Seroprevalence ofTrypanosoma cruziinfection in at-risk blood donors in Catalonia (Spain)

Prevalence of neglected tropical diseases among migrants living in Europe: A systematic review and meta-analysis

BACKGROUND

Migration to Europe has intensified due to recent political conflicts, economic crises, and climate change, introducing an increased risk of neglected tropical diseases (NTDs) within this population. While NTDs typically impact tropical regions, their presence among migrants in Europe presents a growing challenge, compounded by limited research in this area. This study provides the first meta-analysis on the prevalence of NTDs in migrants across European nations.

METHODS

A systematic review and meta-analysis was conducted focusing on studies that included NTD prevalence among migrant populations in Europe, with data sourced until July 2024. Cross-sectional and longitudinal studies were eligible, with bias assessed using the Newcastle-Ottawa Scale. Prevalence rates for various NTDs were calculated using a random-effects model, and meta-regressions were performed to assess potential moderators like sample size, age, and gender.

RESULTS

A total of 148 studies comprising 228,798 migrants were analyzed. The most prevalent NTDs were strongyloidiasis (11.53 %) and schistosomiasis (10.8 %), with American trypanosomiasis also present. Dengue and lymphatic filariasis showed significant rates, though high heterogeneity was noted. Data quality was frequently low, with most studies at a high risk of bias.

CONCLUSIONS

This study underscores the need for robust screening and diagnostic protocols in Europe for NTDs, particularly as clinician familiarity with these diseases is limited. Test-and-treat strategies appear promising, yet more comprehensive efforts are necessary. Establishing a European NTD registry could improve monitoring and management. Future studies should prioritize higher-quality data and address the barriers migrants face in accessing health services.

Chagas Disease in Europe

Chagas disease is currently present in many non-endemic countries and remains a neglected tropical disease globally. A review of the literature identified significant gaps and scarcity of updated information from European countries, with most studies reporting data from Spain and Italy. The index of underdiagnosis may be as high as 70%, affecting mainly females of child-bearing age. Standardized screening of fertile, non-pregnant, women from endemic countries and subsequent treatment is considered an essential strategy to control transmission and prevent new cases, yet no uniform legislation for screening risk groups exists. There is heterogeneity in Europe in terms of preventive strategies to avoid transfusion-related transmission of Chagas disease, not necessarily in line with the European directives, with some countries conducting systematic screening for T. cruzi infection in blood donors, whilst others rely on pre-transfusion questionnaires. The growing burden of the infection in resource-rich areas may provide an opportunity for progress in certain aspects of control and prevention. Options for improving screening strategies, management and linkage to care are reviewed.

Chagas disease prevalence among migrants from El Salvador in Milan: a cross- sectional study of an often-overlooked population

BACKGROUND

Chagas disease (CD) is considered to be highly endemic in El Salvador, where its prevalence is estimated to be 1.3-3.7%. Although more than 40,000 migrants from El Salvador are currently living in Europe (particularly in Spain and Italy), there are few data regarding the prevalence of CD in this population. The aim of this study was to evaluate the prevalence of CD among Salvadorans living in Italy.

METHODS

A cross-sectional serological survey of CD among Salvadorans living in the metropolitan area of Milan was carried out between October 2017 and December 2019. The participants' blood samples were tested for Trypanosoma cruzi antibodies using two different serological assays. The collected demographic data included their biological sex, province of origin, the type of housing in their country of origin, and family history of CD.

RESULTS

Of the 384 subjects who voluntarily participated in the study, five (1.3%, most coming from La Paz) were positive to both serological assays and therefore conclusively diagnosed as having CD. Five other subjects had discrepant serological results but were not positive to a third assay. Three of the five subjects with a diagnosis of CD completed medical staging, one of whom had chronic disease (digestive and cardiac involvement).

CONCLUSIONS

The prevalence of CD among Salvadorans living in Milan is similar to that estimated by the WHO in 2010. Although they are often overlooked in CD surveys, Salvadoran migrants should be included in CD control programs in countries in which the disease is not endemic.

Characterization of Latin American migrants at risk for Trypanosoma cruzi infection in a non-endemic setting. Insights into initial evaluation of cardiac and digestive involvement

BACKGROUND

Trypanosoma cruzi causes Chagas disease (CD), a potentially fatal disease characterized by cardiac disorders and digestive, neurological or mixed alterations. T. cruzi is transmitted to humans by the bite of triatomine vectors; both the parasite and disease are endemic in Latin America and the United States. In the last decades, population migration has changed the classic epidemiology of T. cruzi, contributing to its global spread to traditionally non-endemic countries. Screening is recommended for Latin American populations residing in non-endemic countries.

METHODS

The present study analyzes the epidemiological characteristics of 2,820 Latin American individuals who attended the International Health Service (IHS) of the Hospital Clinic de Barcelona between 2002 and 2019. The initial assessment of organ damage among positive cases of T. cruzi infection was analyzed, including the results of electrocardiogram (ECG), echocardiogram, barium enema and esophagogram.

RESULTS

Among all the screened individuals attending the clinic, 2,441 (86.6%) were born in Bolivia and 1,993 (70.7%) were female. Of individuals, 1,517 (81.5%) reported previous exposure to the vector, which is a strong risk factor associated with T. cruzi infection; 1,382 individuals were positive for T. cruzi infection. The first evaluation of individuals with confirmed T. cruzi infection, showed 148 (17.1%) individuals with Chagasic cardiomyopathy, the main diagnostic method being an ECG and the right bundle branch block (RBBB) for the most frequent disorder; 16 (10.8%) individuals had a normal ECG and were diagnosed of Chagasic cardiomyopathy by echocardiogram.

CONCLUSIONS

We still observe many Latin American individuals who were at risk of T. cruzi infection in highly endemic areas in their countries of origin, and who have not been previously tested for T. cruzi infection. In fact, even in Spain, a country with one of the highest proportion of diagnosis of Latin American populations, T. cruzi infection remains underdiagnosed. The screening of Latin American populations presenting with a similar profile as reported here should be promoted. ECG is considered necessary to assess Chagasic cardiomyopathy in positive individuals, but echocardiograms should also be considered as a diagnostic approach given that it can detect cardiac abnormalities when the ECG is normal.

Adding a piece to the puzzle of Latin American blood donors and the potential risk of Trypanosoma cruzi transmission in Germany

Introduction

Chagas disease (CD) is caused by the Trypanosoma cruzi (T. cruzi) infection and has become a global health concern due to population mobility, as well as non-vectorial transmission routes. Several countries outside Latin America (LA) have reported transfusion-associated transmission, but equivalent studies in Germany are lacking. This study aims to collect first data on the risk of transfusion associated transmission as well as LA blood donors originating from CD endemic countries in Germany

Materials and methods

A total of 305 blood donors who were assumed to be at risk for T. cruzi infection were retrospectively (267) as well as prospectively (38) selected at German blood donation sites in Bavaria and Berlin, and all retrospectively as well as 27 prospectively selected were serologically screened. Prospective study subjects additionally filled out a questionnaire.

Results

All samples tested seronegative for T. cuzi specific antibodies. Prospectively enrolled study subjects all had high socio-economic status including good education. Knowledge regarding CD was limited but willingness to donate frequently was high. Blood donation rates from donors born in LA countries seem to increase from 2015.

Discussion

Although no transfusion associated T. cruzi infection has been documented in Germany, it has likely already happened unnoticed, or will do in the near future. Performing risk-adapted serology-based blood donor screenings in Germany could avoid transfusion-associated transmission events as well as contribute to active case detection. Moreover, larger, and ongoing studies are needed to increase the evidence base as well as end the neglect of CD in Germany.

Diagnosis and Clinical Management of Chagas Disease: An Increasing Challenge in Non-Endemic Areas

Chagas disease (CD) is caused by the parasite Trypanosoma cruzi, and it is endemic in Central, South America, Mexico and the South of the United States. It is an important cause of early mortality and morbidity, and it is associated with poverty and stigma. A third of the cases evolve into chronic cardiomyopathy and gastrointestinal disease. The infection is transmitted vertically and by blood/organ donation and can reactivate with immunosuppression. Case identification requires awareness and screening programmes targeting the population at risk (women in reproductive age, donors, immunocompromised patients). Treatment with benznidazole or nifurtimox is most effective in the acute phase and prevents progression to chronic phase when given to children. Treating women antenatally reduces but does not eliminate vertical transmission. Treatment is poorly tolerated, contraindicated during pregnancy, and has little effect modifying the disease in the chronic phase. Screening is easily performed with serology. Migration has brought the disease outside of the endemic countries, where the transmission continues vertically and via blood and tissue/organ donations. There are more than 32 million migrants from Latin America living in non-endemic countries. However, the infection is massively underdiagnosed in this setting due to the lack of awareness by patients, health authorities and professionals. Blood and tissue donation screening policies have significantly reduced transmission in endemic countries but are not universally established in the non-endemic setting. Antenatal screening is not commonly done. Other challenges include difficulties accessing and retaining patients in the healthcare system and lack of specific funding for the interventions. Any strategy must be accompanied by education and awareness campaigns directed to patients, professionals and policy makers. The involvement of patients and their communities is central and key for success and must be sought early and actively. This review proposes strategies to address challenges faced by non-endemic countries.

Different profiles and epidemiological scenarios: past, present and future

The multiplicity of epidemiological scenarios shown by Chagas Disease, derived from multiple transmission routes of the aetiological agent, occurring on multiple geo-ecobiosocial settings determines the complexity of the disease and reveal the difficulties for its control. From the first description of the link between the parasite, the vector and its domestic habitat and the disease that Carlos Chagas made in 1909, the epidemiological scenarios of the American Trypanosomiasis has shown a dynamic increasing complexity. These scenarios changed with time and geography because of new understandings of the disease from multiple studies, because of policies change at the national and international levels and because human movements brought the parasite and vectors to new geographies. Paradigms that seemed solid at a time were broken down, and we learnt about the global dispersion of Trypanosoma cruzi infection, the multiplicity of transmission routes, that the infection can be cured, and that triatomines are not only a health threat in Latin America. We consider the multiple epidemiological scenarios through the different T. cruzi transmission routes, with or without the participation of a Triatominae vector. We then consider the scenario of regions with vectors without the parasite, to finish with the consideration of future prospects.

Worldwide Control and Management of Chagas Disease in a New Era of Globalization: a Close Look at Congenital Trypanosoma cruzi Infection

Population movements have turned Chagas disease (CD) into a global public health problem. Despite the successful implementation of subregional initiatives to control vectorial and transfusional Trypanosoma cruzi transmission in Latin American settings where the disease is endemic, congenital CD (cCD) remains a significant challenge. In countries where the disease is not endemic, vertical transmission plays a key role in CD expansion and is the main focus of its control. Although several health organizations provide general protocols for cCD control, its management in each geopolitical region depends on local authorities, which has resulted in a multitude of approaches. The aims of this review are to (i) describe the current global situation in CD management, with emphasis on congenital infection, and (ii) summarize the spectrum of available strategies, both official and unofficial, for cCD prevention and control in countries of endemicity and nonendemicity. From an economic point of view, the early detection and treatment of cCD are cost-effective. However, in countries where the disease is not endemic, national health policies for cCD control are nonexistent, and official regional protocols are scarce and restricted to Europe. Countries of endemicity have more protocols in place, but the implementation of diagnostic methods is hampered by economic constraints. Moreover, most protocols in both countries where the disease is endemic and those where it is not endemic have yet to incorporate recently developed technologies. The wide methodological diversity in cCD diagnostic algorithms reflects the lack of a consensus. This review may represent a first step toward the development of a common strategy, which will require the collaboration of health organizations, governments, and experts in the field.

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.

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

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

Trends of Seroprevalence of Chagas´s diseases in healthy blood donors, solid organ donors and heart transplant recipients: experience of a single health care center in Colombia

The prevalence of Chagas disease has decreased in the Americas region due to vector control measures. However, non-vectorial transmission through blood transfusions and organ transplantation has gained importance in recent years. Screening among blood and organ donors are essential to reduce Trypanosoma cruzi transmission and could provide information to estimate population prevalence. We conducted a cross-sectional study on the prevalence of immunoglobulin G (IgG) antibodies against T. cruzi in healthy blood donors, solid organ donors and heart transplant recipients from 2012 to 2019. We found a total of 99 357 IgG T. cruzi results during the study period. The cumulative seroprevalence in healthy blood donors was 0.13% (95% confidence interval (CI) 0.10–0.15), in organ donors was 0.53% (95% CI 0.06–1.92) and in heart transplant recipients was 3.03 (95% CI 0.07–15.75). Seroprevalence trend in healthy blood donors showed annual increase between 2012 and 2015, decreasing in the following years. No trend was seen in organ donors neither heart recipients. Adjusted rates did not show difference by sex and age among blood donors. No significant increases in seroprevalence T. cruzi were found during the study period. T. cruzi transmission remains low.

Chagas disease: Performance analysis of immunodiagnostic tests anti-Trypanosoma cruzi in blood donors with inconclusive screening results

Background

The screening ofTrypanosoma cruzi-infected blood donors using two serological techniques frequently leads to conflicting results. This fact prompted us to evaluate the diagnostic performance of four “in-house” immunodiagnostic tests and two commercially available enzyme-linked immunosorbent assays (ELISAs).

Material and Methods

One hundred and seventy-nine blood donors, whose screening for Chagas disease was doubtful, underwent three in-house ELISAs, one in-house immunoblotting test (TESA-blot), and two commercial ELISAs (bioMérieux and Wiener) in an attempt to define the presence or absence of infection. Simultaneously, 29 donors with previous positive results from three conventional serological tests and 30 donors with constant negative results were evaluated.

Results

The ELISA-Wiener showed the highest rate in sensitivity (98.92%) and the ELISA-bioMérieux, the highest specificity (99.45%), followed by the TESA-blot, which showed superior performance, with lower false-negative (2.18%) and false-positive (1.12%) rates. In series, the combination composed of the TESA-blot and ELISA-bioMérieux showed slightly superior performance, with trifunctional protein deficiency (TFP) = 0.01%.

Conclusion

Our study confirms the high sensitivity and specificity of commercial kits. To confirm the presence or absence of T. cruzi infection, the combination of TESA-blot and ELISA-bioMérieux may be suggested as the best alternative. Individually, the TESA-blot performed the closest to the gold standard; however, it is not commercially available.

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

Introduction

Chagas disease presents bio-psycho-social and cultural determinants for infected patients, their family members, close friends, and society. For this reason, diagnosis and treatment require an active approach and an integral focus, so that we can prevent the disease from creating stigma and exclusion, as is actively promoting access to diagnosis, medical attention and social integration

Methodology

The study was conducted in the Metropolitan Area of Barcelona (Catalonia, Spain) from 2004 to 2017. After an increased detection rates of CHD in our region, the process of construction of community strategies started (2004–2013). Different community interventions with informational, educational, and communication components were designed, developed, implemented, and evaluated. The results of the evaluation helped to determine which intervention should be prioritized: 1) workshop; 2) community event; 3) in situ screening. Afterwards, those strategies were implemented (2014–2017).

Results

Each of the three strategies resulted in a different level of coverage, or number of people reached. The in situ screening interventions reached the highest coverage (956 persons, 58.98%).Clear differences exist (p-value<0.001) between the three strategies regarding the percentage of screenings and diagnoses carried out. The largest number was in the in situ screening intervention, with a total of 830 persons screened despite the greatest number of diagnoses was among the workshop participants (33 persons, 20.75% of those screened). The prevalence of infection found is similar among the three strategies, ranging from 16.63% to 22.32% of the screened patients (p-value = 0.325).

Conclusions

The results of the study show that community interventions seem to be necessary to improve access to diagnosis and treatment of CHD in the area of Barcelona. They also show which strategy is the most appropriate based on the detected needs of the community, the proposed objectives of the intervention, and the given socio-temporal context.

Leveraging Technology to Manage Chagas Disease by Tracking Domestic and Sylvatic Animal Hosts as Sentinels: A Systematic Review

Surveillance of Chagas in the United States show more is known about prevalence in animals and vectors than in humans. Leveraging health information technology (HIT) may augment surveillance efforts for Chagas disease (CD), given its ability to disseminate information through health information exchanges (HIE) and geographical information systems (GISs). This systematic review seeks to determine whether technological tracking of Trypanosoma cruzi–infected domestic and/or sylvatic animals as sentinels can serve as a potential surveillance resource to manage CD in the southern United States. A Boolean search string was used in PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Relevance of results was established and analysis of articles was performed by multiple reviewers. The overall Cohen statistic was 0.73, demonstrating moderate agreement among the study team. Four major themes were derived for this systematic review (n = 41): animals act as reservoir hosts to perpetuate CD, transmission to humans could be dependent on cohabitation proximity, variations in T. cruzi genotypes could lead to different clinical manifestations, and leveraging technology to track T. cruzi in domestic animals could reveal prevalent areas or “danger zones.” Overall, our systematic review identified that HIT can serve as a surveillance tool to manage CD. Health information technology can serve as a surveillance tool to manage CD. This can be accomplished by tracking domestic and/or sylvatic animals as sentinels within a GIS. Information can be disseminated through HIE for use by clinicians and public health officials to reach at-risk populations.

Screening for Trypanosoma cruzi infection in immigrants and refugees: Systematic review and recommendations from the Spanish Society of Infectious Diseases and Clinical Microbiology

BackgroundChagas disease has spread beyond its original borders on the American continent with migration. It can be transmitted from mother to child, through organ transplantation and transfusion of blood and blood products. It is necessary to determine when to screen for this infection.AimOur objective was to evaluate the appropriateness of screening for Trypanosoma cruzi infection in Latin American migrants and their descendants.MethodsWe reviewed the literature using rigorous criteria. The quality of evidence was ranked according to the GRADE classification. An evidence to decision framework was adopted to provide information on the most relevant aspects necessary to formulate recommendations.ResultsThe 33 studies evaluated revealed a prevalence of T. cruzi infection among Latin American migrants in Europe of 6.08% (95% confidence interval (CI): 3.24-9.69; 28 studies). Vertical transmission occurred in three of 100 live births (95% CI: 1-6; 13 studies). The prevalence of cardiovascular disease was 19% (95% CI: 13-27; nine studies), including only 1% severe cardiac events (95% CI: 0-2; 11 studies). The overall quality of evidence was low because of risk of bias in the studies and considerable heterogeneity of the evaluated populations. The recommendations took into account economic studies on the value of screening strategies and studies on acceptability of screening and knowledge of the disease in the affected population.ConclusionsWe identified five situations in which screening for T. cruzi infection is indicated. We recommend screening persons from endemic areas and children of mothers from these areas.

Chagas Disease: From Discovery to a Worldwide Health Problem

Carlos Chagas discovered American trypanosomiasis, also named Chagas disease (CD) in his honor, just over a century ago. He described the clinical aspects of the disease, characterized by its etiological agent (Trypanosoma cruzi) and identified its insect vector. Initially, CD occurred only in Latin America and was considered a silent and poorly visible disease. More recently, CD became a neglected worldwide disease with a high morbimortality rate and substantial social impact, emerging as a significant public health threat. In this context, it is crucial to better understand better the epidemiological scenarios of CD and its transmission dynamics, involving people infected and at risk of infection, diversity of the parasite, vector species, and T. cruzi reservoirs. Although efforts have been made by endemic and non-endemic countries to control, treat, and interrupt disease transmission, the cure or complete eradication of CD are still topics of great concern and require global attention. Considering the current scenario of CD, also affecting non-endemic places such as Canada, USA, Europe, Australia, and Japan, in this review we aim to describe the spread of CD cases worldwide since its discovery until it has become a global public health concern.

Trypanosoma cruzi infection in transfusion medicine

INTRODUCTION

Infection by Trypanosoma cruzi is challenging to blood bank supplies in terms of accurate diagnosis, mostly due to its clinical complexity. Infected individuals may remain asymptomatic for years, albeit they may have circulating parasites potentially transferable to eventual receptors of a transfusion.

OBJECTIVE

Although risk donors are systematically excluded through a survey, an important residual risk for transmission remains, evidencing the need to implement additional actions for the detection of T. cruzi in blood banks.

METHOD

A review of the scientific literature is presented with the objective of identifying relevant publications on this subject.

RESULTS

We discuss the diagnostic considerations of this chronic infection on transfusion medicine and some recent advances in the processing of blood and derivatives units.

CONCLUSION

Finally, recommendations are made on how the transmission of T. cruzi can be avoided through the implementation of better diagnostic and pathogen control measures at blood banks.

Seroprevalence of Trypanosoma cruzi infection among at-risk blood donors in Japan

BACKGROUND

Chagas disease is caused by Trypanosoma cruzi and is endemic in Latin America. In nonendemic countries, including Japan, Chagas disease is primarily a problem in the context of transfusion transmission. Approximately 250,000 immigrants from Latin America reside in Japan, and many of those individuals serve as active blood donors. This study surveyed the seroprevalence of T. cruzi infection among at-risk blood donors in Japan, defined as those who themselves (or whose mothers) were born (or raised) in Latin America, or those with a travel history to Latin America.

STUDY DESIGN AND METHODS

Blood samples were obtained from at-risk donors in two periods, 2004-2012 and 2013-2016. Collected samples were tested for T. cruzi antibodies using both an enzyme-linked immunosorbent assay and a chemiluminescent immunoassay. Samples that tested positive in both assays were additionally tested by polymerase chain reaction, and look-back investigation was conducted when necessary.

RESULTS

Of 18,484 samples obtained from 18,076 at-risk donors, 3 (1:6,025, 0.017%) donors showed seroreactivity by enzyme-linked immunosorbent assay and chemiluminescent immunoassay. All antibody-positive donors were born in Latin America. One of them also was positive for T. cruzi DNA. Eleven previous donations from this donor were subjected to look-back investigation, and five recipients were tested. All five recipients tested negative for T. cruzi antibodies.

CONCLUSION

Seroprevalence of T. cruzi was 0.017% among at-risk donors in Japan. Transfusion-transmitted infection of Chagas disease has not been confirmed to date. Screening for T. cruzi antibodies by targeting at-risk donors is an appropriate strategy for ensuring blood safety in Japan.

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

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

Evaluation of the Elecsys Chagas Assay for Detection of Trypanosoma cruzi-Specific Antibodies in a Multicenter Study in Europe and Latin America

Serology is the preferred method to confirm a Chagas disease diagnosis and to screen blood donors. A battery of assays is often required due to the limited accuracy of single assays. The Elecsys Chagas assay is a newly developed, double-antigen sandwich assay for use on the Elecsys and cobas e immunoassay analyzers, intended to identify individuals infected with Trypanosoma cruzi, for diagnosis and screening. The performance of the Elecsys Chagas assay was evaluated in comparison with those of other widely used T. cruzi antibody assays, at multiple sites (Europe/Latin America). Relative sensitivity and specificity were assessed by using samples from blood donors, pregnant women, and hospitalized patients from regions where Chagas disease is endemic and from regions of nonendemicity. The Elecsys Chagas assay had an overall relative sensitivity of 100% (n = 674). Overall relative specificities were 99.90% (n = 14,681), 100% (n = 313), and 100% (n = 517) for samples from blood donors, pregnant women, and hospitalized patients, respectively. The analytical specificity was 99.83% (n = 594). The Elecsys Chagas assay detected T. cruzi antibodies in two World Health Organization (WHO) standard T. cruzi reference panels (panels 09/188 and 09/186) at a 1:512 dilution, corresponding to a cutoff sensitivity of approximately 1 mIU/ml. The Elecsys Chagas assay demonstrated robust performance under routine conditions at multiple sites in Europe and Latin America. In contrast to other available Chagas assays, the Elecsys assay uses a reduced number of recombinant T. cruzi antigens, resulting in a significantly smaller number of cross-reactions and improved analytical specificity while being highly sensitive.

Heart Failure Secondary to Chagas Disease: an Emerging Problem in Non-endemic Areas

Chagas disease affects millions of people worldwide. Though the majority of infected individuals remain asymptomatic, approximately 30 % of patients progress to develop cardiac manifestations and eventual heart failure. While vectorial transmission occurs predominantly in South America, Central America, and Mexico, millions of people originally from these endemic regions immigrate to non-endemic countries in North America, Europe, and Asia. Outside of rare specialized centers, health-care providers lack experience diagnosing and treating this disease. This lack of experience likely leads to far fewer Chagas disease patients being diagnosed than what actually exist in non-endemic countries, with subsequent adverse effect on patient outcomes and health-care expenses. Underdiagnosis increases the risk of developing cardiomyopathy, associated heart failure, and life-threatening ventricular arrhythmias as the disease progresses.

Strongyloides stercoralis infection increases the likelihood to detect Trypanosoma cruzi DNA in peripheral blood in Chagas disease patients

OBJECTIVES

In a previous study performed by our group, Strongyloides stercoralis infection in patients with Chagas disease was associated with higher proportion of Trypanosoma cruzi DNA detection in peripheral blood. The aim of the study was to confirm this association in a larger cohort of patients.

METHODS

Cross-sectional study of all patients with Chagas disease diagnosed from 2005 to 2015 during blood donation at the Catalan Blood Bank. Demographic data and T. cruzi RT-PCR were collected. S. stercoralis infection diagnosis was based on a serological test.

RESULTS

Two hundred and two blood donors were included. T. cruzi RT-PCR was positive in 72 (35.6%) patients, and S. stercoralis serology was positive in 22 (10.9%) patients. Patients with positive S. stercoralis serology had higher proportion of positive T. cruzi RT-PCR than those with negative serology (54.5% vs. 33.3%, P = 0.050), and the difference increased when taking a serological index cut-off of 2.5, which increases the specificity of the test to detect a confirmed strongyloidiasis (60% vs. 33%, P = 0.017).

CONCLUSIONS

Patients with Chagas disease with positive S. stercoralis serology had higher proportion of positive T. cruzi RT-PCR in peripheral blood than those with negative serology, which reflects the potential immunomodulatory effects of S. stercoralis in T. cruzi co-infected patients.

Benzoic Acid Derivatives with Trypanocidal Activity: Enzymatic Analysis and Molecular Docking Studies toward Trans-Sialidase

Chagas, or American trypanosomiasis, remains an important public health problem in developing countries. In the last decade, trans-sialidase has become a pharmacological target for new anti-Chagas drugs. In this work, the aims were to design and find a new series of benzoic acid derivatives as trans-sialidase (TS) inhibitors and anti-trypanosomal agents. Three compounds (14, 18, and 19) sharing a para-aminobenzoic acid moiety showed more potent trypanocidal activity than the commercially available drugs nifurtimox and benznidazole in both strains: the lysis concentration of 50% of the population (LC50) was <0.15 µM on the NINOA strain, and LC50 < 0.22 µM on the INC-5 strain. Additionally, compound 18 showed a moderate inhibition (47%) on the trans-sialidase enzyme and a binding model similar to DANA (pattern A).

Chagas disease in Europe: A review for the internist in the globalized world

Chagas disease (CD) or American trypanosomiasis identified in 1909 by Carlos Chagas, has become over the last 40years a global health concern due to the huge migration flows from Latin America to Europe, United States, Canada and Japan. In Europe, most migrants from CD-endemic areas are concentrated in Spain, Italy, France, United Kingdom and Switzerland. Pooled seroprevalence studies conducted in Europe show an overall 4.2% prevalence, with the highest infection rates observed among individuals from Bolivia (18.1%). However, in most European countries the disease is neglected with absence of screening programmes and low access to diagnosis and treatment. Physicians working in Europe should also be aware of the risk of autochthonous transmission of Trypanosoma cruzi to newborns by their infected mothers and to recipients of blood or transplanted organs from infected donors. Finally, physicians should be able to recognize and treat the most frequent and serious complications of chronic Chagas disease, namely cardiomyopathy, megacolon and megaesophagus. This review aims to highlights the problem of CD in Europe by reviewing papers published by European researchers on this argument, in order to raise the awareness of internists who are bound to increasingly encounter patients with the disease in their routine daily activities.

Pheophorbide a, a compound isolated from the leaves of Arrabidaea chica, induces photodynamic inactivation of Trypanosoma cruzi

BACKGROUND

Approximately 6-7 million people are infected with Trypanosoma cruzi, the etiological agent of Chagas' disease. Only two therapeutic compounds have been found to be useful against this disease: nifurtimox and benznidazole. These drugs have been effective in the acute phase of the disease but less effective in the chronic phase; they also have many side effects. Thus, the search for new compounds with trypanocidal action is necessary. Natural products can be the source of many important substances for the development of drugs to treat this infection. The present study evaluated the biological activity of an extract and fractions of Arrabidaea chica against T. cruzi and observed morphological and ultrastructural characteristics of parasites exposed to the isolated compound pheophorbide a.

METHODS

The crude hydroethanolic extract of A. chica was prepared. Fractions were obtained by partition and separated by liquid chromatography.

RESULTS

We observed a progressive increase in activity against epimastigote, trypomastigote, and amastigote forms of the parasite over the course of the fractionation process. Interestingly, we isolated a compound known as a photosensitizer that is used in photodynamic therapy. This method of treatment involving a photosensitizer, activation light and molecular oxygen is of great importance due to its selectivity. Pheophorbide a had activity against the protozoan in the presence of light and caused morphological and ultrastructural changes, demonstrating its potential in photodynamic therapy.

CONCLUSIONS

Based on the ability of pheophorbide a to eliminate bloodstream forms of T. cruzi, we suggest its use in blood banks for hemoprophylaxis.

Interdisciplinary approach at the primary healthcare level for Bolivian immigrants with Chagas disease in the city of São Paulo

Background/Methods

In a pioneering cross-sectional study among Bolivian immigrants in the city of São Paulo, Brazil, the epidemiological profile, clinical manifestations and morbidity of Chagas disease were described. The feasibility of the management of Chagas disease at primary healthcare clinics using a biomedical and psychosocial interdisciplinary approach was also tested. Previously, a Trypanosoma cruzi (T. cruzi) infection rate of 4.4% among 633 immigrants was reported. The samples were screened using two commercial enzyme-linked immunoassay (ELISA) tests generated with epimastigote antigens, and those with discrepant or seropositive results were analyzed by confirmatory tests: indirect immunofluorescence (IFI), TESA-blot and a commercial recombinant ELISA. PCR and blood cultures were performed in seropositive patients.

Results

The majority of the 28 seropositive patients were women, of whom 88.89% were of child-bearing age. The predominant clinical forms of Chagas disease were the indeterminate and atypical cardiac forms. Less than 50% received the recommended antiparasitic treatment of benznidazole. An interdisciplinary team was centered on primary healthcare physicians who applied guidelines for the management of patients. Infectologists, cardiologists, pediatricians and other specialists acted as reference professionals. Confirmatory serology and molecular biology tests, as well as echocardiography, Holter and other tests, were performed for the assessment of affected organs in secondary healthcare centers. The published high performance of two commercial ELISA tests was not confirmed.

Conclusion

An interdisciplinary approach including antiparasitic treatment is feasible at the primary healthcare level for the management of Chagas disease in Bolivian immigrants. The itinerant feature of immigration was associated with a lack of adherence to antiparasitic treatment and was considered a main challenge for the clinical management of this population. This approach is recommended for management of the infected population in endemic and nonendemic areas, although different strategies are needed depending on the severity of the disease and the structure of the healthcare system.

Chagas disease affects approximately 6 million Latin American people. It is considered a neglected tropical disease since it mainly affects vulnerable, poverty-stricken people. Public health policies and investments in research on new treatment and control instruments have not been prioritized. In fact, disease urbanization occurred in Latin America in the 80s, and an estimated 15 million people moved from disease-endemic areas to nonendemic areas. Estimations have indicated that 2.9% of immigrants were infected by T. cruzi in 15 European countries, and more than 300,000 infected immigrants resided in the USA. In São Paulo, the estimated number of Bolivian immigrants exceeds 300,000. This study revealed the presence of mild clinical manifestations in predominantly young infected individuals, including reproductive-age women. For the first time, the feasibility of managing chronic Chagas disease at primary healthcare level centers with a biomedical and psychosocial interdisciplinary approach has been reported in the National Public Health System of Brazil. Additionally, the utilized commercial tests did not confirm the previously expected performance for diagnosis of infection. Finally, the itinerant characteristics of the Bolivian immigrant population was reported as a main factor underlying the lack of adherence to antiparasitic treatment and a main challenge for complete clinical management.

Cross-sectional, descriptive study of Chagas disease among citizens of Bolivian origin living in Munich, Germany

PURPOSE

Chagas disease (CD) has become a global health issue mainly due to migration. Germany lacks surveillance data and is home to a large Latin American immigrant population. Recognising that Bolivia is the country with the highest CD prevalence in Latin America, this cross-sectional, descriptive pilot study investigated CD and associated factors among citizens of Bolivian origin living in Munich, Germany.

METHODS

Participants completed a questionnaire in order to collect socioeconomic and health-related data. In addition, serology was performed. In case of positive serological tests, PCR diagnostic and clinical staging together with disease management was initiated. Qualitative research was conducted to identify personal and community barriers as well as strategies to increase CD awareness among the population at risk.

RESULTS

Between June 2013 and June 2014, 43 people from Bolivia (or descendants) were enrolled. A total of 9.3% (4/43), of whom two women were of childbearing age, tested seropositive (ELISA and IFAT), and one also by PCR. For 2/4 positive participants, clinical evaluation was performed and the indeterminate form of CD was diagnosed. Knowledge about CD symptoms and ways of transmission were completely absent among 55.8% (24/43, 2/4 with CD) and 30.2% (13/43, 1/4 with CD) of participants, respectively. A total of 27.9% (12/43, 0/4 with CD) of participants had donated blood prior to the study, whereas 62.8% (27/43, 3/4 with CD) were motivated to donate blood in the future. The qualitative research identified lack of knowledge as well as stigma and fears related to CD.

CONCLUSIONS

Despite the small number of participants, the prevalence of CD as well as the potential risk of non-vectorial transmission was alarming. Campaigns adapted for Latin American migrants as well as control strategies should be developed and put in place in order to prevent non-vectorial transmission and actively detect cases of CD in Germany.

Chagas disease and transfusion medicine: a perspective from non-endemic countries

In the last decades, increasing international migration and travel from Latin America to Europe have favoured the emergence of tropical diseases outside their "historical" boundaries. Chagas disease, a zoonosis endemic in rural areas of Central and South America represents a clear example of this phenomenon. In the absence of the vector, one of the potential modes of transmission of Chagas disease in non-endemic regions is through blood and blood products. As most patients with Chagas disease are asymptomatic and unaware of their condition, in case of blood donation they can inadvertently represent a serious threat to the safety of the blood supply in non-endemic areas. Since the first cases of transfusion-transmitted Chagas disease were described in the last years, non-endemic countries began to develop ad hoc strategies to prevent and control the spread of the infection. United States, Spain, United Kingdom and France first recognised the need for Trypanosoma cruzi screening in at-risk blood donors. In this review, we trace an up-to-date perspective on Chagas disease, describing its peculiar features, from epidemiological, pathological, clinical and diagnostic points of view. Moreover, we describe the possible transmission of Chagas disease through blood or blood products and the current strategies for its control, focusing on non-endemic areas.

Proteomic profile of circulating immune complexes in chronic Chagas disease

Immune complexes (ICs) are the direct and real-time products of humoral immune responses. The identification of constituent foreign or autoantigens within ICs might bring new insights into the pathology of infectious diseases. We applied immune complexome analysis of plasma to the study of Chagas disease caused by Trypanosoma cruzi. Twenty seropositive plasma samples including cardiac and/or megacolon determinate patients (n = 11) and indeterminate (n = 9) were analysed along with 10 seronegative individuals to characterize the antigens bound to circulating ICs. We identified 39 T. cruzi antigens and 114 human autoantigens specific to patients with Chagas. Among those antigens, two T. cruzi antigens (surface protease GP63, glucose-6-isomerase) and six human autoantigens (CD180 antigen, ceruloplasmin, fibrinogen beta chain, fibrinogen beta chain isoform 2 preprotein, isoform gamma-A of fibrinogen γ-chain, serum paraoxonase) were detected in more than 50% of the patients tested. Human isoform short of complement factor H-related protein 2 and trans-sialidase of T. cruzi were more frequently found in the indeterminate (5/9 for both) compared with in the determinate Chagas (0/11, P = 0·046 for human, 1/11, P = 0·0498 for T. cruzi). The immune complexome could illustrate the difference of immune status between clinical forms of chronic Chagas disease.

Selective Testing of At-Risk Blood Donors for Trypanosoma cruzi and Plasmodium spp. in Switzerland

BACKGROUND

Population migrations and overseas recreational travel to regions at risk for tropical diseases are increasing. A major challenge in non-endemic countries is to decrease the number of blood donor deferrals due those tropical disease pathogens, without compromising the high level of blood safety. The protozoans Trypanosoma cruzi and Plasmodium spp., the causative organisms of Chagas disease (CD) and malaria are becoming a major focus in the blood transfusion community.

METHODS

National guidelines of the Blood Transfusion Service of the Swiss Red Cross propose an algorithm for dealing with these pathogens, including a mandatory selective serological testing of donors at risk.

RESULTS

6,978 donors at risk for CD were tested. Three of them were confirmed anti-T. cruzi -positive, and in one case a transfusion-transmitted infection was highly possible. The specificity of the assay was 99.94%. For malaria 12,887 donors were at risk and 178 were confirmed positive. The specificity of the assays was 92.8%.

CONCLUSION

CD and malaria in non-endemic countries may represent a certain risk for blood transfusion. Switzerland chose a selective testing approach. The specificity of the assays is a crucial topic for this approach because it ensures a minimal loss of false-reactive donors and helps towards an easier counselling of implicated donors.

A global systematic review of Chagas disease prevalence among migrants

Human migration has been identified as a potential factor for increased Chagas disease risk and has transformed the disease from a Latin American problem to a global one. We conducted a systematic review of the scientific literature between 2004-2014 in order to: summarize recent seroprevalence estimates of Chagas disease among Latin American migrants, in both endemic and non-endemic settings; compare seroprevalence estimates in migrants to countrywide prevalence estimates; and identify risk factors for Chagas disease among migrants. A total of 320 studies were screened and 23 studies were included. We found evidence that the prevalence of Chagas disease is higher than expected in some migrant groups and that reliance on blood donor screening prevalence estimates underestimates the burden of disease. Overall there is a dearth of high quality epidemiologic studies on the prevalence of Chagas disease in migrants, especially among intra-regional migrants within Latin America. Given that this zoonotic disease cannot likely be eradicated, improved surveillance and reporting is vital to continuing control efforts. More accurate health surveillance of both Latin American migrants and the Chagas disease burden will help countries appropriately scale up their response to this chronic disease. Overall, improved estimates of Chagas disease among migrants would likely serve to highlight the real need for better screening, diagnostics, and treatment of individuals living with the disease.

Serological study of Trypanosoma cruzi, Strongyloides stercoralis, HIV, human T cell lymphotropic virus (HTLV) and syphilis infections in asymptomatic Latin-American immigrants in Spain

OBJECTIVE

We aimed to perform a serological screening for T. cruzi, Strongyloides stercoralis, HIV, human T cell lymphotropic virus (HTLV) and syphilis in Latin American immigrants admitted to hospital in Spain.

METHODS

We have carried out a cross-sectional study of Latin American immigrants admitted to the Hospital General Universitario Alicante (Spain) from June 2012 to May 2014, where screening of Chagas disease, strongyloidiasis, HTLV, HIV and syphilis was performed by serology.

RESULTS

A total 180 patients were included in the study. Patients' median age was 38 years old, 123 (68.3%; 123/180) were female and 57 (31.7%; 57/180) male. Five of the 180 (2.5%) patients were positive for Chagas disease; associated with knowledge about Chagas disease (p=0.005), previous contact with patients with Chagas disease (p=0.04) and being Bolivian (p<0.001). Forty-two of the 157 (26.8%) patients were positive for Strongyloides serology; associated positively with being male (p<0.001), eosinophilia (p=0.001), hyper-IgE (p<0.001) and being Ecuadorian (p=0.001), and negatively associated with being Colombian (p=0.03). Positive serology of latent syphilis was found in 1.8% (3/171) of patients. Serology of HTLV was negative in all cases. No new cases of HIV infection were diagnosed.

CONCLUSIONS

We propose that Latin American immigrant patients admitted to hospital in Spain be screened for strongyloidiasis, Chagas disease and syphilis by serology.

The importance of the multidisciplinary approach to deal with the new epidemiological scenario of Chagas disease (global health)

There are currently two major factors that have modified the epidemiology of Chagas disease in the last decades: climate change and migration flows. In this new scenario, there are new challenges to control and prevent Trypanosoma cruzi infection in endemic countries, such as the control of a wider distribution of triatomine vectors or the reinforcement of vertical transmission programs. In non-endemic areas, few countries are aware of the emergence of this new disease and have established changes in their health systems. To address this new public health challenge, the priorities should be control programs to avoid new cases of T. cruzi infection acquired through vertical transmission, blood transfusion or organ transplant. In both, endemic and non-endemic areas, the international community and all the actors involved in Chagas disease must join efforts mainly in two directions: better management of the infection in affected individuals and more research to cover the knowledge gap mainly in physiopathology, diagnosis and treatment.

[Consensus document for the detection and management of Chagas disease in primary health care in a non-endemic areas]

Chagas disease is caused by the protozoan Trypanosoma cruzi. Although it is commonly transmitted by an insect vector in continental Latin-America, in recent decades, due migration, has been diagnosed in other countries such Spain, the European country with a largest immigrant population of Latin American. For a long time, the patient remains asymptomatic, but some years after this stage, the symptoms can be serious (dilated cardiomyopathy, megacolon, megaesophagus). In addition, detection in pregnant women has a high priority because of the route of vertical transmission. Several specific guidelines about Chagas disease has been developed on the Banks of blood, maternal hospitals, HIV co-infection, organ transplant. But due to the detection of lack of information to primary care professionals, we consider to will be useful this document written and agreed to by family phisicians, pediatricians and specialists in International Health.

Prevalence of Chagas disease in Latin-American migrants living in Europe: a systematic review and meta-analysis

BACKGROUND

Few studies have assessed the burden of Chagas disease in non-endemic countries and most of them are based on prevalence estimates from Latin American (LA) countries that likely differ from the prevalence in migrants living in Europe. The aim of this study was to systematically review the existing data informing current understanding of the prevalence of Chagas disease in LA migrants living in European countries.

METHODS

We conducted a systematic review and meta-analysis of studies reporting prevalence of Chagas disease in European countries belonging to the European Union (EU) before 2004 in accordance with the MOOSE guidelines and based on the database sources MEDLINE and Global Health. No restrictions were placed on study date, study design or language of publication. The pooled prevalence was estimated using random effect models based on DerSimonian & Laird method.

RESULTS

We identified 18 studies conducted in five European countries. The random effect pooled prevalence was 4.2% (95%CI:2.2-6.7%); and the heterogeneity of Chagas disease prevalence among studies was high (I2 = 97%,p<0.001). Migrants from Bolivia had the highest prevalence of Chagas disease (18.1%, 95%CI:13.9-22.7%).

CONCLUSIONS

Prevalence of Chagas in LA migrants living in Europe is high, particularly in migrants from Bolivia and Paraguay. Data are highly heterogeneous dependent upon country of origin and within studies of migrants from the same country of origin. Country-specific prevalence differs from the estimates available from LA countries. Our meta-analysis provides prevalence estimates of Chagas disease that should be used to estimate the burden of disease in European countries.

Evaluation of a chemiluminescent enzyme-linked immunosorbent assay for the diagnosis of Trypanosoma cruzi infection in a nonendemic setting

The disappearance of lytic, protective antibodies (Abs) from the serum of patients with Chagas disease is accepted as a reliable indicator of parasitological cure. The efficiency of a chemiluminescent enzyme-linked immunosorbent assay based on a purified, trypomastigote-derived glycosylphosphatidylinositol-anchored mucin antigen for the serologic detection of lytic Abs against Trypanosoma cruzi was evaluated in a nonendemic setting using a panel of 92 positive and 58 negative human sera. The technique proved to be highly sensitive {100%; 95% confidence interval (CI) = 96-100} and specific (98.3%; 95% CI = 90.7-99.7), with a kappa score of 0.99. Therefore, this assay can be used to detect active T. cruzi infection and to monitor trypanosomicidal treatment.

Impact of chagas disease in bolivian immigrants living in europe and the risk of stigmatization

Background. The prevalence of Chagas disease in endemic countries varies with the kind of vector involved and the socioeconomic conditions of the population of origin. Due to recent immigration it is an emerging public health problem in Europe, especially in those countries which receive immigrant populations with a high prevalence of carriers. The study reviews the impact of the disease on Bolivian immigrants living in Europe, the preventive measures and regulations applied in European countries, and their repercussion on possible stigmatization of certain population groups. Methods. The Bolivian immigrant population resident in 2012 was estimated and the affected population in different European countries was calculated with data on carrier prevalence that were recently published. The preventive measures and regulations available in Europe were also reviewed. MEDLINE-PubMed, GoPubMed, and Embase were consulted for the literature review. Results. The Bolivian immigrant population has the highest prevalence of Chagas carriers (6.7%–25%) compared to the overall Latin American population (1.3%–2.4%). Only in Spain, France, Belgium, UK, Portugal, Italy, Switzerland, The Netherlands, and Germany, preventive measures are applied to this population. The established regulations are insufficient and completely different criteria are applied in the different countries and this could reflect a certain degree of stigmatization.

An approach to the management of Trypanosoma cruzi infection (Chagas' disease) in immunocompromised patients

The epidemiology of Chagas disease has changed in the last decades due to migration movements, population ageing and the emergence of new transmission routes. In endemic countries, health facilities and access to healthcare are improving and T. cruzi infected patients are also benefiting from medical advances. The HIV epidemic has spread to both endemic and non-endemic areas for T. cruzi, organ transplant rates have increased recently, especially in Latin America, and other medical conditions affecting the immune system are increasing their global burden. The natural course of Chagas disease is mainly determined by the host's cellular immune response. These conditions may therefore overlap with T. cruzi infection and alter the disease's natural history which may present with atypical clinical forms and a higher associated morbidity and mortality in immunocompromised patients. The present review aims to contribute to the management of immunosuppressed patients with T. cruzi infection.

[Paediatric Chagas in a non-endemic area]

INTRODUCTION

Immigration has introduced new diseases into Spanish society, one of which is Chagas disease. Young women of childbearing age and children infected with Trypanosoma cruzi from endemic areas are at risk of developing the disease years later, and pregnant women can transmit the infection through the placenta.

METHODS

Serological screening for anti-T.cruzi antibodies was performed on all immigrant children coming from a Chagas endemic area and seen in our Pathology Unit between 2003 and 2008, as well as on newborns of T.cruzi positive infected pregnant women coming from Latin America. Two ELISA tests were used (bioelisa Chagas Biokit® with recombinant antigens, and an 'in house' ELISA with crude antigen). Patients with sufficient sample were also screened by nested PCR (TCZ3/Z4).

RESULTS

A total of 202 children, aged 1 day to 14 years old were included in the study, of whom 22 (10.8%) were diagnosed with asymptomatic infection, 5 of which were congenital as they were born in this country. All infected patients received treatment with benznidazole, with three of them currently with a serologically negative result after treatment.

CONCLUSION

Chagas disease is a new imported paediatric disease that can affect children from endemic countries, but can also be acquired in our country by vertical transmission. Therefore, we believe that it is essential to perform serological screening on all children and pregnant women in the prenatal care from endemic areas, and provide specific treatment for those infected patients, given the good results observed in the paediatric population.

Anti-Trypanosoma cruzi antibody detection in eastern Andalusia (Spain)

BACKGROUND

Chagas disease caused by the protozoan haemoflagellate Trypanosoma cruzi is no longer found exclusively in Latin America; the disease is occurring in Europe, and Spain is the country with the highest prevalence.

METHODS

Our aim was to detect anti-T. cruzi antibodies in blood donors from southeast Spain, and we performed eight serological diagnostic assays on each of 550 blood samples collected in March-June 2010. Two in-house ELISA methods were used to test against a parasite lysate (ELISA-H) and the semi-purified superoxide dismutase excreted by T. cruzi (ELISA-SODe); we also used the Western blot technique against the same antigen (WB-SODe), indirect immunofluorescence (IFA) and four commercial tests.

RESULTS

The serological test results showed a range of seroprevalence values, the lowest being 1.1%, determined by IFA and two commercial tests (Ab rapid and Chagascreen); other values were: 1.3% (commercial ELISA [Chagas ELISA IgG+IgM]); 2.1% (immunochromatographic test [Stick Chagas]); 2.7% (ELISA-H); 4.0% (WB-SODe); and 4.2%, the highest value (ELISA-SODe).

CONCLUSIONS

The excellent specificity of SODe antigen for the detection of antibodies to T. cruzi in donors lead us to affirm that the serological test performed with this biomarker could provide a useful screening and confirmatory test method for cases of Chagas disease.

Bolivian migrants with Chagas disease in Barcelona, Spain: a qualitative study of dietary changes and digestive problems

Due to international migration, Chagas disease, endemic in Latin America, has become more common in non-endemic areas. Chronic Chagas disease can cause damage to the digestive system leading to constipation. However, a range of factors influences constipation and a better understanding of the role of non-Chagas related factors is required to improve management of Chagas-related digestive problems. This study explores perceptions of constipation and changes in food and exercise habits amongst Bolivians in Barcelona, Spain. Bolivian migrants attending the Tropical Medicine Unit (Hospital Clínic, Barcelona) were interviewed about their food habits in Spain and Bolivia, migratory experience, work and leisure activities. Chagas seropositive participants also received radiological examinations. Bolivian migrants experienced dietary changes, influenced by work-related factors, which included reductions in quantities of food and liquid consumed. Almost half the participants reported changes in digestive rhythm since arriving in Spain. Constipation, which was common, in some cases was only recounted during interviews. Bolivian migrants' constipation may be associated with chronic Chagas disease or migration-related dietary changes. Careful questioning using the Rome III criteria is however required to ensure its diagnosis. Radiological studies are also required to confirm the role of Chagas disease and identify potentially serious intestinal damage.

Surveillance of Chagas disease among at-risk blood donors in Italy: preliminary results from Umberto I Polyclinic in Rome

BACKGROUND

Chagas disease is a parasitic disease due to Trypanosoma cruzi, endemic in Central and Southern America, where the protozoon infects about 8-10 million people. In rural areas the infection is acquired mostly through reduviidae insect vectors, whereas in urban ones it is acquired mainly through the transfusion of blood products, vertical transmission and organ transplantation. The important migratory flows of the last decades have focused attention on possible T. cruzi transmission by transfusion also in non-endemic countries, and platelets have been recognised as the main origin of infection for recipients from serologically-positive Latino-American donors.

MATERIALS AND METHODS

In order to avoid the occurrence of transfusion-related cases, in 2010 systematic screening for anti-T. cruzi antibodies was started at the Umberto I Polyclinic in Rome, controlling blood donors born and/or coming from Latin-American countries in which the disease is endemic. The aim of this paper is to report the preliminary results achieved since the introduction of this screening.

RESULTS

Anti-T. cruzi antibodies have been detected to date in 3.9% out of the 128 people examined. A seropositive subject also proved positive by polymerase chain reaction analysis and showed very light parasitaemia.

DISCUSSION

The preliminary results are quite alarming. Indeed, serological findings exceed those reported in other non-endemic countries, and Italian travellers proved to be an insidious possible source of direct transmission. The need for systematic screening of at-risk blood donors also in non-endemic countries is emphasised.