Satisfaction of Malaria Patients with Care by Community Health Workers Trained in Microscopy: A Mixed-Methods Study in Palawan, the Philippines.

Palawan is the malaria-endemic province with the highest prevalence of malaria in the Philippines, and microscopists (community health workers) have been allowed to deliver early diagnosis and prompt treatment of malaria throughout the province since 1999. To improve the quality of care, the present mixed-methods study attempted to identify the factors associated with satisfaction of patients in Palawan with their microscopists by analyzing the patients' perspectives. First, a quantitative cross-sectional study was conducted among 48 ex-patients and their nine microscopists. Ex-patients were asked about their satisfaction with care, and microscopists were asked about their job satisfaction and ability. Structural equation modeling was conducted for data analysis. Second, a qualitative cross-sectional study was performed using narrative interviews. Data were analyzed using the NVivo 10 software program. As a result, both studies revealed high patient satisfaction with microscopists. The quantitative study showed that ex-patients' satisfaction with their microscopists was independently enhanced by two factors: high ability in malaria microscopic observation and low household wealth of the patients. Particularly, specific subpopulations (those with lower household wealth, relatively old people, and ethnic minorities) were more satisfied with the microscopists' care. The qualitative study strengthens this finding by showing that their microscopists offered prompt and precise diagnosis and effective treatment for free. In conclusion, microscopists were shown to have an important role in narrowing the disparities in malaria care in Palawan. It is important to maintain/enhance the ability of microscopists in malaria microscopy to satisfy their patients.

Factors determining job satisfaction of malaria community microscopists in Palawan, the Philippines: a cross-sectional mixed-methods study.

BACKGROUND: This study was conducted to investigate the overall job satisfaction and its associated factors among microscopists as community health workers who specialize in malaria microscopic diagnosis and treatment in Palawan, the Philippines. The study offered new insights to further lessen the burden of malaria and improve treatment by enhancing their commitment and satisfaction. METHODS: A quantitative study was conducted with 217 microscopists who were asked about their sociodemographic characteristics, ability as microscopists (service quality, knowledge of malaria and ability to diagnose malaria by microscopy [malaria microscopy]) and job satisfaction. Structural equation modelling (SEM) was conducted to analyse these factors. A qualitative study was also conducted and four focus group discussions (FGDs) were carried out. RESULTS: SEM identified that the job satisfaction of microscopists was enhanced by ability in malaria microscopy, the annual parasite index and belonging to ethnic minorities. In the FGDs, high job satisfaction was seen in their devotion to the community and increasing knowledge about malaria. CONCLUSIONS: Providing opportunities to improve malaria microscopy ability would increase the overall job satisfaction of microscopists and eventually improve the quality of care.

Entamoeba histolytica infections in a slum community in Manila, Philippines as detected by stool ELISA.

This study aimed to determine the prevalence of Entamoeba histolytica in BASECO, an urban slum community situated in Manila Harbor, Manila, Philippines using stool enzyme-linked immunosorbent assay (ELISA). It also aimed to determine if age, sex, and geographic location are contributory factors to the prevalence of E. histolytica. Stool samples were collected from 627 urban slum community residents of BASECO. Samples were viewed under light microscopy and the different parasites observed were identified. Stool ELISA was done using E. histolytica II antigen detection kits (TECHLAB®). Using E. histolytica II kits, E. histolytica had a prevalence of 9.09% (5/55) among the microscopically-positive samples for E. histolytica/E. dispar indicating a greater prevalence for the nonpathogenic species. No significant difference was observed in the prevalence of infection across all three variables: age, sex and geographic location. The overall prevalence of E. histolytica in BASECO, Manila, Philippines is 0.797% (5/627) which is lower than previous studies done on estimating the prevalence of E. histolytica using various techniques.

Evaluation of crude adult Ascaris suum intestinal tract homogenate in inducing protective IgG production against A. suum larvae in BALB/c mice.

Globally, ascariasis ranks as the second leading intestinal helminth infection. However, progress in developing better control strategies, such as vaccines, remains slow-paced. This study aims to measure antibody production and parasite load in male BALB/c mice immunized with crude Ascaris suum intestinal tract homogenate. Thirty-two (32) mice were randomized into: (1) unvaccinated, uninfected (UU); (2) unvaccinated, infected (UI); (3) vaccinated, uninfected (VU); and (4) vaccinated, infected (VI) groups. A 100-µL vaccine containing 50 µg of homogenized A. suum intestines and Complete Freund's Adjuvant (1:1) were introduced intraperitoneally. Immunizations were done on days 0, 10, and 20. Oral gavage with 1000 embryonated eggs was done on day 30. Blood was obtained at day 40. To measure serum IgG levels, indirect ELISA was done. Microtiter plates were coated with 100 µg larval homogenate, and HRP-conjugated anti-mouse IgG was used as secondary antibody. Parasite load was measured in lung and liver tissues. Tukey's HSD of signal to cut-off ratios of absorbance readings obtained in indirect ELISA procedure for the 1:200 serum dilution showed statistically significant difference between the UU and VI (p = 0.026) as well as between UI and VI (p = 0.003) groups. No statistically significant difference in parasite load was observed in the lungs (p = 0.074), liver (p = 0.130), and both lungs and liver (p = 0.101). Immunization elicited a significant larva-directed IgG production. However, there is no significant difference in parasite loads in either lung or liver tissues across all treatment groups as the larval counts obtained from the study were very low and may not be indicative of the actual parasite load in mice.

Prevalence of Entamoeba histolytica and Entamoeba dispar among residents of an urban slum area in Manila, Philippines as detected by the polymerase chain reaction.

This study aimed to determine the prevalence of Entamoeba histolytica and Entamoeba dispar infections among residents in BASECO compound, Manila, Philippines using polymerase chain reaction (PCR). Formalin-ether concentration technique (FECT)-treated stool samples were examined under the light microscope to determine the presence of Entamoeba, helminths and other protozoan parasites. DNA was directly extracted from the FECT-treated samples and was subjected to PCR to determine E. histolytica and E. dispar infections. In this study, stool samples were collected from 2,232 residents of BASECO compound. Microscopic examination of FECT concentrated samples found 38 samples (1.703%) positive for E. histolytica/E. dispar. The E. histolytica/E. dispar microscopically positive samples were further analyzed by PCR and found 8 samples (0.358%) infected with E. histolytica and 23 samples (1.030%) infected with E. dispar. No statistically significant difference was observed in the sex distribution, while statistically significant difference was observed among the age group and area distribution of both the Entamoeba species. The results demonstrate PCR using DNA extracted from the formalin-fixed stools as an effective epidemiologic detection method of E. histolytica and E. dispar infections.

Bottom-up approach to strengthen community-based malaria control strategy from community health workers' perceptions of their past, present, and future: a qualitative study in Palawan, Philippines.

BACKGROUND: Microscopists have active roles in bringing malaria diagnosis and treatment closer to households in Palawan, the highest malaria-endemic province in the Philippines. To accelerate the elimination of malaria in Palawan, we performed a study based on the bottom-up approach to provide profound data to strengthen this community-based malaria control from the microscopists' point of view. METHODS: We performed a qualitative cross-sectional study in Palawan. Four focus group discussions with 50 microscopists were conducted in Palawan from November 2010 to February 2011. During the discussions, the following open-ended questions were addressed: motivation for applying to be microscopists in the "Past" category; job satisfaction, role, problems, and saddest and happiest experiences working as microscopists in the "Present" category; and willingness towards task shifting in the "Future" category. Data were transcribed and analyzed by framework analysis using the NVivo software program. RESULTS: The present study innovatively proposed the following strategies: reinforcement strategy (adequate supplies and settings), highly prioritized additional strategies (improving social status of microscopists, issuing a travel budget, and including indigenous populations), regional additional strategies (additional malaria control in the southern region and task shifting in the northern region), and less prioritized additional strategies (employment policy and health checkup). CONCLUSION: A bottom-up approach using microscopists' perceptions would be a valuable method to propose practical and effective additional strategies for strengthening community-based malaria control.

Subtype analysis of Blastocystis sp. isolates from human and canine hosts in an urban community in the Philippines.

Blastocystis sp. is a common gut-dwelling protist of both humans and animals. A cross-sectional survey among humans and their dogs was conducted to determine the prevalence of Blastocystis infection and to characterize the subtype (ST) distribution in an urban community in the Philippines. Fecal specimens from 1,271 humans and 145 dogs were collected and inoculated in diphasic culture medium. Prevalence of Blastocystis by culture was 13.0% (95% CI = 11.2-15.0) and 14.5% (95% CI = 9.6-21.2) for humans and dogs, respectively. A total of 168 culture isolates were genotyped using polymerase chain reaction (PCR) with seven pairs of ST-specific sequence-tagged-site (STS) primers. In humans, the ST present in this study were ST1 with 22.6% (95% CI = 17.2-29.0), ST2 with 3.1% (95% CI = 1.3-6.7), ST3 with 41.4% (95% CI= 34.9-48.6), ST4 with 14.8% (95% CI = 10.5-20.6), ST5 with 4.1% (95% CI = 2.0-8.0), and unknown ST with 13.9% (95% CI = 9.6-19.4). In dogs, the ST present in this study were ST1 with 4.3% (95% CI = 0.0-29.0), ST2 with 8.7% (95% CI = 1.3-28.0), ST3 with 17.4% (95% CI = 6.4-37.7), ST4 with 13.0% (95% CI = 3.7-33.0), ST5 with 13.0% (95% CI = 3.7-33.0), and unknown ST with 47.8% (95% CI = 29.2-67.0). This is the first study that reported Blastocystis ST4 in human and canine hosts in the Philippines.

Epidemiologic Study of Blastocystis Infection in an Urban Community in the Philippines.

Blastocystis has been considered as the most common intestinal parasite in humans and has an augmented impact on public health. However, the prevalence of this parasite in the Philippines has not been determined. To contribute to a better understanding of the epidemiology of this infection, a cross-sectional study aimed at providing the first documented data on the prevalence and correlates, sociodemographic factors, hygiene practices, source of water supply, and dog ownership, associated with Blastocystis infection was carried out in randomly selected communities at Pateros, Metro Manila. Fecal samples from respondents were collected and cultured in diphasic agar medium for 3-7 days and examined using light microscopy. Of the 1,271 respondents, 12.98% (95% CI: 11.13-14.83) were detected positive for Blastocystis. Among the correlates of Blastocystis infection, dog ownership was found significantly associated as confirmed by multivariate analysis. Therefore, this factor should be considered in information to create awareness about Blastocystis and to prevent and control Blastocystis infection in particular and diarrheal diseases in general. Further studies using molecular approaches to distinguish subtype and to determine genetic characteristics of isolates from humans and dogs are recommended to analyze their relationship and provide more conclusive evidence of cross-transmission.

Patient Knowledge on Malaria Symptoms Is a Key to Promoting Universal Access of Patients to Effective Malaria Treatment in Palawan, the Philippines.

INTRODUCTION: Palawan, where health care facilities are still limited, is one of the most malaria endemic provinces in the Philippines. Since 1999, microscopists (community health workers) have been trained in malaria diagnosis and feasibility of early diagnosis and treatments have been enhanced throughout the province. To accelerate the universal access of malaria patients to diagnostic testing in Palawan, positive health seeking behavior should be encouraged when malaria infection is suspected. METHODS: In this cross-sectional study, structured interviews were carried out with residents (N = 218) of 20 remote malaria-endemic villages throughout Palawan with a history of suspected malaria from January to February in 2012. Structural equation modeling (SEM) was conducted to determine factors associated with appropriate treatment, which included: (1) socio-demographic characteristics; (2) proximity to a health facility; (3) health seeking behavior; (4) knowledge on malaria; (5) participation in community awareness-raising activities. RESULTS: Three factors independently associated with appropriate treatment were identified by SEM (CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = .000): "living near microscopist" (p < 0.001), "not living near private pharmacy" (p < 0.01), and "having severe symptoms" (p < 0.01). "Severe symptoms" were positively correlated with more "knowledge on malaria symptoms" (p < 0.001). This knowledge was significantly increased by attending "community awareness-raising activities by microscopists" (p < 0.001). CONCLUSIONS: In the resource-limited settings, microscopists played a significant role in providing appropriate treatment to all participants with severe malaria symptoms. However, it was considered that knowledge on malaria symptoms made participants more aware of their symptoms, and further progressed self-triage. Strengthening this recognition sensitivity and making residents aware of nearby microscopists may be the keys to accelerating universal access to effective malaria treatment in Palawan.

Determining the impact of community awareness-raising activities on the prevention of malaria transmission in Palawan, the Philippines.

Palawan has the highest malaria endemicity in the Philippines, and malaria remains a major health burden in the region. In 1999, 344 microscopists were trained in Palawan. This allowed for early diagnosis and prompt treatment throughout the island. To take a significant step toward the elimination of malaria on the island, microscopists implemented community awareness-raising activities aimed at preventing transmission of malaria. The objective of the present study was to determine the impact of these activities on the self-implemented preventive measures against malaria by the ex-patients of the microscopists. Structured interviews were carried out from January to February in 2012, in 20 remote malaria-endemic villages throughout Palawan. In total, 141 ex-patients who had previously been diagnosed malaria-positive by the microscopists, volunteered to participate in the present study. Structural equation modeling was conducted to determine factors associated with self-implemented preventive measures against malaria, which included: (1) place of residence; (2) socio-demographic characteristics; (3) knowledge on malaria; (4) participation in community awareness-raising activities for malaria prevention; and (5) satisfaction with microscopists. Structural equation modeling identified six significant factors independently associated with self-implemented preventive measures against malaria; ethnicity, knowledge on malaria transmission, knowledge on vector species, knowledge on vector's most active time, participation in awareness-raising activities for malaria prevention by microscopists, and satisfaction with microscopists. Tagalog ethnicity (the predominant ethnic group) was positively related to better self-implemented preventive measures. In conclusion, aside from providing early diagnosis and treatment, microscopists played a significant role in self-implemented preventive measures against malaria. The strengthening of awareness-raising activities by microscopists was suggested to be an effective strategy for reducing malaria re-infection in Palawan. These activities should be strengthened to improve preventive measures implemented by ex-patients traveling to mountain areas and to enhance the knowledge on malaria transmission particularly among indigenous residents.

Determining the active role of microscopists in community awareness-raising activities for malaria prevention: a cross-sectional study in Palawan, the Philippines.

BACKGROUND: Malaria remains one of the most prevalent and fatal diseases among the inhabitants of Palawan in the Philippines. Palawan, where healthcare services remain limited, has the highest malaria endemicity in the country. To eliminate malaria, effective prevention measures should be conducted alongside early diagnosis and prompt treatment, which are the major tasks of the trained microscopists in Palawan. However, while the microscopists have implemented community awareness-raising activities aimed at preventing transmission of malaria, the nature and quality of these activities have not been evaluated. The present study identified the factors associated with the strengthening of community awareness-raising activities for malaria prevention implemented by microscopists in Palawan. METHODS: A cross-sectional study was conducted among 127 microscopists in Palawan. Data were collected using self-administered questionnaires from November 2010 to February 2011. For data analysis, structural equation modelling was conducted, based on the questionnaire results, to identify the impact of factors associated with the number of community malaria awareness-raising activities implemented by microscopists using the following assessment indicators: (1) place of assignment; (2) annual parasite index; (3) microscopists' capacity (service quality, knowledge on malaria, and ability in malaria microscopy); (4) self-preventive measures against malaria; and (5) job satisfaction. RESULTS: High microscopists' capacity was found to be a significant factor for a greater number of community awareness-raising activities for malaria prevention. High microscopists' capacity was significantly explained by its two sub-components: high service quality (active detection, diagnosis and treatment, prescription of anti-malarial, and follow-up) and high ability in malaria microscopy (preparation and documentation, slide preparation and observation, safe handling and disposal, and knowledge on the morphology of infected red blood cells). CONCLUSIONS: Microscopists' capacity was identified as a significant factor in community awareness-raising activities for malaria prevention. Thus, the strengthening of service quality and ability in malaria microscopy should be of the highest priority.

Characterization of the Population Demographics and the MSP-1 Block 2 Allele Gene Frequencies of P. falciparum Infected Individuals in Davao, Philippines.

Plasmodium falciparum is one of the causative agents of malaria in humans. This parasite causes the most severe forms of the disease. In order to combat the disease, it is important to have knowledge about the parasite and its interaction with its host. In this study, we profiled 74 patients admitted to hospital in Tagum, Davao, Philippines who were confirmed to be infected with P. falciparum. We correlated the age, sex and parasite load with malaria severity and show that among these, only sex is correlated with disease severity in this population. In addition, we profiled the MSP-1 block 2 allele distribution in the population and found that the most abundant allele form was K1, followed by MAD20. The RO33 allele form was the rarest allele in this population.

Localization and expression profiling of a 31 kDa antigenic repetitive protein Sjp_0110390 in Schistosoma japonicum life stages.

Sj7TR is a 13 kDa repetitive region of a 31 kDa protein in Schistosoma japonicum known as Sjp_0110390 that showed high sensitivity and specificity in antibody detection against schistosomiasis patients. However, the current database for S. japonicum genes characterized it only as an expressed protein. A more thorough understanding of this antigenic protein is therefore necessary to possibly give more information about the nature of this protein and its role in the parasite. In this study, immunolocalization and expression profiling were done for Sjp_0110390 on the different stages of the parasite. Immunofluorescent assay showed that Sjp_0110390 was expressed in the young stages of the parasites including the schistosomula, eggs, aquatic and intra-molluscan stages. This was supported by the reverse-transcriptase PCR which confirmed the stage-specific expression of Sjp_0110390 and Western blot test which detected the protein in the extracted eggs proteins, but not in the adults. Furthermore, it was also highly expressed in infected Oncomelania hupensis nosophora snails suggesting that Sjp_0110390 might have a role in the development of the parasite inside the intermediate host. This result also suggests that Sj7TR might be used not only for human diagnosis but to detect snail infection as well.

Human antibody response to thioredoxin peroxidase-1 and tandem repeat proteins as immunodiagnostic antigen candidates for Schistosoma japonicum infection.

Schistosomiasis continues to be a public health problem in many tropical and subtropical countries. Improving the diagnostic tools for surveillance and monitoring in areas that have reached elimination level will help hasten the possible elimination of this disease. This study therefore aims to develop enzyme-linked immunosorbent assay through the use of recombinant proteins such as thioredoxin peroxidase-1 (SjTPx-1) and four tandem repeat proteins (Sj1TR, Sj2TR, Sj4TR, and Sj7TR). Cutoff values were calculated using 38 serum samples from healthy Japanese volunteers. Sera from 35 schistosomiasis-confirmed patients, four cured from the disease by chemotherapy, and 15 endemic negative controls were used to assess these antigens. SjTPx-1 and Sj7TR both had 85.71% sensitivity. Furthermore, these antigens were also tested against human sera positive for other parasitic infections and showed no or very minimal cross-reaction. These results suggest the potential defined antigens for development of an accurate diagnostic test for schistosomiasis.

Phylogenetic relationship of Plasmodium falciparum populations in the Philippines.

Malaria is one of the major infectious diseases in the Philippines. It is being targeted for control through sustained early diagnosis, treatment and mosquito control. It is in this light that understanding the genetic background of the parasite population is important not only for basic biology of the organism but also for epidemiology and control of the disease. In the present study, molecular phylogenetic relationships of the 3 Plasmodium falciparum populations in the Philippines with the other populations in the world were inferred based on polymorphisms of 9 highly polymorphic microsatellite DNA loci in the parasite genome. A total of 92 P. falciparum isolates collected from 3 provinces (Kalinga, Palawan and Davao del Norte) in the Philippines, and 8 from other populations (3 African, 2 South American, 2 Papua New Guinean, and 1 Thai) that were previously reported, were used for the analysis. The phylogenetic tree showed that the 3 Philippine populations were genetically divergent from each other as compared to the other populations. The branching pattern of the tree suggests that the 3 Philippine populations were relatively close to the Thai population, rather than the Papua New Guinean populations, indicating that the ancestor of the 3 Philippines populations were introduced from Indochina peninsula, and not from countries located south of the Philippines such as Papua New Guinea or Indonesia.