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Chagas Disease/ N.

Llenas

Running Head: CHAGAS DISEASE IN LATIN AMERICA

Chagas Disease in Latin America


UMUC
Nia S. Llenas, B.S.

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Chagas Disease/ N. Llenas

Introduction

In 1909, Brazilian Dr. Carlos Chagas, then working for the Oswald Cruz institute

as a malaria researcher, found a profound number of Amazonian native stricken with a

mysterious disease. Upon discovering large infestations of the “assassin” bugs in their

mud and thatch huts, Dr. Chagas discovered the source of their ailments, triatomine

vectors. Chagas disease (Trypanosoma cruzi), one of the most prevalent diseases in

South and Central America in the early 1990’s, is a major public health concern to

countries that harbor the triatomine vector. Several countries, such as Columbia,

Venezuela and Brazil have attempted to eradicate domestic vectors successfully in urban

areas and met with resistance in rural, poor areas in regards to both domestic and sylvatic

vectors.

These blood sucking vectors, commonly called “vinchuca” or “barbeira”, leave

parasitic feces and urine near the injection site of their victim, which is subsequently

wiped or scratched into the puncture unknowingly. At that point, the victim enters the

acute phase (6-8 weeks) of Chagas, characterized by swelling at the injection site and

febrile symptoms. Fifty to seventy percent of patients then progress into an indeterminate

chronic phase which may last up to 30 years, while others progress to the cardiac phase,

most of who succumb to the disease by means of heart failure, after the parasite has

invaded the heart’s musculature.

In light of recent changes due to urban sprawl and migration, many communities

and public health officials are once again dealing with the fear of Chagas causing

triatomine vectors. This report examines the countries directly affected by Chagas and

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Chagas vectors, the barriers to solving the Chagas dilemma, and organizations involed,

both interior and exterior to the countries affected.

Literature Review

History

Although Chagas was discovered in the early 1900’s, Aufderheide, et al., (2004)

successfully traced Chagas back to 7050 B.C, pre-Spanish conquest, using the

mummified remains of the Chinchorros, Maitas, Incas and eight other ancient subgroups.

Aufderheide, et al., extracted DNA and PCR to test for the presence of T. cruzi cells and,

remarkably, 40.6 percent of the tested mummies were positive for Chagas. Although that

actual vector is unknown, many of these subgroups lived in underground caves that

would ultimately be ideal for triatomine vectors.

Dias, Silveira & Schofield (2002), noted that during the last century, combating

Chagas became a top priority for both political figures in Latin America, as well as public

health organizations and non-profits around the world. In the 1940s, awareness was

heightened as poor villages were surveyed and sprayed against triatomine vectors

Rhodnius, Triatoma and Panstrongylus using the insecticide BHC, which was quite

effective in Venezuela. By the 1980’s, synthetic insecticides garnered much praise as

they required smaller applications for maximal results, leaving less unpleasantries for the

home’s inhabitants to endure.

The commentary of Dias (2007) details the many attempts to control Chagas

throughout Latin America before, during and after the implementation of the Southern

Cone Initiative (SCI). During the 1960’s, no priority was given and localities were using

their own local officers and resources to attempt eradication, proving far too costly to

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maintain at such a high rate for many of the endemic countries, and Chagas, although

most likely contracted through vector-borne transmission, is as likely to be passed on

during transfusion, in contaminated food, as well as congenital transmission.

Subsequently in 1991, the (SCI), under the umbrella of the Pan-American Health

Organization (PAHO) was formed as a collaborative effort by the Ministries of Health in

Argentina, Bolivia, Brazil, Chile, Paraguay and Uruguay, to combat this disease. SCI

and PAHO realized that transmission was preventable through vector control, serology,

and education. This initiative thrust Chagas awareness into the social fabric of at-risk

communities, forcing policy change and new standards to be set.

Assessment and Treatment

In June of 1991, it was decided by the SCI Ministers, that the initiative would

initially focus on three areas:

1. “To eliminate T. infestans of dwellings and peridomesticecotopes

of endemic and probably endemic areas.

2. To reduce and eliminate domestic infestations of triatomine species

in the same zones occupied by T. infestans.

3. To reduce and eliminate the transmission of T. cruzi through blood

transfusion by means of improvement of the blookbanks net and

the efficient selection of blood donors.” (Dias J. C., 2007, p. 13)

Without a format for controlling triatomine vectors, Brazil and Argentina spearheaded the

research and funding for action and awareness, even forming joint ventures with the ill

equipped Uruguay, Paraguay and Bolivia. Successes were reported in each country.

Guhl, Restepo, Angulo, Antunes, Lendrun-Campbell, & Davies (2005 p. 260),

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studied the intense sampling of endemic areas outside of the initial SCI which provided

templates for countries like Colombia as years past. In the case of Colombia, areas were

divided into varying degrees of risk, by collecting serum samples from children rather

than adults, as infection rates in children paint an accurate and up-to date picture of recent

activity. At this point it became clear, that frequent sampling of endemic regions

followed by spraying should be enacted to minimize risk of reinvasion.

Outside of Latin America, the United States is currently dealing with Chagas

infected persons as a result of migration and in some southern states, due to triatomine

vectors. Bern, et al. (2007), provides a detailed clinical review for the American clinician

who may come in contact with Chagas Disease. Current research and assessment skills

are outlined mostly for cardiac phase patients, who are routinely screened by way of the

American College of Cardiology/American Heart Association’s staging of congestive

heart failure. The author, however, fails to address actual patient education, which in a

public health or primary care setting is mandatory.

Current Control

Currently, control efforts have been largely focused on newly endemic regions,

such as the Amazonian region of Brazil and the Andean sub regions of Columbia,

Ecuador, Peru and Venezuela. Both efforts seek to eradicate secondary vectors such as

R. pallescens, T. nitida, T. rychmani, R. ecuadoriensis, R. robustus, R. pictipes, and R.

brethesi. According to the most recent workshop sponsored by the Oswald Cruz

Memorial Institute (2007), several regional initiatives are currently working closely to

increase surveillance and control mechanism throughout Latin America and Mexico,

taking into account the recent increases in migration to countries ill-equipped to handle

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large number of patients presenting Chagas disease and the future transmission. The

workshop proceedings outline specific recommendations for organizations embarking on

Chagas awareness, prevention and control initiatives, including historically successful

methods as well as new technology and science. (Oswaldo Cruz Memorial Institute,

2007)

Regions endemic to Chagas

Chagas disease, initially identified in Brazil, has plagued all of Latin America at

some point in the 20th century, continuing now in many rural areas as one of the major

causes of myocarditis. As Chagas disease spreads across rural South and Central

America, even into the southwestern United States, many organizations have become

synonymous with fighting the disease. All current projects stem from the partnership

between PAHO and SCI, which began in 1991. Since then, each geographical region

now boasts its own cooperative initiative to control the spread of Chagas disease, in

addition to various multinational organizations that currently contribute both funds and

knowledge to this effort. According to the most recent World Health Organization

technical report in 2002, Chagas transmitting vectors are present in the every country in

South and Central America, with each presenting several different species. To date, there

are five initiatives productive in these regions:

i. Southern Cone Initiative, concentrating on Argentina, Bolivia,

Brazil, Chile, Paraguay, and Uruguay.

ii. Central American Countries Initiative (IPCA) concentrated in

Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua,

and Panama.

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iii. Andean Initiative (IPA) concentrated in Columbia, Ecuador, Peru,

and Venezuela.

iv. Intergovernmental Initiative for the Surveillance and Prevention of

Chagas Disease in Amazon (AMCHA) concentrated in the

Amazonian regions of Bolivia, Brazil, Columbia, Ecuador, French

Guiana, Guyana, Peru, Surinam, and Venezuela.

v. Mexican Health Secritariat’s program to control, prevent and

surveil Chagas disease in Mexico. (Oswaldo Cruz Memorial

Institute, 2007)

Barriers to solving Chagas disease

Chagas transmission and triatomine vectors are difficult to interrupt or eradicate

indefinitely for a variety of reasons. Administrative strains placed on governments by

competing epidemics have increasingly threatened continued Chagas progress. In Brazil

and Argentina, threats of dengue, fever, AIDS, and leishmaniasis disease repeatedly have

taken precedence over Chagas (Dias, p.14)

Budgetary concerns also impact disease control and education programs and for

that reason, countries like Uruguay and Paraguay, joined initiatives spear-headed by their

larger, wealthier neighbors. Although, the initial outlay may be of concern to smaller

countries, the return on investment has been documented and shows promise. According

to the Oswald Cruz Memorial Institute (p. 605), Argentina saw a 64% return on

investment, Brazil a 30% return.

Additionally, location may serve as one of the most detrimental factors in the

fight for interruption of Chagas. Substandard-housing (thatch roofs, mud walls, and

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wood slat floors) and proximity to infested villages are some of the characteristics first

noticed by Dr. Chagas at discovery. While a low-risk village may be diligent, in its

spraying activities and education, the surrounding medium-risk villages may harbor both

domestic and sylvatic vectors at an alarming rate, causing transport of vectors between

communities, re-infecting those previously believed to be safe. One example comes from

the Gran Chaco study, in which new infections were scarce, peaking only when a local

traveled and/or slept in a neighboring village (Gurtler, et al., p16196)

Dias (2002, p. 610) also provides a concise list of the challenges for control of

Chagas. He notes issues among countries without national programs who are trying to

launch successful anti-Chagas campaigns, and those maintaining existing efforts in

already established countries. Some of the problems these programs and their

constituents may face include a lack of political interest, archaic surveillance methods,

lack of control over secondary vectors, lack of serological testing of 100% of transfused

blood, and a need for improved medical and social care of those already infected.

Assistance in fighting Chagas

Many agencies located outside of the endemic regions are putting forth effort to

stop Chagas prevelance. The Chagas Space Project, started in 1995, enlists the help of

six universities and two biomedical science institutes from Chile, Argentina, Uruguay,

Costa Rica and the United States. Its chief partner, NASA leads the efforts to find

minerals, which may block receptors in the body that respond to the parasite, by

developing a naturally flawless crystal in space that may unlock the key to the Chagas

mystery (The Chagas space project).

Also, Moto Medic International and Fundacion Pilotos Solidarios have also joined

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forces to bring quality healthcare to rural regions of Latin America, with a hard focus on

prevention of transmission of Chagas. Moto Medic regularly hosts benefits, which can

be seen on You Tube, asking for donations to support its bed-net program, EKG testing

supplies, blood and water quality tests, as well as fumigation. These bed-nets protect

users from triatomine vectors for up to three years, making them a viable option for areas

not routinely sprayed, if used correctly (Moto Medics).

One of the largest organizations reaching out to endemic regions in South and

Central America is Japan International Cooperative Agency (JICA). In 2000, JICA began

helping Guatemala eradicate “vinchuca” by providing spraying equipment and

insecticide, as well as, educating the communities to report infestations immediately to

the proper authorities. The project has most recently spread to Honduras, El Salvador and

Nicaragua. (Japan International Cooperation Agency)

While several organizations serve as action and funding groups, few others may

have raised the awareness to the level of Argentine director Ricardo Preve and actress

Mia Maestro. Preve produced and directed the film, “Chagas: the Hidden Affliction”,

which premiered throughout many prominent cities in the Unites States, Argentina,

Brazil, El Salvador, Canada, and Italy (Schedule). The two are seeking to bring a true

face to Chagas disease, especially in rich countries that historically donate to charities.

All of the proceeds from the film go directly to the Chagas Foundation located in

Georgia. (The Chagas Disease Foundation)

Additional organizations include, Medicine without Borders, the Canadian

International development Agency, World Vision, the European Chagas Disease

Intervention Activity, American Tripanosomiasis, Alcuehealth, and the ECLAT network

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Future for Chagas

The control of Chagas transmission and vectors varies by country and its

respective initiatives commitment to lobbying policy makers, educating residents,

implementing and managing spray routines and funding the search for a cure. All of the

current regional initiatives pattern themselves after the SCI model and seek to follow

their lead closely, which is their biggest strength, as the SCI initiative has served as a

model to African nations battling malaria, African sleeping sickness and dengue.

Many of the historically endemic countries continue to tackle this debilitating

disease and are rewarded with fewer new cases each year in mostly urban areas.

However, problems lie in the newly developed rural areas of the Amazon, where sylvatic

and secondary species are present. In addition, Mexico has recently formed a task force

to combat Chagas, likely due to the increase in immigrants moving thru the country from

El Salvador, Honduras, and others, on their way to America. Also, in areas covered by

the Andean Pact Initiative, such as Columbia, have no specific plan for dealing with

large-scale infestation, like those of the SCI (Guhl et al., p.261-262). These regions must

prepare themselves to continually provide services to their populations to protect them

from the risks of Chagas. Such protections should include regular testing of high and low

risk populations, consistent spraying to include spraying at the sight of triatomine vectors,

immediate medical and social care to those infected, education on prevention, serology

testing of both blood and organ donors, as well as political protection for the program’s

focus.

In countries that seemingly have control of primary vectors, focus is rightfully

shifting towards secondary vectors with the help of outside organizations, their volunteers

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and donations. As awareness grows throughout the world, and Latin Americans migrate

towards more established countries such as the U.S. and Canada, richer nations will begin

to educate themselves on the severity of Chagas, prompting more serious action than the

localized initiatives within. Recent reports on California news stations are already

prompting some awareness for the Chagas migration into the U.S. as evident by the

increasing interest in scholarly reports on serological testing, blood bank awareness and

physician readiness in California.

While the search for a cure for Chagas seems as far off as outer space, there is one

last ray of hope in Dr. James McKerrow at University of California at San Francisco.

Combining a background in cancer research and the love of parasites, the director of the

Sandler Center for Basic Research in Parasitic Disease hopes to find a cure for not on

Chagas but other parasitic diseases plaguing Latin America, the Middle East and Africa.

By combining technology and already F.D.A. approved drugs, his research may be the

last hope for Chagas victims and their families (Dreifus, 2005). Unfortunately many of

them may not see this cure in their lifetime, but hope reigns in the minds of each

generation that follows.

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February 17). A 9,000-year record of Chagas' disease. Retrieved June 11, 2008,

from Proceedings of the National Academy of Science of the Unites States:

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http://www.pnas.org/cgi/content/full/101/7/2034?

maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=peru&searchid

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Bern, C., Montgomery, S. P., Herwaldt, B. L., Rassi, A., Marin-Neto, J. A., Dantas, R.

O., et al. (2007). Evaluation and treatment of Chagas disease in the United States.

Journal of the American Medical Association , 298 (18), 2171-2181.

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Historical aspects, present situation, and perspectives. Oswaldo Cruz Memorial

Institute , 102 (Supplement 1), 11-18.

Dias, J., Silveira, A., & Schofield, C. (2002). The Impact of Chagas disease control in

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Guhl, F., Restepo, M., Angulo, V. M., Antunes, C. M., Lendrun-Campbell, D., & Davies,

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http://www.jica.go.jp/english/about/policy/reform/human/ca.html

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http://www.chagasthemovie.com/schedule.php

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process: http://www.chagaspace.org/eng/theproject/crystallization.htm

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