Archive for December 24, 2016

Editor’s Choice: Editorial Commentary: Decision Science at Work: The Case of Hepatitis C Virus Postexposure Prophylaxis

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.100-101

Joshua A. Barocas and Benjamin P. Linas

1Division of Infectious Diseases, Massachusetts General Hospital

2Boston University Schools of Medicine and Public Health

3Boston Medical Center, Massachusetts

In this issue of Clinical Infectious Diseases, Naggie et al discuss clinical decision making and present the results of a decision analysis examining the cost of hepatitis C virus (HCV) postexposure prophylaxis (PEP) among healthcare workers who experience a needlestick exposure to HCV-positive body fluids.

The authors discuss that, in an era when we can cure essentially all HCV infections, there are only 3 motivations for PEP. First, it may make sense to use PEP to prevent infections if doing so would decrease HCV transmission during the period of active HCV viremia.

The paper succinctly reviews the evidence and quickly makes clear that among healthcare workers in the United States with a known HCV exposure, basic universal precautions reduce the risk of forward transmission to essentially zero.

 

A second motivation might be cost. Given that HCV medications are expensive, a shorter course PEP may be cost saving compared with full treatment for HCV infection. To address the possible economic rationale for PEP, the authors developed a decision tree to estimate the costs of PEP for HCV in a hypothetical cohort of 100 healthcare workers who had suffered a needlestick injury.

They used the model to compare the outcomes with PEP to those with a strategy of “no PEP and treat only patients who develop chronic HCV infection.”

A few notable assumptions were made—namely, that PEP was 100% effective at preventing infection, while treatment for chronic HCV was only 98% effective with the first line of therapy.

In addition, individuals who failed first-line treatment for chronic HCV infection were retreated with 100% . . .

PDF

https://cid.oxfordjournals.org/content/64/1/100.full.pdf+html

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December 24, 2016 at 2:04 pm

Editor’s Choice: Hepatitis C Virus Postexposure Prophylaxis in the Healthcare Worker: Why Direct-Acting Antivirals Don’t Change a Thing

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.92-99

Susanna Naggie, David P. Holland, Mark S. Sulkowski, and David L. Thomas

1Duke Clinical Research Institute

2Duke University School of Medicine, Durham, North Carolina

3Emory University School of Medicine, Atlanta, Georgia

4Johns Hopkins School of Medicine, Baltimore, Maryland

Currently, 380 000–400 000 occupational exposures to blood-borne pathogens occur annually in the United States.

The management for occupational HIV or hepatitis B virus exposures includes postexposure prophylaxis (PEP) when necessary; however, PEP is not recommended for hepatitis C virus (HCV) exposures.

Recent approval of HCV direct-acting antivirals (DAAs) has renewed discussions as to whether these therapies could be used to prevent infection after exposure. There are no published studies addressing this question, but the prescribing of DAAs for PEP has been reported.

We will discuss the differences in transmission of the 3 most common blood-borne pathogens, the natural history of early HCV infection, and the scientific rationale for PEP.

In particular, we will discuss how the low feasibility of conducting an adequately powered clinical trial of DAA use for PEP and the low cost-effectiveness of such an intervention is not supportive of targeting limited resources for such use.

PDF

https://cid.oxfordjournals.org/content/64/1/92.full.pdf+html

December 24, 2016 at 2:02 pm

Editor’s Choice: Coinfection With Zika and Dengue-2 Viruses in a Traveler Returning From Haiti, 2016: Clinical Presentation and Genetic Analysis

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.72-75

BRIEF REPORTS

Nicole M. Iovine, John Lednicky, Kartikeya Cherabuddi, Hannah Crooke, Sarah K. White, Julia C. Loeb, Eleonora Cella, Massimo Ciccozzi, Marco Salemi, and J. Glenn Morris, Jr

1Division of Infectious Diseases, Department of Medicine, College of Medicine

2Emerging Pathogens Institute

3Department of Environmental and Global Health, College of Public Health and Health Professions

4Department of Epidemiology, College of Public Health and Health Professions

5Department of Pathology, Immunology and Laboratory Sciences, College of Medicine, University of Florida, Gainesville

6Department of Infectious Parasitic and Immunomediated Diseases, Reference Centre on Phylogeny, Molecular Epidemiology and Microbial Evolution/Epidemiology Unit, Istituto Superiore di Sanita, Rome, Italy

Zika virus and dengue virus serotype 2 were isolated from a patient with travel to Haiti who developed fever, rash, arthralgias, and conjunctivitis. The infecting Zika virus was related to Venezuelan and Brazilian strains but evolved along a lineage originating from strains isolated in 2014 in the same region of Haiti.

PDF

https://cid.oxfordjournals.org/content/64/1/72.full.pdf+html

December 24, 2016 at 1:59 pm

Editor’s Choice: Effectiveness of Prenatal Tetanus, Diphtheria, and Acellular Pertussis Vaccination on Pertussis Severity in Infants

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.9-14

Kathleen Winter, James D. Cherry, and Kathleen Harriman

1California Department of Public Health, Immunization Branch, Richmond

2Department of Epidemiology, University of Kentucky, Lexington

Background

All US women are recommended to receive a tetanus, diphtheria, and acellular pertussis (Tdap) vaccine at 27–36 weeks gestation during each pregnancy to reduce the risk of pertussis to their infants. The impact of this strategy on severity of disease among infected infants has not been evaluated.

Methods

We use a retrospective cohort study design evaluating whether pertussis-infected infants born in 2011–2015 whose mothers received Tdap vaccine during pregnancy had less severe pertussis, resulting in a lower risk of hospitalization or intensive care unit admission compared with infants born to unvaccinated mothers.

Results

Infected infants of vaccinated mothers were significantly less likely to be hospitalized and had significantly shorter hospital stays compared with infants born to unvaccinated mothers, after adjustment for chronological and gestational age and receipt of diphtheria and tetanus toxoids and acellular pertussis vaccine. Unadjusted and adjusted vaccine effectiveness for preventing hospitalization among infants with pertussis was 72% (95% confidence interval [CI], 49%–85%) and 58% (95% CI 15%–80%), respectively. No infants born to vaccinated mothers required intubation or died of pertussis.

Conclusions

Infants with pertussis whose mothers received Tdap during pregnancy had a significantly lower risk of hospitalization and intensive care unit admission and shorter hospital stays. Prenatal Tdap vaccination is a critical strategy for reducing the morbidity and mortality from pertussis.

PDF

https://cid.oxfordjournals.org/content/64/1/9.full.pdf+html

December 24, 2016 at 1:57 pm

Editor’s Choice: Effectiveness of Prenatal Versus Postpartum Tetanus, Diphtheria, and Acellular Pertussis Vaccination in Preventing Infant Pertussis

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.3-8

Kathleen Winter, Steve Nickell, Michael Powell, and Kathleen Harriman

1California Department of Public Health, Immunization Branch, Richmond

2Department of Epidemiology, University of Kentucky, Lexington

Background

Most severe and fatal cases of pertussis occur in infants <8 weeks of age, before initiation of the primary pertussis vaccine series. Women are recommended to receive tetanus, diphtheria, and acellular pertussis (Tdap) vaccine at the start of the third trimester of each pregnancy to optimize transplacental transfer of antibodies to the fetus. This recommendation was made by the Advisory Committee for Immunization Practices based on immunogenicity data, and no studies in the United States have yet evaluated the effectiveness of this strategy in reducing pertussis incidence in infants.

Methods

We evaluated a cohort of mothers with documented Tdap vaccination histories in the California Immunization Registry to determine whether infants whose mothers received Tdap vaccine at 27–36 weeks gestation had a lower risk of pertussis at <8 weeks of age than infants born to women who received Tdap vaccine within 14 days post partum.

Results

Tdap vaccination received at 27–36 weeks gestation was found to be 85% (95% confidence interval, 33%–98%) more effective than postpartum Tdap vaccination at preventing pertussis in infants <8 weeks of age . Vaccination at 27–36 weeks gestation was more effective at preventing pertussis in infant than vaccination during the second trimester.

Conclusions

Tdap vaccination at 27–36 weeks gestation was 85% more effective than postpartum vaccination at preventing pertussis in infants <8 weeks of age. Efforts should be made by prenatal care providers to provide Tdap vaccine to pregnant women during routine prenatal visits at the earliest opportunity between 27 and 36 weeks gestation.

PDF

https://cid.oxfordjournals.org/content/64/1/3.full.pdf+html

December 24, 2016 at 1:55 pm


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