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      Achievements and Challenges upon the Implementation of a Program for National Control of Congenital Chagas in Bolivia: Results 2004–2009

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          Abstract

          Bolivia is one of the most endemic countries for Chagas disease. Data of 2005 shows that incidence is around 1.09‰ inhabitants and seroprevalence in children under 15 ranged from 10% in urban areas to 40% in rural areas. In this article, we report results obtained during the implementation of the congenital Chagas program, one of the biggest casuistry in congenital Chagas disease, led by National Program of Chagas and Belgian cooperation from 2004 to 2009. The program strategy was based on serological results during pregnancy and on the follow up of children born from positive mothers until one year old; if positive, treatment was done with Benznidazole, 10 mg/Kg/day/30 days with one post treatment control 6 months later. Throughout the length of the program, a total of 318,479 pregnant women were screened and 23.31% were detected positive. 42,538 children born from positive mothers were analyzed at birth by micromethod, of which 1.43% read positive. 10,120 children returned for their second micromethod control of which 2.29% read positive, 7,650 children returned for the serological control, of which 3.32% turned out positive. From the 1,093 positive children, 70% completed the 30 day-treatment and 122 returned for post treatment control with 96% showing a negative result. It has been seen that maternal-fetal transmission rates vary between 2% and 4%, with an average of 2.6% (about half of previously reported studies that reached 5%). In this work, we show that it is possible to implement, with limited resources, a National Congenital Chagas Program and to integrate it into the Bolivian health system. Keys of success are population awareness, health personnel motivation, and political commitment at all levels.

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          Congenital Chagas disease is the infection resulting of the transmission of T.cruzi parasites from an infected pregnant woman to her fetus during the pregnancy or at the time of delivery. This represents a relevant public health issue in endemic and non-endemic countries. The infected newborn detected at birth or before one year old, if treated, can be completely cured. In this work, we report results obtained from 2004 to 2009 during the implementation of a National Program based on PAHO recommendations; the implementation strategy has been adapted into the Bolivian context and integrated into the National Mother and Child Health program. Our conclusions show that it is necessary to test all newborns from positive mothers three times before one year of age. The infant, if positive and treated with a 30 day Benznidazole course, has excellent chances of cure.

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          Most cited references33

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          Epidemiology of Chagas disease in non endemic countries: the role of international migration

          Human infection with the protozoa Trypanosoma cruzi extends through North, Central, and South America, affecting 21 countries. Most human infections in the Western Hemisphere occur through contact with infected bloodsucking insects of the triatomine species. As T. cruzi can be detected in the blood of untreated infected individuals, decades after infection took place; the infection can be also transmitted through blood transfusion and organ transplant, which is considered the second most common mode of transmission for T. cruzi. The third mode of transmission is congenital infection. Economic hardship, political problems, or both, have spurred migration from Chagas endemic countries to developed countries. The main destination of this immigration is Australia, Canada, Spain, and the United States. In fact, human infection through blood or organ transplantation, as well as confirmed or potential cases of congenital infections has been described in Spain and in the United States. Estimates reported here indicates that in Australia in 2005-2006, 1067 of the 65,255 Latin American immigrants (16 per 1000) may be infected with T. cruzi, and in Canada, in 2001, 1218 of the 131,135 immigrants (9 per 1000) whose country of origin was identified may have been also infected. In Spain, a magnet for Latin American immigrants since the 2000, 5125 of 241,866 legal immigrants in 2003 (25 per 1000), could be infected. In the United States, 56,028 to 357,205 of the 7,20 million, legal immigrants (8 to 50 per 1000), depending on the scenario, from the period 1981-2005 may be infected with T. cruzi. On the other hand, 33,193 to 336,097 of the estimated 5,6 million undocumented immigrants in 2000 (6 to 59 per 1000) could be infected. Non endemic countries receiving immigrants from the endemic ones should develop policies to protect organ recipients from T. cruzi infection, prevent tainting the blood supply with T. cruzi, and implement secondary prevention of congenital Chagas disease.
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            Side effects of benznidazole as treatment in chronic Chagas disease: fears and realities.

            Chagas disease is caused by a parasite, Trypanosoma cruzi, transmitted primarily by a triatomine insect and affects approximately 8 million people in Latin American countries. The principal aim of the management of the disease is to avoid the development of cardiomyopathy and transmission by blood transfusion, congenital and organ transplants. Currently, benznidazole is the only etiological treatment commercially available for the disease until new and better drugs can be developed and tested. Benznidazole has been used even though it does not have all the conditions of an ideal drug. The efficacy and tolerance of benznidazole is inversely related to the age of the patient, while its side effects are more frequent in elderly patients. The side effects are systematically evaluated only in controlled studies designed for that purpose. However, the true clinical impact of the side effects could be different, considering that the treatment is for a short duration (between 30 and 60 days) and only carried out once. In this article, we discuss the benefits and risks of the treatment with benznidazole from a clinical point of view to be considered for the management of the treatment of chronic adult Chagas disease patients in the current medical practice.
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              Benznidazole-related adverse drug reactions and their relationship to serum drug concentrations in patients with chronic chagas disease.

              For treating Chagas disease (CD), a current worldwide health problem, only benznidazole and nifurtimox have been approved to be used. In both cases, unwanted drug-related adverse events (ADRs) are frequent when these drugs are used in adults in the chronic stage. The main objective of this study was to establish benznidazole ADRs and their relationship to serum concentrations in patients with chronic Trypanosoma cruzi infection in order to perform more accurate dosages to minimize ADRs. A total of 54 patients were recruited over 12 months. Of these 54 patients, 53 (98%) experienced at least one ADR during follow-up, and the overall average ADR incidence was 2.4 episodes/patient/month. Benznidazole treatment was discontinued in 11 patients, 7 among them due to severe adverse effects. The mean duration of treatment before withdrawal was 11 days. Benznidazole serum concentrations were recorded on days 15, 30, 45, and 60 of follow-up and evaluated according to clinical and epidemiological variables and ADR severity. No relationship was found between the benznidazole serum concentration and the ADRs. The mean (standard deviation) trough serum benznidazole concentrations (all below 20 mcg/ml) on days 15, 30, 45, and 60 were 6.4 (1.9), 6.1 (1.8), 6.2 (2.2), and 5.7 (1.7) μg/ml, respectively. Benznidazole serum concentrations do not appear to be related to the appearance of serious ADRs. Further, well-controlled studies are necessary to establish the optimal regimen for benznidazole in adults with chronic CD.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                plos
                plosntds
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, USA )
                1935-2727
                1935-2735
                July 2013
                11 July 2013
                : 7
                : 7
                : e2304
                Affiliations
                [1 ]APEFE, Programa Nacional de Control de Chagas, Ministry of Health, La Paz, Bolivia
                [2 ]Facultad de Medicina, Universidad Mayor de San Simón (U.M.S.S.), Cochabamba, Bolivia
                National Institutes of Health, United States of America
                Author notes

                The authors have declared that no competing interests exist.

                Analyzed the data: CAV CB FT. Wrote the paper: CAV CB. Design of the National Chagas congenital program: FT CB CAV.

                Article
                PNTD-D-13-00055
                10.1371/journal.pntd.0002304
                3708826
                23875039
                5ed068a3-0bb6-4bc4-bc65-f4db9f615bf1
                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 9 January 2013
                : 24 May 2013
                Page count
                Pages: 14
                Funding
                This work was supported by the Bolivian' Ministry of Health, National Chagas Program and Belgium cooperation through the “Communauté Française de Belgique” (WBI) and APEFE. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Infectious Diseases
                Pediatrics
                Public Health

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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