Comparative evaluation of community interventions for the immigrant population of Latin American origin at risk for Chagas disease in the city of Barcelona

Living labs for migrant health research: the challenge of cocreating research with migrant population and policy makers

The need for the public to take an active role in scientific research is becoming increasingly important, particularly in health-related research. However, the coexistence and alignment of scientific and citizen interests, needs, knowledge and timing is not straightforward, especially when involving migrant populations. To conduct impactful research, it becomes also essential to consider the perspectives of policymakers, thereby adding a layer of complexity to the processes.In this article we address the experience of a living lab created in a research institution and supported by the city council and a local foundation, in which we developed three experiences of patient and public involvement (PPI): (1) accessing to comprehensive care for people at risk of Chagas disease; (2) strategies towards improving access and quality of mental healthcare services in migrants; (3) promoting healthy and safe school environments in vulnerable urban settings.These three challenges provided an opportunity to delve into diverse strategies for involving key stakeholders, including migrant populations, expert researchers and political actors in health research. This article offers insights into the successes, challenges, and valuable lessons learnt from these endeavours, providing a vision that can be beneficial for future initiatives. Each living lab experience crafted its unique governance system and agenda tailored to specific challenge scenarios, giving rise to diverse methods and study designs.We have found that the management of the cocreation of the research question and the institutional support are key to building robust PPI processes with migrant groups.

Chagas Disease in the Non-Endemic Area of Rome, Italy: Ten Years of Experience and a Brief Overview

Chagas disease (CD) is a parasitic infection endemic in Latin America and also affects patients in Western countries due to migration flows. This has a significant impact on health services worldwide due to its high morbidity and mortality burden. This paper aims to share our experience at the National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, in Rome, Italy, where to date, a total of 47 patients-mainly Bolivian women-diagnosed with CD have received treatment with benznidazole, with all but one presenting with chronic disease. Most of the patients were recruited through the first extensive screening program held in 2014 at our Institute. About a quarter of our patients showed adverse effects to benznidazole, including a case of severe drug-induced liver injury, but 83% completed a full course of treatment. In addition to the description of our cohort, the paper reports a brief overview of the disease compiled through a review of the existing literature on CD in non-endemic countries. The growing prevalence of CD in Western countries highlights the importance of screening at-risk populations and urges public concern and medical awareness about this neglected tropical disease. There are still many unanswered questions that need to be addressed to develop a personalized approach in treating patients.

Community-based actions in consulates: a new paradigm for opportunities for systematic integration in Chagas disease detection

Research has shown that multidimensional approaches to Chagas disease (CD), integrating its biomedical and psycho-socio-cultural components, are successful in enhancing early access to diagnosis, treatment and sustainable follow-up.For the first time, a consulate was selected for a community-based CD detection campaign. Two different strategies were designed, implemented and compared between 2021 and 2022 at the Consulate General of Bolivia and a reference health facility in Barcelona open to all Bolivians in Catalonia.Strategy 1 consisted in CD awareness-raising activities before referring those interested to the reference facility for infectious disease screening. Strategy 2 offered additional in-situ serological CD screening. Most of the 307 participants were Bolivian women residents in Barcelona. In strategy 1, 73 people (35.8% of those who were offered the test) were screened and 19.2% of them were diagnosed with CD. Additionally, 53,4% completed their vaccination schedules and 28.8% were treated for other parasitic infections (strongyloidiasis, giardiasis, eosinophilia, syphilis). In strategy 2, 103 people were screened in-situ (100% of those who were offered the test) and 13.5% received a CD diagnosis. 21,4% completed their vaccination schedule at the reference health facility and 2,9% were referred for iron deficiency anemia, strongyloidiasis or chronic hepatitis C.The fact that the screening took place in an official workplace of representatives of their own country, together with the presence of community-based participants fueled trust and increased CD understanding. Each of the strategies assessed had different benefits. Opportunities for systematic integration for CD based on community action in consulates may enhance early access to diagnosis, care and disease prevention.

Implementation of a Community-Based Public Model for the Prevention and Control of Communicable Diseases in Migrant Communities in Catalonia

In high-income countries, migrant populations have a greater epidemiological vulnerability: increased exposure to infectious diseases, difficulties in diagnosis, case follow-up and contact tracing, and obstacles following preventive measures related to cultural and administrative barriers. This study aims to describe the implementation of a community-based program to address these challenges. The target population is the migrant native population from North Africa, South Asia, Sub-Saharan Africa, Eastern Europe, and Latin America resident in Catalonia during 2023. Implementation phases include the identification of the perceived needs, search, recruitment and capacity building of 16 community health workers, and the development of a computer software. From January to June 2023, 117 community-based interventions have been implemented, reaching 677 people: 73 community case and contacts management interventions, 17 community in-situ screenings (reaching 247 people) and 27 culturally adapted health awareness and education actions (reaching 358 people). The program addresses the following infectious diseases: tuberculosis, Chagas disease, hepatitis C, typhoid, scabies, hepatitis B, mumps and tinea capitis. The implementation of a community-based model may be key to improving surveillance communicable diseases, promoting an equitable and comprehensive epidemiological surveillance system.

Diagnostic pathways of Chagas disease in Spain: a qualitative study

BACKGROUND

Due to the mobility of the population in recent years and the spread of Chagas disease (CD) to non-endemic regions, early diagnosis and treatment of CD has become increasingly relevant in non-endemic countries. In order for screening to be effective, health system accessibility must be taken into consideration. This study uses Tanahashi's Health Service Coverage model to gain a deeper understanding of the main diagnostic pathways for Chagas disease in a non-endemic country and the barriers and bottlenecks present in each pathway.

METHODS

This study used a qualitative design with a phenomenological approach. Twenty-one interviews, two focus group sessions, and two triangular group sessions were conducted between 2015 and 2018 with 37 Bolivian men and women diagnosed with CD in Madrid, Spain. A topic guide was designed to ensure that the interviewers obtained the data concerning knowledge of CD (transmission, symptoms, and treatment), attitudes towards CD, and health behaviour (practices in relation to CD). All interviews, focus groups and triangular groups were recorded and transcribed. A thematic, inductive analysis based on Grounded Theory was performed by two researchers.

RESULTS

Three main pathways to CD diagnosis were identified: 1) pregnancy or blood/organ donation, with no bottlenecks in effective coverage; 2) an individual actively seeking CD testing, with bottlenecks relating to administrative, physical, and time-related accessibility, and effectiveness based on the healthcare professional's knowledge of CD; 3) an individual not actively seeking CD testing, who expresses psychological discomfort or embarrassment about visiting a physician, with a low perception of risk, afraid of stigma, and testing positive, and with little confidence in physicians' knowledge of CD.

CONCLUSIONS

Existing bottlenecks in the three main diagnostic pathways for CD are less prevalent during pregnancy and blood donation, but are more prevalent in individuals who do not voluntarily seek serological testing for CD. Future screening protocols will need to take these bottlenecks into consideration to achieve effective coverage.

Opportunistic Community Screening of Chronic Chagas Disease Using a Rapid Diagnosis Test in Pharmacies in Barcelona (Catalonia, Spain): Study Protocol and Pilot Phase Results

Objectives: This study aimed to report the protocol and results from the pilot phase of an opportunistic CP-based CD screening program in Barcelona, Spain.

Methods: Three strategies according to recruitment approach were designed: passive, active and active-community. The study process consisted of signing the informed consent form, recording the patient’s data in a web-based database system, and performing the rapid test and blood collection on dry paper.

Results: Nineteen pharmacies participated and 64 patients were included during the pilot phase of the study. The rapid diagnostic test (RDT) was positive in 2/64 (3.13%) cases. Of the 49 DBS samples that arrived at the laboratory, 22 (45%) were collected incorrectly. After quantitative and qualitative assessment of the program, the dry paper sample and passive strategy were ruled out.

Conclusion: DBS sampling and the passive strategy are not suitable for CD screening in community pharmacies. There is a need to expand the number of participating pharmacies and individuals to determine whether conducting a RDT in community pharmacies is an effective screening method to increase access to CD diagnosis in a non-endemic area.

How people affected by Chagas disease have struggled with their negligence: history, associative movement and World Chagas Disease Day

It is well documented that Chagas disease (CD) can pose a public health problem to countries. As one of the World Health Organization Neglected Tropical Diseases undoubtedly calls for comprehensive healthcare, transcending a restricted biomedical approach. After more than a century since their discovery, in 1909, people affected by CD are still frequently marginalised and/or neglected. The aim of this article is to tell the story of their activism, highlighting key historical experiences and successful initiatives, from 1909 to 2019. The first association was created in 1987, in the city of Recife, Brazil. So far, thirty associations have been reported on five continents. They were created as independent non-profit civil society organisations and run democratically by affected people. Among the common associations' objectives, we notably find: increase the visibility of the affected; make their voice heard; build bridges between patients, health system professionals, public health officials, policy makers and the academic and scientific communities. The International Federation of Associations of People Affected by CD - FINDECHAGAS, created in 2010 with the input of the Americas, Europe and the Western Pacific, counts as one of the main responses to the globalisation of CD. Despite all the obstacles and difficulties encountered, the Federation has thrived, grown, and matured. As a result of this mobilisation along with the support of many national and international partners, in May 2019 the 72nd World Health Assembly decided to establish World Chagas Disease Day, on 14 April. The associative movement has increased the understanding of the challenges related to the disease and breaks the silence around Chagas disease, improving surveillance, and sustaining engagement towards the United Nations 2030 agenda.

Population movements, borders, and Chagas disease

Currently, Chagas disease is a complex global health problem with local and global implications. In the present article, we approach this complexity from the perspective of human mobility and its effects on people's health in places of origin and in transit and destination. We raise key concepts such as human mobility - understood as a possible socio-structural and economic determination of health -, the associated social and institutional barriers and the processes of social exclusion related to Chagas disease. We also propose what we identify as emerging opportunities from the perspective of health as a right. Finally, we propose strategies aimed at addressing Chagas disease from a multidimensional and intersectional perspective in complex, diverse and interconnected territories through migration.

COVID-19: an opportunity of systematic integration for Chagas disease. Example of a community-based approach within the Bolivian population in Barcelona

BACKGROUND

As a Neglected Tropical Disease associated with Latin America, Chagas Disease (CD) is little known in non-endemic territories of the Americas, Europe and Western Pacific, making its control challenging, with limited detection rates, healthcare access and consequent epidemiological silence. This is reinforced by its biomedical characteristics-it is usually asymptomatic-and the fact that it mostly affects people with low social and financial resources. Because CD is mainly a chronic infection, which principally causes a cardiomyopathy and can also cause a prothrombotic status, it increases the risk of contracting severe COVID-19.

METHODS

In order to get an accurate picture of CD and COVID-19 overlapping and co-infection, this operational research draws on community-based experience and participative-action-research components. It was conducted during the Bolivian elections in Barcelona on a representative sample of that community.

RESULTS

The results show that 55% of the people interviewed had already undergone a previous T. cruzi infection screening-among which 81% were diagnosed in Catalonia and 19% in Bolivia. The prevalence of T. cruzi infection was 18.3% (with 3.3% of discordant results), the SARS-CoV-2 22.3% and the coinfection rate, 6%. The benefits of an integrated approach for COVID-19 and CD were shown, since it only took an average of 25% of additional time per patient and undoubtedly empowered the patients about the co-infection, its detection and care. Finally, the rapid diagnostic test used for COVID-19 showed a sensitivity of 89.5%.

CONCLUSIONS

This research addresses CD and its co-infection, through an innovative way, an opportunity of systematic integration, during the COVID-19 pandemic.

Mapping health behaviour related to Chagas diagnosis in a non-endemic country: Application of Andersen’s Behavioural Model

Background

Chagas disease has become a challenge for non-endemic countries since population mobility has increased in recent years and it has spread to these regions. In order to prevent vertical transmission and improve the prognosis of the disease, it is important to make an early diagnosis. And to develop strategies that improve access to diagnosis, it is important to know the factors that most influence the decision of the population to know their serological status. For this reason, this study uses Andersen’s Behavioural Model and its proposed strategies to explore the health behaviours of Bolivian population.

Methods

Twenty-three interviews, two focus groups, and two triangular groups were performed with Bolivian men and women, involving a total of 39 participants. In addition, four interviews were conducted with key informants in contact with Bolivian population to delve into possible strategies to improve the Chagas diagnosis.

Results

The most relevant facts for the decision to being diagnosed pointed out by participants were having relatives who were sick or deceased from Chagas disease or, for men, having their pregnant wife with a positive result. After living in Spain more than ten years, population at risk no longer feels identified with their former rural origin and the vector. Moreover, their knowledge and awareness about diagnosis and treatment still remains low, especially in younger people. Limitations on access to healthcare professionals and services were also mentioned, and proposed strategies focused on eliminating these barriers and educating the population in preventive behaviours.

Conclusions

Based on Andersen’s Behavioural Model, the results obtained regarding the factors that most influence the decision to carry out Chagas diagnosis provide information that could help to develop strategies to improve access to health services and modify health behaviours related to Chagas screening.

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

Background

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

Methodology and principal findings

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

Conclusions

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

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

Analytical Evaluation of Dried Blood Spot and Rapid Diagnostic Test as a New Strategy for Serological Community Screening for Chronic Chagas Disease

Background

Chagas disease is a public health problem not only in Latin America, but also in other regions, including Spain, due to migration movements. Conventional serological diagnosis requires an invasive sample (plasma or serum) and a well-equipped laboratory. To circumvent those limitations, blood samples dried on filter paper (DBS) or Rapid Diagnostic Test (RDT) could be a practical alternative to reference protocol for serological screening in epidemiological studies. We evaluated the usefulness of dried blood sampling and a rapid diagnostic test (Trypanosoma Detect™) for the detection of antibodies against T. cruzi for their use in community-based screening.

Methodology/Principal Findings

A total of 162 stored paired whole-blood and serum samples from Latin American migrants and 25 negative-control blood samples were included. Diagnosis of chronic Chagas disease was performed in serum according to WHO algorithms. Blood samples were retrospectively collected as dried spots and then analyzed using two different serological techniques, enzyme-linked immunosorbent assay (ELISA) and electrochemiluminescence immunoassay (E-CLIA). Whole-blood samples were also used to evaluate a rapid diagnostic test based on immunochromatography. A better correlation with conventional serum was observed in dried blood elutes using E-CLIA than ELISA (97% vs. 77% sensitivity, respectively). Both assays reported 100% specificity. The median cut-off index values of E-CLIA for dried blood were significantly lower than those for serum (138.1 vs. 243.3, P<0.05). The Trypanosoma Detect™ test presented a sensitivity and specificity of 89.6% and 100%, respectively.

Conclusions

The detection of antibodies against T. cruzi in dried blood samples shows a higher sensitivity when using E-CLIA compared with ELISA. Trypanosoma Detect™ is easier to use but has a lower sensitivity. Hence, we propose a sequential strategy based on performing the rapid test first, and a negative result will be confirmed by DBS-ECLIA for use in community Chagas disease screening programs.

Do the new triatomine species pose new challenges or strategies for monitoring Chagas disease? An overview from 1979-2021

Chagas disease persists as one of the most important, and yet most neglected, diseases in the world, and several changes in its epidemiological aspects have been recorded since its discovery. Currently, some of the most relevant changes are related to: (i) the reduction in the incidence of the endemic due to the control of the most important vectors, Triatoma infestans and Rhodnius prolixus, in many countries; (ii) the migration of human populations spreading cases of the disease throughout the world, from endemic to non-endemic areas, transforming Chagas disease into a global threat; and (iii) new acute cases and deaths caused by oral transmission, especially in the north of Brazil. Despite the reduction in the number of cases, new challenges need to be responded to, including monitoring and control activities aiming to prevent house infestation by the secondary vectors from occurring. In 1979, Lent & Wygodzinsky(1) published the most complete review of the subfamily Triatominae, encompassing 111 recognised species in the taxon. Forty-two years later, 46 new species and one subspecies have been described or revalidated. Here we summarise the new species and contextualise them regarding their ecology, epidemiologic importance, and the obstacles they pose to the control of Chagas disease around the world.