2013 Annuary Synthesis of the scientific, community and institutional work

Mundo Sano Foundation A year of celebrations, reflections and work

The year 2013 was marked by the 20th Anniversary of Mundo Sano: we devoted a lot of time to revise our past and reflect upon the future. Apart from working and reflecting, we have decided to share our happiness giving a party. Regarding the past, we can feel the result of our efforts and growth. The focus of our activity – diminishing the impact of neglected diseases – goes in line with what the World Health Assembly ratified at its 66th edition, in May 2013: fostering further development of new technologies to face these en- demic diseases. Working together Our sustained work in the field of research – generating the necessary evidence to contribute to design public policies, with an impact on the health agendas – has also provided good results. With even broader public-private contributions in the form of partnerships, we are currently a voice that can be heard in the national and international spheres. We have a great opportunity ahead into the future. And as usual, this means greater commitment. The opportunity is the result of what has been achieved so far. We have a high- ly experienced team, clear goals and we feel the enormous drive to participate in this type of social work that offers so- lutions and sense to what is being done. The consolidation of links with academic institutions guarantees continued knowledge building. The partnerships are sustained through time with the authorities, thus fulfilling one of our main axi- oms: public-private collaboration. Furthermore, the commu- nities ensure reliability: each time Mundo Sano knocks at a house door, that door opens up. This is a fundamental pillar; without participation of the local population there will not be sustainable results either. At the 20th anniversary celebration we are pleased to be ac- companied by representatives from all different sectors of the society, who offered their support. If our career has led us to a place of opportunities, the chal- lenge is to try to develop them as much as possible, continue gaining partners and accessing into new territories. I expect that these pages can provide you with the essence of what we do and how much it still needs to be built.

Dr. Silvia Gold Mundo Sano President

1 Mundo Sano is a non-profit organization that, since 1993, has been working to reduce the impact of the so-called neglected diseases, like , dengue, and several soil-transmitted helminths, among others. In order to do so, it articulates efforts with health authorities, universities, scientific personalities, civil society organizations, private sector actors and international organizations, generating replicable, scalable and transferrable programs. Its projects involve the communities affected, respecting their idiosyncrasies and habits. The results of community actions and the research carried out on site are being constantly assessed and disseminated through specialized journals, manuals and communication material and in other environ- ments for discussion, since they constitute a clear contribution to scientific knowledge. How Mundo Sano works

2 3 1 Chagas Facing an immense challenge

Chagas disease is originated by Trypanosoma cruzi, a parasite transmitted by vinchucas, which are insects that feed on blood and mainly live in rural and periurban areas of . After biting and feeding on blood, insects defecate immediately thus placing the parasites on the skin through their feces. When the person bitten scratches him or herself, lesions favoring access of the parasite into the body are gener- ated. Other means of transmission are as follows: blood transfusions, organ transplantations and congenitally, which occurs during pregnancy when the women affected transmit the to the babies they will give birth to. Chagas disease is diagnosed through specific blood tests and is treated with orally administered antiparasites. In the congenital cases assisted during the first year of life, the treatment’s efficacy rate is over 90% and there is great evidence of the good results produced by the treat- ment in chronic patients. Mundo Sano drives a series of community actions to prevent, diagnose and treat Chagas disease in endemic 90,000,000 and non-endemic areas of . In , it offers people all over the world are exposed training, develops sensitization programs for Latin to Chagas disease. American migrants and collaborates with several health centers in their diagnosis and treatment programs. 1.5-2 millions estimated people infected with Chagas disease, out of which 200 thousand live in Santiago del Estero province. Initiative

75 % Chagas of European cases of Chagas disease 1 occur in Spain, where it is estimated that there are between 48 thousand and Facing an immense 86 thousand cases of the total 68 thousand to 123 thousand cases in Europe. challenge

4 5 1 Chagas Chagas Week – Neglected Disease, Global Coalition for Chagas Disease. Facing an immense challenge on the score of the World Day of Chagas Disease.

In 2013, Mundo Sano started to work on sanitary improvement of dwellings at Lote 47, a rural spot near of Añatuya, where there are 188 inhabitants and 43 families living there. In the urban area of Pampa del Indio, Chaco, blood collections Mundo Sano has become part of were performed for the first time in order to diagnose Chagas Within the framework of the World Day of Like every year, Mundo Sano organized its symposium the Ibero American network for disease, with over 800 people taking part in it. Actions were sup- Chagas Disease – April 14 – the creation on neglected diseases and supported the realization research on Chagas Disease called ported by the municipality and the epidemiology area of the Minis- of the Global Coalition for Chagas Disease of the 9th Workshop on imported Chagas disease, car- NHePaCHa (New Tools for Diagno- try of Health of the Province. The plan intends to carry out further was announced, as a partnership aimed ried out by the Barcelona Institute for Global Health sis and Evaluation of Patients with diagnosis actions and treat all positive cases at local hospital at joining efforts to face Chagas disease (ISGlobal). Chagas Disease): It is a group of Dr. Dante Tardelli. from a comprehensive point of view, giving In commemoration of the World Day of Chagas research teams from nine countries For the third consecutive year, Mundo Sano and the Secretariat of priority to caring for the patients’ needs Disease­ , it took part in the Chagas Week – Neglected working on the search, develop- Health and Social Medicine of La Plata – a non endemic area – car- and as genuine support to the national Disease, which was held in Cochabamba, Bolivia, ment and improvement of tools ried out the program for diagnosis and treatment of Chagas dis- programs of endemic countries. It is con- where it shared spaces for discussion with experts and biomarkers for diagnosis and ease. The project consists of performing a risk survey to students stituted by Mundo Sano Foundation, the from several organizations like Pedro Alonso of IS- follow-up of people affected and attending public schools and putting into practice the tests for Institute for Global Health (ISGlobal), the Global, Felipe Guhl of Universidad de Los Andes and on the assessment of likely new detection of the infection in those cases identified as suspicious. , the DNDi (Drugs drugs for Chagas disease. Besides, Bernard Pécoul of the Drugs for Neglected Diseases for Neglected Diseases Initiative), the After the cases are positive, treatments are started and a fam- they share experiences, develop Initiative (DNDi), among others. Collective of Applied Studies and Social ily approach is made to detect likely new cases: all of them are strategies and train researchers Furthermore, it participated in a round table Development (CEADES) with the support prescribed to start treatment and perform clinical follow-up at the on the basis of the new knowledge discussing the gaps in research and the tools avail- of Doctors Without Borders (MSF) and the primary health care centers in the municipality. generated. able to fight Chagas disease at the meeting called International Federation of People Affect- In Spain, Mundo Sano launched the program Mothers committed In the local spheres, new tools have Advancing Life – Saving R&D Innovations for People ed by Chagas Disease (FINDECHAGAS). with Chagas disease aimed at educating infected women – coming been developed aimed at achieving Living with Chagas Disease – The Silent Killer, held in In November 2013, Mundo Sano and DNDi from the endemic area and living in Madrid – as health agents ca- a successful management of the Washington, the United States. It also participated signed a far-reaching agreement to devel- pable of developing sensitization actions and community activities data collected in Añatuya, Santiago in the Congress of the Spanish Society for Tropical op a second source of pediatric benznida- both in Spain and in their countries of origin. del Estero, within the framework of Medicine and International Health that was orga- zole – 12.5 mg – which will be produced by actions of vector surveillance and Likewise, as in recent years, a diagnosis campaign was made in nized in Murcia, Spain. Argentine laboratory Elea. Moreover, both control. Currently, and as a result Valencia, together with the Association of Patients affected by The work “Diseño y preparación de formas farmacéu- institutions will carry out several studies of the use of georeferences, Mundo Chagas Disease in Valencia, where 86 Latin American immigrants ticas sólidas de benznidazol para el tratamiento de la that are necessary to maximize the use Sano specialists are aware of the were evaluated, 34 of whom resulted positive and started treat- enfermedad de Chagas” was published in the Revista of the drug both in adults and children, status of domicile infestation in the ment at reference hospitals. argentina de salud pública (volume 4, number 15). It and new research will be started as well. region and possess a detailed da- In 2013, 1,800 residents in Spain were treated with the benznida- was done jointly with researchers from Córdoba and Currently, is the first choice tabase that includes demographic, zole developed in Argentina through a public-private consortium Rosario national universities, and was awarded a dis- drug to treat Chagas disease and it is entomological and social aspects coordinated by Mundo Sano. The medicine (Abarax®) was used by tinction as remarkable work, issued by the Ministry of considered an essential drug by the World of the area under intervention. 94 Spanish health centers. Health of the Nation. Health Organization.

Contributions Strategic Research Action to knowledge partnerships

10,000,000 people are infected by Chagas disease all over the world, according to World Health Organization estimates. Only 1% of those infected have access to the treatment.

6 7 2 Dengue When prevention is key

Dengue is a viral disease transmitted by the Aedes aegypti mosquito and it is endemic in over 125 countries. It is transmitted when a mosquito bites an infected person and a healthy person afterwards. The disease is not trans- mitted from person to person and severe cases can cause death. Recent research indicated that only one out of four cases presents with symptoms. Since there is no preven- tive vaccine, vector control tasks are crucial. For 10 years, Mundo Sano has been developing actions for prevention, sensitization and control in high-risk areas in the north of Argentina. Through home visits, it promotes good practices in water management, given its determining role in the proliferation of the dengue transmission mosquito. In each of the dwellings visited, containers are censed, samples of mosquito larvae and pupae are taken and larvicides are applied in those which cannot be removed or destroyed. The visit is comple- mented with the distribution of explanatory materials about the disease and recommendations on prevention. 50-100 millions dengue cases are diagnosed every year all over the world according to the World Health Organization. 2,5 % of the infected people die. Initiative 500,000 Dengue people have to be hospitalized per 2 year because of the dengue virus. When prevention is key

8 9 2 Dengue Participation in the II When prevention is key International Meeting for the control of Aedes aegypti.

Mundo Sano works on dengue prevention in stra- In all field laboratories, Mundo Sano has a system of tegic sites of Argentina: Clorinda, Formosa (by Pil- The detection of dengue breeding of local strains of Aedes aegypti mosquitoes comayo riverside, in front of Asunción del Paraguay); virus in male specimens (that which are the basis of different studies. At the same Puerto Iguazú, Misiones (on the Triple Frontier with time, in the laboratory of Clorinda it keeps breeding of Brazil and Paraguay) and Tartagal, Salta (less than 60 don’t feed on blood) of Aedes a reference strain (Rockefeller), following standards kilometers away from Yacuiba, Bolivia). There are field and recommendations of the Center of Plague and laboratories there, which are equipped for mosquito aegypti shows the transovarial Insecticide Research (CIPEIN). taxonomic determinations and biological testing. transmission of the virus. Within the framework of the research carried out to- Work teams are composed of members of the local gether with the Zoonosis Service at Muñiz Hospital, community and coordinated by professionals. the dengue virus was detected in male specimens One of the main preventive measures is to avoid the of Aedes aegypti: as males –unlike females– do not proliferation of breeding spots, through periodic feed on blood, this finding shows the transovarial visits to the homes of the intervened locations. Focus Mundo Sano collaborates with provincial transmission of the virus, which could be of greatest lock tasks are also conducted in the homes of people and municipal health authorities in den- importance to maintain viral circulation in interepi- with symptoms of fever, eliminating possible breeding gue prevention: In Puerto Iguazú it works demic periods. spots and applying insecticides to eliminate adult During the month of November, the II International in coordination with municipal teams In Tartagal (Salta), Mundo Sano’s team collaborated mosquitoes from the home and nearby areas. This Meeting for the control of Aedes aegypti was held which conduct focus locks. In this way, with the detection of Aedes aegypti populations task is conducted to prevent the likely transmission in Panama. Mundo Sano shared this debate area samples of mosquito immature stages resistant to regularly used insecticides in control from that potential virus carrier to the neighbors. Be- with prestigious institutions such as the Institute are collected and analyzed in Mundo actions (pyrethroids). This research arose from the sides, in Clorinda, Tartagal and Puerto Iguazú there is of Tropical Medicine Pedro Kourí, the Centers for Sano laboratory, where all the data are concern of the technical staff of the Ministry of collaboration with hospitals and municipalities in the Disease Control (CDC), the Pan American Health recorded for the future generation of Health of the Nation, who observed operational dif- development of aedic indexes used by the Ministry of Organization, the Commemorative Institute Gorgas indexes and the creation of abundance ficulties in the control tasks in the northern area of Health of the Nation, which is essential information and the Latin American Vector Control Network, maps. In addition, it accompanies the the province of Salta. Mundo Sano contributed with for the planning of prevention actions. among others. research project in clinical and immuno- biological material representative of the area to be In the summer of 2013, Mundo Sano conducted pre- Besides, the paper “Processes Affecting Aedes logical aspects of dengue conducted by studied in the laboratories of CIPEIN. ventive actions in some 300 city blocks of Tartagal aegypti (Diptera: Culicidae) Infestation and Abun- Fundación Infant. Besides, it developed a comprehensive data man- city, in a context of high risk: in the neighboring dance: Inference Through Statistical Modeling and For the fifth consecutive year, in Tartagal agement platform that allows, daily, to incorporate locations of Salvador Mazza and Yacuiba (Bolivia) Risk Maps in Northern Argentina” was published, it was fundamental to have the sup- records taken from the field. As a result of this tool’s hundreds of dengue cases were diagnosed. However, in volume 49 of the Journal of Medical Entomology; port and collaboration of Pan American use –which includes entomological, anthropological, thanks to the coordination and speed of lock actions, and the work Record of Aedes aegypti oviposition Energy, the Municipality and Provincial epidemiological, urban and environmental data – the it was possible to contain the situation in Tartagal, in Tartagal was presented at the XIII International Hospital “Juan Domingo Perón”, who ac- collected information is constantly updated and beating the summer period with only 21 confirmed Dengue Course, organized by the Institute Kourí of companied the actions of the community available for analysis. cases. La Habana, Cuba. prevention program.

Contributions Strategic Research Action to knowledge partnerships

40 % More than 125 of the population worldwide countries have reported is exposed to the dengue dengue cases. virus.

10 11 3 Soil-transmitted helminths A commitment with the community

Soil-transmitted helminths are a common sanitary problem in the entire region. According to Pan American Health Organization estimates, approximately 26 million school children in Latin America and the Caribbean are exposed to them. The chronic infection can have serious consequences on health, since it can give rise to malnu- trition, anemia, delayed neurocognitive development and, consequently, high school dropout rates and low productivity. Mundo Sano leads a program for detection and commu- nity treatment in endemic areas of Argentina, adminis- tering two highly efficient antiparasites in a single dose. This project includes assessment of the local epidemi- ology of soil-transmitted helminths, measurement of morbidity variables – including anemia and growth – the study of anthropological aspects and the development of health education activities. Another soil-transmitted helminth is hydatidosis, a disease that is characterized by the formation of cysts in 149 several organs, especially the liver, lungs, kidney, spleen, countries have neglected diseases, bones and central nervous system, which can be asymp- which affect over tomatic for several months, and even years. The cysts can be treated with drugs and, depending on the case, they can undergo surgery. 1,000,000,000 people Mundo Sano works in several locations of the province in a program for diagnosis of hydatidosis in school children. 870,000,000 children are at risk of becoming infected Initiative with some soil-transmitted helminth 127,000,000 3 Soil-transmitted people in Latin America live in poverty helminths and get a daily income lower than two dollars. A commitment with the community

12 13 3 Soil-transmitted helminths Detection and treatment of soil- A commitment with the community transmitted helminths program Amhara, Ethiopia.

In Tartagal, after first The program for diagnosis and treatment of several soil-transmitted helminths continues expanding: apart stage of treatment, anemia from the work performed in the localities of Orán and Mundo Sano participated in the workshop Compre- prevalence diminished from Tartagal, in Salta, first actions were started in the rural hensive efforts to control soil-transmitted helminths in area of Bahir Dar, Amhara, Ethiopia. the region of the Americas: Working together towards 55 to 14%. A total number of 3,000 people were treated in Orán, and a common goal, organized by PAHO in Bogotá, Co- With the approach to soil-transmitted hel- 3,683 in Tartagal. Work was carried out in the outskirts lombia. Health officials from 18 countries in America minths, diagnosis, treatment and research of those localities, where health conditions pose an gathered to stress joint actions and increasing cover- actions are made through the joint work of important risk for the population. age of deworming in children and adults. Mundo Sano with several partners. In Tartagal, after the first stage of treatment, the Besides, it developed anthropological research In Salta, the diagnosis is made with the labora- prevalence of anemia- in people with some type of on perceptions on the space and local knowledge tory of the Institute of Tropical Diseases of parasitosis- diminished from 55% to 14% after admin- regarding parasite infestations in Nueva Jerusalén Orán, which is run by Universidad Nacional de istration of the combined treatment of albendazole and neighborhood of Pichanal, Salta, whose inhabitants, Salta. Meanwhile, the field work is performed ivermectin. after having been treated, moved into new houses in together with the provincial Ministry of Health, In 2013, Mundo Sano started working in Ethiopia, aimed better sanitary conditions. through the work at hospitals Juan Domingo The component of research into soil-transmit- at determining the prevalence of S. stercoralis in chil- A total of 74 households were surveyed, with a major- Perón and San Vicente de Paul, of Tartagal and ted helminth projects is aimed at comparing dren living in the area and developing new comprehen- ity of the population over 20 years of age, aimed at Orán, respectively. two diagnosis methods to determine strongy- sive actions with a focus on soil-transmitted helminths. accounting for the social diversity of those affected In Ethiopia, the program is implemented to- loidiasis: the traditional coproparasitological Furthermore, it is expected to work on health education and identifying the criteria for cleanliness and dirt of gether with Health Institute Carlos III of Spain method and the serological one. The serologi- and apply measures tending to improve aspects of hy- the population affected, the perceptions of the new and a network of local actors, constituted by cal technique would show more sensibility giene and sanitation in the population affected.The first space to live in, and the ways in which they treat and the Regional Office of Amhara, the Regional than the coproparasitological one, enabling a results of this program showed that 80 per cent of the understand parasite infestations, so as to be able to Office of Education of Amhara, Bahir Dar greater detection of Strongyloides stercoralis, children analyzed in eight schools are infected with, at suggest proper health education actions. Regional Health Center and Research Labo- a soil-transmitted helminth that can cause least, one parasite. Given the high level of prevalence, Additionally, the Workshop to discuss the definition ratory, the School of Medicine and Health re- in humans and persist in the body and pursuant to recommendations by the World Health of tools and strategies to implement the programs to Sciences of Bahir Dar University, Woreda for periods even longer than 60 years. Organization, treatment with community reach will be control soil-transmitted helminths was organized. At Health Office in Bahir Dar and the Institute Besides, for massive community treatment of started. the meeting, Dr. Alejandro Krolewiecki of the Institute for Research on Health and Nutrition in Addis these soil-transmitted helminths, efficacy of In that respect, the work carried out by Mundo Sano for of Research on Tropical Diseases of Universidad Na- Abeba. the provision of two antiparasites (albenda- the diagnosis of hydatidosis, more than 500 ultrasound cional de Salta ; Dr. Patrick Lammie of the Centers for Meanwhile, the program for diagnosis of zole and ivermectin) combined in an innova- scans were performed in the rural area of the city of Disease Control and Prevention (CDC); Dr. Luis Alvarez hydatidosis is working jointly with the Direc- tive manner and administered in a single dose Azul, Buenos Aires province, making it possible to iden- of the Veterinary School of Universidad Nacional del torate of Rural Zoonoses of the Buenos Aires is tested, thus simplifying the tify four positive cases and two suspicious cases that Centro of Buenos Aires, and Dr. Fernando Toneguzzo province and the Zoonosis Service of Hospital actions. need complementary studies. of Elea Laboratory made their presentations. Francisco Muñiz.

Contributions Strategic Research Action to knowledge partnerships

+26,000,000 school children in Latin America and the Caribbean are exposed to several types of soil-transmitted helminths.

14 15 Challenges that go beyond borders: from Argentina to the world

Clorinda Provínce of Formosa Barcelona Madrid Puerto Iguazú Valencia Provínce of Misiones Tartagal Provínce of Salta

Pampa del Indio Provínce of Chaco

Añatuya Amhara Region Provínce of Santiago del Estero Argentina Argentina Buenos Aires Etiopía Areas of action Expansion

Mundo Sano is present in strate- As a result of the partnerships engaged in with gic areas of Argentina affected various international organizations, Mundo Sano by various neglected diseases. carries out intervention programs in diverse There, its own work teams work latitudes. In Spain, Mundo Sano counts on a work alongside the local communi- team of its own – in partnership with Valencia África ties. Their models are replicable, General University Hospital and Murcia and transferable and scalable, which Valencia patient associations – which develops is why they can be implemented programs for prevention, training, diagnosis in various scenarios, respecting and treatment of Chagas disease destined to the particularities of the commu- Latin American migrant communities. It also nities intervened. maintains cooperative relationships with the Bar- celona Center for International Health Research (CRESIB), Ramon y Cajal Hospital and ISGlobal, among others. In Ethiopia, it carries out a program of diagnosis and community-based treatment for various parasitoses together with Health Institute Carlos III of Spain, Bahir Dar University and a network of local organizations.

16 17 4 Leishmaniasis Prevention and diagnosis in the country and the city

Leishmaniasis is a transmitted by the bite of small flying insects of nocturnal habits – phle- botomous – which are virtually imperceptible. There are two types of leishmaniasis: cutaneous and visceral. The cutaneous causes serious and multiple skin lesions and the visceral damages various organs (especially the liver and the spleen) and can lead to death. Both can affect humans and animals, domestic and wild ones as well. It does not spread between people, or from animals to people: the transmission occurs when the insect bites an animal or a person infected and then bites a healthy person. Mundo Sano works in rural and urban areas of strategic points in Argentina, where activities of monitoring of vectors are carried out for further research in its laboratories. It also draws risk maps and performs diagnosis on dogs that live with humans in endemic areas.

1,300,000 new cases are identified annually, according to the WHO. 1,000,000 Initiative cases correspond to cutaneous leishmaniasis. 4 Leishmaniasis 300,000 Prevention and cases correspond to visceral leishmaniasis. diagnosis in the country and in the city

18 19 4 Leishmaniasis Unprecedented finding of Lutzomyia Publishing of the paper The first Prevention and diagnosis in the country and the city longipalpis, the visceral leishmaniosis record of Lutzomyia longipalpis in the vector, in the outskirts of Tartagal, Salta. Argentine northwest, in the memory of Oswaldo Cruz Institute. The disease is prevalent in 98 countries around the world: the most impacted areas are the African continent, the South-East of Asia and Latin America.

Monitoring and surveillance of phlebotomous are the Within the framework of the research on leishmani- main actions carried out by Mundo Sano at critical asis carried out in 2013, an unprecedented finding points in Argentina. In 2013, Mundo Sano surveyed, The investigations being conducted by Mundo Sano in the history of north-western Argentina was through three sets of simultaneous monitoring, the in entomological control and diagnosis of risk for made: Mundo Sano and researchers of Universidad presence and abundance of leishmaniasis vector leishmaniasis are published in various environments de Tucumán – both members of the Research insects in Clorinda, Pampa del Indio and Tartagal. of scientific debate. In 2013 the article “Spatial Distri- Network for Leishmaniosis in Argentina (REDILA) These actions add to those being developed in Puer- bution of Phlebotominae in Puerto Iguazú –Misiones, – have identified the presence of Lutzomyia lon- to Iguazu since 2010. The data collected is shared Argentina–Brazil–Paraguay Border Area” was pub- gipalpis, the visceral leishmaniosis vector in the and transferred onto a national map elaborated by lished in volume 55, number 4 of Revista del Instituto There are many agencies that accompany outskirts of Tartagal, Salta. the Research Network for Leishmaniosis in Argenti- de Medicina Tropical of Sao Paulo. Mundo Sano in its work on leishmaniosis Given the importance of this unprecedented na (REDILA) and the National Program for Leishmani- The work Diagnosis of Urban Visceral Leishmaniosis research and diagnosis. In Pampa del finding, provincial and national health authorities osis of the Ministry of Health of the Nation. in Puerto Iguazú City, Misiones Province, Argentina Indio it works together with Universidad were informed and a work plan was established In addition, together with the National Institute of was also presented within the framework of the fifth Nacional del Nordeste and local hospital in order to determine the level of risk of urban Tropical Medicine and the CIPEIN, possible trials are edition of the World Congress on Leishmaniasis that Dante Tardelli. transmission of Lu. longipalpis in the region. To being designed aimed at establishing recommenda- took place in Porto do Galhinas, Brazil. In other localities, it is supported by In- that aim, it is necessary to increase surveillance tions for the control of foci of Lutzomyia longipalpis, Likewise, the memory of Oswaldo Cruz Institute – in stitute Dr. Abraham Willink of Universidad and follow the evolution of the prevalence of the visceral leishmaniasis vector. Actions at the en- its volume 108, December, 2013 – published the paper Nacional de Tucumán, the National Center disease in the dog population. It is also necessary tomological level and the results of the diagnostic The First Record of Lutzomyia longipalpis in the Ar- for Diagnosis of Research on Endemo- to alert the health systems of the region and carry program in the canine population of Puerto Iguazu, gentine Northwest, which reports on an unprecedent- epidemics and the National Institute of out monitoring along time to observe the disper- developed by Mundo Sano in 2012, are fundamental ed finding of the vector of the visceral leishmaniasis Tropical Medicine, both of the Ministry of sion of the insect vectors. elements for the design of this line of work. in Salta, in the north of Argentina. Health of the Nation.

Contributions Strategic Research Action to knowledge partnerships

It is estimated that leishmaniasis causes between 20,000- 40,000 deaths per year.

20 21 5 Research and access to treatments

After twenty years of experience on site and of genera- tion and integration of multiple networks, Mundo Sano is capable of detecting problems of sanitary impact, estab- lishing relationships with the authorities and articulating efforts, both with other organizations and with private sector companies, so as to find the best solution. Towards the end of 2011, the important crisis in benz- nidazole production that hit the world, drove Mundo Sano to face a new challenge: gather, together with the Ministry of Health, pharmaceutical companies Maprimed and Elea to develop in Argentina in a comprehensive 2,481 manner, medicines for the ethiological treatment of people were tested within the framework of Chagas disease. the program for diagnosis and treatment of With all the actors’ commitment, in March 2012 the first Chagas disease that is being carried out in thousand treatments were handing in to the national La Plata, Buenos Aires province: 181 were health authorities; in October said year, it started to be exported and since 2013 all countries in America positive and were treated with benznidazole. can access to the benznidazole produced in Argentina through the strategic fund of the Pan American Health Organization (PAHO). In the same sense, Mundo Sano works on the research and Elea laboratory on the initial development of two 837 antiparasitic drugs – ivermectin and albendazole – people participated in the program for which were not available in Argentina for human use. diagnosis of Chagas disease carried out Currently, after having obtained the registry of the two drugs, progress in being made on their combination, in Pampa del Indio, Chaco, during 2013. which is key to ease community administration in public health programs. 33,210 bottles of benznidazole made in Argentina were bought by the Ministry of Health of the Nation: 17,198 50 mg ones and 16,012 100 mg ones that Research are distributed for free through the National 5 Chagas Program. Furthermore, the medicine and access to was exported to Spain, Australia, Switzerland, Italy and Panamá. treatments

22 23 5 Research and access to treatments Mundo Sano is working jointly with CRESIB in a biomarkers study to be able to find parameters that can evaluate evolution and cure of the disease. Mundo Sano has already started to develop Benznidazole pediatric formulation together with the Drugs for Neglected Diseases iniciative (DNDi).

Mundo Sano designs all its projects on the basis on multidisciplinary and mul- The projects guided towards finding tools or de- tisector platforms, where the expertise velopments that improve access to the treatments and competence of several organization are big efforts in terms of research. In the case converge to add value and transform the of benznidazole, Mundo Sano has contributed to lives of the populations exposed to sev- generate evidence in terms of prevalence, case eral neglected diseases. distribution and scientific progress on the issue. For the development of benznidazole, This information facilitated the work of the it worked in an articulate manner with synthesis of the active principle and the galenic Argentina Ministry of Health and compa- development to manufacture the medicine, which nies Maprimed (in charge of the chemical is produced in 50 mg and 100 mg double-grooved synthesis of the active principle) and Elea pills that are easily diluted to ease administration After developing all the production processes of The important results contributed by the multidis- (responsible for the galenic development, in children and adults. benznidazole in Argentina, Mundo Sano continues ciplinary and multisector experiences are dissemi- registry, production and distribution Likewise, Mundo Sano continues participating in working to make it accessible for all the populations nated by Mundo Sano in several environments for of the drug). Meanwhile, it has already the design of clinical studies and collaborating affected. In this sense, it collaborated in negotiations discussion and scientific debate. Besides, it coordi- started developing its pediatric formula in international research tending to optimize the to distribute the medicine to the governments of nated the project developed by Universidad Nacional together with Drugs for Neglected Dis- results with benznidazole and assess likely devel- endemic countries, through the Revolving Fund of the de Córdoba and Universidad Nacional de Rosario, eases initiative (DNDi). opments of new presentations and formulations. Pan American Health Organization. called “Diseño y preparación de formas farmacéu- In order to treat several soil-transmitted In this sense, work is being made jointly with In Spain, it accompanies the tasks of several re- ticas sólidas de benznidazol para el tratamiento helminths, it works together with Elea CRESIB in a biomarkers study to be able to find search centers and health professionals aimed at de la enfermedad de Chagas”, published in Revista Laboratory in the development of a co- parameters that can evaluate evolution and cure improving access to diagnosis and treatment of the Argentina de Salud Pública and awarded with Special formulation of albendazole and ivermectin of the disease, and research aimed at assessing disease. All these tasks are jointly carried out with Distinction 2013 by the Health Research National for improved administration in deworming new therapeutic candidates was supported. Elea Laboratory. Commission (Comisión Nacional Salud Investiga). programs.

Contributions Strategic Research Action to knowledge partnerships

24 25 6 Sanitary improvement of rural houses

Mundo Sano develops its work and research programs in close relation with the communities affected. Respect and understanding of the habits and uses of the selected communities and the construction of links that are sustained along time make up an addressing modality that makes it possible to improve the strate- gies for vector control. Since 2005, it has been carrying out a program for sani- tary amelioration of the rancho houses in the rural area of Añatuya, Santiago del Estero. Within the framework of this program, it offers workshops of theoretical training for the transfer of knowledge and practices aimed at modifying habits so as to reduce the risks in presence of the vector and at improving the sanitary quality of the domicile environment. All the activities carried out by Mundo Sano – both ento- mological surveillance and sanitary improvement – are based on community participation, which is a key factor to achieve results sustainable along time. A total of 1,688 domicile visits were made during the year 2013, within the framework of the actions for prevention and control of Chagas disease that are performed in the rural and urban area of Añatuya, Santiago del Estero.

A total of 1,119 inhabitants were benefitted with the program for sanitary amelioration of rural houses.

A total of 231 6 Sanitary families changed their living conditions thanks to the program for sanitary improvement of amelioration of rural houses carried out in Añatuya, Santiago del Estero. rural houses

26 27 6 Sanitary improvement of rural houses Programs and strategies for surveillance and control of Triatoma infestans in the city of Añatuya (Santiago del Estero, Argentina) and its rural area presented Improvements such as in the 48th Congress of the Association of roof waterproofing, wall Tropical Medicine of Brazil. plastering, and well and letrine construction were implemented.

Many presentations at scientific congresses have derived from the experiences in Añatuya, Santiago del Estero. Specialists from entire region have high- lighted the effectiveness of these innovative tools for Chagas disease prevention. The program for sanitary improvement of This program is one of the main prevention actions Some of the papers presented are as follows: Pro- rural houses encompasses a series of actions against Chagas disease developed by Mundo Sano in grams and strategies for surveillance and control of derived from different disciplines. After eight Añatuya, Santiago del Estero. It encompasses a set of Triatoma infestans in the city of Añatuya (Santiago years of actions on site, Mundo Sano team activities carried out in different rural spots, which are del Estero, Argentina) and its rural area, at the 48th Both the human resources that coordinate works have measured the results in terms of implemented together with the community. Diagnosis of Congress of the Association of Tropical Medicine of the project for sanitary improvement of chemical treatment of the houses and their the infestation of houses and peridomiciles is done in the Brazil; Lecciones aprendidas en el abordaje de la rural houses and the materials needed for peridomiciles; they found better tools for wa- first place and important sensitization and training activi- enfermedad de Chagas, at the 2nd National Meeting intervention in the domiciles are provided terproofing the roofs and plastering the walls ties are fostered together with the neighbors in each spot. on Neglected Diseases and 14th International Sym- by Mundo Sano to the community. In order and incorporated the construction of wells and After spraying the houses, roofs are waterproofed with posium of Epidemiological Control of Vector-borne to carry out these actions, the support latrines to respond to fundamental needs for plastic material so as to avoid filtrations and preserve Diseases, and “Mejoramiento de viviendas con par- and commitment of the different partners, an adequate quality of life. ceilings and inside plaster. ticipación comunitaria para la prevención y el control such as Grupo Insud, Pfizer Laboratories and Johnson SC is needed. They also presented progress on the methods A mixture of mud and additives obtained from plants de la enfermedad de Chagas en comunidades rurales for data collection and management: Mundo typical of the area, like penca tree is used for the plaster; del sureste de Santiago del Estero”, in volume 13 of INTA (National Institute of Agricultural Sano possesses georeferred tools that are then, walls are whitewashed with lime. Besides, wells are the journal Enfermedades Emergentes. Technology), an institution with broad used to generate specific cartography that ac- made for water storage and latrines for the proper man- At the same time, experts on the issue agree in experience in rural community work, gives counts for the state of situation of the houses agement of human waste. Furthermore, barnyards are highlighting that this program is a genuine example its support at the local level. intervened and the new buildings constructed. rebuilt and if it is necessary, they are relocated so that of community action going beyond the problem of Like all the other programs carried out by Besides, it provides information on demo- animal distribution does not increase the risk of reinfes- the disease, building strong relations between the Mundo Sano, this is accompanied by the graphic, entomological and social aspects. tation with vinchucas in the dwellings. neighbors of the rural spots intervened. provincial health authorities.

Contributions Strategic Research Action to knowledge partnerships

28 29

Contributions Partnerships and agreements: to Science working together

4th International Apart from that, in June, it organized a discus- Mundo Sano is a Joint articulation of efforts is a founding premise Since 2012, it has been part of the global ini- Meeting on Neglect- sion workshop on Chagas: cared for disease Member of the in the work model carried out by Mundo Sano. It tiative Uniting to combat NTDs¸ that is led by ed Diseases and in which specialists from several areas of Group of Founda- is for that reason that during 2013, it was incor- the Bill & Melinda Gates Foundation and the 16th Symposium the health spheres took part. In the meeting, tions and compa- porated as a member of the Group of Foundations World Health Organization. Mundo Sano par- on Epidemiological organized by Mundo Sano and Elea Labora- nies (GDFE) and and Companies (GDFE) and as part of the Board of ticipates through its Challenge project, whose Control of Vector- tory, the clinical aspects of Chagas disease takes part in the Directors of the Social Sector Forum. goal is to expand the reach of the activities borne Diseases Board of Directors were addressed as well as the way to face Apart from that, it is a member of the Global related to Chagas disease that are currently of the Social Sec- treatment both in endemic and non-endemic Chagas Disease Coalition, together with the Drugs underway in the localities in Santiago del tor Forum. areas, taking as an axis the guiding paradigm for Neglected Diseases Initiative (DNDi), the Insti- Estero, Chaco and Buenos Aires. Besides, of the patients’ needs. The speakers were: tute for Global Health of Barcelona (ISGLOBAL), Mundo Sano works jointly with other countries Mahmoud Traina of California University, Los Sabin Vaccine Institute and the Collective of Ap- in Latin America to replicate these models in Angeles, the United States; Sergio Sosa Es- plied Studies and Social Development Juan XXIII the continent and it is already implementing tani, of National Institute of Parasitology Dr. (CEADES). its first project in Ethiopia, . In 2013, Mundo Sano held the 4th Interna- Mario Fatala Chaben, Tomás Orduna of Infec- Uniting to combat NTDs is composed of non- tional Meeting on Neglected Diseases and tious Diseases HospitalDr. Francisco Muñiz profit organizations like the Bill & Melinda 16th Symposium on Epidemiological Control and Jaime Altcheh of Children’s Hospital Dr. Gates Foundation, DNDi and Mundo Sano – the of Vector-borne Diseases, with the support of Ricardo Gutiérrez, among others. only Latin American NGO –, the 13 most impor- the Pan American Health Organization and the In turn, Mundo Sano representatives were tant companies in the pharmaceutical indus- Ministry of Health of Argentina. part of several international meetings like Mundo Sano is try in the world, World Bank and governmental Over 300 professionals from different health The Second Latin American and the Caribbean part of Uniting agencies UKaid and USAID, among others. specialties participated in this meeting, which Congress on global health held in Santiago de to combat NTDs, was aimed at analyzing the impact generated Chile; the session Chagas Disease: a current together with the by migrations regarding neglected diseases, challenge in global health, that took place in Bill & Melinda Gates Foundation, among other goals. Valencia General University Hospital; the 8th DNDi, the 13 Presentations were made by remarkable World Conference on scientific journalism held pharmaceutical health professionals from prestigious institu- in Helsinki, Finland; the Training Course on companies the tions, such as Anavaj Sakuntabhai from the In- Chagas held in Alicante, Spain, and the Ses- World Bank and It also signed a collaborative agreement with stitut Pasteur of Paris, Pilar Aparicio of Carlos sions on immigration and health at Drassanes governmental DNDi to work in the development of a second III Health Institute, Luis Ochoa of Universidad Hospital, in Barcelona, Spain. agencies UKaid source of pediatric benznidazole. As a result of Pontificia Bolivariana of Medellín, Andrea and USAID. this agreement, Argentine laboratory Elea will Gamarnik of Leloir Institute Foundation and be the second producer of benzidazole pediatric Delia Enría of National Institute of Human treatment at a global level. Besides, both organi- Viral Diseases Dr. Julio Maiztegui. zations are expecting to carry out several clinical The meeting ended with projection of the studies that are necessary to optimize the use of institutional spot “Unattended and neglected the drug both in adults and in children. diseases”, directed by filmmaker Carlos Sorín, In turn, within the framework of the projects of which narrates the work that Mundo Sano has diagnosis and treatment of Chagas disease, and been carrying out for 20 years to reduce the thanks to the agreement signed with Bunge y Born impact of several neglected diseases. Foundation, six distance learning courses will be organized for professionals under the primary health care system.

30 31 Acknowledgements Objectives 2014: Realization of the actions de- We stress our deep acknowledge- scribed in the present memory ment to official, private, national have been made possible thanks and international institutions from La Plata to Ethiopia to the tenacious collaboration of which keep strong collaborative Romikin S.A., Chemotécnica S.A., relations and ties with us. Laboratorio Elea S.A., Biogéne- We specially thank the National sis–Bagó S.A., Garruchos S.A.and Commission of Spatial Activities, Grupo Insud as a whole, who have which constantly offers its sup- More than 11,000 kilometers away from the always given their technical and port and technical assistance. financial support, with special capital city of Buenos Aires, in Ethiopia, We have been working together to emphasis on the collaboration implement a platform for remote Mundo Sano continues working to fight soil- given by Grupo Chemo through access to georeferred databases, transmitted helminths, a copy of the innova- Fundación Mundo Sano España. generated at different operation tive and successful experience that it has The following companies have centers in Argentina, with imme- been developing since 2010 in Salta province, collaborated at the 2013 sympo- diate and permanent updating of sium organized by Mundo Sano: the variables recorded. where over 6,600 people treated achieved Laboratorio Elea, Chemotécnica, We would also wish to highlight considerable improvements in their quality Chemo Group, Biogénesis Bagó, the work of the remarkable rep- of life. The program that was started in eight CAIF, SC Johnson, Pan American resentatives from the scientific schools in Amhara, Ethiopia, estimated a Energy, Alto Paraná, Sinergium spheres that accompany us in Biotech, Roemmers, Farmacity, prevalence of soil-transmitted helminths at each of the projects executed at Gas Natural Fenosa, GlaxoSmith- our operation centers and who around 80 per cent. Due to this high level of Kline, Telecom, Novartis, Baliar- permanently join efforts in our prevalence, the next step is to perform mas- da, Bagó, Sanofi Pasteur, Track & actions: Dr. Mario Zaidenberg, sive community treatment.. Trace and Triquim. Dr. Delia Enría, Dr. Héctor Freilij, Likewise, we wish to express Dr. David Gorla, Dr. Ricardo The work on African territory is jointly car- out recognition to Friends for a Gürtler, Dr. Marina Stein, Dr. ried out with the National Center of Tropical Healthier World (Amigos por un Jorge Bolpe, Dr. Joaquim Gascon, Medicine of Health Institute Carlos III, the Mundo Más Sano) who favor the Dr. Daniel Salomón, Dr. Alfredo Catalan International Health Program, both actions carried out by this institu- Seijo, Dr. Elsa Segura, Dr. Sergio tion through their contributions. Sosa Estani, Dr. Alejandro from Spain, and University Bahir Dar within Apart from that, we want to Krolewiecki and Dr. Tomás Or- the framework of the global initiative aimed The work that Mundo Sano has been carrying express our gratitude to SC John- duna, among other remarkable at fighting neglected diseases, which is led son and Pan American Energy professionals. out in several spheres in terms of research, by the Bill & Melinda Gates Foundation and of -UTE Acambuco who particularly Lastly, we wish to offer hearty prevention, diagnosis and treatment of ne- which Mundo Sano is a member of. The next support some of our projects: the acknowledgement to the team glected diseases will be having new chapters program for sanitary improve- of Mundo Sano collaborators stage of the work, also focused on the infant and horizons in 2014. On the one hand, the ment of rural houses in Añatuya, and permanent staff members, population, will be in Benguela province, first municipal program for diagnosis and Santiago del Estero, and of den- whose devotion and commitment Angola. gue prevention in Tartagal, Salta. make it possible to attain the treatment of Chagas in La Plata city, carried goals set and reinforce our strong out together with the Secretariat of Health of belief that it is possible to prog- the Municipality of La Plata, and which is a ress towards new challenges. unique experience in a non-endemic area. It plans to test population to detect the disease Silvia Gold in school children at public schools and, after President Mundo Sano Foundation the positive cases, to address the family for its diagnosis, treatment and clinical follow- up in the local health centers. This project stemmed from a first pilot program developed in La Plata in 2010, where almost 200 people –17 children among them–were treated with benznidazole produced by Elea laboratory and which is distributed through the National Chagas Program. www.mundosano.org

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