NAT testing.

Newer technologies, such as pathogen inactivation (PI), will (ideally)
eliminate these falsely test negative components, regardless of the
original testing method used for detecting the viruses.

© 2010 The Author(s). Vox Sanguinis © 2010 International Society of Blood

7. Abstract: Haemovigilance: an effective tool for improving transfusion

Vox Sang. 2011 Jan;100(1):60-7.

Haemovigilance: an effective tool for improving transfusion practice.

de Vries RR, Faber JC, Strengers PF; Board of the International
Haemovigilance Network.

Department of Immunohematology and Bloodtransfusion, Leiden University
Medical Center, Leiden, The Netherlands.

Haemovigilance is a tool to improve the quality of the blood transfusion
chain, primarily focusing on safety. In this review we discuss the history
and present state of this relatively new branch of transfusion medicine as
well as some developments that we foresee in the near future.

The top 10 results and conclusions are: (1) Haemovigilance systems have
shown that blood transfusion is relatively safe compared with the use of
medicinal drugs and that at least in Europe blood components have reached
a high safety standard. (2) The majority of the serious adverse reactions
and events occur in the hospital. (3) The majority of preventable adverse
reactions are due to clerical errors. (4) Some adverse reactions such as
anaphylactic reactions often are not avoidable and therefore have to be
considered as an inherent risk of blood transfusion. (5) Well-functioning
haemovigilance systems have not only indicated how safety should be
improved, but also documented the success of various measures. (6) The
type of organisation of a haemovigilance system is of relative value, and
different systems may have the same outcome. (7) International
collaboration has been extremely useful. (8) Haemovigilance systems may be
used for the vigilance and surveillance of alternatives for allogeneic
blood transfusion such as cell savers. (9) Haemovigilance systems and
officers may be used to improve the quality of aspects of blood
transfusion other than safety, such as appropriate use. (10)
Haemovigilance systems will be of benefit also for vigilance and
surveillance of the treatment with other human products such as cells,
tissues and organs.

© 2010 The Author(s). Vox Sanguinis © 2010 International Society of Blood

8. Abstract: The effectiveness of harm reduction in preventing HIV among
injecting drug users

N S W Public Health Bull. 2010 Mar-Apr;21(3-4):69-73.

The effectiveness of harm reduction in preventing HIV among injecting drug

Wodak A, Maher L.

Alcohol and Drug Service, St Vincent’s Hospital, Darlinghurst NSW.

There is now compelling evidence that harm reduction approaches to HIV
prevention among injecting drug users are effective, safe and cost-
effective. The evidence of effectiveness is strongest for needle and
syringe programs and opioid substitution treatment.

There is no convincing evidence that needle and syringe programs increase
injecting drug use. The low prevalence approximately 1%) of HIV among
injecting drug users reflects the early adoption and rapid expansion of
harm reduction in Australia.

Countries that have provided extensive needle and syringe programs and
opioid substitution treatment appear to have averted an epidemic,
stabilised or substantially reduced the prevalence of HIV among injecting
drug users.

However, despite decades of vigorous advocacy and scientific evidence, the
global coverage of needle and syringe programs and opioid substitution
treatment falls well short of the levels required to achieve international
HIV control.

9. Abstract: Female sexual partners of injection drug users in Vietnam: an
at-risk population in urgent need of HIV prevention services

AIDS Care. 2010 Dec;22(12):1466-72.

Female sexual partners of injection drug users in Vietnam: an at-risk
population in urgent need of HIV prevention services.

Hammett TM, Van NT, Kling R, Binh KT, Oanh KT.

Abt Associates Inc., Tay Ho District, Hanoi, Vietnam.

Vietnam’s HIV epidemic has been driven by injection drug use, with HIV
prevalence among injection drug users (IDUs) of ~30%. Most IDUs are
sexually active and may infect their female sexual partners (SPs). Male
dominance in sexual decisions is deeply embedded in Vietnamese culture.

There have been few HIV prevention interventions for SPs, who represent an
important potential bridging population in the epidemic. We report
findings from a baseline survey of SPs conducted in 2008 in Hanoi,
Vietnam, where peer-based HIV prevention interventions targeting this
population are now being implemented.

The survey revealed HIV prevalence of 14% among SPs in Hanoi and only 27%
reported condom use with their primary male partners half the time or
more. About 69% of SPs were in serodiscordant or unknown HIV status
relationships but condom use was not more frequent in these relationships
than in concordant partnerships. Many SPs feared angry or violent
responses if they requested condom use, problems that were even more
likely in serodiscordant/unknown status relationships. SPs also reported
limited prior access to HIV prevention services.

Many SPs in Vietnam are at high risk for HIV and in need of HIV prevention
interventions. However, to date, this population has been seriously
underserved. Our interventions are in progress and results will be
reported subsequently.

10. Abstract: The economics of HIV prevention strategies in NSW

N S W Public Health Bull. 2010 Mar-Apr;21(3-4):61-4.

The economics of HIV prevention strategies in NSW.

Hales JR.

Hales Health Consulting.

HIV in Australia was first diagnosed in NSW in the early 1980s, and has
had a significant effect on public health. The NSW Government commenced
its investment in HIV/AIDS in 1984 and the investment now encompasses
research, primary and secondary prevention, and care, treatment and
support for people living with HIV/AIDS.

A recent study examined the historical impact of the HIV/AIDS epidemic and
projected its future impact in NSW. The analysis indicates that the NSW
HIV/AIDS investment program has been highly effective in reducing HIV
transmission, and has also been cost effective in: avoiding future health-
care costs; life years saved; and quality of life benefits.

The analysis also indicates that any scaling back of prevention
initiatives would result in an increase in the number of people living
with HIV.

11. Abstract: Guarding against an HIV epidemic within an Aboriginal
community and cultural framework; lessons from NSW

N S W Public Health Bull. 2010 Mar-Apr;21(3-4):78-82.

Guarding against an HIV epidemic within an Aboriginal community and
cultural framework; lessons from NSW.

Ward J, Akre SP, Kaldor JM.

National Centre in HIV Epidemiology and Clinical Research, University of
New South Wales.

The rate of HIV diagnosis in the Aboriginal and Torres Strait Islander
population in Australia has been stable over the past 5 years. It is
similar to the rate in non-Indigenous people overall, but there are major
differences in the demographical and behaviour patterns associated with
infection, with a history of injecting drug use and heterosexual contact
much more prominent in Aboriginal people with HIV infection.

there are a range of factors, such as social disadvantage, a higher
incidence of sexually transmitted infections and poor access to health
services that place Aboriginal people at special risk of HIV infection.

Mainstream and Aboriginal community-controlled health services have an
important role in preventing this epidemic. Partnerships developed within
NSW have supported a range of services for Aboriginal people. There is a
continuing need to support these services in their response to HIV, with a
particular focus on Aboriginal Sexual Health Workers, to ensure that the
prevention of HIV remains a high priority.

12. Abstract: Hospital cleaning in the 21st century

Eur J Clin Microbiol Infect Dis. 2011 Apr 17.

Hospital cleaning in the 21st century.

Dancer SJ.

Department of Microbiology, Hairmyres Hospital, Eaglesham Road, East
Kilbride, G75 8RG, UK,

More evidence is emerging on the importance of the clinical environment in
encouraging hospital infection. This review considers the role of cleaning
as an effective means to control infection. It describes the location of
pathogen reservoirs and methods for evaluating hospitals’ cleanliness.

Novel biocides, antimicrobial coatings and equipment are available, many
of which have not been assessed against patient outcome. Cleaning
practices should be tailored to clinical risk, given the wide-ranging
surfaces, equipment and building design.

There is confusion between nursing and domestic personnel over the
allocation of cleaning responsibilities and neither may receive sufficient
training and/or time to complete their duties. Since less labourious
practices for dirt removal are always attractive, there is a danger that
traditional cleaning methods are forgotten or ignored. Few studies have
examined detergent-based regimens or modelled these against infection risk
for different patient categories.

Fear of infection encourages the use of powerful disinfectants for the
elimination of real or imagined pathogens in hospitals. Not only do these
agents offer false assurance against contamination, their disinfection
potential cannot be achieved without the prior removal of organic soil.
Detergent-based cleaning is cheaper than using disinfectants and much less
toxic. Hospital cleaning in the 21st century deserves further
investigation for routine and outbreak practices.

13. Abstract: Evaluation of the effects of the VibraJect attachment on
pain in children receiving local anesthesia

Pediatr Dent. 2011 Jan-Feb;33(1):46-50.

Evaluation of the effects of the VibraJect attachment on pain in children
receiving local anesthesia.

Roeber B, Wallace DP, Rothe V, Salama F, Allen KD.

University of Missouri -Kansas City, Kansas City, MO, USA.

PURPOSE: The purpose of this study was to evaluate the effectiveness of
VibraJect, a vibrating attachment for a traditional syringe, in reducing
pain related disruptive behavior and self-reported pain in children
receiving local anesthesia.

METHODS: The procedure involved a randomized, controlled, single-blinded
study of 90 children receiving local anesthesia for routine restorative
procedures. Participants were randomly assigned to either a control
(injection as usual) or experimental (injection using the VibraJect)
group. Participants were recruited from a large, urban pediatric dental
clinic within a university medical center.

RESULTS: Using 2-way analysis of variance and 2-tailed, between-subject t
tests, there were no significant differences between injection with and
without the VibraJect on any measures of pain, including self-reported
intensity, independent direct observations of pain related disruptive
behavior, and subjective dentist ratings.

CONCLUSIONS: VibraJect did not provide any benefits over a conventional
approach to anesthesia injection for children in this study.

14. Abstract: Patients’ perceptions of doctors’ clothing: should we really
be ‘bare below the elbow’?

J Laryngol Otol. 2010 Sep;124(9):963-6.

Patients’ perceptions of doctors’ clothing: should we really be ‘bare
below the elbow’?

Bond L, Clamp PJ, Gray K, Van Dam V.

Department of Otolaryngology, Royal United Hospital Bath NHS Trust, UK.

INTRODUCTION: In September 2007, the Department of Health published
Uniforms and Workwear: an Evidence Base for Guiding Local Policy.
Following this, most National Health Service trusts imposed a ‘bare below
the elbow’ dress code policy, with clinical staff asked to remove ties,
wristwatches and hand jewellery and to wear short-sleeved tops. There is
currently no evidence linking dress code to the transmission of hospital-
acquired infection. We designed the current survey to assess patients’
perceptions of doctors’ appearance, with specific reference to the ‘bare
below the elbow’ policy.

MATERIALS AND METHODS: A questionnaire showing photographs of a doctor in
three different types of attire (‘scrubs’, formal attire and ‘bare below
the elbow’) were used to gather responses from 80 in-patients and 80 out-
patients in the ENT department. Patients were asked which outfit they felt
was the most hygienic, the most professional and the easiest
identification of the person as a doctor. They were also asked to indicate
their overall preference.

RESULTS AND ANALYSIS: Formal attire was considered most professional and
the easiest identification that the person was a doctor. Scrubs were
considered most hygienic. Respondents’ overall preference was divided
between scrubs and formal clothes. ‘Bare below the elbow’ attire received
the lowest votes in all categories.

DISCUSSION: This finding raises significant questions about the Department
of Health policy in question. The authors suggest that an alternative
policy should be considered, with scrubs worn for in-patient situations
and formal attire during out-patient encounters.

15. No Abstract: A managed care organization’s initiative to improve
patient safety in the use of concentrated insulin

J Manag Care Pharm. 2011 Jan-Feb;17(1):70-1.

A managed care organization’s initiative to improve patient safety in the
use of concentrated insulin.

Manno N, Naliboff A.

Free Article

16. Award: Scientific Articles that Impact Latin America and/or the

2011 Fred L. Soper Award for Excellence in Public Health Literature

For Scientific Articles that Impact Latin America and/or the Caribbean

Deadline for submissions: May 13, 2011, 5:00 p.m. ET (Washington, DC,


The Pan American Health Organization (PAHO/WHO ) and Pan American Health
and Education Foundation (PAHEF) is calling for nominations of scientific
articles of significant impact on the public health literature in Latin
America and/or the Caribbean for the 2011 Fred L. Soper Award for
Excellence in Public Health Literature.

The articles must have been published within the three years previous to
the nomination in a scientific journal that is indexed in a medical
database (e.g., PubMed, SciELO) or in the Pan American Journal of Public

Full guidelines are also available at this URL
Anyone may submit a nomination (exceptions are noted in the guidelines),
including editors of journals or authors of articles.

The award consists of a cash prize, a certificate of honor, and a symbolic
representation of the award.

The awardee is invited to attend the annual meeting of the PAHO Directing
Council and will be a guest of honor at PAHO/PAHEF’s awards program event
in Washington, DC.

Premio Fred L. Soper 2011 a la Excelencia en la Literatura de Salud

Artículos científicos con repercusiones para América Latina o el Caribe

Fecha límite: 13 de mayo del 2011, 5:00 p.m. (hora de Washington, DC)


La Organización Panamericana de la Salud (OPS/OMS) y la Fundación
Panamericana de la Salud y Educación (PAHEF) lo invitan a proponer
artículos científicos con repercusiones importantes en la bibliografía de
salud pública en América Latina y/o el Caribe para el Premio Fred L. Soper
2011 a la excelencia en la bibliografía de salud pública.

Los artículos deberán haberse publicado durante los tres años previos al
año en que se los propone para este premio, en una revista científica
indizada en una base de datos médica (por ejemplo, PubMed o SciELO) o en
la Revista Panamericana de Salud Pública.

Las candidaturas pueden presentarse en el sitio web
, donde también pueden consultarse las directrices completas. Casi
cualquier persona puede proponer un artículo (en las directrices se
señalan las excepciones), incluidos los editores de revistas o autores de

la persona galardonada recibirá un premio en efectivo, un certificado de
honor y una representación simbólica del premio, así como una invitación
para asistir a la reunión anual del Consejo Directivo de la OPS y, en
calidad de invitada de honor, al acto de entrega de premios de la OPS y
PAHEF, que tendrán lugar en Washington, DC.

Revista Panamericana de Salud Pública/Pan American Journal of Public
Archives, Join/remove:

17. Project Optimize Newsletter

Project Optimize

Op.ti.mize An electronic newsletter on the vaccine supply chain

The Op.ti.mize e-newsletter is a quarterly publication that highlights
advances and innovations in health care logistics, technologies, and

Developed by Project Optimize, a collaboration between the World Health
Organization and PATH, this newsletter provides an overview of the
project’s current activities and areas of focus.

Sign up for Op.ti.mize on the Emma website.

Click on the links below to access past issues.

18. News

– Global: Medical errors in top 10 killers: WHO
– Canada: Public Open to Drug Injection Site
– India: Fake IV & Glucose Fluids Seized at Jodhpur City Hospital
– Canada: Spring melt reveals needle problem in Prince Albert
– USA: Children at Risk for Disease After Medical Mistake
– Colorado USA: Parents’ horror as they are told to test their infants
for HIV after flu vaccine mix-up
– Nevada USA: Doctor who reused medical devices gets license back but
musthave monitor

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

Global: Medical errors in top 10 killers: WHO
Malathy Iyer, TNN, The Times of India (20.04.11)

MUMBAI: Medicine heals, but this fact doesn`t hold true for every 300th
patient admitted to hospital. Call it the law of averages or blame human
error for it, but the World Health Organization believes that one in 10
hospital admissions leads to an adverse event and one in 300 admissions in

An adverse event could range from the patient having to spend an extra day
in hospital or missing a dose of medicine, said Dr Nikhil Datar, a
gynaecologist and health activist. Unintended medical errors are a big
threat to patient safety.

Although there is no Indian data available on this topic, WHO lists it
among the top 10 killers in the world. While a British National Health
System survey in 2009 reported that 15% of its patients were misdiagnosed,
an American study published in the Journal of the American Medical
Association in 2000 quantified this problem most effectively.

It said that there are 2,000 deaths every year from unnecessary surgery;
7,000 deaths from medication errors in hospitals; 20,000 from other errors
in hospitals; 80,000 from infections in hospitals; and 106,000 deaths
every year from non-error, adverse effects of medications. In all, 225,000
deaths occur per year in the US due to unintentional medical errors.

It is to create awareness both among doctors and patients about errors
dubbed as unintended medical errors that Datar organized a seminar to
discuss patient safety at the Indian Medical Associations office on
Sunday. “In the western nations, it is believed that the incidence of
unintentional medical errors is between 10% and 17% of all cases,” said

The Indian government has woken up to the concept. It set up the National
Initiative on Patient Safety in the All-India Institute of Medical
Sciences a couple of years back.

But the idea, as Dr Akhil Sangal of the Indian Confederation for
Healthcare Accreditation, points out is not to apportion blame. “When
medical negligence occurs, the first question to be asked is who is to
blame. We instead have to evolve to a system in which we ask questions
about how, when and where the negligence occurred,” said Delhi-based Dr

Datar illustrates with an example of a 10-year-old leukemia patient in
Britain who had to be given a chemotherapy injection. “This is a published
report of how due to a series of unintended changes the boy died due to a
wrong injection being given to him,” said Datar. The boy ate food that was
prohibited before the procedure; he was hence taken hours later by a
different department than the cancer doctors. “The injections were given
in a particular order but that day due to the mix-up he got the wrong
injection and died five days later.” The committee exonerated the doctor
because it found the other factors – the when, where and how – had all
played a role in the boy`s death.

“By talking about patient safety, we can reduce the overall mortality and
morbidity associated with hospitalization. Even hospitalization time and
costs could come down as a result,” said Dr Mathew Joseph who is attached
to PGI Chandigarh and is involved in a nationwide study on clinical
practices. “One of our earlier studies had shown unsafe practices
associated with 70% of the injections administered in our country,” Joseph


* One in 10 patients is harmed while receiving hospital care

* The risk of health care-associated infection in some developing
countries is as much as 20 times higher than in developed countries

* At any given time, 1.4 million people worldwide suffer from infections
acquired in hospitals

* At least 50% of medical equipment in developing countries is unusable or
only partly usable. Often the equipment is not used due to lack of skills
or commodities. As a result, diagnostic procedures or treatments cannot be
performed. This leads to substandard or hazardous diagnosis or treatment
that can pose a threat to the safety of patients and may result in serious
injury or death

* In some countries, the proportion of injections given with syringes or
needles reused without sterilization is as high as 70%. This exposes
millions of people to infections. Each year, unsafe injections cause 1.3
million deaths, primarily due to transmission of blood-borne pathogens
such as hepatitis B virus, hepatitis C virus and HIV

* Over 100 million people require surgical treatment every year. Problems
associated with surgical safety in developed countries account for half of
the avoidable adverse events that result in death or disability

* There is a one in 1,000,000 chance of a traveller being harmed while in
an aircraft. In comparison, there is a one in 300 chance of a patient
being harmed while being given health care

Canada: Public Open to Drug Injection Site
Toronto Star, Toronto Canada (15.04.11)

At an HIV conference today in Toronto, researchers are presenting results
of a feasibility study on a supervised drug consumption site in Toronto or

Insite in Vancouver is currently the only such site in Canada. Research
shows that providing a safe place to inject or smoke drugs, where staff
can provide sterile equipment, reduces the transmission of HIV and
hepatitis B and C. Facilities such as Insite also reduce overdoses and
substance abuse, studies indicate.

But the issue is controversial. Since its 2003 opening, critics have
questioned Insite’s usefulness. The federal government is currently trying
to shutter the facility. Canada’s Supreme Court will consider that case in

Toronto requested the feasibility study in 2005, sparking heated exchanges
at City Council and in surrounding communities. A final report is
anticipated this summer.

Dr. Ahmed Bayoumi, study co-leader and scientist at the Center for
Research on Inner City Health at St. Michael’s Hospital, said the team
found people were more likely to support a site whose objective is
reducing HIV, hepatitis, and overdoses.

A theme emerged from the focus groups held with community stakeholders:
Public drug use. “That is a very strong unifying point of agreement, that
interventions to get drug use off the street are beneficial,” said
Bayoumi. “People differ about whether supervised sites will do that, but
many people believe that they will and that is the basis for their

People want scientific evidence warranting the need for a supervised site
in Toronto or Ottawa. They also want the site to be part of a
comprehensive approach to the problem of drug use, the study showed.

“There were very few people who say they would never support a site,”
noted Bayoumi.

India: Fake IV & Glucose Fluids Seized at Jodhpur City Hospital
NTDTV, USA (14.04.11)

Acting on a tip, drug controllers seized fake glucose and intravenous
fluids during a raid at a hospital in India’s northwestern state of
Rajasthan on Thursday.

Officials raided Jodhpur city’s Mahatma Gandhi Hospital and have seized
over 300 bottles of fluids suspected of contamination.

[Narendra Shekhawat, Drug Control Official]:
“We learned that glucose manufactured by Parental Surgical Limited is
still being sold in the market. Based on this information we raided the
Mahatma Gandhi Hospital, during which statements from patients who were
being given these fluids were recorded. The hospital ward was inspected
during which bottles of Parental Surgical Limited have been recovered.”

After the state government stepped in, the bogus fluids were lifted from
the market by drug controllers.

Hospital officials say they will clamp down on those responsible.

[Dr. Arvind Mathur, Director, Mahatma Gandhi Hospital]:
“On the basis of their preliminary investigation, they presented their
reports later, but during the inspection some IV (intravenous) fluid
bottles of the company have been recovered from the cupboard of the ward
in-charge. Under immediate disciplinary actions, we are sending the ward
in-charge to the joint director for his suspension.”

At least 17 maternal deaths occurred after patients were injected with
contaminated fluids and glucose at two government hospitals of the city
earlier this year.

The women died post-delivery after their health deteriorated drastically
after being administered fake IV fluids.

Canada: Spring melt reveals needle problem in Prince Albert
CTV Saskatoon, Canada (14.04.11)

The spring thaw isn’t just revealing cracks and potholes in roadways; it’s
also exposing countless needles on the ground in Prince Albert. While the
needles themselves are cause for alarm — they are also a blunt reminder
of a much deeper social problem; the rampant use of hard drugs in
Saskatchewan communities and the problems associated with addiction.

Like in all big cities, addicts in Prince Albert try to keep their drug
use hidden, often ducking into alleyways or under bridges to shoot up.

Megan Belanger runs Prince Albert’s Needle Exchange program. She says the
city’s problem is symptomatic of an even bigger issue: addiction.

“Quite often the stories that I hear in here from the people that I see on
a regular basis is due to abuse, sexual abuse as a child, being put out on
the streets as a child by family members to make money,” said Belanger.

So which hard drugs are on the streets of Prince Albert? According to the
needle exchange, morphine, Dilantin and cocaine are among the most
actively injected drugs.

The needles pose other serious threats. They can carry HIV, hepatitis, and
other diseases, making the clean-up everyone’s problem.

The needle exchange continues to tackle that problem with drop-off boxes
along city streets, but it’s a big job.

Dr. Leo Lanoie, with the Prince Albert Cooperative Health Centre, says the
problem could be a lot worse.

“In reality, you would be seeing 19 times more, 20 times more needles
because we pick up 95 per cent of them. People are going to get needles,
that’s a no brainer. They don’t have to come. They may reuse the same
needle more often, they may share needles.”

Help is out there for addicts. Counseling is available across the city,
including the Cooperative Health Centre where Dr. Lanoie treats his

USA: Children at Risk for Disease After Medical Mistake, Fort Collins, Colorado USA (13.04.11)

The news that an employee at the Med Peds Clinic in Fort Collins reused
influenza vaccine syringes between patients has prompted a recommendation
that those children be tested for blood-borne diseases including HIV,
hepatitis B and hepatitis C.

In an April 6 letter to parents, the clinic said a medical assistant had
used only half the premeasured children’s vaccine, believing it to be an
adult dose. Although the assistant removed the used needle and replaced it
with a sterile one, the syringes were placed in a box marked “second
doses.” These were then used on children returning for the required second
influenza dose, which is administered within one month of the first.

The medical assistant’s employment has since been terminated.

Although the clinic and the Colorado Department of Public Health and
Environment are urging parents to be “on the safe side” by having their
children tested, department spokesperson Wendy Bamberg listed several
reasons why the risk of infection is low: Only the syringes – not the
needles – were shared; the vaccines are injected into muscle, not the
bloodstream; and the young children involved would be unlikely to be
infected with blood-borne diseases.

Colorado USA: Parents’ horror as they are told to test their infants for
HIV after flu vaccine mix-up
By Daily Mail, (13.04.11)

The parents of children vaccinated at a Colorado clinic have been told to
test their infants for HIV after a mix-up by a medical assistant.
Vaccine syringes were shared between children receiving their paediatric
flu shot, the Med Peds Clinic of Fort Collins has revealed.

Now terrified parents are being told to test their children for blood-
borne diseases such as HIV, Hepatitis B and Hepatitis C.

The mix-up came after the medical assistant halved the amount of vaccine
given to each child, assuming it was an adult dosage. In fact it was a
pre-measured amount suitable for children.

Because children are supposed to receive two doses of the vaccine, the
assistant then removed the used needle from each syringe and replaced it
with a sterile needle – but did not replace the syringe, still half full
of vaccine.

Instead, the assistant stored the used syringes in a box marked ‘second
doses’. that box also contained unused, fully-filled paediatric vaccines.
When the children, aged six to 35 months, returned to the clinic, some of
the half-used vaccines were inadvertently used on them.

Med Peds revealed the chilling mistake in a letter to parents on April 6.
The medical assistant, who has not been identified, has been fired.
Parents reacted with fury to the distressing news.

‘Apparently, somebody wasn’t following policy and procedure and it puts
infants in danger, so [I’m] not a big fan of them right now,’ Cary
Bergeron, whose daughter was vaccinated at the clinic, told 9News.
‘She was born flawless. And now, by someone else’s mistake, something bad
could happen.’

Med Peds said the first concern was for the children who did not receive
the full vaccination.

The clinic said it was ‘a little dismayed’ that procedure hadn’t been
followed, and insisted it was handling the incident with patients

The Colorado Department of Public Health and Environment said the chances
of a child contracting an infectious disease was ‘extremely low’.
But it still warned that the children should be tested six months after
both the first and the second shot.

The Department said it was investigating the incident.

In the letter, the clinic offered its ‘sincere apologies’ for the mistake.
‘Please be confident we have carefully evaluated the facts and
circumstances surrounding this matter and have taken steps to prevent
future incidents from happening,’ the letter said.

Nevada USA: Doctor who reused medical devices gets license back but must
have monitor
By Paul Harasim, Las Vegas Review-Journal, Nevada USA (update 13.04.11)

The Nevada State Medical Board, which suspended Dr. Michael Kaplan’s
medical license in March because he reused single-use medical devices in
prostate biopsy procedures, reinstated his license Tuesday.

And the board stipulated in its reinstatement order that the urologist,
who the board had said stopped reusing single-use needle guides only when
they became “too bloody,” can once again perform invasive procedures at
his office as long as a “third party” health professional is on hand to
monitor his infection control efforts.

“We determined through our investigation to this point that the imminent
risk to the health, safety and welfare of the public has been
ameliorated,” said Doug Cooper, the board’s executive director. “Dr.
Kaplan can immediately see patients without doing invasive procedures, but
if he does an invasive procedure, he must be monitored throughout.”

The Southern Nevada Health District has notified more than 110 of Kaplan’s
patients that they need to get tested for HIV and hepatitis. So far, there
have been no reports of infection.

Two weeks after the board took its suspension action against Kaplan, a
second urologist, Dr. Lawrence Newman, reported himself to the board.
Cooper said he, too, incorrectly believed he could sterilize single-use
plastic endocavity needle guides.

A source close to the state’s infection control efforts said Newman, like
Kaplan, told authorities that a vendor had said the plastic needle guides
could be used more than once. No board action has been taken against

Kaplan said Tuesday that he was “excited to be going back to work.” Never,
he said, did he purposely put patients at risk. A vendor for the
equipment, he said, had given him bad information.

“I wasn’t trying to cut corners,” he insisted. “I never have intended to
make any excuses for what I did. It shouldn’t have been done. But I want
people to know why it happened.”

Dominic Gentile, Kaplan’s attorney, told the Review-Journal that a
Providian Medical Equipment vendor, who was distributing needle guides
made by CIVCO Medical Solutions, admitted to his law firm that he told
Kaplan that the plastic needle guides could be used more than once. A
Providian spokesman issued a statement saying the firm was looking into
the situation, which Gentile fears is a national problem.

“This isn’t an attempt to justify what was done,” Gentile said. “This
shouldn’t have been done. It’s an explanation.”

Patients of both Kaplan and Newman questioned why the doctors would listen
to a salesman rather than follow what they have been taught throughout
their medical careers about single-use devices.

The single-use needle guides, plastic sheaths through which needles are
directed to obtain biopsy material, regularly come in contact with blood
and bodily fluids, which could be passed to another patient if reused.

Lee Hornstein, a former patient of Kaplan’s, was stunned by the board’s

“I’m dumbfounded,” said the 69-year-old retired businessman who got tested
for hepatitis and HIV even though the prostate biopsy he received from
Kaplan wasn’t within the December-to-March time frame in which the board
said Kaplan’s patients were at risk for blood-borne diseases. “Holy
mackerel, the board doesn’t even know yet whether people are going to come
down with infections. Many people have to get tested again in six months.
I guess the board knows something we don’t.”

Cooper said it is not unusual for the board to reinstate a license until a
final disciplinary hearing as long as the board determines the public
safety is not currently at risk. For instance, he said an orthopedic
surgeon who might have had his license suspended because of repeated
problems with a procedure might get his license back pending a final
hearing as long as he stipulates to not doing the procedure in question.

“In this case, we were concerned about infection control, and we’re
confident that has been handled,” Cooper said, noting that Kaplan could
still face stiff penalties at his disciplinary hearing in about 90 days.

In explaining why the board has taken no action against Newman even though
he admitted reusing single-use medical devices on 150 patients over a
three-year period, Cooper noted that Newman reported himself to the board,
stopped the practice and began notifying his patients.

“These are two different cases,” Cooper said.

The monitor who will go to Kaplan’s office will be a health care
professional “trained in infection control,” Cooper said. The monitor must
be approved by the board, and Kaplan is responsible for the cost.

The board listed 13 procedures during which a monitor must be present,
including prostate biopsies, cystoscopies, catheter placements,
vasectomies and removal of scrotal and penile lesions.

Kaplan, who told the R-J that he and his attorney had suggested the idea
of a third party monitor to the board, said he wanted the board “to be
comfortable that our practices are safe.”

A board hearing that was scheduled for today to determine whether Kaplan’s
summary suspension would stay in effect was canceled after Kaplan agreed
to the stipulations of the board.

Gentile said he was impressed that the board acted in a manner that
protects both the public and the physician. He said too often public
agencies don’t act in the interest of fairness but to impress a public
that might be clamoring for action that is unfair.

Kaplan said he wanted to make it “crystal clear” that he always thinks
about his patients’ safety and that he would never do anything to
deliberately put them at risk.

Former patient Hornstein said he wonders how many people would want to
become patients of Kaplan’s because of “his lapse” of professionalism.

“I know he’s going to be exceedingly careful, but still,” he said, letting
his thoughts trail off. “Well, I wish him nothing but the best. After all,
he helped start our prostate cancer support group, so he is a good man.”
* SAFETY OF INJECTIONS brief yourself at:

A fact sheet on injection safety is available at:

* Visit the WHO injection safety website and the SIGN Alliance Secretariat

* NEW: Download the  WHO Best Practices for Injections and Related
Procedures Toolkit  March 2010 [pdf 2.47Mb]:

Use the Toolbox at:

Subscribe or un-subscribe by email to: or on
subscribe online at:

Get SIGN files on the web at:
get SIGNpost archives at:

The SIGN Secretariat, the Department of Essential Health Technologies,
WHO, Avenue Appia 20, CH-1211 Geneva 27, Switzerland. Telephone: +41 22
791 3680, Facsimile: +41 22 791 4836, E- mail:

SIGN meets annually to aid collaboration and synergy among SIGN network
participants worldwide.

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 is searchable. Viewing
requires the free Adobe Acrobat Reader at:

Many SIGN files can be opened in Acrobat Reader. To access all the
features in Adobe Acrobat documents download the Acrobat Reader at:

Translation tools are available at:
All members of the SIGN Forum are invited to submit messages, comment on
any posting,  or to use the forum to request technical information in
relation to injection safety.

The comments made in this forum are the sole responsibility of the writers
and does not in any way mean that they are endorsed by any of the
organizations and agencies to which the authors may belong.

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

Contributions to: or use your reply button!

The SIGN Forum welcomes new subscribers who are involved in injection
safety. Please subscribe by sending an email to:

The SIGN Internet Forum was established at the initiative of the World
Health Organization’s Department of Essential Health Technologies. The
SIGN Forum is moderated by Allan Bass and is hosted on the University of
Queensland computer network.

Comments are closed.