Blood deprivation and heat stress increase mortality in bed bugs (Cimex lectularius) exposed to insect pathogenic fungi or desiccant dust.

Bed bugs (Cimex lectularius L.) have returned as a nuisance pest in the last 20 years. Different bed bug control measures in combination have not been thoroughly studied, although induction of multiple stressors may improve extermination. The effects of heat stress only, heat stress followed by exposure to insect pathogenic fungi, and heat stress followed by exposure to desiccant dust on starved and blood-fed bed bugs were investigated. Five days at 22 °C (control), 32 °C, 34 °C, or 36 °C (heat stress) did not cause mortality in adults. However, their starved first instar nymphs produced after heat stress suffered mortalities of 33%, 56% and 100%, respectively. Exposure to insect pathogenic fungi after heat stress increased the mortality of adults and their progeny compared to exposure to fungi without heat stress. The beneficial effects of heat stress were not observed in blood-fed bed bugs. Desiccant dust killed all nymphs within 2 days and all adults within 3 days regardless of previous heat stress, but survival time was prolonged by access to blood. This study highlights the advantage of combining different methods in pest management, and points to heat stress combined with blood deprivation as possible management elements to increase the control success.

Insecticidal Activity of Doxycycline against the Common Bedbug.

There is an ongoing need for safe and effective anti-bedbug compounds. Here, we tested the toxicity of three antimicrobial agents against bedbugs when administered orally. We reveal that doxycycline has direct insecticidal activity at 250 µg/ml (0.025%) that is particularly strong against immature bedbugs and appears to be independent of antimicrobial activity. Future studies to determine the mechanisms behind this property could be useful for the development of orally active insecticides or anti-bedbug therapeutics.

The double-mutation（M918I + L1014F）kdr allele is fixed in Cimex hemipterus populations in Guangxi, China.

Four putative knockdown resistance (kdr) mutations have been documented in the voltage-gated sodium channel (VGSC) gene of Cimex hemipterus from several countries. However, no information regarding kdr mutations in any Chinese tropical bed bug population is available to date. In this study, a double-mutation（M918I + L1014F）kdr allele was identified in six C. hemipterus populations across Guangxi Zhuang Autonomous Region of China. The frequency of this allele was 100% in all the six examined populations. In addition, only two cytochrome c oxidase I (COI) gene haplotypes, with one synonymous nucleotide variation, were identified in a total of 48 individuals from six locations. The fixation and broad geographic distribution of this resistant allele questions the continued use of pyrethroids in the treatment of tropical bed bug infestations. The very low genetic diversity within and among these populations indicates that these bed bugs may have a single origin.

Bed bugs, Cimex lectularius L., exhibiting metabolic and target site deltamethrin resistance are susceptible to plant essential oils.

Pyrethroid resistance has been a major hurdle limiting the effective control of bed bugs (Cimex lectularius L.). Alternative approaches that include the use of plant essential oils (EOs) have been proposed for effective management of bed bugs. However, EO resistance level comparisons between pyrethroid susceptible and resistant bed bug populations have not been previously conducted. The goal of this study was twofold: (i) determine deltamethrin resistance levels and associated resistance mechanisms in the field-collected Knoxville strain and (ii) quantify resistance levels of the Knoxville strain to five EOs (thyme, oregano, clove, geranium and coriander), their major insecticidal constituents (thymol, carvacrol, eugenol, geraniol and linalool) and an EO-based product (EcoRaider®). First, we found that the Knoxville strain was 72,893 and 291,626 fold more resistant to topically applied deltamethrin in comparison to the susceptible Harlan strain at the LD25 and LD50 lethal dose levels, respectively. Synergist bioassays and detoxification enzyme assays revealed significantly higher activity of cytochrome P450 and esterase enzymes in the resistant Knoxville strain. Further, Sanger sequencing revealed the presence of the L925I mutation in the voltage-sensitive sodium channel α subunit gene. The Knoxville strain that possesses both enzymatic and target site deltamethrin resistance, however, did not show any resistance to EOs, their major insecticidal constituents and EcoRaider® in topical bioassays (resistance ratio of ~1). In conclusion, this study demonstrated that a deltamethrin-resistant strain of bed bugs is susceptible to EOs and their insecticidal constituents.

Essential Oils of Five Baccharis Species: Investigations on the Chemical Composition and Biological Activities.

This paper provides a comparative account of the essential oil chemical composition and biological activities of five Brazilian species of Baccharis (Asteraceae), namely B. microdonta, B. pauciflosculosa, B. punctulata, B. reticularioides, and B. sphenophylla. The chemical compositions of three species (B. pauciflosculosa, B. reticularioides, and B. sphenophylla) are reported for the first time. Analyses by GC/MS showed notable differences in the essential oil compositions of the five species. α-Pinene was observed in the highest concentration (24.50%) in B. reticularioides. Other major compounds included α-bisabolol (23.63%) in B. punctulata, spathulenol (24.74%) and kongol (22.22%) in B. microdonta, ß-pinene (18.33%) and limonene (18.77%) in B. pauciflosculosa, and ß-pinene (15.24%), limonene (14.33%), and spathulenol (13.15%) in B. sphenophylla. In vitro analyses for antimalarial, antitrypanosomal, and insecticidal activities were conducted for all of the species. B. microdonta and B. reticularioides showed good antitrypanosomal activities; B. sphenophylla showed insecticidal activities in fumigation bioassay against bed bugs; and B. pauciflosculosa, B. reticularioides, and B. sphenophylla exhibited moderate antimalarial activities. B. microdonta and B. punctulata showed cytotoxicity. The leaves and stems of all five species showed glandular trichomes and ducts as secretory structures. DNA barcoding successfully determined the main DNA sequences of the investigated species and enabled authenticating them.

A screen of pharmaceutical drugs for their ability to cause short-term morbidity and mortality in the common bed bug, Cimex lectularius L.

The common bed bug, Cimex lectularius L., is a hematophagous ectoparasite that preferentially feeds on humans. Pharmaceuticals present in a person's blood may adversely affect C. lectularius when it feeds. We fed >10,000 C. lectularius on blood samples containing more than 400 different drug doses and drug combinations using an in vitro feeding system to determine insect mortality. The majority of drug doses approximated the peak plasma concentration in humans taking those drugs. Twenty-one drugs were found to cause >17% 12-14-day mortality compared to 8.5% mortality in the control (p < 0.05), but postliminary testing of three of the drugs, famotidine, ethambutol, and primaquine, did not demonstrate an increase in C. lectularius mortality. We also tested 23 drugs for their effects on C. lectularius fecundity. The results may have implications for understanding C. lectularius population dynamics in an infestation.

Insecticidal activity of an essential oil of Tagetes patula L. (Asteraceae) on common bed bug Cimex lectularius L. and molecular docking of major compounds at the catalytic site of ClAChE1.

Emerging resistance to insecticides has influenced pharmaceutical research and the search for alternatives to control the common bed bug Cimex lectularius. In this sense, natural products can play a major role. Tagetes patula, popularly known as dwarf marigold, is a plant native to North America with biocide potential. The aim of this work was to evaluate the biological activity of T. patula essential oil (EO) against adult common bed bugs via exposure to dry residues by the Impregnated Paper Disk Test (IPDT) using cypermethrin as a positive control. We selected the enzyme acetylcholinesterase as a target for modeling studies, with the intent of investigating the molecular basis of any biological activity of the EO. Chemical analysis of the EO was performed using gas chromatography coupled to mass spectrometry (GC-MS). Additionally, oral and dermal acute toxicity tests were performed according to Organization for Economic Cooperation and Development (OECD) guidelines. The sulforhodamine B assay (SRB) was performed to verify the cytotoxicity of EO to HaCaT cells. The EO eliminated 100 % of the bed bugs at 100 mg mL-1 with an LC50 value of 15.85 mg mL-1. GC-MS analysis identified α-terpinolene, limonene, piperitenone, and piperitone as major components of the mixture. Molecular modeling studies of these major compounds suggested that they are acetylcholinesterase inhibitors with good steric and electronic complementarity. The in vitro cytotoxicity evaluation revealed a LC50 = 37.06 µg mL-1 and in vivo acute toxicity showed an LC50 >4000 mg kg-1, indicating that the EO presents low risk of toxic side effects in humans. The T. patula essential oil components provide a promising strategy for controlling bed bug populations with low mammalian toxicity. These findings pave the way for further in vivo studies aimed at developing a safe and effective insecticide.

Toxicity and potential utility of ivermectin and moxidectin as xenointoxicants against the common bed bug, Cimex lectularius L.

The recent resurgence of the common bed bug Cimex lectularius L. throughout western industrialized nations has been facilitated in part by the insect becoming pesticide-resistant. Novel control strategies, including xenointoxication, should be considered to combat C. lectularius. Ivermectin, a U.S. Food and Drug Administration (FDA)-approved treatment for several human parasites, and the antiparasitic drug moxidectin, currently being explored in human clinical trials, were evaluated for efficacy against C. lectularius. Results showed that C. lectularius fed on ivermectin or moxidectin blood concentrations of >25 ng/mL and had significantly higher mortality (50-100 %) than controls (0-6 %) by day 13. Bed bugs that survived a blood meal containing >2.5 ng/mL of ivermectin suffered long-term sequelae including reduced fecundity, feeding difficulty, and incomplete ecdysis. Some insects that survived a blood meal containing ≤75 ng/mL moxidectin were able to feed and reproduce.

Posttreatment Feeding Affects Mortality of Bed Bugs (Hemiptera: Cimicidae) Exposed to Insecticides.

Insecticide sprays and dusts are used for controlling bed bugs, Cimex lectularius L. In natural environments, bed bugs have daily access to hosts after they are exposed to insecticides. The established laboratory insecticide bioassay protocols do not provide feeding after insecticide treatments, which can result in inflated mortality compared with what would be encountered in the field. We evaluated the effect of posttreatment feeding on mortality of bed bugs treated with different insecticides. None of the insecticides tested had a significant effect on the amount of blood consumed and percent feeding. The effect of posttreatment feeding on bed bug mortality varied among different insecticides. Feeding significantly reduced mortality in bed bugs exposed to deltamethrin spray, an essential oil mixture (Bed Bug Fix) spray, and diatomaceous earth dust. Feeding increased the mean survival time for bed bugs treated with chlorfenapyr spray and a spray containing an essential oil mixture (Ecoraider), but did not affect the final mortality. First instars hatched from eggs treated with chlorfenapyr liquid spray had reduced feeding compared with nymphs hatched from nontreated eggs. Those nymphs hatched from eggs treated with chlorfenapyr liquid spray and successfully fed had reduced mortality and a higher mean survival time than those without feeding. We conclude that the availability of a bloodmeal after insecticide exposure has a significant effect on bed bug mortality. Protocols for insecticide efficacy testing should consider offering a bloodmeal to the treated bed bugs within 1 to 3 d after treatment.

Quantitative Sequencing for the Determination of Kdr-type Resistance Allele (V419L, L925I, I936F) Frequencies in Common Bed Bug (Hemiptera: Cimicidae) Populations Collected from Israel.

Human bed bug infestations have dramatically increased worldwide since the mid-1990s. A similar phenomenon was also observed in Israel since 2005, when infestations were reported from all over the country. Two single nucleotide polymorphisms (V419L and L925I) in the bed bug voltage-sensitive sodium channel confer kdr-type resistance to pyrethroids. Using quantitative sequencing (QS), the resistance allele frequencies of Israeli bed bug populations from across the country were determined. Genomic DNA was extracted from samples of 12 populations of bed bugs collected from Israel and DNA fragments containing the V419L or L925I and I936F mutations sites were PCR amplified. The PCR products were analyzed by QS and the nucleotide signal ratios calculated and used to predict the resistance allele frequencies of the unknown populations. Results of the genetic analysis show that resistant nucleotide signals are highly correlated to resistance allele frequencies for both mutations. Ten of the 12 tested populations had 100% of the L925I mutation and 0% of the V419L mutation. One population was heterogeneous for the L925I mutation and had 0% of the V419L mutation and another population was heterogeneous for the V419L mutation and had 100% of the L925I mutation. I936F occurred only at low levels. These results indicate that bed bugs in Israel are genetically resistant to pyrethroids. Thus, pyrethroids should only be used for bed bug management with caution using effective application and careful monitoring procedures. Additionally, new and novel-acting insecticides and nonchemical means of controlling bed bugs should be explored.

Effectiveness of a Sugar-Yeast Monitor and a Chemical Lure for Detecting Bed Bugs.

Effective bed bug (Cimex lectularius L.) monitors have been actively sought in the past few years to help detect bed bugs and measure the effectiveness of treatments. Most of the available active monitors are either expensive or ineffective. We designed a simple and affordable active bed bug monitor that uses sugar-yeast fermentation and an experimental chemical lure to detect bed bugs. The sugar-yeast mixture released carbon dioxide at a similar rate (average 405.1 ml/min) as dry ice (average 397.0 ml/min) during the first 8 h after activation. In naturally infested apartments, the sugar-yeast monitor containing an experimental chemical lure (nonanal, L-lactic acid, 1-octen-3-ol, and spearmint oil) was equally effective as the dry ice monitor containing the same lure in trapping bed bugs. Placing one sugar-yeast monitor per apartment for 1-d was equally effective as 11-d placement of 6-18 Climbup insect interceptors (a commonly used bed bug monitor) under furniture legs for trapping bed bugs. When carbon dioxide was present, pair-wise comparisons showed the experimental lure increased trap catch by 7.2 times. This sugar-yeast monitor with a chemical lure is an affordable and effective tool for monitoring bed bugs. This monitor is especially useful for monitoring bed bugs where a human host is not present.

Blood constituents as phagostimulants for the bed bug Cimex lectularius L.

Many hematophagous arthropods are stimulated by blood constituents to initiate feeding. We used a membrane-based feeding system to identify chemicals that stimulate acceptance and engorgement responses in various life stages of bed bugs. Water was fortified with a variety of compounds (e.g. salts, amino acids, vitamins, nucleotides, cholesterol and fatty acids) in these bioassays. ATP was the most effective phagostimulant in adults and nymphs, resulting in >70% of bed bugs fully engorging. Addition of NaCl to low ATP solutions that alone elicited <50% engorgement significantly enhanced feeding responses of bed bugs. A comparison of feeding responses with solutions of various adenine nucleotides showed that ATP was more stimulatory than ADP, which was more effective than AMP. Feeding assays with physiological levels of other blood constituents such as d-glucose, albumin, globulin, cholesterol and mixtures of vitamins and amino acids did not stimulate engorgement, suggesting that adenine nucleotides are the most important feeding stimulants in bed bugs. Identification of phagostimulants for bed bugs will contribute towards the development of artificial diets for rearing purposes, as well as for the development of alternative methods to eliminate bed bug infestations.

Bed bugs, their blood sources and life history parameters: a comparison of artificial and natural feeding.

A blood-feeding system that utilizes a small amount of whole heparinized human blood in parafilm bags is described in detail, and similarities and differences between artificially fed and naturally rodent-fed bed bugs (Hemiptera: Cimicidae) are discussed. Blood with high levels of heparin (10%) was unsuitable for artificial colony rearing, whereas bed bugs fed on 1% heparinized blood and those that naturally ingested rat blood completed their lifecycle with similar stage structures over time, with no significant differences in mortality. No differences in feeding efficiency or fertility were found in a direct comparison of bed bugs maintained under each of these two treatments, but analysis of the full lifecycle revealed that artificially fed bed bugs became significantly smaller and laid fewer eggs than rodent-fed bed bugs. The level of membrane stretching regulated the number of bed bugs that fed. When the membrane was stretched to twice its length and width, 96% of bed bugs successfully fed through the parafilm. Whole heparinized blood that was stored at 6 °C for ≥ 14 days failed to retain its nutritional value and the amount of blood consumed and number of consecutive moults were significantly reduced.

Biochemical and toxicological properties of two acetylcholinesterases from the common bed bug, Cimex lectularius.

We examined the molecular and enzymatic properties of two acetylcholinesterases (AChEs; ClAChE1 and ClAChE2) from the common bed bug, Cimex lectularius. Native polyacrylamide gel electrophoresis followed by activity staining and Western blotting revealed that ClAChE1 is the main catalytic enzyme and is abundantly expressed in various tissues. Both ClAChEs existed in dimeric form connected by a disulfide bridge and were attached to the membrane via a glycophosphatidylinositol anchor. To determine their kinetic and inhibitory properties, both ClAChE1 and ClAChE2 were in vitro expressed in Sf9 cells using a baculovirus expression system. ClAChE1 showed higher catalytic efficiency toward acetylcholine, supporting the hypothesis that ClAChE1 plays a major role in postsynaptic transmission. An inhibition assay revealed that ClAChE1 is generally more sensitive to organophosphates and carbamates examined although ClAChE2 was >4000-fold more sensitive to malaoxon than ClAChE1. The relatively higher correlation between the in vitro ClAChE1 inhibition and the in vivo toxicity suggested that ClAChE1 is the more relevant toxicological target for organophosphates and carbamates. Although the physiological function of ClAChE2 remains to be elucidated, ClAChE2 also appears to have neuronal functions, as judged by its tissue distribution and molecular and kinetic properties. Our findings help expand our knowledge on insect AChEs and their toxicological properties.

Effect of feeding status on mortality response of adult bed bugs (Hemiptera: Cimicidae) to some insecticide products.

Fresh and aged residual deposits of several insecticide products were tested against bed bug adults to determine if a recent bloodmeal affected their mortality response to the residues. The bed bugs with a recent bloodmeal survived significantly longer compared with the unfed ones on their exposure to fresh or aged residual deposits of chlorfenapyr and aged residual deposits of deltamethrin on a wooden substrate. Even though the survival time of fed bed bugs was significantly longer than that of unfed ones on their exposure to fresh residue of deltamethrin and aged residue of desiccant pyrethrin dust, these treatments resulted in similarly high final mortalities regardless of feeding status of the insects. Mortality responses of fed and unfed bed bugs were similar to fresh or aged residual deposits of imidacloprid + cyfluthrin combination and fresh residual deposits of desiccant pyrethrin dust. Topical application assays indicated that a recent bloodmeal significantly increased the bed bug's survival time for chlorfenapyr, but not for deltamethrin. Pyrethroid-resistant bed bugs also showed a similar increase in their survival time for chlorfenapyr after a bloodmeal. The comparison of mortality responses between fed and unfed bed bugs treated with similar amount of chlorfenapyr per fresh body weight indicated that increased body mass was not the primary cause for this bloodmeal-induced tolerance increase for chlorfenapyr. Because the surviving bed bugs can continue ovipositing, the effectiveness of chlorfenapyr residual deposits in bed bug harborages could be significantly affected by the feeding status of the adult bed bug populations.

Aggregation responses of Cimex hemipterus F. to semiochemicals identified from their excreta.

BACKGROUND & OBJECTIVES: Bedbug Cimex hemipterus lives in cracks and crevices, and shows aggregation activity in the harbourage containing its fecal matter. Limited information is available on the chemicals influencing this aggregation behaviour in C. hemipterus. Possible components responsible for aggregation, if identified and evaluated can be helpful in designing bedbug management. METHODS: Study on the isolation and identification of chemicals from the excreta extract responsible for aggregation has been carried by GC-MS. The compounds identified were evaluated at different concentrations to C. hemipterus and their attraction index was determined. RESULTS: The GC-MS analysis of the excreta extract resulted in identification of 33 different types of semiochemicals such as esters, carboxylic acids, alcohols, aldehydes, ketones and other hydrocarbons. Among these 33 compounds of various groups, the carboxylic acid (E)-2-hexenoic acid and the aldehyde (E)-2-hexenal found to elicit highest positive aggregation behavioural response in all the stages followed by hexenal. INTERPRETATION & CONCLUSION: The fecal matter influence the aggregation behaviour in C. hemipterus. (E)-2-hexenoic acid, hexanoic acid, (E)-2-hexenal and hexanal found to exhibit aggregation in various stages of bedbug life cycle. These chemical components can be further exploited for designing and development tool for management of bedbugs.

Species identification and pyrethroid resistance genotyping of recently resurgent Cimex lectularius and Cimex hemipterus in Korea.

The global resurgence of bed bug infestations, exacerbated by increasing international travel, trade, and insecticide resistance, has significantly impacted Korea. This study identified the bed bug species and performed pyrethroid resistance genotyping of recently resurgent bed bugs in Korea. Thirty-one regional bed bug samples were collected from 5 administrative regions: Gyeonggi-do (n=14), Seoul (n=13), Busan (n=2), Jeonllanam-do (n=1), and Chungcheongbuk-do (n=1). The samples underwent morphological and molecular identification. Twenty-four regional samples (77.4%) were identified as the tropical bed bug, Cimex hemipterus, and the remaining 7 regional samples (22.6%) were identified as the common bed bug, Cimex lectularius. The C. hemipterus regional samples carried at least three mutations associated with knockdown resistance (kdr), including 2 super-kdr mutations. The 7 C. lectularius regional samples possessed at least one of the 3 kdr-related mutations associated with pyrethroid resistance. This study confirms that the prevalent bed bug species recently in Korea is C. hemipterus, replacing the previously endemic C. lectularius. Additionally, the rise in bed bug populations with pyrethroid resistance underscores the necessity of introducing alternative insecticides.

Repellency of N,N-diethyl-3-methylbenzamide (DEET) during host-seeking behavior of bed bugs (Hemiptera: Cimicidae) in binary choice olfactometer assays.

The bed bug (Cimex lectularius L.) is one of the most prolific and burdensome indoor pests, and suppression of bed bug populations is a global priority. Understanding bed bug behavior is important to the development of new tactics for their control. Major gaps exist in our understanding of how host cues, insecticide resistance, and exposure modality impact the repellency of formulated products to bed bugs. Here, we validate the use of a binary choice olfactometer for assessing bed bug repellency behaviors using N,N-diethyl-3-methylbenzamide (DEET) in a dose-dependent manner, while considering the role of host-associated stimuli (with vs. without CO2), exposure modality (olfactory vs. olfactory and contact), and resistance status (susceptible vs. resistant) on repellency. We observed that host-seeking insecticide-susceptible bed bugs were repelled only when olfactorily exposed to high concentrations of DEET. However, exposure to DEET by contact repelled insecticide-susceptible bed bugs at 100-fold lower dose of DEET. Further, we demonstrate for the first time that insecticide-resistant bed bugs were significantly more responsive to DEET than susceptible bed bugs. We conclude that the 2-choice olfactometer is an effective tool for assessing the behavioral responses of bed bugs to spatial and contact repellents.

Identification of a Novel Inhibitor of Cimex lectularius Acetylcholinesterase.

Acetylcholinesterase (AChE) stands as a primary target of commercial insecticides, notably organophosphates and carbamates. Despite their widespread use in agricultural and indoor pest control, concerns over their high toxicity and the emergence of resistance have restricted their efficacy. In this study, we conducted high-throughput virtual screening against both wild-type (WT) and resistant Cimex lectularius AChE utilizing a library encompassing 1 270 000 compounds. From this screening, we identified 100 candidate compounds and subsequently assessed their inhibitory effects on purified AChE enzymes. Among these candidates, AE027 emerged as a potent inhibitor against both WT and resistant AChE, exhibiting IC50 values of 10 and 43 µM, respectively. Moreover, the binding of AE027 significantly stabilized AChE, elevating its melting temperature by approximately 7 °C. Through molecular docking and molecular dynamics simulation, we delineated the binding mode of AE027, revealing its interaction with a site adjacent to the catalytic center, which is distinct from known inhibitors, with differing poses observed between WT and resistant AChE. Notably, the resistance mutation F348Y, positioned at a site directly interfacing with AE027, impedes ligand binding through steric hindrance. Furthermore, we evaluated the toxicity and pharmacokinetic properties of AE027 utilizing bioinformatics tools. These findings lay a crucial foundation for the development of a novel generation of insecticides that can combat both WT and resistant pest populations effectively and safely.

A novel prolixicin identified in common bed bugs with activity against both bacteria and parasites.

The hematophagous common bed bug, Cimex lectularius, is not known to transmit human pathogens outside laboratory settings, having evolved various immune defense mechanisms including the expression of antimicrobial peptides (AMPs). We unveil three novel prolixicin AMPs in bed bugs, exhibiting strong homology to the prolixicin of kissing bugs, Rhodnius prolixus, and to diptericin/attacin AMPs. We demonstrate for the first time sex-specific and immune mode-specific upregulation of these prolixicins in immune organs, the midgut and rest of body, following injection and ingestion of Gr+ (Bacillus subtilis) and Gr- (Escherichia coli) bacteria. Synthetic CL-prolixicin2 significantly inhibited growth of E. coli strains and killed or impeded Trypanosoma cruzi, the Chagas disease agent. Our findings suggest that prolixicins are regulated by both IMD and Toll immune pathways, supporting cross-talk and blurred functional differentiation between major immune pathways. The efficacy of CL-prolixicin2 against T. cruzi underscores the potential of AMPs in Chagas disease management.