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This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.
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Post0215 INJECTION SAFETY 11 January 2000 CONTENTS 0. MODERATORS NOTE: TECHNET AND SIGNPOST LISTSERVES 1. INQUIRY: NEW SAN FRANCISCO CHRONICLE ARTICLE ON INJECTION SAFETY 2. GLOBAL PUSH FOR SAFE NEEDLES: NEW SAN FRANCISCO CHRONICLE ARTICLE 3. CORRECTIONS: GLOBAL PUSH FOR SAFE NEEDLES ARTICLE Contributions to: [][/email] or use your reply button! ___________________________________________________________________________ 0. MODERATORS NOTE: TECHNET AND SIGNPOST LISTSERVES Some informal discussion of the growing and differentiating subscriber base of these 2 moderated Internet forums took place around the Technet'99 meeting in Harare in December. TECHNET Logistics for Health Internet Forum has 373 subscribers while SIGNPost, the Safe Injection Global Network Internet Forum has 140 subscribers. Recently many TECHNET Forum subscribers have joined SIGNpost. To avoid excessive duplication and double postings, it has been proposed to move more of the safe injection discussion, except immunization related postings, to SIGNpost. Under this proposal immunization related injection safety postings would continue to be cross posted. Today's posting is an original TECHNET Post and will be crossposted to SIGNpost. Comments please: [][/email] or use your reply button To subscribe to the SIGNpost list, please send an email to: [][/email] ____________________________________*______________________________________ 1. INQUIRY: NEW SAN FRANCISCO CHRONICLE ARTICLE ON INJECTION SAFETY In the preparation of the recent San Francisco Chronicle, USA, Bill Carlsen, returned to the issue of safe injection after a long absence. Bill sought our help with the article - but due to travel we missed his email. The original series on injection safety were posted in TECHNET Forum postings: post0068 INJECTION SAFETY on 9/10/98, post0078 on 16/11/98, post0080 INJECTION SAFETY 18/11/98, and Post0093 on 21/12/98. URL: ... chive/1999 /12/14/MN8226.DTL The TECHNET, which brought the issue of unsafe injections to the international health agenda, will remain a key partner in seeking to make the right to safe injections a practical reality. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ From: William Carlsen To: "'Allan Bass'" Subject: Injection Safety Date: Fri, 3 Dec 1999 Dear Allan, I have finally finished the long project, totally unrelated to injection safety, that I have been working on over the last year and am now able to return to the problem of syringe and needle reuse. I am putting together a progress report. I can't believe it has been more than a year since our series ran. Despite almost full-time working on the other project, I have tried to keep up by reading the posts on the Technet forum. They have been invaluable. I realize that you are getting ready or are already on your way to Harare for the Technet meeting but I thought I let you know what story I'm planning to pull together and would appreciate any comments you might have, given your unique perspective. Our story will report about the recent WHO-UNICEF joint statement published on the Technet forum November 8. We will also include the information published in the October Bulletin of the World Health Organization, which coincided with the first SIGN meeting held in Geneva in October. And, of course, we want to report on the creation of SIGN, as well as the strategy plan drafted by Porter Novelli in February, and Technet's work. These are all indications of substantial progress. Have we missed any other major developments? What do you see as the next major steps? Have you found that there is a rising level of consciousness around the world on this issue, among health ministers, donors and partners? It appears that SIGN will focus on the curative area of injection safety, while WHO and UNICEF concentrate on immunizations. What is Technet's role? Will it be involved in both, or primarily immunizations? What obstacles do you see lying ahead and how difficult is this going to be, especially in curative area? And do you have any general comments on the progress that has been made over the past year? Is there a feeling like the issue is finally being taken seriously? I'm much appreciative for any help you can give me on this. Also, I would be glad to post the story on Technet, though I doubt any of the subscribers will find anything new because I'm just trying to summarize developments already reported there. I hope the Harare meeting goes well. Kind regards, Bill Carlsen, The San Francisco Chronicle --- To: William Carlsen From: [][/email] Subject: Injection Safety Date: 05/01/00 Dear Bill, Thanks for your email - which reached me after I arrived in Harare - and - I gather after your piece was published. As you had already spoken with Yvan Hutin, you should have been up to date. (I did not travel with a laptop for the first time in years - so my apologies for not replying sooner). Both SIGNpost and TECHNET Forum go back on line today - as I plow through the 800 and some emails.... After I read the article - I'll get back to you. I'll post the article in the next week or so, thanks for your permission in advance. regards and best wishes for the new Century, allan Technet Moderator/SIGNpost Moderator ____________________________________*______________________________________ 2. GLOBAL PUSH FOR SAFE NEEDLES: NEW SAN FRANCISCO CHRONICLE ARTICLE The article. Complete Please see item 3. CORRECTIONS: GLOBAL PUSH FOR SAFE NEEDLES ARTICLE, below, for Gordon Larsen's corrections. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ Global Push for Safe Needles Agencies want to curb spread of deadly viruses William Carlsen, Chronicle Staff Writer Tuesday, December 14, 1999 �2000 San Francisco Chronicle URL: 4/MN8226.DTL The World Health Organization, UNICEF and other international health agencies have begun an aggressive new campaign to halt a global epidemic of lethal diseases spread by contaminated needles. Setting a deadline just three years away, the plan calls for phasing out the use of all standard disposable and sterilizable syringes in developing countries' immunization programs and replacing them with a new genera tion of syringes that can be used only once. The new self-disabling -- or "auto- disable" -- syringe program is part of an even broader initiative by a coalition of world health agencies, including WHO, UNICEF and the federal Centers for Disease Control and Prevention designed to curb the transmission of potentially deadly viruses through unsterile needle use in therapeutic injections as well as in vaccinations. Last year, 1.2 billion immunization shots were given in developing nations. More than 10 billion therapeutic needle punctures and injections are administered annually in those countries. In October, WHO reported that as many as 21 million people a year contract hepatitis, HIV and other deadly viruses from unsafe injection practices -- more than twice the agency's earlier estimates. The next month, on November 8, the new syringe policy was announced and signed by the leaders of WHO, UNICEF, the International Red Cross and the Red Crescent Societies. The sweeping safe injection campaign follows a series of Chronicle articles last year reporting that the practice of reusing syringes in developing countries has been spreading blood-borne viruses at an alarming rate. Internal 1998 WHO reports obtained by The Chronicle estimated that the reuse of contaminated syringes was causing as many as 10 million new infections each year and resulting in more than 1 million deaths -- nearly one every 20 seconds. The articles also reported that auto-disable syringes were developed more than a decade ago, but profit concerns by needle manufacturers and reluctance by health officials to pay the extra cost of the new syringes delayed their widespread use in developing nations. This year, WHO updated its preliminary estimates based on more complete field data. The agency published its findings in a series of articles on injection safety in the October issue of the Bulletin of the World Health Organization. The report estimates that between 10.4 million and 20.9 million people are being infected each year with viruses transmitted through the reuse of contaminated syringes. The report's authors also warn that even the new higher estimates are the result of conservative calculations. "As we review the successes and failures of global health at the end of the 20th century," said an editorial accompanying the articles, "an alarming pattern emerges suggesting that the 'first do no harm' principle may be being violated on a grand scale as a result of unsafe injection practices." "Injection overuse and unsafe practices combine to account for a substantial proportion of the new infections with hepatitis B, hepatitis C and the HIV virus." GLOBAL CRISIS Medical authorities have understood the risks of blood-borne infections from contaminated syringes and needles for more than 50 years. The United States and other industrialized nations have largely solved the problem through the use of cheap, disposable plastic syringes that are used once and discarded. But most developing countries lack the money, the political will and the medical standards to make a wholesale change. Instead, they have relied upon sterilizing reusable syringes or reusing inexpensive disposable syringes. But sterilization programs in those countries often failed because of ineffective training and supervision and, in some cases, the lack of fuel to run the sterilizers. Disposable syringes, which cannot be sterilized for reuse, flooded developing countries in recent years and have compounded the problem because supplies are inadequate and the syringes are used multiple times, sometimes after being recycled from medical waste. WHO officials determined by the mid-1990s that in most developing nations, up to 30 percent of injections in immunization programs -- affecting millions of vulnerable children -- were not sterile, and 50 percent of therapeutic injections were unsafe. These unsafe practices have led to the spread of particularly virulent diseases such as hepatitis, which is caused by several virus strains that attack the liver and are most often fatal when contracted during childhood. In its recent journal articles, WHO officials estimate that 20 to 80 percent of all hepatitis B infections in China, India and Romania are now caused by reused syringes. SINGLE-USE SYRINGES Health officials increasingly have turned to auto-disable syringes as a way to halt the spread of infectious diseases. Developed at WHO's prompting and with U.S. funding in the late 1980s, most auto-disable syringes resemble standard syringes -- with one key difference: They include tiny alterations that automatically lock down a syringe's plunger after an injection. The syringes are manufactured by several firms, including Becton Dickinson, the world's largest syringe maker, and until recently they cost more than twice as much as standard disposable syringes. But John Lloyd, a WHO injection expert, said the price of auto-disable syringes already has dropped from more than 10 cents to a little more than 7 cents apiece, and is set to fall again in the spring. That is only slightly more costly than conventional syringes, which range in price from 4 1/2 cents to 7 cents each. World health officials, using the most conservative figure of 10.4 million annual infections, estimate that the direct medical costs of treating diseases transmitted through syringe reuse now total $535 million annually -- more that three times what it would cost to supply auto- disable syringes to the developing world. UNICEF has been supplying only auto-disable syringes for emergency and mass immunization campaigns for several years. In July, for example, the agency sent thousands of the auto-disable syringes to East Timor when violence there was suspended during a special truce so that 30,000 children could be immunized against six major childhood diseases. And government officials in India asked the agency for 1.5 million of the syringes for vaccinations to prevent an outbreak of measles after a killer cyclone ravaged that nation's east coast last month. But emergency campaigns represent only a fraction of the total immunization programs in the developing world. In March, African immunization managers called on WHO to require the use of auto-disable syringes for all vaccinations, including routine shots that make up the bulk of immunizations worldwide. After meeting in July, WHO and UNICEF officials in November set the year 2003 as the deadline for the shift to auto-disable models. Some field managers, however, argued that such a schedule is unrealistic. They said supplies of the auto-disable syringes are limited, and they objected to the phase-out of sterilizable syringes, insisting that in many regions of the world, sterilization programs are working and are extremely cost-effective because a single syringe can be used as many as 200 times. But WHO, UNICEF, Red Cross and Red Crescent leaders were unswayed. Their new policy states that the agencies no longer will buy or provide funds for standard disposable needles as of Jan. 1, 2001. "By the end of 2001, all countries should use only auto-disable and sterilizable syringes," the agencies said. All sterilizable syringes will be phased out by the end of 2003. The agencies also urged all global donors and other partner organizations involved in immunization programs to finance only auto-disable syringes. To avoid exposing health care workers and communities to accidental needle sticks, the agencies urged that all new auto-disable syringes be distributed "bundled" with the vaccine in safe disposal boxes, which are to be burned and buried when they are filled with the used syringes. Experts estimate that fewer than 100 million auto-disable syringes are being produced annually, and manufacturers will need to increase production by as much as 10 times that amount to meet the new goals. The syringe companies, however, say they can supply enough auto- disable needles to meet the dates set by WHO and UNICEF. "We'll have no problem," said Joel Schoenfeld, head of UNIVEC, a New York needle manufacturer that specializes in auto-disable syringes. "We have the ability to produce half a billion syringes a year. All we need is the order." Becton Dickinson has invested heavily in overseas syringe manufacturing, with plants in India, China, Singapore and Spain that are primarily producing disposable needles. Dr. Zeil Rosenberg, a medical director with the company, said the manufacturer can shift production to meet the demand for auto-disables. "I think this is very doable," he said of the new deadlines set by WHO and UNICEF. "We are completely supportive of this new aggressive policy." Rosenberg said Becton Dickinson also is designing auto-disable syringes that will use various lengths and gauges of needles to meet the expected demand for them in therapeutic injections. Meanwhile, the global campaign to solve the much larger problem of unsafe therapeutic injections is just getting started. In February, a strategic plan commissioned by the U.S. Agency for International Development was circulated among officials from WHO, UNICEF, the federal Centers for Disease Control and Prevention and other interested groups. The proposal called for a separate network of public health professionals to organize and carry out the global campaign. In July, Dr. Yvan Hutin, an infection control expert from the Centers for Disease Control in Atlanta, joined WHO at its Geneva headquarters to head the initiative. In October, the first meeting of the Safety Injection Global Network, or SIGN, was held in Geneva, drawing 50 participants. The publication of the WHO journal articles was timed to coincide with the gathering. Hutin said he is drafting briefing documents to send to health ministers of developing nations. The goal is to raise awareness about the magnitude of the reuse problem, in the medical as well as immunization sectors, and to raise medical standards through international groups of health professionals. A RIGHT TO SAFE INJECTIONS "The issue is much broader than simply using auto-disable syringes for immunizations," said Hutin. "We also have to decrease the overuse of injections and achieve a behavioral change before we can begin to make a difference." The Safety Injection Global Network is also planning pilot projects for five countries that will identify strategies to use in developing a large-scale initiative. The network also intends to work for the passage of a "right to safe injection'" resolution in 2001 by the World Health Assembly, which serves as a global parliament of health ministers. "Things are moving," said Hutin. "We are seeing more and more commitment from governments and partners by the minute. I'm encouraged." Despite its extraordinary magnitude, the epidemic of infection and death caused by unsafe injections so far has received little media attention. Health officials purposely have avoided publicizing the crisis, fearing that mass media attention could undermine the success of immunization programs. Their concern was spelled out in February's global strategic plan, which was drawn up by Porter Novelli, a social marketing firm, at the request of WHO and the U.S. Agency for International Development. "In particular," the proposal said, "there should be no efforts to communicate with the media until there are programs in place to assure safe injections. There is too much potential to create a panic in the service of informing the public." The report said that monitoring the media for news about injection safety issues is also crucial. Citing The Chronicle series, the authors said that "there is a very real risk that similar coverage could gain momentum and this issue could come under a more harsh media spotlight." Once health programs have been established, the proposal said, officials should "place" stories in media outlets like CNN, the New York Times, the British Broadcasting Corp., newsmagazines and wire services. --------------------------------------------------------------------------- THE DEVELOPMENT OF SINGLE-USE SYRINGES The spread of serious infections provoked development of single-use -- or auto-disable -- syringes in the late 1980s. The devices are sold primarily to developing countries through relief agencies, but only a tiny fraction of the 12 billion injections given each year are administered with auto-disable syringes. Glass syringes -- can be reused -- but spread deadly disease when not properly sterilized. Beginning in the early 1960s, many were replaced by disposable plastic syringes designed to be used once and discarded. Standard disposable syringe Includes a plunger and hollow-bore needle for injecting medications or drawing blood and other fluids. Once used, it cannot be properly sterilized, making it a dangerous even lethal instrument when contaminated with infected blood. UNIVEC A slim and simple autodestruct syringe made by a startup company in New York. It was designed to meet WHO standards for immunization programs and loosely resembles a standard syringe. Sources: Industry advertising and Chronicle research --------------------------------------------------------------------------- --World prevalence of the Hepatitis B virus More than 372 million people are now chronic carriers of the hepatitis B virus. Recent estimates of infections from syringe reuse generally track the prevalence of the disease globally. --World prevalence of the Hepatitis C virus Hepatitis C infections from syringe reuse follow the global prevalence of the virus, now carried by more than 177 million people. --World prevalence of HIV HIV infections from syringe reuse track the worldwide prevalence of the virus, which now infects more than 334 million people. Source: World Health Organization and Chronicle research Graphics by Steve Kearsley / The Chronicle --------------------------------------------------------------------------- BC: ESTIMATED TOTAL ANNUAL INFECTIONS FROM SYRINGE REUSE: Hepatitis B: Up to 16 mil. Hepatitis C: Up to 4.7 mil. HIV: Up to 161,000 Annual death rate: 1.3 mil . Sub-Saharan Africa Hepatitis B: 1.56 mil. Hepatitis C: 509,900 HIV: 102,400 . Middle Eastern crescent Hepatitis B: 1.04 mil. Hepatitis C: 141,600 HIV: 240 . Latin America and the Caribbean Infection totals not available . Former Soviet Union and Eastern bloc countries Hepatitis B: 892,600 Hepatitis C: 121,500 HIV: 23,800 . China Hepatitis B: 4.16 mil. Hepatitis C: 2.27 mil. HIV: 570 . India Hepatitis B: 6.26 mil. Hepatitis C: 810,900 HIV: 8,600 . Other Asian/ Pacific Island Hepatitis B: 2.51 mil. Hepatitis C: 820,400 HIV: 25,700 �2000 San Francisco Chronicle Page A1 ____________________________________*______________________________________ 3. CORRECTIONS: GLOBAL PUSH FOR SAFE NEEDLES ARTICLE Gordon Larsen, WHO/V&B, provided these corrections and clarifications. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ From: [][/email] To: [][/email] Subject: Re: New San Francisco Chronicle article on unsafe injection Yes; as it says, "things are moving", but there are a number of inaccuracies in this article: - there is no plan to "phase out all sterilizables by the end of 2003" Although the percentage of sterilizables used is falling and will probably continue to do so, we estimate that some 50% of all routine immunizations will still be given by sterilizables by the end of 2003. We are emphasising the need for improved management and monitoring of sterilization in the new "safety of injections" policy, (eg, by using TST spots, etc), but definitely do not want to give the impression that all counties will be compelled to change to A-Ds by that date. - in the same way, "donors and other partner organizations involved in immunization programmes are urged to finance only A-Ds or sterilizables, but not standard disposables by the end of 2001 ....." - 1999 purchases of immunization A-Ds by UNICEF and PAHO alone are expected to total approximately 150 million, and available global production capacity in 1999 was at least twice that. Production capacity of the established manufacturers in 2000 will be at least 500 million immunization A-Ds, and with technology transfer projects currently in hand, capacity seems likely to be around 1000 million. Some of these TT projects will also provide substantial numbers of A-Ds for therapeutic injections. Gordon

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