The Injection Century: Massive Unsterile Injections and the Emergence of Human Pathogens

[Guest guest]

CDC HIV/STD/TB Prevention News Update

Thursday, December 13, 2001

" The Injection Century: Massive Unsterile Injections and the Emergence of

Human Pathogens "

Lancet (12.08.01) Vol 358; No 9297: P 1989-1992::Ernest Drucker;

G Alacabes; Preston A Marx

The World Health Organization (WHO) estimates that every

year unsafe injections result in 80,000 to 160,000 new HIV-1

infections, 8 million to 16 million hepatitis B infections, and

23 million to 47 million hepatitis C infections worldwide.

Together, these illnesses account for 13 million deaths. Even

within WHO regional immunization programs, an estimated 30

percent of injections are done with unclean syringes that are

commonly reused.

Unsterile administration of drugs also takes place on a

large scale outside medical practice. In many places in the less-

developed world, injectable medications, syringes and needles are

readily available in rural villages. And syringes are now widely

available for the use of illicit substances. Once restricted to

North America and Europe, intravenous opioids are now taken in

more than 120 countries by 10 million to 15 million illicit drug

injectors. The numbers continue to grow, especially in the former

Soviet Union (2 million to 3 million injectors), in Asia, Africa

and Latin America.

Historically, the greatest change in the use of syringes

arose with penicillin after World War II. The mass production and

low price of penicillin led to worldwide export, and it became

synonymous with injections. New high-volume manufacturing

technologies of plastic injection equipment were developed by the

1960s, prices fell accordingly and, today, a small factory with

six workers can make 100 million sets per year at a cost of about

15 cents each.

The role of injecting in the AIDS epidemic is now fully

recognized. Intravenous drug use is thought to account for most

new incident HIV-1 infections in many cities in the United States

and Europe and associated regional outbreaks in Russia and Asia.

Although hepatitis C was not identified until 1989, its epidemic

spread seems to be closely tied with 20th century medical

developments including (unsterile) injection, blood transfusion,

and dialysis.

More than 170 million individuals worldwide are chronic

carriers of hepatitis C, including 1-2 percent of adult

populations of developed countries and 5-10 percent in some less-

developed countries.

By altering the ecological balance of the routes of

transmission of human pathogens, massive unsterile injecting

creates new biological links between human and microorganisms and

the risk of new opportunities for the transmission and

recombination of these organisms. Unsterile injecting may play a

part in facilitating the adaptation of animal pathogens to human

hosts. In the mid-20th century, at least three fully adapted

pathogens emerged from animals to become fully epidemic for

humans (HIV-1 group M, and HIV-2 subtypes A and .

In the 75 years before World War II, a network of colonial

and missionary clinics was the principal base of modern medicine

in sub-Saharan Africa. Sterilization equipment was available and

sterile injecting procedures were generally followed. However,

after WWII, independence movements took control of most medical

care systems, and this era saw the rise of injection doctors

working in country clinics.

The advent of antibiotic therapies quickly built faith in

the power of injections. Studies done in several sub-Saharan

countries in the 1960s indicated that 25-50 percent of households

had received an injection within the previous two weeks. By the

1990s, injections were being administered at 60-96 percent of

outpatient visits.

Other important events in the history of sub-Saharan Africa

might explain the emergence of epidemic HIV by 1959. These

include population growth, urbanization, massive rural migration,

regional wars, changing sexual practices and increased hunting of

simians. None of the suspected vaccine campaigns, like the oral

polio vaccine thought to be contaminated by SIV, offers a

biologically plausible or timely explanation of the simultaneous

appearance of multiple strains of HIV in multiple locations in

Africa.

The emergence of epidemic HIV and hepatitis C virus suggest

that massive unsterile injections can become an important new

catalyst for biological change, and this change can profoundly

reorder some fundamental biological relations between agency,

host and environment, with unpredicted effects for public health.

As the authors note, " Ultimately, the driving force behind

massive unsterile injecting is the global demand for injectable

drugs and their therapeutic effects. But the risk that injecting

these drugs entail are a function of continuing disparities in

access to modern medical care. " If these realities are not

addressed in the global marketplace in drugs and technology,

unsterile injections will continue to spread infectious diseases

throughout the 21st century.

The authors are beginning to collect used syringes and blood

samples in HIV endemic areas of Africa where populations also

have frequent exposure to SIV. These syringes and samples will be

tested by PCR analysis for traces of viral contaminants (DNA of

SIV, HIV, hepatitis B virus, and hepatitis C virus) and the

patterns of exposure to simians and to unsterile injecting will

be documented. These studies will allow the authors to better

understand the historical and contemporary role of unsterile

injecting in emergent infections.

[Guest guest]

CDC HIV/STD/TB Prevention News Update

Thursday, December 13, 2001

" The Injection Century: Massive Unsterile Injections and the Emergence of

Human Pathogens "

Lancet (12.08.01) Vol 358; No 9297: P 1989-1992::Ernest Drucker;

G Alacabes; Preston A Marx

The World Health Organization (WHO) estimates that every

year unsafe injections result in 80,000 to 160,000 new HIV-1

infections, 8 million to 16 million hepatitis B infections, and

23 million to 47 million hepatitis C infections worldwide.

Together, these illnesses account for 13 million deaths. Even

within WHO regional immunization programs, an estimated 30

percent of injections are done with unclean syringes that are

commonly reused.

Unsterile administration of drugs also takes place on a

large scale outside medical practice. In many places in the less-

developed world, injectable medications, syringes and needles are

readily available in rural villages. And syringes are now widely

available for the use of illicit substances. Once restricted to

North America and Europe, intravenous opioids are now taken in

more than 120 countries by 10 million to 15 million illicit drug

injectors. The numbers continue to grow, especially in the former

Soviet Union (2 million to 3 million injectors), in Asia, Africa

and Latin America.

Historically, the greatest change in the use of syringes

arose with penicillin after World War II. The mass production and

low price of penicillin led to worldwide export, and it became

synonymous with injections. New high-volume manufacturing

technologies of plastic injection equipment were developed by the

1960s, prices fell accordingly and, today, a small factory with

six workers can make 100 million sets per year at a cost of about

15 cents each.

The role of injecting in the AIDS epidemic is now fully

recognized. Intravenous drug use is thought to account for most

new incident HIV-1 infections in many cities in the United States

and Europe and associated regional outbreaks in Russia and Asia.

Although hepatitis C was not identified until 1989, its epidemic

spread seems to be closely tied with 20th century medical

developments including (unsterile) injection, blood transfusion,

and dialysis.

More than 170 million individuals worldwide are chronic

carriers of hepatitis C, including 1-2 percent of adult

populations of developed countries and 5-10 percent in some less-

developed countries.

By altering the ecological balance of the routes of

transmission of human pathogens, massive unsterile injecting

creates new biological links between human and microorganisms and

the risk of new opportunities for the transmission and

recombination of these organisms. Unsterile injecting may play a

part in facilitating the adaptation of animal pathogens to human

hosts. In the mid-20th century, at least three fully adapted

pathogens emerged from animals to become fully epidemic for

humans (HIV-1 group M, and HIV-2 subtypes A and .

In the 75 years before World War II, a network of colonial

and missionary clinics was the principal base of modern medicine

in sub-Saharan Africa. Sterilization equipment was available and

sterile injecting procedures were generally followed. However,

after WWII, independence movements took control of most medical

care systems, and this era saw the rise of injection doctors

working in country clinics.

The advent of antibiotic therapies quickly built faith in

the power of injections. Studies done in several sub-Saharan

countries in the 1960s indicated that 25-50 percent of households

had received an injection within the previous two weeks. By the

1990s, injections were being administered at 60-96 percent of

outpatient visits.

Other important events in the history of sub-Saharan Africa

might explain the emergence of epidemic HIV by 1959. These

include population growth, urbanization, massive rural migration,

regional wars, changing sexual practices and increased hunting of

simians. None of the suspected vaccine campaigns, like the oral

polio vaccine thought to be contaminated by SIV, offers a

biologically plausible or timely explanation of the simultaneous

appearance of multiple strains of HIV in multiple locations in

Africa.

The emergence of epidemic HIV and hepatitis C virus suggest

that massive unsterile injections can become an important new

catalyst for biological change, and this change can profoundly

reorder some fundamental biological relations between agency,

host and environment, with unpredicted effects for public health.

As the authors note, " Ultimately, the driving force behind

massive unsterile injecting is the global demand for injectable

drugs and their therapeutic effects. But the risk that injecting

these drugs entail are a function of continuing disparities in

access to modern medical care. " If these realities are not

addressed in the global marketplace in drugs and technology,

unsterile injections will continue to spread infectious diseases

throughout the 21st century.

The authors are beginning to collect used syringes and blood

samples in HIV endemic areas of Africa where populations also

have frequent exposure to SIV. These syringes and samples will be

tested by PCR analysis for traces of viral contaminants (DNA of

SIV, HIV, hepatitis B virus, and hepatitis C virus) and the

patterns of exposure to simians and to unsterile injecting will

be documented. These studies will allow the authors to better

understand the historical and contemporary role of unsterile

injecting in emergent infections.