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)
The presence of HIV has been detected on 14 to 54% of used cookers (Shah et al., 1996). In the field, the correlation between sharing cookers and HIV transmission has also been demonstrated. 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 correlation between the sharing of paraphernalia (cookers, water or filters) and HIV transmission.
Heating a 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 more quickly for any given combination of volume and heat source.
As for the HCV, 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. Cooker sharing is a strong predictor for HCV seroconversion. Pouget et al (2012), in a meta-analysis of 7 scientific publications on hepatitis C seroconversion in association to cooker sharing found a relative risk of 2.42.
A study measuring the HCV seroconversion among a cohort of 317 active Seattle residents who inject drug and who tested negative for HCV antibodies at recruitment, found that those who shared cookers and filters (but not syringes) had a relative risk of HCV seroconversion of 5.9. It was determined that 54% of HCV infections among this group were attributed to cooker and filter sharing.
On the contrary to HIV, heating a drug containing solution will not inactivate the hepatitis C virus (Song et al., 2010).
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…
Cadet-Taïrou A (2012) Résultats ENa-CAARUD 2010 - Profils et pratiques des
usagers. Notes d'information SINTES, OFDT
MC, Heimer R, Abdala N, Goldsamt LA, Sotheran JL, Anderson KT, Gallo TM, Hoffer
LD, Luciano PA, Kyriakides T (1999) HIV-1 Transmission in Injection
Paraphernalia: Heating Drug Solutions May Inactivate HIV-1. JAIDS 22(2): 194
Crofts N, Caruana S, Bowden S, Kerger M.(2000) Minimising
harm from hepatitis C virus needs better strategies.BMJ. 2000 Oct 7;321(7265):899
Debrus M (2008) Impact de nouveaux outils sur les risques de
l’injection. Gestion des risques liés au saignement après l’injection. Prévention
des risques de partage accidentel. www.apothicom.org/downloads/IMPACT%20DE%20NOUVEAUX%20OUTILS%202008.pdf
Doerrbecker J, Behrendt P, Mateu-Gelabert
P, Ciesek S, Riebesehl N, Wilhelm C, Steinmann J, Pietschmann T, Steinmann E.(2013)Transmission
of hepatitis C virus among people who inject drugs: viral stability and
association with drug preparation equipment. J Infect Dis.207(2):281-187
Faran E, Archibald C, Razaque A, Sandstrom P (2009)
Factors associated with an explosive HIV epidemic among injecting drug ysers in
Sargodha, Pakistan. JAIDS. 51(1): 85-90
RJ and Lowy FD (2005) Current concepts. Bacterial infections in drug users. A
review. N Engl J Med 353(18): 1945-1954
Hagan H, Pouget ER, Williams IT, Garfein RL, Strathdee SA, Hudson SM, Latka MH, Ouellet LJ. (2010) Attribution
of hepatitis C virus seroconversion risk in young injection drug users in 5 US
cities. J Infect Dis.201(3):378-385
Hagan H, Thiede H, Weiss
NS, Hopkins SG. Duchin JS, Alexander ER (2001) Sharing of Drug
Preparation Equipment as a Risk Factor for Hepatitis C. Am J Public Health.91: 42–46
Huo D, Bailey SL, Hershow RC, Ouellet L. (2005) Drug
use and HIV risk practices of secondary and primary needle exchange users. AIDS Educ Prev. 17(2):170-184
Koester S, Booth R, Wiebel W (1990)The Risk of HIV Transmission from sharing water, drug mixing containers
and cotton filters among intravenous drug users. International
Journal on Drug Policy. 1 (6) : 28-30
Latkin CA, Kuramoto SJ, Davey-Rothwell
MA, Tobin KE (2010) Social
norms, social networks, and HIV risk behavior among injection drug users. AIDS Behav. 14(5):1159-1168
ER, Hagan H, Des Jarlais DC (2012) Meta-analysis of hepatitis C seroconversion
in relation to shared syringes and drug preparation equipment. Addiction. 107
(6) : 1057-1065
McCoy CB, Metsch LR, Chitwood DD, Shapshak P, Comerford ST. (1998) Parenteral
transmission of HIV among injection drug users: assessing the frequency of
multiperson use of needles, syringes, cookers, cotton, and water. J Acquir
Immune Defic Syndr Hum Retrovirol. 18 Suppl 1:S25-29
Needle RH, Coyle S,
Cesari H, Trotter R, Clatts M, Koester S, Price L, McLellan E, Finlinson A,
Bluthenthal RN, Pierce T, Johnson Y, Jones TS, Williams M (1998) HIV Risk
Behaviors Associated with the Injection Process: Multiperson Use of Drug
Injection Equipment and Paraphernalia in Injection Drug User Networks.
Substance Use & Misuse. 33(12): 2403-2423
J. (2008) Safety, risks and outcomes from the use of injecting paraphernalia.
Scottish Government Social Research. 2008 (www.scotland.gov.uk/socialresearch)
SM, Shapshak P, Rivers JE, Stewart RV, Weatherby NL, Xin KQ, Page JB, Chitwood
DD, Mash DC, Vlahov D, McCoy CB (1996) Detection of HIV-1 DNA in
needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a
preliminary laboratory report. Journal of Acquired Immune
Deficiency Syndromes and Human Retrovirology. 11, (3), 301-306
Song H, Li J, Shi
S, Yan L, Zhuang H, Li K (2010) Thermal stability and inactivation of hepatitis C virus grown in cell
culture.Virology Journal 2010, 7:40
C, Buchman DZ, Callaghan RC, Wender C, Anstice S, Lester B, Scrivo N, Luce J,
Millson M (2010) Giving away used injection equipment: missed prevention
message? Harm reduction journal. 7: 2
Strike C, Hopkins S, Watson TM, Gohil H, Leece P,
Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L,
Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D,
Tzemis D, Zurba N. (2013) Best Practice Recommendations for Canadian Harm
Reduction Programs that Provide Service to People Who Use Drugs and are at Risk
for HIV, HCV, and Other Harms: Part 1. Toronto, ON: Working Group on Best
Practice for Harm Reduction Programs in Canada.
LE, Ouellet LJ, Hershow R, Bailey SL, Williams IT, Williamson J, Monterroso ER,
Garfein RS. (2002) Risk of hepatitis C virus infection among young adult
injection drug users who share injection equipment. Am J Epidemiol. 155(7):645-653
Vlahov, D, Junge B, Brookmeyer R, Cohn S, Riley
E, Armenian H, Beilenson P (1997) Reductions in High-Risk Drug Use Behaviors
Among Participants in the Baltimore Needle Exchange Program. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology.
16 (5): 400-406