Strategies for prevention of transfusion-associated Chagas' disease

Trypanosoma cruzi Transmission Through Blood Samples and Derivatives: Main Routes, Control Strategies, and Recent Advancements in Blood Banks

Neglected Tropical Diseases are a group of 25 conditions caused by diverse agents. They mostly affect people with poorer health outcomes, particularly preventable diseases. The social determinants of health influence the development and progression of these poverty diseases, with inadequate sanitation presenting chronicity, high morbidity, and economic impacts. Chagas disease, a prominent Neglected Tropical Disease caused by the intracellular pathogen Trypanosoma cruzi, is endemic in Latin America but is increasing as a global concern due to population migration. It is transmitted through insect vectors, congenitally, orally via contaminated food and beverage, via transfusions and organ donation, and due to laboratory accidents, among other minor relevant routes. As a silent illness, with many infected individuals remaining asymptomatic, it contributes to underdiagnosis, and delayed treatment that involves nitro derivatives is often discontinued due to side effects. Chagas disease spreads in non-endemic areas like the United States of America and Europe. Blood screening practices vary, with endemic regions implementing universal testing, while non-endemic areas rely on selective methods. Recent innovations, such as riboflavin-ultraviolet light treatment and arylimidamide compounds, represent promising alternatives to reduce transfusion transmission. This review presents an analysis of Trypanosoma cruzi transmission through blood and derivatives, addressing the main routes, globally implemented control strategies, and recent advancements in blood bank safety.

Changes in Age and Geographic Distribution of the Risk of Chagas Disease in Chile from 1989 to 2017

The interruption of vector-borne transmission of Chagas disease was certified in Chile in 1999. Our goal was to determine the effects of the interruption of vector transmission on the age and spatial distributions of the risk of Chagas disease. We analyzed cases of Chagas disease by age and sex between 1989 and 2017, from notified disease reports of the Ministry of Health. Bayesian risk maps were constructed using the Besag-York-Mollie model. The reported cases of Chagas disease had a mean age of 45.9 ± 17.6 years. Small changes in the age distribution were found among different periods (χ²₁₅ = 602.4, p < 0.001). These were explained mainly by numbers lower than those expected in age groups 0-39 years in the 2011-2017 period. Part of the observed reduction in the proportion of individuals in the lower strata could be explained by the aging of the Chilean population. An increase of reported cases was detected after the interruption of vector-borne transmission (F_1,327 = 4.24, p < 0.04), with regional differences (F_14,1308 = 4.35, p < 0.001). The regions of the north-central area that have the highest burden of Chagas tended to decrease the relative risk, while the regions of the south tended to increase and small risk areas appear in zones where there are no insect vectors. There is still no clear evidence of a reduction in the reported cases in Chile. This could be explained mainly by an improvement in the detection of cases, but it cannot be ruled out that vector transmission still exists. The changes in distribution suggest potential impact from human internal migration and blood transfusion. This study provides strong evidence supporting the idea that entomological surveillance and long-term follow-up of Chagas disease need to be maintained after certification of interruption in endemic countries.

Detection of Trypanosoma cruzi antibodies in multitransfused patients in Colombia

INTRODUCTION

Chagas disease is a public health problem in Latin America. Even though vector-borne infection is the most important transmission mode for this disease, other modes such as transfusions require evaluation.

OBJECTIVE

To describe the prevalence of T. cruzi infection in multitransfused patients.

MATERIALS AND METHODS

We detected IgG antibodies against T. cruzi by two immunoassays in samples from multitransfused patients in four hospitals located in Bogotá and Medellín, Colombia. We analyzed the association with known risk factors, and we calculated the odds ratios (OR) with 95% confidence intervals using Stata 11™ statistical software.

RESULTS

In total, 479 samples were tested. Overall, T. cruzi antibody prevalence was 1.88% (nine patients). Five were onco-hematological patients, two were hemodialyzed, one had thalassemia, and one had suffered acute blood loss. We found no hemophilia patients. There was no association between known risk factors for transfusion-transmitted infection (such as the number of transfusion events, number of blood units and type of blood component) and the presence of anti-T. cruzi antibodies in this study. Only the hepatitis C virus infection showed a positive association with the presence of anti-T. cruzi antibodies (OR=5.68, 95% CI: 1.36-23.63).

CONCLUSIONS

The results of this study showed a low frequency of T. cruzi infection in multitransfused patients, suggesting that the risk of transfusion infection in Colombia is low. Known risk factors for transfusion-related infection were not associated with the presence of anti-T. cruzi antibodies.

The effect of gentian violet on human anterior lens epithelial cells

PURPOSE

To evaluate whether the gentian violet staining of the anterior lens capsule during the cataract surgery is cytotoxic for the human lens epithelial cells, as an indirect indication of possible toxicity towards the corneal endothelium and the safety of gentian violet application.

MATERIALS AND METHODS

Two groups of anterior lens capsules obtained during the cataract surgery, gentian violet stained and non-stained, were incubated with fluorescent dye Fura-2. Their fluorescence, upon excitation at 360 and 380 nm, was imaged to monitor changes in free intracellular calcium concentration ([Ca(2+)]i) in response to pharmacological stimulation by acetylcholine. The [Ca(2+)]i homeostasis is the indicator of cellular function. The changes in [Ca(2+)]i were compared between the two groups.

RESULTS

Epithelial cells responded to acetylcholine in both groups of capsules - gentian violet stained (n = 17) and non-stained ones (n = 33). No significant differences of the elicited responses were found in rise time (p = 0.89), decay time (p = 0.61) or amplitude of [Ca(2+)]i (p = 0.96 for 63× and p = 0.26 for 40× objectives) between the two groups of capsules (Student t test).

CONCLUSIONS

The staining of the anterior lens capsule with gentian violet during phacoemulsification in concentration of 0.01%, does not have detectable cytotoxic effects, which would affect the [Ca(2+)]i homeostasis in lens epithelial cells. The data, if extrapolated to corneal endothelium, exposed to the same concentration, suggest that gentian violet in concentration of 0.01% is safe as an adjunct for capsule visualization in cataract surgery.

[Control of transfusional transmission]

The high prevalence of chagasic blood donors in blood centers in Brazil (6.9%) and in Latin America (6.5%) in the 60's and 70's, together with the combat to the vector since the 70's have made transfusion Chagas disease the main mechanism of the disease transmission in the 80's. However, the highly favorable results achieved to eliminate the vector and the serologic screening of blood donors, reduced the prevalence of serum positivity to 0.2% and 1.3%, respectively and the rate of annual transmission through blood transfusion from 20.000 to 13 in four decades in Brazil. Nevertheless, despite outstanding advancements in endemic countries, Chagas disease reached, via migration, non-endemic countries in North America and Europe besides Japan and Australia, placing their blood recipients at risk and turning Chagas disease into a worldwide health problem. Transfusion safety through serologic selection raised another big issue i.e. high proportion of inconclusive reactions as well as two great challenges: the meaning of such exams and what guidelines to provide the donor. However, the strategies adopted by non-endemic countries and the advancements achieved by endemics so far forecast the highly wished vector and transfusion control of Chagas disease.

Trypanosoma cruzi: antiproliferative effect of indole phytoalexins on intracellular amastigotes in vitro

American trypanosomiasis (Chagas disease) continues to be a significant public health problem, and the therapeutic potential of current antichagasic agents (nifurtimox and benznidazole) is rather limited. Here we report on the antitrypanosomal effect of 1-methoxyspirobrassinol and other indole phytoalexins--secondary metabolites produced by Cruciferous plants. These compounds, that previously demonstrated antimicrobial and anticancer properties, displayed significant antiproliferative effects on intracellular amastigotes of Trypanosoma cruzi and may be prospective candidates for antichagasic drug design and development.

Solvent effect on the spectral properties of Neutral Red

Background

The study was aimed at investigating the effect of various solvents on the absorption spectra of Neutral Red, a dye belonging to the quinone-imine class of dyes. The solvents chosen for the study were water, ethanol, acetonitrile, acetone, propan-1-ol, chloroform, nitrobenzene, ethyleneglycol, acetic acid, DMSO and DMF.

Results

The results have shown that the absorption maxima of dyes are dependent on solvent polarity. In non-hydrogen-bond donating solvents, solvation of dye molecules probably occurs via dipole-dipole interactions, whereas in hydrogen-bond donating solvents the phenomenon is more hydrogen bonding in nature. To estimate the contribution of the different variables on the wave number of the Neutral Red dye, regression analyses using the ECW model were compared with the π* scale model. This showed that the unified scale for estimating the solvent effect on the absorption of the Neutral Red dye is more adopted and more applicable than the π* scale model.

Conclusion

Absorption maxima of dyes are dependent on solvent polarity. Solvation of dye molecules probably occurs via dipole-dipole interactions in non-hydrogen-bond donating solvents, whereas in hydrogen-bond donating solvents the phenomenon is more hydrogen bonding in nature. The unified scale for estimating the solvent effect on the absorption of Neutral Red dye is more adopted and more applicable than the π* scale model. This may be due to complications from both π-π* charge transfer interactions and incomplete complexation of the solute; these effects are averaged out in the derived β and π parameters and thus limit their applicability.

Clinical forms of Trypanosoma cruzi infected individuals in the chronic phase of Chagas disease in Puebla, Mexico

In Mexico, despite the relatively high seroprevalence of Trypanosoma cruzi infection in humans in some areas, reported morbidity of Chagas disease is not clear. We determined clinical stage in 71 individuals seropositive to T. cruzi in the state of Puebla, Mexico, an area endemic for Chagas disease with a reported seroprevalence of 7.7%. Diagnosis of Chagas disease was made by two standardized serological tests (ELISA, IHA). Individuals were stratified according to clinical studies. All patients were submitted to EKG, barium swallow, and barium enema. Groups were identified as indeterminate form (IF) asymptomatic individuals without evidence of abnormalities (n = 34 cases); those with gastrointestinal alterations (12 patients) including symptoms of abnormal relaxation of the lower esophageal sphincter and absent peristalsis in the esophageal body, grade I megaesophagus, and/or megacolon; patients with clinical manifestations and documented changes of chronic Chagas heart disease who were subdivided as follows: mild (8 patients)--mild electrocardiographic changes of ventricular repolarization, sinus bradychardia); moderate (6 patients)--left bundle branch block, right bundle branch block associated with left anterior fascicular block); severe (8 patients)--signs of cardiomegaly, dilated cardiomyopathy); and the associated form (3 cases) that included presence of both cardiomyopathy and megaesophagus. These data highlight the importance of accurate evaluation of the prevalence and clinical course of Chagas disease in endemic and non-endemic areas of Mexico.

Emerging infections in transfusion medicine

The risk of transfusion-transmitted infectious diseases (TTIDs) has declined dramatically in high-income nations over the past 2 decades, primarily because of extraordinary success in preventing HIV and other established transfusion-transmitted viruses from entering the blood supply. Despite this achievement, TTIDs remain a public health concern, and attention is refocusing on new and emerging pathogens, such as West Nile virus, infectious proteins (the presumed cause of variant Creutzfeldt-Jakob disease), and other transmissible organisms such as bacteria and parasites. In this article the authors concentrate on this heterogeneous group of infectious agents, describe individual pathogens and the risks they pose to transfusion recipients, and comment on existing and evolving procedures that are designed to protect the blood supply from this threat.

Efeito de dois agentes tripanosomicidas, violeta de genciana e WR6026, na preservação de concentrado de plaquetas

Visando verificar a viabilidade do concentrado de plaquetas, após sua preservação com substâncias, que adicionadas ao sangue sejam capazes de destruir o Trypanosoma cruzi, testamos concentrado de plaquetas estocado com a violeta de genciana e a quinolina WR6026. A viabilidade foi avaliada através da contagem do número de plaquetas, da medida do pH e agregação plaquetária com par de agonistas durante seu período de estocagem. Alterações significativas foram observadas nos concentrados plaquetários tratados com violeta de genciana sugerindo comprometimento da viabilidade plaquetária. Com o WR6026 foram observados valores similares aos controles, abrindo perspectivas para o emprego deste sal na quimioprofilaxia da doença de Chagas transfusional, em regiões altamente endêmicas.

Active substances against trypomastigote forms of Trypanosoma cruzi and microorganisms are produced in sequence by Talaromyces flavus

The conditions for the sequential production of antibiotic activity by Talaromyces flavus were determined. The highest level of activity against Trypanosoma cruzi was obtained from the aqueous extract of the Czapeck's fermentative culture after 48 hours, with lysis of 97.58% of the trypomastigote forms of Trypanosoma cruzi (red blood cells remained normal). The antimicrobial activity was detected in the extracts of fermentative cultures from different media just after 144 hours of incubation. Maximum activities against Micrococcus luteus, Staphylococcus aureus and Candida albicans were present in chloroform, butanolic and water extracts, in this order, when Talaromyces flavus was cultivated at pH 5.0. The minimal inhibitory concentration (MIC) of extracts of Takeuchi's cultures were determined.

Solvent and concentration effects on the visible spectra of tri-para-dialkylamino-substituted triarylmethane dyes in liquid solutions

We have characterized the spectroscopy properties of crystal violet (CV+) and ethyl violet (EV+) in liquid solutions as a function of the solvent type and dye concentration. The analysis of how solvent properties and dye concentration affects the electronic spectra of these tri-para-dialkylamino substituted tryarylmethane (TAM+) dyes was performed on the basis of two spectroscopic parameters, namely the difference in wavenumber (deltanu) between the maximum and the shoulder that appears in the short-wavelength side of the respective maximum visible band (deltanu = 1/lambda(shoulder)-1/lambda(max) cm(-1)), and the wavelength of the maximum absorption (lambda(max)). The solvent and the concentration effects on lambda(max) and deltanu have indicated that both solute/solute (ion-pairing and dye aggregation) and solute/solvent (H-bonding type) interactions modulate the shape of the visible electronic spectra of these dyes in solution. In solvent with small dieletric constant (epsilon < approximately 10), the formation of ion-pairs represents a major contribution to the shaping of these spectra. Upon increasing dye concentration the formation of ion-pairs was characterized by an increase in deltanu observed concomitantly with a red shift in lambda(max) In chloroform and chlorobenzene the ion-pair association constant of CV+ and EV+ with Cl- ions were found to be in the order of 10(6) and 10(5) M(-1), respectively. In trichloroethylene the association constant for the CV+Cl- pair was 10(8) M(-1). In water, dye aggregation instead of ion-pairing represents a major contribution to the shaping of the visible spectra of CV+ and EV+. Dye aggregation was indicated by an increase in deltanu observed concomitantly with a blue shift in lambda(max) upon increasing dye concentration. The distinct behavior of deltanu for dye aggregation and ion-pairing as a function of dye concentration can therefore assist in the characterization of these two distinct phenomena. The solute/solvent interactions were studied in a series of polar solvents in which solute/solute interactions do not occur in any detectable extent. The dependence found for deltanu as a function of the Kamlet-Tafts solvatochromic parameters (alpha, beta and pi*) is in keeping with previous inferences indicating that the splitting in the overlapped absorption band of CV+ and EV+ in hydroxilated solvents arises from a perturbation in the molecular symmetry induced by hydrogen bonding (donor-acceptor) type interactions with solvent molecules. A distinction between the effects of solute/solute and solute/solvent interactions on the visible spectra of these dyes is provided.

Aminoquinolone WR6026 as a feasible substitute for gentian violet in Chagas' disease prophylaxis in preserved blood for transfusional purposes

The search for a colorless, nontoxic and efficient drug to prevent transfusion-associated Chagas' disease (TACD) has been underway unsuccessfully since 1953 when gentian violet was preconized and to date is still being used as the only in vitro trypanocidal agent. The recent findings of aminoquinolone "WR6026" as a trypanocidal agent, led the authors to study the metabolism of red cells stored with this compound, the main objective of which was to define its applicability in TACD control. Ten units of human whole blood collected in CPDA-1 were divided into two equal satellite bags. One had "WR6026" (final concentration 62.5 g/mL) added and the other was used as a control, both were stored at 4 C. At baseline, day 7, 14, 21 and 28, samples were taken for the following measurements: adenosine triphosphate (ATP), hemoglobin, electrolytes (sodium and potassium), gases (pO2 and pCO2) and osmotic fragility. The results of tests and control were analyzed through parametric t-student test. The results were similar in both groups throughout the experiment except for the level of ATP on day 14, which presented significantly higher values in the tests when compared with the controls (p = 0.012). It was concluded that WR6026 does not interfere in the preservation and probably the viability of the erythrocytes also until day 28 of storage. Consequently the authors suggest that WR6026 could emerge as a colorless substitute for gentian violet in the control of TACD in endemic areas.

High prevalence anti-Trypanosoma cruzi antibodies, among blood donors in the State of Puebla, a non-endemic area of Mexico

Blood transfusion is the second most common transmission route of Chagas disease in many Latin American countries. In Mexico, the prevalence of Chagas disease and impact of transfusion of Trypanosoma cruzi-contaminated blood is not clear. We determined the seropositivity to T. cruzi in a representative random sample, of 2,140 blood donors (1,423 men and 647 women, aged 19-65 years), from a non-endemic state of almost 5 millions of inhabitants by the indirect hemagglutination (IHA) and enzyme linked immunosorbent assay (ELISA) tests using one autochthonous antigen from T. cruzi parasites, which were genetically characterized like TBAR/ME/1997/RyC-V1 (T. cruzi I) isolated from a Triatoma barberi specimen collected in the same locality. The seropositivity was up to 8.5% and 9% with IHA and ELISA tests, respectively, and up to 7.7% using both tests in common. We found high seroprevalence in a non-endemic area of Mexico, comparable to endemic countries where the disease occurs, e.g. Brazil (0.7%), Bolivia (13.7%) and Argentina (3.5%). The highest values observed in samples from urban areas, associated to continuous rural emigration and the absence of control in blood donors, suggest unsuspected high risk of transmission of T. cruzi, higher than those reported for infections by blood e.g. hepatitis (0.1%) and AIDS (0.1%) in the same region.

[Chagasic infection prevalence in blood donors at the Regional Blood Donation Center of Iguatu]

The objective of this study is to evaluate the frequency of Trypanosoma cruzi infection among blood donors at the Iguatu Regional Hemocenter, CE, 1996 - 1997, using the Enzyme-linked immunosorbent assay (ELISA) and hemagglutination passive reverse (HPR) tests. Of the 3,232 donors analyzed a total of 61 (1.9%) were seropositive for chagasic infection. The greatest number of infected donors was found in the 41-50 year age group, while the majority of donors were in the 18-30 year age group. Of the total number of donors analyzed 2,991 (92.5%) were men and 57 (1.9%) of these were seropositive. In all 1,825 (56.5 %) of the donors were from a rural area. The results showed that the ELISA test detected 49 cases of infection, but HPR only 38, thereby demonstrating that the use of two or more different tests by blood banks prevents transfusion associated Chagas' disease.

Chagas infection transmission control: situation of transfusional transmission in Brazil and other countries of Latin America

The transmission of the transfusion-associated Chagas disease is an important mechanism of its dissemination in several Latin American countries. The transmission risk depends on five factors: prevalence of infection in blood donors, degree of serological coverage, sensibility of used tests, safety of obtained results and infection risk. The Southern Cone Iniciative set off by the Pan-American Health Organization, in 1991, is contributing to the implementation of blood law in each endemic country, and to reduce the risk of transfusional transmission of this horrible disease. Despite the clear improvement of Brasilian hemotherapy after 1980 (with the creation of the Blood National Program - Pró-Sangue) and the significant reduction of the chagasic infection among its blood donors; socio-economic, politic and cultural unlevels, prevent it from reaching the necessary universality and security. In order to assure both, the Brazilian Ministry of Health decided to restructure its blood system. In May, 1998, a great program was launched, to reach a specific goal: Blood - 100% with quality safety in all its process until 2003. It was divided in 12 projects, intends to guarantee the quality and self sufficiency in blood and hemoderivates.

Effect of molecular structure on the performance of triarylmethane dyes as therapeutic agents for photochemical purging of autologous bone marrow grafts from residual tumor cells

Extensively conjugated cationic molecules with appropriate structural features naturally accumulate into the mitochondria of living cells, a phenomenon typically more prominent in tumor than in normal cells. Because a variety of tumor cells also retain pertinent cationic structures for longer periods of time compared with normal cells, mitochondrial targeting has been proposed as a selective therapeutic strategy of relevance for both chemotherapy and photochemotherapy of neoplastic diseases. Here we report that the triarylmethane dye crystal violet stains cell mitochondria with efficiency and selectivity, and is a promising candidate for photochemotherapy applications. Crystal violet exhibits pronounced phototoxicity toward L1210 leukemia cells but comparatively small toxic effects toward normal hematopoietic cells (murine granulocyte-macrophage progenitors, CFU-GM). On the basis of a comparative examination of chemical, photochemical, and phototoxic properties of crystal violet and other triarylmethane dyes, we have identified interdependencies between molecular structure, and selective phototoxicity toward tumor cells. These structure-activity relationships represent useful guidelines for the development of novel purging protocols to promote selective elimination of residual tumor cells from autologous bone marrow grafts with minimum toxicity to normal hematopoietic stem cells.

Removal of Trypanosoma cruzi by white cell-reduction filters: an electronmicroscopic study

White cell (WBC)-reduction filters have been shown to be effective in removing infectious agents from infected blood products. In this study, the mechanisms of Trypanosoma cruzi (T. cruzi) retention by WBC-reduction filters were assessed. Human packed red blood cell (PRBC) and platelet concentrate (PC) samples were contaminated with T. cruzi organisms (Y strain; 3.4 x 10(6)/ml), and then filtered using WBC-reduction experimental filters that provided about 3 log10 WBC removal. Transmission electron microscopy sections showed that T. cruzi parasites were removed from contaminated PRBC and PC samples primarily by mechanical mechanism without interacting with filter fibers or blood cells. In addition, we found that T. cruzi parasites were also removed by a direct fiber adhesion. These data indicate that T. cruzi parasites are removed from infected blood not only by mechanical mechanism but also by biological mechanism probably mediated by parasite surface proteins.

Transfusion-transmitted diseases: risks, prevention and perspectives

During the past decades major improvements in blood safety have been achieved, both in developed and developing countries. The introduction of donor counseling and screening for different pathogens has made blood a very safe product, especially in developed countries. However, even in these countries, there is still a residual risk for the transmission of several pathogens. For viruses such as the human immunodeficiency virus (HIV), and the hepatitis viruses B and C, this is due mainly to window-period donations. Furthermore, the threat of newly emerging pathogens which can affect blood safety is always present. For example, the implications of the agent causing new variant Creutzfeld-Jakob disease for transfusion practice are not yet clear. Finally, there are several pathogens, e.g. CMV and parvo B19, which are common in the general donor population, and might pose a serious threat in selected groups of immunosuppressed patients. In the future, further improvements in blood safety are expected from the introduction of polymerase chain reaction for testing and from the implementation of photochemical decontamination for cellular blood products. The situation in transfusion medicine in the developing world is much less favorable, due mainly to a higher incidence and prevalence of infectious diseases.

The ethnic minority traveler

Although the ethnic minority traveler is exposed to the same risks as other travelers, there are special considerations that make them vulnerable to certain diseases. In addition, many ethnic minority travelers are traditionally underserved by the medical community and often travel without the benefit of adequate counseling and immunization. The specific disease entities covered in this article include parasitic diseases (e.g. malaria, trypanosomiasis, intestinal helminths), tuberculosis, and other respiratory diseases, dengue, and sexually transmitted diseases and HIV.