Elsa L. Segura

Sustainable vector control and management of Chagas disease in the Gran Chaco, Argentina

Chagas disease remains a serious obstacle to health and economic development in Latin America, especially for the rural poor. We report the long-term effects of interventions in rural villages in northern Argentina during 1984–2006. Two community-wide campaigns of residual insecticide spraying immediately and strongly reduced domestic infestation and infection with Trypanosoma cruzi in Triatoma infestans bugs and dogs and more gradually reduced the seroprevalence of children <15 years of age. Because no effective surveillance and control actions followed the first campaign in 1985, transmission resurged in 2–3 years. Renewed interventions in 1992 followed by sustained, supervised, community-based vector control largely suppressed the reestablishment of domestic bug colonies and finally led to the interruption of local human T. cruzi transmission. Human incidence of infection was nearly an order of magnitude higher in peripheral rural areas under pulsed, unsupervised, community-based interventions, where human transmission became apparent in 2000. The sustained, supervised, community-based strategy nearly interrupted domestic transmission to dogs but did not eliminate T. infestans despite the absence of pyrethroid-insecticide resistance. T. infestans persisted in part because of the lack of major changes in housing construction and quality. Sustained community participation grew out of establishing a trusted relationship with the affected communities and the local schools. The process included health promotion and community mobilization, motivation, and supervision in close cooperation with locally nominated leaders.

Congenital transmission of Trypanosoma cruzi: an operational outline for detecting and treating infected infants in north-western Argentina.

Summary We designed a set of procedures for first‐line local health services to detect and treat the congenital transmission of Trypanosoma cruzi at a province‐wide scale, and field‐tested the programme in the province of Tucumán, northwestern Argentina, from 1992 to 1994. The programme consists of routine screening of pregnant women for seroreactivity to T. cruzi, serological and parasitological follow‐up of the newborn at least twice during the first year of age, treatment of the infected infants, and evaluation of the outcome. 927 (5.5%) of 16 842 pregnant women were seroreactive to T. cruzi by indirect haemagglutination assay and ELISA. Twenty‐one (6.7%) of 315 newborns to seroreactive mothers were diagnosed as infected with T. cruzi parasites microhaematocrit concentration before 30 days of age. Five newborns who initially tested negative had a T. cruzi infection detected by microhaematocrit and/or serological techniques at 3 or 6 months of age. Thus, congenital infection was diagnosed in 26 (7.1%) infants born to seroreactive women and residing in houses free of triatomine bugs. Four of 6 infants born to seroreactive mothers died during the first year of age and had some evidence of T. cruzi infection; one of the deaths was attributed to T. cruzi based on clinical evidence. After specific treatment with nifurtimox or benznidazole, 30 of 32 infants remained parasitologically and serologically negative. This study shows the feasibility of controlling the incidence of congenitally acquired T. cruzi infections at a province‐wide scale by means of a specific screening programme at first‐line health services level.

Congenital Transmission of Trypanosoma cruzi Infection in Argentina

Trypanosoma cruzi, the causative agent of Chagas disease, infects 10–18 million people and may be transmitted to the newborn. Using various data sources, we estimated that nearly 850 congenital cases occurred in Argentina in 1993, or 6.3 expected cases per each reported case in 1994 and in 1994–2001. The congenital transmission of T. cruzi constitutes a sizeable public health problem in the region.

National policy-makers speak out: are researchers giving them what they need?

The objective of this empirical study was to understand the perspectives and attitudes of policy-makers towards the use and impact of research in the health sector in low- and middle-income countries. The study used data from 83 semi-structured, in-depth interviews conducted with purposively selected policy-makers at the national level in Argentina, Egypt, Iran, Malawi, Oman and Singapore. The interviews were structured around an interview guide developed based on existing literature and in consultation with all six country investigators. Transcripts were processed using a thematic-analysis approach. Policy-makers interviewed for this study were unequivocal in their support for health research and the high value they attribute to it. However, they stated that there were structural and informal barriers to research contributing to policy processes, to the contribution research makes to knowledge generally, and to the use of research in health decision-making specifically. Major findings regarding barriers to evidence-based policy-making included poor communication and dissemination, lack of technical capacity in policy processes, as well as the influence of the political context. Policy-makers had a variable understanding of economic analysis, equity and burden of disease measures, and were vague in terms of their use in national decisions. Policy-maker recommendations regarding strategies for facilitating the uptake of research into policy included improving the technical capacity of policy-makers, better packaging of research results, use of social networks, and establishment of fora and clearinghouse functions to help assist in evidence-based policy-making.

Effectiveness of residual spraying of peridomestic ecotopes with deltamethrin and permethrin on Triatoma infestans in rural western Argentina: a district-wide randomized trial

OBJECTIVE To compare the effectiveness of a single residual spraying of pyrethroids on the occurrence and abundance of Triatoma infestans in peridomestic ecotopes in rural La Rioja. METHODS A total of 667 (32.8%) peridomestic sites positive for T. infestans in May 1999 were randomly assigned to treatment within each village, sprayed in December 1999, and reinspected in December 2000. Treatments included 2.5% suspension concentrate (SC) deltamethrin in water at 25 mg active ingredient (a.i.)/m(2) applied with: (a) manual compression sprayers (standard treatment) or (b) power sprayers; (c) 1.5% emulsifiable concentrate (EC) deltamethrin at 25 mg a.i./m(2); and (d) 10% EC cis-permethrin at 170 mg a.i./m(2). EC pyrethroids were diluted in soybean oil and applied with power sprayers. All habitations were sprayed with the standard treatment. FINDINGS The prevalence of T. infestans 1-year post-spraying was significantly lower in sites treated with SC deltamethrin applied with manual (24%) or power sprayers (31%) than in sites treated with EC deltamethrin (40%) or EC permethrin (53%). The relative odds of infestation and catch of T. infestans 1-year post-spraying significantly increased with the use of EC pyrethroids, the abundance of bugs per site before spraying, total surface, and host numbers. All insecticides had poor residual effects on wooden posts. CONCLUSION Most of the infestations probably originated from triatomines that survived exposure to insecticides at each site. Despite the standard treatment proving to be the most effective, the current tactics and procedures fail to eliminate peridomestic populations of T. infestans in semiarid rural areas and need to be revised.

Therapy, diagnosis and prognosis of chronic Chagas disease: insight gained in Argentina

The purpose of this review is to describe research findings regarding chronic Chagas disease in Argentina that have changed the standards of care for patients with Trypanosoma cruzi infection. Indirect techniques (serological tests) are still the main tools for the primary diagnosis of infection in the chronic phase, but polymerase chain reaction has been shown to be promising. The prognosis of patients with heart failure or advanced stages of chagasic cardiomyopathy is poor, but a timely diagnosis during the initial stages of the disease would allow for prescription of appropriate therapies to offer a better quality of life. Treatment of T. cruzi infection is beneficial as secondary prevention to successfully cure the infection or to delay, reduce or prevent the progression to disease and as primary disease prevention by breaking the chain of transmission. Current recommendations have placed the bulk of the diagnostic and treatment responsibility on the Primary Health Care System. Overall, the current research priorities with respect to Chagas disease should be targeted towards (i) the production of new drugs that would provide a shorter treatment course with fewer side effects; (ii) the development of new tools to confirm cure after a full course of treatment during the chronic phase and (iii) biomarkers to identify patients with a high risk of developing diseases.

Microsatellite analysis of genetic structure in natural Triatoma infestans (Hemiptera: Reduviidae) populations from Argentina: its implication in assessing the effectiveness of Chagas’ disease vector control programmes

The genetic structure in populations of the Chagas’ disease vector Triatoma infestans was examined. Comparisons of the levels of genetic variability in populations of this species from areas with different periods since last insecticide treatment and from areas that never received treatment were also carried out. A total of 598 insects from 19 populations were typed for 10 polymorphic microsatellite loci. The average observed and expected heterozygosities ranged from 0.186 to 0.625 and from 0.173 to 0.787, respectively. Genetic drift and limited gene flow appear to have generated a substantial degree of genetic differentiation among the populations of T. infestans. Departures from Hardy–Weinberg expectations due to an excess of homozygotes suggested the presence of null alleles and population subdivision. Microgeographical analysis supports the existence of subdivision in T. infestans populations. Levels of genetic diversity in the majority of the populations of T. infestans from insecticide‐treated localities were similar or higher than those detected in populations from areas without treatment. Since the populations of T. infestans are subdivided, a population bottleneck would result in independent genetic drift effects that could randomly preserve different combinations of alleles in each subpopulation. These events followed by a rapid population growth could have preserved high levels of genetic diversity. This study supports the hypothesis of vector population recovery from survivors of the insecticide‐treated areas and therefore highlights the value of population genetic analyses in assessing the effectiveness of Chagas’ disease vector control programmes.

Etiological treatment of young women infected with Trypanosoma cruzi, and prevention of congenital transmission.

The objective was to detect Trypanosoma cruzi infection in 32 children in Salta, Argentina, born to 16 chronically infected young women who were treated with benznidazole. Tests were performed to assess the efficacy of treatment after 14 years. At the end of the follow up, 87.5% of the women were non-reactive to EIA tests, 62.5% to IHA and 43.8% to IFA. 62.5% of the women were non-reactive according to two or three serological tests. No infected children were detected among the newborns of mothers treated before their pregnancy.

Treatment of Trypanosoma cruzi infection in the undetermined phase. Experience and current guidelines of treatment in Argentina

The goals of specific treatment against Trypa-nosoma cruzi infection, at an individual level, areto eliminate the parasite, to diminish the probabil-ity of developing illness (Chagas disease), and tohinder the chain of T. cruzi transmission as actionsfor the control of vectorial and non vectorial trans-mission (Sosa Estani 1993). Around 1930, inves-tigations began in Argentina to obtain an effectivedrug against T. cruzi. Of all the substances evalu-ated, only nifurtimox (1972) and benznidazol(1974) have been accepted by the Ministry ofHealth as anti-T. cruzi drugs. Both drugs began tobe assessed on the acute phase, and later, on thechronic phase of the disease.

Purification and some properties of the NADP-linked glutamate dehydrogenase from Trypanosoma cruzi.

Abstract 1. 1. The NADP-linked glutamate dehydrogenase (EC 1.4.1.4.) from Trypanosoma cruzi has been purified to electrophoretic homogeneity. 2. 2. The subunit molecular weight was about 64,000, thus suggesting that the native enzyme (molecular weight 280,000) may be a tetramer. 3. 3. The glutamate deamination reaction was activated by KC1, NaCl, Tris-Cl and Tris-phosphate; KCl and NaCl also activated to some extent the reverse reaction. The effect of KCl on the kinetic constants for both directions of the reaction is reported.