Clinical profile of Trypanosoma cruzi infection in a non-endemic setting: Immigration and Chagas disease in Barcelona (Spain)
Introduction
Chagas disease is a zoonosis endemic to Central and South America (Prata, 2001, WHO, 2002). Current data indicate that between 8 and 10 million people are infected in this area (OPS, 2006, CDC, 2007).
Trypanosoma cruzi, its causal agent, is a flagellated protozoan that can easily be isolated from the blood in acute infections (Prata, 2001, Sartori et al., 2007). In endemic areas, T. cruzi infection usually occurs after contact with the faeces of blood-sucking triatomines (Prata, 2001). Congenital, organ transplantation and transfusion-related transmission are the other principal routes of T. cruzi infection (Prata, 2001, Kirchhoff, 1993).
After being infected, patients may enter an acute stage of the disease that is frequently asymptomatic (Prata, 2001, WHO, 2002). This stage may also include acute myocarditis or encephalomyelitis and in 5–10% of cases can provoke death (Prata, 2001). After the acute stage the infection usually becomes chronic and clinically silent. At this point it is described as the indeterminate form (Prata, 2001). 10–30 years later, around half of infected people will develop symptomatic chronic Chagas disease, which is characterized mainly by cardiac and gastrointestinal disorders (Prata, 2001). Cardiac involvement is the main cause of death in this chronic stage (Punukollu et al., 2007). Arrhythmias, heart failure and sudden death are the most threatening complications of this infection. In endemic areas approximately 15–20% cases of infection involved the digestive tract, mainly as mega gastrointestinal syndromes (Prata, 2001).
Currently, this infection is no longer limited to the Americas since the number of immigrants from Latin America is increasing both in North America and Europe (Schmunis, 2007). Consequently, non-vectorial transmission such as congenital, organ transplantation and transfusion transmission have been described in these areas (Muñoz et al., 2007, Riera et al., 2006, CDC, 2006, Flores-Chávez et al., 2008).
Schmunis et al. estimated that approximately 12,000 out of 400,000 Latin American immigrants living in Spain in 2003 were infected by T. cruzi (Schmunis, 2007). By 2007, the number of immigrants from Latin America had increased to 1,600,000 (INE, 2008) and, if the prevalence of infection remains similar, approximately 40,000 of these immigrants are likely to be infected by T. cruzi.
The clinical and epidemiological profile of Chagas disease in non-endemic countries is not well described. An improved understanding of these characteristics may help to improve the diagnosis and management of affected populations in industrialized countries (CDC, 2007, Gascón, 2005, Gascón et al., 2007). Therefore, the aim of this paper is to describe the clinical profile of a series of Latin-American at-risk population that attend the specialised centres for imported infectious diseases in Barcelona.
Section snippets
Design and setting
This study was performed in the two centres for imported diseases in Barcelona: Unitat de Medicina Tropical i Salut Internacional Drassanes, which is a Primary Care Centre, and the Centre for International Health, in the Hospital Clínic, a University hospital.
This was a descriptive study of 489 adult Latin American immigrants attending these two centres for imported diseases over a period of 3 years.
Recruitment and participants
All participants were of Latin American origin, from T. cruzi endemic areas and had come to the
Results
A total of 489 Latin American patients from 14 different countries were included in the study (Table 2). A total of 202 (41%) participants were infected, and 14 (7%) of them had received blood transfusions in their country of origin. PCR was performed on 200 of the infected patients, and was positive in 56 patients (28%). Eleven participants were pregnant women and three of them were infected with T. cruzi. All three mothers and newborns were asymptomatic. Table 3 shows the basic epidemiologic
Discussion
This study is the first of its kind in describing the main features of Chagas disease in a European country. The participants were from various regions of Latin America and were most likely infected with different parasite genotypes. The percentage of infected people from each country was varied. For example, 65% of the Bolivian population in our study was infected with T. cruzi, compared to only 3% of participants from Ecuador. These data may reflect the heterogeneous distribution of Chagas
Characteristics and limitations of the study
The study has some limitations, since 43 patients were lost for prior to the ECG recording. Suboptimal labour conditions, high geographic mobility and the social situation of the immigrant population hamper the continuity of care and consequently caused a number of participants to drop out. However, to our knowledge, this is the first study in a non-endemic area that analyses a population of T. cruzi-infected patients. This study highlights that Chagas disease is no longer limited to Latin
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This study was funded partly by Bayer Foundation and partly by grant 024/13/2004 provided by the Agència d’Avaluació de Tecnologies i Recerca Mèdiques (AATRM, Catalunya, Spain). We would also like to thank to the Departament de Salut de la Generalitat de Catalunya and the Universitat de Barcelona for their support.
Thanks to Eliane Avila for technical support and to Robin Raycroft and Carolyn Daher for the English revision of the manuscript.
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2023, The Lancet Regional Health - Western PacificFamily cluster of Chagas disease among Bolivian immigrants in Italy: High rate of maternal-fetal transmission
2022, Travel Medicine and Infectious DiseaseCitation Excerpt :According to the most recent estimates of the World Health Organisation (WHO), 6–8 million people are infected with T. cruzi worldwide, most of whom live in endemic regions of Latin America.2 However, over the last few decades, recurring socio-economic and political crises in Latin America have induced large-scale domestic migrations from rural to urban settlements, and international migrations mainly to the USA, Europe, Australia, and Japan, both of which have led to the “urbanisation” of the disease, and an increasing occurrence of cases and non vector transmission outside traditionally endemic areas [3–5]. It has been estimated that between 68,000 and 120,000 people with CD are currently living in Europe [6] but, although regional screening campaigns have been conducted in countries that attract the majority of migrants from Latin America (mainly Spain and Italy, but also Belgium, France, Germany, The Netherlands, and the UK) [7–10], the disease is still largely neglected, and it is likely that fewer than 10% of cases are formally diagnosed [6]. Two of the reasons for this under-diagnosis are that CD predominantly affects the poorest migrant populations whose needs are frequently given less priority in national healthcare programmes, and that the prolonged asymptomatic status of infected subjects has failed to generate sufficient awareness of the disease among patients and healthcare providers [11–14].
Chagas disease knocks on our door: a cross-sectional study among Latin American immigrants in Milan, Italy
2018, Clinical Microbiology and InfectionChagas disease in Europe: A review for the internist in the globalized world
2017, European Journal of Internal MedicineCitation Excerpt :These data are indirectly confirmed by the analysis of the clinical features of CD-related hospitalizations in Spain from 1997 to 2011: 75.3% of 1.792 patients were diagnosed as having CD without clinically apparent organ complications [36]. Chronic cardiac Chagas disease (CCCD) has been observed in 11–13% of screened cases in Italy and 19% in Spain [70–72]. However, in a study from Spain describing 485 consecutive patients with chronic CD, 31.5% presented with at least one electrocardiographic abnormality and 5.3% had an abnormal echocardiography [73].