Types of cookers used
Cookers are used to mix and /or heat the
solution to be injected. If sterile cookers are unavailable,
drug users commonly use tea- or tablespoons or drinking cans (Scott, 2008). These
items, being non-sterile, can contain bacteria or fungi, as well as residuals
of other liquids. It is recommended to use sterile, single use cookers to
prepare drug solutions.
The Stericup® is a sterile cooker
that does not contribute to the contamination of the drug containing solution. Scott (2008) states that its fragile nature is an
advantage of the Stericup. Reheated, it becomes flimsy, especially around the
handle which will bend. This may prevent People Who Inject Drugs (PWID) to use
it several times.
reuse is very prevalent amongst PWID (Debrus, 2008; Needle et al., 1998). Furthermore,
depending on context, knowledge,
culture and cooker-availability, cookers are shared by 16 to 65% of PWID (Cadet-Taïrou, 2012; Huo et al., 2005; Strike et al., 2010). Several studies found
that this item is shared more frequently than other paraphernalia (Koester et al.,
1990; Thorpe et al., 2002; Latkin et al., 2010; Strike et al., 2010); moreover,
PWID tend to believe that cooker sharing is associated to a lower risk than
syringe sharing (Latkin et al., 2010).
be shared either for use by one person after another, or to prepare a solution
for several people at the same time (batch preparation). The bigger the cooker
is, the larger the risk of batch preparation. Care should be taken to provide
the smallest cooker suitable for the preparation of a given drug (some drugs,
mainly pills not intended for injection, need larger volumes to dissolve).
Stericup has a capacity of 2.5 ml. Solutions of up to 1.5 ml can be heated in
this cooker. The Maxicup® has a capacity of about 5 ml. Solutions of up to 4 ml
can be heated in this cooker.
In addition to "deliberate" sharing (sometimes due to lack of equipment available at a given time), some
situations may lead to confusion. The presence of large quantities of tools during group injection may, for instance
result in confusion about their ownership, as may the fact of being under the influence of psychoactive
drugs... A survey conducted in France (Debrus, 2008) showed that the vast majority (85%) of PWID has already injected in
the presence of other injectors and
45% of them have ever had adoubt about the ownership of the equipment used. Distribution of tools with different colours
can allow PWID to differentiate the material used. As reuse seems to be rather a rule than an exception, the colours will enable people to, at least,
reuse their own material. The colours also provide a visual support of the message
not to share any harm reduction tools.
The harms associated
with cooker sharing
Blood born viruses (BBVs)
Shah et al. (1996) have detected HIV antibodies, DNA and/ or RNA on 14
to 54% of the used cookers they examined. Epidemiological research also showed
an association between cooker sharing and HIV. Seropositive persons are more
likely to have shared cookers than seronegative persons (Vlahov et al., 1997). The
majority of the research done does not differentiate cookers from other
paraphernalia such as filters and water for injection. Both McCoy et al. (1998)
and Faran et al. (1998) found a strong association between the sharing of
paraphernalia (cookers, water or filters) and HIV transmission.
Heating of the drug containing solution for
more than 15 seconds may inactivate the HIV virus (Clatts ea, 1999). The same
authors recommend the use of thin cookers that reach the inactivation
temperature the fastest for any given combination of volume and heat source.
As for the HCV virus, Crofts et al. (2000) have
shown the presence of this virus on used cookers. Doerrbecker et al. (2013)
have shown that HCV can remain both present and infectious, even after rinsing.
The correlation between cooker sharing and HCV contamination has been confirmed
by several epidemiological studies. Hagan et al. (2001) studied the sharing of cookers and filters
(combined) and found an elevated risk for HCV seroconversion (adjusted relative
risk of 5.9). Cohort studies found cooker sharing to be a strong predictor for
HCV seroconversion (adjusted relative risk of 3.5-Thorpe et al., 2002; adjusted
relative risk of 2.76 – Hagan et al., 2010). Pouget et al (2012), in a meta-analysis of 7
scientific publications on hepatitis C seroconversion in association to cooker
sharing (including the above articles) found a relative risk of 2.42.
On the contrary to HIV, heating of the solution
in a drug using context will not inactivate the hepatitis C virus (Song et al.,
non-sterile cookers (makeshift cookers or the reuse of cookers), even when they
are not shared, can be contaminated by bacteria. Bacteria present in drug
paraphernalia, when injected, can lead to life-threatening bacterial
infections, including abscesses, cellulitis, bone and joint infections, or endocarditis
(Gordon and Lowy, 2005).
The supply of single use cookers potentially reduces the transmission of
BBVs and other infections and improves the hygiene of injection preparation.
Strike et al. (2013) provide several recommendations which we have completed
- Provide individually packed, sterile cookers with a heat resistant handle.
reduce contamination, a new sterile cooker should be used for every
injection. Cookers should thus be distributed in the quantity requested
by PWID, without limitation on the number of cookers distributed. One
sterile cooker should be provided with every sterile needle.
should be encouraged, but not be obliged to come back and dispose of
their paraphernalia as bio-waste materiel at the needle exchange
- Procedures to clean cookers can reduce the amount of pathogens present but will be unable to eliminate germs or virus at 100%.
cookers of the size needed by the participants of your harm reduction
program, and inform your clients on the differences and least harmful
people to use the smallest cooker possible (depending on the drug they
inject) and advice to avoid or reduce batch preparation. The Stericup is
smaller than the Maxicup and should be preferred if feasible.
- Provide cookers which are thin to avoid reuse and to increase the temperature reached when the cooker is heated.
cookers of different colours to remind clients that they are for
personal use and to enable them to do so, even in confusing situations.
- Provide harm reduction information on the use of cookers and the associated risks.
- Provide other harm reduction tools such as syringes, filters, acids, sterile water for injection, alcohol pads…
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