CPS Immunization and Infectious Disease - volume 2

Question 1

Which of the following statements is true?

a) head lice are a vector for disease
b) head lice are a sign of poor hygiene
c) head lice can last up to 3-4 weeks untreated on a child’s head
d) head lice are a health hazard

Answer 1

c) is true

the rest are false, unlike body lice, are not a vector for disease or a sign of poor hygiene

Question 2

Which of the following is TRUE?

a) lice are not spread by to hair to hair contact
b) lice can fly
c) lice can be spread from animals
d) sensitization to lice on the first infestation takes 6-8 weeks
e) carpets in the classroom have a low likelihood of transmission of lice, whereas pillowcases only present a small risk

Answer 2

e) true

b) can’t fly
c) only from humans

head lice are wingless 2-4 mm in size
six legged
blood sucking insects
usually

Question 3

Which of the following is needed for detection of lice infestation?

a) viable nits are often furthest away from the scalp
b) detection by visual examination is not that effective
c) detection of living louse
d) detection of nit

Answer 3

c) don’t need nit, need louse, nit indicates a past infestation that may not be active

the rest false
a) usually close to the scalp (having 5+ nits within 0.6 cm of the scalp was a risk factor for becoming infested with active lice, occurred in

Question 4

Which of the following treatments for lice is most neurotoxic?

a) Pyrethrin
b) Lindane
c) Permethrin
d) Resultzrinse

Answer 4

b) Lindane is most neurotoxic, not a good choice for young infants, pregnant mothers, breastfeeding, can cause seizures

the other major treatments and side effects are as follows?

a) pyrethrin - 1st line made from chrysanthemums, neurotoxic to lice, not to humans,possible allergic reaction if allergic to ragweed, apply to dry hair, leave for 10 minutes, then add water and rinse, repeat 7-10 days later; minimal percutaneous absorption
b) permethrin - 1st line synthetic pyrmethrin (synthetic pyrethrin), after washing with shampoo only (no conditioner), then rinse, then dry hair, repeat treatment in 7 days, does not cause allergic reactions, minimal percutaneous absorption
c) resultzrinse - 50% of isopropyl myristate, 50% ST cyclomethicone, local irritation, not for children<4 year old, keep eyes closed, then apply to dry hair, and scalp, leave for 10 minutes, rinse, repeat in 7 days

malathion and crotamiton lotion not available in Canada

Cochrane review - only 3 appropriate studies, permethrin, malathion and pyrethrins proved to be effective on this basis

Question 5

Which of the following is not a side effect of Lindane?

a) neurotoxicity including seizures
b) anemia
c) allergic reaction especially if allergic to ragweed
d) irritation of the scalp

Answer 5

c) this is for pyrethrins

Lindane - 2nd line, because of neurotoxicity and bone marrow suppression, neurotoxicity and bone can cause seizures, contraindicated if seizures history, possible anemia, irritation of the scalp, not for young infants or pregnant or breastfeeding mothers, banned in California after Lindane in water; safe interval for reapplication not established, most side effects have been after multiple applications or ingestion but there have been reports of side effects even with proper use

Question 6

Which of the following is false ?

a) itching after treatment with insecticide means that resistance has occurred
b) misdiagnosis and over diagnosis of lice could lead to increased reported resistance rates
c) poor application could lead to increased reported “resistance”
d) could have a new infestation after treatment rather than true resistance

Answer 6

a) does NOT mean that resistance has occurred
application of topical insecticide can cause rash, itching and mild burning; can treat itching with topical steroids or antihistamines
reinfestation needs to diagnose by lice
resistance has been reported in numerous countries, some to permethrin documented in US, don’t know the resistance rates in Canada no formal studies, resistance a problem in the UK

Question 7

Which of the following treatments for lice has the best evidence behind it?

a) Septra (TMP-Sulfamethoxazole)
b) ivermectin
c) wet combing (including with vinegar)
d) Resultz (isopropyl myristate and ST-cyclomethicone)

Answer 7

d) a new treatment, currently on phase 3 trials, dissolves the exoskeleton, not ovidicidal, need a second application in one week, minimal side effects of erythema and pruritus of the scalp, apply to dry scalp and rinse off in 10 minutes. for kids > 4 years old only.

for oral Septra, risk of resistance, one RCT using alone and in combo with topical permethrin, not an approved use in Canda;
ivermectin - neurotoxic, should not be used in children

Question 8

Which of the following is an effective way to decrease spread and persistence of head lice?

a) no nit exclusion policies
b) complete disinfection of the house including all stuffed animals, couches etc.
c) washing items that have close contact with the head in hot water and drying in a hot dryer

Answer 8

c) is the answer; only need to wash products that are in close intimate contact with the head (hats, pillows, brushes and combs) in hot water (66 C, drying it in a hot dryer for 15 min, or store in occlusive plastic bag for 2 weeks), data on weather extensive cleaning decreases likelihood of reinfestation is lacking, nits don’t live far awe from scalp, need to be at room temperature to hatch

if close head to head contact, then need to investigate the other person for presence of infestation

no nit exclusion policies - doesn’t hav sound medical rational, detection of active lice shouldn’t lead to exclusion of the affected child, should recommend treatment and discourage close head to head contact, AAP and Public Health of America discourage no nit school policies
should alert families when there is lice, and inform them about diagnosis, misdiagnosis and management of head lice, and lack of risk for serious disease

Question 9

Which of the following is false?

a) The estimated incidence of Hepatitis C virus in Canada is 1-3%
b) more prevalent in people who received blood transfusions before 1990
c) Inuit and First Nations people have increased HCV seroprevalence but decreased progression to chronic HCV infection
d) The majority of people infected with HCV are symptomatic

Answer 9

d) false most are asymptomatic, hard to estimate the seroprevalence,

the rest are true

b) didn’t used to test blood for HCV

Question 10

Which of the following groups has significantly increased prevalence of HCV infection (multiple pics allowed)?

a) hemodialysis patients
b) men who have sex with men
c) IV drug users
d) health care workers exposed to fluids
e) women with sexual partner who is IVDU
f) blood transfusion before 1990

Answer 10

c) IV drug users and hemophiliacs who received factor 8 concentrates at increased risk; 50% of IVDU were seropositive in past studies

the other groups
hemodialysis and health care workers - only a minority of cases
household contact - transmission yet to be proven
sexual contact- minor mode of transmission in Canada, only a small proportion of cases

pregnant women - seroprevalence 1%, biggest risks are previous or current IVDU, sexual partner of IVDU, blood transfusion before 1990, before adolescence, almost exclusively transmitted by perinatal exposure.

Question 11

Which of the following is true of HCV infections?

a) chronic HCV infections have the persistence of HCV RNA for more than 6 months
b) most infections are very symptomatic in the acute stage
c) 50% of acute infections become chronic
d) the cases of HCV that clear infection clear both the RNA and antibodies

Answer 11

a) is the answer

the rest false
a) most are asymptomatic/mild in the acute statge
c) 75% become chronic
d) 25% that clear the infection don’t have the RNA but continue to have persistent antibodies, but small amounts of virus in labs may be detected in peripheral blood mononuclear cells and liver by special techniques.
infectivity and incidence of sequelae of HCV infection in adult patients who clear HCV infection is thought to be low but need more long term studies
adults rarely clear the HCV RNA after 6 months, children 12% in one study

Question 12

Which of the following about HCV in children is false?

a) clearance of vertically acquired HCV infection typically happens before age 7 if it’s going to happen
b) the majority of children have intermittent or chronically elevated aminotransferase levels
c) most children with HCV chronic have hepatomegaly
d) children with chronic HCV in childhood have significantly abnormal histology

Answer 12

d) false - only mildly abnormal histology, gradual histological progress with cirrhosis during childhood only in small number of cases

the rest are true
the correlation between aminotransferase and disease severity are far from perfect, indications for liver biopsy remain uncertain.

Question 13

Which of the following patients has acute HCV?

a) 1 month old of mom with HCV, has antibodies against HCV, no HCV RNA
b) 3 month old of mom with HCV, has antibodies against HCV, no HCV RNA
c) 10 month old old with presence of antibodies against HCV and HCV RNAin child 6 months

Answer 13

c) is the answer, has acute HCV

the other options

a) ->too early to tell, patient may not be viremic yet if age 18months, if still present repeat HCV RNA to ensure HCV cleared. HCV RNA is very sensitive, just not 100%Children who clear HCV have little/no sequelae. children >18 months of age ->seropositive with RNA diagnoses chronic HCV (compared to those who have cleared infection). remember that pretty much all HCV pre adolescent is acquired vertically.
d) is chronic HCV, usually persists indefinitely in the absence of antiviral therapy, but if are going to clear much more likely in children than adults

the other cases

• HCV antibody absent, HCV RNA present - seronegative HCV or very early.
• no HCV antibody or RNA, but presence in peripheral blood mononuclear cells - occult HCV

Question 14

Which of the following does not increase the risk of HCV vertical transmission?

a) higher maternal viral titer
b) maternal IV drug use
c) higher ALT in the year before pregnancy
d) maternal cirrhosis
e) HIV coinfection

Answer 14

b) conflicts regarding how maternal IV drug use affects transmission
in general vertical transmission thought to be 5%
the other factors increase the risk of transmission
HIV confection increases the risk (up to 25% in some studies)
treatment of HIV decreases the increased risk, all infected women in first trimester should be on anti-retrovirals
HCV genotype not known to affect transmission risk
all women with HCV should be screened for HIV and chronic HepB

Question 15

Which of the following women should breastfeed?

a) woman with chronic HCV
b) woman with chronic HCV who has developed jaundice postpartum
c) woman with chronic HCV with bleeding cracked nipples
d) woman with HCV and HIV

Answer 15

a)
rarely transmitted by breast milk, gastric acid inactivates HCV, but can’t totally eliminate that breastfeeding could lead to transmission
theoretical risk
the other examples however should not breastfeed

Question 16

Which of the following procedures should not be done for a woman with known HCV

a) avoid use of scalp electrodes
b) elective C section to avoid transmission
c) avoid amniocentesis

Answer 16

b) for now should avoid scalp electrodes and amnio (since increase blood exchange), since there is some evidence of risk

one study showed benefit of C section, another not ->so for now, don’t make delivery decisions based on HCV, also, although current evidence supports that intrapartum is when most transmission occurs, unclear of relative significance of intrauterine vs intrapartum,
other risk factors - one study unexpectedly infant female sex, PROM inconsistently shown to be risk factor for increased transmission

Question 17

Which of the following people should not be screened for HCV

a) recipients of blood from developing countries or before 1990
b) all pregnant women
c) past and present IV drug users
d) people who had organ transplants from unscreened donors

Answer 17

b) not all , no way to prevent vertical transmission (treatment before pregnancy will lower chance of vertical transmission but not enough to warrant treatment on its own)

the other pregnant women should be tested (since high risk), screening of high risk women;
treatment with antiviral therapy in the post partum period decreases the risk of end stage liver disease and hepatocellular carcinoma in the woman
the following women should be considered high risk:
1. past/present IVDUs
2. recipient of blood products before 1990 in developed countries and/or at any time in developing countries
3. unexplained elevated aminotransferase levels
4. patients who have undergone organ/tissue transplant from unscreened donors.
Past or present IVDUs;

Question 18

Which of the following about ribavarin is true?

a) treatment prior to pregnancy may lower the chance of vertical transmission of HCV
b) ribavarin has been found to be safe in pregnancy
c) treatment during pregnancy can lower chance of vertical transmission HCV
d) treatment before pregnancy is advisable in all women with HCV

Answer 18

a) is true

ribavarin teratogen in animals, not studied in humans
treatment prior to pregnancy will lower chance of transmission if successful, NOT advised unless other indications for therapy
reinfection common if IV drugs is the route of getting it
treatment before pregnancy might be considered in women who are not IVDU and who agree to use birth control until completed treatment.
safety of antivirals during pregnancy to prevent transmission has not been studied

Question 19

Which of the following statements is false?

a) passive antibodies against HCV can last up to 18 months
b) only 5% of women will transmit HCV to their babies
c) serology performed at 12-18 months is the primary diagnostic test
d) special precautions are needed for infants with HCV in the nursery

Answer 19

d) blood is the major source of transmission, no special precautions needed, no saliva, urine or stool transmission known

the rest are true

• HCV serology during infancy is not reliable, HCV antibody can persist up to 18 months (one study showed that 1/2 seronegative by 6 months of age, 95% by 12 months of age) if positive at 12 months need to repeat at 18 months
• earlier diagnosis is unlikely to alter management, but if tremendous parental anxiety or worry about child being lost to follow up, should do a single HCV RNA test at 2 month of age, knowing that 25% of children will clear it

before adolescence HCV almost exclusively from perinatal exposure

Question 20

Which of the following is the correct management for a baby who is HCV RNA positive at 2 months of age?

a) repeat every 6 months
b) repeat every 6 months with aminotransferase levels
c) serology at 12-18 months
d) start antiviral therapy with ribavarin

Answer 20

b) is the answer ->to see if chronic infection or spontaneous clearance

if HCV RNA negative, then will need to do serology at 12-18 months to confirm serorevision

chronic HCV kids - should be cared for by paediatric herpetologist, or ID specialist, since antiviral therapy may be indicated

Question 21

Which of the following is false of immunizations for children with HCV?

a) some evidence that hepatitis A may temporarily inhibit the replication of HCV in an adult study
b) children with hepatitis C are at higher risk of infection with hepatitis B and of more severe infection
c) hepatitis A vaccine should be given starting in month 1 of life
d) hepatitis B vaccine should be given starting in month 1 of life

Answer 21

c) is the answer (we give hep B in month 1 of life, hep A in year 1 of life) logic is that these kids are at higher risk of these other hepatitis and the infections are likely to be more severe

hepatitis A in year 1, but new study A makes it a bit less clear cut

restrictions - no risk of transmission with day to day activities, some say that shouldn’t participate in boxing or wrestling, but this is controversial
no legal or ethical obligation to tell the school

Question 22

Which of the following statements is true?

a) full protection against diseases can be attained with one dose of vaccine
b) herd protection is one way to prevent tetanus
c) cocooning is a helpful way to prevent pertussis
d) unimmunized adults are more affected by infectious disease outbreaks than children

Answer 22

c) is true - cocooning is immunizing those around an infant

the rest are false, unimmunized children are more affected, because of broader social networks
for example 2011 measles in Europe
herd protection doesn’t work for tetanus - microbe lives in the soil,
need multiple doses for full protection, therefore doesn’t make sense to wait for outbreak, single dose acts too slowly , need 2-3 weeks to get protective levels of antibody.

Question 23

Which statements(pick 2) is least effective at convincing parents?

a) A vaccine is 99% safe
b) There is 1% chance of side effects
c) If you decide not to get immunized for HPV, you increase your chance of getting HPV and cervical cancer
d) If you decide to get immunized for HPV, you decrease your chance of getting HPV and cervical cancer and giving HPV to partners

Answer 23

b) and d)
frame in terms of risks, creates anxiety and pushes people to make a decision

don’t dismiss kids from practice if parents refuse immunization, most will change their mind (only 3% are stubborn), complex legal/ethical issues since you need to act in the best interests of the child, address issue of pain with immunization

Question 24

Which of the following bugs is associated with Guillain Barre syndrome?

a) Campylobacter
b) E. coli O157
c) Listeria
d) Salmonella

Answer 24

a) is the answer

E. coli O157 - hemolytic uremic syndrome
Listeria - in newborns of infected pregnant woman
Reactive arthritis - after enteric pathogens
Creutzfeld Jacob - contaminated beef in the UK
recently increase in number of foodborne organisms
includes viruses - cryptosporidium, cyclospora, calcivirus and norovirus, have emerged or found to be food borne

also more immunocompromised patients

salmonella - in uncooked eggs (untracked) since often endemic in egg laying flocks, children should not eat uncooked/undercooked eggs, unpasteurized powdered eggs or products containing raw eggs.

Question 25

Which of the following organisms is not associated unpasteurized milk, cheese and other dairy products?

a) salmonella
b) campylobacter
c) E.Coli O157
d) toxoplasma
e) Brucella

Answer 25

d) Toxoplasma

salmonella, campylobacter, E. Coli O157, Mycobacterium bovis, Brucella, Listeria, Brucella, associated with unpasteurized milk/soft cheeses

children should not drink unpasteurized milk or eat unpasteurized soft cheeses

table in the CPS statement

Question 26

Which of the following is not associated with unpasteurized fruit and vegetable juices?

a) E. coli O157
b) Campylobacter
c) Salmonella
d) Clostridium botulinum

Answer 26

b) not associated

the other 3 are associated, children should only drink pasteurized juice products unless freshly squeezed.

Question 27

Which of the following is not associated with raw or undercooked meat or poultry?

a) salmonella
b) campylobacter
c) Shigella
d) Trichinosis

Answer 27

c) Shigella is the answer

associated with raw or undercooked meat or poultry
Salmonella, campylobater, E Coli O157, Trichinosis, Brucella, Toxoplasmosis, Yersinia, Listeria,
children should not eat raw or undercooked meat or poultry

Question 28

Which of the following is not associated with raw shellfish?

a) salmonella
b) vibrios
c) norovirus
d) hepatitis A

Answer 28

a)

the other 3 are associated, there are also many other toxins/pathogens/parasites associated
children should not eat raw shellfish, some people say that they should not eat any raw fish

Question 29

Which of the following is not associated with unwashed fresh fruit and vegetables?

a) Cryptosporidium
b) campylobacter
c) Giardia
d) Shigella

Answer 29

b) campylobacter not associated

associated with unwashed fresh fruit and vegetables

• crytosporidium, calcivirus, cyclospora, Giardia, Shigella, E Coli O157, other E. coli, hepatitis A
• children should only eat washed fruits and veggies

sprouts - associated with salmonella, E Coli 157, hepatitis A
- children should avoid eating raw or undercooked sprouts

honey - C. botulinum - don’t give to kids < 1 year old

cream filled pastry - i.e. egg salad , caesar dressing - Staph aureus, bacillus cereus, should eat immediately or keep in fridge

Question 30

Which of the following is true?

a) most fruit and veggies sold in Canada are produced here
b) irradiation of foods eliminates all microbes
c) organic produce may have an increased of infection compared to non organic
d) uncooked ground beef is mainly a concern because of Salmonella

Answer 30

c) is true
the rest are false

a) >50% are from the developing world
b) does not irradiate all microbes, but properly irradiated foods does eliminate most microbes, also, irradiated foods are not radioactive
d) main risk is E coli O157

Question 31

Which of the following is false about how to prevent foodborne illnesses in the immunocompromised?

a) cook meats to appropriate temperatures and measure internal temperatures, meat pates should be avoided or heated
b) should not eat food with raw or undercooked eggs
c) avoid soft cheese and cheeses with live microbial cultures, avoid strawberries and raspberries
d) can eat normal alfalfa sprouts

Answer 31

d) false avoid raw sprouts

**remember that you treat them essentially like pregnant women

Question 32

Which of the following statement is false?

a) large population based studies have not found a link between MMR vaccine and autism
b) several lab studies using PCR techniques have shown the detection of measles virus in intestinal biopsies and peripheral blood mononuclear cells or autistic children; subsequent studies have refuted these claims
c) autism rates have decreased since thimeserol has been removed from vaccines
d) multiple recent studies have shown that there is no association between thimeserol and autism

Answer 32

c) is false

the initial study has been recalled, theory was the colonic MMR impaired nutrient absorption and brain development, was based on the experiences of 8 children/parents

large population based epidemiological studies have shown no association between MMR and autism

PCR techniques vulnerable to errors - real time PCR subsequent study showed that no evidence of measles persistence in colon and in peripheral blood mononuclear cells, also have negated elevated levels of antibodies in autistic children by recent work.

thimeserol - contains ethyl mercury - in 1999 US AAP and Public Health called for removal of thimeserol from vaccines as a precaution, thimeserol was used to prevent bacteriological contamination of multi use vaccines; at the time in Canada DTAPHib did not contain thimeserol, only hepB and influenza had thimeserol at the time. multiple subsequent studies showed no association between thimeserol and autism.

in Canda, influenza vaccine and hepB contain thimeserol, have option for thimeserol free HepB. ethyl mercury cleared much more quickly than methyl mercury. long term goal is to remove thimeserol from all vaccines. influenza vaccine still has thimeserol, those without are not routinely commercially available, and only one is approved in children

Question 33

Which of the following about hepatitis B is false?

a) no cases of transmission from discarded needle recorded
b) most stable blood borne virus
c) can survive up to one week under optimal conditions
d) risk of transmission from occupational needle stick injury as high as 40%

Answer 33

a) false - there has been a case reported

the rest are true, occupational transmission from needle stick estimated 2-40% depending on level of viremia
when source is HepBsAg positive

although HepB now recommended for all children in Canada, most programs target children older than those sustaining these injuries
anti HepB Ig and vaccine are effective if administered promptly

Question 34

Which of the following is least likely to be transmitted by needle stick injury?

a) HepB
b) HepC
c) HIV

Answer 34

c) HIV - 0.2-0.5%from known HIV seropositive source based on prospective studies
HepC 3-10%, fragile virus, not felt to survive super long; one case of hepC from discarded needle
hepB - 2-40% based on level of viremia

Question 35

Which of the following statements is false?

a) HIV infection from discarded needles is extremely unlikely
b) alpha interferon and ribavarin are effective for post exposure prophylactic of hep C
c) If injury from discarded needle involves fresh blood and some of the blood is injected, infection with HIV is theoretically possible and prophylaxis is indicated
d) In occupational needle stick injuries, prophylaxis with zidovudine reduces risk of transmission from positive source by 80%

Answer 35

b) false, helpful for treatment but not for prophylaxis; need to know if hepC infection happens since 50-60% of children will have a asymptomatic lifelong infection that will need specialist follow up and potentially treatment for chronic hepatitis down the line

the rest are true
unlikely - often dried blood, HIV quite fragile virus (although has been found to survive 42 days in some cases)
prophylaxis with multiple antiretroviral drugs is likely even more effective, 2-3 drugs use is controversial, still trying to figure out the best kind of prophylaxis

Question 36

Which of the following is an appropriate management of needle stick injury acquired by a child in the community?

a) clean the injury, determine the extent of immunization status for tetanus and HBV, document the circumstances of the injury, get baseline HBV, HCV and HIV status, testing needles for viruses, assess for risk of viruses for needle user and test for them if possible
b) clean the injury, determine the extent of immunization status for tetanus and HBV, document the circumstances of the injury, get baseline HBV, HCV and HIV status, start HIV prophylaxis
c) clean the injury, determine the extent of immunization status for tetanus and give vaccine/Ig if needed and HBV, document the circumstances of the injury, get baseline HBV, HCV and HIV status, assess for risk of viruses for needle user and test for them if possible
d) clean the injury, determine the extent of immunization status for tetanus and give vaccine/Ig if needed and HBV, give hepB vaccine and Immunoglobulin document the circumstances of the injury, get baseline HBV, HCV and HIV status, assess for risk of viruses for needle user and test for them if possible

Answer 36

c) is the answer, don’t test the needle for viruses, results likely to be negative, but negative doesn’t rule out infection (rather, if you know the user, test the needle user)

prophylaxis for HIV only if blood is high risk of HIV, contains fresh blood, likely injected

if considering antiretroviral prophylaxis for HIV do CBCdiff, AST/ALT, ALP, BUN/Cr

hep B -

if known to be HBV antibody or HbSAg positive, no action required (since known infection - check)
not fully vaccinated against hepB - test for Ab and Ag ->if not available in 48 hours, then give HepBIg immediately, give vaccine ASAP (within 1 week at the latest)
if anti-hepB-ve and hepBsAg -ve, then complete vaccine series
if anti hep B +ve or hepBsAg +ve then discontinue, if hepBsAg +ve then arrange appropriate follow up (since means that +ve)

if fully vaccinated, test for anti HepBs antibody, if +ve no further action needed (since adequate immunity obtained), if negative, test for hepBsAg, if negative, give hepBIg and hep B vaccine, if hepB Sag +ve then arrange appropriate follow up.
if don’t get results within 48 hours then give a dose of the vaccine (see table)

Question 37

Which of the following is incorrectly paired for hep B serology ?

a) immune due to vaccination -> hepBsAg -ve, anti hepBs antibody, anti hepB core -ve
b) acutely infected ->hepBsAg +ve, anti hepBs antibody -ve, anti hepB core +ve
c) acutely infected -> hepBsAg +ve, anti hepBs antibody +ve, anti hepB core +ve
d) immune due to natural infection ->hepBsAg -ve, anti hepBs antibody +ve, anti hepB core +ve

Answer 37

c) anti hepB surface antibody -ve in acutely infected
this antibody indicates adequate immunity has developed

anti core indicates that natural infection occurred

http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

Question 38

Which of the following is true of antiretroviral treatment for HIV prophylaxis?

a) should be started at any point after the injury
b) for low risk situations lopinavir/ritonavir
c) for high risk zidovidune, lamivudine
d) generally minimal side effects, should monitor for anemia, increased liver enzymes (generally transient)

Answer 38

d) is the answer

the rest false

a) ideally within 1-4 hours, no benefit after 72 hours, if parents not sure, better to start then d/c
b) for low risk -zidovidune, lamivudine; for high risk these plus lopinavir/ritonavir

duration of prophylaxis is 28 days, may interfere with other meds

Question 39

Which of the following is considered high risk for HIV transmission?

a) blood from needle of unknown source squirted onto scratches
b) blood from needle of unknown source squirted into mouth
c) suspected splash of blood onto lips
d) suspected splash of blood into eye

Answer 39

b) is the answer ->considered high risk, also large volume of blood into non intact skin ->high risk

if from known HIV positive, automatically high risk

the type of needle - large lumen needle with visible needle is highest risk
(see table)

for prophylaxis -follow up at 2,4,6 weeks for CBCdiff, AST, ALT, BUN/Cr

4 weeks -second HBV vaccine if only one received or if not antigen or antibody on initial testing
6 weeks ->test for HIV antibody
3 months -> test for HIV antibody and hepC antibody
6 months ->test for HIV antibody, and hepC antibody, and anti hepBsAg, give third dose of hepB vaccine if only 2 previous received
if infection occurs, test the baseline

Question 40

Which of the following is true?

a) 75% of neonatal HSV worldwide is cause by HSV2
b) the use of instrumentation does not affect HSV transmission
c) most HSV presents with a known history of infection in the mother
d) in utero HSV presents similarly to intrapartum tranmission

Answer 40

a) true - 75% worldwide cause by HSV2; in Canada one study in 2003 found 63% of cases caused by HSV1, some studies showed 10 % and 17% caused by HSV2 in Canada

the rest false

b) it does affect it, so does nature of maternal infection, duration of ROM, method of delivery and instrumentation
c) false - even for HSV1, most transmission >75% for newly acquired and asymptomatic infection, intrapartum; can also get HSV from non maternal sources; >75-90 of women with HSV2 don’t know they have the infection - have never had or not noticed external genital lesions
d) false - rare, but presents differently - chorioretinitis, skin lesions, CNS disorders, intrauterine transmission is rare

Question 41

Which of the following mothers has newly acquired non-primary infection?

a) infection of HSV with no antibodies to either type of HSV 1 or 2
b) infection of one HSV type in the presence of antibodies to the other type
c) infection of HSV type in the presence of antibodies to that type

Answer 41

b) is the answer

the others are

a) first episode primary infection
c) recurrent HSV infection

Question 42

Which of the following women is at the greatest risk of transmitting HSV to their baby?

a) term baby with mom with recurrent infection of HSV2
b) term baby with mom with infection of HSV1 with detection of antibodies to HSV2
c) term baby with mom with primary infection of HSV1 with no antibodies to either HSV1 or HSV2
d) 31 week baby born to mom with recurrent infection of HSV2

Answer 42

c) transmission rate though to be 60%, no antibodies to transmit

• primary infection is the highest risk of transmission
• recurrent infection is the lowest, provided that baby born >32 weeks (since antibodies that are type specific will cross the placenta to the baby)

for b) - mom with antibodies to the other type, some cross-reactivity, transmission thought to be 30%
recurrent episode -

Question 43

Which of the following reduces the chance of transmission of HSV?

a) caeserean section
b) acyclovir or valacyclovir prophylaxis from 36 weeks gestation
c) fetal scalp electrodes
d) vacuum assisted deliveries
e) prolonged rupture of membranes

Answer 43

a) reduces the risk but doesn’t eliminate it

the rest don’t
b) reduces viral shedding and recurrent genital HSV but unsure if it translates to a reduced risk for HSV infection
c and d) procedures that can cause scalp abrasions or breaks in the infants skin during labour increase the risk of transmission
PROM also increases the risk of transmission

Question 44

Which of the following is false?

a) most HSV cases present within the first four weeks of life
b) liver and lung involvement is common with disseminated HSV infection
c) many babies with disseminated HSV don’t have skin lesions
d) a normal CSF examination excludes a diagnosis of CNS HSV

Answer 44

d) is the answer - false - a normal initial CSF examination does not exclude a diagnosis of CNS HSV. think of HSV with fever, irritability, abnormal CSF, seizures

a) true - most present within 4 weeks, can present until 6 weeks, so anyone with symptoms until day 42 should be evaluated for it. Intrauterine transmission presents at birth.
b) true - lung and liver involved in disseminated HSV
c) true - many don’t have skin lesions. one study showed that 39% with disseminated diesease, 32% with CNS disease and 17% with SEM disease did not have skin lesions at any time, another sutyd 75% presented with fever alone. non specific more likely when

Question 45

Which of the following is false?

a) disseminated HSV is the most lethal
b) disseminated HSV leads to the most neurological complications
c) treatment with acyclovir significantly reduces the mortality rates of HSV infection
d) long term neurological sequelae have been reported in babies with SEM disease (with no CNS involvement

Answer 45

b) false - CNS disease 70% have complications, disseminated disease is 25%

the rest true a) true - before anti virals, 85% with disseminated and 50% with CNS disease died, disseminated disease more common with newly acquired HSV since no antibodies yet.

c) true acyclovir (60 mg/kg/day)reduced the mortality rates to 29% and 15% respectively. canadian study reported 15% mortality
d) true BUT more recent studies show that no neuro sequelae in SEM disease alone, likely these infants had unrecognized neurological sequelae

Question 46

Which of the following is not an appropriate way to test for HSV?

a) blood PCR
b) viral culture of eye swabs
c) direct immunofluorescence of skin lesions
d) direct immunofluorescence of oropharyngeal swab

Answer 46

d) can only use direct immunofluorescence only for skin lesions (not from mucous membrane or oropharyngeal swab, these aren’t reliable)

the rest are appropriate
a) viral cultures from oropharynx, nasopharynx, skin lesions, mucous membranes (eye and mouth) swab, rectal swabs, blood buffy coat and CSF
b) PCR testing of CSF, mucous membranes and blood
enzyme immunoassays for HSV in skin lesions

Question 47

Which of the following is false?

a) HSV isolation by culture is the definitive way to diagnose non CSF HSV disease
b) It is not necessary to do CSF HSV DNA PCR if there are normal cell counts and biochemical features in the CSF
c) HSV DNA PCR is the most sensitive test for diagnosis of CNS HSV infection
d) the use of HSV DNA PCR for viremia measurement is less well established than HSV CNS DNA PCR

Answer 47

b) false - can be normal, especially in early stages of infection so should still do the test

the rest are true

a) some centres offer only PCR since believed to be more sensitive, detection of virus in superficial cultures may represent skin contamination during birth if samples obtained in first 24 hours, when positive >24 hours after birth likely represent active infection
d) higher loads in patients who succumbed, disseminated had higher loads in blood, CNS had higher loads in CNS

also, infant serology is not useful
- may have mother’s antibodies
- transplacental antibodies can’t be differentiated from those made by the infant
some babies who are severely affected may not make antibodies
-assays for HSV IgM antibodies which are commercially available have limited reliability

Question 48

Which of the following is an adequate course of treatment for SEM HSV disease with eye involvement?

a) 14 days of IV acyclovir at 60 mg/kg/day with 1% trifluridine drops
b) 21 days of IV acyclovir at 60 mg/kg/day with 1% trifluridine drops
c) 14 days of IV acyclovir at 60 mg/kg/day, followed by 7 days of PO acyclovir at 60 mg/kg/day
d) 21 days of IV acyclovir at 60 mg/kg/day the suppressive therapy with PO acyclovir

Answer 48

a) need to have the 1% trifluridine drops if there is eye involvement

14 days for SEM disease, 21 days for CNS disease or disseminated disease

oral ACV has limited bioavailability

higher doses associated with neutropenia, need adequate hydration to prevent nephrotoxicity

since high prevalence of neurological sequelae, need long term follow up with neurodevelopment, hearing and ophthalmological assessments

suppressive therapy - for CNS disease (including disseminated with CNS involvement), improves neurodevelopment outcomes, not as clear evidence for disseminated or SEM disease but might still offer, dose is 300 mg/m2 divided tid x 6 monhts

optho consult

Question 49

Which of the following is the appropriate management for a healthy 12 hour old infant born by C section to a mother with first episode primary infection before rupture of membranes?

a) immediate swabs of mucous membranes and nasopharyngeal swabs for HSV then discharge home pending results with counselling regarding signs of HSV
b) obtain swabs of mucous membranes and nasopharyngeal swabs for HSV at 24 hours then discharge home pending results with counselling regarding signs of HSV
c) immediate complete septic work up including CNS DNA PCR and blood PCR, as well as liver function tests and initiation of acyclovir treatment pending results
d) HSV IgM serologies for the baby at 24 hours, as well as swabs of mucous membranes and nasopharyngeal swabs then discharge home pending results with counselling regarding signs of HSV

Answer 49

b) Risk is very low when you have either primary or non primary with C/S before ROM

is the right answer - do the swabs at least 24 hours, if you do it earlier can be false contamination, if child is well can d/c home pending results. low risk of transmission with this set up.
–some experts recommend doing blood PCR and CNS PCR and studies as well **
acyclovir treatment only if positive for HSV

doing complete work up including CNS DNA
testing for mom with lesions helps establish the type of infection and should be done if possible, antibodies typically take 3 weeks to develop following infection

if mom has lesions but no type specific antibodies then assume primary infection, if antibodies to both types then assume recurrent infection

same management for 1st episode primary or non primary

serology not a helpful test for HSV

Question 50

Which of the following is the appropriate management for a healthy baby born vaginally to a mom with first episode primary or non primary HSV?

a) obtain HSV IgM serologies as well as swabs of mucous membranes and nasopharyngeal swabs then d/c home pending results with counselling
b) obtain mucous membrane and nasopharyngeal swabs for HSV PCR and discharge home pending results with counselling
c) obtain mucous membrane and nasopharyngeal swabs for HSV PCR and start acyclovir in hospital and stop if swabs are negative
d) obtain mucous membrane and nasopharyngeal swabs for HSV PCR and start acyclovir in hospital and continue for at least 10 days (even if swabs are negative)

Answer 50

d) is the answer
same for vaginal or C/S with ROM
this is the highest risk of transmission (primary episode, and contact with fluids) so stay in hospital with treatment
controversy whether swabs need to be > 24 hours, some people also recommend blood PCR +/- CNS PCR right off the bat
if blood or mucous membranes are positive then need to do CNS PCR before stopping acyclovir

if mom testing shows that recurrent disease, can stop acyclovir
if mom testing shows primary/non primary or non available , then treat for 10 days even if infant swabs are negative

Question 51

Which of the following is the correct approach for a healthy 16 hour old baby born to a mother with recurrent HSV and active genital lesions by vaginal delivery?

a) immediate swabs of mucous membranes and nasopharyngeal swabs for HSV then discharge home pending results with counselling regarding signs of HSV
b) immediate complete septic work up including CNS DNA PCR and blood PCR, as well as liver function tests and initiation of acyclovir treatment pending results
c) obtain mucous membrane swabs at 24 hours and discharge pending results with counselling about signs of HSV
d) HSV IgM serologies for the baby at 24 hours, as well as swabs of mucous membranes and nasopharyngeal swabs then discharge home pending results with counselling regarding signs of HSV

Answer 51

c) is the answer, some people also advocate for blood PCR

low risk of transmission with recurrent HSV

recurrent HSV with C/S is same management as primary/non primary with C/S (no ROM)

**mom’s with history of HSV but not active lesions (including women on prophylaxis) -> no need for swabs, just observe for symptoms
if HSV was in third trimester then consider mucous membrane swabs

Question 52

Which of the following is false?

a) For CNS HSV, treatment should be stopped after 21 days of IV acyclovir
b) HSV should be considered for pneumonia that is not responding to treatment after 24 hours
c) HSV should be considered for children with unexplained coagulopathy or bleeding during venipuncture
d) suppressive therapy is needed for CNS disease, and should monitor CBC, BUN and Cr while on suppressive therapy

Answer 52

a) false

for CNS HSV, should sample the PCR towards the end of the 21 day course , if still positive should continue treatment with weekly CSF sampling until negative, then stop acyclovir

neutropenia and nephrotoxicity are the biggest risks

Question 53

Which of the following is not the appropriate precaution for the exposure at hand?

a) neonates with HSV infection ->contact precautions until lesions crusted over
b) asymptomatic neonates of mother with HSV ->contact precautions for 2 weeks or until swabs at 24 hours are negative
c) staff with skin lesions should keep their lesions covered when caring for neonates, if they have active herpetic whitlow should avoid caring for neonates
d) mother with oral HSV - no breastfeeding and wear a mask until lesions have crusted over (or until> 6 weeks of age)

Answer 53

d) false - can breastfeed as long as no herpes on the booby. mother with herpes should be on contact precautions in hospital until lesions have crusted

the rest are okay
2 weeks precautions because that is the incubation period
some people don’t think you need to do contact precautions if C section with rom

Question 54

side effects of zamivudine and lamivudine (3TC)

Answer 54

anemia
neutropenia
elevated LFTs

Question 55

side effects of lopinavir/ritonavir

Answer 55

n/v abdo discomfort