*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *SAFE INJECTION GLOBAL NETWORK* SIGN 2009 30 November to 2 December 2009 at WHO HQ Geneva Post00517 HCWM + Job + Abstracts + News 21 October 2009 CONTENTS 1. Abstract: Health care waste management: a neglected and growing public health problem worldwide 2. Abstract: Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials 3. Abstract: Inadequate pain management during routine childhood immunizations: the nerve of it 4. Abstract: Alternative approaches to vaccine delivery 5. Abstract: Modeling the transmission dynamics and control of hepatitis B virus in China 6. Abstract: Multistate outbreak of Serratia marcescens bloodstream infections caused by contamination of prefilled heparin and isotonic sodium chloride solution syringes 7. Abstract: The relationship between intravenous infusate colonisation and fluid container hang time 8. Abstract: Prevalence and Correlates of HIV Infection Among Male Injection Drug Users in Detention, Tehran, Iran 9. Abstract: A comparison of the handling and accuracy of syringe and vial versus prefilled insulin pen (FlexPen) 10. Abstract: More than hand hygiene is needed to affect methicillin- resistant Staphylococcus aureus clinical indicator rates: Clean hands save lives, Part IV 11. Abstract: Airborne transmission of disease in hospitals 12. Abstract: EU Water Framework Directive and Stockholm Convention: can we reach the targets for priority substances and persistent organic pollutants? 13. Abstract: Modifying peripheral IV catheters with side holes and side slits results in favorable changes in fluid dynamic properties during the injection of iodinated contrast material 14. Abstract: Evaluation of a new needle catching instrument for suturing simple wounds in the Emergency Department 15. No Abstract: Use of glyceryl trinitrate patches in the treatment of accidental digital injection of epinephrine from an autoinjector 16. No Abstract: Comment on: needlestick injury management--what's the solution? 17. No Abstract: author reply: Is double gloving an effective barrier to protect surgeons against blood exposure due to needlestick injury? 18. No Abstract: Preamble for chapter D , Hygiene Management, of the guidelines for hospital hygiene and infection prevention: guidelines of the Commission for Hospital Hygiene and Infection Prevention 19. TECHNICAL SPECIALIST (Contracts), L-3 UNICEF Health Technology Centre 20. Public Campaign Warns Citizens of Dangers of Counterfeit Medicines in Cambodia 21. News - PCV vaccines can save the lives of millions of children - Australia: In the wash-up, doctors forget about hygiene - Global: Over 80 countries mark world handwashing day - USA: Botox lawsuit raises issues on injections - Doctor says sales representatives promote reuse of single-use vials - Canada: Low risk of blood-borne virus through re-use of syringes in IV lines - Developing countries swamped in healthcare rubbish: Growing mountains of medical waste threaten health in countries without proper disposal facilities - Global: Handwashing Program Targets Childhood Deaths in Africa - USA: Florida Hospital Confirms Patients Infected by Reused IV Bags - BMTS Furthers Development of Its Demolizer(R) Home Unit - Puerto Rico: PR group tests syringe vending machine for addicts - USA: Nurse reused IV supplies - Patients of Broward General nurse test positive for diseases- It's unknown if her unsafe practices caused the infections - USA: Investigation Of Contaminated Heparin Syringes Highlights Medication Safety Issues This edition of SIGNpost is located at: http://uqconnect.net/signfiles/Archives/SIGN-POST00517.txt 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: sign@uq.net.au Normally, items received by Tuesday will be posted in the Wednesday edition. Subscribe or un-subscribe by email to: sign@uq.net.au, sign@who.int More information follows at the end of this SIGNpost! Visit the WHO injection safety website and the SIGN Alliance Secretariat at: http://www.who.int/injection_safety/en/ __________________________________________________________________________ _____________________________________*____________________________________ 1. Abstract: Health care waste management: a neglected and growing public health problem worldwide __________________________________________________________________________ Tropical Medicine & International Health Volume 14 Issue 11, Pages 1414 - 1417 Health care waste management: a neglected and growing public health problem worldwide Michael O. Harhay 1 , Scott D. Halpern 2 , Jason S. Harhay 3 and Piero L. Olliaro 4,5 1 Graduate Program in Public Health Studies, University of Pennsylvania School of Medicine, Philadelphia, PA, USA 2 Departments of Medicine, Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA 3 Muhlenberg College, Allentown, PA, USA 4 UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), Geneva, Switzerland 5 Centre for Tropical Medicine and Vaccinology, University of Oxford, Churchill Hospital, Oxford, UK Corresponding Author Piero L. Olliaro, UNICEF/UNDP/WB/WHO Special Programme for Research and Training in Tropical Diseases (TDR), Avenue Appia 20, 1211 Geneva 27, Switzerland. Tel.: +41 22 7913734; Fax +41 22 791 4774; E-mail: olliarop@who.int The objective of this Short Communication is to promulgate an inventory of 87 papers pertaining to health care waste management practices and challenges in 40 low and middle income countries worldwide amassed through a multi-language systematic review. Herein, we discuss the major gaps, failures, and frequently reported themes by geographic region. Following this we outline a proposed research agenda moving forward, and conclude that greater research and attention towards these unintended consequences of technologic progress in medical care delivery is needed to address and understand this growing public health threat around the world. © 2009 Blackwell Publishing Ltd __________________________________________________________________________ _____________________________________*____________________________________ 2. Abstract: Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials __________________________________________________________________________ Clin Ther. 2009;31 Suppl 2:S48-76. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V; HELPinKIDS Team. Collaborators (14) Division of Pharmacy Practice, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada. anna.taddio@utoronto.ca BACKGROUND: Vaccine injections are the most common reason for iatrogenic pain in childhood. With the steadily increasing number of recommended vaccinations, there has been a concomitant increase in concern regarding the adequacy of pain management. Physical interventions and injection techniques that minimize pain during vaccine injection offer an advantage over other techniques because they can be easily incorporated into clinical practice without added cost or time. Their effectiveness, however, has not previously been studied using a systematic approach. OBJECTIVE: The purpose of this review was to determine the effectiveness of physical interventions and injection techniques for reducing pain during vaccine injection in children. METHODS: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of physical interventions and injection techniques on pain during injection of vaccines in children 0 to 18 years of age, using validated child self- reported pain or assessments of child distress or pain made by others (parent, nurse, physician, observer). We sought to determine the effects of: (1) different formulations of the same vaccine; (2) position of the child during injection; (3) intramuscular versus subcutaneous injection; (4) cooling of the skin at the injection site with ice before injection; (5) stroking the skin or applying pressure close to the injection site before and during injection; (6) order of vaccine injection when 2 vaccines were administered sequentially; (7) simultaneous versus sequential injection of 2 vaccines; (8) vaccine temperature; (9) aspiration before injection; (10) anatomic location of injection; (11) aspects of the needle (gauge, length, angle of insertion, speed of injection); and (12) combinations of these interventions. All meta- analyses were performed using a fixed-effects model. RESULTS: Nineteen RCTs involving 2814 infants and children (0-18 years of age) were included in the systematic review. One study included children > or=16 years and adults (n = 150). Interventions with positive findings are summarized here. In 2 trials that used child self-reports of pain during administration of measles-mumps-rubella vaccine (total, 680 children with complete data), the Priorix vaccine caused less pain than the M-M-R(II) vaccine (standardized mean difference [SMD], -0.66; 95% CI, -0.81 to -0.50; P < 0.001). In 3 trials (404 children), the number needed to treat (NNT) with Priorix to prevent 1 child from crying was 3.2 (95% CI, 2.6-4.2). In 4 trials (281 infants and children), sitting children up or having parents hold infants appeared to cause less pain than the supine position, but the difference was not statistically significant; however, significant heterogeneity was found among the studies, and a qualitative approach was used for data analysis. A benefit was observed for 3 of the 4 studies; the SMD ranged from -0.4 to -0.8 (P < 0.05 for all analyses). The negative findings observed for the remaining study may have been the result of methodologic heterogeneity. Stroking the skin close to the injection site before and during injection reduced pain in 1 trial (66 children; SMD, -0.53; P = 0.03). One study (120 children) found that when diphtheria-polio-tetanus-acellular pertussis-Haemophilus influenzae type b (DPTaP-Hib; Pentacel) and pneumococcus (Prevnar) were injected sequentially during the same office visit, observer- and parent-reported pain scores were lower when DPTaP-Hib was injected first (SMD, -0.40 and -0.57, respectively; P /= 45 yr). CONCLUSIONS:: This study supports that incarceration is contributing to the increased spread of HIV. Harm reduction programs should be urgently expanded, particularly among incarcerated IDU. __________________________________________________________________________ _____________________________________*____________________________________ 9. Abstract: A comparison of the handling and accuracy of syringe and vial versus prefilled insulin pen (FlexPen) __________________________________________________________________________ Diabetes Technol Ther. 2009 Oct;11(10):657-61. A comparison of the handling and accuracy of syringe and vial versus prefilled insulin pen (FlexPen). Asakura T, Seino H, Nakano R, Muto T, Toraishi K, Sako Y, Kageyama M, Yohkoh N. Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Niigata University of Pharmacy and Applied Life Sciences, Niigata, Japan. asa-mac@m7.dion.ne.jp BACKGROUND: To determine the preferable method for self-injecting insulin, we compared the handling, safety, and dose accuracy of a conventional disposable syringe and vial with FlexPen (Novo Nordisk A/S, Bagsvaerd, Denmark), a prefilled pen. METHODS: Insulin therapy-naive healthcare professionals (HCPs) (n = 30), unfamiliar with insulin delivery, injected 10 U of insulin into a sponge pad using either a syringe and vial or the FlexPen, both with 30-gauge 8- mm needles, on day 1. The following day, they used the alternative method. They evaluated the handling of the two methods on device-specific questionnaires and compared overall preference on a third questionnaire. To evaluate dose accuracy, 30 insulin therapy- experienced HCPs and 20 insulin therapy-naive HCPs were asked to deliver 10 U of insulin using each method, and the amount discharged was weighed. RESULTS: FlexPen was rated easier to use and overall more preferable than the syringe and vial by insulin therapy-naive HCPs (P < 0.001). The pen device was more accurate than the syringe and vial when used by experienced HCPs (mean +/- SD dose delivered, 9.91 +/- 0.11 U vs. 9.82 +/- 0.25 U, respectively; P < 0.001) and by insulin therapy-naive HCPs (9.91 +/- 0.12 U vs. 9.74 +/- 0.85 U; P < 0.001). CONCLUSIONS: Insulin therapy- naive HCPs found FlexPen easier to handle and preferable to use compared to a conventional syringe and vial. Both insulin therapy-experienced and - naive HCPs were able to deliver insulin significantly more accurately with the FlexPen than with a syringe and vial (P < 0.001). __________________________________________________________________________ _____________________________________*____________________________________ 10. Abstract: More than hand hygiene is needed to affect methicillin- resistant Staphylococcus aureus clinical indicator rates: Clean hands save lives, Part IV __________________________________________________________________________ Med J Aust. 2009 Oct 19;191(8):S26-31. More than hand hygiene is needed to affect methicillin-resistant Staphylococcus aureus clinical indicator rates: Clean hands save lives, Part IV. McLaws ML, Pantle AC, Fitzpatrick KR, Hughes CF. Hospital Infection Epidemiology and Surveillance Unit, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia. m.mclaws@unsw.edu.au. OBJECTIVE: To examine whether improved hand hygiene compliance in health care workers after a statewide hand hygiene campaign in New South Wales hospitals was associated with a fall in rates of infection with multiresistant organisms. DESIGN AND SETTING: Data on rates of new methicillin-resistant Staphylococcus aureus (MRSA) infections (expressed as four clinical indicators) are reported by some Australian hospitals to the Australian Council on Healthcare Standards (ACHS) for accreditation purposes and are mandatorily reported by all NSW hospitals to the NSW Department of Health. Infections are classified according to whether they are acquired in the intensive care unit (ICU) or other wards and whether they are from sterile sites (blood cultures) or non-sterile sites. The clinical indicators reflect four different site categories (ICU sterile site, ICU non-sterile site, non-ICU sterile site and non-ICU non-sterile site) and are expressed as the number of new health care-associated infections per 10 000 acute care bed-days. Clinical indicator rates were examined for any decline between the pre-campaign period (July-December 2005) and post-campaign period (January-July 2007), and were compared with trends over a similar period in states without a hand hygiene campaign. MAIN OUTCOME MEASURES: Pre-campaign and post-campaign rates for four MRSA clinical indicators. RESULTS: Between the pre- and post-campaign periods, there was a 25% fall in MRSA non-ICU sterile site infections, from 0.60/10 000 bed-days to 0.45/10 000 bed-days (P = 0.027), and a 16% fall in ICU non-sterile site infections, from 36.36/10 000 bed-days to 30.43/10 000 bed-days (P = 0.037). The pre- and post-campaign rates of MRSA infection from ICU sterile sites (5.28/10 000 bed-days v 4.80/10 000 bed-days; P = 0.664) and non-ICU non-sterile sites (5.92/10 000 bed-days v 5.66/10 000 bed-days; P = 0.207) remained stable. Australia-wide MRSA data reported to the ACHS showed a 45% decline in infections from ICU non-sterile sites, from 25.89/10 000 bed-days to 14.30/10 000 bed-days (P < 0.001), and a 46% decline in infections from non-ICU non-sterile sites, from 3.70/10 000 bed-days to 1.99/10 000 bed-days (P < 0.001) over the period 2005-2006. CONCLUSION: Two out of four clinical indicators of MRSA infection remained unchanged despite significant improvements in hand hygiene compliance in NSW hospitals. The reduction in MRSA infections from ICU non-sterile sites in NSW hospitals was mirrored in ACHS data for other Australian states and cannot be assumed to be the result of improved hand hygiene compliance. Concurrent clinical and infection control practices possibly influence MRSA infection rates and may modify the effects of hand hygiene compliance. More sensitive measurements of hand hygiene compliance are needed. __________________________________________________________________________ _____________________________________*____________________________________ 11. Abstract: Airborne transmission of disease in hospitals __________________________________________________________________________ J R Soc Interface. 2009 Oct 14. Airborne transmission of disease in hospitals. Eames I, Tang JW, Li Y, Wilson P. University College London, , Gower Street, London WC1E 7JE, UK. Hospital-acquired infection (HAI) is an important public health issue with unacceptable levels of morbidity and mortality, over the last 5 years. Disease can be transmitted by air (over large distances), by direct/indirect contact or a combination of both routes. While contact transmission of disease forms the majority of HAI cases, transmission through the air is harder to control, but one where the engineering sciences can play an important role in limiting the spread. This forms the focus of this themed volume. In this paper, we describe the current hospital environment and review the contributions from microbiologists, mechanical and civil engineers, and mathematicians to this themed volume on the airborne transmission of infection in hospitals. The review also points out some of the outstanding scientific questions and possible approaches to mitigating transmission. __________________________________________________________________________ _____________________________________*____________________________________ 12. Abstract: EU Water Framework Directive and Stockholm Convention: can we reach the targets for priority substances and persistent organic pollutants? __________________________________________________________________________ Environ Sci Pollut Res Int. 2009 Aug;16 Suppl 1:S92-7. EU Water Framework Directive and Stockholm Convention: can we reach the targets for priority substances and persistent organic pollutants? Fuerhacker M. Institute of Sanitary Engineering and Water Pollution Control, University of Natural Resources and Applied Life Sciences Vienna, Vienna, Austria. maria.fuerhacker@boku.ac.at BACKGROUND, AIM AND SCOPE: Water is a renewable resource and acceptable quality is important for human health, ecological and economic reasons, but human activity can cause great damage to the natural aquatic environment. Managing the water cycle in a sustainable way is the key to protect natural resources and human health. On a global level, the microbiological contamination of water sources is a major problem in connection with poverty and the United Nations Millennium Development Declaration is an important initiative to handle this problem. In terms of environmental health, persistent organic pollutants (POPs) circulate globally; as they travel long distances, they are found in remote areas far from their original source of application and can cause damage wherever they move to. On a global scale, United Nations Environmental Programme (UNEP) issued the Stockholm Convention to reduce POPs; in the European Union (EU), one intention of the Water Framework Directive (WFD) is to reach the good chemical status of waters; beside these regulations, there are other directives in support of these goals. The aim of this paper is to discuss whether the Stockholm Convention and the WFD allows meeting the targets of protection of human and environmental health, which are established in the different directives and how could we approach the targets. MATERIALS AND METHODS: The aims and scopes of different directives are compiled and compared with the actual quality of water, different approaches of standard settings are compared and potential treatment options are discussed. RESULTS: Under the Stockholm Convention on POPs, which came into force in May 2004, governments are required to develop a National Implementation Plan (NIP) setting out how they will address their obligations under the convention and how they will take measures to eliminate or reduce the release of POPs into the environment by the use of best available techniques (BAT) and application of best environmental practices (BEP). On a European level, the WFD has been in place as the main European legislation to protect our water resources and the water environment of Europe since 2000. It requires managing river basins so that the quality and quantity of water does not affect the ecological services of any specific water body. Nevertheless, the goals of other directives as for drinking water, bathing water and urban wastewater treatment are not yet harmonised mainly concerning microbiological, priority substances and priority hazardous substances (PS/PHS) contamination. Following the detection of substances, a risk assessment with sound effect data needs to be performed also for regulatory decisions and priorisation of measures to remove emerging contaminants. Beside personal care products and industrial contaminants, faecal pollution of recreational waters is one of the major hazards facing users, although microbial contamination from other sources as well as chemical and physical aspects also affects the suitability of water for recreation. As in arid and semiarid areas, wastewater is considered for irrigation with regulatory needs of hygienic and chemical parameters-health-based targets- to avoid the contamination of crops and food. In surface waters, currently, the relationships between physical and chemical properties and the biological state of surface waters were quite well-understood to enable the management of catchments and rivers to achieve ecological quality. DISCUSSION: Nevertheless, more work is needed to find out the actual impact of the regulations for single chemicals and complex mixtures, in terms of environmental quality standards to achieve a 'good chemical status', on the good biological status. In a next step after the adoption of the list of PS/PHS substances, which also includes the POPs, the Urban Wastewater Treatment Directive (UWWTD) needs to be adjusted and existing or new treatment options (BATs) should comply with the new requirements of the different directives. CONCLUSIONS: Relevant substances threaten human health and the environment by new effects such as CMR, endocrine-disrupting effects or neurotoxicity which are not yet considered in an adequate way by assessment methods and regulatory standards and the application of abatement technologies. The Registration, Evaluation, Authorisation and Restriction of Chemicals helps to control the sources, but WFD, the Stockholm Convention and UWWTD need to be harmonised and a rolling revision process should react on new developments. Finally, to answer the question if the Stockholm Convention and the WFD (2000/60/EC) could reach the target-I would state that they provide a very valuable frame to approach the targets, but there is still way to go to reach them on an EU level and on a global scale, also under the aspects of the Stockholm Convention and the Millennium Development Goals. PERSPECTIVES: The compilation of the goals of different regulations and combined actions will save a lot of administrative efforts and money. __________________________________________________________________________ _____________________________________*____________________________________ 13. Abstract: Modifying peripheral IV catheters with side holes and side slits results in favorable changes in fluid dynamic properties during the injection of iodinated contrast material __________________________________________________________________________ AJR Am J Roentgenol. 2009 Oct;193(4):970-7. Modifying peripheral IV catheters with side holes and side slits results in favorable changes in fluid dynamic properties during the injection of iodinated contrast material. Weber PW, Coursey CA, Howle LE, Nelson RC, Nichols EB, Schindera ST. Department of Mechanical Engineering, Duke University, Durham, NC 27710, USA. OBJECTIVE: The purpose of this study was to compare a standard peripheral end-hole angiocatheter with those modified with side holes or side slits using experimental optical techniques to qualitatively compare the contrast material exit jets and using numeric techniques to provide flow visualization and quantitative comparisons. MATERIALS AND METHODS: A Schlieren imaging system was used to visualize the angiocatheter exit jet fluid dynamics at two different flow rates. Catheters were modified by drilling through-and-through side holes or by cutting slits into the catheters. A commercial computational fluid dynamics package was used to calculate numeric results for various vessel diameters and catheter orientations. RESULTS: Experimental images showed that modifying standard peripheral IV angiocatheters with side holes or side slits qualitatively changed the overall flow field and caused the exiting jet to become less well defined. Numeric calculations showed that the addition of side holes or slits resulted in a 9-30% reduction of the velocity of contrast material exiting the end hole of the angiocatheter. With the catheter tip directed obliquely to the wall, the maximum wall shear stress was always highest for the unmodified catheter and was always lowest for the four- side-slit catheter. CONCLUSION: Modified angiocatheters may have the potential to reduce extravasation events in patients by reducing vessel wall shear stress. __________________________________________________________________________ _____________________________________*____________________________________ 14. Abstract: Evaluation of a new needle catching instrument for suturing simple wounds in the Emergency Department __________________________________________________________________________ Eur J Emerg Med. 2009 Oct 9. Evaluation of a new needle catching instrument for suturing simple wounds in the Emergency Department. Breslin T, Geary U, Bennett K, Shields D, Kennedy U. St. James's Hospital Emergency Department, Trinity College Dublin, Ireland. OBJECTIVES: The Needlecatcher comprises a tissue forceps at one end, with a 'piston and barrel' system, which acts as a needle grasper, at the other end of the instrument. It minimizes exposure of the needle during suturing, potentially reducing risk of injury. We evaluate its effect on operator safety during simple wound closure. METHODS: Video analysis of 10 clinicians (six junior doctors and four advanced nurse practitioners) closing a standard simulated wound using their normal technique was performed. They were trained in the use of the Needlecatcher, and used it for 10 weeks closing simple wounds in the Emergency Department. Video analysis of wound closure was repeated, using the new instrument. Clinicians filled out a questionnaire for each episode of wound closure, which assessed how they perceived their safety was affected by the device. RESULTS: Video analysis of clinicians showed that the needle was secured in an instrument and thus unexposed for an average of 60% of the duration of the procedure by standard technique, compared with 95% using the Needlecatcher, with a change of 35% [95% confidence interval (CI): 14-58%, P = 0.005]. Episodes where the needle was grasped by an operator's finger were reduced by 50% (95% CI: 15-85%, P = 0.028). In the questionnaire study of 53 episodes of wound closure, operators perceived their safety to be increased in 38 (71.7%, 95% CI: 66.2-77.2%) episodes, were neutral in 10, and felt their safety was reduced in five. CONCLUSION: The Needlecatcher showed the potential to reduce the risk of needlestick injury while suturing. __________________________________________________________________________ _____________________________________*____________________________________ 15. No Abstract: Use of glyceryl trinitrate patches in the treatment of accidental digital injection of epinephrine from an autoinjector __________________________________________________________________________ Eur J Emerg Med. 2009 Aug;16(4):227-8. Use of glyceryl trinitrate patches in the treatment of accidental digital injection of epinephrine from an autoinjector. Nagaraj J, Reddy S, Murray R, Murphy N. __________________________________________________________________________ _____________________________________*____________________________________ 16. No Abstract: Comment on: needlestick injury management--what's the solution? __________________________________________________________________________ Ann R Coll Surg Engl. 2009 Oct;91(7):627; author reply 627-8. Comment on: Ann R Coll Surg Engl. 2009 Jan;91(1):12-7. Comment on: needlestick injury management--what's the solution? McCann PA. __________________________________________________________________________ _____________________________________*____________________________________ 17. No Abstract: author reply: Is double gloving an effective barrier to protect surgeons against blood exposure due to needlestick injury? __________________________________________________________________________ Infect Control Hosp Epidemiol. 2009 Sep;30(9):928-9; author reply 929. Comment on: Infect Control Hosp Epidemiol. 2009 Jan;30(1):53-6. Is double gloving an effective barrier to protect surgeons against blood exposure due to needlestick injury? Bouvet E, Pellissier G, Abiteboul D, L'Hériteau F; Group for the Prevention of Occupational Infections in Healthcare Workers. Collaborators (3) Bouvet E, Pellissier G, Abiteboul D. __________________________________________________________________________ _____________________________________*____________________________________ 18. No Abstract: Preamble for chapter D , Hygiene Management, of the guidelines for hospital hygiene and infection prevention: guidelines of the Commission for Hospital Hygiene and Infection Prevention __________________________________________________________________________ Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2009 Sep;52(9):949-50. [Preamble for chapter D , Hygiene Management, of the guidelines for hospital hygiene and infection prevention: guidelines of the Commission for Hospital Hygiene and Infection Prevention] [Article in German] Commission for Hospital Hygiene and Infection Prevention. __________________________________________________________________________ _____________________________________*____________________________________ 19. TECHNICAL SPECIALIST (Contracts), L-3 UNICEF Health Technology Centre Take the lead on UNICEF position on cold chain and waste management related projects with partners. __________________________________________________________________________ Technical Specialist - Contracts (L-3) UNICEF MAKE A LASTING DIFFERENCE FOR CHILDREN TECHNICAL SPECIALIST (Contracts), L-3 Health Technology Centre UNICEF Supply Division, Copenhagen, Denmark If you are a passionate and committed professional and want to make a lasting difference for children, the world's leading children's rights organization would like to hear from you. UNICEF seeks a Technical Specialist for our Supply Division, based in Copenhagen, Denmark who will, under the general guidance of the Contracts Manager, provide advice on technical issues related to the supply of cold chain and waste management products to Procurement Services customers. Supports UNICEF’s ability to strengthen country capacity in the area of cold chain and waste management products and supplies. Take the lead on UNICEF position on cold chain and waste management related projects with partners. The duties include: 1. Taking the lead and representing UNICEF position on cold chain and waste management projects with partners. 2. Prepares and maintains technical specifications for cold chain and waste management products by Procurement Services Centre. 3. Technical adjudication of RFQ/ITB/RFPs on cold chain and waste management products. 4. Prepares analyses of UNICEF cold chain and waste management supply, background information, recommendations for improving the suitability and range of products, resulting in more appropriate equipment, better delivery and lower costs. 5. Strengthens the technical capacity of UNICEF Country Offices to respond to external enquiries for cold chain and waste management supplies and infrastructure. 6. Expands UNICEF Supply Division’s product mix in cold chain and waste management supplies and infrastructure in collaboration with commercial unit. 7. Supports Procurement Services Centre in identifying opportunities, and preparing price quotations for special projects on cold chain and waste management products and related services. 8. Identifies and taking the lead on priority training and capacity building needs in UNICEF Country Offices to respond to external queries. 9. Conducts market research on sourcing for extended range of cold chain and waste management products. Qualifications and Competencies: - Advanced university degree in refrigeration engineering or other technical related field. Studies in business administration an asset. - Minimum five years of progressively relevant professional experience. Extensive hands-on working experience. Sales/marketing experience in private sector, or experience in institutional procurement of cold chain and waste management products. Experience in UNICEF (WHO, WB) desirable. - Current knowledge of the latest developments and technology in the field of work. - Strong Technical and communications skills required written and spoken. - Proven ability to initiate conceptualize, plan and execute ideas as well as transfer knowledge and skills. - Leadership and teamwork abilities. - Membership in professional associations relevant to commodity group. - Ability to work in a multi-cultural environment and establish harmonious and effective working relationships. - Able to work independently and problem solving oriented. - Computer skills, including internet navigation and various office applications. - High level of responsibility and accountability - Knowledge management skills - reporting - Fluency in English and another UN language is required The contract duration is for one year and contract renewals will be subject to availability of funding. Remuneration: UNICEF’s salary and benefits package is based on the United Nations Common System. For further information on the UN Common System salaries and benefits, please visit the United Nations Web site at www.un.org/Depts/OHRM [2] Applications for this position must be received by 01 November 2009. Please note that candidates will be assessed on foundational and functional competencies and that diversity and gender balance are also factors in the selection process. Only shortlisted candidates will be contacted. Visit us at http://www.unicef.org UNICEF is a smoke-free environment How to apply Please send detailed resume, cover letter and completed United Nations Personal History Form, in English, quoting 63051R to: Chief, Human Resources: cphintrecruit@unicef.org [4]. The UN Personal History form can be found at the following web address: http://www.unicef.org/supply/index_employment.html [5] . Contact Name: Human Resources Department Job Contact Email: cphintrecruit@unicef.org Source URL: http://jobs.euractiv.com/job/technical-specialist-contracts-l-3-5319 Links: [1] http://jobs.euractiv.com/company/unicef-1368 [2] http://www.un.org/Depts/OHRM [3] http://www.unicef.org [4] mailto:cphintrecruit@unicef.org [5] http://www.unicef.org/supply/index_employment.html [6] http://jobs.euractiv.com/reg_newsletter.html [7] http://twitter.com/euractivjobsite __________________________________________________________________________ _____________________________________*____________________________________ 20. Public Campaign Warns Citizens of Dangers of Counterfeit Medicines in Cambodia Crossposted from E-DRUG with thanks. http://list.healthnet.org/mailman/listinfo/e-drug __________________________________________________________________________ Date: Thu, 08 Oct 2009 From: "Francine Pierson" Subject: [e-drug] Public Campaign Warns Citizens of Dangers of Counterfeit Medicines in Cambodia Dear All, Please see the below press release. Best regards, Francine Pierson USP .......................................................................... __________________________________________________________________________ FOR IMMEDIATE RELEASE CONTACT: Francine Pierson 301/816-8588; fp@usp.org Public Campaign Warns Citizens of Dangers of Counterfeit Medicines in Cambodiaand Greater MekongSubregion USAID, USP Screen Public Service Announcements, Documentary to Raise Awareness of Serious Public Health Threat in Developing Countries October 8, 2009, Phnom Penh, Cambodia As part of a large-scale effort to combat the dire public health consequences of counterfeit medicines on citizens in developing countries, a public service announcement (PSA) campaign is being launched in Cambodia this week by the United States Agency for International Development (USAID) and the United States Pharmacopeial (USP) Convention - with the cooperation and support of authorities in Cambodia. The PSAs are being broadcast nationally on Cambodian television and throughout Southeast Asia, where the proliferation of substandard and counterfeit medicines intended to treat HIV/AIDS, malaria, tuberculosis and other life-threatening conditions remains a major threat to the lives and livelihood of citizens struggling with these diseases. Translated into five languages, the 'Pharmacide' PSAs are being screened at an October 8th ceremony in Phnom Penh, Cambodia, by Flynn Fuller, USAID Cambodia Mission director; Patrick Lukulay, Ph.D., director of USP's Drug Quality and Information (DQI) Program, which is supported by USAID; and Mark Hammond of Living Films, who directed the PSAs as well as a short documentary that is also being screened. The PSA campaign is an activity of the DQI Program. Implemented by USP, a nonprofit scientific organization that develops globally recognized standards for the quality of medicines, the DQI Program advances strategies to improve the quality of medicines on four continents. A key function of the program is rooting out substandard and counterfeit medicines, which the World Health Organization estimates account for between 10 and 30 percent of all medicines in the developing world. 'Counterfeit and substandard medicines pose a grave threat to patients in Southeast Asia, but their presence in these countries remains a largely unknown problem,' said Mr. Fuller. 'These poor-quality medicines can contribute to adverse reactions in patients, including protracted illness and death, but may go undetected as severe symptoms and death may be wrongly attributed to the course of their disease. This is a fate that no one deserves. It is a problem that USAID, USP and national authorities take very seriously, and we hope to reach patients directly through this PSAcampaign.' 'Though they may look similar or almost identical to the intended medicine, counterfeit drugs may contain little or no active ingredient,' added Dr. Lukulay. 'It can be very difficult for patients to discern any difference, often requiring complex testing to determine the authenticity of a medicine. However, the difference can truly be life and death, which is why it is so essential for citizens to purchase medicines from a licensed pharmacy. The PSAs underscore the consequences of purchasing these drugs through alternative means, which is unfortunately an attractive option among an economically deprived population because of the lower cost. We hope that once citizens are made aware of the consequences, they will not look at this as a viable alternative.' Further compounding the problem, Lukulay added, 'not only do substandard drugs affect the individual taking them, but those that contain some but not all of an active ingredient can contribute to the development of drug-resistant strains of these diseases. This is a serious public health threat in developing countries, impacting not only the individual patient but the greater population of citizens, all of whom may suffer when a medicine is no longer effective because resistance has developed.' The PSAs show the life cycle of a counterfeit drug from the counterfeiter to the dealer to the victim. It notes that 'counterfeiting is a crime against humanity, against you,' and urges citizens to always use a licensed pharmacy when purchasing medicines. Through the DQI Program, USP advances the quality of medicines via a variety of activities that include implementing active surveillance programs in which medicines are taken off the market and tested; establishing 'sentinel sites' within countries to perform testing; and training local chemists working in government laboratories, medical students and other qualified parties to conduct such testing in a cost-effective manner. To view the PSA and video from the event, visit www.youtube.com/uspharmacopeia. For more information, please visit www.usp.org ( http://www.usp.org/ )or email mediarelations@usp.org. ### USP's Advancing Public Health Since 1820 The United States Pharmacopeial (USP) Convention is a scientific, nonprofit, standards-setting organization that advances public health through public standards and related programs that help ensure the quality, safety, and benefit of medicines and foods. USP's standards are recognized and used worldwide. For more information about USP visit http://www.usp.org ( http://www.usp.org/ ). Francine Pierson USP __________________________________________________________________________ _____________________________________*____________________________________ 21. News - PCV vaccines can save the lives of millions of children - Australia: In the wash-up, doctors forget about hygiene - Global: Over 80 countries mark world handwashing day - USA: Botox lawsuit raises issues on injections - Doctor says sales representatives promote reuse of single-use vials - Canada: Low risk of blood-borne virus through re-use of syringes in IV lines - Developing countries swamped in healthcare rubbish: Growing mountains of medical waste threaten health in countries without proper disposal facilities - Global: Handwashing Program Targets Childhood Deaths in Africa - USA: Florida Hospital Confirms Patients Infected by Reused IV Bags - BMTS Furthers Development of Its Demolizer(R) Home Unit - Puerto Rico: PR group tests syringe vending machine for addicts - USA: Nurse reused IV supplies - Patients of Broward General nurse test positive for diseases- It's unknown if her unsafe practices caused the infections - USA: Investigation Of Contaminated Heparin Syringes Highlights Medication Safety Issues Selected news items reprinted under the fair use doctrine of international copyright law: http://www4.law.cornell.edu/uscode/17/107.html __________________________________________________________________________ PCV vaccines can save the lives of millions of children from News-Medical.Net (20.10.09) A study published in The Cochrane Review this month concludes that pneumococcal conjugate vaccines (PCV), already known to prevent invasive pneumococcal disease (IPD) and x-ray defined pneumonia, was also effective against child deaths. The findings were based on a systematic review of the results of 6 randomized and controlled trials conducted in the US, Africa, Philippines, and Finland. Eighty percent of children were less likely to develop vaccine-type IPD, 58% all-serotype IPD, and 27% x-ray defined pneumonia than children who did not receive the vaccine. Eleven percent of child deaths were also prevented. In total, 113,044 children were included in the six trials - 57,015 children in the PCV group and 56,029 in the control group. "Pneumococcal disease is driving a global health crisis, particularly in the developing world," said Marilla G. Lucero of the Research Institute for Tropical Medicine and primary author of the study. "This study underscores the value of vaccines in preventing this deadly disease and saving children's lives." Pneumococcal disease, or Streptoccoccus pneumoniae, is a leading cause of pneumonia, meningitis, sepsis and other life-threatening ailments. It takes the lives of 1.6 million people each year, including more than 800,000 children despite the existence of safe and effective vaccines to prevent it. Ninety-five percent of child pneumococcal deaths occur in the developing world, largely unreached by the existing vaccines as yet. WHO recommends that all countries prioritize introduction of PCV, particularly those with high child mortality rates. In 2000, the United States became the first country to license a 7-valent pneumococcal vaccine (PCV-7), which has virtually eliminated severe pneumococcal disease caused by vaccine serotypes in the U.S. Since then, 37 countries have implemented universal or widespread use of PCV-7, nearly all of which are in the industrialized world. New financial mechanisms, including the GAVI Alliance's Advance Market Commitment, are now in place to help low-income countries prevent pneumococcal deaths in their own countries. Next generation PCVs are expected to shortly become available and will provide expanded serotype coverage of strains common in the developing world. "While early detection and treatment can save lives, this review highlights the effectiveness of pneumococcal conjugate vaccines for preventing pneumococcal disease before it occurs," said Dr. Orin Levine, executive director of PneumoADIP at the Johns Hopkins Bloomberg School of Public Health. "Low-income countries can now have the opportunity to introduce pneumococcal vaccine on an unprecedented timetable and at prices their governments can afford. We recommend that all countries eligible for GAVI support apply now and take immediate steps to prioritize prevention." Source: Johns Hopkins University Bloomberg School of Public Health .......................................................................... __________________________________________________________________________ Australia: In the wash-up, doctors forget about hygiene By Natasha Wallace, Sydney Morning Herald, Australia (19.10.09) DOCTORS are by far the worst health workers when it comes to washing their hands, with fewer than half managing to do so despite knowing its importance in reducing infection rates, a survey of public hospitals has found. The study, published in the Medical Journal of Australia today, found that the compliance rate for hand hygiene among doctors was just 39 per cent in July last year. NSW Health introduced alcohol-based hand rub and conducted the Clean Hands Saves Lives campaign in all hospitals from February, 2006 to February, 2007. The study, by researchers at the University of NSW and the Clinical Excellence Commission, found that before the campaign, the hand hygiene compliance rate was only 30 per cent for doctors. It improved to 58 per cent by November, 2006, at the peak of the campaign, but dropped again to 39 per cent in July last year. This was despite doctors wearing "It's OK to ask" badges during the campaign, encouraging patients to check whether they had washed their hands. Compliance by nurses was much better, the study found. Before the campaign, 55 per cent of nurses complied, which steadily climbed to 68 per cent in February 2007 and then fell slightly to 65 per cent in July last year. The overall rate for health workers over the pre-campaign survey and four post-campaign surveys improved from 47 per cent to 61 per cent. The rates are based on a mean of 7747 hand hygiene opportunities. The NSW president of the Australian Medical Association, Brian Morton, said mandatory education was needed because there was "a perception that not every time you touch a patient you pick up a handful of germs". But Dr Morton also blamed the poor rates on a lack of time and not enough hand basins and supplies of alcoholic-based rub, which was introduced to all hospitals in 2006. He did not support punitive measures, which NSW Health said it would introduce, in line with the Garling recommendations, by the end of the year. The policy would see doctors potentially sacked after three warnings or even deregistered for persistent non-compliance. Halving infections rates could save 1500 lives a year, NSW Health said. "I don't think it's actually going to improve hand washing and hygiene levels. It will add to the bullying culture that already exists," Dr Morton said. One of the study's authors, Mary-Louise McLaws, the director of Public Health Programs at the University of NSW, said she was sympathetic to doctors, and punitive measures were "draconian". Annette Pantle, of the Clinical Excellence Commission, said poor hand hygiene was a worldwide problem. This story was found at: http://www.smh.com.au/national/in-the-washup-doctors-forget-about- hygiene-20091018-h303.html .......................................................................... __________________________________________________________________________ Global: Over 80 countries mark world handwashing day KaiserNetwork.org (19.10.09) VOA News reports that more than 80 countries marked Global Handwashing Day Thursday. The news service writes that "[d]iarrhea is the third cause of death in West and Central Africa, which is responsible for 30 percent of the world's deaths of children under the age of five." According to UNICEF Executive Director Ann Veneman, "Health experts suggest that if people [wash their hands] regularly, the incidence of diarrhea can be reduced by as much as 40 percent." Handwashing with clean water is not always possible in part of Africa, says UNICEF's Jane Bevan: "It is often a problem and we have to do as best we can, and quite often we are supporting schools to develop water supplies as well and also looking at alternatives solutions ..." (Shryock, 10/15). According to UNICEF, "despite its life-saving potential, handwashing with soap is seldom practised and is not always easy to promote," IANS/Times of India reports. In India alone, diarrhea kills nearly 1,000 children under age 5 every day, UNICEF says. Using soap and water to wash hands is "one of the most effective and affordable health interventions," reports the Times of India (10/16). According to Xinhua, "higher rates of handwashing with soap would significantly contribute towards meeting the [Millennium Development Goal] 4 of reducing deaths of children under the age of five by two-thirds by 2015" (10/15). .......................................................................... __________________________________________________________________________ USA: Botox lawsuit raises issues on injections - Doctor says sales representatives promote reuse of single-use vials By Paul Harasim, Las Vegas Review-Journal, Las Vegus NV USA (18.10.09) Single-use medication vials used on more than one patient. That practice at the Endoscopy Center of Southern Nevada, public health officials have repeatedly said, contributed to the hepatitis C outbreak in the Las Vegas Valley. Now a federal lawsuit filed in California by Las Vegas physician Ivan Goldsmith argues that sales representatives for Allergan Inc., maker of the popular anti-wrinkle drug Botox, promote multipatient use of its 50- unit or 100-unit single-use vials. Goldsmith's lawsuit alleges that doctors can only make a profit using Botox if they reuse the single-use vials that the drug comes in. But the complaint also raises issues that go beyond dollars and cents, ones that the community has been acutely aware of since the hepatitis C outbreak became public in February of last year. The Botox business model "created an unacceptable and unreasonable risk of serious and debilitating injuries and illnesses, including HIV and Hepatitis B and C," states the lawsuit, filed Sept. 29 in U.S. District Court for the Central District of California. Allergan spokeswoman Kellie Reagan said the product's prescribing label has always been clear: single use only. She wouldn't comment, however, on how Allergan's sales representatives promote the drug's use. Goldsmith said in the lawsuit that Allergan misrepresented to him "the true and permissible use of the product." Most patients need far less Botox than is provided by Allergan in either its 50-unit or 100-unit vials, the lawsuit said. And, according to the suit, the medication can't be saved for later use on the same patient because, once a vial is opened, it must be thrown away within four hours of first use. Physicians and medical spa providers of Botox contacted by the Review- Journal said Allergan's sales representatives have consistently said vials of Botox could be used for multiple patients. "No matter what training seminar or continuing medical education course I went to, the Allergan people always said a vial was for multiuse," said Sandra Bledsoe, who operates Focus Medical Weight Loss & Spa. "Many patients only need 15 or 20 units at a time." "Allergan seminars have demonstrated multiple patient use of the product for years," said Las Vegas plastic surgeon Dr. Julio Garcia, who said he has attended the company's seminars. Garcia said doctors felt they could be safe if they used a new syringe and needle for each injection, which, even if against the rules, would result in sterile treatments. The problem comes when mistakes happen, said Dr. Joseph Niamtu, a Richmond, Va.-based cosmetic facial surgeon long active with the American Academy of Cosmetic Surgeons and the Cosmetic Surgery Foundation. "Someone inadvertently picks up a contaminated syringe and inoculates the entire vial," he said. That may sound familiar. Last year, health officials revealed that authorities investigating a cluster of hepatitis C cases had observed nurses at the Endoscopy Center's Shadow Lane clinic reusing syringes in a manner that contaminated single- use vials of medication. Nine hepatitis cases were linked to the practice, and more than 50,000 people were urged to get tested for blood-borne diseases. Medical officials say no cases of hepatitis C have been connected to Botox injections. Still, Dr. Ihsan Azzam, state epidemiologist for the Nevada State Health Division, said concerns about blood-borne diseases in relation to the administration of Botox can't be dismissed. He said discussions with some of the state's medical providers have made it clear to him that multipatient use of single-use Botox vials continues in Nevada. The Review-Journal also contacted providers who say the practice is ongoing. "I think we need to include use of Botox as a risk factor when we talk about hepatitis," Azzam said. He noted that after he sent a bulletin to physicians and other medical providers about injection safety in the wake of the hepatitis C crisis in Las Vegas, some providers who administered Botox in their practices were not supportive. In his directive, which echoes the position of the Centers for Disease Control and Prevention, he wrote: "Do not administer medications from single-dose vials to multiple patients or combine leftover contents for later use." He said a number of providers called him to say that they wouldn't follow the regulations because they knew how to safely administer Botox to multiple patients from a single-dose vial. "I was very surprised," Azzam said Thursday, adding he hopes state inspectors will catch those who refuse to abide by medical regulations. "Some seemed to be daring me to come after them." If caught, physicians' licenses would be at risk. Azzam said Botox providers told him it would not be possible to make a profit if the injection practices he supported were followed. "I followed the rules," Goldsmith said last week. "And it killed me financially." Goldsmith is asking the court that his lawsuit be certified as a class action, arguing that more than 100 doctors who invested in the product are affected nationwide, with their economic losses exceeding more than $5 million. In his lawsuit, Goldsmith said a 100-unit vial of Botox could cost him $1,000, but a patient treatment might only be $500. Because it is a single-use drug, the rest would then have to be thrown away. "You were losing money that way, not making it," Goldsmith said. "The patient didn't want to eat the cost." Goldsmith has had a run-in with the Nevada State Board of Medical Examiners, which last year subpoenaed some of his patient records. The board said it had received information that Goldsmith illegally dispensed compounded medications, dispensed medications without having a pharmacist on site, allowed clerks to dispense medications, and used human growth hormone on patients without meeting Food and Drug Administration criteria. Goldsmith has denied the allegations and, more than a year after the board's subpoena, no action has been taken. Garcia said he is following the rules regarding Botox injections, but knows that many in the medical community aren't doing so. Last year he wrote a letter to the state medical board saying patient safety could be compromised because spa personnel continue to inject Botox "with the doctor not present." That issue has been in the news lately, the result of recent attempts by the medical board to keep medical assistants from injecting Botox. That effort failed. "The possibilities of infection, given what is going on when it comes to injecting Botox by whomever, are terrifying," Garcia said. "We're not talking about 40,000 or 50,000 people. We're talking about hundreds of thousands of injections" in Southern Nevada. Tracy Jones, a Las Vegas saleswoman, said while she has been a frequent user of Botox, she generally doesn't know if she is the only one receiving Botox from a vial. "It's not something people ask," she said. Most medical providers are well aware that Botox, like any injectable medication, can be contaminated when drawn up into a syringe. To prevent contamination in his Botox injections, Niamtu, the Virginia facial surgeon, said he and his staff every day will draw up five sterile 20-unit syringes of Botox from a 100-unit vial. Though he said that may not be in accordance with CDC guidelines that say single-use vials cannot be used for more than one patient, Niamtu said he must walk a tightrope between the "practical and the optimal." He said "something will have to be done," if medical officials in other states become as aggressive in enforcing regulations as he believes they are in Nevada. "Doctors can't throw away that much medication, and patients aren't going to pay for the extra," Niamtu said. "Allergan will have to step up to the plate and make different quantities of the drug. It may cost them a little more." A new company called Dysport is manufacturing a similar product, and the competition could force Allergan to provide smaller dosage vials to physicians who want them, he said. "You can't have doctors worrying about breaking the law or guidelines or whatever," Niamtu said. The Review-Journal had little trouble finding medical providers who said they and their companies knowingly broke state and federal regulations. Medical assistants at two different spas said their owners only stopped multipatient use of single-use vials of Botox "until things quieted down" after the hepatitis outbreak was announced. "We just couldn't handle it financially," said one medical assistant who asked to remain anonymous. "We would have gone out of business." One business that seems to be going well in Las Vegas is known for throwing Botox parties. That's an ongoing phenomenon across the country where friends get together and drink champagne while their wrinkles are needled away. A phone call to inquire about the cost of a Botox party was greeted with this information: "It will be cheaper if all the partiers use the same vial." Find this article at: http://www.lvrj.com/news/botox-lawsuit-raises-issues-on- injections-64690212.html Copyright © Las Vegas Review-Journal, 1997 - 2008 Go Green! Subscribe to the electronic Edition at www.reviewjournal.com/ee/ .......................................................................... __________________________________________________________________________ Canada: Low risk of blood-borne virus through re-use of syringes in IV lines By Heather Polischuk, Leader-Post, Canada (17.10.09) REGINA - A safety review of the re-use of syringes in intravenous lines found the risk of contracting a blood-borne virus through the practice is "statistically negligible." The province-wide assessment, led by Chief Medical Officer Moira McKinnon and a team of experts, further concluded follow-up testing for patients isn’t required. The assessment was conducted after the Ministry of Health found out that health facilities in five Saskatchewan health regions - including a hospital in the Sun Country Health Region - had occasions in which previously used syringes were used to administer medication into IV lines. The practice was common until late 1997 when Health Canada advised against it. Besides Sun Country, re-use was reported in Cypress, Sunrise, Prince Albert Parkland and Prairie North health regions. In the Sun Country case, anesthetists in the operating room of Weyburn’s General Hospital occasionally injected part of a syringe into a patient’s IV tubing, then replaced the syringe’s needle with a new one and injected the remainder of the drug into another patient’s IV line. The practice was stopped immediately upon the region learning about it. There have been no reported cases of blood-borne virus (BBV) transmission due to syringe reuse in a Saskatchewan health facility, the Ministry of Health reported. McKinnon said the risk of BBV infection is one in one million for affected residents of four of the five health regions and about three in one million for the fifth, the Prairie North Health Region. "Even the higher of those risks is so low as to make further testing unnecessary," McKinnon said in a news release issued Friday morning. Although no one will have to undergo testing, provincial surveillance will be stepped up to quickly identify any possible connection between BBV infections and a particular health-care site or facility. The report is available online at www.health.gov.sk.ca. Anyone with questions or concerns can contact HealthLine at 1-877-800-0002. -with files from Pamela Cowan © Copyright (c) The Regina Leader-Post .......................................................................... __________________________________________________________________________ Developing countries swamped in healthcare rubbish: Growing mountains of medical waste threaten health in countries without proper disposal facilities Emerging Health Threats News (16.10.09) Half the world’s population could be at risk from exposure to mounting volumes of improperly disposed medical waste, according to a review published this month in Tropical Medicine and International Health. "The documented growth in and poor disposal of health care waste appears to represent a real threat to the health of at least 40… low and middle income nations," write Michael Harhay, from the University of Pennsylvania, USA, and colleagues. Some experts are wary of pinning down the number of people at risk because data are limited. But they admit the problem is growing. Hospitals and clinics around the world can generate up to 6 kg of hazardous waste per person per year. This can be anything from soiled dressings to diagnostic samples, body parts, and used needles. In many wealthy countries, hazardous medical waste is separated from rubbish and is disposed of using incinerators with emission-cleaning equipment. But low-income countries rarely have the tools to dispose of dangerous waste properly, leaving a reservoir of dangerous pathogens lurking in the environment. In October 2008 in Afghanistan, the by-products of a polio vaccination campaign that served 1.6 million people were thrown into a Kabul rubbish tip, causing "infectious injury" to people scavenging for re-usable items in the area. An investigation revealed that the country has no regulations to control the disposal of medical waste. At least 60 hospitals in the city have no access to incinerators and other tools that can dispose of it. To better understand how many people could be affected by poor waste management practices in low- and middle-income countries, Harhay and colleagues reviewed the available literature. Looking at 82 reports from 37 countries, they found that medical workers are under-trained in waste disposal, not provided with sufficient information, and have no access to systems that segregate medical rubbish. There is also widespread confusion over who is responsible locally for the sorting and disposal of medical waste, a task that is under-funded, they add. A black market of used medical products also exists in some countries. Earlier this year, 240 people developed hepatitis B in the Indian state of Gujarat after receiving injections from re-used syringes that had been sold on for profit. Research suggests that up to six million jabs are given annually using second-hand equipment in Indian health facilities. Six of the world’s most populated countries - China, India, Brazil, Pakistan, Bangladesh and Nigeria - have problems with the management of healthcare waste, according to the report. The authors say this puts around 50% of the global population at risk from the environmental, occupational, and public health consequences of improper disposal. "In almost all settings, it was reported that the volume of waste was increasing beyond management capacity," they write. As more low- and middle-income countries treat increasing numbers of people with chronic conditions, and as patients live longer, the problem will only grow further, they add. Ashok Shekdar, from the Nagpur Institute of Technology in India, agrees the problem is growing, but says it is difficult to make predictions about the number of people affected as reliable data are scarce. He does not believe that half the world’s population is at risk. In countries with a growing economy, such as India, there is no shortage of funds for healthcare waste management, explains Shekdar. But if these processes are to work effectively, he says, they must be part of a wider framework for general garbage collection run by local authorities - services that are sometimes neglected in poorer regions. In countries with limited resources, the WHO recommends that medical waste is incinerated. But they recognise this is not ideal, explains Harhay, as the mix of needles, plastics and other materials can release harmful chemicals into the atmosphere and leave piles of ash made up of highly condensed pollutants. These toxic by-products can get into homes and water supplies. Exposure to them can cause health problems such as asthma, chronic obstructive pulmonary disease, and mercury poisoning, adds Harhay. In the review, his team found that developing countries reported their incinerators to be broken down or antiquated, prompting medical workers to throw healthcare waste into municipal dumps. In some cases, waste was openly burned and buried on site, they explain. Around 15-20% of healthcare waste is made up of items harbouring infectious agents, explains Shekdar. Incineration is not the only option to make it safe, he says. It may be more appropriate to disinfect this portion of the waste and then dispose of it together with other rubbish. Harhay believes that better sorting and recycling of re-useable bits of waste can help to reduce the overall volume of medical rubbish. "But this is not often possible without overall waste management systems, such as private companies that will handle disposal," he says. Just burning the rubbish in an incinerator is not the answer, explains Harhay . A better solution lies in changing the way health care is delivered, so that less dangerous waste is generated in the first place. "What we really need is new and more efficient tools, such as needleless modes of drug delivery, forms of vaccines that are inhalable diagnostics that can use salvia rather than the need to draw blood," says Harhay. "Innovation across the board is the only true answer." .......................................................................... __________________________________________________________________________ Global: Handwashing Program Targets Childhood Deaths in Africa By Ricci Shryock, VOA News, USA (15.10.09) Dakar It is Global Handwashing Day, marked to encourage children all over the world to use soap when washing their hands. The push is part of an effort to reduce diseases such as diarrhea, which causes 415,000 deaths each year in West and Central Africa. In West and Central Africa 16 percent of child deaths are caused by diarrhea, according to the regional U.N. Children's Fund. UNICEF regional director in Senegal Gianfranco Rotigliano says the Global Handwashing event highlights disease prevention. "We have a very, low, low sanitation level, so we have a series of conditions in the region that are unfortunately leading to this kind of situation," he said. Diarrhea is the third cause of death in West and Central Africa, which is responsible for 30 percent of the world's deaths of children under the age of five. Handwashing with soap can significantly reduce disease, says UNICEF Executive Director Ann M. Veneman. "Health experts suggest that if people do this regularly, the incidence of diarrhea can be reduced by as much as 40 percent," she said. But the region's water, sanitation and hygiene specialist for UNICEF, Jane Bevan, says families who live in the area do not have always access to clean water. "It is often a problem and we have to do as best we can, and quite often we are supporting schools to develop water supplies as well and also looking at alternatives solutions, using ash," she said. As part of its strategy to combat diarrhea, UNICEF hopes to provide more oral rehydration therapy treatment, vitamin-A supplements and improved water resources to populations that need it, says Veneman. "An estimated 2.5 billion people in the world are still not using improved sanitation facilities," she said. More than 80 countries are taking part in Global Handwashing Day. .......................................................................... __________________________________________________________________________ USA: Florida Hospital Confirms Patients Infected by Reused IV Bags Newsinferno.com (15.10.09) Earlier this month we wrote about yet another case of potential hospital- spread hepatitis that was discovered in Fort Lauderdale, Florida. Now, NBC Miami says that some Broward General Medical Center patients received reused IV bags and have tested positive for some infectious diseases. Nurse Qui Lan violated infection-control protocols that, according to the Sun Sentinel previously, her staff said occurred with Lan’s full knowledge. Lan put over 1,800 patients at risk with her shoddy infection practices when administering saline solution to patients who were at Broward undergoing cardiac chemical stress tests. Broward said it is not clear how those who have tested positive for infectious diseases originally became infected. "Based on the current Broward County disease prevalence data, we expect some of the screening results to be positive for infection exposure and we will need to conduct an individual evaluation to help determine the origin," said Dr. David Droller, head of Epidemiology and Infectious Diseases at Broward, in a statement, quoted NBC Miami. "At this time, we will make certain the individual receives appropriate care and follow-up," added Dr. Droller. Broward is offering free testing for HIV/AIDS and Hepatitis B and C to those patients who underwent stress tests at its facility, reported NBC Miami; to date, preliminary results have been received back on testing conducted on 254 former patients. All three pathogens are blood borne in nature. Police spokesman Sgt. Frank Sousa said the hospital requested the investigation of Qui Lan, 59, said the Sun Sentinel previously. Officials at the hospital said they learned that Lan was reusing catheter tubing and saline bags on multiple patients, said the Sun Sentinel. The tubing and bags were meant for one-time patient use during the cardiac chemical stress tests. NBC Miami said Lan handled IVs during cardiac stress testing since 2004. Lan has an active Florida nursing license and a clean record, said the Sun Sentinel last week. She was suspended on September 8 and resigned on the 9th; the hospital reported her to the Florida Board of Nursing, said the Sun Sentinel, which added that authorities believe Lan has left the United States. James Thaw, Broward’s CEO, told the Sun Sentinel that the hospital notified patients and arranged for off-site testing in the month before it notified the police. This is the most recent in a string of similar incidents in which medical supplies have been tampered with or used in ways that expose countless patients to disease. We have been following the scandals with the Department of Veterans Affairs’ centers in three cities in which colonoscopy and endoscopy equipment were reused without being properly sanitized. To date, noted the Sun Sentinel some 50 veterans have tested positive for blood borne pathogens. Most recently, a surgical tech who worked out of two Colorado hospitals and hospitals in New York and Texas was charged and sentenced after it was discovered she was swapping syringes containing the narcotic pain reliever Fentanyl with saline after injecting herself. She has tested positive for hepatitis. .......................................................................... __________________________________________________________________________ BMTS Furthers Development of Its Demolizer(R) Home Unit Market Wire (14.10.09) Author : Biomedical Technology Solutions Holdings, Inc. Category : Press Release ENGLEWOOD, CO -- 10/14/09 -- Biomedical Technology Solutions Holdings, Inc. ("BMTS" or the "Company"; www.bmtscorp.com) (OTCBB: BMTL) is pleased to announce significant developments on the commercialization of its Demolizer® Home unit, a safe and environmentally friendly biomedical waste disposal device designed to enable diabetics and others using syringes at home to safely destroy their sharps waste and dispose of it in the regular trash or send it to a BMTS' recycling partner. Through treatment in the Demolizer® Home unit, used syringes and lancets are sterilized and grossly melted so that they cannot be reused and no longer pose a risk of infection. BMTS' engineers have neared conclusion of the design aspects of the device and have progressed it from conception to bench testing and are implementing the patent process. In 2006, an estimated 8 million people in the U.S. administered 3 billion injections at home annually. Most of these contaminated syringes end up in the ordinary municipal waste stream posing a sizeable risk to public health and sanitation workers. With the changing demographics, the number of self-administered injections in the U.S. is expected to grow 165% over the next ten years. That translates to 21 million people administering 8 billion injections by 2016. Don Cox, President and CEO of BMTS, explains the significance of the Home unit. "Many states are starting to focus on this growing public health and environmental problem. California and Massachusetts have enacted new laws prohibiting landfill disposal of home-generated sharps. The problem facing the states is that there really is not a viable, low-cost and environmentally sound solution to address this emerging concern. We are designing the Demolizer® Home unit to fill this important market gap and we are very excited about our role in preventing a significant portion of the over 3 billion contaminated syringes from either being transported through the mail or ending up untreated in landfills in our communities." Custom designed to meet the needs of today's nine million people in the U.S. that regularly self-administer injections in the home to treat diabetes and other diseases, the Demolizer® Home unit provides a safe and environmentally friendly alternative to traditional mail-back programs at a significant cost savings. While pressure to reduce healthcare costs continues to mount, the expected cost for treatment and disposal using the Demolizer® Home unit is approximately 20% of the cost of mail back solutions, saving the average diabetic over $250 per year. The unit's compact, countertop design, low energy demands and dry heat technology fit well within any household by converting sharps waste to common trash at the push of a button. In addition to its convenience and cost savings, the Demolizer® Home unit delivers environmental and safety benefits including a recyclable end product and a reduction in the volume of untreated syringes in the U.S. mail system and in the municipal waste stream. It also significantly minimizes the ancillary demand on fossil fuels and toxic emissions associated with vehicles on the road transporting this dangerous waste. The underlying patented technology, the Demolizer® II commercial point of care system, is approved or meets requirements for treatment in 47 states having undergone review by as many as 78 governmental agencies, paving the way for broad recognition in an increasingly restrictive regulatory environment. The Demolizer® Home unit is being designed to the same sterilization standards as the commercially successful Demolizer® II. Dr. James Marsden, Kansas State University's Regents Distinguished Professor and member of BMTS' Advisory Board, explains "We are very excited to be working with BMTS on this important technology. The Demolizer® Home unit will deliver high level sterilization (over 99.9999% effective) of even the most resistant organisms and all of the important bloodborne pathogens of interest from a public health perspective. Broad scale adoption of this technology would have a significant impact on the safety of our communities and environment." Sanitary workers, family members and the public in general benefit from a real solution to the enormous public health challenge associated with current transporting and land filling of most of the over 3 billion injections used at home in the US today. To meet continually escalating demand to render sharps waste sanitary and safe for regular trash at home or recycling, BMTS' one-of-a-kind, patented Demolizer® Home unit will continue to meet the needs of our aging population and the estimated 21 million people who will administer eight billion injections at home by 2016, while promoting public health safety benefits. The Company expects to launch the Home unit in early 2010. About Biomedical Technology Solutions Holdings, Inc. Biomedical Technology Solutions Holdings, Inc., located in Englewood, Colorado sells the Demolizer® II through its wholly owned subsidiary Biomedical Technology Solutions, Inc. BMTS' patented Demolizer® Technology converts infectious biomedical waste into non-infectious material. BMTS' products provide biomedical waste treatment solutions for the over 1,000,000 low to medium volume medical waste generators in the US and a global market five times larger than the US. For more information, visit our investor relations page at www.bmtscorp.com. About the Demolizer® II The Demolizer® II is the GREEN alternative to biomedical waste disposal. The device is the only patented, portable, and self-contained system able to process both sharps and typical red bag biomedical waste onsite. The processed waste is rendered sterile and discarded as common trash eliminating up to 100% of the cost associated with its disposal. The Demolizer® II meets or exceeds all EPA and CDC guidelines and is approved or meets treatment requirements in 47 states after review by 78 governmental agencies. The device uses no chemicals or liquids, plugs into a normal outlet through a surge protector, and automatically records and prints state required documentation. The Demolizer® II provides a safer, more environmentally GREEN method for biomedical waste disposal. Safe Harbor for Forward-Looking Statements The statements contained in this press release may include certain projections and forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended and Section 21E of the Securities Exchange Act of 1934, as amended. Such statements involve a number of risks and uncertainties. Such statements reflect the Company's current views with respect to future events and financial performance. No assurances can be given however, that these events will occur or that such expectations will be achieved and that actual results could differ materially from those described. Actual results of future operations of Biomedical Technology Solutions Holdings, Inc. may differ materially from those indicated by these forward-looking statements as a result of various important factors. Copyright © 2008 Market Wire. All rights reserved. .......................................................................... __________________________________________________________________________ Puerto Rico: PR group tests syringe vending machine for addicts The Associated Press (13.10.09) SAN JUAN, Puerto Rico -- A needle exchange program in Puerto Rico is testing a vending machine that provides drug users with clean syringes after-hours to fight the spread of HIV and hepatitis C. Dr. Jose Vargas Vidot is the founder of Community Initiative, the U.S. island territory's only needle-exchange group. He says a single machine will make clean syringes available at night outside the group's office in Hato Rey. Vargas said Tuesday that drug counseling offices that distribute syringes are open only during daylight hours. The vending machine program targets young addicts reluctant to seek help. Drug users can get syringes, cookers, cotton filters, gauze and sterile water to prepare drugs for injection by inserting a special card. .......................................................................... __________________________________________________________________________ USA: Nurse reused IV supplies - Patients of Broward General nurse test positive for diseases- It's unknown if her unsafe practices caused the infections By Bob LaMendola, South Florida Sun Sentinel (13.10.09) An undisclosed number of patients at Broward General Medical Center who were treated by a nurse who re-used intravenous supplies have tested positive for infectious diseases, the hospital said Tuesday. Officials said it's unknown if those patients were infected because of registered nurse Qui Lan's unsafe practices, or were infected previously or by some other means. An estimated 1,851 patients potentially were exposed to blood-borne diseases HIV, hepatitis C and hepatitis B while getting chemical stress tests for their hearts from January 2004 to early September of this year. Hospital officials said Lan has admitted that while giving the tests she reused IV bags and tubing that was supposed to be discarded after every patient. Patients who received regular treadmill stress tests were not exposed. Broward General is offering to test all those patients for the diseases and, so far, results are back on 254. Hospital spokeswoman Cathy Meyer declined to disclose the number of positive results, saying that in a community with tens of thousands of HIV and hepatitis patients, it's inevitable some will test positive, even if the hospital is not the source. "There are going to be positive results. As of now, it's too preliminary to give results," Meyer said. "It's too soon to tell what caused the infections." The Fort Lauderdale hospital is phoning those who tested positive and bringing them in for more tests in hopes of determining how they were infected, as well as counseling them on their diseases, Meyer said. As of Monday, only 533 of the 1,851 were confirmed to have received letters from the hospital urging them to be tested. One infectious disease expert said it may be impossible to definitively prove whether the infections were caused by Lan's actions. Patients with those diseases often show no symptoms for years and may be exposed in many ways, said Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University. "It can be hard to resolve," Schaffner said. The Department of Veterans Affairs has been dealing with the same problem while investigating the use of non-sterile colonoscopy equipment at Miami's VA hospital and two others. So far, 50 veterans have tested positive for blood-borne illnesses. Fort Lauderdale police are conducting a criminal investigation of Lan, who admitted she knew it was wrong to reuse the IV equipment. Her attorney, Allison Gilman, could not be reached for comment with calls and e-mails. Lan, 59, grew up in Malaysia, got her nursing degree in London and came to the United States for a nursing job in 1976, according to personnel records released Tuesday by Broward Health, the tax-assisted entity that owns Broward General. She came to Broward County in 1982 as a traveling nurse and since then worked at several local hospitals before getting hired by Broward General in July 2001. Her file shows no disciplinary action. She ended her 37-year nursing career Sept. 6 after a tipster reported seeing her engage in unsafe practices and she resigned to take "retirement," records show. By then she was working part time earning $37.21 per hour. For more information about the testing, go to www.browardhealth.org/patientnotice or call 800-545-5716. Staff Writer Diane Lade contributed to this report. Copyright © 2009, South Florida Sun-Sentinel .......................................................................... __________________________________________________________________________ USA: Investigation Of Contaminated Heparin Syringes Highlights Medication Safety Issues ScienceDaily (13.10.09) ScienceDaily (Oct. 13, 2009) - An outbreak of bloodstream infections appears to have been caused by the contamination of pre-filled heparin and saline syringes made by a single company, according to a report in the October 12 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The subsequent investigation revealed that the company was not in compliance with safety regulations and identified challenges and areas for improvement in medication monitoring systems. Between October 2007 and February 2008, the Centers for Disease Control and Prevention (CDC) received reports of clusters of bloodstream infections caused by the bacteria Serratia marcescens at health care facilities in several states, according to background information in the article. Based on initial information from facilities in Texas and Illinois, the investigation into the cause of the outbreak focused on syringes pre-filled with the blood thinner heparin and saline from one company (company X). David Blossom, M.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues report that the company was able to provide records for other facilities that had received the same syringes. The CDC contacted these recipients and posted requests on e-mail distribution lists to solicit additional infection case reports. Culture specimens were taken from unopened pre-filled heparin and saline syringes at facilities reporting infections as well as at company X. A total of 162 S. marcescens bloodstream infections in nine states were reported among patients at facilities using syringes from the same company. Cultures of unopened pre-filled heparin and saline syringes manufactured by this company grew S. marcescens. Of 83 blood samples that contained S. marcescens submitted to the CDC from seven states, 70 (84 percent) contained bacteria genetically related to that grown from the pre-filled syringes. "To ensure the sterility of manufactured medical products, companies must adhere to the U.S. Food and Drug Administration's Good Manufacturing Practices [GMPs], a comprehensive body of regulations that govern all aspects of production," the authors write. "An onsite inspection of the manufacturer by the FDA revealed poor compliance with the FDA's GMPs and quality system regulations. Within days of this inspection, company X discontinued production of all medical products." The company also issued a voluntary national recall of the pre-filled syringes. "Close collaboration among federal agencies, public health authorities and clinicians was critical to the identification of the cause of this outbreak," the authors conclude. "In the course of the investigation, we also identified several challenges to medical product tracking that should be addressed promptly so that disease outbreaks caused by exposure to contaminated medications can be dealt with more efficiently in the future." For example, a large number of distributors acted as intermediaries between the manufacturer and the health care facilities that used the products, and none of the syringes bore company X's name on the label, but rather had the names of subsidiaries or different companies. In addition, some batches of the syringes were contaminated whereas others were not; this intermittent nature made identifying the source of the outbreak more difficult. This suggests that investigations of potential contamination must include both epidemiologic and laboratory components, since initial laboratory tests may prove inconclusive. ( Editorial: FDA Must Be Given Tools to Ensure Drug Safety "The analysis accompanying this commentary describes a serious contamination of heparin marketed in pre-filled syringes," writes William K. Hubbard, B.A., M.A., former FDA associate commissioner, in an accompanying editorial. "Subsequent FDA investigation determined that the manufacturer had failed to adhere to the agency's quality control requirements. But an even more notorious recent case of a drug manufacturing problem was that of imported heparin believed to have contributed to dozens of deaths and an unknown number of injuries." "We simply must, as a nation, recognize that we cannot reverse this trend toward globalization, that the solution to a safe drug supply is a strong FDA, not reliance on foreign governments," Mr. Hubbard concludes. "Throughout the 20th century, the FDA was a major contributor to our overall societal 'safety net' and came through for us many times when challenged with threats to our food and drug supply. Now, when we need them more than ever, we must be there to help the FDA," through measures such as increased funding and staffing. Journal references: David Blossom; Judith Noble-Wang; John Su; Stacy Pur; Roy Chemaly; Alicia Shams; Bette Jensen; Neil Pascoe; Jessica Gullion; Eric Casey; Mary Hayden; Matthew Arduino; Daniel S. Budnitz; Isaam Raad; Gordon Trenholme; Arjun Srinivasan; for the Serratia in Prefilled Syringes Investigation Team Group. Multistate Outbreak of Serratia marcescens Bloodstream Infections Caused by Contamination of Prefilled Heparin and Isotonic Sodium Chloride Solution Syringes. Arch Intern Med, 2009; 169 (18): 1705-1711 [link] William K. Hubbard. Can the Food and Drug Administration Ensure That Our Pharmaceuticals Are Safely Manufactured? Arch Intern Med, 2009; 169 (18): 1655-1656 [link] Adapted from materials provided by JAMA and Archives Journals. Syringes Highlights Medication Safety Issues. ScienceDaily. Retrieved October 21, 2009, from http://www.sciencedaily.com/releases/2009/10/091012225819.htm __________________________________________________________________________ _____________________________________*____________________________________ __________________________________________________________________________ * SAFETY OF INJECTIONS brief yourself at: www.injectionsafety.org A fact sheet on injection safety is available at: http://www.who.int/mediacentre/factsheets/fs231/en/index.html * Visit the WHO injection safety website and the SIGN Alliance Secretariat at: http://www.who.int/injection_safety/en/ Download the latest injection safety Best Practices review at: http://www.uqconnect.net/signfiles/Files/BestPracticesJul2003.pdf Use the Toolbox at: http://www.who.int/injection_safety/toolbox/en/ Subscribe or un-subscribe by email to: sign@uq.net.au, sign@who.int or on subscribe online at: http://www.who.int/injection_safety/sign/en/ Get SIGN files on the web at: http://www.uqconnect.net/signfiles/Files/ get SIGNpost archives at: http://www.uqconnect.net/signfiles/Archives/?M=D 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@who.int _____________________________________*____________________________________ __________________________________________________________________________ SIGN meets annually to aid collaboration and synergy among SIGN network participants worldwide. The 2009 SIGN annual meeting will be held from 30 November to Wednesday 2 December 2009 at WHO Headquarters in Geneva Switzerland. The PQS (performance Quality and Safety) consultative meeting with the industry, will be held back to back with the SIGN meeting on 3rd and 4th December 2009. Get the final report of the SIGN Meeting 2008, Moscow, Russian Federation [2.36Mb] at: http://www.who.int/injection_safety/2008MeetingReport.pdf Many SIGN files can be opened in Acrobat Reader. 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Please subscribe by sending an email to: sign@who.int _____________________________________*____________________________________ 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. http://www.uq.edu.au __________________________________________________________________________