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Amendment to anti rabies post exposure therapy (PET) protocol

Dr. Kanthi Nanayakkara
Head / department of Rabies and Vaccine Q C,
Medical Research Institute, Colombo 8.

Rabies is a viral infection caused by a lyssa virus. It is a zoonotic disease which is prevalent among mammals. Rabies is endemic in Sri Lanka and the main carrier identified in transmitting the disease to humans is the dog followed by cats and other wild animals.
Transmission is usually through infected saliva via a bite of an infected animal, saliva contaminated scratches or a lick on broken skin or mucous membranes. The virus targets nervous tissue and will enter the peripheral nerves and travels up along the spinal cord to the brain stem and the brain, causing an invariably fatal encephalo-myelitis.

The incubation period of rabies depends on the size of the inoculum as well as the distance from the viral entry to the central nervous system. It may be as short as few days or as long as few years, but is usually around 1 – 3 months.

Rabies is 100% fatal without anti rabies prophylaxis (pre exposure or post exposure). The comparatively long incubation period provides an opportunity for highly effective PET.

PET consists of: (i) thorough washing and flushing of the wound; (ii) a series of rabies vaccine administrations started immediately after an exposure, and if indicated (iii) Rabies Immunoglobulin (RIG) infiltration into and around the wound, promptly after exposure.
In Sri Lanka anti rabies pre and post exposure prophylaxis is offered free of charge to people who are at risk of rabies, from most government hospitals throughout the country except few very small hospitals. Rabies PET is done according to a DGHS circular which has been based on available WHO recommendations and country experiences, to make the treatment uniform in all hospitals in the country. By adhering to this protocol patients following animal exposures will receive correct and the recommended treatment. In addition, by avoiding unnecessary vaccinations, wastage of expensive biologicals with limited availability can be prevented. Periodic revisions to this circular has been carried out, with the introduction of tissue culture vaccines in the entire country, implementation of intra dermal (ID) ARV schedules and changes in the ID protocols, all of which has been done according to WHO guidelines. The present PET protocol was issued in March 2016 - DGHS/Circular2016-127(MRI-ARPET). According to this protocol, it was recommended to do a sensitivity test (ST) prior to administering equine rabies immunoglobulin (ERIG) for major exposures and the volume was calculated according to the patient’s body weight (20IU/Kg). After infiltrating all the wounds adequately, any remaining ERIG was injected IM on the thighs.

On 20th of April 2018, the WHO released its latest position paper on rabies (Weekly Epidemiological Record - WHO, 20 April 2018, No16,2018,93,201-220). This position paper replaces the 2010 WHO position on rabies vaccines. It presents new evidence in the field of rabies and the use of rabies vaccines, focusing on programmatic feasibility, simplification of vaccination schedules and improved cost-effectiveness. Among other recommendations regarding rabies PET, there were two major changes on the administration of ERIG in this new position paper.

For optimal effectiveness, the maximum dose calculation for RIG is 40 IU/kg body weight for equine derived RIG (ERIG), and 20 IU/kg body weight for human derived RIG (HRIG).
Administration of rabies immunoglobulin (RIG)

• The present WHO guideline does not recommend skin testing (ST) before administration of Equine Rabies Immunoglobulin (ERIG), as such tests poorly predict severe adverse events and their results should not be the basis for non-administration of ERIG when indicated

• However the treating medical officers should be prepared to manage anaphylaxis, which although rare, could occur during the administration of ERIG

• Maximum dose of ERIG is 40IU/kg of body weight. There is no minimum dose

• The entire immunoglobulin dose or as much as anatomically feasible should be infiltrated carefully into or as close as possible to all wounds

• WHO no longer recommends injecting the remainder of the calculated RIG dose IM at a distance from the wound as evidence suggest that there is no or little additional protection against rabies as compared with infiltration of the wound/s alone

An amendment to the existing ARV PET protocol was issued including these recommendations under the Director General of Health Services on the 10th of July 2018 with the following recommendations.

Considering the WHO guidelines on Rabies PET (2018),
 ST should no longer be performed before administering ERIG
 RIG should be infiltrated as much as possible to the site of the wound/s only
A course of ARV should always follow the infiltration of RIG

References;
1. Vaccines and rabies immunoglobulins for humans, WHO Expert Consultation on Rabies, WHO Technical Report Series:2018:1012 (3)
2. Rabies vaccines: WHO position paper, Weekly epidemiological record, WHO, 20 April 2018,No 16,2018,93, 201-220

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LABORATORY INFORMATION MANAGEMENT SYSTEM – NIHS Kalutara

By Dr R.Jayasuriya
Consultant Microbiologists
NIHS
Kalutara

The ministry of health and the Sri Lanka Collage of Microbiologists has initiated the process to move away from the paper based system and to implement a common Laboratory Information Management System (LIMS) in all state sector microbiology laboratories.

The Phase 1 of the project is the Development of a laboratory information management system to be deployed at NIHS Kalutara .

The Project is funded by an Iinnovative research grant under the Second Health Sector Development Project (SHSDP).

Following a delay of almost 2 years the project finally got under way by awarding the tender for the development of software to “Science Land Information Technology (Pvt) Ltd “.

The tender for the setting up of a Network and provision of a server at NIHS Kalutara was awarded to “Office Network Pvt Ltd " and the work was fully completed by 30/09/2017

The Software development process was initiated at NIHS Kalutara on the 15th May 2017 . The software is now been deployed and tested at NIHS Kalutara .

Ordinary General Meeting of the Sri Lanka College of Microbiologists (SLCM)

An ordinary general meeting of the SLCM will be held on Friday, 4th May 2018 from 2.00pm to 3.30pm (after the CME) at the Aldo Castellani Auditorium of the Medical Research Institute, Colombo 8.

Please be present.

The agenda is as follows.

1. Minutes of the previous Ordinary General Meeting
2. Matters arising from the minutes
3. Annual Scientific Sessions 2018
4. Revision of Hospital Infection Control Manual/ National IPC guidelines
5. Anti-Fraud Policy
6. Guideline to select a candidate when more than one member has expressed interest in taking part in fellowship/as a resource person for a conference.
7. To appoint a committee -Marking scheme to select a candidate when more than one member has expressed interest in taking part.
8. Keeping only one petty cash account, sweep account
9. Projects: UK project, York project and Fleming fund
10. Change of Secretary and Director board

Dr. Pavithri Bandara / Dr. Kishani Dinapala

Joint Secretaries

27th Annual Scientific Sessions

International Conference on Infectious Diseases and AntimicrobialResistance –

08th -10th August 2018 at the Hotel Taj Samudra, Colombo

Theme - Communicate and collaborate for clinical excellence

 

Objectives of the Program

  • To raise awareness among clinicians including primary care physicians , policy makers and the public of the burden of AMR and on strategies for prevention and control of Infections and AMR in South Asia.
  • To disseminate knowledge and skills pertaining to infectious diseases and AMR within the South Asian region
  • To promote basic and applied research in infectious diseases and AMR.
  • To promote collaboration among clinicians and researchers in the region to study the epidemiology, laboratory diagnosis, management and prevention and control of infections and AMR.

 

Looking Back at the 2nd South Asian Melioidosis Congress

The 2nd South Asian Melioidosis Congress was held at the Cinnamon Lakeside Hotel on 29th and 30th August. As its name implies, this was the second Congress on Melioidosis to be held in this region, involving countries like India, Sri Lanka, Bangladesh, Nepal, Bhutan and Pakistan, to increase awareness about melioidosis.

Melioidosis is a neglected tropical disease that is frequently mis-or under-diagnosed in the region. Hence, the theme of the conference, “Unearthing a subterranean infection”. Revealing the hidden burden of infection requires the co-operation of a network of microbiologists, epidemiologists, infectious disease specialists, and public health personnel. The 2nd South Asian Melioidosis Congress aimed to allow researchers and clinical personnel to meet and learn from global experts on the disease and develop collaborations within and between countries in the region and groups overseas with the ultimate goal of reducing the morbidity and mortality of this potentially fatal infection.

The objectives of the 2nd SAMC were:

  1. To raise awareness among clinicians, public health personnel, policy makers and the public of the burden of disease caused by melioidosis in South Asia.
  2. To disseminate knowledge and skills pertaining to melioidosis within the South Asian region
  3. To promote basic and applied research in melioidosis.
  4. To promote collaboration among clinicians and researchers in the region to study the epidemiology, clinical and laboratory diagnosis, management and prevention and control of melioidosis.

The target audience were Clinical Microbiologists, other Clinicians, Infectious Disease specialists, Laboratory personnel, Epidemiologists, Public Health personnel, Veterinarians, Policy makers and Researchers in Infectious Diseases.

Organising Committee

  • Patron: Prof Vasanthi Thevanesam (Sri Lanka)
  • Chairperson: Dr Enoka Corea (Sri Lanka)
  • Prof Chiranjay Mukhopadhayay (India)
  • Prof Tim Inglis (Australia)
  • Prof David Dance (Laos)
  • Dr Herbert Schweizer (US)
  • Dr Dharshan de Silva (Sri Lanka)
  • Dr Thushari Dissanayake (Sri Lanka)
  • Dr Nayomi Dhanthanarayana (Sri Lanka)
  • Dr Malika Karunaratne (Sri Lanka)
  • Ms Ranmalie Abeysekara (Sri Lanka)
  • Dr Muditha Abeykoon (Sri Lanka)

The academic progamme consisted of a series of lectures delivered by world renowned experts in all areas of melioidosis including history, epidemiology, clinical presentation, immune response, laboratory diagnosis, soil surveillance etc. International speakers from the USA, Netherlands, Australia, Austria, Thailand, India and Bangladesh were the resource persons at this conference. In addition, case presentations were presented by researchers from Sri Lanka, Malaysia and India. A “Meet the Expert” session where researchers and clinicians could meet and interact with the expert of their choice was held.

Twenty four e-posters were presented. First, second and third prizes were awarded to the poster presenters at a valedictory ceremony.

Outcome

The 2nd SAMC was highly successful with the participation of 160 persons on the 29th August and 150 persons on the 30th August. This included 18 speakers from overseas, 2 local speakers, 2 observers from the region (from Nepal and Pakistan) and 4 Indian researchers who were awarded travel scholarships and a further 21 overseas registrants.

List of resource persons

  1. Tim Inglis Perth                Australia
  2. Adam Merrit Perth                Australia
  3. Natkunam Ketheesan Townsville       Australia
  4. David Dance Vientiane         Laos
  5. Ivo Steinmetz Vienna             Austria
  6. Joost Wiersinga Amsterdam     Netherlands
  7. Direk Limmathurotsakul Bangkok          Thailand
  8. Narisara Chandratita Bangkok          Thailand
  9. Ganjana Lertmemongkolchai Bangkok          Thailand
  10. Wirongrong Chierakul Bangkok Thailand
  11. Chiranjay Mukhopadhyay Manipal           India
  12. Vandana KE Manipal           India
  13. Chaitanya TAK Manipal           India
  14. Tushar Shaw Manipal           India
  15. Shariful Alam Jilani Dhaka              Bangladesh
  16. Herbert Schweitzer Florida             USA
  17. Apichai Tuanyok Florida             USA
  18. Mohan Natesan Maryland         USA
  19. Enoka Corea Colombo         Sri Lanka
  20. Dharshan de Silva Colombo         Sri Lanka

Other important information

The Chief Guest for the opening ceremony was Dr Razia Pendse, WHO Representative in Sri Lanka.

The abstracts were reviewed by reviewers from the Sri Lankan Society for Microbiology (SSM).

The Defense Threat Reduction Agency provided travel awards to 5 speakers and 4 poster presenters.

Travel scholarships were given by the National Institutes of Health, Bethesda, USA, to participants from the region.

NHSL Commemorates Global Hand washing Day 2017 with Hand Washing Ceremony of a Different Nature

By ; ​​ Dr. Geethika Patabendige

Global Handwashing Day is an annual global advocacy day dedicated to increasing awareness and understanding about the importance of hand washing as to prevent infectious diseases and save lives. It is celebrated annually on​​ October 15​​ worldwide and it is an opportunity to encourage public and healthcare workers to wash their hands at critical times.

The 2017 Global Handwashing Day theme is “Our Hands Our Future!”​​ emphasizing how hand washing protects our health allowing us to build our own future. It is very timely in the era of increasing trend of multidrug resistant and pandrug resistant microorganisms in healthcare as well as community settings.​​ 

The infection control unit of​​ NHSL organized​​ ​​ a hand washing ceremony in two sessions morning and afternoon filled with different types of educational activities namely hand washing step dances, dramas, ”viridu”, presentations,​​ hand washing demonstrations and hands on experiences etc.​​ ​​ targeting the healthcare workers in commemorating the Global hand Washing Day 2017​​ on October 20 , 2017​​ because we strongly believe that behavioural change in the healthcare workers is of utmost importance in preventing and controlling healthcare associated infections for which WHO five moments of hand washing contributes very strongly.​​ 

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