El impacto de las condiciones socioeconómicas en la evolución de la enfermedad de Chagas crónica

Looking through the lens of social science approaches: A scoping review of leishmaniases and Chagas disease research

Scholars have called for increased attention to sociocultural, economic, historical, and political processes shaping Neglected Tropical Diseases (NTDs) ecology. We conducted a scoping review to identify major research themes and the knowledge gaps in social science literature in leishmaniases or Chagas disease (CD). Following the scoping review protocol, we first determined the focus of the review to be centered on identifying research that approaches leishmaniases and CD from social science perspective and was indexed by large, biomedically focused databases. We then searched PubMed and Web of Science using "Leishmaniasis" and "Chagas disease" with "social science" or "anthropology" as search terms. We analyzed 199 articles (123 on leishmaniases and 76 on CD), categorizing them into three main research themes. Sociocultural dimensions of the diseases (leishmaniases=60.2 %; CD=68.4 %) primarily focused on individuals' knowledge, practices, and behaviors, barriers to accessing healthcare (especially in endemic regions), psychosocial effects, stigma, and traditional treatments. Research focused on socioeconomic dimensions of the diseases (leishmaniases=29.3 %; CD=19.7 %) included topics like household characteristics, social capital, and infrastructure access. A final theme, the historical and political contexts of the diseases (Leishmaniases=10.5 %; CD=11.9 %) was less common than other themes. Here, studies consider civil war and the (re)emergence of leishmaniasis, as well as the significance of CD discovery for scientific and public health in Brazil, which is the most common country for research on both leishmaniases and CD that draws on social science approaches. Future directions for research include focusing on how social institutions and economic factors shape diseases education, control measures, healthcare access, and quality of life of people affected by NTDs. Greater attention to social sciences can help mitigate and undo the ways that structural biases have infiltrated biomedicine.

Comparative proteomic analysis of Trypanosoma cruzi TcI lineage epimastigotes unveils metabolic and phenotypic differences between fast- and slow-dividing strains

Trypanosoma cruzi, the causative agent of Chagas disease, is a genetically and phenotypically diverse species, divided into 5 main phylogenetic lineages (TcI to TcVI). TcI is the most widespread lineage in the Americas. Proteomics is a suitable tool to study the global protein expression dynamics in pathogens. Previous proteomic studies have revealed a link between (i) the genetic variability; (ii) the protein expression; and (iii) the biological characteristics of T. cruzi. Here, two-dimensional electrophoresis (2DE) and mass spectrometry were used to characterize the overall protein expression profiles of epimastigotes from four distinct TcI strains displaying different growth kinetics. Ascending hierarchical clustering analysis based on the global 2DE protein expression profiles grouped the strains under study into two clusters that were congruent with their fast or slow growth kinetics. A subset of proteins differentially expressed by the strains in each group were identified by mass spectrometry. Biological differences between the two groups, including use of glucose as an energy source, flagellum length, and metabolic activity, were predicted by proteomic analysis and confirmed by metabolic tests and microscopic measurements performed on the epimastigotes of each strain. Our results show that protein expression profiles are correlated with parasite phenotypes, which may in turn influence the parasite's virulence and transmission capacity.

Chagas Disease: Seroprevalence and Associated Factors in Indigenous Communities of the Southern Limit of Argentine Chaco

Chagas disease is more prevalent in socially vulnerable communities in the Gran Chaco Eco-region. The study evaluated the seroprevalence of Chagas disease and associated factors between May 2014 and September 2015, in indigenous communities of Santa Fe, Argentina, in the southern Chaco. Lysate ELISA and indirect hemagglutination tests were used to detect antibodies against Trypanosoma cruzi, and recombinant ELISA was used in the case of disagreement. Household surveys were conducted with the head of household about risk factors for the disease. Serological tests were conducted on 298 people from three indigenous communities, 127 male and 171 female. Seroprevalence was 18.5%. A total of 64 surveys were conducted; 82.8% of the heads of household were male, with a median age of 39 years, and 61.0% had not completed primary school. In 35.9% of the households, there was at least one member of the cohabiting group infected with T. cruzi. The level of education of the head of household showed a statistically significant association with Chagas disease (OR = 3.43), among all the risk factors studied. The prevalence of infection is lower than that of other indigenous communities of the Gran Chaco, probably because environmental conditions are moderating and disfavoring the establishment of the insect vector in homes, but also because of socioeconomic differences with the rest of the eco-region. Beyond this, serological controls are needed to prevent vertical transmission.

"You will ask me: which am I?": the clinical practice of Chagas as a latent risk

Drawing on observation-based ethnography, interviews of health personnel and document review, this article describes and examines how, in clinical handling of Chagas disease, infection is treated as latent risk. It suggests that how this risk is managed has enabled a clinical practice to be conducted among people classified as at the indeterminate stage, by adding a dimension of possibility (Is it going to happen?) and potentiality (When and where?). This allows measures to be taken, including administration of medication or permanent monitoring. The reification of latent risk as a phenomenon that is manageable through a process of medicalisation engages, in turn, with other conceptions and specific experiences of risk among the affected groups. Framing the clinical practices deployed to address this risk as objects of study is a first step towards being able to describe and include them concretely in health system organisation.

Risk Score for Predicting 2-Year Mortality in Patients With Chagas Cardiomyopathy From Endemic Areas: SaMi-Trop Cohort Study

Background

Risk stratification of Chagas disease patients in the limited‐resource setting would be helpful in crafting management strategies. We developed a score to predict 2‐year mortality in patients with Chagas cardiomyopathy from remote endemic areas.

Methods and Results

This study enrolled 1551 patients with Chagas cardiomyopathy from Minas Gerais State, Brazil, from the SaMi‐Trop cohort (The São Paulo‐Minas Gerais Tropical Medicine Research Center). Clinical evaluation, ECG, and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) were performed. A Cox proportional hazards model was used to develop a prediction model based on the key predictors. The end point was all‐cause mortality. The patients were classified into 3 risk categories at baseline (low, <2%; intermediate, ≥2% to 10%; high, ≥10%). External validation was performed by applying the score to an independent population with Chagas disease. After 2 years of follow‐up, 110 patients died, with an overall mortality rate of 3.505 deaths per 100 person‐years. Based on the nomogram, the independent predictors of mortality were assigned points: age (10 points per decade), New York Heart Association functional class higher than I (15 points), heart rate ≥80 beats/min (20 points), QRS duration ≥150 ms (15 points), and abnormal NT‐proBNP adjusted by age (55 points). The observed mortality rates in the low‐, intermediate‐, and high‐risk groups were 0%, 3.6%, and 32.7%, respectively, in the derivation cohort and 3.2%, 8.7%, and 19.1%, respectively, in the validation cohort. The discrimination of the score was good in the development cohort (C statistic: 0.82), and validation cohort (C statistic: 0.71).

Conclusions

In a large population of patients with Chagas cardiomyopathy, a combination of risk factors accurately predicted early mortality. This helpful simple score could be used in remote areas with limited technological resources.

Identification of bloodmeal sources of triatomines captured in the Paraguayan Chaco region of South America by means of molecular biology analysis

The Paraguayan Chaco is an isolated environment with its own unique ecosystem. In this region, Chagas disease remains a health problem. Chagas disease is caused by the parasite Trypanosoma cruzi, and it is primarily transmitted by triatomines. In order to identify the blood meal sources of triatomines, specimens of the vector were collected in domestic and peridomestic areas and the PCR-RFLP method was implemented. Cytochrome b was amplified from the samples and later subjected to digestion with two restriction enzymes: Hae III and Xho I.It was possible to generate distinct restriction patterns on the amplified material to identify several blood meal sources for the vectors. We employed the blood from several species as positive controls: human, chicken, canine, feline, and armadillo blood. However, we identified only 3 sources for the blood meals of the insect vectors: human, chicken and canine blood. In total, 76 triatomines were captured. T. cruzi was not found in any of them. In 61% of the captured specimens, the blood meal sources for the vectors could be identified. In 30% of these cases, the presence of DNA from more than one vertebrate was detected in the same triatomine. The most common blood meal source found was chicken blood. The presence of human and chicken blood in triatomines captured in domestic and peridomestic areas strongly suggests that the parasite can freely move amongst both areas regardless of food availability. Free vector movement in these areas constitutes an epidemiological threat for the inhabitants of the community under study.

Dynamics of T Cells Repertoire During Trypanosoma cruzi Infection and its Post-Treatment Modulation

Chagas disease courses with different clinical phases and has a variable clinical presentation and progression. The acute infection phase mostly exhibits a non-specific symptomatology. In the absence of treatment, the acute phase is followed by a chronic phase, which is initially asymptomatic. This chronic asymptomatic phase of the disease is characterized by a fragile balance between the host's immune response and the parasite replication. The loss of this balance is crucial for the progression of the sickness. The virulence and tropism of the T. cruzi infecting strain together to the inflammation processes in the cardiac tissue are the main factors for the establishment and severity of the cardiomyopathy. The efficacy of treatment in chronic Chagas disease patients is controversial. However, several studies carried out in chronic patients demonstrated that antiparasitic treatment reduces parasite load in the bloodstream and leads to an improvement in the immune response against the Trypanosoma cruzi parasite. The present review is mainly focused on the cellular patterns associated to the clinical status and the evolution of the disease in chronic patients, as well as the effectiveness of the treatment related to T. cruzi infection control. Therefore, an emphasis is placed on the dynamics of specific-antigens T cell subpopulations, their memory and activation phenotypes, their functionality and their contribution to pathogenesis or disease control, as well as their association with risk of congenital transmission of the parasite.

"It's Like a Phantom Disease": Patient Perspectives on Access to Treatment for Chagas Disease in the United States

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.

Avian antibodies (IgY) against Trypanosoma cruzi: Purification and characterization studies

Trypanosoma cruzi is a flagellated protozoan belonging to the Trypanosomatidae family, the etiologic agent of Chagas disease. Currently, there is neither a licensed vaccine nor effective treatment, characterizing an unmet clinical need. The IgY refers to the egg yolk immunoglobulin (Y=yolk) and its production and use are subjects of many studies due to the diversity of its diagnostic and therapeutic applications. Several researchers have shown that the use of specific IgY may prevent and/or control infectious and parasitic diseases. Based on these evidences, the aim of this study was to immunize chickens with trypomastigotes of T. cruzi in order to produce highly effective and pure antibodies (IgY), as well as extract, characterize, quantify, and verify cytotoxic effects of IgY anti-T. cruzi. After the induction of IgY production by chickens, the eggs were collected and the IgY was extracted by method of precipitation of polyethylene glycol 6000. The IgY anti-T. cruzi characterization was performed using polyacrylamide gel electrophoresis (SDS-PAGE), western-blot and enzyme-linked immunosorbent assay (ELISA). Moreover, the cytotoxic or proliferative effects of IgY anti-T. cruzi was verified by MTT assay. The concentration of IgY in yolk was 8.41±1.47mg/mL. The characterization of IgY reveled bands of stained peptides with molecular weight between 75 and 50kDa and 37 and 25kDa. In the ELISA test was observed that there was antigen-antibody reaction throughout the sample period. The concentrations of 1, 5 and 10mg/mL of IgY anti-T. cruzi presented no cytotoxic of proliferative effects in mononuclear and VERO cells in vitro. The results indicated that T. cruzi is able to generate a high production of specific immunoglobulins in chickens, it did not cause damage to the cell membrane and no proliferative effect.

"I Cannot Be Worried": Living with Chagas Disease in Tropical Bolivia

BACKGROUND

Chagas disease (CD) profoundly affects the social and emotional dimensions of patients' lives, and disproportionately impacts poor, marginalized populations in Latin America. Biomedical treatment for CD fails to reach up to 99% of the people affected, and in any case seldom addresses the emotional health or socioeconomic conditions of patients. This study examines patient strategies for coping with CD in the department of Santa Cruz, Bolivia.

METHODOLOGY

In this ethnographic study, semistructured interviews took place from March-June 2013 with 63 patients who had previously tested positive for CD. During the fieldwork period, participant observation was conducted and patient family members, providers, community members, and public health officials were consulted.

PRINCIPAL FINDINGS

Patients often experienced emotional distress when diagnosed with CD, yet were generally unable to find biomedical treatment. Respondents stressed the need to avoid powerful emotions which would worsen the impact of CD symptoms. To manage CD, patients embraced a calm state of mind, described in Spanish as tranquilidad, which partially empowered them to return to a normal existence.

CONCLUSIONS

In the perceived absence of biomedical treatment options, patients seek their own means of coping with CD diagnosis. Rather than fatalism or resignation, patients' emphasis on maintaining calm and not worrying about CD represents a pragmatic strategy for restoring a sense of normalcy and control to their lives. Programs focused on treatment of CD should remain mindful of the emotional and social impact of the disease on patients.

The Role of Gender in Chagas Disease Prevention and Control in Honduras: An Analysis of Communication and Collaboration Networks

In Honduras, where Chagas disease is a serious health and environmental concern, prevention measures face the challenge of achieving widespread and long-term sustainable adoption by communities. The article integrates social network analysis and a gender-sensitive approach to understand the role of men and women in the implementation of a community-level intervention, based on the adoption of housing improvements to reduce the presence of the insect vector. A total of 108 people in the community of El Salitre were interviewed. Data were collected on socio-demographic characteristics, participation in project activities, communication and collaboration networks related to Chagas disease prevention, knowledge of Chagas disease, and adoption of housing improvements techniques. Communication mostly occurred between the same gender individuals and was associated with knowledge of Chagas disease. Socioeconomic status, Chagas disease knowledge, and collaboration with men were associated with women adopting housing improvements. For men, however, participation in project activities, formal education, and collaboration with women were associated with adoption. These findings suggest that men and women were driven by distinct concerns, interests, and motivations when adopting new Chagas disease prevention strategies. Participatory community interventions that seek to generate health knowledge and foster collaborations to reduce health risk should address gender differences.

Endemic Cardiovascular Diseases of the Poorest Billion

The poorest billion people are distributed throughout the world, though most are concentrated in rural sub-Saharan Africa and South Asia. Cardiovascular disease (CVD) data can be sparse in low- and middle-income countries beyond urban centers. Despite this urban bias, CVD registries from the poorest countries have long revealed a predominance of nonatherosclerotic stroke, hypertensive heart disease, nonischemic and Chagas cardiomyopathies, rheumatic heart disease, and congenital heart anomalies, among others. Ischemic heart disease has been relatively uncommon. Here, we summarize what is known about the epidemiology of CVDs among the world’s poorest people and evaluate the relevance of global targets for CVD control in this population. We assessed both primary data sources, and the 2013 Global Burden of Disease Study modeled estimates in the world’s 16 poorest countries where 62% of the population are among the poorest billion. We found that ischemic heart disease accounted for only 12% of the combined CVD and congenital heart anomaly disability-adjusted life years (DALYs) in the poorest countries, compared with 51% of DALYs in high-income countries. We found that as little as 53% of the combined CVD and congenital heart anomaly burden (1629/3049 DALYs per 100 000) was attributed to behavioral or metabolic risk factors in the poorest countries (eg, in Niger, 82% of the population among the poorest billion) compared with 85% of the combined CVD and congenital heart anomaly burden (4439/5199 DALYs) in high-income countries. Further, of the combined CVD and congenital heart anomaly burden, 34% was accrued in people under age 30 years in the poorest countries, while only 3% is accrued under age 30 years in high-income countries. We conclude although the current global targets for noncommunicable disease and CVD control will help diminish premature CVD death in the poorest populations, they are not sufficient. Specifically, the current framework (1) excludes deaths of people <30 years of age and deaths attributable to congenital heart anomalies, and (2) emphasizes interventions to prevent and treat conditions attributed to behavioral and metabolic risks factors. We recommend a complementary strategy for the poorest populations that targets premature death at younger ages, addresses environmental and infectious risks, and introduces broader integrated health system interventions, including cardiac surgery for congenital and rheumatic heart disease.

Ecological and sociodemographic determinants of house infestation by Triatoma infestans in indigenous communities of the Argentine Chaco

BACKGROUND

The Gran Chaco ecoregion, a hotspot for Chagas and other neglected tropical diseases, is home to >20 indigenous peoples. Our objective was to identify the main ecological and sociodemographic determinants of house infestation and abundance of Triatoma infestans in traditional Qom populations including a Creole minority in Pampa del Indio, northeastern Argentina.

METHODS

A cross-sectional survey determined house infestation by timed-manual searches with a dislodging aerosol in 386 inhabited houses and administered questionnaires on selected variables before full-coverage insecticide spraying and annual vector surveillance. We fitted generalized linear models to two global models of domestic infestation and bug abundance, and estimated coefficients via multimodel inference with model averaging.

PRINCIPAL FINDINGS

Most Qom households were larger and lived in small-sized, recently-built, precarious houses with fewer peridomestic structures, and fewer livestock and poultry than Creoles'. Qom households had lower educational level and unexpectedly high residential mobility. House infestation (31.9%) was much lower than expected from lack of recent insecticide spraying campaigns and was spatially aggregated. Nearly half of the infested houses examined had infected vectors. Qom households had higher prevalence of domestic infestation (29.2%) than Creoles' (10.0%), although there is large uncertainty around the adjusted OR. Factors with high relative importance for domestic infestation and/or bug abundance were refuge availability, distance to the nearest infested house, domestic insecticide use, indoor presence of poultry, residential overcrowding, and household educational level.

CONCLUSIONS AND SIGNIFICANCE

Our study highlights the importance of sociodemographic determinants of domestic infestation such as overcrowding, education and proximity to the nearest infested house, and corroborates the role of refuge availability, domestic use of insecticides and household size. These factors may be used for designing improved interventions for sustainable disease control and risk stratification. Housing instability, household mobility and migration patterns are key to understanding the process of house (re)infestation in the Gran Chaco.

Towards a paradigm shift in the treatment of chronic Chagas disease

Treatment for Chagas disease with currently available medications is recommended universally only for acute cases (all ages) and for children up to 14 years old. The World Health Organization, however, also recommends specific antiparasite treatment for all chronic-phase Trypanosoma cruzi-infected individuals, even though in current medical practice this remains controversial, and most physicians only prescribe palliative treatment for adult Chagas patients with dilated cardiomyopathy. The present opinion, prepared by members of the NHEPACHA network (Nuevas Herramientas para el Diagnóstico y la Evaluación del Paciente con Enfermedad de Chagas/New Tools for the Diagnosis and Evaluation of Chagas Disease Patients), reviews the paradigm shift based on clinical and immunological evidence and argues in favor of antiparasitic treatment for all chronic patients. We review the tools needed to monitor therapeutic efficacy and the potential criteria for evaluation of treatment efficacy beyond parasitological cure. Etiological treatment should now be mandatory for all adult chronic Chagas disease patients.

Clinical characteristics and outcome of 107 adult patients with chronic Chagas disease and parasitological cure criteria

BACKGROUND

The cure in adult patients with chronic Chagas disease and the relationship between parasitological and clinical evolution is still under debate. The aim of this study was to analyze the clinical, epidemiological and progression features of the disease in a patient population who became serologically negative either spontaneously or post-etiological treatment.

METHODS

We included 107 patients over 20 years old with three different confirmed reactive anti-Trypanosoma cruzi serologic tests on admission, and a minimum of two years of follow-up. Patients were assigned to clinical groups according to Kuschnir. Change of clinical group was considered a heart disease progression criterion, and seronegative conversion of two or three as parasitological cure criterion.

RESULTS

From 107 patients with parasitological cure, 82 had received treatment (77%) and 25 became spontaneously seronegative (23%). Forty-six (43%) and 61 (57%) patients had two and three negative serological tests, respectively. No differences in clinical groups, ECG, echocardiogram and heart disease progression were found in patients who became negative spontaneously or post-treatment. The clinical progression and ECG changes were observed in 5/107 (5%) and 11/107 (10%) respectively, in a mean of 10 years follow-up.

CONCLUSIONS

Adults with chronic Chagas disease can cure, mostly post-etiological treatment, but also spontaneously, showing a favourable clinical outcome.

American trypanosomiasis

American trypanosomiasis is a parasitic disease caused by the flagellate protozoan Trypanosoma cruzi. Chagas disease is endemic in Latin America, where an estimated 10-14 million people are infected, and an emerging disease in Europe and the USA. Trypanosoma cruzi is transmitted by blood-sucking bugs of the family Reduviidae. Rhodnius prolixus, Panstrongylus megistus, Triatoma infestans, and T. dimidiata are the main vectors in the sylvatic cycle. Non vector-borne transmission includes blood transfusion, congenital and oral transmission, transplantation, and accidental infections. Most cases of acute infection occur in childhood and are usually asymptomatic, although severe myocarditis and meningoencephalitis may occur. Approximately 30% of T. cruzi-infected people will develop the chronic stage of the disease. Chronic chagasic cardiomyopathy is characterized by progressive heart failure, arrhythmias, intraventricular conduction defects, sudden death, and peripheral thromboembolism. Acute exacerbation can occur in individuals with involvement of cellular immunity such as advanced AIDS (acquired immunodeficiency syndrome), and transplant-associated immunosuppression. Neurological involvement may present with encephalitis, meningoencephalitis, or a space-occupying cerebral lesion called chagoma. Chagas disease is a major cause of ischemic stroke in Latin America. Several epidemiological studies have found an association between T. cruzi infection and cardioembolic ischemic stroke. Benznidazole and nifurtimox are the two available trypanocide drugs against T. cruzi.

Prevalence and risk factors for Chagas disease in pregnant women in Casanare, Colombia

Knowledge of the prevalence and risk factors associated with maternal infection is the first step to develop a surveillance system for congenital transmission of Chagas disease. We conducted a cross-sectional study in Casanare, a disease-endemic area in Colombia. A total of 982 patients were enrolled in the study. A global prevalence of Trypanosoma cruzi infection of 4.0% (95% confidence interval [CI] = 2.8-5.3%) was found. Multivariate analysis showed that the most important risk-associated factors were age > 29 years (adjusted odds ratio [aOR] = 3.4, 95% CI = 0.9-12.4), rural residency (aOR = 2.2, 95% CI = 1.0-4.6), low education level (aOR = 10.2, 95% CI = 1.6-82.7), and previous knowledge of the vector (aOR = 2.2, 95% CI = 1.0-4.9). Relatives and siblings of infected mothers showed a prevalence of 9.3%. These findings may help physicians to investigate congenital cases, screen Chagas disease in siblings and relatives, and provide early treatment to prevent the chronic complications of Chagas disease.

Metabolic, mental health, behavioural and socioeconomic characteristics of migrants with Chagas disease in a non-endemic country

OBJECTIVES

Chronic Chagas disease causes cardiopathy in 20-40% of the 8-10 million people affected. The prevalence of atherogenic factors increases rapidly in Latin America. Somatic, mental, behavioural and social characteristics of the 80,000 Latino migrants with Chagas disease in Europe are not known. We postulate that they may accumulate these factors for poor health--notably cardiovascular-outcomes.

METHODS

This study took place at the Geneva University Hospitals in 2011. Latin American migrants with Chagas disease diagnosed in Geneva since 2008 were contacted. Interviews and blood tests assessed behavioural, socioeconomic, metabolic and cardiovascular factors.

RESULTS

One hundred and thirty-seven patients (women: 84.7%; median age: 43 years) with chronic Chagas disease were included in the study. The majority were Bolivians (94.2%), undocumented (83.3%), uninsured (72.3%) and living below the Swiss poverty line (89.1%). Prevalence of obesity was 25.5%, of hypertension 17.5%, of hypercholesterolemia 16.1%, of impaired fasting glucose 23.4%, of diabetes 2.9%, of metabolic syndrome 16.8%, of anxiety 58.4%, of depression 28.5%, of current smoking 15.4% and of sedentary lifestyle 62.8%. High (>10%) 10-year cardiovascular risk affected 12.4%.

CONCLUSIONS

Latin American migrants with Chagas disease accumulate pathogenic chronic conditions of infectious, non-transmissible, socioeconomic and behavioural origin, putting them at high risk of poor health, notably cardiovascular, outcomes. This highlights the importance of screening for these factors and providing interventions to tackle reversible disorders; facilitating access to care for this hard-to-reach population to prevent delays in medical interventions and poorer health outcomes; and launching prospective studies to evaluate the long-term impact of these combined factors on the natural course of Chagas disease.

Chagas disease: coming to a place near you

Chagas disease, or American trypanosomiasis, is a parasitic infection caused by the flagellate protozoan Trypanosoma cruzi, an organism that is endemic to Latin America. While Chagas disease is primarily a vector-borne illness, new cases are emerging in non-endemic areas due to globalization of immigration and non-vectorial transmission routes. This article discusses the mode of transmission, evolving epidemiology, pathogenesis, diagnosis, treatment and prevention and control of the disease.

Trypanosomiasis, cardiomyopathy and the risk of ischemic stroke

American (Chagas disease) and African (sleeping sickness) trypanosomiasis are neglected tropical diseases and are a heavy burden in Latin America and Africa, respectively. Chagas disease is an independent risk factor for stroke. Apical aneurysm, heart failure and cardiac arrhythmias are associated with ischemic stroke in chagasic cardiomyopathy. Not all chagasic patients who suffer an ischemic stroke have a severe cardiomyopathy, and stroke may be the first manifestation of Chagas disease. Cardioembolism affecting the middle cerebral artery is the most common stroke subtype. Risk of recurrence is high and careful evaluation of recurrence risk should be addressed. Repolarization changes, low voltage and prolonged QT interval are common electrocardiography alterations in human African trypanosomiasis, and can be found in more than 70% of patients. Epidemiological studies are needed to asses the risk of stroke in African trypanosomiasis perimyocarditis.