Current News New guidance on post-exposure prophylaxis for HIV World Rabies Day 2008: awareness is the best defence against rabies Infection Reports

The United Kingdom (UK) Expert Advisory Group on AIDS (EAGA) has recently published revised guidelines on the use of post-exposure prophylaxis (PEP) for HIV following occupational exposure


New guidance on post exposure prophylaxis for HIV
The Expert Advisory Group on AIDS (EAGA) has recently published revised guidelines [1] on the use of post-exposure prophylaxis (PEP) for HIV following occupational exposure which should be read in conjunction with local needlestick injury policy. This document replaces both the guidelines issued in February 2004 [2] and the interim update following the withdrawal of Viracept (nelfinavir) issued in July 2007 [3] and is consistent with guidelines produced by the British Association for Sexual Health and HIV (BASHH) for the provision of PEP following sexual (non-occupational) exposure [4].
There have been several sections clarified and amended, together with the addition of a new annex (Annex H), which summarises the evidence from animal and clinical studies on the maximum interval between exposure and starting PEP.
Some of the key changes to the guidelines are highlighted below.
PEP should be initiated as soon as possible after the exposure, ideally within an hour, following a careful risk assessment. In a change to previous guidelines, PEP is now generally not recommended after 72 hours post-exposure. The recommended follow-up period after occupational exposure to HIV has been shortened and is now a minimum of 12 weeks after the HIV exposure or, if PEP has been taken, a minimum of 12 weeks from when PEP was stopped. The PEP regimen for starter packs has been revised and simplified: Truvada (300mg tenofovir and 200mg emtricitabine (FTC)) once a day plus Kaletra (200mg lopinavir and 50mg ritonavir) twice a day is now recommended. The guidelines have clarified the implications of the Human Tissue Act 2004 and the Mental Capacity Act 2005 with regard to testing incapacitated source (adult) patients for serious communicable diseases without consent. A recommendation for good practice is that hospitals should have capacity to obtain a source patient HIV test result within eight hours (ideally) and no longer than 24 hours after blood is obtained. This is to minimise healthcare workers' exposure to PEP drugs where the source is found to be uninfected.
Prevention of avoidable exposure is crucial [5] and all healthcare workers should be educated on the risks from occupational exposures and the importance of seeking urgent medical advice. Employers should ensure that local PEP policies enable healthcare workers to have immediate 24 hour access to advice on PEP, to drugs and to appropriate support.

World Rabies Day 2008: awareness is the best defence against rabies
Sunday 28 September is World Rabies Day -a global initiative led by the Alliance for Rabies Control to raise awareness and understanding about the importance of rabies prevention worldwide. The primary message of World Rabies Day is that rabies is a preventable disease, and yet kills 55,000 people needlessly each year, half of which are children under the age of 15 [1].
The disease is transmitted to humans mainly by bites, but exposure may also occur through contamination of broken skin or mucous membranes with saliva from an infected animal or bat. Infection with rabies virus causes an acute encephalomyelitis, with two classic forms: furious (encephalitis) and paralytic (dumb).
In many countries rabies is primarily a disease of children, who are particularly at risk due to their close contact with dogs, the major global source. This is because children are more likely to suffer multiple bites and scratches to the face and head, both of which carry a higher risk of contracting rabies. In addition children are often unaware of the danger that dogs transmit rabies and may not tell their parents when a bite, lick, or scratch has occurred from an infected animal.
Since virtually all human rabies is caused by dog bites, vaccination of canine populations has proved extremely successful in reducing its incidence in humans. In Mexico , for example, a 92% reduction in the prevalence of canine rabies due to vaccination was accompanied by an 82% reduction in the number of reported human deaths from the infection [2].
For the UK population the key public health issue is for those who may be at risk because of their work (see below) or as a result of travelling to countries where rabies is circulating in animals. Travellers should stay away from stray or unattended animals and, if bitten in a country where rabies is present, wash the wound immediately and seek medical advice; if a person has not had treatment in that country they should still seek medical advice immediately on return, even if the bite was weeks before.
The UK has been free of indigenous classical animal rabies for over a century but occasional cases have occurred in quarantined animals (most recently earlier this year [3]), creating a hazard that warrants vaccination of those working with imported animals.
The last UK case of indigenously acquired classical rabies in a human was in 1902. Cases occurring since then have all been acquired abroad, usually through dog bites.
More recently European Bat Lyssavirus 2 (EBLV2), a rabies-like virus, has been isolated in bats in the UK, and in 2002 a man who was a licensed bat handler died in Scotland from infection with EBLV2 [4]. As a result the Department of Health recommended that a ll bat handlers, whether licensed or not, should be vaccinated against rabies as a precaution. In addition i ndividuals who are bitten or scratched by a bat within the UK should seek medical attention as soon as possible to determine whether they need post-exposure prophylaxis (PEP).
About World Rabies Day at the official web site (www.worldrabiesday.org) and in the Alliance for Rabies Control's September 2008 newsletter at www.rabiescontrol.net/ARCnewsletter9.pdf

Methods
Methods of data collection for COVER, sentinel MMR coverage and neonatal hepatitis B vaccination coverage are described on the HPA website at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListDate/Page/1209454766294?p=1 209454766294.

Results
Data were received from all Health Boards (HBs) in Scotland and Northern Ireland, Administrative Regions (ARs) in Wales, and 148/152 Primary Care Trusts (PCTs) in England. Scotland's national coverage data will be published on 30 th September and therefore tables 1 to 3 do not contain individual figures for Scotland, although Scottish data have been included to produce UK estimates.
Four London PCTs using the Child Health Interim Application (CHIA) child health system were unable to provide any data this quarter. Problems with producing coverage data using the CHIA system have been reported previously [4] and ongoing data quality concerns and caveats have been issued by nine London PCTs. Six reporting PCTs (five in London) have not published data for PCV booster at 24 months due to data quality concerns. These factors contribute to the continuing need for caution in evaluating the vaccination programme in London.
Individual PCT data for this quarter are published on the HPA website at http://www.hpa.org.uk/infections/topics_az/cover/default.htm.

Coverage at 12 months
Excluding Scotland, 44 of the 155 participating PCTs/HBs/ARs (28%) achieved at least 95% coverage at 12 months for three doses of diphtheria, tetanus, pertussis, polio and Hib vaccine (DTaP/IPV/Hib3) and 51 (26%) at least two doses of MenC vaccine. In this fourth evaluation of PCV coverage at 12 months 40 PCTs/HB/ARs (26%) achieved at least 95%. At least 90% coverage at 12 months for DTaP/IPV/Hib3, MenC2 and PCV2 was achieved for all countries and all English SHAs apart from London.
UK coverage at 12 months for DTaP/IPV/Hib3 decreased by 0.3% compared with the previous quarter, MenC remained the same, and PCV increased by 0.3% (  n/a n/a n/a n/a n/a  [4]. Despite this, coverage was still lower than corresponding values for other English regions. In particular, coverage for MMR2 was 55.6% and DTaP/IPV was 54.5%, at least 20% lower than coverage in most other regions. Scotland $ 14 (14) n/a n/a n/a n/a n/a n/a  Projections make the assumption that p remains constant over the period of the projection. Data at 20 months is not shown to simplify the graph as the line is close to that plotted for the 24 month data.

Neonatal hepatitis B vaccine coverage data in England
The data presented in  Data was received for 126/152 (83%) PCTs in England , 6% more than reported in the last quarter, but similar to the number reporting in October to December 2007 [4,5]. Some of the returns may relate to only part of the PCT due to mergers [6]. Coverage in England for three doses in those aged one year decreased 5% to 65% [4] (Table 5). Although this is lower than the coverage obtained for routine antigens at this age (table 1) the population at risk are highly mobile and high uptake is difficult to achieve. By far the largest number of infants at risk is in London where coverage was above the national average at 75% at 12 months. Coverage in England for four doses in those aged 24 months decreased by 3% to 46% compared to the last quarter [4].

Commentary
In UK MMR coverage at 24 months fell again this quarter, down 0.5% to 83.6%. This is the fifth successive quarterly decrease, down 2% on the same time last year [7]. However, increased estimates for sentinel MMR coverage at 16 months recorded between June to August this year suggest that routine 24 month coverage may begin to increase early next year (table 4 and  figure). This increase, and any impact of the ongoing MMR catch-up programme announced in August [8], should be detected in future COVER reports.

Polio eradication: the global situation and up-dated information for the UK, 2007
The Global Polio Eradication Initiative was established in 1988 at a time when over 350,000 children were paralysed by polio each year in more than 125 countries.
By 2007, endemic countries -those that have never interrupted polio transmission -had been reduced to a historic low of four: Afghanistan, India, Nigeria and Pakistan. A total of 1208 cases occurred in these four countries in that year. An additional 107 cases occurred following importation into eight other African and Asian countries that had previously interrupted transmission [1].
In 2007, stakeholders in polio eradication launched a new, intensified effort to achieve eradication. By the end of that year, the incidence of polio had been reduced by 35% and cases due to type 1 wild poliovirus had fallen by 81% [2]. Most outbreaks in re-infected countries had been stopped. However, by 17 September 2008, 1210 polio cases had still been reported globally, of which 1135 were in the four endemic countries (table 1).  (table 3), with the last case occurring in 2000 in an OPV vaccine recipient.  * This is a case of polio in a UK resident but it was acquired and diagnosed in India and no poliovirus was isolated for this case.

Data on enterovirus surveillance
In addition to clinical surveillance, confirmed enterovirus infections continue to be reported by laboratories in England and Wales (table 4). Enteroviruses include polio and non-polio viruses, the latter include Coxsackie and Echoviruses. These infections are mostly asymptomatic or mildly symptomatic, although in a few instances can result in aseptic meningitis or encephalitis. As in recent years, 2007 was also a low year with no summer epidemic of enterovirus meningitis. No isolates of polio have been reported in 2007 and the reduction in isolates of poliovirus is likely to be explained by the change in the routine UK immunisation schedule from OPV to IPV in 2004.