A strategy for scaling up access to comprehensive care in adults with Chagas disease in endemic countries: The Bolivian Chagas Platform

Abstract

BackgroundBolivia has the highest prevalence of Chagas disease (CD) in the world (6.1%), with more than 607,186 people with Trypanosoma cruzi infection, most of them adults. In Bolivia CD has been declared a national priority. In 2009, the Chagas National Program (ChNP) had neither a protocol nor a clear directive for diagnosis and treatment of adults. Although programs had been implemented for congenital transmission and for acute cases, adults remained uncovered. Moreover, health professionals were not aware of treatment recommendations aimed at this population, and research on CD was limited; it was difficult to increase awareness of the disease, understand the challenges it presented, and adapt strategies to cope with it. Simultaneously, migratory flows that led Bolivian patients with CD to Spain and other European countries forced medical staff to look for solutions to an emerging problem.InterventionIn this context, thanks to a Spanish international cooperation collaboration, the Bolivian platform for the comprehensive care of adults with CD was created in 2009. Based on the establishment of a vertical care system under the umbrella of ChNP general guidelines, six centres specialized in CD management were established in different epidemiological contexts. A common database, standardized clinical forms, a and a protocolized attention to adults patients, together with training activities for health professionals were essential for the model success. With the collaboration and knowledge transfer activities between endemic and non-endemic countries, the platform aims to provide care, train health professionals, and create the basis for a future expansion to the National Health System of a proven model of care for adults with CD.ResultsFrom 2010 to 2015, a total of 26,227 patients were attended by the Platform, 69% (18,316) were diagnosed with T. cruzi, 8,567 initiated anti-parasitic treatment, more than 1,616 health professionals were trained, and more than ten research projects developed. The project helped to increase the number of adults with CD diagnosed and treated, produce evidence-based clinical practice guidelines, and bring about changes in policy that will increase access to comprehensive care among adults with CD. The ChNP is now studying the Platform’s health care model to adapt and implement it nationwide.ConclusionsThis strategy provides a solution to unmet demands in the care of patients with CD, improving access to diagnosis and treatment. Further scaling up of diagnosis and treatment will be based on the expansion of the model of care to the NHS structures. Its sustainability will be ensured as it will build on existing local resources in Bolivia. Still human trained resources are scarce and the high staff turnover in Bolivia is a limitation of the model. Nevertheless, in a preliminary two-years-experience of scaling up this model, this limitations have been locally solved together with the health local authorities.

Healthcare professionals and students’ awareness of Chagas disease: design and validation of ChaLKS (Chagas Level of Knowledge Scale)

“…At the same time, international aid work in Latin America has changed drastically in the past decade, also affecting social organizations. This change is also relevant from the Spanish perspective [14,15]. However, similarly to the health sector, there are scarce data about aid workers' and volunteers' knowledge on CD prior to working with populations in or from endemic regions.…”

The continuous challenge of Chagas disease treatment: bridging evidence-based guidelines, access to healthcare, and human rights

“…The globalization of the disease is increasingly recognized and has thereby broadened the debate on the right to health, demanding an integrated response between countries [1][2][3] . Despite its relevance as a public health problem, great failures persist in national health systems in providing access to diagnosis and treatment for affected people [3][4][5][6] .…”

“…In addition to the etiological treatment, the comprehensive care of Chagas disease is very limited, especially, the chronic forms of the disease 5,8 . The chronic nature of the disease and the need to prevent disability and to rehabilitate the affected people create persisting challenges.…”

“…In Brazil, a new Consensus on Chagas disease was published in December 2016; bringing in a more structured and evidence-based guideline 1,4 . Other countries, such as Bolivia, Colombia, and Argentina are in the process of developing new adjusted national guidelines for Chagas disease 5,8 . In addition to the initial non-availability of evidence-based guidelines, there was also a lack of minimum standardization between and within the different countries, which created even greater obstacles for an integrated global response 9,10 .…”

“…Some national strategies have been developed in endemic countries as a solution to unmet demands in improving access to Chagas disease diagnosis and treatment 1,9 . In Bolivia, critical issues involve further scaling-up of diagnosis and treatment, and its sustainability in a scenario of limited local resources 5 . In Argentina, the development of an integrated strategy to decentralize diagnosis and treatment has been defi ned as a crucial issue in the national health systems.…”