Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique.

BACKGROUND: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. METHODS: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. RESULTS: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). CONCLUSION: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.

Performance-based incentives may be appropriate to address challenges to delivery of prevention of vertical transmission of HIV services in rural Mozambique: a qualitative investigation.

BACKGROUND: Performance-based incentives (PBIs) have garnered global attention as a promising strategy to improve healthcare delivery to vulnerable populations. However, literature gaps in the context in which an intervention is implemented and how the PBIs were developed exist. Therefore, we (1) characterized the barriers and promoters to prevention of vertical transmission of HIV (PVT) service delivery in rural Mozambique, where the vertical transmission rate is 12 %, and (2) assessed the appropriateness for a PBI's intervention and application to PVT. METHODS: We conducted 24 semi-structured interviews with nurses, volunteers, community health workers, and traditional birth attendants about the barriers and promoters they experienced delivering PVT services. We then explored emergent themes in subsequent focus group discussions (n = 7, total participants N = 92) and elicited participant perspectives on PBIs. The ecological motivation-opportunity-ability framework guided our iterative data collection and thematic analysis processes. RESULTS: The interviews revealed that while all health worker cadres were motivated intrinsically and by social recognition, they were dissatisfied with low and late remuneration. Facility-based staff were challenged by factors across the rest of the ecological levels, primarily in the opportunity domain, including the following: poor referral and record systems (work mandate), high workload, stock-outs, poor infrastructure (facility environment), and delays in obtaining patient results and donor payment discrepancies (administrative). Community-based cadres' opportunity challenges included lack of supplies, distance (work environment), lack of incorporation into the health system (administration), and ability challenges of incorrect knowledge (health worker). PBIs based on social recognition and that enable action on intrinsic motivation through training, supervision, and collaboration were thought to have the most potential for targeting improvements in record and referral systems and better integrating community-based health workers into the health system. Concerns about the implementation of incentives included neglect of non-incentivized tasks and distorted motivation among colleagues. CONCLUSIONS: We found that highly motivated health workers encountered severe opportunity challenges in their PVT mandate. PBIs have the potential to address key barriers that facility- and community-based health workers encounter when delivering PVT services, specifically by building upon existing intrinsic motivation and leveraging highly valued social recognition. We recommend a controlled intervention to monitor incentives' effects on worker motivation and non-incentivized tasks to generate insights about the feasibility of PBIs to improve the delivery of PVT services.

AFLP polymorphisms allow high resolution genetic analysis of American Tegumentary Leishmaniasis agents circulating in Panama and other members of the Leishmania genus.

American Tegumentary Leishmaniasis is caused by parasites of the genus Leishmania, and causes significant health problems throughout the Americas. In Panama, Leishmania parasites are endemic, causing thousands of new cases every year, mostly of the cutaneous form. In the last years, the burden of the disease has increased, coincident with increasing disturbances in its natural sylvatic environments. The study of genetic variation in parasites is important for a better understanding of the biology, population genetics, and ultimately the evolution and epidemiology of these organisms. Very few attempts have been made to characterize genetic polymorphisms of parasites isolated from Panamanian patients of cutaneous leishmaniasis. Here we present data on the genetic variability of local isolates of Leishmania, as well as specimens from several other species, by means of Amplified Fragment Length Polymorphisms (AFLP), a technique seldom used to study genetic makeup of parasites. We demonstrate that this technique allows detection of very high levels of genetic variability in local isolates of Leishmania panamensis in a highly reproducible manner. The analysis of AFLP fingerprints generated by unique selective primer combinations in L. panamensis suggests a predominant clonal mode of reproduction. Using fluorescently labeled primers, many taxon-specific fragments were identified which may show potential as species diagnostic fragments. The AFLP permitted a high resolution genetic analysis of the Leishmania genus, clearly separating certain groups among L. panamensis specimens and highly related species such as L. panamensis and L. guyanensis. The phylogenetic networks reconstructed from our AFLP data are congruent with established taxonomy for the genus Leishmania, even when using single selective primer combinations. Results of this study demonstrate that AFLP polymorphisms can be informative for genetic characterization in Leishmania parasites, at both intra and inter-specific levels.

Trypanosoma rangeli genotypes association with Rhodnius prolixus and R. pallescens allopatric distribution in Central America.

Previous kDNA polymorphism-based reports have revealed the existence of two Trypanosoma rangeli genotypes (KP1+ and KP1-): SL and SSU rRNA gene polymorphism-based studies have revealed that five genotypes (A-E) are distributed throughout different Latin-American countries. Some evidence has shown that the genotypes' biogeographical distribution is associated with sympatric Rhodnius species. 12 T. rangeli isolates from humans and reservoirs from El Salvador, Guatemala, Honduras, Costa Rica and Panama were characterised by kDNA and mini-exon gene intergene spacer analysis and compared to 12 previously characterised isolates from humans and vectors from Colombia, Guatemala, Honduras and Venezuela. Central American isolates corresponded to genotypes called KP1(+) or lineage A and KP1(-) or lineage C. Such dimorphism was corroborated by randomly amplified polymorphic DNA (RAPD) in 22 selected isolates; a dendrogram was thus produced having two defined branches. One branch grouped KP1(-) or lineage C strains isolated from Rhodnius colombiensis (Colombia), humans (Panama), Procyon lotor and Choloepus hoffmanni (Costa Rica). The other group was formed by KP1(+) or lineage A strains isolated from Rhodnius prolixus (Colombia, Venezuela) and humans (El Salvador, Guatemala, Honduras). These results present evidence that both groups infect different mammals (humans, domestic and silvatic animals) having no association with any particular vertebrate species; however, T. rangeli KP1(+) or (A) strains have been isolated in Central America in areas where R. prolixus circulate (Honduras, El Salvador and Guatemala) and KP1(-) or (C) strains have been isolated in areas where Rhodnius pallescens is the main vector (Panama and Costa Rica) indicating a parasite-vector association. The same lineages circulate in Andean countries (Colombia, Venezuela, Ecuador and Peru), KP1+ being associated with members of the prolixus group (R. prolixus and Rhodnius robustus) and KP1- with members of the pallescens group (R. pallescens, R. colombiensis and Rhodnius ecuadoriensis).

Phylogeography and genetic variation of Triatoma dimidiata, the main Chagas disease vector in Central America, and its position within the genus Triatoma.

BACKGROUND: Among Chagas disease triatomine vectors, the largest genus, Triatoma, includes species of high public health interest. Triatoma dimidiata, the main vector throughout Central America and up to Ecuador, presents extensive phenotypic, genotypic, and behavioral diversity in sylvatic, peridomestic and domestic habitats, and non-domiciliated populations acting as reinfestation sources. DNA sequence analyses, phylogenetic reconstruction methods, and genetic variation approaches are combined to investigate the haplotype profiling, genetic polymorphism, phylogeography, and evolutionary trends of T. dimidiata and its closest relatives within Triatoma. This is the largest interpopulational analysis performed on a triatomine species so far. METHODOLOGY AND FINDINGS: Triatomines from Mexico, Guatemala, Honduras, Nicaragua, Panama, Cuba, Colombia, Ecuador, and Brazil were used. Triatoma dimidiata populations follow different evolutionary divergences in which geographical isolation appears to have had an important influence. A southern Mexican-northern Guatemalan ancestral form gave rise to two main clades. One clade remained confined to the Yucatan peninsula and northern parts of Chiapas State, Guatemala, and Honduras, with extant descendants deserving specific status. Within the second clade, extant subspecies diversity was shaped by adaptive radiation derived from Guatemalan ancestral populations. Central American populations correspond to subspecies T. d. dimidiata. A southern spread into Panama and Colombia gave the T. d. capitata forms, and a northwestern spread rising from Guatemala into Mexico gave the T. d. maculipennis forms. Triatoma hegneri appears as a subspecific insular form. CONCLUSIONS: The comparison with very numerous Triatoma species allows us to reach highly supported conclusions not only about T. dimidiata, but also on different, important Triatoma species groupings and their evolution. The very large intraspecific genetic variability found in T. dimidiata sensu lato has never been detected in a triatomine species before. The distinction between the five different taxa furnishes a new frame for future analyses of the different vector transmission capacities and epidemiological characteristics of Chagas disease. Results indicate that T. dimidiata will offer problems for control, although dwelling insecticide spraying might be successful against introduced populations in Ecuador.

Genotyping of Panamanian Trypanosoma cruzi stocks using the calmodulin 3'UTR polymorphisms.

Mutations in the 3' untranslated region of calmodulin gene have recently been reported to be specific to different Trypanosoma cruzi lineages. In the present report, this molecular marker was used to genotype 24 T. cruzi isolates from humans and vectors from different endemic areas in Panama. The finding of solely T. cruzi I genotype might explain the low morbidity of Chagas' disease in the region when compared to other countries in Latin America.

Evaluation of serological tests to identify Trypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spp.

Five commercially available enzyme-linked immunosorbent assays (ELISAs), one in-house ELISA, and two hemagglutination assays were evaluated to determine their diagnostic accuracy for Chagas' disease in two studies. In study 1, ELISA kits showed 100% sensitivity, but specificities ranged from 82.84% to 100% when leishmaniasis cases were included and from 95.57% to 100% when leishmaniasis cases were excluded. Kits using recombinant antigens or synthetic peptides are more specific than those using crude extracts from Trypanosoma cruzi epimastigote forms. Kits evaluated in Panama, in study 2, showed 75% to 100% sensitivity and 97.12% to 100% specificity. These data were obtained by using a Western blot assay with T. cruzi trypomastigote excreted-secreted antigens as a reference test to confirm T. cruzi infection.

Molecular characterization of human Trypanosoma cruzi isolates from endemic areas in Panama.

The present work provides information on Trypanosoma cruzi genotype circulating in endemic areas of Chagas disease in Panama. A total of 26 crude stocks of T. cruzi, isolated from the blood of persons with different clinical profiles of Chagas disease were collected and crio-conserved until used. Most of the stocks had been characterized by means of isoenzyme electrophoresis on cellulose acetate membranes. The clinical profiles of infected persons included 9 (34.6%) asymptomatic and 17 acute (65.4%) including 5 (19.2%) fatal cases, 2 under 5 years old and 3 adults. A multiplex-PCR assay based on the amplification of the non-transcribed spacer of the mini-exon gene was performed. All stocks of T. cruzi included in the study were found to correspond to Tc I group. This result supports the predominance of T. cruzi-I in the transmission cycles affecting the human population in the Republic of Panama.

Molecular characterization of human Trypanosoma cruzi isolates from endemic areas in Panama

The present work provides information on Trypanosoma cruzi genotype circulating in endemic areas of Chagas disease in Panama. A total of 26 crude stocks of T. cruzi, isolated from the blood of persons with different clinical profiles of Chagas disease were collected and crio-conserved until used. Most of the stocks had been characterized by means of isoenzyme electrophoresis on cellulose acetate membranes. The clinical profiles of infected persons included 9 (34.6 percent) asymptomatic and 17 acute (65.4 percent) including 5 (19.2 percent) fatal cases, 2 under 5 years old and 3 adults. A multiplex-PCR assay based on the amplification of the non-transcribed spacer of the mini-exon gene was performed. All stocks of T. cruzi included in the study were found to correspond to Tc I group. This result supports the predominance of T. cruzi-I in the transmission cycles affecting the human population in the Republic of Panama.

Trypanosoma rangeli sialidase: lack of activity in stocks from Panama and other regions.

A total of 33 crude and cloned Trypanosoma rangeli stocks found as natural infections in human from Panama and other endemic areas of Central and South America were evaluated as producers of sialidase (SA) activity through the MU-NANA fluorescence test. Negative results were observed in 6 of the isolates: Panama (4), Honduras (1), and Brazil (1). In addition, an immunoblotting analysis confirm the presence of the SA antigen in these stocks without enzymatic activity. These findings must be considered in the interpretation of the biological significance of T. rangeli SA and in the proper characterization and identification of this parasite.

Trypanosoma rangeli sialidase: lack of activity in stocks from Panama and other regions

A total of 33 crude and cloned Trypanosoma rangeli stocks found as natural infections in human from Panama and other endemic areas of Central and South America were evaluated as producers of sialidase (SA) activity through the MU-NANA fluorescence test. Negative results were observed in 6 of the isolates: Panama (4), Honduras (1), and Brazil (1). In addition, an immunoblotting analysis confirm the presence of the SA antigen in these stocks without enzymatic activity. These findings must be considered in the interpretation of the biological significance of T. rangeli SA and in the proper characterization and identification of this parasite.

Serodiagnosis of chronic and acute Chagas' disease with Trypanosoma cruzi recombinant proteins: results of a collaborative study in six Latin American countries.

An enzyme-linked immunosorbent assay to diagnose Chagas' disease by a serological test was performed with Trypanosoma cruzi recombinant antigens (JL8, MAP, and TcPo). High sensitivity (99.4%) and specificity (99.3%) were obtained when JL8 was combined with MAP (JM) and tested with 150 serum samples from chagasic and 142 nonchagasic individuals. Moreover, JM also diagnosed 84.2% of patients in the acute phase of T. cruzi infection.

Antigenic significance of a Trypanosoma rangeli sialidase.

The Trypanosoma rangeli-secreted sialidase was purified by bovine submaxillary gland mucin-sepharose affinity chromatography. In immunoblotting analysis, antibodies raised against this molecule recognized polypeptides of 73 kDa in T. rangeli medium supernatant (TrSialr) and of 70 kDa in the cell lysates of T. rangeli (TrSials) and T. cruzi (TcSialL) epimastigotes. TrSialr, TrSials, and TcSialL were subjected to proteolytic cleavage with papain; the resultant peptide pattern displayed differences in the immunoblotting profiles. TrSials was purified by immunoprecipitation, and this protein band was recognized by sera from T. cruzi-infected chronic mice and Chagas' disease patients. In contrast, TrSialr was not recognized by these sera. The antibodies from the infected mice also recognized a band of 70 kDa present in the medium. These preliminary observations imply that the released and somatic sialidases are partially different molecules, with probably different biological roles. The related proteins recognized in T. rangeli and T. cruzi epimastigotes share many antigenic characteristics but have some structural differences, probably related to their function in the parasitic cell. On the basis of the strong antigenicity of TrSials, this molecule is proposed as the antigen for the detection of antibodies arising during T. cruzi infection.

Experimental Trypanosoma rangeli infection in a mature model

Trypanosoma rangeli experimental murine infections were performed in order to study parasitemias and anti-parasite antibody levels. Three groups of mice were used: a) mice infected with metatrypomastigotes derived from infected bugs; b) mice which received four reinoculations of metatrypomastigotes and c) mice immunosuppressed with cyclophosphamide. The results showed that bloodstream parasites can be found from the first day post inoculation reaching a peak at day 5 or 7 and then start to decline. Parasites disappeared completely from the circulation after 20-25 days. However in the immunosuppressed group, parasites were found in blood up to 45 days post infection. The humoral immune response was monitored using an ELISA test and low levels of specific IgG and IgM unoglobulins were found. However the IgG titers were lower than the IgM. One could conclude that IgM was the predominant immunoglobulin isotype induced in a T. rangeli experimental infection because the highest titers were observed in the reinoculated group. IgM antibodies also showed the most prominent crossreactivities with T. cruzi antigens

Hidatidosis poliquística hepática. Informe clínico e histopatológico del segundo caso de equinococosis autóctono en la República de Panamá / Hephatic polischistic hidatidosis. Clinic report and histopathologic in the second case of autochthonous equinoccoccosis in the República de Panamá

Se describe la historia clínica y exámenes de laboratorio efectuados en el segundo caso autóctono de hidatidosis hepática confirmado en la República de Panamá. La paciente tenía 48 años de edad y era de sexo femenino, vivía en la Provincia de Colón (María Chiquita) y nunca había salido del territorio panameño. La hidatidosis hepática que tenía era de la variedad poliquística y fértil. Sus numerosos protoscóleces fueron identificados en el material de la biopsia obtenida al momento de la laparotomía que se le practicó en el Hospital Amador Guerrero, de Colón (República de Panamá). El quiste era multifocular y estaba localizada en el lóbulo izquierdo del hígado; pero tenía también otra tumoración quística en el lóbulo derecho. Se estudió las características dimensionales y morfológicas de los "garfios" del rostellum en los protoscóceles, para la determinación de la especie patógena y se demostró que coincidían con los del Echinococcus vogeli, el cual es la más frecuente causa de hidatidosis humana en Centro y Sudamérica

Evaluación del receptor soluble de interleucina-2 en pacientes con tripanosomiasis Americana en Panamá / Evaluation of soluble receptor of inter leukin-2 in patients with Trypanosomiasis americana in Panamá

Se evalúan los niveles del receptor soluble de interleucina-2 (sIL-2R) en sueros de pacientes que presentaban la forma clínica aguda o crónica de la Enfermedad de Chagas. El valor promedio de sIL-2R observado en pacientes en fase aguda fue de 3282+-1715 u/ml., en pacientes en fase crónica fué de 511+-207 U/ml. y en sujetos controles fué de 366+-108 U/ml.. Al correlacionar los datos obtenidos con los niveles de anti-cuerpos específicos en estos pacientes observamos que títulos altos de sIL-2R (1000 U/ml. Se asociaron a la presencia de anticuerpos anti T. cruzi en infecciones recientes ó agudas. Esta correlación no fué estrictamente cuantitativa ó directamente proporcional. En pacientes crónicos con niveles elevados de anticuerpos específicos anti T. cruzi no mostraron correlación con la presencia de niveles séricos de sIL-2R, los cuales pueden ser bajos en casos crónicos de largo seguimiento. Consideramos que la presencia de niveles altos de receptor soluble de interleucina-2 se relaciona con la actividad del parásito y su interacción con el huésped. Finalmente, se discute la posibilidad del uso del sIL-2R como marcador de fase aguda y su importancia como indicador de riesgo de enfermedad

Evaluación del desarrollo de la respuesta inmunológica en pacientes con leishmaniasis cutánea / Development evaluation of the inmunologic response in patients with cutaneous leishmaniasis

Este estudio presenta datos epidemiológicos e inmunológicos sobre Leishmaniasis cutánea en Panamá, en donde la recurrencia ocurrió en un 65 (por ciento) de los casos estudiados. La evaluación del desarrollo de la respuesta inmune celular demostró, durante el curso de la evolución clínica de los casos primarios y recurrentes, que el índice de estimulación (IE) era menor de 3 en los casos recurrentes y mayores de 3 en los casos primarios. De allí la importancia de estudiar cuantitativamente la población de linfocitos secretados, para explicar la diferencia que se observa en la respuesta inmune

Evaluación de la contrainmunoelectroforesis como método de diagnóstico de la Toxoplasmosis / Counter immuno electrophoresis as a method of diagnosis of toxoplasmosis

En este trabajo se evalúa la posibilidad de utilizar la contrainmunoelectroforesis (CIE) como prueba de diagnóstico serológico de la toxoplasmosis. Un total de 959 muestras de sangre humana fueron analizadas para determinar la presencia de anticuerpos específicos contra un extracto (congelación-descongelación) de taquizoitos de Toxoplasmas gondii. Las reacciones entre este antígeno y muestras de sueros positivos, con el título de >-512 por inmunofluorescencia indirecta, se caracterizaron por la formación de una o más líneas verticales de precipitado. El suero de ratones intraperitonealmente infectados también resultó como fuente de antígeno soluble que reaccionó con sueros positivos en la misma forma. Los resultados indican que la CIE detecta niveles de anticuerpos para Toxoplasma gondii que se consideran diagnósticos de infección activa

Ciclo de vida de Panstrongylus humeralis Usinger 1939, bajo condiciones de laboratorio (Reduviiae Triatominae) / Life cycle of Panstrougylus humeralis Usinger 1939 (Reduviidae Triatominae) under laboratory conditions

Panstrongylus humeralis, vector potencial de la enfermedad de Chagas, se ha reportado solamente en la República de Panamá, específicamente en la isla de Barro Colorado, áreas aledañas al Canal de Panamá y en Bayano. En el laboratorio con temperatura de 27-C y humedad relativa (HR) de 100%, se dió seguimiento al desarrollo embrionario de 680 huevos de Panstrongylus humeralis. El desarrollo de los huevos bajo estas condiciones fue de 13 a 23 días con un promedio de 18.8 días y 100% de eclosión. Los estadios ninfales y adultos obtenidos fueron alimentados semanalmente sobre Columba livia (paloma castilla) y mantenidos a HR entre 70 y 80%. El ciclo completo de huevo a adulto demoró un promedio de 149 días bajo estas condiciones. Las ninfas de primero a quinto estadio, tuvieron una duración promedio de 17.9, 16.6, 21.6, 30.9 y 43.6 días respectivamente, estableciéndose una diferencia de 5.4 días adicionales en las ninfas de quinto estadio que evolucionaron a hembra, comparada con la duración del quinto estadio ninfal y la evolución de los machos, lo que no representó una diferencia significativa