Recomendaciones para el diagnóstico, seguimiento y tratamiento de la embarazada y del niño con enfermedad de Chagas

Chagas Disease in Europe

Chagas disease is currently present in many non-endemic countries and remains a neglected tropical disease globally. A review of the literature identified significant gaps and scarcity of updated information from European countries, with most studies reporting data from Spain and Italy. The index of underdiagnosis may be as high as 70%, affecting mainly females of child-bearing age. Standardized screening of fertile, non-pregnant, women from endemic countries and subsequent treatment is considered an essential strategy to control transmission and prevent new cases, yet no uniform legislation for screening risk groups exists. There is heterogeneity in Europe in terms of preventive strategies to avoid transfusion-related transmission of Chagas disease, not necessarily in line with the European directives, with some countries conducting systematic screening for T. cruzi infection in blood donors, whilst others rely on pre-transfusion questionnaires. The growing burden of the infection in resource-rich areas may provide an opportunity for progress in certain aspects of control and prevention. Options for improving screening strategies, management and linkage to care are reviewed.

Pediatric Chagas disease in the non-endemic area of Madrid: A fifteen-year review (2004–2018)

Background

Chagas disease (CD) has become an emerging global health problem in association with the immigration of individuals from endemic areas (in LatinAmerica) to other countries.Spain is the country in Europe with the highest number of CD cases. Concerning pediatric CD, treatment is not only better tolerated by younger children but also has greater cure possibilities. The aim of this study was to describe clinical and epidemiological aspects of CD in a pediatric population diagnosed of 10 hospitals in the Community of Madrid during the 2004–2018 period, as well as the safety and efficacy of CD treatment on this population.

Methodology/Principal findings

A multicenter, retrospective, descriptive study was conducted. The studied population included all identified children under the age of 18 with a diagnosis of CD. Diagnosis was performed with a positive parasitological test (with subsequent confirmation) or confirmed persistence of positive serology beyond 9 months, for children younger than one year-old, and with two different positive serological tests, for children older than one.

Fifty-one children were included (59% male; 50.9% born in Spain). All mothers were from Latin America. The median age at diagnosis was 0.7 months for those under one year of age, and 11.08 years for those older than one year-old. Only one case presented a symptomatic course (hydrops faetalis, haemodynamic instability at birth, ascites, anaemia). For 94% treatment was completed. Considering patients who received benznidazole (47), AE were recorded in 48,9%. Among the 32 patients older than one year-old treated with benznidazole, 18 (56.25%) had adverse events whereas in the 15 under one year, 5(33,3%) did. Eigtheen (78.2%) of the patients with benznidazole AE were older than one year-old(median age 11.4 years). Of the patients treated with nifurtimox (9), AE were reported in 3 cases (33,3%).

Cure was confirmed in 80% of the children under one year-old vs 4.3% in those older (p<0.001). Loss to follow- up occurred in 35.3% of patients.

Conclusions/Significances

Screening programs of CD since birth allow early diagnosis and treatment, with a significantly higher cure rate in children treated before one year of age, with lower incidence of adverse events. The high proportion of patients lost to follow-up in this vulnerable population is of concern.

Chagas disease, caused by the protozoan Trypanosoma cruzi, has traditionally been confined to endemic locations in South America (with vectorial transmission), but is nowadays emerging in Europe, mainly in Spain, due to immigration.

A series of characteristics of this disease condition its management. It is usually asymptomatic (especially in early stages), it can be transmitted from mothers to child (vertical transmission) and treatment is more effective at a younger age or during the early stages of infection. For these reasons early diagnosis and treatment of infected children is a priority. To date, there are few publications on pediatric CD series in non-endemic regions. In this paper we describe the epidemiological and clinical characteristics of 51 children diagnosed with pediatric CD in a non-endemic area, as well as the the safety and efficacy of treatment in this patient population.

We found that most patients were asymptomatic at diagnosis. The cure percentage was clearly higher when they were treated before one year-old (80% vs 4.3% in children older than one).Adverse events to treatment have occurred especially in older children, being frequent in this age group (median age 11 years).

The high proportion of patients lost to follow-up that occurs in this vulnerable population is also noteworthy (35.3% in our case). We highlight, as a conclusion of our study, the need of carrying out systematic screening for this disease (women of childbearing age, children of mothers with positive serology) to reduce the rate of vertical transmission and to achieve higher cure rates and better tolerance to treatment.

Roadblocks in Chagas disease care in endemic and nonendemic countries: Argentina, Colombia, Spain, and the United States. The NET-Heart project

Background

Chagas disease (CD) is endemic in Latin America; however, its spread to nontropical areas has raised global interest in this condition. Barriers in access to early diagnosis and treatment of both acute and chronic infection and their complications have led to an increasing disease burden outside of Latin America. Our goal was to identify those barriers and to perform an additional analysis of them based on the Inter American Society of Cardiology (SIAC) and the World Heart Federation (WHF) Chagas Roadmap, at a country level in Argentina, Colombia, Spain, and the United States, which serve as representatives of endemic and nonendemic countries.

Methodology and principal findings

This is a nonsystematic review of articles published in indexed journals from 1955 to 2021 and of gray literature (local health organizations guidelines, local policies, blogs, and media). We classified barriers to access care as (i) existing difficulties limiting healthcare access; (ii) lack of awareness about CD and its complications; (iii) poor transmission control (vectorial and nonvectorial); (iv) scarce availability of antitrypanosomal drugs; and (v) cultural beliefs and stigma. Region-specific barriers may limit the implementation of roadmaps and require the application of tailored strategies to improve access to appropriate care.

Conclusions

Multiple barriers negatively impact the prognosis of CD. Identification of these roadblocks both nationally and globally is important to guide development of appropriate policies and public health programs to reduce the global burden of this disease.

Chagas disease (CD) has been described as an epidemic in Latin America, but its geographical influence is global. One of the biggest challenges in providing care for patients with CD is to improve access to early diagnosis and treatment in order to avoid chronic cardiovascular and gastrointestinal complications. However, different roadblocks interfere with the optimal care of these patients, which facilitates disease progression. While some barriers to care are global in scope, there are additionally national and even local obstacles for patients with CD. Appropriate delineation of these barriers will allow for the development of targeted interventions to improve the outlook for CD patients in both endemic and nonendemic countries alike.

Evaluation of the Performance of the Loopamp Trypanosoma cruzi Detection Kit for the Diagnosis of Chagas Disease in an Area Where It Is Not Endemic, Spain

In Spain, PCR is the tool of choice for the diagnosis of congenital Chagas disease (CD) and serology for diagnosing chronic CD. A loop-mediated isothermal amplification test for Trypanosoma cruzi DNA detection showed good analytical performance and ease of use.

In Spain, PCR is the tool of choice for the diagnosis of congenital Chagas disease (CD) and serology for diagnosing chronic CD. A loop-mediated isothermal amplification test for Trypanosoma cruzi DNA detection showed good analytical performance and ease of use. We aimed to evaluate the performance of the Loopamp Trypanosoma cruzi detection kit (Eiken Chemical Co. Ltd., Japan) (Tcruzi-LAMP) for congenital and chronic CD diagnosis using well-characterized samples. We included samples from 39 congenital and 174 chronic CD cases and from 48 uninfected children born to infected mothers and 34 nonchagasic individuals. The sensitivity, specificity, and accuracy of Tcruzi-LAMP were estimated using standard case definitions for congenital CD (positive result by parasitological or PCR tests or serology after 9 months of age) and chronic CD (positive serology by at least two tests). The Tcruzi-LAMP results were read by visual examination and a real-time fluorimeter. For congenital CD, Tcruzi-LAMP sensitivity was 97% for both types of reading; specificity was 92% by visual examination and 94% by fluorimeter. For chronic CD, sensitivity was 47% and specificity 100%. The accuracy in congenital CD was >94% versus 56% in chronic CD. The agreement of Tcruzi-LAMP with PCR tests was better in congenital CD (kappa, 0.86 to 0.91) than in chronic CD (kappa, 0.67 to 0.83). The Loopamp Trypanosoma cruzi detection kit showed good performance for the diagnosis of congenital CD. Tcruzi-LAMP, like PCR, can be useful for the screening and early diagnosis of congenital infection.

Chagas disease screening in pregnant Latin American women: Adherence to a systematic screening protocol in a non-endemic country

BACKGROUND

Chagas disease (CD) is a chronic parasitic disease caused by Trypanosoma cruzi and is endemic to continental Latin America. In Spain, the main transmission route is congenital. We aimed to assess adherence to regional recommendations of universal screening for CD during pregnancy in Latin American women in the province of Alicante from 2014 to 2018.

METHODOLOGY/PRINCIPAL FINDINGS

Retrospective quality study using two data sources: 1) delivery records of Latin American women that gave birth in the 10 public hospitals of Alicante between January 2014 and December 2018; and 2) records of Chagas serologies carried out in those centers between May 2013 and December 2018. There were 3026 deliveries in Latin American women during the study period; 1178 (38.9%) underwent CD serology. Screening adherence ranged from 17.2% to 59.3% in the different health departments and was higher in Bolivian women (48.3%). Twenty-six deliveries (2.2%) had a positive screening; CD was confirmed in 23 (2%) deliveries of 21 women. Bolivians had the highest seroprevalence (21/112; 18.7%), followed by Colombians (1/333; 0.3%) and Ecuadorians (1/348; 0.3%). Of 21 CD-positive women (19 Bolivians, 1 Colombian, 1 Ecuadorian), infection was already known in 12 (57.1%), and 9 (42.9%) had already been treated. Only 1 of the 12 untreated women (8.3%) was treated postpartum. Follow-up started in 20 of the 23 (87.0%) neonates but was completed only in 11 (47.8%); no cases of congenital transmission were detected. Among the 1848 unscreened deliveries, we estimate 43 undiagnosed cases of CD and 1 to 2 undetected cases of congenital transmission.

CONCLUSIONS/SIGNIFICANCE

Adherence to recommendations of systematic screening for CD in Latin American pregnant women in Alicante can be improved. Strategies to strengthen treatment of postpartum women and monitoring of exposed newborns are needed. Currently, there may be undetected cases of congenital transmission in our province.

An observational longitudinal study to evaluate tools and strategies available for the diagnosis of Congenital Chagas Disease in a non-endemic country

OBJECTIVES

Congenital Chagas Disease (CCD) has become a global health problem. Early diagnosis and treatment is essential for the cure of the disease. Our aim was to evaluate techniques and samples used for the diagnosis of CCD in order to improve diagnostic strategies.

METHODS

A total of 181 children born in Spain from Latin American Chagas-infected mothers were consecutively enrolled and studied by microhematocrit, PCR and serology tests at 0-2, 6 and 9-12 months of age and followed up when it was required. Samples of cord blood and peripheral blood were collected for T. cruzi detection by PCR. Parasite culture was performed in patients with a positive PCR.

RESULTS

Of 181 children, 7 children (3.9%) were lost to follow-up. A total of 174 children completed follow-up, 12 were diagnosed with CCD (6.9%) and 162 (93.1%) as uninfected children (negative serology tests at the end of the follow-up). Traditional parasitological diagnosis by microhematocrit had a poor performance (sensitivity was 10%), while PCR in peripheral blood showed high sensitivity (90.9%) and specificity (100%), allowing the early diagnosis of 9 infected children during the first 6-months-old. In the other 3 congenital cases, diagnosis was only possible at 12 months by serological and molecular techniques. However, PCR in cord blood showed low sensitivity (33.3%) and less specificity (96.4%) for the diagnosis.

CONCLUSION

PCR in peripheral blood has proven to be the most adequate strategy for the diagnosis of CCD, allowing an early and reliable diagnosis.

Congenital transmission of Chagas disease in a non-endemic area, is an early diagnosis possible?

BACKGROUND

Chagas disease (CD) is an emergent disease in Europe, due to immigration. The aims of this study are to describe the epidemiological characteristics of a cohort of Chagas infected pregnant women in Spain, to assess the vertical transmission (VT) rate and evaluate the usefulness of the PCR in the diagnosis of congenital infection in the first months of life.

METHODS

A descriptive, retrospective study including Chagas seropositive pregnant women who were attended at three tertiary hospitals in Madrid, from January 2012 to September 2016. Infants were examined by PCR at birth and 1 month later and serologically studied at 9 months or later. Children were considered infected when the parasite was detected by PCR at any age or when serology remained positive without decline over the age of 9 months.

RESULTS

We included 122 seropositive-infected pregnant women, 81% were from Bolivia and only 8.2% had been treated before. 125 newborns were studied and finally 109 were included (12.8% lost the follow-up before performing the last serology). The VT rate was 2.75% (95% CI: 0,57-8,8%). Infected infants had positive PCR at birth and 1 month later. All of them were treated successfully with benznidazole (PCR and serology became negative later on). All non-infected children presented negative PCR. The mean age at which uninfected patients had negative serology was 10.5 months.

CONCLUSIONS

The VT rate is in keeping with literature and confirms the need to carry out a screening in pregnant women coming from endemic areas. PCR seems to be a useful tool to provide early diagnosis of congenital CD.

Hepatic changes by benznidazole in a specific treatment for Chagas disease

Chagas disease (Cd) is the third most common parasitic disease that causes damage to human health. Even a century after its description by Carlos Chagas and advances in its control, it remains a neglected disease. To eradicate the parasite or reduce the parasitic load, specific treatment for Trypanosoma cruzi (T. cruzi) is advisable; benznidazole (BNZ) is the drug that is currently prescribed. The purpose of this study is to report the adverse events (AE) due to the use of BNZ as a specific treatment for Cd, with a particular focus on hepatic changes. This was an observational, cross-sectional cohort study that included patients who were treated with BNZ. The medical records of patients who joined the Grupo de Estudo em doença de Chagas [Chagas Disease Study Group]/UNICAMP/Brazil and were treated with BNZ were reviewed for epidemiological, clinical, laboratory and AE parameters for the drug. The 204 patients who were assessed had an average age of 40.6 years ± 13.5 years, and 104 of them were women (50.98%). Fourteen (6.86%) individuals were in the acute phase of Cd, and 190 (93.13%) were in its chronic phase. AEs occurred in 85 patients (41.66%), 35 (41.17%) of whom had AEs related to the liver, characterized by an elevation of AST liver enzymes, ALT, alkaline phosphatase and gamma-glutamyltransferase (γGT). Other AEs that were observed included the following: 48 cases of cutaneous changes (56.47%), 8 cases of epigastric pain (9.41%), 7 cases of blood alteration (8.23%), and 3 cases of peripheral neuropathy (3.52%). Treatment was interrupted in 32 patients (37.64%) due to AD. Adverse events related to the liver secondary to the use of BNZ for Cd-specific treatment were frequent in this study and were characterized by an elevation of liver enzymes. Therefore, it is suggested that these enzymes be monitored during treatment with benznidazole.

Chagas disease

Chagas disease is an anthropozoonosis from the American continent that has spread from its original boundaries through migration. It is caused by the protozoan Trypanosoma cruzi, which was identified in the first decade of the 20th century. Once acute infection resolves, patients can develop chronic disease, which in up to 30-40% of cases is characterised by cardiomyopathy, arrhythmias, megaviscera, and, more rarely, polyneuropathy and stroke. Even after more than a century, many challenges remain unresolved, since epidemiological control and diagnostic, therapeutic, and prognostic methods must be improved. In particular, the efficacy and tolerability profile of therapeutic agents is far from ideal. Furthermore, the population affected is older and more complex (eg, immunosuppressed patients and patients with cancer). Nevertheless, in recent years, our knowledge of Chagas disease has expanded, and the international networking needed to change the course of this deadly disease during the 21st century has begun.

Knowledge and experiences of Chagas disease in Bolivian women living in Spain: a qualitative study

Background

In Europe, Spain has the highest number of people with Chagas disease (CD). Bolivian migrants account for 81% of the reported cases. One of the priorities in controlling the disease is prevention of mother-to-child transmission. Despite under-diagnosis in Spain being estimated at 90%, there are currently few studies that explore the social and cultural dimensions of this disease.

Objective

The aim of this study was to explore the knowledge and experiences of Bolivian women with CD, in order to generate a useful understanding for the design and implementation of public health initiatives.

Design

Qualitative study based on semi-structured interviews, triangular groups, and field notes.

Participants

Fourteen Bolivian women with CD living in Madrid.

Results

The participants were aware that the disease was transmitted through the vector, that it could be asymptomatic, and that it could also be associated with sudden death by heart failure. They opined that the treatment as such could not cure the disease but only slow it down. There was a sense of indifference along with a lack of understanding of the risk of contracting the disease. Participants who presented with symptoms, or those with relatives suffering from the disease, were concerned about fatalities, cardiac problems, and possible vertical transmission. There was also a fear of being rejected by others. The disease was described as something that affected a large number of people but only showed up in a few cases and that too after many years. There was a widespread assumption that it was better not to know because doing so, allows the disease to take hold.

Conclusions

Disease risk perception was very low in Bolivian women living in Madrid. This factor, together with the fear of being screened, may be contributing to the current rate of under-diagnosis.

Economic evaluation of Chagas disease screening in Spain

Although Spain is the European country with the highest Chagas disease burden, the country does not have a national control program of the disease. The purpose of this study is to evaluate the efficiency of several strategies for Chagas disease screening among Latin American residents living in Spain. The following screening strategies were evaluated: (1) non-screening; (2) screening of the Latin American pregnant women and their newborns; (3) screening also the relatives of the positive pregnant women; (4) screening also the relatives of the negative pregnant women. A cost-utility analysis was carried out to compare the four strategies from two perspectives, the societal and the Spanish National Health System (SNHS). A decision tree representing the clinical evolution of Chagas disease throughout patient's life was built. The strategies were compared through the incremental cost-utility ratio, using euros as cost measurement and quality-adjusted life years as utility measurement. A sensitivity analysis was performed to test the model parameters and their influence on the results. We found the "Non-screening" as the most expensive and less effective of the evaluated strategies, from both the societal and the SNHS perspectives. Among the screening evaluated strategies the most efficient was, from both perspectives, to extent the antenatal screening of the Latin American pregnant women and their newborns up to the relatives of the positive women. Several parameters influenced significantly on the sensitivity analyses, particularly the chronic treatment efficacy or the prevalence of Chagas disease. In conclusion, for the general Latin American immigrants living in Spain the most efficient would be to screen the Latin American mothers, their newborns and the close relatives of the mothers with a positive serology. However for higher prevalence immigrant population the most efficient intervention would be to extend the program to the close relatives of the negative mothers.

[Consensus document for the detection and management of Chagas disease in primary health care in a non-endemic areas]

Chagas disease is caused by the protozoan Trypanosoma cruzi. Although it is commonly transmitted by an insect vector in continental Latin-America, in recent decades, due migration, has been diagnosed in other countries such Spain, the European country with a largest immigrant population of Latin American. For a long time, the patient remains asymptomatic, but some years after this stage, the symptoms can be serious (dilated cardiomyopathy, megacolon, megaesophagus). In addition, detection in pregnant women has a high priority because of the route of vertical transmission. Several specific guidelines about Chagas disease has been developed on the Banks of blood, maternal hospitals, HIV co-infection, organ transplant. But due to the detection of lack of information to primary care professionals, we consider to will be useful this document written and agreed to by family phisicians, pediatricians and specialists in International Health.

Screening of imported infectious diseases among asymptomatic sub-Saharan African and Latin American immigrants: a public health challenge

Migrants from developing countries are usually young and healthy but several studies report they may harbor asymptomatic infections for prolonged periods. Prevalence of infections were determined for asymptomatic immigrants from Latin America and sub-Saharan Africa who ettended to a European Tropical Medicine Referral Center from 2000 to 2009. A systematic screening protocol for selected infections was used. Data from 317 sub-Saharan Africans and 383 Latin Americans were analyzed. Patients were mostly young (mean age 29 years); there were significantly more males among sub-Saharan Africans (83% versus 31.6%) and pre-consultation period was longer for Latin Americans (5 versus 42 months). Diagnoses of human immunodeficiency virus (HIV), chronic hepatitis B and C virus infection, and latent tuberculosis were significantly more frequent in sub-Saharan Africans (2.3% versus 0.3%; 14% versus 1.6%; 1.3 versus 0%; 71% versus 32.1%). There were no significant differences in prevalence for syphilis and intestinal parasites. Malaria and schistosomiasis prevalence in sub-Saharan Africans was 4.6% and 5.9%, respectively, and prevalence of Chagas disease in Latin Americans was 48.5%. Identifying and treating asymptomatic imported infectious diseases may have an impact both for the individual concerned and for public health. Based on these results, a systematic screening protocol for asymptomatic immigrants is proposed.

Mother-to-child transmission of Trypanosoma cruzi infection (Chagas disease): a neglected problem

Congenital Chagas disease may be considered a global health problem and the underdiagnosis of congenital infections should be a matter of concern. Vertical transmission is an important mode of transmission of Trypanosoma cruzi infection in non-endemic areas. Treatment in the early phases of the infection can prevent progression of the disease and is curative in the majority of cases. Prevention strategies should focus on early detection and treatment of congenital cases, screening at-risk women during pregnancy and treatment of non-pregnant women of childbearing age. Management of congenital Chagas disease and T. cruzi infection during pregnancy is discussed.