Knowledge about Chagas Disease among Family and Community Medicine Residents in a Non-Endemic Region: A Cross-Sectional Study.

Chagas disease (CD) is a parasitic disease endemic to continental Latin America that has globalized in recent years. The most relevant mechanisms of transmission of CD in non-endemic countries are transfusion with infected blood and mother-to-child transmission. There is limited information regarding practicing physicians' knowledge of CD transmission, clinical presentation, and treatment in non-endemic countries, including Spain. Our objective was to analyze the level of knowledge about CD in family and community medicine residents and how it has evolved over the last 5 years. A cross-sectional study was performed in the framework of the training program for family and community medicine specialists in Alicante, Spain. Convenience sampling was used to enroll 214 fourth-year family and community medicine residents from 2016 to 2020. Participants completed the validated Chagas Level of Knowledge Scale questionnaire prior to attending the seminar "Health Care for the Immigrant Population." The mean score on the scale was 7.1/10 points. Only 12 participants (5.6%) answered all questions correctly. Resident physicians who reported having received prior information on CD scored better than those who were not informed (mean, 7.2 versus 6.1 points). Participants from Latin America had scores similar to those of the rest of the participants. Over the 5-year study period, questionnaire scores tended to increase. Knowledge about CD among family and community medicine residents has improved in recent years, although it is still not optimal. Specific training on CD during specialized health care training is warranted.

Benefits of early use of high-flow-nasal-cannula (HFNC) in patients with COVID-19 associated pneumonia.

Introduction: Severe COVID-19 is associated with hypoxemic bilateral pneumonia that leads to mechanical ventilation in a considerable proportion of patients. To the best of our knowledge, there are no recommendations about the best time to initiate high flow nasal cannula (HFNC). Patients and methods: Retrospective study of all patients admitted for COVID-19 pneumonia who required HNFO between March 2020 and February 2021. Patients were grouped in early HNFC or late HNFC, according to the modified Kirby index. Results: 53 patients were included. Forty-four of them were included in the early HFNC and 9 in late HNFC. There were no statistically significant clinical-epidemiological differences. Early use of HFNC was associated with a decrease in the need for intubation (29.5 vs. 66.6%, p = 0.044), hospital stay (18.8 d vs. 36 d, p = 0.022) and mortality (22.7 vs. 55.5%, p = 0.061). Conclusions: Early HFNC use is associated with a decrease in the need for intubation, mortality and overall hospital stay.

Introducción: La COVID-19 grave se asocia con una neumonía bilateral hipoxemiante, que desemboca en la necesidad de ventilación mecánica en un considerable número de pacientes. Hasta la fecha no existen recomendaciones acerca del momento óptimo para el inicio de la ONAF. Pacientes y métodos: Estudio retrospectivo de todos los pacientes ingresados por neumonía por COVID-19 y que precisaron ONAF entre marzo de 2020 y febrero de 2021. Se agruparon los pacientes en función del momento de inicio de la ONAF de acuerdo con la PaFi modificada. Resultados: Se incluyeron 53 pacientes, en 44 se inició la ONAF precozmente y en nueve de ellos se inició tardíamente. No existieron diferencias clínico-epidemiológicas significativas. La utilización precoz de la ONAF se asoció con una disminución de la necesidad de intubación (29,5 vs. 66,6%, p = 0,044), de la estancia hospitalaria (18,8 d vs. 36 d, p = 0,022) y de la mortalidad (22,7 vs. 55,5%, p = 0,061). Conclusiones: El empleo precoz de la ONAF se asocia con una disminución de la necesidad de intubación, de la mortalidad y de la estancia hospitalaria global.

[Benefits of early use of high-flow-nasal-cannula (HFNC) in patients with COVID-19 associated pneumonia]. / Beneficio del empleo precoz de la oxigenoterapia nasal de alto flujo (ONAF) en pacientes con neumonía por SARS-CoV-2.

INTRODUCTION: Severe COVID-19 is associated with hypoxemic bilateral pneumonia that leads to mechanical ventilation in a considerable proportion of patients. To the best of our knowledge, there are no recommendations about the best time to initiate high flow nasal cannula (HFNC). PATIENTS AND METHODS: Retrospective study of all patients admitted for COVID-19 pneumonia who required HNFO between March 2020 and February 2021. Patients were grouped in early HNFC or late HNFC, according to the modified Kirby index. RESULTS: 53 patients were included. Forty-four of them were included in the early HFNC and 9 in late HNFC. There were no statistically significant clinical-epidemiological differences. Early use of HFNC was associated with a decrease in the need for intubation (29.5 vs. 66.6%, p = 0.044), hospital stay (18.8 d vs. 36 d, p = 0.022) and mortality (22.7 vs. 55.5%, p = 0.061). CONCLUSIONS: Early HFNC use is associated with a decrease in the need for intubation, mortality and overall hospital stay.

Chagas Disease-Related Mortality in Spain, 1997 to 2018.

BACKGROUND: Chagas disease (CD) is associated with excess mortality in infected people in endemic countries, but little information is available in non-endemic countries. The aim of the study was to analyze mortality in patients admitted to the hospital with CD in Spain. METHODS: A retrospective, observational study using the Spanish National Hospital Discharge Database. We used the CD diagnostic codes of the 9th and 10th International Classification of Diseases to retrieve CD cases from the national public registry from 1997 to 2018. RESULTS: Of the 5022 hospital admissions in people with CD, there were 56 deaths (case fatality rate (CFR) 1.1%, 95% confidence interval (CI) 0.8%, 1.4%), 20 (35.7%) of which were considered directly related to CD. The median age was higher in those who died (54.5 vs. 38 years; p < 0.001). The CFR increased with age, peaking in the 70-79-year (7.9%, odds ratio (OR) 6.27, 95% CI 1.27, 30.90) and 80-89-year (16.7%, OR 14.7, 95% CI 2.70, 79.90) age groups. Men comprised a higher proportion of those who died compared to survivors (50% vs. 22.6%; p < 0.001). Non-survivors were more likely to have neoplasms (19.6% vs. 3.4%; p < 0.001), heart failure (17.9% vs. 7.2%; p = 0.002), diabetes (12.5% vs. 3.7%; p = 0.001), chronic kidney failure (8.9% vs. 1.6%; p < 0.001), and HIV (8.9% vs. 0.8%; p < 0.001). In the multivariable analysis, the variables associated with mortality were age (adjusted OR (aOR) 1.05; 95% CI: 1.03, 1.07), male sex (aOR 1.79, 95% CI 1.03, 3.14), cancer (aOR: 4.84, 95% CI 2.13, 11.22), and HIV infection (aOR 14.10 95% CI 4.88, 40.73). CONCLUSIONS: The case fatality rate of CD hospitalization was about 1%. The mortality risk increased with age, male sex, cancer, and HIV infection.

Community-based screening of Chagas disease among Latin American migrants in a non-endemic country: an observational study.

BACKGROUND: Chagas disease is a parasitic disease endemic to Latin America, but it has become a disease of global concern due to migration flows. Asymptomatic carriers may host the parasite for years, without knowing they are infected. The aim of this study is to assess prevalence of Chagas disease and evaluate the participants' level of knowledge between Latin American migrants attending a community-based screening campaign. METHODS: Three community-based campaigns were performed in Alicante (Spain) in 2016, 2017 and 2018, including educational chats and blood tests for Trypanosoma cruzi serology. Participants completed a questionnaire assessing knowledge about the mechanisms of transmission, disease presentation, diagnosis, and treatment. People seropositive for T. cruzi underwent diagnostic confirmation by two different tests. Results were analyzed by multivariable logistic regression and expressed as adjusted odds ratios (aORs), adjusting for age, sex, and time in Spain. RESULTS: A total of 596 participants were included in the study; 17% were aged under 18 years. Prevalence in adults was 11% [54/496; 95% confidence interval (CI): 8.3-14.5%] versus 0% among children. All but one case were in Bolivians. Diagnosis was independently associated with having been born in Bolivia (aOR: 102, 95% CI: 13-781) and a primary school-level education (aOR: 2.40, 95% CI: 1.14-5.06). Of 54 people diagnosed with Chagas disease (most of whom were asymptomatic), 42 (77.7%) returned to the clinic at least once, and 24 (44.4%) received treatment. Multivariable analysis showed that coming from Argentina (aOR: 13, 95% CI: 1.61-1188) or Bolivia (aOR: 1.90, 95% CI: 1.19-3.39) and having received information about Chagas disease in Spain (aOR: 4.63, 95% CI: 2.54-8.97) were associated with a good level of knowledge on the disease. Having primary level studies (aOR: 0.59, 95% CI: 0.34-0.98) and coming from Ecuador (aOR: 4.63, 95% CI: 2.52-847) were independently associated with a lower level of knowledge. CONCLUSIONS: Community-based interventions are a good strategy for diagnosing neglected diseases such as Chagas disease in non-endemic countries and for identifying and treating infected, asymptomatic individuals.

Chagas disease screening in pregnant Latin American women: Adherence to a systematic screening protocol in a non-endemic country.

BACKGROUND: Chagas disease (CD) is a chronic parasitic disease caused by Trypanosoma cruzi and is endemic to continental Latin America. In Spain, the main transmission route is congenital. We aimed to assess adherence to regional recommendations of universal screening for CD during pregnancy in Latin American women in the province of Alicante from 2014 to 2018. METHODOLOGY/PRINCIPAL FINDINGS: Retrospective quality study using two data sources: 1) delivery records of Latin American women that gave birth in the 10 public hospitals of Alicante between January 2014 and December 2018; and 2) records of Chagas serologies carried out in those centers between May 2013 and December 2018. There were 3026 deliveries in Latin American women during the study period; 1178 (38.9%) underwent CD serology. Screening adherence ranged from 17.2% to 59.3% in the different health departments and was higher in Bolivian women (48.3%). Twenty-six deliveries (2.2%) had a positive screening; CD was confirmed in 23 (2%) deliveries of 21 women. Bolivians had the highest seroprevalence (21/112; 18.7%), followed by Colombians (1/333; 0.3%) and Ecuadorians (1/348; 0.3%). Of 21 CD-positive women (19 Bolivians, 1 Colombian, 1 Ecuadorian), infection was already known in 12 (57.1%), and 9 (42.9%) had already been treated. Only 1 of the 12 untreated women (8.3%) was treated postpartum. Follow-up started in 20 of the 23 (87.0%) neonates but was completed only in 11 (47.8%); no cases of congenital transmission were detected. Among the 1848 unscreened deliveries, we estimate 43 undiagnosed cases of CD and 1 to 2 undetected cases of congenital transmission. CONCLUSIONS/SIGNIFICANCE: Adherence to recommendations of systematic screening for CD in Latin American pregnant women in Alicante can be improved. Strategies to strengthen treatment of postpartum women and monitoring of exposed newborns are needed. Currently, there may be undetected cases of congenital transmission in our province.

Healthcare Professionals and Students' Awareness of Chagas Disease: Design and Validation of Chagas Level of Knowledge Scale (ChaLKS).

There are few studies evaluating awareness of Chagas disease among healthcare professionals attending migrants from Latin America or working in Chagas-endemic areas. The objective of this study was to design and validate instruments for assessing knowledge about Chagas disease among healthcare students and residents as well as students and professionals of social and other health science disciplines. Two validated scales have been developed: the 10-item Chagas Level of Knowledge Scale for healthcare professionals (ChaLKS-Medical) and the 8-item ChaLKS-Social&Health for potential aid workers from those fields. Both scales were considered adequate in terms of readability, internal consistency, construct validity, and discriminant validity. The mean number of correct answers on the ChaLKS-Medical among respondents from non-healthcare versus healthcare sectors was 1.80 versus 7.00 (P < 0.001). The scores on the ChaLKS-Social&Health also discriminated between the knowledge levels in these two groups (1.76 versus 6.78, P < 0.001). Knowledge among medical/pharmacy students and residents on the ChaLKS-Medical was acceptable and different (mean: 5.8 and 7.4, respectively; P < 0.001). Respondents' knowledge of Chagas disease was greater in those who had previously received information on the disease; this was true in both respondents from the healthcare sector (mean correct answers, ChaLKS-Medical: 7.2 versus 4.3, P < 0.001) and in potential aid workers (mean correct answers, ChaLKS-Social&Health: 5.1 versus 1.1, P = 0.001). The metric properties of both scales are adequate for their use in supporting aid operations in Chagas-endemic countries or in providing health and social care to migrant populations in non-endemic countries.

Asymptomatic Strongyloidiasis among Latin American Migrants in Spain: A Community-Based Approach.

Strongyloides stercoralis infection is frequently underdiagnosed since many infections remain asymptomatic. AIM: To estimate the prevalence and characteristics of asymptomatic S. stercoralis infection in Latin American migrants attending a community-based screening program for Chagas disease in Spain. METHODOLOGY: Three community-based Chagas disease screening campaigns were performed in Alicante (Spain) in 2016, 2017, and 2018. Serological testing for S. stercoralis infection was performed using a non-automatized IVD-ELISA detecting IgG (DRG Instruments GmbH, Marburg, Germany). RESULTS: Of the 616 migrants from Central and South America who were screened, 601 were included in the study: 100 children and adolescents (<18 years of age) and 501 adults. Among the younger group, 6 participants tested positive (prevalence 6%, 95% confidence interval [CI] 2.5% to 13.1%), while 60 adults did so (prevalence 12%, 95% CI 9.3% to 15.3%). S. stercoralis infection was more common in men than in women (odds ratio adjusted [ORa] 2.28, 95% CI 1.289 to 4.03) and in those from Bolivia (ORa 2.03, 95% CI 1.15 to 3.59). Prevalence increased with age (ORa 1.02, 95% CI 0.99 to 1.05). In contrast, a university education had a protective effect (ORa 0.29, 95% CI 0.31 to 0.88). Forty-one (41/66; 62.1%) of the total cases of S. stercoralis infection were treated at the health care center. Positive stool samples were observed in 19.5% of the followed-up positive cases. CONCLUSION: Incorporating serological screening for S. stercoralis into community-based screening for Chagas disease is a useful intervention to detect asymptomatic S. stercoralis infection in Central and South American migrants and an opportunity to tackle neglected tropical diseases in a transversal way. The remaining challenge is to achieve patients' adherence to the medical follow-up.