Delirium in HIV-infected patients admitted to acute medical wards post universal access to antiretrovirals in South Africa.

BACKGROUND: Delirium is associated with increased mortality and length of hospital stay. Limited data are available from HIV-infected acute hospital admissions in developing countries. We conducted a prospective study of delirium among acute medical admissions in South Africa (SA), a developing country with universal antiretroviral therapy (ART) access and high burdens of tuberculosis (TB) and non-communicable disease. OBJECTIVES: To identify the prevalence of, risk factors for and outcomes of delirium in HIV-infected individuals in acute general medical admissions. METHODS: Three cohorts of adult acute medical admissions to Groote Schuur and Victoria Wynberg hospitals, Cape Town, SA, were evaluated for prevalent delirium within 24 hours of admission. Reference delirium testing was performed by either consultant physicians or neuropsychologists, using the Confusion Assessment Method. RESULTS: The study included 1 182 acute medical admissions, with 318 (26.9%) HIV-infected. The median (interquartile range) age and CD4 count were 35 (30 - 43) years and 132 (61 - 256) cells/µL, respectively, with 140/318 (44.0%) using ART on admission. The prevalence of delirium was 17.6% (95% confidence interval (CI) 13.7 - 22.1) among HIV-infected patients, and delirium was associated with increased inpatient mortality. In multivariable logistic regression analysis, factors associated with delirium were age ≥55 years (adjusted odds ratio (aOR) 6.95 (95% CI 2.03 - 23.67); p=0.002), and urea ≥15 mmol/L (aOR 4.83 (95% CI 1.7 - 13.44); p=0.003), while ART use reduced risk (p=0.014). A low CD4 count, an unsuppressed viral load and active TB were not predictors of delirium; nor were other previously reported risk factors such as non-opportunistic acute infections or polypharmacy. CONCLUSIONS: Delirium is common and is associated with increased mortality in HIV-infected acute medical admissions in endemic settings, despite increased ART use. Older HIV-infected patients with renal dysfunction are at increased risk for inpatient delirium, while those using ART on admission have a reduced risk.

Efficacy of South African Babesia bovis vaccine against field isolates.

A high-passage Babesia bovis vaccine containing only one genotype population was, although protective, inferior compared to the immunity afforded by a lower passage of the same strain containing two populations. The 24 times serially passaged South African B. bovis S vaccine strain contain only a single parasite population (Bv80 allele A 558bp). Forty-four field isolates sampled were all found different with regard to the number and composition of the parasite populations present in each isolate. The extensive genotypic diversity in South Africa and the limited genotypic diversity observed in the S24 vaccine, raised the question on its ability to protect against such diverse populations. The 6 isolates selected for challenge in the current study originated from geographically distinct populations that also possessed thirteen unique genotypes based on the Bv80 gene and included strains that resulted in clinical disease. The strain coverage was therefore much greater than in previous studies on the protective ability of the S24 vaccine. Challenge of vaccinated cattle indicated that the vaccine gave adequate protection against 5/6 isolates. Protection against the remaining isolate proved inadequate. However, field observations in the region where this isolate originated from, showed only minor mortalities in vaccinated animals compared to losses experienced in unvaccinated herds. This study demonstrated the ability of the South African B. bovis S24 vaccine to protect cattle against challenge from local field isolates containing single or multiple parasite populations.

Co-transmission of the non-transmissible South African Babesia bovis S24 vaccine strain during mixed infection with a field isolate.

The South African Babesia bovis live blood vaccine, originating from a field isolate attenuated by 23 serial syringe passages in splenectomized calves, has lost the ability to infect the natural vector Rhipicephalus (Boophilus) microplus. In this study, infection with mixed parasites from the vaccine strain and a field isolate, resulted in transmission of both genotype populations. Comparing the field isolate and transmitted combination indicated no significant difference in their virulence, while challenge of vaccinated cattle with these isolates showed the ability of the vaccine to protect against both. Limiting dilution of the transmitted combination, followed by infection of splenectomized cattle (n=34) yielded no single infections for the vaccine strain genotype, seven clonal lines of the field isolate and one mixture of vaccine strain and field isolate. Only one of two field isolate clonal lines selected for vector transmission study was transmitted. Showing that B. bovis isolates can contain both tick transmissible and non-transmissible subpopulations. The findings of this study also indicate the probability of vaccine co-infection transmission occurring in the field, which may result in new genotype populations of B. bovis. However, the impact of this recombination with field isolates is considered negligible since a genotypically diverse population of B. bovis is already present in South Africa.

Genotypic diversity in Babesia bovis field isolates and vaccine strains from South Africa.

Genotypic diversity in Babesia bovis (cause of Asiatic redwater in cattle) vaccine strains and field isolates from South Africa were investigated using the Bv80 gene as well as microsatellites. The S11 vaccine strain possessed both A and B alleles of the Bv80 gene, as well as genotypic diversity within each allele type as defined by repeat variation resulting in different amplicon sizes. Rapid serial passage of vaccine strain from passage S10 to S24 resulted in loss of genotypic diversity that yielded a single allele A genotype with an amplicon size of 558 bp. This suggested that clonal selection occurred during rapid passaging. Extensive genotypic diversity exists in 44 field isolates characterized with both Bv80 A and B alleles, but can be readily distinguished from the S24 vaccine strain using either the Bv80 allele specific PCR assays or using multi-locus micro-satellite typing. This indicated that no recent documented clinical cases of Asiatic redwater were caused by the reversion to virulence of the current vaccine strain.

Serological responses to Babesia bovis vaccination in cattle previously infected with Babesia bigemina.

Serological responses of field cattle (260) on a farm in KwaZulu-Natal, South Africa were determined before and after vaccination with the commercial Babesia bovis live-blood vaccine, using the indirect fluorescent antibody test (IFAT). All the cattle tested negative for B. bovis antibodies before vaccination while 83% of them had significant antibody titres (>or=1/80) to Babesia bigemina, indicating a high degree of natural exposure to the latter parasite. By Day 60 post-vaccination only 53% of the cattle had seroconverted to B. bovis. This raised the question as to why only half of the vaccinated cattle had seroconverted. The possibility of previous exposure to B. bigemina infection interfering with the development of detectable antibodies to B. bovis was therefore investigated under controlled conditions. It was found that simultaneous vaccination with B. bigemina and B. bovis (n=6), and B. bigemina vaccination followed by B. bovis vaccination (n=12), had no effect on the animals' immune responses to B. bovis vaccination. All of these cattle developed a significant antibody response. However, only 58% of cattle (n=12) which had previously been inoculated with the B. bigemina field isolate, obtained from the trial farm, seroconverted (>or=1/80) after B. bovis vaccination, yet parasites for B. bovis could be demonstrated microscopically in all of the animals in this group. These findings confirmed the serology results from the field trial. When challenged with a B. bovis field isolate, cattle in this group did not show clinical reactions compared with an unvaccinated control group. The judicious use of IFAT to establish vaccination success obtained with the current South African B. bovis vaccine is indicated.

Live vaccines against bovine babesiosis.

Bovine babesiosis is an important tick-borne disease caused by Babesia bovis, B. bigemina and B. divergens. The first steps taken in the development of an effective vaccination strategy against bovine babesiosis followed the observations that animals, recovered from natural infection with Babesia were strongly protected against subsequent challenge. Further investigation indicated that the use of donor blood from recovered animals to infect recipient animals did not produce the severe form of the disease. The past century has seen a refinement of this original carrier-donor system to one using attenuated less virulent strains with standardized doses of known parasite concentration to ensure reliability. With the implementation of good manufacturing practices further changes were necessary in the production of these vaccines, such as freezing for long-term storage to allow sufficient time for pre-release safety and effectivity testing. Regardless of these improvements the vaccines are not without problems and breakdowns and breakthroughs occur from time to time. Despite considerable research efforts into the development of alternative more consumer friendly vaccines, none is immediately forthcoming and the live attenuated babesiosis vaccines are still used in many countries.

Effect of diminazene block treatment on live redwater vaccine reactions.

One third of the manufacturer's prescribed dose of diminazene has long been used to block treat the South African unfrozen Babesia bigemina and Babesia bovis (redwater) vaccine reactions, with no known adverse effects. It is known that the inhibitory effect of antibabesial drugs is more pronounced in animals inoculated with the frozen vaccine than those with the unfrozen vaccine. Reports of vaccine failures in some animals in which diminazene was used for block treatment of the reactions following inoculation with frozen South African redwater vaccine led us to reinvestigate the required waiting period before treatment and the reduced dose necessary for successful treatment and development of immunity. Results from febrile reactions in cattle following vaccination indicated day 7 as the optimal day for administering block treatment. Treatment of B. bigemina vaccine reactions in cattle on day 7 at a level of 0.35 mg/kg (1/10, fraction of the normal dose) diminazene killed all the parasites while B. bovis vaccine parasites survived treatment using diminazene at levels between 0.35 mg/kg and 1.16 mg/kg. However, various other factors, such as the degree of natural resistance of different cattle breeds and individual animals, the accuracy of diminazene content according to the manufacturer's label claim and the accuracy of the drug dose administered, all influence the successful immunization of animals. Consequently block treating of Babesia vaccines with diminazene on day 7 after vaccination is not recommended.

Residual effect of antibabesial drugs on the live redwater blood vaccines.

It has been demonstrated that the attenuated organisms used in the unfrozen South African Babesia bovis and B. bigemina (redwater) vaccines are susceptible for longer periods to the residual effect of the anti-babesial drugs diminazene and imidocarb dipropionate than the virulent field strains. Reports of vaccine failures in some animals vaccinated with the frozen South African redwater vaccines after prophylactic treatment with imidocarb dipropionate have led us to reinvestigate the validity of the recommended prescribed waiting periods. Results indicated that waiting periods before administration of the frozen B. bovis and B. bigemina vaccines in animals that have been treated with diminazene at 3.5 mg/kg live weight, compare favorably with results initially obtained for the unfrozen vaccines at 4 and 8 weeks, respectively. However, the inhibitory effect of imidocarb dipropionate at 3.0 mg/kg live weight on the infectivity of both frozen B. bovis and B. bigemina vaccines is longer than previously anticipated and necessitated changing the minimum waiting periods before administration of these vaccines from 8 to 12 weeks and 16 to 24 weeks, respectively.

A comparison of the standard approach and the NONMEM approach in the estimation of bioavailability in man.

There has recently been concern about confidence intervals calculated using the standard error of parameter estimates from NONMEM, a computer program that uses a non-linear mixed-effects model to calculate relative bioavailability (F), because of possible downward bias of these estimates. In this study an alternate approach, the log-likelihood procedure, was used to calculate the confidence intervals for F from NONMEM. These were then compared with those calculated using the standard error of the parameter estimates, the traditional NONMEM approach, and the standard model-independent method, to determine whether bias exists. By use of data from a single dose, open cross-over study of ibuprofen using 14 healthy male volunteers, NONMEM was shown to give results consistent with those obtained using the standard model-independent method of analysis and could be a useful tool in the determination of F where conditions for using the standard method of analysis are not optimum. The width of the confidence interval for F using the log-likelihood procedure was narrower and non-symmetrical when compared with that obtained using the traditional NONMEM approach. The width of the confidence interval obtained using the traditional NONMEM method was similar to that from the standard approach, however the parameter estimate for F was higher than that obtained from the standard method. This could have been because of an outlier in the data set to which the standard approach is more sensitive. No downward bias was found in the confidence intervals from NONMEM. The bioavailability data set was of relatively low variability and more research with highly variable data is necessary before it can be concluded that the confidence intervals calculated from NONMEM can be used for hypothesis testing.

Evaluation of a 3 ml heartwater (cowdriosis) infective blood vaccine dose.

Three milliliters of blood from the present commercially produced heartwater infective blood vaccine (Ball3 stock) was experimentally tested in sheep and cattle for infectivity and efficacy. Results obtained for this vaccine dose were statistically not different from results for the prescribed 5 ml vaccine dose.

The isolation and transmission of an unidentified Babesia sp. to cattle by Hyalomma truncatum Koch 1844.

An unidentified Babesia sp. which causes a mild disease in cattle was isolated in a splenectomized ox that received pooled blood from field cattle. That this organism is pleomorphic and resembles Babesia occultans makes it difficult to differentiate between these organisms microscopically. Initially, it was suspected that this Babesia could be B. occultans. Several attempts to transmit this parasite transovarially with Hyalomma marginatum rufipes, the vector of B. occultans, failed. Continued efforts to identify possible vectors, using Boophilus microplus, Rhipicephalus evertsi evertsi and Rhipicephalus appendiculatus, all failed. The only tick thus far identified that could have transmitted the infection transovarially in the adult stage was the two-host tick Hyalomma truncatum.

A selective procedure for the field isolation of pathogenic Streptococcus spp. of rainbow trout (Salmo gairdneri).

A procedure established for the selective isolation of the species of Streptococcus responsible for rainbow trout streptococcosis in South Africa, consisted of the inoculation of samples into nutrient broth which had been supplemented with 100 micrograms/ml of nalidixic acid, 160 micrograms/ml of oxolinic acid or 200 micrograms/ml of sodium azide. After incubation, the sample was plated onto tetrazolium agar on which the rainbow trout pathogenic Streptococcus species grew as a red colony. The colonies were isolated from the tetrazolium agar and identified as rainbow trout pathogenic isolates by biochemical and serological tests. In the laboratory the selective procedure is capable of detecting about 2 bacteria per ml. This procedure was used in the field and biochemically identical Streptococcus species were found in the mud and a freshwater crab from the water source of a site with a history of streptococcosis.

Isolation and identification of trout viruses in South Africa.

A total of 3,257 samples of diseased rainbow trout were examined for the presence of viruses from January 1983 to December 1987. A virus closely related to the VR 299 serotype of infectious pancreatic necrosis virus was isolated from 13 cases. An additional 7,228 viscera samples from asymptomatic fish were collected during the same period and a similar virus was isolated from 2 sites. During the same period 2,892 ovarian fluid samples were collected and a similar virus was isolated from 1 site. A similar virus was also isolated from one consignment of imported trout ova. A total of 5,550 ova was examined during this period. The viruses were identified by various tests as being closely related to the VR299 serotype of infectious pancreatic necrosis virus. All these samples tested negative for infectious haematopoietic necrosis virus, viral haemorrhagic septicaemia virus and herpesvirus salmonis.

Babesia bigemina vaccine: comparison of the efficacy and safety of Australian and South African strains under experimental conditions in South Africa.

A Babesia bigemina vaccine strain (G strain) of reduced virulence was obtained from Australia and tested experimentally for efficacy and virulence. The strain caused mild reactions in 10 animals and afforded good protection to challenge with a virulent South African strain. The virulence of the local vaccine strain was not noticeably reduced after 3 slow passages in intact calves and it was consequently replaced by the Australian strain in the Onderstepoort babesiosis vaccine.