Chagas disease has recently emerged as an important, potentially chronic or lethal, illness in many non-endemic areas such as USA, Canada, Japan, Australia and several European countries. Unfortunately, only few governments in non-endemic countries have implemented adequate public health measures to avoid autochthonous transmission and provide appropriate care to subjects that are affected
Chagas Disease in Non-Endemic Countries, Still a Neglected Public Health Issue
by Alessandro Bartoloni*
and Lorenzo Zammarchi**
Infectious Diseases Unit, Department of Experimental & Clinical Medicine
University of Florence School of Medicine, Florence, Italy
Worldwide, an estimated 8 million persons, are thought to have Chagas disease, the majority of whom living in continental Latin America, where the disease is endemic 1. Chagas disease is caused by Trypanosoma cruzi, a protozoan parasite transmitted principally by blood sucking insects of the subfamily Triatominae 1 that typically live in cracks in the walls of mud and straw houses in rural Latin American communities. Transmission can also occur congenitally and by laboratory accidents, contamination of food with feces of triatomines, and transfusion or transplantation of infected blood or organs 1. Acute infection with T. cruzi is usually asymptomatic and is followed by a chronic asymptomatic phase that, in about one-third of cases, leads to severe organ involvement (cardiomyopathy and/or intestinal megasyndromes) after 10 to 30 years 1. The infection may reactivate and cause severe manifestations in immunosuppressed patients 1.
The disease has recently emerged in many non-endemic countries such as USA, Canada, Japan, Australia and several European countries, due to increasing population movements from Latin America in the last decade. Nowadays an estimated 300,000 of these persons live in the United States 1 and some thousands of them in Europe and other non-endemic countries 2. In particular, it was estimated that in 2009 there were between 68,000 and 122,000 cases in Europe, mostly concentrated in Spain, Italy, France and United Kingdom, but only 3-6% of these are estimated to be detected 3.
The high rate of under diagnosis can be explained mostly by the long period between the infection and the development of cardiac and digestive involvement during which the patient may be completely asymptomatic. However, even in case of symptomatic disease it can be misdiagnosed with other cosmopolite conditions since physicians in non-endemic countries are not familiar with Chagas disease and may not consider the disease in differential diagnosis. For example, Chagas disease associated cardiomyopathy is clinically similar to other causes of cardiomyopathy, and no sign or symptom is pathognomonic, then the etiologic diagnosis may not be considered, appropriate diagnostic testing might not be requested or performed, and, therefore, the diagnosis might be often missed 4. However confirming that Chagas disease is the cause of cardiomyopathy may have implications for patient treatment and prognosis and for possible testing and treatment of family members. A recent cross-sectional study showed that 13% of Latino immigrants with dilated cardiomyopathy who were living in New York City had Chagas disease 4.
The under-detection of Chagas disease may have not only clinical consequences but even public health implications since this disease can be transmitted in non-endemic countries even in absence of an effective vector. Transmission of T. cruzi through transfusion of blood and other hemocomponents, organ transplant 5,6, laboratory accident 7, travel to Latin America 8, and mother-to-child vertical transmission 9 has been already demonstrated in non-endemic countries.
So far few non-endemic countries have implemented adequate public health measures to avoid autochthonous transmission and provide appropriate care to subjects that are affected. Country such as Spain, United Kingdom and France have already implemented a routine serological systematic screening for Chagas disease in blood donors at risk 10. In the US, the “American Association of Blood Banks” has introduced serological screening for all blood donors since 2007 11.
To the best of our knowledge, no European countries have implemented at national level a screening for Latin American childbearing women and this activity is currently carried out only in circumscribed regions such as Catalonia, Comunitat Valenciana (Spain) or Tuscany (Italy) 12, 13,14. Screening for Chagas disease in pregnant women allows to perform diagnostic test in the neonates of the sero-positive mothers to early recognize a congenital infection, which may occur in about 5% of newborns, and to provide antiparasitic treatment to affected neonates, which is almost 100% effective in eradicate the disease in this stage 15,16. The cost-effectiveness of this intervention has been supported by an economical model in Spain 17.
There is still much work to do in the field of research. For example, the only two currently available drugs for antiparasitic treatment (benznidazole and nifurtimox) are not enough effective and safe especially in adults 18. In particular, the role of antiparasitic treatment in preventing or reducing the risk of development of organ chronic damage in chronically infected patients is still unclear.
To summarize, Chagas disease is of public health importance in non-endemic areas, not only because patients might develop, in case of progression, a severe and potentially lethal disease or a chronic disease representing a high cost in terms of disability-adjusted life years and quality adjusted life years, but also because there is a risk of autochthonous transmission.
As already agreed by several experts at the 6th European Congress of Tropical Medicine and International Health in Verona, Italy, September 2009, it is time to take a step forward and move from technical recommendations to public health decisions 19.
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*Professor Alessandro Bartoloni is an Italian physician graduated at the University of Florence -Italy in 1983. He later obtained his specialization in Infectious Diseases at the University of Siena in 1987 and received his Diplome in Tropical Medicine at the Leopold Institute of Tropical Medicine in 1991.
Author of over 160 papers and multiple book chapters, Prof. Bartoloni is currently Associate Professor of the Infectious Diseases Unit, Department of Experimental & Clinical Medicine, University of Florence; Head of the Infectious and Tropical Diseases Unit, Careggi Hospital, Florence, and Director of the Tuscany Regional Reference Center for Tropical Medicine, in Florence. He has longstanding field experience as co-ordinator of the research activity that the Infectious Diseases Unit of the University of Florence is carrying out in Latin America since 1986. His main research interests include: epidemiology of antimicrobial resistant bacteria, tropical medicine, parasitology.
**Dr Lorenzo Zammarchi is an Italian physician graduated at the University of Florence -Italy in 2006. He then obtained his specialization in Infectious Diseases at the same University in 2011. Since 2011 he’s working as researcher fellow investigating cysticercosis and tuberculosis within the COHEMI-project financed by the European Commission. He is currently researcher at the Infectious Diseases Unit, Department of Experimental & Clinical Medicine, University of Florence, and works in the Tuscany Regional Reference Center for Tropical Medicine, in Florence.