Fifteen diseases are considered neglected in Brazil, according to the World Health Organization (WHO). Disseminating them to the general population and disseminating the municipal law that established the Neglected Diseases Awareness Week were some of the objectives of the III Seminar to Combat Chagas Disease and the I Seminar of the Neglected Diseases Awareness Week.
The two events, held simultaneously, took place last Friday (11), in the GGBS auditorium at Unicamp. Authorities on the subject discussed the state of the art of these pathologies and more specifically Chagas disease. Among the neglected diseases are leishmaniasis, Buruli ulcer, dengue fever, schistosomiasis, leprosy, etc..
The seminars took place in the context of World Day to Combat Chagas Disease, April 14, decided at the II Assembly of the International Federation of Associations of People Affected by Chagas Disease (FINDECHAGAS) in 2012, in Barcelona, Spain, and the relevance of date on which Brazilian researcher Carlos Chagas communicated the discovery of this disease to the scientific community, informed professor Eros de Almeida, one of the organizers of the events and coordinator of the Chagas Disease Study Group (GEDoCh) from Unicamp.
In addition to GEDoCh, the events were organized by the HC Social Service and the Association of Chagas Disease Patients of Campinas and Region (Accamp).
Eros revealed, for example, that tuberculosis a few years ago was considered a neglected disease. Today it is no longer. “In fact, it is not the disease that is neglected, but the population it affects, which does not receive the same attention, given that the pathology occurs in poorer contexts”, he clarified.
According to the doctor, practically all neglected infectious diseases are under control today. But he recognizes that there are obstacles to this control, especially in the case of tropical diseases, as political interest and investment are needed. For Chagas disease, this has already been done, after a long cost-benefit analysis. It was found that what is spent caring for patients could control the pathology several times over. A study indicated that what is spent on cardiac pacemaker implantation, megacolon and megaesophagus surgeries would certainly be enough to control it.
The year 1991 was a milestone in attention to the control of Chagas disease globally, starting with countries in the Southern Cone such as Brazil, Argentina, Uruguay, Chile, Paraguay and Bolivia. That was when the first meeting was held by the World Health Organization (WHO) and the Pan American Health Organization (PAHO). Governments have committed to controlling vector transmission through triatoma infestans and transfusion. The resources were applied and, 14 years after injecting these resources, Brazil, Chile and Uruguay achieved this control. Argentina and Paraguay only partially.
In the 1970s, it was estimated that the country had 100 new cases of the disease per year. Today, there are no more than a thousand. “Following the triatoma infestans, transmission was also controlled through blood transfusion. From 15% at that time, we are at 0,20%. By taking care of the main transmission, new cases stop appearing, leaving only chronic ones,” said Eros.
Transmission
For 43 years, cases of chronic Chagas disease have been treated on Mondays at the Chagas Disease Study Group Outpatient Clinic at HC. They do not occur much anymore at the expense of blood transfusion and vector transmission. Nowadays, the transmission that emerges is oral, due to contaminated drinks and food. “Açaí juice is the most incriminated, followed by sugarcane juice. The insect is not always noticeable in a large volume of food, which undergoes grinding. It is not that the food is contaminated by the microbe. His vector is there”, described Eros. Unlike processed juices, which do not allow transmission (if pasteurized), natural juices are the biggest villains.
There are many ways of transmitting Chagas disease. The main ones are vector, by the barber; by blood and from mother to child. The secondary ones are oral transmission, laboratory accidents and organ transplantation. There are also hypothetical transmissions (use of contaminated syringe, saliva and sexual transmission) because the trypanosoma, the microbe, does not have a fixed location in the organism. In case of donation, as the microbe circulates in the blood, the idea is to improve the quality of the blood with serological screening.
Despite this, there is still a lack of vigilance, because the disease has a risk of returning and becoming more harmful. Of a thousand new cases per year, a percentage is still vectorial, not due to triatoma infestans. This is because it only survives in homes, and with insecticide it is possible to control it.
After 2006, Brazil was certified by the WHO as a country in which vector transmission by triatoma infestans and Chagas disease transfusion were controlled. However, there are still outbreaks in Rio Grande do Sul, on the border. There's more: there are more than 120 species that transmit the disease and four more wild ones, which are able to stay at home. “As the barber is resident, he returns, and the disease persists. Therefore, surveillance will have to be a priority, given that chronic cases currently number 1,5 million in the country”, said the doctor.
Treatment
Eros highlighted that Chagas disease is neglected when it comes to investment. To give you an idea, there are 17 AIDS medications in the country. For Chagas disease, only one: benznidazole. It is unbelievable that, 110 years after the discovery of the disease, there are no new medications for the chronic phase”, he lamented. "WSince there is no longer an acute phase in the country, this medicine is not even useful; and, in the chronic phase, there is no certainty that it will lead to a cure, because the effectiveness of the microbe in adults and the elderly is closely linked to the acute phase."
When the disease becomes chronic, the person has an asymptomatic period: from ten to 40 years. Many times you don't even know you have the disease. But a good number go on to have heart problems and may have to deal with shortness of breath, palpitations, being unable to exert themselves, and swollen legs. It may even suffer sudden death.
The disease manifests itself in the intestine. When it reaches the esophagus, the person will have difficulty swallowing more solid foods and begin to choke. The condition progresses until he cannot even swallow water. The person becomes malnourished and needs surgery. “When it goes to the large intestine, it is difficult to defecate for months. Heart transplant is a possibility. So from this point of view, this is not a neglected disease, as the SUS carries out transplants and provides medicines”, he stressed.
A component of the acute phase that has a secondary form of transmission involves immunosuppressed individuals undergoing transplantation in endemic regions. It is essential to know if he has Chagas disease because, when immunosuppressed, the parasite (controlled by the body) becomes active again, due to the person's low immunity.
This became more evident after the discovery of AIDS. This is because individuals with chronic Chagas disease in endemic areas acquired AIDS and Chagas disease worsened in greater numbers than in transplant recipients. The person would then develop a fever, meningoencephalitis and serious illness. The parasite appeared in the peripheral blood, leading to death. “But the good news is that, when a flare-up is diagnosed and benznidazole is used, it prevents the person from dying.”
initiatives
Present at the event at Unicamp, Francisco Edilson Ferreira de Lima Júnior, from General Coordination of Communicable Diseases of the Ministry of Health (MS), explained that neglected diseases are included in different coordinations in the MS. In the coordination of communicable diseases, the body where he works, he works with leishmaniasis (visceral and integumentary), Chagas disease and rabies.
He explained that, in relation to Chagas disease, what is a priority at the moment is the publication of a clinical protocol of therapeutic guidelines, which is currently being finalized. It is based on scientific evidence and involves the participation of the scientific community and the population. One challenge, he highlighted, is to establish surveillance of chronic cases, to have an estimate and establish actions for this unknown population in Brazil. The first step will be to establish lines of care to avoid complications from chronic Chagas disease and early deaths from this disease.
In relation to visceral leishmaniasis, work continues on several fronts: implementing strategies to control the disease and funding research. “I highlight the incorporation of the evaluation of the effectiveness of collars impregnated with insecticide for dogs”, reported Francisco Edilson.
There are still several areas of transmission of Chagas disease in Brazil, especially in the North and Northeast. There are currently no advanced control strategies for the disease. The collar, in preliminary studies, has shown itself to be an ally with great potential.
Yet another front involves a protocol of therapeutic guidelines, whose discussions at this time are aimed at verifying whether liposomal amphotericin B will be indicated as the drug of first choice for patients.
In relation to visceral leishmaniasis, the decentralization of the rapid test, already available online, is being studied. “We would like it to be offered in primary care in endemic areas, in municipalities with transmission”, he plans.
As for cutaneous leishmaniasis, he pointed out, the broader debate relates to treatment. “We have already incorporated an innovative therapy: the intralesional application of antimoniate meglumine, whose commercial name is glucantime. This medication was prescribed systemic intravenously or intramuscularly, but now there are plans for injections at the site of the injury, which reduce treatment time and toxicity. Recently, miltefosine, an oral drug, was added. It's something innovative, as it is less toxic and facilitates adherence to treatment."
When talking about another neglected disease, rabies, the coordinator highlighted that it is radiotransmitted by bats. “And a relatively controlled situation is dog rabies, with the exception of the border with Bolivia. The discussion now is the establishment of a pre-exposure vaccine so that there are no outbreaks, as in the regions of Pará and Amazonas, especially in children.”
In terms of surveillance, the MS has a technical nucleus for Chagas disease. In the State of São Paulo, this surveillance is carried out by the Superintendency of Endemic Disease Control (Sucen). And the main watchdog is the municipality, now decentralized due to better control.
Currently, 3.500 patients are followed by GEDoCh for chronic illness. This group was created at the Faculty of Medical Sciences by doctor Silvio Carvalhal, in the 1970s. He thought that pathology had to have differentiated care because the patients were simple and it was very serious in the active population. Years later, Argentine professor Daniel Manigot came to work at Unicamp with Silvio Carvalhal's Chagas disease. He took over the group and service took off. Other centers emerged in Recife and Rio de Janeiro.
Community
Social worker Ana Maria de Arruda Camargo informed that the HC is working with the association of people with Chagas disease. "It is essential that this association works from the perspective of associativism, but also as an association that demands rights and articulates with other associations. Accamp is affiliated with FINDECHAGAS. It held the shared presidency with the Association of Chagas Patients in Greater São Paulo (ACHAGRASP ) for two administrations (2012-2014 and 2014-2016) and was registered in Campinas.
In 2013, the association mobilized along these lines and made a demand to the Campinas City Council. On 22/3/2017, the municipal law was approved creating the Municipal Awareness Week about Neglected Diseases. “Initially the project was only for Chagas disease, but, as Campinas is a reference in health and education, it would be important to look at other diseases as well”, stated Ana Maria. “This involved a four-year struggle and today it is already a reality. The week is reinforcing the issue of guaranteed rights and gives visibility to these diseases, which are still a challenge. Brazil signed a commitment with the UN to control and eliminate neglected tropical diseases by 2030.”
While the Campinas law was not approved, there was a mobilization by Accamp to request the approval of a federal law. This project had public discussions, scientific events, with the participation of different segments of society, organizations, institutions and is currently being processed in the last committee, in the Federal Chamber. “It will have been another advance, as ancient diseases, such as leprosy and other neglected tropical diseases, face a series of challenges, in terms of elimination, treatment, diagnosis, follow-up, monitoring and attention to system users”, said Ana Maria.
Read on Journal of Unicamp a text about Leishmaniasis and Chagas disease.
