PLoS Negl Trop DisplosplosntdsPLoS Neglected Tropical Diseases1935-2735Public Library of ScienceSan Francisco, USAPNTD-D-10-0014410.1371/journal.pntd.0001135Research ArticleMedicineInfectious diseasesNeglected tropical diseasesChagas diseasePrimary carePublic healthHealth screeningInfectious DiseasesPublic Health and EpidemiologyChagas Disease among the Latin American Adult Population Attending in
a Primary Care Center in Barcelona, SpainChagas Disease in Barcelona,
SpainRocaCarme1*PinazoMaría Jesús2López-ChejadePaolo3BayóJoan1PosadaElizabeth2López-SolanaJordi1GállegoMontserrat3PortúsMontserrat3GascónJoaquim2and the Chagas-Clot Research Group¶El Clot Primary Care Center, Institut
Català de la Salut, Universitat de Barcelona, Barcelona,
SpainBarcelona Centre for International Health
Research (CRESIB), Hospital Clinic-Universitat de Barcelona, Barcelona,
SpainParasitology Laboratory, Facultat de
Farmàcia, Universitat de Barcelona, Barcelona, Spainda Costa SantiagoHeltonEditorNational Institutes of Health, United States of America* E-mail: croca.bcn.ics@gencat.cat
Conceived and designed the experiments: CR JG MP. Performed the experiments:
CR MJP JB JL-S EP Chagas-Clot Research Group. Analyzed the data: CR MJP JB
MG MP JG. Contributed reagents/materials/analysis tools: PL-C MG MP. Wrote
the paper: CR JG MP MG MJP JB.
¶ Membership of the Chagas-Clot Research Group is provided in the
Acknowledgments.
The authors have declared that no competing interests exist.
42011264201154e1135611201014220112011Roca et alThis is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and
source are credited.Chagas Disease Has Now Gone GlobalBackground/Aims
The epidemiology of Chagas disease, until recently confined to areas of
continental Latin America, has undergone considerable changes in recent
decades due to migration to other parts of the world, including Spain. We
studied the prevalence of Chagas disease in Latin American patients treated
at a health center in Barcelona and evaluated its clinical phase. We make
some recommendations for screening for the disease.
Methodology/Principal Findings
We performed an observational, cross-sectional prevalence study by means of
an immunochromatographic test screening of all continental Latin American
patients over the age of 14 years visiting the health centre from October
2007 to October 2009. The diagnosis was confirmed by serological methods:
conventional in-house ELISA (cELISA), a commercial kit (rELISA) and ELISA
using T cruzi lysate (Ortho-Clinical Diagnostics) (oELISA).
Of 766 patients studied, 22 were diagnosed with T. cruzi
infection, showing a prevalence of 2.87% (95% CI,
1.6–4.12%). Of the infected patients, 45.45% men and
54.55% women, 21 were from Bolivia, showing a prevalence in the
Bolivian subgroup (n = 127) of 16.53%
(95% CI, 9.6–23.39%).
All the infected patients were in a chronic phase of Chagas disease:
81% with the indeterminate form, 9.5% with the cardiac form
and 9.5% with the cardiodigestive form. All patients infected with
T. cruzi had heard of Chagas disease in their country
of origin, 82% knew someone affected, and 77% had a
significant history of living in adobe houses in rural areas.
Conclusions
We found a high prevalence of T. cruzi infection in
immigrants from Bolivia. Detection of T.
cruzi–infected persons by screening programs in non-endemic
countries would control non-vectorial transmission and would benefit the
persons affected, public health and national health systems.
Author Summary
Chagas disease is a parasitic infection caused by the protozoan
Trypanosoma cruzi, and is becoming an emerging health
problem in non-endemic areas because of growing population movements. The
clinical manifestations of chronic T. cruzi infection include
the latent form (the indeterminate chronic form), the cardiac form, the
digestive or cardiodigestive form, and sudden death. Therefore, many diagnoses
of Chagas disease are based on epidemiological suspicion rather than on clinical
signs and symptoms. This study showed that the prevalence of Chagas disease in
Latin American patients attending at a health center in Barcelona is
2,87% and the highest prevalence was found among Bolivian patients
(16,53%). All the infected patients were in a chronic phase of Chagas
disease. Detection of T. cruzi–infected persons by
screening programs in non-endemic countries would control non-vectorial
transmission and would benefit the persons affected, public health and national
health systems. The data obtained in this study and the experiences described
elsewhere suggest that it is advisable to perform Chagas disease screening in
non-endemic countries on all patients from continental Latin America who:
(1)have a suggestive epidemiologic history, (2)are pregnant, (3)are
immunosuppressed, (4)have symptoms suggestive of Chagas disease, or (5)request
screening.
The study was funded by the Catalan Society for Family and Community Medicine
(8th call, 2007) and Àmbit Barcelona Ciutat-Institut Català de la
Salut. The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.Introduction
Trypanosoma cruzi (T. cruzi) is a flagellate
protozoan that causes Chagas disease (CD). It is traditionally linked to rural areas
of continental Latin America, where it is transmitted by a variety of bug vectors.
In recent decades, the epidemiological pattern of this disease has undergone
considerable changes [1]. In the endemic countries of Latin America, the regional
Chagas programs are working to interrupt vector-borne and transfusional
transmission, to control congenital Chagas disease and to support initiatives aimed
at improving diagnosis, management and surveillance of the disease [2]. In non-endemic
countries that receive immigrants from Latin America or send tourists to endemic
areas, CD is an emerging disease and has become a public health problem because it
can be transmitted by non-vectorial mechanisms [3], [4].
Spain is a major European host country for people from Latin America. According to
the Spanish National Institute of Statistics, in 2009 more than 1.8 million
immigrants from Latin America were registered, accounting for 3.85% of the
total population [5]. In recent years several studies of CD in non-endemic
countries [6]–[9] have focused in particular on non-vectorial transmission
mechanisms such as pregnancy and childbirth [10], [11], blood transfusion [12], [13] and organ
transplantation [14],
[15].
However, when reviewing the literature we found little information on imported CD in
non-endemic countries at the primary care level [16], which is ideal for
screening the general population [17].
The clinical manifestations of chronic T. cruzi infection include
the latent form (the indeterminate chronic form), which occurs in 60% of
cases [18], the
cardiac form [19],
the digestive or cardiodigestive form, and sudden death [20]. Therefore, many diagnoses of CD
are based on epidemiological suspicion rather than clinical signs and symptoms.
The objectives of the present study were (1) to assess the prevalence of
Trypanosoma cruzi infection in the adult Latin American
population treated at a health center in Barcelona, Spain; (2) to analyze the
clinical phase of the disease; and (3) to determine whether screening for imported
CD in primary care should be recommended.
MethodsStudy design and scope
We performed an observational, cross-sectional prevalence study at the health
center of the Clot district, Barcelona. This center serves a population of 25442
people, with a total foreign population of 13.5% and a Latin American
population of 6.3% (according to the 2008 census of the Barcelona City
Council) [21].
The staffs participating in the study were 14 general practitioners, 13 nurses,
1 gynecologist and 1 midwife.
Ethical conduct
The study protocol was approved by the Ethical Committee of the Jordi Gol
Institute for Research in Primary Care of the Institut Català de
la Salut (Catalan Health Institute).
Written informed consent was requested from all participants. When participants
were children, their parents/guardians provided informed consent.
Patients
During the period October 2007 to October 2009, all patients from continental
Latin America under 14 years of age who presented at the health center for any
health reason were invited to participate in the study. After obtaining informed
consent, we collected clinical and epidemiological data.
We ascertained the reasons why the patients visited their doctor/nurse by
reviewing the electronic patient charts. On a patient's first visit to a
primary care centre the Preventive Activities and Health Promotion Program
(PAPPS) is initiated [22], and at the Clot health center this program included
CD screening of all persons originating from continental Latin America.
Serological techniques
Serological screening was performed with an immunochromatographic test (ICT) that
uses recombinant antigens of T. cruzi (TcD, TcE, PEP-2 and
SAPA) on whole blood collected by finger prick.
If the screening was positive, a venous blood sample was collected to confirm the
diagnosis at the Parasitology Laboratory of the Faculty of Pharmacy, University
of Barcelona. We used 2 enzyme-linked immunosorbent assay (ELISA) methods: a
conventional, in-house ELISA (cELISA) with whole T. cruzi
epimastigote antigens [23] and a commercial kit with the recombinant antigens
TcD, TcE, PEP-2 and TcLo1.2 (rELISA).
In accordance with international criteria established by the World Health
Organization, sera that were reactive in two serological methods were considered
positive [24].
Positive results were confirmed by a third ELISA using T cruzi
lysate (Ortho-Clinical Diagnostics) (oELISA). In a subsample of 101 patients we
performed the ELISA serologies (cELISA and rELISA) regardless of the result of
the ICT, in order to test the usefulness of this test in screening for CD in
primary care [25].
Management of patients
All patients infected with T. cruzi were referred to the
Tropical Medicine Unit of Hospital Clínic de Barcelona and clinically
evaluated by a complete review of the epidemiologic history and consistent
symptoms/signs, a general physical examination and an electrocardiogram. If the
electrocardiogram was pathologic, it was assessed with an echocardiogram or
24-hour Holter according to the disease detected. If symptoms consistent with
gastrointestinal involvement were detected [26], an esophageal, gastric and
duodenal transit assessment or a barium enema was performed. Benznidazole (5
mg/kg/day for 60 days) was offered to all patients aged 18–50 years
without advanced Chagas cardiomyopathy and no other contraindication for start
benznidazole (pregnancy, severe renal or hepatic insufficiency [27]. None of them
refused to start it.
Statistical calculations
The sample size was calculated for an alpha level of 0.05 and a precision of
±0.05% in a bilateral comparison, assuming maximum uncertainty
(50% prevalence); for a population of 1516 subjects [28] a random sample of 758 was
necessary.
The programs SPSS version 17.0 and Epidat version 3.1 were used for the
statistical analysis. The χ2 test was used to compare hypotheses of
independence between two categorical variables and the Student
t test for continuous variables. The confidence interval
for all hypothesis comparisons was 95% and the tests were 2-tailed.
Results
A total of 766 persons from continental Latin America were included in the study. The
epidemiological data are presented in Table 1 and the countries of origin in Table 2.
10.1371/journal.pntd.0001135.t001
Epidemiologic data.
Variables
Without CD n = 744
With CD n = 22
p, statistical significance
MenWomen
296 (39.8%)448 (60.2%)
10 (45.45%)12 (54.5%)
Not statistically significant (NS)
Age; years (SD)
36.43 (12.2)
39.86 (9.88)
NS
Journeys to country of origin in last 12 months
Yes 303 (40.7%)No 441 (59.3%)
Yes 6 (27.27%)No 16 (72.73%)
NS
Had lived in rural areas
Yes 248 (33.3%)No 496 (66.7%)
Yes 17 (77.22%)No 5 (22.73%)
p<0.001
Had lived in adobe houses
Yes 166 (22.3%)No 578 (77.7%)Don't
know —
Yes 17 (77.3%)No 4 (18.2%)Don't know
1(4.5%)
p<0.0001
Had received transfusion in country of origin
Yes 53 (7.1%)No 691 (92.9%)
Yes 3 (13.64%)No 19 (86.36%)
NS
Had heard of CD in country of origin
Yes 317 (42.6%)No 427 (57.4%)
Yes 22 (100%)No 0 (0%)
p<0.0001
Knew someone with CD
Yes 89 (12%)No 655 (88%)
Yes 18 (81.81%)No 4 (18.19%)
p<0.0001
10.1371/journal.pntd.0001135.t002
Countries of origin.
Country
Total n = 766 (%)
Infected by T. cruzi
n = 22 (%)
Peru
173 (22.9)
Ecuador
171 (22.3)
Bolivia
127 (16.6)
21 (95.45)
Colombia
102 (13.3)
Argentina
63 (8.2)
Venezuela
31 (4)
Brazil
23 (3)
Chile
22 (2.9)
Paraguay
19 (2.5)
1 (4.55)
Uruguay
14 (1.8)
Honduras
12 (1.6)
El Salvador
5 (0.5)
Mexico
2 (0.2)
Guatemala
1 (0.1)
Panama
1 (0.1)
Of the 766 patients analyzed, 27 were reactive to the ICT and 20 of these were
reactive in cELISA, rELISA and oELISA. Also, 2 patients of the 101 tested by ICT,
cELISA, and rELISa regardless of the result of the first were reactive in cELISA and
rELISA. Both were also positive in oELISA, so they were considered positive.
A total of 22 patients were diagnosed with CD, corresponding to a prevalence of
2.87% (95% CI, 1.6–4.12%) in the sample studied. Of
these, 21 were from Bolivia; the prevalence of CD in the subgroup of Bolivian
patients studied (n = 127) was 16.53% (95% CI,
9.6–23.39%). The remaining patient was from Paraguay.
All the patients infected by T. cruzi were in the chronic phase of
CD. The clinical form and the reasons why they visited the health center are
presented in Table 3. Four
patients (18.2%) had been previously diagnosed in the country of origin, but
none of them mentioned it in the primary care visit because they thought it was a
health problem proper to their country that would be unknown to the Spanish health
staff (this information was obtained when they were asked for informed consent to
participate in the study). None of them were aware of their clinical phase and 2
patients had received incomplete treatment.
10.1371/journal.pntd.0001135.t003
Clinical phase of Chagas disease (CD) and reasons for visit.
Clinical symptoms not suggestive of CD
Clinical symptoms suggestive of CD
PAPPSa
Total no. of patients with T. cruzi
infection and complete studyn = 21b
Diagnosed in country of origin
Not previously diagnosed
Indeterminate form18
8
1c
3
5
17 (81%)
Cardiac form19
1
-
1
-
2 (9.5%)e
Digestive form26
-
-
-
-
0 (0%)
Cardiodigestive form
-
1d
-
1
2 (9.5%)f
9 (42.8%)
2 (9.5%)
4 (19.1%)
6 (28.6%)
21 (100%)
PAPPS: Preventive Activities and Health Promotion Program.
Of the 22 patients diagnosed with CD, one failed to complete the
tests.
Dysphagia dating from >1 year earlier.
Longstanding palpitations and dysphagia.
One case with right bundle Branch block, and other with a T-wave
inversion in inferior leads.
One case: right bundle branch block associated with left anterior
hemiblock and hypotonia of the lower esophageal sphincter. Second case:
right bundle branch block with severe hypotonia of the lower esophageal
sphincter and distal esophageal hypoperistalsis.
Discussion
The prevalence of T. cruzi infection in the sample studied was
2.87% and in the subgroup of Bolivian patients it was 16.53%. In the
medical literature we found few studies of similar characteristics to ours
(involving screening of the adult Latin American population in primary care) and
their results varied [29], [12] due to the heterogeneity of the populations analyzed and
the distribution of CD in Latin America.
The laboratory confirmation of a clinical suspicion of CD is based on consistent
results of at least 2 different immunological tests [24]. ICTs are attractive in primary
care because they are easy to use in routine clinical practice and do not require
sophisticated facilities or specialized staff. In the substudy that we performed in
101 patients [25], for the ICT used we found a sensitivity of 92.5%
and a specificity of 96.8%. Other studies have evaluated the sensitivity and
specificity of ICTs [30], [31] with similar results. The current sensitivity of ICTs
must be increased so that they can be used as effective screening tests. Meanwhile,
they should be combined with other methods that offer greater sensitivity [25], [31].
The highest prevalence was found among Bolivian patients, in agreement with other
studies performed in Spain [9], [16] and other non-endemic countries [12], [32]. No cases were diagnosed among
the Peruvian or Ecuadorian patients, who formed 45% of the sample, probably
due to the heterogeneous distribution of CD in endemic countries and the lower
seroprevalence of T. cruzi estimated in Peru (0.69%) and
Ecuador (1.74%) [33].
An epidemiologic history of having lived in rural areas and/or adobe houses showed a
significant relationship with T. cruzi infection, consistent with
the dominant vector-borne transmission mechanism in the countries of origin. All
patients with T. cruzi infection had heard of CD in their countries
of origin and approximately 82% knew someone who was affected. These data
should be taken into account for establishing CD screening criteria in immigrants
from endemic zones, because mere knowledge of the disease may be considered as an
indirect indicator of its presence in the region of origin.
In non-endemic countries CD screening programs have been aimed at particularly
susceptible groups: in blood banks (France [34], the USA [35] and Spain [36]), and in
pregnant Latin American women and their neonates (the Spanish autonomous communities
of Catalonia [37] and Valencia [38]). In our study only
9.5% of the patients with T. cruzi infection had visited the
health center due to clinical symptoms suggestive of CD. As it is a silent disease
that has recently appeared in non-endemic countries, we stress the importance of
establishing in these countries health screening programs based on compatible
epidemiologic history among the general immigrant population from endemic areas.
These programs should be multidisciplinary [3], supported by the best
scientific evidence possible, and promoted by the health authorities.
In non-endemic countries, detecting persons infected by T. cruzi is important in
order to control the transmission (vertical, by transfusion, or by organ
transplant), reduce reactivations in immunodepressed persons, and delay the onset of
the chronic cardiac form through antiparasite treatment [39], all of which have a great
impact on the persons affected, on public health, and on health systems.
Nevertheless, the best solution for CD is a combination of treatment and prevention
in endemic countries [40], [41], where many programs and initiatives are underway [2], [42].
The data obtained in this study and the experiences described elsewhere [4], [12], [14], [16], [20], [27] suggest that it
is advisable to perform CD screening in non-endemic countries on all patients from
continental Latin America who: (1) have a suggestive epidemiologic history (having
lived in a rural area, in adobe houses or having knowledge of CD in the country of
origin), (2) are pregnant, (3) are immunosuppressed, (4) have symptoms suggestive of
CD, or (5) request screening.
We thank OPERON S.A. for the disinterested supply of the ICTs. We also thank Silvia
Tebar, Antoni Soriano and Lluís Valerio for their collaboration.
Chagas-Clot research group
Physicians: Ignacio Aoiz Linares, Isabel Arias Moliz, Joan Bayó
Llibre, Marta Buela, Francesc-Xavier Cano Sana, Ester Casajuana Brunet, Josefina
Filomena, Sarai de la Fuente Gilabert, Francisco-Javier García-Alfaro, Carlos
Gonzalvo Orero, Laura Haro, MCarmen Igualada Delgado, Fernando Martín
González, Elena Mellado, Itsaso Mendizábal Condon, Verónica
Moldón, Melania Priego, Ricard Riel Cabrera, Carme Roca Saumell, Núria
Sellarés, Rosa Senán Sanz, Mireia Ventura Fontanet, Nieves Vizcay
Guruchaga, Josep Lluís Abad Rodríguez, Manel Honrado.
Nurses: Teresa Areny Ribera, Gloria Camacho García, Consuelo
Cantalapiedra Caicedo, Florencio Cardosa Oliver, Monica Espelt, M.Isabel
Fernández Fraga, Josep Manel Grau Granero, Jordi López-Solana,
M.Concepción López–Navarro, Esther Montero Moya, Anna Parcerisa
Miralles, Marineus Puig García, Gloria Rosillo Sanz, Anna Urpí
Fernández, M.José Lapuerta. Clinical assistants: Lurdes
Martínez-Vidal, Rosa Fernández. Health Technicians: Josep
Maria Escribà Jordana, Isabel Plaza Espuña.
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