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Edwardsiella ictaluri is a causative agent of enteric septicemia of catfish (ESC), a seriously lethal disease in Vietnamese catfish (Pangasius hypophthalmus). A safe and effective vaccine against ESC is currently an urgent demand due to antibiotic overuse in pangasius farms has led to an alarming antimicrobial resistance. In this study, two E. ictaluri wzzE mutants (WzM-L3, deficient in a 1038bp-entire wzzE gene and WzM-S3, a 245bp-partial deletion of wzzE) were developed and their protection efficiacy was evaluated in hatched pangasius against ESC by immersion vaccination. As comparing to the high virulent wild-type strain who caused 73.33% of death on pangasius fingerlings immersed at 7.1â¯×â¯106â¯CFUâ¯ml-1, both mutants showed extremely low mortality rates at 3.33% (WzM-S3) and 0% (WzM-L3) on pangasius fingerlings immersed at high concentration of 1.5â¯×â¯107â¯CFUâ¯mL-1 and 9.7â¯×â¯106â¯CFUâ¯ml-1, respectively. Interestingly, both WzM-S3 and WzM-L3 had a remarkably high protection against ESC, as RPS % were found at 89.29% and 90%, respectively. The mutant WzM-L3 is a potential live attenuated vaccine against ESC in Vietnamese catfish farms with good protection and simple practice.
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Vacinas Bacterianas/imunologia , Peixes-Gato/imunologia , Edwardsiella ictaluri/imunologia , Infecções por Enterobacteriaceae/veterinária , Doenças dos Peixes/prevenção & controle , Animais , Vacinas Bacterianas/genética , Peixes-Gato/microbiologia , Edwardsiella ictaluri/genética , Infecções por Enterobacteriaceae/imunologia , Infecções por Enterobacteriaceae/prevenção & controle , Doenças dos Peixes/imunologia , Doenças dos Peixes/microbiologia , Deleção de Genes , Mutação , Vacinas Atenuadas/genética , Vacinas Atenuadas/imunologiaRESUMO
Background: Honey is a nutritious food made by bees from nectar and sweet deposits of flowering plants and has been used for centuries as a natural remedy for wound healing and other bacterial infections due to its antibacterial properties. Honey contains a diverse community of bacteria, especially probiotic bacteria, that greatly affect the health of bees and their consumers. Therefore, understanding the microorganisms in honey can help to ensure the quality of honey and lead to the identification of potential probiotic bacteria. Methods: Herein, the bacteria community in honey produced by Apis cerana was investigated by applying the next-generation sequencing (NGS) method for the V3-V4 hypervariable regions of the bacterial 16S rRNA gene. In addition, lactic acid bacteria (LAB) in the honey sample were also isolated and screened for in vitro antimicrobial activity. Results: The results showed that the microbiota of A. cerana honey consisted of two major bacterial phyla, Firmicutes (50%; Clostridia, 48.2%) and Proteobacteria (49%; Gammaproteobacteria, 47.7%). Among the 67 identified bacterial genera, the three most predominant genera were beneficial obligate anaerobic bacteria, Lachnospiraceae (48.14%), followed by Gilliamella (26.80%), and Enterobacter (10.16%). Remarkably, among the identified LAB, Lactobacillus kunkeei was found to be the most abundant species. Interestingly, the isolated L. kunkeei strains exhibited antimicrobial activity against some pathogenic bacteria in honeybees, including Klebsiella spp., Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa and Staphylococcus aureus. This underscores the potential candidacy of L. kunkeei for developing probiotics for medical use. Taken together, our results provided new insights into the microbiota community in the A. cerana honey in Hanoi, Vietnam, highlighting evidence that honey can be an unexplored source for isolating bacterial strains with potential probiotic applications in honeybees and humans.
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Anti-Infecciosos , Mel , Microbiota , Humanos , Abelhas/genética , Animais , RNA Ribossômico 16S/genética , Bactérias/genética , Microbiota/genéticaRESUMO
Panax vietnamensis Ha et Grushv. is a precious medicinal species native to the tropical forests of Vietnam. Due to habitat loss and over-harvesting, this species is endangered in Vietnam. To conserve the species, we investigated genetic variability and population structure using nine microsatellites for 148 individuals from seven populations across the current distribution range of P. vietnamensis in Vietnam. We determined a moderate genetic diversity within populations (HO = 0.367, HE = 0.437) and relatively low population differentiation (the Weir and Cockerham index of 0.172 and the Hedrick index of 0.254) and showed significant differentiation (P < 0.05), which suggested fragmented habitats, over-utilization and over-harvesting of P. vietnamensis. Different clustering methods revealed that individuals were grouped into two major clusters, which were associated with gene flow across the geographical range of P. vietnamensis. This study also detected that ginseng populations can have undergone a recent bottleneck. We recommend measures in future P. vietnamensis conservation and breeding programs.
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Panax , Humanos , Panax/genética , Panax/química , Vietnã , Melhoramento Vegetal , Repetições de Microssatélites/genética , Povo Asiático , Variação Genética/genéticaRESUMO
BACKGROUND: Porcine epidemic diarrhea virus (PEDV) is a dangerous virus causing large piglet losses. PEDV spread rapidly between pig farms and caused the death of up to 90% of infected piglets. Current vaccines are only partially effective in providing immunity to suckling due to the rapid dissemination and ongoing evolution of PEDV. METHODS: In this study, the complete genome of a PEDV strain in Vietnam 2018 (IBT/VN/2018 strain) has been sequenced. The nucleotide sequence of each fragment was assembled to build a continuous complete sequence using the DNASTAR program. The complete nucleotide sequences and amino acid sequences of S, N, and ORF3 genes were aligned and analyzed to detect the mutations. RESULTS: The full-length genome was determined with 28,031 nucleotides in length which consisted of the 5'UTR, ORF1ab, S protein, ORF3, E protein, M protein, N protein, and 3'UTR region. The phylogenetic analysis showed that the IBT/VN/2018 strain was highly virulent belonged to the G2b subgroup along with the Northern American and Asian S-INDEL strains. Multiple sequence alignment of deduced amino acids revealed numerous mutations in the S, N, and ORF3 regions including one substitution 766P > L766 in the epitope SS6; two in the S0subdomain (135DN136 > 135SI136 and N144> D144); two in subdomain SHR1 at aa 1009L > M1009 and 1089S > L1089; one at aa 1279P > S1279 in subdomain SHR2 of the S protein; two at aa 364N > I364 and 378N > S378 in the N protein; four at aa 25L > S25, 70I > V70, 107C > F107, and 168D > N168 in the ORF3 protein. We identified two insertions (at aa 59NQGV62 and aa 145N) and one deletion (at aa 168DI169) in S protein. Remarkable, eight amino acid substitutions (294I > M294, 318A > S318, 335V > I335, 361A > T361, 497R > T497, 501SH502 > 501IY502, 506I > T506, 682V > I682, and 777P > L777) were found in SA subdomain. Besides, N- and O-glycosylation analysis of S, N, and ORF3 protein reveals three known sites (25G+, 123N+, and 62V+) and three novel sites (144D+, 1009M+, and 1279L+) in the IBT/VN/2018 strain compared with the vaccine strains. Taken together, the results showed that mutations in the S, N, and ORF3 genes can affect receptor specificity, viral pathogenicity, and the ability to evade the host immune system of the IBT/VN/2018 strain. Our results highlight the importance of molecular characterization of field strains of PEDV for the development of an effective vaccine to control PEDV infections in Vietnam.
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Interleukin (IL)-1 beta (IL-1ß), IL-2, Interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α) in the pleural fluid are valuable biomarkers in early diagnosis of Tuberculous Pleural Effusion (TPE). This study aimed to analyze the diagnostic values of some cytokines (IFN-γ, TNF-α, IL-1ß, and IL-2) in pleural fluid for identifying TPE in Vietnam. We performed a cross-sectional study on tuberculosis (TB) patients with pleural effusion. Pleural IFN-γ, TNF-α, IL-1ß, IL-2 were measured by ELISA® Kit (Abcam, USA) on Biotek system. Receiver operating characteristic curves (ROC), an area under the curve (AUC), sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (ACC) of IFN-γ, TNF-α, IL-1ß, IL-2 in identifying TBE were assessed. Among 386 patients, 234 (60,6%) had TPE, and 152 (39,4%) did not have TPE. The median of IL-2, TNF-α, and IFN-γ levels were significantly higher in TPE compared to the non-TPE group (p<0.05). AUC for IL-1ß, IL-2, TNF-α, and IFN-γ were 0.54, 0.57, 0.62. 0.84 (p<0.05), respectively. The sensitivity of IL-1ß, IL-2, TNF-α, and IFN-γ in the diagnosis of TPE were 82.1, 53.4, 77.8, and 80.3, while the specificity was 28,4, 69.7, 47.4, and 80.9, respectively. IFN-γ and TNF-α are potential biomarkers in diagnosing TPE.
Assuntos
Citocinas/análise , Derrame Pleural/diagnóstico , Tuberculose Pleural/diagnóstico , Adulto , Idoso , Área Sob a Curva , Biomarcadores/análise , Estudos Transversais , Feminino , Humanos , Interferon gama , Interleucina-1beta , Interleucina-2 , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Fator de Necrose Tumoral alfa , VietnãRESUMO
BACKGROUND: Deformed wing virus (DWV) is a virulent virus that causes honeybee disease. DWV can exist as a latent infection in honeybees, outbreak into epidemics, and cause serious damage to beekeeping cross the world, including Vietnam. METHODS: The two DWV strains circulating in Vietnamese honeybee, Apis cerana, were first isolated from adult honeybees in North Vietnam (DWV-NVN) and South Vietnam (DWV-SVN). Their complete nucleotide sequences were determined, aligned, and compared with other DWV strains. RESULTS: The two Vietnamese DWV strains comprised 10,113 bp and contained a large single open reading frame (ORF) of 2,893 amino acids, initiating at nucleotide 1,130 and terminating at nucleotide 9,812. Multiple nucleotide sequence alignment between these two DWV-VN strains and DWV strains in A. mellifera was performed. The DWV-VN strains showed a low genetic identity (from 91.4% to 92.0%) with almost of these strains, but lower identities (89.2% and 89.4%) with UK2 and (89.6%) with the China2 strain. Low identities (91.7% and 91.9%) were also observed between the China3 strain (in A. cerana) and the DWV-VN strains, respectively. The deduced amino acid sequence alignment showed high genetic similarities (97.0%-97.9%) when the USA1, Chile, Italy1, France, UK1, UK2, Japan, Korea2, China1, China2 and China3 strains were compared to the DWV-VN strains. This ratio was 96.7% and 96.8% when the Korea1 strain was compared to the DWV-SVN and DWV-NVN strains, respectively. Numerous amino acid substitutions were identified in the L, VP3, and RdRp sequences. Notably, we observed six substitutions positioned at amino acids 27 (E > I), 98 (S > T), 120 (A > V), 153 (M > T), 170 (D > F), and 174 (Y > F) in the L protein, two amino acid changes at positions 980 (S > A) and 1032 (E > T) in VP3, and one amino acid change at position 2627 (R > C) unique to the DWV-VN strains. Phylogenetic analysis based on complete genome sequences, RdRp sequences and Simplot analysis indicated that there was a significant difference between DWV-VN strains in A. cerana and DWV strains in A. mellifera. The results suggested that the genetic variations of the DWV-VN strains in A. cerana help them to adapt geographical conditions and may lead to change the viral pathogenicity of DWV-VN strains.
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Genetic mutations of the Methyl-CpG-binding protein-2 (MECP2) gene underlie Rett syndrome (RTT). Developmental processes are often considered to be irrelevant in RTT pathogenesis but neuronal activity at birth has not been recorded. We report that the GABA developmental shift at birth is abolished in CA3 pyramidal neurons of Mecp2-/y mice and the glutamatergic/GABAergic postsynaptic currents (PSCs) ratio is increased. Two weeks later, GABA exerts strong excitatory actions, the glutamatergic/GABAergic PSCs ratio is enhanced, hyper-synchronized activity is present and metabotropic long-term depression (LTD) is impacted. One day before delivery, maternal administration of the NKCC1 chloride importer antagonist bumetanide restored these parameters but not respiratory or weight deficits, nor the onset of mortality. Results suggest that birth is a critical period in RTT with important alterations that can be attenuated by bumetanide raising the possibility of early treatment of the disorder.
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Proteína 2 de Ligação a Metil-CpG/fisiologia , Neurônios/patologia , Receptores de GABA-A/metabolismo , Síndrome de Rett/patologia , Transmissão Sináptica/efeitos dos fármacos , Ácido gama-Aminobutírico/metabolismo , Animais , Bumetanida/farmacologia , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Plasticidade Neuronal , Neurônios/efeitos dos fármacos , Neurônios/metabolismo , Sistema Respiratório/efeitos dos fármacos , Síndrome de Rett/tratamento farmacológico , Síndrome de Rett/genética , Síndrome de Rett/metabolismo , Inibidores de Simportadores de Cloreto de Sódio e Potássio/farmacologia , Potenciais SinápticosRESUMO
CONTEXT: Seasonal flu outbreaks are linked to the circulation of influenza virus type A or B. Special attention has always been paid to influenza A epidemics; but recently, several studies have investigated the impact of influenza B virus epidemics, particularly as, since the 1980s, two antigenically different influenza B lineages co-circulate, raising the issue of vaccine matching. OBJECTIVES: We present the results of influenza B burden during nine influenza seasons (2003-2013) and vaccine matching of the circulating lineages. PATIENTS AND METHODS: Clinical and virological influenza surveillance data, collected by the Regional Groups for Influenza Surveillance Network in France, allows for studying the burden of influenza in the practice of the population of ambulatory care physicians. RESULTS AND CONCLUSION: Our analysis is based on 37,801 samples, of which 12,036 were virologically confirmed influenza cases (31.8%), including 3576 cases of influenza B (29.7% of influenza cases). Influenza B viruses significantly circulated during six seasons. For each season, the influenza B epidemic peaked later than the influenza A epidemic. Influenza B is very common in children of school age but also affects other age groups. Finally, more than one-third of the analyzed influenza B viruses belonged to a different lineage than the one used in the composition of the trivalent vaccine. Our results are comparable to those described in other countries.
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Vírus da Influenza B , Influenza Humana/epidemiologia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , França/epidemiologia , Humanos , Vacinas contra Influenza , Influenza Humana/prevenção & controle , Pessoa de Meia-Idade , Estações do Ano , Fatores de Tempo , Adulto JovemRESUMO
Pancreatic ductal adenocarcinoma (PDA) is a critical health issue in the field of cancer, with few therapeutic options. Evidence supports an implication of the intratumoral microenvironment (stroma) on PDA progression. However, its contribution to the role of neuroplastic changes within the pathophysiology and clinical course of PDA, through tumor recurrence and neuropathic pain, remains unknown, neglecting a putative, therapeutic window. Here, we report that the intratumoral microenvironment is a mediator of PDA-associated neural remodeling (PANR), and we highlight factors such as 'SLIT2' (an axon guidance molecule), which is expressed by cancer-associated fibroblasts (CAFs), that impact on neuroplastic changes in human PDA. We showed that 'CAF-secreted SLIT2' increases neurite outgrowth from dorsal root ganglia neurons as well as from Schwann cell migration/proliferation by modulating N-cadherin/ß-catenin signaling. Importantly, SLIT2/ROBO signaling inhibition disrupts this stromal/neural connection. Finally, we revealed that SLIT2 expression and CAFs are correlated with neural remodeling within human and mouse PDA. All together, our data demonstrate the implication of CAFs, through the secretion of axon guidance molecule, in PANR. Furthermore, it provides rationale to investigate the disruption of the stromal/neural compartment connection with SLIT2/ROBO inhibitors for the treatment of pancreatic cancer recurrence and pain.
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Peptídeos e Proteínas de Sinalização Intercelular/metabolismo , Proteínas do Tecido Nervoso/metabolismo , Neurônios/patologia , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/patologia , Animais , Axônios/efeitos dos fármacos , Axônios/metabolismo , Caderinas/metabolismo , Comunicação Celular/efeitos dos fármacos , Compartimento Celular/efeitos dos fármacos , Linhagem Celular Tumoral , Movimento Celular/efeitos dos fármacos , Meios de Cultura/farmacologia , Fibroblastos/metabolismo , Fibroblastos/patologia , Regulação Neoplásica da Expressão Gênica/efeitos dos fármacos , Humanos , Masculino , Camundongos Nus , Modelos Biológicos , Neurônios/efeitos dos fármacos , Neurônios/metabolismo , Neoplasias Pancreáticas/genética , Células de Schwann/efeitos dos fármacos , Células de Schwann/metabolismo , Células de Schwann/patologia , Transdução de Sinais/efeitos dos fármacos , Células Estromais/efeitos dos fármacos , Células Estromais/metabolismo , Células Estromais/patologia , Transcriptoma/genética , Microambiente Tumoral/efeitos dos fármacos , Microambiente Tumoral/genética , beta Catenina/metabolismo , Neoplasias PancreáticasRESUMO
OBJECTIVES: To determine the success of additional bacillus Calmette-Guérin (BCG) therapy for transitional cell carcinoma recurring after a complete response (CR) to the initial treatment course of BCG. METHODS: All patients treated with BCG with a minimum follow-up of 5 years were reviewed to identify complete responders who subsequently recurred and received additional BCG therapy. The duration of initial response and the incidence and duration of a second CR were recorded. RESULTS: Of 11 patients with an initial CR to a 6-week course of BCG, 9 (82%) achieved a second CR and 5 of the 9 (42%) maintained tumor-free status beyond 5 years of follow-up (median 87 months, range 64 to 110). Patients who again recurred after the second CR did not benefit from further BCG therapy. CONCLUSIONS: A repeat course of BCG is a reasonable option of therapy for transitional cell carcinoma that has recurred after a CR to a prior course of BCG. Careful monitoring by cytology, cystoscopy, and biopsy is mandatory to direct nonresponders to prompt alternative therapy and to ensure continued disease-free status among responders.
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Adjuvantes Imunológicos/uso terapêutico , Vacina BCG/uso terapêutico , Carcinoma de Células de Transição/terapia , Recidiva Local de Neoplasia/terapia , Neoplasias da Bexiga Urinária/terapia , Seguimentos , Humanos , Indução de RemissãoRESUMO
BACKGROUND: The increases in extra-pulmonary tuberculosis (EPTB) have been largely due to human immunodeficiency virus co-infection. The rates of EPTB have remained constant despite the decline in pulmonary tuberculosis (PTB) cases. OBJECTIVE: To evaluate covariates associated with EPTB. METHODS: A 4-year cohort of EPTB patients was compared with PTB cases. Enrollees were assessed for TB risk, medical records were reviewed, and Mycobacterium tuberculosis isolates were fingerprinted. RESULTS: We identified 538 EPTB cases (28.6%) in a total of 1878 enrollees. The most common sites of infection were lymph nodes (43%) and pleura (23%). EPTB cases included 320 (59%) males, 382 (71%) patients were culture-positive, and 332 (86.9%) patient isolates were fingerprinted. Fewer EPTB than PTB patients belonged to clustered M. tuberculosis strains (58% vs. 65%; P = 0.02). A multivariate model identified an increased risk for EPTB among African Americans (OR = 1.9, P = 0.01), HIV-seropositive (OR = 3.1, P < 0.01), liver cirrhosis (OR = 2.3, P = 0.02), and age <18 years (OR = 2.0, P = 0.04). Patients with concomitant pulmonary and extra-pulmonary infections were more likely to die within 6 months of TB diagnosis (OR = 2.3, P < 0.01). CONCLUSIONS: African American ethnicity is an independent risk factor for EPTB. Mortality at 6 months is partly due to the dissemination of M. tuberculosis and the severity of the underlying co-morbidity.
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Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Etnicidade/estatística & dados numéricos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Adulto , Distribuição por Idade , Idoso , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Probabilidade , Medição de Risco , População Rural , Distribuição por Sexo , Taxa de Sobrevida , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/epidemiologia , Estados Unidos/epidemiologia , População UrbanaRESUMO
OBJECTIVE: To determine the predictors of recurrence of tuberculosis (TB), the drug resistance pattern of Mycobacterium tuberculosis strains recovered from recurrent TB patients, and the frequency of re-infection with a new M. tuberculosis strain among patients with recurrent disease. DESIGN: A population-based, retrospective case-control study using the Houston Tuberculosis Initiative database. RESULTS: We found that, among 100 patients with recurrent TB who completed adequate therapy for a first episode of TB, not receiving directly observed therapy, pulmonary disease, HIV/AIDS diagnosis, not having a family physician, being unemployed and using public transportation were predictors of recurrent disease. There was a significant increase in drug-resistant M. tuberculosis strains in the second episode of disease compared to the first episode (21.3% vs. 8.2%, P = 0.04). Exogenous re-infection with a new strain of M. tuberculosis was found to cause 24-31% of recurrent TB. CONCLUSION: Recurrent TB in Houston is associated with a significant increase in drug-resistant M. tuberculosis strains. Re-infection with a new M. tuberculosis strain causes a significant proportion of recurrent TB in an area of low TB incidence. Patients with HIV/AIDS constitute a population at increased risk of disease recurrence.
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Tuberculose/epidemiologia , Adulto , Portador Sadio/epidemiologia , Estudos de Casos e Controles , Cidades/epidemiologia , Humanos , Mycobacterium tuberculosis/genética , Vigilância da População , Recidiva , Fatores de Risco , Fatores Socioeconômicos , Texas/epidemiologia , Tuberculose/microbiologia , Tuberculose/terapia , Saúde da População UrbanaRESUMO
Mouse cytotoxic T-lymphocyte antigen-2α (CTLA-2α), Drosophila CTLA-2-like protein (crammer), and Bombyx cysteine protease inhibitor (BCPI) belong to a novel family of cysteine protease inhibitors (I29). Their inhibitory mechanisms were studied comparatively. CTLA-2α contains a cysteine residue (C75), which is essential for its inhibitory potency. The CTLA-2α monomer was converted to a disulfide-bonded dimer in vitro and in vivo. The dimer was fully inhibitory, but the monomer, which possessed a free thiol residue, was not. A disulfide-bonded CTLA-2α/cathepsin L complex was isolated, and a cathepsin L subunit with a molecular weight of 24,000 was identified as the interactive enzyme protein. Crammer also contains a cysteine residue (C72). Both dimeric and monomeric forms of crammer were inhibitory. A crammer mutant with Cys72 to alanine (C72A) was fully inhibitory, while the replacement of Gly73 with alanine (G73A) caused a significant loss in inhibitory potency, which suggests a different inhibition mechanism from CTLA-2α. BCPI does not contain cysteine residue. C-terminal region (L77-R80) of BCPI was essential for its inhibitory potency. CTLA-2α was inhibitory in the acidic pH condition but stabilized cathepsin L under neutral pH conditions. The different inhibition mechanisms and functional considerations of these inhibitors are discussed.
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BACKGROUND: In almost 30 years since economic reforms or 'renovation' (Doimoi) were launched, Vietnam has achieved remarkably good health results, in many cases matching those in much higher income countries. This study explores the contribution made by Universal Health Insurance (UHI) policies, focusing on the past 15 years. We conducted a mixed method study to describe and assess the policy process relating to health insurance, from agenda setting through implementation and evaluation. DESIGN: The qualitative research methods implemented in this study were 30 in-depth interviews, 4 focus group discussions, expert consultancy, and 420 secondary data review. The data were analyzed by NVivo 7.0. RESULTS: Health insurance in Vietnam was introduced in 1992 and has been elaborated over a 20-year time frame. These processes relate to moving from a contingent to a gradually expanded target population, expanding the scope of the benefit package, and reducing the financial contribution from the insured. The target groups expanded to include 66.8% of the population by 2012. We characterized the policy process relating to UHI as incremental with a learning-by-doing approach, with an emphasis on increasing coverage rather than ensuring a basic service package and financial protection. There was limited involvement of civil society organizations and users in all policy processes. Intertwined political economy factors influenced the policy processes. CONCLUSIONS: Incremental policy processes, characterized by a learning-by-doing approach, is appropriate for countries attempting to introduce new health institutions, such as health insurance in Vietnam. Vietnam should continue to mobilize resources in sustainable and viable ways to support the target groups. The country should also adopt a multi-pronged approach to achieving universal access to health services, beyond health insurance.