Skip to content

News Archives

  

Volume 2 No 39; 26 September 2008

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.

The HPA operates enhanced surveillance for occupational exposure to bloodborne viruses [6]. Data are collected on the types of exposures, the staff involved and circumstances surrounding exposure events to inform and develop national prevention policies. The scheme monitors the implementation of national HIV PEP policy, and informed this revision of the guidance. Occupational health physicians and clinicians involved in the care of healthcare workers exposed to bloodborne viruses are encouraged to report these incidents (in confidence) to the Health Protection Agency's Centre for Infections, Colindale, or Health Protection Scotland.  

References

1. Department of Health. HIV Post-Exposure Prophylaxis: guidance from the UK Chief Medical Officers' Expert Advisory Group of AIDS. London: Department of Health, 2008. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_088185

2. Department of Health. UK Health Departments. HIV post-exposure prophylaxis: guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS. London: Department of Health, February 2004. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4083638

3. Public Health Link: Update to HIV post-exposure prophylaxis (PEP) guidance from the Expert Advisory Group on AIDS (EAGA) following the recent recall of Viracept. London: Department of Health, July 2007. Available at:
http://www.info.doh.gov.uk/doh/embroadcast.nsf/vwDiscussionAll/
1D1582812A934F1A80257322002ED694

4. Fisher M, Benn P, Evans B, Pozniak A, Jones M, MacLean S, et al. UK Guidelines for the use of post-exposure prophylaxis for HIV following sexual exposure. Intl J STD AIDS 2006; 17: 81-92. Available at: http://www.bashh.org/documents/58/58.pdf

5. Department of Health. The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections. London: Department of Health, January 2008. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_081927

6. Health Protection Agency. Surveillance of occupational exposure to bloodborne viruses in healthcare workers. Page on HPA website [online] 17 April 2008 [accessed 26 September 2008]. Available at:
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733839945.

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).

Further information

About PEP: see Chapter 27, Immunisation against infectious disease ("The Green Book") at:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1216022456494)

Expert advice and supply of vaccine and immunoglobulin: from the HPA Centre for Infections (tel 020 8200 4400).

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

References

1. WHO. Human and Animal Rabies, Rabies: A neglected zoonotic disease. Available at: http://www.who.int/rabies/en/ [accessed on July 23, 2008].

2. Fooks T and Harkess G. Rabies - a "one health approach", Health Protection Matters, Spring 2008 (number 10), Health Protection Agency. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1208245975751?p=1158945066420

3. Health Protection Agency. An imported case of canine rabies in a quarantine centre in London: immediate public health management of the incident, April 2008. Health Protection Report 2008; 2 (18): news. Available at: http://www.hpa.org.uk/hpr/archives/2008/news1808.htm#rab

4. Fooks AR, McElhinney LM, Pounder DJ, Finnegan CJ, Mansfield K, Johnson N, et al. Case report: isolation of a European bat lyssavirus type 2a from a fatal human case of rabies encephalitis. J Med Virol 2003; 71(2): 281-9.