Distribución espacial y análisis de conglomerados de la enfermedad de Chagas en Perú 2015-2020

Addressing the neglect: Chagas disease in London, UK.

Chagas disease, a neglected tropical disease that due to population movements is no longer limited to Latin America, threatens a wide spectrum of people(travellers, migrants, blood or organ recipients,newborns, adoptees) also in non-endemic countries where it is generally underdiagnosed. In Italy, the available epidemiological data about Chagas disease have been very limited up to now, although the country is second in Europe only to Spain in the number of residents from Latin American. Among 867 at-risk subjectsscreened between 1998 and 2010, the Centre for Tropical Diseases in Negrar (Verona) and the Infectious and Tropical Diseases Unit, University of Florence found 4.2% patients with positive serology for Chagas disease (83.4% of them migrants, 13.8% adoptees).No cases of Chagas disease were identified in blood donors or HIV-positive patients of Latin American origin. Among 214 Latin American pregnant women,three were infected (resulting in abortion in one case).In 2005 a case of acute Chagas disease was recorded in an Italian traveller. Based on our observations, we believe that a wider assessment of the epidemiological situation is urgently required in our country and public health measures preventing transmission and improving access to diagnosis and treatment should be implemented.

BackgroundScreening of transfusion-transmissible infectious agents of blood components is carried out in order to guarantee the safety of the transfusion process. The objective of this investigation was to characterize cases positive for transfusion-transmissible infectious agents in blood donations in the North of Portugal.MethodData from 2010 to 2022 of the Local Health Unit-Santo Antonio were used for this study. In specific epidemiological situations, malaria, Chagas disease and West Nile virus were screened.Main resultsOver 12 years, the health unit, received 137,751 donations with 108 positive tests. The proportions of human immunodeficiency viruses, syphilis, human hepatitis viruses type B and C varied between 0 and 44/100,000 donations. In this period, two cases of malaria were detected in 2020–2021, and 21 were detected in 2022 corresponding to 52.1/1000 donations screened. In 2022, two cases of Chagas disease and no cases of West Nile virus were detected.ConclusionThese results highlight the importance of a rigorous investigation at the time of donation in which the donor's history, including origin and movement in areas of greater geographic risk, are assessed. The recent and increasing detection of cases of malaria and Chagas disease confirms the presence of emerging infectious diseases transmitted by vectors, including mosquitoes, in blood donors. The increased risk of vector-borne diseases in Europe is a public health problem and represents a new challenge in screening donations.

Chagas' disease is an emerging and neglected disease in the Brazilian Amazon region, where T. cruzi I predominates among the acute cases of the disease; and T. cruzi III/Z3, a population cluster from sylvatic areas of the Amazon basin, is rarely associated with human infections. On 23rd April 2007, the Foundation for Health Surveillance of the State of Amazonas, Brazil reported an outbreak of acute Chagas disease in the municipality of Coari on the Solimões River banks. Fresh blood examination confirmed the infection in 25 patients. Parasite culture in LIT medium was successful for 18 isolates. Molecular characterization was performed by PCR of the non-transcribed spacer of the mini-exon and by sequencing of the mitochondrial cytochrome c oxidase subunit II (COII) gene. The T. cruzi isolates were all from genotype Z3, and sequencing revealed that all isolates had equal COII sequences compatible with TcIII type, suggesting a single source of infection. To our knowledge, this is the first outbreak of acute cases caused uniquely by the genotype TcIII/Z3. Wild vectors harbouring TcIII stocks contribute to transmission when the triatomine species reaches human food chain or when humans invade the forest environment, where sylvatic cycle constitutes a reservoir of parasites that might be associated with specific epidemiological and clinical traits of the emergent Chagas disease in the Amazon.

No vector transmitted cases of Chagas disease had been notified in the state of São Paulo since the 1970s. However, in March, 2006, the death of a six-year-old boy from the municipality of Itaporanga was notified to the Center for Epidemiological Survey of the São Paulo State Health Secretariat: an autochthonous case of acute Chagas disease. The postmortem histopathological examination performed in the Hospital das Clínicas of the Botucatu School of Medicine confirmed the diagnosis. Reference to hospital records, consultation with the health professionals involved in the case and interviews with members of the patient's family supplied the basis for this study. We investigated parasite route of transmission, probable local reservoirs and vectors. No further human cases of acute Chagas disease were diagnosed. No locally captured vectors or reservoirs were found infected with Trypanosoma cruzi. Alternative transmission hypotheses - such as the possible ingestion of foods contaminated with vector excreta - are discussed, as well as the need to keep previously endemic regions and infested houses under close surveillance. Clinicians should give due attention to such signs as uni- or bilateral palpebral edema, cardiac failure, myocarditis, pericarditis, anasarca and atypical signs of nephrotic syndrome or nephritis and consider the diagnostic hypothesis of Chagas disease.

Dear Sir, We would like to contribute to the article by Angheben and co-workers which was recently published in Blood Transfusion1. The Authors described a case of reactivation of Chagas disease in a paediatric patient who underwent a bone marrow transplant (BMT) in a non-endemic country. To our understanding, since no data related to the patient’s infection status prior to the BMT were clearly provided by the Authors, it is very difficult to concur that this was truly a case of Chagas disease reactivation after a BMT. Chagas disease in transplant recipients may occur in one of the following ways: (i) via the blood transfusion given during the BMT. Blood transfusions from donors with asymptomatic parasitaemia represent a major form of transmission in some endemic areas, and have also been described in non-endemic countries2; (ii) through reactivation of a latent infection which could have previously been acquired by vector-borne transmission, blood transfusion or congenital transmission; and (iii) de novo acquisition of the infection via the graft which, in this case, could have been caused by the transplanted bone marrow itself. With respect to the first point, if the patient had been transfused in Italy, the possibility of transfusion-transmitted T. cruzi infection during the BMT period would also have to be considered. In this event, the blood component most likely to be implicated in the transmission would be platelets, as recently reported by some Authors2. However, in the text the Authors stated that the patient was transfused in Argentina during her treatment for leukaemia, but not in Italy while undergoing the allogeneic BMT. As a result, this possibility can reasonably be ruled out. With respect to reactivation of a latent infection, the information indicating a possible Chagas disease reactivation was that the patient had major risk factors for prior infection, i.e. having lived in and/or being born in an area in which T. cruzi is endemic, having been transfused in Argentina and, in addition, having a mother who was also from an endemic area. However, some essential data are missing: i.e. the recipient’s infection status prior to the BMT, information regarding the proposed route of transmission, such as the blood donors, and investigations into her mother’s T.cruzi infection status. In addition, the article did not specify which region of Argentina the patient came from, which could have been valuable information since not all regions in Argentina are equally affected and certain areas are currently free of T. cruzi transmission, such as the Provinces of Buenos Aires, Chubut and Santa Cruz3. On the other hand, this case could possibly have been example of BMT-transmitted T. cruzi. It would have been helpful to investigate the donor to exclude this route of transmission, especially considering that he or she was from California which, in fact, is among the regions with the greatest number of Latin-American immigrants in the United States and, consequently, has the highest proportion of Latin-American donors. In addition, this population has been increasing over the years and performing a recipient tracing study could have helped to identify an infected BMT donor. Cases of transplant-related Chagas disease have mainly been described in organ transplant recipients in Latin America. Transplants from infected donors whose status is unknown at the time of the transplantation can result in the recipient acquiring severe acute Chagas disease4. However, all blood components from infected donors have the potential to transmit the infection. In fact, T. cruzi can survive in platelet components with anticoagulant solution for up to 5 days when stored at room temperature2, for 18 days in red blood cells at 4 oC, and can also survive cryopreservation and thawing5. Theoretically, bone marrow may also transmit T. cruzi infection. There are various factors that support the belief that this case was a reactivation of Chagas disease (the patient’s clinical features, the major risk factors for a previous, although unconfirmed, infection by Chagas disease prior to the BMT) but, equally, there were also factors to support a BMT-transmitted Chagas’ disease (the donor was from California, no proof that the patient was infected prior to the BMT). Since both these options are possible, we suggest that this report should be considered as a possible case of Chagas disease reactivation after a BMT; it is certainly a very interesting report concerning a case of this disease in an immunosuppressed patient. Given that Chagas disease can be fatal in such patients, as demonstrated in the case described, the recommendation to implement measures to prevent the transmission or reactivation of Chagas disease in transplant recipients is in itself an outstanding contribution already made by the Authors. We totally agree with the Authors on this point since this recommendation could be of vital future importance for patients with similar conditions, and because it has also been successfully proven in BMT patients with Chagas disease in Latin America.

Background: Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is considered a public health problem in Latin America. In Colombia, it affects more than 437,000 inhabitants, mainly in Casanare, an endemic region with eco-epidemiological characteristics that favor its transmission. The objective of this study was to describe the clinical and epidemiological characteristics of the cases of acute CD in Casanare, eastern Colombia, in the period 2012–2020.Methods: In the present study, 103 medical records of confirmed cases of acute CD were reviewed. The departmental/national incidence and fatality were compared by year; the climatological data of mean temperature, relative humidity, and precipitation per year were reviewed and plotted at IDEAM (Colombian Meteorology Institute) concerning the number of cases of acute CD per month, and it was compared with the frequency of triatomines collected in infested houses by community surveillance. Univariate, bivariate, and multivariate analyses were performed, comparing symptoms and signs according to transmission routes, complications, and age groups.Results: The incidence was 3.16 cases per 100,000 inhabitants, and the fatality rate was 20% in the study period. The most frequent symptoms included: fever 98.1%, myalgia 62.1%, arthralgia 60.2%, and headache 49.5%. There were significant differences in the frequency of myalgia, abdominal pain, and periorbital edema in oral transmission. The main complications were pericardial effusion, myocarditis, and heart failure in the group over 18 years of age. In Casanare, TcI Discrete Typing Unit (DTU) has mainly been identified in humans, triatomines, and reservoirs such as opossums and dogs and TcBat in bats. An increase in the number of acute CD cases was evidenced in March, a period when precipitation increases due to the beginning of the rainy season.Conclusions: The results corroborate the symptomatic heterogeneity of the acute phase of CD, which delays treatment, triggering possible clinical complications. In endemic regions, clinical suspicion, diagnostic capacity, detection, and surveillance programs should be strengthened, including intersectoral public health policies for their prevention and control.

Chagas disease, a potentially life-threatening disease caused by the protozoan parasite Trypanosoma cruzi, has become a concern in the United States as a result of human emigration from Latin America where Chagas disease is endemic (1). It is estimated that as many as 8 million people living in Mexico, and Central and South America have Chagas disease.* Most cases of Chagas disease in the United States are chronic infections; however, rare cases of acute congenital infections and autochthonous vectorborne transmission have been reported (2). To understand how data are collected and used, a review of state-level public health surveillance for Chagas disease was conducted through semistructured interviews with health officials in six states (Arizona, Arkansas, Louisiana, Mississippi Tennessee, and Texas) where Chagas disease is reportable and one (Massachusetts) where it was previously reportable. States implemented surveillance in response to blood donor screening for Chagas disease and to identify the route of disease transmission. Many states reported primarily chronic cases and had limited ability to respond to local transmission because acute cases were infrequently reported. Surveillance remains important in states with large populations of immigrants or frequent travelers from countries with endemic disease and for states with a risk for local transmission. Surveillance efforts can also help increase awareness among providers and assist in linking patients with Chagas disease to treatment to help prevent cardiac and gastrointestinal complications.

A doença de chagas é uma infecção parasitária transmitida por insetos hematófagos conhecidos popularmente como “barbeiros”, “chupão” ou “chupança”. A Organização Mundial da Saúde estima que cerca de 6 a 7 milhões de pessoas estejam contaminadas em todo mundo, estando a grande maioria na América Latina. No Brasil, a região norte é responsável por quase a totalidade dos casos. O objetivo geral deste estudo é demonstrar a incidência da doença de chagas aguda na cidade de Belém/ Pará nos anos de 2021 e 2022. Os objetivos específicos são determinar o tipo de contaminação, verificar a sazonalidade e relacionar a sazonalidade com o tipo de contaminação. Trata-se de um estudo epidemiológico, retrospectivo e descritivo que utiliza dados de acesso público do Departamento de Informática do Sistema Único de Saúde sobre notificações de casos de doença de chagas aguda notificados no ano de 2021 e 2022. Foram confirmados 35 casos da doença de chagas no município de Belém no período estudado, o principal meio de contaminação foi a transmissão oral com 31 casos confirmados. Os meses de agosto a novembro representaram o período de maior incidência da doença, com acréscimo principalmente nos casos de contaminação oral. Provavelmente estes resultados estejam relacionados ao aumento no consumo de alimentos contaminados com o Trypanosoma cruzi. Concluímos que a doença de chagas aguda representa um problema de saúde pública e que está sendo negligenciada em ações de combate, tratamento e prevenção.

Background Chagas disease is a highly pathogenic infection with a prevalence of approximately 5.7 million cases worldwide and greater than 300,000 cases in the United States. Up to 40% of immigrants to the United States are from highly endemic Latin American countries. An estimated 40,000 women of childbearing age in the United States are infected, with a 1–5% risk of vertical transmission. The impact of this disease is extensive, often life-long, and difficult to eradicate. The purpose of our study was to better understand current knowledge and experience among pediatric cardiologists in the United States with the cardiac presentations of Chagas disease to determine where to focus educational programs and critical content. Methods We prospectively disseminated a 19-question survey to pediatric cardiologists via the PediHeart, WSOPC, and Pediatric CHF listservs three times between September and November 2019. The survey included demographic, multiple-choice and Likert-scale questions. We used Qualtrics to ensure anonymity. Respondents outside of the United States were excluded. Results Of 140 responses received, 120 cardiologists treated pediatric patients in the United States. Over half (62.5%) of respondents served a >10% Latin American patient population. Most providers (87%) had not seen a case of Chagas disease in their practice; however, most (72%) also had never tested for Chagas. In response to the statement: “I feel comfortable recognizing cardiac presentations of Chagas disease in children”, (85%) of respondents disagreed. Most respondents selected that they would not include Chagas on their differential diagnosis for cardiac presentations that included conduction anomalies, myocarditis, and/or apical aneurysms (Figure 1). However, when considering patients who recently immigrated from Latin American nations, inclusion of Chagas in the differential diagnosis increased. In response to the statement: “If I was offered a lecture on Chagas-related heart disease, I would be likely to attend,” 87% of respondents agreed. Conclusions In our sample of pediatric cardiologists, very few had seen cases of Chagas disease, albeit very few tested for it or included it in their differential diagnosis. However, most individuals agreed that education on Chagas disease would be worth-while. Education could help ensure these cases are not missed in pediatrics. Future analysis should focus on changes in provider knowledge and/or testing as the incidence grows, or as educational programs are implemented.

BackgroundChagas disease is a pathogenic parasitic infection with approximately 8 million cases worldwide and greater than 300,000 cases in the United States (U.S.). Chagas disease can lead to chronic cardiomyopathy and cardiac complications, with variable cardiac presentations in pediatrics making it difficult to recognize. The purpose of our study is to better understand current knowledge and experience with Chagas related heart disease among pediatric cardiologists in the U.S.MethodsWe prospectively disseminated a 19-question survey to pediatric cardiologists via 3 pediatric cardiology listservs. The survey included questions about demographics, Chagas disease presentation and experience.ResultsOf 139 responses, 119 cardiologists treat pediatric patients in the U.S. and were included. Most providers (87%) had not seen a case of Chagas disease in their practice; however, 72% also had never tested for it. The majority of knowledge-based questions about Chagas disease cardiac presentations were answered incorrectly, and 85% of providers expressed discomfort with recognizing cardiac presentations in children. Most respondents selected that they would not include Chagas disease on their differential diagnosis for presentations such as conduction anomalies, myocarditis and/or apical aneurysms, but would be more likely to include it if found in a Latin American immigrant. Of respondents, 87% agreed that they would be likely to attend a Chagas disease-related lecture.ConclusionsPediatric cardiologists in the U.S. have seen very few cases of Chagas disease, albeit most have not sent testing or included it in their differential diagnosis. Most individuals agreed that education on Chagas disease would be worth-while.

Background and Objectives: Chagas disease is a parasitic infection caused by the protozoan Trypanosoma cruzi and a public health problem in Brazil. Transmission occurs through the triatomine vector, oral, vertical, transfusional, and accidental routes. This study aims to outline the epidemiological profile of the disease in the North and Northeast regions between 2018 and 2022, analyzing case distribution and sociodemographic factors. Methods: This is an epidemiological and descriptive study. Data on confirmed cases of acute Chagas disease in the North and Northeast regions between 2018 and 2022 were collected using secondary data from the Notifiable Diseases Information System (SINAN). The variables analyzed include sex, age group, race/color, and mode of transmission. The data were processed using Microsoft Excel and TABNET. Results: The state of Pará accounted for 78.29% of cases. The sex distribution was 52.26% for men and 47.74% for women. The most affected age group was 20 to 39 years (34.69%), and most cases occurred in brown individuals (83.51%). The primary transmission route was oral, associated with the consumption of contaminated food. Conclusion: The distribution of cases highlights the predominance of oral transmission, mainly in Pará. The epidemiological profile indicates a higher incidence among young adults and men, reflecting occupational and socioeconomic factors. The reduction recorded in 2020 suggests an impact of the Covid-19 pandemic on case reporting. The study reinforces the need for oral transmission control and expanded epidemiological surveillance.

Chagas disease is caused by the protozoan Trypanosoma cruzi and can be transmitted to humans by a triatomine vector (only in Latin America), from mother to child, transfusion, transplant or orally. After an acute phase of several weeks, the disease progresses asymptomatically for decades. Approximately 40 % of the subjects in this phase progress to the chronic phase, which is characterized by progressive heart failure with severe arrhythmias and/or dilations of the digestive tract. The movement of an increasingly number of migrants from Latin America to Europe establishes Chagas disease as a public health problem in this region. In Portugal the number of Latin American immigrants has increased year after year. Brazil is highlighted as the main country of origin. However, the number of Latin American residents with Chagas disease in Portugal is unknown. The World Health Organization recommends screening tests for T. cruzi to prevent transmission in non-endemic countries. This prevention would be made at the level of blood transfusions, organ transplantation and vertical transmission. However, only a few European countries perform systematic screening for Chagas disease. In Portugal there are nine confirmed cases of Chagas disease, which compared to the estimated number of existing cases constitutes a huge discrepancy. Two epidemiological studies for detection of T. cruzi were made in our country, one of which is still ongoing. These studies have not, to date, found positive cases. Chagas disease is still a neglected disease, poorly understood by most of the health professionals and diagnosis and treatment are still far from ideal. The challenges established by its globalization may help in moving forward towards its erradication

Dear Sir, We read the article “Reactivation of Chagas disease after a bone marrow transplant in Italy: first case report” by Angheben et al1. It is well known that Chagas disease, caused by a protozoa, Trypanosoma cruzi, is an autochthonous disease with a widespread distribution from the south of the United States to Mexico and South America. The disease can also affect people in Europe with its presence related to migratory flows. In non-endemic countries, Chagas disease can be acquired by congenital transmission, blood transfusion and organ transplantation. Transfusion is considered the second most common mode of transmission for T. cruzi; it is estimated that approximately 10–20% of blood from chronically infected donors is infective considering that T. cruzi remains viable in stored whole blood and citrated blood samples stored at refrigerator and room temperatures, respectively. Furthermore, it is known that this disease can be fatal, especially in immunosuppressed patients2, following reactivation of latent infections. The most common symptoms of Chagas disease reactivation are both cardiac and gastrointestinal manifestations. Most of the infected people are not aware of their status because the disease frequently causes few or no symptoms during the acute phase and evolves commonly to a clinically silent phase. Several cases of acute Chagas disease following solid organ and bone marrow transplantation have been described in the past. The first case of Chagas disease reactivation after a bone marrow transplant recorded in Italy is of great interest: the case was a 9-year old Argentinean girl with a diagnosed acute lymphoblastic leukaemia1. The authors of the case report hypothesised that a probable cause of reactivation of Chagas disease in the patient could have been immunosuppression secondary to the bone marrow transplant and Graft-versus-Host disease prophylaxis (cyclosporine A and a short course of methotrexate). In accordance with this hypothesis, there is another report of immunosuppression associated with cord blood transplantation seeming to be responsible for the fatal outcome of Chagas disease in a 25-year old male with high-risk acute myeloid leukemia3. Immunosuppression, which has become an increasingly relevant clinical condition in the last 50 years, modifies the natural history of several diseases, including T. cruzi infection: patients become predisposed to the development or reactivation of opportunistic infections with particular and often severe clinical outcomes. Several guidelines for the treatment of immunosuppressed patients with Chagas disease have been published recently, but there is no international consensus on the management of reactivation in these patients. In cases of reactivation, early anti-parasitic treatment with benznidazole and/or nifurtimox has proven to be highly effective and posaconazole should be indicated when these fail. Importantly, little is known about the relationship between the incidence of neoplastic disease and T. cruzi infection, or about whether the immune response, induced by this infection, modifies the development or localisation of neoplasms. Based on clinical observations in immunosuppressed patients some authors have speculated that benznidazole treatment might actually cause neoplasms. The relationship between immunosuppression and neoplastic disease in patients with T. cruzi infection has been analysed from three perspectives as reported by Pinazo et al.4: (i) neoplastic disease as a potentially immunosuppressive condition that increases the likelihood of reactivation of infections; (ii) neoplastic disease occurring as a result of treatment with benznidazole, either alone or in combination with immunosuppressive drugs; and (iii) neoplastic disease as a condition that is potentially more common in patients with Chagas disease. Clinical studies with long-term follow-up have found no evidence of a higher incidence of histological signs of malignancy with immunosuppressive therapy, concluding that benznidazole and its association with other immunosuppressive drugs do not contribute to an increased incidence of neoplastic disease4. However, reactivation of T. cruzi infection must be considered in patients with chronic Chagas disease and neoplastic diseases requiring intensive and/or long-term pharmacological immunosuppression4. Currently, it is not easy to make general evidence-based recommendations for the management of T. cruzi-infected patients or for the prevention of reactivation. Clinicians should bear in mind that the natural course of T. cruzi infection can be modified by other diseases or their treatment. Furthermore, there have been no reports of a relationship between Chagas disease reactivation and other immunosuppressive drugs used in the treatment of systemic autoimmune diseases and it has not been shown that these diseases have a direct role in the progression of T. cruzi infection. The main goal in T. cruzi-infected patients with an immunosuppressive condition could be to prevent reactivation by close monitoring. To do this, an early diagnosis of T. cruzi infection in immunosuppressed individuals is extremely important and should be considered prior to immunosuppressive treatment. For this reason, investigations for parasitaemia, detectable by Strout or quantitative buffy coat testing or microhaematocrit methods, are recommended, especially in immunosuppressed patients during follow-up. The only effective form of prevention for T. cruzi infection would be to avoid the use of blood or organs from donors who come from countries where Chagas disease is endemic or to perform serological screening for T. cruzi on these donors. Chagas disease is considered an emerging problem in Italy5. Since chronic T. cruzi infection is often asymptomatic, most infected organ donors will not have a known history of the disease and laboratory screening is essential. Although there is already some infrastructure at a national level5, there is not yet a systematic programme of reference centres for neglected diseases. Thus, Italy should implement a national network to prevent donations of blood and/or organs from T. cruzi-infected donors, improving the access to diagnosis. In addition, an infrastructure that ensures detection and treatment of acute and chronic cases, as well as congenital infections, should be developed. In conclusion, it is important to extend epidemiological programmes to control Chagas disease in blood donors, stem cell donors and recipients by serological screening, in order to prevent adverse outcomes, especially in immunosuppressed patients.

En 1919 se diagnosticó el primer caso de Enfermedad de Chagas en el Perú (1), pero dos años antes se había demostrado infección por T. cruzi en triatomideos capturados en un valle del departamento de Arequipa (2). Posteriormente no se efectuó investigación alguna sobre esta enfermedad hasta 1943-1944 (3), que se hicieron los primeros estudios epidemiológicos, diagnosticando el segundo caso y demostrando infección natural por T. cruzi en cobayos y perros de una zona, donde hoy sabemos que la enfermedad es endémica. Es a partir de 1950-51 (4) (5), que se intensifican las investigaciones y el informe que tuvimos ocasión de presentar a los VI Congresos Internacionales de Medicina Tropical y Malaria (6), reunimos 204 casos diagnosticados por varios investigadores en encuestas efectuadas en 7 departamentos y el primero que procedía de Madre de Dios (Arequipa, Tacna, Moquegua, San Martín, Cajamarca y Amazonas); además de información sobre triatomideos, animales reservorios de T. cruzi y otros importantes aspectos epidemia lógicos de esta Trypanosomiasis en esos mismos departamentos y en Tumbes, Piura La Libertad, Lima, Junín, lea y Cuzco.