Chagas disease screening in pregnant Latin American women: Adherence to a systematic screening protocol in a non-endemic country

BackgroundChagas disease (CD) is a chronic parasitic disease caused by Trypanosoma cruzi and is endemic to continental Latin America. In Spain, the main transmission route is congenital. We aimed to assess adherence to regional recommendations of universal screening for CD during pregnancy in Latin American women in the province of Alicante from 2014 to 2018.Methodology/Principal findingsRetrospective quality study using two data sources: 1) delivery records of Latin American women that gave birth in the 10 public hospitals of Alicante between January 2014 and December 2018; and 2) records of Chagas serologies carried out in those centers between May 2013 and December 2018. There were 3026 deliveries in Latin American women during the study period; 1178 (38.9%) underwent CD serology. Screening adherence ranged from 17.2% to 59.3% in the different health departments and was higher in Bolivian women (48.3%). Twenty-six deliveries (2.2%) had a positive screening; CD was confirmed in 23 (2%) deliveries of 21 women. Bolivians had the highest seroprevalence (21/112; 18.7%), followed by Colombians (1/333; 0.3%) and Ecuadorians (1/348; 0.3%). Of 21 CD-positive women (19 Bolivians, 1 Colombian, 1 Ecuadorian), infection was already known in 12 (57.1%), and 9 (42.9%) had already been treated. Only 1 of the 12 untreated women (8.3%) was treated postpartum. Follow-up started in 20 of the 23 (87.0%) neonates but was completed only in 11 (47.8%); no cases of congenital transmission were detected. Among the 1848 unscreened deliveries, we estimate 43 undiagnosed cases of CD and 1 to 2 undetected cases of congenital transmission.Conclusions/SignificanceAdherence to recommendations of systematic screening for CD in Latin American pregnant women in Alicante can be improved. Strategies to strengthen treatment of postpartum women and monitoring of exposed newborns are needed. Currently, there may be undetected cases of congenital transmission in our province.     

Prevalence,Clinical Staging and Risk for Blood-Borne Transmission of Chagas Disease among Latin American Migrants in Geneva,Switzerland

Background

Migration of Latin Americans to the USA, Canada and Europe has modified Chagas disease distribution, but data on imported cases and on risks of local transmission remain scarce. We assessed the prevalence and risk factors for Chagas disease, staged the disease and evaluated attitudes towards blood transfusion and organ transplant among Latin American migrants in Geneva, Switzerland.

Methodology/Principal Findings

This cross-sectional study included all consecutive Latin American migrants seeking medical care at a primary care facility or attending two Latino churches. After completing a questionnaire, they were screened for Chagas disease with two serological tests (Biomérieux ELISA cruzi; Biokit Bioelisa Chagas). Infected subjects underwent a complete medical work-up. Predictive factors for infection were assessed by univariate and multivariate logistic regression analysis.1012 persons (females: 83%; mean age: 37.2 [SD 11.3] years, Bolivians: 48% [n = 485]) were recruited. 96% had no residency permit. Chagas disease was diagnosed with two positive serological tests in 130 patients (12.8%; 95%CI 10.8%–14.9%), including 127 Bolivians (26.2%; 95%CI 22.3%–30.1%). All patients were in the chronic phase, including 11.3% with cardiac and 0.8% with digestive complications. Predictive factors for infection were Bolivian origin (OR 33.2; 95%CI 7.5–147.5), reported maternal infection with T. cruzi (OR 6.9; 95%CI 1.9–24.3), and age older than 35 years (OR 6.7; 95%CI 2.4–18.8). While 22 (16.9%) infected subjects had already donated blood, 24 (18.5%) and 34 (26.2%) considered donating blood and organs outside Latin America, respectively.

Conclusions

Chagas disease is highly prevalent among Bolivian migrants in Switzerland. Chronic cardiac and digestive complications were substantial. Screening of individuals at risk should be implemented in nonendemic countries and must include undocumented migrants.     

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.     

Urban Chagas disease in children and women in primary care centres in Buenos Aires,Argentina

The primary objective of this study was to estimate the prevalence of this disease inwomen of childbearing age and children treated at health centres in underservicedareas of the city of Buenos Aires. Demographic and Chagas disease status data werecollected. Samples for Chagas disease serology were obtained on filter paper and thereactive results were confirmed with conventional samples. A total of 1,786 subjectswere screened and 73 positive screening results were obtained: 17 were from childrenand 56 were from women. The Trypanosoma cruzi infection risk wasgreater in those individuals who had relatives with Chagas disease, who rememberseeing kissing bugs, who were of Bolivian nationality or were born in the Argentineprovince of Santiago del Estero. The overall prevalence of Chagas disease was 4.08%.Due to migration, Chagas disease is currently predominantly urban. The observedprevalence requires health programme activities that are aimed at urban children andtheir mothers. Most children were infected congenitally, which reinforces the needfor Chagas disease screening of all pregnant women and their babies in Argentina. Theactive search for new cases is important because the appropriate treatment inchildren has a high cure rate.     

Roadblocks in Chagas disease care in endemic and nonendemic countries: Argentina,Colombia, Spain,and the United States. The NET-Heart project

BackgroundChagas disease (CD) is endemic in Latin America; however, its spread to nontropical areas has raised global interest in this condition. Barriers in access to early diagnosis and treatment of both acute and chronic infection and their complications have led to an increasing disease burden outside of Latin America. Our goal was to identify those barriers and to perform an additional analysis of them based on the Inter American Society of Cardiology (SIAC) and the World Heart Federation (WHF) Chagas Roadmap, at a country level in Argentina, Colombia, Spain, and the United States, which serve as representatives of endemic and nonendemic countries.Methodology and principal findingsThis is a nonsystematic review of articles published in indexed journals from 1955 to 2021 and of gray literature (local health organizations guidelines, local policies, blogs, and media). We classified barriers to access care as (i) existing difficulties limiting healthcare access; (ii) lack of awareness about CD and its complications; (iii) poor transmission control (vectorial and nonvectorial); (iv) scarce availability of antitrypanosomal drugs; and (v) cultural beliefs and stigma. Region-specific barriers may limit the implementation of roadmaps and require the application of tailored strategies to improve access to appropriate care.ConclusionsMultiple barriers negatively impact the prognosis of CD. Identification of these roadblocks both nationally and globally is important to guide development of appropriate policies and public health programs to reduce the global burden of this disease.     

Integrate study of a Bolivian population infected by Trypanosoma cruzi,the agent of Chagas disease

A cross section of a human population (501 individuals) selected at random, and living in a Bolivian community, highly endemic for Chagas disease, was investigated combining together clinical, parasitological and molecular approaches. Conventional serology and polymerase chain reaction (PCR) indicated an active transmission of the infection, a high seroprevalence (43.3%) ranging from around 12% in < 5 years to 94.7% in > 45 years, and a high sensitivity (83.8%) and specificity of PCR. Abnormal ECG tracing was predominant in chagasic patients and was already present among individuals younger than 13 years. SAPA (shed acute phase antigen) recombinant protein and the synthetic peptide R-13 were used as antigens in ELISA tests. The reactivity of SAPA was strongly associated to Trypanosoma cruzi infection and independent of the age of the patients but was not suitable neither for universal serodiagnosis nor for discrimination of specific phases of Chagas infection. Anti-R-13 response was observed in 27.5% only in chagasic patients. Moreover, anti-R13 reactivity was associated with early infection and not to cardiac pathology. This result questioned previous studies, which considered the anti-R-13 response as a marker of chronic Chagas heart disease. The major clonets 20 and 39 (belonging to Trypanosoma cruzi I and T. cruzi II respectively) which circulate in equal proportions in vectors of the studied area, were identified in patients' blood by PCR. Clonet 39 was selected over clonet 20 in the circulation whatever the age of the patient. The only factor related to strain detected in patients' blood, was the anti-R-13 reactivity: 37% of the patients infected by clonet 39 (94 cases) had anti-R13 antibodies contrasting with only 6% of the patients without clonet 39 (16 cases).     

The potential economic value of a Trypanosoma cruzi (Chagas disease) vaccine in Latin America

Background

Chagas disease, caused by the parasite Trypanosoma cruzi (T. cruzi), is the leading etiology of non-ischemic heart disease worldwide, with Latin America bearing the majority of the burden. This substantial burden and the limitations of current interventions have motivated efforts to develop a vaccine against T. cruzi.

Methodology/Principal Findings

We constructed a decision analytic Markov computer simulation model to assess the potential economic value of a T. cruzi vaccine in Latin America from the societal perspective. Each simulation run calculated the incremental cost-effectiveness ratio (ICER), or the cost per disability-adjusted life year (DALY) avoided, of vaccination. Sensitivity analyses evaluated the impact of varying key model parameters such as vaccine cost (range: $0.50–$200), vaccine efficacy (range: 25%–75%), the cost of acute-phase drug treatment (range: $10–$150 to account for variations in acute-phase treatment regimens), and risk of infection (range: 1%–20%). Additional analyses determined the incremental cost of vaccinating an individual and the cost per averted congestive heart failure case. Vaccination was considered highly cost-effective when the ICER was ≤1 times the GDP/capita, still cost-effective when the ICER was between 1 and 3 times the GDP/capita, and not cost-effective when the ICER was >3 times the GDP/capita. Our results showed vaccination to be very cost-effective and often economically dominant (i.e., saving costs as well providing health benefits) for a wide range of scenarios, e.g., even when risk of infection was as low as 1% and vaccine efficacy was as low as 25%. Vaccinating an individual could likely provide net cost savings that rise substantially as risk of infection or vaccine efficacy increase.

Conclusions/Significance

Results indicate that a T. cruzi vaccine could provide substantial economic benefit, depending on the cost of the vaccine, and support continued efforts to develop a human vaccine.     

Gastrointestinal lymphomas in a North American population: clinicopathologic features from one major Central-Midwestern United States tertiary care medical center

ABSTRACT: BACKGROUND: Gastrointestinal (GI) lymphomas are very common types of extranodal lymphomas, and we hypothesize there are regional differences in subtype, distribution in the GI tract, and epidemiological features among the different populations. METHODS: We retrospectively evaluated the clinical, molecular and histologic features of North American primary and secondary GI lymphomas diagnosed from 2000?2009 seen at our institution. We utilized immunohistochemistry and fluorescence in situ hybridization to further evaluate a subset of the gastric lymphomas. RESULTS: Extranodal marginal zone lymphomas of mucosal associated lymphoid tissue (MALTs) and diffuse large B cell lymphomas (DLBCLs) were the most common subtypes of GI lymphomas. Select gastric DLBCLs (N?=?6) and MALTs (N?=?13) were further examined for API2-MALT1 and IGH translocations, and P16 and P53 protein expression. Gastric MALTs showed frequent API2-MALT1 (38%) but not IGH translocations (0%), and the DLBCLs showed neither translocation. Expression of P16 and P53 proteins and the proliferative index were compared between high grade gastric lymphomas (gastric DLBCLs) and low grade gastric lymphomas (gastric MALTs). P53 overexpression (P?=?0.008) and a high proliferation index [Ki-67] (P?=?0.00042) were significantly associated with gastric DLBCL, but no statistically significant difference was observed in P16 expression (p?=?0.108) between gastric DLBCL and gastric MALT. CONCLUSION: Our study revealed that GI lymphomas from a Central-Midwestern North American population showed differences and similarities to non-North American cohorts. In addition, API2-MALT1, P16 and P53 abnormalities occurred frequently in gastric lymphomas from this North American population. Virtual slides: The virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1415505838687793.     

Clandestine induced abortion: prevalence,incidence and risk factors among women in a Latin American country

Background

Clandestine induced abortions are a public health problem in many developing countries where access to abortion services is legally restricted. We estimated the prevalence and incidence of, and risk factors for, clandestine induced abortions in a Latin American country.

Methods

We conducted a large population-based survey of women aged 18–29 years in 20 cities in Peru. We asked questions about their history of spontaneous and induced abortions, using techniques to encourage disclosure.

Results

Of 8242 eligible women, 7992 (97.0%) agreed to participate. The prevalence of reported induced abortions was 11.6% (95% confidence interval [CI] 10.9%– 12.4%) among the 7962 women who participated in the survey. It was 13.6% (95% CI 12.8%– 14.5%) among the 6559 women who reported having been sexually active. The annual incidence of induced abortion was 3.1% (95% CI 2.9%– 3.3%) among the women who had ever been sexually active. In the multivariable analysis, risk factors for induced abortion were higher age at the time of the survey (odds ratio [OR] 1.11, 95% CI 1.07– 1.15), lower age at first sexual intercourse (OR 0.87, 95% CI 0.84– 0.91), geographic region (highlands: OR 1.56, 95% CI 1.23– 1.97; jungle: OR 1.81, 95% CI 1.41– 2.31 [v. coastal region]), having children (OR 0.82, 95% CI 0.68– 0.98), having more than 1 sexual partner in lifetime (2 partners: OR 1.61, 95% CI 1.23– 2.09; ≥ 3 partners: OR 2.79, 95% CI 2.12– 3.67), and having 1 or more sexual partners in the year before the survey (1 partner: OR 1.36, 95% CI 1.01– 1.72; ≥ 2 partners: OR 1.54, 95% CI 1.14– 2.02). Overall, 49.0% (95% CI 47.6%– 50.3%) of the women who reported being currently sexually active were not using contraception.

Interpretation

The incidence of clandestine, potentially unsafe induced abortion in Peru is as high as or higher than the rates in many countries where induced abortion is legal and safe. The provision of contraception and safer-sex education to those who require it needs to be greatly improved and could potentially reduce the rate of induced abortion.In most developing countries, induced abortion is legal only if the pregnancy threatens the health or life of the mother. Many women, therefore, seek clandestine abortions, which are too often unsafe and place the woman at risk of complications and death.¹Forty percent of women live in countries where abortion is legally restricted.² In 2003, an estimated 55% of induced abortions in developing countries were unsafe, and 97% of all unsafe abortions were in developing countries.³ Induced abortion is highly restricted in most countries in Latin America and the Caribbean.¹ According to the World Health Organization (WHO), the region of Latin America and the Caribbean has the same estimated incidence of clandestine induced abortions as Africa (3% per year among women aged 15–44 years).⁴ It also has the highest proportion of maternal death from unsafe abortion (12%).⁵ Women who have complications from clandestine abortions may not seek medical help for fear of being reported to legal authorities by health care workers.^6,7Elimination of unsafe abortions is a key component of sexual and reproductive health care.⁸ There is a public health need to determine more accurately the burden of, and risk factors for, clandestine induced abortion in different countries. Because of data limitations, the WHO reports only regional estimates.⁴ The lack of official records and underreporting by those involved make this task difficult, requiring that estimates calculated by different methods be compared.Rates of clandestine induced abortion are estimated with the use of either direct methods, such as population-based surveys and surveys of providers of illegal abortions, or indirect methods, such as the application of multipliers to recorded rates of hospital admission or death attributed to induced abortions.^4,9We performed a large, representative, population-based survey to determine the prevalence and incidence of, and risk factors for, induced abortion in an urban population of a Latin American country where access to abortion services is legally restricted.     

Occurrence of enteroviruses in marine sediment along the coast of Barcelona, Spain

A survey of the occurrence of enteroviruses in marine sediment was undertaken in an area receiving polluted effluents. Enteroviruses were detected in 21 out of 38 samples (55%). Viruses were found as far as 5 km from the shoreline and at a depth of 82 m. Multiple correlations between enteroviruses and bacteria, detected in the same samples, were computed. No correlation could be demonstrated between virus numbers and any other parameter in sediment samples collected south of Barcelona. This lack of correlation is probably due to the different decay rates shown by bacteria and viruses. In contrast, the cases where pollution resulted from a more recent deposition, as in sediment samples collected north of Barcelona, enterovirus levels were correlated with fecal streptococci levels.     

Effectiveness of a Pilot Partner Notification Program for New HIV Cases in Barcelona,Spain

Background

An estimated 30% of HIV cases in the European Union are not aware of their serological status. This study aimed to assess the effectiveness of a pilot HIV partner notification program.

Methods

HIV cases diagnosed between January 2012 and June 2013 at two healthcare settings in Barcelona were invited to participate in a prospective survey. We identified process and outcome measures to evaluate this partner notification program, including the number of partners identified per interviewed index case, the proportion of partners tested for HIV as a result of the partner notification, and the proportion of new HIV diagnoses among their sex or needle-sharing partners.

Results

Of the 125 index cases contacted, 108 (86.4%) agreed to provide information about partners. A total of 199 sexual partners were identified (1.8 partners per interviewed index case). HIV outcome was already known for 58 partners (70.7% were known to be HIV-positive), 141 partners were tested as result of partner notification, and 26 were newly diagnosed with HIV. The case-finding effectiveness of the program was 18.4%.

Conclusion

This pilot program provides evidence of the effectiveness of a partner notification program implemented in healthcare settings. This active partner notification program was feasible, acceptable to the user, and identified a high proportion of HIV-infected patients previously unaware of their status.     

Genetic polymorphisms in TNFA/TNFR2 genes and Chagas disease in a Colombian endemic population

In this study we investigated the association of functional single nucleotide polymorphisms of tumor necrosis factor-alfa (TNFA) and TNF receptor 2 (TNFR2) genes in determining the susceptibility to Chagas' disease. This study included 313 patients from Colombia serologically positive for Trypanosoma cruzi antigens (cardiomyopathic, N=159; asymptomatic, N=154). Genotypes were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism method. We found a significant difference in the distribution of the TNFA -1031C (p=0.0153, OR=1.69, CI=1.10-2.58) and -308A (p=0.0002, OR=2.60, CI=1.53-4.39) alleles between cardiomyopathic and asymptomatic subjects. In addition, we observed that the TNFR2 +676T allele was monomorphic in our population. Our results suggest that TNFA -1031C and -308A gene polymorphisms may influence the susceptibility to develop chagasic cardiomyopathy in the population under study.     

Monoterpene emissions from ornamental trees in urban areas: a case study of Barcelona, Spain

Research on biogenic volatile organic compound (BVOC) emissions has mainly focused on native species in natural ecosystems. However, much of the ozone and aerosol formation occurs in city atmospheres due to BVOC emissions by local urban vegetation. Plant composition of urban habitats is often dominated by non-native ornamental plant species, for which only limited data on BVOC emissions are available. To gain insight into the influence of ornamental vegetation on the urban atmospheric reactivity in Barcelona, Spain, we studied volatile isoprenoid emissions in 11 widespread ornamental tree species (three conifers and nine angiosperms). We found significant monoterpene emissions in all studied species, with normalized emission potentials (T=30 degrees C, photosynthetic photon flux density (PPFD)=1000 micromol x m(-2) x s(-1)) ranging between 0.2 to 110 microg x g(-1) (dry weight) h(-1). Depending on species, the emissions were dominated by alpha- and beta-pinene, myrcene, alpha- and beta-phellandrene, carene, limonene and eucalyptol. These data demonstrate that ornamental plants may significantly contribute to the BVOC load in urban atmospheres and also underscore the importance of broadleaf angiosperms as significant monoterpene emitters.     

Contraceptive practices and fertility among Southeast Asian,black, and white mothers attending a maternal infant care program

Abstract

The purpose of this analysis was to determine if there were differences in selected fertility characteristics including parity, pregnancy spacing, age at first pregnancy, age of menarche, breastfeeding postpartum, and contraceptive practices among white, black, Hmong, and other Southeast Asian mothers attending a maternal infant care program in Minneapolis, Minnesota, during 1980–82.

White and black mothers were younger than the Hmong and other Asian mothers. The lowest mean age of first pregnancy was among blacks. Ages of first pregnancy were similar for whites, Hmong, and other Asians, although the mean age of menarche was approximately two years later for Hmong and other Southeast Asian mothers compared to the white and black mothers.

Based on self reports at the first postpartum visit one month after delivery, 39 per cent of the whites and 25 per cent of the blacks were breastfeeding. In comparison 8.7 per cent of the Hmong and 17 per cent of the other southeast Asian mothers were breastfeeding.

Maternal age and age at first pregnancy were significant predictors of parity for whites, blacks, Hmong, and the other Southeast Asians. Ever‐use of contraception was a significant predictor of parity only for Hmong.

The highest proportion of ever‐users of contraception was among the white mothers (80 per cent) followed by the blacks (69.3 per cent) and other Asian mothers (34.8 per cent). Hmong mothers had the lowest proportion having used contraception (17.1 per cent).     

Contraceptive practices and fertility among Southeast Asian, black, and white mothers attending a maternal infant care program

The purpose of this analysis was to determine if there were differences in selected fertility characteristics including parity, pregnancy spacing, age at 1st pregnancy, age of menarche, breastfeeding postpartum, and contraceptive practices among white, black, Hmong, and other Southeast Asian mothers attending a maternal infant care program in Minneapolis, Minnesota, during 1980-1982. White and black mothers were younger than the Hmong and other Asian mothers. The lowest mean age of 1st pregnancy was among blacks. Ages of 1st pregnancy were similar for whites, Hmong, and other Asians, although the mean age of menarche was approximately 2 years later for Hmong and other Southeast Asian mothers compared to the white and black mothers. Based on self reports at the 1st postpartum visit 1 month after delivery, 39% of the whites and 25% of the blacks were breastfeeding. In comparison 8.7% of the Hmong and 17% of the other southeast Asian mothers were breastfeeding. Maternal aged age at 1st pregnancy were significant predictors of parity for whites, blacks, Hmong, and other Southeast Asians. Ever-use of contraception was significant predictor of parity only for Hmong. The highest proportion of ever-users of contraception was among the white mothers (80%) followed by the blacks (69.3%) and other Asian mothers (34.85). Hmong mothers had the lowest proportion having used contraception (17.1%).