Evaluación de la calidad del diagnóstico de malaria en la red local de laboratorios y en los laboratorios intermedios en el contexto de la eliminación de la enfermedad en Ecuador / Quality evaluation of malaria diagnosis in the local laboratories network and in intermediate laboratories in a setting towards the disease elimination in Ecuador

Resumen Introducción. El cumplimiento de la meta de eliminación de la malaria en Ecuador en el 2020 exige contar con la capacidad requerida para el diagnóstico microscópico ajustado a los estándares de calidad de la Organización Mundial de la Salud (OMS) y de la Organización Panamericana de la Salud (OPS) y proveer el tratamiento adecuado a los pacientes. Objetivo. Conocer la idoneidad o competencia de los microscopistas de la red pública local para el diagnóstico parasitológico de la malaria y el desempeño de los laboratorios intermedios de referencia. Materiales y métodos. Se hizo un estudio descriptivo de corte transversal a partir de la información obtenida en los talleres de evaluación de idoneidad en el diagnóstico microscópico de la red de laboratorios en las coordinaciones zonales de salud utilizando un panel de láminas para evaluar la concordancia del diagnóstico. Además, se calificó el desempeño de los laboratorios intermedios en el diagnóstico en el marco del programa de evaluación externa del desempeño. Los resultados se compararon con los obtenidos por el laboratorio supranacional de Perú. Resultados. En los 11 talleres realizados, se evaluó la idoneidad de 191 microscopistas, de los cuales 153 (80,1 %) aprobaron las pruebas. Las medianas de los indicadores fueron las siguientes: concordancia entre la detección y el resultado, 100 % (Q1- Q3: 96-100); concordancia en la especie, 100 % (Q1- Q3: 93-100); concordancia en el estadio, 93,0 % (Q1- Q3: 86-95) y concordancia en el recuento, 77 % (Q1- Q3: 71-82). En el programa de evaluación externa de desempeño, los tres laboratorios intermedios obtuvieron una concordancia del 100 % en el resultado y una del 96 % en la especie. Conclusiones. Los indicadores de competencia de la red local y de desempeño de los laboratorios intermedios alcanzaron altos estándares de calidad acordes con el proceso de entrenamiento implementado en el país.

Abstract Introduction: To reach the goal of malaria elimination in Ecuador for the year 2020, it is necessary to have a laboratory network with the capacity to perform microscopic diagnosis according to the WHO/PAHO quality standards and to provide the adequate treatment of cases. Objective: To determine the level of competence for parasitological diagnosis of the microscopists from the local public network and the performance of intermediate reference laboratories. Materials and methods: We conducted a cross-sectional study based on the information collected in workshops carried out to appraise the competence for microscopic diagnosis of the local laboratory network (zonal health coordinating offices 1 to 8) using a slide panel to evaluate diagnosis agreement, as well as the diagnostic performance of the intermediate laboratories using an external quality assessment program. The results were compared against the reference standards of the supranational laboratory in Perú. Results: We evaluated the competencies of 191 microscopists in 11 workshops and 153 (80.1%) of them were approved. The medians of the indicators were the following: concordance for parasite detection, 100% (Q1- Q3: 96-100), concordance for species identification, 100% (Q1- Q3: 93-100), and concordances for stage identification, 93.0% (Q1- Q3: 86-95) and parasite counting, 77.0% (Q1- Q3: 71-82). In the external quality assessment, the three intermediate laboratories obtained 100% in parasite detection concordance and 96% for species detection concordance. Conclusions: The results for the primary network and the performance indicators for the intermediate laboratories showed the high-quality standards of the training program implemented in the country.

Melatonin in Chagas´ disease: Possible therapeutic value / La melatonina en la enfermedad de Chagas: Su posible valor terapéutico

Chagas' disease is a severe health problem in Latin America, causing approximately 50 000 deaths a year, with approximately 18 million infected people. About 25-30% of the patients infected with Trypanosoma cruzi develop the chronic form of the disease. The protective response against T. cruzi depends on both innate and acquired immunity involving macrophages, natural killer cells, T and B lymphocytes, and the production of proinflammatory Th-1 cytokines. In addition, an increased nitric oxide (NO) production in macrophages leading to effective microbicidal action is needed to control parasitemia. Melatonin is detectable in T. cruzi and may play a role in promoting infection whereas, when administered in high doses during the acute phase of T. cruzi infection, it can decrease parasitemia while reducing NO production. During chronic disease progression, the sustained oxidative stress concomitant to myocardial damage could be reduced by administering melatonin. It is hypothesized that the coordinated administration of a melatonin agonist like the MT1/MT2 agonist ramelteon, that lacks antioxidant activity and may not affect NO production during the acute phase, and of melatonin in doses high enough to decrease oxidative damage, to preserve mitochondrial and to prevent cardiomyopathy during the chronic phase, could be a novel add-on treatment of Chagas´ disease.

La enfermedad de Chagas es un problema grave de salud en América Latina, causando cerca de 50 000 muertes al año y unos 18 millones de infectados. Alrededor del 25-30% de los pacientes infectados con Trypanosoma cruzi desarrollan la forma crónica de la enfermedad. La respuesta de defensa ante el T. cruzi depende de la inmunidad innata y adquirida con la participación de macrófagos, células “natural killer”, linfocitos T y B, y la producción de citoquinas proinflamatorias de tipo Th-1. Además, el aumento en la producción de óxido nítrico (NO) en los macrófagos lleva a una acción microbicida eficaz necesaria para controlar la parasitemia. La melatonina es detectable en T. cruzi y podría desempeñar un papel en la promoción de la infección como lo hace en el paludismo, mientras que, cuando se administra en dosis farmacológicas altas durante la fase aguda de la infección por T. cruzi, disminuye la parasitemia, aun en presencia de una reducción de la producción de NO. Durante la progresión de la enfermedad de Chagas a la cronicidad, el estrés oxidativo aumentado con el concomitante daño miocárdico podría reducirse por la administración de melatonina, de reconocida acción antioxidante. Se propone como un nuevo enfoque complementario en el tratamiento de la enfermedad de Chagas la administración durante la fase aguda de un agonista MT1/MT2 de la melatonina como el ramelteon, que carece de actividad antioxidante y podría no afectar a la producción de NO, y de melatonina durante la fase crónica de en dosis suficientemente altas como para disminuir el daño oxidativo y prevenir la miocardiopatía.

Effect of Chloroquine Prophylaxis on Birthweight and Malaria Parasite Load among pregnant women delivering in a regional hospital in Cameroon

This survey was conducted between December, 1997 and August, 1998 at the Chantal Biya Maternity Section of the Ebolowa Provincial Hospital, Cameroon. A total of 231 parturient mothers who gave birth to 232 neonates were included in the study. Ninety-five of them (41.1 percent) took anti-malaria prophylaxis (chroloquine) in the index pregnancy, and 136 (58.9 percent) did not. Both groups were similar with respect to socio-demographic characteristics except for educational level of the mother, which was significantly higher in the group on prophylaxis (x2 = 8.05; df = 2, p = 0.02). The overall prevalence of maternal parasitaemia was 37.2 percent. The group on chloroquine (TG) experienced a lesser parasitaemia (26.3 percent) than the non-prophylactic group (CG) (44.9 percent odds ratio (OR) = 2.28, CI = 1.24 - 4.19). The proportion of women with severe parasitaemia (>4000 parasites/ul) was also lower in the TG than CG (17.6 percent vs. 7.3 percent; OR = 2.69, CI = 1.04 - 7.23). A modest reduction in low birthweight was found in the TG which was not significant (23.4 percent vs 16.0 percent; p = 0.16). In conclusion, chloroquine given to prevent malaria in pregnancy was found to be effective in reducing peripheral malaria parasitaemia, but improvement in birthweight could not be demonstrated. Among other factors, impaired biological activity of the drug at the level of the placenta where parasite sequestration frequently occurs might be the explanation. We recommend that further investigation be carried out in the study area to evaluate this finding, and if confirmed, institute appropriate changes in the present policy of chloroquine prophylaxis in pregnancy.

Vaccine development against Theileria parasite.

Bovine piroplasmosis caused by Theileria sergenti is a major cause of economical loss in grazing cattle in Japan. We found that parasite stocks and isolates consist of genetically and antigenically mixed population. To differentiate parasite populations bearing 2 allelic forms of p32, an immunodominant piroplasm surface protein, 2 sets of oligonucleotide primers were designed to amplify either of the 2 alleles by polymerase chain reaction (PCR). By using this allele-specific PCR, we found that the majority of T. sergenti-infected calves in Japan harbored mixed parasite populations with C and I type parasites. Amino acid sequence of p32 contains Lys-Glu-Lys (KEK) motif which is one of tripeptide necessary for malaria parasite to invade erythrocytes. We produced 2 vaccine candidates, recombinant baculovirus p32 and synthetic peptide containing KEK motif. Immunization of either recombinant p32 or synthetic peptide containing a KEK sequence with adjuvant resulted in low parasitemia and reduced the clinical symptoms compared to control calves. Interestingly, parasites with a p32 allelic form corresponding to one used as the immunogen were suppressed. Therefore, a cocktail vaccine containing KEK peptides derived from C and I type parasites is desired for control Theileria parasite infection in Japan.