Autochthonous Chagas Disease in the United States: How Are People Getting Infected?

Genetic Diversity of Trypanosoma cruzi in the United States of America: The Least Endemic Country for Chagas Disease

Chagas disease (CD), caused by Trypanosoma cruzi and endemic in Latin America, has become an emergent health problem in non-endemic countries due to human migration. The United States (US) is the non-Latin American country with the highest CD burden and cannot be considered as non-endemic, since triatomine vectors and reservoir animals have been found. Populations of T. cruzi are divided into genetic subdivisions, which are known as discrete typing units (DTUs): TcI to TcVI and TcBat. Autochthonous human T. cruzi infection in the US is sporadic, but it may change due to environmental factors affecting the geographic distribution of triatomines. We aimed to perform a literature review of the genetic diversity of T. cruzi in triatomine vectors and mammalian hosts, including human cases, in the US. The 34 analyzed studies revealed the presence of T. cruzi in 18 states, which was mainly concentrated in Texas, Louisiana and New Mexico. TcI and TcIV were the principal DTUs identified, being TcI the most genotyped (42.4%; 917/2164). This study represents a first attempt to compile the molecular epidemiology of T. cruzi in the US, which is fundamental for predicting the progression of the infection in the country and could be of great help in its future management.

Predictor Variables in the Spread of Chagas Disease in Rural Areas

Over a hundred years ago after the discovery of Chagas disease (CD) in Brazil, the World Health Organization estimates a number of 6 to 7 million people infected by Trypanosoma cruzi worldwide. Therefore, the goal of this work was to identify variables related to the spread of infection by T. cruzi in humans living in rural areas, seeking predictor variables. A systematic review of the literature has been conducted, with a search in the Scopus platform, using the search string "Chagas disease" and "rural", resulting in 85 valid and analyzed scientific studies (1977 and 2022). Twenty-seven predictor variables have been acquired, and 19 of them have been grouped, such as: socioeconomic and educational, housing, environmental, sanitary, and cultural; and 8 variables related to T. cruzi seropositive individuals. The predictor variables yielded significant results (p-value < 0.05) in 59.5% of the cases (195/328), with a median of 66.7%. In other words, studies relating to 50% of the 27 variables showed significance equal to or greater than 66.7% of the time. The independent variables with the highest proportion of significant data (p-value < 0.05) were Education (87.6%), Intradomicile building (70%), Domestic animals (69.6%), and Triatomines (69.2%) in the households. Some variables reached 100%; however, few articles were found, indicating the need for further research, especially for Sanitation and Culture. It has been concluded that, in the several contexts found, the social vulnerability and lack of information led the individual to living in environments where inhabitability is inadequate, to perform limited work activity and develop habits and behaviors which impair them in an environmental insalubrity situation, favorable to the access of vectors and pathogens of anthropozoonoses such as CD.

Chagas Disease and Leishmaniasis, Sympatric Zoonoses Present in Human from Rural Communities of Venezuela

PURPOSE

Trypanosoma cruzi and Leishmania spp. coexist in several endemic areas, and there are few studies of Chagas disease and leishmaniasis coinfection worldwide; for this reason, the objective of this work was to determine the Chagas disease and leishmaniasis coinfection in several rural communities co-endemic for these diseases.

METHODS

A total of 1107 human samples from six co-endemic rural communities of Cojedes state, Venezuela, were analyzed. Serum samples were evaluated by ELISA, indirect hemagglutination, and indirect immunofluorescence for Chagas disease diagnosis, and individuals were evaluated for leishmaniasis by leishmanin skin test (LST). Approximately, 30% of the individuals were also analyzed by PCR (blood clot samples) for T. cruzi and for Leishmania spp.

RESULTS

The 14.7% of the individuals were positive to Trypanosoma cruzi infection by serology, and 25.8% were positive to Leishmania spp. current or past infection by LST. Among the group with PCR results, 7.8% were positive for T. cruzi, and 9.4% for Leishmania spp. The coinfection T. cruzi/Leishmania spp. was 6.5%. The T. cruzi DTUs of the positive blood clot samples were TcI, revealed using the molecular markers: (i) intergenic region of the miniexon, (ii) D7 divergent domain of the 24Sα rDNA, (iii) size-variable domain of the 18S rDNA, and (iv) hsp60-PCR-RFLP (EcoRV). The Leishmania species identified were L. (Leishmania) mexicana and L. (Viannia) braziliensis.

CONCLUSION

A high prevalence was found for T. cruzi and Leishmania spp. single and coinfections in almost all communities studied, being these results of relevance for the implementation of control programs in co-endemic areas.

Abundant triatomines in Texas dog kennel environments: Triatomine collections, infection with Trypanosoma cruzi, and blood feeding hosts

Triatomine insects are vectors of the protozoan parasite Trypanosoma cruzi- the causative agent of Chagas disease. Chagas disease is endemic to Latin America and the southern United States and can cause severe cardiac damage in infected mammals, ranging from chronic disease to sudden death. Identifying interactions among triatomines, T. cruzi discrete typing units (DTUs), and blood feeding hosts is necessary to understand parasite transmission dynamics and effectively protect animal and human health. Through manual insect trapping efforts, kennel staff collections, and with the help of a trained scent detection dog, we collected triatomines from 10 multi-dog kennels across central and south Texas over a one-year period (2018-2019) and tested a subset to determine their T. cruzi infection status and identify the primary bloodmeal hosts. We collected 550 triatomines, including Triatoma gerstaeckeri (n = 515), Triatoma lecticularia (n = 15), Triatoma sanguisuga (n = 6), and Triatoma indictiva (n = 2), with an additional 10 nymphs and 2 adults unable to be identified to species. The trained dog collected 42 triatomines, including nymphs, from areas not previously considered vector habitat by the kennel owners. Using qPCR, we found a T. cruzi infection prevalence of 47 % (74/157), with T. lecticularia individuals more likely to be infected with T. cruzi than other species. Infected insects harbored two T. cruzi discrete typing units: TcI (64 %), TcIV (23 %), and mixed TcI/TcIV infections (13 %). Bloodmeal host identification was successful in 50/149 triatomines, revealing the majority (74 %) fed on a dog (Canis lupus), with other host species including humans (Homo sapiens), raccoons (Procyon lotor), chickens (Gallus gallus), wild pig (Sus scrofa), black vulture (Coragyps atratus), cat (Felis catus), and curve-billed thrasher (Toxostoma curviostre). Given the frequency of interactions between dogs and infected triatomines in these kennel environments, dogs may be an apt target for future vector control and T. cruzi intervention efforts.

Trypanosoma cruzi infection in mammals in Florida: New insight into the transmission of T. cruzi in the southeastern United States

In Latin America, synanthropic mammalian reservoirs maintain Trypanosoma cruzi, a parasitic protozoan, where they facilitate the transmission of the parasite to humans and other reservoir hosts in peridomestic settings. In the United States, raccoons (Procyon lotor) and Virginia opossums (Didelphis virginiana) are known synanthropic T. cruzi reservoir hosts; however, the role these species have in the peridomestic transmission cycle in the US is not well understood. This study aimed to identify the suite of mammalian reservoirs of T. cruzi in Florida. We also compared infection prevalence in raccoon populations sampled from within and outside of the estimated distribution of the common T. cruzi vector in Florida to gain insight into how the arthropod vector distribution impacts the distribution of infected reservoirs in the state. Finally, to investigate the impact of peridomestic landscapes on parasite prevalence, we compared the prevalence of T. cruzi-infected raccoons and opossums across five paired peridomestic and sylvatic sites. We live-trapped and collected peripheral blood samples from 135 raccoons, 112 opossums, 18 nine-banded armadillos (Dasypus novemcinctus), and nine species of rodents in north central Florida. Using quantitative PCR methods, we found that raccoons (42.2%, 95% CI [34.2-50.7%]) and opossums (50.9%, 95% CI [41.8-60.0%]) were infected with T. cruzi and the prevalence across habitats was similar for both raccoons (peridomestic: n = 77, 44.2%, 95% CI [33.6-55.3%], sylvatic: n = 58, 39.7%, 95% CI [28.1-52.5%]) and opossums (peridomestic: n = 66, 48.5%, 95% CI [36.8-60.3%], sylvatic: n = 46, 54.3%, 95% CI [40.2-67.8%]). Raccoons sampled outside the estimated distribution of Triatoma sanguisuga were not infected with T. cruzi (n = 73, 0.0%, 95% CI [0.0-5.0%]). Our study did not indicate that peridomestic habitats in Florida maintained a higher infection prevalence than their sylvatic counterparts; however, we did find a difference in prevalence within vs. outside the estimated vector distribution in Florida.

TRYPANOSOMA CRUZI INFECTION IN THREE SLENDER-TAILED MEERKATS (SURICATA SURICATTA)

Trypanosoma cruzi is a protozoan parasite primarily transmitted by triatomine insects (Hemiptera: subfamily Reduviidae) and is the cause of Chagas disease (CD). This report describes three cases of CD in a mob of five slender-tailed meerkats (Suricata suricatta) living in an outdoor exhibit at one zoological institution in Texas. The index case was a 9.5-yr-old female that presented with ataxia, lethargy, and pleural effusion. This case was diagnosed with CD postmortem via cytology, T. cruzi PCR of whole blood and lung fluid, and histology. Blood was opportunistically collected from the remaining four meerkats 28 d after the death of the index case and tested by PCR and serology. The second case was a clinically normal 7.5-yr-old male that tested PCR and antibody positive and the third case was a clinically normal 9-yr-old female that tested PCR positive. The second animal presented depressed, with pneumonia, and with continuous shivering 53 d after blood collection, and clinically improved after treatment with antibiotics and supportive care. Fifteen days later, the animal was found minimally responsive and died shortly thereafter. Histologic examination revealed Trypanosoma sp. amastigotes in the myocardium and the tissue was positive for T. cruzi DNA. The third meerkat, which received two separate courses of benznidazole over a span of almost 2 yr, was monitored routinely by PCR and serology and appeared clinically normal until found dead on exhibit 93 d after completion of the second treatment. Myocardium was positive for T. cruzi DNA. To the authors' knowledge, this case series is the first to document Chagas disease in meerkats and features associated cytologic and histologic findings.

Putative 14th Century Outbreak of Foodborne Chagas Disease, Mexico

A severe epidemic erupted in Coyoacán at the southern end of Lake Texcoco, in Central Mexico, around 1330. Chroniclers of the 16th century reported that after disrupted fish supply, the inhabitants of Coyoacán had suffered high morbidity and mortality. They developed edema of their eyelids, face, and feet, and hemorrhagic diarrhea. Many died, mainly the young and the old. Pregnant women miscarried. The disease is classically considered an illness of nutritional origin. However, its clinical picture and the circumstances of its emergence are remarkably consistent with an outbreak of foodborne Chagas disease, possibly acquired upon the hunting and consumption of alternative food sources, such as infected opossums (Didelphis spp.), unique reservoirs of Trypanosoma cruzi.

Trypanosoma cruzi dysregulates expression profile of piRNAs in primary human cardiac fibroblasts during early infection phase

Trypanosoma cruzi, the etiological agent of Chagas Disease, causes severe morbidity, mortality, and economic burden worldwide. Though originally endemic to Central and South America, globalization has led to increased parasite presence in most industrialized countries. About 40% of infected individuals will develop cardiovascular, neurological, and/or gastrointestinal pathologies. Accumulating evidence suggests that the parasite induces alterations in host gene expression profiles in order to facilitate infection and pathogenesis. The role of regulatory gene expression machinery during T. cruzi infection, particularly small noncoding RNAs, has yet to be elucidated. In this study, we aim to evaluate dysregulation of a class of sncRNAs called piRNAs during early phase of T. cruzi infection in primary human cardiac fibroblasts by RNA-Seq. We subsequently performed in silico analysis to predict piRNA-mRNA interactions. We validated the expression of these selected piRNAs and their targets during early parasite infection phase by stem loop qPCR and qPCR, respectively. We found about 26,496,863 clean reads (92.72%) which mapped to the human reference genome. During parasite challenge, 441 unique piRNAs were differentially expressed. Of these differentially expressed piRNAs, 29 were known and 412 were novel. In silico analysis showed several of these piRNAs were computationally predicted to target and potentially regulate expression of genes including SMAD2, EGR1, ICAM1, CX3CL1, and CXCR2, which have been implicated in parasite infection, pathogenesis, and various cardiomyopathies. Further evaluation of the function of these individual piRNAs in gene regulation and expression will enhance our understanding of early molecular mechanisms contributing to infection and pathogenesis. Our findings here suggest that piRNAs play important roles in infectious disease pathogenesis and can serve as potential biomarkers and therapeutic targets.

Prevalence of Trypanosoma cruzi, the Etiologic Agent of Chagas Disease, Infection in Texas Skunks (Mammalia: Mephitidae)

Background: Chagas disease is one of the world's most neglected tropical diseases, infecting over six million people across the Americas. The hemoparasite Trypanosoma cruzi is the etiological agent for the disease, circulating in domestic, peridomestic, and sylvatic transmission cycles that are maintained by triatomine vectors and a diversity of wild and synanthropic hosts. Public health and wildlife management interventions targeting the interruption of T. cruzi transmission rely on an understanding of the dynamics driving the ecology of this zoonotic pathogen. One wildlife host that purportedly plays a role in the transmission of Chagas disease within the southern United States is the striped skunk (Mephitis mephitis), although infection prevalence in this species is poorly understood. Materials and Methods: To this end, we conducted a PCR-based surveillance of T. cruzi in 235 wild skunks, representing 4 species, across 76 counties and 10 ecoregions in Texas, United States, along with an evaluation of risk factors associated with the infection. Results: We recovered an overall T. cruzi prevalence of 17.9% for all mephitid taxa aggregated, ranging between 6.7% for plains spotted skunks (Spilogale putorius interrupta) and 42.9% for western spotted skunks (Spilogale gracilis). We report the first cases of T. cruzi infection in plains spotted and American hog-nosed skunks (Conepatus leuconotus), of important note for conservation medicine since populations of both species are declining within Texas. Although not statistically significant, we also detected trends for juveniles to exhibit greater infection risk than adults and for differential sex biases in T. cruzi prevalence between taxa, which align with variations in species-specific seasonal activity patterns. No geographic or taxonomic risk factors were identified. Conclusion: Our study contributed key data for population viability analyses and epidemiologic models in addition to providing a baseline for future T. cruzi surveillance among skunks and other wildlife species.

Identification of the parasite, Trypanosoma cruzi, in multiple tissues of epidemiological significance in the Virginia opossum (Didelphis virginiana): Implications for environmental and vertical transmission routes

BACKGROUND

Trypanosoma cruzi, a parasitic protozoan, is endemic to the Americas and the causative agent of Chagas disease in humans. In South America, opossums facilitate transmission via infected anal gland secretions in addition to transmission via triatomine vectors. In North America, the Virginia opossum is a reservoir host for the parasite with transmission routes that are not clearly defined. The unique biology of this marsupial provides the opportunity to investigate vertical transmission in this wildlife species in situ. Our objectives were to investigate alternative routes of transmission that may facilitate spillover into other species and to determine if vertical transmission was evident.

METHODOLOGY/PRINCIPAL FINDINGS

Virginia opossums were sampled at 10 trapping locations over a 10-month period in a 5-county region of north central Florida. Peripheral blood, fecal swabs, and anal gland secretions were collected from each adult individual, and peripheral blood was collected from joey opossums. Total DNA was extracted from each collected sample type, and T. cruzi infected individuals and the infecting Discrete Typing Unit (DTU) were identified using real time PCR methods. Adult Virginia opossums (n = 112) were infected with T. cruzi (51.8%, 95% CI [42.6-60.8%]) throughout the sampled period and at each location. T. cruzi DNA was found in each of the three biological sample types. Vertical transmission of T. cruzi was inferred in one litter of mother-dependent (n = 20, 5.0%, 95% CI [0.9-23.6%]) joey opossums where 2 joeys from this same litter were rtPCR positive for T. cruzi.

CONCLUSIONS/SIGNIFICANCE

We inferred vertical transmission from mother to neonate which may serve to amplify the prevalence of T. cruzi in adult Virginia opossums. T. cruzi DNA was detected in the anal gland secretions of Virginia opossums. Infected anal gland secretions suggest a possible environmental route of transmission for T. cruzi via the deposition of contaminated feces and spraint at wildlife latrines. Only DTU1 was identified in the sampled population which is consistent with human autochthonous cases in the United States.

Chagas Heart Disease: Beyond a Single Complication, from Asymptomatic Disease to Heart Failure

Chagas cardiomyopathy (CC), caused by the protozoan Trypanosoma cruzi, is an important cause of cardiovascular morbidity and mortality in developing countries. It is estimated that 6 to 7 million people worldwide are infected, and it is predicted that it will be responsible for 200,000 deaths by 2025. The World Health Organization (WHO) considers Chagas disease (CD) as a Neglected Tropical Disease (NTD), which must be acknowledged and detected in time, as it remains a clinical and diagnostic challenge in both endemic and non-endemic regions and at different levels of care. The literature on CC was analyzed by searching different databases (Medline, Cochrane Central, EMBASE, PubMed, Google Scholar, EBSCO) from 1968 until October 2022. Multicenter and bioinformatics trials, systematic and bibliographic reviews, international guidelines, and clinical cases were included. The reference lists of the included papers were checked. No linguistic restrictions or study designs were applied. This review is intended to address the current incidence and prevalence of CD and to identify the main pathogenic mechanisms, clinical presentation, and diagnosis of CC.

Climate change and the prevention of cardiovascular disease

Climate change is a worsening global crisis that will continue negatively impacting population health and well-being unless adaptation and mitigation interventions are rapidly implemented. Climate change-related cardiovascular disease is mediated by air pollution, increased ambient temperatures, vector-borne disease and mental health disorders. Climate change-related cardiovascular disease can be modulated by climate change adaptation; however, this process could result in significant health inequity because persons and populations of lower socioeconomic status have fewer adaptation options. Clear scientific evidence for climate change and its impact on human health have not yet resulted in the national and international impetus and policies necessary to slow climate change. As respected members of society who regularly communicate scientific evidence to patients, clinicians are well-positioned to advocate on the importance of addressing climate change. This narrative review summarizes the links between climate change and cardiovascular health, proposes actionable items clinicians and other healthcare providers can execute both in their personal life and as an advocate of climate policies, and encourages communication of the health impacts of climate change when counseling patients. Our aim is to inspire the reader to invest more time in communicating the most crucial public health issue of the 21st century to their patients.

The Trypanosoma cruzi TcrNT2 Nucleoside Transporter Is a Conduit for the Uptake of 5-F-2'-Deoxyuridine and Tubercidin Analogues

Among the scarce validated drug targets against Chagas disease (CD), caused by Trypanosoma cruzi, the parasite's nucleoside salvage system has recently attracted considerable attention. Although the trypanocidal activity of tubercidin (7-deazapurine) has long been known, the identification of a class of 7-substituted tubercidin analogs with potent in vitro and in vivo activity and much-enhanced selectivity has made nucleoside analogs among the most promising lead compounds against CD. Here, we investigate the recently identified TcrNT2 nucleoside transporter and its potential role in antimetabolite chemotherapy. TcrNT2, expressed in a Leishmania mexicana cell line lacking the NT1 nucleoside transporter locus, displayed very high selectivity and affinity for thymidine with a K_m of 0.26 ± 0.05 µM. The selectivity was explained by interactions of 2-oxo, 4-oxo, 5-Me, 3'-hydroxy and 5'-hydroxy with the transporter binding pocket, whereas a hydroxy group at the 2' position was deleterious to binding. This made 5-halogenated 2'-deoxyuridine analogues good substrates but 5-F-2'-deoxyuridine displayed disappointing activity against T. cruzi trypomastigotes. By comparing the EC₅₀ values of tubercidin and its 7-substituted analogues against L. mexicana Cas9, Cas9^ΔNT1 and Cas9^ΔNT1+TcrNT2 it was shown that TcrNT2 can take up tubercidin and, at a minimum, a subset of the analogs.

Evaluation of a Geographic Screening Protocol for Chronic Parasitic Infections Before Kidney Transplant: An Institutional Experience in Minnesota

Pretransplant recommendations advise risk-based screening for strongyloidiasis, schistosomiasis, and Chagas disease. We evaluated the implementation of a chronic parasite screening protocol at a health system in a nonendemic region serving a large foreign-born population. Candidates listed for kidney transplant at Hennepin Healthcare (Minneapolis, MN) between 2010 and 2020 were included. Country of birth and serologic screening for strongyloidiasis, schistosomiasis, and Chagas disease were retrospectively obtained from electronic medical records. Parasite screening frequency and seropositivity was assessed before and after implementation of a geographic risk factor-based screening protocol in 2014. Cost-efficiency of presumptive treatment was modeled. Of 907 kidney transplant candidates, 312 (34%) were born in the United States and 232 (26%) outside the United States, with the remainder missing country of birth information. The 447 (49%) candidates evaluated after implementation of the screening protocol had fewer unidentified countries of birth (53%-27%, P < 0.001) and were more frequently screened for strongyloidiasis, schistosomiasis, and Chagas disease (14%-44%, 8%-22%, and 1-14%, respectively, all Ps < 0.001). The number of identified seropositive candidates increased after protocol implementation from two to 14 for strongyloidiasis and from one to 11 for schistosomiasis, with none seropositive for Chagas disease. The cost-efficiency model favored presumptive ivermectin when strongyloidiasis prevalence reaches 30% of those screened. Implementing a geographic risk screening protocol before kidney transplant increases attention to infectious disease risk associated with country of birth and identification of chronic parasitic infections. In populations with higher strongyloidiasis prevalence or lower ivermectin costs, presumptive treatment may be cost-efficient.

Chagas disease in Oklahoma

Chagas disease, caused by infection with the protozoan Trypanosoma cruzi, is one of the leading public health problems in the Western Hemisphere. The parasite is mainly transmitted by contact with infected insect vectors but other forms of transmission are important in endemic areas. In the United States, while the disease is largely restricted to immigrants from endemic countries in Latin America, there is some risk of local acquisition. T. cruzi circulates in a sylvatic cycle between mammals and local triatomine insects in the southern half of the country, where human residents may be at risk for incidental infection. There are several reported cases of locally-acquired Chagas disease in the United States, but there is a paucity of information in Oklahoma. We present a brief summary of the available data of Chagas disease in Oklahoma to raise awareness and serve as a foundation for future research.

Our Current Understanding of Chagas Disease and Trypanosoma cruzi Infection in the State of Florida — an Update on Research in this Region of the USA

Purpose of Review

Chagas disease (CD) is a neglected tropical disease caused by the protozoan parasite, Trypanosoma cruzi. Parasite transmission primarily occurs through direct interaction with an infected triatomine insect vector (kissing bug), but other routes are known. We aim to review the literature and discuss the unique circumstances of CD in the US state of Florida.

Recent Findings

Florida is home to naturally occurring kissing bugs that are invading homes and harbor T. cruzi. The state is also home to a diverse population of immigrants from Chagas-endemic regions in Latin America. In the USA, Florida is the state with the third highest estimated burden of CD, although the true prevalence is unknown.

Summary

Chagas disease is a chronic infection that often remains silent for decades. Those who manifest chronic disease may eventually die from debilitating cardiac and/or gastrointestinal manifestations. Florida is an opportune region of the USA for the study of CD, due to the existence of endemic transmission cycles in addition to the burden among people born in Chagas-endemic regions.

Evidence of likely autochthonous Chagas disease in the southwestern United States: A case series of Trypanosoma cruzi seropositive blood donors

Background

Chagas disease is a parasitic infection that can insidiously cause non‐ischemic cardiomyopathy. Given the largely silent nature of this progressive disease, asymptomatic blood donors pose potential blood transfusion risk. Blood donation screening has become an unintentional form of Chagas disease surveillance, with thousands of new cases identified since national surveillance was initiated in 2007.

Study Design and Methods

We recruited T. cruzi‐positive blood donors identified from California and Arizona blood centers for confirmatory blood screening and assessment of lifetime infection risk.

Results

Among eight suspected cases, we identified four confirmed US autochthonous infections. The current manuscript details the transmission sources, healthcare‐seeking behaviors post‐blood donation resulting, and clinical course of disease among persons without any history of travel to endemic Latin American countries.

Discussion

This manuscript presents four additional US‐acquired Chagas disease cases and identifies an opportunity for blood centers to assist in confronting barriers surrounding Chagas disease in the US.

Recommendations for Screening and Diagnosis of Chagas Disease in the United States

BACKGROUND

Chagas disease affects an estimated 326 000-347 000 people in the United States and is severely underdiagnosed. Lack of awareness and clarity regarding screening and diagnosis is a key barrier. This article provides straightforward recommendations, with the goal of simplifying identification and testing of people at risk for US healthcare providers.

METHODS

A multidisciplinary working group of clinicians and researchers with expertise in Chagas disease agreed on 6 main questions, and developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, after reviewing the relevant literature on Chagas disease in the United States.

RESULTS

Individuals who were born or resided for prolonged time periods in endemic countries of Mexico and Central and South America should be tested for Trypanosoma cruzi infection, and family members of people who test positive should be screened. Women of childbearing age with risk factors and infants born to seropositive mothers deserve special consideration due to the risk of vertical transmission. Diagnostic testing for chronic T. cruzi infection should be conducted using 2 distinct assays.

CONCLUSIONS

Increasing provider-directed screening for T. cruzi infection is key to addressing this neglected public health challenge in the United States.

Biological Parameters of Two Triatoma protracta Subspecies (Hemiptera: Reduviidae)

In recent years, concerns about Chagas disease in the United States have increased. Triatomine bug (Hemiptera: Reduviidae) populations are the vectors of the parasite Trypanosoma cruzi Chagas (Trypanosomatida: Trypanosomatidae), which causes Chagas disease, although the route of transmission is considered inefficient in United States. However, more studies on triatomine feeding and defecation behavior are needed. In this study, six related biological parameters from two populations of Triatoma protracta protracta (Uhler) and T. p. woodi (Uhler) from Mexican locations near the U.S. border were evaluated. The four population life cycles were less than 6 mo (161-171 d), with 9-10 blood meals needed to molt. Mortality rates were similar (31-38%) among the four populations. Triatoma p. woodi from Hidalgo, Coahuila was the most aggressive one. Feeding times were over 10 min, increasing with instar in all populations. Defecation behaviors varied among populations. High percentages of male and female fourth- and fifth-instar nymphs of T. p. protracta from Imuris and both populations of T. p. woodi defecated immediately after or <1 min of feeding. Lower percentages were observed for T. p. protracta from Jacumé. Because most parameters were similar among the four populations, independent of their subspecies and their geographic origin, we considered that T. p. protracta and T. p. woodi are efficient vectors of T. cruzi. In contrast, defecation patterns were noticeably different among some of the four triatomine populations studied. Our results highlight the importance of studying the biological parameters of local triatomine populations. They also contribute to increasing the knowledge of North American triatomine behavior and defecation patterns.

Anaphylactic Reactions Due to Triatoma protracta (Hemiptera, Reduviidae, Triatominae) and Invasion into a Home in Northern California, USA

Simple Summary

Kissing bugs are bloodsucking insects found throughout the Western Hemisphere, including the United States, but also within certain regions of the Western Pacific, India, the Middle East, and Africa. Within the Americas, these insects are known to harbor a parasite known as Trypanosoma cruzi, the causative agent of an infection in humans and other mammals known as Chagas disease. The infection can be spread through the fecal matter of the kissing bug when exposed to the skin or ingested from contaminated food or drink products. Kissing bugs will invade human homes and bite residents and their pets. The bite from a kissing bug can also lead to serious allergic reactions, including anaphylaxis. A potentially life-threatening allergic response typically needs emergency medical attention. We describe a home that was invaded by kissing bugs in northern California where the resident developed serious allergic reactions to the bite. The kissing bugs were identified and a blood meal investigation found the presence of human blood as well as the parasite, Trypanosoma cruzi. The resident was tested extensively for chronic Chagas disease due to his repeated exposure to the kissing bug but was found to not have the disease. Those who live in regions where kissing bugs are found naturally should be aware that their bites can be highly allergenic.

Abstract

Background: Triatoma protracta is a triatomine found naturally throughout many regions of California and has been shown to invade human dwellings and bite residents. A man living in Mendocino County, California, reported developing anaphylactic reactions due to the bite of an “unusual bug”, which he had found in his home for several years. Methods: We conducted environmental, entomological, and clinical investigations to examine the risk for kissing bug invasion, presence of Trypanosoma cruzi, and concerns for Chagas disease at this human dwelling with triatomine invasion. Results: Home assessment revealed several risk factors for triatomine invasion, which includes pack rat infestation, above-ground wooden plank floor without a concrete foundation, canine living in the home, and lack of residual insecticide use. Triatomines were all identified as Triatoma protracta. Midgut molecular analysis of the collected triatomines revealed the detection of T. cruzi discrete typing unit I among one of the kissing bugs. Blood meal PCR-based analysis showed these triatomines had bitten humans, canine and unidentified snake species. The patient was tested for chronic Chagas disease utilizing rapid diagnostic testing and laboratory serological testing, and all were negative. Conclusions: Triatoma protracta is known to invade human dwellings in the western portions of the United States. This is the first report of T. cruzi-infected triatomines invading homes in Mendocino County, California. Triatoma protracta is a known vector responsible for autochthonous Chagas disease within the United States, and their bites can also trigger serious systemic allergic reactions, such as anaphylaxis.

Chagas Disease Ecology in the United States: Recent Advances in Understanding Trypanosoma cruzi Transmission Among Triatomines, Wildlife, and Domestic Animals and a Quantitative Synthesis of Vector-Host Interactions

Chagas disease, a neglected tropical disease present in the Americas, is caused by the parasite Trypanosoma cruzi and is transmitted by triatomine kissing bug vectors. Hundreds of vertebrate host species are involved in the ecology of Chagas disease. The sylvatic nature of most triatomines found in the United States accounts for high levels of animal infections but few reports of human infections. This review focuses on triatomine distributions and animal infections in the southern United States. A quantitative synthesis of available US data from triatomine bloodmeal analysis studies shows that dogs, humans, and rodents are key taxa for feeding triatomines. Imperfect and unvalidated diagnostic tools in wildlife complicate the study of animal T. cruzi infections, and integrated vector management approaches are needed to reduce parasite transmission in nature. The diversity of animal species involved in Chagas disease ecology underscores the importance of a One Health approach for disease research and management. Expected final online publication date for the Annual Review of Animal Biosciences, Volume 10 is February 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Kissing Bug Intrusions into Homes in the Southwest United States

Kissing bugs readily enter homes in the Sonoran Desert and bite the residents. Their saliva is highly antigenic, causing local and systemic skin reactions and life-threatening anaphylaxis. We attempted to determine what characteristics of homesites may have contributed to home intrusion by kissing bugs. Extensive and detailed information about the homes and the home environment was collected from 78 homeowners in Tucson who suffered kissing bug intrusions. Homeowners collected 298 Triatoma rubida in and around their homes. Of the homes entered by kissing bugs, 29 of 46 (63%) contained bugs harboring Trypanosoma cruzi. Although in the aggregate, homeowners were bitten > 2200 times, no individual tested positive for Chagas disease (N = 116). Although yearly intrusion likely occurs in some homes, T. rubida does not domiciliate within homesites in the Desert Southwest. We conclude there is little risk to homeowners for Chagas disease given the current behavior of resident kissing bugs and absent ingesting kissing bug fecal matter.

High variation in immune responses and parasite phenotypes in naturally acquired Trypanosoma cruzi infection in a captive non-human primate breeding colony in Texas, USA

Trypanosoma cruzi, the causative agent of human Chagas disease, is endemic to the southern region of the United States where it routinely infects many host species. The indoor/outdoor housing configuration used in many non-human primate research and breeding facilities in the southern of the USA provides the opportunity for infection by T. cruzi and thus provides source material for in-depth investigation of host and parasite dynamics in a natural host species under highly controlled and restricted conditions. For cynomolgus macaques housed at such a facility, we used a combination of serial blood quantitative PCR (qPCR) and hemoculture to confirm infection in >92% of seropositive animals, although each method alone failed to detect infection in >20% of cases. Parasite isolates obtained from 43 of the 64 seropositive macaques were of 2 broad genetic types (discrete typing units, (DTU's) I and IV); both within and between these DTU groupings, isolates displayed a wide variation in growth characteristics and virulence, elicited host immune responses, and susceptibility to drug treatment in a mouse model. Likewise, the macaques displayed a diversity in T cell and antibody response profiles that rarely correlated with parasite DTU type, minimum length of infection, or age of the primate. This study reveals the complexity of infection dynamics, parasite phenotypes, and immune response patterns that can occur in a primate group, despite being housed in a uniform environment at a single location, and the limited time period over which the T. cruzi infections were established.

History of indigenous Trypanosoma cruzi infection in humans, animals and triatomines in California, USA

This historical review highlights previously undescribed potential foci for sylvatic and domestic locally acquired Chagas disease in California. The review starts in the 1910s, when Trypanosoma cruzi was first discovered through scientific triatomine investigations. Next, the natural transition around the mid-1900s into clinical investigations of the domestic and peridomestic environments and their epidemiologic profiles is detailed. The review closes with the shift to applied genetic, diagnostic and scientific applications surrounding Chagas disease infected individuals in the state. Throughout the course of the review, transmission foci and their unique clinical and epidemiologic characteristics are described. This in-depth review has merit for clinicians, veterinarians and public health officials working with vector-borne diseases in the southwestern USA.