Appraisal of snakebite incidence and mortality in Bolivia.

No information has been yet published on snakebite in Bolivia. The country includes very different ecological situations leading to various epidemiological risks. A study has been carried out to evaluate the incidence and location of snakebite, particularly in relation with altitude, in order to improve management. Investigations on snakebite epidemiology were based on a) cases treated in health facilities as reported by health authorities and b) household surveys carried out in areas with high variations of altitude, in various regions of Bolivia. An average of 700 bites was treated each year in Bolivia (national annual incidence = 8 bites per 100,000 people) with a great disparity between districts. Household surveys showed annual incidences ranged from 30 to 110 bites per 100,000 inhabitants depending on location. Annual mortality ranged 0.1-3.9 per 100,000 people. A significant and constant inverse correlation was shown between snakebite incidence and altitude, which may be explained by both snake and human distributions and activities. Notification of snakebite is useful for improving patient management and informing antivenom distribution. It should also involve the report of deaths and clinical details of envenomation.

Evaluation of compliance to congenital Chagas disease treatment: results of a randomised trial in Bolivia.

BACKGROUND: A randomised, unblinded, clinical trial comparing two benznidazole regimens for congenital Chagas disease was carried out to determine whether simplification and reduction in the length of treatment could lead to better treatment compliance. METHODS: This study was conducted in Santa Cruz, Bolivia. Serological screening was carried out in pregnant women, and parasites were sought in the blood of newborns from seropositive mothers. Infected infants were randomly assigned to two treatment groups. Recovery was assessed by parasite seeking at 1 month and 2 months as well as serological tests at 9 months. Assessment of treatment adherence was based on weekly home visits and use of electronic monitors. RESULTS: Benznidazole was given to 63 newborns in group A (5 mg/kg in two daily doses for 60 days) and 61 newborns in group B (7.5 mg/kg in a single daily dose for 30 days). There was no difference in compliance between the two groups. The study confirmed the efficacy and good tolerance of both benznidazole regimens in the treatment of congenital Chagas disease. CONCLUSIONS: The short treatment should be preferred as it allows reducing the dose of benznidazole as well as the cost of treatment.

Influence of pregnancy on Trypanosoma cruzi parasitemia in chronically infected women in a rural Bolivian community.

To determine the role of pregnancy on Trypanosoma cruzi parasitemia, a matched cohort study was carried out in a rural Bolivian community comparing parasite rates in gravidae, puerperae, and non-pregnant infected women. A selection of 67 chronically infected women, who delivered between March 2004 and May 2005, were initially evaluated during the third trimester of pregnancy and again after delivery. They were matched for age, parity, and location with 104 seropositive non-pregnant women, who likewise had submitted blood for microscopic examination for T. cruzi parasites in June 2005. Seroreactive pregnant women had a higher rate of T. cruzi parasitemia (14.9%) than matched non-pregnant infected women (2.9%; P = 0.004). After delivery, parasitemia significantly decreased during puerperium (1.5%) compared with the period of pregnancy (14.9%; P = 0.03). This study showed an increase of parasite loads in maternal peripheral blood, during the third trimester, and a significant decline after delivery.

Door-to-door screening as a strategy for the detection of congenital Chagas disease in rural Bolivia.

OBJECTIVE: To demonstrate the feasibility of a house-to-house screening system used for congenital Chagas disease in rural areas based on an active search for pregnant women and newborns in their homes in addition to passive case detection in health facilities. METHODS: Exploratory phase conducted by the research team followed by an operational period coordinated by municipal health service. A blood sample was taken for serological and parasitological tests of Trypanosoma cruzi from pregnant women who were searching antenatal care or visited at home by field investigators. Infants born to T. cruzi-infected women were examined for infection at birth and again at 1 and 7 months of age. RESULTS: 64.5% of the pregnant women were infected. Congenital infection was diagnosed at birth in 4.0% (12/299) of the children born to seroreactive mothers. Twelve additional cases of infection (4%) were diagnosed in children between 1 and 7 months of age. Finally, 37% of the children were lost to follow-up in the exploratory phase and 53% during the operational phase (P=0.002), significantly fewer than in most passive case detection studies. CONCLUSION: Despite poorer outcomes after door-to-door screening activities have been transferred to the health system, a combined strategy based on active and passive case detection appeared to be efficient for identifying rural cases of congenital Chagas disease.

Antibody drop in newborns congenitally infected by Trypanosoma cruzi treated with benznidazole.

OBJECTIVE: To compare the drop of Chagas antibody titres between non-infected and congenitally infected newborns treated by two doses of benznidazole, aiming at evaluating the recovery time and giving recommendations regarding serological criteria of recovery. METHODS: During a clinical trial, the drop of Trypanosoma cruzi antibody titres measured by ELISA tests was followed during the first year of life in congenitally infected newborns treated with different doses of benznidazole and compared to T. cruzi antibody titres in non-parasitaemic newborns. Confirmation of recovery was given by two negative serological tests: Chagas Stat-Pak (CSP) (immunochromatography) and Chagatest v3.0 (ELISA). RESULTS: In non-parasitaemic infants of infected mothers, antibodies of maternal origin disappeared in <8 months while in infected infants, T. cruzi antibodies decreased more slowly and disappeared in 9-16 months allowing to confirm the recovery. All CSP tests were negative before the ninth month while about 10% of ELISA tests remained positive at the 12th month. CONCLUSIONS: Recovery may be confirmed in most cases at 10 months. The CSP test was compared to Chagatest v3.0 ELISA and appeared to give a reliable response. The decrease rate of antibodies does not depend on treatment modes.

Sensitivity and specificity of Chagas Stat-Pak test in Bolivia.

OBJECTIVE: To compare the results of an immunochromatographic test performed on whole blood, Chagas Stat-Pak, with those of an ELISA test using recombinant antigens. METHOD: We tested 995 subjects of a rural population of all ages in the south of Bolivia, 459 pregnant women of the same population and 1030 urban women giving birth from the east of Bolivia. RESULTS: The sensitivity of the CSP test for the entire studied population (n = 2484) was 94.73% [93.35-96.10]; the specificity was 97.33% [96.50-98.15]. However, the specificity differed significantly between rural pregnant and urban birthing women, which could be attributed either to differences of parasite strain or Chagas prevalence. CONCLUSION: The test is simple of use, reliable, relatively inexpensive (<2 US$ each test) and its performances are compatible with a field use for large-scale screenings.

Epidemiological evaluation of Chagas disease in a rural area of southern Bolivia.

We evaluated the prevalence of Chagas disease using a rapid screening test (Chagas Stat-Pak), confirmed by ELISA, in Caraparí, a village of 9000 inhabitants in southern Bolivian Chaco. The prevalence of Trypanosoma cruzi was estimated in a sample of 995 people. The prevalence adjusted on age was 51.2% and was proportionally related to age. We also observed a very significant cline from the south to the north of the locality, where the prevalence ranged from 40 to 80%. In children younger than 11 years, the prevalence was 21.5%, which confirmed the importance of residual vector transmission despite several years of vector control. Among women of procreation age, the prevalence was 63.9%, resulting in a high risk of congenital transmission. The control of the disease requires an increase in vector control and improvement of dwellings before considering children's treatment with trypanocide.

Serodiagnóstico de la Trypanosomiasis Americana en una población infantil: análisis epidemiológico / Serodiagnostic of the trypanosiomasis american in a poblation childlike, epidemiological analysis

La enfermedad de Chagas, ha sido reconocida como un problema mayor de Salud Pública estos últimos años. En Bolivia, la población infantil presenta un alto riesgo de infección por Trypanosoma cruzi en zonas endémicas. En este estudio, 1479 sueros provenientes de niños de 4 a 10 años de una zona peri-urbana de la ciudad de Cochabamba fueron analizados. Dos pruebas serológicas (IFI) y (ELISA) fueron utilizadas para la detección de anticuerpos anti Trypanosoma cruzi y todos los individuos fueron evaluados por un cuestionario epidemiológico y un examen clínico. Un 5.6 por ciento de seropositividad fue encontrado en el total de individuos estudiados. Esta población comprende dos grupos de niños provenientes de dos estratos sociales diferentes. Esta situación esta correlacionada significativamente con el riesgo de infección por Trypanosoma cruzi. Por otra parte, el análisis estadístico realizado entre las variables clínicas, hematológicas y antropométricas en relación a la infección Trypanosoma cruzi, nos demuestra una dependencia neta entre estas variables, salvo algunos aspectos antoropométricos (talla, peso) y hemáticos (población de segmentados) que presentan una tendencia relativa