OCCUPATIONAL EXPOSURES TO BODY FLUIDS AND BEHAVIORS REGARDING THEIR PREVENTION AND POST-EXPOSURE AMONG MEDICAL AND NURSING STUDENTS AT A BRAZILIAN PUBLIC UNIVERSITY

A cross-sectional study was conducted to assess the frequencies and characteristics of occupational exposures among medical and nursing students at a Brazilian public university, in addition to their prevention and post-exposure behavior. During the second semester of 2010, a self-administered semi-structured questionnaire was completed by 253/320 (79.1%) medical students of the clinical course and 149/200 (74.5%) nursing students who were already performing practical activities. Among medical students, 53 (20.9%) suffered 73 injuries, which mainly occurred while performing extra-curricular activities (32.9%), with cutting and piercing objects (56.2%), in the emergency room (39.7%), and as a result of lack of technical preparation or distraction (54.8%). Among nursing students, 27 (18.1%) suffered 37 injuries, which mainly occurred with hollow needles (67.6%) in the operating room or wards (72.2%), and as a result of lack of technical preparation or distraction (62.1%). Among medical and nursing students, respectively, 96.4% and 48% were dissatisfied with the instructions on previously received exposure prevention; 48% and 18% did not always use personal protective equipment; 67.6% and 16.8% recapped used needles; 49.3% and 35.1% did not bother to find out the source patient's serological results post-exposure; and 1.4% and 18.9% officially reported injuries. In conclusion, this study found high frequencies of exposures among the assessed students, inadequate practices in prevention and post-exposure, and, consequently, the need for training in “standard precautions” to prevent such exposures.

Human exposure to potential rabies virus transmitters in Olinda, State of Pernambuco, between 2002 and 2006

The aim of the present study was to evaluate the data on human exposure to potential rabies virus transmitters in Olinda, State of Pernambuco, Brazil. Data from 7,062 patients who underwent antirabies prophylactic treatment in Olinda between 2002 and 2006 were analyzed. As expected, dogs and cats were involved in most of the cases; i.e. 82.3 and 16.3%, respectively. Attacks by nonhuman primates, bats and other species (unspecified) were also reported. Among the 7,062 patients who underwent antirabies treatment, 582 patients abandoned the treatment, either by indication from the health unit (195) or by their own decision (387). In conclusion, this study has indicated that prophylaxis for human rabies in this urban area will require a multifaceted approach, including health education, post-exposure prophylaxis, systematic vaccination for dogs and cats, and possibly selective control over wild animals such as hematophagous bats.

Adverse reactions associated with a Fuenzalida-Palacios rabies vaccine: a quasi-experimental study

The Fuenzalida-Palacios rabies vaccine has been used in South America for rabies post-exposure prophylaxis. To determine the frequency of adverse reactions associated with this vaccine compared to a control group a quasi-experimental study was carried out in Uberlândia, Brazil, from May 1997 to April 1998. Victims of bites or other injuries by dogs or other mammals and who received or not post-exposure prophylaxis with Fuenzalida-Palacios rabies vaccine were compared as to the occurrence of a list of signs and symptoms. Out of 2,440 victims of bites and other injuries from dogs and other mammals 2,114 participated in the study; 1,004 of them provided follow-up information within 10 to 15 days. Headache and pain at the injection sites were the most commonly found symptoms (125/1,000). No neuroparalytic event was detected. Patients who were given Fuenzalida-Palacios rabies vaccine and those who were not had similar incidences of symptoms (risk ratios close to 1). Regarding the occurrence of adverse reactions, Fuenzalida-Palacios rabies vaccine is a valid alternative for rabies post-exposure prophylaxis.

Evaluation of preventive measures for mother-to-child transmission of HIV in Aracaju, State of Sergipe, Brazil

INTRODUCTION: The main route of human immunodeficiency virus (HIV) infection in children is from mother to child. The preventive measures established for the Aids Clinical Trial Group protocol 076 (ACTG 076) significantly reduces HIV vertical transmission rates. This study aims to evaluate the implementation of the ACTG 076 protocol in the maternity units of State of Sergipe, Brazilian northeast. METHODS: This is a descriptive, retrospective study with a quantitative approach, with HIV positive women and children exposed, attending a Maternity reference for high-risk pregnancies. Data were obtained from patient records registered in the years 1994 to 2010. RESULTS: Amongst the 110 pregnant women and exposed newborns, the ACTG 076 protocol was fully utilized in only 31.8% of the participants. During the prenatal period, zidovudine (ZDV) was taken by 79.1% of the pregnant women. Only 49.1% of HIV seropositive patients used ZDV during delivery. Two (1.8%) children were considered infected and 50 (45.5%) do not have a conclusive diagnosis to date. CONCLUSIONS: There were significant deficiencies in the prevention of mother-to-child transmission of HIV, including lack of compliance with the three phases of the ACTG 076 protocol; inadequacies in prenatal care; inappropriate mode of delivery and lack of adequate follow up of exposed children.

Studies on human anti-rabies immunization in Brazil: II - Preliminary evaluation of the 2-1-1 schedule for human pre-exposure anti-rabies immunization, employing suckling mouse brain vaccine

This study reports preliminary results of virus neutralizing antibody (VNA) titers obtained on different days in the course of human anti-rabies immunization with the 2-1-1 schedule (one dose is given in the right arm and one dose in the left arm at day 0, and one dose is apllied on days 7 and 21), recommended by WHO for post-exposure treatment with cell culture vaccines. A variant schedule (double dose on day zero and another on day 14) was also tested, both employing suckling mouse brain vaccine. A complete seroconversion rate was obtained after only 3 vaccine doses, and almost all patients (11 of 12) presented titers higher than 1.0 IU/ml. Both neutralizing response and seroconversion rates were lower in the group receiving only 3 doses, regardless of the sample collecting day. Although our results are lower than those found with cell culture vaccines, the geometry mean of VNA is fully satisfactory, overcoming the lower limit recommended by WHO of 0.5 IU/ml. The 2-1-1 schedule could be an alternative one for pre exposure immunization, shorter than the classical 3+1 regimen (one dose on days 0, 2, 4 and 30) with only three visits to the doctor, instead of four.

Short duration of neutralizing antibody titers after pre-exposure rabies vaccination with suckling mouse brain vaccine

The human anti-rabies pre-exposure treatment currently used in Brazil, employing a 1-ml dose of suckling mouse brain vaccine (SMBV) administered on days 0, 2, 4 and 28, was compared to an alternative treatment with two 1 ml-doses on day 0, and one 1 ml-dose injected on days 7 and 21. The latter induced higher virus-neutralizing antibody (VNA) titers on day 21. Both Brazilian rabies vaccines produced with PV or CVS rabies virus strains were tested. Two additional volunteer vaccinee groups, receiving the pre-exposure and the abbreviated post-exposure schedules recommended by the WHO using cell-culture vaccine (CCV) produced with PM rabies virus strain, were included as reference. The VNA were measured against both PV and CVS strains on days 21, 42 and 180 by the cell-culture neutralization microtest. The PV-SMBV elicited higher seroconversion rates and VNA by day 21 than the CVS-SMBV. Both, however, failed to induce a long-term immunity, since VNA titers were <0.5 IU/ml on day 180, regardless of the schedule used. Cell-culture vaccine always elicited very high VNA on all days of collection. When serum samples from people receiving mouse brain tissue were titrated against the PV and CVS strains, the VNA obtained were similar, regardless of the vaccinal strain and the virus used in the neutralization test. These results contrast with those obtained with sera from people receiving PM-CCV, whose VNA were significantly higher when tested against the CVS strain.

Reduced schedule of human anti-rabies immunization with Fuenzalida & Palacios vaccine: additional data

It was reevaluated a reduced schedule for anti-rabies post-exposure immunization with newborn mice nervous tissue vaccine (Fuenzalida 8c Palacios) in a group of 30 non exposed volunteers. The vaccine was administered by intramuscular injections on days zero, 2, 4, 16 and 27, in the deltoid area. Antibody levels were determinated by a simplified serum neutralization microtest on days zero, 16 and 37. On days 16 and 37 the antibody levels of the whole group was >0.5 IU/ml and >1.0 IU/ml, respectively. The cell mediated immunity was precociously detected (on day 4) by the delayed type hipersensitivity skin test. Our results show that this reduced schedule elicited an early and effective humoral and cellular immune response. However it is necessary other studies with larger groups of vaccinees in order to obtain definitive conclusion.

Antemortem diagnosis of human rabies in a veterinarian infected when handling a herbivore in Minas Gerais, Brazil

The Ministry of Health's National Human Rabies Control Program advocates pre-exposure prophylaxis (PEP) for professionals involved with animals that are at risk of contracting rabies. We report an antemortem and postmortem diagnosis of rabies in a veterinarian who became infected when handling herbivores with rabies. The antemortem diagnosis was carried out with a saliva sample and a biopsy of hair follicles using molecular biology techniques, while the postmortem diagnosis used a brain sample and conventional techniques. The veterinarian had collected samples to diagnose rabies in suspect herbivores (bovines and caprines) that were subsequently confirmed to be positive in laboratory tests. After onset of classic rabies symptoms, saliva and hair follicles were collected and used for antemortem diagnostic tests and found to be positive by RT-PCR. Genetic sequencing showed that the infection was caused by variant 3 (Desmodus rotundus), a finding confirmed by tests on the brain sample. It is essential that professionals who are at risk of infection by the rabies virus undergo pre-exposure prophylaxis. This study also confirms that molecular biology techniques were used successfully for antemortem diagnosis and therefore not only allow therapeutic methods to be developed, but also enable the source of infection in human rabies cases to be identified accurately and quickly.

CHEMOPROPHYLAXIS TO CONTROL LEPROSY AND THE PERSPECTIVE OF ITS IMPLEMENTATION IN BRAZIL: A PRIMER FOR NON-EPIDEMIOLOGISTS

The occurrence of leprosy has decreased in the world but the perspective of its elimination has been questioned. A proposed control measure is the use of post-exposure chemoprophylaxis (PEP) among contacts, but there are still questions about its operational aspects. In this text we discuss the evidence available in literature, explain some concepts in epidemiology commonly used in the research on this topic, analyze the appropriateness of implementing PEP in the context of Brazil, and answer a set of key questions. We argue some points: (1) the number of contacts that need to receive PEP in order to prevent one additional case of disease is not easy to be generalized from the studies; (2) areas covered by the family health program are the priority settings where PEP could be implemented; (3) there is no need for a second dose; (4) risk for drug resistance seems to be very small; (5) the usefulness of a serological test to identify a higher risk group of individuals among contacts is questionable. Given that, we recommend that, if it is decided to start PEP in Brazil, it should start on a small scale and, as new evidence can be generated in terms of feasibility, sustainability and impact, it could move up a scale, or not, for a wider intervention.

A potential vector of Schistosoma mansoni in Uruguay

Susceptibily experiments were carried out with a Biomphalaria straminea-like planorbid snail (Biomphalaria aff. straminea, species inquirenda) from Espinillar, near Salto (Uruguay), in the area of the Salto Grande reservoir, exposed individually to 5 miracidia of Schistosoma mansoni (SJ2 and BH2 strains). Of 130 snails exposed to the SJ2 strain, originally infective to Biomphalaria tenagophila, 30 became infected (23%). The prepatent (precercaria) period ranged from 35 to 65 days. The cercarial output was irregular, following no definite pattern, varying from 138 to 76,075 per snail (daily average 4.3 to 447.5 and ending up with death. Three specimens that died, without having shed cercarie, on days 69 (2) and 80 after exposure to miracidia, had developing secondary sporocysts in their tissues, justifying the prospect of a longer precercarial period in these cases. In a control group of 120 B. teangophila, exposed to the SJ2 strain, 40 became infected, showing an infection rate (33.3%) not significantly different from that of the Espinillar snail (X [raised to the power of] 2 = 3.26). No cercarie were produced by any of the Espinilar snails exposed to miracidia of the BH2 strain, originally infective to Biomphalaria glabrata. Four specimens showed each a primary sporocyst in one tentacle, which disappeared between 15 and 25 days post-exposure, and two others died with immature, very slender sporocysts in their tissues on days 36 and 54. In a control group of 100 B. glabrata exposed to BH2 miracidia, 94 shed cercariae (94%) and 6 remained negative. Calculation of Frandsen's (1979a, b) TCP/100 index shows that "Espinillar Biomphalaria-SJ2 S. mansoni" is a vector-parasite "compatible" combination. Seeing that tenagophila-borne schistosomiasis is prevalent in Rio de Janeiro and São Paulo states and has recently spread sothwards to Santa Catarina state, and the range of B. tenagophila overlaps taht of the Espinillar Biomphalaria, the possibility of schistosomiais establishing itself in Uruguay, although not imminent, is not to be disregarded.

Residual effect of lambdacyhalothrin on Triatoma infestans

Insecticidal residual effect and triatomine infestation rates in houses of a community fumigated with lambdcyhalothrin (Icon) are reported. No mortality was observed in 5th-instar Triatoma infestans nymphs in 72-hr exposure test on three different surfaces, one month after fumigation for a dose of 31.5 mg am/m2. However, during post-exposure observation a mortality of 60% was recorded for those insect exposed on sprayed woodboard. The results observed with mud-containing treated walls, were markedly poorer (0% of mortality). Twelve month after spraying 40% of mortality was observed on first-instar T. infestans nymphs in 72-hr exposure test on woodboard, but lower mortality rates were observed in mud-containing materials. When the effect of deltamethrin (109 mg ai/m2) and lambdcyhalothrin (94 mg ai/m2) was compared, the former did not appear to be superior at similar loads. Both have showed a mortality rate of 30% on 5th-instar T. infestans nymphs three months post-fumigation. The dose utilized in the field fumigation was enough to get a significant (p < 0.0001) control of triatomine domestic infestation, since it was sufficient to keep 95% of the houses uninfested throughout 21 months following treatment, when compared with baseline situation. A remarkable knock-down effect on adult and nymphs forms of the insect and a high in situ mortality were observed as a result of its application, even at very low doses.

Reproductive activity alterations on the Biomphalaria glabrata exposed to Euphorbia splendens var. hislopii latex

The reproductive activity of Biomphalaria glabrata exposed to Euphorbia splendens var. hislopii latex was evaluated. Parameters related to fecundity and fertility were observed. The snails were exposed to the LD50 (1 mg/l) of crude latex. At the first week post exposure (p.e.), the egg laying was reduced. After the fourth week p.e., an increase of the number of eggs/snail occurred. The results showed a marked reduction in the hatching of the snails, revealing an interference of latex exposure with the reproductive process of B. glabrata of E. splendens var. hislopii. The LD50 of the latex may be used as an alternative method to control the size of the populations of B. glabrata in field.

Clinical trial of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

The objective of the present study was to determine the efficacy of prophylactic administration of gabexate for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, hyperamylasemia and pancreatic pain. Patients scheduled for ERCP were randomized into two groups in a double-blind manner: the patients in the gabexate group were treated with continuous intravenous infusion of 300 mg gabexate dissolved in 500 mL Ringer's solution at 111 mL/h, starting 30 min before the endoscopic maneuvers and continuing up to 4 h after them; placebo group patients were treated only with Ringer's solution also starting 30 min before the endoscopic maneuvers and continuing up to 4 h. Data for 193 patients were analyzed. The incidence of post-ERCP pancreatitis was 3 patients (3.1%) in the gabexate group and 10 (10.5%) in the placebo group (P = 0.040). The incidence of hyperamylasemia was 33 patients (33.7%) in the gabexate group and 42 (43.7%) in the placebo group (P = 0.133). The incidence of pancreatic pain was 15 patients (15.3%) in the gabexate group and 28 (29.5%) in the placebo group (P = 0.018). The results suggest that a 4.5-h infusion of gabexate (for a total of 300 mg) could prevent post-ERCP pancreatitis and pancreatic pain.

Hexachlorophene as a topically applied chemical for prophylaxis against Schistosoma mansoni infections in mice

Treatment of mouse tail skins with hexachlorophene (1.25% w/v) in absolute methanol or 70% isopropanol suppressed Schistosoma mansoni infections by more than 95% even when the application was performed up to three days prior to exposure to cercarial suspensions by tail immersion. Treatment with concentrations of 0.313% or higher one day prior to exposure provided at least 98% protection when the treated surface was not subjected to water washes of greater duration than 1/2 hour. Tail immersion application of 1.25% hexachlorophene one day prior to exposure still provided 87-92% protection after 3 hours water wash. Wipe application of 1.25% hexachlorophene three days prior to exposure still provided 93% protection following 3 hours water wash. High cercarial recoveries from exposure tubes at the end of exposure periods indicated high antipenetrant activity for hexachlorophene. Sufficient hexachlorophene leached from treated tail skins into the surrounding water to affect subsequently added cercariae so that they were no longer infective to untreated mice.

Successful control program to implement the appropriate antibiotic prophylaxis for cesarean section

OBJECTIVE: Describe implementation of a successful program to reduce doses (cefazolin 2 to 1 g) used for antimicrobial prophylaxis. METHODS: Evaluation of an intervention program to reduce prophylactic antimicrobial doses. The intervention included weekly staff discussions, automatic dispensation of 1g-vial of cefazolin by the pharmacy unless expressly requested by surgeon and increase in post-discharge surveillance as a strategy to reassure surgeons of the safety of the reduction. In the pre and post intervention periods, a prospective study of antimicrobial consumption and surgical site infections were measured. RESULTS: There were 5,164 and 5,204 deliveries in 2001-2002 and 2003-2004, respectively; 1,524 (29.5%) and 1,363 (26%) were cesarean sections. There was a 45% decrease in cefazolin vials used on average per cesarean section (2.29 to 1.25). Patients evaluated increased from 16% to 67% and the SSI rates in both periods were 3.34% to 2.42%, respectively. CONCLUSION: An ample intervention, including administrative and educational measures, led to high compliance with dose reduction and saved more than US$4,000 in cefazolin, considered important because government reimbursement in Brazil for cesarean section is $80.