Drain fluid creatinine-to-serum creatinine ratio as an initial test to detect urine leakage following cystectomy: A retrospective study.

INTRODUCTION: Urine leak following radical cystectomy is a known complication. Among the various methods to diagnose this, assessment of drain fluid creatinine is a relatively easy procedure. We aimed to ascertain the validity of the drain fluid creatinine-to-serum creatinine ratio (DCSCR) as an initial indicator of urinary leak in patients undergoing radical cystectomy. METHODS: We retrospectively identified consecutive patients with documentation of drain fluid creatinine in the postoperative period following cystectomy and urinary diversion at our institution between January 2009 and December 2018. All continent diversions and any patient with a DCSCR >1.5:1 underwent contrast study postoperatively. A diagnosis of urine leak was made following confirmatory imaging. Receiver operative characteristic curves were created, and Youden's index was used to determine the strength and clinical utility of DCSCR as a diagnostic test. RESULTS: Two hundred forty-four of the 340 patients included in the study underwent cystectomy with conduit and 81 underwent neobladder creation. Sixteen out of 340 (4.7%) patients had radiologically confirmed urinary leak. DCSCR was elevated in all ureteric anastomotic leaks and in 1 out of the 7 neobladder-urethral anastomotic (NUA) leaks. The sensitivity and specificity of DCSCR to predict all urinary leaks were 68.8% and 80.9% at 1.12 (area under the curve [AUC] = 0.838), whereas at a value of 1.18 (AUC = 0.876) and with the exclusion of NUA leaks, the sensitivity was 77.8% and specificity was 87.6%. CONCLUSIONS: DCSCR is a good preliminary test for identifying patients who need prompt confirmatory testing for localizing urinary leaks. A drain creatinine level just 18% higher than the serum creatinine level can signify a urine leak. This is different from general assumptions of a higher DCSCR.

Point-of-care CD4+ technology implementation in Free State, South Africa, was associated with improved patient health outcomes.

BACKGROUND: Point-of-care (POC) CD4+ technologies have the potential to increase patient access to treatment and care through rapid testing and result delivery at or close to where patients seek care. South African (SA) guidelines suggest the use of CD4+ testing to prioritise patients most in need of antiretroviral therapy (ART) and to support identification of patients with advanced HIV disease and opportunistic management of patients on ART. Understanding the patient impact of implementing POC CD4+ testing in the intended setting and operated by lower cadres of healthcare worker or non-professional healthcare facility staff will provide valuable insight into the appropriate use and placement of POC CD4+ technologies throughout SA. OBJECTIVES: To determine the patient impact (turnaround time of tests, loss to follow-up, and proportions of eligible patients proceeding to the next steps in the testing and treatment cascade) of implementing POC CD4+ testing technologies compared with conventional laboratory-based CD4+ testing. METHODS: This retrospective cohort study included all HIV-positive adults from 30 healthcare facilities in Free State Province, SA. Healthcare facilities were placed into two groups (POC and laboratory referral) using a stratified randomisation technique based on the presence of a POC CD4+ technology and minimal ART volumes. Patients who received a CD4+ test prior to ART initiation between September 2012 and September 2014 were included. Data were collected from patient charts and the POC devices. RESULTS: For new patients, the average time from HIV diagnosis and CD4+ testing was reduced from 7.6 days in the laboratory referral group to 4.5 days in the POC group, a decrease of almost 60%. Additionally, 59.6% of patients in the POC group received their HIV diagnosis and CD4+ test result on the same day, compared with 37.5% in the laboratory referral group (risk ratio (RR) 1.49; 95% confidence interval (CI) 1.01 - 2.18). Fewer patients were lost between HIV diagnosis and CD4+ testing (2.7% v. 8.6%) (RR 0.02; 95% CI 0.05 - 0.78) in the POC group. The average test error rate across the study time period was 8.4%; however, the error rate remained <5% for the final 5 months of the study. CONCLUSIONS: Introduction of the Alere Pima POC CD4+ technology in the Free State, operated by nurses and lay counsellors, was associated with positive patient outcomes across all parameters analysed. While this study highlighted an effective conventional laboratory network, a full costing and affordability analysis coupled with patient impact and access data from this study will provide further insight into the potential deployment strategies of POC CD4+ technologies in SA.

Comparing the detection of exposure to Ehrlichia ruminantium infection on a heartwater-endemic farm by the pCS20 polymerase chain reaction assay and an indirect MAP1-B enzyme linked immunosorbent assay.

Detection of heartwater is not always easy especially because all the serological assays so far available either have poor sensitivity or specificity. The indirect MAP-1B ELISA has been reported to be the most specific test for heartwater, although it does also detect antibodies to some closely related ehrlichial agents. This study was undertaken to compare two methods for the detection of heartwater infection caused by the ehrlichial agent Ehrlichia (Cowdria) ruminantium. Fifteen cattle on a heartwater-endemic farm infested with high numbers of Amblyomma hebraeum ticks, and hence exposure to E. ruminantium infection were monitored over an 8-week period by pCS20 PCR and an indirect MAP-1B ELISA. Infection was detected by pCS20 PCR in most animals with the highest number of positives (60%) in week 6 of the study. Similarly, exposure to E. ruminantium was detected by indirect MAP-1B ELISA in some animals, with the highest number of seropositives (27%) at weeks 2-6 of the study. The data demonstrated a fluctuating rickettsaemia in cattle in a heartwater-endemic area. Comparison of the two tests indicated that the pCS20 PCR assay was more reliable because it detected more infections than the indirect MAP-1B ELISA and would therefore be the method of choice for detection of E. ruminantium infection.

The prevalence of Cowdria ruminantium in free-living adult Amblyomma hebraeum collected at a communal grazing area and in 2 wildlife reserves in South Africa.

In order to detect the prevalence of Cowdria ruminantium in the vector tick, Amblyomma hebraeum, free-living, unfed adult ticks were collected with the aid of pheromone/CO2 traps. Ticks were collected at the Rietgat communal grazing area, as well as in the southwestern Kruger National Park and in the Songimvelo Game Reserve, all located in heartwater-endemic areas of South Africa. The presence of C. ruminantium in these ticks was determined by polymerase chain reaction (PCR) analysis. Ticks from the Rietgat communal grazing area were assayed in 2 batches and 4.7% of the one and 11.3% of the other were positive for infection, while 5.7% of the ticks collected in the Kruger National Park and 25% in the Songimvelo Game Reserve were positive. These results support the contention that a vector-wildlife cycle of transmission of C. ruminantium, the cause of heartwater in domestic ruminants, can be maintained in the absence of the latter animals.

Resistance of leopard tortoises and helmeted guineafowl to Cowdria ruminantium infection (heartwater).

Experimental infection trials were conducted to investigate susceptibility of leopard tortoises (Geochelone pardalis) and helmeted guineafowl (Numida meleagris) to infection with Cowdria ruminantium, the causative agent of heartwater, a tickborne disease of domestic and wild ruminants. Ten guineafowl were inoculated intravenously with a virulent dose of C. ruminantium derived from bovine endothelial cell cultures, and four leopard tortoises were exposed to C. ruminantium infection by the feeding of infected Amblyomma hebraeum ticks. Uninfected A. hebraeum ticks (on both tortoises and guineafowl) and Amblyomma marmoreum ticks (on tortoises only) were fed on the animals during weeks 2 and 3 post-exposure in an attempt to detect infection. These ticks were analyzed for C. ruminantium infection by xenodiagnosis and with the C. ruminantium-specific pCS20 polymerase chain reaction (PCR) assay. Attempts to detect infection in ticks fed on either species were negative by both tests. These results suggest that leopard tortoises and helmeted guineafowl are refractory to C. ruminantium infection and, therefore, are unlikely to be capable of introducing heartwater directly into new areas. However, leopard tortoises are efficient hosts of A. marmoreum and A. hebraeum and are likely to be important epidemiologically in the transport and maintenance of these tick vector species.

Antibody responses to MAP 1B and other Cowdria ruminantium antigens are down regulated in cattle challenged with tick-transmitted heartwater.

Serological diagnosis of heartwater or Cowdria ruminantium infection has been hampered by severe cross-reactions with antibody responses to related ehrlichial agents. A MAP 1B indirect enzyme-linked immunosorbent assay that has an improved specificity and sensitivity for detection of immunoglobulin G (IgG) antibodies has been developed to overcome this constraint (A. H. M. van Vliet, B. A. M. Van der Zeijst, E. Camus, S. M. Mahan, D. Martinez, and F. Jongejan, J. Clin. Microbiol. 33:2405-2410, 1995). When sera were tested from cattle in areas of endemic heartwater infection in Zimbabwe, only 33% of the samples tested positive in this assay despite a high infection pressure (S. M. Mahan, S. M. Samu, T. F. Peter, and F. Jongejan, Ann. N.Y. Acad. Sci 849:85-87, 1998). To determine underlying causes for this observation, the kinetics of MAP 1B-specific IgG antibodies in cattle after tick-transmitted C. ruminantium infection and following recovery were investigated. Sera collected weekly over a period of 52 weeks from 37 cattle, which were naturally or experimentally infected with C. ruminantium via Amblyomma hebraeum ticks, were analyzed. MAP 1B-specific IgG antibody responses developed with similar kinetics in both field- and laboratory-infected cattle. IgG levels peaked at 4 to 9 weeks after tick infestation and declined to baseline levels between 14 and 33 weeks, despite repeated exposure to infected ticks and the establishment of a carrier state as demonstrated by PCR and xenodiagnosis. Some of the serum samples from laboratory, and field-infected cattle were also analyzed by immunoblotting and an indirect fluorescent-antibody test (IFAT) to determine whether this observed seroreversion was specific to the MAP 1B antigen. Reciprocal IFAT and immunoblot MAP 1-specific antibody titres peaked at 5 to 9 weeks after tick infestation but also declined between 30 and 45 weeks. This suggests that MAP 1B-specific IgG antibody responses and antibody responses to other C. ruminantium antigens are down regulated in cattle despite repeated exposure to C. ruminantium via ticks. Significantly, serological responses to the MAP 1B antigen may not be a reliable indicator of C. ruminantium exposure in cattle in areas of endemic heartwater infection.

Population-based evaluation of the Ehrlichia ruminantium MAP 1B indirect ELISA.

The indirect MAP 1B ELISA based on the recombinant MAP 1B fragment of the immunodominant MAP I protein of Ehrlichia ruminantium is considered to be the most sensitive and specific assay for the serodiagnosis of heartwater. In this study, we evaluated its reliability in detecting exposure to E. ruminantium in field populations of domestic ruminants in Zimbabwe. Cattle and goat herds in endemically stable areas with high infection pressure and an expected close to 100% prevalence of E. ruminantium exposure were sampled. Bovine sera (858) and caprine sera (706) collected at seven locations representative of the two main production systems (communal lands and large scale commercial farms) in the two main agroecological zones of Zimbabwe (highveld and lowveld) were analysed. The prevalence of MAP 1B-specific antibodies in goats was similar and high, ranging from 67 to 100%, at all except one site (43%). Age-specific differences in goats (1, 2, 3, 4, 5 years) were not observed. In contrast, MAP 1B seroprevalence in cattle was significantly lower (P < 0.001), ranging from 46 to 61% in the lowveld communal area and from 24 to 33% in the remaining areas (P < 0.001). Age-specific differences in seroprevalence (1, 2, 3, 4, 5-7 + years) were similarly not evident in cattle (P < 0.15). Hence, the indirect MAP 1B ELISA may be an unreliable indicator of past exposure to heartwater in field-infected cattle in Zimbabwe. Although the reasons for this low response in field cattle are not fully understood, this study illustrates the need for field validation of the performance of new diagnostic tests prior to their use for epidemiological purposes.

Does geographic range affect the attractant-aggregation-attachment pheromone of the tropical bont tick, amblyomma variegatum?

The tropical bont tick, Amblyomma variegatum, transmits heartwater in sub-Saharan Africa and in the Caribbean. This species has a broad geographic distribution, ranging from Madagascar and other islands in the Indian Ocean through most of sub-Saharan Africa, to several islands in the eastern Caribbean Sea. Blood fed male A. variegatum secrete an attraction-aggregation-attachment (AAA) pheromone which, combined with CO2, excites host finding and formation of feeding clusters of these ticks. However, it is not known whether the composition of the pheromone varies throughout A. variegatum's geographic range. Extracts of fed male ticks were examined for phenols and volatile organic acids by gas chromatography and mass spectrometry to determine whether differences occur in the pheromone components of populations of this species across the geographic range (Guadeloupe, Zimbabwe, Zambia and Rwanda). No significant difference in the chemical composition of the pheromone in relation to geographic range was found. No significant differences in rates of attachment in response to native versus foreign extracts were found in on-host attachment tests comparing ticks from two countries. Guadeloupe (Caribbean) and Zimbabwe (African). This finding was confirmed in more detailed studies with ticks from Guadeloupe and four African countries (Kenya, Rwanda, Zambia and Zimbabwe). On-host attachment assays from these countries did not detect consistent differences in response to extracts from different locations. In an olfactometer bioassay, females were not consistently more attracted to extracts from their native locality than from any of the foreign localities. We conclude that despite the widespread distribution of A. variegatum over both hemispheres, no significant differences in pheromone composition or biological responses to male tick pheromone secretions occur.

Evidence of Cowdria ruminantium infection (heartwater) in Amblyomma sparsum ticks found on tortoises imported into Florida.

Amblyomma marmoreum and A. sparsum ticks were collected from tortoises imported into Florida from Africa and were tested for Cowdria ruminantium infection using a C. ruminantium-specific pCS20 polymerase chain reaction assay. In I shipment imported from Zambia, 15 of the 38 A. sparsum male ticks collected from the leopard tortoises (Geochelone pardalis) were found to be positive for infection with C. ruminantium. In contrast, all 148 A. marmoreum tested were negative for C. ruminantium infection. This is the first reported evidence of the introduction of heartwater-infected ticks into the United States, but there were no opportunities to confirm isolation of C. ruminantium from the ticks by either culture or transmission studies.

Competence of the African tortoise tick, Amblyomma marmoreum (Acari: Ixodidae), as a vector of the agent of heartwater (Cowdria ruminantium).

The ability of the African tortoise tick, Amblyomma marmoreum, to acquire and transmit Cowdria ruminantium infection was investigated experimentally with transmission trials and with a C. ruminantium-specific polymerase chain reaction (PCR) detection assay. Laboratory-reared A. marmoreum larvae and nymphs were fed on small ruminants with clinical heartwater. After molting, the resultant nymphs were fed on Cowdria ruminantium-naive sheep (n = 3), and the adults were ground and inoculated intravenously into sheep (n = 5). Fatal heartwater developed in the 5 recipient animals, demonstrating larvae-nymph transmission and nymph-adult acquisition of infection. Cowdria ruminantium infection was also detected in adult A. marmoreum by PCR analysis, although at lower frequency (10%) than in Amblyomma hebraeum ticks (43%), the major vector of C. ruminantium in southern Africa, which had been fed simultaneously on the infected animals (P<0.0001). Amblyomma marmoreum, therefore, can be an effective vector of C. ruminantium. The potential role of this species in heartwater epidemiology and in the spread of the disease to new areas is highlighted by these results and by the fact that immature stages of this tick feed readily on domestic and wild animals susceptible to C. ruminantium.

Detection of the agent of heartwater, Cowdria ruminantium, in Amblyomma ticks by PCR: validation and application of the assay to field ticks.

We have previously reported that the pCS20 PCR detection assay for Cowdria ruminantium, the causative agent of heartwater disease of ruminants, is more sensitive than xenodiagnosis and the pCS20 DNA probe for the detection of infection in the vector Amblyomma ticks. Here, we further assessed the reliability of the PCR assay and applied it to field ticks. The assay detected DNA of 37 isolates of C. ruminantium originating from sites throughout the distribution of heartwater and had a specificity of 98% when infected ticks were processed concurrently with uninfected ticks. The assay did not detect DNA of Ehrlichia chaffeensis, which is closely related to C. ruminantium. PCR sensitivity varied with tick infection intensity and was high (97 to 88%) with ticks bearing 10(7) to 10(4) organisms but dropped to 61 and 28%, respectively, with ticks bearing 10(3) and 10(2) organisms. The assay also detected C. ruminantium in collections of Amblyomma hebraeum and Amblyomma variegatum field ticks from 17 heartwater-endemic sites in four southern African countries. Attempts at tick transmission of infection to small ruminants failed with four of these collections. The pCS20 PCR assay is presently the most characterized and reliable test for C. ruminantium in ticks and thus is highly useful for field and laboratory epidemiological investigations of heartwater.

Comparison of efficacy of American and African Amblyomma ticks as vectors of heartwater (Cowdria ruminantium) infection by molecular analyses and transmission trials.

The ability of Amblyomma americanum, Amblyomma cajennense, Amblyomma maculatum, and Amblyomma variegatum to acquire and transmit Cowdria ruminantium infection was investigated. Uninfected nymphs were fed on clinically reacting C. ruminantium-infected sheep and then analyzed for infection by specific DNA detection assays and by tick transmission trials. By polymerase chain reaction (PCR), the mean infection prevalence of A. maculatum ticks (50.7%) was similar to that of A. variegatum, Elevage strain (43.5%; P = 0.83) and Petit Bourg strain (45.9%; P = 0.26) ticks. Though Amblyomma hebraeum were not tested by PCR, by DNA probe their infection prevalence was 94%. In contrast, A. americanum and A. cajennense ticks demonstrated very low susceptibility to C. ruminantium, and the prevalence of infection by PCR was approximately 1%. The higher susceptibility of A. maculatum and A. variegatum to C. ruminantium correlated with superior vector efficiency, depicted by similar prepatent periods and severity of disease transmissions to sheep. Amblyomma americanum and A. cajennense failed to transmit infection, confirming that low susceptibility to C. ruminantium correlates with the poor vector status of these species. These results highlight the importance of A. maculatum as a potential vector that is likely to play a major role in the establishment and maintenance of heartwater, if the disease were to be introduced to the U.S.A., Central, and South America.

Prevalence of Cowdria ruminantium infection in Amblyomma hebraeum ticks from heartwater-endemic areas of Zimbabwe.

Analysis of the transmission dynamics of Cowdria ruminantium, the tick-borne rickettsial agent of heartwater in ruminants, requires accurate measures of infection in vector populations. To obtain these, Amblomnia hebraeum ticks were collected at two heartwater-endemic locations in the lowveld and highveld regions of Zimbabwe and assessed for C. ruminantium infection with specific polymerase chain reaction (PCR) and DNA probe detection assays. At the lowveld site, 11.2% (50/446) of adult ticks and 8.5% (23/271) of nymphs carried C. ruminantium, as detected by PCR. At the highveld site, the prevalence of infection in adult ticks was 10.2% (40/392). DNA probe analysis revealed that most infections at both sites were of low intensity; only 9% and 23% of all nymph and adult tick infections, respectively, were greater than 70000 organisms, the detection limit of the DNA probe. However, the majority (70%) of probe-detectable adult tick infections were high, between 10(7) and 10(9) organisms/tick, while those within nymphs were lower, between 10(5) and 10(6) organisms/tick.

Predicting the effect of vaccination on the transmission dynamics of heartwater (Cowdria ruminantium infection).

We used a mathematical description of the transmission dynamics of the tick-borne infection Cowdria ruminantium in commercial beef enterprises in Zimbabwe to consider the potential impact of a candidate vaccine to prevent heartwater. The important characteristics of the vaccine were (1) a delay in development of full protection, (2) prevention of clinical disease but not of infection and (3) a waning period of protection in the absence of challenge. We considered three different scenarios in which the vaccine might be used: prophylactically in susceptible cattle prior to the introduction of infection into a herd; in susceptible cattle in the face of an epidemic (i.e., when the infection is introduced and disease is first noticed); and at equilibrium (i.e., when parasite, vector and host have been co-existing for some time). The epidemic rise in infection was modelled assuming two different patterns (i.e., resulting from slow and fast increases in tick challenge). Vaccination (administered both in the face of an epidemic and prophylactically) reduced and delayed the peak of the epidemic. With insufficiently frequent revaccination, this can result in the epidemic occurring during a period of susceptibility, so that the benefit derived from a more-efficacious vaccine is lower than that from a less-efficacious vaccine. A vaccine of only 30% or 50% efficacy (if given to the whole herd) can have important effects on both morbidity and mortality if administered with sufficient frequency. However, a highly efficacious vaccine (e.g., 90%) can have only minimal effect if revaccination occurs too infrequently - especially if the epidemic of disease occurs when tick challenge is high and vaccination-related immunity has waned. There was a fairly consistent pattern of decreasing returns on increasing protection, although this was reversed in the situation of annual vaccination undertaken prophylactically combined with an epidemic of infection that occurred when the tick challenge was relatively low. Vaccination in equilibrium situations was most beneficial at low and intermediate tick challenges. There was very little effect of vaccination in high-transmission areas regardless of vaccine efficacy and/or frequency of revaccination because most animals were infected during periods of innate or maternally derived immunity (i.e., under endemic stability). Our results suggest that where relatively high tick challenge can be achieved and consistently maintained, vaccination may be used in susceptible herds to minimise losses in a policy of transition to endemic stability.

Cowdria ruminantium infection in ticks in the Kruger National Park.

Adult Amblyomma hebraeum ticks, the principle vector of heartwater (cowdriosis) of domestic ruminants in southern Africa, were collected in pheromone traps placed in Kruger National Park, an exclusively wildlife sanctuary in South Africa. These ticks transmitted Cowdria ruminantium, the rickettsial agent causing heartwater, to a susceptible goat, resulting in acute, fatal disease. C ruminantium was isolated in bovine endothelial cell culture from the plasma of this animal during the febrile stage of the disease and transmitted to susceptible goats, causing fatal heartwater. The prevalence of C ruminantium infection in 292 ticks was determined by polymerase chain reaction (PCR) analysis to be 1.7 per cent (95 per cent confidence interval 0.71 to 4.0 per cent). A DNA probe analysis, which is less sensitive than PCR, detected infection in three of the five PCR-positive ticks. The remaining infections were below the detection limit of the DNA probe, which is approximately 70,000 organisms. This is the first evidence that a vector-wildlife cycle of transmission of C ruminantium can be maintained independently of domestic ruminants.

Susceptibility and carrier status of impala, sable, and tsessebe for Cowdria ruminantium infection (heartwater).

Three species of wild African ruminants, impala (Aepyceros melampus), sable (Hippotragus equinus), and tsessebe (Damaliscus lunatus), were experimentally inoculated with in vitro culture-derived Cowdria ruminantium organisms, the tick-borne causative agent of heartwater in domestic ruminants, to determine their susceptibility to infection. No clinical disease was observed in any of the ruminants. However, C. ruminantium was detected in the sable by the transmission of heartwater to susceptible sheep, through the tick vector Amblyomma hebraeum, at 10 and 37 days postinfection (PI). Attempts to detect infection in the impala and tsessebe by tick transmission at 54 days PI failed. The impala and tsessebe were reinoculated with C. ruminantium organisms at 146 days after the first inoculation; however, a tick transmission attempt at 66 days after the reinoculation also failed. Seroconversion, as detected by immunoblotting, was demonstrated in the sable and the tsessebe but not in the impala. The results demonstrate that sable can be carriers of C. ruminantium. The susceptibility of tsessebe and impala, however, remains undetermined.

An assessment of the economic impact of heartwater (Cowdria ruminantium infection) and its control in Zimbabwe.

Heartwater, caused by the rickettsial organism Cowdria ruminantium, is a serious constraint to livestock development in much of sub-Saharan Africa. Traditionally, the disease has been controlled by the use of chemical acaricides to control the vector tick. The University of Florida/USAID-supported heartwater research project (based in Zimbabwe) is developing a new inactivated vaccine to control the disease. In order that the vaccine is used effectively, the project has been studying the epidemiology of the disease in different livestock production systems of Zimbabwe, and evaluating the economic impact of the disease and of its future control using a vaccine such as the one under development. Initially, field studies were conducted to characterise the communal and commercial livestock-productions systems at risk from heartwater and to understand the epidemiology of the disease. The data from these studies were then applied to an infection-dynamics model of heartwater, which was used to provide estimates of disease incidence and impact under various scenarios over a period of 10 yr. Two principal outputs of the epidemiological model (cumulative annual heartwater incidence and infection-fatality proportion) were key inputs into an economics model. The estimated total annual national losses amount to Z$ 61.3 million (US$ 5.6 million) in discounted value terms over 10 yr. Annual economic losses per animal in the commercial production system (Z$ 56 discounted values) are 25 times greater than the losses in the communal system (Z$ 2.2). The greatest component of economic loss is acaricide cost (76%), followed by milk loss (18%) and treatment cost (5%). Losses in outputs other than milk (beef, traction and manure) appear to be minimal. A new vaccine has the promise of a benefit: cost ratio of about 2.4:1 in the communal and 7.6:1 in the commercial system. A control strategy based on a new vaccine would yield additional non-financial benefits to farmers and the government resulting from reductions in the use of chemical acaricides.

The control of heartwater on large-scale commercial and smallholder farms in Zimbabwe.

As part of a series of studies associated with the development of improved vaccines for heartwater (a tick-borne disease of ruminant livestock caused by Cowdria ruminantium), field surveys were carried out to assess losses associated with the disease and the costs associated with controlling it in the two main agro-ecological zones of Zimbabwe (lowveld and highveld) where heartwater is believed to be endemic and epidemic, respectively. In each zone, a cross-sectional study was performed in the main farming systems (smallholder (SH) and large-scale commercial (LSC) beef and dairy), followed by longitudinal studies in the same sectors to improve data accuracy for some parameters. Suspected heartwater-specific mortality in cattle was similar in all LSC sectors (p = 0.72) accounting for a median 1% mortality risk. Heartwater-specific mortality in SH areas was not assessed due to poor diagnostic ability of the farmers. Few LSC farms and SH households kept sheep; suspected heartwater-specific mortality in LSC sheep was 0.8% in the lowveld and 2.4% in the highveld. Goats were a major enterprise in SH areas but not on LSC farms. Suspected heartwater mortality in LSC goats was 0.8% at one site in the highveld and 17.5% on a farm in the lowveld. Application of acaricides was the major control method for heartwater and other tick-borne diseases on both SH and LSC farms. On LSC farms, plunge dipping was used most frequently and the number of acaricide applications ranged widely between 3 and 52 per year. The total cost of acaricides per head per annum was higher in highveld dairies than in highveld and lowveld beef enterprises (p = 0.03). In SH areas, cattle plunge dipping was conducted by the government with an average frequency of 8 +/- 2 (sd) immersions per annum in both the lowveld and highveld. The type of tick control on sheep and goats in all production systems was highly variable (ranging from none to hand removal or intensive acaricide treatment). Suspected heartwater cases on LSC farms were treated with tetracyclines; treatment was not reported in SH areas. Reported treatment costs were high (median Z$ 120) and highly variable (range Z$-833). Vaccination against heartwater with the live, blood-based vaccine was reported on only one LSC farm. LSC farms applying acaricide 30 or more times per year reported higher morbidity (p < 0.0001) and mortality (p < 0.0001) than farms applying acaricides less than 30 times a year. This finding supports the use of reduced tick control in the management of heartwater in Zimbabwe.

The distribution of heartwater in the highveld of Zimbabwe, 1980-1997.

Heartwater, the tick-borne disease caused by the rickettsia Cowdria ruminantium has historically been confined to the southern and western lowvelds of Zimbabwe. Since 1986, however, cases of heartwater have been diagnosed with increasing frequency in the central and eastern regions of the previously heartwater-free highveld plateau. During the same period, collections of the two major tick vectors of heartwater in Zimbabwe, Amblyomma hebraeum and Amblyomma variegatum, were made for the first time in these areas, suggesting that spread of these ticks was responsible for the changed distribution of the disease. The factors associated with this spread have not been determined, but increased cattle and wildlife movement and reduced intensity of dipping undoubtedly play important roles. Currently, the distribution of heartwater and its vectors in the highveld is still largely restricted to the central and eastern regions. The northern regions of the highveld appear to be predominantly uninfected, though it is likely that, eventually, heartwater will spread further with considerable impact on livestock production in Zimbabwe.

Investigating the epidemiology of heartwater (Cowdria ruminantium infection) by means of a transmission dynamics model.

A mathematical model of the transmission dynamics of Cowdria ruminantium by the ixodid tick Amblyomma hebraeum in the bovine host is developed and used to investigate the epidemiology of heartwater across a range of vector challenge. The processes described are supported by empirical data. The pattern of outcome measures (incidence, case-fatality and proportion of infected hosts) predicted agrees with those described anecdotally from field experience and empirical observation, and demonstrates the concept of endemic stability. The underlying theory is explored and it is shown that endemic stability may be due principally to the protection of calves against disease by either innate or maternally derived factors. The role of vertical infection in the establishment and maintenance of endemic stability is also investigated. Although increasing the vertical infection proportion results in endemic stability occurring at progressively lower levels of tick challenge, the concomitant reduction in incidence and case-fatality predictions across the range of tick challenge means the endemically stable state simultaneously becomes less discernible. Model limitations and future developments are discussed. The essential role of a transmission dynamics model in assessing the impact of new vaccines in conjunction with vector control programmes is highlighted.