Postexposure Prophylaxis Protocol Research Articles

Rabies postexposure prophylaxis protocol option for unvaccinated domestic animals, Texas: 2010-2019.

To assess data on rabies postexposure prophylaxis (PEP) in domestic animals following Texas' protocol and to describe preexposure and postexposure vaccination failures from 2010 through 2019. 1,218 unvaccinated animals that received PEP, 925 unvaccinated animals that were euthanatized instead of receiving PEP, and 3 preexposure vaccinated dogs that developed rabies. Zoonotic incident reports from 2010 through 2019 were reviewed for information regarding animals with no known rabies vaccination that received PEP or were euthanatized in accordance with state protocol after exposure to a laboratory-confirmed rabid animal; reports were also reviewed for any preexposure and postexposure vaccination failures. The state-required PEP protocol was to immediately vaccinate the animal against rabies, confine the animal for 90 days, and administer booster vaccines during the third and eighth weeks of the confinement period. From 2010 through 2019, 1,218 exposed animals received PEP; 99.8% did not develop rabies. Three failures were recorded, all in animals < 12 weeks of age when PEP was initiated. Additionally, 925 exposed animals were euthanatized instead of receiving PEP. One true preexposure vaccination failure was recorded. The Texas PEP protocol was used during the 10-year period. Results indicated that this protocol is a viable option for unvaccinated domestic animals exposed to rabies. Alternative protocols warrant additional consideration.

Knowledge, Attitude, and Practice (KAP) of post exposure prophylaxis for fifth year dental students at a private Egyptian university: a cross-sectional study

BackgroundHealth care professionals including dental staff are at greater risk of occupational exposure to life threatened blood-borne pathogens. Occupational exposures will continue to occur despite improved techniques of prevention and using the post exposure prophylaxis (PEP) in these situations are of great importance. Therefore, the aim of this study was to assess the knowledge, attitude, and practice of post exposure prophylaxis for fifth year dental students at a private Egyptian university.MethodsThis cross-sectional study was conducted among 404 dental students in the fifth year at a private Egyptian university from July 2019 to March 2020. Data were collected using self-administrated questionnaires including personal information, knowledge, attitude, and practice questions.ResultsOur study showed that the total mean knowledge score was (0.45 ± 0.50), for attitude (0.70 ± 0.46), and that for practice (0.45 ± 0.50). There was no gender difference regarding PEP (P > 0.05). A total of 213 (47.5%) dental students believed that PEP should be indicated for any needlestick injury in the workplace. A number of 379 of the students (94%) chose “Yes” when asked if they thought PEP is important. While, 143 students (32.5%) were unaware of the existence of PEP service and protocol when asked about the reasons for not taking PEP after occupational exposure.ConclusionsKnowledge and practice of fifth year dental students at a private Egyptian university toward post exposure prophylaxis are not satisfactory. Awareness and curriculum modifications are important regarding PEP.

The Knowledge of Post Exposure Prophylaxis for Hepatitis B Virus and the Related Factors among Health Care Workers in Accra, Ghana

Background: Post Exposure Prophylaxis (PEP) of Hepatitis B virus (HBV) is important, especially in healthcare settings with low HBV vaccination uptake and high prevalence of HBV among the general public. It is important for Health Care Workers (HCWs) to have adequate knowledge of PEP for HBV for effective adherence following occupational exposure. This study assessed the level of knowledge of PEP for HBV among HCWs. Methods: A cross-sectional study involving 174 HCWs from five facilities in the Greater Accra Region. Selection was by random sampling after stratification into six professional categories. A structured, pretested questionnaire was used to collect data. SPSS software was used to analyse data. Chi-square test was used to determine significance, ANOVA and logistic regression analysis were done. Results: Thirty three percent of the HCWs had knowledge scores of less than 50%, whereas only 27% had good knowledge of PEP for HBV. The average mean of knowledge score was 47.85 (CI=44.35-51.35). An analysis of variance identified a statistically significant difference between the scores obtained by the various cadres (P=0.01). A logistic regression analysis revealed that nurses and midwives had lower odds of having a good knowledge of PEP for HBV (aOR=0.4; 95% CI=0.1-0.9). Conclusion: Respondents demonstrated inadequate knowledge of PEP for HBV in this study. In poor settings where HBV disease burden is high and HBV vaccination coverage among HCWs is suboptimal, good knowledge of PEP for HBV is recommended for effective adherence to PEP protocols among HCWs, who are at risk of exposure to HBV.

Animal bites and post-exposure prophylaxis in Central-West Tunisia: a 15-year surveillance data

BackgroundRabies is a disease that still exists in developing countries and leads to more fatalities than other zoonotic diseases. Our study aimed to describe the profile of human exposures to animals over fifteen years and to assess the post-exposure prophylaxis (PEP) practices in the governorate of Kasserine (Tunisia) on pre- and post-revolution (2011).MethodsWe carried out a descriptive study using surveillance data from a region in Central-West Tunisia. All humans exposed to animals, residents in Kasserine Governorate and declared to the regional directorate of primary health care (RDPH) from January 1st, 2004 to December 31st, 2018 were included.ResultsA total of 45,564 cases of human exposures to animals were reported over the fifteen-year period of the study with an annual average of 3089.2 ± 403.1. The standardized incidence rate (SIR) of human exposures to animals was 694 per year per 100,000 inhabitants (inh).The most listed offending animal was the dog (91.3%) and the most reported type of exposure was bites (63.7%). The trend in human exposures to animals increased significantly over time. The number of exposures by vaccinated dogs decreased significantly and by unvaccinated and stray dogs increased steeply. When comparing pre-and post-revolution periods, the yearly average of animal exposures post-2011 was significantly greater than the average prior to 2011 (3200 ± 278.5 vs 2952.8 ± 483) (p < 0.001). The yearly average of animal bites post-2011 was significantly greater than the average prior to 2011 (2260.5 ± 372.1 vs 1609.8 ± 217.9) (p < 0.001). The average number of vaccine doses per animal exposure was 2.4. Concerning PEP protocols, protocol A (2 and 3 doses) was indicated in 79% of animal exposures cases. From 2004 to 2018, a downward trend was noted for protocol A (r = − 0.29, p < 0.001) and an upward trend for protocol B (3 and 5 doses) (r = 0.687, p < 0.001). During our study period, 5 fatal cases of human rabies were declared.ConclusionRabies remains a major public health problem in Tunisia. The political dynamics had an impact on the health care system and rabies control. Preventive measures should be applied adequately to decrease the burden of this disease.

Knowledge, practice, and awareness of dental undergraduate and postgraduate students toward postexposure prophylaxis and needlestick injuries

Background: The aim of the present study was to assess the knowledge, awareness, and practice of dental undergraduate, interns, and postgraduate students toward postexposure prophylaxis (PEP) and needlestick injuries. Materials and Methods: A cross-sectional, questionnaire-based survey was carried out among undergraduate, interns and postgraduate dental students in an institutional dental hospital in India. The students were required to fill a self-administered questionnaire with close ended questions with responses indicated by a simple tick box format. The questionnaire was divided into three sections intended to collect information on (1) sociodemographic characteristics, (2) knowledge, and (3) practice habits toward needlestick injury (NSI) and PEP of the respondents. Results: An adequate score (&gt;70% correct response) to knowledge about NSI and PEP was obtained by 60.2% (50/83) of the respondents, while 47% (39/83) of the student participants obtained an adequate score (&gt;70% score) to appropriate practice habits toward NSI and PEP. A high proportion (84.3%) of the student were vaccinated against Hepatitis B virus, but only 6% were aware of their serum antibody to HBsAg. 61.5% of the student reported experiencing NSI during clinical practice with 3.6% of the students taking PEP. The most common reason for not taking PEP was ignorance of PEP protocol (27.7%) and lack of support to report the incidence (18.1%). The postgraduate students scored better than the undergraduate students in both the knowledge and practice parameters, but the results were not statistically significant (P &gt; 0.05). Conclusion: This study shows that dental students' knowledge, practice, and awareness toward NSI and PEP is inadequate. The current classroom education must be supplemented with additional interventions to ingrain appropriate practice habits.

Predictors of adherence to HIV Post-Exposure Prophylaxis protocol among frontline healthcare workers at the Ho Teaching Hospital, Ghana

BackgroundHuman Immunodeficiency Virus (HIV) is a global public health threat, and all frontline Health care workers (HCWs) are at a higher risk of exposure to body fluids from potential HIV patients and to sharp instruments. Though timely Post Exposure Prophylaxis (PEP) decreases the possibility of seroconversion to HIV after occupational exposure, most HCWs rarely adhere to the PEP protocol. This study aims to determine the predictors of adherence to PEP among frontline healthcare workers in the Ho Teaching Hospital, Ghana. MethodsA facility-based cross-sectional study was conducted among 199 frontline HCWs. Data were collected using a pretested self-administered questionnaire and analyzed using STATA version 14 software. Binomial logistic regression was performed at the 0.05 level of significance and 95% confidence interval. FindingsOverall, 17.9% of HCWs adhered to PEP. Frontline HCWs who perceived they had low and very low risk of occupational exposure to HIV transmission were 96% [AOR = 0.04 (95% C.I: 0.00, 0.39) P = 0.006] and 94% [AOR = 0.06 (95% C.I: 0.00, 0.62) P = 0.019] respectively less likely to adhere to PEP. HCWs who received training on PEP were 4 times more likely to adhere to PEP compared to those who had never received it [AOR = 4.24 (1.31, 13.19) P = 0.013]. ConclusionAdherence to PEP protocol among HCWs was low. Therefore, there is a need for interventions to increase the perception of risk of occupational exposure to HIV transmission and to intensify training on PEP among frontline HCWs in the Ho Teaching Hospital. This will go a long way to increase their adherence to PEP.

Epidemiology of human rabies in South Africa, 2008 - 2018.

Human rabies cases continue to be reported annually in South Africa (SA). Previous investigations have shown the association between the occurrence of human rabies cases and dog rabies cases in the country. To describe the epidemiology of laboratory-confirmed human rabies cases in SA for the period 2008 - 2018. A retrospective document review of laboratory-confirmed human rabies cases for the period 2008 - 2018 was performed using a case register and related documentation available from the National Institute for Communicable Diseases. A total of 105 human rabies cases were laboratory confirmed from 2008 to 2018, with cases reported from all the provinces of SA except the Western Cape. Children and adolescents were most affected by the disease during the study period. In almost half of the cases, medical intervention was not sought after exposure. When victims did seek healthcare, deviations from post-exposure prophylaxis protocols were reported in some cases. The epidemiological trends of human rabies cases reported in SA for the period 2008 - 2018 remained largely the same as in previous reports. Dog-mediated rabies remains the main source of human rabies in SA.

Attitudes about community pharmacy access to HIV prevention medications in California

ObjectiveIncreasing access to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) is a high priority for the Ending the HIV Epidemic Initiative. Expanding access to PrEP and PEP through a variety of health care settings, including community pharmacies, may increase access in communities most in need. California is the first state to allow community pharmacists to furnish PrEP and PEP directly to consumers. Our objective was to assess attitudes among key stakeholders about a California policy to allow community pharmacists to furnish HIV PrEP and PEP. MethodsWe conducted a qualitative case study with key pharmacy stakeholders. Semistructured phone interviews were audio-recorded and transcribed verbatim. We generated analytical memos for each interview and working with these analytical memos, we conducted a constant comparison across cases to identify commonalities and differences. ResultsWe launched the study in October 2018 and interviewed pharmacists (n = 7) working in a variety of settings, including retail-, clinic-, and community-based pharmacies. We also interviewed medical providers (n = 2) working in high-volume PrEP clinics and sought input from representatives of large retail chain pharmacies (n = 2). Overall, pharmacists and medical provider informants shared similar opinions about the central benefits as well as the key challenges related to pharmacist-delivered PrEP and PEP services. Benefits included: community pharmacists are widely accessible, PrEP and PEP protocols are similar to other preventative medications, policy may lead to efficiencies in the health care workforce, and community pharmacists are authorities on medication adherence. Challenges included: implementation issues may limit pharmacist involvement, and missed opportunities to diagnose and treat other health conditions. ConclusionThis study characterizes the types of benefits and challenges that can be expected when PrEP and PEP prescribing privileges are extended to community pharmacists. This information may be useful to policymakers and other stakeholders considering legislation to permit direct prescription of PrEP and PEP by pharmacists.

RABIES IMMUNOGLOBULIN: Brief history and recent experiences in Côte d'Ivoire

BackgroundRabies is a fatal viral zoonosis mainly transmitted via dog bites. The estimated 59′000 annual deaths caused by the disease are preventable through correct and timely administration of post-exposure prophylaxis (PEP). PEP should be initiated as soon as possible after an exposure to a rabies suspected animal and consists of a course of active vaccinations and administration of rabies immunoglobulin (RIG) in case of severe exposure. However, RIG is not accessible in most rabies endemic countries and its impact on survival in combination with modern vaccines and its cost-effectiveness is unclear. We examined the effect of equine RIG (eRIG) in a field-trial in Côte d'Ivoire, a developing country with low but chronic rabies burden and persistent lack of RIG, similar to a majority of rabies endemic countries attempting elimination of the disease. MethodsData from 3367 patients attending anti-rabies centers (Centres Anti-Rabiques, CARs) of the National Institute for Public Hygiene (Institut National d'Hygiène Publique, INHP) in the departments of Bouaké and San Pédro in Côte d'Ivoire was prospectively collected between April 2016 and March 2018. We identified 1594 patients at risk of rabies infection as eligible for RIG administration. Depending on local availability of eRIG and vaccination protocol applied, PEP consisted of active immunization only (non-eRIG group, n = 1145) or active and passive immunization (eRIG group, n = 449). Patients were followed-up by phone interviews at least 15 months after their exposure to assess for rabies suspected deaths. ResultsFollow-up data was available for 641 patients in the non-eRIG group (56%) and 242 in the eRIG group (54%). Three suspected or possible rabies deaths occurred in each of the two groups, corresponding to a possible rabies mortality of 1.2% (95% CI 0.3–3.6%) in the eRIG group and 0.5% (95% CI 0.1–1.4%) in the non-eRIG group. The difference in proportions was small and not statistically significant (0.7%, p = 0.21). Deaths in both groups were associated with treatment delay after exposure and non-compliance to PEP protocol. No death occurred after correct and timely active immunization independent of eRIG administration. ConclusionThe provision of eRIG did not lead to a measurable reduction of rabies burden in our study population. This underlines that improved access to active vaccines will be effective in reducing rabies deaths even if access to eRIG remains difficult in developing countries. A possible benefit of eRIG administration for severely exposed patients cannot be excluded based on these results.

Pattern of Animal Bites and Delays in Initiating Rabies Postexposure Prophylaxis among Clients Receiving Care in Korle-Bu Teaching Hospital.

Introduction Each year, an estimated 25000 rabies death occurs in Africa. Post-exposure prophylaxis (PEP) remains the only proven approach in preventing rabies deaths. Most of rabies deaths occur among those who delayed, did not receive, or complete rabies PEP. The aim of this study was to determine the pattern of animal bite, factors associated with delays in initiating, and nonadherence to rabies PEP regimen. Method Data on clients reporting for rabies PEP in a tertiary hospital setting in Ghana were collected from 2013 to 2016. Demographics, place, and source of exposure were collected. Other information obtained included adherence to the PEP protocol and GPS coordinates of the town of animal bites. The shortest distance between the GPS coordinates of town of animal bite and the site of administration of the rabies PEP was calculated. A total of 1030 individuals received rabies PEP over the period. Results Overall, 52.9% (545) were males while 47.1% (485) were females. Majority of the cases were between the age group 1–10 years accounting for 29.2%. Dog bites accounted for 96.5% (n = 994). Cats, nonhuman primates, human bites, respectively, accounted for 1.8% (n = 18), 1.2% (n = 12), and 0.6% (n = 6) of all bites. Majority of bites occurred at home (66.2% (n = 646)). Also, 31.6% (n = 308) and 2.3% (n = 22) of bites occurred on the streets and neighbors/friends' homes, respectively. Only, 18.7% initiated PEP within 24 hours of bite. Rabies PEP regimen completion rate was 95.2% (n = 976). The median distance travelled to access rabies PEP was 7.87 km (IQR, 3.58–16.27) km. Overall, 34.7% (n = 344) had the animal bite within 4.99 km radius of the treatment room of KBTH. Clients who delayed in initiating rabies PEP were 2.6 (95% CI, 1.3–5.1) times more likely to be males and 2.0 (1.1–3.9) times more likely to receive bites in a location more than 5 km radius from the KBTH treatment room. Gender, age, and distance of bite from the treatment room were not associated with the likelihood of not completing rabies PEP schedule. Discussion. Bites from suspected rabies infected animals remain a problem in southern Ghana. There are significant delays in initiating PEP for rabies prevention. Most animal bite victims are children ten years and below. Male gender and bites more than 5 km radius from the site of rabies PEP administration were most significant factors associated with delays in initiating rabies PEP. There is the need for adopting strategies to encourage prompt initiation and adherence to PEP.

Predictors of Adherence to HIV Post-Exposure Prophylaxis Protocol Among Frontline Healthcare Workers at the Ho Teaching Hospital, Ghana

Predictors of Adherence to HIV Post-Exposure Prophylaxis Protocol Among Frontline Healthcare Workers at the Ho Teaching Hospital, Ghana

Cross-sectional survey on occupational needle stick injuries amongst prehospital emergency medical service personnel in Johannesburg.

IntroductionPrehospital personnel are exposed to challenging situations that place them at increased risk of sustaining a needle stick injury (NSI). Blood borne infections such as HIV and Hepatitis B or C may be transmitted from a NSI. Sub-Saharan Africa has the largest number of people living with HIV globally. There is no data pertaining to NSI among Emergency Medical Service (EMS) personnel in South Africa. This study aimed to investigate the cumulative incidence, knowledge, attitudes and practices pertaining to NSIs amongst a select group of prehospital personnel in Johannesburg.MethodsThis was a prospective, questionnaire based, cross-sectional survey of personnel employed at three EMS service providers in Johannesburg.ResultsOf the 240 subjects that participated in the study, there was a total of 93 NSIs amongst 63 (26.3%) subjects. Of these, 41 (65.1%) had sustained one previous NSI, 16 (25.4%) had two NSIs, 5 (7.9%) had three NSIs and one (1.6%) had five NSIs. Almost two-thirds (n = 60; 64.5%) of NSIs were sustained during intravenous line insertion. Most of the study subjects were male (n = 145, 60.4%), between the age of 25–29 years (n = 67, 27.9%), had a BLS qualification as the highest level of training (n = 89, 37.1%), had >10 years of EMS experience (n = 69; 28.8%) and were up to date with their Hepatitis B vaccination at the time of the study. HIV post exposure prophylaxis (PEP) was initiated in 82 (88.2%) out of the 93 NSI incidents. However, the recommended 28-day course of therapy was only completed in 68 (82.9%) out of the 82 cases where PEP was initiated.ConclusionPrehospital personnel are at risk of sustaining a NSI. There is a need to promote awareness with regards to the risks, preventive measures, awareness of PEP protocols and the timely initiation and completion of HIV PEP amongst EMS personnel in Johannesburg.

Sharps and needle-stick injuries among medical residents and healthcare professional students: pattern and reporting in Italy—a cross-sectional analytical study

ObjectivesHealthcare workers, in the course of their professional activity, are potentially exposed to chemical, physical and above all biological risks. The aims of our study were to investigate the extent...

Pattern of animal bite, adherence and delays in initiating post exposure prophylaxis for rabies prevention

Background: Rabies infection is a disease of public health importance. It is one of the neglected tropical diseases with almost 100% case fatality rate after onset of symptoms. The only proven approach in preventing rabies following exposure is Post Exposure Prophylaxis (PEP). Majority of death from rabies occurs among those who did not receive or complete PEP for rabies. Delays in initiating PEP also contribute to death from rabies. The aim of this study is to determine the pattern of animal bite, delays in initiating PEP and adherence to PEP for rabies prevention. Methods & Materials: Data on clients reporting for PEP for rabies prevention in a tertiary hospital setting in Ghana was collected from 2013 to 2016. Demographics, place and source of exposure were collected. Information on adherence to the PEP protocol was also collected. Results: Of the 1030 participants, 52.9% (545) were males while 47.1% (485) were females. The median age was 22 years (interquartile range = 27 years). Majority of the cases were between the age group 1-10 years accounting for 29.2%. 5.6% were >59 years old. Dog bites accounted for 96.5% (n = 994). Cats, Non-human primates, human bites respectively accounted for 1.8% (n = 18), 1.2% (n = 12) and 0.6% (n = 6) of all bites. Majority of bites occurred at home accounting for 66.2% (n = 646). 31.6% (n = 308) and 2.3% (n = 22) of bites occurred on the streets and neighbors/friends homes respectively. 18.7% initiated PEP within 24 hours of bite. 37.8%, 31.7% initiated PEP within 1–2 days, and 3-7 days respectively. 11.7% however initiated treatment after one week. With regards to compliance to PEP schedules, 95.2% (n = 976) completed all five doses of intramuscular post exposure prophylaxis. With regards to trends, majority of dog bites occurs between November and March. Conclusion: Bites from suspected rabies infected animals remain a problem in southern Ghana. There are significant delays in initiating PEP for rabies prevention. Most animal bite victims are children ten years and below and occurred at home.

Determinants of appropriate knowledge on human immunodeficiency virus postexposure prophylaxis among professional health-care workers in Sokoto, Nigeria.

Introduction:The prevention of human immunodeficiency virus (HIV/AIDS) among health-care workers (HCWs) has remained a major topical issue worldwide. Accidental transmission of HIV infection to HCWs during occupational exposure is a real threat today. The study aimed to assess the knowledge, attitude, and practice of postexposure prophylaxis (PEP) among HCWs in a tertiary health institution in Sokoto, Northwestern Nigeria.Methodology:The study was carried out at Usmanu Danfodiyo University Teaching Hospital, Sokoto, through a cross-sectional descriptive study design; a total of 156 participants were recruited using a stratified sampling technique. Data were collected using a semi-structured, self-administered questionnaire and analyzed using SPSS computer software after obtaining ethical clearance from the Health Ethics and Research Committee of the teaching hospital.Results:A total of 87.2% (136) of the respondents had heard of PEP and 71.8% (112) thought that HIV/AIDs could be prevented through PEP. A total of 71.2% (111) had good knowledge about PEP, whereas 86.8% (118) had a positive attitude toward PEP.Conclusion:Although the study demonstrated high knowledge and positive attitude toward PEP, the observance of safety measures against needlestick injuries that could result in HIV infections was abysmally low. There is the need to create more awareness and strengthen the use of PEP protocol by all cadres of health workers as this will go a long way in minimizing blood-borne infections.

Development of an HIV Postexposure Prophylaxis (PEP) Protocol for Trainees Engaging in Academic Global Health Experiences.

Global health (GH) education programs have become increasingly common in U.S. medical schools and graduate medical education programs, with growing numbers of medical students, residents, and fellows participating in clinical experiences in settings with high HIV prevalence and limited resources. However, there are no guidelines for provision of HIV postexposure prophylaxis (PEP) to trainees engaging in these academic GH experiences. Faculty of the Global Health Education Programs (GHEP) at the David Geffen School of Medicine at UCLA and GH partner institutions recognized the need for PEP access for trainees engaged in GH experiences. In 2013-2014, key UCLA faculty collaborated in the development of the UCLA GHEP PEP Protocol, which includes provision of PEP medications to trainees prior to departure, an on-call infectious disease/HIV specialist to advise trainees who have exposures, and a system for following up with exposed trainees while on the GH rotation and after their return. Between February 2014 and September 2016, 112 medical students and 110 residents received education on the PEP protocol during their predeparture orientation. The protocol was used for 28 exposures (27 occupational, 1 nonoccupational), with PEP recommended in 3 occupational cases (all needlesticks) and the single nonoccupational case. There were no reported HIV seroconversions. The authors plan to formally evaluate the PEP protocol, conduct a qualitative assessment with trainees and both UCLA and GH partner faculty, and discuss best practices with institutions across the United States and with GH partners.

Rabies Postexposure Prophylaxis Noncompletion After Dog Bites: Estimating the Unseen to Meet the Needs of the Underserved.

Postexposure prophylaxis (PEP) prevents human rabies and is accessible in Cambodia principally in Phnom Penh, the capital. Timely, affordable access to PEP is a challenge for the mainly rural population. We aimed to identify districts independently associated with PEP noncompletion to position frontline vaccination centers. We analyzed the 2009-2013 database at the Rabies Prevention Center at the Institut Pasteur du Cambodge, Phnom Penh. Logistic regressions identified nongeographic determinants of PEP noncompletion as well as the districts that were independently associated with noncompletion after adjustment for these determinants. The influence of distance by road was estimated using a boosted regression-trees model. We computed a population attributable fraction (rabies index (RI)) for each district and developed a map of this RI distribution. A cartographic analysis based on the statistic developed by Getis and Ord identified clusters of high-RI districts. Factors independently associated with noncompletion were patients' district of residence, male sex, age 15-49 years, initial visit during rice harvest, the dog's status (culled or disappeared), and a prescribed PEP protocol requiring more than 3 PEP sessions (4 or 5). Four clusters of high-RI districts were identified using this analytical strategy, which is applicable to many vaccination or other health services. Positioning frontline PEP centers in these districts could significantly widen access to timely and adequate PEP.

HIV- PEP (Post Exposure Prophylaxis) Access Project

Post-Exposure Prophylaxis (PEP) is a preventive strategy that aims to avert the transmission of HIV to an exposed individual following occupational and non-occupational exposure, e.g. sexual contact, injecting drug use (IDU), needle stick injuries. Timely access to PEP (Within 72 hours) is an integral component to treatment as prevention alongside early treatment to achieve a significant reduction in a new transmission of HIV. In Queensland, it is estimated that around 5000 people live with HIV. The year 2014 saw an increase of 35% newly diagnosed cases of HIV as compared to the year 2013, thus the need to impede the spread of this pandemic is crucial. This project aims to improve the out of hour access to PEP in Queensland through Emergency Departments(ED). A mapping activity of access to PEP across Queensland was carried out by the project team through: • Consultation with the Queensland Department of Health, Communicable Diseases Branch (CDB) • A Community Survey to scope the experiences of people accessing PEP. • Consultation with Community organisations, Public/Private hospitals, HIV Public Health Team, Sexual Health Clinics to scope issues received regarding access to PEP. • Enquiry to all HHS Emergency Departments, Directors of Emergency Medicine and Nurse Unit Managers prescribing PEP to obtain local PEP protocol implementation. A PEP working group was formed that comprised of state-wide representatives from HIVFQ, sexual health clinics, hospital emergency dept., community groups and the Communicable Disease Branch of Queensland Department of Health. Some of the key points identified by the working group were: • Demand for PEP is steadily increasing each year. • People have positive experiences accessing PEP at sexual health clinics, however, some negative experiences were reported by those accessing PEP out of hours at Hospital Emergency Departments (EDs). • Some hospital EDs were less knowledgeable about PEP and were unable to locate the clinical guidelines in a timely manner. • Wait times in EDs averaged 4 hours, which was an added stressor for people waiting for PEP. • Some people experienced stigma, discrimination and judgements when trying to access PEP at EDs. The working group met to review the current PEP landscape and developed the following interventions to improve access to PEP: • Development of a user-friendly PEP Folder for Emergency and Pharmacy Departments including algorithms and flowcharts. This will be rolled out with nursing and pharmacy champions around Queensland, who are best placed to raise awareness of PEP (and PrEP3). • Coordination of resources available to the community including updating the clinic search tool on the ENDHIV website and PEP Emergency Card. • Production of PEP education/training videos for hospital staff to be incorporated into all Queensland hospital pre-vocational trainings and other clinical inductions • Endorsement of the resources from the Queensland Emergency Department State Advisory Panel. We hope these interventions will not only help reduce new transmission of HIV, but also educate clinicians and community on testing, treatment and stigma associated with HIV, thus working towards an HIV-free generation

Pertussis Outbreak Among Soldiers During Basic Training: The Need for Updated Protocols.

Pertussis is a highly contagious, vaccine preventable upper respiratory disease. The incidence of the disease has been rising in the past few decades. During the winter of 2015, an upper respiratory outbreak occurred in one of Israel Defense Forces basic training bases in northern Israel. Following the detection of the first primary cases, a suspected outbreak investigation was initiated in conjunction with more rigorous clinical and laboratory testing efforts to include specific antibody enzyme-linked immunosorbent assay assays and polymerase chain reaction to diagnose pertussis. Initially, 1,596 soldiers were surveyed clinically using a questionnaire and physicians' interviews for upper respiratory disease symptoms. A total of 158 soldiers were further evaluated and 38.6% (61) of those were diagnosed as having pertussis (with laboratory evidence). Based on the protocol that we developed during the course of this outbreak, a postexposure prophylaxis was given to every soldier for whom there was a high level of suspicion for infection and met the inclusion criteria for the postexposure prophylaxis protocol. The effects of the postvaccination waning immunity among a vaccinated population were demonstrated, thus the need of maintaining a high index of suspicion of Brodetella pertussis as a causative agent during respiratory diseases outbreaks in young soldiers.

Factors for early death in rabies- the bitter truth.

Sir, Early death phenomenon in rabies reported by Sadeghi et al.[1] is informative and has long been recognized in patients whose incubation period is shorter than average in patients who were inadequately vaccinated with or without accompanying immunoglobulin and develop rabies.[2] However, we would like to recall other factors related to virus, patients, therapeutic agents, and care providers contributing to early death, so as to introduce appropriate measures to ensure quality in service and enforce patient safety. The high viral load inoculated at the site of bite, which infects motor endplates and motor axons without previous replication in the muscle and its virulence. Those related to patients are anatomical site of bite such as head and neck,[3] or bite in highly innervated areas such as fingers as noted in this case,[1] which has close proximity to central nervous system, and nonfeasibility to infiltrate adequate dose of human rabies immunoglobulin (HRIG). Next is the functional status of the immune system, which may be immune enhancement or “early death” phenomenon through B cells during the incubation period, and/or nonspecific immunosuppressive effect following rabies infection. Rabies nucleoprotein acts as a weak superantigen, and directly induces proliferation of human CD4 Th2 cells bearing the V8 TCR, which suppresses the immunity through polyclonal antibody response.[4] Matters related to therapeutic agents are questionable status of the potency of vaccine and HRIG, due to inherent technical constraints and electricity problems in countries such as India. Certain important factors related to health care providers are nonadherence to World Health Organization (WHO) postexposure prophylaxis protocol. Furthermore, health care providers should avoid prescribing antimalarials and other drugs that interfere with the effectiveness of rabies vaccine or HRIG. To overcome these, we need identification of other responsible factors so as to empower the health care providers for effective services and community health education.[5] Our motto shall be “no death due to rabies” through community education, early intervention, quality assurance of therapeutic agents, and adherence to WHO protocol.