Trends in Parasitology
ReviewThe future of Chagas disease control
Section snippets
Is Chagas disease conquered?
On 9 June 2006, at their 15th annual meeting, the Intergovernment Commission of the Southern Cone Initiative against Chagas disease formally declared Brazil to be free of Chagas disease transmission due to Triatoma infestans. This represents a remarkable achievement considering that this species had been the primary domestic vector infesting rural houses in >700 municipalities of the 12 most populated states of Brazil, in addition to vast areas of neighbouring countries of the Southern Cone (
The balance of success
The Southern Cone Initiative against Chagas disease followed a resolution by the Ministers of Health of Argentina, Bolivia, Brazil, Chile, Paraguay and Uruguay, meeting in Brasilia (Brazil) in 1991. It focused on the interruption of T. cruzi transmission by eliminating domestic vectors (particularly T. infestans), together with extended screening of blood donors to reduce the risk of transfusional transmission, and the promotion of maternal screening for infection followed by specific treatment
Vector control strategy
When the Southern Cone programme was launched in 1991, it was believed that the main vector in the countries affected, T. infestans, could be eliminated over most of its range. This idea was based on historical reconstruction [19] progressively supported by genetic studies 20, 21, 22 indicating that, in most Southern Cone countries, T. infestans had been accidentally imported in relatively recent times, particularly during the past 100 years. The control interventions could be seen as
Case detection and treatment
The change from an elimination strategy to one of continual selective intervention carries implicit acceptance that occasional accidental transmission might occur – chiefly due to adventitious silvatic vectors entering houses. In the past, such an idea was seen to be problematic because of the belief that treatment of human cases would be satisfactory only if administered within the early acute phase of infection, although accumulating experience begins to indicate otherwise.
The two drugs
Outline for the future
The future scenario for Chagas disease control must continue to be based on the idea of eliminating all existing domestic populations of Triatominae but then accepting that reinfestation might occur or that adventitious silvatic Triatominae might enter a house and cause disease transmission without establishing a new domestic colony – as in Amazonia. In such a scenario, large-scale vector control campaigns of the style of the multinational initiatives would become progressively less relevant as
Concluding remarks: towards a sustainable end-point
The most consistently successful programme against Chagas disease has been that of the Brazilian state of Sao Paulo – a programme initiated with a state-wide ‘attack phase’ in 1964–1967 and continued through a series of strategic adjustments in accordance with the changing epidemiological circumstances (D. Wanderley, PhD thesis, Universidade de Sao Paulo, Brazil, 1994). Although T. infestans was probably eliminated from Sao Paulo by 1990, a system of community-based surveillance is maintained
Acknowledgements
This review has benefited from international collaboration through the Latin American Network for Research on the Biology and Control of Triatominae (ECLAT). We also thank Sergio Sosa-Estani for additional information about current trials of specific treatment for Chagas disease in chronically infected adults, and David E. Gorla for access to unpublished geographic information systems (GIS) studies of Triatoma infestans distribution.
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