The political commitment
Maintenance of the political commitment is critical for the control of Chagas disease. The case of the Central American countries allows the delineation of lessons to sustain such political commitment. Along the road of the IPCA activities, three strategies have been implemented: (1) establishment of the Chagas Day at the regional and national level; (2) constitution of a national roundtable for Chagas; and (3) strengthening of information and monitoring systems.
Political and public interest in Chagas disease need to be activated on a regular basis, because the less visible the vectors become as a result of successful interventions the more likely the health agencies relax or even languish in surveillance activities. Political commitment is a key drive to maintain the interest, but this is only sustainable and effective when built into governmental systems with key policies, active stakeholders, and good evidence.
An effective policy, which strategically attracts social attention, is the regulation to celebrate a national day to recognize the importance of Chagas disease once a year. In 2008, the IPCA countries proposed and agreed to establish the Central American Chagas Day, the 9th of July, the birthdate of the discoverer of the disease, Carlos Chagas. This proposal was also agreed as a resolution in a meeting of the Council of Ministers of Health of Central America (COMISCA) later in the same year. Since then, Guatemala, El Salvador, Honduras, and Nicaragua began celebrating the annual Chagas day at the national level to raise awareness through media and at the local level to promote vector surveillance and prevention of Chagas disease infection. In El Salvador in 2010, the Ministry of Health established an official agreement with the Ministry of Education to celebrate the National Chagas Day. As a result of these initiatives, the number of participating schools incremented from 668 in 2008 to 1647 in 2012. These campaigns also augmented the number of villages notified with vectors from 306 in 2008 to 1471 in 2011.
Involvement of different stakeholders can contribute to maintain the undervalued and underbudgeted disease control interventions, especially by supporting the National Programs. The National Chagas Program in Guatemala, El Salvador and Honduras constituted a national roundtable, involving officials of other programs (e.g., Epidemiology, Blood Bank, National Reference Laboratory, and Health Promotion) of the Ministry of Health, scholars from local universities, staff of international cooperation agencies and NGOs involved in activities related to Chagas disease. Members of the roundtable supported production and monitoring of national strategic plans of the National Chagas Program, and also provided information including progress, plans and challenges of their own activities and feedback to activities of others during regular meetings held every few months. In sustaining the momentum of disease control efforts, e.g., the roundtable members supported orientation of a new coordinator of the National Chagas Program after personnel changes and provided ideas for alternative cost-effective approaches such as house improvement methods62 and bug search campaigns,52 which could also be used to transform and vitalize disease control approaches. Such external support can empower the National Program in terms of management, leadership and political economy.
Evidence is crucial because lack of data can cause not only misunderstanding but the end of budgets and activities. Good evidence derives from systematic data collection and analysis. The national information and monitoring systems play vital roles in understanding the vector distribution patterns. In Guatemala, El Salvador, Honduras, and Nicaragua, where native vector, T. dimidiata, is found in almost all departments, regular reporting projected a rough national map signaling the degree of infection risks and apparent coverage of surveillance activities. To analyze the situation and progress, the National Chagas Program held biannual evaluation meetings, where the departmental health offices presented data including vector notification, response coverage and absence of data every 6 months in the presence of members of other departments and the roundtable.19 Although budget constraints may change styles of evaluation meetings, the National Programs and departmental health offices would benefit from such opportunities to present and discuss ongoing activities, and to continue improving interventions. At the regional level, consolidated data of each country became more understandable and comparable at the annual IPCA meetings through a standardized presentation format. Spatial projection of surveillance data at the regional level, if carried out annually, may also encourage political commitment.
The experience accumulated over the last decades—illustrated by the examples given earlier—seems to suggest that control of Chagas disease vectors is feasible, and results in strikingly reduced rates of infection incidence and prevalence. The end point for elimination of Chagas disease as a public health problem can be then described when all existing domestic infestations of Triatominae have been eliminated, and local health authorities are structured and equipped to diagnose and treat occasional new infections, and to eliminate—perhaps through contracts with local pest control operators—any incipient domestic vector infestation. Epidemiologically, the situation might then resemble that of Lyme disease in Europe—the vector ticks (Ixodes ricinus) are present in gardens (which may be said to comprise both peridomestic and sylvatic habitats), and there is a risk of Borrelia transmission; however, the ticks do not enter houses (and if they did, would be rapidly dealt with), and if a new infection occurs, it is relatively simple to diagnose and can be treated.
Although Chagas disease will not be eliminated in the sense of ceasing to exist as a human disease, we believe that it could be eliminated as a serious public health problem—when all existing domestic vector populations have been eliminated, and all aspects of current control programs are adequately incorporated into routine local health programs. The products, equipment, and experience are available for this, and strategies have been developed both for the initial campaigns and their consolidation through active vigilance, and for subsequent integration of the surveillance activities into routine public health activities.6 But all comes to nought without political commitment and leadership, which in turn liberates the required resources. In a few countries, there is still no coherent national program; in others the national program is in disarray, with spraymen and vehicles idle as they lack the minimum resources to mobilize. Perhaps the initial successes of the multinational initiatives were too widely hailed, but relieving some 60 million people from the molestation of Triatominae and risk of disease (as some have claimed) still leaves some 40 million with little protection—which is both inappropriate and unethical, given the demonstrated feasibility of the large-scale control interventions. Paradoxically perhaps, a renewed urgency to complete the control interventions may come from the previously nonendemic countries now receiving migrants from Latin America—some of whom require treatment for their chronic Chagas infection, and some of whom pose a new risk for onward transmission by blood transfusion or organ transplant (cf. Ref. ). It is to be hoped that the domestic Latin American vectors can be eliminated before they too begin to arrive in Europe and elsewhere.63