General Research Topic: To determine whether it is possible to implement monthly screening for acquisition of Toxoplasma infection during gestation in the US and Panama as best standard of care, to improve maternal and child health, and using point of care testing. This program will be analyzed to compare possible benefits in terms of individual, public-maternal child health, and cost savings for the government and other health care providers. Serologic testing for toxoplasmosis has been found to be beneficial for patient care, feasible, to save lives and quality of life and to be cost savings in France and Austria, and has been adapted in Brazil and Ecuador. Panama has passed a law that mandates a serologic test during pregnancy. Also reporting is mandated. But students in the past spring and summer have studied how well this is working, and although this definitely has been implemented, with remarkable success, and education programs have been shown to be successful in a variety of formats for patients, in the medical community at large the physicians have limited knowledge and skill with this approach. There is limited implementation of screening with on average between 30% and 60% of health clinics screening. Limitation of knowledge, reagents and appreciation of the importance are the limitations. Educational materials for health clinic physicians and obstetricians to implement this improved standard of care have been prepared and found to be effective teaching materials for high school students, medical students are being tested now, patients, and in the next phase of the project will be incorporated into education programs that will be tested to determine how well they help physicians to improve knowledge and care. In the US two obstetricians will implement monthly screening using standard tests along with a point of care test to determine whether this can be implemented easily and conveniently in the US as well. We will try to implement true point of care testing in the clinic to determine if that is felt to be a beneficial approach that might make screening easier and less expensive.

Aim 1-To determine whether monthly testing for acquisition of toxoplasma during gestation can be implemented in practices in the US and in Panama with standard testing (list price $650 per test x 10 tests in the US, we will work to find a much more economical way to test with this reference test because the charge of $650 is the real road block in the US. It makes it not feasible to do the test. Point of care test ($4 per test) would make it feasible. The longer range goal is to have the first and last test be performed by a multiplexed nano test that detects antibodies to Toxoplasma IgG and IgM, CMV IgG and IgM, Rubella, HIV, Syphillis, Hepatitis B, Zika Virus ($25 per test) for the first and last of the monthly test. This plasmongold test works with 1 microliter of saliva is, expected to be available in early 2017. In between the first and end of gestation test Toxoplasma serology can be checked with the LD Bio test which is a tractable, low tech and easy system. We have proven both are effective and inexpensive in France and the US in research laboratory settings. The challenges will be: 1-developing an effective education program for physicians in the US and Panama City. Then, extending this in more rural areas in Panama where there is care for pregnant women who may have a baby with congenital toxoplasmosis. Thus, one goal will be to implement this education and care program and assess its effectiveness for physicians at multiple levels, particularly for obstetricians and in the health clinics, and especially in indigenous communities where 8 different languages are spoken. In the US we expect to be able to document that this type of program is effective and feasible in a pilot study knowing that the present tests for which obstetricians are capitated and must pay from their capitated often total $1000 resources, $650 per test x 10 tests = $6500 which simply is not feasible. 2. In Panama in these settings another major challenge and goal will be to assure treatment and follow up is available for the patients detected. We anticipate during the spring and summer there will be 18 pregnant women identified and 6-8 babies identified among the 6000 pregnant women screened. 2400 will be screened prospectively with 1200 seronegative women requiring monthly screening and approximately ~6 seroconversions identified and medicines made available. 3600 are likely to appear only for delivery. Thus this will be the beginning of comparing the severity of disease in the babies born in both circumstance and ease of management in both circumstances in Panama.; 3-An economist will perform a concomitant cost/ benefit/ DALY analysis. These materials will be discussed with the Ministry of Health and efficacy of establishing this system and cost will be considered. The goal will be to determine whether it can create a paradigm for use of this system throughout Panama that improves well being and care, and is cost savings for care for children and pregnant women through prevention of disabling diseases. Aim 2- To genotype the isolates from placenta and peripheral blood for 6 patients with full genome sequencing. This will be implemented to begin to determine whether there is association of parasite genotype with manifestations at birth. We are especially interested in whether there is polymorphism in the genotypes of parasites on either side of the canal which formed as a land bridge separating the two continents, and whether this leads to different manifestations of babies born on either side of the canal. The students will help with collection of samples, isolation of parasites. Full genome sequencing will be performed on DNA isolated in Panama and sequencing will be performed at JCVI. In the US we may by referral have about the same number of isolates. This is a project of Zuleima Caballeros, PhD and Claudia Renfugio, PhD, DVM, students will contribute and it will be continued/ extended in Panama after students leave.

The overarching goal and significance of the project will be to implement this education, screening, treatment program on a limited scale in the US and Panama; This will allow us to assess the efficacy of attempting to do so through physician education, implementing gestational serologic screening using inexpensive point of care testing and assessing its ease of use, robustly implementing a perinatal infections clinic and follow up program (XN,XS, D,MT, MS). This will allow us to begin to identify the types of parasites in Panama which we expect to be genetically diverse (ZC,CR) and confirm areas of high prevalence of infection and disease identified last summer. The goal of this program is to improve care and maternal and child health in Panama' for toxoplasma infections but also to provide a broader basis to prevent other illnesses that effect pregnant women and their children. This will build an understanding of the parasites in this area in terms of genetics, susceptibility to medicines, epitopes that will allow vaccine in Panama to be efficacious.