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Memórias do Instituto Oswaldo Cruz
Fundação Oswaldo Cruz, Fiocruz
ISSN: 1678-8060 EISSN: 1678-8060
Vol. 102, Num. s1, 2007, pp. 5-10
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Memórias
do
Instituto
Oswaldo
Cruz,
Vol.
102,
No.
Suppl.
I,
2007,
pp.
5-10
Workshop
on
Epidemiology
and
Social
Determining
Factors
of
Chagas
Disease.
Basic
information
for
surveillance
and
control
policy
in
Latin
America
Introduction,
Regional
Context,
Precedings,
and
Recommendations
Code
Number:
oc07126
ALC+UE Health (Alcuehealth) project is a joint initiative between Latin America, the Caribbean, and European Union with the objective of strengthening co-operation and developing a network with knowledge on high priority aspects of public health, through research projects, training programs, and seminars with specialists and experts, with the final goal of transforming knowledge into practice and policies of health.
Chagas disease is a neglected disease related to poverty which affects excluded social groups. It displays intrinsic and extrinsic biological factors with a complex life cycle where vector, human host, and environmental factors affect control strategies.
Extrinsic factors can be altered and it is thought that Public Health multi-disease and interprogrammatic activities within integrated interventions can support and possibly accelerate its prevention and control, especially in usually excluded population groups.
To accomplish this purpose, the Organización Pan-ame-ricana de la Salud/Organización Mundial de la Salud (OPS/OMS) is developing a strategic plan to prevent and control neglected diseases such as Chagas, considered a priority.
The Workshop on Epidemiology and Social Determining Factors of Chagas Disease had the aimed at evaluating its present situation in the Southern Cone, Central America, Andean Countries, Amazon region, and Mexico, with the purpose of obtaining basic data to formulate a surveillance policy and control, which could be used as a model to other emerging infectious and neglec-ted diseases.
The Workshop has also looked into the expansion of the diseases due to international migration, to access to diagnosis, treatment of the infection/Chagas disease in both endemic and non-endemic countries, as well as a strategy on neglected/emerging diseases that affect neglected population groups.
Chagas disease is an endemic vector transmitted parasitic disease with alternative routes of transmission (transfusional, congenital and oral, among others) and whose epidemiology is based on poverty and low quality of living conditions, housing and the environment. It is estimated today that 12 to 14 millions of people are infected.
It is an American pathology, endemic in 21 countries, that causes important morbimortality with different epidemiological determinants according to the ecological, biological, social, historical, economical, and cultural aspects that compose the subregional ecosystem with local characteristics for transmission.
It is an excellent model to design and reproduce strategies of prevention, monitoring, and control directly related to Chagas disease itself as well as to other endemic pathologies, as based upon: (a) a complex epidemiology that integrates vectors, reservoirs, population affected or at risk, and several transmission routes; (b) ecological and epidemiological variants with bio-geographically restrictions; (c) social, economic, and cultural factors associated to house and near house-living activities, affecting local population and ethnic groups, local and regional economies, community practices and attitudes, among others; (d) capacity to expand the borders of its endemic areas based on man acting as reservoirs and related to national and international migrations; (e) being a major but neglected disease affecting millions of people; (f) constituting an emergent disease for determined areas in which it was not previously identified, or recurring in areas with increased prevalence as a result of environmental or social changes, or expanding by migration; (g) representing for many countries and agendas a neglected disease, with low priority politically, scientifically or technologically.; (h) being supported, however, by a forceful and coherent scientific community, which contributed to delineate and reinforce visible public health actions in prevention, control, surveillance, and care in all affected regions, with decisive contributions; (i) having generated at national level positive decisions which led to the integration of subregional control projects, known as "Initiatives"; (j) having achi-eved outcomes of major impact in control and continuously confirming the social responsibility that society has in defending health of large populations at risk.
Since 1991, Subregional Initiatives, supported by the OPS Technical Secretary and subregional programs, were developed aiming at control of Chagas disease in endemic countries.
These initiatives, in coordination with the National Programs, have produced, horizontally, technical cooperation between countries and generated strategies and methodologies for prevention, monitoring, and control. Supported by the participation and contribution of the countries RD scientific community a number of actions took place with results being evaluated, in a coordinated and complementary form.
The following Initiatives are still productive:
1. Southern Cone Initiative established in 1991, integrated by Argentina, Bolivia, Brazil, Chile, Paraguay, and Uruguay, aimed at eliminating Triatoma infestans and to interrupt transfusional transmission of American trypanosomiasis.
2. Central American Countries Initiative (IPCA) : established in 1997, integrated by Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama, aimed at interrupting vectorial and transfusional transmission of Chagas disease.
3. Andean Initiative, (IPA) established in 1997, integrated by Colombia, Ecuador, Peru, and Venezuela, aimed at vector control and interruption of transfusional transmission of Chagas disease.
4. Intergovernmental Initiative for the Surveillance and Prevention of Chagas Disease in Amazon (AMCHA), was established in 2004, integrated by Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Suri-nam, and Venezuela.
5. Control, prevention and surveillance of Chagas disease in Mexico, since 2003, under the responsibility of the Mexican Health Secretariat, at the National Centre of Epidemiological Surveillance, and Control of Diseases.
PRECEDING
AND REGIONAL CONTEXTS
Southern
Cone Initiative (SCI) aimed at eliminating Triatoma infestans and to interrupt transfusional transmission of American trypanosomiasis
Incosur
was the first "Initiative" resulting from a number of
scientific events and exhibiting visible achievements on the vectorial
and transfusional control of the disease, as carried out in a number
of countries. A major effort from the Latin American scientific
community was seen, which contributed with their experience and
knowledge on strategies for control, associated to major encouragement
of policy makers. The role of OPS, throughout this process, in terms
of integration, technical support, as well as subsistence in developing
a succesful programme, was fundamental. Officially, it began in
1991 with the aim of maintaing and consolidating already existing
programs (Argentina, Brazil, Chile, and Uruguay) and to definitively
initiate other activities and programs (Bolivia and Paraguay, and
later on, South of Peru). The main objectives were the control of T. infestans (the main resident vector) and to increase serologic
coverage of blood donors. As this Initiative progressed, other relevenat
subjects were associated, such as the control and surveillance of
secondary vector species, better care of infected people and attention
to surveillance/treatment of congenital transmission.
Central
America Countries Initiative (IPCA) aimed at interrupting vectorial
and transfusional transmission of Chagas disease
In 1997,
at the XIII Reunion of the Central America Health sector (RESSCA)
held in the city of Belize, approved a Resolution no.13, stating
that the "Control of Chagas disease is a priority activity
to Central America countries", with the implementation of a
multinational program to interrupt vectorial and transfusional transmission
of the disease. The program is known as IPCA and it was launched
in October 1997 in the city of Tegucigalpa, Honduras. In collaboration
with OPS, the Intergovernmental Technical Commission was created
acting as Technical Secretary. This commission followed and evaluated
programmed activities in the countries, looking for international
cooperation support and participation of non-governamental organizations
(NGOs), encouraging exchange of knowledge and experiences aiming
at reinforcing prevention and control. Since its foundation, the
Intergovernmental Technical commission of IPCA has organized eight
annual meetings, the last being held in Tegucigalpa, Honduras, in
December 2005.
The
IPCA objectives are: (1) elimination of Rhodnius prolixus in Central America; (2) control of intradomiciliary vectorial transmission
of T. dimidiata; (3) elimination of transfusional transmission
of Trypanosoma cruzi.
R.
prolixus is an introduced species in Central America that can
only be found inside houses, making it susceptible to eradication
by the commonly application of residual insecticides and entomological
surveillance.
On the
other hand, T. dimidiata is a wild species whose origin is
thought to have been the Yucatán Peninsula and that is found
all over Central America, both intradomicilliary and peridomicilliary
and in urban areas. Its elimination is not possible and control
strategies are based on intradomicilliary transmission.
The
main achievements of IPCA, since its foundation in 1997 until now,
with a major effect on the subregion view of Chagas disease, are
the following: (a) significant advances in the accomplishment of
IPCA first objective, with the foreseen elimination of R. prolixus from Central America; (b) 99% control of transfusional transmission;
(c) technical cooperation between countries through TCC/OPS/Chagas/El
Salvador/Guatemala/Honduras projects, with the formalization of
the "Rules and Regulations for Diagnosis, Treatment, and Epidemiological
Surveillance" in the three countries; (d) substantial achievements
in the inter-sectorial coordination, strengthening and widening
of international cooperation in IPCA member countries, with the
support of bilateral agencies, as the Japanese International Cooperation
Agency (JICA), the Canadian International Development Agency (ACDI),
other multilateral agencies, such as OPS, NGOs such as Medecins
Sans Frontieres (MSF) and World Vision (WVI), the European Community
with projects "Chagas Disease Intervention Activities"
(CDIA) and "American Tripanosomiasis Update" (SSA-ATU),
as well as the ECLAT network; (e) widening the etiological treatment
coverage area in both interrupted vectorial transmission and low
surveillance areas; (f) designing sera-epidemiological diagnostic
strategies, entomological surveillance, and collective treatment
with community participation; (g) approval of Resolution no. 5 at
the XXI RESSCA held in the city of Belize, in September 2005, concerning
Chagas disease: "to take responsibility in achieving, within
the period of 2 years, a minimal of 50% coverage of T. dimidiata vectorial control in endemic regions and to develop a T. cruzi universal serological test to be used by all public and private
donor blood banks".
IPCA
challenges for the near future are: (a) to develop alternative strategies
to the control and surveillance of T. dimidiata; (b) to carry
out surveillance of other triatomines emerging species such as R.
pallescens, T. nitida and T. ryckmani; (c) to
maintain 100% coverage of quality control of transfusional transmission
with serological tests; (d) to support politically countries with
successful measures and help introducing these in others, initiating
these activities; (e) to maintain international cooperation support;
(f) to develop entomological surveillance involving community participation;
(g) to plan epidemiological surveillance and preventive education;
(h) to supply medication and etiological treatment; (i) to assure
sustainability of national programs and the Central America Initiative.
Andean
Countries Initiative (ACI) to control vectorial and transfusional
transmission of Chagas disease
The
Chagas Andean Subregional program and the Chagas Andean Initiative
are a cooperative activity involving Colombia, Ecuador, Peru, and
Venezuela with specific characteristics: (a) a large geographic
area widely distributed; (b) it exhibits important eco-biological
diversity; (c) biogeographic factors are influenced by latitude
and altitude; (d) shows diverse epidemiologic situations of chagasic
endemism; (e) there is social, economical, and cultural diversity;
(f) ethnic diversity; (g) different peri and intradomicilliary structure
and characteristics; (h) diverse T. cruzi vectors are implicated
in transmission; (i) there are diverse development patterns and
control/surveillance programs aimed at Chagas disease.
Although
the Initiative, funded in 1997, went already through periods of
discontinuity it has given strong support to prevention, control,
surveillance, and health care with institutions for Chagas disease,
developed by the member countries.
The
antivectorial control plan was based on a proposal developed by
the Initiative, on operational actions and an approach on sustainable
prioritisation of the risk concept.
Some
triatomine species of the subregion considered as important epidemiological
vectors are feasible of being controlled or eliminated, such as R. prolixus (Colombia and Venezuela); T. dimidiata and R. ecuadoriensis (Ecuador); and R. ecuadoriensis and T. infestans (Peru) as a consequence of being species strictly
associated with antropomorphic constructions.
In what
health care of Chagas disease is concerned, namely diagnosis, handling,
and treatment of patients, major efforts are needed to optimize
the national health system resources, aiming at a better quantification
of prevalence, morbidity, and mortality, with improvements of treatment
aspects in terms of prescription, opportunity, accessibility, and
drug availability.
The
main aims of the Chagas Andean Initiative are the control of vectorial
and transfusional T. cruzi transmission and/or some of its
members have been supported by CDIA/EC, SSA/EC, ECLAT, CIDA, TDR/OMS
and OPS Technical Secretary.
A interesting
feature of the four member countries is that they are part of both
the Andean and the Amazon geoepidemiological programs of endemic
Chagas disease. As relevant groups and research institutions have
already shown collaborative work and with the subregional program
it will be easier to develop Chagas disease better organized and
coordinated international and horizontal technical cooperation.
The
Chagas Andean Initiative is a subregional ongoing project that is
a strong reliable tool for member countries to record and validate
their advances/goals in an integrity international cooperation program.
Intergovernmental
Initiative for the surveillance and prevention of Chagas disease
in Amazon (AMCHA)
Transmission
of T. cruzi to humans was thought not not to occur in the
large area of the Amazons. It was to considered an open natural
space disease or a result from human activities, and that in shadow
areas, such as the Amazons territory, it was constrained to episodic
or accidental cases, as a result of incursion of men on the parasite
sylvatic cycle. Endemic transmission in domiciliary habitats would
have been a consequence of degradation of natural conditions and
displacement of vectors and reservoirs from primitive ecotopes now
adjusted and adapted to human housing conditions.
Chagasic
zoonosis in the Amazons is known since early reports. In 1924, Carlos
Chagas identified T. cruzi in monkeys of the region. Emergence of the disease was not dependent on domiciliary conditions
and transmissions patterns seem to differ from those where endemism
was already established.
Although
big environmental changes and new occupational activities occurred/are
ocurring in the Amazons, there was no evidence on a domiciliary
colonization associated to a transmission pattern, such as in naturally
endemic infections.
Only
a few vector domiciliations have been reported, in restricted areas
of some countries: T. maculata, P. geniculatus, R. neglectus,
and R. stali.
With
rare exceptions, not much knowledge exists on the mechanisms of
transmission. These are summarized, as follows: (i) oral transmission by contamination of food with feces, from the infected
triatomines themselves or by the contamination with the infected
reservoirs, (ii) domiciliary vectorial transmission, without
colonization, by the episodic or repetitive incursion of specimens
into houses, (iii) extra domiciliary vectorial transjmission,
by the incursion of people into the forest and by the contact with
wild triatomines, as it happens with R. brethesi, in the
"piaçaba" extraction.
These
elements create a particular epidemiological pattern that requires
a special approach. This demands that study and development of methods
and techniques be adjusted to the different biological dynamics
of the parasite, in the region.
Several
areas were identified that presented a direct relation between the
cumulative risk of T. cruzi transmission and people age,
which is in conformity with the disease endemic pattern. This situation
occurs mainly where R. robustus, R. pictipes, and R. brethesi which are in direct contact with the population,
without eliminating, however, the importance of other potentially
vector species.
The
development of new methods and instruments of surveillance and control
should also consider, existing opportunities, represented by established
resources, such as the on going surveillance of malaria which affects
large populations in the Amazons region, and take into account operational
difficulties due to the extension of the territory and its inaccessibility.
There
are several documented observations that demonstrate the existence
of endemic situations, with low levels of transmission, but with
proved severe clinical forms, similar to the ones described in Sucumbíos
(Ecuador), Guianía (Colombia), Cayena and Cacao (French Guiana),
and in the region of Alto and Medio Río Negro and in the
state of the Amazonas (Brazil).
Several
countries have recognized Chagas disease as an emerging problem
and the scientific community and control related organizations are
mobilized in the search of a coordinated action to deal with it.
As a concrete result, the I International Technical Meeting was
held in 2002 in Palmarí, where some guidelines for the investigation,
surveillance, and evaluation of possibilities of control were established.
In this meeting the AMCHA was established and OPS/OMS was recommended
as its Technical Secretariat. In addition, meetings in Manaus (Brazil)
in 2004 and in Cayenne (French Guiana) in 2005 were held. The following
was agreed:
1. A
network/international surveillance system adap-ted to the Amazon
subregion, with guidelines for the surveillance and prevention of
Chagas disease, was required.
2. Proposals
of diagnosis and clinical studies of the disease were discussed.
3. Research
directed to the epidemiology, diagnosis, and treatment of the disease
was needed.
It was
also agreed that the strategy for implementing the Initiative should
be based on a progressive characterization of the disease and infection
patterns with risk assessment.
Control,
prevention, and surveillance of Chagas disease in Mexico
The
disease is known in Mexico since 1891, where Latreille detected
one of the most important vectors in Mexico and Central America: T. dimidiata. Hoffman published a paper about possible
hosts of T. cruzi in triatomines found in Veracruz.
In 1936, Luis Mazzotti identified the two first human cases coming
from Oaxaca, and several infected triatomines. In the last 15 years,
the interest on the disease has grown and there are today
at least six groups dedicated to research and two to medical care.
General
aspects related to infection/Chagas disease in Mexico are: (a) 19
geographic regions limited by two coasts (Mexican Golf and Pacific
Ocean), two "cordilleras" that cross the country from
North to South, a central plateau close to the shore and two peninsulas,
Yucatán and Baja California, with specific characteristics
and important ecological and biological diversity; (b) biogeographic
patterns influenced by latitude and altitude; (c) diverse epidemiological
situations of chagasic endemism, poorly known; (d) social, economical,
ethnic, and cultural diversity, with predominance of rural areas
and with fast growing non-planned urbanizations; (e) different housing
structures with peri and intradomicilliary characteristics; (f)
diverse T. cruzi vectors implicated in transmission; (g)
recognized difficulty in establishing a final diagnosis of the situation;
(h) passive surveillance of the disease, associated to research
and with inquiries of people with self diagnosis of the disease;
(i) control driven by associated antimalarial activities that affected
transmission in the last years due to the rationalized use of intradomiciliary
insecticides, reducing in 90% malaria in the last 10 years.
Mexico
has adhered to the initiatives, mainly at the elimination of the
intradomiciliary transmission to, and has already promoted a national
plan which reinforces on going programs.
Authorities
were encouraged to constitute a Technical National Group coordinated
by the National Centre of Epidemiological Surveillance and Control
of Diseases, and with the participation of the National Centre of
Blood Transfusion, the National Institute of Cardiology, and the
Independent National University of Mexico.
Chagas
disease here can not be associated to a specific anti-vectorial
control procedure, but for almost 50 years, the spreading of malaria
control has shown a positive side effect on it as almost all of
the known area of infection by triatomines coincides with malaria
affected regions. With an effective malaria programme, a specific
Chagas disease control program becomes necessary. On its own. The
model to control malaria integrates housing and basic saniation
actions. These actions will be evaluated to observe its impact on
the vectors of the Chagas disease. Further, the basic actions for
controlling malaria, dengue, alacranism, and, more recently, Chagas
vectors, will now be jointly evaluated.
Some
of the triatomine species considered as important epidemiological
vectors can be controlled: R. prolixus (under surveillance
because it was recently detected a small number of specimens in
three localities in Chiapas and Oaxaca) and T. dimidiata. Other
native species of vectorial relevance are: T. barberi, T. gerstaeckeri, T. longipennis, T. mazzottii, T. pallidipennis, T. picturata,
and T. phyllosoma.
In order
to detect active and passive infection/Chagas disease, an epidemiological
surveillance system is required. It is necessary to improve MD's
knowledge on clinical care, diagnosis, handling, and treatment of
infected/patient affected by the disease. This improvement should
be established at a national level optimizing health centre capacities,
and starting by quantification of prevalences, carryng out surveys
on morbidity and mortality within specific groups, as in premature
sudden death. Optimization of opportunity, accessibility, and drug
availability is necessary and this seems to have been resolved with
WHO, OPS, and the Mexican Health Secretariat interventions.
More
specific objectives are: the control of domiciliary chagasic vectors,
control transfusional transmission, and to reduce through treatment
and suitable handling of patients, all clinical complications.
The
Mexican initiative to control Chagas disease has the support of
technical cooperation and medical supplies from WHO, Technical Secretariat
of OPS, and National Technical Group.There is also known interest
between Mexico and other Central American countries in developing
integrate dactions. According to this, the following should be developed:
1. Identification
of research groups and institutions with known capacity for prevention,
control, surveillance, and health care of Chagas.
2. Stimulate
greater development in operational activities with improved organized
and coordinated horizontal and international cooperation between
member countries.
3. Wider
participation in the quality control of diagnosis of the disease.
International
migration and epidemiological, social, and control consequences
of Chagas disease/infection in non-endemic countries
All
Iniitiatives took into account the present situation of Chagas disease/infection
in the different endemic regions with analysis of the different
environmental contexts, a variety of socio-economical and cultural
aspects, which support domiciliation of certain triatomine species
responsible for the introduction and maintenance of the endemism.
Knowledge about these epidemiological factors is behind the application
of control measures.
In non-endemic
countries the main concern about the disease lies on the diagnosis
and handling of patients, depending on the magnitude and country
of origin of emigration. Assessment can be made through knowledge
of the epidemiology and morbidity situations in those countries
of origin taking into account that the United States, European Union,
Canada, Australia, and Japan are the host countries for Latin-American
emigrants. In these regions, with absence of domiciliary triatomines,
infection can be transmitted by blood transfusion and derivatives,
organ transplants or by congenital route.
RECOMMENDATIONS
OF THE WORKSHOP ON EPIDEMIOLOGICAL AND SOCIAL DETERMINING FACTORS
OF CHAGAS DISEASE
General
recommendations
1. To
relocate Chagas disease control, handling, and health care as one
of the priorities of the Millennium Objectives, namely Objective
6 "fight against diseases"; Under the ALC+UE Health (ALCUEH)
project, search for international and inter-institutional commitments
in supporting activities aimed at the control of the disease.
2. To
establish protocols between ALCUE and Chagas Subregionals Initiatives
to facilitate implementation of RD activities and strongly support
the Initiatives national and scientific-technical representation.
3. To
create, with ALCUEH support, planning interactions, interchange,
and mobility between Chagas clinical working groups.
4. To
contribute to the development of Chagas clinical care components
as integrated in Subregional Initiatives establishing its morbidity
and impact in the countries Public Health according to the document Consulta Técnica Subregional OPS/MSF sobre Organización
y Estructura de la Atención Médica del Enfermo o Infectado
por T. cruzi/enfermedad de Chagas (OPS/DPC/CD/353/05). [Technical
Subregional Consultation OPS/MSF on Organization and Structure of
medical care of the Patient or infected by T. cruzi/Chagas
disease (OPS/DPC/CD/353/05)].
5. To
use the main program that originated ALCUE to overcome major problems
such as inaccessibility of diagnosis and treatment which affect
millions of infected/Chagasic patients.
6. To
promote contacts and workshops between ALCUEH and specialized areas
of health from the subregional integration projects (MERCOSUR,
Convenio Hipólito Unanue, Organización del Tratado
de Cooperación Amazónica, Reunión del Sector
Salud de Centroamérica and República Dominicana/RESSCAD),
strongly supporting by all means, prevention, surveillance, control,
and health care of Chagas disease.
7. to
facilitate the search and active diagnosis of patients and its corresponding
etiological and non-etiological treatment.
8. To
encourage the proper care of Chagas infected/patient in non-endemic
countries, through interconsultation of local health care centres
and their counterparts in Latin-America, and to emphasize the need
on quality proven serological reagents and etiological medicines.
9.
To
continuously
evaluate
control
activities
of
Chagas
disease,
as
a
neglected
disease,
through
multidisease,
inter-sector,
and
integrated
programmes.
Recommendations
concerning management of knowledge and information
1. To
contribute to the development of generation models, aiming at the
elaborateion and dissemination of information and knowledge to different
decision makers involved in Chagas disease prevention, surveillance,
control, and health care such as politicians, academic and technical
staff, NGO's, and communitarian stakeholders.
2. To
design web-accessible informatic tools to disseminate virtual training
as well as information in high-priority aspects of prevention, surveillance,
control, and health care of Chagas disease.
3. To
promote a Media strategy of information on problems, results, and
data, with regular updating on Chagas disease, at a regional and
global scenario, by means of workshops (with health and social specialized
press) coordinated by national programs.
4. To
review and disseminate available information about Chagas disease
to attract attention on the need of understanding the epidemiology
of the disease in and outside Latin America.
5. To
make an annual review of the most relevant and important information
of Chagas disease, in the so called "grey literature"
(non indexed Latin-American journals, articles, news, among others)
with good interpretation of knowledge on this disease. As a possible
approach, ALCUE could coordinate efforts in the future with the
SciELO project and Bireme.
Recommendations
on human resources qualification
1. To
promote actual and virtual activities for the training of professionals
and technicians on different aspects of Chagas disease.
2. To
promote actual and virtual activities for the training of the affected
communities related to prevention, surveillance, control, and health
care of Chagas disease, taking into account cultural aspects of
ethnies including specific languages in minority populations.
3. To
promote discussions on Chagas disease at university programs and
curricula updating the approaches and perspectives related to the
disease in order to provide scientific background to health professionals
and related staff.
4. To
organize human resource qualification programs specially on post-graduation
skills in the same themes and subjects, according to national and
international needs.
5. To
promote training to sanitary first health care professionals concerning
diagnosis and full handling of the patient with chagasic infection,
in order to improve on access to diagnosis and treatment.
Recommendations
to technological and knowledge transfer
1. To
implement and support actions to promote knowledge and technological
transfer from institutions and research centres to national control
and health care programs.
2. To
organize, through ALCUEH, workshops on planning and proposal submission
with national and international agencies, in order to support and
reinforce the critical mass required at controlling Chagas disease.
3. To
integrate human resource training activities and dissemination of
information through the existing projects and networks, such as
CDIA, SSA, ECLAT, which work within OPS policies and strategies
and adjusted to region and continental initiatives.
4. To
promote exchange of information aimed at improving accessibility
and effectiveness of diagnosis and treatment methods of Chagas disease.
Recommendations
to knowledge production
1. To
promote applied research, based on field campaigns that could generate
in biological, economical, sociological, and medical knowledge aimed
at the protection and recovery of people at risk, infected or ill.
2. To
develop sustainable alternatives to all activities associated to
control, health care and surveillance.
Recommendations
to non-endemic countries
1. To
guarantee that Chagas disease does not justify exclusion when laboral
or public health reasons are at stake.
2. Blood
donors must be examined by serologic tests when epidemiological
antecedents are compatible with the hypothesis of infection. When
this is not possible, donors should be excluded.
3. T.
cruzi serological tests should be done to pregnant women whose
file reveals that epidemiological antecedents are compatible with
the hypothesis of infection and to new born babies whose mothers
have positive serology.
4. To
promote free access to diagnosis and treatment whenever required.
5. Non
endemic countries should register and use validated diagnosis reagents.
6. To
develop training modules of Chagas health care in medical schools
especially in host countries for emigrants.
7. Problems
related to migration of chagasic patients would diminished if specific
medication for the treatment of the disease was more effective and
this should also take into account that drug producing industry
exists in these countries.
Rio de
Janeiro, 20 to 23 February 2006
PARTICIPANTS
Invited
Aluízio
Prata - Federal University of Triangulo Mineiro, Minas Gerais, Brazil
Antonieta
Rojas de Arias - CDIA, Paraguay
Antonio
Carlos Silveira - PAHO Consultant, Brazil
Carlos
Ponce - Secretariat of Health, Honduras
Cristina
Zackiewicz - DNDi, Latin-America
Elisa
Mayén de Ponce - Secretariat of Health, Honduras
Faustino
Torrico - CUMETROP, Universidad Mayor de San Simon, Bolívia
Felipe
Guhl - CIMPAT, University de los Andes, Colômbia
Gabriel
A Schumunis - PAHO, USA
Hugo
Marcelo Aguilar - Andean Coutries Health Organization, Ecuador
Jean
Jannin - WHO, Switzerland
João
Carlos Pinto Dias - Fiocruz, Brazil
Jorge
Fernando Mendez-Galvan - Secretariat of Health, Mexico
Luis
Villa - Medicos sin Fronteras, Spain
Roberto
Briceño Leon - Laboratory of Social Sciences, Venezuela
Roberto
Salvatella - PAHO, Uruguay
Rodrigo
Zeledón - Laboratory of Zoonosis, National University
of Costa Rica
Rubens
Storino - University of La Plata, Argentina
Steven
Ault - PAHO, USA
Virgilio
E do Rosário - ALCUE Health, Portugal
Virginia
Rodrigues - Laboratory of Social Science, Venezuela
Wilson
Oliveira - Federal University of Pernambuco, Brazil
Volunteers
Angela
Cristina Veríssimo Junqueira - Fiocruz, Brazil
Tereza
Cristina Monte Gonçalves - Fiocruz, Brazil
Organizers
José
Rodrigues Coura - Fiocruz, Brazil
Pedro
Albajar Viñas - Fiocruz, Brazil
Secretariat
Elton
Batista de Faria - Fiocruz, Brazil
Laura
Eveline Pereira Martins - Fiocruz, Brazil
Copyright
2007
Instituto
Oswaldo
Cruz
-
Fiocruz
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