Experiences of stigma and subsequent reduced access to health care among women who inject drugs.

INTRODUCTION: Research into stigma and injecting drug use has typically involved predominantly male participants, with limited research about the unique experience of women who inject drugs. METHODS: This study used survey methods to assess reduced access to health care due to stigma among a sample of women who inject drugs. Women (n = 232) completed a survey as part of a broader national study of people who inject drugs. RESULTS: Only 46 (19.9%) women reported that they had not experienced any injecting drug use-related stigma in the past year and most commonly noted 'sometimes' experiencing injecting-related stigma (36.8%) with more than 75% of women reporting that health workers had treated them negatively because of their injecting drug use. Most women undertook strategies to prevent experiencing stigma, such as not disclosing drug use to a health worker (81.3%), not attending follow-up appointments (76.7%) and delaying accessing health care (76.8%). Women with lower levels of personal wellbeing, who had experienced poorer treatment by health workers, had engaged in greater past month injecting, were employed and identified as lesbian, gay, bisexual, transgender or queer (LGBTQ) reported more reduced access to health care. DISCUSSION AND CONCLUSIONS: Stigma has concerning health care implications for women who inject drugs and this research highlights the importance of understanding the impact of stigma in impeding health care access. Public health interventions should focus on addressing the systemic factors that reduce health care access for women who inject and take account of the impact of stigma in diminishing the quality and accessibility of health care for this group.

Single-visit hepatitis C point-of-care testing, linkage to nursing care, and peer-supported treatment among people with recent injecting drug use at a peer-led needle and syringe program: The TEMPO Pilot Study.

BACKGROUND: Point-of-care hepatitis C virus (HCV) RNA testing can facilitate single-visit diagnosis and treatment. This study evaluated a single-visit test and treat intervention integrating point-of-care HCV RNA testing, linkage to nursing care, and peer-supported engagement/delivery of treatment among people with recent injecting drug use at a peer-led needle and syringe program (NSP). METHODS: TEMPO Pilot is an interventional cohort study of people with recent injecting drug use (previous month) recruited between September 2019-February 2021 from one peer-led NSP in Sydney, Australia. Participants received point-of-care HCV RNA testing (Xpert HCV Viral Load Fingerstick), linkage to nursing care, and peer-supported engagement/delivery of treatment. The primary endpoint was the proportion initiating HCV therapy. RESULTS: Among 101 people with recent injecting drug use (median age 43; 31% female), 27% (n = 27) were HCV RNA detectable. Treatment uptake was 74% (20 of 27; sofosbuvir/velpatasvir, n = 8; glecaprevir/pibrentasvir, n = 12). Among people initiating treatment (n = 20), 45% (n = 9) initiated treatment at the same visit, 50% (n = 10) in the next 1-2 days, and 5% on day 7 (n = 1). Two participants initiated treatment outside the study (overall treatment uptake 81%). Reasons for not initiating treatment included loss to follow-up (n = 2), no reimbursement (n = 1), not suitable for treatment (mental health) (n = 1), and inability to perform liver disease assessment (n = 1). In the full analysis set, 60% (12 of 20) completed treatment and 40% (8 of 20) had a sustained virological response (SVR). In the evaluable population (excluding people without an SVR test), SVR was 89% (8 of 9). CONCLUSION: Point-of-care HCV RNA testing, linkage to nursing, and peer-supported engagement/delivery led to high HCV treatment uptake (majority single-visit) among people with recent injecting drug use attending a peer-led NSP. The lower proportion of people with SVR highlights the need for further interventions to support treatment completion.

Awareness of HCV Status and Preferences for Testing and Treatment among People with Recent Injecting Drug Use at a Peer-Led Needle and Syringe Program: The TEMPO Pilot Study.

BACKGROUND: New technologies and therapies allow the possibility of a single-visit test and treat model for hepatitis C virus (HCV), addressing some of the barriers to care faced by people who inject drugs. METHODS: The TEMPO Pilot Study was an interventional cohort study evaluating a single-visit test and treat intervention among people with recent injecting drug use at a one peer-led needle and syringe program (NSP) in Sydney, Australia between September 2019 and February 2021. This analysis evaluated awareness of HCV status and agreement of self-report with HCV RNA test results. The analysis also assessed acceptability of: modality of result delivery, modality of blood sampling, site of treatment, and duration of treatment. RESULTS: Among 101 participants (median age 43; 31% female), 100 had a valid HCV RNA test result and 27% (27/100) were HCV RNA detectable. Overall, 65% (65/100) were aware of their status. Among people with a positive HCV RNA result, 48% (13/27) were aware of their status. People preferred same-day HCV test results (95%, 96/101), and preferred to receive results in person (69%, 70/101). Receiving treatment at an NSP was acceptable (100%, 101/101) and 78% (79/101) were willing to discuss their health with a peer NSP worker. CONCLUSION: Half of people with current HCV infection were aware of their status. The high acceptability of simplified testing and treatment pathways delivered at NSPs indicates that this is an appropriate strategy to improve HCV awareness and treatment uptake in this population.

Barriers to help-seeking among music festival attendees in New South Wales, Australia.

INTRODUCTION: Prompt help-seeking behaviour by music festival attendees can reduce risks associated with drug use; however, little is known about perceived barriers to help-seeking when experiencing or witnessing illness at music festivals. We explored potential barriers and their association with festivalgoer characteristics. METHODS: We conducted an on-site cross-sectional survey of attendees at New South Wales music festivals in 2019/2020. Perceived barriers to help-seeking in the hypothetical event of the respondent or a friend becoming unwell at the festival were assessed, and regression analyses were conducted to identify characteristics associated with these barriers. RESULTS: Across six festivals, 1229 people were surveyed and four-fifths (83.2%) reported ≥1 barrier: 32.7% fear of getting in trouble with the police, 20.6% not knowing where to find help, 17.2% not knowing how unwell someone might be and 15.3% concern about friends or relatives finding out. In multivariable analyses, people of diverse sexuality and people using drugs that day had greater odds of reporting fear of trouble with the police. People reporting drug use that day had lower odds of reporting not knowing where to find help. Men, gender-diverse people and people using drugs that day had greater odds of reporting concern about friends or relatives finding out. DISCUSSION AND CONCLUSIONS: Our data substantiate concerns regarding policing strategies and their impact on festivals. Initiatives to support conversations about drugs with friends and families may be best targeted to younger people and those from gender-diverse backgrounds.

The Overdose Response with Take Home Naloxone (ORTHN) project: Evaluation of health worker training, attitudes and perceptions.

INTRODUCTION: Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings. METHODS: Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout. RESULTS: A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training. DISCUSSION/CONCLUSIONS: The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.

Wastewater analysis for psychoactive substances at music festivals across New South Wales, Australia in 2019-2020.

INTRODUCTION: Implementation of wastewater surveillance at music festivals has been limited to date. We aimed to use wastewater analysis and a self-report survey to determine the range of psychoactive substances being used during a music festival season in New South Wales, Australia. METHODS: We sampled six single-day music festivals requiring a music festival license in New South Wales from March 2019 to March 2020; between 15% and 100% of portaloos (temporary, un-fixed toilet facilities) were sampled at each festival. Samples were screened for 98 psychoactive substances and/or their metabolites with results qualitatively expressed as detection frequencies for each substance at each festival and across all festivals. We compared these data with the results of surveys of self-reported drug use at four of the six festivals. RESULTS: Festival attendance ranged from 6200 to 14,975 people. Amphetamine, cocaine, ketamine, methylone, MDMA, MDA, alprazolam, diazepam, etizolam, oxazepam and temazepam were found in almost all samples from all festivals. Ethylone, mephedrone and methcathinone were also found in over 50% of festivals. A norfentanyl (a fentanyl metabolite) and n-ethylpentylone were found at 2/6 and 1/6 festivals. No festival survey participant reported intentionally taking cathinones. DISCUSSION: The detection frequency for cathinones was higher than expected relative to recent other data sources and this may represent adulteration or substitution. Similarly, the appearance of etizolam may be related to the use of counterfeit alprazolam. The detection of highly toxic substances such as N-ethylpentylone and norfentanyl may warrant public health alerts. CONCLUSION: If provided close to real time, wastewater analysis at festivals could be complemented with information sources such as drug checking, on-site surveys, medical presentations and intelligence from peer networks to feed into early warning systems, public health alerts and peer-based harm reduction education during the festival season.

Correlates of higher-risk drug-related behaviours at music festivals in New South Wales, Australia.

INTRODUCTION: There are few contemporary data on illicit drug use at music festivals. We describe drug use patterns and prevalence of specific higher-risk drug-related behaviours, and their associations with festivalgoer characteristics. METHODS: We approached attendees at six major music festivals in New South Wales, Australia, from November 2019 to March 2020. Participants self-completed an anonymous survey on prior and intended drug use and associated higher-risk behaviours; double dropping; higher-volume ethanol alongside drug use; higher quantity 3,4-methylenedioxymethamphetamine (MDMA); mixing stimulants; and preloading. Logistic regression and UpSet analyses were performed to identify festivalgoer characteristics and the intersection of high-risk behaviours, respectively. RESULTS: Of 1229 participants, 372 (30.3%) used or planned to use drugs at the festival. In multivariable analyses, men and those purchasing drugs both inside and outside the venue had greater odds of engaging in higher-risk behaviours. Of those using MDMA, 47.9% reported double dropping. People using drugs for the first time had 3.3 (95% confidence interval 1.2-8.7) greater odds of higher-volume ethanol alongside drug use. People reporting that police/police dog presence influenced their decision to take drugs had 2.2 (95% confidence interval 1.4-3.6) greater odds of preloading. In UpSet analysis, preloading was the most common intersection (17% of those using drugs). DISCUSSIONS AND CONCLUSIONS: Engagement in the five higher-risk drug behaviours was common, particularly amongst males and those using drugs for the first time, while police/police dog presence appeared to influence higher-risk behaviours amongst festival attendees. This information can be used to inform harm reduction advice, public health and law enforcement strategies.

A Systematic Review of Interventions Used to Increase Blood Donor Compliance with Deferral Criteria.

BACKGROUND AND OBJECTIVES: Pre-donation screening of potential blood donors is critical for ensuring the safety of the donor blood supply, and donor deferral as a result of risk factors is practised worldwide. This systematic review was conducted in the context of an expert review convened by the Australian Red Cross Lifeblood in 2013 to consider Lifeblood's injecting drug use (IDU)-related policies and aimed to identify studies assessing interventions to improve compliance with deferral criteria in blood donation settings. MATERIALS AND METHODS: MEDLINE/PubMed, OVID Medline, OVID Embase, LILACS, and the Cochrane Library (CENTRAL and DARE) databases were searched for studies conducted within blood donation settings that examined interventions to increase blood donor compliance with deferral criteria. Observational and experimental studies from all geographical areas were considered. RESULTS: Ten studies were identified that tested at least one intervention to improve blood donor compliance with deferral criteria, including computerized interviews or questionnaires, direct and indirect oral questioning, educational materials, and a combination of a tickbox questionnaire and a personal donor interview. High-quality evidence from a single study was provided for the effectiveness of a computerized interview in improving detection of HIV risk behaviour. Low-quality evidence for the effectiveness of computerized interviews was provided by 3 additional studies. Two studies reported a moderate effect of direct questioning in increasing donor deferral, but the quality of the evidence was low. CONCLUSION: This review identified several interventions to improve donor compliance that have been tested in blood donation settings and provided evidence for the effectiveness of computerized interviews in improving detection of risk factors.

Perceptions of people who inject drugs towards HIV pre-exposure prophylaxis in Australia.

Background People who inject drugs (PWID) are a priority for HIV prevention. This study aimed to determine perceptions, potential eligibility and willingness to use PrEP among PWID in Sydney. METHODS: Clients completed a cross-sectional survey to collect data on demographics, perceived risk of HIV and willingness to use PrEP, which were then analysed. RESULTS: Twelve (7%) of 172 HIV-negative participants were eligible for PrEP under current guidelines for injecting reasons, of whom three would also be eligible for sexual risk, leaving nine (5%) eligible for injecting reasons alone. Half had heard of PrEP and, of these, 65% would consider taking it. Most (88%) thought they would continue using needle syringe program services. A minority (8%) indicated they may be likely to share needles and syringes or be less concerned about injecting partners' HIV status (26%). CONCLUSIONS: Although PrEP will benefit a small proportion of PWID, this may equate to a significant number nationally. Policy development around PrEP incorporating affected populations will best support the community of people currently injecting to keep rates of HIV low.

Care, agency and criminality: Making sense of authorised extended distribution in the accounts of key stakeholders.

INTRODUCTION: One of the current harm reduction debates in Australia concerns the legalisation of the extended distribution of sterile needles and syringes, a practice that is currently unlawful in most Australian settings. METHODS: We used data from a unique pilot program of authorised extended distribution to document the opinions held by 22 key stakeholders -service staff, drug users and police - about the risks and benefits of authorisation, and to analyse the ways in which drug users were understood within these. RESULTS: Opinions were strongly in favour of authorising extended distribution, based on the belief that this would reduce the transmission of hepatitis C. However, stakeholders also identified that distributors risked attention from police and some noted that the consequences of this would be borne by distributors themselves and not the services that support them. These opinions rested on specific assumptions about people who inject, some of which reflect negative constructions of drug users as a source of danger to the public or as helpless 'addicts' with little control over their risk reduction. But there were other representations that positioned drug users more positively as responsible agents with a strong duty of care to themselves and others whose choices are often limited by inadequate service structures. Staff participants drew on these understandings in careful and strategic ways, arguing for the rationality and expertise of drug users, while also problematizing the individualised approach that any form of authorised extended distribution might take. CONCLUSION: We argue that localised and incremental changes such as those that took place to support this pilot project, and the extensive support for extended distribution among stakeholders in this study including police, creates meaningful opportunities to think about extended distribution differently, which can in turn support conditions for future discussions about legislative change.

Trends in hepatitis B prevalence and associated risk factors among Indigenous and non-Indigenous prison entrants in Australia, 2004 to 2013.

OBJECTIVE: This study describes and compares prevalence trends of markers for hepatitis B (HBV) from 2004 to 2013 and HBV risk factors between Indigenous and non-Indigenous prison entrants. METHODS: A cross-sectional survey carried out over two weeks in 2004, 2007, 2010 and 2013 in reception prisons in New South Wales, Queensland, Western Australia and Tasmania. RESULTS: The study included 2,223 prison entrants; 544 were Indigenous. Indigenous prison entrants had significantly higher hepatitis B core antibody (anti-HBc) prevalence than non-Indigenous prisoners in 2004 (29% vs. 18%, P=0.026), 2007 (40% vs. 15%, P<0.001) and 2010 (21% vs. 16% 2010, P=0.002), and similar anti-HBc prevalence to non-Indigenous entrants in 2013 (14% vs. 14%, P=0.888), with a significant decline from 2007 for Indigenous entrants (P=0.717)ᶺ . Being more than 30 years old and coming from an area classified as 'non-highly accessible' were associated with anti-HBc positivity in both populations. For Indigenous prison entrants, first time in prison and survey year was associated with anti-HBc positivity. For non-Indigenous participants, a history of injecting drug use and body piercings was associated with anti-HBc positivity. CONCLUSION: There are unique risk factors associated with HBV prevalence for both Indigenous and non-Indigenous prison entrants. Implications for public health: In developing public health programs and policies for HBV, consideration of similarities and differences of associated HBV risk factors between Indigenous and non-Indigenous offenders is required.

Patterns of Peer Distribution of Injecting Equipment at an Authorized Distribution Site in Sydney, Australia.

BACKGROUND: Extended distribution refers to the practice whereby people who inject drugs pass on sterile injecting equipment to their networks and can be a means to access people who inject drugs who do not attend state-sanctioned needle and syringe programs. While it is legal, to possess a sterile syringe for the purpose of injecting drugs in New South Wales, Australia, it is a criminal offence to pass this equipment on for others to use. In 2013 a pilot project was established to trial the authorization of "extended" peer distribution. This research describes patterns of distribution among attendees participating in this trial. METHODS: A cross-sectional survey was conducted during one week in October 2014 of the trial with 200 clients. The survey focused on the extent, characteristics, and perceived risks and benefits of extended distribution practices within peer groups. RESULTS: Extended distribution is widespread, not in an organized or intentional manner but as a consequence of day-to-day drug using activities. The profiles of those who do and do not distribute were similar. Willingness to distribute small quantities of equipment to others was higher than willingness to distribute larger quantities, and willingness to distribute was related to perceived benefits of extended distribution. Police scrutiny was a key reason for not wanting to distribute. CONCLUSION: Extended peer distribution is widespread though mostly not organized. This study supports the evidence that drug users act responsibly to prevent harm and promote the use of sterile equipment among their peers.

Gonorrhoea testing and positivity in non-remote Aboriginal Community Controlled Health Services.

Background Gonorrhoea occurs at high levels in young Aboriginal and Torres Strait Islander people living in remote communities, but there are limited data on urban and regional settings. An analysis was undertaken of gonorrhoea testing and positivity at four non-remote Aboriginal Community Controlled Health Services participating in a collaborative research network. METHODS: This was a retrospective analysis of clinical encounter data derived from electronic medical records at participating services. Data were extracted using the GRHANITE program for all patients aged 15-54 years from 2009 to 2013. Demographic characteristics and testing and positivity for gonorrhoea were calculated for each year. RESULTS: A total of 2971 patients (2571 Aboriginal and/or Torres Strait Islander) were tested for gonorrhoea during the study period. Among Aboriginal and/or Torres Strait Islander patients, 40 (1.6%) tested positive. Gonorrhoea positivity was associated with clinic location (higher in the regional clinic) and having had a positive chlamydia test. By year, the proportion of patients aged 15-29 years tested for gonorrhoea increased in both men (7.4% in 2009 to 15.9% in 2013) and women (14.8% in 2009 to 25.3% in 2013). Concurrent testing for chlamydia was performed on 86.3% of testing occasions, increasing from 75% in 2009 to 92% in 2013. Factors related to concurrent testing were sex and year of test. CONCLUSIONS: The prevalence of gonorrhoea among young Aboriginal and/or Torres Strait Islander people in non-remote settings suggests that the current approach of duplex testing for chlamydia and gonorrhoea simultaneously is justified, particularly for women.

Prevalence of Hepatitis C Among Australian Aboriginal and Torres Strait Islander people: A Systematic Review and Meta-Analysis.

CONTEXT: Aboriginal and Torres Strait Islanders (Aboriginal) account for approximately 3% of the Australian population. They have the poorest health, economic and social outcomes. Higher notification rates of hepatitis C antibodies (anti-HCV) have been reported among Aboriginal compared with non-Aboriginal people. The identification of Aboriginal people in national surveillance has some weaknesses, with only four of the eight jurisdictions included in national reporting. To address some of these limitations, we aim to estimate the pooled prevalence of anti-HCV among Aboriginal people in Australia. EVIDENCE ACQUISITION: We searched the databases: Pubmed, Web of Science and Informit, and the New South Wales and Northern Territory Public Health Bulletins. A study was included if it reported the number of Aboriginal people testing positive for anti-HCV and the number tested for anti-HCV. A meta-analysis by population-group was conducted if three or more studies reported a prevalence estimate. Variables included: author, year of publication, study design, study period, gender (female, male), age, population group (Aboriginal people in prison, Aboriginal people who inject drugs), number testing anti-HCV positive, number tested for anti-HCV and prevalence (%). Due to a long time period, we separated the studies estimating the prevalence anti-HCV among Aboriginal people in prison into two time periods, 1994 - 2004 and 2005 - 2012. RESULTS: Overall, 15 studies met our inclusion criteria. Among Aboriginal people in prison, the pooled prevalence of anti-HCV was 18.1% (95%CI: 6.6 - 29.7). The pooled prevalence among Aboriginal people in prison was 25.7% (95%CI: 4.1-47.3) in studies published between 1994 - 2004 and 14.5% (95%CI: 1.7 - 27.3) in studies published from 2005 - 2012. The pooled prevalence of anti-HCV was 58.7% (95%CI: 53.9 - 63.5) among Aboriginal people who inject drugs and 2.9% (95%CI: 0.30 - 6.1) among Aboriginal people who did not inject drugs, however there was significant heterogeneity (I(2) > 90.0%, P < 0.01). There was significant selection bias in the studies as most included individuals who inject drugs. CONCLUSIONS: Our analysis shows that the overall prevalence of anti-HCV was significantly biased towards people who inject drugs; resulting in an over-estimation of anti-HCV prevalence among Aboriginal people. Our review highlights that unsafe injecting is the main transmission route for HCV infection among Aboriginal people in Australia.

Antivirals in the management of an influenza pandemic.

The Australian Government has an extensive stockpile of antivirals (neuraminidase inhibitors) to be used if an influenza pandemic occurs. Neuraminidase inhibitors reduce the duration of the symptoms of seasonal influenza infection by 1 day on average, when used as treatment within 48 hours of disease onset. Neuraminidase inhibitors prevent infection in up to 74% of people when administered as prophylaxis. Resistance of seasonal influenza viruses to neuraminidase inhibitors is low. The safety and efficacy (including resistance) of neuraminidase inhibitors against pandemic influenza or the virus of current concern in pandemic planning, influenza A/H5N1, is not known, and further research is needed.

Handwashing practice and policy variability when caring for central venous catheters in paediatric intensive care.

It has been estimated that there may be as many as 150,000 healthcare associated infections (HCAI) in Australia each year, contributing to 7,000 deaths, many of which could be prevented through the implementation of appropriate infection control practices. Contact with contaminated hands is a primary source of HCAI. Intensive care staff have been identified as one of the least adherent groups of health care professionals with handwashing; they are less likely to practise hand antisepsis before invasive procedures than staff working in other patient care specialties. The study examined the self-reported clean and aseptic handwashing practices of nurses working in paediatric intensive care units (PICUs) across Australia and New Zealand, the patterns in variation between nurses' reported handwashing practices and the local policies, and patterns in the duration of procedural handwashing for specific procedures. A survey was undertaken in 2001 in which participating tertiary paediatric hospitals provided copies of their infection control policies pertaining to central venous catheter (CVC) management; five nurses on each unit were asked to provide information in relation to their handwashing practices. Seven hospitals agreed to participate and 30 nurses completed the survey. The study found an enormous level of variation among and between nurses' reported practices and local policies. This variation extended across all aspects of handwashing practices - duration and extent of handwash, type of solution and drying method used. The rigour of handwashing varied according to the procedure undertaken, with some evidence that nurses made their own risk assessments based on the proximity of the procedure to the patient. In conclusion, this study's findings substantiate the need for standardisation of practice in line with the current Centers for Disease Control and Prevention Guidelines, including the introduction of alcohol handrub.

The role of specialist nurses in improving treatment adherence in children with a chronic illness.

Adherence to medical treatment is an ongoing challenge for families and young people with chronic medical conditions. One factor that is likely to influence treatment success is the quality of professional relationships both within the health care team and between the family, child and professionals. This paper explores the topic of professional relationships and adherence and provides an example of how a multidisciplinary team can improve the health and quality of life of paediatric patients. More specifically, the paper argues for the crucial role of the specialist nurse in supporting patients and their relationships with the health care team.

Central venous access and handwashing: variability in policies and practices.

This study examined variability in handwashing policy between hospitals, variability in handwashing practices in nurses and how practice differed from policy in tertiary paediatric hospitals in Australia and New Zealand. Eight of the possible nine major paediatric hospitals provided a copy of their handwashing and/or central venous access device (CVAD) policies, and 67 nurses completed a survey on their handwashing practices associated with CVAD management. A high degree of variability was found in relation to all the questions posed in the study. There was little consistency between policies and little agreement between policies and clinical practice, with many nurses washing for longer than required by policy. Rigour of handwashing also varied according to the procedure undertaken and the type of CVAD with activities undertaken farther from the insertion site of the device more likely to be performed using a clean rather than an aseptic handwashing technique. As both patients and nursing staff move within and between hospitals, a uniform and evidence-based approach to handwashing is highly desirable.