Varicella post-exposure management for pediatric oncology patients.

INTRODUCTION: The objective was to evaluate health care providers' (HCP) adherence to and efficacy of varicella post-exposure prophylaxis (PEP) recommendations. It was an observational, prospective, multicenter study set in Ile-de-France, France. METHODS: All children under 18 with a cancer diagnosis, currently or within 3months of receiving cancer treatment, regardless of varicella zoster virus (VZV) serostatus or previous personal history of varicella, were eligible. Study participants with significant exposure were reviewed prospectively for PEP indications. Main outcome measures were the percentage of exposure situations for which HCP were guideline-compliant, the proportion of available VZV serostatuses and the incidence of breakthrough varicella after different PEP approaches. RESULTS: A total of 51 patients from 15 centers were enrolled after 52 exposure episodes. Median age at exposure was 5 years (range, 1-15). Exposure within the household led to 38% of episodes. Prophylactic treatment consisted in specific anti-VZV immunoglobulins (V-ZIG) (n=19) or in oral aciclovir (n=15). No prophylactic treatment was given for 18 patients (in compliance, n=16). In compliance with guidelines, 17 patients received V-ZIG, 11 did not develop varicella (65%, [95% CI, 39-90%]); 15 received aciclovir, 13 did not develop varicella (87%, [95% CI, 67-100%]). Breakthrough varicella occurred in 11 patients, with simple clinical course in all cases; in 8/47 (17%) episodes when PEP was guideline-compliant versus 3/5 (60%) when not. DISCUSSION: Recommendations have been respected and are efficient. PEP needs to be standardized and a study carried out to define the optimal approach. Anti-VZV immunization of seronegative family members should be encouraged.

Re-examining Hepatitis B Postexposure Prophylaxis Following Pediatric Community-acquired Needle-stick Injury in an Era of a National Immunization Registry.

BACKGROUND: Long-term hepatitis B immunity has been demonstrated following the completion of the primary vaccination series in childhood. Some guidelines recommend a hepatitis B surface antibody (anti-HBs) directed approach following community-acquired needle-stick injury (CANSI) to inform hepatitis B postexposure prophylaxis (PEP) management. We assessed the utility of anti-HBs testing post-CANSI, as well as the costing of, and adherence to PEP at a pediatric hospital. METHODS: Children presenting to an Australian tertiary pediatric hospital post-CANSI (2014-2019) were identified retrospectively using medical and laboratory records. Immunization status was obtained from the Australian Immunisation Registry. RESULTS: Fifty-six children with CANSI were identified. Of those with immunization records, all had completed hepatitis B vaccinations (n = 52). At presentation, 44% (n = 23) had anti-HBs <10 IU/L, which was more likely in older (≥6 years, 68%) versus younger children (OR 4.59, P < 0.02). HBIG and hepatitis B vaccine adherence was 65% (15/23) and 78% (18/23), respectively. All children (n = 14) with anti-HBs ≥4 weeks postvaccination ±HBIG, demonstrated an anamnestic response. No hepatitis B infections were detected. Using completed immunizations versus anti-HBs levels as a marker of immunity to direct PEP resulted in a projected cost savings of AUD$ 4234. CONCLUSION: Anti-HBs levels <10 IU/L, despite previous vaccinations, were frequent in children post-CANSI, with many demonstrating an anamnestic response. Adherence to postexposure HBIG and hepatitis B vaccine was suboptimal using an anti-HBs directed approach. These data support re-evaluating PEP in an era of the national immunization registry; completion of hepatitis B vaccinations as a marker of immunity provides a practical approach, ensuring optimized care for pediatric CANSI.

Rabies post-exposure prophylaxis in Germany - What are the challenges?

Rabies post-exposure prophylaxis (R-PEP) including wound treatment, vaccination and application of rabies immunoglobulin (RIG) is essential in preventing rabies mortality. Today, Germany is officially declared free from terrestrial rabies and rabies is only found in bats. However, physicians in A&E Departments are frequently consulted on the need for R-PEP. We retrospectively analysed patients who received R-PEP at the A&E Department of the University Hospital Bonn between 01.01.2013 and 30.06.2019. Demographic data, travel history, clinical and laboratory findings, previous rabies vaccinations and R-PEP vaccination regimen were recorded. During the study period, 90 patients received R-PEP at the University Hospital Bonn, in 10 cases without indication for R-PEP. Altogether, we found deviations from R-PEP guidelines in 51% (n = 41/80). Infiltration of RIG was missed in 12 patients and incorrectly administrated in 24 patients. Furthermore, vaccination scheme was incorrect in 11 patients. Correct wound washing and documentation of tetanus status was missing in 14% and 63% of patients, respectively. Despite rabies elimination in Germany patients frequently seek advice for R-PEP, the majority returning from foreign travel. Our data show that there is a high need for education on indication for R-PEP before and after travel and for implementation of precise R-PEP guidelines in daily clinical practice.

Profilaxia pós-exposição ao HIV em populações vulneráveis: estudo longitudinal retrospectivo em um ambulatório da rede pública do Rio Grande do Sul, 2015-2018 / Profilaxis post exposición al VIH en poblaciones vulnerables: estudio longitudinal retrospectivo en un ambulatorio de salud pública en Rio Grande do Sul, Brasil, 2015-2018 / HIV post-exposure prophylaxis in vulnerable populations: a retrospective longitudinal study in a public health outpatient clinic in Rio Grande do Sul, Brazil, 2015-2018

Objetivo: Descrever o perfil de usuários que iniciaram a profilaxia pós-exposição ao HIV (PEP) em um serviço público, avaliando o uso dessa tecnologia pelas populações-chave recomendadas pelo Ministério da Saúde do Brasil. Métodos: Estudo longitudinal retrospectivo, com uso de dados secundários de usuários atendidos entre 2015 e 2018. Foram calculadas frequências absolutas e relativas e o teste do qui-quadrado de Pearson foi utilizado para comparar características comportamentais. Resultados: Dos 270 usuários, foram mais frequentes adultos jovens (45,4%), homens (74,7%), raça/cor da pele branca (76,3%), alta escolaridade (65,7%) e múltiplas parcerias sexuais (40,7%). Entre as populações-chave, observou-se maior frequência de usuários de álcool e/ou outras drogas (49,6%) e homens que fazem sexo com homens (38,1%), enquanto pessoas transgênero (2,2%) e profissionais do sexo (4,8%) fizeram menor uso da PEP. Conclusão: O uso de PEP não foi homogêneo entre os grupos vulneráveis avaliados, com baixa frequência de pessoas transgênero e profissionais do sexo.

Objetivos: Describir el perfil de los usuarios que comenzaron la profilaxis post exposición al VIH (PEP) en un servicio público, evaluando el uso de esta tecnología por las poblaciones clave recomendadas por el Ministerio de Salud de Brasil. Métodos: estudio longitudinal retrospectivo, con datos secundarios de usuarios atendidos entre 2015-2018. Se calcularon frecuencias absolutas y relativa y se utilizó chi-cuadrado de Pearson para comparar características de comportamiento. Resultados: De los 270 usuarios estudiados, hubo mayor frecuencia de adultos jóvenes (45,4%), blancos (76,3%), hombres (74,7%), con educación superior (65,7%) y múltiples parejas sexuales (40,7%). Entre las poblaciones clave, hubo mayor frecuencia de usuarios de alcohol y/u otras drogas (49,6%) y hombres que tienen sexo con hombres (38,1%), mientras que personas transgénero (2,2%) y trabajadoras sexuales (4,8%) hizo menos uso de PEP. Conclusión: El uso de PEP no fue homogéneo entre los grupos vulnerables evaluados, con baja frecuencia de personas transgénero y trabajadoras sexuales.

Objective: To describe the profile of people who initiated HIV post-exposure prophylaxis (PEP) in a public health service, evaluating the use of this technology by key populations as recommended by the Brazilian Ministry of Health. Methods: This was a retrospective longitudinal study using secondary data on service users receiving care between 2015-2018. Absolute and relative frequencies were calculated and Pearson's chi-square test was used to compare behavioral characteristics. Results: Of the 270 people evaluated, there was a higher frequency of young adults (45.4%), males (74.7%), people of white race/skin color (76.3%), with a high level of education (65.7%) and with multiple sex partners (40.7%). Among the key populations, there was a higher frequency of people who use alcohol and/or other drugs (49.6%) and men who have sex with men (38.1%), while transgender people (2.2%) and sex workers (4.8%) used PEP less. Conclusion: The use of PEP was not homogeneous among the vulnerable groups evaluated, with low frequency of transgender people and sex workers.

Adherence to guideline recommendations for human rabies immune globulin patient selection, dosing, timing, and anatomical site of administration in rabies postexposure prophylaxis.

Rabies is a fatal disease that mandates proper prophylaxis after a rabies virus exposure to prevent death. This study evaluated adherence to Centers of Disease Control and Prevention (CDC) recommendations for rabies immune globulin (IG) patient selection, dosing, timing of administration, and anatomical site of administration for rabies postexposure prophylaxis. This retrospective, cross-sectional study included patients who received at least one dose of rabies IG or rabies vaccine at a multi-hospital health system from January 2015 through June 2018. This study included 246 patients, and all of them received at least one dose of rabies vaccine. Two patients had a history of rabies vaccination, did not have an indication for rabies IG, and appropriately did not receive additional rabies IG. Rabies IG was administered to 91% (223 of 244) of patients with an indication. Of 223 patients who received rabies IG, 219 (98%) received doses within 10% of 20 IU/kg of body weight, and all 223 (100%) received rabies IG within 7 days of the first rabies vaccine administration. Only 56% (96 of 170) of patients with a wound that could be infiltrated with rabies IG actually received rabies IG via infiltration into and around the wound. This multi-hospital health system study demonstrated high adherence to guideline recommendations for rabies IG patient selection (91%), dosing (98%), and timing (100%). However, only 56% of eligible patients received rabies IG infiltration at wound sites as recommended by guidelines.

CE: HIV Update: An Epidemic Transformed.

: The field of HIV treatment and prevention has evolved rapidly over the past four decades. New therapies that are more potent and streamlined have transformed HIV into a chronic disease, while the use of such preventive strategies as preexposure prophylaxis and postexposure prophylaxis provide effective options for reducing the risk of HIV infection. These medical breakthroughs have enabled more people living with HIV (PLWH) to reach older adulthood. But they also mean that nurses are seeing more PLWH who have developed long-term complications of living with HIV or of exposure to antiretroviral therapy, as well as concurrent chronic conditions associated with advanced age. Nurses play a critical role in caring for PLWH and those at risk for HIV infection. This article discusses HIV epidemiology, describes the current state of HIV treatment and prevention, and highlights common comorbidities often seen in PLWH who are over age 50.

[Knowledge attitudes and practices of hairdressing salon staff on HIV infection in Lome Togo]. / Connaissances attitudes et pratiques du personnel des salons de coiffures sur l'infection à VIH à Lomé Togo.

INTRODUCTION: this study aims to describe the knowledge, attitude and practices of hairdressers about HIV infection in Lomé. METHODS: we conducted a descriptive study whose population included hair salon owners and apprentices in the Agoè-Nyivé prefecture, Lomé, between October 1 2016 and March 31 2017. The different parameters studied were data on the general knowledge about HIV, attitudes and practices about HIV/AIDS in the hair salons. RESULTS: a total of 203 owners and apprentices were interviewed in the 68 hair salons in the Agoè-Nyivé prefecture. The study population (100%) knew about HIV/AIDS. Among the participants, 79.3% of them defined it as a sexually transmitted infection. Gloves and aprons were worn before some hairstyling gestures in 33 (51.5%) and 35 (48.5%) hair salons respectively. Moreover, in 60 (88.2%) hair salons, sharp instruments were disinfected prior to their use. However, alcohol was the disinfectant the most commonly used by the majority of the staff of hairdressing salons (89.3%). Moreover, boiling for an average of 7 minutes was performed by 79.8% of hairdressers. In the event of blood exposure accident, 69.6% of staff of hair salons cleaned the exposed site with alcohol. CONCLUSION: this study shows that hairdressers and their apprentices have good knowledge about HIV infection/AIDS, its modes of transmission and prevention means in hair salons. However, it highlights that the disinfection of soiled equipment and the behaviour of hairdressers and their apprentices in the case of blood exposure accident are sometimes improper.

The indications and safety of polyvalent immunoglobulin for post-exposure prophylaxis of hepatitis A, rubella and measles.

Derived from pooled blood donations, polyvalent immunoglobulins are used for post-exposure prophylaxis as one aspect of the public health management of hepatitis A, rubella and measles. This review summarizes the safety profile of these blood products and the current recommendations for their use for the prevention of hepatitis A, rubella and measles among people who have been exposed to these diseases. The current recommendations are drawn from the most recent publicly available national guidelines of the United States, Australia, New Zealand, Canada and the United Kingdom as accessed in February 2019.

[Revision of the rabies policy in the Netherlands]. / Gewijzigde Nederlandse rabiësrichtlijnen.

Revision of the rabies policy in the Netherlands The WHO aims to eliminate dog-transmitted rabies deaths in humans by 2030 ('zero by 30'). The Dutch rabies policy advisory board has revised its national rabies guidelines on the basis of the WHO guidelines revised in 2018. In the revised Dutch guidelines, there is increased focus on the importance of instant wound care after potential exposure to the rabies virus. Pre-exposure prophylaxis (PrEP) is limited to two vaccines given on days 0 and 7, rather than the previous regime of three vaccines. Post-exposure prophylaxis (PEP) no longer consists of five vaccines for unvaccinated individuals; instead it is four vaccines on days 0, 3, 7, and 14-28. For type III wounds, when indicated, rabies immunoglobulin (RIG) is only injected into and around the wound bed; residual volumes are no longer administered intramuscularly. RIG no longer needs to be administered in cases of potential mucosal contact exposure to the rabies virus where there is no injury. The vaccination scheme for PrEP (3) and PEP (5) does not change for immunocompromised patients, and RIG is administered regardless of the vaccination status of the affected individual.

Characteristics and factors associated with post-exposure prophylaxis (PEP) treatment of dog and cat bites among left-behind children: a cross-sectional study in two cities of China.

OBJECTIVE: Animal injury is a significant cause of morbidity and mortality worldwide. Dog bites account for tens of millions of injuries annually and the highest risk is among children. However, children may not receive postexposure prophylaxis (PEP) treatment timely and appropriately after rabies exposure. This study aimed to investigate the characteristics and factors associated with PEP treatment of dog and cat bites among left-behind children. DESIGN: A cross-sectional study using questionnaire was conducted in primary and high schools. SETTING: Shenzhen and Shantou cities, Guangdong Province, China. PARTICIPANTS: A total of 9380 participants were included and 2236 of them were with a history of dog and cat bites. RESULTS: 1188 (53.1%) boys and 1048 (46.9%) girls suffered from animal bites. Bitten in holidays was less likely to receive PEP treatment (OR 0.512, 95% CI 0.377 to 0.695) than those bitten in school days. Bitten while being with family (OR 1.418, 95% CI 1.040 to 1.934) and bitten at roadside (OR 1.842, 95% CI 1.297 to 2.171), bitten by unvaccinated animals (OR 1.745, 95% CI 1.246 to 2.443) tended to receive PEP treatment. Compared with unbroken skin, bleeding (OR 1.789, 95% CI 1.165 to 2.745) and laceration (OR 3.834, 95% CI 2.310 to 6.366) were showed as treatment prompting factors. CONCLUSIONS: Bitten in holidays was found as a risk factor of receiving PEP treatment of animal bites. Certain measures should be taken to raise left-behind children's awareness of receiving PEP treatment timely and appropriately after dog and cat bites.

Paralytic rabies: An acute flaccid myelitis after inadequate post exposure prophylaxis.

Rabies has two distinct clinical syndromes, encephalitic (or 'furious') and paralytic (or 'dumb'). The paralytic form presents as acute flaccid myelitis and is more common in patients who received post-exposure anti-rabies vaccination without rabies immunoglobulins. We have recently had the opportunity to manage a middle-aged man presenting as 'dumb' paralytic rabies.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Prophylactic Anticonvulsants in the Treatment of Adults with Metastatic Brain Tumors.

TARGET POPULATIONS: Adults with solid brain metastases who have not experienced a seizure. QUESTION 1: Do prophylactic antiepileptic drugs (AEDs) decrease the risk of seizures in nonsurgical patients with brain metastases who are otherwise seizure-free? RECOMMENDATION: Level 3: Prophylactic AEDs are not recommended for patients with brain metastases who did not undergo surgical resection and are otherwise seizure-free. QUESTION 2: Do prophylactic AEDs decrease the risk of seizures in patients with brain metastases and no prior history of seizures in the postoperative setting? RECOMMENDATION: Level 3: Routine postcraniotomy AED use for seizure-free patients with brain metastases is not recommended.The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_8.

Analysis on the risks of severe adverse events in rabies post-exposure prophylaxis and appropriate decision-making procedure.

Severe adverse events (AEs) following post-exposure rabies vaccination had been occasionally described in previous studies. Once AEs occurred, immediate medical treatment and appropriate change of vaccine and vaccination schedule were of significance. It was also important and challengeable to determine the relationship among adverse reactions, vaccines residues and laboratory tests for patients, to choose a proper vaccine in resumed vaccination, to avoid the reoccurrence of AEs and to ensure adequate immune response. Here, we present steps about how to cope with AEs by giving an example with a two-year-old girl who was identified as category II exposure to rabies, suffered from anaphylaxis after first dose administration with human diploid rabies vaccine (HDCV) so vaccination was temporarily suspended. Dexamethasone was prescribed to her in anti-allergy therapy. Allergy tests indicated that the patient was not sensitive to allergens and heterologous proteins. Vaccine test report showed that residual kanamycin existed in that batch of vaccines. This reminded us to provide her antibiotic skin sensitivity test which found she was allergic to kanamycin. Thus, we could conclude it was the cause of AEs. Then, 0.5 mL lyophilized Purified Vero Cell Rabies Vaccine (PVRV) without any residues was enrolled in the resumed vaccination. To ensure successful immunization, immunogenicity test was also provided which showed adequate immune response (RVNA ≥ 0.5 IU/mL) starting from day14. Besides, no further AEs occurred afterward. This study emphasized the importance of in-depth survey, analysis and implied the necessity to scientifically and properly choose the optimal vaccine for patients and appropriately provide treatments if AEs occurred.

The Provision of HIV Post-Exposure Prophylaxis in the Context of Child Sex Trafficking.

Child sex trafficking (CST) victims are at risk for HIV infection due to a convergence of both social and biological factors. However, sparse recommendations and guidelines exist for providers on the provision of HIV non-occupational post-exposure prophylaxis (nPEP) for CST patients. We evaluated whether pediatricians would provide HIV nPEP in a clinical vignette where a patient disclosed ongoing involvement in CST. Participants were relatively divided regarding whether they would provide HIV nPEP; 58.8% responded yes and 41.2% responded no. This highlights the need for medical guidelines to address the complex and case specific considerations of providing nPEP to these victims.

Rabies vaccines: WHO position paper, April 2018 - Recommendations.

This article presented the World Health Organization's (WHO) recommendations on the use of Rabies vaccines excerpted from the Rabies vaccines: WHO position paper - April 2018 published in the Weekly Epidemiological Record [1] This position paper replaces the 2010 WHO position paper on rabies vaccines [2]. It presents new evidence in the field of rabies and the use of rabies vaccines, focussing on programmatic feasibility, simplification of vaccination schedules and improved cost-effectiveness. The recommendations concern the 2 main immunization strategies, namely vaccination for post-exposure prophylaxis and vaccination for pre-exposure prophylaxis. In the context of post-exposure prophylaxis, recommendations are also provided on the use of rabies immunoglobulins. Footnotes to this paper provide a number of core references including references to grading tables that assess the quality of the scientific evidence, and to the evidence-to-recommendation tables. In accordance with its mandate to provide guidance to Member States on health policy matters, WHO issues a series of regularly updated position papers on vaccines and combinations of vaccines against diseases that have an international public health impact. These papers are concerned primarily with the use of vaccines in large-scale immunization programmes; they summarize essential background information on diseases and vaccines, and conclude with WHO's current position on the use of vaccines in the global context. Recommendations on the use of cholera vaccines were discussed by the Strategic Advisory Group of Experts (SAGE) in October 2017; evidence presented at these meetings can be accessed at: http://www.who.int/immunization/sage/meetings/2017/october/presentations_background_docs/en/.

Screening for Anthrax Postexposure Antibiotic Prophylaxis-The New York City Approach.

Individuals exposed to spores of B. anthracis must take a course of antibiotics as postexposure prophylaxis (PEP) to prevent inhalation anthrax. During an anthrax event, public health authorities are responsible for conducting dispensing operations to offer PEP to exposed individuals. Jurisdictions have developed antibiotic PEP screening algorithms to determine which antibiotic is appropriate for each individual. Variability exists with regard to screening questions and dispensing decisions based on responses to those questions. It is likely that individuals with similar profiles will receive different antibiotics based solely on the jurisdiction in which they receive their PEP. This lack of consistency among jurisdictions may lead to a loss of confidence in the public health response among the public, the healthcare community, the media, and government leaders, which could compromise the response itself. We present New York City's planning assumptions, screening algorithm, a rationale for our screening questions, and our reasons for excluding screening questions asked by other jurisdictions. We hope that our efforts may assist others in developing and refining their algorithms and associated public messaging and encourage standardization with neighboring jurisdictions where appropriate.

The first report evaluating the post-exposure rabies prophylaxis in children exposed to animals in the Lublin Province (Eastern Poland) in 2010-2016 - a retrospective study.

INTRODUCTION: Rabies continues to be one of the most important viral diseases and remains a significant threat to public health across the globe. The World Health Organization (WHO) has determined that most rabies cases occur in children. Dog bites on humans are a major public-health problem. Poland has not achieved rabies free status yet. Post-exposure prophylaxis (PEP) in humans can effectively prevent death after exposure to a potentially infected animal. THE AIM: The main objective of this study was to estimate the frequency of PEP among children exposed to animals, who had attended consultations at the Department of Infectious Diseases for Children in the Jan Bozy Hospital in Lublin. PATIENTS AND METHODS: We retrospectively analyzed the medical records from the period of 2010-2016 of all pediatric patients (0-17 years of age) who had been exposed to animals and attended consultations at the Department of Infectious Diseases for Children in the Jan Bozy Hospital in Lublin. RESULTS: During the studied period, 519 children who had been exposed to animals attended consultations, and a prophylactic procedure consisting of active immunization was applied to 32.8%. The male children accounted for 55.3%. The mean age was 9.2 years. The biggest group of children (406) had been exposed to dogs, 62 children to cats, and 15 to rats. Most children had upper-limbs injuries. During the studied period, i.e. 2010-2016, there were 1713 confirmed cases of rabid animals in Poland, and 60 cases were recorded in the Lublin Province. We did not observe any cases of rabies in our exposed and vaccinated patients. CONCLUSIONS: The number of rabid animals in the Lublin Province had decreased to low levels, but the expected decrease in the number of PEP's administered did not occur. Since all children were vaccinated in accordance with the recommendations, the possible reason for vaccination's being administered in the quantities greater than the number of rabid animals recorded in the Lublin Province are bites by animals unavailable for veterinary observations and also the lack of more frequent reports regarding the current epizootic situation of rabies. The use of rabies immunoglobulin (RIG) in children in the Lublin Province is at a very low level, i.e. at 0.58%. The yearly numbers of exposed pediatric patients were at similar levels, which indicates that education programs should be introduce to reduce the number of animal bites in children.

Prevention Strategies Against HIV Transmission: A Proactive Approach.

Human immunodeficiency virus (HIV) has now transformed into a manageable chronic condition. Highly active antiretroviral therapy (HAART) has proven efficacious at controlling the disease progression. Based on compelling evidence, the Department of Health and Human Services (DHHS) and the Infectious Disease Society of America (IDSA) developed guidelines for the management of persons infected with HIV. However, there are approximately 50 000 new cases of HIV in the United States each year. In this article, we review proactive methods to reduce the transmission of HIV, which include reinforcing patient education, gel-coated condoms that destroy HIV, HIV vaccinations, and adequately utilizing pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP). Further development and consistent utilization of innovative prevention tools can significantly reduce the incidence of HIV infections regardless of HIV status.