RESUMO
As a result of globalization and constant migratory flows, Chagas disease is now present in almost all continents. The management and treatment of the disease is often influenced by the economic and social context of the societies that host patients. In this manuscript, we aim to provide a comparative review of approaches to patients with Chagas disease in the Americas and Europe.
Assuntos
Doença de Chagas , América , Doença de Chagas/tratamento farmacológico , Europa (Continente) , HumanosRESUMO
As a result of globalization and constant migratory flows, Chagas disease is now present in almost all continents. The management and treatment of the disease is often influenced by the economic and social context of the societies that host patients. In this manuscript, we aim to provide a comparative review of approaches to patients with Chagas disease in the Americas and Europe.
RESUMO
Chagas disease is the neglected tropical disease of greatest public health impact in the United States, where it affects over 300,000 people. Diverse barriers limit healthcare access for affected people; fewer than 1% have obtained testing or treatment. We interviewed 50 people with Chagas disease in Los Angeles, California, and administered a cultural consensus analysis questionnaire. Participants were asked about their experiences and perceptions of Chagas disease, access to healthcare, and strategies for coping with the disease. In participants' narratives, the physical and emotional impacts of the disease were closely interwoven. Participant explanatory models highlight difficulties in accessing care, despite a desire for biomedical treatment. Obtaining testing and treatment for Chagas disease poses substantial challenges for US patients.
Assuntos
Doença de Chagas , Adulto , Antropologia Médica , América Central/etnologia , Doença de Chagas/etnologia , Doença de Chagas/psicologia , Doença de Chagas/terapia , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Los Angeles , Masculino , México/etnologia , Pessoa de Meia-IdadeRESUMO
As the global COVID-19 pandemic advances, it increasingly impacts those vulnerable populations who already bear a heavy burden of neglected tropical disease. Chagas disease (CD), a neglected parasitic infection, is of particular concern because of its potential to cause cardiac, gastrointestinal, and other complications which could increase susceptibility to COVID-19. The over one million people worldwide with chronic Chagas cardiomyopathy require special consideration because of COVID-19's potential impact on the heart, yet the pandemic also affects treatment provision to people with acute or chronic indeterminate CD. In this document, a follow-up to the WHF-IASC Roadmap on CD, we assess the implications of coinfection with SARS-CoV-2 and Trypanosoma cruzi, the etiological agent of CD. Based on the limited evidence available, we provide preliminary guidance for testing, treatment, and management of patients affected by both diseases, while highlighting emerging healthcare access challenges and future research needs.
Assuntos
COVID-19/diagnóstico , COVID-19/epidemiologia , Doença de Chagas/diagnóstico , Doença de Chagas/epidemiologia , Doenças Negligenciadas , COVID-19/terapia , Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/epidemiologia , Doença de Chagas/terapia , Comorbidade , Estudos Transversais , Seguimentos , Previsões , Acessibilidade aos Serviços de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Fatores de RiscoRESUMO
Chagas disease (CD) in the United States is severely underdiagnosed, due to an absence of systematic screening as part of routine healthcare. We screened 189 relatives of 86 existing patients and found a CD prevalence of 7.4%. Screening close relatives of previously diagnosed individuals can effectively identify new CD cases.
Assuntos
Doença de Chagas/epidemiologia , Família , Adulto , Doença de Chagas/diagnóstico , Doença de Chagas/etiologia , Eletrocardiografia , Feminino , Humanos , Los Angeles/epidemiologia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Vigilância da População , Prevalência , Trypanosoma cruzi , Adulto JovemRESUMO
Chagas disease (CD) affects > 6 million people globally, including > 300,000 in the United States. Although early detection and etiological treatment prevents chronic complications from CD, < 1% of U.S. cases have been diagnosed and treated. This study explores access to etiological treatment from the perspective of patients with CD. In semi-structured interviews with 50 Latin American-born patients of the Center of Excellence for Chagas Disease at the Olive View-UCLA Medical Center, we collected demographic information and asked patients about their experiences managing the disease and accessing treatment. Patients were highly marginalized, with 63.4% living below the U.S. poverty line, 60% lacking a high school education, and only 12% with private insurance coverage. The main barriers to accessing health care for CD were lack of providers, precarious insurance coverage, low provider awareness, transportation difficulties, and limited time off. Increasing access to diagnosis and treatment will not only require a dramatic increase in provider and public education, but also development of programs which are financially, linguistically, politically, and geographically accessible to patients.
Assuntos
Doença de Chagas/terapia , Acessibilidade aos Serviços de Saúde , Feminino , Humanos , Seguro Saúde , Idioma , Masculino , Pobreza , Meios de Transporte , Estados UnidosRESUMO
Chagas disease (CD) affects over 300 000 people in the USA, many with limited access to healthcare. Although early detection and treatment prevents life-threatening complications, <1% of people with CD receive diagnosis, and routine screening is virtually nonexistent in the USA. We describe a program that led to an increase in CD screening in the Latin American-born population of Los Angeles.
Assuntos
Doença de Chagas/prevenção & controle , Serviços Preventivos de Saúde , California , Doença de Chagas/diagnóstico , Hispânico ou Latino , Humanos , Programas de RastreamentoRESUMO
AbstractChagas disease (CD), with associated conduction abnormalities, is a common indication for pacemaker implantation in Latin America. The prevalence of CD in Latin American immigrants with pacemakers residing in the United States has never been studied. This single-center cross-sectional study included pacemaker patients who were aged 18 years or more with a previous residence in Latin America for at least 6 months. Patients with an implantable cardioverter-defibrillator, cardiac resynchronization therapy, or iatrogenic and/or congenital heart block were excluded. Serological testing for Trypanosoma cruzi was performed at enrollment. A total of 80 patients were enrolled, and CD was diagnosed in six patients (7.5%). Patients with CD were more likely to be from El Salvador (P = 0.001). Other clinical, therapeutic, electrocardiographic, and echocardiographic variables were similar between the CD and non-CD groups. There is a high prevalence of CD among Latin American immigrants with pacemakers in Los Angeles.
Assuntos
Anticorpos Antiprotozoários/sangue , Cardiomiopatia Chagásica/diagnóstico por imagem , Cardiomiopatia Chagásica/etnologia , Marca-Passo Artificial , Trypanosoma cruzi/isolamento & purificação , Idoso , Idoso de 80 Anos ou mais , Cardiomiopatia Chagásica/parasitologia , Cardiomiopatia Chagásica/cirurgia , Estudos Transversais , El Salvador/etnologia , Eletrocardiografia , Emigrantes e Imigrantes , Feminino , Hispânico ou Latino , Humanos , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Trypanosoma cruzi/imunologiaRESUMO
Background: According to an estimate from the Centers for Disease Control and Prevention (CDC), Chagas disease (CD) may affect 1.31% of Latin American immigrants in the United States, with >300 000 cases. However, there is a lack of real-world data to support this estimate. Little is known about the actual prevalence of this neglected tropical disease in the United States, and the bulk of those infected are undiagnosed. Methods: From April 2008 to May 2014, we screened 4,755 Latin American-born residents of Los Angeles County. Blood samples were tested for serologic evidence of CD. We collected demographic data and assessed the impact of established risk factors on CD diagnosis, including sex, country of origin, housing materials, family history of CD, and awareness of CD. Results: There were 59 cases of CD, for an overall prevalence of 1.24%. Prevalence was highest among Salvadorans (3.45%). Of the 3,182 Mexican respondents, those from Oaxaca (4.65%) and Zacatecas (2.2%) had the highest CD prevalence. Salvadoran origin (aOR = 6.2; 95% CI = 2.8-13.5; P < .001), prior knowledge of CD (aOR = 2.4; 95% CI = 1.0-5.8; P = .047), and exposure to all 3 at-risk housing types (adobe, mud, and thatched roof) (aOR = 2.5; 95% CI = 1.0-6.4; P = .048) were associated with positive diagnosis. Conclusions: In the largest screening of CD in the United States to date outside of blood banks, we found a CD prevalence of 1.24%. This implies >30 000 people infected in Los Angeles County alone, making CD an important public health concern. Efficient, targeted surveillance of CD may accelerate diagnosis and identify candidates for early treatment.
Assuntos
Doença de Chagas/epidemiologia , Emigrantes e Imigrantes , Hispânico ou Latino , Adolescente , Adulto , Feminino , Humanos , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estudos Soroepidemiológicos , Testes Sorológicos , Adulto JovemRESUMO
Chagas disease (CD) affects over six million people and is a leading cause of cardiomyopathy in Latin America. Given recent migration trends, there is a large population at risk in the United States (US). Early stage cardiac involvement from CD usually presents with conduction abnormalities on electrocardiogram (ECG) including right bundle branch block (RBBB), left anterior or posterior fascicular block (LAFB or LPFB, respectively), and rarely, left bundle branch block (LBBB). Identification of disease at this stage may lead to early treatment and potentially delay the progression to impaired systolic function. All ECGs performed in a Los Angeles County hospital and clinic system were screened for the presence of RBBB, LAFB, LPFB, or LBBB. Patients were contacted and enrolled in the study if they had previously resided in Latin America for at least 12 months and had no history of cardiac disease. Enzyme-linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA) tests were utilized to screen for Trypanosoma cruzi seropositivity. A total of 327 consecutive patients were screened for CD from January 2007 to December 2010. The mean age was 46.3 years and the mean length of stay in the US was 21.2 years. Conduction abnormalities were as follows: RBBB 40.4%, LAFB 40.1%, LPFB 2.8%, LBBB 5.5%, RBBB and LAFB 8.6%, and RBBB and LPFB 2.8%. Seventeen patients were positive by both ELISA and IFA (5.2%). The highest prevalence rate was among those with RBBB and LAFB (17.9%). There is a significant prevalence of CD in Latin American immigrants residing in Los Angeles with conduction abnormalities on ECG. Clinicians should consider evaluating all Latin American immigrant patients with unexplained conduction disease for CD.
Assuntos
Doença de Chagas/fisiopatologia , Adolescente , Adulto , Doença de Chagas/epidemiologia , Doença de Chagas/etnologia , Eletrocardiografia , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Coração/fisiopatologia , Hispânico ou Latino/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estados Unidos/epidemiologia , Estados Unidos/etnologia , Adulto JovemRESUMO
Trypanosoma cruzi usually infects humans via triatomine insects in Latin America. Vector-borne transmission in the United States is exceedingly rare. We describe (1) the first case of probable autochthonous transmission reported in California in more than 30 years and (2) the first ever reported case in the greater Los Angeles area.
RESUMO
BACKGROUND: Nifurtimox is 1 of only 2 medications available for treating Chagas disease (CD) and currently the only drug available in the United States, but its safety and tolerance have not been extensively studied. This is the first study to evaluate tolerance of nifurtimox in US patients with CD. METHODS: This investigation assessed side effects in a sample of 53 patients with CD, all Latin American immigrants, who underwent treatment with nifurtimox (8-10 mg/kg in 3 daily doses for 12 weeks) from March 2008 to July 2012. The frequency and severity of adverse events (AEs) was recorded. RESULTS: A total of 435 AEs were recorded; 93.8% were mild, 3.0% moderate, and 3.2% severe. Patients experienced a mean of 8.2 AEs; the most frequent were anorexia (79.2%), nausea (75.5%), headache (60.4%), amnesia (58.5%), and >5% weight loss (52.8%). Eleven patients (20.8%) were unable to complete treatment. Experiencing a moderate or severe AE (odds ratio [OR], 3.82; P < .05) and Mexican nationality (OR, 2.29; P < .05) were significant predictors of treatment discontinuation, but sex and cardiac progression at baseline were not. Patients who did not complete treatment experienced nearly 3 times more AEs per 30-day period (P = .05). CONCLUSIONS: Nifurtimox produces frequent side effects, but the majority are mild and can be managed with dose reduction and/or temporary suspension of medication. The high frequency of gastrointestinal symptoms and weight loss mirrors results from prior investigations. Special attention should be paid during the early stages of treatment to potentially severe symptoms including depression, rash, and anxiety.
Assuntos
Doença de Chagas/tratamento farmacológico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Nifurtimox/efeitos adversos , Tripanossomicidas/efeitos adversos , Adulto , Idoso , Doença de Chagas/epidemiologia , Doença de Chagas/parasitologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Nifurtimox/uso terapêutico , Fenótipo , Fatores de Risco , Índice de Gravidade de Doença , Avaliação de Sintomas , Resultado do Tratamento , Tripanossomicidas/uso terapêutico , Trypanosoma cruzi , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Sudden unexpected death in epilepsy (SUDEP) is a major cause of death in those with drug-resistant epilepsy (DRE). There is a need for inventories and biomarkers associated with the risk for SUDEP. OBJECTIVE: To explore the revised SUDEP Risk Inventory (SUDEP-7) in a cohort with DRE and determine the association with Heart Rate and other covariates. METHODS: Twenty-five subjects with severe DRE were enrolled in a clinical trial for epilepsy. Baseline demographics, duration of epilepsy, seizure types, seizure frequency, seizure severity, AEDs, and vital signs were collected. Heart rate variability (HRV) was calculated from 1-h recordings of ECG. A SUDEP Risk Inventory (SUDEP-7) was administered, which included seven validated and weighted risk factors initially identified by Walczak et al. as factors associated with SUDEP risk. RESULTS: The total score on the revised SUDEP-7 ranged from 1 to 7, mean = 3.4 (SD 1.8). The SUDEP Risk Inventory score was inversely correlated with RMSSD (Pearson r = -0.45, p = 0.027). The following variables were significantly associated with RMSSD: epilepsy duration (p = 0.02), age (p = 0.03), and developmental intellectual disability (p < 0.001). The correlation between RMSSD and SUDEP-7 tended to persist also after the adjustment for patient age (r = -0.40, p = 0.05). Two subjects died of SUDEP: their SUDEP-7 scores were above average and in the upper twenty-fifth and fiftieth percentiles, respectively (6 and 4, mean = 3.4). CONCLUSION: RMSSD, a measure of low frequency HRV, was significantly associated with SUDEP Risk Inventory (SUDEP-7) scores. Using a multivariate model, the covariates of developmental intellectual disability, age, and duration of epilepsy were also significantly associated with decreased HRV. The correlation between decreased HRV and a higher SUDEP-7 score remained unchanged even after the adjustment for patient age. The results suggest that older age, greater duration of epilepsy, and the presence of developmental intellectual disability may increase the risk of SUDEP through their direct influence on decreasing the vagus nerve-mediated HRV. Further validation of the SUDEP-7 inventory is indicated. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00871377.
RESUMO
BACKGROUND: Chagas disease is a well-known cause of cardiomyopathy in Latin America; however, 300 000 individuals are estimated to have Chagas disease in the United States. This study examined the prevalence and impact of Chagas cardiomyopathy (CCM) in a US population. We hypothesized that patients with CCM would have increased morbidity and mortality when compared with patients with non-CCM. METHODS AND RESULTS: This is a single-center, prospective cohort study. Enrollment criteria were new diagnosis of nonischemic cardiomyopathy (left ventricular ejection fraction ≤40%) and previous residence in Latin America for at least 12 months. Serological testing for Trypanosoma cruzi was performed at enrollment. The primary end point was all-cause mortality or heart transplantation. The secondary end point was heart failure-related hospitalization. A total of 135 patients were enrolled, with a median of 43 months of follow-up. Chagas disease was diagnosed in 25 (19%) patients. The primary end point occurred in 9 patients (36%) in the CCM group and in 11 patients (10%) in the non-CCM group (hazard ratio [HR], 4.46; 95% confidence interval, 1.8-10.8; P=0.001). The secondary end point occurred in 13 patients (52%) in the CCM group and in 35 patients (32%) in the non-CCM group (HR, 2.22; 95% confidence interval, 1.2-4.2; P=0.01). CONCLUSIONS: There is a high prevalence of Chagas disease among Latin American immigrants diagnosed with nonischemic cardiomyopathy in Los Angeles. Advanced CCM portends a poor prognosis and is associated with increased all-cause mortality/heart transplantation and heart failure-related hospitalization.
Assuntos
Cardiomiopatias/etnologia , Doença de Chagas/etnologia , Emigrantes e Imigrantes , Idoso , California/epidemiologia , Feminino , Seguimentos , Humanos , América Latina/etnologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos ProspectivosRESUMO
Chagas disease is a major neglected tropical disease caused by persistent chronic infection with the protozoan parasite Trypanosoma cruzi. An estimated 8 million people are infected with T. cruzi, however only 2 drugs are approved for treatment and no vaccines are available. Thus there is an urgent need to develop vaccines and new drugs to prevent and treat Chagas disease. In this work, we identify T cell targets relevant for human infection with T. cruzi. The trans-sialidase (TS) gene family is a large family of homologous genes within the T. cruzi genome encoding over 1,400 members. There are 12 highly conserved TS gene family members which encode enzymatically active TS (functional TS; F-TS), while the remaining TS family genes are less conserved, enzymatically inactive and have been hypothesized to be involved in immune evasion (non-functional TS; NF-TS). We utilized immunoinformatic tools to identify HLA-A2-restricted CD8(+) T cell epitopes conserved within F-TS family members and NF-TS gene family members. We also utilized a whole-genome approach to identify T cell epitopes present within genes which have previously been shown to be expressed in life stages relevant for human infection (Non-TS genes). Thirty immunogenic HLA-A2-restricted CD8(+) T cell epitopes were identified using IFN-γ ELISPOT assays after vaccination of humanized HLA-A2 transgenic mice with mature dendritic cells pulsed with F-TS, NF-TS, and Non-TS peptide pools. The immunogenic HLA-A2-restricted T cell epitopes identified in this work may serve as potential components of an epitope-based T cell targeted vaccine for Chagas disease.
Assuntos
Antígenos de Protozoários/imunologia , Linfócitos T CD8-Positivos/imunologia , Biologia Computacional/métodos , Epitopos de Linfócito T/imunologia , Glicoproteínas/imunologia , Antígeno HLA-A2/metabolismo , Neuraminidase/imunologia , Trypanosoma cruzi/imunologia , Animais , Antígenos de Protozoários/genética , ELISPOT , Feminino , Glicoproteínas/genética , Humanos , Interferon gama/metabolismo , Camundongos Transgênicos , Neuraminidase/genética , Vacinas Protozoárias/administração & dosagem , Vacinas Protozoárias/imunologia , Trypanosoma cruzi/genéticaRESUMO
The US-based Center of Excellence for Chagas Disease performed an observational study on the safety and tolerance of benznidazole 5 mg/kg/day for 60 days in 30 adults with chronic Chagas disease. The side-effect profile was suboptimal, including 5 cases of debilitating neuropathy and an unusually high angioedema rate.
Assuntos
Doença de Chagas/tratamento farmacológico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Nitroimidazóis/efeitos adversos , Tripanossomicidas/efeitos adversos , Adolescente , Adulto , Idoso , Angioedema/induzido quimicamente , Angioedema/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nitroimidazóis/uso terapêutico , Doenças do Sistema Nervoso Periférico/induzido quimicamente , Doenças do Sistema Nervoso Periférico/epidemiologia , Estudos Retrospectivos , Tripanossomicidas/uso terapêutico , Estados Unidos , Adulto JovemRESUMO
Approximately 300,000 persons have Chagas disease in the United States, although almost all persons acquired the disease in Latin America. We examined awareness of Chagas disease among Latin American immigrants living in Los Angeles, California. We surveyed 2,677 persons (age range = 18-60 years) in Los Angeles who resided in Latin America for at least six months. A total of 62% of the participants recalled seeing triatomines in Latin America, and 27% of the participants reported triatomine bites at least once per year while living abroad. A total of 86% of the participants had never heard of Chagas disease. Of persons who had heard of Chagas disease, 81% believed that it was not serious. More than 95% of those who had heard of Chagas disease would want to be tested and treated. Most Latin American immigrants living in Los Angeles recalled exposure to vectors of Chagas disease. However, they have little knowledge of this disease. Increasing awareness of Chagas disease is needed in this high-risk population.
Assuntos
Doença de Chagas/epidemiologia , Emigrantes e Imigrantes , Conhecimentos, Atitudes e Prática em Saúde , Hispânico ou Latino , Adolescente , Adulto , Animais , Estudos Transversais , Feminino , Humanos , América Latina/etnologia , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores Socioeconômicos , Triatoma/parasitologia , Trypanosoma cruzi/isolamento & purificação , Adulto JovemRESUMO
Chagas disease, which is caused by the protozoan parasite Trypanosoma cruzi, can lead to severe cardiac and gastrointestinal disease. Most persons acquire this infection through contact with vector bugs carrying T. cruzi in endemic areas of Latin America. Infection can also be acquired by congenital, transfusion, transplantation, and foodborne transmission. Although an estimated 300,000 persons with Chagas disease live in the United States, little is known about the burden of chagasic heart disease. It is not known how often congenital or vector-borne transmission of T. cruzi occurs in the United States, although it is known that infected mothers and infected vector bugs are found in this country. Better diagnostic tests and treatment drugs are needed to improve patient care, and research is needed to define transmission risks and develop strategies to prevent new infections and reduce the burden of disease.