Complementary Approach to Therapy in Chagas’ Disease
Andréa Silvestre de Sousa
Fernanda de Souza Nogueira Sardinha Mendes
Mauro Felippe Felix Mediano
National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, RJ – Brazil
The vector transmission control measures instituted in Brazil in the last thirty years were responsible for a significant decrease in the number of new cases of Chagas’ disease. Even today, between 2 and 5 million Brazilians are affected by the disease, most of them presenting its chronic form, having been infected for an average of 20 or 30 years.
The infeasibility of eradicating Chagas’ disease stems from its characterization as an anthropozoonosis, perpetuating itself in its sylvatic cycle through countless relationships between more than 100 species of vectors and reservoir mammals. In this way, constant surveillance actions are justified, especially in view of the multiple geographic scenarios and the difficulty of effective control in a country of continental extension. Many areas are still vulnerable to the possibility of new cases from secondary vectors, in addition to the perspective of oral transmission, with increasingly frequent outbreaks in the Amazon, a region currently responsible for more than 90% of reported cases of acute Chagas’ disease in the Country.
As a disease that reflects conditions of social vulnerability, its epidemiology is also affected by population displacements of economic and/or political motivation. Recent internal migrations from Latin America, motivated by social inequalities between the different regions of the continent and the search for better living conditions, make Brazil a country of influx of endemic populations of Chagas’ disease, highlighting the recent immigration of Bolivians, a population of highest worldwide seroprevalence of this disease. These individuals often enter without official documentation, work in precarious conditions in the service and textile manufacturing sectors in large Brazilian urban centers, especially São Paulo, driving the need to review disease control and health care strategies. This movement caused a change in the epidemiological profile of Chagas’ disease in our country, increasing the number of cases among young people and women of childbearing age, with higher rates of maternal-fetal transmission in relation to the expectations of the Brazilian population. Therefore, it is essential to prepare our health systems for these continuous epidemiological changes, so that they are able to diagnose and timely care for all those affected.
In historical terms, we witnessed in Brazil the displacement of a large contingent of people affected by Chagas’ disease in the 1960s and 1970s, coming from hyperendemic rural areas, going in search of better employment and housing conditions – a movement called rural exodus. Unaware of their condition as carriers of the disease and the association between their diagnosis and the poor housing conditions of their rural past, these individuals were inserted in large urban centers, especially in the southeastern region of the country, working mainly as non-specialized workers. Because they were unaware of their diagnosis and were initially in the asymptomatic chronic form of the disease, they were not identified by the health services in these large cities, losing the opportunity to receive specific treatment in the early stages of the disease, when it is more effective. Today, these are the millions of Brazilians affected by Chagas’ disease that make up our statistics, living mostly in urban centers, still in conditions of social vulnerability, with restricted access to health services, mostly between the fifth and sixth decades of life, presenting mainly the chronic form of the disease, with or without cardiac and/or digestive symptoms, subject to comorbidities and general health problems of the population in this same age group.
The population assisted at the National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), in the city of Rio de Janeiro, comprises mostly individuals referred from blood banks, coming from endemic areas of Brazil, having migrated in the 70s, mainly from the interior of Minas Gerais (25%) and Bahia (25%) or other rural areas in northeastern Brazil. At the beginning of their follow-up, they were mainly in the indeterminate chronic form of Chagas’ disease, and today, with an average age of around 57 years, they are mainly in the chronic cardiac form, in addition to having numerous comorbidities, such as systemic arterial hypertension (SAH), diabetes mellitus (DM), dyslipidemia and metabolic syndrome.
Effectively organizing care and guiding the treatment of Chagas’ disease depends on an adequate knowledge of the epidemiological context of the population in the region in question. In a country with scenarios as diverse as Brazil, we may be facing a scenario with cases mostly in the acute phase, affecting individuals of all age groups and in outbreaks, in rural and/or urban areas, with high lethality (Brazilian Amazon); or at the opposite extreme, with cases mostly among the elderly, in the chronic phase of the disease, currently living in urban areas (Rio de Janeiro), which may or may not have suffered the influx of new cases of young people of childbearing age, with high rates of maternal-fetal transmission (greater São Paulo). When managers and health professionals are not aware of these continuous population movements, the invisibility of this population increases, and the consequence of this neglect is the scenario we currently know, with an increasing number of chronic cases in an advanced stage of disease evolution, with high morbidity and mortality. Unfortunately, however, many health professionals are still unaware of the problem that lies before their eyes in large urban centers and mistakenly believe that Chagas’ disease is restricted to rural areas, or is even about to cease to exist.
Health care, in its various levels of complexity and specialties, and the organization of broad access to diagnosis and treatment are decisive points in the organization of the Unified Health System (SUS). Today, we seek to abandon the fragmented and reductionist view of the biological care model, expanding it to the lines of care, considering human beings complex structures, interrelated with the social environment in which they were raised and live today, as well as the psychological consequences of this interaction, that is, the human being evaluated as a central figure of the biopsychosocial model.
Chagas’ disease is a rich example of a condition in which social and psychological conditions directly impact the quality of care and the success of treatment. We are no longer talking about a reductionist approach focused only on the specific treatment of this disease, using available triapanocidal drugs (benznidazole in our country), but on care related to all health conditions of the affected individuals.
Thus, the importance of knowledge of the epidemiological and social scenario in which individuals with the disease are inserted becomes clear. Following the previous line of discussion, the central focus in cases of Chagas’ disease in the acute phase, affecting a generally younger population, should, in fact, be to promote specific treatment, in addition to guiding the general population and health professionals in prevention of new cases or disease progression. In centers where the affected individuals present mainly with the symptomatic chronic forms of the disease, in addition to the numerous comorbidities and diseases related to the population aging process, our greatest commitment should be to carry out symptomatic treatment and rehabilitation, aiming not only to reduce of morbidity and mortality, but also the improvement of quality of life.
The reception of individuals with Chagas’ disease and their families, their diagnosis and initial care can and should be carried out in primary health care units. The multi-professional look allows for greater success in identifying their main demands, in addition to providing adherence to care, as doctors, nurses, nutritionists, physical educators, psychologists, social services and, when necessary, meet in the same work process. pharmaceutical care, acting through guidelines, with a responsible attitude towards user care. While it is important for the patient to have access to these services, minimizing travel and providing care close to the place of residence significantly increase this adherence.
In addition to a complete anamnesis and physical examination, with a special focus on the manifestations of chronic Chagas’ disease (evidence of heart disease, nutritional status, dysphagia and intestinal constipation), it is essential that everyone has access, even in primary care, to an electrocardiogram, simple, low-cost and widely available test, capable of identifying individuals with chronic chagasic heart disease, differentiating them from those without cardiac involvement, who in general can continue their evaluation at this level of care. Given the potentially progressive nature of Chagas’ disease, anamnesis, physical examination and electrocardiogram should be repeated annually, even in asymptomatic patients, assessing future needs for referrals to other levels of health care.
It is estimated that approximately 80% of cases of Chagas’ disease may remain under follow-up in basic health units, being evaluated for their most prevalent comorbidities (such as SAH and DM), in addition to other diseases associated with aging (neurological and osteoarticular diseases, among others). It contributes to greater resolution in the basic network, the expanded exercise of multiple professionals, in relation to each other and with the user and his family, in contrast to the hegemonic model of a clinic centered on the prescriptive act and on the production of procedures, overloading the reference system and counter-referral, with mechanically generated referrals to specialty services, without having exhausted the diagnostic possibilities in the basic network, in an attitude that demonstrates a lack of solidarity with the service and accountability in user care.
In this model of comprehensive care, users and their families, with their fears and anxieties, must be welcomed and oriented regarding possible limitations and symptoms, whether or not they are directly related to Chagas’ disease. Still in the primary care unit, they should be instructed on general lifestyle changes, care with healthy eating and anti-constipation, encouragement of regular physical activity, cessation of smoking, alcoholism and the use of other drugs, general medical-labor and personal relationship guidelines. The information that individuals with the indeterminate chronic form of the disease do not have a higher risk of death than the general population should be made explicit; who should not be exposed to discriminatory or stigmatizing situations at work or in social relationships, dispelling myths of contagion or inexorable progression to heart disease and death. Even those diagnosed with chronic chagasic heart disease should be advised that there are different prognoses within this same clinical form, and that, except in specific cases of advanced heart failure, the prognosis can be greatly optimized with symptomatic pharmacological treatment and cardiovascular rehabilitation.
Around 15% of users will need care in intermediate units, with specific cardiological or digestive exams, and only a percentage of 5% of them should actually be monitored in specialized units, with the availability of more advanced technology, with implants of cardiac devices, transplants and surgeries to correct megacolon and/or megaesophagus. The comprehensive care model should also be applied to these advanced levels of care, with multidisciplinary care, creation of work groups where self-care is promoted, with appropriate nutritional guidelines and pharmaceutical care, adjusting prescriptions to the user’s level of education. and their families, minimizing the risks of undesirable drug interactions and incorrect use of drugs.
Comprehensive care should not be evaluated as a utopian goal, but a possible process of organizing lines of care that makes the functioning of the SUS more effective, prioritizing the attention of most users in a satisfactory way at the level of primary health care. Chagas’ disease, as a model of aggravation closely related to social vulnerabilities, persists as a challenge to health, demanding more than ever a multi-professional look, capable of increasing success in care and quality of life of affected individuals. Even if they reach us late, decades after their contagion, we can allow, if not the cure, global care, promoting better living and health conditions for this population.