Potencial transmisión congénita de la enfermedad de Chagas en la segunda generación de jóvenes embarazadas que asistieron a su control prenatal en el departamento de Cordillera, Paraguay

Trypanosoma cruzi es el agente causal de la enfermedad de Chagas. En Paraguay se estima que existen 165.000 personas infectadas y actualmente la principal vía de transmisión es la congénita, con una prevalencia del 5% y con alrededor de 400 niños infectados nacidos por año. El departamento de Cordillera es área endémica de la Región Oriental del país, donde se implementó el Programa de Control Prenatal de Chagas en el año 1995. El objetivo de este estudio fue inferir sobre la potencial transmisión congénita de la enfermedad de Chagas en jóvenes embarazadas de segunda generación de Cordillera que asistieron a su control prenatal en el período 2010-2012, 15 años después de la implementación del Programa de Control Prenatal. De 9.588 embarazadas; 482 fueron seropositivas (5%); 2,74% en el grupo de 12 a 19 años, 4,93% de 20 a 30 años, 8,03% de 31 a 40 años y 16,11% de 41 a 48 años. Para estimar el origen de la transmisión congénita de segunda generación se tuvo en cuenta a las 72 seropositivas de 12 a 19 años y según la base de datos de las respectivas madres 61 eran seropositivas. Con esta información se estima que la transmisión a embarazadas de segunda generación de 12 a 19 años fue congénita en un 85% indicando una transmisión congénita muy significativa en la población de estudio. Esta información ayudaría al Programa Nacional de Chagas en el fortalecimiento del control de la transmisión congénita de la enfermedad de Chagas en el país.

Trypanosoma cruzi is the causative agent of Chagas disease. In Paraguay, it is estimated that 165,000 people are infected and currently the main route of transmission is the congenital one, with a prevalence of 5% and about 400 infected children are born per year. The Department of Cordillera is an endemic area of the Eastern Region of the country, where the Chagas Prenatal Control Program was implemented in 1995. The aim of this study was to infer the potential congenital transmission of Chagas disease towards second generation pregnant women from the Department of Cordillera who attended their prenatal control in the period 2010-2012, 15 years after the implementation of the Prenatal Control Program. Of 9,588 pregnant women; 482 were seropositive (5%); 2.74% in the group aged 12 to 19 years, 4.93% aged 20 to 30 years, 8.03% aged 31 to 40 years, and 16.11% aged 41 to 48 years. To estimate the origin of second generation congenital transmission, the 72 seropositive women aged 12 to 19 years were taken into account and according to the database of their respective mothers, 61 mothers of the 72 were seropositive. With this información, it can be estimated that 85% of the transmission to second generation pregnant women aged 12 to 19 years was congenital showing a very significant congenital transmission in the study population. This information could help the National Chagas Program in strengthening the control of congenital transmission of Chagas disease in the country.

Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention in Iquitos, Peru: a mixed methods study.

Background: Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a screen-and-treat approach with visual triage and ablative therapy for cervical cancer prevention in Iquitos, Peru. Methods: We conducted semi-structured interviews with nurse-midwives (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analysis. We utilize manifest content analysis to describe barriers to follow-up according to the nurse-midwives and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women and report discrepancies and concordances between nurse-midwives and women regarding reasons for loss to follow-up. Results: Women in this study expressed a desire to receive treatment. Barriers, including fragmented and incomplete registry systems, made receiving follow-up care more challenging. Nurse-midwives faced structural barriers in attempting to deliver positive results to women who were challenging to contact, and women did not have clear knowledge of how to receive their HPV results. Women faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier. Reported financial barriers were minimal. There was agreement between women's and nurse-midwives' reported barriers to follow-up in slightly over half of the cases. Conclusion: This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

"Day or night, no matter what, I will go": Women's perspectives on challenges with follow-up care after cervical cancer screening in Iquitos, Peru: a qualitative study.

BACKGROUND: The study's objective was to explore the factors associated with loss to follow-up among women with abnormal cervical cancer screening results in Iquitos, Peru from women's perspectives. METHODS: In-depth interviews were conducted with 20 screen-positive women who were referred for follow-up care but for whom evidence of follow-up was not found. Interview transcripts were thematically analyzed inductively, and the codes were then categorized using the Health Care Access Barriers Model for presentation of results. RESULTS: All interviewed women were highly motivated to complete the continuum of care but faced numerous barriers along the way, including cognitive barriers such as a lack of knowledge about cervical cancer and poor communication from health professionals regarding the process, structural barriers such as challenges with scheduling appointments and unavailability of providers, and financial barriers including out-of-pocket payments and costs related to travel or missing days of work. With no information system tracking the continuum of care, we found fragmentation between primary and hospital-level care, and often, registration of women's follow-up care was missing altogether, preventing women from being able to receive proper care and providers from ensuring that women receive care and treatment as needed. CONCLUSIONS: The challenges elucidated demonstrate the complexity of implementing a successful cervical cancer prevention program and indicate a need for any such program to consider the perspectives of women to improve follow-up after a positive screening test.

Nurses' and teachers' perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study.

Globally, over 300,000 women die of cervical cancer annually. Given that human papillomavirus vaccines are highly effective in the primary prevention of cervical cancer, it is important to explore the barriers and facilitators to vaccination uptake in areas where the burden of disease remains high. This study, informed by the socio-ecological model, aimed to qualitatively explore vaccination uptake via in-depth interviews with eleven nurses and ten teachers involved in vaccine delivery in Iquitos, Peru. The results highlighted that vaccine uptake was influenced by multiple factors including individuals' knowledge and attitudes, community beliefs, geography, and policy level variables. Findings suggested that professionals were informed and supportive of the HPV vaccination program but perceived that parents were uninformed about the vaccine. There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making.

Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach.

The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.

Integrative Systems Praxis for Implementation Research (INSPIRE): An Implementation Methodology to Facilitate the Global Elimination of Cervical Cancer.

BACKGROUND: The World Health Organization (WHO) has called for a systems thinking approach to health systems strengthening to increase adoption of evidence-based interventions (EBI). The Integrative Systems Praxis for Implementation Research (INSPIRE) methodology operationalizes the WHO systems thinking framework to meet cervical cancer elimination-early detection and treatment (CC-EDT) goals. METHODS: Using a systems thinking approach and grounded in the consolidated framework for implementation research, INSPIRE integrates multiple research methodologies and evaluation frameworks into a multilevel implementation strategy. RESULTS: In phase I (creating a shared understanding), soft systems methodology and pathway analysis are used to create a shared visual understanding of the CC-EDT system, incorporating diverse stakeholder perspectives of the "what, how, and why" of system behavior. Phase II (finding leverage) facilitates active stakeholder engagement in knowledge transfer and decision-making using deliberative dialogues and multiple scenario analyses. Phase III (acting strategically) represents stakeholder-engaged implementation planning, using well-defined implementation strategies of education, training, and infrastructure development. In phase IV (learning and adapting), evaluation of key performance indicators via a reach, effectiveness, adoption, implementation, and maintenance framework is reviewed by stakeholder teams, who continuously adapt implementation plans to improve system effectiveness. CONCLUSIONS: The INSPIRE methodology is a generalizable approach to context-adapted implementation of EBIs. IMPACT: Replacing static dissemination of implementation "roadmaps" with learning health systems through the integration of systems thinking and participatory action research, INSPIRE facilitates the development of scalable and sustainable implementation strategies adapted to local contexts.

Seroprevalencia de la enfermedad de chagas en embarazadas del departamento de cordillera antes y después de la implementación del control prenatal de chagas en los periodos 1997 y 2011 / Seroprevalence of chagas disease in pregnant women of the cordillera department before and after the implementation of prenatal control of chagas in the periods 1997 and 2011

La enfermedad de Chagas es causada por el parásito Trypanosoma cruzi, afecta aproximadamente a 10 millones de individuos se encuentra presente en casi toda América Central y del Sur. En Paraguay se estima que existen aproximadamente 150.000 personas infectadas, de las cuales 61.000 son mujeres en edad fértil y que estarían naciendo alrededor de 600 niños infectados por transmisión congénita por año. El departamento de Cordillera es una zona endémica de la Región Oriental del país, donde la seroprevalencia en mujeres embarazadas en la década de los noventa era alrededor del 12%. Este estudio descriptivo de corte transverso retrospectivo se planteó con el fin determinar la seroprevalencia de la enfermedad de Chagas en embarazadas del departamento de Cordillera que asistieron a su control prenatal en los años 1997 y 2011. Se realizó el análisis de la base de datos de embarazadas del departamento de Cordillera. Se analizaron los resultados de la serología para T. cruzi de 7.898 embarazadas en 5 laboratorios de diagnóstico correspondiente a 20 distritos del departamento de Cordillera. Se encontró que la prevalencia de infección con T. cruzi en embarazadas en éste departamento en el año 1997 fue del 15% y en el 2011 del 6%, lo que marca un descenso del 9%. La información obtenida contribuye al sistema de control prenatal de la enfermedad en la III Región Sanitaria del departamento de Cordillera, porque demuestra la efectividad del sistema de diagnóstico prenatal y los métodos de prevención implementados por el Ministerio de Salud Pública y Bienestar Social.

Chagas disease is caused by the Trypanosoma cruzi parasite, affects approximately 10millons individuals worldwide and is present in almost all Central and South America. InParaguay, 150,000 people are estimated to be infected, 61,000 of them are women inreproductive age and about 600 congenitally infected children would be born per year. TheCordillera department is an endemic area of the Oriental Region of the country, whereseroprevalence in pregnant women in the 90’s was around 12%. This retrospectivetransversal descriptive study was designed to determine the seroprevalence of Chagasdisease in pregnant women of the Cordillera department that attended prenatal controlduring 1997 and 2011. Analysis of the database of pregnant women of the Cordillera department was carried out. Serology for T. cruzi of 7,898 pregnant women performed in 5laboratories corresponding to 20 districts of the Cordillera was analyzed. The prevalence ofT. cruzi infection in pregnant women of this department in the year 1997 was 15% and in2011 it was 6%, which indicates a reduction of 9%. The collected information contributes tothe prenatal control system of the disease in the III Sanitary Region of the Cordilleradepartment, since it showed the efficiency of the prenatal diagnosis system and themethods of prevention implemented by the Ministry of Public Health.

Alfa-Glucosidasa con Posible Acción Hidrolítica Sobre Aminoglicósidos en la Sangre y el Vestíbulo de Ratas / Alpha-glucosidase with possible hydrolytic action over aminoglycosides in the blood and vestibule of rats

Antecedentes e hipótesis. La estreptomicina (STP)es un antibiótico aminoglicósido que se usa en el tratamiento de la tuberculosis, con efectos tóxicos importantes sobre la función vestibular. Los antecedentes farmacocinéticos muestran que la STP se acumula en un principio en la parte perilinfática y por mecanismos aún no descritos pasa a la endolinfa donde su principal blanco de acción son los cilios sensorios de las células pilosas vestibulares. Consideramos importante averiguar que parte de la molécula de STP es la responsable de su toxicidad vestibular, y tenemos evidencias que señalan la parte estreptidina (STD)como la porción activa, por lo que se propone que la STP actúa fragmentada por acción de una alfa-glucosidasa que hidroliza el enlace -1,4 con la liberación de la STD y que esté presente ya sea en el vestíbulo, en el torrente sanguíneo o en ambos. Método. Se determinó la actividad de alfa-glucosidasa en el suero y en homogeneizado vestibular de la rata usando p-nitrofenil--d-glucósido como sustrato; siguiendo el p-nitrofenilo (pNP)liberado espectrofotométricamente a 400 nm. Resultados. Se encontró alfa-glucosidasa tanto en el suero como en el vestíbulo de la rata con actividades específicas de 0.035 y 1.3 nmol de pNP/mg proteína/min respectivamente. Conclusión. La actividad encontrada en vestíbulo es semejante a la de la alfa-glucosidasa lisosomal del hígado de la rata (1.5 nmol de pNP/mg proteína/min)por lo que es posible que la alfa-glucosidasa presente en el suero y en el vestíbulo pueda romper a la STP, liberando la parte STD que actuaría sobre el oído

Estreptomicina: propiedades fisicoquímicas y toxicidad vestibular / Streptomycin, physical and chemical characteristics and vestibular toxicity

Propósito: Los antibióticos aminoglucósidos estreptomicina (STP) y kanamicina (KAN) son tóxicos para las células sensoriales del vestíbulo y de la cóclea, respectivamente. Químicamente están constituidos por estreptidina (STD) un derivado del inositol y dos azúcares, la esteptosa (Stosa) y la N-metilglucosamida (nm-GLUN); sin embargo, en la STP, la STD tiene dos sustituyentes guanidino, los que están ausentes en la KAN. Por lo tanto, se propone estudiar si la vestíbulo-toxicidad específica de la STP se debe a los grupos guanidino. Material y Métodos: Se incubaron en vitro, membranas celulares aisladas de los órganos vestibulares, con 3H-espermidina (3H-Spdina), un análogo estructural de la STP. Se midió la capacidad de los siguientes compuestos: STP, STD, KAN, guanidina (GUA) y n-acetilglucosamina (na-GLUN) para desplazarlos específicamente. Resultados: Se encontró que el orden de desplazamiento de la 3HSPdina para esas sustancia era STP=STD KanGUAn-a-GLUN. Conclusiones: Los resultados sugieren fuertemente que la STP debe su especificidad vestibulotóxica, a la presencia de los grupos guanidino en la porción de STD de su molécula, los que interactuarían por sus cargas positivas con estructuras membranales vestibulares relacionadas con la transducción, muy probablemente los cilios sensorios de las células ciliadas vestibulares