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Caridi TL, Mariño-Polo F, Farra CG, Mingus AM, Memon A, Grijalva MJ, Bates BR. Health literacy & Chagas disease knowledge: A cross-sectional study in Southern Loja Province, Ecuador. PEC INNOVATION 2024; 4:100287. [PMID: 38799258 PMCID: PMC11126796 DOI: 10.1016/j.pecinn.2024.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/22/2024] [Accepted: 05/04/2024] [Indexed: 05/29/2024]
Abstract
Objective Health literacy is associated with many patient outcomes. This study sought to determine the association between a person's level of health literacy and their knowledge about Chagas disease. Methods A cross-sectional survey was conducted with people living in two counties in rural Loja Province, Ecuador who attended a mobile health clinic. The communities in which the study was conducted are at high risk of Chagas disease and have limited access to both health care and educational resources. The Spanish version of Short Assessment for Health Literacy measured health literacy. The Chagas Disease Knowledge questionnaire measured knowledge of Chagas disease. T-tests and correlational analysis were used to assess associations. Results Overall 85 people participated in this study. A majority of the respondents were female (64.1%), and a plurality were married (40.7%) and had education less than secondary (40.7%). The average age of the sample was 44.31 ± 18.85. Health literacy levels and Chagas disease knowledge in the communities were low. About half of people had inadequate health literacy. No association between health literacy and Chagas knowledge was found. Conclusion Health literacy levels and Chagas disease knowledge were not found to be correlated. Explanations for the lack of association may include common causes of inadequate investment in Chagas disease education as well as neglect of health systems in rural Ecuador. Efforts to improve both health literacy and Chagas disease knowledge in poorer, rural areas of Ecuador are needed. Innovation This is the first study to assess relationships between health literacy and knowledge of Chagas disease in an uninfected population. For novel conditions, relationships between health literacy and disease knowledge should be investigated before communication campaigns are adapted.
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Affiliation(s)
- Talia L. Caridi
- Heritage College of Osteopathic Medicine, Ohio University, 6775 Bobcat Way Dublin, Ohio 43016, Dublin, OH, USA
| | - Fernanda Mariño-Polo
- Facultad de Medicina, Pontifical Catholic University of Ecuador, Avenida 12 de Octubre 1076, Quito 170143, Ecuador
| | - Cora G. Farra
- Department of Sociology & Anthropology, Bentley Annex 162, Ohio University, Athens, OH, USA
| | - Alison M. Mingus
- Honors Tutorial College, Ohio University, 35 Park Place, Athens, OH, USA
| | - Athar Memon
- School of Communication Studies, Ohio University, 418 Schoonover Center for Communication, 20 East Union Street, Athens, OH, USA
| | - Mario J. Grijalva
- Infectious and Tropical Disease Institute, Heritage College of Osteopathic Medicine, Ohio University, 191 West Union Street, Athens, OH, USA
- Biomedical Sciences Department, Heritage College of Osteopathic Medicine, Ohio University, Irvine Hall 112, Athens, OH, USA
- Center for Research on Health in Latin America, Pontifical Catholic University of Ecuador, Calle San Pedro y Pambacienda, Quito 170530, Ecuador
| | - Benjamin R. Bates
- School of Communication Studies, Ohio University, 418 Schoonover Center for Communication, 20 East Union Street, Athens, OH, USA
- Infectious and Tropical Disease Institute, Heritage College of Osteopathic Medicine, Ohio University, 191 West Union Street, Athens, OH, USA
- Center for Research on Health in Latin America, Pontifical Catholic University of Ecuador, Calle San Pedro y Pambacienda, Quito 170530, Ecuador
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Ochoa-Diaz MM, Orozco-Garcia D, Fernandez-Vasquez RS, Eyes-Escalante M. Knowledge, Attitudes and Practices of Chagas a Neglected Tropical Disease in Rural Communities of the Colombian Caribbean, CHAGCOV Study. Acta Parasitol 2024; 69:1148-1156. [PMID: 38592371 DOI: 10.1007/s11686-024-00833-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Chagas disease (CD) a Neglected Tropical Diseases is an important public health issue in countries where is still endemic, included in the Sustainable Development Goals (SDG). Traditionally restricted to rural areas with diverse routes of transmissions from vectorial to oral with acute manifestations but being more common diagnosed in chronic stages. The aim of this investigation was to characterize the Knowledge, Attitudes and Practices (KAP) related to Chagas disease (CD) in two rural settlements of the Colombian Caribbean with previous records of the disease and/or the parasite. METHODS A cross-sectional descriptive study was made in two rural settlements in Colombia and surveillance instrument was developed to measure Knowledge, Attitudes and Practices (KAP) related to Chagas disease (CD). RESULTS In a population with > 60% women and access to social security around 66.5%; 81,6% were homeowners with access to water and electricity > 90% but only 9% of sewerage. The level of knowledge about CD was around 62% but lack of specificity about comprehension of transmission routes (74,6%), and symptoms (85,3%) were found; concluding that 86% of the surveyed sample had very poor level of knowledge about the disease despite preventive campaigns carried out in the two communities studied. CONCLUSIONS Despite of a low frequency of CD in this Caribbean areas, the presence of vector, risk factors plus poor level of knowledge about the disease justify that public health intervention strategies should be implemented and monitored over time to maintain uninterrupted surveillance of Chagas Disease.
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Affiliation(s)
- Margarita M Ochoa-Diaz
- School of Medicine, Universidad del Sinú Seccional Cartagena, 130001, Cartagena, Colombia.
- Research Group GIBACUS, Tropical Medicine, Cartagena, Colombia.
| | - Daniela Orozco-Garcia
- School of Medicine, Universidad del Sinú Seccional Cartagena, 130001, Cartagena, Colombia
- Research Group GIBACUS, Tropical Medicine, Cartagena, Colombia
| | - Ronald S Fernandez-Vasquez
- School of Medicine, Universidad del Sinú Seccional Cartagena, 130001, Cartagena, Colombia
- Research Group GIBACUS, Tropical Medicine, Cartagena, Colombia
| | - Melisa Eyes-Escalante
- School of Biology, Tropical Medicine Doctorate, Universidad del Atlántico, Barranquilla, Colombia
- Research Group Biodiversidad del Caribe Colombiano, Barranquilla, Colombia
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Nogueira de Brito R, Tanner S, Runk JV, Hoyos J. Looking through the lens of social science approaches: A scoping review of leishmaniases and Chagas disease research. Acta Trop 2024; 249:107059. [PMID: 37918504 DOI: 10.1016/j.actatropica.2023.107059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/04/2023]
Abstract
Scholars have called for increased attention to sociocultural, economic, historical, and political processes shaping Neglected Tropical Diseases (NTDs) ecology. We conducted a scoping review to identify major research themes and the knowledge gaps in social science literature in leishmaniases or Chagas disease (CD). Following the scoping review protocol, we first determined the focus of the review to be centered on identifying research that approaches leishmaniases and CD from social science perspective and was indexed by large, biomedically focused databases. We then searched PubMed and Web of Science using "Leishmaniasis" and "Chagas disease" with "social science" or "anthropology" as search terms. We analyzed 199 articles (123 on leishmaniases and 76 on CD), categorizing them into three main research themes. Sociocultural dimensions of the diseases (leishmaniases=60.2 %; CD=68.4 %) primarily focused on individuals' knowledge, practices, and behaviors, barriers to accessing healthcare (especially in endemic regions), psychosocial effects, stigma, and traditional treatments. Research focused on socioeconomic dimensions of the diseases (leishmaniases=29.3 %; CD=19.7 %) included topics like household characteristics, social capital, and infrastructure access. A final theme, the historical and political contexts of the diseases (Leishmaniases=10.5 %; CD=11.9 %) was less common than other themes. Here, studies consider civil war and the (re)emergence of leishmaniasis, as well as the significance of CD discovery for scientific and public health in Brazil, which is the most common country for research on both leishmaniases and CD that draws on social science approaches. Future directions for research include focusing on how social institutions and economic factors shape diseases education, control measures, healthcare access, and quality of life of people affected by NTDs. Greater attention to social sciences can help mitigate and undo the ways that structural biases have infiltrated biomedicine.
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Affiliation(s)
- Raíssa Nogueira de Brito
- Department of Anthropology, University of Georgia, Athens, GA 30602, United States; Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA 30602, United States.
| | - Susan Tanner
- Department of Anthropology, University of Georgia, Athens, GA 30602, United States
| | - Julie Velásquez Runk
- Environment and Sustainability Studies Program, Wake Forest University, Winston Salem, NC 27109, United States; Smithsonian Tropical Research Institute, Balboa, Ciudad de Panamá 0843-03092, Republic of Panama
| | - Juliana Hoyos
- Odum School of Ecology, University of Georgia, Athens, GA 30602, United States
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Apodaca Michel B, Navarro M, Pritsch M, Du Plessis JD, Shock J, Schwienhorst-Stich EM, Zirkel J, Schrader H, Saavedra Irala C, Rubilar G, Gunesch C, Kasang C, Zoller T, Gagyor I, Parisi S. Understanding the widespread use of veterinary ivermectin for Chagas disease, underlying factors and implications for the COVID-19 pandemic: a convergent mixed-methods study. BMJ Open 2022; 12:e058572. [PMID: 36115669 PMCID: PMC9485649 DOI: 10.1136/bmjopen-2021-058572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Veterinary ivermectin (vet-IVM) has been used widely in Latin America against COVID-19, despite the lack of scientific evidence and potential risks. Widespread vet-IVM intake was also discovered against Chagas disease during a study in Bolivia prior to the pandemic. All vet-IVM-related data were extracted to understand this phenomenon, its extent and underlying factors and to discuss potential implications for the current pandemic. DESIGN A convergent mixed-methods study design including a survey, qualitative in-depth interviews (IDI) and focus group discussions (FGD). SETTING A cross-sectional study conducted in 2018 covering the geographic area of Monteagudo, an endemic municipality for Chagas disease. PARTICIPANTS A total of 669 adult household representatives from 26 communities participated in the survey, supplemented by 14 IDI and 2 FGD among patients, relatives and key informants. RESULTS 9 IDI and 2 FGD contained narratives on vet-IVM use against Chagas disease. Five main themes emerged: (1) the extent of the vet-IVM phenomenon, (2) the perception of vet-IVM as a treatment for Chagas disease, (3) the vet-IVM market and the controversial role of stakeholders, (4) concerns about potential adverse events and (5) underlying factors of vet-IVM use against Chagas disease.In quantitative analysis, 28% of participants seropositive for Chagas disease had taken vet-IVM. Factors associated with multivariate analysis were advanced age (OR 17.01, 95 CI 1.24 to 36.55, p=0.027 for age above 60 years), the experience of someone close as information source (OR 3.13, 95 CI 1.62 to 5.02, p<0.001), seropositivity for Chagas disease (OR 3.89, 95 CI 1.39 to 6.20, p=0.005) and citing the unavailability of benznidazole as perceived healthcare barrier (OR 2.3, 95 CI 1.45 to 5.18, p=0.002). Participants with an academic education were less likely to report vet-IVM intake (OR 0.12, 95 CI 0.01 to 0.78, p=0.029). CONCLUSIONS Social determinants of health, the unavailability of treatment and a wonder drug image might contribute to the phenomenon of vet-IVM.
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Affiliation(s)
- Boris Apodaca Michel
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
- Medical Department, Centro Integral Dermatológico, Monteagudo, Plurinational State of Bolivia
| | - Miriam Navarro
- Department of Public Health, Science History and Gynecology, Universidad Miguel Hernández, Alicante, Spain
| | - Michael Pritsch
- Division of Infectious Diseases and Tropical Medicine, University Hospital LMU Munich, Munich, Germany
| | - Jeremy Douglas Du Plessis
- Department of Mathematics and Applied Mathematics, University of Cape Town, Rondebosch, South Africa
| | - Jonathan Shock
- Department of Mathematics and Applied Mathematics, University of Cape Town, Rondebosch, South Africa
| | - Eva-Maria Schwienhorst-Stich
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
- Medical Faculty, University of Würzburg, Würzburg, Germany
| | - Janina Zirkel
- Medical Faculty, University of Würzburg, Würzburg, Germany
| | - Hanna Schrader
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Saavedra Irala
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
- Medical Department, Centro Integral Dermatológico, Monteagudo, Plurinational State of Bolivia
| | - Gonzalo Rubilar
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
| | - Carolin Gunesch
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
| | - Christa Kasang
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
| | - Thomas Zoller
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ildiko Gagyor
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Sandra Parisi
- Department of Medical and Social Projects, DAHW, Würzburg, Germany
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
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Murphy N, Cardinal MV, Bhattacharyya T, Enriquez GF, Macchiaverna NP, Alvedro A, Freilij H, Martinez de Salazar P, Molina I, Mertens P, Gilleman Q, Gürtler RE, Miles MA. Assessing antibody decline after chemotherapy of early chronic Chagas disease patients. Parasit Vectors 2021; 14:543. [PMID: 34670602 PMCID: PMC8527601 DOI: 10.1186/s13071-021-05040-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/26/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Chagas disease remains a significant public health problem in Latin America. There are only two chemotherapy drugs, nifurtimox and benznidazole, and both may have severe side effects. After complete chemotherapy of acute cases, seropositive diagnosis may revert to negative. However, there are no definitive parasitological or serological biomarkers of cure. METHODS Following a pilot study with seven Bolivian migrants to Spain, we tested 71 serum samples from chronic patients (mean age 12.6 years) inhabiting the Argentine Chaco region. Benznidazole chemotherapy (5-8 mg/kg day, twice daily for 60 days) was administered during 2011-2016. Subsequently, pre-and post-chemotherapy serum samples were analysed in pairs by IgG1 and IgG ELISA using two different antigens and Chagas Sero K-SeT rapid diagnostic tests (RDT). Molecular diagnosis by kDNA-PCR was applied to post-treatment samples. RESULTS Pilot data demonstrated IgG1 antibody decline in three of seven patients from Bolivia 1 year post-treatment. All Argentine patients in 2017 (averaging 5 years post-treatment), except one, were positive by conventional serology. All were kDNA-PCR-negative. Most (91.5%) pre-treatment samples were positive by the Chagas Sero K-SeT RDT, confirming the predominance of TcII/V/VI. IgG1 and IgG of Argentine patients showed significant decline in antibody titres post-chemotherapy, with either lysate (IgG, P = 0.0001, IgG1, P = 0.0001) or TcII/V/VI peptide antigen (IgG, P = 0.0001, IgG1, P = 0.0001). IgG1 decline was more discriminative than IgG. Antibody decline after treatment was also detected by the RDT. Incomplete treatment was associated with high IgG1 post-treatment titres against lysate (P = 0.013), as were IgG post-treatment titres to TcII/V/VI peptide (P = 0.0001). High pre-treatment IgG1 with lysate was associated with Qom ethnicity (P = 0.045). No associations were found between gender, age, body mass index and pre- or post-treatment antibody titres. CONCLUSIONS We show that following chemotherapy of early chronic Chagas disease, significant decline in IgG1 antibody suggests cure, whereas sustained or increased IgG1 is a potential indicator of treatment failure. Due to restricted sensitivity, IgG1 should not be used as a diagnostic marker but has promise, with further development, as a biomarker of cure. We show that following chemotherapy of early chronic Chagas disease, a significant decline in IgG1 antibody suggests cure, whereas sustained or increased IgG1 is a potential indicator of treatment failure. Due to restricted sensitivity, IgG1 should not be used as a diagnostic marker but has promise, with further development, as a biomarker of cure.
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Affiliation(s)
- Niamh Murphy
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - M Victoria Cardinal
- Facultad de Ciencias Exactas y Naturales, Laboratorio de Eco-Epidemiología, Universidad de Buenos Aires, Ciudad Universitaria, Av. Int. Güiraldes 2180, C1428EHA, Buenos Aires, Argentina
- CONICET-Universidad de Buenos Aires, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Buenos Aires, Argentina
| | - Tapan Bhattacharyya
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Gustavo F Enriquez
- Facultad de Ciencias Exactas y Naturales, Laboratorio de Eco-Epidemiología, Universidad de Buenos Aires, Ciudad Universitaria, Av. Int. Güiraldes 2180, C1428EHA, Buenos Aires, Argentina
- CONICET-Universidad de Buenos Aires, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Buenos Aires, Argentina
| | - Natalia P Macchiaverna
- Facultad de Ciencias Exactas y Naturales, Laboratorio de Eco-Epidemiología, Universidad de Buenos Aires, Ciudad Universitaria, Av. Int. Güiraldes 2180, C1428EHA, Buenos Aires, Argentina
- CONICET-Universidad de Buenos Aires, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Buenos Aires, Argentina
| | - Alejandra Alvedro
- Facultad de Ciencias Exactas y Naturales, Laboratorio de Eco-Epidemiología, Universidad de Buenos Aires, Ciudad Universitaria, Av. Int. Güiraldes 2180, C1428EHA, Buenos Aires, Argentina
- CONICET-Universidad de Buenos Aires, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Buenos Aires, Argentina
| | - Héctor Freilij
- Hopital de Niños "Dr. Ricardo Gutiérrez", CABA, Argentina
| | | | - Israel Molina
- Barcelona Institute for Global Health (IS Global), Barcelona, Spain
| | | | | | - Ricardo E Gürtler
- Facultad de Ciencias Exactas y Naturales, Laboratorio de Eco-Epidemiología, Universidad de Buenos Aires, Ciudad Universitaria, Av. Int. Güiraldes 2180, C1428EHA, Buenos Aires, Argentina
- CONICET-Universidad de Buenos Aires, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Buenos Aires, Argentina
| | - Michael A Miles
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Ramos-Sesma V, Navarro M, Llenas-García J, Gil-Anguita C, Torrus-Tendero D, Wikman-Jorgensen P, García-López M, Amador-Prous C, Ventero-Martín MP, Guevara-Hernández P, Garijo-Saiz A, Sanchez-Sanchez A, Bernal-Alcaraz C, Pujades-Tarraga AI, Muñoz-Perez R, Flores-Chávez M, Ramos-Rincón JM. Community-based screening of Chagas disease among Latin American migrants in a non-endemic country: an observational study. Infect Dis Poverty 2021; 10:117. [PMID: 34526137 PMCID: PMC8441044 DOI: 10.1186/s40249-021-00897-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Chagas disease is a parasitic disease endemic to Latin America, but it has become a disease of global concern due to migration flows. Asymptomatic carriers may host the parasite for years, without knowing they are infected. The aim of this study is to assess prevalence of Chagas disease and evaluate the participants' level of knowledge between Latin American migrants attending a community-based screening campaign. METHODS Three community-based campaigns were performed in Alicante (Spain) in 2016, 2017 and 2018, including educational chats and blood tests for Trypanosoma cruzi serology. Participants completed a questionnaire assessing knowledge about the mechanisms of transmission, disease presentation, diagnosis, and treatment. People seropositive for T. cruzi underwent diagnostic confirmation by two different tests. Results were analyzed by multivariable logistic regression and expressed as adjusted odds ratios (aORs), adjusting for age, sex, and time in Spain. RESULTS A total of 596 participants were included in the study; 17% were aged under 18 years. Prevalence in adults was 11% [54/496; 95% confidence interval (CI): 8.3-14.5%] versus 0% among children. All but one case were in Bolivians. Diagnosis was independently associated with having been born in Bolivia (aOR: 102, 95% CI: 13-781) and a primary school-level education (aOR: 2.40, 95% CI: 1.14-5.06). Of 54 people diagnosed with Chagas disease (most of whom were asymptomatic), 42 (77.7%) returned to the clinic at least once, and 24 (44.4%) received treatment. Multivariable analysis showed that coming from Argentina (aOR: 13, 95% CI: 1.61-1188) or Bolivia (aOR: 1.90, 95% CI: 1.19-3.39) and having received information about Chagas disease in Spain (aOR: 4.63, 95% CI: 2.54-8.97) were associated with a good level of knowledge on the disease. Having primary level studies (aOR: 0.59, 95% CI: 0.34-0.98) and coming from Ecuador (aOR: 4.63, 95% CI: 2.52-847) were independently associated with a lower level of knowledge. CONCLUSIONS Community-based interventions are a good strategy for diagnosing neglected diseases such as Chagas disease in non-endemic countries and for identifying and treating infected, asymptomatic individuals.
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Affiliation(s)
| | - Miriam Navarro
- Public Health, Science History and Gynecology Department, Universidad Miguel Hernández de Elche, Alicante, Spain
- Epidemiology Unit Public Health Center of Elche, Alicante, Spain
| | - Jara Llenas-García
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
- Clinical Medicine Department, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain
| | - Concepción Gil-Anguita
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Diego Torrus-Tendero
- Internal Medicine Department, General University Hospital of Alicante-Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain
- Parasitology Area, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain
| | - Philip Wikman-Jorgensen
- Internal Medicine Department, University Hospital of Sant Joan, (Sant Joan d'Alacant, Spain)- FISABIO, Alicante, Spain
| | - María García-López
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Concepción Amador-Prous
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | | | - Pedro Guevara-Hernández
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Ana Garijo-Saiz
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Ares Sanchez-Sanchez
- Pediatric Department, General University Hospital of Alicante-ISABIAL, Alicante, Spain
| | - Cristina Bernal-Alcaraz
- Internal Medicine Department, Hospital Vega Baja de Orihuela (Alicante, Spain)-Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Alicante, Spain
| | - Ana-Isabel Pujades-Tarraga
- Internal Medicine Department, Hospital Marina BaixaLa Vila Joiosa (Alicante, Spain)-FISABIO, Alicante, Spain
| | - Roser Muñoz-Perez
- Digestive Service, General University Hospital of Alicante-ISABIAL, Alicante, Spain
| | - María Flores-Chávez
- Reference and Research Laboratory in Parasitology, National Center of Microbiology/Mundo Sano Foundation, Madrid, Spain
| | - José-Manuel Ramos-Rincón
- Clinical Medicine Department, University Miguel Hernández of Elche, Sant Joan d'Alacant, Spain.
- Internal Medicine Department, General University Hospital of Alicante-Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain.
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