Correspondence
Access to Chagas disease treatment in nonendemic countries: the case of Spain Access to diagnosis and treatment of a neglected tropical disease is a global challenge, both in endemic and nonendemic countries. Ana RequenaMéndez and colleagues (April, 2017)1 suggest that screening for Chagas disease in asymptomatic Latin American adults living in Europe is a cost-effective strategy. Mundo Sano— aware of the difficulties that migrants face coming from areas where Chagas disease is endemic in accessing healthcare services—has been boosting this strategy in Spain since 2011, and with Strongyloides stercoralis screening, since 2016. Within the discussion, RequenaMéndez and colleagues pointed out two main challenges in the implementation of Chagas disease screening programmes, among others: legislative differences across Europe and changes in migratory flows. We fully agree with these considerations and have discussed them in relation to Chagas disease screening in Germany, a European country where the scenario could change in the future.2 We would like to highlight that these differences need to be considered also at a regional level, and not only regarding screening but also treatment. In Spain, the European country with the highest prevalence of Chagas disease, the health-care system legislation varies among the different regions. Since the benznidazole (firstline treatment for Chagas disease) shortage was announced in November 2011, a public–private partnership was established in Argentina to produce a new benznidazole. With the impulse of Mundo Sano, in just over a year (December, 2012), the drug became available again in Spain thanks to its official recognition as a foreign medication by the Spanish Agency of Drugs and Sanitary Products www.thelancet.com/lancetgh Vol 5 June 2017
(AEMPS).3 Patients have to pick the drug up at the hospital or at the regional health service (Foreign Drugs Supply Department), depending on the region where the patient is settled. The price of the drug is also different among Spanish regions. Therefore, because Spain is the only country in Europe with authorised access to benznidazole, this situation could indirectly add new barriers to those seeking Chagas disease screening or treatment, potentially hampering their comprehensive care. Although specific treatment in the chronic phase remains controversial, as Marianela Castillo-Riquelme says,4 mother-tochild transmission of T cruzi can be avoided by treating infected women before pregnancy.5 More than 5200 Chagas disease patients have been treated in 160 Spanish health-care centres following the normal procedures of the national and regional health-care system in the past 4 years (unpublished, Navarro M), representing around 10% of all estimated Chagas disease cases in Spain. 6 These data are striking because, although no official global figures exist, no more than 1% of those infected are believed to receive any treatment at all.7 Mundo Sano is collecting data about the abovementioned heterogeneity to generate useful evidence for public health policymakers who seek to improve access to Chagas disease diagnosis and treatment.
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Navarro M, Berens-Riha N, Hohnerlein S, et al. Cross-sectional, descriptive study of Chagas disease among citizens of Bolivian origin living in Munich, Germany. BMJ Open 2017; 7: e013960. Law 29/2006, of July 26, regulating the availability of drugs in special situations. Government of Spain´s Official Newsletter. July 20, 2009. http://www.boe.es/boe/ dias/2009/07/20/pdfs/BOE-A-2009–12002. pdf (accessed March 21, 2017). Castillo-Riquelme M. Chagas disease in non-endemic countries. Lancet Glob Health 2017; 5: e379–80. Fabbro, DL, Danesi, E, Olivera, V, et al. Trypanocide treatment of women infected with Trypanosoma cruzi and its effect on preventing congenital Chagas. PLoS Negl Trop Dis 2014; 8: e3312. Navarro M, Navaza B, Guionnet A, et al. Chagas disease in Spain: need for further public health measures. PLoS Negl Trop Dis 2012; 6: e1962. Ribeiro I, Sevcsik AM, Alves F, et al. New, improved treatments for Chagas disease: from the R&D pipeline to the patients. PLoS Negl Trop Dis 2009; 3: e484.
We thank Bárbara Navaza (University of California, Riverside, CA, USA) for proofreading of the manuscript. We declare no competing interests. Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.
*Miriam Navarro, Juan J de los Santos
[email protected] Fundación Mundo Sano, Madrid 28046, Spain 1
Requena-Méndez A, Bussion S, Aldasoro E, et al. Cost-effectiveness of Chagas disease screening in Latin American migrants at primary health-care centres in Europe: a Markov model analysis. Lancet Glob Health 2017; 5: e439–47.
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