Challenges That Hinder Parturients to Deliver in Health Facilities: a Qualitative Analysis in Two Districts of Indonesia

Background: There are many challenges women face to be able to give birth in health facilities in many parts of Indonesia. This study explores the roles and observations of close-to-community maternal health providers and other community members on potential barriers faced by women to deliver in health facilities in two districts within The Archipelago. Methods: Employing an explorative qualitative approach, 110 semi-structured interviews and 7 focus group discussions were conducted in 8 villages in Southwest Sumba, in the East Nusa Tenggara province, and in 8 villages in Cianjur, in the West Java province. The participants included village midwives, Posyandu volunteer (village health volunteers), traditional birth attendants (TBAs), mothers, men, village heads and district health officials. Results: The main findings were mostly similar in the two study areas. However, there were some key differences. Preference for TBA care, traditional beliefs, a lack of responsiveness of health providers to local traditions, distance, cost of travel and indirect costs of accompanying family members were all barriers to patients attending health facilities for the birth of their child. TBAs were the preferred health providers in most cases due to their close proximity at the time of childbirth and their adherence to traditional practices during pregnancy and delivery. Conclusions: Improving collaborations between midwives and TBAs, collaboration, and responsiveness to traditional practices within health facilities and effective health promotion campaigns about the benefits of giving birth in health facilities may increase the use of health facilities in both study areas.&nbsp

Identifikasi Mutasi Noktah Pada Gen Voltage Gated Sodium Channel Aedes Aegypti Resisten Terhadap Insektisida Pyrethroid Di Semarang Jawa Tengah

The identification of a point mutation in voltage-gated sodium channel gene was conducted on the major of dengue vector Aedes aegypti from Simongan Village, Semarang Municypality Central Java, which occurred to be resistant toward malathion and cypermethrin base on WHO methodology standard (impregnated paper). The objectives of this studi was to identify the point mutation on the codon 1014 of voltage gated sodium channel gene of Ae. aegypti mosquitoes which was associated with the vector resistance of pyrethroid group. The detection of a point mutation of voltage-gated sodium channel was conducted using DNA extraction and semi nested polymerase chain reaction (PCR) amplification of the mosquitoes resistant strain. The susceptibility test (as a screening resistant phenotype) showed that few samples of Ae. aegypti from Simongan Village, Semarang Municypality Central Java resistant to malathion 0,8 % ( organophosphate group ) and cypermethrin 0,25 % (pyrethroid group). The sequencing result showed that there has been a mutation from the leucine (TTA) which turned to be phenylalanin (TTT) (kdr-w type) on the codon 1014 at the voltage gated sodium channel gene of Ae. aegypti mosquitoes from Simongan Village, Semarang Municypality Central Java, which was associated with the pyrethroid insecticide resistance. There were 78 % mosquitoes which brought mutation alel kdr-w type on the codon 1014 F. Therefore dengue vector control activities should not use any pyrethroid insecticide group. Key Words : Resistance, Aedes aegypti, Voltage Gated Sodium Channel (VGSC), Point Mutation. Abstrak Identifikasi mutasi noktah pada gen Voltage Gated Sodium Channel (VGSC) telah dilakukan pada nyamuk Aedes aegypti dari Kelurahan Simongan Kota Semarang, yang telah resisten terhadap insektisida Malathion dan Cypermethrin pada screening susceptibility test (Standar WHO Impregnated paper). Tujuan penelitian adalah untuk mendeteksi mutasi pada kodon 1014 gen VGSC nyamuk Aedes aegypti yang berkaitan dengan resistensi vektor terhadap insektisida kelompok pirethroid. Deteksi mutasi gen VGSC dilakukan dengan metode ekstraksi DNA dan amplifikasi seminested PCR pada nyamuk yang telah resisten. Hasil penapisan uji resistensi menunjukan beberapa sample nyamuk Aedes aegypti dari Kota Semarang resisten terhadap insektisida cypermethrin 0,25 % (kelompok pyrethroid) dan malathion 0,8 % (kelompok organofosfat). Berdasarkan hasil konfirmasi sekuensing telah terjadi mutasi pada kodon 1014 dari leusin (TTA) menjadi fenilalanin (TTT) tipe kdr-w, gen VGSC pada nyamuk Aedes aegypti dari Kelurahan Simongan Kota Semarang, yang berkaitan dengan resistensi terhadap insektisida kelompok pyrethroid. Terdapat 78% dari sembilan larva membawa mutasi alel kdr-w pada kodon 1014F. Berdasarkan hasil penelitian ini, disarankan bahwa pengendalian vekor DBD di Kota Semarang menggunakan insektisida bukan dari kelompok pyrethroid. Kata Kunci : Resistensi, Aedes aegypti, Voltage Gated Sodium Channel (VGSC), Mutasi Noktah

Evaluation of the implementation of single screening and treatment for the control of malaria in pregnancy in Eastern Indonesia: a systems effectiveness analysis.

BACKGROUND: Indonesia introduced single screening and treatment (SST) of pregnant women for the control of malaria in pregnancy in 2012. Under this policy pregnant women are screened for malaria at their first antenatal clinic (ANC) visit and on subsequent visits are tested for malaria only if symptomatic. The implementation of this policy in two districts of Indonesia was evaluated. Cross sectional survey structured observations of the ANC visit and exit interviews with pregnant women were conducted to assess health provider compliance with SST guidelines. Systems effectiveness analysis was performed on components of the strategy. Multiple logistic regression was used to test for predictors of women being screened at their first ANC visit. RESULTS: A total of 865 and 895 ANC visits in Mimika and West Sumba across seven and ten health facilities (plus managed health posts) respectively, were included in the study. Adherence to malaria screening at first ANC visit among pregnant women was 51.4% (95% CI 11.9, 89.2) in health facilities in Mimika (94.8% in health centres) and 24.8% (95% CI 10.3, 48.9) in West Sumba (60.0% in health centres). Reported fever was low amongst women presenting for their second and above ANC visit (2.8% in Mimika and 3.5% in West Sumba) with 89.5% and 46.2% of these women tested for malaria in Mimka and West Sumba, respectively. Cumulative systems effectiveness for SST on first visit to ANC was 7.6% for Mimika and 0.1% for West Sumba; and for second or above visits to ANC was 0.7% in Mimika and 0% in West Sumba. Being screened on a 1st visit to ANC was associated with level of health facility in both sites. CONCLUSION: Cumulative systems effectiveness of the SST strategy was poor in both sites. Both elements of the SST strategy, screening on first visit and passive case detection on second and above visits, was driven by the difference in implementation of malaria testing in health centres and health posts, and by low malaria transmission levels and reported fever

Polymorphism of Human FcγRIIa and Its Association with P. Falciparum Density and Efficacy of Dihydroartemisinin- Piperaquine

FcγRlla dimorphism has been related to the ability of the host to eliminate malaria parasite so it is necessary to investigate the allele polymorphism FcγRlla of population in malaria-endemic areas in Indonesia in order to know the role of immunity in eliminating malaria parasite. A total of 120 samples of Dried Blood Spot (DBS) falciparum malaria acquired from DHP drug efficacy studies in 5 regions in Indonesia were analyzed by Polymerase Chain Reaction (PCR) and sequencing, to look at variants of FcγRIIa-131 allele and its Association with Parasite DensityandEfficacy ofDihydroartemisinin- Piperaquine. The FcγRIIa gene analysis indicated that genotype RH has the highest frequency (50.8%) compared to RR (17.5%) and HH (31.7%). Allele R131 showed a protective effect against High Density Parasitemia (HDP) (>5000 parasites/μL; odds ratio [OR]= 0.133, 95% confidence interval [CI]= 0.053–0.334, P< 0.001) and associated with longer gametocytes carrier clearance time (> 72 hours; Relative Risk [RR]= 1,571, 95% confidence interval [CI]= 1,005–2,456, P= 0.090). &nbsp

Effect of Bean Extract (Phaseolus vulgaris L) to LDL and Ox-LDL and Relation of Ox-LDL on LOX-1 Gene Polymorphism 3'UTR188CT

Aim: To find out whether bean extract has effects on levels of LDL and Ox-LDL and relation of Ox-LDL on LOX-1 gene polymorphism 3'UTR188CT. Method: This research is true randomized experiment  with a pretest - posttest  design  and control group. Samples were 35 subjects divided into 4 groups. Laboratory experiments using bean extract test affects LDL and plasma levels of Ox-LDL by Enzyme -linked Immunosorbent Assay (ELISA), test LOX-1 gene polymorphism 3'UTR188CT with restriction enzyme. To evaluate effect of bean extract to LDL and Ox-LDL level were compared with unpaired t-test. To evaluate difference of Ox-LDL level on LOX-1 gene polymorphism 3'UTR188CT using ANOVA. Results: There was a decrease of LDL found in all treatment groups and elevated levels of Ox-LDL. TT genotype had higher levels of plasma Ox-LDL both before (49,9 ± 8,3 vs. CC 39.9 ± 19.4 and CT 42,8 ± 61,2,p .648 ) and after treatment (60.3 ± 5.7 vs. CC 55.93 ± 12.6 and CT 53.9 ± 10.3, p .630) than other genotype.Conclusion: Bean extract can lower LDL cholesterol although it can also increased plasma level of Ox-LDL. TT genotype had higher levels of plasma Ox-LDL than other genotypes. Require further study to other antioxidants may have a beneficial effect by lowering the levels of Ox-LDL. Keywords : Bean extract, LDL, Ox-LDL level, genotype, atherosclerosi

Performance of four HRP-2/pLDH combination rapid diagnostic tests and field microscopy as screening tests for malaria in pregnancy in Indonesia: a cross-sectional study.

BACKGROUND Malaria in pregnancy poses a major public health problem in Indonesia with an estimated six million pregnancies at risk of Plasmodium falciparum or Plasmodium vivax malaria annually. In 2010, Indonesia introduced a screen and treat policy for the control of malaria in pregnancy at first antenatal visit using microscopy or rapid diagnostic tests (RDTs). A diagnostic study was conducted in Sumba, Indonesia to compare the performance of four different RDTs in predominately asymptomatic pregnant women under field condition. METHODS Women were screened for malaria at antenatal visits using field microscopy and four HRP-2/pLDH combination RDTs (Carestart™, First-Response(®), Parascreen(®) and SD-Bioline(®)). The test results were compared with expert microscopy and nested PCR. End user experience of the RDTs in the field was assessed by questionnaire. RESULTS Overall 950 were recruited and 98.7 % were asymptomatic. The prevalence of malaria was 3.0-3.4 % by RDTs, and 3.6, 5.0 and 6.6 % by field microscopy, expert microscopy and PCR, respectively. The geometric-mean parasite density was low (P. falciparum = 418, P. vivax = 147 parasites/µL). Compared with PCR, the overall sensitivity of the RDTs and field microscopy to detect any species was 24.6-31.1 %; specificities were >98.4 %. Relative to PCR, First-Response(®) had the best diagnostic accuracy (any species): sensitivity = 31.1 %, specificity = 98.9 % and diagnostic odds ratio = 39.0 (DOR). The DOR values for Carestart™, Parascreen(®), SD-Bioline(®), and field microscopy were 23.4, 23.7, 23.5 and 29.2, respectively. The sensitivity of Pan-pLDH bands to detect PCR confirmed P. vivax mono-infection were 8.6-13.0 %. The sensitivity of the HRP-2 band alone to detect PCR confirmed P. falciparum was 10.3-17.9 %. Pan-pLDH detected P. falciparum cases undetected by the HRP-2 band resulting in a better test performance when both bands were combined. First Response(®) was preferred by end-users for the overall practicality. CONCLUSION The diagnostic accuracy to detect malaria among mostly asymptomatic pregnant women and perceived ease of use was slightly better with First-Response(®), but overall, differences between the four RDTs were small and performance comparable to field microscopy. Combination RDTs are a suitable alternative to field microscopy to screen for malaria in pregnancy in rural Indonesia. The clinical relevance of low density malaria infections detected by PCR, but undetected by RDTs or microscopy needs to be determined

Evaluation of the national policy of single screening and treatment for the prevention of malaria in pregnancy in two districts in Eastern Indonesia: health provider perceptions.

BACKGROUND: Malaria in pregnancy has devastating consequences for both the expectant mother and baby. Annually, 88.2 (70%) of the 125.2 million pregnancies in malaria endemic regions occur in the Asia-Pacific region. The control of malaria in pregnancy in most of Asia relies on passive case detection and prevention with long-lasting insecticide-treated nets. Indonesia was the first country in the region to introduce, in 2012, malaria screening at pregnant women's first antenatal care visit to reduce the burden of malaria in pregnancy. The study assessed health providers' acceptability and perceptions on the feasibility of implementing the single screening and treatment (SST) strategy in the context of the national programme in two endemic provinces of Indonesia. METHODS: Qualitative data were collected through in-depth interviews with 86 health providers working in provision of antenatal care (midwives, doctors, laboratory staff, pharmacists, and heads of drug stores), heads of health facilities and District Health Office staff in West Sumba and Mimika districts in East Nusa Tenggara and Papua provinces, respectively. RESULTS: Health providers of all cadres were accepting of SST as a preventive strategy, showing a strong preference for microscopy over rapid diagnostic tests (RDTs) as the method of screening. Implementation of the policy was inconsistent in both sites, with least extensive implementation reported in West Sumba compared to Mimika. SST was predominantly implemented at health centre level using microscopy, whereas implementation at community health posts was said to occur in less than half the selected health facilities. Lack of availability of RDTs was cited as the major factor that prevented provision of SST at health posts, however as village midwives cannot prescribe medicines women who test positive are referred to health centres for anti-malarials. Few midwives had received formal training on SST or related topics. CONCLUSIONS: The study findings indicate that SST was an acceptable strategy among health providers, however implementation was inconsistent with variation across different localities within the same district, across levels of facility, and across different cadres within the same health facility. Implementation should be re-invigorated through reorientation and training of health providers, stable supplies of more sensitive RDTs, and improved data capture and reporting

Intermittent screening and treatment or intermittent preventive treatment compared to current policy of single screening and treatment for the prevention of malaria in pregnancy in Eastern Indonesia: acceptability among health providers and pregnant women.

BACKGROUND: The control of malaria in pregnancy in much of Asia relies on screening asymptomatic women for malaria infection, followed by passive case detection and prevention with insecticide-treated nets. In 2012, Indonesia introduced screening for malaria by microscopy or rapid diagnostic tests (RDTs) at pregnant women's first antenatal care (ANC) visit to detect and treat malaria infections regardless of the presence of symptoms. Acceptability among health providers and pregnant women of the current 'single screen and treat' (SSTp) strategy compared to two alternative strategies that were intermittent preventive treatment (IPTp) and intermittent screening and treatment (ISTp) was assessed in the context of a clinical trial in two malaria endemic provinces of Eastern Indonesia. METHODS: Qualitative data were collected through in-depth interviews with 121 health providers working in provision of antenatal care, heads of health facilities and District Health Office staff. Trial staff were also interviewed. Focus group discussions were conducted with 16 groups of pregnant women (N = 106) to discuss their experiences of each intervention in the trial. RESULTS: Health providers and pregnant women were receptive to screening for malaria at every ANC visit due to the increased opportunity to detect and treat asymptomatic infections. A primary concern for providers was the accuracy and availability of RDTs used for screening in the SSTp and ISTp arms, which they considered less accurate than microscopy. Providers had reservations about giving anti-malarials presumptively as IPTp, due to concerns of causing potential harm to mother and baby and as a possible driver of drug resistance. Pregnant women were accepting of all three interventions. Women in the IPTp arm were happy to take anti-malarials presumptively to protect themselves and their babies against malaria. CONCLUSIONS: The findings indicate that, within a trial context, malaria screening of pregnant women at every ANC visit ISTp was an acceptable strategy among both health providers and pregnant women owing to an existing culture of screening and treatment. The adoption of IPTp however would require a considerable shift in health provider attitudes and a clear communication strategy. By contrast, pregnant women welcomed the opportunity to prevent malaria infections during pregnancy

Challenges in the Control and Elimination of Plasmodium vivax Malaria

The human malaria parasite Plasmodium vivax imposes unique challenges to its control and elimination. Primary among those is the hypnozoite reservoir of infection in endemic communities. It is the dominant source of incident malaria and exceedingly difficult to attack due to both inability to diagnose latent carriers and the potentially life-threatening toxicity of primaquine in patients with an inborn deficiency of G6PD, the only therapeutic option against hypnozoites. Large segments of endemic populations are not eligible for primaquine, and alternative strategies for managing the threat of relapse in any group have not been optimized or validated. Association of risk of primaquine failure against latent P. vivax with impaired alleles of P450 2D6 exacerbates the substantial pool of primaquine ineligibles. Resistance to chloroquine against acute P. vivax malaria commonly occurs; alternative therapies like ACTs are effective but seldom evaluated as a partner drug to primaquine in the essential radical cure. Many of the Anopheles mosquito vector of P. vivax in South and Southeast Asia, where >90% of infections occur, thrive in a diversity of habitats and exhibit wide ranges of feeding and breeding behavior. This chapter explores many of these challenges and possible approaches in controlling and eliminating endemic vivax malaria