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Addressing the challenge of Chagas disease in a non-endemic country: the collaboration between Médecins Sans Frontières (MSF), the NGO OIKOS and the Center of Tropical Diseases of Sacro Cuore Hospital (Negrar) in Bergamo province (Northern Italy) Ernestina Carla Repetto*1,6, Ada Maristella Egidi1, Andrea Angheben2,5, Mariella Anselmi3,5, Ahmad Al Rousan1, Gabriel Ledezma1, Rosita Ruiz1, Carlota Torrico1, Mariachiara Buoninsegna4, Fabio Andreoni4, Barbara Maccagno1, Gianfranco De Maio1, Silvia Garelli1. 1 Médecins Sans Frontières 2 Center of Tropical Medicine of Sacro Cuore Don Calabria Hospital, Negrar, Verona (Italy) 3 Centro de Epidemiología Comunitaria y Medicina Tropical (CECOMET) Esmeraldas (Ecuador) 4 OIKOS Onlus, Bergamo (Italy) 5 COHEMI Project 6 PhD Fellow, University of Brescia (Italy) *Corresponding author: Ernestina Carla Repetto, msfocb-rome-med@brussels.msf.org, +39.342.3788813.

Chagas Disease

Method

Conclusion

It’s is an infection caused by a protozoon named Trypanosoma cruzi. The main way of transmission in endemic countries (Central and South America) is trough the bite of an insect (Triatominae), contaminated blood transfusions, from mother to child during pregnancy and delivery and trough ingestion of contaminated food by infected stool. If untreated it may become chronic infection and cause cardiac and digestive problems.

Health promotion was regularly carried out by health promoters selected from the LAC, focusing on young people (<30 years), in order to encourage testing. Monthly serological screening for Trypanosoma cruzi antibodies was carried out with two different ELISA tests, Biokit® and BiosChile®, in accordance with international and World Health Organization guidelines. It was offered to all migrants from LA living in Bergamo province, without any restrictions on age, sex or residence permit status. An epidemiological questionnaire was used to assess the risk of having CD. Second-line diagnostics (disease staging) and benznidazole (5 mg/kg/day for 60 days) were provided by CTD.

Our results predict that a large number of Bolivians living in Bergamo could be affected by CD (at least 3500 of the 18,000 total estimated resident Bolivians).

Results From June to December 2012, over 2.000 people were approached during health promotion activities and 784 people were screened (67.5% females). 139 people tested positive (138 Bolivians and 1 child born in Italy to a Bolivian mother). The overall sero-prevalence was 17.7%; the sero-prevalence among Bolivians was 19.8%. Chart 1 shows the countries of origin of screened people. No positive cases were found among LA country different from Bolivia, so far. Among total screened Bolivians, males and females had different seroprevalence (15.7% vs 22.6%) and different mean (SD) age distribution (33.7 years [±12.7] vs 36.8 [±12.6]), respectively (Chart 2), but the mean (SD) age of positive Bolivian males and females did not differ (43.3 years [±9.8] vs 44.2 [±10.8]). Chart 1. Country of origin distribution among screened population (Jun-Dec 2012)

Background Migration has expanded the geographical limits of Chagas disease (CD) beyond Latin America (LA) [1]. Italy is thought to be one of the most affected countries in Europe but a specific CD programme has not been implemented at national level [2]. With the aim of increasing awareness and testing of CD, MSF strengthened an ongoing programme of screening among the LA Community (LAC) living in the Bergamo province of northern Italy. The programme was started in 2009 by the NGO OIKOS and the Centre for Tropical Diseases (CTD) Sacro Cuore Hospital (Negrar). Bergamo province hosts the biggest Bolivian community in Italy, as well as people coming from other LA countries. A descriptive prospective community-based sero-prevalence survey was started in June 2012; ethics approval was granted by the Research Ethics Board of Verona province.

Bolivia

Ecuador

Peru Born in Italy

Brazil Italians travellers

Argentina El Salvador

Chile

Chart 2. Age distribution among screened Bolivians according to sex

In Italy the lack of screening protocols and the difficulties in obtaining treatment in the public health system are of particular concern, and need to be quickly addressed by Italian health authorities. Our model of intervention could provide a possible way forward to tackle CD at national level. We need more data to confirm these results in other Italian regions, however our observed seroprevalence is in line with that noted recently in Spain [3]. We also need further work to understand the difference in prevalence between men and women, to better explore the burden of CD in Italy and to expand the access to diagnosis and treatment for this population in need. From Eurosurveillance 2011 (Basile L et al). Estimates of migrants from CD endemic countries residents in Europe, 2009. SPAIN

1.754.295

UNITES KINGDOM

497.517

ITALY

387.648

THE NETHERLANDS

237.572

FRANCE

168.870

PORTUGAL

121.124

GERMANY

85.313

SWITZERLAND

82.755

BELGIUM

43.810

TOTAL

3.378.814

References From Eurosurveillance 2011 (Basile L et al). Estimates of CD in Europe, 2009.

From "Dossier Statistico Immigrazione 2012" CARITAS e MIGRANTES (31/12/2011)

3.378.814 PEOPLE FROM ENDEMIC AREA

Regular migrants resident in Lombardia region: 974.134 (Morocco, Albania, Egypt, China, India)

123.078 POTENTIALLY INFECTED BY CHAGAS

Regular migrants resident in Bergamo province: 113.534, max estimated Bolivians: 18.000.

1) Basile L, Jansà JM, Carlier Y, et al. Chagas disease in European countries: the challenge of a surveillance system. Euro Surveill 2011;16:pii=19968. 2) Angheben A, Anselmi M, Gobbi F, et al. Chagas disease in Italy: breaking an epidemiological silence. Euro Surveill 2011;16(37):pii=19969. 3) Navarro M, Navaza B, Guionnet A, Lopez-Velez R. Chagas Disease in Spain: Need for Further Public Health Measures. PLoS Negl Trop Dis 2012; 6:e1962.doi:10.1371/journal.pntd.0001962.


Addressing the challenge of Chagas disease in a non-endemic country