Broad patterns in domestic vector-borne Trypanosoma cruzi transmission dynamics: synanthropic animals and vector control

A description of the epidemiological dynamics of Chagas disease via mathematical modeling

Chagas disease is caused by the protozoan Trypanosoma cruzi, which parasitizes many mammals, including humans. Its vectors are blood-feeding hematophagous triatomine insects of different species, which vary according to the geographical area. One of the 17 neglected diseases targeted by the World Health Organization, Chagas disease is endemic to the Americas, but has spread to other countries due to human migratory movements. In this study, we describe the epidemiological dynamics of Chagas disease in an endemic area, considering the main transmission mechanisms and the demographic effects of birth, mortality, and human migration in this phenomenon. We apply mathematical models as a methodological approach to simulate the interactions between reservoirs, vectors, and humans using a system of ordinary differential equations. The results show that the Chagas disease control measures currently in place cannot be relaxed without endangering the progress achieved to date.

Effectiveness of fluralaner treatment regimens for the control of canine Chagas disease: A mathematical modeling study

BACKGROUND

Canine Chagas disease is caused by the protozoan parasite Trypanosoma cruzi and transmitted by insect triatomine vectors known as kissing bugs. The agent can cause cardiac damage and long-term heart disease and death in humans, dogs, and other mammals. In laboratory settings, treatment of dogs with systemic insecticides has been shown to be highly efficacious at killing triatomines that feed on treated dogs.

METHOD

We developed compartmental vector-host models of T. cruzi transmission between the triatomine and dog population accounting for the impact of seasonality and triatomine migration on disease transmission dynamics. We considered a single vector-host model without seasonality, and model with seasonality, and a spatially coupled model. We used the models to evaluate the effectiveness of the insecticide fluralaner with different durations of treatment regimens for reducing T. cruzi infection in different transmission settings.

RESULTS

In low and medium transmission settings, our model showed a marginal difference between the 3-month and 6-month regimens for reducing T. cruzi infection among dogs. The difference increases in the presence of seasonality and triatomine migration from a sylvatic transmission setting. In high transmission settings, the 3-month regimen was substantially more effective in reducing T. cruzi infections in dogs than the other regimens. Our model showed that increased migration rate reduces fluralaner effectiveness in all treatment regimens, but the relative reduction in effectiveness is minimal during the first years of treatment. However, if an additional 10% or more of triatomines killed by dog treatment were eaten by dogs, treatment could increase T. cruzi infections in the dog population at least during the first year of treatment.

CONCLUSION

Our analysis shows that treating all peridomestic dogs every three to six months for at least five years could be an effective measure to reduce T. cruzi infections in dogs and triatomines in peridomestic transmission settings. However, further studies at the local scale are needed to better understand the potential impact of routine use of fluralaner treatment on increasing dogs' consumption of dead triatomines.

Challenges of using modelling evidence in the visceral leishmaniasis elimination programme in India

As India comes closer to the elimination of visceral leishmaniasis (VL) as a public health problem, surveillance efforts and elimination targets must be continuously revised and strengthened. Mathematical modelling is a compelling research discipline for informing policy and programme design in its capacity to project incidence across space and time, the likelihood of achieving benchmarks, and the impact of different interventions. To gauge the extent to which modelling informs policy in India, this qualitative analysis explores how and whether policy makers understand, value, and reference recently produced VL modelling research. Sixteen semi-structured interviews were carried out with both users- and producers- of VL modelling research, guided by a knowledge utilisation framework grounded in knowledge translation theory. Participants reported that barriers to knowledge utilisation include 1) scepticism that models accurately reflect transmission dynamics, 2) failure of modellers to apply their analyses to specific programme operations, and 3) lack of accountability in the process of translating knowledge to policy. Political trust and support are needed to translate knowledge into programme activities, and employment of a communication intermediary may be a necessary approach to improve this process.

Ecomorphological variation of the Triatoma guasayana wing shape in semi-arid Chaco region

Triatoma guasayana (Hemiptera, Reduviidae), considered a secondary vector of Chagas disease, invades rural dwellings through flight dispersal during the warm season in semi-arid Chaco of Argentina. The objective of this study was to define and compare morphometrics features in the relative body size and wing shape of T. guasayana related to temperature and rainfall between spring, summer and end of summer. A total of 188 adults were collected in rural communities in the northwest of the province of Córdoba (central Argentina). Relative body size [body length (mm) / wing length (mm)] and 11 landmarks on the right wing were recorded. The temperature ( °C) and precipitation (mm) data were extracted from the MODIS sensor and Terra Climate dataset, respectively. Correlations between climatic variables and morphological variation were analyzed using Partial Least Square (PLS). Males at the end of summer were smaller than those at spring or summer (F = 4.48; df = 2; p = 0.01), whereas females were similar in relative body size at all seasons (F = 0.76; df = 2; p = 0.47). The PLS in males showed a correlation between wing shape and temperature (r = 0.48; p = 0.03) and precipitation (r = 0.50; p = 0.02) while in females only the temperature was the correlation significant (r = 0.35; p = 0.03). Triatoma guasayana has elongated and thin wings in spring that become short and wide at the end of summer. The morphotype of early summer could allow sustained long-duration flights, while the morphotype of end of summer would be related to short flights, correlated with the dispersive behavior of the species. The results in this study suggest that wing morphology of T. guasayana has phenotypic plasticity, and that temperature and rainfall could be considered modulator factors during the developmental stage.

Modelling the dynamics of Trypanosoma rangeli and triatomine bug with logistic growth of vector and systemic transmission

In this paper, an insect-parasite-host model with logistic growth of triatomine bugs is formulated to study the transmission between hosts and vectors of the Chagas disease by using dynamical system approach. We derive the basic reproduction numbers for triatomine bugs and Trypanosoma rangeli as two thresholds. The local and global stability of the vector-free equilibrium, parasite-free equilibrium and parasite-positive equilibrium is investigated through the derived two thresholds. Forward bifurcation, saddle-node bifurcation and Hopf bifurcation are proved analytically and illustrated numerically. We show that the model can lose the stability of the vector-free equilibrium and exhibit a supercritical Hopf bifurcation, indicating the occurrence of a stable limit cycle. We also find it unlikely to have backward bifurcation and Bogdanov-Takens bifurcation of the parasite-positive equilibrium. However, the sustained oscillations of infected vector population suggest that Trypanosoma rangeli will persist in all the populations, posing a significant challenge for the prevention and control of Chagas disease.

Domestic host availability modifies human-triatomine contact and host shifts of the Chagas disease vector Triatoma infestans in the humid Argentine Chaco

Domestic animals may affect human-vector contact and parasite transmission rates. We investigated the relationships between host-feeding choices, site-specific host availability, bug nutritional status, stage and abundance of Triatoma infestans Klug (Heteroptera: Reduviidae) in rural houses of Pampa del Indio during spring. We identified the bloodmeal sources of 865 triatomines collected in 70 sites from four main ecotopes. The main sources in domiciles were human (65.9%), chicken (23.4%) and dog (22.4%); dog (64.4%, 35.3%) and chicken (33.1%, 75.4%) in kitchens and storerooms, respectively; and chicken (94.7%) in chicken coops. Using random-intercept logistic regression clustered by domicile, the fraction of human-fed triatomines strongly decreased with increasing proportions of chicken- and dog-fed bugs, dropping from 96.4% when no chicken or dog slept indoors at night to 59.4% when both did. The fraction of dog-fed bugs significantly decreased with increasing human and chicken blood indices, and marginally increased with an indoor-resting dog. Mixed blood meals occurred 3.62 times more often when a chicken or a dog slept indoors. Host blood source did not affect mean body weight adjusted for body length and bug stage. Indoor-resting chickens and dogs greatly modified human-bug contact rates, and may be targeted with long-lasting systemic insecticides to suppress infestation.

Preliminary Characterization of Triatomine Bug Blood Meals on the Island of Trinidad Reveals Opportunistic Feeding Behavior on Both Human and Animal Hosts

Chagas disease is a neglected tropical disease caused by infection with Trypanosoma cruzi. The parasite is endemic to the Americas, including the Caribbean, where it is vectored by triatomine bugs. Although Chagas disease is not considered a public health concern in the Caribbean islands, studies in Trinidad have found T. cruzi-seropositive humans and T. cruzi-infected triatomine bugs. However, little is known about triatomine bug host preferences in Trinidad, making it difficult to evaluate local risk of vector-borne T. cruzi transmission to humans. To investigate this question, we collected triatomine bugs in Trinidad and diagnosed each one for T. cruzi infection (microscopy and PCR). We then carried out a blood meal analysis using DNA extracted from each bug (PCR and sequencing). Fifty-five adult bugs (54 Panstrongylus geniculatus and one Rhodnius pictipes) were collected from five of 21 sample sites. All successful collection sites were residential. Forty-six out of the 55 bugs (83.6%) were infected with T. cruzi. Fifty-three blood meal hosts were successfully analyzed (one per bug), which consisted of wild birds (7% of all blood meals), wild mammals (17%), chickens (19%), and humans (57%). Of the 30 bugs with human blood meals, 26 (87%) were from bugs infected with T. cruzi. Although preliminary, our results align with previous work in which P. geniculatus in Trinidad had high levels of T. cruzi infection. Furthermore, our findings suggest that P. geniculatus moves between human and animal environments in Trinidad, feeding opportunistically on a wide range of species. Our findings highlight a critical need for further studies of Chagas disease in Trinidad in order to estimate the public health risk and implement necessary preventative and control measures.

A voluntary use of insecticide treated nets can stop the vector transmission of Chagas disease

One of the stated goals of the London Declaration on Neglected Tropical Diseases is the interruption of domiciliary transmissions of Chagas disease in the region of the Americas. We used a game-theoretic approach to assess the voluntary use of insecticide treated nets (ITNs) in the prevention of the spread of infection through vector bites. Our results show that individuals behave rationally and weigh the risks of insect bites against the cost of the ITNs. The optimal voluntary use of ITNs results in predicted incidence rates that closely track the real incidence rates in Latin America. This means that ITNs are effective and could be used to control the spread of the disease by relying on individual decisions rather than centralized policies. Our model shows that to completely eradicate the vector transmission through the voluntary individual use of ITNs, the cost of ITNs should be as low as possible.

Morphological variability and ecological characterization of the Chagas disease vector Triatoma dimidiata (Hemiptera: Reduviidae) in El Salvador

There are 8 million people with Chagas disease worldwide and in El Salvador approximately 39% of the population is at risk of contracting the disease. One of the principal challenges in mitigating Chagas is evaluating the role of the vector ecology of triatomine species in the transmission of the Trypanosoma cruzi parasite in anthropogenically modified habitats, where new patterns of transmission frequently arise. Field studies of triatomine vector ecology in El Salvador have largely focused on describing parameters that contribute to infestation patterns, which may themselves be rooted in the morphological variability that exists in triatomine populations. The objective of this study was to evaluate the morphology of the vector species Triatoma dimidiata with respect to the characteristics of the ecological landscape the vector inhabits throughout El Salvador. We used image analyses to evaluate T. dimidiata morphological variability and then used Geographic Information Systems to intersect the morphological point-data with map layers containing different environmental characteristics. Our study found that the variation in the size, shape, and coloration of T. dimidiata varied in relation to elevation, Holdridge life zone, soil type and land use. We further characterize the local morphological adaptations of T. dimidiata with respect to the local ecological, biological, and geographical conditions in El Salvador. We suggest that future studies consider a molecular exploration of local T. dimidiata species complex in El Salvador, especially since morphological studies of triatomine species complex have found that variability correlate with the genetic variability of the population.

Modelling triatomine bug population and Trypanosoma rangeli transmission dynamics: Co-feeding, pathogenic effect and linkage with chagas disease

Trypanosoma rangeli (T. rangeli), a parasite, is not pathogenic to human but pathogenic to some vector species to induce the behavior changes of infected vectors and subsequently impact the transmission dynamics of other diseases such as Chagas disease which shares the same vector species. Here we develop a mathematical model and conduct qualitative analysis for the transmission dynamics of T. rangeli. We incorporate both systemic and co-feeding transmission routes, and account for the pathogenic effect using infection-induced fecundity and fertility change of the triatomine bugs. We derive two thresholds R_v (the triatomine bug basic reproduction number) and R₀ (the T. rangeli basic reproduction number) to delineate the dynamical behaviors of the ecological and epidemiological systems. We show that when R_v>1 and R₀>1, a unique parasite positive equilibrium E* appears. We find that E* can be unstable and periodic oscillations can be observed where the pathogenic effect plays a significant role. Implications of the qualitative analysis and numerical simulations suggest the need of an integrative vector-borne disease prevention and control strategy when multiple vector-borne diseases are transmitted by the same set of vector species.

A model of insect control with imperfect treatment

Insecticide spraying of housing units is an important control measure for vector-borne infections such as Chagas disease. However, some vectors may survive treatment, due to imperfect spraying by the operator or because they hide deep in the cracks or other places, and re-emerge in the same unit when the effect of the insecticide wears off. While several mathematical models of this phenomenon have been previously described and studied in the literature, the model presented here is more basic than existing ones. Thus it is more amenable to mathematical analysis, which is carried out here. In particular, we demonstrate that an initially very high spraying rate may push the system into a region of the state space with low endemic levels of infestation that can be maintained in the long run at relatively moderate cost, while in the absence of an aggressive initial intervention the same average cost would only allow a much less significant reduction in long-term infestation levels.

Trypanosoma cruzi transmission dynamics in a synanthropic and domesticated host community

Trypanosoma cruzi is the causative agent of Chagas disease, a Neglected Tropical Disease affecting 8 million people in the Americas. Triatomine hematophagous vectors feed on a high diversity of vertebrate species that can be reservoirs or dead-end hosts, such as avian species refractory to T. cruzi. To understand its transmission dynamics in synanthropic and domesticated species living within villages is essential to quantify disease risk and assess the potential of zooprophylaxis. We developed a SI model of T. cruzi transmission in a multi-host community where vector reproduction and parasite transmission depend on a triatomine blood-feeding rate accounting for vector host preferences and interference while feeding. The model was parameterized to describe T. cruzi transmission in villages of the Yucatan peninsula, Mexico, using the information about Triatoma dimidiata vectors and host populations accumulated over the past 15 years. Extensive analyses of the model showed that dogs are key reservoirs and contributors to human infection, as compared to synanthropic rodents and cats, while chickens or other domesticated avian hosts dilute T. cruzi transmission despite increasing vector abundance. In this context, reducing the number of dogs or increasing avian hosts abundance decreases incidence in humans by up to 56% and 39%, respectively, while combining such changes reduces incidence by 71%. Although such effects are only reached over >10-years periods, they represent important considerations to be included in the design of cost-effective Integrated Vector Management. The concomitant reduction in T. cruzi vector prevalence estimated by simulating these zooprophylactic interventions could indeed complement the removal of colonies from the peridomiciles or the use of insect screens that lower vector indoor abundance by ~60% and ~80%. These new findings reinforce the idea that education and community empowerment to reduce basic risk factors is a cornerstone to reach and sustain the key objective of interrupting Chagas disease intra-domiciliary transmission.

Complementary Paths to Chagas Disease Elimination: The Impact of Combining Vector Control With Etiological Treatment

Background

The World Health Organization’s 2020 goals for Chagas disease are (1) interrupting vector-borne intradomiciliary transmission and (2) having all infected people under care in endemic countries. Insecticide spraying has proved efficacious for reaching the first goal, but active transmission remains in several regions. For the second, treatment has mostly been restricted to recently infected patients, who comprise only a small proportion of all infected individuals.

Methods

We extended our previous dynamic transmission model to simulate a domestic Chagas disease transmission cycle and examined the effects of both vector control and etiological treatment on achieving the operational criterion proposed by the Pan American Health Organization for intradomiciliary, vectorial transmission interruption (ie, <2% seroprevalence in children <5 years of age).

Results

Depending on endemicity, an antivectorial intervention that decreases vector density by 90% annually would achieve the transmission interruption criterion in 2–3 years (low endemicity) to >30 years (high endemicity). When this strategy is combined with annual etiological treatment in 10% of the infected human population, the seroprevalence criterion would be achieved, respectively, in 1 and 11 years.

Conclusions

Combining highly effective vector control with etiological (trypanocidal) treatment in humans would substantially reduce time to transmission interruption as well as infection incidence and prevalence. However, the success of vector control may depend on prevailing vector species. It will be crucial to improve the coverage of screening programs, the performance of diagnostic tests, the proportion of people treated, and the efficacy of trypanocidal drugs. While screening and access can be incremented as part of strengthening the health systems response, improving diagnostics performance and drug efficacy will require further research.

Considering Dogs as Complementary Targets of Chagas Disease Control

This review describes the role that dogs play in Latin American countries where Chagas disease is endemic. Multiple studies determined the high frequency with which canine populations are infected with Trypanosoma cruzi. The infection prevalence of dogs is greater than that of humans and the presence of infected dogs in households is associated with a higher risk of human infection. Dog infectiousness to triatomine vectors is several-fold higher than that of humans, thereby underscoring their major role in the domestic transmission of T. cruzi. Insecticide spraying of houses is in most cases efficacious but the lack of sustainability hinders this vector-focused strategy. Multi-pronged approaches have been adopted to improve control measures but dog intervention was never included. Experimental evaluation of systemic insecticides or deltamethrin-impregnated collars suggested that dog intervention leading to triatomine killing could curb domestic transmission of T. cruzi. Larger field studies are required to determine its applicability and efficacy. However, the implementation of dog intervention could complement other control measures currently in place, mostly in periods when vector spraying has been interrupted.

What makes an effective Chagas disease vector? Factors underlying Trypanosoma cruzi-triatomine interactions

The Chagas disease is caused by the parasite Trypanosoma cruzi, which infect blood-feeding triatomine bugs to finally reach mammal hosts. Chagas disease is endemic in Latin America, and is ranked among the 13 neglected tropical diseases worldwide. Currently, an estimate of 7 million people is infected by T. cruzi, leading to about 22 000 deaths per year throughout the Americas. As occurs with other vectors, a major question towards control programs is what makes a susceptible bug. In this review, we focus on findings linked to insect gut structure and microbiota, immunity, genetics, blood sources, abiotic factors (with special reference to ambient temperature and altitude) to understand the interactions occurring between T. cruzi and triatomine bugs, under a co-evolutionary scenario. These factors lead to varying fitness benefits and costs for bugs, explaining why infection in the insect takes place and how it varies in time and space. Our analysis highlights that major factors are gut components and microbiota, blood sources and temperature. Although their close interaction has never been clarified, knowledge reviewed here may help to boost the success of triatomine control programs, reducing the use of insecticides.

Natural infection by Trypanosoma cruzi in triatomines and seropositivity for Chagas disease of dogs in rural areas of Rio Grande do Norte, Brazil

INTRODUCTION

Chagas disease is caused by the protozoa Trypanosoma cruzi. Its main reservoir is the domestic dog, especially in rural areas with favorable characteristics for vector establishment and proliferation. The aims of this study were to collect data, survey and map the fauna, and identify T. cruzi infection in triatomines, as well as to assess the presence of anti-T. cruzi antibodies in dogs in rural areas of the municipality of Mossoró, Brazil.

METHODS

An active entomologic research was conducted to identify adult specimens through an external morphology dichotomous key. The analysis of natural infection by T. cruzi in the insects was performed by isolation in culture and polymerase chain reaction. The antibody testing for T. cruzi in dogs was performed by enzyme-linked immunosorbent assay and indirect immunofluorescence assay.

RESULTS

A total of 68 triatomines were captured, predominantly the Triatoma brasiliensis brasiliensis (Neiva 1911) species. The vector mapping displayed areas with greater risk for parasite transmission. Of the examined triatomines (51 specimens), 41.2% (21/51) were positive on polymerase chain reaction, and all were negative on culture. In the serum testing, 11% (25/218) of dogs were seropositive, but no association was found between the serologic results and the presence and infection by T. cruzi in triatomines.

CONCLUSIONS

This study demonstrated the movement of T. cruzi in the studied area, by the presence of vectors and naturally infected domestic reservoirs. The mapping of the studied rural area demonstrates the risk of disease transmission.

Are the London Declaration's 2020 goals sufficient to control Chagas disease?: Modeling scenarios for the Yucatan Peninsula

BACKGROUND

The 2020 Sustainable Development goals call for 100% certified interruption or control of the three main forms of Chagas disease transmission in Latin America. However, how much will achieving these goals to varying degrees control Chagas disease; what is the potential impact of missing these goals and if they are achieved, what may be left?

METHODS

We developed a compartmental simulation model that represents the triatomine, human host, and non-human host populations and vector-borne, congenital, and transfusional T. cruzi transmission between them in the domestic and peridomestic settings to evaluate the impact of limiting transmission in a 2,000 person virtual village in Yucatan, Mexico.

RESULTS

Interruption of domestic vectorial transmission had the largest impact on T. cruzi transmission and prevalence in all populations. Most of the gains were achieved within the first few years. Controlling vectorial transmission resulted in a 46.1-83.0% relative reduction in the number of new acute Chagas cases for a 50-100% interruption in domestic vector-host contact. Only controlling congenital transmission led to a 2.4-8.1% (30-100% interruption) relative reduction in the total number of new acute cases and reducing only transfusional transmission led to a 0.1-0.3% (30-100% reduction). Stopping all three forms of transmission resulted in 0.5 total transmission events over five years (compared to 5.0 with no interruption); interrupting all forms by 30% resulted in 3.4 events over five years per 2,000 persons.

CONCLUSIONS

While reducing domestic vectorial, congenital, and transfusional transmission can successfully reduce transmission to humans (up to 82% in one year), achieving the 2020 goals would still result in 0.5 new acute cases per 2,000 over five years. Even if the goals are missed, major gains can be achieved within the first few years. Interrupting transmission should be combined with other efforts such as a vaccine or improved access to care, especially for the population of already infected individuals.

Evolutionary ecology of Chagas disease; what do we know and what do we need?

The aetiological agent of Chagas disease, Trypanosoma cruzi, is a key human pathogen afflicting most populations of Latin America. This vectorborne parasite is transmitted by haematophageous triatomines, whose control by large‐scale insecticide spraying has been the main strategy to limit the impact of the disease for over 25 years. While those international initiatives have been successful in highly endemic areas, this systematic approach is now challenged by the emergence of insecticide resistance and by its low efficacy in controlling species that are only partially adapted to human habitat. In this contribution, we review evidences that Chagas disease control shall now be entering a second stage that will rely on a better understanding of triatomines adaptive potential, which requires promoting microevolutionary studies and –omic approaches. Concomitantly, we show that our knowledge of the determinants of the evolution of T. cruzi high diversity and low virulence remains too limiting to design evolution‐proof strategies, while such attributes may be part of the future of Chagas disease control after the 2020 WHO's target of regional elimination of intradomiciliary transmission has been reached. We should then aim at developing a theory of T. cruzi virulence evolution that we anticipate to provide an interesting enrichment of the general theory according to the specificities of transmission of this very generalist stercorarian trypanosome. We stress that many ecological data required to better understand selective pressures acting on vector and parasite populations are already available as they have been meticulously accumulated in the last century of field research. Although more specific information will surely be needed, an effective research strategy would be to integrate data into the conceptual and theoretical framework of evolutionary ecology and life‐history evolution that provide the quantitative backgrounds necessary to understand and possibly anticipate adaptive responses to public health interventions.

Modelling the influence of host community composition in a sylvatic Trypanosoma cruzi system

Species composition of wild reservoir hosts can influence the transmission and maintenance of multi-host vector borne pathogens. The 'pace of life' hypothesis proposes that the life history strategy of reservoir hosts can influence pathogen transmission of vector borne generalist pathogens. We use empirical data to parameterize a mathematical model that investigates the impacts of host life history traits on vector transmission dynamics of the vector-borne multi-host parasite Trypanosoma cruzi in habitats characterized by different degrees of deforestation and varying host community structure. The model considers susceptible and infected vector and host populations. When comparing the proportion of vectors infected with T. cruzi predicted by the model with empirical data, we found a trend of increasing vector infection as anthropogenic landscape disturbance increases for both data and model output. The model's vector infection rates were significantly lower than empirical results, but when incorporating host congenital transmission in the model, vector infection approaches field data. We conclude that intervened habitats associated with r-selected host species communities predict higher proportions of infected vectors.

Modeling Chagas disease in Chile: From vector to congenital transmission

Chagaś disease is a human health problem in Latin America. It is highly prevalent in northern Chile between the Arica-Parinacota and Coquimbo regions, with reported incidence of 3-11/100000 inhabitants and mortality of 0.3-0.4/100000. The interruption of vector transmission was reported in 1999 by means of the elimination of the primary vector, Triatoma infestans, from human dwellings, thus the epidemiologic dynamics of this disease should be modified. Here we model the dynamics of Chagaś disease based on previous models for vector and congenital transmission, propose a model that includes both transmission forms and perform simulations. We derive useful relationships for the reproductive number (R₀) showing that it may be expressed as the sum of the vector (R_0V) and congenital (R_0C) contributions. The vector contribution is larger than the congenital one; without the former Chagaś disease vanishes exponentially in two to three generations. Sensitivity analyses showed that the main parameters that intervene are the human bite rate, the density of vectors per human and the mortality rate of the insect vectors. Our model showed that the success of the eradication of Chagaś disease is based on the interruption of domestic transmission. Once this is obtained, the control strategies should focus on avoiding the domiciliation of wild vectors, re-colonization by the primary vector, and an adequate coverage of congenital case treatment.

Comparison and validation of two computational models of Chagas disease: A thirty year perspective from Venezuela

BACKGROUND

Mathematical models can help aid public health responses to Chagas disease. Models are typically developed to fulfill a particular need, and comparing outputs from different models addressing the same question can help identify the strengths and weaknesses of the models in answering particular questions, such as those for achieving the 2020 goals for Chagas disease.

METHODS

Using two separately developed models (PHICOR/CIDMA model and Princeton model), we simulated dynamics for domestic transmission of Trypanosoma cruzi (T. cruzi). We compared how well the models targeted the last 9 years and last 19 years of the 1968-1998 historical seroprevalence data from Venezuela.

RESULTS

Both models were able to generate the T. cruzi seroprevalence for the next time period within reason to the historical data. The PHICOR/CIDMA model estimates of the total population seroprevalence more closely followed the trends seen in the historic data, while the Princeton model estimates of the age-specific seroprevalence more closely followed historic trends when simulating over 9 years. Additionally, results from both models overestimated T. cruzi seroprevalence among younger age groups, while underestimating the seroprevalence of T. cruzi in older age groups.

CONCLUSION

The PHICOR/CIDMA and Princeton models differ in level of detail and included features, yet both were able to generate the historical changes in T. cruzi seroprevalence in Venezuela over 9 and 19-year time periods. Our model comparison has demonstrated that different model structures can be useful in evaluating disease transmission dynamics and intervention strategies.

Quantification by real-time PCR of Trypanosoma cruzi DNA in samples of Triatoma infestans used in xenodiagnosis of chronic Chagas disease patients

BACKGROUND

Trypanosoma cruzi multiplies and differentiates in the digestive tract of triatomine insects. Xenodiagnosis (XD) is a parasitological tool in which the insect vectors acts as a biological culture medium to amplify and detect T. cruzi infection in mammals. The sensitivity of XD has been overcome by the application of PCR in fecal samples (FS) of XD (PCR-XD). In this study, T. cruzi amplified in Triatoma infestans fed by XD on individuals with chronic Chagas disease (CChD) is quantified by real-time PCR (qPCR-XD).

FINDINGS

Under informed consent, 100 individuals were evaluated. In 21 of them XD, PCR-XD and qPCR-XD were positive. For the contrary, 79 were negative XD. In 58 (73.4 %) and 66 cases (83.5 %) of them, PCR-XD (Fisher's exact test P = 0.005) and qPCR-XD (Fisher's exact test: P = 0.037) respectively, were positive. In cases with positive XD, qPCR-XD allowed to establish that in 9/21 cases (42.9 %) the parasite burden fluctuated between 100 and 1,000 par. eq./ml. Otherwise, in 32/79 (40.5 %) cases with negative XD, a parasite burden between 1 and 10 par. eq./ml was determined. All samples showed amplification of exogenous internal control (X12, Ct average: 31.8), so problems in the DNA extraction (excess or loss of genetic material), unspecific amplification and/or inhibition in qPCR-XD reactions were ruled out. Additionally, in all the patients qPCR in blood (qPCR-B) was performed. In the cases with positive XD, the concordance between the positivity of qPCR-XD and qPCR-B was 100 %, nevertheless, the parasite burden in blood was lower and different than XD (Chi-square test: χ (2)  = 91.82, df = 5, P = 0.0001). In the cases with negative XD the ranges of qPCR-XD and qPCR-B were similar (Chi-square test: χ (2)  = 6.71, df = 5, P = 0.1520).

CONCLUSIONS

This study allowed the detection and quantification of T. cruzi by qPCR-XD in FS of Tr. infestans fed on patients with CChD. The highest parasite burden was observed in positive XD cases. qPCR-XD could be used in different studies related with the complex T. cruzi-vector-host interactions.

Increased mortality attributed to Chagas disease: a systematic review and meta-analysis

BACKGROUND

The clinical outcomes associated with Chagas disease remain poorly understood. In addition to the burden of morbidity, the burden of mortality due to Trypanosoma cruzi infection can be substantial, yet its quantification has eluded rigorous scrutiny. This is partly due to considerable heterogeneity between studies, which can influence the resulting estimates. There is a pressing need for accurate estimates of mortality due to Chagas disease that can be used to improve mathematical modelling, burden of disease evaluations, and cost-effectiveness studies.

METHODS

A systematic literature review was conducted to select observational studies comparing mortality in populations with and without a diagnosis of Chagas disease using the PubMed, MEDLINE, EMBASE, Web of Science and LILACS databases, without restrictions on language or date of publication. The primary outcome of interest was mortality (as all-cause mortality, sudden cardiac death, heart transplant or cardiovascular deaths). Data were analysed using a random-effects model to obtain the relative risk (RR) of mortality, the attributable risk percent (ARP), and the annual mortality rates (AMR). The statistic I(2) (proportion of variance in the meta-analysis due to study heterogeneity) was calculated. Sensitivity analyses and publication bias test were also conducted.

RESULTS

Twenty five studies were selected for quantitative analysis, providing data on 10,638 patients, 53,346 patient-years of follow-up, and 2739 events. Pooled estimates revealed that Chagas disease patients have significantly higher AMR compared with non-Chagas disease patients (0.18 versus 0.10; RR = 1.74, 95% CI 1.49-2.03). Substantial heterogeneity was found among studies (I(2) = 67.3%). The ARP above background mortality was 42.5%. Through a sub-analysis patients were classified by clinical group (severe, moderate, asymptomatic). While RR did not differ significantly between clinical groups, important differences in AMR were found: AMR = 0.43 in Chagas vs. 0.29 in non-Chagas patients (RR = 1.40, 95% CI 1.21-1.62) in the severe group; AMR = 0.16 (Chagas) vs. 0.08 (non-Chagas) (RR = 2.10, 95% CI 1.52-2.91) in the moderate group, and AMR = 0.02 vs. 0.01 (RR = 1.42, 95% CI 1.14-1.77) in the asymptomatic group. Meta-regression showed no evidence of study-level covariates on the effect size. Publication bias was not statistically significant (Egger's test p=0.08).

CONCLUSIONS

The results indicate a statistically significant excess of mortality due to Chagas disease that is shared among both symptomatic and asymptomatic populations.

Quantitative analyses and modelling to support achievement of the 2020 goals for nine neglected tropical diseases

Quantitative analysis and mathematical models are useful tools in informing strategies to control or eliminate disease. Currently, there is an urgent need to develop these tools to inform policy to achieve the 2020 goals for neglected tropical diseases (NTDs). In this paper we give an overview of a collection of novel model-based analyses which aim to address key questions on the dynamics of transmission and control of nine NTDs: Chagas disease, visceral leishmaniasis, human African trypanosomiasis, leprosy, soil-transmitted helminths, schistosomiasis, lymphatic filariasis, onchocerciasis and trachoma. Several common themes resonate throughout these analyses, including: the importance of epidemiological setting on the success of interventions; targeting groups who are at highest risk of infection or re-infection; and reaching populations who are not accessing interventions and may act as a reservoir for infection,. The results also highlight the challenge of maintaining elimination 'as a public health problem' when true elimination is not reached. The models elucidate the factors that may be contributing most to persistence of disease and discuss the requirements for eventually achieving true elimination, if that is possible. Overall this collection presents new analyses to inform current control initiatives. These papers form a base from which further development of the models and more rigorous validation against a variety of datasets can help to give more detailed advice. At the moment, the models' predictions are being considered as the world prepares for a final push towards control or elimination of neglected tropical diseases by 2020.