Increasing access to comprehensive care for Chagas disease: development of a patient-centered model in Colombia

[Evaluation of a change in the serological diagnostic algorithm for Chagas disease in ColombiaAvaliação da mudança do algoritmo de diagnóstico sorológico da doença de Chagas na Colômbia]

Objective

To evaluate the effects of changing the algorithm for serological diagnosis of T. cruzi infection in departmental-level public health laboratories and in the National Reference Laboratory of Colombia, from the perspective of access to diagnosis.

Methods

A descriptive, cross-sectional study was carried out, based on secondary sources between 2015 and 2021, consolidating the number of serological tests carried out by the laboratories. A survey was developed to identify benefits and limitations in the implementation of the new algorithm for serological diagnosis. Totals, proportions, and averages of the number of tests were estimated by comparing two different periods.

Results

Information from 33 public health laboratories was analyzed, 87.9% of which processed serological assays during the period under study. The use of serological tests increased after the publication of the new guideline in 2017, and the capacity to perform the second test increased from four to 33 public health laboratories. In absolute terms, ELISAs for antigens and recombinant antigens became the most performed tests in Colombia after 2017.

Conclusions

The change in the algorithm for serological diagnosis of Chagas disease in Colombia in 2017 had positive effects on access to diagnosis since it facilitated the use of the second test. This change resulted in increased diagnostic coverage. The country's laboratories have access to a simple, timely, quality algorithm that could be implemented in almost any clinical laboratory in the country.

Design and feasibility of an implementation strategy to address Chagas guidelines engagement focused on attending women of childbearing age and children at the primary healthcare level in Argentina: a pilot study

Background

Chagas is a public health problem, especially in Latin America, exacerbated by migratory movements and increasing urbanization. Argentina is among the countries with the highest estimated prevalence in the region, with 1,500,000 people infected, with mother to child as the main mode of transmission. Vertical transmission has been significantly reduced by treating women of childbearing age; several guidelines in the region recommend treatment as a primary prevention strategy for the child and a secondary prevention strategy for women and their families. Despite recommendations, women of childbearing age are not always treated, and children do not receive timely diagnosis and treatment. The objective of this research was to design an implementation strategy to improve using Chagas guidelines focused on attending women of childbearing age and children at the primary healthcare level and pilot it in three primary health care centers in Argentina.

Methods

We conducted a pilot feasibility study using the Consolidated Framework for Implementation Research. A qualitative process evaluation was conducted using semi-structured interviews with health care providers and observations in primary health care centers.

Results

We developed a multifaceted implementation strategy including training, flowcharts and reminders, a register of suspected and confirmed cases, and the selection of a management facilitator. The pilot study took place between September 2019 and May 2020. The implementation level was heterogeneous and varied depending on the components, being the facilitating factors, the simplicity of the intervention, professionals’ willingness to expand the indication of serologic tests, and staff commitment to the adoption of intervention components. The main barriers found were the change of authorities at the local level, some professionals´ reluctance to administer etiological treatment, staff shortages, lack of diagnostic supplies, and the health emergency caused by the COVID-19 pandemic.

Conclusions

Behavioral change strategies should be applied to improve implementation to address some of the main barriers, including support actions offered by opinion leaders, medical experts, and local health authorities. Rapid diagnostic tests should be readily available to maintain behavior changes. We suggest further refinement of the strategy and its implementation in more centers to assess outcomes prospectively with a hybrid implementation research design.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01886-6.

Roadblocks in Chagas disease care in endemic and nonendemic countries: Argentina, Colombia, Spain, and the United States. The NET-Heart project

Background

Chagas disease (CD) is endemic in Latin America; however, its spread to nontropical areas has raised global interest in this condition. Barriers in access to early diagnosis and treatment of both acute and chronic infection and their complications have led to an increasing disease burden outside of Latin America. Our goal was to identify those barriers and to perform an additional analysis of them based on the Inter American Society of Cardiology (SIAC) and the World Heart Federation (WHF) Chagas Roadmap, at a country level in Argentina, Colombia, Spain, and the United States, which serve as representatives of endemic and nonendemic countries.

Methodology and principal findings

This is a nonsystematic review of articles published in indexed journals from 1955 to 2021 and of gray literature (local health organizations guidelines, local policies, blogs, and media). We classified barriers to access care as (i) existing difficulties limiting healthcare access; (ii) lack of awareness about CD and its complications; (iii) poor transmission control (vectorial and nonvectorial); (iv) scarce availability of antitrypanosomal drugs; and (v) cultural beliefs and stigma. Region-specific barriers may limit the implementation of roadmaps and require the application of tailored strategies to improve access to appropriate care.

Conclusions

Multiple barriers negatively impact the prognosis of CD. Identification of these roadblocks both nationally and globally is important to guide development of appropriate policies and public health programs to reduce the global burden of this disease.

Chagas disease (CD) has been described as an epidemic in Latin America, but its geographical influence is global. One of the biggest challenges in providing care for patients with CD is to improve access to early diagnosis and treatment in order to avoid chronic cardiovascular and gastrointestinal complications. However, different roadblocks interfere with the optimal care of these patients, which facilitates disease progression. While some barriers to care are global in scope, there are additionally national and even local obstacles for patients with CD. Appropriate delineation of these barriers will allow for the development of targeted interventions to improve the outlook for CD patients in both endemic and nonendemic countries alike.

Acute Pediatric Chagas Disease in Antioquia, Colombia: A Geographic Location of Suspected Oral Transmission

Chagas disease, Trypanosoma cruzi infection, is an insidious cause of heart failure in Latin America. Early diagnosis and treatment are critical to prevent irreversible myocardial damage that progressively accumulates over decades. Several structural barriers account for the less than 1% of cases in Colombia being treated, including poor physician knowledge, especially considering that some regions are considered non-endemic. The two cases reported here represent an emerging epidemiologic scenario associated with pediatric Chagas disease. Both cases are suspected oral transmitted parasitic infection in a geographic region of Colombia (Andean region of Antioquia) where no previous oral transmission of Chagas disease had been reported. Their clinical histories and course of disease are presented here to increase physician awareness of the epidemiologic risk factors and clinical manifestations associated with pediatric oral Chagas disease in Antioquia department, Colombia.

Social determinants in the access to health care for Chagas disease: A qualitative research on family life in the "Valle Alto" of Cochabamba, Bolivia

Introduction

Chagas disease is caused by the Trypanosoma cruzi infection. It is a neglected tropical disease with considerable impact on the physical, psychological, familiar, and social spheres. The Valle Alto of Cochabamba is a hyperendemic region of Bolivia where efforts to control the transmission of the disease have progressed over the years. However, many challenges remain, above all, timely detection and health-care access.

Methods

Following the Science Shop process, this bottom-up research emerged with the participation of the civil society from Valle Alto and representatives of the Association of Corazones Unidos por el Chagas from Cochabamba. The aim of this study is to explore the social determinants in the living realities of those affected by Chagas disease or the silent infection and how families in the Valle Alto of Cochabamba cope with it. An interdisciplinary research team conducted a case study of the life stories of three families using information from in-depth interviews and performed a descriptive qualitative content analysis and triangulation processes.

Findings

Findings provide insights into social circumstances of the research subjects’ lives; particularly, on how exposure to Trypanosoma cruzi infection affects their daily lives in terms of seeking comprehensive health care. Research subjects revealed needs and shared their experiences, thus providing an understanding of the complexity of Chagas disease from the socioeconomic, sociocultural, political, and biomedical perspectives. Results enlighten on three dimensions: structural, psychosocial, and plural health system. The diverse perceptions and attitudes toward Chagas within families, including the denial of its existence, are remarkable as gender and ethnocultural aspects. Findings support recommendations to various stakeholders and translation materials.

Conclusions

Intersectional disease management and community involvement are essential for deciding the most appropriate and effective actions. Education, detection, health care, and social programs engaging family units ought to be the pillars of a promising approach.

Challenges in the care of patients with Chagas disease in the Brazilian public health system: A qualitative study with primary health care doctors

BACKGROUND

Care to patients with Chagas disease (CD) is still a challenge for health systems in endemic and non-endemic countries. In the Brazilian public health system, the expansion of Primary Health Care (PHC) services to remote and disadvantaged areas has facilitated the access of patients with CD to medical care, however this is in a context where care gaps remain, with insufficient public funding and inadequate distribution of services. Considering the need for studies on care to patients with CD in different settings, this study explored the challenges of family doctors to provide care to patients with CD in an endemic region in Brazil with high coverage of public PHC services.

METHODS AND FINDINGS

This is a qualitative study. A focus group with 15 family doctors was conducted in a municipality participating in a multicenter cohort that monitors almost two thousand patients with CD in an endemic region in Brazil. The data were analyzed using a thematic content analysis technique. The family doctors pointed out the following challenges for care to patients with CD: unsatisfactory medical training (academic education not suitable for the clinical management of the disease, and lack of training on CD in PHC); uncertainties regarding antiparasitic treatment in the chronic phase of the disease; difficulty in patients' access to specialized care when necessary, especially to the cardiologist; and trivialization of the disease by patients as a barrier to seeking care.

CONCLUSION

The access of CD patients to adequate medical care, even in regions with high coverage of public PHC services, still represents an important challenge for health systems. The results of this study may contribute to the development of strategies to improve the clinical management of CD in PHC.

A four-step process for building sustainable access to diagnosis and treatment of Chagas disease

The vast majority of people with Chagas disease (CD) are undiagnosed and untreated. Improving access to diagnosis and treatment for CD involves confronting a wide range of barriers. This report discusses a collaborative approach to eliminate barriers and increase the availability of CD testing and treatment. Potential areas for intervention are selected based on burden of disease, support of local champions, and commitment from national and local authorities. A 4D approach (diagnose, design, deliver, and demonstrate impact) is then implemented. The diagnose step involves gathering key stakeholders at a seminar to collaboratively identify important barriers and propose solutions. The design step creates a specific plan to act upon the seminar’s conclusions with consensus on core indicators. The deliver step entails implementing the plan at pilot locations, while simultaneously strengthening health system capacity for CD testing and treatment. Lastly, the demonstrate impact step compares baseline data with annual post-implementation data to measure progress. In Colombia, this approach has helped simplify testing procedures and increase CD testing and treatment access in pilot communities, though challenges remain. The 4D approach represents one of several pathways toward ensuring that the best therapeutic and diagnostic products reach people affected by neglected tropical diseases.

Sociocultural dynamics that influence Chagas disease health care in Colombia

Chagas disease (CD) is a Latin America endemic and neglected tropical disease that affects primarily poor people living in rural areas. Its current low profile leads to many diagnostic, treatment, and control challenges. This study aimed to identify and characterize the sociocultural dynamics that influence CD health care in Colombia. Data for our ethnographic study was collected in 2013 and included participant observation in two main endemic areas in Colombia. In addition, 81 people belonging to four groups (patients and family members; health care workers; researchers; and officers) were recruited through snowball sampling technique and participated in informal and semi-structured interviews. People from the first two groups also participated in social cartography excercises. Data analysis resulted in the identification of three main sociocultural dynamics. Local Understandings: Patients reported confusions around disease transmission, treatment effectiveness and development of future complications. Providers' Knowledge and Training: Failures in professional's knowledge and training mostly affect the primary level of care in rural areas. Professionals undergo minimal training during medical school and lack access to continuous education. In contrast, clinicians working at tertiary university hospitals or at the CD unit of the Colombian National Institute of Health (NIH) exhibited great knowledge and competency. Health Care System Barriers: The Colombian market-based health care reform augmented access barriers, which impacted CD care greatly. We identified geographic and bureaucratic itineraries that depended on type of insurance plan, insurance contracts with service providing institutions, and levels of care. This study shows that people's experience of these sociocultural dynamics vary depending on their mobility from rural to urban contexts. It unveils the importance of analyzing the structure of the health care system. In the Colombian case, its for-profit orientation has become one of the most important obstacles for comprehensive, integrated, and timely health care responses.