A case of confirmed pre-symptomatic transmission of mpox

Mpox virus is known to be transmissible from the onset of clinical manifestations. We report the first case in Japan of a man who contracted mpox through close contact with an individual with pre-symptomatic infection. Given that transmission before symptom onset has recently been reported from various countries, the importance of prophylaxis for reducing the risk of infection and controlling the disease should be emphasized.

Comparing recombinant human rabies monoclonal antibody (ormutivimab) with human rabies immunoglobulin (HRIG) for postexposure prophylaxis: A phase III, randomized, double-blind, non-inferiority trial

OBJECTIVES

To evaluate the immunogenicity and safety of an anti-rabies monoclonal antibody (mAb), ormutivimab, compared with human rabies immunoglobulin (HRIG).

METHODS

This phase III trial was designed as a randomized, double-blind, non-inferiority clinical trial in patients aged ≥18 years with suspected World Health Organization category Ⅲ rabies exposure. The participants were randomized 1:1 to ormutivimab and HRIG groups. After thorough wound washing and injection of ormutivimab/HRIG on day 0, the vaccination was administered on days 0, 3, 7, 14, and 28. The primary endpoint was the adjusted geometric mean concentration (GMC) of rabies virus-neutralizing activity (RVNA) on day 7. The endpoint of safety included the occurrence of adverse reactions and serious adverse events.

RESULTS

A total of 720 participants were recruited. The adjusted-GMC of RVNA (0.41 IU/ml) on day 7 in ormutivimab group was not inferior to that in the HRIG group (0.41 IU/ml), with ratio of adjusted-GMC of 1.01 (95% confidence interval: 0.91, 1.14). The seroconversion rate of the ormutivimab group was higher than that of the HRIG group on days 7, 14, and 42. Most local injection sites and systemic adverse reactions reported from both groups were mild to moderate in severity.

CONCLUSION

ormutivimab + vaccine can protect victims aged ≥18 years with category Ⅲ suspected rabies exposure as a component of postexposure prophylaxis. ormutivimab has a weaker influence on the immunity response of rabies vaccines.

CLINICAL TRIALS REGISTRATION

ChiCTR1900021478 (the Chinese Clinical Trial Registry of World Health Organization).

Prevention of Perinatal Hepatitis B Transmission

Hepatitis B virus (HBV) is efficiently transmitted to newborn infants in the perinatal period and can lead to chronic infection, cirrhosis, liver cancer, and death. Despite the availability of effective prevention measures necessary to eliminate perinatal HBV transmission, significant gaps remain in the implementation of these prevention measures. All clinicians who care for pregnant persons and their newborn infants need to know the key prevention measures including (1) identification of HBV surface antigen (HBsAg)-positive pregnant persons, (2) antiviral treatment of HBsAg-positive pregnant persons with high viral loads, (3) timely postexposure prophylaxis of infants born to HBsAg-positive persons, (4) and timely universal vaccination of newborn infants.

Modeling on the Effects of Deliberate Release of Aerosolized Inhalational Bacillus anthracis (Anthrax) on an Australian Population

This study aimed to determine optimal mitigation strategies in the event of an aerosolized attack with Bacillus anthracis, a category A bioterrorism agent with a case fatality rate of nearly 100% if inhaled and untreated. To simulate the effect of an anthrax attack, we used a plume dispersion model for Sydney, Australia, accounting for weather conditions. We determined the radius of exposure in different sizes of attack scenarios by spore quantity released per second. Estimations of different spore concentrations were then used to calculate the exposed population to inform a Susceptible-Exposed-Infected-Recovered (SEIR) deterministic mathematical model. Results are shown as estimates of the total number of exposed and infected people, along with the burden of disease, to quantify the amount of vaccination and antibiotics doses needed for stockpiles. For the worst-case scenario, over 500,000 people could be exposed and over 300,000 infected. The number of deaths depends closely on timing to start postexposure prophylaxis. Vaccination used as a postexposure prophylaxis in conjunction with antibiotics is the most effective mitigation strategy to reduce deaths after an aerosolized attack and is more effective when the response starts early (2 days after release) and has high adherence, while it makes only a small difference when started late (after 10 days).

Evaluation of Our Rabies Prevention Practices: Is Our Approach Correct?

Background

Rabies disease is zoonotic disease-causing encephalitis and resulting in death. It is possible to prevent the disease with suitable prophylaxis approaches. This study examined the compliance of post-exposure prophylaxis approaches with the guidelines and the reasons for non-compliance in contact cases at risk of rabies.

Methods

This retrospective cross-sectional study includes patients who continued the vaccination program from 2014-2018 at the Ordu University Medical Faculty Hospital Rabies Vaccination Center in Ordu, Turkey. Cases were assessed in terms of sociodemographic features, previous rabies vaccination history, features of the contact with rabies risk, attendance duration after contact, and whether all stages of prophylaxis were completed after contact.

Results

Of the 748 cases attending the vaccination center, the age range was 1- 91 yr, with a mean age of 28.12 ± 21.60 yr. Of cases, 62.3% were male (n =466) and 37.7% were female (n =282). Of risky contact, 60% comprised stray animals. Of recorded cases, 55.2% displayed approaches compatible with guidelines. Among incompliant approaches, the most frequent was administering vaccines even though observation was sufficient. (n = 174, 52%).

Conclusion

Contact with risk of rabies may result in insufficient administration of the stages in prophylaxis after contact, or contrarily, mistaken administration based on acting with a sense of excessive safety. Stray dogs or domestic animals without sufficient vaccinations comprise a significant risk despite all efforts. In order to prevent risky contact, there is a need for the development of correct strategies and to ensure continuity of in-service training for health professionals.

Healthcare-associated exposure to Borna disease virus 1 (BoDV-1)

The Borna disease virus 1 (BoDV-1) causes severe and often fatal encephalitis in humans. The virus is endemic in parts of Germany, Liechtenstein, Switzerland and Austria. As an increasing number of human BoDV-1 encephalitis cases is being diagnosed, the chance for healthcare professionals to come into contact with infected tissues and bodily fluids from patients with known acute bornavirus encephalitis is also increasing. Therefore, risk assessments are needed. Based on three different incidences of possible exposure to BoDV-1 including an autopsy knife injury, a needlestick injury, and a spill accident with cerebrospinal fluid from patients with acute BoDV-1 encephalitis, we perform risk assessments and review published data. BoDV-1 infection status of the index patient's tissues and bodily fluids to which contact had occurred should be determined. There is only scarce evidence for possible postexposure prophylaxis, serology, and imaging in healthcare professionals who possibly came into contact with the virus. Despite decade-long laboratory work with BoDV-1, not a single clinically apparent laboratory infection has been published. Given the increasing number of severe or fatal BoDV-1 encephalitis cases, there is a growing need for efficacy-tested, potent antiviral therapeutics against BoDV-1 in humans, both in clinically ill patients and possibly as postexposure prophylaxis in healthcare professionals.

Congenital and Perinatal Varicella Infections

Varicella-zoster virus (VZV) is a human pathogen of the α-herpesvirus family. Some fetuses infected in utero around 8-20 weeks of pregnancy show signs of congenital varicella syndrome (CVS). Infants born to mothers who develop varicella within 5 days before and 2 days after delivery can experience severe disease with increased mortality. The best diagnostic modality is polymerase chain reaction (PCR), which can be done using vesicular swabs or scrapings, scabs from crusted lesions, tissue from biopsy samples, and cerebrospinal fluid. The prevention and management of varicella infections include vaccination, anti-VZV immunoglobulin, and specific antiviral drugs. In this article, we have reviewed the characteristics of VZV, clinical manifestations, management of perinatal infections, and short- and long-term prognosis.

Prevalence of indications for adult hepatitis A vaccination among hepatitis A outbreak-associated cases, Three US States, 2016-2019

BACKGROUND

Safe and effective hepatitis A vaccines have been recommended in the United States for at-risk adults since 1996; however, adult vaccination coverage is low.

METHODS

Among a random sample of adult outbreak-associated hepatitis A cases from three states that were heavily affected by person-to-person hepatitis A outbreaks, we assessed the presence of documented Advisory Committee on Immunization Practices (ACIP) indications for hepatitis A vaccination, hepatitis A vaccination status, and whether cases that were epidemiologically linked to an outbreak-associated hepatitis A case had received postexposure prophylaxis (PEP).

RESULTS

Overall, 74.1% of cases had a documented ACIP indication for hepatitis A vaccination. Fewer than 20% of epidemiologically linked cases received PEP.

CONCLUSIONS

Efforts are needed to increase provider awareness of and adherence to ACIP childhood and adult hepatitis A vaccination and PEP recommendations in order to stop the current person-to-person hepatitis A outbreaks and prevent similar outbreaks in the future.

Occupational Health Update: Evaluation and Management of Exposures and Postexposure Prophylaxis

Health care personnel (HCP) are at risk of exposure to infectious agents depending on their job duties and other factors. Risks include percutaneous exposure to blood-borne pathogens via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, hepatitis C virus); exposure by direct contact, droplet, or airborne transmission of pathogens through direct patient care (eg, pertussis, invasive meningococcus infections, tuberculosis); and through indirect contact transmission related to the contaminated health care environment (eg, Clostridioides difficile). Occupational health programs must effectively identify and respond to potential exposures and provide guidance to HCP on postexposure prophylaxis.

Measles in a measles-eliminated country: A case report of a measles-infected postpartum mother and infant in Japan

Japan has maintained measles elimination status since 2015. However, sporadic outbreaks of measles have been continuously reported. Here, we report a case of a measles-infected postpartum mother and infant in Japan. A 28-year-old Japanese woman, who had previously received a dose of the measles vaccination, experienced fever 5 days postpartum. Subsequently, a maculopapular rash appeared, and she was diagnosed with measles. Moreover, her baby developed a fever and maculopapular rash on the 13th day of life, 2 days after postexposure prophylaxis with intravenous immunoglobulin, and was also diagnosed with measles. Both showed full recovery. This case suggests that measles can still be a threat in a measles-eliminated country, and the administration of two doses of measles vaccination to women prior to childbearing age is crucial to protect newborns from measles.

Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study

OBJECTIVES

The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV) contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival.

MATERIAL AND METHODS

Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or nonoccupational exposure to HIV in 2016 and 2017 were included.

RESULTS

A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2% vs 46.9%, respectively), previous use of PEP (23.9% vs 13.1%), alcohol intake (36.2% vs 18.5%), drug use (34.6% vs 8.6%), and chemsex (sexualized drug use) (26.1% vs 0%) (P .001, all comparisons). Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prior use of the PEP pathway (P .001), drug use (P = .03), and chemsex (P .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P .001).

CONCLUSION

Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men.

Two measles clusters in connection with short inner-European air travels indicating impediments to effective measles control: A cluster analysis

Importation and transmission of measles via air travel is a public health concern to countries, which are close to or have achieved elimination, i.e., to the majority of countries in Europe. In 2018, two measles cases occurred in Berlin residents, who flew within Europe while being infectious. In addition to contact tracing through passenger manifests, we contacted national authorities in flight destination countries or embarking countries and inquired about epidemiologically linked measles cases to the two Berlin index cases. We identified eight epidemiologically linked cases (six males, median age: 32 years) from three countries associated with three air-travels. Consequently measles was imported to Germany (Bavaria), Denmark and possibly Sweden. Our investigations revealed impediments to an effective public health response indicating the need to revisit current guidelines and methods to better control transmission of measles related to air travel.

Hepatitis B in Pregnant Women and their Infants

Chronic hepatitis B is a global health problem affecting approximately 350 million to 400 million individuals worldwide, and mother to child transmission remains the major mode of transmission. Approximately 50% of chronically infected individuals acquire infection, either perinatally or early in childhood, predominantly in areas where hepatitis B virus (HBV) is endemic. Management of HBV in pregnancy presents a unique set of challenges. All infants born of hepatitis B surface antigen-positive mothers should receive postexposure immune prophylaxis with hepatitis B immunoglobulin and HBV vaccination within 24 hours of birth and need close follow-up for the first few years of life.

Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention

Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.

Rabies postexposure prophylaxis in international travellers: Results from a Spanish travellers referral unit

BACKGROUND

Rabies represents a major public health issue for travellers because pretravel preexposure (PrEP) rabies vaccination is not routinely indicated. For those unvaccinated, adequate postexposure prophylaxis (PEP), including rabies immunoglobulin (RIG) if needed, is the only effective method to prevent this fatal disease.

METHODS

Descriptive retrospective study at a National Referral Unit for Tropical and Travel Medicine in Madrid, Spain, among travellers treated with PEP for rabies (January 2012-December 2017). Demographic, clinical and management data were reviewed.

RESULTS

168 patients were treated for possible rabies exposure (53% females, median age 35 years; IQR: 31-42). Southeast Asia accounted for more than half of the cases (N=86, 57.3%; CI 95% 49-65%). Dogs were the primary animal involved (n=67, 44.9%; CI 37-53%). After the bite, in half of the cases (n=88, 52.4%; CI 44-60%) PEP rabies vaccine was started abroad, and the vaccine plus RIG in about 10% (n=22, 13.1%; CI: 8-19%). Most of patients classified as category III did not received RIG at all (n=88, 69.3% CI: 60-77%).

CONCLUSIONS

Although indicated, most travellers did not receive RIG abroad, nor appropriate first doses of PEP. Clinicians should be aware of the importance of appropriate PrEP in selected individuals.

Pediatric Considerations for Postexposure Human Immunodeficiency Virus Prophylaxis

Exposures that carry risk of transmission of blood-borne disease are rare in pediatrics, but expose patients and families to great anxiety. Specialists in pediatric infectious diseases are often asked about initial antimicrobial prophylaxis in these cases. Guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus have evolved as new formulations and medications become available and greater experience obtained in assessing relative risks of different exposures and relative costs and benefits for different interventions. This article discusses the evidence behind recent updates to Centers for Disease Control and Prevention guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus, focusing on application in the pediatric population.

Use of hepatitis A vaccine for post-exposure prophylaxis in individuals over 40 years of age: A systematic review of published studies and recommendations for vaccine use

INTRODUCTION

Hepatitis A can cause widespread outbreaks. Until 2018, postexposure prophylaxis (PEP) in the United States for individuals >40 years consisted of immune globulin (IG) administered as soon as possible after exposure, ideally within 14 days whereas those aged ≤40 should receive hepatitis A (HepA) vaccine. However, state health departments reporting difficulty quickly accessing and administering IG, costs of higher IG doses and importance of long-term HAV protection prompted CDC to review immunogenicity data for use of HepA vaccine for PEP in older adults. We reviewed literature on use of HepA vaccine in adults >40 years and existing recommendations for HepA vaccine for use as PEP in other countries.

METHODS

We searched PubMed and EMBASE from January 1, 1992-January 7, 2017 using the terms "hepatitis A vaccine∗" and "HAV vaccine∗." Two reviewers read each abstract and articles were preserved if they included results (seroprotection, mean titers) within 28 days of HepA vaccine administration in adults >40 years. Additionally, we reviewed PEP recommendations from six other jurisdictions.

RESULTS

A total of 1,039 unique articles were identified, of which eight were retained and two added from references. Three studies included direct comparisons between individuals aged >40 years and those ≤40 years and one other study included three age groups over 40 years, finding lowest immunogenicity in the oldest adults. All found higher proportions seroprotected (definition varied by study) in younger age groups (ages varied by study) at 15 days post-vaccination but similar seroprotection at 30 days. Most other jurisdictions reviewed recommended vaccine alone or in conjunction with IG for PEP in older adults.

CONCLUSIONS

Immunogenicity of HepA vaccine may be diminished in older adults, especially in the very oldest age groups. HepA vaccine should be administered as soon as possible within 14 days after exposure to achieve the best possible immune response.

Danger in the streets: exposures to bloodborne pathogens after community sharp injuries in Rio de Janeiro, Brazil

OBJECTIVE

Exposures to sharps injuries occurring in the community are relatively frequent. We describe characteristics of community sharp exposures reported in the city of Rio de Janeiro from 1997 to 2010.

METHODS

A cross-sectional analysis of exposure reports to sharps in the community reported to a surveillance system, designed for health care workers, of the Municipal Health Department of Rio de Janeiro. The characteristics of exposed individuals analyzed included types of exposure, the circumstances of the accident, and the prophylaxis offered.

RESULTS

582 exposures were studied. Median age was 30 years and 83 (14%) involved children with less than 10 years of age. Two hundred and seventeen (37%) occurred with sharps found in the streets. The exposure was percutaneous in 515 (89%) and needles where involved in 406 (70%) of them. The sharps were present in the trash in 227 (39%) or in the environment in 167 (29%) of the reports. Professionals who work with frequent contact with domestic or urban waste were 196 (38%). The source was known in 112 (19%) of the exposures and blood was involved in 269 (46%). Only 101 (19%) of the injured subjects reported a complete course of vaccination for hepatitis B. Antiretroviral prophylaxis was prescribed for 392 (68%) of the exposed subjects.

CONCLUSIONS

Sharps injuries occurring in the community are an important health problem. A great proportion would be avoided if practices on how to dispose needles and sharps used outside health units were implemented.

Occupational Health Update: Focus on Preventing the Acquisition of Infections with Pre-exposure Prophylaxis and Postexposure Prophylaxis

Health care personnel are commonly exposed to infectious agents via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, and hepatitis C virus), direct patient care (eg, pertussis and meningococcus), and the contaminated environment (eg, Clostridium difficile). An effective occupational program is a key aspect of preventing acquisition of an infection by offering the following: (1) education of health care personnel regarding proper handling of sharps, early identification and isolation of potentially infectious patients, and hand hygiene; (2) assuring immunity to vaccine-preventable diseases; and, (3) immediate availability of a medical evaluation after a nonprotected exposure to an infectious disease.

Three-day regimen of oseltamivir for postexposure prophylaxis of influenza in wards

Inpatients who had been in close contact with patients with influenza were given oseltamivir [75mg capsules once daily for adults or 2mg/kg (maximum of 75mg) once daily for children] for three days as postexposure prophylaxis (PEP). The index patients with influenza were prescribed a neuraminidase inhibitor and were discharged immediately or transferred to isolation rooms. The protective efficacy of oseltamivir for three days was 93% overall [95% confidence interval (CI) 53-99%; P=0.023] and 94% for influenza A (95% CI 61-99%; P=0.017), which is comparable to that of seven- to 10-day regimens of oseltamivir as PEP.

Prevalence of Needlestick Injuries Among Healthcare Workers in the Accident and Emergency Department of a Teaching Hospital in Nigeria

Background:

Healthcare workers (HCWs) are continually exposed to hazards from contact with blood and body fluids of patients in the healthcare setting.

Aim:

To determine the prevalence of needlestick injuries (NSIs) and associated factors among HCWs in the Accident and Emergency Department of the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria.

Subjects and Methods:

This was a cross-sectional study. Data were collected using a structured, self-administered questionnaire and analyzed using IBM SPSS version 20. Univariate, bivariate, and binary logistic regression analyses were done. The level of significance was set at P < 0.05.

Results:

The prevalence of NSIs 12 months preceding the study was 51.0% (50/98). Doctors 8/10 (80.0%) and nurses 28/40 (70.0%) had the highest occurrence. Recapping of needles 19/50 (38.0%) and patient aggression 13/50 (26.0%) were responsible for most injuries. The majority 31/50 (62.0%) of the injuries were not reported. The uptake of postexposure prophylaxis (PEP) was low 11/50 (22.0%). The factors that were significantly associated with NSI include age 30 years and above (odds ratio [OR] =0.28, confidence interval [CI] = 0.11–0.70), work duration of three years and above (OR = 0.29, CI = 0.11–0.75), and being a nurse (OR = 3.38, CI = 1.49–9.93) or a paramedic (OR = 0.18, CI = 0.06–0.52).

Conclusion:

The high prevalence of NSIs among the HCWs, especially in doctors and nurses is an indication that HCWs in UBTH are at great risk of contracting blood-borne infections. Efforts should be made to ensure that injuries are reported and appropriate PEP undertaken following NSIs.

Should travellers to rabies-endemic countries be pre-exposure vaccinated? An assessment of post-exposure prophylaxis and pre-exposure prophylaxis given to Danes travelling to rabies-endemic countries 2000-12

BACKGROUND

Since 2000, a steady increase of vaccines used for both rabies Post-exposure prophylaxis (PEP) and rabies Pre-exposure prophylaxis (PrEP) given to Danish travellers was observed. This study aims to evaluate whether the increase of PEP and PrEP was due to increased travelling, increased awareness of the need for PrEP, or more animal bites per travel, leading to more PEP being administered, in order to assess the need for changing the recommendations. We also described in which countries Danish travelers most frequently reported possible exposure to rabies, and evaluated the timeliness of rabies PEP, including rabies immunoglobulin (RIG).

METHODS

We included all Danes reported to the National Database for Rabies Treatment as having started rabies PEP either abroad or after returning to Denmark, between 2000 and 2012. Data on the yearly number of Danish travelers from 2004 to 2012 to Thailand were collected to calculate the incidence of animal bites at this destination. We also included data on rabies vaccines sold for PrEP or for booster vaccination in Denmark.

RESULTS

PEP after possible exposure to rabies abroad increased yearly by 8.8 %. Likewise vaccines sold for PrEP increased by 8.2% annually. The number of Danish travelers to Thailand increased by 7.3% per year, resulting in a stable incidence of animal bites per 100,000 travelers. Seventy-five % started PEP in the country of exposure, while only 10 % received RIG.

CONCLUSIONS

The yearly increase in PEP and PrEP are parallel to the yearly increase in number of travelers, and can thus be explained by the increased rate of traveling, and not by a rise in awareness of rabies risk or more bites per traveler.Even short term travelers should be given the option of including PrEP in their travel immunisation program, as PEP and especially RIG is not always available in rabies-endemic countries.

The acceptable duration between occupational exposure to hepatitis B virus and hepatitis B immunoglobulin injection: Results from a Korean nationwide, multicenter study

BACKGROUND

Postexposure prophylaxis for occupational exposure to hepatitis B virus (HBV) plays an important role in the prevention of HBV infections in health care workers (HCWs). We examined data concerning the acceptable duration between occupational exposure and administration of a hepatitis B immunoglobulin (HBIG) injection in an occupational clinical setting.

METHODS

A retrospective analysis was conducted with data from 143 cases of HCWs exposed to HBV in 15 secondary and tertiary teaching hospitals between January 2005 and June 2013. Data were taken from the infection control records of each hospital.

RESULTS

Active vaccination after HBV exposure was started in 119 cases (83.2%) and postvaccination testing for hepatitis B antibody showed positive seroconversion in 93% of cases. In 98 cases (68.5%), HBIG was administered within 24 hours after HBV exposure; however, 45 HCWs (31.5%) received an HBIG injection more than 24 hours postexposure and 2 among the 45 received an injection after 7 days. Although 31.5% received an HBIG injection more than 24 hours postexposure, no cases of seroconversion to hepatitis b antibody positivity occurred.

CONCLUSIONS

For susceptible HCWs, HBIG administered between 24 hours and 7 days postexposure may be as effective as administration within 24 hours in preventing occupational HBV infection.

Significant intolerability of efavirenz in HIV occupational postexposure prophylaxis

BACKGROUND

Completion of human immunodeficiency virus (HIV) occupational postexposure prophylaxis (PEP) is important for successful prophylaxis.

AIM

To determine factors associated with failure to complete the four-week HIV PEP.

METHODS

A retrospective study was conducted among healthcare workers (HCWs) accidentally exposed to blood or body fluids of patients at the Bamrasnaradura Infectious Diseases Institute, Thailand, between March 1996 and June 2014. Logistic regression analysis was used to determine factors associated with failure to complete the four-week HIV PEP.

FINDINGS

In total, 225 exposure episodes were reported. The mean age of HCWs was 33.1 (standard deviation 9.9) years, and 189 (84%) were female. Nurses (43%) were exposed most frequently. The HIV status of the source was defined in 149 (66%) episodes, and 101 (68%) of these were positive. Of 225 exposures, PEP was prescribed in 155 (69%) cases, with intentional discontinuation in 26 cases. Ninety-one of 129 (71%) HCWs completed the four-week regimen. Multi-variate analysis showed that a regimen of two nucleotide reverse transcriptase inhibitors (NRTI) + efavirenz (EFV) was the only significant factor associated with non-completion of the four-week course (odds ratio 37.8, 95% confidence interval 4.2-342.3; P < 0.01). Other factors including age, sex, staff position, status of the source and other PEP regimens were not associated with non-completion of the four-week course (P > 0.05). None of the HCWs were documented to have HIV seroconversion.

CONCLUSION

A regimen of two NRTIs + EFV was significantly associated with premature discontinuation of occupational PEP. This regimen should not be used for HIV prophylaxis following occupational exposure.

Nosocomial exposure to active pulmonary tuberculosis in a neonatal intensive care unit

BACKGROUND

Nosocomial transmission of tuberculosis (TB) in a neonatal intensive care unit (NICU) is a recognized risk. We investigated TB transmission to neonates and health care workers (HCWs) exposed to a nurse with active TB in a NICU.

METHODS

A NICU nurse in a tertiary referral hospital in Seoul, Korea, developed pulmonary TB. The investigation included 108 infants and 75 HCWs. Tuberculin skin test (TST) and chest radiograph were performed at baseline. Isoniazid prophylaxis was started in neonates. After 3 months of prophylaxis, infants underwent repeat TST and chest radiograph. HCWs underwent a second TST after 3 months.

RESULTS

Baseline chest radiographs were negative in infants and HCWs. Four (3.7%) of 108 infants screened had a positive TST, including 2 conversions, and received isoniazid for 6-9 months. Among the 59 HCWs screened, 27 (45.8%) had an initial positive TST result, and 6 (10.2%) had a positive TST result at 3 months. Four of the 6 HCWs with TST conversions received isoniazid treatment for 9 months. In the 2-year period after exposure, none of the exposed infants or HCWs developed active TB.

CONCLUSION

In this investigation, 4 (3.7%) of 108 infants exposed to a nurse with active TB developed latent TB infection. They were given isoniazid therapy without any adverse events and did not progress to TB disease in the 2 years after exposure.

Worldwide rabies deaths prevention--A focus on the current inadequacies in postexposure prophylaxis of animal bite victims

The World Health Organization reports that over 60,000 humans die of rabies annually, worldwide. Most occur in remote regions of developing countries. Almost all victims received no postexposure rabies prophylaxis (PEP). There are no facilities or health personnel able to provide it in many areas where the disease is prevalent. A first approach to correct this problem would be by extending provision of modern PEP to areas where human rabies is most prevalent.

Is ribavirin prophylaxis effective for nosocomial transmission of Crimean-Congo hemorrhagic fever?

Crimean-Congo hemorrhagic fever (CCHF) is a viral zoonotic disease that is transmitted primarily through contact with ticks. Nosocomial cases and outbreaks of CCHF have been reported from many countries. Health care workers (HCWs) are at risk of exposure to CCHF. In our study, we evaluated seven HCWs' exposure to confirmed CCHF patients' infected blood and body fluids and prophylactic efficacy of the ribavirin on nosocomial transmission of CCHF retrospectively. Between 2007 and 2013, 150 CCHF cases were admitted to our clinic. During the follow-up of these patients, four doctors and three nurses had contact with infected blood and body fluids through needle stick injury, contact of skin and mucosal surfaces, and probable aerosolization. All of the index cases' diagnoses of CCHF were confirmed during the contact. Ribavirin prophylaxis was administered within 0.5-1 h in six out of seven cases. All of these cases' CCHF virus PCR results were negative. One physician had no contact with infected blood or body fluid, so ribavirin prophylaxis was not administered. The physician developed CCHF and diagnosis was confirmed. Although efficacy of ribavirin for prophylaxis is not clear and very few data exist on prophylactic usage of ribavirin, lack of clinical manifestations in our cases that were given ribavirin compared with the developed clinical manifestations in the physician may be explained by the prophylactic efficacy of the ribavirin.

Postexposure management of healthcare personnel to infectious diseases

Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

[Risk estimation of blood-borne infections by emergency room personnel]

BACKGROUND

Emergency department personnel are at risk of occupational exposure to blood-borne pathogens. Previous studies have shown that the prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) virus infections among trauma patients is higher compared to the general population.

OBJECTIVES

The aim of the study was to investigate the compliance rates of trauma team members in applying standard precautions, knowledge about the transmission risk of blood-borne infections and perceived risk of acquiring HIV, HBV and HCV.

METHODS

An anonymous questionnaire was distributed to 100 trauma team members including physicians, nurses and medical students from different medical departments (e.g. surgery, radiology, anesthesia and internal medicine).

RESULTS

The results of the questionnaire showed that trauma team members had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of HCV infection and underused standard precautions during treatment of emergency trauma patients.

CONCLUSION

Further educational measures for emergency department personnel are required to increase the knowledge of occupational infections and compliance with standard precautions. Every healthcare worker needs to be sufficiently vaccinated against HBV. In the case of injury awareness of all measures of post-exposure prophylaxis is of utmost importance for affected personnel.

Prevention of human immunodeficiency virus and AIDS: postexposure prophylaxis (including health care workers)

Postexposure prophylaxis (PEP), which is designed to prevent human immunodeficiency virus (HIV) infection after an exposure, is one of several strategies for HIV prevention. PEP was first used after occupational HIV exposures in the late 1980s, with the Centers for Disease Control and Prevention issuing the first set of guidelines that included considerations regarding the use of antiretroviral agents for PEP after occupational HIV exposures in 1990. Use of PEP has been extended to nonoccupational exposures, including after sexual contact or injection-drug use. This article provides a rationale for PEP, assessment of the need for PEP, and details of its implementation.

Best practice for needlestick injuries

PURPOSE

Needlestick injuries (NSIs) are a significant health hazard. Occupational transmission of bloodborne pathogens among healthcare workers (HCWs) is rare but has been repeatedly reported in the literature.

METHODS

In October 2010, new regulations were introduced for medical aftercare of HCWs following NSIs at the University Hospital Frankfurt. In June 2013, a university hospital-wide early intervention program was introduced that gives HCWs immediate 24/7/365 access to an HIV postexposure prophylaxis kit after confirmed or probable occupational HIV exposure.

RESULTS

Interdisciplinary collaboration between the attending surgeon and occupational health as well as infectious disease specialists facilitates optimal postexposure medical treatment of HCWs who suffer NSIs. Complete reporting of NSIs is a prerequisite for achieving optimal treatment of the affected HCWs.

CONCLUSION

An NSI is an emergency and needs to be evaluated immediately and, if necessary, treated as soon as possible. A standardized algorithm for initial diagnostic and treatment has proven to be helpful.

Medical graduates' knowledge of bloodborne viruses and occupational exposures

A survey of medical graduates commencing employment as junior doctors was performed to investigate knowledge of bloodborne viruses and occupational exposure management, coupled with their experience of occupational exposures. There was a mismatch between general knowledge (excellent) and knowledge of postexposure management (poor), and graduates had commonly experienced an occupational exposure and not reported it. The knowledge deficit regarding postexposure management and history of poor practice (ie, nonreporting) following an exposure implies that the transition period from student to junior doctor may be associated with increased occupational health and safety risk.