Good afternoon, I appreciate your fortitude and hopefully your time won't be wasted here. This is a presentation that actually is a comprehensive review of the current management of most clinically significant workplace biohazards in the biomedical research industry and healthcare industry. These are protocols that have been developed over the past 50 years and I'm going to be talking about current management of exposures, not just to bloodborne pathogens, but to some of the diseases that are very common in biomedical research, like simian B virus, some of the chimeric vaccine viruses, and obviously tuberculosis and emerging diseases. To introduce myself a little bit, I'm Michael Soury, I started off as a general preventive medicine resident in the Air Force, was an EIS officer, taught the general preventive medicine residency program, taught the global medicine course, and then left the Air Force and went into the Army. And there I did internal medicine and then a fellowship in infectious disease. I left the military, I didn't do 20, but I left the military to do ID, but at the time where I settled, which was in the Washington metropolitan area, the biomedical industry was starting to explode and they were being hard pressed to find occupational medicine physicians who would take care of their occupationally related HIV exposures and things like that. So I grandfathered into occupational medicine, and now occupational medicine is like the tail wagging a dog, it's probably 85% of what I do. The reason actually for this lecture was because I've been the preceptor for over 100 occupational environmental medicine residents at Johns Hopkins and at USIS, and they were asking me to talk about this topic because they were running across it very often. It was becoming almost a requirement for the job that they knew something about how to deal with these exposures, and it's unfortunately not been a, it's been a weakness of many OEM training programs to not really talk about it. So this is why I'm here, and hopefully you get something out of it. So before I go any further, I just want to talk about definitions, because the definition, the words are used wrong in many articles, studies, even in daily use. So prophylaxis is a defense or protection, treatment is actually medical care given to treat an illness or an injury that already exists. And supportive and palliative care is just focusing on relieving symptoms of a disease that has already taken one. So I think that where I started off back in the early 80s after seeing my first AIDS patient in 1981 and 900 later, I can tell you that to me post-exposure prophylaxis meant putting silver nitrate into the eye of a baby so they didn't get gonococcal neonatorum, or giving minocycline or rifampin for meningococcal exposures, or chloroquine or Phancidar for exposure in malarious areas, or Pepto-Bismol for Tourista's disease to prevent that. So to me that was the scope of post-exposure prophylaxis. And with the AIDS epidemic, with the development of hepatitis B vaccines, all of this sort of started to change with our focus on blood-borne pathogens. In addition to talk about definitions, I want to talk about, go over again, the various types of prevention. Because you have to understand that prophylaxis is used in all of those levels of prevention. So quaternary prevention is something I'll talk about later, but it's not really exclusive to the others. And I think that it is something that we deal with now. Anytime you get a request for a pre-authorization, you're dealing with quaternary prevention. Primary prevention, intervening before health effects occur, either through altering risky behavior, chlorinating the water in water cooling towers to prevent Legionella, banning substances that we know are harmful, certain pesticides, promoting heat and altitude acclimation primarily in our military. Vaccinations obviously is the first thing I think of in primary prevention. But PrEP is also in there. And prophylaxis to the various diseases and conditions that travelers are exposed to. So we do a lot of primary prevention in our day-to-day activities. Secondary prevention, obviously we're dealing with screening to identify disease that is already present and in the early stages in order to prevent the development of illness. And periodic mammograms, regular blood tests, blood pressure testing, using probiotics before you use antibiotics, especially in an inpatient setting, HIV, post-exposure prophylaxis, COVID, post-exposure prophylaxis. These are all sort of examples of secondary prevention. Tertiary is managing disease post-diagnosis to slow and stop a disease progression. These obviously are chemotherapy, rehabilitation, use of certain therapies. And also screening protocols that we have for hepatitis C, for prion disease in order to catch it early. There's obviously in some situations there's only supportive care that we can give. So for a variety of emerging diseases, all we can do is put them in a room and support them and hope that they'll recover. Quaternary prevention, that's more the focus to prevent medical intervention that is likely to cause more harm than good. To me, JAMA came out with a statement just in February 29th that said that the last days of people facing terminal diagnoses in the United States are all too often filled with aggressive and ultimately unhelpful medical care. And so offering alternatives or offering palliative therapy is an example of quaternary prevention. Okay. So we certainly deal with that. We see the overuse of certain medical procedures. But in our focus on evidence-based medicine and clinical practice is really based on quaternary prevention. So I just give a few examples of that. These examples are really pulled from my clinical experience in dealing with this as an infectious disease physician and internist and also in OCMED. So as I mentioned, quaternary prevention isn't exclusive to these others. We should view it not necessarily as a separate prevention but part of the others. So again, talking about primary preventions, giving you examples of what primary prevention is and isn't is important. So to me, primary preventions, as I mentioned, are vaccines or SBE prophylaxis before dental procedures, PrEP for discordant couples so that the HIV victim doesn't infect the HIV partner, Zyfaxan for Teresa's disease, giving Diflucan to prevent esophageal candidiasis in immunosuppressed chemotherapeutic or patients who receive chemotherapy. And then there's all kinds of therapies that we already have been seeing in the past three years for COVID. They're termed primary prevention. These are usually used in our immunosuppressed high-risk patients. Secondary prevention, attempting to block again the injury. To me, you can categorize a lot of these particular medications and treatments that we give to HIV patients, the nukes, the non-nukes, the protease inhibitors, the integrase strand transfer inhibitors. These are all examples of trying to block and reduce injury in people who already are infected. And obviously, we've gone through an alphabet list of various antivirals and monoclonals. And we seem to just mainly shift to a different monoclonal that will be able to effectively treat that particular variant that's circulating like Omicron. Tertiary prevention, to me, this is essentially doing the best we can for a condition that can't be cured and certainly trying to reduce the amount of severe disease in people. And to me, there are some conditions here that are simply supportive. We have nothing to really offer severely infected individuals with various diseases, a lot of them being the emerging diseases that we read about or see. Ordinary prevention can be anything from just managing gestational diabetes or intensive glycemic control in high-risk diabetics with a lot of comorbidity or evaluating the extended use of hormonal replacement therapy in those that are at risk for breast cancer or DVTs. So I wanted to kind of give you examples of what I view are primary, secondary, tertiary, quaternary. Now infection control uses all of these. And oftentimes, having been chief of infection control for 20 years at a local community hospital in Washington, D.C., I can tell you that this could be a whole separate lecture. But we have our problems are in many ways similar to travelers, people who have travel clinics because we got pregnant health care workers. We have immunosuppressed health care workers. And then we have our emergency response employees that have perhaps less protection and more exposure and outbreaks. So these use the hierarchy of control. They do everything that we do in occupational medicine. So blood-borne pathogens is something that we all are aware of. When OSHA came out with their exposure plan in the early 90s, we all started to realize that there were precautions that were helpful in preventing exposure. We engineered various blunted needles and devices to reduce the exposure to sharps, double-gloving, all these types of practices. And I think that in many ways, those have significantly reduced exposure to these blood-borne pathogens. We give standard immunizations. You could consider this pre-exposure prophylaxis. And obviously, these are the standard ones that we deal with in childhood and in health care facilities. Though we tend to not rely on histories of these vaccinations but rather titers, nevertheless, the focus is on these vaccine-preventable diseases. There are special-use vaccines in biomedical industry that we use. We do have, at least in my clinic, I give smallpox, I give anthrax, I give tularemia because the workers are dealing with these particular agents. And frankly, it isn't going to play well in a court of law when a company has to defend why they didn't offer a vaccine-preventable disease to their employee who got sick. So there's certainly no, very little resistance in the companies to offer these. However, it's usually voluntary. And I would highly suggest that you document any declinations. We have certain agents that are very suitable for post-exposure prophylaxis. So we're dealing with PrEP, so HIV. SIV is simian immunodeficiency virus, and SHIVA is simian human immunodeficiency virus. These are chimeric viruses that are used in research with non-human primates. You're all familiar with the use of Tamiflu and other agents for influenza, monoclonals for COVID. We have certain agents that have been shown to be effective for Marburg and Ebola. And obviously we do a lot of, as I mentioned, the pre-exposure vaccination, not just routine but also if they're actually working with dengue or yellow fever and plague and things like that. There are certain agents that are effective for bacterial, to prevent bacterial infections. And these are the ones that we think about. So for like ehrlichiosis, we would give doxycycline. If you go down the various agents, fungal, rickettsial, spirochetal, mycobacterial, there are agents that we use, and these are to prevent the infection. There are also non-infectious examples like using Rho immune globulin for immune thrombocytopenia purpura. Viral diseases, these are ones that now we're talking about agents that aren't very helpful or suitable for post-exposure prophylaxis. We don't have any treatment to date for hepatitis C, and there are a variety of viral diseases that have no vaccines. But more importantly, they don't have any heralding sign that allows us to consider giving anything to them because by the time they present to us in the clinic, they have already have a well-established disease. So it's past the point of doing any prevention. Certain vector-borne diseases like Zika, encephalitis, the hemorrhagic fevers because of their epidemiology and their mode of transmission and incubation periods also don't allow us to really catch it in the early phases. Spirochetal diseases like relapsing fever and syphilis are very subclinical, and so by the time they present, we've lost that window of opportunity to prevent it. There are certain bacterial diseases that aren't very helpful, obviously the enteric pathogens when people are traveling overseas. Even though radiating meat has been found to be protective for E. coli 0157 against hemolytic uremic syndrome, very few people are using it. There are some, and then Legionella and Q fever and these other agents usually are ones that have already presented themselves, and there's no way that we can predict the population at risk clearly enough to protect them either with antibiotics or vaccines. And then there's nosocomial infections that just tend to occur despite our best efforts at antibiotic stewardship and isolation. And the mycobacterial and rickettsial diseases, fungal diseases, these are examples of those that are not suitable for post-exposure prophylaxis. There are some novel agents that have no known antidotes, prions, nanoparticles. When you, nanoparticles, if you take something and make it a nanoparticle like silver, it becomes antibacterial or it develops a biological activity. The problem is that nanoparticles are so small that they will go right through an N95 respirator which is tested to be good to 0.3 microns. And then emerging diseases that by their nature tend to just always catch us by surprise. So we'll talk about PrEP for viral diseases. We can view these vaccine-preventable diseases in that same format, giving influenza to our immunosuppressed patients or giving monoclonals ahead of time to our immunosuppressed individuals who are high-risk for COVID. The vaccine-preventable diseases, obviously, as we discussed, are all examples of that. Other examples, giving Bactrim to an AIDS patient with a CD4 count less than 200, or obviously giving malaria prophylaxis, especially to those that are non-immune, the typical traveler coming from a developed country. Mycobacterial, BCG, is a phenomenal drug. That was just a talk on latent TB, but BCG is a phenomenal vaccine that has saved millions and millions of children. It prevents them from getting the TB meningitis that usually kills them. It does not prevent them from getting the infection, and eventually they may reactivate their latent disease, but at least they didn't die below the age of three. Immune-and-fungal diseases, we deal with that all the time, especially in our cancer and immunosuppressed patients. We see it a lot in hospitals where they're having active construction. On the other side of that ceiling tile is aspergillus, and that's the reason why they cordon off with plastic any time they're running wires through a hospital because they're just raining down aspergillus, and that becomes a problem, especially in our cancer wards. So the non-infectious examples of PrEP would be doing some type of acclimation for heat, as they did in Vietnam, or altitude sickness with Diamox or transderm patches, or in the military giving amphetamines, copolymine capsules to the young trainees so that they can at least get through their initial air sickness. So when people think of PrEP, though, they are really thinking of what CDC has been promoting for the past five years, and that is a method to reduce the spread of HIV in the population. We did that a long time ago back in the mid-'80s with AZT when it came out with discordant couples, and we found that it was effective, and Geberding in San Francisco showed that she could actually prevent the infection from a needle stick in healthcare workers by just giving AZT, and she did a study of about 2,400 that actually started the process of giving post-exposure prophylaxis. So generally, what's different a little bit about HIV PrEP and occupational HIV post-exposure prophylaxis is the timing. Generally for PrEP, you can have a window of 72 hours. With occupational HIV exposure, originally back in the 90s, CDC said it had to be within two hours. Well, frankly, there is no way, even in an emergency room, that you'll get anything done in two hours. Even if you order it, it's going to take a while to get from the pharmacy. Our best performance of it, where I'm at, where we do give a lot of HIV exposure prophylaxis is four hours, and we do that by actually having the medication in the clinic to give them their first dose or to keep it in a lockbox in their research facility because their exposures can occur at any time, and if these facilities are 24-7, then the exposure could occur on the weekend or in the evening. We also will give certain kits to people, to groups that are doing field studies in remote areas of Africa or Indonesia in case they have exposures. So this is how we sort of deal with HIV, to get it within that four-hour window. A 72-hour window is kind of hard for me to expect that it's going to be effective, but at the same time, it's realistic for how things happen. You go to Las Vegas, but you don't know if it was Friday night, Saturday night, or Sunday when you got maybe the exposure, and you come back a little remorseful on Monday and want prophylaxis, you're within a 72-hour window. I also can tell you that even if they're after 72 hours, I'll still give them prophylaxis. But I will tell them that it may not be as effective, and so I think being honest with them. I've had situations where I've begged a person to take prophylaxis because the exposure was so severe, and they wouldn't take it. And then I've had other situations where there was no exposure. There wasn't even a hole in the glove or whatever, and they were freaking out. And I give them prophylaxis. And so I think we're physicians, we treat the patient. But the reality is that these medications, there's a lot of animal studies that have shown that if you give it early enough, it's effective. Later on, the effectiveness is reduced. The other problem is the disparity of both PrEP and HIV post-exposure prophylaxis in our populations. And we saw that also with monkeypox, those that were getting vaccinated weren't exactly the populations that were at highest risk. So there's always those types of issues. There was a significant funding earmarked by the Biden administration March of last year to try, over a 10-year period, to use to push PrEP in order to reduce the prevalence of HIV in the U.S. So what is the regimen? It's the same regimen that we use for HIV occupational exposures. It's using Truvada and as a single drug, Descovy is essentially an equivalent drug to Truvada. Doses are a little bit different. There's some issues with some side effects that occur, especially with people that have reduced renal function. But nevertheless, it seems to be well tolerated and has made a major difference. I will say that in the occupational side of the house that you're going to be dealing with, it's nice to know exactly the time that the exposure occurred because then you can sort of feel like you're ahead of the power curve with respect to introducing to them some prophylaxis. Back between 1985 and 2013, there were 58 confirmed cases and 150 possible cases of occupationally acquired HIV infection. Since 1999, there's only been one infection and currently, the U.S. Public Health Service does not consider HIV to be an occupational risk factor for healthcare workers. We're that good at taking care of usually occupational exposures. So obviously, not all exposures are the same. There's some that are more higher risk, the percutaneous injuries. There's certain fluids, especially if they're blood contaminated, that are high risk. But at the same time, there are some fluid exposures that are very low risk and don't really necessitate the need for prophylaxis. I usually start off with what I learned in epidemiology. First verify there's an epidemic before you spend all that money and take all those people over there. It may be better reporting or, you know, all the other biases. So usually, I'll ask if they could fill up the glove and see if it's leaking or try to get a better idea of the host or the source of this exposure. And sometimes, you realize that there really wasn't a concern. At the present time, there's been some changes from early on where they, based on the severity of the test, they would say, hey, you need to take two drugs or three drugs. Now they're essentially saying it doesn't matter how severe the exposure was, the three-drug regimen is sufficient. But it needs to include some dual nuke and an integrase transfer inhibitor. There's other combinations that you can use. As I mentioned, the regimen for occupational HIV exposure is the same in many respects to what we deal with in other exposures. As I mentioned, it's important to try to give it within four hours. And there is some animal in vitro and occupational studies that support that. But frankly, if you miss the window, I would give it anyway. But just be forthcoming and telling them that it's not likely to be as effective. There are some regimens that I have used in the past. And these are mainly because our HIV population is very experienced. And by that, I mean they've gone through several different regimens already. And they're already resistant to the first-line regimens. And so my advice is that if you know that there was a source who was HIV positive, call the primary physician or the treating physician and ask them two questions. One, do they have a detectable viral load? And two, what is the regimen that they're currently taking? Because if they have no detectable viral load, that's the regimen you want to use on this exposure. If they're failing their therapy, you don't want to use any of those in that regimen. So this is very important to sort of assess. Now, it's not necessarily as simple as just giving them Truvada and Encentris all the time. I'd say 95% of the time, that's all you need to do. Just give Truvada and Encentris or Raltigravir, and your work is done. I will say on this particular slide, there are some that you shouldn't probably use without an ID consult. And there are just some that nobody uses because risk to the fetus or certain serious allergic reactions. But nevertheless, if there's ever a question, let me go to that slide, call that number. That's your get out of jail number. Because if you call that number, what you're going to do is you're going to wake up a very tired infectious disease fellow at San Francisco General Hospital. And you're going to present the case to him, and he's going or she's going to tell you what they would do. Right or wrong, at least it's cover, okay, because you at least did your due diligence in an unusual case and asked them what do you do. And I've had situations where there was multi-drug resistant HIV. So in those situations, you call this number, the National Clinician Consultative Center. You can call them about non-occupational exposures too. But just call that number, and they'll be a great help to you. They also have a little quick guide that has some frequently asked questions. Let me just go back a little bit. The other one is Hepatitis B, which was a nemesis for us back in the 70s. Healthcare workers, dental hygienists, dialysis nurses, they had rates of around 75% if they were working with human blood. So and at that time, we didn't have any vaccine. Hepatovax came out around 83. It was human derived. Two years later, Rekamavax came out, and that's what we've been using pretty much ever since. But it changed the face of the whole disease and the epidemiology of it. OSHA essentially promoted it with their exposure plan and pretty much codified its use. It's I think one of the things that was a plus in the AIDS epidemic. This is the one, you can pull this slide, this table out of the MMWR, but this one is pretty much what I ask most of the residents to try to memorize or understand. And it's really dealing with both vaccinated, unvaccinated, vaccinated, and those that you just don't know if they've been vaccinated. The key is in the individuals who are non-responders, which are about 6% of the population that received an initial series of Hepatitis B and the unvaccinated, you need to give Hyper-B immunoglobulin within 24 hours. Unfortunately, in my practice, my big nemesis is Hepatitis C, because I've got nothing to offer anybody who has a Hepatitis C exposure. I can tell them that we'll draw your blood now, we'll draw it in 3 months, 6 months, if you turn positive we'll get you to a GI doctor who will be able to cure you, but you'll have to pay out $120,000 for the medication. It's a 12 week regimen, but it does cure you of Hepatitis C. What we want, and what we've been wanting for 40 years, is a vaccine, and we have not been able to develop a vaccine. There is currently a trial at NIH using some of these very expensive drugs for 14 days to try to see if that will be helpful. But at the present time, it's not FDA approved. So, in many cases, Hepatitis B, Hepatitis C, it used to be that you pulled a person out of their work, they couldn't do surgery, they couldn't take care of patients. At this point in time, they're not making those restrictions, they're just saying don't donate any of your tissue to anybody. They're not even asking them to modify sexual practices. And I think that this is based on a lot of epidemiological studies. As I mentioned, the pipeline, I throw this in because, to me, I live by checklists. This isn't like giving penicillin for a strep infection and, you know, it's over. You have to follow these people, you have to explain to them about the side effects of these medications and their limitations, and you're following them out for up to six months. And they can get lost to follow-up, they may not keep their appointment, and if they fall through the cracks and something bad happens, they're going to come back to you and say, why didn't you call them, why didn't you follow up on that? So, to me, I make sure my staff does checklists, I make sure that they pass on this information and that it actually is checked off, that they talk to them about all of these aspects of what exposure meant, what does the treatment mean, what are the side effects. There was some talk about laboratory workers, laboratory animal workers, and there's a whole lot of problems that they present and they're usually my headaches in the clinic because they have all kinds of conditions that may prevent them from receiving vaccines that they need to receive. They obviously have the standard repetitive injuries, allergies is a big problem, and we still have to make sure that they're in compliance with OSHA respiratory and hearing protection programs. Those that are working with select agents also have to undergo a biosurety program, that is since 9-11 handled by CDC, it's called personal reliability or suitability program, that's a headache too. So, animal lab workers have a lot of things that you need to do surveillance on. We do a lot of serological testing on them, we don't do serobanking, we try to discourage it as much as possible. It is still used in some settings like where they harvest valves, pig valves and stuff like that, they still require serobanking of their personnel, but we live with titers and the titers differ for rabies. Usually it's good for two years if you're a vet, but if you're working with the agent itself, the rabies virus, it's good only for six months, you got to retiter them. If you give smallpox, it's good for 10 years if you're working with vaccinia. If you're working with monkeypox, it's only good for three years. If you're working with variola, which is only in a few labs in the world, you got to do it every year. So, there are standards and requirements. There was a talk about tuberculosis, I will say that I like their talk about tuberculosis. One thing they left out was that was the only situation where OSHA had to actually rescind one of their acts and that occurred in 95. They had a plan of how they were going to eliminate TB and then there was this epiphany that they had where they realized that they couldn't. This act would not reduce TB. Why? Because most TB results from reactivation of latent TB and because of that they rescinded it, they went on to essentially do a one-page questionnaire, which to me is kind of a waste of time because most of the people from hyper endemic areas of TB coming in to to work and these companies realize that if they check yes to any of those things on that questionnaire that they're gonna have to see me or get an x-ray, but more importantly they have in their mind that they may lose their job. So it's garbage in garbage out in my opinion. It's it's not getting less common and it's more of a problem now because of the latent TB that we have because of all of the immunosuppression that we're doing. Our targeted biologics are require us to do testing for TB and to treat people who've had for TB prior to their receiving it. The even in the AIDS epidemic we were able to show that if an age in prison systems if somebody got a TB within a matter of six weeks it has already spread through the entire prison system and you started you were starting to see active cases. So immunosuppression is a major problem. Animal caretakers the lifeblood of a most non-human primate facilities is their macaques is their monkeys very susceptible to TB. They're going to put their workers at a higher standard than OSHA then CDC requires. They're going to require them to take medicine even if they're over 35 even if they have a negative chest x-ray and because they don't want to lose their lifeblood which is their animal colonies and they apply it across the board. So there's no exceptions to the rule. So this this is how they try to deal with this sort of growing problem. And when you think about it a lot of the low-level work that is done cage washing animal caretaking is usually entry jobs for a lot of immigrants in the U.S. It's a great job. They actually go up through a progression and become vet techs and degreed and it's a great life, but initially they may actually be at risk of activating. The risk of a positive TB skin test or even if you use a t-spot or any other test is really dependent upon the host and their exposure. So typical exposure to a typical likelihood of reactivating for someone who is positive, but the negative chest x-ray is about 0.1 per year. If you if they're a recent converter, that means within two years they went from negative to positive, they're jumping considerably and that is an indication from CDC to treat those converters. If they've had a household contact, it's almost equivalent to being a converter. And an abnormal chest x-ray with a positive PPD has sort of an intermediate risk. And HIV, anyone who's HIV positive, even if they have a CD4 count of over a thousand, should be treated. There are standard therapies, which was discussed in the last meeting here this afternoon. And a lot of people like to do the short course therapies, the accelerated latent therapies, but they really didn't find that there was much difference in efficacy. Compliance may be an issue, but I can tell you that the major stumbling block in accelerated regimens is not side effects, it's actually cost. And so I've had institutions that actually their whole job is to study TB. They don't want me to use any type of other tests than a PPD because it's so much cheaper. And they don't want me to give any other type of prophylaxis except INH because it's so much cheaper. So just keep that in mind that if you have a magnitude of scales difference like in a large university institution like University of Pennsylvania or the government of some federal agency, you can buy whatever you want. You can but you can get all the quantifier on gold you want, but in outside it really runs around 350 to 450 a pop. Not $50 a pop like you see in Johns Hopkins. So it makes a difference when in the private sector what they are willing to pay. So PPDs are are used all the time. All right. So just examples of the common vaccinations that we give to animal caretakers and talking about three more things real quickly. Simian B virus, that is essentially the equivalent of herpes in humans. Fever blisters, but when a human gets simian virus infection it's a rabies encephalitis picture. Now the only difference between these people who have rabies and those who have B virus encephalitis is that you can actually treat and prevent, prophylaxis them against getting the B viral encephalitis. There's no vaccine for it. And so the treatment is high dose Valtrex for 14 days. So and this applies to the adventure traveler who shouldn't have been petting that monkey in Indonesia because that's a macaque because this is a disease of macaques. All right. So it's usually bites, scratches, spitting into the eye or to some mucous membrane. So we see this. I probably see it once every two weeks. Some type of exposure like this from primate facilities. There's a Dr. Hilliard at Georgia State who is the guru, who is the expert on B virus, and she has seen a phenomenal number of deaths. The latest one sadly was at CDC, a veterinarian who didn't report that she had exposure to the eye and she died within a matter of a week or so and they couldn't save her. And they couldn't save her. So we also have simian immunodeficiency virus. That's the second of the three that I'm going to talk about. This particular virus is we've known about it since the early 90s and I've had to treat people who have been exposed to it. We're not sure that it can't cause AIDS in humans. It hasn't to date. But we still, because we don't have a large number to go with, we'll treat them just like an HIV exposure. HIV is used actually in research. What they'll do is they'll gut it out, take a bunch of the genome out, put something else into it, see if they can get an immune response. Those, when they do that, it's called lentivirus. So these are lentivirus research, but there's levels of lentiviral attenuation. So the more I gut out the genome of the HIV, I move from first-generation, second-generation, third-generation lentiviruses. The first generation are considered non-highly attenuated, very similar to what we see with vaccinia. Vaccinia also has three levels of attenuation depending on how much you gut out. It's the first one, the first generation that is considered non- highly attenuated. We'll give those people vaccinia if they're working with it. For lentivirus, if they're exposed to first-generation, we'll give, we'll treat them just like they had an HIV infection. So that is my world. That's what I deal with. You're going to probably deal with this at your level. I wanted you to have the full scope as far as I'm concerned of post-exposure prophylaxis. What follows here is all the references that you would ever need, and all I can say is don't forget that 800 number, okay, when you have an exposure. Any questions? No questions? I want to just eat. Okay, I can't blame you. All right. Well, thank you very much for your time. And again, I'll be here at the podium for a little bit. Yeah, there's a handout and the slides are available for you to use. They should be part of the, because I loaded them up, and they actually asked for the handouts. So you should have handouts. I'll check with, yeah, but it, but there's, it should be in the major thing. There should be a link to get the handout, as well as the the PowerPoint. Okay. All right. No, I want you to have this information. Yes, sir. Like foamy virus. Yeah, simian foamy virus. Yeah. The, there was a study that actually came out, I think it was 12 years ago, where CDC actually asked workers who had serum bank their sera to give them their sera, so they could actually, who, and they had been working with primates, and they found that there was a handful of people that actually sera converted to simian foamy virus and these other retroviruses. And then they actually did another study on the spouse, to see if the spouse converted. None of them converted. And all of the people that converted, those few six or so, never developed any disease. So they, it has a very, we don't prophylaxis them for that, but we don't know what to, how to necessarily identify it, because those tests are limited to CDC. Yeah. Well, I mean, if you're going to call it shiva or SIV, I would just treat it like an HIV infection. Is it, it may be overkill. It's certainly a thousand bucks for both bottles, taking 28 days, but if you don't know, it's probably worth it. Oh, yes. Right, I talked with Charles Yomberg, who left a while back, I believe. And then, I was trying to think, there were some others that, yeah, I, I've worked with them, even before they were, when many of them were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they were, when they 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