Chagas Disease Control: Perspectives and Challenges in 2009

1. FIOCRUZ – CHAGAS DISCOVERY CENTENARY - 2009Eradication or elimination of transmission in Chagas disease.Perspectives in 2009. João Carlos Pinto Dias Fiocruz – Academia Mineira de Medicina - CNPq

2. HISTORICO REFERENCIAL DE LA ENFERMEDAD DE CHAGAS EN AMERICA. ETAPAS RECORRIDAS 1900 1909 1910 1920 1930 1940 1950 1960 1970 1980 1990 Descripción de Carlos Chagas R.prolixus en CA XDG & RFC T.infestans en Brasil central Etapa de caracterización y jerarquización de la enfermedad HCH en el control de triatomineos CCC Digest. TiF~HAI PERIODO DE LOS PROGRAMAS NACIONALES DE CONTROL … Nifurtimox Benzidazol Piretroides en control vectorial HiV – Avance bancos de sangre Amiodarone IECA 1991>>> desarrollo de las INICIATIVAS SUBREGIONALES DE CONTROL Avance de la decentralización Aumento de indicaciones al TE Reconocimiento del riengo para los paises no endémicos 2000 - 2009 Adaptado de Schmunis, 2009

3. Two sides of a general consensus: • One hundred years after its discovery by Carlos Chagas, American Trypanosomiasis remains an epidemiological and a socio-political challenge • The scientific community plays an extremely fundamental role in facing Chagas Disease

4. Chagas Disease: estimated figures for Latin American Region in 2007 Total Population: 531,432,850 Number of infected individuals: 15,632,000 Incidence of vector transmisión: 41,200 (yearly) Congenital transmission: 14,385 cases/year Seropositive women in fertile age: 1,809,507 Population under risk in endemic areas: 28,595,000 Cardiopathies: 1,772,365 General prevalence in blood banks: 1.28% Source: Dr. R. Salvatella, PAHO, 2007

5. Chagas Disease - 2009 Epidemiological features at the present (endemic countries) • At least 12 million of infected individuals in 18 countries • Still significant incidence in endemic area; • Continuous migration to non endemic regions; • Increasing importance in Amazonic region; • Morbidity around 30% among infected people; • Regional Differences: G-I coincident with lower morbidity in relation to G II; • Increasing importance of oral transmitted disease; • Increasing importance of the disease in higher age groups; • Increasing importance of secondary species of triatomines and peridomestic foci;

6. The meaning of American Trypanosomiasis eradication AT was formerly a primitive enzootic phenomenon, that suffered an evolution to a widespread anthropozoonosis. • Today, new epidemiological situations have been detected, such as oral transmission and domestic invasion by wild triatomines • Other epidemiological situations possibly can emerge, since the social and ecological context of this endemic and metaxenic disease is extremely complex • This disease has a lack of effective treatment in all its phases and no immunoprophylaxis is available. • More over, the natural circulation of Trypanosoma cruzi continue to be largely spread in sylvatic ecotopes all over the American Continent. Because of these reasons, AT cannot be eradicated and transmission elimination of HCD became a new concept

7. Controlling HCD.The task of elimination: • Is it a realistic possibility? • Does it mean a demagogic proposition? • Does it represent an inconspicuous optimism? • Could the best results represent a stimulating effect to not yet controlled Countries? • Could the proclamation of the best results emulate the weakness of current control programmes? • Is it affecting the interest in CD research ?

8. First of all, the control of Human Chagas Disease must be considered AN ATTAINABLE GOAL • Several epidemiological parameters are indicating the reduction of morbidity and transmission in all endemic areas under control • The regular maintenance of adequate epidemiological surveillance is fundamental • The cost benefit relation of HCD control is absolutely favorable (but its priority is low)

9. Political Features It must be recognized that: • HCD means poor and socially marginal population • Thus, the main preventive actions and programmes must be necessarily carried on by the public governmental sector, And so, political decisions are involved...

10. A very important antecedent at the beginning of national programmes (1979) The theoretical Rabinovich model for twenty years simulation, involving both technical and political approaches: • Under continual and adequate chemical control and blood banks coverage the reduction of HCD transmission would reach more than 95% of efficacy; • The same results should be obtained if minimum salary of endemic countries was improved (300%)

11. Epidemiological changes of human Chagas Disease in LatinAmerica,between 1990 and 2000Source. TDR/WHO, PAHO, WHO 11

12. Evolution of Triatoma infestans in Brazil 1995 1976 2002 1998 2006: ELIMINATION CERTIFIED BY PAHO/WHO 12 Source: Brazilian Ministry of Health

13. Controle do vetor e incidência BRASIL: Eliminação da transmissão da DCh, 1982-99. Fonte OPAS, 2000.

14. Diferenças regionais de mortalidade por DCh no Brasil Fonte: DATASUS

15. General figures about HCD in Brazil, in different times 15

16. Um exemplo muito especial de controleDoença de Chagas em Bambuí em três momentos(Ataque vetorial em 1956 – Vigilância contínua desde 1974)

17. General framework of this evolutionin Brazil • The existence of a continuous vector control programme between 1980 and 2000; • The effective implementation of blood bank control programmes since 1980; • The increasing urbanization of the whole population (75% of rural population in 1950 > 25% in 2007); • The progressive improvement of rural dwellings and modernization of agriculture since the 1970’s 17

18. Disease burden in Latin America and Caribe Chagas Millions of DALYs Source: WB 18

19. The basic protagonists of this fight in Brazil • The scientific community, with continuous research and political participation in government decisions. • The national sector of Public Health. • The effective participation of public institutions such as the Oswaldo Cruz Foundation, the Ministry of Health and several Universities. • The interest and the stimulation of PAHO and WHO 19

20. El consenso actual sobre las dificultades y desafíos en la prevención y control • Gran Chaco • Cuenca Amazónica • Surgimiento de resistencia a insecticidas en T. infestans • Peridomicilio control y vigilancia • Control de triatominos autóctonos • Transmisión de T.cruzi como agente de ETA • Mejorar el diagnóstico, manejo y tratamiento de Chagas congénito • Desarrollar prioridad política en países con transmisión activa • Reducción de la prioridad política en países con transmisión interrumpida • Conceptualización de interrupción de la transmisión transfusional • Accesibilidad a adecuada y suficiente atención médica integral • Disponibilidad y mejoramiento del tratamiento etiológico Adaptación jcpd/2009

21. Perspectivas e desafios, cem anos depois. • Uma doença disseminada, com transmissão vetorial e transfusional reduzida em vastas áreas, a merecer vigilância permanente, basicamente por sistemas públicos e descentralizados de saúde • Um acervo de mais de 10 milhões de crônicos para detectar e cuidar • As possibilidades de surtos orais de transmissão, vinculados a situações aleatórias de triatomismo silvestre • A consolidação de expertícia e ciência regionais • A incorporação de novos atores na luta antichagásica • A consolidação de iniciativas intergovernamentais de cooperação científica e sanitária, nas áreas endêmicas.

22. For the next two decades, what can be expected ? • The progressive reduction and focalization of domestic vector population; • Important changes of sylvatic ecotopes submitted to anthropic activities (puzzle and concentration phenomena); • The possible expansion of agriculture existing frontiers; • The reduction of rural human population; • The increasing of urbanization and the human migration into non endemic areas.

23. Expected Future (cont.) The next two decades probably will be characterized by the progressive reduction and focalization of domestic vector population, following predictable changes of sylvatic ecotopes (puzzle and concentration) and the reduction of rural human population. The transfusion transmitted disease probably will be completely controlled (consolidation), but eventual cases of congenital transmission still will occur, in spite of progressively being reduced. Oral transmitted cases seem to continue their appearance in different ecological situations, generally being linked with natural foci of American Trypanosomiasis. A progressive reduction of HCD prevalence is expected in endemic areas, correlated with control activities and with the mortality of already infected individuals. As a consequence, the social and political visibility of the disease must be reduced, as well as the priorities for control and research (Dias 2006, 2007, Dias et al. 2002

24. Considering vector programmes: • There will be a progressive reduction of domestic vector infestation and disease transmission in areas under regular control; • Some triatomine foci will probably remain within the pockets of poverty, isolation, and of poor political and sanitary infrastructure.

25. Possible risks and problems for HCD control programmes in the near future: • Progressive weakness of the national programmes and surveillance, as a consequence of other priorities and health system decentralization ; • Progressive loosing of prepared human resource, because of no renovation, resource deviation, reduction of regular supervision and/or capability on the part of central and regional levels etc.; • Loosing of epidemiological information. This is a very critical question in terms of programme planning and priority definitions; • Absence or weakness of the educative component, leading to the weakness of surveillance and community participation;

26. Scoring some risks for the next future • Epidemiological: • Recrudescence of classical vectors (low) • Increasing of housing colonization by wild vectors (low) • Appearance of new endemic areas of vector transmission (low) • Recrudescence of transmission in blood banks (very low) • Increasing of congenital transmission (very low) • Increasing of oral transmission (unpredictable) • Institutional: • Incompetence of decentralized structures (high) • Decreasing of priority in PAHO and WHO (possible) • Loosing of consistence & effectiveness of the current Initiatives (possible) • Scientific: • Lack of priority and financial help (high) • Decreasing of scientific interest (middle/high) • Political: major decreasing of priority (high)

27. Some very specific challenges for us • How to maintain the critical mass of research and service? How long ? • Is it possible a new “malaria like” situation in this history ? • How to maintain the national references for control programmes, in view of decentralization and political weakness of endemic countries ? • What will be the research priorities and the general agenda for the next two decades ? • What could be the new protagonists for medical attention and disease control beyond governments and public sector?

28. Final remarks The complete victory against HCD has not been achieved and much remains to be done. The greatest danger in the case of good news lies in inconsequential triumphalism and slackening of control measures. The decentralization of Health Programmes all around Latin America, transformed radically the classic control activities in municipal programmes. Another correlated problem emerges from the usual political instability of local (municipal) governments, putting under risk the sustainability of surveillance activities. 28

29. Opportune considerations in attempt with the centenary of Carlos Chagas discovery(1909 – 2009) This history represents a remarkable scientific conquest and a realistic responsibility to Brazil, in terms of Latin American Public Health; Carlos Chagas heritage presupposes the continuity of his dreams and his work; The best celebration of this splendid history concerns with the commitment for Chagas Disease control, representing also an opportunity for the scientific development in Latin America. . 29

30. Nas lembranças, um futuro melhor

31. Ao fim de sua vida, Chagas manifestava seu sonho maior, bem acima das glórias acadêmicas..... E a luta seguirá por eles... Apud A.Jemmio, Bolivia, 2007