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Reifler KA, Wheelock A, Hall SM, Salazar A, Hassan S, Bostrom JA, Barnett ED, Carrion M, Hochberg NS, Hamer DH, Gopal DM, Bourque D. Chagas cardiomyopathy in Boston, Massachusetts: Identifying disease and improving management after community and hospital-based screening. PLoS Negl Trop Dis 2024; 18:e0011913. [PMID: 38241361 PMCID: PMC10830043 DOI: 10.1371/journal.pntd.0011913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/31/2024] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Limited data exist regarding cardiac manifestations of Chagas disease in migrants living in non-endemic regions. METHODS A retrospective cohort analysis of 109 patients with Chagas disease seen at Boston Medical Center (BMC) between January 2016 and January 2023 was performed. Patients were identified by screening and testing migrants from endemic regions at a community health center and BMC. Demographic, laboratory, and cardiac evaluation data were collected. RESULTS Mean age of the 109 patients was 43 years (range 19-76); 61% were female. 79% (86/109) were diagnosed with Chagas disease via screening and 21% (23/109) were tested given symptoms or electrocardiogram abnormalities. Common symptoms included palpitations (25%, 27/109) and chest pain (17%, 18/109); 52% (57/109) were asymptomatic. Right bundle branch block (19%, 19/102), T-wave changes (18%, 18/102), and left anterior fascicular block (11%, 11/102) were the most common electrocardiogram abnormalities; 51% (52/102) had normal electrocardiograms. Cardiomyopathy stage was ascertained in 94 of 109 patients: 51% (48/94) were indeterminate stage A and 49% (46/94) had cardiac structural disease (stages B1-D). Clinical findings that required clinical intervention or change in management were found in 23% (25/109), and included cardiomyopathy, apical hypokinesis/aneurysm, stroke, atrial or ventricular arrhythmias, and apical thrombus. CONCLUSIONS These data show high rates of cardiac complications in a cohort of migrants living with Chagas disease in a non-endemic setting. We demonstrate that Chagas disease diagnosis prompts cardiac evaluation which often identifies actionable cardiac disease and provides opportunities for prevention and treatment.
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Affiliation(s)
- Katherine A. Reifler
- Section of Infectious Disease, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Alyse Wheelock
- Section of Preventative Medicine and Epidemiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Samantha M. Hall
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Alejandra Salazar
- Section of Infectious Disease, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Shahzad Hassan
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - John A. Bostrom
- Cardiovascular Division, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Elizabeth D. Barnett
- Section of Pediatric Infectious Disease, Department of Pediatrics, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Malwina Carrion
- Boston University College of Health and Rehabilitation Sciences: Sargent College, Massachusetts, United States of America
| | - Natasha S. Hochberg
- Section of Infectious Disease, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Davidson H. Hamer
- Section of Infectious Disease, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Center for Emerging Infectious Disease Policy & Research, Boston University, Boston, Massachusetts, United States of America
| | - Deepa M. Gopal
- Cardiovascular Division, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Daniel Bourque
- Section of Infectious Disease, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
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Irish A, Whitman JD, Clark EH, Marcus R, Bern C. Updated Estimates and Mapping for Prevalence of Chagas Disease among Adults, United States. Emerg Infect Dis 2022; 28:1313-1320. [PMID: 35731040 PMCID: PMC9239882 DOI: 10.3201/eid2807.212221] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Geographic scale estimates of disease in older Latin America–born US residents may be useful for prevention and early recognition of chronic sequelae. We combined American Community Survey data with age-specific Trypanosoma cruzi prevalence derived from US surveys and World Health Organization reports to yield estimates of Chagas disease in the United States, which we mapped at the local level. In addition, we used blood donor data to estimate the relative prevalence of autochthonous T. cruzi infection. Our estimates indicate that 288,000 infected persons, including 57,000 Chagas cardiomyopathy patients and 43,000 infected reproductive-age women, currently live in the United States; 22–108 congenital infections occur annually. We estimated ≈10,000 prevalent cases of locally acquired T. cruzi infection. Mapping shows marked geographic heterogeneity of T. cruzi prevalence and illness. Reliable demographic and geographic data are key to guiding prevention and management of Chagas disease. Population-based surveys in high prevalence areas could improve the evidence base for future estimates. Knowledge of the demographics and geographic distribution of affected persons may aid practitioners in recognizing Chagas disease.
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Ramos-Sesma V, Navarro M, Llenas-García J, Gil-Anguita C, Torrus-Tendero D, Wikman-Jorgensen P, García-López M, Amador-Prous C, Ventero-Martín MP, Guevara-Hernández P, Garijo-Saiz A, Sanchez-Sanchez A, Bernal-Alcaraz C, Pujades-Tarraga AI, Muñoz-Perez R, Flores-Chávez M, Ramos-Rincón JM. Community-based screening of Chagas disease among Latin American migrants in a non-endemic country: an observational study. Infect Dis Poverty 2021; 10:117. [PMID: 34526137 PMCID: PMC8441044 DOI: 10.1186/s40249-021-00897-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Chagas disease is a parasitic disease endemic to Latin America, but it has become a disease of global concern due to migration flows. Asymptomatic carriers may host the parasite for years, without knowing they are infected. The aim of this study is to assess prevalence of Chagas disease and evaluate the participants' level of knowledge between Latin American migrants attending a community-based screening campaign. METHODS Three community-based campaigns were performed in Alicante (Spain) in 2016, 2017 and 2018, including educational chats and blood tests for Trypanosoma cruzi serology. Participants completed a questionnaire assessing knowledge about the mechanisms of transmission, disease presentation, diagnosis, and treatment. People seropositive for T. cruzi underwent diagnostic confirmation by two different tests. Results were analyzed by multivariable logistic regression and expressed as adjusted odds ratios (aORs), adjusting for age, sex, and time in Spain. RESULTS A total of 596 participants were included in the study; 17% were aged under 18 years. Prevalence in adults was 11% [54/496; 95% confidence interval (CI): 8.3-14.5%] versus 0% among children. All but one case were in Bolivians. Diagnosis was independently associated with having been born in Bolivia (aOR: 102, 95% CI: 13-781) and a primary school-level education (aOR: 2.40, 95% CI: 1.14-5.06). Of 54 people diagnosed with Chagas disease (most of whom were asymptomatic), 42 (77.7%) returned to the clinic at least once, and 24 (44.4%) received treatment. Multivariable analysis showed that coming from Argentina (aOR: 13, 95% CI: 1.61-1188) or Bolivia (aOR: 1.90, 95% CI: 1.19-3.39) and having received information about Chagas disease in Spain (aOR: 4.63, 95% CI: 2.54-8.97) were associated with a good level of knowledge on the disease. Having primary level studies (aOR: 0.59, 95% CI: 0.34-0.98) and coming from Ecuador (aOR: 4.63, 95% CI: 2.52-847) were independently associated with a lower level of knowledge. CONCLUSIONS Community-based interventions are a good strategy for diagnosing neglected diseases such as Chagas disease in non-endemic countries and for identifying and treating infected, asymptomatic individuals.
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Affiliation(s)
| | - Miriam Navarro
- Public Health, Science History and Gynecology Department, Universidad Miguel Hernández de Elche, Alicante, Spain
- Epidemiology Unit Public Health Center of Elche, Alicante, Spain
| | - Jara Llenas-García
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
- Clinical Medicine Department, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain
| | - Concepción Gil-Anguita
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Diego Torrus-Tendero
- Internal Medicine Department, General University Hospital of Alicante-Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain
- Parasitology Area, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain
| | - Philip Wikman-Jorgensen
- Internal Medicine Department, University Hospital of Sant Joan, (Sant Joan d'Alacant, Spain)- FISABIO, Alicante, Spain
| | - María García-López
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Concepción Amador-Prous
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | | | - Pedro Guevara-Hernández
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Ana Garijo-Saiz
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Ares Sanchez-Sanchez
- Pediatric Department, General University Hospital of Alicante-ISABIAL, Alicante, Spain
| | - Cristina Bernal-Alcaraz
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Ana-Isabel Pujades-Tarraga
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Roser Muñoz-Perez
- Digestive Service, General University Hospital of Alicante-ISABIAL, Alicante, Spain
| | - María Flores-Chávez
- Reference and Research Laboratory in Parasitology, National Center of Microbiology/Mundo Sano Foundation, Madrid, Spain
| | - José-Manuel Ramos-Rincón
- Clinical Medicine Department, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain.
- Internal Medicine Department, General University Hospital of Alicante-Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain.
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Hochberg NS, Wheelock A, Hamer DH, Marcus R, Nolan MS, Meymandi S, Gilman RH. Chagas Disease in the United States: A Perspective on Diagnostic Testing Limitations and Next Steps. Am J Trop Med Hyg 2021; 104:800-804. [PMID: 33534741 DOI: 10.4269/ajtmh.19-0871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 10/13/2020] [Indexed: 12/17/2022] Open
Abstract
Chagas disease is a neglected tropical disease that affects an estimated 300,000 people in the United States. This perspective piece reviews diagnostic challenges and proposes next steps to address these shortfalls.
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Affiliation(s)
- Natasha S Hochberg
- 1Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.,2Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.,3Center for Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Alyse Wheelock
- 1Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.,3Center for Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Davidson H Hamer
- 1Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.,3Center for Infectious Diseases, Boston Medical Center, Boston, Massachusetts.,4Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Rachel Marcus
- 5Latin American Society of Chagas (LASOCHA), Medstar Union Memorial Hospital, Baltimore, Maryland
| | - Melissa S Nolan
- 6Department of Epidemiology, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,7Department of Pediatrics, Section of Pediatric Tropical Medicine, National School of Tropical Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Sheba Meymandi
- 8Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Robert H Gilman
- 9Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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5
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Testing for Chagas disease in an at-risk population. J Card Fail 2020; 27:109-111. [PMID: 32905847 DOI: 10.1016/j.cardfail.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 11/23/2022]
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Asymptomatic Strongyloidiasis among Latin American Migrants in Spain: A Community-Based Approach. Pathogens 2020; 9:pathogens9060511. [PMID: 32599871 PMCID: PMC7350301 DOI: 10.3390/pathogens9060511] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/14/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Strongyloides stercoralis infection is frequently underdiagnosed since many infections remain asymptomatic. Aim: To estimate the prevalence and characteristics of asymptomatic S. stercoralis infection in Latin American migrants attending a community-based screening program for Chagas disease in Spain. Methodology: Three community-based Chagas disease screening campaigns were performed in Alicante (Spain) in 2016, 2017, and 2018. Serological testing for S. stercoralis infection was performed using a non-automatized IVD-ELISA detecting IgG (DRG Instruments GmbH, Marburg, Germany). Results: Of the 616 migrants from Central and South America who were screened, 601 were included in the study: 100 children and adolescents (<18 years of age) and 501 adults. Among the younger group, 6 participants tested positive (prevalence 6%, 95% confidence interval [CI] 2.5% to 13.1%), while 60 adults did so (prevalence 12%, 95% CI 9.3% to 15.3%). S. stercoralis infection was more common in men than in women (odds ratio adjusted [ORa] 2.28, 95% CI 1.289 to 4.03) and in those from Bolivia (ORa 2.03, 95% CI 1.15 to 3.59). Prevalence increased with age (ORa 1.02, 95% CI 0.99 to 1.05). In contrast, a university education had a protective effect (ORa 0.29, 95% CI 0.31 to 0.88). Forty-one (41/66; 62.1%) of the total cases of S. stercoralis infection were treated at the health care center. Positive stool samples were observed in 19.5% of the followed-up positive cases. Conclusion: Incorporating serological screening for S. stercoralis into community-based screening for Chagas disease is a useful intervention to detect asymptomatic S. stercoralis infection in Central and South American migrants and an opportunity to tackle neglected tropical diseases in a transversal way. The remaining challenge is to achieve patients’ adherence to the medical follow-up.
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7
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Herrick JA, Nordstrom M, Maloney P, Rodriguez M, Naceanceno K, Gallo G, Mejia R, Hershow R. Parasitic infections represent a significant health threat among recent immigrants in Chicago. Parasitol Res 2020; 119:1139-1148. [PMID: 32008064 PMCID: PMC7075846 DOI: 10.1007/s00436-020-06608-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/14/2020] [Indexed: 12/19/2022]
Abstract
Parasitic infections are likely under-recognized among immigrant populations in the USA. We conducted a cross-sectional study to evaluate if such infections have health impacts among recent immigrants in Chicago and to identify predictive factors for parasitic infections. A total of 133 recent immigrants were enrolled, filling out a standardized medical questionnaire and providing blood and stool samples. Appriximately 12% of subjects (15/125) who provided a blood or stool sample for testing were found to have evidence of current or prior infection with a pathogenic parasite, of which Toxocara spp. (8 subjects, 6.4%) and Strongyloides stercoralis (5 subjects, 4%) were most commonly identified. Parasitic infection was more likely among subjects who had immigrated within the previous 2 years and those with a self-reported history of worms in the stool. The most useful surrogate markers identified for parasitic infections were an elevated immunoglobulin E level (seen in 46.7% (7/15) of subjects with parasitic infections and 20% (22/110) of uninfected individuals, p = 0.04) and the presence of Blastocystis hominis cysts on Ova & Parasite exam (detected in 38.5% (5/13) of subjects with parasitic infections who provided a stool sample and 5.1% (5/98) of uninfected subjects, p = 0.002). Our study found that parasitic infections may be common in recent US immigrants, which highlights an important health disparity among a vulnerable population that merits further study. Additionally, clinical risk factors, symptoms, and laboratory findings traditionally thought to be associated with parasites were commonly found but not predictive of infection in this study population.
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Affiliation(s)
- Jesica A. Herrick
- grid.185648.60000 0001 2175 0319Department of Medicine, Division of Infectious Diseases, Immunology, and International Medicine, University of Illinois at Chicago, 808 South Wood, M/C 735, Chicago, IL 60612 USA
| | - Monica Nordstrom
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago School of Public Health, Chicago, IL USA
| | - Patrick Maloney
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago School of Public Health, Chicago, IL USA
| | - Miguel Rodriguez
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago School of Public Health, Chicago, IL USA
| | - Kevin Naceanceno
- grid.39382.330000 0001 2160 926XDepartment of Medicine, Section of Infectious Diseases, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX USA
| | - Gloria Gallo
- grid.39382.330000 0001 2160 926XDepartment of Medicine, Section of Infectious Diseases, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX USA
- grid.411249.b0000 0001 0514 7202Science and Technology Institute, Federal University of São Paulo, São José dos Campos, São Paulo, Brazil
| | - Rojelio Mejia
- grid.39382.330000 0001 2160 926XDepartment of Medicine, Section of Infectious Diseases, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX USA
| | - Ron Hershow
- grid.185648.60000 0001 2175 0319Department of Medicine, Division of Infectious Diseases, Immunology, and International Medicine, University of Illinois at Chicago, 808 South Wood, M/C 735, Chicago, IL 60612 USA
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago School of Public Health, Chicago, IL USA
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8
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Bern C, Messenger LA, Whitman JD, Maguire JH. Chagas Disease in the United States: a Public Health Approach. Clin Microbiol Rev 2019; 33:e00023-19. [PMID: 31776135 PMCID: PMC6927308 DOI: 10.1128/cmr.00023-19] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trypanosoma cruzi is the etiological agent of Chagas disease, usually transmitted by triatomine vectors. An estimated 20 to 30% of infected individuals develop potentially lethal cardiac or gastrointestinal disease. Sylvatic transmission cycles exist in the southern United States, involving 11 triatomine vector species and infected mammals such as rodents, opossums, and dogs. Nevertheless, imported chronic T. cruzi infections in migrants from Latin America vastly outnumber locally acquired human cases. Benznidazole is now FDA approved, and clinical and public health efforts are under way by researchers and health departments in a number of states. Making progress will require efforts to improve awareness among providers and patients, data on diagnostic test performance and expanded availability of confirmatory testing, and evidence-based strategies to improve access to appropriate management of Chagas disease in the United States.
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Affiliation(s)
- Caryn Bern
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - Jeffrey D Whitman
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - James H Maguire
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Forsyth C, Meymandi S, Moss I, Cone J, Cohen R, Batista C. Proposed multidimensional framework for understanding Chagas disease healthcare barriers in the United States. PLoS Negl Trop Dis 2019; 13:e0007447. [PMID: 31557155 PMCID: PMC6762052 DOI: 10.1371/journal.pntd.0007447] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chagas disease (CD) affects over 300,000 people in the United States, but fewer than 1% have been diagnosed and less than 0.3% have received etiological treatment. This is a significant public health concern because untreated CD can produce fatal complications. What factors prevent people with CD from accessing diagnosis and treatment in a nation with one of the world's most advanced healthcare systems? METHODOLOGY/PRINCIPAL FINDINGS This analysis of barriers to diagnosis and treatment of CD in the US reflects the opinions of the authors more than a comprehensive discussion of all the available evidence. To enrich our description of barriers, we have conducted an exploratory literature review and cited the experience of the main US clinic providing treatment for CD. We list 34 barriers, which we group into four overlapping dimensions: systemic, comprising gaps in the public health system; structural, originating from political and economic inequalities; clinical, including toxicity of medications and diagnostic challenges; and psychosocial, encompassing fears and stigma. CONCLUSIONS We propose this multidimensional framework both to explain the persistently low numbers of people with CD who are tested and treated and as a potential basis for organizing a public health response, but we encourage others to improve on our approach or develop alternative frameworks. We further argue that expanding access to diagnosis and treatment of CD in the US means asserting the rights of vulnerable populations to obtain timely, quality healthcare.
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Affiliation(s)
- Colin Forsyth
- Drugs for Neglected Diseases initiative, North America, New York, New York, United States of America
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California, United States of America
| | - Sheba Meymandi
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California, United States of America
| | - Ilan Moss
- Drugs for Neglected Diseases initiative, North America, New York, New York, United States of America
| | - Jason Cone
- Médecins sans Frontières/Doctors Without Borders USA, New York, New York, United States of America
| | - Rachel Cohen
- Drugs for Neglected Diseases initiative, North America, New York, New York, United States of America
| | - Carolina Batista
- Drugs for Neglected Diseases initiative, Latin America, Rio de Janeiro, Brazil
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10
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Forsyth CJ, Hernandez S, Flores CA, Roman MF, Nieto JM, Marquez G, Sequeira J, Sequeira H, Meymandi SK. "It's Like a Phantom Disease": Patient Perspectives on Access to Treatment for Chagas Disease in the United States. Am J Trop Med Hyg 2018; 98:735-741. [PMID: 29380723 PMCID: PMC5930901 DOI: 10.4269/ajtmh.17-0691] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Chagas disease (CD) affects > 6 million people globally, including > 300,000 in the United States. Although early detection and etiological treatment prevents chronic complications from CD, < 1% of U.S. cases have been diagnosed and treated. This study explores access to etiological treatment from the perspective of patients with CD. In semi-structured interviews with 50 Latin American-born patients of the Center of Excellence for Chagas Disease at the Olive View-UCLA Medical Center, we collected demographic information and asked patients about their experiences managing the disease and accessing treatment. Patients were highly marginalized, with 63.4% living below the U.S. poverty line, 60% lacking a high school education, and only 12% with private insurance coverage. The main barriers to accessing health care for CD were lack of providers, precarious insurance coverage, low provider awareness, transportation difficulties, and limited time off. Increasing access to diagnosis and treatment will not only require a dramatic increase in provider and public education, but also development of programs which are financially, linguistically, politically, and geographically accessible to patients.
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Affiliation(s)
- Colin J Forsyth
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Salvador Hernandez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Carmen A Flores
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Mario F Roman
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - J Maribel Nieto
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Grecia Marquez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Juan Sequeira
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Harry Sequeira
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
| | - Sheba K Meymandi
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California
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11
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L-arginine supplementation reduces mortality and improves disease outcome in mice infected with Trypanosoma cruzi. PLoS Negl Trop Dis 2018; 12:e0006179. [PMID: 29337988 PMCID: PMC5786330 DOI: 10.1371/journal.pntd.0006179] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/26/2018] [Accepted: 12/19/2017] [Indexed: 11/19/2022] Open
Abstract
Chagas disease caused by Trypanosoma cruzi is a neglected disease that affects about 7 million people in Latin America, recently emerging on other continents due to migration. As infection in mice is characterized by depletion of plasma L-arginine, the effect on infection outcome was tested in mice with or without L-arginine supplementation and treatment with 1400W, a specific inhibitor of inducible nitric oxide synthase (iNOS). We found that levels of L-arginine and citrulline were reduced in the heart and plasma of infected mice, whereas levels of asymmetric dimethylarginine, an endogenous iNOS inhibitor, were higher. Moreover, L-arginine supplementation decreased parasitemia and heart parasite burden, improving clinical score and survival. Nitric oxide production in heart tissue and plasma was increased by L-arginine supplementation, while pharmacological inhibition of iNOS yielded an increase in parasitemia and worse clinical score. Interestingly, electrocardiograms improved in mice supplemented with L-arginine, suggesting that it modulates infection and heart function and is thus a potential biomarker of pathology. More importantly, L-arginine may be useful for treating T. cruzi infection, either alone or in combination with other antiparasitic drugs. Trypanosoma cruzi is the causative agent of the neglected Chagas disease in humans. During infection in mice, depletion of plasma L-arginine is correlated with mortality. L-arginine is a semi-essential amino acid needed for cell proliferation, and is the substrate of arginase 1 (Arg-1) and inducible nitric oxide synthase (iNOS), which is involved in the immune response against infections. Observed L-arginine depletion is likely caused by increased Arg-1 activity, but the effect on immune response are still unknown. Our hypothesis is that L-arginine depletion may block nitric oxide (NO) production by iNOS, which is needed for parasite killing. To test this hypothesis, mice were supplemented with and without L-arginine, and the differential effect of treatment with an iNOS inhibitor was determined. L-arginine supplement was beneficial to the mice, lowering mortality and improving disease outcome and heart function. The beneficial effect was associated with increased levels of NO, thus low levels of L-arginine and NO are considered candidate markers of pathology. Finally, as L-arginine is a common dietary supplement, it may be useful for treatment of Chagas patients, either alone or in combination with antiparasitic drugs.
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Chatelain E, Ioset JR. Phenotypic screening approaches for Chagas disease drug discovery. Expert Opin Drug Discov 2017; 13:141-153. [PMID: 29235363 DOI: 10.1080/17460441.2018.1417380] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chagas disease, caused by the parasite Trypanosoma cruzi, is a global public health issue. Current treatments targeting the parasite are limited to two old nitroheterocyclic drugs with serious side effects. The need for new and safer drugs has prompted numerous drug discovery efforts to identify compounds suitable for parasitological cure in the last decade. Areas covered: Target-based drug discovery has been limited by the small number of well-validated targets - the latest example being the failure of azoles, T. cruzi CYP51 inhibitors, in proof-of-concept clinical trials; instead phenotypic-based drug discovery has become the main pillar of Chagas R&D. Rather than focusing on the technical features of these screening assays, the authors describe the different assays developed and available in the field, and provide a critical view on their values and limitations in the screening cascade for Chagas drug development. Expert opinion: The application of technological advances to the field of Chagas disease has led to a variety of phenotypic assays that have not only changed the disease discovery landscape but have also helped us to gain a better understanding of parasite/host interactions. Recent examples of target resolution from phenotypic hits will uncover new opportunities for drug discovery for Chagas disease.
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Affiliation(s)
- Eric Chatelain
- a Drugs for Neglected Diseases initiative (DNDi), R&D Department , Geneva , Switzerland
| | - Jean-Robert Ioset
- a Drugs for Neglected Diseases initiative (DNDi), R&D Department , Geneva , Switzerland
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