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      Barriers to Treatment Access for Chagas Disease in Mexico

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          According to World Health Organization (WHO) prevalence estimates, 1.1 million people in Mexico are infected with Trypanosoma cruzi, the etiologic agent of Chagas disease (CD). However, limited information is available about access to antitrypanosomal treatment. This study assesses the extent of access in Mexico, analyzes the barriers to access, and suggests strategies to overcome them.

          Methods and Findings

          Semi-structured in-depth interviews were conducted with 18 key informants and policymakers at the national level in Mexico. Data on CD cases, relevant policy documents and interview data were analyzed using the Flagship Framework for Pharmaceutical Policy Reform policy interventions: regulation, financing, payment, organization, and persuasion. Data showed that 3,013 cases were registered nationally from 2007–2011, representing 0.41% of total expected cases based on Mexico's national prevalence estimate. In four of five years, new registered cases were below national targets by 11–36%. Of 1,329 cases registered nationally in 2010–2011, 834 received treatment, 120 were pending treatment as of January 2012, and the treatment status of 375 was unknown. The analysis revealed that the national program mainly coordinated donation of nifurtimox and that important obstacles to access include the exclusion of antitrypanosomal medicines from the national formulary (regulation), historical exclusion of CD from the social insurance package (organization), absence of national clinical guidelines (organization), and limited provider awareness (persuasion).

          Conclusions

          Efforts to treat CD in Mexico indicate an increased commitment to addressing this disease. Access to treatment could be advanced by improving the importation process for antitrypanosomal medicines and adding them to the national formulary, increasing education for healthcare providers, and strengthening clinical guidelines. These recommendations have important implications for other countries in the region with similar problems in access to treatment for CD.

          Author Summary

          Chagas disease is a vector-borne disease caused by the parasite Trypanosoma cruzi. The disease is most frequently transmitted by triatomine insects but can also be passed through blood donation or from mother to child at birth. Experts estimate that 8 million people are infected with Chagas disease globally and that 1.1 million of these infections are found in Mexico. Most public health programs for Chagas disease focus on preventing new infections through vector control and screening the blood supply. However, in recent years there has been a greater focus on treating the disease with one of two available medications, benznidazole or nifurtimox. This study explores access to these two drugs in Mexico. The study shows that less than 0.5% of those who are infected with the disease received treatment in Mexico in years. The study also identified important factors that limit access in Mexico, including the exclusion of both drugs from the national health insurance program and problems importing these medications. Finally, the paper suggests ways that these problems can be overcome in Mexico, while providing helpful insight for other countries that struggle with similar problems in treating this disease.

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          Most cited references 25

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          Chagas disease.

          Chagas disease is a chronic, systemic, parasitic infection caused by the protozoan Trypanosoma cruzi, and was discovered in 1909. The disease affects about 8 million people in Latin America, of whom 30-40% either have or will develop cardiomyopathy, digestive megasyndromes, or both. In the past three decades, the control and management of Chagas disease has undergone several improvements. Large-scale vector control programmes and screening of blood donors have reduced disease incidence and prevalence. Although more effective trypanocidal drugs are needed, treatment with benznidazole (or nifurtimox) is reasonably safe and effective, and is now recommended for a widened range of patients. Improved models for risk stratification are available, and certain guided treatments could halt or reverse disease progression. By contrast, some challenges remain: Chagas disease is becoming an emerging health problem in non-endemic areas because of growing population movements; early detection and treatment of asymptomatic individuals are underused; and the potential benefits of novel therapies (eg, implantable cardioverter defibrillators) need assessment in prospective randomised trials. Copyright 2010 Elsevier Ltd. All rights reserved.
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            A framework for the study of access to medical care.

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              Global economic burden of Chagas disease: a computational simulation model.

              As Chagas disease continues to expand beyond tropical and subtropical zones, a growing need exists to better understand its resulting economic burden to help guide stakeholders such as policy makers, funders, and product developers. We developed a Markov simulation model to estimate the global and regional health and economic burden of Chagas disease from the societal perspective. Our Markov model structure had a 1 year cycle length and consisted of five states: acute disease, indeterminate disease, cardiomyopathy with or without congestive heart failure, megaviscera, and death. Major model parameter inputs, including the annual probabilities of transitioning from one state to another, and present case estimates for Chagas disease came from various sources, including WHO and other epidemiological and disease-surveillance-based reports. We calculated annual and lifetime health-care costs and disability-adjusted life-years (DALYs) for individuals, countries, and regions. We used a discount rate of 3% to adjust all costs and DALYs to present-day values. On average, an infected individual incurs US$474 in health-care costs and 0·51 DALYs annually. Over his or her lifetime, an infected individual accrues an average net present value of $3456 and 3·57 DALYs. Globally, the annual burden is $627·46 million in health-care costs and 806,170 DALYs. The global net present value of currently infected individuals is $24·73 billion in health-care costs and 29,385,250 DALYs. Conversion of this burden into costs results in annual per-person costs of $4660 and lifetime per-person costs of $27,684. Global costs are $7·19 billion per year and $188·80 billion per lifetime. More than 10% of these costs emanate from the USA and Canada, where Chagas disease has not been traditionally endemic. A substantial proportion of the burden emerges from lost productivity from cardiovascular disease-induced early mortality. The economic burden of Chagas disease is similar to or exceeds those of other prominent diseases globally (eg, rotavirus $2·0 billion, cervical cancer $4·7 billion) even in the USA (Lyme disease $2·5 billion), where Chagas disease has not been traditionally endemic, suggesting an economic argument for more attention and efforts towards control of Chagas disease. Bill & Melinda Gates Foundation, the National Institute of General Medical Sciences Models of Infectious Disease Agent Study. Copyright © 2013 Elsevier Ltd. All rights reserved.
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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
                October 2013
                17 October 2013
                : 7
                : 10
                Affiliations
                [1 ]Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
                [2 ]Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
                [3 ]Regional Center for Public Health Research, National Institute for Public Health, Tapachula, Mexico
                [4 ]State of Morelos Secretary of Health, Program on Chagas Disease, Cuernavaca, Mexico
                Emory University, United States of America
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: JMM CSS JMR MRR. Performed the experiments: JMM CSS JMR. Analyzed the data: JMM CSS JMR MRR. Contributed reagents/materials/analysis tools: JMM CSS JMR MOS TB MRR. Wrote the paper: JMM CSS JMR MOS TB MRR.

                Article
                PNTD-D-13-00367
                10.1371/journal.pntd.0002488
                3798390

                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.

                Page count
                Pages: 10
                Funding
                We would like to thank the David Rockefeller Center for Latin American Studies and the Harvard Global Health Institute for generously supporting this research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article

                Infectious disease & Microbiology

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