Chagas disease and housing improvement in northeastern Brazil: a cross-sectional survey

Predictor Variables in the Spread of Chagas Disease in Rural Areas

Over a hundred years ago after the discovery of Chagas disease (CD) in Brazil, the World Health Organization estimates a number of 6 to 7 million people infected by Trypanosoma cruzi worldwide. Therefore, the goal of this work was to identify variables related to the spread of infection by T. cruzi in humans living in rural areas, seeking predictor variables. A systematic review of the literature has been conducted, with a search in the Scopus platform, using the search string "Chagas disease" and "rural", resulting in 85 valid and analyzed scientific studies (1977 and 2022). Twenty-seven predictor variables have been acquired, and 19 of them have been grouped, such as: socioeconomic and educational, housing, environmental, sanitary, and cultural; and 8 variables related to T. cruzi seropositive individuals. The predictor variables yielded significant results (p-value < 0.05) in 59.5% of the cases (195/328), with a median of 66.7%. In other words, studies relating to 50% of the 27 variables showed significance equal to or greater than 66.7% of the time. The independent variables with the highest proportion of significant data (p-value < 0.05) were Education (87.6%), Intradomicile building (70%), Domestic animals (69.6%), and Triatomines (69.2%) in the households. Some variables reached 100%; however, few articles were found, indicating the need for further research, especially for Sanitation and Culture. It has been concluded that, in the several contexts found, the social vulnerability and lack of information led the individual to living in environments where inhabitability is inadequate, to perform limited work activity and develop habits and behaviors which impair them in an environmental insalubrity situation, favorable to the access of vectors and pathogens of anthropozoonoses such as CD.

[Estimation of prevalence of chronic Chagas disease in Brazilian municipalitiesEstimación de la prevalencia de la enfermedad de Chagas crónica en los municipios brasileños]

Objective

The objective of this study is to estimate the prevalence of chronic Chagas disease (CCD) in Brazil: in the general population, in women, and in women of childbearing age.

Methods

A meta-analysis of the literature was conducted to extract data on the prevalence of CCD in municipalities in Brazil in the 2010-2022 period: in the general population, in women, and in women of childbearing age. Municipal-level CCD indicators available in health information systems were selected. Statistical modeling of the data extracted from the meta-analysis (based on data obtained from information systems) was applied to linear, generalized linear, and additive models.

Results

The five most appropriate models were selected from a total of 549 models tested to obtain a consensus model (adjusted R2 = 54%). The most important predictor was self-reported CCD in the primary health care information system. Zero prevalence was estimated in 1 792 (32%) of Brazil's 5 570 municipalities; in the remaining 3 778 municipalities, average prevalence of the disease was estimated at 3.25% (± 2.9%). The number of carriers of CCD was estimated for the Brazilian population (~3.7 million), for women (~2.1 million) and for women of childbearing age (~590 000). The disease reproduction rate was calculated at 1.0336. All estimates refer to the 2015-2016 period.

Conclusions

The estimated prevalence of CCD, especially among women of childbearing age, highlights the challenge of vertical transmission in Brazilian municipalities. Mathematical projections suggest that these estimates should be included in the national program for the elimination of vertical transmission of Chagas disease.

Kissing Bug Intrusions into Homes in the Southwest United States

Kissing bugs readily enter homes in the Sonoran Desert and bite the residents. Their saliva is highly antigenic, causing local and systemic skin reactions and life-threatening anaphylaxis. We attempted to determine what characteristics of homesites may have contributed to home intrusion by kissing bugs. Extensive and detailed information about the homes and the home environment was collected from 78 homeowners in Tucson who suffered kissing bug intrusions. Homeowners collected 298 Triatoma rubida in and around their homes. Of the homes entered by kissing bugs, 29 of 46 (63%) contained bugs harboring Trypanosoma cruzi. Although in the aggregate, homeowners were bitten > 2200 times, no individual tested positive for Chagas disease (N = 116). Although yearly intrusion likely occurs in some homes, T. rubida does not domiciliate within homesites in the Desert Southwest. We conclude there is little risk to homeowners for Chagas disease given the current behavior of resident kissing bugs and absent ingesting kissing bug fecal matter.

Assessing the entomo-epidemiological situation of Chagas disease in rural communities in the state of Piauí, Brazilian semi-arid region

BACKGROUND

In northeastern Brazil, the wild nature of Trypanosoma cruzi vectors has challenged control actions. This study aims to describe the entomological and epidemiological scenario of Chagas disease in rural communities in the state of Piauí.

METHODS

A cross-sectional study (n=683 individuals/244 dwellings) was carried out to obtain serum samples, sociodemographic data and intra- and peridomestic triatomines.

RESULTS

The overall seroprevalence rate was 8.1%, with no positive tests among subjects <30 y of age. Prevalence rates reached 34.3% and 39.1% among subjects 61-75 and >75 y of age, respectively; 1474 triatomines were collected, of which 90.3% were found in peridomiciliary structures and 9.7% inside houses; 87.2% were classified as Triatoma brasiliensis. T. cruzi infection rates in insects were 0.5% by light microscopy and 0.9% by culture in NNN/LIT medium. Five cultivated isolates were submitted to molecular genotyping, three of which were identified as T. cruzi I and two as T. cruzi II.

CONCLUSIONS

Although no vector transmission currently occurs, prevalence rates are high in adults and the elderly. This disease should be targeted by primary healthcare providers. Insect surveillance and control activities should not be discontinued in an environment favourable to the perpetuation of house colonization by triatomines.

The risk of oral transmission in an area of a Chagas disease outbreak in the Brazilian northeast evaluated through entomological, socioeconomic and schooling indicators

Chagas disease is a neglected tropical disease strongly associated with low socioeconomic status, affecting nearly 8 million people - mainly Latin Americans. The current infection risk is based on acute case reports, most of which are typically associated with oral transmissions. In the semi-arid region of Northeastern Brazil, serious outbreaks of this transmission type have surged in the last years. One of those occurred in 2016 in the state of Rio Grande do Norte. Rural residents of four municipalities surrounding Marcelino Vieira ingested sugar cane juice - which was probably ground with Trypanosoma cruzi-infected insects. Eighteen cases of Chagas disease were confirmed serologically, with two deaths reported. Socioeconomic information, schooling of residents and the structure of peridomestic and domestic environments in the rural area of Marcelino Vieira, along with entomological indicators, were investigated to understand better the factors related to the outbreaks in this region. We found triatomines (mainly Triatoma brasiliensis) in 35% (24/67) of domiciliary units and all rocky outcrops inspected (n = 7). Overall, 25% (91/357) of examined T. brasiliensis were infected by T. cruzi in artificial ecotopes, with almost the same prevalence in the sylvatic environment (22%; 35/154). Among all ecotopes investigated, wood/tile/brick piles were the ones linked to high insect infestations and triatomine T. cruzi infection prevalence. Ninety-five percent of people interviewed recognized the triatomines and knew the classic route of transmission of disease - triatomine bite-dependent. However, only 7.5% admitted knowledge that Chagas disease can also be acquired orally - which poses a risk this transmission route currently recognized. Here, we highlight the physical proximity between humans and triatomine populations with high T. cruzi infection prevalence as an additional risk factor to oral/vector contaminations. In sum, residents have low income, low level of education, and/or a willful disregard for the routes of Chagas disease transmission (specifically oral transmission), a combination of factors that may have favored the Chagas disease outbreak. We here provide recommendations to avoid further outbreaks.

Rethinking the old hypothesis that new housing construction has an impact on the vector control of Triatoma infestans: A metapopulation analysis

Triatoma infestans (Hemiptera: Reduviidae) is a hematophagous insect, vector of the parasite Trypanosoma cruzi, etiological agent of the Chagas disease. In the south of La Rioja, Argentina, the persistent infestation by triatomines encouraged a program of construction of brand new dwellings in rural areas since 2008, to reduce infestation. According to the metapopulation theory approach, each dwelling was considered to be a patch with different degrees of quality concerning the availability of shelters for T. infestans. Accordingly, brand new dwellings (BNDs) are considered of lower quality for triatomines, compared to traditional dwellings (TDs). The main objective of this study was to analyse the occupancy in patches of different quality and to evaluate the effect of BNDs in the control of T. infestans. 397 patches from three departments of the southern part of La Rioja province were analysed during the period from 2014 to 2017. Six samplings were carried out to estimate the occupancy by T. infestans in patches assigned with different qualities. During the studied period, changes in the occupancy status of the patches among samplings were recorded, and the metapopulation variables which affect the occupancy of T. infestans were analysed. The results showed that all patches, even those considered of lower quality and smaller size, were occupied by T. infestans in a range from 3.8% to 25.5%. In general, the probability of T. infestans occupancy among samplings showed no difference among all studied patches. The occupancy of patches by T. infestans was associated with "department", "number of patches" and "number of positive patches in the radius of 400 m" (analysis GEE models). However, "patch quality", "size", and "distance" showed no effect on T. infestans occupancy. 44.1% of patches with BND were occupied at least once during the study period. Some of these showed "persistent occupancy" by T. infestans. No differences in the T. infestans occupancy between BNDs and TDs were observed. These results allowed us to analyse the impact of the new housing construction as a vector control measure in the metapopulation context of La Rioja province.

Determinants of intentions to prevent triatomine infestation based on the health belief model: An application in rural southern Ecuador

INTRODUCTION

Control of triatomine infestation is a key strategy for the prevention of Chagas disease (CD). To promote this strategy, it is important to know which antecedents to behavioral change are the best to emphasize when promoting prevention.

OBJECTIVE

The aim of this study was to determine predictors for intention to prevent home infestation based on the Health Belief Model (HBM), a commonly used health intervention planning theory.

MATERIALS & METHODS

A cross-sectional study was conducted with 112 heads of household in six communities with endemic and high rates of triatomine infestation in Loja province, Ecuador. The data was collected by a questionnaire including perceived severity, susceptibility, benefits to action, barriers to action, and self-efficacy. These data were also used to predict actual infestation of homes.

RESULTS

Community members reported strong intentions to prevent home infestation. HBM constructs predicted about 14% of the observed variance in intentions. Perceived susceptibility and severity did not predict behavioral intention well; perceived barriers to small-scale action that reduce likelihood of infestation and self-efficacy in participating in surveillance systems did. Self-efficacy and perception of barriers were equally powerful predictors. The HBM constructs, however, did not predict well actual infestation.

CONCLUSION

The findings supported the HBM as a way to predict intentions to prevent infestation of the home by triatomine bugs. The findings highlight that messages emphasizing self-efficacy in participating in surveillance systems and overcoming barriers to small-scale action that reduce likelihood of infestation, rather than a focus on risk, should be central messages when designing and implementing educational interventions for CD. The gap between behavioral intention and actual infestation reveals the need to assess home practices and their actual efficacy to fully enact and apply the HBM.

Multiple Approaches to Address Potential Risk Factors of Chagas Disease Transmission in Northeastern Brazil

Chagas disease is one of the most significant systemic parasitosis in Latin America, caused by Trypanosoma cruzi, which is mainly transmitted by hematophagous insects, the triatomines. This research was carried out in both domestic and wild environments throughout a Northeastern rural locality. Triatomines were captured in both peridomicile and wild environments, obtaining 508 specimens of triatomines, of which 99.6% were Triatoma brasiliensis. Insects were captured in 10 (18.5%) peridomiciles with an average of 8.3 triatomines per residence. Triatoma brasiliensis nymphs and adults were found in six peridomiciles, generating a 11.1% colonization. No T. cruzi infection was detected in the 447 peridomestic insects analyzed. On the other hand, of the 55 sylvatic T. brasiliensis molecularly examined for T. cruzi, 12 (21%) were positive, all harboring T. cruzi I. The blood meal analysis by enzyme-linked immunosorbent assay from gut content revealed that both peridomestic and wild triatomine populations fed mainly on birds, refractory to the parasite, which may explain the null rate of natural infection prevalence in the domestic environment. However, infected triatomines for potential home infestation within the radius of insect dispersion capacity were registered in rock outcrops around the dwellings. Anthropogenic environmental influences are able to rapidly alter these scenarios. Therefore, to avoid disease transmission to humans, we recommend constant vector control combined with periodic serological surveillance. The associated methodology presented herein may serve as a model for early detections of risk factors for Chagas disease transmission in the Brazilian Northeast.

Enduring extreme climate: Effects of severe drought on Triatoma brasiliensis populations in wild and man-made habitats of the Caatinga

Background

Triatoma brasiliensis, a triatomine-bug vector of Chagas disease, evolved in the semiarid Caatinga, where it occupies rocky outcrops, shrubby cacti, and human dwellings. Dwellings and rocks are considered high-quality microhabitats for this saxicolous species, whereas cacti probably represent secondary, lower-quality microhabitats. This ‘microhabitat-quality hierarchy’ hypothesis predicts that T. brasiliensis populations occupying dwellings or rocks should endure harsh environmental conditions better than their cactus-living relatives.

Methods/Findings

We tested this prediction by comparing T. brasiliensis infestation (proportion of microhabitats with bugs), density (bugs per microhabitat), and crowding (bugs per infested microhabitat) in dwellings, rocks, and cacti sampled before and during the extreme drought that ravaged the Caatinga in 2012–2016. We used random-intercepts generalized linear mixed models to account for microhabitat spatial clustering and for variations in bug-catch effort; we assessed model performance and computed model-averaged effect estimates using Akaike’s information criterion. Pre-drought infestation was similar across microhabitat types; during the drought, infestation remained stable in dwellings and rocks but dropped in cacti. Pre-drought bug density declined from dwellings to rocks to cacti; an additional decline associated with the drought was largely comparable across microhabitats, albeit perhaps somewhat larger in cacti. Finally, pre-drought bug crowding was higher in dwellings than in rocks or cacti and changed little during the drought–possibly with a downward trend in dwellings and an upward trend in cacti.

Conclusions

Triatoma brasiliensis populations fared better in dwellings and rocks than in cacti during extreme drought. Estimates of microhabitat and drought effects on infestation, density, and crowding suggest that only a few cacti (versus many rocks and dwellings) represent good-quality habitat under such extremely harsh conditions. Our findings provide empirical support to the microhabitat-quality hierarchy hypothesis, and imply that T. brasiliensis can endure extreme climate by exploiting high-quality microhabitats, whether wild or man-made, in the semiarid Caatinga.

Triatomine bugs, the vectors of Chagas disease, feed on vertebrate blood and occupy diverse microhabitats in close association with their hosts. Each bug species is adapted to particular, ‘primary’ microhabitats. Many species, however, also use ‘secondary’ microhabitats, sometimes including man-made structures. Secondary wild microhabitats are probably of lower overall quality than primary microhabitats, whereas human dwellings can be of higher overall quality if they provide a stable and abundant blood supply. This suggests that there may be a ‘hierarchy’ of triatomine microhabitat quality–top-quality dwellings, high-quality primary microhabitats, and low-quality secondary wild microhabitats. To test this hypothesis, we measured the impact of a severe drought on Triatoma brasiliensis populations living in dwellings and wild habitats, both primary (rocks) and secondary (shrubby cacti). Dwelling and rock bug populations remained largely stable during the drought, whereas most cactus-living populations either became extinct or shrunk to an undetectable size. A few cacti, however, supported relatively large bug colonies even during the drought, suggesting that they were of higher-than-average quality. Our findings provide support to the microhabitat-quality hierarchy hypothesis, and show that T. brasiliensis (and perhaps other triatomines) can endure extreme climate by exploiting (natural or man-made) high-quality microhabitats.

Using the health belief model to identify communication opportunities to prevent Chagas disease in Southern Ecuador

Background

Chagas disease (CD) is a life-threatening illness caused by the protozoan parasite Trypanosoma cruzi, which is transmitted by triatomine bugs. Triatomine bugs inhabit poorly constructed homes that create multiple hiding spots for the bugs. Modifying the actual structure of a home, along with the homeowners’ practices, can reduce triatomine infestation. This research was designed to collect culturally-relevant information to develop a health campaign to decrease risk of CD transmission by promoting home maintenance and better hygiene in rural communities of southern Ecuador.

Methods and main findings

The Health Belief Model (HBM) guided focus group discussions and the interpretation of the results. Four focus groups ranging from 4 to 10 participants were conducted between May and June 2014 in three communities of Loja province in Southern Ecuador. A thematic analysis was used to identify within the data related to perceptions of susceptibility, severity, benefits, barriers and self-efficacy related to CD and its prevention. The results provide clear guidance for the development of Chagas-prevention messages.

Conclusion

Data obtained emphasize the importance of standardizing messages presented to the communities for CD prevention. Messages should provide more information on the protective nature of the behaviors promoted for CD prevention; overcoming barriers such as cost and convenience, and build on facilitating factors, including community members’ interest on quality of life, protection of their families, and relationship with the land.

This study focuses on Chagas disease (CD) prevention in southern Ecuador. This region has a high rate of triatomine infestation. We used the Health Belief Model (HBM) to understand why people do or do not engage in CD preventive behaviors, particularly those related to home improvement. Additionally, we wanted to learn how to communicate most effectively about CD prevention. We gathered information about community member’s perceptions of CD in four focus groups, with a total of 26 participants. Our results indicate that communities do not see triatomines and CD as a threat. Lack of structures, cost, and convenience were the three key barriers mentioned by research participants for implementing CD preventive behaviors. However, participants were open to work with prevention programs since they saw it as an opportunity for community members to work together under the motivation of improving their living conditions. Capitalizing on motivators and removing barriers will be important for subsequent communication campaigns. Messages evoking fear of triatomine bugs and CD will contradict participants’ personal experience; instead, messages focusing how these behaviors will improve communities’ quality of life, protect their families, and strengthen their relationship with the land, will be more acceptable and appealing.

Community-Based Entomological Surveillance Reveals Urban Foci of Chagas Disease Vectors in Sobral, State of Ceará, Northeastern Brazil

Background

The aim of this work was to explore the potential risk of vector-borne Chagas disease in urban districts in northeastern Brazil, by analyzing the spatiotemporal distributions and natural infection rates with Trypanosoma cruzi of triatomine species captured in recent years. The main motivation of this work was an acute human case of Chagas disease reported in 2008 in the municipality of Sobral.

Methodology/principal findings

We analyzed data from community-based entomological surveillance carried out from 2010 to 2014. Triatomine natural T. cruzi infection was assessed by examination of insect feces by optical microscopy. Sites of triatomine capture were georeferenced through Google Earth and analyzed with ArcGIS. A total of 191 triatomines were collected, consisting of 82.2% Triatoma pseudomaculata, 7.9% Rhodnius nasutus, 5.8% T. brasiliensis, 3.7% Panstrongylus lutzi, and 0.5% P. megistus, with an overall natural infection index of 17.8%. Most infestations were reported in the districts of Dom José (36.2%), Padre Palhano (24.7%), and Alto do Cristo (10.6%). The overwhelming majority of insects (185/96.9%) were captured inside houses, and most insects tended to be collected in intermittent peaks. Moreover, captured triatomines tended to constitute colonies. The acute case reported in 2008 was found to be situated within a T. pseudomaculata hotspot.

Conclusion

The triatomine collection events carried out by dwellers were aggregated in time and space into distinct foci, suggesting that insects are intermittently and artificially introduced into the city, possibly via accidental migration from their natural reservoirs. The relatively high T. cruzi infection rate indicates considerable circulation of the parasite in these areas, increasing the risk of vector-borne Chagas disease infection. These data suggest a need to strengthen epidemiological surveillance and integrate appropriate control actions targeting triatomines, T. cruzi reservoirs, and human populations. Our data also identify Chagas disease transmission as a hazard in urban areas of Sobral.

Assessment of the Housing Improvement Program for Chagas Disease Control in the Northwestern municipalities of Rio Grande do Sul, Brazil

INTRODUCTION:

The Housing Improvement Program for Chagas Disease Control (HIPCDC) was established in 2001 in Northwestern Rio Grande do Sul State, aiming to improve the conditions of the domiciliary and peridomiciliary environments to make them resistant to triatomine colonization. This study aimed to assess the impact of the HIPCDC on triatomine control by developing local population and authority awareness on the issue.

METHODS:

The study was conducted by means of questionnaires applied to local authorities and the program beneficiaries. Three municipalities - Ajuricaba, Coronel Barros, and Crissiumal - were visited.

RESULTS:

A program coordinator from each municipality and 62 individuals from selected households were interviewed. The authorities reported difficulties in the implementation of the program due to differences between the project development period and financial resource availability, in addition to a lack of understanding by the community not included in the program. As for the houses, most improvements were made in the peridomiciliary environments; moreover, construction of 4 new residences, as well as the renovation of others, was also reported. Regarding suggestions to the program, requests for better planning (44.9%) and renovation quality (36.7%) were highlighted. With reference to the presence of triatomine bugs, prior to the HIPCDC adaptations, 12.9% of the respondents reported coming across at least one specimen at home, as compared to 22.6% who found these insects in peridomiciliary areas.

CONCLUSIONS:

Despite reports of difficulties in carrying out the HIPCDC, there was an improvement in the housing conditions, with no triatomine occurrence reports after the program implementation.

Overcoming research barriers in Chagas disease-designing effective implementation science

Chagas disease is a complex tropical parasitic infection. It affects a significant portion of the population in Latin America, especially in areas of poverty and poor access to health care. It also affects immigrants in high-income countries who lack access to health care due to their legal status. Millions of people are at risk of contracting the disease, and approximately 30 % of chronically infected patients will develop cardiomyopathy. The cost of caring for patients that have been infected is substantial. Basic science research has introduced new concepts and knowledge for the parasite and vector biology as well as better understanding of the pathophysiology of the disease. These research findings nevertheless require effective and timely translation into clinical practice. Likewise, the design of new research projects should account for the multiple system-based barriers. Implementation science facilitates the applicability of research findings and identifies barriers to its execution. Creation of implementation science measures to reach and sustain research programs with greater potential to impact Chagas disease are lacking. This point of view proposes opportunities for implementation science in Chagas disease and strategies for researching effective interventions for preventing and treating the disease.