[The various meanings of Brazil's certification as free of Chagas disease]

The article discusses Brazil's recent certification as free of Chagas disease transmission by Triatoma infestans, analyzing the various meanings ascribed to this position. Resulting mainly from measures by both the Chagas Disease Control Program (PCDCh) established in Brazil in 1975 and the Southern Cone Initiative launched in 1991, this certification has been interpreted in ways that lead to confusion between the elimination of Chagas disease transmission by T. infestans and eradication of the disease. The present status of vector transmission control in Brazil is discussed, with emphasis on the Northeast, in most States of which T. infestans is not the main species involved in transmission. The article highlights the need to broaden the discussion of the readings and consequences involved in the present control achievements in light of possible harm from misinterpretations that might jeopardize further efforts to control the disease.

DNA immunization with Trypanosoma cruzi HSP70 fused to the KMP11 protein elicits a cytotoxic and humoral immune response against the antigen and leads to protection

Murine immunization with Trypanosoma cruzi KMP11-HSP70 fused genes but not the KMP11 gene alone elicited both an immunoglobulin G2a long-lasting humoral immune response against KMP11 protein and activation of CD8+ cytotoxic T lymphocytes specific for two KMP11 peptides containing A2 motifs. Moreover, protection against the parasite challenge was observed after immunization with the chimeric gene.

DNA sequences encoding CD4+ and CD8+ T-cell epitopes are important for efficient protective immunity induced by DNA vaccination with a Trypanosoma cruzi gene

Immunization of BALB/c mice with a plasmid containing the gene for Trypanosoma cruzi trans-sialidase (TS) induced antibodies that inhibited TS enzymatic activity, CD4+ Th1 and CD8+ Tc1 cells, and protective immunity against infection. We used this model to obtain basic information on the requirement of CD4 or CD8 or B-cell epitopes for an effective DNA-induced immunity against T. cruzi infection. For that purpose, mice were immunized with plasmids containing DNA sequences encoding (i) the entire TS protein, (ii) the TS enzymatic domain, (iii) the TS CD4+ T-cell epitopes, (iv) the TS CD8+ T-cell epitope, or (v) TS CD4+ and CD8+ T-cell epitopes. Plasmids expressing the entire TS or its enzymatic domain elicited similar levels of TS-inhibitory antibodies, gamma interferon (IFN-gamma)-producing T cells, and protective immunity against infection. Although the plasmid expressing TS CD4 epitopes was immunogenic, its protective efficacy against experimental infection was limited. The plasmid expressing the CD8 epitope was poorly immunogenic and provided little protective immunity. The reason for the limited priming of CD8+ T cells was due to a requirement for CD4+ T cells. To circumvent this problem, a plasmid expressing both CD4+ and CD8+ T-cell epitopes was produced. This plasmid generated levels of IFN-gamma-producing T cells and protective immunity comparable to that of the plasmid expressing the entire catalytic domain of TS. Our observations suggest that plasmids expressing epitopes recognized by CD4+ and CD8+ T cells may have a better protective potential against infection with T. cruzi.

Bone marrow-derived macrophages grown in GM-CSF or M-CSF differ in their ability to produce IL-12 and to induce IFN-gamma production after stimulation with Trypanosoma cruzi antigens

Trypanosoma cruzi is the etiological agent of Chagas' disease in man. Control of parasitism at the beginning of experimental infection depends on cytokine-activated macrophages that synthesize nitric oxide (NO). We investigated macrophage populations derived in the presence of M-CSF (M-MØ) or GM-CSF (GM-MØ) regarding their ability to control intracellular parasitism by T. cruzi and to synthesize IL-12 and NO. Both macrophage populations supported intracellular multiplication of the parasite; when activated by IFN-gamma, GM-MØ exerted better control of parasitism. Stimulation of GM-MØ with T. cruzi or Staphylococcus aureus resulted in IL-12 production and higher levels of NO synthesis in comparison with stimulated M-MØ. Mice immunized with parasite-Ag-pulsed GM-MØ but not with pulsed M-MØ had increased IFN-gamma and IL-2 production in lymph nodes. However, when immunization was followed by infection with live parasites, transient elevation of IFN-gamma production was observed in both GM-MØ- and M-MØ-immunized mice, without reduction of blood parasite levels.

Specific molecular targets to control tropical diseases

Chagas' disease or American trypanosomiasis is considered by the Word Health Organization to be one of the important tropical parasitic diseases worldwide together with malaria and schistosomiasis. The etiologic agent of this illness is the kinetoplastid protozoon Trypanosoma cruzi. The present chemotherapy for the treatment of Chagas' disease remains unsolved. The drugs currently in use are old, ineffective and toxic. Bearing in mind the metabolic differences between the parasite and the mammalian host, some attractive interesting molecular targets for drug design are presented.

Chagas disease prevention through improved housing using an ecosystem approach to health

This Chagas disease prevention project via housing improvement aims to determine the efficiency of different interventions in vector control. The following study describes the target communities, disease magnitude, and housing improvements. Transmission levels are analysed from an ecological and socioeconomic perspective. Special interest was focused on the peridomicile as the origin of domiciliary reinfestation. In the original project, three intervention programs were proposed, one for each of the three communities: (a) an insecticide spraying program; (b) a housing improvement program; and (c) a combined program of spraying and housing improvement. The three communities currently have different risks of exposure to triatominae reinfestation as a consequence of the type of intervention carried out. A new multidisciplinary approach which integrates participatory, community-based research and socioeconomic dimensions will allow to determine the efficiency of models for territorial ordering, community education, and environmental interventions in Chagas disease control.

[Chagas disease, environment, participation, and the state]

Human Chagas Disease (HCD) affects 16 million Latin Americans and is related to environmental and social questions like education, anthropogenic changes, housing, and migration. HCD requires domiciliation of the vector, which is introduced from sylvatic ecotopes or transported passively by humans. HCD is difficult to treat but possible to prevent. As a disease concentrating among poor individuals and regions, its control requires government intervention, involving education, community participation, and access to medical care. Public policies are required for HCD control, requiring participation by political parties and social control of public agencies to ensure program continuity. A consistent environmental policy is needed to prevent the spread of HCD to new areas such as the Amazon Region. Finally, partnerships among affected countries can help foster HCD control, raising self-esteem and helping promote a new political order in Latin America.

Modeling household transmission of American trypanosomiasis

American trypanosomiasis, or Chagas disease, caused by the protozoan parasite Trypanosoma cruzi and transmitted by blood-feeding triatomine bugs, is a chronic, frequently fatal infection that is common in Latin America. Neither adequate drugs nor a vaccine is available. A mathematical model calibrated to detailed household data from three villages in northwest Argentina shows that householders could greatly reduce the risk of human infection by excluding domestic animals, especially infected dogs, from bedrooms; removing potential refuges for bugs from walls and ceilings; and using domestically applied insecticides. Low-cost, locally practicable environmental management combined with intermittent use of insecticides can sustainably control transmission of T. cruzi to humans in rural Argentina and probably elsewhere.

Biogeography of Triatominae (Hemiptera: Reduviidae) in Ecuador: implications for the design of control strategies

Chagas disease control strategies strongly depend on the triatomine vector species involved in Trypanosoma cruzi transmission within each area. Here we report the results of the identification of specimens belonging to various species of Triatominae captured in Ecuador (15 species from 17 provinces) and deposited in the entomological collections of the Catholic University of Ecuador (Quito), Instituto Oswaldo Cruz (Brazil), the Natural History Museum London (UK), the London School of Hygiene and Tropical Medicine (UK), the National Institute of Hygiene (Quito), and the Vozandes Hospital (Quito). A critical review of published information and new field records are presented. We analysed these data in relation to the life zones where triatomines occur (11 life zones, excluding those over 2,200 m altitude), and provide biogeographical maps for each species. These records are discussed in terms of epidemiological significance and design of control strategies. Findings relevant to the control of the main vector species are emphasised. Different lines of evidence suggest that Triatoma dimidiata is not native to Ecuador-Peru, and that synanthropic populations of Rhodnius ecuadoriensis in southern Ecuador-northern Peru might be isolated from their sylvatic conspecifics. Local eradication of T. dimidiata and these R. ecuadoriensis populations might therefore be attainable. However, the presence of a wide variety of native species indicates the necessity for a strong longitudinal surveillance system.

Pasteurization of human milk to prevent transmission of Chagas disease

Although admittedly transmission of Trypanosoma cruzi infection through breastfeeding is a rare event, it involves serious risks. To test the effectiveness of pasteurization in preventing this mode of infection, three sets of samples of human milk were tested: a - contaminated with T. cruzi and pasteurized; b - contaminated with T. cruzi and non-pasteurized; c - non-contaminated and pasteurized. Samples from all sets were orally and intraperitoneally administered to 90 BALB/c mice. The animals inoculated with contaminated, non-pasteurized samples, got the infection. Controls and the animals inoculated with contaminated and pasteurized milk were not infected. The hypothesis was accepted that pasteurization inactivates T. cruzi trypomastigotes.

Trypanosomiasis control

In July 2000, Heads of State of the 36th Session of the Organisation for African Unity signed a potentially important declaration on African trypanosomiasis, urging member states "to act collectively to rise to the challenge of eliminating the problem through concerted efforts in mobilising the necessary human, financial and material resources required to render Africa tsetse-free within the shortest time possible". To many, such an ambitious dream is received with some scepticism, recalling the doubts that surrounded a similar declaration signed in Brasilia in 1991, which paved the way for the Southern Cone Initiative against American trypanosomiasis (Chagas disease). True, the two diseases are quite different. But the operational challenges are quite similar, and there are sufficient biological parallels to suggest that the Latin American experience in controlling Chagas disease may provide a useful model for the control of African trypanosomiasis.

Parasite polyclonal activators: new targets for vaccination approaches?

Taking into consideration that the immune response following infection promotes the expansion of lymphocyte clones that are essentially non-specific, ensuring both parasite evasion and persistence inside the host, what would be the major consequences of this polyclonal response to the development of immunopathology? We favor the hypothesis that the polyclonal B cell responses triggered by the infection is responsible of the host susceptibility and is a major contributor to the maintenance of a progressive disease. In particular, the activation of B cells by parasite mitogens would contribute to the class determination of T cell responses and to the inhibition of macrophages - target cells for parasite multiplication and also responsible for parasite clearance. We also envisage that the activation of T cells by parasite 'superantigens', and the ensuing energy and deletion of these cells, processes that are frequently observed, would contribute for the immunosuppression as well as to parasite escape and persistence in the host. We had concentrated our efforts on the study of the non-specific aspects of the immune response following Trypanosoma cruzi infection. We aimed at finding new strategies to modulate and control the mechanisms leading to both the immunosuppression and the development of chronic auto-immunity leading to rational vaccine approaches against parasite infection and immunopathology.

Triatoma infestans in Greater Buenos Aires, Argentina

The Health Administration Agencies of many municipalities in Greater Buenos Aires (GBA) receive frequent reports on triatomines in houses. The aim of this work was to identify and describe the dispersal foci of Triatoma infestans in an urban neighborhood of GBA, and contribute to the knowledge of the epidemiological situation in the region. In June 1998, potentially infested places were entomologically evaluated. T. infestans was only detected in a hen building for egg production, which housed approximately 6,000 birds. A total of 2,930 insects were collected. Density was about 9 triatomines/m(2). The proportions of fifth instar nymphs and adults were significantly higher than those of the other stages (p<0.001). The number of triatomines collected largely exceeded the highest domestic infestation found in one house from rural endemic areas of Argentina. Though triatomines were negative for Trypanosoma cruzi, they could acquire the parasite by coming in contact with infected people living in GBA. Besides, the numerous and widely distributed places housing hens and chickens, would favor the settlement of the vector. Together, both facts may constitute a risk of parasitic vectorial transmission. It is recommended to intensify systematic activities of vector search and case detection in GBA.

Bacterial symbiosis and paratransgenic control of vector-borne Chagas disease

The triatomine vectors of Chagas disease are obligate haematophagous insects, feeding on vertebrate blood throughout their entire developmental cycle. As a result of obtaining their nutrition from a single food source, their diet is devoid of certain vitamins and nutrients. Consequently, these insects harbour populations of bacterial symbionts within their intestinal tract, which provide the required nutrients that are lacking from their diet. We have isolated and characterised symbiont cultures from various triatomine species and developed a method for genetically transforming them. We can then reintroduce them into their original host species, thereby producing stable paratransgenic insects in which we are able to express heterologous gene products. Using this methodology, we have generated paratransgenic Rhodnius prolixus that are refractory for infection with Trypanosoma cruzi. Two examples of potentially refractory genes are currently being expressed in paratransgenic insects. These include the insect immune peptide cecropin A and active single chain antibody fragments. We have also developed an approach that would allow introduction of genetically modified bacterial symbionts into natural populations of Chagas disease vectors. This approach utilises the coprophagic behaviour of these insects, which is the way in which the symbionts are transmitted among bug populations in nature. The production and ultimate release of transgenic or paratransgenic insects for public health applications is potentially very promising but also worthy of much careful consideration with respect to environmental, political, and human safety concerns.

Antigen-specific Th1 but not Th2 cells provide protection from lethal Trypanosoma cruzi infection in mice

Infection with Trypanosoma cruzi results in the development of both type 1 and type 2 patterns of cytokine responses during acute and chronic stages of infection. To investigate the role of Th1 and Th2 subsets of CD4(+) T cells in determining the outcome of T. cruzi infection in mice, we have developed T. cruzi clones that express OVA and have used OVA-specific TCR-transgenic T cells to generate OVA-specific Th1 and Th2 cells. BALB/c mice receiving 10(7) OVA-specific Th1 cells and then challenged with OVA-expressing T. cruzi G-OVA.GPI showed significantly lower parasitemia and increased survival in comparison to mice that received no cells. In contrast, recipients of OVA-specific Th2 cells developed higher parasitemias, exhibited higher tissue parasitism and inflammation, and had higher mortality than recipients of Th1 cells after infection with T. cruzi G-OVA.GPI. Mice receiving a mixture of both Th1 and Th2 OVA-specific cells also were not protected from lethal challenge. The protective effect of the OVA-specific Th1 cells was OVA dependent as shown by the fact that transfer of OVA-specific Th1 or Th2 cells failed to alter the course of infection or disease in mice challenged with wild-type T. cruzi. Immunohistochemical analysis of OVA-specific Th1 and Th2 cells at 4, 15, and 30 days postinfection revealed the persistence and expansion of these cells in mice challenged with T. cruzi G-OVA.GPI but not in mice infected with wild-type T. cruzi. We conclude that transfer of Ag-specific Th1 cells but not Th2 cells protect mice from a lethal infection with T. cruzi.

[Current situation with chagas disease vector control in the Americas]

This article identifies and describes various epidemiological aspects in the natural transmission of Chagas disease in the Americas. It also examines the relative importance of the principal vector species in the disease's transmission and the control levels that are feasible in each instance. Estimations of the population at risk, number of infected cases, and number of chronic cases are presented. Prospects for control are discussed on the basis of past results to predict the expected results with introduced species like Triatoma infestans in the Southern Cone and Rhodnius prolixus in Central America and with the other autochthonous species in areas where they are found. Finally, the article discusses the role of other transmission mechanisms in the maintenance of endemic Chagas disease.

[Chagas disease in Brazil]

This article presents the current situation for Chagas disease vectors in Brazil, based on data from the Brazilian National Health Foundation (FNS). Over the course of the last 20 years, continuous chemical control has resulted in a clear reduction of triatomine densities and Trypanosoma cruzi in Brazilian dwellings. Results have been particularly promising in relation to Triatoma infestans and Panstrongylus megistus, considered the most important species in the past. In parallel, data from school serological surveys, hospitalized patients, and mortality records show an important decrease in the disease. Nevertheless, some areas of the Brazilian Northeast and some residual foci of Triatoma infestans and Panstrongylus megistus remain as major challenges for public health authorities, requiring effective epidemiological surveillance. States and municipalities are required to assume this task at present, as the traditional Brazilian National Health Foundation is undergoing decentralization.

[Epidemiological surveillance of Chagas disease]

Chagas disease still constitutes an important medical problem in affected countries. In some, the extent of the disease is still unknown and control programs have not been implemented. In others the disease has been reduced due to regular control programs and other economic and social factors. Epidemiological surveillance with community participation to guard against disease transmission is now the basic challenge. Applied research and in-depth reformulation of health systems are required to establish efficient and sustainable Chagas disease surveillance programs, considering low density of peridomiciliary vectors as the most relevant factor. In addition, a large population of already infected, poor individuals require specific medical attention and social security. As a consequence of health care decentralization, Federal institutions such as the Brazilian National Health Foundation (FNS) are being progressively decommissioned, and new participants must be engaged in the process. Communities themselves, together with regional and local institutions, must take charge of surveillance in order to guarantee its efficiency and sustainability.

[Operational aspects of Triatoma brasiliensis control]

Vector control strategies against indigenous species is not easy, due to their capacity to reinvade treated premises from sylvatic ecotopes. Between August 1996 and December 1997 we conducted a study on reinfestation of houses after spraying in a county in the State of Ceará. Of 277 houses examined, 113 (40.8%) were infested (21.7% intradomiciliary and 35.4% peridomiciliary). Of the 433 Triatominae collected, 207 were Triatoma brasiliensis (49% of which intradomiciliary, with a mean of 1.8 insects/house) and 226 were Triatoma pseudomaculata (97% peridomiciliary). The age structure of the two indicated a univoltine development cycle for T. brasiliensis and two cycles per year for T. pseudomaculata. Four months after spraying with deltamethrin SC 25mg ia/m2, 9.7% of the houses were still positive, mainly with peridomestic infestations. Intradomiciliary wall bioassays showed persistence of the insecticide up to 9 months after spraying. Considering the high potential for recolonization of treated premises from sylvatic foci, we propose an operational strategy combining traditional evaluations and community-based surveillance with increased selective interventions and community education.

[Microclimatic properties of the Triatoma brasiliensis habitat]

Vector-borne transmission of Chagas disease in Northeast Brazil is basically by Triatoma brasiliensis. It is thus crucial to determine this species' microclimatic preferences as limiting factors for its distribution and ability to infest domestic environments. We analyze the microclimatic properties of the shelters in which these insects are found in wild, domestic, and peridomiciliary environments in the State of Ceará, at Brazil. We measure temperature and relative humidity (RH) every 15 minutes for 3 days. Thermal variation was greatly dampened inside both domiciliary refuges and the more protected internal places in wild stony sites. For RH, we observed a similar dampening pattern, but mean RH was lower in both domiciliary refuges and wild ones inside stony sites as compared to reference levels in the surrounding environment. The results are discussed with regard to this species' microclimatic preferences in the laboratory and its potential as determinants of its geographical distribution.

[Peridomiciliary changes and implications for Triatoma brasiliensis control]

A total of 9,906 annexes from 1,541 rural dwellings of Boa Viagem County, Ceará, Brazil, infested by Triatoma brasiliensis and Triatoma pseudomaculata were investigated and immediately sprayed with pyrethroid insecticide, followed by revisions at 6, 12, and 18 months. The initial infestation rate of annexes was 4.0%, with predominant infestation in animal shelters (7.0%). Mean insect density was low, regardless of triatomine species or type of annex. A progressive decrease in the number of initial annexes was observed (66% of remaining annexes), mainly those classified as "piles of materials". Only 3% of the annexes were modified by the population. New constructed annexes were important as new foci of infestation. Some 25% were infested at the end of observation period, significantly more than the "old" annexes (4.0%), a difference attributed to insecticide spraying at the beginning of the intervention. Reinfestation occurred slowly and was more frequent in animal shelters No differences were observed between traditional pyrethroid and slow-release organophosphate formulations. Selective spraying of "new" annexes is recommended.

[Epidemiological surveillance in the Chagas disease control program in Minas Gerais State, Brazil (1984-1998)]

This paper describes the surveillance phase of the Chagas Disease Control Program in Minas Gerais State. Surveillance was conducted by the County Health Services with community participation in the planning, decision-making, and maintenance processes and is intended to be sustainable in the context of Brazil's Unified National Health System (SUS).