Towards a paradigm shift in the treatment of chronic Chagas disease.

Treatment for Chagas disease with currently available medications is recommended universally only for acute cases (all ages) and for children up to 14 years old. The World Health Organization, however, also recommends specific antiparasite treatment for all chronic-phase Trypanosoma cruzi-infected individuals, even though in current medical practice this remains controversial, and most physicians only prescribe palliative treatment for adult Chagas patients with dilated cardiomyopathy. The present opinion, prepared by members of the NHEPACHA network (Nuevas Herramientas para el Diagnóstico y la Evaluación del Paciente con Enfermedad de Chagas/New Tools for the Diagnosis and Evaluation of Chagas Disease Patients), reviews the paradigm shift based on clinical and immunological evidence and argues in favor of antiparasitic treatment for all chronic patients. We review the tools needed to monitor therapeutic efficacy and the potential criteria for evaluation of treatment efficacy beyond parasitological cure. Etiological treatment should now be mandatory for all adult chronic Chagas disease patients.

Social determinants in the access to health care for Chagas disease: A qualitative research on family life in the "Valle Alto" of Cochabamba, Bolivia.

INTRODUCTION: Chagas disease is caused by the Trypanosoma cruzi infection. It is a neglected tropical disease with considerable impact on the physical, psychological, familiar, and social spheres. The Valle Alto of Cochabamba is a hyperendemic region of Bolivia where efforts to control the transmission of the disease have progressed over the years. However, many challenges remain, above all, timely detection and health-care access. METHODS: Following the Science Shop process, this bottom-up research emerged with the participation of the civil society from Valle Alto and representatives of the Association of Corazones Unidos por el Chagas from Cochabamba. The aim of this study is to explore the social determinants in the living realities of those affected by Chagas disease or the silent infection and how families in the Valle Alto of Cochabamba cope with it. An interdisciplinary research team conducted a case study of the life stories of three families using information from in-depth interviews and performed a descriptive qualitative content analysis and triangulation processes. FINDINGS: Findings provide insights into social circumstances of the research subjects' lives; particularly, on how exposure to Trypanosoma cruzi infection affects their daily lives in terms of seeking comprehensive health care. Research subjects revealed needs and shared their experiences, thus providing an understanding of the complexity of Chagas disease from the socioeconomic, sociocultural, political, and biomedical perspectives. Results enlighten on three dimensions: structural, psychosocial, and plural health system. The diverse perceptions and attitudes toward Chagas within families, including the denial of its existence, are remarkable as gender and ethnocultural aspects. Findings support recommendations to various stakeholders and translation materials. CONCLUSIONS: Intersectional disease management and community involvement are essential for deciding the most appropriate and effective actions. Education, detection, health care, and social programs engaging family units ought to be the pillars of a promising approach.

Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?

OBJECTIVES: To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success. METHODS: Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit. RESULTS: We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness. CONCLUSIONS: Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.

Improving sputum microscopy services for the diagnosis of tuberculosis in Peru and Bolivia.

SETTING: Sixteen primary care health centres in Peru and Bolivia. OBJECTIVES: To assess the utilisation of microscopy services in Peru and Bolivia and determine if clinical audit, a quality improvement tool, improves the utilisation of these services. DESIGN: We estimated the percentage of patients with suspected tuberculosis (TB) in whom sputum microscopy was effectively utilised in Peru and Bolivia over two 6-month periods before and after a clinical audit intervention that included standards setting, measuring clinical performance and feedback. RESULTS: Before the intervention, only 31% (95%CI 27-35) of TB suspects were assessed with sputum microscopy in Peru. In Bolivia, 30% (95%CI 25-35) underwent at least two sputum microscopy examinations. After clinical audit, the availability of sputum microscopy results improved by respectively 7% (95%CI 1-12, P < 0.05) and 23% (95%CI 15-30, P < 0.05) over 2 years in Peru and Bolivia. CONCLUSIONS: Despite World Health Organization recommendations that all TB suspects should undergo sputum microscopy before treatment, results are available for further assessment for only one third. This is a potentially serious obstacle to TB case detection. Clinical audit can bring some improvement. We recommend regular monitoring of effective utilisation of microscopy services and investigations to ascertain organisational and structural issues in their uptake and use.

Intradomiciliary and peridomiciliary captures of sand flies (Diptera: Psychodidae) in the leishmaniasis endemic area of Chapare province, tropic of Cochabamba, Bolivia.

In South America, cutaneous leishmaniasis is the most frequent clinical form of leishmaniasis. Bolivia is one of the countries with higher incidence, with 33 cases per 100,000 individuals, and the disease is endemic in 70% of the territory. In the last decade, the number of cases has increased, the age range has expanded, affecting children under 5 years old, and a similar frequency between men and women is found. An entomological study with CDC light traps was conducted in three localities (Chipiriri, Santa Elena and Pedro Domingo Murillo) of the municipality of Villa Tunari, one of the main towns in the Chapare province (Department of Cochabamba, Bolivia). A total of 16 specimens belonging to 6 species of the genus Lutzomyia were captured: Lu. aragaoi, Lu. andersoni, Lu. antunesi, Lu. shawi, Lu. yuilli yuilli and Lu. auraensis. Our results showed the presence of two incriminated vectors of leishmaniasis in an urbanized area and in the intradomicile. More entomological studies are required in the Chapare province to confirm the role of vector sand flies, the intradomiciliary transmission of the disease and the presence of autochthonous cases of cutaneous leishmaniasis.

Acute-phase proteins and serologic profiles of chagasic children from an endemic area in Bolivia.

Chagas' disease represents a major public health problem in Latin America. In endemic areas, it is important to detect acute and even asymptomatic infections in children so that specific therapy can be started immediately. We studied 203 sera from children from the region of Cochabamba, Bolivia. A high percentage of seropositive individuals was found in the three villages studies. Levels of alpha-2 macroglobulin (A2M) and C-reactive protein (CRP) increased in a significant number of children with acute Chagas' disease. The combined analysis of serologic and biochemical parameters can define the different stages of acute infection by Trypanosoma cruzi: 1) an early stage, with an increase only in specific immunoglobulin M (IgM) levels; 2) intermediate stages, with high specific IgM and IgG levels and/or high anti-galactose (anti-Gal) levels and increased A2M and/or CRP levels; and 3) a late acute stage, with low IgM levels but high A2M, CRP, anti-Gal, and specific IgG levels. The detection of high IgG levels alone is indicative of the chronic/indeterminate stage of Chagas' disease. We also show serologic differences between seropositive asymptomatic villagers and symptomatic patients undergoing medical care; asymptomatic cases presented higher levels of A2M and lower levels of specific antibodies.

Application of the enzyme-linked immunoelectrotransfer blot to filter paper blood spots to estimate seroprevalence of cysticercosis in Bolivia.

An enzyme-linked immunoelectrotransfer blot (EITB) assay was used to study the prevalence of cysticercosis in rural Bolivia. Dried blood spots on filter paper from fingersticks were used as assay samples. Before the serosurvey, experiments were performed to show that samples eluted from dried whole blood on filter paper exhibited no decrease in sensitivity when compared with the more traditional serum samples used in the EITB. Fingerstick blood dried on filter paper is a convenient, economical way of transporting and storing field samples for epidemiologic surveys of cysticercosis in developing countries. This report shows the utility of this sample collection method in underdeveloped countries where refrigeration is not possible and where venipuncture is a problem. Blood was obtained from randomly selected residents in three rural regions of Bolivia: Chuquisaca (n = 1,859), Cochabamba (n = 1,516), and Tarija (n = 1,010). The estimated seroprevalence on 10% of the sample collected for the three regions were 9%, 4.5%, and 2%, respectively.

Early, intermediate, and late acute stages in Chagas' disease: a study combining anti-galactose IgG, specific serodiagnosis, and polymerase chain reaction analysis.

The acute phase of Chagas' disease was classified as early, intermediate, and late based on the levels of anti-Galalpha, 3Gal IgG (Gal) and specific IgM (M) and IgG (G) anti-T. cruzi reactivity. While the early phase was M+G-Gal-, the intermediate phase was M+G-Gal+, M+G+Gal-, or M+G+Gal+, and the late phase was M-G+Gal+. This sequence of stages was consistent with our previous studies on acute-phase proteins. Analysis by the polymerase chain reaction (PCR) of parasite DNA in 65 blood samples of children living in Cochabamba, Bolivia showed a significant correlation (90.8%) between ELISA and PCR positivity. A lower correlation was observed between indirect hemagglutination, PCR (58%), and ELISA. Electrocardiographic analysis of 43 children studied by the PCR did not show any alteration typical of acute chagasic myocarditis. The PCR positivity was observed in eight samples where only Gal was increased, suggesting a very early T. cruzi infection, when specific antibodies were not yet present. By associating anti-Gal IgG with specific serology, early T. cruzi infection can be detected with greater precision. We suggest the use of anti-Gal antibody reactivity as an aid for the detection of recent T. cruzi infections, at least in endemic areas where diseases caused by other trypanosomatids do not overlap.

Evaluation of a competitive antibody enzyme immunoassay for specific diagnosis of Chagas' disease.

A competitive enzyme immunoassay based on the use of a monoclonal antibody (MAb) specific for "component 5" of Trypanosoma cruzi was evaluated. The antigenicity and immunogenicity of this component has been observed in natural and experimental infections. The studies were conducted in an area of Bolivia where mixed infections with Leishmania braziliensis are frequent and present a problem in the accurate diagnosis of T. cruzi infections. The specificity and sensitivity of this assay as compared to the indirect immunofluorescence and ELISA tests were demonstrated. The present test has proved to be more specific than the immunofluorescence and ELISA tests.

Leishmaniasis in the lowlands of Bolivia, prevalence of the disease in two groups of localities with different settlement ages in Carrasco Tropical, Cochabamba.

The invasion of the Bolivian Jungle has brought the new colonists some unfamiliar diseases, among which we study Leishmaniasis. A previous study described the situation in Yapacaní. Departamento of Santa Cruz, a primary rain forest lowland area. We now focus on the characteristics of Carrasco Tropical, close to a hilly territory of the andean mountains. We studied 11 localities ("colonies") grouped as unions with different lengths of residence in the area. We considered males and females over 15 years old as "at risk" and studied in them all forms of leishmanial infection, through clinical and laboratory (smears) means, including the Montenegro Skin Test (IDRM). Cutaneous ulcers and scars were seen in 2.9% (10 patients of 339 at risk, 6 from "27 de octubre", a younger settlement, 4 from the older Tamboradas): mucocutaneous lesions in 3 (1 from the younger settlement); and skin scars alone in 10.3% (35 from the younger area). The only 2 females with positive findings in the study were seen in this latter group. Transmission is apparently associated with the primary forest which exists at the foot of the Andes in the area, which is visited preferentially by young men.

Tripanosomátidos aislados de mamíferos silvestres en tres departamentos de Bolivia (Cochabamba, Potosí y Santa Cruz de la Sierra) / Trypanosomatidae isolated from wild mammals in three departments of Bolivia (Cochabamba, Potosi and Santa Cruz de la Sierra)

Objetivos: el objetivo de la investigación fue aislar protozoarios kinetoplástidos a partir de mamíferos silvestres en tres departamentos de Bolivia, con la finalidad de identificar reservorios de tripanosomátidos que podrían causar infección en diferentes reservorios y enfermedades en el humano. Métodos: Los mamíferos silvestres fueron capturados en el Chaco, valles interandinos y la zona tropical de Bolivia, utilizando trampas Sherman, Havahard y Tomahawk. Los animales capturados fueron anestesiados para realizar el xenodiagnóstico y la extracción de sangre por punción cardiaca; el aislamiento de tripanosomátidos se realizó por hemocultivo utilizando medios de cultivo NNN y su respectiva identificación por las técnicas de PCR-RFLP en el laboratorio de Biología molecular IIBISMED. Resultados: fueron capturados 236 mamíferos silvestres pertenecientes a 30 especies, de las cuales 7 especies presentaron infección por hemoflagelados. Trypanosoma cruzi fue aislado de Didelphis marsupialis, D. albiventris, Galea musteloides, Graomys domorum y Andalgalomis pearsoni; T.c marinkellei y T. dionisii fueron aislados de Carolia perspicillata (murciélagos) y otros kinetoplástidos no identificados por herramientas moleculares disponibles fueron aislados de mamíferos del género Graomys y Andalgalomys, capturados en las provincias Campero de Cochabamba y Cordillera del departamento de Santa Cruz. Conclusiones: El T. cruzi, T.c. marinkellei, T. dionisii y otros tripanosomátidos se encuentran infectando a marsupiales (Didelphis), roedores (Graomys y Andalgalomys) y cobayos silvestres (Galea) los cuales se encuentran en su ciclo silvestre en las zonas estudiadas.

Objectives: The aim of this research was isolate kinetoplastid protozoan from wild mammals in three departments of Bolivia, to identify Trypanosomatids reservoirs that could cause infection in different reservoirs and disease in humans. Methods: The wild mammals were caught in the Chaco, valleys and the tropical zone of Bolivia, using Sherman, Havahard and Tomahawk traps. Captured animals were anesthetized and xenodiagnosis and blood cardiac puncture was performed; trypanosomatides isolation using blood culture was done in NNN culture media and the respective identification was performed by PCR-RFLP techniques in the molecular biology laboratory of IIBISMED. Results: 236 wild mammals belonging to 30 species were captured, of which 7 species showed infection by hemoflagellates. Trypanosoma cruzi was isolated from Didelphis marsupialis, D. albiventris, Galea musteloides, Graomys domorum and Andalgalomis pearsoni; T.c. marinkellei and T. dionisii were isolated from Carolia perspicillata (bats) and other kinetoplastid not identified by available molecular tools were also isolated from Andalgalomys and Graomys mammals genus, from Campero and Cordillera provinces of Cochabamba and Santa Cruz. Conclusions: The T. cruzi, T.c. marinkellei, T. dionisii and other trypanosomatids are infecting marsupials (Didelphis), rodents (Graomys and Andalgalomys) and wild guinea pigs (Galea) which are found in a sylvatic cycle in the studied areas.

Interleukin-6 (IL-6) production in mice infected with Trypanosoma cruzi: effect of its paradoxical increase by anti-IL-6 monoclonal antibody treatment on infection and acute-phase and humoral immune responses.

Trypanosoma cruzi infection of mice triggered endogenous production of interleukin-6 (IL-6) during the ascending phase of parasitemia. Injections of anti-IL-6 monoclonal antibody in infected mice at the time of the serum IL-6 peak paradoxically increased IL-6 levels to 60- to 80-fold those in infected mice receiving unrelated immunoglobulins. This early and transient increase in circulating IL-6 levels modified neither the immunoglobulin nor T. cruzi-specific antibody levels of immunoglobulin G1 (IgG1), IgG2a, IgG3, IgM, IgA, and IgE isotypes or the final outcome of infection nor the blood or tissular parasite levels. However, it tended to delay mortality of mice and to increase the levels of the acute-phase protein serum amyloid P component.

Endogenous IFN-gamma is required for resistance to acute Trypanosoma cruzi infection in mice.

In order to study the role of endogenous IFN-gamma in Trypanosoma cruzi infection in mice, a potent murine IFN-gamma-specific mAb was injected i.p. on days -1, 7, and 14, relative to infection. Irrespective of the parasite inocula (100 or 25,000), groups of antibody-treated mice had significantly greater cumulative mortality rates than did appropriate controls. In antibody-treated mice, mean survival times were also significantly shorter, and maximum mean parasitemia levels were significantly higher, than in controls. Moreover, the number of amastigote nests in tissues was higher than in control mice and attained a maximum at the same time as parasitemia. As evident from kinetic studies of neutralizing activity, injected mAb were rapidly consumed in infected, but not in noninfected, mice, which is suggestive of massive IFN-gamma production during the early parasitemic phase of the disease. Nevertheless, IFN-gamma remained undetectable in the sera of infected but untreated mice. Unexpectedly, however, a peak of IFN-like antiviral activity, characterizable as a mixture of IFN-gamma and IFN-beta, appeared in mAb-treated mice that survived to infection at a time when neutralizing activity of injected mAb had drastically decreased in the circulation. We hypothesize that this high level of artificially induced endogenous IFN-gamma, not neutralized by the amounts of injected mAb, was due to the more intense parasite multiplication occurring in mAb-treated mice, which in turn may have induced an increased amount of various cytokines. TNF-alpha was not found in the serum of our mice. The humoral immune response entered its exponential phase at a time point later than that when protection by endogenous IFN-gamma was evident. Treatment with IFN-gamma-specific antibody, as applied in our study, failed to affect the level of different Ig isotypes or of T. cruzi-specific antibodies. Our study clearly indicates that IFN-gamma is produced early in acute T. cruzi infection and exerts a protective effect that is probably independent from the humoral immune response.

The endogenous balance of soluble tumor necrosis factor receptors and tumor necrosis factor modulates cachexia and mortality in mice acutely infected with Trypanosoma cruzi.

To better understand the role of tumor necrosis factor (TNF) during Trypanosoma cruzi infection in BALB/c mice, we have investigated the kinetics of circulating tumor necrosis factor (TNF), soluble TNF receptor 1 (sTNR1), and sTNFR2 levels, as well as the interactions between such factors, in relation to parasitemia, cachexia, and mortality of acutely infected animals. Our data show that the parasitemic phase of T. cruzi infection in mice is associated with high levels of circulating TNF and sTNFR2, resulting in the formation of cytokine-receptor complexes and some degree of neutralization of TNF bioactivity. Although sTNR2 levels always exceeded TNF levels, low sTNFR/TNF circulating ratios were associated with cachexia in all infected mice, whereas the lowest ratios were observed in dying animals harboring the highest parasitemia. We also studied the modulation of sTNFR/TNF ratios induced by anti-TNF antibodies administered to infected animals and their consequences on the outcome of the infection. The injection of anti-TNF monoclonal antibody (MAb) TN3 into infected mice resulted in a paradoxical overproduction of TNF (associated with a higher parasitemia), lowered the sTNFR/TNF circulating ratios, and considerably worsened cachexia and mortality of animals. Another anti-TNF MAb (1F3F3) decreased the in vivo availability of TNF as well as parasite levels and reduced cachexia. Altogether, such results highlight that, besides playing a beneficial role early in infection, TNF also triggers harmful effects in the parasitemic phase, which are limited by the in vivo simultaneous endogenous production of soluble receptors.

Maternal Trypanosoma cruzi infection upregulates capacity of uninfected neonate cells To produce pro- and anti-inflammatory cytokines.

The possibility of maternal in utero modulation of the innate and/or adaptive immune responses of uninfected newborns from Trypanosoma cruzi-infected mothers was investigated by studying the capacity of their whole blood cells to produce cytokines in response to T. cruzi lysate or lipopolysaccharide-plus-phytohemagglutinin (LPS-PHA) stimulation. Cells of such newborns occasionally released gamma interferon (IFN-gamma) and no interleukin-2 (IL-2) and IL-4 upon specific stimulation, while their mothers responded by the production of IFN-gamma, IL-2, and IL-4. Infection in mothers was also associated with a hyperactivation of maternal cells and also, strikingly, of cells of their uninfected neonates, since their release of proinflammatory (IL-1beta, IL-6, and tumor necrosis factor alpha [TNF-alpha]) as well as of anti-inflammatory (IL-10 and soluble TNF receptor) cytokines or factors was upregulated in the presence of LPS-PHA and/or parasite lysate. These results show that T. cruzi infection in mothers induces profound perturbations in the cytokine response of their uninfected neonates. Such maternal influence on neonatal innate immunity might contribute to limit the occurrence and severity of congenital infection.

The cachexia associated with Trypanosoma cruzi acute infection in mice is attenuated by anti-TNF-alpha, but not by anti-IL-6 or anti-IFN-gamma antibodies.

BALB/c male mice acutely infected with Trypanosoma cruzi underwent a severe weight loss (around 20%, from day 18 to 31 post-infection), when compared to age-matched uninfected animals. Though mice regained weight later, when blood parasites were hardly detectable, wasting extended over the chronic phase of infection. The onset and the magnitude of weight loss were related to the mouse susceptibility to infection, since they were respectively earlier and higher in male mice which will die than in surviving ones, in males than in females, and in BALB/c than in B6D2 [(C57B1/6 x DBA/2)F1], a mouse strain more resistant to infection. Fat weight of infected mice (male BALB/c) was reduced by 60 to 80%, whereas lean mass was unaffected and water content rose by 6 to 10% in acute and chronic infection. Haematocrit was also decreased by 15-16% in acute infection. Animals failed to compensate their energetic loss since their food intake remained similar to that of uninfected animals. Injections of neutralizing anti-TNF-alpha monoclonal antibody into infected male mice, during the first two weeks but not later in infection, significantly attenuated the weight loss. Early administration of anti-IL-6 or anti-IFN-gamma MoAbs did not improve the mouse wasting. Taken together, these data show that TNF is a key agent of cachexia occurring in the acute T. cruzi infection in mice.

Maternal and congenital syphilis in Bolivia, 1996: prevalence and risk factors.

OBJECTIVES: The present study was carried out in seven maternity hospitals to determine the prevalence of maternal syphilis at the time of delivery and the associated risk factors, to conduct a pilot project of rapid syphilis testing in hospital laboratories, to assure the quality of syphilis testing, and to determine the rate of congenital syphilis in infants born to women with syphilis at the time of delivery--all of which would provide baseline data for a national prevention programme in Bolivia. METHODS: All women delivering either live-born or stillborn infants in the seven participating hospitals in and around La Paz, El Alto, and Cochabamba between June and November 1996 were eligible for enrolment in the study. FINDINGS: A total of 61 out of 1428 mothers (4.3%) of live-born infants and 11 out of 43 mothers (26%) of stillborn infants were found to have syphilis at delivery. Multivariate analysis showed that women with live-born infants who had less than secondary-level education, who did not watch television during the week before delivery (this was used as an indicator of socioeconomic status), who had a previous history of syphilis, or who had more than one partner during the pregnancy were at increased risk of syphilis. While 76% of the study population had received prenatal care, only 17% had syphilis testing carried out during the pregnancy; 91% of serum samples that were reactive to rapid plasma reagin (RPR) tests were also reactive to fluorescent treponemal antibody-absorption (FTA-ABS) testing. There was 96% agreement between the results from local hospital laboratories and national reference laboratories in their testing of RPR reactivity of serum samples. Congenital syphilis infection was confirmed by laboratory tests in 15% of 66 infants born to women with positive RPR and FTA-ABS testing. CONCLUSION: These results indicate that a congenital syphilis prevention programme in Bolivia could substantially reduce adverse infant outcomes due to this disease.

Estudio de costo/beneficio de un programa de control de Enfermedad de Chagas Congénita en Bolivia / Cost effectiveness study of a control program of congenital Chagas disease in Bolivia

Cost effectiveness analysis of Chagas' vertical transmission control program in Bolivia: Today, Bolivia is the most concerned country in America by Chagas disease: Trypanosoma cruzi infection affects 20% of whole population, around 1800000 inhabitants, and mother-to-child transmission is around 5%, from 1.6 to 9.8%. Direct and indirect costs derived from disease complications and death, from birth to adulthood, add up around US$ 21 millions per year for 2,718 infected new-borns. This cost falls on individual, family and society, when the nation is struggling in a depressed economy. On the other side, an effective control program could detect and treat all cases with an investment of US$ 123 per infected new-born, or US$ 1.2 per new-born in Bolivia. Indirect benefits, apart of suffering relieve and improving of life quality, are related with Chagas vector control program, increasing the demand thanks to increasing risk awareness and also induced demand testing all pregnant women in endemic areas. So the conclusion is that such investment is profitable.

Tratamiento integral de la enfermedad de Chagas congenita: la experiencia boliviana / Integral treatment of congenital Chagas disease: the Bolivian experience

We have analyzed the response to the treatment with benznidazol in newborns and nurslings in the Hospital Materno Infantil Germán Urquidi of Cochabamba, Bolivia, between 1999 and 2002. It is important an integral treatment of the nursling with a subsequent information directed to the family. The response was close to 100% when the treatment was correctly administrated. They were not adverse effects and the detected biochemical alterations did not present clinical significance.