*SAFE INJECTION GLOBAL NETWORK* SIGNPOST *SAFE INJECTION GLOBAL NETWORK* Post00506 IPCAN 2009 + MDV + Abstracts + News 29 July 2009 CONTENTS 1. 1st African Congress on Infection Prevention Control 2. RFI: Multidose vials: Vaccines 3. Abstract: Sharps management and the disposal of clinical waste 4. Abstract: Occupational transmission of bloodborne diseases to healthcare workers in developing countries: meeting the challenges 5. Abstract: Laboratory-acquired infections 6. Abstract: Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting 7. Abstract: Seroepidemiology of hepatitis C antibodies among dentists and their self-reported use of infection control measures 8. Abstract: Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study 9. Abstract: How to protect yourself after body fluid exposure 10. Abstract: Circumstances surrounding occupational blood exposure events in the National Study to Prevent Blood Exposure in Paramedics 11. Abstract: "Antibiotics are not automatic anymore"--the French national campaign to cut antibiotic overuse. 12. Abstract: Outcomes of early switching from intravenous to oral antibiotics on medical wards 13. Abstract: Pain control in local analgesia 14. Abstract: Blunt needles for the reduction of needlestick injuries during cesarean delivery: a randomized controlled trial 15. Abstract: Perceptions, attitudes, and behavior towards patient hand hygiene 16. Abstract: Nurse Satisfaction Using Insulin Pens in Hospitalized Patients 17. Abstract: Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007 18. Abstract: A population-based case-control study on viral infections and vaccinations and subsequent multiple sclerosis risk 19. Abstract: Impact of Hepatitis B Vaccination in Children Born to HBsAg- Positive Mothers: a 20-year Retrospective Study 20. Abstract: Prion safety of transfusion plasma and plasma-derivatives typically used for prophylactic treatment 21. Abstract: Pathogen reduction of blood components 22. Abstract: Fresh-frozen plasma, pathogen-reduced single-donor plasma or bio-pharmaceutical plasma? 23. Abstract: Processing loaner instruments in an ambulatory surgery center 24. Abstract: Transcutaneous immunization by lipoplex-patch based DNA vaccines is effective vaccination against Japanese encephalitis virus infection 25. Abstract: Bacterial contamination of stethoscopes in pediatric units at a university hospital 26. Abstract: The surgical mask: are new tests relevant for OR practice? 27. No Abstract: Surgical preparation solutions and preoperative skin disinfection 28. No Abstract: Current opinions on the role of pathogen reduction technology in improving the viral safety of blood and derivatives 29. News - India: Hepatitis B threat looms large - USA: Doctor tied to hepatitis C outbreak deemed fit for hearing - Philippines: Seller of fake vaccines arrested: OFW dies from A(H1N1) virus - USA: UW hospital warns patients of possible disease exposure - USA: Vets Affected by VA Hospital Errors to File Claims - USA: Second Colorado Facility Linked to Hepatitis C Outbreak - USA: House Passes Spending Bill; Amendment To Block Removal Of Needle Exchange Funding Ban Defeated - India: Bill Gates Wins Indira Gandhi Prize in India - India: Toxic biomedical waste being burnt on hospital premises - USA: Unsafe Injections Put Patients at Risk for Hepatitis and HIV: Health Department Won't Release Name of Doctor's Office - India: Azad announces rewards for ‘whistleblowers’ to fight fake drugs - USA: Hundreds may have been pricked with used needle - USA: A malfunction has many worried about blood borne diseases - Africa: Branson Proposes Public Health Agency for Afric - Canada: Review blames old habits for reuse of dirty syringes in Alberta hospital This edition of SIGNpost is located at: http://uqconnect.net/signfiles/Archives/SIGN-POST00506.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/ Revised injection safety assessment tool: TOOL C [pdf 1.78Mb] http://www.who.int/injection_safety/Injection_safety_final-web.pdf 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/ * Get SIGN files on the web at: http://www.uqconnect.net/signfiles/Files/ * SIGNpost archives: http://www.uqconnect.net/signfiles/Archives/?M=D Get the final report of the SIGN Meeting 2008, Moscow, Russian Federation [2.36Mb] at: http://www.who.int/injection_safety/2008MeetingReport.pdf __________________________________________________________________________ _____________________________________*____________________________________ 1. 1st African Congress on Infection Prevention Control __________________________________________________________________________ From: "IPCAN 2009 Conference" Subject: 1st African Congress on Infection Prevention Control - 21 - 23 September 2009, Speke Resort, Kampala, Uganda Dear Colleague Below is the flyer for the above conference which includes program topics. This conference is supported by WHO, IFIC and WFHSS and will be the first conference in the Infection Prevention Control field to be held in Africa. Please note that the closing date for submission of abstracts via the web- site www.ipcan2009.co.za is 31 July 2009 and the early bird registration will close on 28 July 2009. Please register now to avoid disappointment. Please feel free to contact me for any additional information. _________________________________________________________________________ 1st African Congress On Infection Prevention Control - 2009 Hosted By Infection Prevention Control African Network (Ipcan) 21 - 23 September 2009 at Speke Resort Kampala * Registration can be done by fax - +27 86 570 8231 / from Uganda 010 27 86 570 8231 * There is a $100 prize for the best free paper * The provisional programme Topics - Infection Prevention & Control in Africa - Emerging Infectious Diseases: IPC implications - Occupationally acquired diseases - Water as a vector for infection: concerns in Africa - Blood borne virus transmission: safety aspects - The World of sterilization of medical devices - The impact of HIV on IPC programmes in Africa. - The role of copper in IPC- looking into the future - Community based IPC, rituals and practice - TB containment guidelines: can these be implemented in Africa? - Transfer of technologies to manufacture IPC technologies in Africa - Monitoring & Evaluation: Getting it right? - Education Programmes in IPC: what is happening in Africa - Bundling: a new concept in IPC management - Managing Healthcare Waste - What is new in phlebotomy? WHO draft guidelines - Healthcare associated infections: current situation in Africa * Invited speakers from - World Health Organisation - International Federation of Infection Control - World Federation of Hospital Sterile Supplies Please visit the website at: http://www.ipcan2009.co.za __________________________________________________________________________ _____________________________________*____________________________________ 2. RFI: Multidose vials: Vaccines Crossposted from Technet21.org with thanks __________________________________________________________________________ From: eggersr Subject: Are there vaccines that have to be discarded in less than 6 hours after opening? In the course of the revision of the WHO Multi-dose Vial Policy (MDVP) we came across the question if there were any vaccines in multidose vials that had to be discarded less than 6 hours after having been opened. Some package inserts seem to indicate this, but it is not clear whether it would deteriorate greatly or become dangerous if aseptic technique was applied and the vaccine kept under proper cold chain and storage conditions. I would be interested if such vaccines existed and what scientific data there is to back the statement. Rudi Eggers __________________________________________________________________________ _____________________________________*____________________________________ 3. Abstract: Sharps management and the disposal of clinical waste __________________________________________________________________________ Br J Nurs. 2009 Jul 23-Aug 4;18(14):860-4. Sharps management and the disposal of clinical waste. Blenkharn JI. Dangerous errors in clinical waste management continue to occur and inappropriate items find their way into clinical waste sacks that are not designed to hold sharp or heavy items, or fluids. Although great attention is given to the safe use of sharps, needles still find their way into waste sacks instead of a sharps bin. * Sharps injuries among ancillary and support staff, and waste handlers working in the disposal sector, can occur at a rate greater than for health-care staff. * Blood and body fluid exposures from carelessly packaged clinical waste are similarly common, with almost 100% of waste handlers having blood splashes on their clothing within four hours of starting a shift. Blood splashes are also common on the outside surfaces of sharps bins and on the frames supporting clinical waste sacks. Using forensic techniques, blood residues invisible to the naked eye can be detected on all surfaces of most sharps bins and on the bench top, walls and floor where the bins were positioned. Care is required when disposing of clinical waste, to protect and maintain the immediate environment from contamination, and to ensure the safety of those who come into contact with waste as it passes along the disposal chain. __________________________________________________________________________ _____________________________________*____________________________________ 4. Abstract: Occupational transmission of bloodborne diseases to healthcare workers in developing countries: meeting the challenges __________________________________________________________________________ Hosp Infect. 2009 Aug;72(4):285-91. Occupational transmission of bloodborne diseases to healthcare workers in developing countries: meeting the challenges. Lee R. Nuffield Centre for International Health and Development, Leeds, UK. Healthcare workers have increased chance of acquiring bloodborne pathogens through occupational exposure in developing countries due to a combination of increased risk and fewer safety precautions. As loss of workers can seriously undermine developing health systems, it is important that risks are minimised. A literature search was conducted to investigate the risks of transmission of three pathogens: human immunodeficiency virus, hepatitis B and hepatitis C viruses; and to identify factors that influenced the risk with reference to developing countries. There are many difficulties faced by developing countries in minimising the risk of occupational exposure. Efforts have been made to address the problems both on international and national levels. It is imperative that all healthcare workers are protected in order to prevent the loss of such a crucial component of developing healthcare systems. __________________________________________________________________________ _____________________________________*____________________________________ 5. Abstract: Laboratory-acquired infections __________________________________________________________________________ Clin Infect Dis. 2009 Jul 1;49(1):142-7. Laboratory-acquired infections. Singh K. Department of Pathology and Infectious Diseases, Rush University Medical Center, Chicago, Illinois 60612, USA. Kamaljit_Singh@rush.edu Laboratory-acquired infections due to a wide variety of bacteria, viruses, fungi, and parasites have been described. Although the precise risk of infection after an exposure remains poorly defined, surveys of laboratory- acquired infections suggest that Brucella species, Shigella species, Salmonella species, Mycobacterium tuberculosis, and Neisseria meningitidis are the most common causes. Infections due to the bloodborne pathogens (hepatitis B virus, hepatitis C virus, and human immunodeficiency virus) remain the most common reported viral infections, whereas the dimorphic fungi are responsible for the greatest number of fungal infections. Because of the increasing attention on the role of the laboratory in bioterrorism preparation, I discuss the risk of laboratory-acquired infection with uncommon agents, such as Francisella tularensis and Bacillus anthracis. Physicians who care for a sick laboratory worker need to consider the likelihood of an occupationally acquired infection while advising exposed laboratory workers about postexposure prophylaxis. In addition, physicians should be aware of the importance of alerting the laboratory if infection with a high-risk agent is suspected. __________________________________________________________________________ _____________________________________*____________________________________ 6. Abstract: Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting __________________________________________________________________________ Int Arch Occup Environ Health. 2009 Jul 22. Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting. Wicker S, Rabenau HF. Occupational Health Service, Hospital of the Johann Wolfgang Goethe- University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany, Sabine.Wicker@kgu.de. PURPOSE: Exposures to bloodborne pathogens pose a serious risk to dental healthcare workers (DHCW). Despite improved methods of preventing exposures like needlestick injuries (NSI), occupational exposures still continue to occur. The purpose of this study was to evaluate the incidence of occupational exposures to patient body fluids among German DHCW, to assess the rate of reporting of such incidents, and to evaluate the association of various factors with these exposures. METHODS: Data was obtained through an anonymous questionnaire. RESULTS: Our study confirms that occupational skills are an important factor concerning NSI. It turned out that dental students (0.74 NSI p. a.) had nearly twice the number of NSI compared with dentists with more or less than 10 years working experience (0.42, 0.49 NSI p. a., respectively, P < 0.0001). Overall, 54.3% (n = 144/265) of respondents had sustained at least one NSI in their professional life. Only 28.5% of injured dental students and DHCW reported all of their NSI, the main reason (19.1%) for not reporting NSI was little or no perception of risk on behalf of the respondent. One-fourth of respondents were not wearing a mask and 55.6% were not wearing protective goggles during their last occupational exposures. CONCLUSIONS: Occupational exposure to blood or body fluids is a common problem among DHCW and dental students. Measures must be adopted by official institutions, public health service, occupational health association and universities in order to reverse this situation. __________________________________________________________________________ _____________________________________*____________________________________ 7. Abstract: Seroepidemiology of hepatitis C antibodies among dentists and their self-reported use of infection control measures __________________________________________________________________________ Community Dent Health. 2009 Jun;26(2):99-103. Seroepidemiology of hepatitis C antibodies among dentists and their self- reported use of infection control measures. Ashkenazi M, Fisher N, Levin L, Littner MM. Department of Pediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel. malka.ashkenazi@gmail.com OBJECTIVES: To determine the prevalence of hepatitis C virus (HCV) antibodies among dentists graduated from various countries and assess the use of infection control measures in their dental practice. RESEARCH DESIGN: The study included 301 Israeli dentists who attended an annual dental conference. Participants filled out a structured questionnaire regarding demographic (age, gender, number of siblings, number of children) and occupational characteristics. Venous blood was examined for presence of HCV antibodies by enzyme immunoassay and confirmed by a third generation line immunoassay, which assesses antibodies to HCV-core antigens (INN-LIA HCV Ab III update, 100% sensitivity, 100% specificity). RESULTS: The prevalence of HCV antibodies among Israeli dentists was 1/301 (0.33%), similar to the prevalence range (0.1-0.5%) among the general Israeli population. The studied population included dentists (30.6%) who immigrated from Asia, Eastern Europe and the former USSR, where HCV prevalence ranges from 3.1% to 26.5%. Dentists routinely used gloves (99.6%), gown (93.3%), autoclaves (90.3%), dry heat (29.1%) and mask (81%). Dentists who graduated after 1985 used a mask or gown significantly more often than dentists who graduated before 1985 (p < 0.001 and p = 0.004, respectively). CONCLUSION: It seems that dentists who usually adhere to basic infection control measures are not at an increased risk for HCV. __________________________________________________________________________ _____________________________________*____________________________________ 8. Abstract: Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study __________________________________________________________________________ BMC Infect Dis. 2009 May 29;9:78. Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study. Zafar A, Habib F, Hadwani R, Ejaz M, Khowaja K, Khowaja R, Irfan S. Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi, Pakistan. afia.zafar@aku.edu BACKGROUND: Accidental exposure to blood and body fluids is frequent among health care workers. They are at high risk of nosocomial transmission of blood borne pathogens due to injuries caused by used sharps. We are reporting impact of surveillance and educational program on the rate of needle stick injuries among health care workers at a tertiary care hospital in Pakistan. METHODS: At Aga Khan University Hospital sharp injuries are reported to infection control office. To reduce these incidents a quality improvement project was inducted in the year 2005. Health care workers were educated; surveillance data from 2002 to 2007 was analyzed and compared with various risk factors. RESULTS: During study period 1382 incidents were reported. Junior doctors sustained highest number of injuries (n = 394; 28.5%) followed by registered nurses (n = 283; 20.4%). Highest number of incidents was reported during blood collection (19%). An increasing trend was observed in the pre intervention years (2002-04). However noticeable fall was noted in the post intervention period that is in year 2006 and 2007. Major decline was noted among nurses (from 13 to 5 NSI/100 FTE/year). By relating and comparing the rates with various activities directly linked with the use of syringes a significant reduction in incidents were found including; hospital admissions (p-value 0.01), surgeries and procedures performed (p = 0.01), specimens collected in the laboratory (p = 0.001) and patients visits in clinics (p = 0.01). CONCLUSION: We report significant reduction in needle stick injuries especially during post intervention study period. This is being achieved by constant emphasis on improving awareness by regular educational sessions, implemented as a quality improvement project. __________________________________________________________________________ _____________________________________*____________________________________ 9. Abstract: How to protect yourself after body fluid exposure __________________________________________________________________________ Nursing. 2009 May;39(5):22-8; quiz 28-9. How to protect yourself after body fluid exposure. Davenport A, Myers F. Scripps Mercy Hospital, San Diego, CA, USA. An accidental exposure to blood or other potentially infectious material (OPIM) such as cerebrospinal or pleural fluid can be a life changing experience. Among the bloodborne and OPIM pathogens are HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). Postexposure prophylaxis (PEP) exists for HBV and HIV, but not for HCV, which is the most common chronic bloodborne infection in the United States; approximately 3.2 million persons are chronically infected. Fortunately, however, exposure to blood or OPIM usually doesn't translate into disease transmission. In this article, we'll discuss how you can minimize the risk of disease transmission if you or a coworker is accidentally exposed to blood or another potentially infectious body fluid. But first, let's review some key definitions. __________________________________________________________________________ _____________________________________*____________________________________ 10. Abstract: Circumstances surrounding occupational blood exposure events in the National Study to Prevent Blood Exposure in Paramedics __________________________________________________________________________ Ind Health. 2009 Apr;47(2):139-44. Circumstances surrounding occupational blood exposure events in the National Study to Prevent Blood Exposure in Paramedics. Leiss JK, Sousa S, Boal WL. Epidemiology Research Program, Cedar Grove Institute for Sustainable Communities, 6919 Lee Street, Mebane, NC 27302, USA. More than 20% of U.S. paramedics are exposed to blood each year. Little is known about the circumstances that lead to these exposures. The objective of this study was to describe blood exposure events among U.S. paramedics. A mail survey was conducted in 2002-2003 among a nationally representative sample of licensed paramedics. Eighty percent of needle/lancet sticks involved non-safety devices. A third of mucous membrane exposures occurred even though the paramedic was wearing eye or face protection; in half of the events, the exposures were caused by the patient vomiting, spitting, or coughing up blood; in a third of the events, the patient was being uncooperative or combative. In 83% of the non-intact skin exposures, the paramedic was wearing disposable gloves; the non-intact skin was covered before the call in a third of the events, but the cover did not prevent exposure; 40% of the events occurred when the patient was being uncooperative or combative. These results suggest that blood exposure among paramedics could be reduced through increased use of safety devices and personal protective equipment, improved engineering and design, and increased compliance with Universal Precautions, and that paramedics need techniques for avoiding blood exposure while treating uncooperative or combative patients. __________________________________________________________________________ _____________________________________*____________________________________ 11. Abstract: "Antibiotics are not automatic anymore"--the French national campaign to cut antibiotic overuse. __________________________________________________________________________ PLoS Med. 2009 Jun 2;6(6):e1000080. "Antibiotics are not automatic anymore"--the French national campaign to cut antibiotic overuse. Huttner B, Harbarth S. Infection Control Program, University of Geneva Hospitals and Medical School, Geneva, Switzerland. Benedikt Huttner and Stephan Harbarth discuss the implications of a new study that examined the impact of a national campaign in France to reduce antibiotic overuse. __________________________________________________________________________ _____________________________________*____________________________________ 12. Abstract: Outcomes of early switching from intravenous to oral antibiotics on medical wards __________________________________________________________________________ J Antimicrob Chemother. 2009 Jul;64(1):188-99. Outcomes of early switching from intravenous to oral antibiotics on medical wards. Mertz D, Koller M, Haller P, Lampert ML, Plagge H, Hug B, Koch G, Battegay M, Flückiger U, Bassetti S. Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland. OBJECTIVES: To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards. METHODS: During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before-after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes). RESULTS: In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%-29%, P = 0.001; 6.0-5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185). CONCLUSIONS: On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used. __________________________________________________________________________ _____________________________________*____________________________________ 13. Abstract: Pain control in local analgesia __________________________________________________________________________ Eur Arch Paediatr Dent. 2009 Jun;10(2):71-6. Pain control in local analgesia. Meechan JG. School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, England, NE2 4BW Email: J.G.Meechan@ncl.ac.uk. AIM: This is to review the factors involved in administering local analgesia (LA) to children. REVIEW: This paper describes those aspects that a dentist can control and considers strategies to reduce injection discomfort. The main factors affecting successful use of LA in children are detailed. These include equipment factors, such as needles, syringes and cartridges and patient factors focussing on expectation of pain and anxiety of a child, area of the mouth to be injected, and the appropriate LA technique. In addition safety aspects of using LA in children are discussed. CONCLUSION: A number of factors that are under the influence of the dentist can affect the discomfort of LA. Knowledge of safe LA doses is important to ensure that toxic reactions do not occur. __________________________________________________________________________ _____________________________________*____________________________________ 14. Abstract: Blunt needles for the reduction of needlestick injuries during cesarean delivery: a randomized controlled trial __________________________________________________________________________ Obstet Gynecol. 2009 Aug;114(2 Pt 1):211-6. Blunt needles for the reduction of needlestick injuries during cesarean delivery: a randomized controlled trial. Sullivan S, Williamson B, Wilson LK, Korte JE, Soper D. From the Departments of 1Obstetrics and Gynecology and 2Biostatistics, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston, South Carolina. OBJECTIVE:: To compare the rate of glove perforation as a proxy for needlestick injuries between blunt and sharp needles used during cesarean- delivery closure and to survey physician satisfaction with blunt needles. METHODS:: Patients requiring cesarean delivery were assigned randomly to receive closure with either blunt (study group) or sharp needles (control group). Patient demographics, operator experience, and other clinical variables were collected. Physicians reported any percutaneous injuries and were surveyed regarding satisfaction with the assigned needles. Glove perforation was determined using a validated water-test method. Differences between patient groups were tested using chi and Fisher exact test for categorical variables and Student t-test or Wilcoxon rank-sum test for continuous variables. RESULTS:: There were 194 patients enrolled in the trial: 97 in the control group and 97 in the study group. There were no statistical differences between groups in patient demographics. There were no differences between groups in clinical variables, type of cesarean delivery, or experience level of the surgeon. There was a significant reduction in total glove perforation rate for the primary surgeon with blunt needles (7.2%) compared with sharp needles (17.5%) (relative risk [RR] 0.66, 95% confidence interval [CI] 0.49-0.89) as well as for the assistant surgeon (RR 0.54, 95% CI 0.41-0.71). There was poor correlation between reported perforations and those detected by water test (R=0.3). Physicians reported that they were not as satisfied with blunt needles compared with sharp needles (P=.001). CONCLUSION:: There was a significant decrease in the rate of glove perforation for surgeons and assistants performing cesarean-delivery closure with blunt needles. Assistant surgeons had the greatest reduction in glove perforations. However, physicians reported decreased satisfaction performing the surgery with blunt needles. CLINICAL TRIAL REGISTRATION:: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00844636 LEVEL OF EVIDENCE:: I. __________________________________________________________________________ _____________________________________*____________________________________ 15. Abstract: Perceptions, attitudes, and behavior towards patient hand hygiene __________________________________________________________________________ Am J Infect Control. 2009 Jul 21. Perceptions, attitudes, and behavior towards patient hand hygiene. Burnett E. Department of Infection Prevention and Control, University of Dundee School of Nursing & Midwifery, Ninewells Hospital, NHS Tayside, United Kingdom. BACKGROUND: Hand hygiene is the single most important intervention to prevent the spread of health care-associated infection. However, improvement strategies predominantly focus on health care workers with limited emphasis on patient hand hygiene. This study aimed to explore perceptions, attitudes, and self-reported behavior towards patient hand hygiene among clinical ward nurses within an acute hospital environment. METHODS: A mixed methodologic, descriptive, cross-sectional survey design using questionnaires exploring perceptions, attitudes, and self-reported behavior was used. RESULTS: Despite clinical ward nurses demonstrating good perceptions and positive attitudes toward patient hand hygiene, they were not found to be independently associated with positive behavior. A positive, modest correlation was found between perceptions and attitudes (P<.001), but a negative, weak correlation was found between perceptions and self-reported behavior (P=.001) and attitudes and self-reported behavior (P<.001). CONCLUSION: Despite epidemiologic evidence to suggest that hand hygiene is an important part of preventing health care- associated infection, patients are not provided the opportunity to do so. Human behavior is extremely complex and is the consequence of multiple interdependent influences from biology, environment, education, and culture. Major beliefs and barriers that alter nurses' preexisting behavior toward patient hand hygiene must be acknowledged. __________________________________________________________________________ _____________________________________*____________________________________ 16. Abstract: Nurse Satisfaction Using Insulin Pens in Hospitalized Patients __________________________________________________________________________ Diabetes Educ. 2009 Jul 24. Nurse Satisfaction Using Insulin Pens in Hospitalized Patients. Davis EM, Bebee A, Crawford L, Destache C. Creighton University School of Pharmacy and Health Professions. Purpose The purpose of this study was to evaluate nurse satisfaction using pen devices compared with vials/syringes to administer insulin to hospitalized patients with diabetes. Methods A quasi-experimental 1-group posttest only study design was utilized to distribute a satisfaction survey to 54 registered nurses in a community hospital after implementation of insulin pen devices from July 2005 to May 2006 on 2 medical-surgical floors. Nurses completed a voluntary, anonymous, self- administered, postassessment, investigator- developed survey asking about the number of years practiced as a nurse and experience administering insulin to patients. The survey also asked about insulin administration satisfaction questions comparing insulin pen devices to vials/syringes, and estimated time to teach patients to self- inject insulin using either delivery method during the study period. Results In comparison to vials/syringes, the majority of nurses agreed that insulin pens were more convenient, simple and easy to use, and an overall improvement compared with conventional vials/syringes. There were no insulin-related needlestick injuries using the insulin pens and safety needles. Conclusion Nurses were satisfied with multiple aspects of insulin pens compared with vials/syringes. Implementation of insulin pen devices does not increase nursing time spent to teach patients to self-inject insulin and does not increase insulin-related needlestick injuries. __________________________________________________________________________ _____________________________________*____________________________________ 17. Abstract: Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007 __________________________________________________________________________ BMC Infect Dis. 2009 Jul 25;9(1):115. Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. Ding JG, Sun QF, Li KC, Zheng MH, Miao XH, Ni W, Hong L, Yang JX, Ruan ZW, Zhou RW, Zhou HJ, He WF. BACKGROUND: Nosocomial infections are a major threat to patients in the intensive care unit (ICU). Limited data exist on the epidemiology of ICU- acquired infections in China. This retrospective study was carried out to determine the current status of nosocomial infection in China. METHODS: A retrospective review of nococomial infections in the ICU of a tertiary hospital in East China between 2003 and 2007 was performed. Nosocomial infections were defined according to the definitions of Centers for Disease Control and Prevention. The overall patient nosocomial infection rate, the incidence density rate of nosocomial infections, the excess length of stay, and distribution of nosocomial infection sites were determined. Then, pathogen and antimicrobial susceptibility profiles were further investigated. RESULTS: Among 1980 patients admitted over the period of time, the overall patient nosocomial infection rate was 26.8 % or 51.0 per 1000 patient days., Lower respiratory tract infections (LRTI) accounted for most of the infections (68.4%), followed by urinary tract infections (UTI, 15.9%), bloodstream (BSI, 5.9%), and gastrointestinal tract (GI, 2.5%) infections. There was no significant change in LRTI, UTI and BSI infection rates during the 5 years. However, GI rate was significantly decreased from 5.5% in 2003 to 0.4% in 2007. In addition, A. baumannii, C. albicans and S. epidermidis were the most frequent pathogens isolated in patients with LRTIs, UTIs and BSIs, respectively. The rates of isolates resistant to commonly used antibiotics ranged from 24.0% to 93.1%. CONCLUSIONS: There was a high and relatively stable rate of nosocomial infections in the ICU of a tertiary hospital in China through year 2003-2007, with some differences in the distribution of the infection sites, and pathogen and antibiotic susceptibility profiles from those reported from the Western countries. Guidelines for surveillance and prevention of nosocomial infections must be implemented in order to reduce the rate. __________________________________________________________________________ _____________________________________*____________________________________ 18. Abstract: A population-based case-control study on viral infections and vaccinations and subsequent multiple sclerosis risk __________________________________________________________________________ Eur J Epidemiol. 2009 Jul 26. A population-based case-control study on viral infections and vaccinations and subsequent multiple sclerosis risk. Ahlgren C, Torén K, Odén A, Andersen O. Institute of Clinical Neuroscience, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden, cecilia.ahlgren@neuro.gu.se. Viral infections are probably involved in the pathogenesis of multiple sclerosis (MS). A recent cohort study in the Gothenburg population revealed no change in MS incidence associated with the introduction of the Swedish measles, mumps and rubella vaccination programmes. The aim of the present study was to clarify whether these infections or vaccinations, and two other infections, varicella and infectious mononucleosis, influence MS risk. We performed a population-based case-control study in Gothenburg that included 509 MS cases and 2,067 controls, born 1959-1986. Data on infections and vaccinations were obtained from questionnaires and from child health and school health records. We found no significant associations between measles, mumps, rubella or varicella and MS risk. These results were consistent between the two source materials. Infectious mononucleosis was associated with significantly higher MS risk (odds ratio 2.03, 95% CI 1.52-2.73). Overall, there was no significant association between measles-mumps- rubella (MMR) vaccination and MS risk, while those MMR vaccinated before age ten only were at significantly higher MS risk (odds ratio 4.92, 95% CI 1.97-12.20). Those MMR vaccinated both before and after age ten had intermediate MS risk. Infection with measles, mumps, rubella and varicella did not influence MS risk in contrast to infectious mononucleosis which conferred doubled MS risk. The association with 'early' MMR vaccination only was an isolated finding, limited by a small number of subjects and multiple testing. Most likely this was a chance finding. Future studies could investigate it on an a priori basis. __________________________________________________________________________ _____________________________________*____________________________________ 19. Abstract: Impact of Hepatitis B Vaccination in Children Born to HBsAg- Positive Mothers: a 20-year Retrospective Study __________________________________________________________________________ Infection. 2009 Jul 23. Impact of Hepatitis B Vaccination in Children Born to HBsAg-Positive Mothers: a 20-year Retrospective Study. Bracciale L, Fabbiani M, Sansoni A, Luzzi L, Bernini L, Zanelli G. Infectious Diseases Clinic, Dept. of Molecular Biology, Siena University, Siena, Italy. BACKGROUND: Preventive measures remain the best approach to control the spread of hepatitis B virus (HBV) infection. PATIENTS AND METHODS: To evaluate the effectiveness of vaccination against HBV, we conducted a 20- year retrospective study on 100 subjects, born to hepatitis B surface antigen (HBsAg)-positive mothers, who had received post-exposure prophylaxis at the Clinic of Infectious Diseases (Siena University, Italy) during 1984-2004. All patients were tested for the presence of HBsAg, anti-HBs and anti-HB core antigen (anti-HBc). RESULTS: Two subjects (2%) acquired the infection as shown by the presence of anti-HBc. Of the 98 patients who did not acquire the infection, 62 of these (63.3%) had an anti-HBs concentration considered protective (>/= 10 mIU/ml). The percentage of protected subjects decreased in relation to time from vaccination with a significant reduction (p = 0.009) of anti-HBs geometric mean titre (GMT) after 5 years, which reached the level of 10 mIU/ml after about 15 years. No patients without protective concentration have acquired the infection as of today. Only 12% of the HBsAg-positive mothers were followed in specialized structures after pregnancy, reflecting the scarce knowledge of the problem in the general population. CONCLUSION: Our data, while confirming the effectiveness of anti hepatitis B vaccination, highlight the need for post-vaccination follow-up, particularly in high- risk categories, to prolong protection, through booster doses if necessary. We show, moreover, the importance of maintaining active surveillance in the territory to improve follow-up to chronic carriers and to sensitize families. __________________________________________________________________________ _____________________________________*____________________________________ 20. Abstract: Prion safety of transfusion plasma and plasma-derivatives typically used for prophylactic treatment __________________________________________________________________________ Transfus Apher Sci. 2008 Aug;39(1):59-67. Prion safety of transfusion plasma and plasma-derivatives typically used for prophylactic treatment. Svae TE, Neisser-Svae A, Bailey A, Reichl H, Biesert L, Schmidt T, Heger A, Römisch J. Octapharma Pharmazeutika Produktionsges.m.b.H, Pre-Clinical Research and Development Department, Oberlaaerstrasse 235, Vienna, Austria. tor- einar.svae@octapharma.com Reports about transfusion-related transmissions of variant Creutzfeldt- Jakob disease have urged the need for more information regarding the risk for prion contaminated units in the blood supply and the safety of transfusion plasma and biopharmaceuticals derived from this precious raw material. According to a possible epidemiological model, the risk in many European countries is the same or lower than that of human immunodeficiency virus. Comprehensive investigations have shown that the prion safety margin of both single-donor and pooled solvent/detergent treated transfusion plasma is high. Furthermore, prophylactic treatment using plasma-derivatives poses a very low risk in terms of prion disease despite extensive lifetime exposure. __________________________________________________________________________ _____________________________________*____________________________________ 21. Abstract: Pathogen reduction of blood components __________________________________________________________________________ Transfus Apher Sci. 2008 Aug;39(1):75-82. Pathogen reduction of blood components. Solheim BG. Institute of Immunology, Rikshospitalet Medical Centre, University of Oslo, Oslo, Norway. bjagees@online.no Thanks to many blood safety interventions introduced in developed countries the risk of transfusion transmitted infections has become exceedingly small in these countries. However, emerging pathogens still represent a serious challenge, as demonstrated by West Nile virus in the US and more recently by Chikungunya virus in the Indian Ocean. In addition bacterial contamination, particularly in platelets, and protozoa transmitted by blood components still represent sizeable risks in developed countries. In developing countries the risk of all transfusion transmitted infections is still high due to insufficient funding and organisation of the health service. Pathogen reduction of pooled plasma products has virtually eliminated the risk of transfusion transmitted infections, without compromising the quality of the products significantly. Pathogen reduction of blood components has been much more challenging. Solvent detergent treatment which has been so successfully applied for plasma products dissolves cell membranes, and can, therefore, only be applied for plasma and not for cellular blood components. Targeting of nucleic acids has been another method for pathogen inactivation of plasma and the only approach possible for cellular blood products. As documented in more than 15 year's track record, solvent detergent treatment of pooled plasma can yield high quality plasma. The increased risk for contamination by unknown viruses due to pooling is out weighed by elimination of TRALI, significant reduction in allergic reactions and standardisation of the product. Recently, a promising method for solvent detergent treatment of single donor plasma units has been published. Methylene blue light treatment of single donor plasma units has a similar long track record as pooled solvent detergent treated plasma; but the method is less well documented and affects coagulation factor activity more. Psoralen light treated plasma has only recently been introduced (CE marked in Europe, but not licensed by the FDA), while the method of Riboflavin light treatment of plasma still is under development. In addition to pathogen reduction the methods, however, result in some reduction of coagulation factor activity. For platelets only Psoralen and Riboflavin light treatment have been implemented. Both are CE marked products in Europe but only approved for clinical trials in the USA. The methods affect platelet activity, but result in clinically acceptable platelets with only slightly reduced CCI and increased demand for platelet transfusions. Pathogen reduction of red blood cells with FRALE (S-303) or INACTINE (PEN110) has so far resulted in the formation of antibodies against neo- epitopes on red blood cells. A promising method for Riboflavin treatment of red blood cells is under development. This manuscript reviews the current experience and discusses future trends. __________________________________________________________________________ _____________________________________*____________________________________ 22. Abstract: Fresh-frozen plasma, pathogen-reduced single-donor plasma or bio-pharmaceutical plasma? __________________________________________________________________________ Transfus Apher Sci. 2008 Aug;39(1):69-74. Fresh-frozen plasma, pathogen-reduced single-donor plasma or bio- pharmaceutical plasma? Hellstern P. Institute of Hemostaseology and Transfusion Medicine, Academic City Hospital, Bremserstrasse 79, Ludwigshafen, Germany. peterhellstern@medicusnet.de Three types of therapeutic plasma are available that differ in their manufacturing processes, composition, clinical efficacy, and side effects. Quarantine-stored, not pathogen-reduced fresh-frozen plasma (QFFP) is prepared from single whole blood or plasma donations. The manufacture of pathogen-reduced single-donor plasmas such as methylene blue-light treated (MLP) or amotosalen-ultraviolet light treated plasma (ALP) involves the addition of a chemical followed by irradiation and subsequent removal of the chemical. Both plasma types show substantial fluctuation of clotting factor and inhibitor levels according to interindividual variations, and both carry the risk of inducing transfusion-associated lung injury (TRALI). Photo-oxidation in pathogen- reduced single-donor plasmas reduces clottable fibrinogen and other clotting factors markedly, and there is a lack of clear evidence showing whether this is harmful or not. MLP also appears to be less effective clinically than QFFP. Like clotting factor or inhibitor concentrates, solvent/detergent-treated plasmas (SDP) are bio- pharmaceutical preparations derived from large plasma pools, and variations in plasma protein levels from batch-to-batch are for that reason low. The SD manufacturing process inevitably involves a considerable reduction of plasmin inhibitor (PI), and moderate reduction of all other clotting factors and inhibitors in the final plasma bags. Clinical studies and broad clinical use have however shown that this does not significantly reduce clinical efficacy or increase adverse events. SDPs obviously do not induce TRALI and the risk of allergic reactions is significantly lower than for QFFP. Common to all three plasma types is that the time between donation and freezing the plasma, and whether plasma from whole blood or apheresis plasma is used as starting material, are decisive determinants for the clotting factor and inhibitor potencies in the final bags. Plasma frozen 3-6h after donation, and apheresis plasma, contain markedly greater amounts of clotting factors and inhibitors than plasma frozen 15-24h after collection or plasma from whole blood. Lyophilisation and the pooling of single-donor plasma units with ABO blood group in suitable proportions (Uniplas) facilitate SDP handling and logistics without loss of clinical efficacy. SDP is obviously at least as cost-effective as QFFP if non-infectious adverse events including TRALI are taken into account, at least in younger patients and patients with good prognosis. __________________________________________________________________________ _____________________________________*____________________________________ 23. Abstract: Processing loaner instruments in an ambulatory surgery center __________________________________________________________________________ AORN J. 2009 May;89(5):861-6; quiz 867-70. Processing loaner instruments in an ambulatory surgery center. Huter-Kunish GG. Bergen Ambulatory Surgery Center, Saddle Brook, NJ, USA. Loaner instruments often do not arrive at receiving facilities in the time frame or the condition that is needed to use them safely. Their cleaning and decontamination status may be unknown. There may be no inventory of what has been loaned or information about processing requirements for the instrument's use. These situations can create problems for both the loaning facility and the receiving facility and must be addressed to reduce costs from damage to or loss of instruments. The use of documents and checklists to verify the cleaning,decontamination, and sterilization processes used allows ambulatory surgery centers to solve these problems,cut costs, and protect staff members and patients. __________________________________________________________________________ _____________________________________*____________________________________ 24. Abstract: Transcutaneous immunization by lipoplex-patch based DNA vaccines is effective vaccination against Japanese encephalitis virus infection __________________________________________________________________________ J Control Release. 2009 May 5;135(3):242-9. Transcutaneous immunization by lipoplex-patch based DNA vaccines is effective vaccination against Japanese encephalitis virus infection. Cheng JY, Huang HN, Tseng WC, Li TL, Chan YL, Cheng KC, Wu CJ. Department of Food Science, National Taiwan Ocean University, Keelung, Taiwan; Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan. Skin, the biggest organ of human body, contains antigen presenting cells such as Langerhans cells (LCs) that modulate various immune responses. The skin therefore is an ideal venue to effect the transcutaneous immunization (TCI). Most current immunization procedures make use of needles and syringes for vaccine administration, which however have raised many safety concerns. To overcome the stratum corneum barrier of the skin without carrying out any skin penetration, cationic liposomes, DC-Chol/DOPE and DOTAP, were employed as vehicles for the transdermal antigen DNA delivery in this study. The optimal ratio of liposomes to DNAs for maximal transfection efficiency was determined to be 5:1 (w/w) for both formulas in BHK-21 cell transfection assays. This ratio was applied to lipoplex in tests on the dorsal skin of hair-removed mice. Reporter genes were found expressed in epidermis and spleen over 3 days. C3H/HeN mice transcutaneously immunized with the skin patch containing liposome- pCJ-3/ME (lipoplex-patch; pCJ-3/ME expressing the whole membrane and envelope protein genes of Japanese encephalitis virus (JEV)) can induce effective and protective antibodies against the infection with 50 times the 50% lethal dose (LD(50)) of JEV. The developed lipoplex-patch DNA vaccines have proven to be simple and noninvasive, by which the antibodies incurred provide marked therapeutic effects in test animals. __________________________________________________________________________ _____________________________________*____________________________________ 25. Abstract: Bacterial contamination of stethoscopes in pediatric units at a university hospital __________________________________________________________________________ Rev Soc Bras Med Trop. 2009 Mar-Apr;42(2):217-8. [Bacterial contamination of stethoscopes in pediatric units at a university hospital] [Article in Portuguese] Xavier MS, Ueno M. Departamento de Medicina, Universidade de Taubaté, Taubaté, SP. Evaluation of the contamination of stethoscopes used in pediatric units of a hospital and emergency service showed that 87% of them presented contaminated diaphragms. Coagulase-negative Staphylococcus was the microorganism most frequently isolated. The resistance to antibiotics indicates that stethoscopes should be considered to be an important vehicle for disseminating bacteria resistant to antibiotics. __________________________________________________________________________ _____________________________________*____________________________________ 26. Abstract: The surgical mask: are new tests relevant for OR practice? __________________________________________________________________________ AORN J. 2009 May;89(5):883-91. The surgical mask: are new tests relevant for OR practice? Belkin NL. Since the turn of the 20th century, when researchers were discovering the presence of bacteria in droplets from the nose and mouth and the role these bacteria played in disease transmission, masks have been used as a method to protect both health care providers and patients from respiratory diseases. In 1926, the first study was published that indicated masks might also play a role in reducing the incidence of surgical site infections. That report spearheaded the development of new mask materials and designs and devices to demonstrate their filtering efficiency. This article provides a historical review of the work done by researchers over the years and examines whether tests to determine the filtering efficiency of surgical masks, including those recently adopted by the US Food and Drug Administration (FDA), are relevant to actual OR conditions. (c) AORN, Inc, 2009. __________________________________________________________________________ _____________________________________*____________________________________ 27. No Abstract: Surgical preparation solutions and preoperative skin disinfection __________________________________________________________________________ J Hand Surg Am. 2009 May-Jun;34(5):940-1. Surgical preparation solutions and preoperative skin disinfection. Bhavan KP, Warren DK. Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA. __________________________________________________________________________ _____________________________________*____________________________________ 28. No Abstract: Current opinions on the role of pathogen reduction technology in improving the viral safety of blood and derivatives __________________________________________________________________________ Transfus Apher Sci. 2008 Aug;39(1):49-50. Current opinions on the role of pathogen reduction technology in improving the viral safety of blood and derivatives. Seghatchian J. __________________________________________________________________________ _____________________________________*____________________________________ 29. News - India: Hepatitis B threat looms large - USA: Doctor tied to hepatitis C outbreak deemed fit for hearing - Philippines: Seller of fake vaccines arrested: OFW dies from A(H1N1) virus - USA: UW hospital warns patients of possible disease exposure - USA: Vets Affected by VA Hospital Errors to File Claims - USA: Second Colorado Facility Linked to Hepatitis C Outbreak - USA: House Passes Spending Bill; Amendment To Block Removal Of Needle Exchange Funding Ban Defeated - India: Bill Gates Wins Indira Gandhi Prize in India - India: Toxic biomedical waste being burnt on hospital premises - USA: Unsafe Injections Put Patients at Risk for Hepatitis and HIV: Health Department Won't Release Name of Doctor's Office - India: Azad announces rewards for ‘whistleblowers’ to fight fake drugs - USA: Hundreds may have been pricked with used needle - USA: A malfunction has many worried about blood borne diseases - Africa: Branson Proposes Public Health Agency for Afric - Canada: Review blames old habits for reuse of dirty syringes in Alberta hospital Selected news items reprinted under the fair use doctrine of international copyright law: http://www4.law.cornell.edu/uscode/17/107.html __________________________________________________________________________ India: Hepatitis B threat looms large Express News Service, Express Buzz, India (28.07.09) CUTTACK: Orissa might still be enjoying the position of a low-prevalence State as far as Hepatitis B virus (HBV) is concerned but the threat looms large over the region. Lack of awareness among the general public and low vaccination rate notwithstanding, fast changing demographic profile, lifestyle patterns and even medical practices have heightened the risk of greater exposure to the virus by the population. Among the lowest in India, the prevalence of HBV is less than one per cent against the national average of about 3 to 4 per cent. This is mainly due to a relatively safe lifestyle patterns and insulated existence, wherein contact with outsiders has been infrequent and problems of injectable drug abuse low. Invasive methods in medicine is also largely avoided while practices like blood donation is still to pick off. Blood contact is the major route for spread of the virus. But with the social changes, the scene can be altered. With opening up of society and access to the good and bad practices as well, the threat has increased, says Chairman of Kalinga Gastroenterology Foundation Prof SP Singh. The issue assumes more dangerous proportions when the health care workers also are not very sensitive to the issue. A study among the students of the SCB Medical College has revealed that almost 50 per cent has not been vaccinated. The vaccination among paramedics, particularly nurses, was an abysmal at around 2 per cent. Health care workers are most vulnerable to HBV exposure in the clinical setting and recapping of needle is the most common cause of injury or contact with infected blood by the students. The challenges posed by spread of HBV is being realised by the medical fraternity, which has begun to call for formulation of a comprehensive National policy to combat the major public health problem. There has to be guidelines on management of HBV carriers and patients while prevention mechanism, like including it in the mass vaccination programme, should be strengthened. “States like Sikkim, Jammu and Kashmir and New Delhi have already done so and there is an urgent need for Orissa to follow suit,” Singh said. A symposium was conducted to mark the World Hepatitis B Eradication Day tomorrow, here to discuss the problem. Prominent experts like Prof Prabha Sawant, Dr PK Sethi, Dr Shrikant Mukewar, Dr Ganesh M along with Prof Sidhartha Das, RMRC Director Dr SK Kar and Dr CR Panda took part among others. .......................................................................... __________________________________________________________________________ USA: Doctor tied to hepatitis C outbreak deemed fit for hearing By Marshall Allen, Las Vegas Sun - Las Vegas,NV,USA (28.07.09) Dr. Dipak Desai, whose clinic caused a hepatitis C outbreak due to unsafe injection practices, is medically competent to defend himself in a disciplinary hearing with the Nevada State Medical Board, according to documents released Tuesday. A preliminary neurological assessment of Desai, who had suffered a stroke, showed he was not mentally fit to defend himself — which might have robbed Nevadans in their pursuit of justice in the case. But follow-up assessments by other specialists, combined with Desai's improvements since April, show he may be "impaired" but not "unable" in his ability to assist his attorneys, said Dr. Thomas Kinsora, a clinical neuropsychologist and specialist in neurocognition. "He is competent, and that means we are going to hearing," said Louis Ling, executive director of the medical board. Kinsora said Desai "is clearly aware of the charges against him, has a good knowledge of the facts of the case and understanding of the role of the key players in the judicial system." Desai may be on the borderline in his ability to assist in his defense, Kinsora wrote, but is "acceptably" competent. .......................................................................... __________________________________________________________________________ Philippines: Seller of fake vaccines arrested: OFW dies from A(H1N1) virus Jeamma E. Sabate & Madel R. Sabater, Manila Bulletin - Philippines (28.07.09) National Bureau of Investigation (NBI) agents arrested a former medical representative of a drug company and seized several cartons of fake flu vaccines worth P4 million during a raid in San Pedro, Laguna, an NBI official said on Tuesday. NBI Director lawyer Nestor M. Mantaring also warned the public against purchasing fake flu vaccines. Mantaring identified the suspect as Jennifer M. Cristobal, 28, businesswoman, and resident of 19 Lily St., Sampaguita Village, San Pedro, Laguna. She is said to be former medical representative of of Sanofi Pasteur. “We estimate that the amount of confiscated fake vaccines from the raided house-establishment possibly amounting to P4 million,” said Deputy Director for Special Investigation Services (SIS) lawyer Rickson L. Chiong in a press briefing on Tuesday. The raid stemmed from the complaint of Sanofi Pasteur, a company registered with the Bureau of Food and Drugs (BFAD) that manufactures and markets pharmaceutical products vaccines, including VAXIGRIP (Inactivated Influenza Vaccine). The product and trademark of the Sanofi Pasteur is also registered with the Intellectual Property Office. Meanwhile, the Department of Foreign Affairs (DFA) on Tuesday said an overseas Filipino worker (OFW) in Hong Kong infected with influenza A (H1N1) died of severe pneumonia. The OFW, a 37-year-old female from Tarlac province, died at 5:47 p.m. of Monday at the United Christian Hospital in Kowloon, Hong Kong, according to the DFA. She is survived by her husband and a six-month old son, the DFA said. The DFA said the Filipina was diagnosed with severe pneumonia last July 7. It was however confirmed as a serious case of A(H1N1) four days later. The NBI Anti-Fraud and Computer Crimes Division (AFCCD) headed by Assistant Regional Director (ARD) Vicente de Guzman III said that they received information that certain individuals in Laguna were engaged in the sale and distribution of a vaccine claimed to be VAXIGRIP which is being presented as a Sanofi Pasteur product. The Sanofi Pasteur requested the NBI to conduct investigation into the reported selling of fake flu vaccine. Head Agent Palmer Mallari, executive officer of the NBI-AFCCD, said surveillance indicated that Cristobal of KNJ Marketing was allegedly engaged in the illegal and unauthorized manufacture, distribution and/or sale of counterfeit products, particularly Sanofi Pasteur pharmaceutical products such as but not limited to “VAXIGRIP.” NBI agents bought two 5 mL vials of VAXIGRIP Multidose and tests showed that they were counterfeit vaccines and the vials contained only mineral water. Armed with search warrants issued by the San Pedro (Laguna) Regional Trial Court (RTC) Branch 31, the NBI operatives raided the establishment last Friday. Cristobal was arrested after selling VAXIGRIP vaccines to NBI agents. Seized during the operation were 180 vials of VAXIGRIP vaccines, 10 boxes of syringes, Prime Gold Enterprises official receipts, delivery receipts, certificate of product registration, labels, marketing paraphernalia, computer set, telefax, and printers. The genuine flu vaccine is sold P4,000 each and Cristobal sold her products at P3,000 each. Source URL: http://www.mb.com.ph/articles/213257/seller-fake-vaccines-arrested Copyright 2009. Manila Bulletin .......................................................................... __________________________________________________________________________ USA: UW hospital warns patients of possible disease exposure WQOW TV News 18, Madison Wisconsin USA (27.07.09) Madison (AP) - University Hospital has notified 53 neurosurgery patients that they are at "extremely low" risk of contracting a deadly brain disorder because of possible exposure to contaminated surgical instruments. The surgical tools were used on a woman who died Tuesday of the brain disorder, Creutzfeldt-Jakob (KROYTS'-felt YAH'-kuhb) disease. All the patients had surgery when the instruments were still in use. The hospital stopped using them when tests confirmed the woman's diagnosis. UW Hospital chief medical officer, Dr. Carl Getto, says the instruments were sterilized, but that experts believe that's not enough to destroy contamination. CJD symptoms include rapidly progressing dementia, with death often coming within a year. .......................................................................... __________________________________________________________________________ USA: Vets Affected by VA Hospital Errors to File Claims Bill Poovey, Associated Press (27.07.09) An attorney representing about 60 veterans will ask the US Department of Veterans Affairs to pay disability benefits and damages for mistakes that may have exposed them to blood-borne infections. Mike Sheppard of Nashville said he expects other affected veterans will join the complaint. Sheppard's clients are among the 10,320 former patients at VA facilities in Murfreesboro, Tenn., Miami, and Augusta, Ga., who were warned they could have been exposed to hepatitis and HIV due to endoscopy equipment errors at the three centers. Updated records indicate that among the 9,141 who heeded VA warnings to get screened for infections, 12 have tested positive for hepatitis B, 37 for hepatitis C, and eight for HIV. Among those filing claims are veterans who have tested positive for HIV and hepatitis and others who suffered emotional distress after the VA provided them with initial positive test results that turned out to be incorrect, said Sheppard. He plans to file medical malpractice and emotional distress claims with the VA within 30 to 45 days. Other veterans are likely to seek compensation beyond the VA's offer of free medical care, said Sheppard. "I've gotten calls from all over the country," he noted. According to Sheppard, the compensation requested will vary depending on the veterans' age, ailments, and other factors. "It's a case by case basis," he said. The VA has said there is no way to prove that the positive tests stem from the endoscopy mistakes. In a statement, the agency expressed regret but also said veterans have been informed of their legal right "to submit disability claims on account of VA negligence." .......................................................................... __________________________________________________________________________ USA: Second Colorado Facility Linked to Hepatitis C Outbreak Newsinferno.com (27.07.09) Late last week, we reported that 19 patients from Rose Medial Center tested positive for hepatitis C, contracted as a result of contact with surgical technician Kristen Diane Parker. The Colorado Department of Health and Environment is now reporting that initial results indicate confirmed cases of the dangerous and, sometimes deadly, virus have been received out of the Audubon Surgery Center. Parker worked at Rose from Oct. 21 to April 13 and at Colorado Springs’ Audubon Surgery Center from May 4 until June 29. Parker also worked at Christus St. John Hospital outside Houston, Texas between May 2005 and Oct. 2006, the Associated Press (AP) previously reported and at Northern Westchester Hospital in New York’s Mount Kisco between Oct. 8, 2007, and Feb. 28, 2008. Investigations continue in all three states and patients continue to be tested. Parker, 26, allegedly swapped sterile Fentanyl syringes with dirty—potentially hepatitis C-contaminated—saline-filled syringes, endangering countless patients. Hepatitis C is spread by contact with infected body fluids, especially blood. The disease attacks the liver, and can lead to cirrhosis or cancer of the liver. There is no vaccine for hepatitis C and the disease can be fatal. The disease is incurable, but can be treated. “It was disappointing to see the first case linked to Audubon Surgery Center,” said Mark Salley Department of Health and Environment spokesman, quoted NewsChannel13/KRDO. Of those whose hepatitis C is linked to Parker, 14 are from Rose and one, from Audubon, said KRDO; 13 are scheduled for sequencing, additional genetic testing, which will provide more confirmation that the virus genotype is the same as Parker’s. “According to the CDC, it’s 99.4 percent certain to be linked to the former employee,” Salley said, reported KRDO. The state expects more positive hepatitis C results to come in as a result of the testing, said KRDO. “There was no knowing if the employee would continue her activity here,” Salley said, “but with this case, it appears she may have,” he added, reported KRDO. The link to Colorado’s page on testing and results can be accessed at: http://www.cdphe.state.co.us/dc/Hepatitis/hepc/InvestigationCaseTable.html According to Jeffrey Dorschner, spokesman for the U.S. attorney’s office in Colorado, “Nineteen people tested positive for hepatitis C who had surgery at Rose Medical Center, have the same genotype as Parker, and did not have hepatitis C prior to surgery,” the Denver Post quoted last week. This development, said the Denver Post, represented the first direct link between the contamination and Parker. The paper also reported that additional charges could be made in future indictments and that, if convicted, Parker could face life in prison. Parker was indicted last week on 42 counts by a federal grand jury, 21 counts of product tampering and 21 counts of obtaining a controlled substance by deceit, reported the Denver Post. These charges, said the Denver Post, only relate to Parker’s alleged activities at Rose. Parker was also charged with three criminal counts earlier in the month that were connected to stealing Fentanyl, the Denver Post noted. The Denver Post reported that additional charges could be made in future indictments and that, if convicted, Parker could face life in prison. Although Parker alleges she did not know she was infected with hepatitis C at the time the crimes were committed, the AP previously reported that Parker tested positive with the virus before she began working at Rose, but that Parker never followed-up on the diagnosis. The Denver Post noted that Parker was told at a pre-employment exam at Rose that she was likely infected with hepatitis C and Parker, herself, told police she shared needles when she used heroin. .......................................................................... __________________________________________________________________________ USA: House Passes Spending Bill; Amendment To Block Removal Of Needle Exchange Funding Ban Defeated The Kaiser Daily U.S. HIV/AIDS Report, Kaisernetwork.org (27.07.09) The House on Friday passed a $730.5 billion bill (HR 3293) "to fund health, education and labor programs in fiscal 2010 after narrowly defeating an attempt to strip language that would lift the ban on federal needle exchange programs," in the U.S., CQ Today reports (Wolfe, 7/24). Lawmakers voted 211-218 to reject an amendment by Mark Souder (R-Ind.) that sought to keep the ban in place, the AP/Lewiston Sun Journal reports (Taylor, 7/25). The bill that passed includes a restriction against using federal funds for needle exchanges within 1,000 feet of day care centers, schools, parks, playgrounds, pools and youth centers, the Washington Post reports. Ronald Johnson, deputy executive director of the Washington, D.C.,-based advocacy group AIDS Action, said, "This is the first time in over 20 years that we are on the verge of recognition by the federal government of the proven cost-effectiveness and impact of syringe exchange as a very important tool for prevention of HIV infection and viral hepatitis," adding, "Allowing the local community to use federal funds is very critical to stopping these epidemics" (Fears, 7/25). The bill also drops funding for abstinence-only sex education and "would provide $114 million for a new teenage pregnancy prevention initiative," the Sun Journal article states (7/25). .......................................................................... __________________________________________________________________________ India: Bill Gates Wins Indira Gandhi Prize in India Ashok Sharma, Associated Press (07.25.09) On Saturday, Microsoft co-founder Bill Gates was awarded India's Indira Gandhi Prize for Peace, Disarmament and Development. Gates was recognized for his work with the Bill & Melinda Gates Foundation, which has committed nearly $1 billion for health and development projects in India, a government statement said. Most of the money has gone toward HIV/AIDS prevention and polio eradication. One HIV prevention initiative has targeted 280,000 high-risk individuals, the statement said. "It is a shining example of partnership between government and civil society in a critically important sector," said Indian Prime Minister Manmohan Singh, who attended the ceremony. .......................................................................... __________________________________________________________________________ India: Toxic biomedical waste being burnt on hospital premises Times of India, TNN (24.07.09) KANPUR: One normally goes to health institutions to get cured of their infections. But that doesn't seem to be the case at Tuberculosis and Respiratory Disease Centre here in the city. In the backyard of the Centre, situated in the Rawatpur area, biomedical waste including used needles, syringes, human anatomical waste, contaminated cotton bandages and discarded medicines are burnt indiscriminately on a routine basis. The smoke, which carries hazardous toxic gases, is harmful for the employees, the patients and those who visit them. As per the rules of biomedical waste management, waste from the Centre should be collected in two separate dustbins -- one for non-hazardous and another for hazardous material, like needles and syringes. This waste is then supposed to be taken by Medical Pollution Control Committee (MPCC) and dumped into Bhaunti biomedical waste plant. However, the waste is being disposed off manually in the hospital in violation of these rules. A Class IV employee of the Centre disclosed that all the medical waste of the hospital is either being burnt or collected by rag-pickers. The employee said, "The waste collection van hardly comes to the hospital and the waste keeps on collecting forming a heap. This waste has to be disposed off soon so that the infection doesn't spread. It is for this reason we are instructed by the hospital authorities to burn the waste." One of the doctors at the Centre said, "MPCC vans are irregular in collecting waste, because of which we have to burn the collected waste instead of letting it pile up in the Centre campus. He added, "Earlier, we used to treat the hazardous biomedical waste to lessen its harmful effects, finally dumping it in the backyard. But not all waste material can be buried like this. Thus, we started to send our medical waste to Lala Lajpat Rai( LLR) Hospital which has its own incinerator." However, the incinerator installed on the LLR hospital premises is dysfunctional. Radhey Shyam, regional officer of Uttar Pradesh Pollution Control Board (UPPCB) said, "Tuberculosis hospitals are burning the medical waste on their campus due to non-operational incinerator at LLR." This despite the fact that there are two biomedical waste treatment plants at Bithoor and Bhaunti. According to the sources, incinerator at the MPCC plant in Bhaunti can incinerate 10 tons of waste in 8 hours, however, it runs for just three hours to burn 500 kg of waste brought here every day from private nursing homes. To comment on this, MPCC authorities were not available. Waste mis-Management In Kanpur, there are 410 government/semi-government, private nursing homes/hospitals and defence hospitals which generate around 3,550 kg of medical waste every day. According to the Biomedical Waste (Management and Handling) Rules, 2000, the hospitals should collect biomedical waste such as human body waste and waste from lab cultures in yellow plastic bags and wastes like discarded needles and syringes in red plastic bags. Toxic smoke # Inhalation of smoke by a TB patient can lead to spasms causing air passage to constrict and possible heart failure # It may lead to asthma # It can lead to skin allergy and allergic bronchitis .......................................................................... __________________________________________________________________________ USA: Unsafe Injections Put Patients at Risk for Hepatitis and HIV: Health Department Won't Release Name of Doctor's Office Kallie Cart, The Associated Press, WSAZ-TV - Huntington,WV,USA (24.07.09) CHARLESTON, W.Va. (WSAZ) -- A doctor's office in Charleston may have put more than 110 patients at risk of contracting hepatitis and HIV by using unsafe injection practices. Dr. Rahul Gupta at the Kanawha-Charleston Health Department said Friday that officials began investigating the office after eight patients showed up at the hospital with staph infections. Two of the cases were very serious. All of the patients have recovered. Dr. Gupta says the common link among all of the patients was a doctor's office in Charleston. All had received injections from the doctor between May 4 and May 6. The Health Department has refused to name the doctor or where this happened, citing patient confidentiality. But Dr. Gupta does say it's a doctor's office in Charleston, where only one doctor operates with a staff. As a result of that investigation, the health department discovered "unsafe injection practices" being used. Dr. Gupta says they weren't using the same needles on multiple patients, but they found at least one case where one needle was being used in multiple vials of medicine, which is also considered syringe re-usage. As a result of the investigation, the Kanawha-Charleston Health department has sent out letters to 110 people who received injections from the doctor between April 27 and May 13. They are being advised to consider being tested for Hepatitis B, Hepatitis C and HIV. "The overall risk of disease transmission of one of these diseases Hepatitis B, Hepatitis C and HIV at a population level is very low so the individuals need to understand that their risk is low to very low," Dr. Gupta says. He said the office has been ordered to stop performing injections until its procedures are deemed safe. .......................................................................... __________________________________________________________________________ India: Azad announces rewards for ‘whistleblowers’ to fight fake drugs Toufiq Rashid,Indian Express - New Delhi,India (23.07.09) New Delhi : During his tenure as the Chief Minister of Jammu and Kashmir, Ghulam Nabi Azad’s reward scheme for informers foiling grenade attacks had reaped results. Now, as Union Health Minister, he has announced a rewards scheme for those providing specific information on spurious, adulterated, misbranded and sub-standard drugs, cosmetics and medical devices. The Health Minister made the announcement in Parliament on Wednesday. “I propose to introduce a whistleblower policy seeking people’s participation in providing information on any unlawful activity in the manufacture of drugs. Under the policy, the informer would also be entitled to a monetary reward. The details of the scheme are being worked out,” he said. The Minister also said that changes in the amendment Bill for the Drugs & Cosmetics Act will soon be made to create a Central Drug Authority. According to sources, the note for the scheme has already been prepared. The Drug Controller General of India with other officials will be the nodal authoritiy for overseeing the functioning of the reward scheme mentioned above. The government will engage senior advocates, having sufficient experience in cases relating to drugs, as its counsel in the cases. Moreover, special designated courts will hear the cases to ensure a speedy trial. Special instructions will be given for drug testing laboratories to speed up investigations. The Ministry has set up a committee under the Drug Controller General of India to frame suitable guidelines for awarding penalties to those involved in the spurious drug trade. The CDSCO is conducting an all India survey to assess the extent of availability of spurious drugs in the country by drawing samples from different regions and states. The data is being collected on the basis of statistical principles provided by the Indian Statistical Institute, Hyderabad. The samples are being analysed and action is will be taken soon. “This would be a great help in identifying the geographical areas where spurious drugs are available,” an official said. The project, which is receiving World Bank assistance for capacity building, has already strengthened the Central Drug Laboratories. .......................................................................... __________________________________________________________________________ USA: Hundreds may have been pricked with used needle Kristy Ondo, WECT-TV6 - Wilmington,NC,USA (23.07.09) WILMINGTON, NC (WECT) - Hundreds of patients at a Wilmington health clinic are finding out they may have been stuck with unsanitary needles and could have been exposed to infectious diseases like AIDS. Alfred Thomas, the CEO of New Hanover Community Health Center on North 4th Street, says a lancet machine that tests blood sugar malfunctioned. A worker discovered that fresh needles were not rotating, meaning someone could have been pricked with a used needle. 283 people have used the machine since it arrived at the clinic in January. The clinic is now working to contact those people and test them for HIV and Hepatitis. Thomas says 50 people have come in for testing so far, and all tests have been negative. He says they will start making phone calls if the other patients don't show up for tests soon. ©2009 WECT. .......................................................................... __________________________________________________________________________ USA: A malfunction has many worried about blood borne diseases WWAY NewsChannel 3 - Wilmington,NC,USA (22.07.09) A letter was sent out as a warning to 283 patients from the New Hanover Community Health Care Center, telling them there could be a chance they may have been exposed to a virus. This comes after an employee discovered a malfunction in a device used for testing diabetes patients. There is a chance more than one patient may have been stuck with the same lancet. "The day we found out that the machine did not work properly, we immediately took it out of service," explained New Hanover Community Health Center CEO Alfred Thomas. Cape Fear Community College nursing director, Brenda Holland said exposure to the same needle could mean patients may have contracted a blood borne illness. "Hepatitis C, D, HIV those microorganisms could potentially be introduced into another person who did not already have that disease." Anyone whose blood was tested with the device from January 1st to June 3rd is being asked to come in to the center for re-testing, free of charge. "There safety and their health is our primary concern, and we want to do everything to ensure that takes place," said Thomas. The device was pulled out of service in June, along with similar ones that were in use. A number of patients have already been re-tested for wrongful exposure; so far no one has tested positive. .......................................................................... __________________________________________________________________________ Africa: Branson Proposes Public Health Agency for Afric Associated Press (22.07.09) PRETORIA, South Africa - British billionaire Richard Branson says he is working with the South African government on creating a public health agency for Africa. Branson and South African President Jacob Zuma said in a statement Wednesday they had discussed jointly establishing the equivalent of the U.S. Centers for Disease Control and Prevention. More talks will be held to refine the idea. Branson is urging other business leaders, foundations and international bodies to join in a project he says "will ultimately help save millions of lives" on a continent beset by AIDS, TB and other illnesses. The CDC model supports research, collects data and issues health alerts. Branson spokesman Nick Fox says the proposed hub could expand to serve other African countries. Branson supports development projects across Africa. © Copyright 2009 Associated Press. .......................................................................... __________________________________________________________________________ Canada: Review blames old habits for reuse of dirty syringes in Alberta hospital The Canadian Press - CALGARY (21.07.09) CALGARY - Isolation and old habits were the main reasons why a remote northern Alberta hospital recycled syringes that were meant to be used only once, says a report by the province's health watchdog. The report concludes staff at the High Prairie Health Complex were unaware it was no longer a medical practice to reuse needles to inject medicines into intravenous tubes. "In this rural setting, they had become isolated from the evolution of these standards," Dr. John Cowell of the Health Quality Council of Alberta said Tuesday. "This was a failure of education and being aware of standards and working fundamentally in isolation from the rest of the system." But Cowell added that didn't let the hospital off the hook. "Regardless of where your location is, you must be aware of changing standards." The report recommends closer monitoring of far-flung facilities and better staff training. Last fall, provincial officials revealed that hundreds of patients at the hospital would need to be tested for blood-borne diseases after it was learned that nurses were reusing syringes, which were intended to be used once and discarded. The needles were used to inject IV tubes and were never directly used on patients. Still, Alberta Health Services tested about 1,500 dental and endoscopic patients for diseases from HIV to hepatitis. No infections related to the used syringes were found. The practice introduces a remote chance of both infection and mis- medication and was largely phased out nearly a decade ago, the council found. But, somehow, High Prairie never got the message. The report blames a local "culture of autonomy" that was "linked with physical isolation from external influences" for the survival of techniques banned everywhere else. It also says some nurses didn't entirely understand the intravenous equipment. The council recommends the province tighten up reporting and review requirements to make sure all facilities use best practices. "We think it's a combination of the administration as well as the professions not being enabled to stay up-to-date," Cowell said. Last year's elimination of regional health boards in favour of one provincial "superboard" should help ensure knowledge is up-to-date across Alberta, said Health Department spokesman John Tuckwell. "That was one aspect of administration's decision to amalgamate all the health boards," he said. The province has clarified regulations on syringes and will examine the report's other recommendations, he added. Paula Beard of the Canadian Patient Safety Institute said it's too early to tell if the superboard really can improve communication, but she praised the report's emphasis on clear standards, practices and lines of authority. "Simple instructions often make for the best outcomes and in a complex industry that's not always easily achieved," she said. Still, Beard said, health professionals should be expected to remain current in their field. "We all have an individual accountability to remain excellent in whatever chosen field we're in." Cowell said that in an age of electronic communications, there's no reason for any geographic area to remain isolated. The High Prairie case also initiated a risk review in several Saskatchewan hospitals into the reuse of needles. The findings are expected to be released in August. Copyright © 2009 The Canadian Press. __________________________________________________________________________ _____________________________________*____________________________________ __________________________________________________________________________ * 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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