Chagas disease
Chagas in the Americas

Bolivia: Breaking the Silence

Dr Tom Ellman, Head of mission, Médecins Sans Frontières (MSF) in Bolivia

Médecins Sans Frontières (MSF) has been treating people with Chagas disease in Bolivia since 2002. Despite considerable challenges and difficulties in the field, the four projects MSF has been involved in since then have demonstrated the importance and the feasibility of providing diagnosis and treatment even in the remotest areas. These experiences have been instrumental in helping to change attitudes toward the disease and promoting access to treatment. Of the many countries where Chagas disease is endemic, Bolivia is hit the hardest. Over 1 million of the country’s 9 million inhabitants are infected with the disease, and 4 million are at risk. The disease is most frequent among those who live in poverty or in rural areas, but, through migration, urban populations are heavily affected too.

Treating is compelling
More than 10% of Bolivians are believed to carry the parasite – the vast majority unaware that they are infected. If they are not treated, one-third will develop serious heart or intestinal damage that could debilitate or kill them. And 10, 20, 30 or 40 years after having been infected, they may suddenly die.
The challenges are vast: how to explain to people who seem healthy that they have a deadly disease and need to take a drug that makes them feel unwell for 60 days? How to encourage health workers to prescribe a treatment that they are scared to use? MSF, in collaboration with partners at government, municipal, and community levels, is developing and researching innovative approaches related to prevention, diagnosis, and treatment - approaches that are appropriate and potentially sustainable in the socio-economic and cultural contexts where the disease is most common. 
While in 2006 the National Chagas Programme started diagnosing and treating patients under 15 years of age in various parts of the country, access to treatment remains unavailable for the great majority. Moreover, the lack of effective, rapid diagnostic tests for the disease further reduces access, as it means diagnosis can only be done where specialised laboratory tests are available. MSF projects have focused on reversing this situation, both by demonstrating simple and effective strategies for increasing access, and by advocating for treatment within Bolivia and internationally. MSF also supports the idea of creating a price fund to stimulate research and development (R&D) into better diagnostics for Chagas disease.

Overcoming treatment fears
There are, however, still several basic barriers to treatment: the lack of interest in researching drugs for diseases of poverty; the difficulties inherent in proving efficacy of treatment in the absence of a reliable test of cure; and persistent myths that exaggerate the dangers of treatment. The perception of risk is not matched by the reality. While there is no doubt that side effects of treatment are a major problem and that they are more frequent in older children and adults, research from MSF projects has shown that the vast majority are mild and safely manageable.
The 60 or 90 days required for treatment, and the cost of the drugs also increase the difficulty of ensuring effective treatment. Local medical personnel often tell adult patients - incorrectly - that there is no treatment for Chagas. In fact, evidence clearly shows that chronically infected adults, as well as children, benefit from treatment, even when there is already evidence of cardiac damage. Better, safer, faster-acting drugs are urgently needed, but in the meantime the existing drugs must be provided for all those who need them. MSF's first project opened in October 2002, treating children in O'Connor province – a rural area of South-Eastern Bolivia. Since 2007, MSF has been building new approaches in its response to Chagas, based on experiences from this first project, and a second, in the outskirts of the city of Sucre. Between them, these projects screened about to 30,000 children, and treated 2,500.

Working with DNDi
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MSF proves: Treatment implementation in rural areas is possible
The outcome of MSF's field experience in two Chagas programmes in Bolivia demonstrates the feasibility of implementing Chagas disease diagnosis and treatment programmes in poor, remote, rural areas, as well as in the urban environment. While side effects were frequent, only three children required hospital stays to manage these, and there were no deaths due to side effects.

Entre Rios, Bolivia, 2002-2006. The MSF programme aimed to treat all children younger than 15 years of age in a rural area of Southern Bolivia. A total of 7,613 children were screened, of whom 1,475 were confirmed with T. Cruzi infection, giving a seroprevalence rate of 19.4%. Seroprevalence by age group was 5.0% in younger than 5 years old; 14.8% in the 5-9 year-old-age group; 31.0%  in the 10-14 year-old-age group; and 51.7% for 15-16 year olds. Of these, 1,409 patients began treatment – 1,363 completed at least 30 days of treatment and 1,276 completed at least 55 days (defined as a complete standard course of treatment). A total of 28 (2%) children stopped treatment due to adverse events.

Treatment is a priority

Faustino Torrico, Professor of Parasitology and Infectiology, Universidad Mayor de San Simon, Cochabamba, Bolivia and member of the Scientific Advisory Committee of DNDi:

"In Bolivia, where one million (12%) of the total population is infected with T. Cruzi, the need for an effective treatment is now a priority. Until the year 2000, more than 60% of the country was virtually infested with vinchucas (Kissing bugs). In several places, we found that up to 100% of the adult population was infected. Since 2000, the national Chagas control programme has carried out systematic and comprehensive vector control programmes in the six Chagas-endemic departments. Today the risk of infection is low in 50% of the municipalities, but there are still areas of resistance, where infestation is higher than 20%. Many challenges lie ahead, but the results are promising. The actions were made possible by grants received from the Inter-American Development Bank (IADB). Unfortunately, the funding finished in 2007 and currently there is a transfer of roles and responsibilities from the central level of the Ministry of Health to local municipalities, whose contributions differ depending on their circumstances – which explains, in part, the difference in our response activities to the disease at the municipal level."

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