On September 23, 2022, the members of the Chagas Disease Clinical Research Platform[1] and the Global Chagas Coalition[2], attending the 10th Meeting of the Chagas Platform in Bogotá, Colombia, agreed to this document, which is addressed to governments, organizations, funders, and other actors involved in the fight against Chagas disease. The document sets out priorities for action and calls for intensified efforts to achieve the elimination of Chagas disease as a public health problem, as stipulated in the WHO Roadmap for Neglected Diseases (2021-2030)[3] and PAHO’s Neglected Infectious Diseases Elimination Initiative[4], both aligned with the United Nations Sustainable Development Goals (SD).
The COVID-19 pandemic had a devastating impact on the population and the limited resources of the health systems of countries affected by Chagas disease, delaying the implementation of research and development initiatives and the expansion of access to treatment for this disease. In this context, the members and attendees of the Chagas Platform and the Global Chagas Coalition, together with representatives of the Associations of People Affected by Chagas Disease, call for an update of the transversal commitments of the Letter of Santa Cruz, signed at the 8th Meeting of the Chagas Platform in 2018, and propose the present Bogotá Manifesto.
Since 2018, new evidence has led to a paradigm shift in the approach to the disease. This evidence, endorsed by the WHO, suggests that the control of the disease can be expanded and accelerated through an improvement in the strategies for controlling mother-to-child transmission. The mother-child dyad can be the gateway to provide comprehensive care to the family and the community at risk, integrating key actions such as the early detection of cases in children, young people and adults, including both acute and chronic cases, and appropriate treatment and follow-up of patients.
Key initiatives have emerged in this area, such as PAHO’s ETMI+ strategy,[5] which includes Chagas disease as part of routine care for maternal health services along with syphilis, HIV and hepatitis.
More recently, at the 27th Ibero-American Summit of Heads of State and Government, held in Andorra in 2021, member countries approved the Ibero-American Initiative “No Baby with Chagas”, reinforcing their commitment to contribute to the elimination of mother-to-child transmission of the disease based on a multidimensional approach.[6]
In several countries, significant advances have been made in vector transmission control and detection of seropositive donors in blood banks in high-burden areas. However, many people with the infection still lack access to basic comprehensive care.
The time to provide care is now. But access to diagnosis and treatment remains a challenge. The complexity of current diagnostic methods makes them difficult to implement in primary healthcare and is often a barrier to strategies for timely diagnosis. The available treatments have proven effective, especially for the pediatric population, and to varying degrees in other groups depending on the stage of the disease. However, these treatments can be improved with shorter and more tolerable administration regimens. Therefore, research should be encouraged and strengthened for new regimens of current treatments; simpler, more effective and faster diagnostic methods; and new chemical entities, adjuvant vaccines and biomarkers that unequivocally confirm the efficacy of treatment in chronically infected adults.
Moreover, several persistent barriers hamper our understanding of the true burden of disease. Both affected countries and international agencies are working on improving monitoring and data collection systems. Some countries have already implemented surveillance and reporting systems, but these need to be scaled up and implemented effectively (assuring the commitment and involvement of local healthcare personnel, who gather the information). Â So far, we only have estimates indicating 70 million people at risk, between 6 and 7 million people affected, 30,000 new cases each year in the Americas region (including 8,000 infants born with the infection), and over 12,000 people who die from Chagas disease annually[7]. Further, according to estimates, the vast majority of affected people have not yet been diagnosed or treated.
The WHO’s approval in 2019 of 14 April as World Chagas Day was a collective achievement, joining the call of the associations of affected people who together form the International Federation FINDECHAGAS. The symbolic power of this dedicated day has placed Chagas disease in a more visible place on the global agenda and has certainly stimulated some of the projects and advances described above. However, there is still much to be done to increase visibility.
It is time to regather strength, adapt plans to the new global landscape, and reaffirm our commitments and calls to the international health community. Importantly, civil society organizations and affected people should form part of current and future global and regional initiatives composed of affected countries.
Specifically, the organizations of the Global Chagas Coalition and the members of the Chagas Platform, together with associations of people affected by the disease, call on governments, donors and organizations involved in Chagas to commit to redoubling efforts in the following priority areas:
- Continue improving access to diagnosis, treatment and comprehensive care for people affected by Chagas disease in all its dimensions, guaranteeing:
- The implementation of decentralized, comprehensive routes of care, which allow the provision of care and follow-up in health centers close to the homes of all affected persons, supported by effective referral and counter-referral systems.
- The adoption of simplified diagnostic algorithms adapted for use in primary healthcare, based on evidence generated by the scientific community.
- Prioritization of the systematic implementation of screening in women of reproductive age, pregnant women, and infants – not only to achieve control of congenital transmission, but to facilitate the early detection of cases in women’s families and communities – including children, young people and adults.
- Encourage investment in research and development to obtain simpler, safer diagnostic and therapeutic tools. This includes undertaking research to optimise current diagnostic algorithms and treatment regimens, as well as developing new tools. At the same time, more progress is needed to discover biomarkers that accurately identify people at risk for progression to organ involvement, and to provide definitive evidence of therapeutic response in chronic patients who have received treatment, as well as vaccines adjuvant to treatment. To validate biomarkers and help inform and guide research priorities, a multi-country, multi-site, collaborative, long-term cohort study should be designed and implemented.
- Improve surveillance and control of the disease, expanding systems of mandatory notification of Chagas cases and clinical complications. This will provide a better understanding of the true situation, burden and distribution of the disease, contributing to the overall data collection system[8], including forecasting of demand for diagnostic and treatment tools, so that more effective plans can be developed and adapted to different contexts.
- Strengthen and facilitate access to training and information resources for both healthcare personnel and affected people, facilitating the provision of up-to-date, high-quality care.
- Promote coordination between the various actors involved in providing comprehensive care and guarantee the participation of affected people and their associations in the design and implementation of strategies which are adapted to the epidemiological and sociocultural contexts of their communities.
- Continue to support activities related to World Chagas Day as an opportunity to highlight global efforts to reduce the impact of Chagas disease, as well as promote actions to improve access to comprehensive care.
These commitments represent a proposed framework of action in solidarity with the struggle of affected people, countries and international organizations. In this crucial decade, we ask all to support these commitments to bring us closer to the elimination of Chagas disease as a public health problem.
Presented in the city of Santa Fe de Bogotá, on September 23, 2022.
[1] The Chagas Clinical Research Platform was formed in 2009 and today has over 400 members from 150 institutions and 24 countries throughout the world. It is a network of highly specialized people and organizations who share the latest knowledge in the search for new tools to combat the disease.
[2] The Global Chagas Coalition is the largest alliance of private organizations, in close collaboration with public institutions, whose objective is to increase access to diagnosis and treatment. Founded in 2012 by organizations including DNDi, Mundo Sano Foundation, ISGlobal, CEADES Foundation, and Baylor College, it is now composed of over 20 public and private entities from the global health community.
[3] https://apps.who.int/iris/bitstream/handle/10665/332421/WHO-UCN-NTD-2020.01-spa.pdf?sequence=1&isAllowed=y
[4] https://www.paho.org/es/iniciativa-eliminacion-hacia-generaciones-mas-sanas-libres-enfermedades
[5] https://www.paho.org/en/topics/elimination-mother-child-transmission-hiv-syphilis-perinatal-hepatitis-b-and-congenital
[6] https://cuidachagas.org/es/ and https://www.segib.org/programa/iniciativa-iberoamericana-sobre-chagas-congenito-ningun-bebe-con-chagas-el-camino-hacia-nuevas-generaciones-libres-de-chagas/
[7] The estimates are based on data from 2010 publications and need to be updated in the coming years.
[8] https://www.who.int/activities/implementing-an-information-and-surveillance-system-of-chagas-disease#cms
