Clinical, epidemiological characteristics and indications for liver biopsy and treatment in immigrants with chronic hepatitis B at a referral hospital in Madrid.

The increase in immigration from less developed countries to Europe has led to an increase in the incidence of hepatitis B infection. The objective of this study was to describe the clinical, epidemiological characteristics and indications for treatment of chronic hepatitis B in a cohort of immigrants, given the relative lack of current evidence. We performed a noninterventional retrospective chart review; different characteristics depending on geographical origin were compared. A case-control study was also performed to describe factors potentially associated with chronic or past hepatitis B virus (HBV) infection. We selected a random sample of 436 patients out of the 2989 immigrants attending during the study period (1989-2008). Hepatitis B serology was performed in 74% (322/436): 10.6% had chronic HBV infection (95% CI: 7.4-13.7%), and 46.9% had evidence of past infection (95% CI: 41.7-52.0%). The average age was 31 years, 60% were men, and 70% were sub-Saharan Africans. Chronic infection was related to being men (OR 2.03; 95%CI: 1.29-3.18), younger (OR 0.98; 0.96-0.99) and sub-Saharan African (OR 5.41; 2.71-10.83). Past or current infection was related to male sex (OR 2.80; 1.81-4.30), longer time elapsed until first seen at the unit (OR 0.998; 0.997-1.000), HIV infection (OR 4.99; 1.15-21.60) and being sub-Saharan African (OR 15.46; 8.97-27.18). These associations were not confirmed after adjustment for geographical origin. In 27% and 29.5% of patients, liver biopsy and treatment, respectively, would have been indicated. Prevalence of chronic HBV infection amongst immigrants is high, especially in sub-Saharan Africans. Almost a third could be considered for liver biopsy or antiviral therapy.

Gastro-intestinal Chagas disease in migrants to Spain: prevalence and methods for early diagnosis.

Each year in Spain, the number of Latin American immigrants who present with chronic Trypanosoma cruzi infection increases. Although gastro-intestinal abnormalities are not as common as cardiomyopathy in such infection, they can still lead to an impaired quality of life. In a recent study based in Madrid, the frequencies of gastro-intestinal involvement in a cohort of Latin American immigrants infected with T. cruzi, and the role of early diagnostic techniques in the detection of such involvement, were explored. Between January 2003 and April 2009, all Latin Americans who attended the Tropical Medicine Unit of the Hospital Universitario Ramón y Cajal were tested for T. cruzi infection, in IFAT and ELISA. Each subject found both IFAT- and ELISA-positive was considered to be infected (chronically) and checked for symptoms indicative of Chagas disease. Each infected subject giving informed consent was investigated further, using an electrocardiogram, an echocardiogram and oesophageal manometry. Between January 2003 and June 2008, every infected subject who consented was also explored using a barium swallow and barium enema. After July 2008, however, only subjects showing oesophageal and/or colonic symptoms were investigated in this manner. Of the 248 patients found infected with T. cruzi, 118 underwent oesophageal manometry, 75 a barium enema and 48 a barium swallow. Thirteen (11%) showed evidence of oesophageal involvement (incomplete relaxation of the lower oesophageal sphincter; three cases) or bowel involvement (five cases of dolichosigma, three of dolichocolon and two of megacolon). Only six of these 13 had any gastro-intestinal symptoms (all six were suffering from constipation). None of the barium swallows revealed any pathology. It appears that oesophageal manometry can reveal mild abnormalities not detected by barium swallow, even in asymptomatic patients, while barium enemas are useful in the detection of colonic involvement.

Lack of association between blood-based detection of Trypanosoma cruzi DNA and cardiac involvement in a non-endemic area.

Cases of chronic Chagas disease have been increasing in non-endemic areas due to the growth in immigration. This study examined the association between positive Trypanosoma cruzi-DNA detection in blood by PCR and presence of chagasic cardiac involvement in a cohort of immigrants in a European city. No association was found in this study between the positive T. cruzi blood PCR and cardiac involvement.

EuroTravNet: imported Chagas disease in nine European countries, 2008 to 2009.

In recent years, Chagas disease has emerged as a disease of importance outside of endemic areas, largely as a result of migration. In Europe, clinicians may have to treat infected migrants from endemic areas as well as people with acute infections transmitted congenitally,through organ donation or blood transfusion.We describe here the characteristics of patients diagnosed with chronic Chagas disease at the core clinical sites of the EuroTravNet network during 2008 and 2009. Of the 13,349 people who attended the sites, 124 had chronic Chagas disease. Most (96%) were born in Bolivia and the median number of months in the country of residence before visiting a EuroTravNet core site was 38 months (quartile (Q1)­Q3: 26­55). The median age of the patients was 35 years (Q1­Q3: 29­45) and 65% were female. All but one were seen as outpatients and the most frequent reason for consultation was routine screening. Considering that Chagas disease can be transmitted outside endemic regions and that there is effective treatment for some stages of the infection, all migrants from Latin America (excluding the Caribbean) should be questioned about past exposure to the parasite and should undergo serological testing if infection is suspected.

Targeted screening and health education for Chagas disease tailored to at-risk migrants in Spain, 2007 to 2010.

Chagas disease is endemic in Latin America, but migration has expanded the disease's geographical limits. Spain is the most affected country in Europe. From 2007, a specific Chagas disease programme aimed at at-risk migrants was developed in three Spanish cities (Madrid, Jerez de la Frontera and Alicante). The objectives of the programme were to increase participants' knowledge and decrease their fears about the disease and to encourage them to undergo screening for Trypanosoma cruzi infection. The programme was specially focused on migrants from Bolivia and Latin American women of childbearing age. Culturally tailored interventions were carried out in non-clinical settings. A total of 276 migrants were screened using a rapid immunochromatographic test following talks on the disease: the results were then later confirmed by standard serological tests. Of those tested, 44 (15.9%) were confirmed cases of Chagas disease. All of them came from Bolivia and a quarter were pregnant women. Of the 44 cases, 31 were later followed up at a specialised Chagas disease clinic. We consider that the adaptation of the programme to the target population's needs and collaboration with non-governmental organisations and migrants' associations contributed to the acceptance of the programme and the increasing number of patients seen at a specialised clinic.

Chagas disease in Latin American migrants: a Spanish challenge.

Chagas' disease affects millions in Latin America and is the leading cause of cardiomyopathy and death due to cardiovascular disease in patients aged 30-50 years. As a consequence of immigration it has settled in several European countries, where besides imported cases, autochthonous infections arise through vertical transmission and blood/organ donation. All Latin American immigrants who attended our Unit were screened for T. cruzi infection (ELISA and IFAT ± PCR). An ECG and echocardiogram were requested for all positive patients, and oesophageal manometry, barium swallow and barium enema were requested according to patient symptoms. All patients under 50 years without severe cardiac involvement and who had not received correct treatment previously were treated with benznidazole 5 mg/kg/day for 60 days. Patients were followed-up with serology and PCR 1 month after treatment ended and every 6 months thereafter. A total of 1146 Latin Americans were screened for T. cruzi (357 positive serology results). The typical patient profile was a Bolivian female, of rural origin, in her fourth decade of life, without evidence of visceral involvement. Treatment tolerance was poor, with 29.7% discontinuing treatment due to adverse reactions. Among those with adverse reactions (52%), the most frequent were cutaneous hypersensitivity (68.7%), gastrointestinal upset (20%) and nervous system disturbances (16.2%). T. cruzi infection is no longer limited to Latin America. Poor treatment tolerance can limit current treatment options. More epidemiological data are necessary to estimate the magnitude of a problem of great relevance for public health and health resource planning.