Guideline of the Brazilian Society of Cardiology on Diagnosis and Treatment of Patients with Chagas Disease Cardiomyopathy / Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.

Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz. 

Human chagas disease and migration in the context of globalization: some particular aspects.

Human Chagas disease originated in Latin America, being spread around the world in relation with multiple bioecological, sociocultural, and political factors. The process of the disease production and dispersion is discussed, emphasizing the human migration and correlated aspects, in the context of globalization. Positive and negative consequences concern the future of this trypanosomiasis, mainly in terms of the ecologic and sociopolitical characteristics of the endemic and nonendemic countries.

Tendencias sociales de la enfermedad de Chagas para las próximas décadas / Social tendencies of Chagas disease in the next decades

La existencia de la enfermedad de Chagas humana se considera el resultado de un conjunto complejo de determinantes bioecológicos y sociales. Su cumbre de incidencia se produjo entre los años 1950 y 1970, observándose una tendencia a la disminución en las décadas siguientes. Innumerables elementos socioculturales y políticos están presentes también en la expansión geográfica de la enfermedad, en su prevención y en la atención médica a los infectados. Para las próximas décadas se espera una mayor reducción de la transmisión, especialmente vectorial y transfusional, como producto de las acciones de control y de los cambios en el sistema de producción, en paralelo con la urbanización y con las acciones antrópicas extensivas en las áreas endémicas. Se espera también una reducción en la morbilidad, dependiente de un mejor acceso a los sistemas de salud y de los constantes avances en la medicina. Sin embargo, la enfermedad seguirá siendo muy importante por dos o tres décadas más, dejando como principales desafíos la vigilancia sobre su transmisión y la atención a los individuos ya infectados. Está prevista una disminución en la visibilidad de la enfermedad, con reflejos negativos en la prioridad política de las acciones sobre su atención y control.

Chagas disease is known to be the result of a complex set of bio-ecological and social determinants. The maximum incidence of the disease occurred between 1950 and 1970, with a downward tendency observed in the following decades. Innumerable socio-cultural and political elements take part in the geographic expansion of the disease, the prevention of the disease and in the medical attention given those infected. Over the next decades a major reduction in transmission is expected, especially in the vector and transfusion routes, as a consequence of control-oriented programs and changes in the production system, in conjunction with urbanization processes and extensive anthropic actions in endemic areas. A reduction in morbidity is also expected, owing to better access to the health system and to medical advances. Nevertheless, Chagas disease will continue to have great importance in the next two to three decades, the main challenges being surveillance of disease transmission and the medical attention provided to infected individuals. A reduction in the visibility of the disease, with negative repercussions in the political priority given to medical attention and disease control, is also anticipated.

Etiological treatment during early chronic indeterminate Chagas disease incites an activated status on innate and adaptive immunity associated with a type 1-modulated cytokine pattern.

Pro-inflammatory immune response is usually associated with Chagas disease pathogenesis, but is also relevant to treatment effectiveness. Cross-sectional studies have suggested that this activated state may persist for years after therapeutic intervention. However, short-term longitudinal investigation has suggested that the Benznidazole treatment (Bz-treatment) leads to decreased immunological activation. In order to elucidate this issue, we performed a longitudinal study to evaluate the immunological status following Bz-treatment during early indeterminate Chagas disease. Our results demonstrated that Bz-treatment led to higher activation status of circulating monocytes but was negatively associated with the number of IL-12(+)CD14(+) cells. Moreover, Bz-treatment triggered a high frequency of circulating CD3(-)CD16(+)CD56(-) NK cells, in addition to elevated activation status associated with a type 1-modulated cytokine pattern. Bz-treatment induced substantial T and B-cell activation status associated with an overall IL-10 modulated type 1 cytokine profile. In summary, these findings provide new information regarding immune activation status following the etiological treatment of Chagas disease. These results suggest that in addition to the increased number of activated leukocytes in the peripheral blood, Bz-treatment may also involve a qualitative change in their functional capacity that drives their activation state toward a modulated cytokine profile. These changes may account for the benefits of etiological treatment of Chagas disease.

Programa para el control y la eliminación de la enfermedad de Chagas en Bolivia 1998-2002 / Program for control and erradication of Chagas disease

En Bolivia la situación de la enfermedad de Chagas es de estrema gravedad, de acuerdo con los datos que se presentan en este documento. En este momento, coherente con sus compromisos y su prioridad social, el gobierno y el pueblo de Bolivia han tomado una decisión histórica y definitiva, que es la de implementar efectivamente un programa especial de eliminación de la Enfermedad de Chagas humana de nuestro país, através de un esfuerzo compartido e integrado con los distintos niveles operativos, con las instancias nacionales y regionales de gobierno, con la participación imprescindible de la población responsable y con agencias e instituciones del país y del exterior, lado al lado con los países amigos y vecinos

Las enfermedades tropicales y el enfoque de género / Tropical diseases and the gender approach

Basado en un texto de mayor extensión presentado en el Taller "Research and Gender in Tropical Diseases", realizado en la OPS, Washington, D.C., 25-26 enero 1996

Tropical diseases and the gender approach

Condensed translation of a presentation at the workshop "Research and Gender in Tropical Diseases", which took place at PAHO HQS., Washington, D.C., 25-26 January 1996

Avaliaçao do programa de controle vetorial da doença de Chagas em Minas Gerais, Brasil, com referencia especial ao Triatoma sordida / Evaluation of the Chagas' disease vector control program in Minas Gerais, Brazil, with special reference to Triatoma sordida

Dados compilados até 1979 pelo Programa de Controle da Doença de Chagas (PCDCH) no Estado de Minas Gerais indicavam que o Triatoma infestan era o vetor da doença de Chagas mais comumente encontrado dentro e nas vizinhanças das habitaçoes humanas. Entretanto, depois de uma década, este quadro se alterou, provavelmente em consequencia das açoes de controle; houve poucos espécimes do T. infestans capturados e o T. sordida passou a ser o inseto vetor predominante. O objetivo desde trabalho foi avaliar a eficácia do PCDCH em Minas Gerais durante o período 1979-1989, especialmente com respeito ao T. sordida. Assim, revisaram-se os dados compilados sobre os triatomíneos para dois distritos de saúde de Minas Gerais, Monte Claros e Uberaba, considerados os com maior infestaçao pelo T sordida. A seguir, compararam-se os dados de um levantamento serológico de 1987 para infecçao pelo Trypanosoma cruzi humano em sete municípios dessas regioes com dados serológicos anteriores (1978) referentes às mesmas localidades. De un modo geral, os dados sobre os triatomíneos capturados documentaram um forte declínio do T. infestans tanto dentro dos domicílios em seus arredores. Os dados indicaram igualmente que embora a captura de T. sordida tenha se mantido estável (em Uberaba) ou aumentado sensivelmente (em Mostes Claros), nao houve nenhum aumento acentuado na quantidade de T. sordida capturada dentro dos domicílios. A conclusao foi de que as medidas de controle estavam protegendo as unidades domiciliares contra la infestaçao triatomínica, tanto em Montes Claros como em Uberaba; que a situaçao em Uberaba achava-se relativamente estável e que o acentuado aumento en Mostes Claros de populaçoes de T. sordida nos arredores dos domicílios estava associado com o corte de matas e a mudança nos padroes dos assentamentos. A queda acentuada de prevalencia de infecçoes pelo T. cruzi humano, observada na comparaçao dos dados dos levantamentos serológicos de 1978 com os de 1987 forneceu provas adicionais quanto a eficácia das atividades do programa de controle durante esse período (AU)

Avaliaçao do programa de controle vetorial da doença de Chagas em Minas Gerais, Brasil, com referencia especial ao Triatoma sordida / Evaluation of the Chagas' disease vector control program in Minas Gerais, Brazil, with special reference to Triatoma sordida

Dados compilados até 1979 pelo Programa de Controle da Doença de Chagas (PCDCH) no Estado de Minas Gerais indicavam que o Triatoma infestan era o vetor da doença de Chagas mais comumente encontrado dentro e nas vizinhanças das habitaçoes humanas. Entretanto, depois de uma década, este quadro se alterou, provavelmente em consequencia das açoes de controle; houve poucos espécimes do T. infestans capturados e o T. sordida passou a ser o inseto vetor predominante. O objetivo desde trabalho foi avaliar a eficácia do PCDCH em Minas Gerais durante o período 1979-1989, especialmente com respeito ao T. sordida. Assim, revisaram-se os dados compilados sobre os triatomíneos para dois distritos de saúde de Minas Gerais, Monte Claros e Uberaba, considerados os com maior infestaçao pelo T sordida. A seguir, compararam-se os dados de um levantamento serológico de 1987 para infecçao pelo Trypanosoma cruzi humano em sete municípios dessas regioes com dados serológicos anteriores (1978) referentes ãs mesmas localidades. De un modo geral, os dados sobre os triatomíneos capturados documentaram um forte declínio do T. infestans tanto dentro dos domicílios em seus arredores. Os dados indicaram igualmente que embora a captura de T. sordida tenha se mantido estável (em Uberaba) ou aumentado sensivelmente (em Mostes Claros), nao houve nenhum aumento acentuado na quantidade de T. sordida capturada dentro dos domicílios. A conclusao foi de que as medidas de controle estavam protegendo as unidades domiciliares contra la infestaçao triatomínica, tanto em Montes Claros como em Uberaba; que a situaçao em Uberaba achava-se relativamente estável e que o acentuado aumento en Mostes Claros de populaçoes de T. sordida nos arredores dos domicílios estava associado com o corte de matas e a mudança nos padroes dos assentamentos. A queda acentuada de prevalencia de infecçoes pelo T. cruzi humano, observada na comparaçao dos dados dos levantamentos serológicos de 1978 com os de 1987 forneceu provas adicionais quanto a eficácia das atividades do programa de controle durante esse período (AU)

Publicado em inglés no Bull. PAHO. Vol. 28(3), 1994

Evaluation of the Chagas' disease vector control program in Minas Gerais, Brazil, with special reference to Triatoma sordida

As of 1979, data gathered by the Chagas' Disease Control Program (CDCP) in the Brazilian state of Minas Gerais indicated that Triatoma infestans the Chagas' disease vector most commonly found in and around human dwellings. A decade later, however, this picture had changed, presumably as a result of control efforts; few specimens of T. infestans were collected; and Triatoma sordida had become the most commonly collected vector insect. The aim of the work reported here was to assess the effectiveness of the CDCP in Minas Gerais in 1979-1989, with special reference to T. sordida. For this purpose, 1979-1989 triatomine collection data were reviewed for the two Minas Gerais health districts (Montes Claros and Uberaba) believed to have the heaviest T. sordida infestations. In addition, 1987 data from a serologic survey for human Trypanosoma cruzi infections in seven municipalities of these regions were compared with earlier (1978) serologic data from the same locales. In general, the triatomine collection data documented the precipitous decline of T. infestants in and around human dwellings. They also indicated that while the T. sordida collections had remained stable (in Uberaba) or increased markedly (in Montes Claros), there had been no great upsurge in the numbers of T. sordida collected inside dwellings. It was concluded that control measures were preventing extensive house reinfestations in both Montes Claros and Uberaba; that the situation in Uberaba was relatively stable; and that the marked increase in T. sordida populations around homes in Montes Claros was associated with forest clearing and changing settlement patterns. A marked drop in the incidence of human t. cruzi infections, indicated by comparison of the 1978 and a987 serologic surveys, provided further supporting evidence that the control program activities carried out in this period were effective

Evaluation of the Chagas' disease vector control program in Minas Gerais, Brazil, with special reference to Triatoma sordida

As of 1979, data gathered by the Chagas' Disease Control Program (CDCP) in the Brazilian state of Minas Gerais indicated that Triatoma infestans the Chagas' disease vector most commonly found in and around human dwellings. A decade later, however, this picture had changed, presumably as a result of control efforts; few specimens of T. infestans were collected; and Triatoma sordida had become the most commonly collected vector insect. The aim of the work reported here was to assess the effectiveness of the CDCP in Minas Gerais in 1979-1989, with special reference to T. sordida. For this purpose, 1979-1989 triatomine collection data were reviewed for the two Minas Gerais health districts (Montes Claros and Uberaba) believed to have the heaviest T. sordida infestations. In addition, 1987 data from a serologic survey for human Trypanosoma cruzi infections in seven municipalities of these regions were compared with earlier (1978) serologic data from the same locales. In general, the triatomine collection data documented the precipitous decline of T. infestants in and around human dwellings. They also indicated that while the T. sordida collections had remained stable (in Uberaba) or increased markedly (in Montes Claros), there had been no great upsurge in the numbers of T. sordida collected inside dwellings. It was concluded that control measures were preventing extensive house reinfestations in both Montes Claros and Uberaba; that the situation in Uberaba was relatively stable; and that the marked increase in T. sordida populations around homes in Montes Claros was associated with forest clearing and changing settlement patterns. A marked drop in the incidence of human t. cruzi infections, indicated by comparison of the 1978 and a987 serologic surveys, provided further supporting evidence that the control program activities carried out in this period were effective

Published in Portugues in the BOSP. Vol. 118(3):211-19, March 1995

Enfermedad de Chagas: epidemiología, clínica, terapéutica / Chagasdisease

Transmisión, curso de la infección, morbilidad y mortalidad, clínica, diagnóstico de laboratorio y quimioterpia de la Enfermedad de Chagas y de sus complicaciones cardiovasculares y gastrointestinales

Enfermedad de Chagas: epidemiología, clínica, terapéutica / Chagas’disease

Transmisión, curso de la infección, morbilidad y mortalidad, clínica, diagnóstico de laboratorio y quimioterpia de la Enfermedad de Chagas y de sus complicaciones cardiovasculares y gastrointestinales