Introducing a Regulatory Sandbox Into the Indonesian Health System Using e-Malaria as a Use Case: Participatory Action Study

BACKGROUND

Regulatory sandboxes offer an alternative solution to address regulatory challenges in adopting disruptive technologies. Although regulatory sandboxes have been widely implemented in the financial sector across more than 50 countries, their application to the health sector remains limited.

OBJECTIVE

This study aims to explore stakeholders' perspectives on introducing a regulatory sandbox into the Indonesian health system using e-malaria as a use case.

METHODS

Using a participatory action research approach, this study conducted qualitative research, including desk reviews, focus group discussions, and in-depth interviews with stakeholders. This study sought to understand stakeholders' concerns and interests regarding the regulatory sandbox and to collaboratively develop a regulatory sandbox model to support the malaria program.

RESULTS

The study revealed that most stakeholders had limited awareness of the regulatory sandbox concept. Concerns have been raised regarding the time required to establish regulations, knowledge gaps among stakeholders, data protection issues, and limited digital infrastructure in malaria endemic areas. Existing regulations have been found to be inadequate to accommodate disruptive healthtech for malaria. Nevertheless, through a collaborative process, stakeholders successfully developed a regulatory sandbox model specifically for e-malaria, with the crucial support of the Ministry of Health.

CONCLUSIONS

The regulatory sandbox holds the potential for adoption in the Indonesian health system to address the limited legal framework and to facilitate the rapid and safe adoption of disruptive healthtech in support of the malaria elimination program. Through stakeholder involvement, guidelines for implementing the regulatory sandbox were developed and innovators were successfully invited to participate in the first-ever trial of a health regulatory sandbox for e-malaria in Indonesia. Future studies should provide further insights into the challenges encountered during the e-malaria regulatory sandbox pilot study, offering a detailed account of the implementation process.

Blastocystis hominis infection in HIV/AIDS children with extraintestinal symptom: a case report

Background: Blastocystis hominis is an intestinal parasite that can induce both intra- and extraintestinal symptoms. This article aims to describe the symptom findings in cases of HIV children co-infected with B. hominis. Case Presentation: A 3-year-old boy with HIV/AIDS came with diarrhea and skin rashes. The direct smear technique, formalin-ethyl acetate concentration technique, Jones medium culture, and trichrome staining were all used to investigate a single stool specimen from this patient. The results of the examination showed B. hominis infection with intensity <5/high power field (HPF). Extraintestinal symptoms such as skin rashes were not seen in this patient after appropriate treatment. Conclusion: B. hominis infection can cause extraintestinal symptoms such as a red rash on the skin. When a patient presents with a skin rash of unknown origin, having their stool tested for parasites is a concern.

Identifying forms of interventions towards cross border malaria in the Asia-Pacific region: a scoping review protocol

INTRODUCTION

An ambitious epidemiology strategy has been set by the WHO, targeting malaria elimination for at least 35 countries in 2030. Challenges in preventing malaria cross borders require greater attention to achieve the elimination target. This scoping review aims to identify successful forms of interventions to control malaria transmission across national borders in the Asia-Pacific region.

METHODS AND ANALYSIS

This scoping review will search four electronic databases (PubMed, ScienceDirect, EBSCOhost and ProQuest) limiting the time of publication to the last 10 years. Two independent reviewers will screen all titles and abstracts during the second stage. Study characteristics will be recorded; qualitative data will be extracted and evaluated, while quantitative data will be extracted and summarised. Overall, we will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.

ETHICS AND DISSEMINATION

This scoping review has received ethical approval from the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada. The results will be disseminated through peer-reviewed publications, conference presentations and policy briefs.

A participatory approach to address within-country cross-border malaria: the case of Menoreh Hills in Java, Indonesia

BACKGROUND

Malaria remains a significant public health issue in Indonesia. Most of the endemic areas are in the eastern parts of Indonesia, but there are a few remaining foci of persistent endemic malaria in Java, particularly in Menoreh Hills, a region bordering three districts of two provinces on this island. Despite a commitment to build a partnership to eliminate cross-border malaria, there is a lack of understanding of how this partnership might be translated into an implementable strategic plan. The study aims to provide evidence of how a participatory approach was used to strengthen the cross-border collaboration and stakeholders' capacity to develop a joint strategic, operational, and costing plan for cross-border malaria elimination.

METHODS

A participatory action research was conducted from January to August 2017, involving participants from the village, district, provincial, and national levels. This study was conducted in seven phases, including document review, focus group discussions (FGDs), planning and costing workshops, and a dissemination meeting. A total of 44 participants from primary health centres (PHC) and 27 representatives of affected villages in three districts, 16 participants from the district and provincial malaria programmes and planning bureaus, and 11 participants from the national level were involved in the processes. Data on priority issues, costing, programme coverage, and administration were collected. Thematic coding and feedback were used for analysis.

RESULTS

Problems identified by stakeholders included low community awareness and participation in malaria prevention, high mobility across three districts, lack of financial and human resources, lack of inter-district coordination, and poor implementation of migration surveillance. Cross-border strategies identified to address malaria were improving cross-border migration surveillance, strengthening the network, governance, and advocacy of malaria control implementation across borders, and developing the malaria information system. A working group composed of the three districts' representatives authorized to decide on cross-border issues will be created.

CONCLUSIONS

The participatory approach was applicable in cross-border malaria planning for within-country settings and useful in enhancing stakeholders' capacities as implementers. While done in a participatory way, the joint plan crafted was a non-binding agreement; stakeholders should advocate to ensure adequate funds are poured into mobilizing the programme.

Correlation of Nutritional Status with Hookworm and Strongyloides stercoralis Infection in Children Under Five Years in Kokar Public Health Center, Alor Regency, East Nusa Tenggara

Malnutrition can reduce immune response particularly in cytokine (IL-4, IL-5, IL-10) production and immune effector (eosinophil, IgE, and mast cell), thus increasing the probability of intestinal nematode infection. Through this study, intestinal nematode infections occurred among children under five years, at different nutrition status, in Kokar Public Health center, Alor Regency, East Nusa Tenggara was captured. Hookworm and Strongyloides stercoralis were studied as both of them have devastating impacts compare to other helminthes compare to other helminths. This study is a cross- sectional study with a quote sampling technique. As many as 238 children, aged 12-59 months living in Kokar’s Public Health Center area, Alor regency were recruited in this study i.e. 7.7% severely underweight, 19.2% underweight, 70.5% normal and 2.6% overweight. Data were collected in August - October 2016. Hookworm and S. stercoralis infection were determined from collected fecal samples of all subjects using either Baermann test, Koga Agar Plate (KAP), or Harada- Mori culture method. The prevalence of hookworm and S. stercoralis infection was 8.82%, and 0,42%. Correlation between nutritional status and hookworm infection were analyzed by Mann-Whitney test with p value = 0.54 (p > 0.05). Prevalence of hookworm and S. stercoralis among children under five years in Kokar were 8.82% and 0.42%. There was no significant correlation between nutritional status with hookworm infection prevalence.

Genetic diversity of Merozoite surface protein 1-42 (MSP1-42) fragment of Plasmodium vivax from Indonesian isolates: Rationale implementation of candidate MSP1 vaccine

Morbidity and mortality related to malaria in Indonesia are attributed to both Plasmodium falciparum and P. vivax parasites. In addition to vaccines for P. falciparum, vaccines against P. vivax are urgently needed for the prevention of the disease. An extensively studied antigen is the carboxyl-terminus of the 42 kDa region of P. vivax merozoite surface protein-1 (PvMSP1-42). The design of a vaccine based on this antigen requires an understanding of the extent of polymorphism. However, there is no information on the genetic diversity of the antigen in Indonesia. This study aimed to profile the diversity of PvMSP1-42 and its two subdomains (PvMSP1-33 and PvMSP1-19) among Indonesian P. vivax isolates. A total of 52 P. vivax-infected blood samples were collected from patients in two different endemic areas in Indonesia: Banjarmasin (Kalimantan) and Sumba Timur (Nusa Tenggara Timur). The polymorphic characteristics and natural selection of PvMSP1-42 were analyzed using the DnaSP, MEGA, and Structure software. Thirty distinct haplotypes of PvMSP1-42 were identified. They displayed amino acid changes compared to the reference PVP01 sequence. Most of the mutations were concentrated in the 33 kDa fragment. PvMSP1-42 of the Indonesian isolates appeared to be under positive selection. Recombination may also play a role in the resulting genetic diversity of PvMSP1. In conclusion, PvMSP1-42 of Indonesian isolates displayed allelic polymorphisms caused by mutation, recombination, and positive selection. These results will aid the understanding of the P. vivax population in Indonesia and to develop a PvMSP1 based vaccine against P. vivax.

Epidemiology and risk factors of Strongyloides stercoralis infection in Papua, Indonesia: a molecular diagnostic study

Strongyloides stercoralis is a parasitic worm that is of considerable clinical relevance. Indeed, it may persist asymptomatically for many years, but can lead to potentially fatal dissemination when the host's immune status is impaired. As commonly employed stool microscopy techniques (e.g. Kato-Katz thick smear) fail to detect S. stercoralis, the epidemiology is poorly understood. In 2013, we conducted a cross-sectional household survey in the district of Mimika in Papua, Indonesia. A total of 331 individuals, aged 1 month to 44 years, had a single stool sample subjected to real-time polymerase chain reaction (PCR) for S. stercoralis diagnosis. The prevalence of S. stercoralis infection was 32.0% (106/331 individuals); higher than any of the three main soil-transmitted helminths (Ascaris lumbricoides, 23.9%; Trichuris trichiura, 18.4%; and hookworm, 17.2%). Amongst the S. stercoralis-infected individuals, 73.6% were concurrently infected with another helminth, with hookworm being the most frequent co-infection (27.4%). Fourteen percent of the S. stercoralis infections had low cycle threshold values on real-time PCR, which may indicate a higher infection intensity. Multivariate logistic regression analysis revealed that age ≥5 years (adjusted odds ratio (OR) 5.8, 95% confidence interval (CI): 3.1-10.8) was significantly associated with S. stercoralis infection. There is a need for in-depth clinical and diagnostic studies to elucidate the public health impact of S. stercoralis infection in Indonesia.

Intravenous artesunate plus oral dihydroartemisinin-piperaquine or intravenous quinine plus oral quinine for optimum treatment of severe malaria: lesson learnt from a field hospital in Timika, Papua, Indonesia

BACKGROUND

Intravenous artesunate and its follow on full course dihydroartemisinin-piperaquine are the standard treatment for severe malaria in Indonesia. The current policy suggests that intravenous and oral quinine could be used when standard therapy is not available. Its pragmatic use of both treatment combinations in a field hospital is evaluated.

METHODS

A retrospective study among hospitalized malaria patients receiving intravenous anti-malarial treatments at Mitra Masyarakat Hospital, Timika from April 2004 to December 2013 was conducted. The length of hospital stay (LoS) and the risk of malaria recurrence within 28 days after hospital admission were compared between patients receiving intravenous artesunate and oral dihydroartemisinin-piperaquine (Iv Art + DHP) and those receiving intravenous and oral quinine (Iv + Oral Qu).

RESULTS

Of 10,514 patients requiring intravenous therapy, 2759 received Iv + Oral Qu and 7755 received Iv Art + DHP. Plasmodium falciparum infection accounted for 65.8% (6915), while Plasmodium vivax, Mixed infections, Plasmodium malariae and Plasmodium ovale were accounted for 17.0% (1789), 16.4% (1729), 0.8% (79) and 0.01% (2) of the infections, respectively. The majority of severe malaria hospital admissions were highland Papuans (78.0%, 8201/10,501). In total 49% (5158) of patients were older than 15 years and 3463 (32.9%) were children under 5 years old. The median LoS was shorter in patients receiving intravenous artesunate compared to those treated with intravenous quinine (median = 2 [IQR 1-3] versus 3 days [IQR 2-4], p < 0.0001). Patients treated with intravenous quinine had higher risk of being hospitalized longer than 2 days (aOR of 1.70 [95% CI 1.54-1.88], p < 0.0001). The risk of recurrences within 28 days after hospital admission was 1.94 times higher (95% CI aHR 1.57-2.39, p < 0.0001) in patients receiving intravenous quinine with follow on oral quinine treatment than in patients treated with DHP after intravenous artesunate therapy.

CONCLUSIONS

Intravenous artesunate reduced the LoS of malaria patients and in combination with DHP reduced the risk of malaria recurrence within 28 days after hospital admission compared to those with Iv + Oral Qu treatment. Thus, ensuring continuous supply of intravenous artesunate and artemisinin-based combination therapy (ACT) should be a priority.

Comparison of mini-flotac and Kato-Katz methods for detecting soil-transmitted helminth eggs in 10% formalin preserved stools stored >=12 months

In Soil-Transmitted Helminth (STH) control programs, microscopic examination is applied as a standard method for detecting the presence and the number of STH eggs. The time limitations of fresh specimen processing, especially for an accurate quantitative diagnosis, cause the specimen processing to be delayed or should be performed at a referral laboratory. This deferment requires preservatives to keep the stool integrity without reducing the accuracy. The aims of this study were: 1) to compare the proportion of positive samples and the intensity of A. lumbricoides, T. trichiura, and hookworm infection based on the examination of fresh samples and stool preserved by 10% formalin for >12 months and 2) to determine the most reliably accurate between Kato-Katz and mini-FLOTAC methods in detecting A. lumbricoides, T. trichiura, and hookworm eggs in preserved stools both qualitatively and quantitatively. Seventy-eight (78) stool samples were examined by mini-FLOTAC, and KatoKatz methods. Proportion of positive samples of A. lumbricoides, T. trichiura, and hookworms in fresh and in >=12 months 10% formalin preserved stools had no significant difference. Helminths density (eggs per gram of stool/EPG) in fresh samples was fewer compared to EPG in preserved samples (p <0.05) which leads to a lower proportion of moderate and high level groups in fresh stools samples compared to those in preserved samples (p <0.05). In preserved samples, as qualitative method, mini-FLOTAC detected more A. lumbricoides and T. trichiura eggs than Kato-Katz, while hookworm eggs were detected more by Kato-Katz than the miniFLOTAC. As a quantitative detection, Kato-Katz showed higher calculation of STH EPG than mini-FLOTAC. Using 10% formalin preservation for stool samples, the STH eggs' morphology could still be well identified. Homogenization process and low number of samples tested, were acknowledged as the limitation of this study.

Spatiotemporal patterns of malaria at cross-boundaries area in Menoreh Hills, Java, Indonesia

Background

Comprehensive reports of malaria in Menoreh Hills, Central Java, Indonesia, a unique district cross-boundaries area under three districts and two provinces have been published previously. However, no study was performed to identify the hotspots of malaria in this cross-boundaries area, Kaligesing and Bagelen Subdistricts in Purworejo, Jawa Tengah Province and Kokap Subdistrict in Kulon Progo, Yogyakarta Province, using a longitudinal spatial data.

Methods

Monthly reports of malaria cases at primary health centres during 2005–2015 were collected and processed with ArcGIS and SaTScan to identify the malaria distribution at the village level. Malaria distribution was analysed using global spatial autocorrelation (Moran index) in ArcGIS. Cluster analysis was conducted using SaTScan purely spatial clustering and purely temporal clustering. Cluster characteristics resulted from three different approach were compared and analysed.

Results

During the last 11 years, 3812 malaria cases were reported and the number of high case incidence (HCI) villages were increased continuously. Malaria spatial distribution in Menoreh Hills was clustered spatially. Using three different approaches of time period ranges, consistent conclusion was found i.e. most likely clusters always occurred in the Purworejo district while the secondary clusters appeared later in the cross-boundaries districts.

Conclusion

Spatiotemporal analysis of an 11 years surveillance data showed that hotspots of malaria cases in Menoreh Hills were continuously located in Purworejo district. The success of malaria elimination in the cross boundaries area of Menoreh Hills might be depended on the success in malaria case management and surveillance in this hotspot area.

Diagnostic comparison of Baermann funnel, Koga agar plate culture and polymerase chain reaction for detection of human Strongyloides stercoralis infection in Maluku, Indonesia

Human infection with the nematode Strongyloides stercoralis, which may have a life-threatening course, primarily occurs in tropical settings. Epidemiological data on the occurrence of strongyloidiasis are scarce, and microscopic stool-based detection methods are insensitive. Polymerase chain reaction (PCR) assays have been developed, yet conflicting results have been reported. Our goal was to determine whether there was diagnostic agreement between an in-house PCR and two microscopic techniques, the Baermann funnel (BM) and the Koga agar plate culture (KAP) for the detection of S. stercoralis in stool samples. Eighty ethanol-fixed stool samples stemming from a cross-sectional survey in Maluku, Indonesia, were purposefully selected for PCR analysis. The final sample size comprised four groups, each with 20 samples: group 1, positive for S. stercoralis on both BM and KAP; group 2, positive only by BM; group 3, positive only by KAP; and group 4, negative on both BM and KAP. A Strongyloides-specific PCR targeting the internal transcribed spacer 2 (ITS2) region was carried out in an Indonesian reference laboratory. The overall agreement between PCR and microscopy was 61% (49/80 samples), being highest in group 1 (15/20, 75%) and lowest in group 3 (9/20, 45%). PCR revealed eight additional S. stercoralis infections in group 4. Future studies should elucidate the 'true' infection status of samples that are negative by PCR, but positive upon microscopy. Taken together, there is a lack of agreement between microscopy and PCR results for the diagnosis of human S. stercoralis infection in Indonesia. ClinicalTrials.gov (identifier: NCT02105714).

Prevalence of intestinal protozoan infections and association with hygiene knowledge among primary schoolchildren in Salahutu and Leihitu districts, Central Maluku regency, Indonesia

The objectives of this study were to estimate the prevalence of intestinal protozoan infections and to determine the association with hygiene knowledge among primary schoolchildren in Central Maluku regency, Indonesia. A cross-sectional study was conducted among fourth- and fifth-grade primary schoolchildren during May to June 2015. Stool specimens were examined using direct and modified Ziehl-Neelsen staining methods. Hygiene knowledge was obtained from a pre-tested questionnaire. Data were analyzed using SPSS^® version 22.0 statistic software. Of the 170 students surveyed, 69 (40.6%) were infected with one (32.9%) or more (7.7%) intestinal protozoans. The age ranged from 8 to less than 15 years old. The most frequent protozoan detected was Cryptosporidium sp. (24.7%), followed by Entamoeba coli (13.5%), Giardia lamblia (5.9%), Entamoeba histolytica/Entamoeba dispar (3.5%), Chilomastix mesnili (0.6%), and Iodamoeba bütschlii (0.6%). The most frequently detected multi-infection was Cryptosporidium sp. with E. coli (4.1%). Only 10 of 170 students had lack of knowledge regarding hygiene, nevertheless this is a significant risk factor for intestinal protozoan infections (P < 0.05). Education on personal and environmental hygiene should be improved and implemented to prevent and control intestinal protozoan infections in this population.

Change of strategy is required for malaria elimination: a case study in Purworejo District, Central Java Province, Indonesia

Background

Malaria has been targeted for elimination from Indonesia by 2030, with varying timelines for specific geographical areas based on disease endemicity. The regional deadline for malaria elimination for Java island, given the steady decrease of malaria cases, was the end of 2015. Purworejo District, a malaria-endemic area in Java with an annual parasite incidence (API) of 0.05 per 1,000 population in 2009, aims to enter this elimination stage. This study documents factors that affect incidence and spatial distribution of malaria in Purworejo, such as geomorphology, topography, health system issues, and identifies potential constraints and challenges to achieve the elimination stage, such as inter-districts coordination, decentralization policy and allocation of financial resources for the programme.

Methods

Historical malaria data from 2007 to 2011 were collected through secondary data, in-depth interviews and focus group discussions during study year (2010–2011). Malaria cases were mapped using the village-centroid shape file to visualize its distribution with geomorphologic characteristics overlay and spatial distribution of malaria. API in each village in Purworejo and its surrounding districts from 2007 to 2011 was stratified into high, middle or low case incidence to show the spatiotemporal mapping pattern.

Results

The spatiotemporal pattern of malaria cases in Purworejo and the adjacent districts demonstrate repeated concentrated occurrences of malaria in specific areas from 2007 to 2011. District health system issues, i.e., suboptimal coordination between primary care and referral systems, suboptimal inter-district collaboration for malaria surveillance, decentralization policy and the lack of resources, especially district budget allocations for the malaria programme, were major constraints for programme sustainability.

Conclusions

A new malaria elimination approach that fits the local disease transmission, intervention and political system is required. These changes include timely measurements of malaria transmission, revision of the decentralized government system and optimizing the use of the district capitation fund followed by an effective technical implementation of the intervention strategy.

Early malaria resurgence in pre-elimination areas in Kokap Subdistrict, Kulon Progo, Indonesia

Background

Indonesia is among those countries committed to malaria eradication, with a continuously decreasing incidence of malaria. However, at district level the situation is different. This study presents a case of malaria resurgence Kokap Subdistrict of the Kulon Progo District in Yogyakarta Province, Java after five years of low endemicity. This study also aims to describe the community perceptions and health services delivery situation that contribute to this case.

Methods

All malaria cases (2007–2011) in Kulon Progo District were stratified to annual parasite incidence (API). Two-hundred and twenty-six cases during an outbreak (May 2011 to April 2012) were geocoded by household addresses using a geographic information system (GIS) technique and clusters were identified by SaTScan software analysis (Arc GIS 10.1). Purposive random sampling was conducted on respondents living inside the clusters to identify community perceptions and behaviour related to malaria. Interviews were conducted with malaria health officers to understand the challenges of malaria surveillance and control.

Results

After experiencing three consecutive years with API less than 1 per thousand, malaria in Kokap subdistrict increased almost ten times higher than API in the district level and five times higher than national API. Malaria cases were found in all five villages in 2012. One primary and two secondary malaria clusters in Hargotirto and Kalirejo villages were identified during the 2011–2012 outbreak. Most of the respondents were positively aware with malaria signs and activities of health workers to prevent malaria, although some social economic activities could not be hindered. Return transmigrants or migrant workers entering to their villages, reduced numbers of village malaria workers and a surge in malaria cases in the neighbouring district contributed to the resurgence.

Conclusion

Community perception, awareness and participation could constitute a solid foundation for malaria elimination in Kokap. However, decreasing number of village malaria workers and ineffective communication between primary health centres (PHCs) within boundary areas with similar malaria problems needs attention. Decentralization policy was allegedly the reason for the less integrated malaria control between districts, especially in the cross border areas. Malaria resurgence needs attention particularly when it occurs in an area that is entering the elimination phase.