Older adults and non-response to rabies post-exposure prophylaxis: Challenges and approaches.

Rabies vaccines are highly effective and immunogenic in most populations, including when used as rabies post-exposure prophylaxis (RPEP); however, there is mounting evidence that the immune response to rabies vaccines, though predicted to be adequate, may be lower in older adults. Despite this, there are no specific recommendations in Canadian guidance to monitor the serological response of older adults following RPEP. Furthermore, while Canadian guidance recommends the intramuscular route for RPEP vaccination, there is good evidence supporting the immunogenicity, effectiveness and safety of RPEP vaccination using the intradermal route. We present a case of an 87-year-old male with rabies exposure who failed to respond to two series of RPEP with intramuscular rabies vaccination but responded to a third series using intradermal vaccine administration and provide reasoning for subsequent management. This case is brought forward to prompt discussion and research as to the utility of completing serology in older adults receiving RPEP as well as vaccination strategies, including route of administration, in those who do not respond to an initial course of RPEP vaccination.

Innovative public health response to an event on the fringe of regulatory changes.

SETTING: During a period of regulatory uncertainty, a local public health unit in Ontario was notified of an exhibition for electronic nicotine delivery systems (ENDS) and novel tobacco delivery products (NTDs), specifically e-cigarettes and waterpipes, which have seen increasing use particularly among youth. Relevant statutes creating regulatory uncertainty included a new provincial Electronic Cigarettes Act (ECA) with certain sections awaiting proclamation, and a local waterpipe bylaw awaiting approval, which would have prohibited the use of these products in public spaces if they entered into force ahead of the exhibition date. Public health staff had concerns the event would normalize use of ENDS/NTDs, particularly among youth, and also planned to enforce already proclaimed ECA sections, as well as the existing Smoke-Free Ontario Act (SFOA) with regulations applicable to use of tobacco shisha in waterpipes. INTERVENTION: Public health staff contacted event organizers and proprietors to communicate obligations under the SFOA and ECA, as well as share hypothetical implications from pending regulatory changes, including risk of charges for regulatory non-compliance if regulations came into force ahead of the planned event. OUTCOMES: Following discussion with health unit staff and legal consultation, the exhibition was cancelled. IMPLICATIONS: By directly communicating regulatory uncertainty, a public health unit was able to achieve local health goals. In this situation, public health advised exhibition proprietors of potential event disruption implicated by forthcoming regulatory changes. Subsequent cancellation of the event prevented potential adverse health impacts for at-risk groups. A similar communications approach could be used to achieve public health goals during a period of regulatory uncertainty.

The Therapeutic Utility of Employment in Treating Drug Addiction: Science to Application.

Research on a model Therapeutic Workplace has allowed for evaluation of the use of employment in the treatment of drug addiction. Under the Therapeutic Workplace intervention, adults with histories of drug addiction are hired and paid to work. To promote drug abstinence or adherence to addiction medications, participants are required to provide drug-free urine samples or take prescribed addiction medications, respectively, to gain access to the workplace and/or to maintain their maximum rate of pay. Research has shown that the Therapeutic Workplace intervention is effective in promoting and maintaining abstinence from heroin, cocaine and alcohol and in promoting adherence to naltrexone. Three models could be used to implement and maintain employment-based reinforcement in the treatment of drug addiction: A Social Business model, a Cooperative Employer model, and a Wage Supplement model. Under all models, participants initiate abstinence in a training and abstinence initiation phase (Phase 1). Under the Social Business model, Phase 1 graduates are hired as employees in a social business and required to maintain abstinence to maintain employment and/or maximum pay. Under the Cooperative Employer model, cooperating community employers hire graduates of Phase 1 and require them to maintain abstinence to maintain employment and/or maximum pay. Under the Wage Supplement Model, graduates of Phase 1 are offered abstinence-contingent wage supplements if they maintain competitive employment in a community job. Given the severity and persistence of the problem of drug addiction and the lack of treatments that can produce lasting effects, continued development of the Therapeutic Workplace is warranted.