Pragmatic data and observations related to the epidemiology of Chagas disease

Chagas' disease or American trypanosomiasis is a parasitic zoonosis which constitutes and important public health problem in most of the Latin American countries. According to the development of socio-political events in the world, it is possible at present to speak of rural-periurban Chagas' disease and urban Chagas' disease. Rural-periurban Chagas' disease. In its endemo-enzootic condition it is distributed in vast areas from Mexico in the north and Argentina and Chile in the south. It is calculated that the population at risk is about 90 million persons, not less than 16-18 million are Trypanosoma cruzi infected and approximately 38% of these present or have presented pathology caused by the parasite. Organs most frequently affected: heart, esophagus and colon. The corresponding biological vectors are hematophagus triatomid bugs, with greater than 100 species synantropic (st) or sylvatic (sv), existing between parallels 41 N. and 46 S., but only about 36, which have been found infected, have some relationship with man because their adaptation to human dwelling. The human parasitose is less extended due to the fact that the vectors of the region are predominantly sv. The known reservoirs are more than 180 species of terrestrial mammals: domestic, st and sv. Man is possibly the most important. Some available relevant epidemiological information is summarized as follows: Additionally, some autochthonous cases of T. cruzi human infection have been registered in the United States, Trinidad-Tobago, Guyana and Belize. Moreover, infected vectors and/or sv reservoirs have been observed in almost a dozen of Caribbean countries. Urban Chagas' disease. As a consequence of possible better salaries and many other motivations, in the last decades there have been significant and constant migrations from rural to urban areas in many Latin American countries. This situation has facilitated the dissemination of T. cruzi infection through infected reservoirs--mostly humans--and/or passively transported infected vectors. In most of the cases these rural-urban migrations occur in chagasic endemic areas within a same country or in neighbouring ones; in others, the migration can involve countries where Chagas' disease does not exist, transmission being via blood transfusion or placental. According to some estimates, with a mean rate of 1.5% chagasic infected blood donors the minimum risk of T. cruzi transmission is nearly 12.5-25.0% when the volumen of transfused blood is 500 ml.(ABSTRACT TRUNCATED AT 400 WORDS)     

Emerging Chagas disease in Amazonian Brazil

In the Amazon Basin, Trypanosoma cruzi infection is enzootic, involving a variety of wild mammals and at least 10 of the 16 reported silvatic triatomine bug species. Human cases of Chagas disease are increasing, indicating that the disease may be emerging as a wider public health problem in the region: 38 cases from 1969 to 1992, and 167 in the past eight years. This article reviews the status of Chagas disease in Amazonian Brazil, including known reservoirs and vectors, and the genetic diversity of T. cruzi. At least three subspecific groups of T. cruzi-T. cruzilZ1, T. cruziZ3 and T. cruziZ3/Z1 ASAT--are present. It appears that T. cruzil has an extant capacity for genetic exchange. Attention is also drawn to the risk of domestic endemicity, in addition to the tasks facing the disease control authorities.     

Rural housing for control of Chagas disease in Venezuela

The home is an important protective element for the health of its inhabitants - but these inhabitants often include not only the householders but also domestic pests and vectors of disease. This is particularly so in Latin America where domestic triatomine bugs thrive in many of the poorer quality rural houses, emerging from their crevices at night to feed and transmit Trypanosoma cruzi in their faeces. At the public health level, there is neither drug nor vaccine suitable for controlling T. cruzi - causative agent of Chagas disease - but transmission can be interrupted by control of the domestic vectors. Traditionally, vector control has involved spraying houses with residual insecticides, but a more long-term solution, with many colateral benefits, is to improve rural housing in such a way that colonization by triatomine bugs is inhibited. Such an approach involves development of low-cost techniques for house construction, and mobilization of rural communities to make use of them. In this, Venezuela has played a leading role, as Roberto Briceno-Leon reports.     

The impact of Chagas disease control in Latin America: a review

Discovered in 1909, Chagas disease was progressively shown to be widespread throughout Latin America, affecting millions of rural people with a high impact on morbidity and mortality. With no vaccine or specific treatment available for large-scale public health interventions, the main control strategy relies on prevention of transmission, principally by eliminating the domestic insect vectors and control of transmission by blood transfusion. Vector control activities began in the 1940s, initially by means of housing improvement and then through insecticide spraying following successful field trials in Brazil (Bambui Research Centre), with similar results soon reproduced in S?o Paulo, Argentina, Venezuela and Chile. But national control programmes only began to be implemented after the 1970s, when technical questions were overcome and the scientific demonstration of the high social impact of Chagas disease was used to encourage political determination in favour of national campaigns (mainly in Brazil). Similarly, large-scale screening of infected blood donors in Latin America only began in the 1980s following the emergence of AIDS. By the end of the last century it became clear that continuous control in contiguous endemic areas could lead to the elimination of the most highly domestic vector populations - especially Triatoma infestans and Rhodnius prolixus - as well as substantial reductions of other widespread species such as T. brasiliensis, T. sordida, and T. dimidiata, leading in turn to interruption of disease transmission to rural people. The social impact of Chagas disease control can now be readily demonstrated by the disappearance of acute cases and of new infections in younger age groups, as well as progressive reductions of mortality and morbidity rates in controlled areas. In economic terms, the cost-benefit relationship between intervention (insecticide spraying, serology in blood banks) and the reduction of Chagas disease (in terms of medical and social care and improved productivity) is highly positive. Effective control of Chagas disease is now seen as an attainable goal that depends primarily on maintaining political will, so that the major constraints involve problems associated with the decentralisation of public health services and the progressive political disinterest in Chagas disease. Counterbalancing this are the political and technical cooperation strategies such as the "Southern Cone Initiative" launched in 1991. This international approach, coordinated by PAHO, has been highly successful, already reaching elimination of Chagas disease transmission in Uruguay, Chile, and large parts of Brazil and Argentina. The Southern Cone Initiative also helped to stimulate control campaigns in other countries of the region (Paraguay, Bolivia, Peru) which have also reached tangible regional successes. This model of international activity has been shown to be feasible and effective, with similar initiatives developed since 1997 in the Andean Region and in Central America. At present, Mexico and the Amazon Region remain as the next major challenges. With consolidation of operational programmes in all endemic countries, the future focus will be on epidemiological surveillance and care of those people already infected. In political terms, the control of Chagas disease in Latin America can be considered, so far, as a victory for international scientific cooperation, but will require continuing political commitment for sustained success.     

Trypanosoma cruzi (Kinetoplastida Trypanosomatidae): ecology of the transmission cycle in the wild environment of the Andean valley of Cochabamba, Bolivia

An active Trypanosoma cruzi transmission cycle maintained by wild rodents in the Andean valleys of Cochabamba Bolivia is described. Wild and domestic Triatoma infestans with 60% infection with T. cruzi were found and was evidenced in 47.5% (rodents) and 26.7% (marsupial) by parasitological and/or serologycal methods. Phyllotis ocilae and the marsupial species Thylamys elegans, are the most important reservoirs followed by Bolomys lactens and Akodon boliviensis. In spite of both genotypes (TCI and TCII) being prevalent in Bolivia, in our study area only T. cruzi I is being transmitted. Our data suggest that wild T. infestans and wild small mammals play an important role in the maintenance of the transmission cycle of T. cruzi. Furthermore, the finding of high prevalence of T. cruzi infection in wild T. infestans point to the risk of the dispersion of Chagas' disease.     

Trypanosoma cruzi from the Paraguayan Chaco: isoenzyme profiles of strains isolated at Makthlawaiya

At Makthlawaiya, in the Paraguayan Chaco, the prevalence of Trypanosoma (Schizotrypanum) cruzi infection among both domestic Triatoma infestans and domestic dogs was 38%, and IgG anti-T. cruzi antibody was detected by the quantitative enzyme-linked immunosorbent assay (ELISA) in 80% (105/133) of human sera. Ninety percent (25/28) of T. cruzi strains isolated from both T. infestans and dogs showed heterozygous isoenzyme profiles for glucose phosphate isomerase, phosphoglucomutase and 6-phosphogluconate dehydrogenase. These strains appeared to be closely related to Bolivian zymodeme 2. Three Paraguayan T. cruzi strains showed homozygous isoenzyme profiles, similar to those of major Brazilian zymodemes. It was concluded that T. cruzi strains with heterozygous isoenzyme profiles predominate in domestic transmission cycles in this highly endemic area of the Paraguayan Chaco.     

Multilocus enzyme electrophoresis analysis of Trypanosoma cruzi isolates from a geographically restricted endemic area for Chagas' disease in Argentina

A set of 65 Trypanosoma cruzi stocks from dogs, opossums, insect vectors and humans was isolated in a geographically restricted endemic area for Chagas' disease in Argentina and was analysed by multilocus enzyme electrophoresis for 15 loci. The results show that at least five multilocus genotypes (clonets) circulate in the study area, one belonging to T. cruzi IIe, one to T. cruzi IId and three clonets belonging to T. cruzi I; and they confirm the presence of these lineages in the country. The three clonets attributed to T. cruzi I were identical to each other for all loci except for Sod-2, where three different patterns were identified. These patterns suggest the presence of two homozygous genotypes and one heterozygous genotype. Our results also suggest association of clonet IIe with dogs, clonet IId with humans and the three T. cruzi I clonets with Didelphis albiventris. On the other hand, there was no significant association between Triatoma infestans and any particular clonet circulating in the area. These findings are consistent with the hypothesis of natural selection, from mixed populations of T. cruzi in vectors, toward more restricted populations in mammals. The epidemiological implications of the possible selection of different clonets by different mammal hosts and the significance of two homozygous genotypes and one heterozygous genotype for the Sod-2 locus are discussed.     

Epidemiology of Chagas disease in Ecuador. A brief review

Chagas disease is a complex public health problem that has been underestimated in Ecuador. Here we review the relevant published information, and present unpublished and new data that help to understand the current Chagas disease epidemiological situation and its evolution in the country. Three main characteristics have been identified: (i) persistence of Trypanosoma cruzi transmission in already known foci; (ii) a marked endemicity in some urban areas of Guayaquil; and (iii) the transformation of new Amazon foci into truly endemic areas. The situation in other suspect areas remains uncertain. Five Triatominae species have been implicated in the transmission of T. cruzi to people in Ecuador (Triatoma dimidiata, Rhodnius ecuadoriensis, R. pictipes, R. robustus and Panstrongylus geniculatus), but some others may also play a role in some areas (P. rufotuberculatus, P. howardi, T. carrioni and P. chinai). Other Triatominae reported seem to have little or no epidemiological relevance (T. venosa, T. dispar, Eratyrus mucronatus, E. cuspidatus, P. lignarius and Cavernicola pilosa). High frequency of acute cases and severe chronic disease has been observed. Although cardiomyopathy is more frequent, serious digestive disease is also present. It is estimated that around 120,000-200,000 people may be infected. 2.2 to 3.8 million people are estimated to live under transmission risk conditions.     

Triatomines involved in domestic and wild Trypanosoma cruzi transmission in Concepción, Corrientes, Argentina

An entomological and serological survey was performed in three localities of the Department of Concepción, Province of Corrientes, Argentina in 1998 and 1999, to identify triatomines species involved in domestic and wild transmission of Chagas disease. Triatomines were collected by man/hour capture in 32 houses randomly selected and 44 nearby outdoor ecotopes. Trypanosoma cruzi infection in triatomines was assessed by direct microscopic observation (400x) of feces and polymerase chain reaction. Serological techniques used for people were Indirect Hemagglutination Test and Indirect Fluorescent Test. Triatomines were collected in 28.1% of the houses and 31.8% of the wild biotopes. Triatoma infestans (Klug 1834) was exclusively found indoors and T. cruzi infected 60% of them. Triatoma sordida (St?l 1859) was mainly found in extradomestic ecotopes where trypanosome infection rate reached 12.7%. Serological study of 98 local people showed that 29.6% were seroreactive; most of their houses were closed to wild biotopes colonized by T. sordida. Results indicate that there is an active T. infestans mediated transmission of Chagas disease in this zone that yields important human prevalence and that the populations of T. sordida in wild biotopes not only sustain the wild T. cruzi cycle but also represent an actual risk for people living in the area.     

Natural programmed cell death in T. cruzi epimastigotes maintained in axenic cultures

Trypanosoma cruzi, a parasitic protozoan, is the agent of Chagas' disease or American trypanosomiasis, an endemic pathology in Latin America, affecting up to 18 million people, with high public health costs. Programmed cell death (PCD) has many functions in development and tissue remodeling in metazoans. In protozoa, it could represent concomitant or alternative mechanisms for clonal selection, immune response evasion, and population size regulation. In this work, we describe the natural occurrence of PCD in T. cruzi epimastigotes during the stationary phase of growth in axenic culture or under nutrient deprivation. Thus, we have observed phosphatidylserine externalization, cellular volume decrease, caspase-like protein activity, and DNA fragmentation. Additionally, serum deprivation also induces autophagic characteristics such as monodansylcadaverine-labeled vesicles accumulation and redistribution of proteins homologous to Atg8. In agreement with our results, apoptosis may play an important role in parasite survival. Then, identification and modulation of molecular targets inducing programmed cell death in T. cruzi may lead to new potential therapeutic approaches for Chagas' disease.     

Control measures for Chagas disease

Chagas disease, also known as American trypanosomiasis, is a potentially life-threatening illness caused by the protozoan parasite, Trypanosoma cruzi. The main mode of transmission of this disease in endemic areas is through an insect vector called triatomine bug. Triatomines become infected with T. cruzi by feeding blood of an infected person or animal. Chagas disease is considered the most important vector borne infection in Latin America. It is estimated that between 16 and 18 millions of persons are infected with T. cruzi, and at least 20,000 deaths each year. In this work we formulate a model for the transmission of this infection among humans, vectors and domestic mammals. Our main objective is to assess the effectiveness of Chagas disease control measures. For this, we do sensitivity analysis of the basic reproductive number R? and the endemic proportions with respect to epidemiological and demographic parameters.     

Chagas disease in the Amazon region

The risk that Chagas disease becomes established as a major endemic threat in Amazonia (the world's largest tropical biome, today inhabited by over 30 million people) relates to a complex set of interacting biological and social determinants. These include intense immigration from endemic areas (possibly introducing parasites and vectors), extensive landscape transformation with uncontrolled deforestation, and the great diversity of wild Trypanosoma cruzi reservoir hosts and vectors (25 species in nine genera), which maintain intense sylvatic transmission cycles. Invasion of houses by adventitious vectors (with infection rates > 60%) is common, and focal adaptation of native triatomines to artificial structures has been reported. Both acute (approximately 500) and chronic cases of autochthonous human Chagas disease have been documented beyond doubt in the region. Continuous, low-intensity transmission seems to occur throughout the Amazon, and generates a hypoendemic pattern with seropositivity rates of approximately 1-3%. Discrete foci also exist in which transmission is more intense (e.g., in localized outbreaks probably linked to oral transmission) and prevalence rates higher. Early detection-treatment of acute cases is crucial for avoiding further dispersion of endemic transmission of Chagas disease in Amazonia, and will require the involvement of malaria control and primary health care systems. Comprehensive eco-epidemiological research, including prevalence surveys or the characterization of transmission dynamics in different ecological settings, is still needed. The International Initiative for Chagas Disease Surveillance and Prevention in the Amazon provides the framework for building up the political and scientific cooperation networks required to confront the challenge of preventing Chagas disease in Amazonia.     

Triatoma infestans in Greater Buenos Aires, Argentina

The Health Administration Agencies of many municipalities in Greater Buenos Aires (GBA) receive frequent reports on triatomines in houses. The aim of this work was to identify and describe the dispersal foci of Triatoma infestans in an urban neighborhood of GBA, and contribute to the knowledge of the epidemiological situation in the region. In June 1998, potentially infested places were entomologically evaluated. T. infestans was only detected in a hen building for egg production, which housed approximately 6,000 birds. A total of 2,930 insects were collected. Density was about 9 triatomines/m(2). The proportions of fifth instar nymphs and adults were significantly higher than those of the other stages (p<0.001). The number of triatomines collected largely exceeded the highest domestic infestation found in one house from rural endemic areas of Argentina. Though triatomines were negative for Trypanosoma cruzi, they could acquire the parasite by coming in contact with infected people living in GBA. Besides, the numerous and widely distributed places housing hens and chickens, would favor the settlement of the vector. Together, both facts may constitute a risk of parasitic vectorial transmission. It is recommended to intensify systematic activities of vector search and case detection in GBA.     

First report of colonies of sylvatic Triatoma infestans (Hemiptera: Reduviidae) in the Paraguayan Chaco, using a trained dog

In the Gran Chaco region, control of Triatoma infestans has been limited by persistent domestic infestations despite the efforts of the Vector Control Services. In Paraguay, this region is the highest endemic area in the country, showing high levels of indoor and outdoor infestation. Although sylvatic T. infestans have been found in the Bolivian and Argentine Chaco, similar searches for sylvatic populations of this species in Paraguay had been unsuccessful over the last 20 years. Here we present a new approach to detecting sylvatic Triatominae, using a trained dog, which has successfully confirmed sylvatic populations of T. infestans and other triatomine species in Paraguay. A total of 22 specimens corresponding to dark morph forms of T. infestans were collected, and 14 were confirmed as T. infestans by the mitochondrial cytochrome B gene analysis. Through this analysis, one of which were previously reported and a second that was a new haplotype. Triatomines were captured from amongst vegetation such as dry branches and hollows trees of different species such Aspidosperma quebracho-blanco, Bulnesia sarmientoi and Stetsonia coryne. The colonies found have been small and without apparent infection with Trypanosoma cruzi. During the study, Triatoma sordida and Triatoma guasayana have also been found in ecotopes close to those of T. infestans.     

Determinants of the domiciliary density of Triatoma infestans, vector of Chagas disease

In two heavily infested rural villages of Santiago del Estero, Argentina, where no indoor-spraying with residual insecticides had ever been carried out by official control services, we studied the influence of roof and wall structure, domestic use of insecticide, family size and the number of domestic dogs, on the domiciliary density of Triatoma infestans (Klug). Bug density was significantly associated with (1) the interaction between insecticide use and type of roof, (2) the structure of indoor walls, (3) the number of dogs sharing sleeping areas of people (room-mate dogs), and (4) the number of people plus room-mate dogs, but not with just the number of people resident in the house. The interaction between insecticide use and a roof made of 'simbol', a locally available grass (Pennisetum sp.), also reflected a younger age structure of domestic bug populations. In infested houses, the density of bugs infected with Trypanosoma cruzi Chagas was significantly correlated with overall bug density. Our data suggest that the application of environmental management measures by the affected people, such as plastering of walls and modification of roofs, coupled with keeping dogs away from bedrooms and application of insecticides, should limit the domestic population density of T. infestans and thus reduce the transmission of T. cruzi to people.     

Monitoring the domiciliary and peridomiciliary invasion process of Triatoma rubrovaria in the State of Rio Grande do Sul, Brazil

The presence of Triatoma rubrovaria in Brazil has only been confirmed in the States of Paraná and Rio Grande do Sul (RS), where it is found naturally infected with Trypanosoma cruzi. In the wild environment it occurs in rocky habitats and has an eclectic diet, feeding from cockroaches, reptiles and mammals. Data from the Chagas Disease Control Program obtained by the Funda??o Nacional de Saúde, between 1975 and 1997, indicate a growing domiciliary and peridomiciliary invasion of T. rubrovaria in RS, where it has become the most frequently Triatominae species captured in this state since the control of Triatoma infestans. In order to monitor this process, we analyzed collection data derived from 22 years of control campaigns against T. infestans. Collection data for triatomines from domestic habitats show an inverse relationship, with high numbers of T. infestans and low numbers of T. rubrovaria during 1976-1987, compared to the following ten years, 1986-1997, when the number of T. infestans dropped drastically and that of T. rubrovaria increased. There are no consistent indications of intradomiciliary colonization by T. rubrovaria, since only low numbers of nymphs have been captured in the intradomiciliary ecotopes. Nevertheless, this species appears to have preadaptive characteristics for anthropic ecotopes, and should be kept under constant epidemiological surveillance.     

Distribution of domestic triatominae and stratification of Chagas Disease transmission in Oaxaca, Mexico

Mexico has 18 species of Triatomine bugs (Hemiptera: Reduviidae) reported to be vectors of Trypanosoma cruzi. Chagas Disease is widespread in Mexico, with up to 3.5% seropositivity of human transfusion blood. The State of Oaxaca has the longest history of endemic Chagas Disease, based on acute and chronic case reports, and of entomological surveys in the country. However, the State health care services need more information on current risks of vector transmission. In order to identify and characterize areas of transmission in Oaxaca and to stratify the vector potential, the distribution of domestic Triatominae was surveyed during 1996-98 in collaboration with the primary health care services and local communities. Villages were studied in 11% of 570 municipalities in Oaxaca. Eight triatomine species were found in domestic and peri-domestic habitats: Triatoma barberi Usinger, T. bolivari Carcavallo et al., T. dimidiata (Latreille), T. mazzottii Usinger, T. nitida Usinger, T. pallidipennis (Stal), T. phyllosoma (Burmeister) and Rhodnius prolixus Stal. For each triatomine species in Oaxaca, the range of distribution and habitat characteristics are described. Habitat partitioning, principally based on altitude and mean annual precipitation, limited the overlap of distribution between species. Relatively consistent altitude of human settlements facilitates the dispersion of individual species within microregions. Entomological indices of house infestation were used to estimate that approximately 50% of the human population (1,874,320 inhabitants) would be at risk of vector transmission, with a minimum of 134,320 infected people and 40,280 chronic cases of Chagas Disease currently in Oaxaca.     

Does inhibition of Trypanosoma cruzi key enzymes affect parasite life cycle and geographic distribution?

The hemoflagellate protozoan parasite Trypanosoma cruzi is the causative agent of the Chagas disease, a progressive fatal cardiomyopathy that afflicts more than 20 million people in Central and South America. The T. cruzi life cycle is affected by changes in temperature and pH, the parasite replication being facilitated in mammalian hosts rather than in insect vectors. Here, we postulate that the modulation of key enzymes by pH- and temperature-dependent substrate inhibition may affect the T. cruzi life cycle and limit the geographic range covered by the parasite.     

Chagas disease: control,elimination and eradication. Is it possible?

From an epidemiological point of view, Chagas disease and its reservoirs and vectors can present the following characteristics: (i) enzooty, maintained by wild animals and vectors, with broad occurrence from southern United States of America (USA) to southern Argentina and Chile (42ºN 49ºS), (ii) anthropozoonosis, when man invades the wild ecotope and becomes infected with Trypanosoma cruzi from wild animals or vectors or when the vectors and wild animals, especially marsupials, invade the human domicile and infect man, (iii) zoonosis-amphixenosis and exchanged infection between animals and humans by domestic vectors in endemic areas and (iv) zooanthroponosis, infection that is transmitted from man to animals, by means of domestic vectors, which is the rarest situation in areas endemic for Chagas disease. The characteristics of Chagas disease as an enzooty of wild animals and as an anthropozoonosis are seen most frequently in the Brazilian Amazon and in the Pan-Amazon region as a whole, where there are 33 species of six genera of wild animals: Marsupialia, Chiroptera, Rodentia, Edentata (Xenarthra), Carnivora and Primata and 27 species of triatomines, most of which infected with T. cruzi . These conditions place the resident populations of this area or its visitors - tourists, hunters, fishermen and especially the people whose livelihood involves plant extraction - at risk of being affected by Chagas disease. On the other hand, there has been an exponential increase in the acute cases of Chagas disease in that region through oral transmission of T. cruzi , causing outbreaks of the disease. In four seroepidemiological surveys that were carried out in areas of the microregion of the Negro River, state of Amazonas, in 1991, 1993, 1997 and 2010, we found large numbers of people who were serologically positive for T. cruzi infection. The majority of them and/or their relatives worked in piassava extraction and had come into contact with and were stung by wild triatomines in that area. Finally, a characteristic that is greatly in evidence currently is the migration of people with Chagas disease from endemic areas of Latin America to non-endemic countries. This has created a new dilemma for these countries: the risk of transmission through blood transfusion and the onus of controlling donors and treating migrants with the disease. As an enzooty of wild animals and vectors, and as an anthropozoonosis, Chagas disease cannot be eradicated, but it must be controlled by transmission elimination to man.