Barriers to surveillance and control of re-emergence of the Chagas disease vector Triatoma infestans in Arequipa, Peru

Vector control is usually designed as a top-down system with limited capacity to respond to the unique characteristics of each epidemiological setting, or to adjust to routine stressors that challenge ongoing programs, such as resource limitations and competing priorities. Here, we investigated barriers in Chagas disease vector surveillance and control systems in Arequipa, Peru. We conducted in-depth interviews and a focus group with key stakeholders (n = 32) at different levels of the health system and community. For interviews, we used process maps to illustrate the workflow for passive and active surveillance. Additionally, we held a focus group with vector control specialists to present the findings from the interviews and discuss the results. We identified barriers at each step of the process, including systemic, operational, financial, and policy limitations. For passive surveillance, community participation was limited by practical challenges in capturing the insect and uncertainty about the pathways to report it. Systemic barriers were related to the use of a data system that did not meet the needs for recording and managing data on vector control activities. At the policy level, the establishment of quotas on the number of houses staff are required to inspect ignores important determinants for infestation and lacks an appropriate sampling design. We discuss the impact of the reported barriers to effective conduction of surveillance and control activities and the initiatives and strategies that have been designed and assessed to bridge these gaps in order to collaboratively design a more resilient health system.Author summary: Vector control strategies are usually based on hierarchical systems, resulting in the limited capacity to adapt to particular epidemiological scenarios or adjust to routine stressors. In Arequipa, Peru, despite successful control of the insects that transmit Chagas disease, challenges to sustain vector surveillance and control activities are numerous. We examined the barriers to sustained vector control by conducting in-depth interviews and focus groups with multiple stakeholders at different levels of the system. We identified significant barriers at each step of the passive and active surveillance processes, resulting in limited potential to respond to infestations and loss of information. At the individual level, barriers to reporting infestation included difficulties in capturing the vector and uncertainty about where or to whom to report it. At the operational level, we identified barriers regarding the quality and consistency of house inspections, as well as competing priorities, such as multiple tasks assigned to vector control specialists. At the system level, the use of an inadequate Health Information System (HIS) with no structure to record relevant information related to vector control activities. At the policy level, establishment of quotas on the number of houses to inspect without considering appropriate sampling. Development of resilient health systems is a collective endeavor involving affected communities, health staff and actors from multiple sectors. It is urgent to review strategies to better design resilient control systems for vector-borne diseases.