Proceedings--Workshop on Needle Exchange and Bleach Distribution Programs (1994) / Chapter Skim
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BLEACH DISTRIBUTION PROGRAMS
BLEACH DISTRIBUTION PROGRAMS
Pages 253-304
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From page 255... ...
can be found in injection equipment and the efficacy of bleach as a disinfectant, and the compliance of IDUs to bleach cleansing protocols, under simulated field conditions. Bloody needle/syringe units collected from Miami, Florida, shooting galleries or from community outreach prevention participants were selected for these studies.
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From page 256... ...
Injecting drug users value the mixing of blood for several reasons: some repeated pumping and drawing back of the blood-drug mix allows the user to titrate the dose and avoid overdose or the full effects of potential contamination often present in drug preparations; the drawing of blood into the syringe also indicates that the needle has hit a usable vein; some believe that this "pre-m~xing" enhances a drug's effects. Since injecting drug users often inject with needles and syringes previously used by others, particularly if they are administering the drugs in "shooting galleries" (places where injecting drug users gather to take drugs)
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From page 257... ...
Environments such as bath houses, houses or areas of prostitution, and shooting galleries represent this scenario.~° Frequent injection in "shooting galleries" long has been considered to be particularly associated with HIV infection among IDUs.~ ~2 i3 In these environments, individuals rent used needle and syringe units which typically are reconditioned to extend their usable life far beyond nine uses, which is the average number reported by injection drug users who reuse their own or share their personal injecting equipment with others.l4 The risk-laden practices of "frontloading" and "backloading" are also more likely to occur in these group environments.8 9 Research and clinical observation suggest that "booting", the use of shooting galleries, and the sharing of needles combine to explain the increasing Dronortion of 1~ ~ 1 ~ injecting drug users infected with HI-' mu eh^~;~- ~F ~1= /~`,';~= .; her . 111~ b11~1111g Ot llO~UlO/ bylill8~ U111~ 11~ been well documented as a primary vector for the spread of the AIDS virus among IDUs.~23 In particular, frequency of injection in shooting galleries has been associated with HIV-1 seropositivicy among IDUs.4s6 Recent studies have identified the presence of HIV-1 antibody in a large sample of needle/syringe units collected from shooting galleries in Miami, Florida.78 In an effort to reduce exposure to HIV-1 among out-of257
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From page 258... ...
This article presents the research procedures and findings of these interdisciplinary studies that attempt to establish empirical bases underlying revised guidelines and protocols that will increase the effectiveness of risk reduction strategies utilized in community prevention programs. While household bleach has been shown to inactivate HIV-1 in clinical and laboratory settings,~9 there have been few studies which have directly examined the efficacy of bleach disinfection of injection equipment under conditions which realistically approximate the field conditions faced by IDUs.202~.
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From page 259... ...
Needle/syringe units are routinely reconditioned to extend their useful life far beyond the average nine uses reported by injecting drug users in Miami who reuse or share personal works.7 In order to examine the potential for HIV-l transmission through the use of injection equipment available in these high-risk settings, needle/syringe units were collected from these shooting galleries frequented by parenteral drug users in Miami and were tested for antibodies to HTV-1 (see Table I)
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From page 260... ...
in needle/syringe units, addressed the effects of bleach cleansing. While household bleach has been shown to inactivate HIV-1 in clinical and laboratory settings, there have been few studies which have directly examined the efficacy of bleach disinfection of injection equipment under conditions which realistically approximate the field conditions faced by IDUs.
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From page 261... ...
These results validated the methodology for the simulated field cleansing of the needle/syringe units collected from the Miami shooting galleries. Simulated Field Cleansing of Used Needles/Syringes Using a method previously described,7 the needle/syringe units were graded as to appearance and only those showing visible blood were selected and numbered.
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From page 262... ...
The results of testing the needle/syringe units, collected from four Miami shooting galleries, are provided in Table 4. Of the 108 needIe/syringe units not rinsed with bleach and water, more than half of these tested positive for HTV-]
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From page 263... ...
Cells were killed by exposure to 30 seconds or longer of undiluted bleach.
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From page 264... ...
Second, blood was left in syringes for various periods of time up to 24 hours, to simulate needles utilized in shooting galleries. Third, the cleansing procedure taught in the Miami community HIV-]
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From page 265... ...
Our investigations focused on the specific complianceinfluencing factors of protocol recall and knowledge, as demonstrated by skills performance. Shortly following enrollment in an HIV risk reduction study, a cohort of IDUs were taught a bleach cleansing procedure that was "standard" among similar projects in a national program sponsored by the National Institute on Drug Abuse.
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From page 266... ...
Although these data do not inform us Of accrual arlherence in the fie.lr1 ~itil~tir~n · · ~ · they are instructive regarding those bleach cleansing steps which need special emphasis. They also remind us that, regardless of how effective bleach may be in killing the virus, the probability of reliable performance of protocol procedures is contingent upon the number of steps and precision required.
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From page 267... ...
It is alarming that more than 50% of the cleansed needle/syringe units collected more recently from shooting galleries tested positive for antibody to HIV-l, illustrating the potential of exposing other IDUs to HIV-~. In the study conducted two years previously, the seropositivity of needIe/syringe units with visible blood residue collected from three Miami shooting galleries was only 20%.78 These data emphasize the necessity of continuing to provide and expand prevention programs even in high prevalence settings.
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From page 268... ...
The Miami intervention site has maintained the standard protocol except to advise the clients to have minimal exposure of no less than 15 seconds with each of the two bleach flushes followed by two water rinses. The San Francisco site has opted for more bleach flushes, recommending five such bleach cleansing steps with the reminder that bleach must be inside the syringe and needle for at least 30 seconds.
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From page 269... ...
Risk factors for human immunodeficiency virus infection in intravenous drug users.
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From page 270... ...
McCoy CB, Shah SM, Page IB, Rivers JE, Weatherby NE, Chitwood DD, and Mash DC. Preliminary laboratory studies of inactivation of HIV-1 in needles and syringes containing infected blood using undiluted household bleach.
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From page 271... ...
Copping, running and paraphernalia laws: Contextual variables and needle risk behavior among injection drug users in Denver. Human Organization.
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From page 273... ...
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From page 276... ...
"Inactivation of Human Immunodeficiency virus-1 at Short Time Intervals Using Undiluted Bleach" Joumal of Acquired Immune Def ciency Syndromes 6:218-219, 1993.
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From page 277... ...
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From page 278... ...
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From page 279... ...
Table ~ SKILLS/COMPLIANCE EVALUATION NEEDLE CLEANING SKILL DEMONSTRATION: DETAILED Number of Times Discarded Needle/Syringe Waste F,11.d Appropriately Filled Needle/Syringe I % of Total | One | Tv To or l R % With Bleach l (n)
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From page 280... ...
FIGURE 1 MIAMI NEEDLE PROJECT Field needles collected and graded Randomization Laboratory N o Bleach Bleach HIV- ~ Western Blot HIV- ~ p24 antigen capture HIV- ~ culture 280
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From page 281... ...
0.3 0.2 0.1 0.0 1 ~ SOS .~' TV _ '5% 1 2 3 4 5 6 7 8 9 10111213141SI617181920212223242S2627t8t9303t3233343536373839404142434445 Days Shooting Three Times a Day 0.9 Q8 0.7 0.6 o.s 0.4 0.3 0.2 Q1 0.0 1.0 0.9 0.8 0.? 0.6 0.5 ,~ 04 0.3 0.2 0.1 0.0 S6X , golf 1 I ~ I ~ 10,it / SO 1 2 3 4 5 6 7 t 9 10 I t 12 13 14 15 16 t7 18 19 20 21 22 23 24 25 26 27 2t 29 30 31 32 ~ 34 ~ X 37 38 39 40 41 42 43 44 45 Days Shooting Five Times A Day ~ at' I ~ I / BOXY .
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From page 282... ...
Figure 3 MEASUREMENT AND POLICY ISSUES OF PROTOCOL RECOMMENDATIONS /UTILI~TION INTERVENTION/THERAPEUTIC PROTOCOL None -- -- - > Partial -- -- - > Complete Effectiveness Compliance EFFECTIVENESS None -- -- - > Partial -- -- - > Complete Risk Reduction (Prevention) Curative Value Increase Survival Decrease Mortality Increase Satisfaction Quality of Life Decrease Pain Efficacy (Costs/Benefits)
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From page 283... ...
FIGURE 4. | DALE'S LEARNING CONE OF EXPERIENCE ~ | A People Generally Remember: 10% of what they read 20% of what they hear 30% of what they see 50% of what they hear / and see 70% of what they / my or write 90% of what they/ say as they do / a thing / ~ / 7*
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From page 284... ...
Laboratories began research with the human immunodeficiency virus (HIV) soon after.
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From page 285... ...
In the laboratory, cell free HTV can be grown in CD4+ tissue culture cells. Generally, the virus containing supernatant fluid is harvested and the titer of cell free virus ranges from 104 to 106 per unit volume, titers higher than generally found in blood.
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From page 286... ...
CDC recommends a 1:100 dilution of household bleach for cleaning blood-contaminated environmental surfaces that have been previously cleaned of visible material (22~. The underlying principle is to remove as much of the organic material prior to using a Cl compound for disinfection.
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From page 287... ...
This is the only safe recommendation for injecting drug users who cannot or will not stop injecting drugs. Disinfection procedures can reduce the amount of HIV or HIV-infected cells present in the injecting equipment, but can not guarantee complete inactivation even time.
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From page 288... ...
1991. Survival and Disinfectant Inactivation of the Human Immunodeficiency Virus: A Critical Review.
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From page 289... ...
at short time intervals using undiluted bleach.
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From page 290... ...
TABLE 1 Descending Order of Resistance to Germicidal Chemicals* BACTERIAL SPORES Bacillus subtilis MYCOBACTERIA Mycobacterium tuberculosis var.
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From page 291... ...
CDC Process Classification "Sterilization" (sporicidal chemical prolonged contact time) "High-Level Disinfection" (sporicidal chemical, short contact time)
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From page 292... ...
Ethanol Isopropyl ChIorhexidine solutions Quaternary Ammonium compounds Phenolics Detergents Triton X-100 Tri (n-butyl) phosphate + sodium cholate Spermicides Nonoxynol - 9 *
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From page 293... ...
HTV in pelleted state (20) 52,500 ppm NaOCl = Undiluted household bleach *
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From page 294... ...
. Insufficient contact time of disinfectant with the syringe was one of several factors hypothesized to be related to the apparent modest protective effect of disinfections Several recent laboratory studies have noted that 30 seconds of continuous contact time 294 .
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From page 295... ...
METHODS To obtain a more objective assessment of TDU syringe cleaning techniques than have been typically obtained through questionnaires, we recently conducted a study which videotaped 161 active IDUs demonstrating the cleaning strategies used during their last injection episode. Videotaping allowed us to obtain bleach contact time, and quantity techniques intrinsic to the IDU environment.
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From page 296... ...
of the 85 bleach users had a total contact time of less than 30 seconds, and that 39 (demo) had a total flush time less than 30 seconds.
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From page 297... ...
The discrepancy between the considerations recently disseminated in the NIDA/CSAT/CDC Prevention Bulletining and the actual practices observed here indicate the need for further education of IDUs on effective HIV prevention strategies. Whether drug users are amenable to using bleach and lengthening the contact time with the disinfectant requires further study.
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From page 298... ...
McCoy CB, Rivers JE, Chitwood DD, Mash DC, Weatherby NE, Inciardi JA, Shah SM, Brown BS. Inactivation of human immunodeficiency virus-1 at short time intervals using undiluted bleach.
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From page 299... ...
Inadequate bleach contact times during syringe cleaning among injection drug users. J Acquir Immune Defc Syndr 1994, 7(7)
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From page 300... ...
TABLE 1 Demographic Characteristics of Injection Drug Users Enrolled in Study of Bleach Contact Times, Baltimore Maryland, 1992 Characteristic N Percent (161) Gender Male 144 89.4 Female 17 10.6 Race Age Education Income HIV Status Black Non-black <35 >35 Median 150 11 58 1 nO 38.5 range < 12 years 79 49.1 > 12 years 82 50.9 >$2500/6 month 22 13.7 <$2500/6 months 134 83.2 No Income 4 2.5 Unknown ~ 0.6 93.2 7.8 36.0 64.0 (25.2 - 64.1)
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From page 301... ...
Total Draw Time 12.4 4.l 45.0 Total Contact Time IS.2 4.3 138.3 Total Flush Time 31.5 8.S 153.4 TABLE 3 Proportion of Bleach Users with Total Contact and Total Flush Times Less Than 30 Seconds and Greater Than or Equal to 30 Seconds N (85) Percent Total Contact Time < 30 seconds 68 80.0 > = 30 seconds 17 20.0 Total Flush Time (Draw + Contact)
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From page 302... ...
3.18 [1.21,8.34] HIV Status Seronegative 27 (69.2)
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From page 303... ...
But that is not a practical option in the real world of injection drug use. Some general principles about how to disinfect syringes with bleach are known, however: reducing the bioburden -- the amount of blood or other material that wall interfere with the effectiveness of the bleach -- is important; contact time is very important (Ionger is better)
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