I have started a new blog, which I hope to post to at least once or twice a week, called A Rural Virologist.  The link is http://www.theotokos.co.za/umtata/

My first post:


This blog may become more silent.

This is me getting my rabies vaccine, dose 2, day 7.  I got the first dose last week.  One more in 3 weeks.


Soon I'll no longer have the urge to bite the postman.

In some parts of the world, rabies is a problem, and South Africa's Kwazulu Natal region has reported an increase among dogs.  Port Shepstone has the highest concentration in KZN, says the Pretoria News of 3 Jan 2007.  Countrywide, there were 28 cases of human rabies infection reported in 2006, according to the National Institute for Communicable Diseases, the NICD.

People who may be exposed to rabies, such as lab workers, veterinary surgeons, etc., should be vaccinated with three doses, on day 0, day 7, and day 28, with one intramuscular dose each time, if they are immunocompitent.  A booster at least every 5 years is required.

Post-exposure prophlyaxis is the prevention of rabies in people who have been bitten, or otherwise significantly exposed to, an animal with rabies.

For those who have up-to-date pre-exposure prophylaxis, a booster on day 0 and day 3 is required, with no antibodies given, as they may interfere with an adequate response of the body's own immune system which has memory for rabies antigen.

The majority of people will not have been vaccinated prior to exposure.

The wound should be washed thoroughly - 5-10 minutes of flushing with water, with 5% chlorhexidine in the water if possible.  Cat bites are deep with small pucture wounds, and a syringe can be used to flush them.  70% alcohol or iodine-based disinfectants should then be used, as they inactivate rabies viruses.  Don't forget tetanus toxoid and antibiotics.

Further sharp trauma to the wound should be avoided, as this may enhance rabies virus infection of nerve or muscle tissue.  This includes stitching the wound and repeated needle trauma during local anaesthetic or immunoglobulin administration.

There should be NO delay in giving antibody and vaccine - some authorities recommend waiting to see if the animal develops illness (NEJM 16 Dec 2004, which gives otherwise excellent advice) but this is incorrect.  This gives up to 10 days without prevention, during which the virus has plenty of time to infect and start multiplying.  Vaccination can be stopped if the animal ends up being considered rabies-free, but the time spent determining whether or not that is the case is not to interfere with treatment.

They should get rabies immunoglobulin on the day they report for medical care.  The usual dose is 20 IU/kg if the immunoglobulin used is of human origin, and 40 IU/kg if it comes from horses.  As much as possible should be given into the wounds, and if necessary, diluted up to 50% in saline.  The maximum dose of immunoglobulin should not be exceeded, as it will interfere with the vaccine.  Any remaining immunoglobulin should be given into the deltoid muscle at the shoulder - preferably not the buttock, as absorption may be poor.

The vaccine should be given into the deltoid muscle, preferably into the opposite muscle to any bites on the arm, which have been injected with rabies antibody, and definitely not into the same muscle as any remaining antibody.  Never into the buttock, where it will not be as effective in producing an adequate immune response.

The vaccine is given on day 0 (the day the patient presents for medical care), day 3, day 7, day 14, and day 28.  The commonly used vaccine is Verorab.

A double dose of vaccine on day 0 should be given if the patient is immunocompromised, e.g. taking steroids, takes chloroquine for malaria prophylaxis, if antibody was given before vaccine was obtained, or if day 0 was more than 48 hours after exposure.

If no antibody is immediately available, vaccine can be given, and the antibody given within 7 days.

If no vaccine is available, and will become available soon, antibody and vaccine should be given together.

Official rabies guidelines should be consulted - never base treatment on a website, even if it is a virologist's website!

The best guidelines I've seen have been compiled by a team of experts from the Departments of Health and Agriculture, and are relevant for both human and animal medical personnel.  [PDF, 1.1 MB]

Once upon a time, long long ago, infections like genital herpes, syphilis, and gonorrhoea were called "venereal diseases."


Then a more scientific term was developed - sexually transmitted.  So they were called Sexually Transmitted Diseases - STDs.

Then along came political correctness.

Diseases were terrible things - nobody wanted to be called "DISEASED."

So they called them infections.  Now STDs are known as STIs - Sexually Transmitted Infections.

But surely INFECTION is a bad thing too?  "I have an INFECTION."  "I AM INFECTED."  It sounds like you have an STD.  That's not good.

Why not simply refer to the acquired organisms as "flora."  After all, they are flora - not "normal flora", but rather acquired flora.  We won't call them "unnatural flora" because that might mean something bad.

And SEXUALLY TRANSMITTED is harsh.  It implies sordid activities.

Why not just call it love?  And the flora is not TRANSMITTED - it sounds like you spread it to other people, causing them harm.  Just call them what they are - acquired flora.

Love-acquired flora.  LAF.  Plural LAFs.

Why not call them LAFs?  Or will they be LAF'd at for carrying their political correctness to the logical end?

Here is an interesting report from the National Institute for Communicable Diseases, in their December 2006 Communiqué:


The online (non-e-mail) version exists, but only up till August 2006 at present.

Six Imprisoned Health-Care Workers in Libya Are Pawns in a Far Larger Strategic Game

The repercussions are enormous

Author: Laurie Garrett

Source: PLoS Medicine

PDF (56K)
HTML

Certainly something to read in the current politically tense world.

This is a link to the Medical and Science Issues blog's Technorati profile.

Technorati Profile

This sounds like a lot of fun:

Sewage. To simulate chemical-toilet and holdingtank sewage, which is generally stronger than typical domestic wastewater, a simulated sewage with a suspended-solids concentration of about 1,000 mg/liter was used in this study. The sewage contained per liter: 3.5 g (wet weight) of fecal material, 10 ml of urine, 0.25 g of toilet tissue, 0.4 ml of liquid hand soap, 100 ml of domestic raw sewage, and 885 ml of dechlorinated tapwater. The components were combined and blended for 1 min, and the mixture was used immediately.

Source: Sobsey MD, Wallis C, Melnick JL. Chemical disinfection of holding-tank sewage. Appl Microbiol 1974; 28: 861-6.  Abstract on PubMed via Amedeo.

Taken from the article's Materials and Methods section.

My HOD cc'd me on an e-mail where he said and quoted:

Another very relevant document has come out today:

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings

It contains the following summary:

Major revisions from previously published guidelines are as follows:

For patients in all health-care settings

• HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
• Persons at high risk for HIV infection should be screened for HIV at least annually.
• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
• Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings.

For pregnant women

• HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
• HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
• Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

Interesting how attitudes are shifting in the USA.

Other recent posts on my blog re opt-out testing:
Opt-out HIV testing
Normalising HIV Diagnosis and Treatment

I believe things will change for South Africa soon.

A bit old - 2004 - but it gave me a good laugh at the time.

The study describes 5 patients with malaria, with management followed up with the OptiMAL dipstick test.

Patients 1 and 4 were treated with intravenous quinine; patient 5 was treated with chloroquine; and patients 2 and 3 were given e-mail.

A second patient with malaria was unconscious and severely anaemic (Hb, 6 g/dl), with an asexual count of 298,880 parasites/ul. He was given e-mail, however, he died on the next day. The third patient was suffering from Parkinson’s disease with a parasite count of 112,800 parasites/ul (Hb 10 g/dl). He was also administered e-mail and subsequent follow-up on days 2 and 7 revealed clearance of parasitaemia by both tests.

Singh N, Nagpal AC. Performance of the OptiMAL dipstick test for management of severe and complicated malaria cases in a tertiary hospital, central India. J Infect 2004; 48: 364-5. Abstract on PubMed.

I think the opt-out system of HIV testing is a fairly good idea.  Of course, it will have to be looked at carefully, and checks put in place to ensure confidentiality and avoidance of stigma.  That is something I am not sure South Africa is ready for, but I'm also not sure that it isn't ready for it.  Many of my patients have suffered from faulty bigoted public perceptions of HIV and AIDS.  But only by attempting progress can we find out whether an opt-out system would change that for the better or the worse.

My HOD sent me these links ... I hadn't seen them before.  They deal with this issue.  Also see the article by Judge Edwin Cameron elsewhere on my blog.

Testing stigma - 16 May 2006, Mail & Guardian

One critic of Cameron's approach is Mark Heywood of the Aids Law Project, who said that while people should be encouraged to test for HIV, Cameron was "trying to de-exceptionalise, when HIV remains an exception. For most people, HIV diagnosis remains full of dangers and access to treatment is far from guaranteed."

HIV: pre-test counselling 'a luxury' - 17 August 2006, Mail & Guardian

"Where the right conditions exist, we should therefore re-medicalise the diagnosis of HIV, by making it a normal part of medical treatment, subject only to a patient's deliberate and express refusal to be tested."

We may well be witnessing a change in the approach to HIV testing here in South Africa.

In the recent August 2006 Transcript, the newsletter of the Southern African HIV Clinicians Society, the following article by Supreme Court Judge Edwin Cameron caught my attention.  I've posted it here with his permission.

---

Normalising HIV Diagnosis and Treatment

By Judge Edwin Cameron

My friend Ronald Louw was dean of the law school at the University of KwaZulu-Natal, a proudly gay man, and a treatment activist who was fully informed about AIDS and the fact that it can now be effectively treated and managed.  He was also HIV+ – yet he didn’t know this fact about himself until he was tested and diagnosed on 15 May 2005 – the very day that he was admitted to hospital in Port Elizabeth with severe effects of late-stage AIDS.  He died seven weeks later. His death tells us much about the state of the epidemic in our country today.

Ronald Louw was white, an academic, comparatively affluent and gay.  In this he was different from most of the people on our continent who face death from AIDS.  Yet in his fears, the shame he felt, the self-disentitlement he experienced, he shared all too much with many others in this epidemic of fear and shame.  And in his death he also shared too much, since like him too many are dying unnecessarily of AIDS.

AIDS is no longer a necessarily fatal condition.  It is now a medically manageable disease.  In many millions of cases throughout the world, it can be and is being successfully treated.  Long-term survivors of AIDS are no longer a rare and unexplained exception – for those with access to treatment, they are the norm:  Well over 90% of AIDS patients with access to anti-retroviral medication recover well from their illness and return to productive, re-energised living.  I know this myself, after nine years of successful anti-retroviral treatment.

My friend Professor Debbie Marriott, who runs the St Vincent’s AIDS Clinic at the Sydney General Hospital – one of the world’s oldest and best-regarded AIDS treatment facilities – recently told me that if she had to choose, today, between diagnosis with chronic hypertension (high blood pressure), insulin-dependent diabetes, and AIDS – a choice no one would want to make – she would choose AIDS.  This is because AIDS is more manageable than the other conditions.  Yet far too few people know it.

We know about external stigma and discrimination.  Yet Ronald Louw did not die of these.  He died of something more insidious:  the fear, self-disablement, feelings of contamination, self-rejection and self-loathing experienced by people with HIV, and those who fear they have HIV, even when they know that they will receive support, protection, treatment and acceptance.

In the 1980s, we hedged diagnostic procedures for HIV with elaborate measures to ensure confidentiality and knowledge and consent.  There was good reason: the only product of HIV testing, all too often, was victimisation, ostracism and discrimination.

But this has changed.  Because of the activists’ struggle, treatment is now widely available.  Even in many desperately resource-deprived settings, anti-retroviral treatment is becoming more accessible.

Yet many people, offered the choice of diagnostic procedures whose unusual nature is emphasised, prefer not to be tested.  This I believe is partly because HIV diagnosis is treated as exceptional, and is hedged around with fuss and palaver and hullabaloo, including the requirement of express and specific consent, and the insistence on pre-test counseling.  This may come at a direct cost in lives.

I do not advocate coercion.  Patients should not be coerced (or only extremely rarely) into any procedure.  But where diagnosis could preserve the patient’s life – and where continued ignorance will surely hasten death – the healthcarer’s duty of beneficence demands that accurate, early diagnosis of the treatable condition should be encouraged.  Where possible, diagnosis should be a routine and uncontroversial element in the patient management process.

Where the right conditions exist, we should therefore re-medicalise the diagnosis of HIV, by making it a normal part of medical treatment, subject only to a patient’s deliberate and express refusal to be tested:

• Is anti-retroviral or other life-saving interventive treatment available for offer to the patient?
• Is there some assurance that the consequence of diagnosis will not be discrimination and ostracism?
• Does the patient have some assurance that test will be treated as confidential?

Those conditions are still rare in Africa.  But where they do exist, we must move urgently to normalise the treatment and diagnosis of AIDS.  It has already happened in Botswana, and we should follow suit.

And where these conditions exist, we should even forgo insistence on pre-diagnostic counseling, despite its acknowledged educational benefits.  Counseling should be retained provided that a health care facility is able to offer it without sacrificing the time and energy of its healthcare personnel.  That time is urgently required for diagnosis and treatment of HIV.

It is true that AIDS is a dread disease, and that pre-test counseling assists those with it to adjust to their condition.  But malaria, cancer and insulin-dependent diabetes are also dread, potentially fatal, diseases – yet no testing or counseling protocols inhibit their diagnosis and effective management.

In a mass epidemic of HIV, where mass treatment is now be a realisable fact, pre-test counseling may be a luxury we can no longer afford.  Our commitment to normalising AIDS must now include a commitment to equate its medical diagnosis and management with that of other treatable dread conditions.  That way we can and will save many lives in Africa: and it is that commitment that human rights lawyers and health-care providers have in common.

END

---

Interesting criticism:

What a joke.

The Department of Health reports on human bocavirus on their website, while the minister of health promotes garlic and beetroot for the treatment of HIV.

HIV affects more people than the number of beetroot she has eaten ... bocavirus fades into the background relative to the impact of AIDS in this country.

Ultramontanist and ultramontanism seem to be good words for Googlewhacking.

Ultramontanist desynchronisation - no results
Ultramontanist desynchronization - no results
Ultramontanism desynchronisation - 1 result

The Americans can't spell.

The two words ultramontanist and exhaler together produce zero results on Google ... at the moment anyway.  Reporting things like that tends to change them.  The Heisenberg principle, or something like that.

At the 2006 XVI International AIDS Conference in Toronto that has just ended, researchers presented a study done on AIDS patients in Zambia, where a group of patients was given antiretroviral drugs, and half the group was given extra food.  The half not given extra food was left to starve - to remain "food insecure".

The criteria for inclusion were people who were starving ["food insecure"], and the intent was to give half this group extra nourishment, while leaving half the group in their original starving ["food insecure"] state.

The specific criteria that defined "food insecurity" were:

Household income
          <$10.00 a month if the patient was not primary earner
          <$40.00 a month if the patient was the primary earner
Household purchased
          <5Kg maize meal per person in household per month
Household members reported cutting or skipping meals during past month daily or every other day

The researchers also give us the following information about Lusaka, where the study was done:

Population 1.5 million
HIV Prevalence 22% (of which 35% are starving ["food insecure"])
Food Insecure >25%

If we do a few calculations:

The entire population: 1.5 million
Starving ["food insecure"]: >375 000
HIV positive: 330 000
HIV positive and starving ["food insecure"]: 115 500

The powerpoint presentation that was shown to researchers attending the conference can be found at the AIDS 2006 Conference site.  The Powerpoint presentation's direct link is here.  The abstract can be found here.

The title of the talk was:

Nutritional Supplementation for Food Insecure Patients on Antiretroviral Therapy: Impact of a Pilot Program in Zambia

Presented by:

Karen Megazzini, MMSc, MIH, PA-C [1] [2]
Centre for Infectious Disease Research in Zambia
University of Alabama at Birmingham
August 14, 2006

The researchers and their affiliations:

Megazzini K., Washington S., Sinkala M., Lawson-Marriott S., Stringer E., Krebs D., Levy J., Chi B., Cantrell R., Zulu I., Mulenga L., Stringer J.

Centre for Infectious Disease Research in Zambia, Lusaka, Zambia [link]
Lusaka Urban District Health Management Team, Lusaka, Zambia
World Food Programme, Lusaka, Zambia [link] [e-mail]
University Teaching Hospital, Medicine, Lusaka, Zambia [link] [link]

If I'd been assessing their ethics, I would not have allowed this study.

We know patients with food are better off than starving ["food insecure"] patients, so why bother testing this out on HIV patients?  The outcome aside, it's really something that is unnecessary to know, if we aim to feed people anyway.

How can we benefit from this study?

Maybe the researchers wanted to know if starving ["food insecure"] people would still benefit from antiretroviral drugs.  The powerpoint show states that their objective was: "Evaluate whether food supplementation improved early outcomes among food insecure, HIV-infected groups receiving ART"

Is there a group of HIV-infected people that we want to treat, but stop feeding?

We would hopefully discover that we don't have to feed the starving ["food insecure"] HIV-infected people, just give them antiretrovirals, and the drugs will work anyway.  But can we imagine a situation where we would want to avoid feeding them, while giving them antiretrovirals?

Is there a situation where we would want to treat HIV-infected people without having to alleviate hunger?  Perhaps it may be useful, if financial constraints limited us to one or the other.  We'd have to decide which path to choose - feed them, or treat their HIV.  We'd have to decide which one comes first.  Or would we?  I don't think that would be necessary.

Is it ethical to take a group of people with two serious conditions, and treat only one condition to see if the other condition, when untreated, affects the treatment of the first condition?

If we took a group of tuberculosis patients and did the same, would the study be ethical if half the group were left in a state of starvation ["food insecurity"]?

If we took a group of diabetics with high blood pressure needing treatment, would it be ethical to treat half the group only for diabetes, while watching to see if their raised blood pressure stabilised once the diabetes, which can cause damage resulting in high blood pressure, was controlled?

My answer: never.

Perhaps the researchers should also answer all these questions.

Ministry investigates polio in Ghanzi area
29 June, 2006

GHANZI - Two children have been admitted to the Ghanzi Primary Hospital on suspicion that they might have contracted polio which recently broke out in Namibia, says Emang Gower, a health official.

That report is from the Botswana Press Agency (BOPA), via The Daily News website.

Only a few days ago, the region was planning their response to the polio outbreak in Namibia:

Ghanzi on alert to curb polio spread
21 June, 2006

GHANZI - The Ghanzi District Council has devised strategies to prevent the spread of polio from Namibia

They must be in quite a panic.  It was only a few weeks ago that our lab - Tygerberg NHLS - cultured polio from the first patient - that caused chaos.  Will it reach South Africa, which has been polio free since 1987, and if it does, when?  I've been tested, and I'm still immune to polio.  I don't know about my friends and family though.

Our department was recently involved in giving a talk on polio at the Stellenbosch University's medical campus - unfortunately I missed that, as I was away at a funeral.  An upcoming conference will have another talk by us.

28 June stats have 17 dead, and 138 cases of paralysis.  Remember that for every case of paralysis, there are about 100 people spreading the virus without symptoms.

The Aranos polio 1 wildtype virus from Namibia apparently clusters with the strains from Angola on phylogenetic analysis of a 906 nt fragment of the genome.  Further analysis will be interesting.

The last time polio was seen in Namibia was 1995.  This has changed in the last week, when an outbreak of polio was diagnosed.

We isolated poliovirus type 1 on 1 June from the patient in Aranos who fell ill on 6 May.  This has now been confirmed by the WHO reference lab in the region for polio, the NICD in Johannesburg, who typed it as wildtype poliovirus 1.  They also received specimens from later patients (current count = 34 patients, 7 deaths) once the outbreak had been identified as being an outbreak.  Here is our story [see item 1].

After a long fuss, much anxiety, and many phone calls back and forth around Southern Africa, the bad news has broken - Namibia has an outbreak of wildtype poliovirus type 1.

There are 3 types - 1, 2, and 3, funnily enough.  There are also 3 vaccine types, corresponding to these three - known as Sabin strains 1-3.  These are usually given to children in about 5 doses in the first few years of life.  South Africa has been polio-free since 1987, when we had our last case.

Currently poliovirus is classified as a BSL 2 pathogen, which may change when eradication efforts have managed to eliminate the virus completely.  The recent outbreak in Nigeria has damaged the progress of the WHO's elimination campaign, and the current outbreak in Namibia will cause Southern Africa to start worrying.  We're hoping it won't spread to South Africa.

In the South African press - Polio claims seven in Namibia

AllAfrica.com - Namibia: Mystery Disease Kills Three

In the Namibian press (Republikein) - Angs: Dit is polio

In ProMed - Poliomyelitis - worldwide [08]: Namibia, conf.

A note about the Namibian article - our lab is indeed accredited.  We have SANAS accreditation; the article refers to WHO accredited labs that are designated as specific reference centres for polio, measles, viral haemorrhagic fevers (like Ebola, Marburg, Crimean-Congo Fever) and other pathogens monitored by the WHO.  The article makes us sound like a backwater lab in the bush run out of a tent ... that is certainly not the case.

May 2006 - The WHO Rapid Advice Guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus are now available - PDF (full version) and HTML (summary) formats.  The WHO site also has other guidelines for avian influenza.

The ProMed post "Human Rabies-like Disease Due To Duvenhage Virus Infection" refers to a case we recently dealt with in our lab.  Fascinating - this is the 2nd isolate from a human ever, and the 4th isolate ever in any species.  Twice recorded in bats, there seems to be a spot of Duvenhage in the North West province.

Duvenhage is one of the seven classified Lyssaviruses, of which Rabies is the most well known.  In Africa, we have rabies, Duvenhage, Mokola, and Lagos Bat virus.  Mokola has never been found in bats, and outside of the Americas, nor has rabies.  Of these four, Lagos Bat virus has not yet been found in humans.  Other Lyssaviruses from elsewhere include the European Bat viruses 1 and 2, and Australian Bat Lyssaviruses.  Tentative species are Kotonkan virus, Obodhiang virus, and Rochambeau virus.  Those not yet classified into the Lyssavirus genus by the ICTV include Aravan and Irkut Bat virus.

One correction for the post - Dr Blumberg doesn't work in our lab; Dr Nutt does.

From a recent Medscape update:

According to the March 3 edition of The New York Times, last year, 20 states proposed about 80 bills that would cut noncitizens' access to healthcare or other services or would compel benefit agencies to report applicants with immigration violations. Do you approve or disapprove of this type of immigration policy? To vote or view results of the poll, click here.

You may need to be registered with Medscape to vote.

The World Health Organisation's guidelines for infection control with avian influenza can be found here.

Infection control recommendations for avian influenza in health-care facilities.

Just a quick word of support for FinchTV, the software I used for editing the chromatograms of the DNA sequences I obtained in my MMed project on mother to child transmission of HIV.

I found a good medical blog via Medscape, called Clinical Cases and Images - looks pretty good.  It's run by Dr. Ves Dimov, and aimed at medical doctors in training, in practice, or specialising further.

The British Medical Journal also mentioned it recently - 3 December 2005 issue.