WHF IASC Roadmap on Chagas Disease.

Background: Chagas Disease is a neglected tropical disease caused by the protozoan Trypanosoma cruzi, with some of the most serious manifestations affecting the cardiovascular system. It is a chronic, stigmatizing condition, closely associated with poverty and affecting close to 6 million people globally. Although historically the disease was limited to endemic areas of Latin America recent years have seen an increasing global spread. In addition to the morbidity and mortality associated with the disease, the social and economic burdens on individuals and society are substantial. Often called the 'silent killer', Chagas disease is characterized by a long, asymptomatic phase in affected individuals. Approximately 30% then go on develop chronic Chagas cardiomyopathy and other serious cardiac complications such as stroke, rhythm disturbances and severe heart failure. Methods: In a collaboration of the World Hearth Federation (WHF) and the Inter-American Society of Cardiology (IASC) a writing group consisting of 20 diverse experts on Chagas disease (CD) was convened. The group provided up to date expert knowledge based on their area of expertise. An extensive review of the literature describing obstacles to diagnosis and treatment of CD along with proposed solutions was conducted. A survey was sent to all WHF Members and, using snowball sampling to widen the consultation, to a variety of health care professionals working in the CD global health community. The results were analyzed, open comments were reviewed and consolidated, and the findings were incorporated into this document, thus ensuring a consensus representation. Results: The WHF IASC Roadmap on Chagas Disease offers a comprehensive summary of current knowledge on prevention, diagnosis and management of the disease. In providing an analysis of 'roadblocks' in access to comprehensive care for Chagas disease patients, the document serves as a framework from which strategies for implementation such as national plans can be formulated. Several dimensions are considered in the analysis: healthcare system capabilities, governance, financing, community awareness and advocacy. Conclusion: The WHF IASC Roadmap proposes strategies and evidence-based solutions for healthcare professionals, health authorities and governments to help overcome the barriers to comprehensive care for Chagas disease patients. This roadmap describes an ideal patient care pathway, and explores the roadblocks along the way, offering potential solutions based on available research and examples in practice. It represents a call to action to decision-makers and health care professionals to step up efforts to eradicate Chagas disease.

Chagas en Uruguay, 1937-2016. Información básica para su prevención, control y atención / Chagas in Uruguay, 1937-2016. Basic information for prevention, control and care

La enfermedad de Chagas, enfermedad transmitida por vectores y endémica de las Américas, ha sido una de las enfermedades parasitarias de mayor prevalencia, morbilidad y mortalidad en Uruguay. Avances en su prevención y control han logrado interrumpir sus vías de transmisión vectorial y transfusional, en la actualidad la transmisión congénita es la más importante en el país, y prácticamente la única que genera nuevos casos. Pensar en Chagas como etiología de cuadros infecciosos inespecíficos, cardiopatías o megaformaciones digestivas, en pacientes con antecedentes personales, familiares y/o ambientales sugestivos de riesgo de infección, es importante para los médicos uruguayos, especialmente en el norte del país.

Chagas disease, endemic in the Americas, is transmitted by vectors and has been one of the parasitic diseases with highest prevalence, morbility and mortality in Uruguay. Progress made in terms of prevention and control have contributed to interrupting vectorial and transfusional transmission. Today, congenital transmission is the most important way of transmission in Uruguay, and it is the only one that causes new cases. Uruguayan physicians need to think about Chagas disease as a condition with non-specific infectious presentation, heart disease or digestive megaformations in patients with a medical history, family history and/or environment characteristics that are compatible with risk of infection.

A regional fight against Chagas disease: lessons learned from a successful collaborative partnership.

OBJECTIVE: To identify the intangible elements that characterize the successful effort to fight Chagas disease in the Americas, determine how they contributed to the overall success of the partnership, and learn lessons from the experience that could be applied to other programs. METHODS: This study was based on the Partnership Assessment Tool (PAT) developed by the Nuffield Institute for Health ("the Institute") at the University of Leeds (London). The PAT draws heavily on scientific literature and the extensive experience of sociologists and health experts working for the Institute. The Pan American Health Organization (PAHO) modified the tool slightly to adapt it to its needs and provide a general structure for the study. The six key principles of the PAT framework were applied in the design of the research questionnaires. RESULTS: The findings show that a successful collaboration requires a clear objective; a good-quality pool of data; and comprehensive qualitative and quantitative knowledge of the problem, its dimensions, and its impact. The collaboration was elaborated from a common idea and a shared, quantified plan based on data gathered by independent scientists plus a strategy with explicit milestones. The clarity of purpose allowed for an improved synergy of efforts and made it possible to resolve differences in opinions and approaches. CONCLUSIONS: PAHO's experience with effective collaborations such as the joint initiative to fight Chagas disease provides a rich knowledge base for analysis of the advantages, limitations, and paradigms of community involvement, collaborative practices, and partnerships.

A regional fight against Chagas disease: lessons learned from a successful collaborative partnership / Lucha regional contra la enfermedad de Chagas: lecciones aprendidas de una alianza colaborativa exitosa

Objective. To identify the intangible elements that characterize the successful effort to fight Chagas disease in the Americas, determine how they contributed to the overall success of the partnership, and learn lessons from the experience that could be applied to other programs. Methods. This study was based on the Partnership Assessment Tool (PAT) developed by the Nuffield Institute for Health ("the Institute") at the University of Leeds (London). The PAT draws heavily on scientific literature and the extensive experience of sociologists and health experts working for the Institute. The Pan American Health Organization (PAHO) modified the tool slightly to adapt it to its needs and provide a general structure for the study. The six key principles of the PAT framework were applied in the design of the research questionnaires. Results. The findings show that a successful collaboration requires a clear objective; a good-quality pool of data; and comprehensive qualitative and quantitative knowledge of the problem, its dimensions, and its impact. The collaboration was elaborated from a common idea and a shared, quantified plan based on data gathered by independent scientists plus a strategy with explicit milestones. The clarity of purpose allowed for an improved synergy of efforts and made it possible to resolve differences in opinions and approaches. Conclusions. PAHO's experience with effective collaborations such as the joint initiative to fight Chagas disease provides a rich knowledge base for analysis of the advantages, limitations, and paradigms of community involvement, collaborative practices, and partnerships.

Objetivo. Establecer los elementos intangibles que caracterizan la exitosa iniciativa para combatir la enfermedad de Chagas en la Región de las Américas, determinar cómo contribuyeron al éxito general de la alianza y extraer enseñanzas de la experiencia que podrían ser aplicadas a otros programas. Métodos. Este estudio se basó en la Herramienta de Evaluación de Alianzas (PAT, por sus siglas en inglés: Partnership Assessment Tool) creada por el Nuffield Institute for Health ("el Instituto") de la Universidad de Leeds (Londres). La PAT utiliza en gran medida la bibliografía científica y la vasta experiencia de los sociólogos y expertos en salud que trabajan para el Instituto. La Organización Panamericana de la Salud (OPS) modificó ligeramente la herramienta para adaptarla a sus necesidades y proporcionar una estructura general para el estudio. En el diseño de los cuestionarios de investigación, se aplicaron los seis principios clave del marco de la PAT. Resultados. Los resultados indican que una colaboración exitosa requiere un objetivo claro; una base de datos de buena calidad; y un conocimiento exhaustivo cualitativo y cuantitativo del problema, sus dimensiones y su repercusión. La colaboración se elaboró a partir de una idea común y un plan compartido y cuantificado basado en datos recopilados por científicos independientes, junto a una estrategia con hitos explícitos. La claridad de los objetivos permitió una mejor sinergia de las iniciativas e hizo posible la resolución de las diferencias de opiniones y enfoques. Conclusiones. La experiencia de la OPS en materia de colaboraciones eficaces, como la iniciativa conjunta para combatir la enfermedad de Chagas, proporciona una rica base de conocimientos para analizar las ventajas, las limitaciones y los paradigmas de la participación comunitaria, las prácticas colaborativas y las alianzas.

Interruption of vector transmission by native vectors and "the art of the possible".

In a recent article in the Reader's Opinion, advantages and disadvantages of the certification processes of interrupted Chagas disease transmission (American trypanosomiasis) by native vector were discussed. Such concept, accepted by those authors for the case of endemic situations with introduced vectors, has been built on a long and laborious process by endemic countries and Subregional Initiatives for Prevention, Control and Treatment of Chagas, with Technical Secretariat of the Pan American Health Organization/World Health Organization, to create a horizon target and goal to concentrate priorities and resource allocation and actions. With varying degrees of sucess, which are not replaceable for a certificate of good practice, has allowed during 23 years to safeguard the effective control of transmission of Trypanosoma cruzi not to hundreds of thousands, but millions of people at risk conditions, truly "the art of the possible."

El proyecto subregional cono sur de control y vigilancia de la hidatidosis / The southern cone sub-regional project on cystic echinococosis control and surveillance

El Proyecto Subregional Cono Sur de Control y Vigilancia de la Hidatidosis: Argentina, Brasil, Chile y Uruguay, es una herramienta conjunta y colaborativa de los países para promover la implantación o el fortalecimiento de los programas de control. Se hace una descripción de los antecedentes, de los aspectos institucionales que regulan su organicidad y funcionamiento y de las líneas de acción definidas en el proyecto técnico operativo. Se destaca los logros obtenidos a través de los Proyectos de Cooperación Técnica entre Países así como el desarrollo de enfoques integrales e innovadores y la formación de recursos humanos de los programas de control. Algunos de los desafíos futuros son: lograr la sustentabilidad del Proyecto, implementar los grupos técnicos de análisis y evaluación a solicitud de los países, mejorar los sistemas de información regionales, continuar las actividades de capacitación y entrenamiento de recursos humanos y la expansión y fortalecimiento de la cooperación técnica entre países.

Southern Cone Sub-Regional Project on Cystic Echinococcosis Control and Surveillance: Argentina, Brasil, Chile and Uruguay, is a joint and collaborative tool with the aim of promoting the implementation or the strengthening of programs for disease control. The paper describes the background, the institutional aspects that regulates the structure and functions, as well as the guidelines defined in the technical and operational project. The article emphasize the achievements through Projects of Technical Cooperation among Countries, and the development of integrated and innovative approaches for prevention and control of the disease and training of human resources of the control programs. Some of the challenges are: to achieve the sustainability of the project, implementation of technical groups for analysis and assessment at request of the countries, improvement of the regional information systems, to continue training human resources of the control programs and to expand and strengthen the technical cooperation among countries.

[The Southern Cone Sub-Regional Project on Cystic Echinococcosis Control and Surveillance]. / El Proyecto Subregional Cono Sur de Control y Vigilancia de la Hidatidosis.

Southern Cone Sub-Regional Project on Cystic Echinococcosis Control and Surveillance: Argentina, Brasil, Chile and Uruguay, is a joint and collaborative tool with the aim of promoting the implementation or the strengthening of programs for disease control. The paper describes the background, the institutional aspects that regulates the structure and functions, as well as the guidelines defined in the technical and operational project. The article emphasize the achievements through Projects of Technical Cooperation among Countries, and the development of integrated and innovative approaches for prevention and control of the disease and training of human resources of the control programs. Some of the challenges are: to achieve the sustainability of the project, implementation of technical groups for analysis and assessment at request of the countries, improvement of the regional information systems, to continue training human resources of the control programs and to expand and strengthen the technical cooperation among countries.

Evaluation and treatment of chagas disease in the United States: a systematic review.

CONTEXT: Because of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease). OBJECTIVE: To examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection. Evidence Acquisition Literature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field. EVIDENCE SYNTHESIS: The patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation. CONCLUSIONS: Chagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

The future of Chagas disease control.

In the past 15 years, there have been major advances in the control of Chagas disease in most of the countries endemic for this infection. Attention now turns to the future continuity of surveillance and control interventions - especially in regions where control has been so successful that the epidemiological significance of Chagas disease is in steep decline. The effort and expenditure of the recent past cannot continue indefinitely, but a degree of surveillance and selective intervention will be required because of the risk of new infestations and infections resulting from adventitious silvatic vectors accidentally entering houses. In this review, we summarize the progress of multinational control initiatives against Chagas disease. In addition, we suggest that the most sustainable approach to future surveillance involves both the primary healthcare system and university-based teams, with progressively greater attention given to case detection and treatment. Such an idea is not new, but we believe that it merits extensive discussion because of the different ways that research and health interventions are financed and because of the need to establish clearer reporting links between the research communities and the national health authorities.