COVID-19 and Chagas: people living with the disease are at risk of serious complications
People affected by Chagas disease are part of the risk group for severe cases of COVID-19 and demand extra attention and care11/06/2020
In face of the pandemic caused by the new coronavirus, the management of people with risk factors, including cardiovascular disease, represents a major challenge. The cardiovascular complications seen in people with the SARS-CoV-2, infection, which causes COVID-19, result from several mechanisms, ranging from direct injury by the virus to complications secondary to the inflammatory and thrombotic response triggered by the infection. Adequate care for these people requires attention to the cardiovascular system in search of better clinical results.
In the United States, for example, doctors who treat people with Chagas disease show concern for about 30 to 45 thousand people who are at risk for COVID-19 complications due to problems related to Chagas disease. In the USA, only 0.3% of the 300 thousand people living with Chagas disease have access to treatment, and many of them come from socially vulnerable populations that are especially affected by the COVID-19 crisis.
In Brazil, it is estimated that 410 to 964 thousand people have chagasi cardiopathy and are at increased risk in the face of the pandemic and need extra attention and care. Professor and cardiologist at the Federal University of Minas Gerais (UFMG), Dr. Rosália Morais Torres, reiterates the general concern about the situation of people affected by the disease in Brazil, especially those diagnosed with chagasi cardiopathy. “There is, at the moment, a great gap of knowledge in relation to the evolution and prognosis of people with chagasi cardiopathy who become infected with SARS-CoV-2. The presence of chronic or acute chagasi cardiopathy puts these people within the risk groups for evolution to the most severe clinical forms of COVID-19 and extra attention should be paid to these cases, given the complexity and diversity of cardiac manifestations of Chagas disease, to its also inflammatory nature (as well as COVID-19) and propensity to the formation of thrombi, even if by different mechanisms”, she highlights. In addition, those with chronic Chagas disease who, except in the Amazon region, are in the older age groups and already suffer from co-morbidities, such as hypertension and diabetes mellitus. Unfortunately, in relation to the COVID-19 and Chagas disease co-infection, there are currently many questions and few answers”, she acknowledges.
Advance of the pandemic to the interior of Pará increases the risks of association with acute Chagas disease
The pandemic of the new coronavirus brings many problems and imposes several challenges, one of which is in the Amazon region. Cardiologists from Pará and all professionals involved in health care for people with Chagas disease are concerned about the possibility of an association between SARS-CoV-2 infection and Chagas disease. Although there is still no case described, the advance of the pandemic to the interior of the state of Pará increases the risks of its association with acute Chagas disease.
Cardiologist and professor at the Federal University of Pará (UFPA), Dra. Dilma do Socorro Moraes de Souza, calls attention to a scenario of challenges in the Northern Region of Brazil, today deeply affected by the pandemic, with 24.465 confirmed cases and 2.216 deaths, in the State of Pará, until May 25. “In the case of acute Chagas disease, we are concerned with co-infection by COVID-19, since, in the Amazon Region, it is an endemic disease that follows a seasonal curve. The number of cases of acute Chagas disease starts to increase from June onwards and has a peak in the second semester, being associated with the consumption of unhygienic foods, where açaí is the most related food”, she stresses. Also, according to the Cardiologist at the Hospital de Clínicas Gaspar Vianna Foundation, the state will face two diseases that develop with febrile syndrome, which can cause diagnostic confusion in the initial phases. “Both have, in their evolution, thrombo-inflammatory characteristics, and we still have no evidence regarding the specific treatment of COVID-19 and the drug interaction with antiretrovirals associated or not with benznidazole. In this way, we have launched an alert for this future challenge, from diagnostic suspicion to treatment”, she explains.
Absence of a program within Primary Health Care for patients with chronic Chagas cardiopathy
Another point highlighted by Dr. Rosália Torres in relation to Chagas disease patients and, particularly, in relation to those with chronic Chagas cardiopathy is the monitoring of people with chronic Chagas disease in the public health network. “There is no specific plan/program for this until today”, she regrets to say that, although there is an expressive number of people diagnosed with Chagas disease in the country, there is no specific program, within Primary Health Care, to monitor them. “Generally, these patients enter the system as having systemic arterial hypertension, diabetes mellitus, that is, they enter due to other co-morbidities and not as, primarily, patients with Chagas disease”, she reports. For the cardiologist, the patient with chronic Chagas heart disease needs care that involves the entire health system, as many have severe forms of complex handling. “In hospitals, it is not uncommon for a patient to be hospitalized as having heart failure and only when it is already too late the Chagas etiology of his clinical picture is configured. We have to assume our human ethical responsibility to look for ways to make this continuous and individualized care possible”, she concludes.
Fear, stigma, limited access to the health system and lack of awareness in the medical community and health professionals in general are among the barriers that prevent the most vulnerable people from reaching the attention and essential care for Chagas disease, one of the main causes of heart disease in the Americas. All of these barriers are compounded by the pandemic. Further research is needed on the interaction between Trypanosoma cruzi and SARS-CoV-2. However, people with heart problems have been more susceptible to complications related to the new coronavirus and up to 30% of people with Chagas disease suffer from heart complications.
2020 marks the first World Day to Combat Chagas Disease
On April 14 the global community celebrated the first World Day of Chagas Disease. For Dr. Alberto Novaes Ramos Jr, a professor at the Federal University of Ceará (UFC), the year 2020 represented the first opportunity to mark this day of confrontations and struggles, an opportunity also covered by the critical challenges imposed by the pandemic by COVID-19. “In the midst of social distance and the occurrence of cases and deaths worldwide, April 14 reinforced the importance of Brazilian science and facing the serious situations of inequality that impose a critical social vulnerability on the majority of the world population”, he points out. Still according to him, poverty and extreme poverty are commonplace as a social determinant of Chagas disease and of so many diseases that prevail in neglected people and populations, as well as the expression of greater clinical and epidemiological severity of COVID-19 in Brazil and around the world. Professor Novaes also recalls that the SARS-Cov-2 infection has already reached the entire Brazilian territory in different degrees of expression, in particular in more socially vulnerable territories, and the increase in the number of cases already overburdens the Unified Health System (SUS).
In the opinion of Dr. Novaes, we live in a unique and critical moment in our history, and we face the challenge of not only looking for strategies on how to deal with cases of Chagas disease in the midst of the pandemic, but also on learning how to maintain mobilization in the future for the issues that they involve coping with the disease amid agendas aimed at COVID-19 or other diseases that gain priority for society. For him, in times of COVID-19, Brazilian science should also be emphasized as a political movement for delimiting spaces and facing critical social inequalities that have been amplified in the country and in the world, whether in endemic or non-endemic areas. “Extend the role of affected people and make their voices echo. This thought applies both to COVID-19, as well as to Chagas disease or any public health problem for the coming years”, adds the professor.
The date highlights one of the most neglected tropical diseases that continues to affect millions of people worldwide. The International Federation of Associations of People Affected by Chagas Disease (FindeChagas) chose April 14 as “International Day for People Affected by Chagas”, for the symbolism of this day. This date has been used by FindeChagas to demand better strategies for coping with the disease. The creation of a World Day was presented to the member states of the World Health Organization (WHO) as a historic opportunity to transform the reality of millions of people and their families and communities. It is worth remembering that FindeChagas was officially created in October 2010 and currently comprises more than 20 associations spread across different countries (Argentina, Australia, Bolivia, Brazil, Colombia, Spain, United States, Italy, Mexico, Switzerland and Venezuela).
WHO this year was part of the campaign “Lets make Chagas disease visible now” and reinforced that awareness and the timely recognition of this disease, which is still frequently diagnosed late, is essential to improve the success rates of antiparasitic treatment with a cure, together with the interruption of its transmission. He also reiterated that there are important social and economic interventions as well as in the health sector, all based on evidence, including greater access to diagnosis in screening actions (blood, organs and newborns and children), early case detection, immediate treatment of cases (antiparasitic and for cardiac and digestive complications), vector control, hygiene and food safety.
Known as a silent and silenced disease and even though more than 110 years have passed since its discovery, despite advances, only a proportion less than 10% of people with Chagas disease is diagnosed, and only approximately 1% of those with an established diagnosis effectively receives treatment with antiparasitic drugs. According to WHO estimates, in the region of the Americas, especially in Latin America, about 6 to 7 million people have the disease, which causes, in addition to disability due to chronic Chagas heart disease, about 12 thousand deaths per year. Brazil was close, but still has not managed to control the disease in its territory. Currently millions of people are living with Trypanosoma cruzi infection. Such a situation reveals the magnitude of the disease as a chronic condition. The change in the epidemiological profile of new cases of the disease has changed, with the traditional scenario of intra-household vector transmission giving way to transmission linked to the wild cycle of the parasite with high concentration in the Amazon region, with about 300 new cases per year of the disease in its acute phase.
For the recognition of the millions of Brazilians with Chagas disease in its chronic phase, a relevant milestone for Brazil was the publication of Ordinance No. 264, of February 17 2020, which amended Consolidation Ordinance No. 4/GM/MS, of September 28 2017, to include chronic Chagas disease, in the National Compulsory Notification List of diseases, conditions and public health events in public and private health services throughout the national territory. This ordinance reflects the decades-long struggle to give greater perspective to Chagas disease in the country, enabling more reliable approximations about the real magnitude in our population.