Nurses' knowledge of the management of diabeticpatients at Juba Teaching Hospital

Introduction: Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycaemia and is a major health problem. The International Diabetes Federation (IDF) estimated that there were 425 million people with diabetes in the world in 2017 with the number rising most rapidly in middle- and low-income countries. The prevalence of DM in Juba City in 2017 was reported to be 11.8%.Objective: To assess nurses' knowledge of the management of diabetic patients and factors associated with it in Juba Teaching Hospital - the only referral hospital in South Sudan.Method: This was descriptive cross-sectional study, carried out in March 2018, in which 40 nurses were randomly selected. Data were collected using a pre-tested questionnaire and analysed using SPSS version 20 for Windows software. Results: Of the 40 participants 31(77.5%) were females. The mean age was 35.6±10.7 years and median work experience was 9 years and 10 months; overall 57.6% of the participants correctly answered the questions on diabetic care. The factors cited for poor management of diabetic patients included lack of hospital guidelines (47.5%), insufficient salary to motivate staff (77.5%), inadequate nurse to patient ratio for good patient care (60.0%), and no resources for special training (57.5%). Conclusion: Many nurses in JTH have inadequate knowledge for diabetic management and most are interested in receiving more training

Temporal trends in the incidence of HIV infection in antenatal clinic attendees in Addis Ababa, Ethiopia, 1995-2003.

BACKGROUND: The HIV incidence data are relevant in depicting the current dynamics and trend of the epidemic. Using a new laboratory method for HIV-1 incidence, we aimed at estimating a 10-year trend in HIV-1 incidence in Addis Ababa, Ethiopia. METHODS: We determined the temporal trends in HIV incidence based on a total of 7744 serum specimens from pregnant women who attended antenatal clinics in Addis Ababa between 1995 and 2003. HIV incidence was determined by IgG-capture HIV-1 BED incidence enzyme immunoassay following a validation using a well-characterized panel of serial serum specimens from subtype C-infected seroconverters. FINDINGS: Of the 1350 HIV+ specimens tested as part of the annual sentinel survey between 1995 and 2003, a total of 1332 (98.7%) were tested by BED HIV-1 incidence assay. The incidence rate of HIV-1 infection declined significantly from 7.7% (95% CI, 3.9-11.5%) in 1995 to 2.0% (95% CI, 0.7-3.3%) in 2003. Although there was a trend, amongst the age group of 15-29 years, in age-specific decline in incidence, it was not statistically significant. No change in HIV incidence rate was observed for the group aged above 30 years. INTERPRETATION: A corresponding decline in the incidence of HIV infection was observed with the decline in the prevalence of HIV infection between 1995 and 2003 in Addis Ababa City. Whether the declines were because of changes in sexual behaviours or other reasons needs to be explored. The BED HIV-1 incidence assay provides a valuable tool in obtaining information on recent HIV-1 infection.

A comparative study of the fluorescent antibody test for rabies diagnosis in fresh and formalin-fixed brain tissue specimens.

Many diagnostic methods have been used to detect rabies virus antigen. The preferred method for routine diagnosis of rabies in fresh or frozen brain tissues is the fluorescent antibody test (FAT). In this study, the FAT was used to evaluate the rabies status of fresh/frozen brain specimens from more than 800 rabies-suspected cases, in more than 14 different species of animals. A comparable brain specimen from each case was fixed in 10% buffered formalin and examined by the FAT. The evaluation of rabies status between fresh and formalin-fixed tissues was in agreement in more than 99.8% of the cases. When fresh tissue is not available for testing, these results validate the use of this procedure for routine diagnosis of rabies in formalin-fixed brain tissues.

Immunogenicity and efficacy of Fermi-type nerve tissue rabies vaccine in mice and in humans undergoing post-exposure prophylaxis for rabies in Ethiopia.

Rabies is an acute viral encephalitis that is invariably fatal following the manifestations of clinical signs. To subvert the course of the disease, rabies post-exposure prophylaxis (PEP) is widely utilized. The immunogenicity and efficacy of Fermi-type rabies vaccine produced in Ethiopia was determined in mice subjected to intracranial challenge with rabies virus, and in humans undergoing rabies PEP in Ethiopia. Mice were randomly assigned into 5 groups. Group 1 received 0.25 ml each of phenolized saline intraperitoneally for 14 consecutive days. Mice in groups 2-5 received 0.25 ml of rabies vaccine for human PEP for the same period of time. Blood samples were drawn from the retro-orbital vein of all mice on designated days for the determination of rabies virus neutralizing antibody (VNA) using the mouse serum neutralization test. Mice were subsequently challenged intracranially with rabies virus at a concentration of 64 MICLD50 90 days post initial vaccination. Rabies neutralizing antibody titers in the sera of immunized mice ranged from 4.6 to 25 IU/ml. Booster vaccine doses did not seem to induce significant increases in the immune response of vaccinated mice, all of whom withstood intracranial challenge with rabies virus. Rabies VNA was further determined in 12 patients vaccinated in accordance with the prescribed dosage of Fermi-type vaccine for human rabies PEP. Most had > 0.5 IU/ml of rabies VNA by day 14, and none detectable at day 1. In contrast to mice, booster doses of vaccine may contribute to slightly higher rabies VNA titers in humans but our small sample size, on top of significant defaulter rates in the study participants, limits our interpretation of the effects of booster vaccine doses. The results of this study are the first documentation of the efficacy and immunogenicity of the Ethiopian Fermi type nerve tissue vaccine in both humans and mice.

An evaluation of immunofluorescence and PCR methods for detection of rabies in archival Carnoy-fixed, paraffin-embedded brain tissue.

Direct immunofluorescence and PCR detection methods were compared for sensitivity in evaluating the rabies status of archival specimens of Carnoy-fixed, paraffin-embedded brain tissue. The material consisted of 23 samples obtained during a rabies outbreak in Finland in 1988, and one sample isolated from a bat researcher who died of rabies in Finland in 1985. These results were compared with the original diagnoses performed on the fresh tissues. The immunofluorescence assay detected 100% (12/12) of the rabies-positive archival cases. A PCR assay designed to detect a 139-bp target near the 5' end of the rabies nucleoprotein gene also detected 100% (12/12) of the samples identified as positive in the fresh tissue specimens. A PCR assay designed to detect a 304-bp target spanning the 139-bp target of the first assay detected only 67% (8/12) of the original cases. No false positives were recorded. Both immunofluorescence detection of antigen and PCR detection of a short region of the nucleoprotein gene are useful in determining the rabies status of fixed, paraffin embedded (archival) material.

Use of anti-glycoprotein monoclonal antibodies to characterize rabies virus in formalin-fixed tissues.

Seventy anti-rabies virus monoclonal antibodies (Mabs) were tested for reactivity with rabies and rabies-related viruses in formalin-fixed (FF) tissues. Forty-three of the Mabs were directed against the glycoprotein and 27 were directed against the nucleocapsid as determined by enzyme immunoassays and neutralization tests. Twenty of the anti-glycoprotein Mabs and one of the anti-nucleocapsid Mabs reacted with the rabies challenge virus strain (CVS) in FF tissue. These 21 Mabs were screened against other lyssaviruses in FF tissues: five rabies virus strains (coyote, skunk, raccoon, red bat, and silver-haired bat), and four rabies-related viruses (Australian bat lyssavirus, Duvenhage virus, Lagos bat virus, and Mokola virus). One of the anti-glycoprotein Mabs was reactive with all the virus strains screened. Another of the anti-glycoprotein Mabs reacted with all of the rabies virus strains tested, but not with any of the rabies-related virus strains tested. The remaining Mabs had reactivity patterns that could be useful for characterizing lyssaviruses in FF tissues.

Epidemiology of human rabies in the United States, 1980 to 1996.

PURPOSE: To summarize the epidemiologic, diagnostic, and clinical features of the 32 laboratory-confirmed cases of human rabies diagnosed in the United States from 1980 to 1996. DATA SOURCES: Data were obtained from case reports of human rabies submitted to the Centers for Disease Control and Prevention by state or local health authorities. STUDY SELECTION: All cases of human rabies reported in the United States from 1980 to 1996 in which infection with rabies virus was confirmed by laboratory studies. DATA EXTRACTION: Patients were reviewed for demographic characteristics, exposure history, rabies prophylaxis, clinical presentation, treatment, clinical course, diagnostic laboratory tests, identification of rabies virus variants, and the number of medical personnel or family members who required postexposure prophylaxis after coming in contact with an exposed person. DATA SYNTHESIS: 32 cases of human rabies were reported from 20 states. Patients ranged in age from 4 to 82 years and were predominantly male (63%). Most patients (25 of 32) had no definite history of an animal bite or other event associated with rabies virus transmission. Of the 32 cases, 17 (53%) were associated with rabies virus variants found in insectivorous bats, 12 (38%) with variants found in domestic dogs outside the United States, 2 (6%) with variants found in indigenous domestic dogs, and 1 (3%) with a variant found in indigenous skunks. Among the 7 patients with a definite exposure history, 6 cases were attributable to dog bites received in foreign countries and 1 was attributable to a bat bite received in the United States. In 12 of the 32 patients (38%), rabies was not clinically suspected and was diagnosed after death. In the remaining 20 cases (63%), the diagnosis of rabies was considered before death and samples were obtained specifically for laboratory confirmation a median of 7 days (range, 3 to 17 days) after the onset of clinical signs. Of the clinical differences between patients in whom rabies was diagnosed before death and those in whom it was diagnosed after death, the presence of hydrophobia or aerophobia was significantly associated with antemortem diagnosis (odds ratio, 11.0 [95% CI, 1.05 to 273.34]). The median number of medical personnel or familial contacts of the patients who received postexposure prophylaxis was 54 per patient (range, 4 to 179). None of the 32 patients with rabies received postexposure prophylaxis before the onset of clinical disease. CONCLUSIONS: In the United States, human rabies is rare but probably underdiagnosed. Rabies should be included in the differential diagnosis of any case of acute, rapidly progressing encephalitis, even if the patient does not recall being bitten by an animal. In addition to situations involving an animal bite, a scratch from an animal, or contact of mucous membranes with infectious saliva, postexposure prophylaxis should be considered if the history indicates that a bat was physically present, even if the person is unable to reliably report contact that could have resulted in a bite. Such a situation may arise when a bat bite causes an insignificant wound or the circumstances do not allow recognition of contact, such as when a bat is found in the room of a sleeping person or near a previously unattended child.

Effects of carbohydrate modification of Quillaja saponaria Molina QH-B fraction on adjuvant activity, cholesterol-binding capacity and toxicity.

The iscom is an efficient antigen-presenting system for various antigens inducing both MHC class I and class II restricted immune responses. Protective immunity has been evoked against a variety of infectious agents. The saponin adjuvant Quil A, which was originally used to form iscoms, is composed of a mixture of structurally similar triterpenoids from Quillaja saponaria Molina having different biological activities. A purified, toxic Quillaja triterpenoid fraction with strong adjuvant activity, designated QH-B, was used to study whether modification of the carbohydrate moiety with sodium periodate would alter the toxicity without harming adjuvant activity and cholesterol-binding capacity. Most sugars, and in particular Api, Gal and Xyl, were modified by periodate treatment with only minor changes of the molecular weights indicating no loss of sugar residues. The adjuvant activity of QH-B was reduced in a dose-related manner, and at a concentration of 25 mM sodium periodate a significant reduction in toxicity was observed. The differences in both toxicity and adjuvant activity of the periodate-treated QH-B could be derived from alterations in the structure of the sugars Gal and Xyl, while modification of Api may influence adjuvant activity but not toxicity in vivo. The cholesterol-binding capacity, a prerequisite for iscom formation, was not affected by periodate oxidation at the doses tested. However, the use of modified QH-B as described in the present study for iscom-matrix formation resulted in "saponin-lipid complexes" which, to a various degree or totally, deviated from the characteristic iscom morphology.

Procedures for reproducible detection of rabies virus antigen mRNA and genome in situ in formalin-fixed tissues.

Procedures allowing the reproducible in situ detection of rabies virus antigen and RNAs (both genome and message) in formalin-fixed tissue are described. These procedures can be used on sequential tissue sections and thereby permit comparison of results from tests detecting both antigen and RNA in the same tissue. This antigen-detecting procedure has also been used to identify both the phylogenetically distant rabies viruses from silver-haired bat and vampire bat and the rabies-related viruses Mokola, Duvenhage, and Lagos bat. One of the critical steps in these procedures is the digestion (and the resulting exposure of the target molecules) with proteinase K. These methods may be useful for the identification of other viruses of public health importance. Because in many situations only formalin-fixed tissue is available for postmortem diagnosis, the technical ability to identify a virus antigen and nucleic acid in such tissues greatly extends potential diagnostic capabilities.

Molecular characterization of carrier rabies isolates.

We compared the genomes of nine dog rabies virus isolates using two molecular methods. The viruses used in the comparison included three Ethiopian rabies strains from carrier dogs, a street strain from a rabid dog from the same geographic area, two saliva isolates made from an experimentally infected carrier dog, the virus isolated from the tonsil of this carrier dog at necropsy, and two laboratory strains. We produced overlapping polymerase chain reaction (PCR) segments spanning 97% of the genome. Restriction analysis of these PCR products with AvaII, Bcll, and BamHI detected 39 variable sites representing 668 nucleotides (nt) or 5.5% of the genome. We also compared the DNA and the deduced peptide sequences of a 200-nt segment of the 3' end of the rabies nucleoprotein gene. Previous work with these Ethiopian carrier viruses and the endemic street strain had failed to show any differences among them. Both restriction mapping and sequence analysis of 200 nt of the nucleoprotein gene allowed us to individually identify these isolates. Phylogenetic analyses of these data sets showed only the two saliva isolates of the experimentally infected carrier dog to be identical. Each of the viruses in this study, including the one isolated from the tonsil of the experimentally infected carrier dog, could be distinguished by these techniques.

Immunogenicity, efficacy and safety of an oral rabies vaccine (SAG-2) in dogs.

A study of immunogenicity and efficacy of Street Alabama Gif (SAG-2) attenuated rabies virus vaccine in laboratory beagles was conducted. Four groups of ten dogs each received either 1.0 ml of SAG-2 orally on the tongue or 1.5 ml in baits. On day 180 postvaccination, all dogs were challenged with a street rabies virus. The antibody response in groups that received the vaccine directly on the tongue was higher than in those vaccinated with baits, but the difference between groups was not statistically significant. All vaccinated dogs survived, whereas 80% of controls died of rabies. Our findings demonstrate that the SAG-2 is a safe and effective vaccine for oral immunization of canines.

Possible human-to-human transmission of rabies in Ethiopia.

This report describes two unusual human rabies patients, a 41 year old woman and a 5 year old boy. The only known source of exposure for both patients was to family members who died of rabies. The clinical histories of these two patients suggest the possibility of naturally occurring human-to-human transmission of rabies.

The ascension of wildlife rabies: a cause for public health concern or intervention?

The epidemiology of rabies in the United States has changed substantially during the last half century, as the source of the disease has changed from domesticated animals to wildlife, principally raccoons, skunks, foxes, and bats. Moreover, the changes observed among affected wildlife populations have not occurred without human influence. Rather, human attraction to the recreational and economic resources provided by wildlife has contributed to the reemergence of rabies as a major zoonosis. Although human deaths caused by rabies have declined recently to an average of one or two per year, the estimated costs associated with the decrease in deaths amount to hundreds of millions of dollars annually. In future efforts to control rabies harbored by free-ranging animal reservoirs, public health professionals will have to apply imaginative, safe, and cost-effective solutions to this age-old malady in addition to using traditional measures.

Adjuvant activity of non-toxic Quillaja saponaria Molina components for use in ISCOM matrix.

It is well established that ISCOMs function efficiently as an antigen-presenting system and protective immunity has been evoked against a variety of infectious agents. The built-in saponin adjuvant from Quillaja saponaria Molina is responsible for the strong immunoenhancing activity displayed by the ISCOM. However, to allow the use of ISCOMs in human vaccines it is necessary to determine the immunological properties and toxicity of chemically defined Quillaja components. Thus, the present study was carried out in a mouse model to determine the adjuvant activity and toxicity of "free", isolated Quillaja components, as well as formulated into particles, i.e. ISCOM matrix. The purified Quillaja components and the ISCOM matrix formulations were examined for their adjuvant activity in a model system consisting of purified influenza virus antigen and Quillaja saponins. It was demonstrated that a Quillaja component, designated QH-C, either as a "free" component or in an ISCOM matrix, has a strong adjuvant activity, but little or no toxicity in the doses tested. In addition, QH-C in the form of ISCOM matrix does not induce any local reactions at the site of injection. Thus, ISCOMs containing the QH-C component, devoid of toxicity, but with strong adjuvant activity, can prove to be useful in adjuvant formulations for human use.

Immunogenicity of rabies vaccines used during an urban epizootic of rabies in Mexico.

From 1 July 1987 to 31 December 1988, 30% of 247 rabid dogs in Hermosillo, Mexico had a positive history of rabies vaccination. Serosurveys suggested that inactivated suckling mouse brain vaccine (INACT-SMBV) and inactivated tissue culture vaccine (INACT-TC) used before and during the epizootic were poor immunogens. Prospective studies showed that only about one-third of dogs vaccinated with INACT-SMBV were seropositive 5 weeks after vaccination. Lack of vaccine potency was the most likely cause of poor immunogenicity. Rabies vaccines should be evaluated periodically by measuring antibody responses in animals. In some circumstances, minimum seroconversion rates and antibody titres in vaccinated animals may be better measures of immunogenicity than relative potency.

Canine rabies.

Dog rabies is still epizootic in most countries of Africa, Asia and South America and in these countries dogs are responsible for most human deaths from the disease. The incubation period in dogs may vary from one week to several months and may be influenced by the site of infection and the virus dose and strain. Diagnosis by clinical signs alone is inadequate since many rabid dogs develop dumb rabies which can easily be overlooked and others die without showing signs of rabies. Rabies virus may be excreted in the saliva before clinical signs appear and may lead to infection of an unsuspecting and untreated bite victim. Dogs may recover from clinical rabies and may then intermittently excrete virus in the saliva. Prevention of human rabies depends on the control of canine rabies which can only be achieved by mass-immunization and control of stray dog populations.

Comparisons of nucleotide and deduced amino acid sequences of the glycoprotein genes of a Chinese street strain (CGX89-1) and a Chinese vaccine strain (3aG) of rabies virus.

We analyzed the glycoprotein gene sequences of a Chinese street rabies virus strain (CGX89-1) and a Chinese human rabies vaccine strain (3aG). The complete glycoprotein gene sequence of each strain has 1575 nucleotides and encodes a polypeptide of 524 amino acids. The overall nucleotide homology of these glycoprotein genes is 84.5%, and the deduced amino acid homology is 89.5%. Twenty-one percent of the base changes result in amino acid substitutions. Comparison of the homologies of the glycoprotein genes showed that the most conserved region is the ectodomain, whereas the most variable regions are the transmembrane and cytoplasmic domains. The overall nucleotide homologies of the 3aG glycoprotein and the CGX89-1 glycoprotein compared with the Pasteur virus glycoprotein are 91.2% and 84.1% respectively. The glycoprotein gene sequences presented here, the first from isolates of Chinese origin, provide insights into the biologically significant regions of this rabies gene.

Surveillance for lesions of bovine spongiform encephalopathy in U.S. cattle.

The appearance of bovine spongiform encephalopathy (BSE) as a new disease of cattle in 1985-1987 increased worldwide interest in various aspects of human and animal spongiform encephalopathies. In the United States, a part of the surveillance effort has been directed toward prospective examination of bovine brain specimens for lesions of BSE. One focus area has been to obtain specimens from cattle that (1) are two years of age or older, (2) have documented signs of neurologic disease, and (3) have received protein supplement as a substantial part of the i.v. ration. Another focus area has been to examine rabies-suspect cases that were rabies-negative. A third area has been to obtain the results of bovine neuropathology examinations being conducted at other state and regional laboratories. Specimens have been obtained by direct submission and by referral from other public health and veterinary diagnostic laboratories. Many of the cases have been classified as having (1) inflammatory lesions such as listeriosis, pseudorabies, brain abscesses and inflammation of undetermined cause, (2) degenerative lesions such as polio-encephalomalacia, lead poisoning, Wallerian degeneration, siderocalcinosis, and lipofuscinosis, (3) neoplastic lesions such as meningioma and Schwannoma, and (4) no significant findings. Other case results were reported as inflammation or no significant findings. Of the 459 cases reported here none has contained lesions with the characteristics and distribution typical of BSE.

Sickness and recovery of dogs challenged with a street rabies virus after vaccination with a vaccinia virus recombinant expressing rabies virus N protein.

Dogs were vaccinated intradermally with vaccinia virus recombinants expressing the rabies virus glycoprotein (G protein) or nucleoprotein (N protein) or a combination of both proteins. The dogs vaccinated with either the G or G plus N proteins developed virus-neutralizing antibody titers, whereas those vaccinated with only the N protein did not. All dogs were then challenged with a lethal dose of a street rabies virus, which killed all control dogs. Dogs vaccinated with the G or G plus N proteins were protected. Five (71%) of seven dogs vaccinated with the N protein sickened, with incubation periods 3 to 7 days shorter than that of the control dogs; however, three (60%) of the five rabid dogs recovered without supportive treatment. Thus, five (71%) of seven vaccinated with the rabies N protein were protected against a street rabies challenge. Our data indicate that rabies virus N protein may be involved in reducing the incubation period in dogs primed with rabies virus N protein and then challenged with a street rabies virus and, of more importance, in subsequent sickness and recovery.

An immune stimulating complex (ISCOM) subunit rabies vaccine protects dogs and mice against street rabies challenge.

Dogs and mice were immunized with either a rabies glycoprotein subunit vaccine incorporated into an immune stimulating complex (ISCOM) or a commercial human diploid cell vaccine (HDCV) prepared from a Pitman Moore (PM) rabies vaccine strain. Pre-exposure vaccination of mice with two intraperitoneal (i.p.) doses of 360 ng ISCOM or 0.5 ml HDCV protected 95% (38/40) and 90% (36/40) of mice, respectively, against a lethal intracerebral (i.c.) dose with challenge virus strain (CVS). One 360 ng i.p. dose of ISCOM protected 87.5% (35/40) of mice against i.c. challenge with CVS. Three groups of five dogs were vaccinated intramuscularly (i.m.) with 730 ng of rabies ISCOM prepared from either the PM or the CVS rabies strains, and they resisted lethal street rabies challenge. Postexposure treatment of mice with three or four 120 ng i.m. doses of ISCOM protected 90% (27/30) and 94% (45/48), respectively, of mice inoculated in the footpad with street rabies virus, but three doses of HDCV conferred no protection. When four doses of HDCV were administered postexposure, 78% (32/41) of the mice died of anaphylactic shock; 21% (11/52) of mice had already died of rabies 4 days after the third vaccine dose was administered.