Needles and syringes as Ebola fomites

[Emily]

http://www.mcb.uct.ac.za//ebola/ebolasho.html

Excerpts on Ebola virus from:
EMERGING AND RE-EMERGING VIRUSES: AN ESSAY
By:
Alison Jacobson
Department of Microbiology
University of Cape Town

...

The index case in 1976 was never identified, but this large outbreak resulted in 280 deaths of 318 infections. The outbreak was primarily the result of person to person spread and transmission by contaminated needles in outpatient and inpatient departments of a hospital and subsequent person to person spread in surrounding villages. In serosurveys in Zaire, antibody prevalence to Ebola virus has been 3 to 7%. The incubation period for needle- transmitted Ebola virus is 5 to 7 days and that for person to person transmitted disease is 6 to 12 days...

[Emily]

Re: Needles and syringes as Ebola fomites

http://www.ncbi.nlm.nih.gov/pubmed/10593026

Bull World Health Organ. 1999;77(10):789-800.
Unsafe injections in the developing world and transmission of bloodborne pathogens: a review.
Simonsen L1, Kane A, Lloyd J, Zaffran M, Kane M.
Author information

1World Health Organization, Geneva, Switzerland.

Abstract

Unsafe injections are suspected to occur routinely in developing countries. We carried out a literature review to quantify the prevalence of unsafe injections and to assess the disease burden of bloodborne infections attributable to this practice. Quantitative information on injection use and unsafe injections (defined as the reuse of syringe or needle between patients without sterilization) was obtained by reviewing the published literature and unpublished WHO reports. The transmissibility of hepatitis B and C viruses and human immunodeficiency virus (HIV) was estimated using data from studies of needle-stick injuries. Finally, all epidemiological studies that linked unsafe injections and bloodborne infections were evaluated to assess the attributable burden of bloodborne infections. It was estimated that each person in the developing world receives 1.5 injections per year on average. However, institutionalized children, and children and adults who are ill or hospitalized, including those infected with HIV, are often exposed to 10-100 times as many injections. An average of 95% of all injections are therapeutic, the majority of which were judged to be unnecessary. At least 50% of injections were unsafe in 14 of 19 countries (representing five developing world regions) for which data were available. Eighteen studies reported a convincing link between unsafe injections and the transmission of hepatitis B and C, HIV, Ebola and Lassa virus infections and malaria. Five studies attributed 20-80% of all new hepatitis B infections to unsafe injections, while three implicated unsafe injections as a major mode of transmission of hepatitis C. In conclusion, unsafe injections occur routinely in most developing world regions, implying a significant potential for the transmission of any bloodborne pathogen. Unsafe injections currently account for a significant proportion of all new hepatitis B and C infections. This situation needs to be addressed immediately, as a political and policy issue, with responsibilities clearly defined at the global, country and community levels.

[Emily]

Re: Needles and syringes as Ebola fomites

Unsafe injections could be the most dangerous fomites of them all due to serial passage adaptation.

The injection century: massive unsterile injections and the
emergence of human pathogens

Ernest Drucker, Phillip G Alcabes, Preston A Marx

...

Although many animal viruses have made the genetic
transition to human pathogens in the past?eg,
smallpox?people have been exposed to SIVs for
millennia, living in close proximity to and hunting
primates in Africa19 without the emergence of HIV. But, in
the mid-20th century, at least three fully adapted HIV
strains emerged to become epidemic (HIV-1 group M,
and HIV-2 subtypes A and B), and five or six other HIVs
also arose, but did not complete the full transition to
epidemic status.20?22 To become a transmissible pathogen
in human beings, every one of these SIVs must have
undergone full adaptation to human hosts in a short
period. The crossover of several SIVs and the emergence
of several fully adapted strains of HIV in a brief period
suggests that some biologically relevant modern event
(such as increases in the probability of serial passage
through unsterile injecting) might be responsible.
Alternatively, if HIV existed in Africa earlier but was
hidden in remote pockets that never emerged as visible or
reportable disease, as Hahn and others have proposed,23,24
the increased transmission opportunities associated with
greatly increased unsterile injections in the 1950s could
have operated similarly to their role in the Egyptian
schistosomiasis campaign?ie, by disseminating
previously sequestered viruses and enabling their
epidemic emergence. In either case, the history of
injecting in Africa is of great interest with respect to the
origin and emergence of the AIDS pandemic.

...

Although there is greater awareness of this problem
today?eg, the work of the Safe Injecting Global
Network,29 as recently as 1998, WHO still recommended
re-use of syringes up to 200 times in vaccination
programmes,30 relying on sterilisation routines that
WHO?s own studies show are usually not followed...

Serial human passage of simian immunodeficiency virus by unsterile injections and the emergence of epidemic human immunodeficiency virus in Africa

[Emily]

Re: Needles and syringes as Ebola fomites

A danger of unintentional serial passage of Zaire ebola - creation of prolonged persistence:

http://www.sciencedirect.com/science...42682299999154

Virology
Volume 262, Issue 1, 15 September 1999, Pages 114?128
Ebola Virus Defective Interfering Particles and Persistent Infection
Philippe Calain,Martha C. Monroe,Stuart T. Nichol
Elsevier 15 September 1999
Abstract

Ebola virus (Zaire subtype) is associated with high mortality disease outbreaks that commonly involve human to human transmission. Surviving patients can show evidence of prolonged virus persistence. The potential for Ebola virus to generate defective interfering (DI) particles and establish persistent infections in tissue culture was investigated. It was found that serial undiluted virus passages quickly resulted in production of an evolving population of virus minireplicons possessing both deletion and copyback type DI genome rearrangements. The tenth undiluted virus passage resulted in the establishment of virus persistently infected cell lines. Following one or two crises, these cells were stably maintained for several months with continuous shedding of infectious virus...

[AlaskaDenise]

Re: Needles and syringes as Ebola fomites

...The tenth undiluted virus passage resulted in the establishment of virus persistently infected cell lines...

Amazing!

.

[Emily]

Re: Needles and syringes as Ebola fomites

http://bmb.oxfordjournals.org/content/73-74/1/123.short

Br Med Bull (2005) 73-74 (1): 123-137. doi: 10.1093/bmb/ldh054
Lessons from nosocomial viral haemorrhagic fever outbreaks
Susan P. Fisher-Hoch
- Author Affiliations

Department of Epidemiology, University of Texas Houston Health Science Center, School of Public Health, Brownsville Campus, Brownsville, TX, USA

Abstract

The outbreak of Marburg haemorrhagic fever in Angola in 2004?2005 shows once again the devastating and rapid spread of viral haemorrhagic fevers in medical settings where hygiene practices are poorly applied or ignored. The legacy of years of war and poverty in Angola has resulted in very poor medical education and services. The initial high rate of infection among infants in Angola may have been related to poor hospital practices, possibly administration of vaccines. Though the outbreak in Angola was in a part of Africa not previously known to have filovirus infection, prior ecological modelling had predicted this location and many others. Prevention of future outbreaks will not be easy. The urgent need is dissemination of knowledge and the training, discipline and resources for good clinical practice. Educating the public to demand higher standards could be a powerful tool. Good practices are difficult to establish and maintain on the scale needed.

[Emily]

Re: Needles and syringes as Ebola fomites

http://www.ncbi.nlm.nih.gov/pmc/arti...536233/?page=1

Bull World Health Organ. 1983; 61(6): 997?1003.
PMCID: PMC2536233
Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread
Roy C. Baron, Joseph B. McCormick, and Osman A. Zubeir

Ebola virus was first identified in 1976 (1-3) in
association with two simultaneous outbreaks of
haemorrhagic fever in southern Sudan (4) and northeastern
Zaire (5). The illness included fever, headache,
and malaise at onset, with profuse vomiting
and diarrhoea developing 2-4 days later (6-9).
Altogether, 55% of the cases in Sudan and 887o in
Zaire were fatal. Haemorrhagic manifestations were
prominent features in patients who died, but were observed
less commonly in survivors. The outbreaks
were recognized after they had been amplified within
hospital settings, and were further perpetuated by
secondary household spread. While the use of unsterile
needles was implicated as a mode of transmission
in the Zaire hospital, much of the person-toperson
transmission apparently resulted from close
physical contact. In the Sudan outbreak, the first few
cases occurred among textile factory workers in the
town of Nzara (4, 10, 11). However, no animal
reservoir was found during subsequent environmental
studies in the factory (12), and the natural
host of the virus has remained undetermined.

[Emily]

Re: Needles and syringes as Ebola fomites

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153011/

Epidemiol Health. 2014; 36: e2014014.
Published online Aug 18, 2014. doi: 10.4178/epih/e2014014
PMCID: PMC4153011
What do we really fear? The epidemiological characteristics of Ebola and our preparedness
Moran Ki

...

The first known Ebola patient was a 44-year old man who had managed the construction of a school in northern Zaire (currently the Democratic Republic of Congo, DRC). On August 26, 1976, the patient presented at a hospital with a high fever. He received an injection of chloroquine for presumptive malaria and had a clinical remission of his symptoms the next four days. On the sixth day, the patient had a fever of 39.2?C and began to hemorrhage. On September 8 (the 14th day), the patient died with severe hemorrhage. For the following months, until late-October, there was an outbreak of Ebola, with 280 of the 318 patients subsequently dying from the disease [1].

Unfortunately, in the hospital that treated the first case of Ebola, all 17 hospital employees were exposed to the patient, resulting in 13 being infected, and 11 dying. When the pathway of infection for this outbreak was examined, 85 of the 318 patients (26.7%) were found to have received an injection at their respective hospitals. There were no survivors among the patients who were infected through injections. At the time, syringes and needles were sometimes rinsed between patients in a pan of warm water. At the end of the day they were sometimes boiled [1].

When this outbreak was investigated to determine the source of the infection, no particular behavior of interest was presented by the first case prior to infection. Although the patient purchased, cooked, and ate bushmeat (antelopes), other members of his party who had touched and eaten the same bushmeat had not contracted Ebola. During the search through the hospital?s records from January 1974 to the beginning of the epidemic, only one case resembled Ebola. This case was an adult man who was hospitalized on August 20, 1976, with ?epistaxis and diarrhea.? The person left against medical advice on August 30, and could not be found, despite an active search during the investigations [1]. It is possible that the first Ebola case was injected using a contaminated syringe or needle that had been used to treat the patient with ?epistaxis and diarrhea.?...

[alert]

Re: Needles and syringes as the most dangerous Ebola fomites

It seems unusual that people infected with Ebola by syringe injection would have a higher fatality rate than those infected otherwise, especially considering other patients might have repeated exposure to the virus, perhaps resulting in a higher viral load.

Or could patients infected by injection have also received co-infections (malaria, hepatitis, etc.) explaining the 100% mortality rate?

[Emily]

Re: Needles and syringes as the most dangerous Ebola fomites

Alert, I think they screened for all tropical diseases known in 1976 during that outbreak, but a retrospective screening of samples stored from the outbreak found HIV in some of them. Interestingly, that remains the oldest source of HIV identified. I think the virus is dated to the early 1930's somehow, though, and that is about the time the Yambuku Mission Hospital and the heavy use of unsterilized syringes started.
http://www.ncbi.nlm.nih.gov/pubmed/3336420

N Engl J Med. 1988 Feb 4;318(5):276-9.
The prevalence of infection with human immunodeficiency virus over a 10-year period in rural Zaire.
Nzilambi N1, De Cock KM, Forthal DN, Francis H, Ryder RW, Malebe I, Getchell J, Laga M, Piot P, McCormick JB.
Abstract
In 1985 we tested 659 human serum samples, collected in the remote Equateur province of Zaire in 1976, for antibody to human immunodeficiency virus (HIV). Five (0.8 percent) were positive, and HIV was isolated from one of these. Follow-up investigations in 1985 revealed that three of the five seropositive persons had died of illnesses suggestive of acquired immunodeficiency syndrome (AIDS), and two remained healthy but seropositive....

McCormick was talking about that in an interview on television tonight.

[Emily]

Re: Needles and syringes as Ebola fomites

http://www.popline.org/node/367731

A syringe that self-destructs.
Author: Newman A
Source: JOHNS HOPKINS MAGAZINE. 1989 Feb; 41(1):10-1.
Abstract:

The reuse of unsterilized syringes is spreading AIDS, hepatitis B and the African Ebola-Marburg virus. In the US 25% of the AIDS cases are related to intravenous drug abuse. In developing countries syringe reuse is related to poor health care delivery systems. In these countries syringes are used over 5 times before sterilization; in some countries the syringes are distributed by people who sell injections of vitamins and antibiotics. In 1986 Halsey challenged the medical community to design a syringe that would not transmit these diseases, and shortly thereafter a separate challenge was issued by the World Health Organization. The requirements of this syringe are its self destruction after use, little requiring retraining of medical personal, and no more than 1 cent to the cost, and be simple to make. These challenges brought 70 various syringe entries and all but 3 were eliminated. The Hopkins syringe is similar to a regular syringe except it has a polymer insert that seals up after one use. When water flows around the polymer insert it swells and closes off the passageway preventing any liquid from flowing in or out of the syringe. Another syringe seals up in 2.5 minutes which allows the health worker time to draw and inject a patient before the syringe destructs. By using hydrogels that are already approved for use in contact lenses and food substances, the safety has been tested. Companies looking at production costs estimate that the polymer insert will add only 1/4 of a cent to the cost of a syringe.
Language: English Year: 1989
- See more at: http://www.popline.org/node/367731#sthash.oKDSnnbQ.dpuf

http://www.sciencedirect.com/science...62407911627796

New Scientist

Volume 212, Issue 2838, 12 November 2011, Pages 31
Inventor: My self-destructing syringe could save millions of lives
Jon White
Unsafe injections kill 1.3 million people a year says Marc Koska, who is on a mission to stop syringe reuse...