Will a new 2017 global leadership commit to NTDs?

Influence of angiotensin II type 1 receptors and angiotensin-converting enzyme I/D gene polymorphisms on the progression of Chagas' heart disease in a Brazilian cohort: Impact of therapy on clinical outcomes

Chagas disease (CD), a neglected tropical disease, is caused by infection by the protozoan Trypanosoma cruzi. One-third of CD patients develop cardiac disease (CARD), an inflammatory and fibrotic process that may progress to heart failure associated with reduced left ventricular ejection fraction (LVEF). The determinants of CD progression are still uncertain. In non-infectious conditions, the angiotensin-converting enzyme (ACE) functional insertion (I)/deletion (D) and type 1 angiotensin II receptor (AT1R) +1166A>C gene polymorphisms have been linked to clinical outcomes. In a Brazilian cohort of 402 patients with positive serology for CD, in a case-control study we used PCR for genotyping the ACE rs4646994 I/D and AGTR1 rs5182C>T, rs275653 -119C>T, rs2131127A>G and rs5186 +1166A>C polymorphisms to evaluate association with CARD and progression to heart failure. Patients were classified as non-CARD (stage A; 109), and mild (stage B1; 161) or severe (stage C; 132) CARD. The groups were compared using unconditional logistic regression analysis and adjusted for non-genetic covariates (age, gender, and trypanocidal treatment). ACE II genotype appeared less frequent in C patients (15% in C vs 20% in B1 and 27% in A). After covariate adjustments, the ACE D allele showed a borderline association with susceptibility to severe CARD (C vs A: OR = 1.9; P = 0.08). AGTR1 +1166AC genotype showed a borderline association with protection against the progression and severity of CARD (C vs A: OR = 0.6; P = 0.09; C vs B1: OR = 0.6; P = 0.07; C vs A + B1: OR = 0.6; P = 0.05). However, adjustments for multiple comparisons showed no association of ACE I/D and AGTR1 polymorphisms with susceptibility and severity of CARD. The rs275653/rs2131127/rs5186/rs5182 T/A/C/T haplotype was protective against progression to the severe form of CARD (C vs B1: OR = 0.3; P = 0.03). Moreover, patients with ACE II and AGTR1 rs5186 +1166AC genotypes presented higher LVEF%. In C patients, TNF serum levels were higher in ACE D carriers than in II genotype. Although limited in number, a cross-sectional observation suggests that C-stage patients treated with benznidazole years prior to administration of ACE inhibitors/AT1R antagonists show reduced TNF serum levels and improved LVEF%. Therefore, variants of ACE and AGTR1 genes may influence the outcome of Chagas' heart disease and should be explored in precision medicine. Further, pharmacotherapies may improve immunological abnormality and clinical outcome in CD patients. Altogether, these data support prospective studies of this cohort and replication in other cohorts.

What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh

Background

Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh.

Methods

This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach.

Results

Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities.

Conclusions

This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.

Neglected tropical diseases in Brazil: lack of correlation between disease burden, research funding and output

OBJECTIVES

To assess the correlation between the burden of seven priority neglected tropical diseases (NTDs) included in the Brazilian National Agenda of Priorities in Health Research - tuberculosis, Chagas disease, leprosy, malaria, leishmaniasis, dengue and schistosomiasis - and their respective research funding and output.

METHODS

This retrospective review obtained data on disease burden from the Global Burden of Disease Study and funding data from open access sources. Publications were retrieved from Scopus and SciELO, and characterised according to the type of research conducted. Correlation between funding, research output and burden was assessed by comparing the 'expected' and 'observed' values for funding and publications relative to the proportional burden for each disease.

RESULTS

There was an emphasis in basic biomedical research (average 30% of publications) and a shortage of health policy and systems (average 7%) and social sciences research (average 3%). Research output and funding were poorly correlated with disease burden. Tuberculosis, Chagas disease and schistosomiasis accounted for more than 75% of total NTD-related DALYs, but accounted for only 34% of publications. Leprosy, leishmaniasis and malaria, together, received 49% of NTD-related funding despite being responsible for only 9% of DALYs.

CONCLUSIONS

The analysis evidenced a lack of correlation between disease burden, research output and government funding for priority NTDs in Brazil. Our findings highlight the importance of monitoring health needs, research investments and outputs to inform policy and optimise the uptake of evidence for action, particularly in developing countries, where resources are scarce and the research capacity is limited. The results contribute to health policy by highlighting the need for improving coordination of scientific activities and public health needs for effective impact.