Chagas Disease

Report: Conclusions and Recommendations
Washington D.C., May 3 - 4 2018

Context and purpose of the meeting

Enfermedad de Chagas en las Américas: una revisión de la situación actual de salud pública y su visión para el futuroChagas disease is caused by infection with the flagellated protozoan Trypanosoma cruzi (T. cruzi), which circulates among insect vectors of the subfamily Triatominae (Hemiptera: Reduviidae) and some 120 species of mammals, including humans, reflecting its zoonotic nature and representing diverse and complex transmission cycles in sylvatic and domestic environments. 

Domiciliary triatomines, efficient exploiters of ecotopes found primarily in and around substandard rural dwellings (and to a lesser extent, peri-urban and urban structures), are the main vectors for the transmission of T. cruzi infection in humans. They are responsible for concentrating the burden of disease in rural communities, whose socioenvironmental contexts foster and perpetuate its existence. 

It is important to point out that the migration of rural populations to cities in recent years, even outside Latin America have "urbanized" congenital and transfusion transmission, altering the epidemiology of the disease. The new epidemiological landscape also includes episodes of oral transmission, mainly in the Amazon basin, which have not yet been adequately characterized.

The geography of Chagas disease endemicity includes 21 countries ranging in latitude from 40° N (southern United States) to 45° S (southern Argentina and Chile). Despite the complexity of the epidemiological scenario and the enormous challenges entailed in collecting data on this subject, a substantial decline in the incidence and prevalence of the infection has been observed in recent decades. This progress is attributed mainly to improvements in the quality of life of populations, the progress made by national Chagas and/or vector control programs, the intensification of blood bank screening and detection activities, and medical care for managing morbidity and mortality in some countries. 

Given the success in reducing the incidence of T. cruzi infection through the creation of sub-regional initiatives for Chagas control and the action taken by countries to control vector and transfusion transmission of the parasite, this is a good time to utilize these platforms and introduce new objectives, considering the advances in the different fields of biomedicine. 

In this context, the Pan American Health Organization (PAHO)--aware of its responsibility to adapt to the ever-changing economic and social situation in the countries as reflected by changes in the health structures and epidemiological profiles of diseases--recognizes that the dynamics of Chagas disease have changed since prevention and control activities were first implemented in the Americas in 1991. 

Accordingly, PAHO recently held a meeting to examine all aspects of what has already been done, as well as the current and future challenges in the approach to Chagas disease, resulting in the adoption of a public health vision and establishing the service objective of finding alternative solutions to the current health problems associated with this endemic disease. 

The purpose of the meeting was to create an entity that would bring together the various actors--including government representatives from endemic countries; civil society organizations working in endemic areas; affected people and/or representatives from communities at risk for the infection; national and international institutions actively engaged in fighting the endemic disease; academic and research institutions with knowledge, experience, and an understanding of the situation in the Americas; bilateral and multilateral institutions; and the private sector--to participate in a strategic review and discussion of all matters relevant to the surveillance, detection, diagnosis, treatment, prevention, control, and elimination of Chagas disease in the countries of the Americas. 

The objectives, conclusions, and recommendations of that meeting are presented below.

General objective

Analyze the epidemiology of Chagas disease and formulate the major lines of future work to maintain the progress achieved and tackle the problems yet to be solved in the current situation, trends, and circumstances. 

Specific objectives, conclusions, and recommendations

Session 1. Vector-borne transmission of Chagas disease. 

1.1. Specific objective

Analyze current vector control, its progress, and the work pending; lay the foundation for strategies and methodologies that increase the coverage and quality of interventions. 

1.2. Conclusions

1.2.1. In addition to positive socioeconomic changes and donor screening in blood banks, strategies for controlling the primary domiciliary vector-based on PAHO guidelines and in the context of South-South cooperation through sub-regional intergovernmental initiatives-have led to a significant reduction in Chagas endemicity levels, evidenced in the decline in prevalence and incidence, with the consequent inferred impact on financial costs and potential years of life lost. 

1.2.2. Sub-regional initiatives, created as partnerships strategically managed by the countries themselves, have led to country empowerment, the sharing of experiences, the adoption of agreements, and the implementation and monitoring of interventions to meet their goals and objectives. 

1.2.3. PAHO therefore acknowledges the efforts of the people from the health sector, academic and research institutions, social organizations, and cooperation agencies who work every day with a sustained commitment at the local level to give priority to promoting and maintaining the prevention, control/elimination, and treatment of Chagas disease. 

1.2.4. Vector control has been effective in eliminating allochthonous domiciliary vector species in six countries and the state of São Paulo in Brazil, and in controlling them in all or part of the territory of 11 other countries, protecting 209 million people in an area 7 million km2 and signifying the interruption of vector-borne transmission of T. cruzi in 17 countries in the Region. 

1.2.5. Advances in the elimination/control of domiciliary vector-borne transmission of T. cruzi have led to changes in the transmission dynamic that are creating the conditions for the emergence of other entomological scenarios, such as peri-domiciliary or sylvatic cycles involving autochthonous species. These latter should be studied and characterized to learn about the risk they pose to the human population. 

1.2.6. Recent studies on the variability of the parasite have shed new light on the different scenarios of the disease's transmission cycles and its pathogenesis in humans. Thus, the main purpose of molecular characterization of the multiple genotypes of T. cruzi is to determine their association with clinical disease, its pathogenesis and aspects of its epidemiology. 

1.2.7. Mention should be made of country efforts to improve unhealthy, precarious rural or peri-urban housing as a Chagas vector control measure, enhancing the overall quality of life of their populations. 

1.2.8. Entomological surveillance with quality and coverage criteria still needs improvement in the countries of the Region. 

1.3. Recommendations

1.3.1. Improve knowledge about the vector-borne transmission of T. cruzi to humans in all environments and circumstances, characterizing the spectrum of possibilities and evaluating the real epidemiological importance of each scenario to develop new strategies and methodologies for integrated triatomine control. 

1.3.2. Encourage the countries to achieve/maintain the interruption of domiciliary, vector borne transmission of T. cruzi throughout their territory, following the recommendations of PAHO. 

1.3.3. Develop and strengthen operational research to increase the effectiveness of entomological surveillance and interventions to combat vectors in areas where transmission through autochthonous vectors or vectors from the sylvatic cycle of T. cruzi is a risk, prioritizing the lines of action and issues to be addressed in the short and medium term. In particular, it is recommended that new tools be investigated and developed for preventing or reducing the presence of autochthonous triatomines in dwellings or their contact with humans in the enzootic environment of Chagas. 

1.3.4. Establish laboratories and a sufficient quantity of capable human resources to support entomological surveillance and the implementation and evaluation of the vector control required in endemic countries. 

1.3.5. Improve knowledge about insecticide resistance in triatomines and its mapping and management with the support of centers and networks specializing in this area. 

1.3.6. Provide continuity and expand the intersectoral and interinstitutional associations and partnerships that have led to the progress achieved to date. 

2. Session 2. Transfusion transmission of Chagas disease. 

2.1. Specific objective

Review the current situation regarding transfusion transmission of T. cruzi, cementing and reaffirming achievements and planning improvements that will lead to the sustainability of coverage and an improvement in the quality of activities. 

2.2. Conclusions

2.2.1. Universal Chagas screening in blood banks in the 21 endemic countries of the Region has been an effective strategy for controlling transfusion transmission. 

2.2.2. This demands the continuity, sustainability, coverage, and quality of screenings in the public sector, social security system, private sector, and other areas. 

2.2.3. Mention should be made of the solidarity and support provided by the São Paulo Blood Center (Hemocentro) in the dissemination of good practices and quality control of Chagas screening in blood banks. 

2.3. Recommendations

2.3.1. Agree on the goals and targets necessary for achieving and obtaining national certification of the "interruption of transfusion-transmitted T. cruzi." This should be part of the technical manual for elimination that describes how to accomplish this. 

2.3.2. The technical manual that will be prepared should include the necessary information on the organization, functions, operation, supervision, and evaluation of the comprehensive prevention of transfusion transmission.

2.3.3. It is imperative to adjust and coordinate the algorithms for the care of blood donors who test positive during screening. This includes confirming the diagnosis, referring them through clear and established flow charts to capable clinical personnel, and beginning their management and eventual treatment. 

2.3.4. Reinforce good practices and the internal and external quality control mechanisms for serological testing when screening blood donors for Chagas disease. This should extend to the screening of organ donors and transplant recipients. 

2.3.5. Promote voluntary altruistic blood donation as the ideal safety mechanism in donation. 

2.3.6. Consider the possibility of false positives and negatives in the techniques used in screening blood donors in order to implement safe, practical solutions for improving quality control. 

2.3.7. Include the PAHO blood unit in the work to screen blood donors for Chagas and improve the quality of the screening. 

3. Session 3. Care for Chagas disease. 

3.1. Specific objective

Develop approaches for sustained, effective, efficient, timely, adequate, and affordable comprehensive medical care geared to universal coverage for people infected with T. cruzi

3.2. Conclusions

3.2.1. Due to a variety of factors and causes, some 6-8 million people infected with T. cruzi have limited opportunities to access the health services and resulting comprehensive care (detection, diagnosis, treatment, rehabilitation, and monitoring) for Chagas disease. 

3.2.2. The diagnosis and treatment of children and adolescents infected with T. cruzi is the most effective medical intervention for curing Chagas disease in its early stages. 

3.2.3. There is evidence of therapeutic indications with a positive impact on the etiological treatment of adults with chronic T. cruzi infection in specific situations - for example, women of reproductive age. 

3.3. Recommendations

3.3.1. Achieve universal access to comprehensive care for all people infected with T. cruzi, whatever their age and the stage of their disease, eliminating the misconception that Chagas disease is an untreatable illness. 

3.3.2. Therefore, intensify strategies to identify people with Chagas disease in all countries and territories in the Americas. 

3.3.3. All countries, at all levels of care, should improve and update the necessary capacities of parasitological and/or immunological laboratories for diagnosing Chagas disease, in keeping with their level of complexity within the corresponding national health system. 

3.3.4. Aligning with PAHO's new diagnostic and treatment guidelines for Chagas disease, access to etiological treatment should be guaranteed for any patient with a completed diagnosis of Chagas and no formal contraindications that meet one or more of the following criteria, 

- acute stage of Chagas disease 

- pediatric age 

- recent chronic infection 

- woman of reproductive age 

- pathological immunodepression or immunosuppression 

- accidental inoculation with T. cruzi

3.3.4. Any patient infected with T. cruzi can potentially benefit from etiological treatment of the infection, but in the case of patients with chronic infection, its administration should be indicated by agreement between the treating physician and the patient after an accurate and thorough evaluation of the situation and a determination of the risks and benefits. 

3.3.5. It is necessary to ensure the availability of drugs for the etiological treatment of Chagas disease in all their presentations (for adult and pediatric use), providing free and universal access. 

3.3.6. Provide comprehensive care for cases, emphasizing a family-based approach.  Care should include counseling, guidance, and monitoring. Treatment for Chagas disease is not simply etiological but requires physio-pathological and symptomatic treatment and the early detection of potential complications, depending on the characteristics of each case. 

3.3.7. There is an urgent need for new drugs capable of curing trypanosome infection and improving conditions, the outlook for cure, and the management of the disease at the personal and societal levels. Additionally, drugs to reverse heart damage are also needed and the use of new therapeutic regimens and strategies for existing drugs should be explored. 

3.3.8. Regarding the diagnostic tests, there is an urgent need for specific, newly quantifiable and sensitive techniques for diagnosing trypanosome infection and evaluating the efficacy of the drugs. Thus, research in this field should be given the highest priority in order to improve the outlook for diagnosis, even considering rapid tests. 

3.3.9. Ongoing training, both formal and informal, should be provided to health workers (physicians, nurses, technicians, aides, etc.) to keep their knowledge about Chagas disease relevant and enable them to properly do their work in prevention, control, and care. 

4. Session 4. Congenital transmission of Chagas disease. 

4.1. Specific objective

Adopt a comprehensive approach to the diagnosis and treatment of congenital Chagas disease as a public health problem; and its integrated management from the standpoint of maternal and child health through the Framework for Elimination of Mother-to-Child Transmission of HIV, Syphilis, Hepatitis B, and Chagas (EMTCT Plus). 

4.2. Conclusions

4.2.1. For many countries that have had success in controlling vector-borne and transfusion transmission of Chagas disease, vertical transmission (from mother to fetus) may currently be the primary mode of T. cruzi transmission. 

4.2.2. By the same token, this form of transmission may also be occurring in urban areas where there is no vector-borne transmission but, instead, the migration of infected populations from endemic areas. 

4.2.3. Vertically transmitted Chagas cases that receive accurate and timely diagnosis and treatment are cured with a positive impact on morbidity, mortality, and the economic burden of the disease. 

4.3. Recommendations

4.3.1. For complete and accurate diagnosis and treatment of congenital Chagas, it is essential and strategic to include it in the PAHO platform for the elimination of mother-to-child transmission of Chagas disease, known by the acronym EMTCT Plus, which works in a comprehensive manner to simultaneously eliminate other, more visible vertically transmitted diseases that receive more attention: HIV/AIDS, hepatitis B, and congenital syphilis. The goal is the interruption of transmission and the prevention of new cases.  

4.3.2. The intervention necessary for the prevention, diagnosis, and treatment of congenital Chagas disease requires services for girls and women in the adolescent and pre-pregnancy stage; during pregnancy itself; in the perinatal period for newborns; and in the maternal and child postnatal period. To this end, it is important to create algorithms for case referral. 

4.3.3. Universal serological screening for every pregnant woman during prenatal check ups is recommended as a diagnostic procedure, and establishment of treatment procedures for verified cases of infected newborns. 

4.3.4. For the newborns of mothers seropositive for T. cruzi, it is essential to perform an immediate perinatal parasitological study which, if positive, will warrant etiological treatment and, if negative, will call for serological monitoring beginning at 8 months to determine the absence or presence of infection. 

4.3.5. Prior to pregnancy or once exclusive breastfeeding has ended, mothers seropositive for T. cruzi should receive etiological treatment to reduce their parasite load and eliminate the possibility of future vertical transmission. 

4.3.6. Cross-cutting interventions should be conducted to investigate and detect Chagas disease in the entire family of an infected newborn and/or child of a mother who is seropositive for Chagas. Furthermore, all steps should be taken to protect the newborn's home from infestation with triatomine vectors.

Session 5. The complex challenge of Chagas disease: patients, community, civil society organizations, and international cooperation agencies. 

5.1 Specific objective

Review the situation and opportunities for improving coordination among government agencies, civil society organizations, international cooperation agencies, patient associations, and PAHO itself, identifying the strengths and weaknesses of the current scenarios. 

5.2 Conclusions: 

5.2.1. There is growing recognition of the multidimensional nature of Chagas disease, whose characterization involves the study of a complex web of sociocultural, political, biological, environmental, and health factors. Within this framework, in Chagas, as in other vector-borne diseases, biological factors interact with the socioeconomic, cultural and environmental dynamics of the locations in which the cases occur. 

5.2.2. It is essential to maintain and increase the support from national, international, bilateral, and multilateral technical cooperation agencies, both public and private, to guarantee the sustainability of the progress achieved and improve the quality and coverage of interventions in the existing endemic areas. 

5.3 Recommendations

5.3.1. The comprehensive integrated approach to Chagas disease that its multidimensional nature requires should be grounded in community-oriented concepts with an intersectoral focus. To this end, government institutions, civil society organizations, international cooperation agencies, and patient associations should work together to explore new connections that will increase opportunities for synergy and collaboration for better prevention, management, and control of this disease. 

6. Session 6. Surveillance and access to information on Chagas disease. 

6.1. Specific objective

Review current surveillance and access to information on Chagas disease in the Americas and propose feasible alternatives and action to improve the quality, frequency, and representativeness of data and epidemiological information that support decision-making in health regarding the management of this disease. 

6.2. Conclusions

6.2.1. Given the diversity of factors in the natural and social history of Chagas disease, the management of health promotion, prevention, control, and treatment interventions, as well as the monitoring of control/elimination targets, calls for strengthening public health surveillance and information systems with a multidimensional approach by transmission scenario. 

6.2.2. It is therefore necessary to design comprehensive new indicators that are clear, quantifiable, and harmonize sufficiently with the monitoring of the Sustainable Development Goals (SDG) and the Plan of Action for the Elimination of Neglected Infectious Diseases and Post-elimination Actions 2016-2022. These indicators should be constructed jointly with the countries to facilitate technical and political decision-making to meet the targets set with clear and objective monitoring of the progress made. 

6.2.3. It is likewise essential to have more robust data on Chagas disease and integrated analysis of the data, duly incorporating it in the countries' information and/or statistical systems. 

6.2.4. Mathematical models are a robust tool for inferring the quantification of Chagas disease and the strength of its transmission. Modelling also makes it possible to estimate distribution, progression, and the respective burden of disease, and even the potential impact of some interventions used for its control and elimination. However, mathematical models are no substitute for the national information or statistical services, whose data and information are the basic inputs for decision making to fight this disease. 

6.3. Recommendations

6.3.1. Given the ecological, geographic, and demographic heterogeneity of Chagas disease, the creation of more and better instruments and tools is recommended for proper characterization of its risk and transmission scenarios. 

6.3.2. It is recommended that national morbidity and mortality surveillance systems include compulsory notification of acute and chronic cases of Chagas disease that incorporates at least the variables of age and sex. 

6.3.3. It is imperative to adopt a methodology for measuring the burden of disease, taking the asymmetrical capacities of country surveillance systems into account. 

6.3.4. Given the preliminary evidence of the benefits of mathematical models in data analysis, it is recommended that pilot studies for validation and analysis be conducted in Chile, Paraguay, and Brazil, duly accompanied by external evaluation. Adaptation of the methodology should involve country participation and it should be geared for use at the local level. 

6.3.5. Given the multidimensional approach required for complete and useful surveillance of Chagas disease, the diversity of potential sources of information should be considered. It is also important to generate capacity for the necessary and sufficient integrated analysis of these sources, pursuant to the requirements of each program (and each country), duly harmonized with the health surveillance systems. 

6.3.6. Considering the multidimensional approach required for the surveillance of Chagas disease, it is therefore recommended that a working group be formed to: review the timeliness, sources, and quality of the information; standardize definitions; determine the requirements; and propose an efficient and viable model for surveillance and integrated data analysis for Chagas disease. 

 


Participants

ABRIL, MARCELO

Director Ejecutivo  Fundación Mundo Sano
Paraguay 1535, C1061ABC
Buenos Aires, Argentina
T. (54 11) 4872-1333
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www.mundosano.org

ABAD-FRANCH, FERNANDO

FIOCRUZ
Instituto René Rachou / IRR -- Fiocruz eN Minas Gerais, Brazil
This email address is being protected from spambots. You need JavaScript enabled to view it.
www.minas.fiocruz.br

ANGELERI PATRICIA

Directora Nacional de Epidemiología
Ministerio de Salud de la Nación
Av. 9 de Julio 1925
C1073ABA - Ciudad Autónoma de Buenos Aires, Argentina
T. (54-11)4379-9023
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ALBAJAR VINAS, Pedro

Medical Officer (Chagas Disease) 
Innovative and Intensified Disease Management (CDS)
World Health Organization
Geneva, Switzerland
T. +41 22 791 1261
M. +41794466802
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ALTCHEH  JAIME

Jefe Servicio ParasitologÍa- Chagas
Hospital de Niños Ricardo Gutierrez
Director centro colaborador en Chagas Pediátrico OPS/OMS
Investigador clínico GCBA
Investigador principal CONICET
IMIPP (Instituto Multidisciplinario de investigación en patologías pediátricas) CONICET - GCBA
Gallo 1330, C1425, Buenos Aires
M. 54 9 11 4470 9763
T.  54   11 4963 4122
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BATISTA, CAROLINA 

Responsable por el Programa de Acceso Chagas
Drugs for Neglected Diseases initiative - Latin America
Rua Santa Heloisa 5| Jardim Botânico| Rio de Janeiro-RJ 22460-080 | Brazil
M. + 552 98122-2304
This email address is being protected from spambots. You need JavaScript enabled to view it. 

BAZZANI, ROBERTO 

Senior Program Specialist | Especialista Principal de Programa
International Development Research Centre International
Centro Internacional de Investigaciones para el Desarrollo
Regional Office for Latin America and the Caribbean | Oficina Regional para América Latina y el Caribe
T. +598-29150492 ext. 3244
Montevideo Uruguay
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www.idrc.ca | www.crdi.ca

BERN, CARYN

Professor
School CSF School of Medicine
Department Epidemiology & Biostatistics
Address 550 16th. Street
San Francisco, CA 94158
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CHUIT, ROBERTO

Director de Instituto de Epidemiología
Academia Nacional de Medicina
J.A. Pacheco de Melo 3081 C1425UM
Buenos Aires, Argentina
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DAGNE, DANIEL ARGAW

Coordinator 
Innovative and Intensified Disease Management (CDS)
World Health Organization
Geneva, Switzerland
T. +41 22 791 4532
M. +41795946409
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ECHEVERRÍA, LUIS EDUARDO

Presidente del consejo científico de enfermedad de Chagas de la Sociedad Interamericana de Cardiología: SIAC 
Jefe del programa de insuficiencia cardiaca y trasplante de corazón
Fundación Cardiovascular de Colombia
Calle 155 A # 23-58, Urbanización el Bosque
Floridablanca, Santander, Colombia.
T.: 57-7-639-9292
C.: 57-320-3400438
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ESPINAL, CARLOS

Director, Global Health Consortium
Department of Health Promotion and Disease Prevention
Florida International University
Robert Stempel College of Public Health & Social Work
11200 S.W. 8th St AHC5 417
Miami, Florida,33199
T. 305-348-7916
M. 703-203-5862
(Fax) 305-384-8341
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FERRERO, LUIS

Gerente Ejecutivo de Negocios Especiales 
Laboratorio Elea Phoenix S.A.
Sanabria 2353 (C1417AZE), Ciudad Autónoma de Buenos Aires, Argentina
T. (5411) 4379 4300 (Int. 1293)
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www.elea.com | www.phoenix.com.ar

FREILIJ, HECTOR 

Consultor del Hospital de Niños Ricardo Gutiérrez, Buenos Aires
Pringes 867
Buenos Aires 1183 Argentina
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GILMAN, ROBERTH H. 

Professor
International Health Department
Johns Hopkins Bloomber School of Public Health
615 N. Wolfe St.
Baltimore, MD 21205, This email address is being protected from spambots. You need JavaScript enabled to view it.

GUHL NANNETTI, FELIPE

Profesor Emérito
Facultad de Ciencias
Departamento de Ciencias Biológicas
Universidad de los Andes
Director
Centro de Investigaciones en Parasitología Tropical CIMPAT
Bloque A, Calle 18A No 0-33 Of. 204
CP: 111711. l Bogotá, Colombia.
T. +(571) 3394949 ext 2775  / +(571)-3324540
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KANN, SIMONE 

Professor
Maximillian Universität Wurzburg Sanderring 2
97070 Würzburg Germany
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LEDESMA, OSCAR 

Director
Centro de Enfermedad de Chagas y Patología Regional
Ministerio de Salud de Santiago del Estero
Avda Belgrano  y Bolivia No. 2050
4200 Santiago del Estero, Argentina
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LEVY, MICHAEL Z.

Associate Professor
Department of Biostatistics, Epidemiology & Informatics
Fellow, Kleinman Center for Energy Policy (while on Sabbatical)
University of Pennsylvania
714 Blockley Hall, 423 Guardian Drive
Philadelphia, PA 19104-6021
Phone:  215-746-8131 office
Lab in Peru:  +5154421625
Lab Website: www.chirimacha.com
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LOTROWSKA, MICHEL 

Michel Lotrowska - Acting Executive Director
Drugs for Neglected Diseases initiative - Latin America
Rua Santa Heloisa 5| Jardim Botânico| Rio de Janeiro-RJ 22460-080 | Brazil
T: +55 21 2529 0401 |
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www.dndial.org 

LUQUETTI, ALEJANDRO 

Consultor Independiente
Rua 4 No 611, Setor Oeste
74110-140 Goiania, GO Brasil
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LEVI, JOSÉ EDUARDO 

Virology Lab, Tropical Medicine Institute
University of São Paulo, Brazil
Rua Dr Enéas de Carvalho Aguiar 470
CEP 05403-000
T. + 55 11 3061 8666 Mobile + 55 11 999913305
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LLAU, ANTHONI 

Florida International University
Robert Stempel College of Public Health & Social Work
11200 S.W. 8th St AHC5 417
Miami, Florida,33199

MADEJA, ULRICH-DIETMAR 

Access to Medicines
Bayer AG Pharmaceuticals
Commercial Operations EMEA-EMA,
Global Health Care Programs
13342 Berlin, Germany
T. +49 30 468 11803
Fax:   +49 30 468 11450
M.  +49 170 8596 201
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http://www.bayer.com

MANUEL VALENCIA, YURIKA VIOLETA 

Funcionaria adscrita al Programa de Enfermedades Transmitidas por Vector 
Centro Nacional de Programa Preventivos y Control de Enfermedades (CENEPRECE)
Subsecretaria de Prevención y Promoción de la Salud
México, DF., México
This email address is being protected from spambots. You need JavaScript enabled to view it.

MARCUS, RACHEL

Medical Director
Latin American Society of Chagas (LASOCHA)
12108 Tamar Ct.
Bristow, Virginia 20136
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MONROY ESCOBAR, MARÍA CARLOTA

Investigadora Principal
Laboratorio de Entomología Aplicada y Parasitología -LENAP-
Universidad de San Carlos de Guatemala
http://www.chagasecohealth.com/
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NOVICK, GABRIEL E.

Senior Advisor on Healthcare Policies and Governance and Integrated Healthcare Systems Design, and Management
Past Deputy Minister of Health and Sub secretary of Planning of the City of Buenos Aires.
Current CMO of Swiss Medical Group, Argentina
Faculty Tufts University, USA
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NOUVELLET PIERRE, VICTOR MARIE

University of Sussex
School of Life Sciences
JMS BUILDING 5B7
Brighton, BN1 9RH
United Kingdom
Tel: +44 7863 762 681
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PARRA GARCÉS, ALONSO

Oficina Zoonosis y Control de Vectores
División de Políticas Públicas Saludables y Promoción
Subsecretaría de Salud Pública
Ministerio de Salud de Chile
Teléfono: (+56 2) 2574 0441 | Anexo: 240441
Cell: 56-9 50047195
Monjitas 565, Oficina 1008
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PÉREZ DELGADILLO, OCTAVIO LENIN

Responsable del Componente Nacional de Chagas
Ministerio de Salud de Nicaragua
Managua, Nicaragua
Tel.: (505) 880-68992
Work: 2264-7730 ext. 1478
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PICOLLO, MARIA INES

Directora 
Centro de Investigaciones de Plagas e Insecticidas (CIPEIN)
Juan Bautista La Salle 4397, villa Martelli
1603, Buenos Aires, Argentina
This email address is being protected from spambots. You need JavaScript enabled to view it.; mpicollo@gmail,com

PINAZO, MJ 

ISGlobal
Institut de Salut Global de Barcelona
Hospital Clínic - Universitat de Barcelona
Carrer Rosselló 132, Barcelona 08036
Tel.+34 93 227 4135
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www.isglobal.org

QUIJANO ARANGO, M. MÓNICA

Entresto Access for All (EA4A) Head 
Latin America & Canada Region
Calle 93 B n. 16 -31- Bogotá, Colombia
M. +573203475742, Telefone : + 576544444
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RAMOS, VITÓRIA

Analista em Assuntos Humanitários
Humanitarian Affairs and Advocacy Officer
Medicos sin Fronteras
+55 21 2555-5179
+55 21 98595-8049
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RIBEIRO GARZONI, LUCIANA L.A.

Pesquisadora Associada em Saúde Pública 
Laboratório de Inovações em Terapias,
Ensino e Bioprodutos - Instituto Oswaldo Cruz
Coordenadora/Assessora de Promoção da Saúde -
Vice-Presidência de Ambiente, Atenção e Promoção da Saúde
Fundação Oswaldo Cruz - Ministério da Saúde
T: 55 21 25621297; 55 21 38851834; 55 21 996158154
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SANCHO, JAVIER 

Responsable de Comunicación de la Iniciativa Chagas y Coalición Chagas
c/Rosselló, 132, 5th 2nd 08036
Barcelona, España
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SANCHEZ, JENNY 

Latin American Society of Chagas (Lasocha)
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SCHAEUBINGER, MONICA MIRANDA 

Postdoctoral Fellow
International Health Department
Johns Hopkins Bloomber School of Public Health
615 N. Wolfe St.
Baltimore, MD 21205
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SOSA ESTANI, SERGIO

Responsable del Programa Clínico de Chagas
Drugs for Neglected Diseases initiative - Latin America
Rua Santa Heloisa 5| Jardim Botânico
Rio de Janeiro-RJ 22460-080, Brasil
C.: +5521 99899-5816
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VALDEBENITO PINO, JORGE 

Encargado Nacional Prevención y Control Enfermedad de Chagas
Departamento de Enfermedades Transmisibles
División de Prevención y Control Enfermedades
Ministerio de Salud de Chile
T. (+56 2) 2574 7965, Anexo: 247965
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VERA SOTO, MAURICIO JAVIER

Consultor
Carrera 147, 145-49 casa 129
Quintas de Santa Rita, IV etapa
Bogotá, Colombia c.: 57-315-397-0376
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VILLAR, JUAN CARLOS 

Director del grupo de Cardiología Preventiva
Universidad Autónoma de Buracamanga
Avenida 42 No 48-11
Bucaramanga, Colombia
c.: 57-321-452-0087
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VIEIRA ALVES, RENATO

Coordenador-Geral de Doenças Transmissíveis
Departamento de Vigilância das Doenças Transmissíveis - DEVIT
Secretaria de Vigilância em Saúde - Ministério da Saúde (SVS/MS) Brasil
SRTVN Quadra 701, Via W 5 Norte
Lote D Edifício PO700  70719-040
T. +55 (61) 3315-3569
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VILLALBA DE FELTES, CESIA

Jefa del Programa Nacional de Vigilancia de Chagas
Dirección General de Vigilancia de la Salud
Ministerio de Salud Pública y Bienestar Social de Paraguay
Asunción, Paraguay
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YOSHIOKA, KOTA

Japan International Cooperation Agency (JICA)
1776 I Street, NW, Suite 895
Washington, DC 20006
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PAHO/WHO 

 

BEZERRA, HAROLDO 

Regional Advisor  Public Health Entomology and Vector control 
Neglected, Tropical and Vector-Borne Diseases
PAHO/WHO
T. + 1 202-974-4630
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CASTELLANOS, LUIS GERARDO 

Unit Chief  Neglected, Tropical and Vector-Borne Diseases
Communicable Diseases and Environmental Determinants of Health
PAHO/WHO
T. + 1 202 974 3191
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COTO, HECTOR

International Consultant
Public Health Entomology and Vector control
Neglected, Tropical and Vector-Borne Diseases
PAHO/WHO
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COELHO, GIOVANINI

Advisor, Prevention and Control of  Vector Borne Diseases
Neglected, Tropical and Vector Borne Diseases
PAHO/WHO
T.: +1 20-974-3541
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GHIDINELLI, MASSIMO

Unit Chief, HIV, Hepatitis, Tuberculosis and Sexually Transmitted Infections
PAHO/WHO
T. +1 (202) 9743614
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NICHOLLS, SANTIAGO

Advisor, Neglected Infectious Diseases 
Neglected, Tropical and Vector Borne Diseases Unit
PAHO/WHO
T. +1 202 9743078
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FREDDY PEREZ

Advisor, Communicable Diseases Research 
PAHO/WHO
T. + 1(202) 974-3486
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SABOYÁ, MARTHA

Advisor, Neglected Infectious Diseases Epidemiology
Communicable Diseases and Environmental Determinants of Health Department (CDE)
Neglected, Tropical and Vector Borne Diseases Unit (VT)
PAHO/WHO
T. +1 202 316 9636
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SALVATELLA, ROBERTO 

Advisor, Chagas Program
PAHO/WHO
Montevideo, Uruguay
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Related Links

Protecting achievements; expanding diagnosis and treatment; and preventing mother to child transmission - All vital elements of the fight against Chagas

- PAHO: Chagas Disease Website 

Chagas Disease in the Americas: A Review of the Current Public Health Situation and a Vision for the Future. Report: Conclusions and Recommendations


Chagas disease, or American trypanosomiasis, is a tropical parasitic disease caused by the flagellate protozoan Trypanosoma cruzi (T. cruzi).  Considered a neglected tropical disease or disease of poverty, Chagas is endemic in 21 countries of the Americas. The T. cruzi is transmitted to humans and other mammals by a vector insect, the blood-sucking bugs of the subfamily Triatominae, popularly known as the conenose bugs and kissing bugs. The triatomine bugs are capable of colonizing poorly constructed homes in rural, suburban and urban areas.

Etiology


Chagas disease is the most prevalent communicable tropical disease in Latin America. The most important vectors are the Triatoma infestans in Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay and Peru; the R. prolixus in Colombia, Venezuela and Central America; the T. dimidiata in Ecuador and Central America; and the Rhodnius pallescens in Panama.

Source of Infection


Triatomine bugs can infect rodent, marsupials and other wild mammals. These triatomine bugs can also infect domesticated animals such as dogs and cat, and bring the T. cruzi (agent of the disease) inside human dwellings. 

Transmission Mode


The T. cruzi parasites are mainly transmitted by the infected feces of blood-sucking triatomine bugs. These bugs typically found in the Americas, live in the cracks of poorly constructed homes in rural or suburban areas. Normally they hide during the day and become active at night when they feed on blood, including human blood. They usually bite an exposed area of skin or mucosa membranes (lips, conjunctiva, etc.), and the bug defecates close to the bite. The parasites enter the body when the person instinctively smears the bug feces into the bite, and contaminate the eyes, the mouth, or any lesion in the skin. 

Although less common T. cruzi can also be transmitted through blood transfusions (20% if the cases) or organ transplant, vertically from an infected mother to child during pregnancy or childbirth (1% of the cases), and by the accidental ingestion of food contaminated with T. cruzi.

Signs and Symptoms


Chagas disease has two clinical forms or phases: an acute phase and a chronic phase.  Many people (70- 80% of the infected) are asymptomatic all of their lives, while a 20-30% of the ones infected evolve into  the chronic phase, which includes symptoms that indicate damages  to the tissue of the  heart, digestive system and/ or nerves system. 

The acute phase, when it is symptomatic, lasts for about two months after infection. During the acute phase, a high number of parasites circulate in the blood. 

Signs and Symptoms for acute Chagas disease can be absent or mild and include the following:

  • Signs of entry of the parasite
  • Rash and inflammatory nodules (Chagoma)
  • Swelling of periorbital soft tissue (Romaña's sign). 
  • Fever
  • Headache
  • Nausea, diarrhea or vomiting
  • Enlarged lymph glands
  • Difficulty breathing
  • Muscle, abdominal or chest pain. 

Although not typical, a first visible sign can be a skin chancre, called chagoma, or a purplish swelling of the lids of one eye. If the infection is left untreated, it can advance into the chronic phase. 

A first visible signal can be a skin lesion, called "inoculation chagoma" a regional subcutaneous nodule with adenitis at the site of the bite; and in cases of ocular inoculation, very typical but rare (2% o f acute symptomatic cases) is possible to identify the "sign of Romagna" bipalpebral edema, with retroauricular adenitis. If the infection is not treated, it can progress to the chronic phase.

Over several years or even decades, Chagas disease affects the central nervous system and the enteric nervous system, the digestion system and the heart.  Specific medical treatments and surgery may be necessary. 

Signs and symptoms for chronic Chagas disease can include the following: 

  • About 30% of people will develop cardiac damage:
    • Cardiomyopathy
    • Heart rhythm abnormalities 
    • Apical aneurysm.  
    • Sudden death or heart failure caused by progressive destruction of the heart muscle.
  • Less than 10% of patients  will experience enlargement of the gastrointestinal tract and organs, and gastrointestinal motor disorders 
  • Enlargement of the esophagus 
  • Enlargement of the colon.
  • Disturbances of gastric emptying
  • Colon and gallbladder motor disorders.

Diagnosis


Chagas diagnosis is always clinical, epidemiological and based on laboratory testing (parasitology and serology).

During the acute phase, Chagas disease can be diagnosed through parasitological methods, given the large number of parasites circulating in the blood. In the acute stage, the studies focus on the search and recognition of Trypanosoma cruzi in direct examination and staining of blood smears (methodology: direct parasitological), and in determining the seropostivity of serology tests. 

For chronic stage of the disease, Diagnosis is based on clinical assessment, serology and epidemiological history. The definitive diagnosis of T. cruzi infection depends on the positive result of at least two different serologic tests (ELISA, indirect immunofluorescence and indirect hemagglutination) that detect specific antibodies in patient sera.

Prevention and Control


There is no vaccine for the disease Chagas. Integrated vector control is the most effective method of preventing Chagas disease in Latin America, including chemical control by insecticides in infested homes, improvements in houses to prevent vector infestation, personal preventive measures such as bed nets, and informative education and communication to the community about vector-borne diseases.

Serological screening in blood donors is necessary to prevent infection through blood transfusion and organ transplant.

Chagas screening in pregnant women during prenatal care is needed to provide early diagnosis and treatment to newborns and other children of infected mothers.

Good hygiene practices in food preparation, transportation, storage and consumption; screening of blood donors; testing of organ, tissue or cell donors and receivers; and screening 

Treatment


Chagas disease may be etiologically treated in order to eliminate the infection T. cruzi with benznidazole or nifurtimox. If treatment was initiated during the acute phase, both drugs are effective in killing the parasite. 

Every infected child should be treated. 

Nevertheless, the efficacy of both drugs diminishes the longer a person has been infected, although all patients including chronic cases benefit from improved clinicopathologic changes if treated.   Benznidazole and nifurtimox should not be taken by pregnant women.

The potential benefits of medication in chronic cases preventing or delaying the development of Chagas disease should be weighed against the long duration of treatment (up to 2 months), possible adverse reactions (occurring in up to 40% of treated patients), age, comorbidities, and other important characteristics of each patient.

The patients correctly diagnosed patients should receive further medical or surgical, pathophysiological or symptomatic, treatment, specific to each case

PAHO/WHO Sub-regional Initiatives


Chagas disease is associated with multiple social and environmental factors that expose millions of people to infection.  Among the main risk factors for Chagas disease are living in poorly constructed housing - particularly in rural and suburban areas - having limited resources, residing in areas of poverty that are socially or economically unstable or have high rates of migration, and belonging to groups linked to seasonal farm work and crop harvests. This disease contributes and perpetuates the cycle of poverty, reduces learning capacity, productivity, and the ability to generate income.

In the early 1990's, the countries affected by Chagas disease, especially those where the disease was endemic, were organized to combat this public health threat. Along with the Pan American Health Organization/ World Health Organization, country representatives generated a successful scheme for horizontal technical cooperation between countries, called the Sub-regional Initiatives for Prevention and Control of Chagas Disease. These initiatives have been developed in the Southern Cone (1992), Central America (1997), Andean countries (1998), Amazonian Countries (2003), and Mexico (2004). These countries have contributed in creating substantial improvements in the situation through the interruption of vector transmission in all or part of the territory of the affected countries, the elimination of exotic species of vectors, the introduction of universal screening of blood donors, the detection of congenital cases, the reduction of prevalence in children, reduction in morbidity, expansion of access to diagnosis and treatment, and improvement of the quality of diagnosis, clinical care, and treatment of infected and ill persons.

The initiatives in the Americas have helped achieve significant reductions in the number of acute cases of disease and the presence of domiciliary triatomine vectors in endemic areas. The estimated number of people infected with T. cruzi worldwide dropped from 30 million in 1990 to 6 to 8 million in 2010. In those 20 years, the annual incidence decreased from 700,000 to 28,000 new cases of infection and the burden of Chagas disease decreased from 2.8 million in  1990-2006 to disability-adjusted life years lost to less than half a million years.

While substantial progress has been made, not all countries have managed to achieve the goals that have been proposed. New challenges have emerged such as the spread of disease due to the migration of people living in endemic countries to non-endemic countries, the need to ensure the sustainability of programs, confronting the emergence or re-emergence of cases of Chagas disease, recovering from natural disasters, expanding coverage of diagnosis and treatment, and achieving universal access to treatment.

Geographical distribution of Chagas disease in the Americas according to the status of transmission by the main vector in each area. Year: 2011.

Achievements in prevention, control, and healthcare of Chagas disease, by Subregion:

  • Southern Cone. Interruption of vector transmission of T. cruzi by T. infestans and elimination of vector as a public health threat in Uruguay (1997-2012); interruption of vector transmission of T. cruzi by T. infestans in Chile (1999), Brazil (2006), Paraguay (Eastern Region, 2008, Alto Paraguay, 2013), Argentina (8 provinces between 2001 and 2013), and Bolivia (Department of La Paz and Dpto.de Potosí, 2011 - 2013).

  • Central America. Interruption of vector transmission of T. cruzi by R. prolixus in Guatemala (2008), El Salvador (2010), Honduras (2010), Nicaragua (2010). Costa Rica (2010) and Belize (2010). Characterization of transmission from the sylvatic cycle in Panama (2013).

  • Andean Region. Interruption of vector transmission of T. cruzi by T. infestans in Peru (Departments of Tacna and Moquegua) and by Rhodnius prolixus in 10 Municipalities in Casanare, Boyacá, Santander and Arauca in Colombia (2013).

  • Amazon Region. Surveillance and prevention network in Brazil, Ecuador, Colombia, Guyana, French Guyana and Peru. Response to Chagas outbreaks of foodborne diseases. 

  • Mexico. Elimination of R. prolixus is certified in Chiapas and Oaxaca.

Paraguay interrupts vector transmission of Chagas in the home

Paraguay has succeeded in interrupting the vector transmission of Trypanosoma cruzi in the home, the parasite that causes Chagas disease. This was verified last week by a group of international independent experts convened by the Pan American Health Organization (PAHO).

:: Communication Materials

Communicable Diseases and Health Analysis Department
Neglected, Tropical and Vector Borne Diseases Unit
Chagas Disease Program
www.paho.org/chagasdisease