1256 STERILITY PROBLEMS AND THE DIABETIC SIR,-Dr Koivisto and Dr Felig (May 20, p. 1072) suggest that routine skin preparation in diabetic patients may not be necessary to prevent infection at injection sites; we suggest that the sterility of the injection materials deserves consideration. Several aspects of the use of disposable and non-disposable needles and syringes by diabetics have been discussed in your columns over the years. When one of our patients, a 13-yearold girl, had a subcutaneous abscess at the site of her insulin injections, from which Staphylococcus aureus was cultured, we decided to do a bacteriological study of the materials used by insulin-dependent diabetic children.’ We studied 41 diabetics aged 3-16 years. Over a period of 2 years their injection material and insulin were checked four times for sterility. To disinfect the top of the insulin vial and the site of injection 28 children used ethanol 75%, 7 used chlorhexidine digluconate in ethanol 75%, and 6 used diethylether. 28 patients used non-disposable needles and syringes which were stored in ethanol 75% by 25 patients and stored in the dry state by 3. Swabs were taken from the patients’ noses and from the skin at the radial pulse and the site of insulin injections, and from the syringes and the inside of the containers used for storing needles and syringes. Blood agar, McConkey agar, Sabouraud agar, and Lowenstein-Jensen (without glycerol) were used as culture media, as well as brain-heart broth. The needles were stabbed thrice in the solid media. The container fluid and the insulin from vials were filtered and the filters were cut aseptically and cultured on the solid media.
From 100 unused disposable needles and syringes and the insulin from 17 unused vials no microorganisms could be cultured. 15 children used contaminated needles and syringes and 18 children had contaminated containers (see table). Only 5 of POSITIVE CULTURES
was often not sterile (1-100 bacteria/ml) may be explained by the non-sporicidal activity of alcohol and the reduced antibacterial activity due to evaporation of the ethanol and contamination with organic matter.3 The containers were on the average. only two-thirds full. The Dutch Diabetic Association used to advise 75% ethanol as well as diethylether for cleaning the skin and the top of the insulin vial, and 7 patients used ether despite our instructions to use 0 - 5 % chlorhexidine digluconate in 75% ethanol. Diabetic children should use disposable needles and syringes. The alternative, boiling needles and syringes immediately before use, does not guarantee sterility but is preferable to storing in a disinfectant. In view of the frequency of contaminatipn of the insulin vials used by children provided with disposable needles and syringes, smaller vials or even singledose insulin merit consideration. Regular instruction is essential even with disposable materials.
75% ethanol,
Laboratory for Medical Microbiology, Hospital Epidemiology, University of Groningen, Groningen, Netherlands Division of
Department of Pædiatrics,
University
of Groningen
J. DANKERT N. M. DRAYER
HERPESVIRUSES AND CANCER
SIR,-Dr Huang and
Dr Roche (May 6, p. 957) state that association has yet been reported between a particular R.N.A. or D.N.A. virus and carcinoma of the colon". In 1973 I reported such an association for Marek’s disease herpesvirus (M.D.H.v.) and human cancer, including carcinoma of the colon. I used an immunological technique capable of detecting 10-16 g (0-1 fg), a sensitivity more than a million times that of radioimmunoassay methods. This association was based on the finding of common antigenicity between glycoprotein antigens extracted from human cancers and those extracted from tumours of chickens infected with M.D.H.V.4 Common anti-genicity was also demonstrated between glycoprotein antigens from human cancers and similarly prepared antigens from M.D.H.V. grown in tissue culture.5 At the third international symposium on Detection and Prevention of Cancer6 I reported additional evidence for such an association.
"...
no
Serum antibodies to glycoprotein antigens prepared from found more often in patients with cancer, especially those with early cancer, than in non-malignant controls or when similar antigens were prepared from other herpesviruses, such as EpsteinBarr virus, HSV-1, and HSV-2. (2) These glycoprotein viral antigens from M.D.H.V. (but not from other herpes viruses, mouse hepatitis virus, and influenza virus) were found in desoxyribose-purine fragments (D.P.F.) of all nine types of human cancer tissue studied (including cancer of the colon), but not in normal lung D.P.F. or D.P.F. from fibroid uterus. (3) Certain types of cancer and antigens obtained from certain strains of M.D.H.V. were associated, both in serological studies and in the studies with D.P.F. preparations. For example, carcinoma of the colon was associated with the GA strain of M.D.H.V., while carcinoma of breast was associated with the CR-64 strain. No such association was found with glycoprotein antigens from the other herpesviruses studied. (4) Cross-antigenicity studies suggested that Epstem-Barr virus is more related to the M.D.H.V. group of animal viruses than to the herpesviruses of human origin (HSV-1, HSV-2); the Epstem-Barr virus may represent an nt.D.H.v. strain which has adapted to man. Although cytomegalovirus was not included in my studies
(1)
M.D.H.V. were
*Number of children with contaminated items.
the 28 children used injection material that was free of microThe first time that the injection materials of these 28 children were cultured, 22 children were found to be using non-sterile material. Of 277 cultures taken from the non-disposable needles, syringes, containers, and container fluids 1% were positive for Staphylococcus aureus, representing material from 3 children. From the container fluid Bacillus sp. were cultured several times and once Clostridium fallax, an anaerobic spore-forming bacterium, which can cause serious infections, was found.2 In both groups of patients (users of disposable and non-disposable material), we found, surprisingly, that many of the insulin vials were not sterile (see table). The insulin vials were used on average for 5 days by both groups. Differences in the bacterial flora of the patients’ noses and skin are unlikely to be the cause. There were no differences in the frequency of potentially pathogenic microorganisms in the nasal or skin flora between the users of disposable and nondisposable material. That the container fluid itself, originally
organisms.
‘
1.
2.
Rouwé, C., Van Damme-Lombaerts, R., Drayer, N. M., Zijlstra, J. B., Dankert, J. Ned. T. Geneesk. 1978, 122, 9. Smith, L. D., Holdeman, L. V. The Pathogenic Anaerobic Bacteria; p. 398.
Springfield, 1968.
with the herpesviruses, this virus is not expected to play more than an opportunistic role. M.D.H.V. is highly oncogenic in several species, but there is no evidence for the oncogenicity of cytomegalovirus.7 Furthermore, cytomegalovirus has been 3. Sykes, C. Disinfection and Sterilization; p. 341. London, 1967. 4. Makari, J. G. Oncology, 1973, 28, 164. 5. Makari, J. G. ibid. p. 177. 6. Makan, J. G. in Prevention and Detection of Cancer (edited by H. E. Neiburg); part 1, vol. I, p. 263. New York, 1977. 7. Davis, B. D., and others. Microbiology; p. 1247. New York, 1967.
From 100 unused disposable needles and syringes and the insulin from 17 unused vials no microorganisms could be cultured. 15 children used contaminated needles and syringes and 18 children had contaminated containers (see table). Only 5 of POSITIVE CULTURES
was often not sterile (1-100 bacteria/ml) may be explained by the non-sporicidal activity of alcohol and the reduced antibacterial activity due to evaporation of the ethanol and contamination with organic matter.3 The containers were on the average. only two-thirds full. The Dutch Diabetic Association used to advise 75% ethanol as well as diethylether for cleaning the skin and the top of the insulin vial, and 7 patients used ether despite our instructions to use 0 - 5 % chlorhexidine digluconate in 75% ethanol. Diabetic children should use disposable needles and syringes. The alternative, boiling needles and syringes immediately before use, does not guarantee sterility but is preferable to storing in a disinfectant. In view of the frequency of contaminatipn of the insulin vials used by children provided with disposable needles and syringes, smaller vials or even singledose insulin merit consideration. Regular instruction is essential even with disposable materials.
75% ethanol,
Laboratory for Medical Microbiology, Hospital Epidemiology, University of Groningen, Groningen, Netherlands Division of
Department of Pædiatrics,
University
of Groningen
J. DANKERT N. M. DRAYER
HERPESVIRUSES AND CANCER
SIR,-Dr Huang and
Dr Roche (May 6, p. 957) state that association has yet been reported between a particular R.N.A. or D.N.A. virus and carcinoma of the colon". In 1973 I reported such an association for Marek’s disease herpesvirus (M.D.H.v.) and human cancer, including carcinoma of the colon. I used an immunological technique capable of detecting 10-16 g (0-1 fg), a sensitivity more than a million times that of radioimmunoassay methods. This association was based on the finding of common antigenicity between glycoprotein antigens extracted from human cancers and those extracted from tumours of chickens infected with M.D.H.V.4 Common anti-genicity was also demonstrated between glycoprotein antigens from human cancers and similarly prepared antigens from M.D.H.V. grown in tissue culture.5 At the third international symposium on Detection and Prevention of Cancer6 I reported additional evidence for such an association.
"...
no
Serum antibodies to glycoprotein antigens prepared from found more often in patients with cancer, especially those with early cancer, than in non-malignant controls or when similar antigens were prepared from other herpesviruses, such as EpsteinBarr virus, HSV-1, and HSV-2. (2) These glycoprotein viral antigens from M.D.H.V. (but not from other herpes viruses, mouse hepatitis virus, and influenza virus) were found in desoxyribose-purine fragments (D.P.F.) of all nine types of human cancer tissue studied (including cancer of the colon), but not in normal lung D.P.F. or D.P.F. from fibroid uterus. (3) Certain types of cancer and antigens obtained from certain strains of M.D.H.V. were associated, both in serological studies and in the studies with D.P.F. preparations. For example, carcinoma of the colon was associated with the GA strain of M.D.H.V., while carcinoma of breast was associated with the CR-64 strain. No such association was found with glycoprotein antigens from the other herpesviruses studied. (4) Cross-antigenicity studies suggested that Epstem-Barr virus is more related to the M.D.H.V. group of animal viruses than to the herpesviruses of human origin (HSV-1, HSV-2); the Epstem-Barr virus may represent an nt.D.H.v. strain which has adapted to man. Although cytomegalovirus was not included in my studies
(1)
M.D.H.V. were
*Number of children with contaminated items.
the 28 children used injection material that was free of microThe first time that the injection materials of these 28 children were cultured, 22 children were found to be using non-sterile material. Of 277 cultures taken from the non-disposable needles, syringes, containers, and container fluids 1% were positive for Staphylococcus aureus, representing material from 3 children. From the container fluid Bacillus sp. were cultured several times and once Clostridium fallax, an anaerobic spore-forming bacterium, which can cause serious infections, was found.2 In both groups of patients (users of disposable and non-disposable material), we found, surprisingly, that many of the insulin vials were not sterile (see table). The insulin vials were used on average for 5 days by both groups. Differences in the bacterial flora of the patients’ noses and skin are unlikely to be the cause. There were no differences in the frequency of potentially pathogenic microorganisms in the nasal or skin flora between the users of disposable and nondisposable material. That the container fluid itself, originally
organisms.
‘
1.
2.
Rouwé, C., Van Damme-Lombaerts, R., Drayer, N. M., Zijlstra, J. B., Dankert, J. Ned. T. Geneesk. 1978, 122, 9. Smith, L. D., Holdeman, L. V. The Pathogenic Anaerobic Bacteria; p. 398.
Springfield, 1968.
with the herpesviruses, this virus is not expected to play more than an opportunistic role. M.D.H.V. is highly oncogenic in several species, but there is no evidence for the oncogenicity of cytomegalovirus.7 Furthermore, cytomegalovirus has been 3. Sykes, C. Disinfection and Sterilization; p. 341. London, 1967. 4. Makari, J. G. Oncology, 1973, 28, 164. 5. Makari, J. G. ibid. p. 177. 6. Makan, J. G. in Prevention and Detection of Cancer (edited by H. E. Neiburg); part 1, vol. I, p. 263. New York, 1977. 7. Davis, B. D., and others. Microbiology; p. 1247. New York, 1967.
