Información de la revista
Vol. 29. Núm. 4.Julio - Agosto 2015
Páginas e19-e22Páginas 241-322
Respuestas rápidas
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Visitas
2081
Vol. 29. Núm. 4.Julio - Agosto 2015
Páginas e19-e22Páginas 241-322
Brief original article
DOI: 10.1016/j.gaceta.2015.03.012
Open Access
Prevalence of Chagas disease in the Bolivian population of Majorca (Spain)
Prevalencia de la enfermedad de Chagas en población boliviana de Mallorca (España)
Visitas
2081
Pedro Favila Escobioa, Joana Ribasb,
Autor para correspondencia
, Marta G. Morilloc, Ginna Rodríguez-Ramírezc, Jeronima Vicens-Ferrerd, Magdalena Estevae
a Escola Graduada Health Center, Family Medicine Majorca Teaching Unit, Majorca Primary Health Care Department, Balearic Institute of Health, Palma Majorca, Baleares, Spain
b Emergencies Department, Hospital Son Llàtzer, Balearic Institute of Health, Levante, Palma Majorca, Baleares, Spain
c Son Pisá Health Center, Family Medicine Majorca Teaching Unit, Majorca Primary Health Care Department, Balearic Institute of Health, Palma Majorca, Baleares, Spain
d Camp Redó Health Center, Family Medicine Majorca Teaching Unit, Majorca Primary Health Care Department, Balearic Institute of Health, Palma Majorca, Baleares, Spain
e Family Medicine Majorca Teaching Unit, Research Unit, Majorca Primary Health Care Department, Balearic Institute of Health, Instituto de Investigación Sanitaria de Palma (idiSPA), Palma Majorca, Baleares, Spain
Este artículo ha recibido
2081
Visitas

Under a Creative Commons license
Información del artículo
Resumen
Texto Completo
Bibliografía
Descargar PDF
Estadísticas
Tablas (2)
Table 1. Distribution of Bolivian study subjects according to sociodemographic characteristics and Chagas infection risk factors in two health care centers in Palma (Majorca), October 2011-March 2012.
Table 2. Distribution of knowledge variables about Chagas disease among Bolivian immigrants from two health care centers in Palma (Majorca) October 2011-March 2012.
Mostrar másMostrar menos
Abstract
Objective

To establish the prevalence of Trypanosoma cruzi infection in Bolivian (Spain) participants.

Methods

A cross sectional study was carried out in Majorca. Bolivian residents older than 18 years assigned to the family physicians of two primary care centers were randomly selected from the health card population database. Participants were invited to attend a serology test and an interview. T. cruzi infection was confirmed after two positive ELISA tests. If the result was positive or dubious, the serological test was sent to the National Microbiology Center for confirmation.

Results

A total of 251 participants were included (response rate 36.3%). The overall seroprevalence of Chagas infection was 19.1% (95% CI: 14.06-24.19). Seroprevalence was higher in participants from highly endemic provinces, those from rural areas, those who had lived in mud houses, and in those whose mother or a family member had contracted this infection.

Conclusion

This study demonstrates a high prevalence of T. cruzi in Bolivian residents, which was strongly associated with established risk factors.

Keywords:
Trypanosoma cruzi
Infection
Prevalence
Primary health care
Immigrants
Epidemiology
Resumen
Objetivo

Este estudio pretende estimar la seroprevalencia de la infección por Tripanosoma cruzi en sujetos bolivianos.

Métodos

Estudio descriptivo transversal en Mallorca (España), en el cual sujetos bolivianos mayores de 18 años, asignados a médicos de familia de dos centros de salud, fueron seleccionados aleatoriamente de la base de Tarjeta Sanitaria Individual. Se citaron en el centro de salud para prueba serológica y entrevista. Se confirma como caso dos pruebas de ELISA positivas. Los resultados positivos o dudosos se enviaron al Centro Nacional de Microbiología para su confirmación.

Resultados

Se incluyeron 251 sujetos (tasa de respuesta 36,3%). La seroprevalencia fue del 19,1% (intervalo de confianza del 95%: 14,06-24,19). La seroprevalencia fue mayor en quienes vivían en provincias endémicas, áreas rurales, casas de adobe o cuya madre o algún familiar había sufrido la infección.

Conclusión

Este trabajo evidencia una alta prevalencia en personas bolivianas residentes que se asocia con los factores de riesgo ya establecidos

Palabras clave:
Infección
Trypanosoma cruzi
Prevalencia
Atención primaria
Inmigrantes
Epidemiología
Texto Completo
Introduction

Chagas disease is one of the seventeen called neglected tropical diseases, as well as the parasitosis with the highest morbidity and socioeconomic impact in the American continent.1 It is caused by a flagellate protozoan, Trypanosoma cruzi, transmitted by the bite of an haematophagus insect.2 Approximately 70% of infected patients will continue asymptomatic and the rest will develop symptoms.

Since the 80s, and due to the important migratory movements from endemic areas, it was predicted that in a near future Chagas disease would become a public health issue in non-endemic countries. The lack of identification and treatment increases the risk of health complications and transmission.3

Spain is estimated to be, after USA, the country with the highest number of immigrants from Latin America,3 as well as one of the non-endemic countries with the highest prevalence of Chagas disease.4 In 2012 there were 1,633,755 Latin American immigrants in our country, from those, a 12.18% came from Bolivia,5 where an 80% of the country is endemic. The Balearic Islands present the same figures, with 59,126 Latin American immigrants, of which 10.81% were born in Bolivia5. Most of these people will be attended in primary care at sometime therefore, it is necessary to provide estimates of the presence of Chagas infection in primary care Bolivian population. This study aims to estimate the prevalence of Chagas disease in Bolivian subjects living in Majorca (Spain).

Material and methods

We carried out a descriptive study (October 2011-March 2012) in Palma health centers of Escuela Graduada (22,060 inhabitants) and Son Pisà (23,000 inhabitants) with a percentage of non UE immigrant population of around 12%. At the beginning of the study, 8,731 Bolivians were registered with a general practitioner (GP) in Majorca, of those 7,646 lived in Palma city and 1,609 (18.43%) were registered in the study health centers.

Subjects included were those born in Bolivia, 18 years and older. Subjects were excluded if they had a great disability, had no telephone or rejected to participate. We estimated a sample size of 264 subjects for a 7% prevalence,6 a precision of 3% and 95% confidence level. Considering possible low response rate, we decided to contact 691 subjects.

Subjects were selected through computer systematic random sampling from the list of Bolivians registered in the Health Card population data base of the two health centers (where most of the authors were working). Individuals were invited to participate by telephone and given an appointment. After signing an informed consent, an interview and a blood extraction were carried out.

The serological sample was sent to the microbiology laboratory at Son Espases Hospital. A first immunochromatographic serological diagnostic method was performed (SD Chagas Ab Rapid Bioline Standard Diagnostics, Inc) with 90.4% sensitivity and 94% specificity.7 A negative test was considered negative for Chagas disease. If the result was positive or doubtful, the sample was sent to the National Microbiology Center laboratory for its confirmation through a second different ELISA (“IFI in house”) with 98.5% sensitivity and 100% specificity.8

Data were collected on age and sex; T. cruzi risk factors, knowledge about the disease and results of the serology.

The chi-squared test was used to assess the relationship between the prevalence of T. cruzi infection and categorical variables and Student's t test for age. A backward conditional logistic regression analysis was performed to evaluate the independent effect of risk factors over the prevalence. All significant variables in the bivariate analysis were included. Reception of any Chagas treatment was excluded because colinearity with previous Chagas results was detected. The study received the approval of the Majorca Primary Care Research Committee.

Results

We included 251 subjects of the initial sample (691). Reasons for not participation were: 281 did not answer to 3 phone calls, 32 rejected participation, 24 changed address, 57 wrong telephone number, 19 previous serology and 27 <18 years old.

Epidemiological data are presented in Table 1. Forty eight were positive, which means a prevalence of 19.1% (CI95%: 14.06-24.19), no false positive cases were detected. A total of 75% of men and 70% of women were between 18- 39 years old. Most of the studied risk factors were significantly related with the presence of Chagas disease. Subjects coming from Cochabamba, Santa Cruz and Chupisaca regions presented significantly higher prevalence that those from other regions, as well as subjects reporting having lived in rural areas, mud houses or those referring a history of infection for their mother or relatives. No significant differences were found for age, sex, years out of Bolivia or transfusion experience. Five subjects declared not having seen the insect but all had more than one risk factor. In the adjusted model, predictive factors for infection were: women 2.09 (95%CI: 0.9-4.59), reported familiar infection 2.65 (95%CI: 1.19-5.76) and having seen the insect 4.79 (95%CI: 1.37-16.70).

Table 1.

Distribution of Bolivian study subjects according to sociodemographic characteristics and Chagas infection risk factors in two health care centers in Palma (Majorca), October 2011-March 2012.

Variables  TotalN (%)  Serology +N (%)  Serology - N (%) 
Sex
Men  145 (57.8)  22 (15.2)  123 (84.8)   
Women  106 (42.2)  26 (54.2)  80 (24.5)  0.06 
Mean age (SD)  34.62 (9.3)  35.5 (10.2)  34.4 (9.1)  0.58 
Province of origin
La Paz  47 (19.0)  3 (6.4)  44 (93.6)   
Santa Cruz  56 (22.6)  11 (19.6)  45 (80.4)   
Cochabamba  111 (44.8)  22 (19.8)  89 (80.2)   
Chupisaca-Potosi-Tarija  22 (8.9)  15 (68.2)  7 (31.8)   
Other provinces less risk  12 (4.8)  1 (8.3)  11 (91.7)  0.08 
Time since leaving Bolivia
<4 years  24 (9.6)  5 (20.8)  19 (79.2)   
≥4 years  227 (90.4)  43 (18.9)  184 (81.1)  0.82 
Area
Rural  126 (50.2)  33 (26.2)  93 (73.8)   
Urban  125 (49.8)  15 (12.0)  110 (88.0)  0.004 
House
Mud  147 (58.8)  36 (24.5)  111 (75.5)   
Brick  103 (41.2)  12 (11.7)  91 (88.3)  0.01 
Mother serology
Positive  14 (7.4)  8 (57.1)  6 (42.9)   
Negative  176 (92.6)  24 (76.5)  150 (57.1)  <0.001 
Chagas in relatives
Yes  67 (30.2)  20 (29.9)  47 (70.1)   
No  155 (69.8)  17 (11.0)  138 (89.0)  0.001 
Have seen the insect
Yes  168 (67.7)  42 (25.0)  126 (75.0)   
No  80 (32.3)  5 (6.2)  75 (93.8)  <0.001 
Experience of transfusion
Yes  30 (12.0)  6 (20.0)  24 (80.0)   
No  221 (88.0)  42 (19.0)  179 (81.0)  0.89 
Previous Chagas results
Positive  39 (15.5)  5 (71.4)  2 (28.6)   
Negative  212 (84.5)  21 (19.6)  86 (80.4)  0.002 
Previous Chagas treatment
Yes  4 (1.7)  3 (75.0)  1 (25.0)   
No  236 (98.3)  45 (19.1)  192 (80.9)  0.006 

SD: standard deviation.

A total of 35 (14.5%) subjects declared being blood donors, 5 of them (14.3%) resulted in positive serology. Furthermore, 5 (2%) subjects declared being organ donors; 2 of them (40%) with positive results for T. cruzi.

As shown in Table 2, there is an important level of information about the disease. There were no statistically significant differences on the knowledge level according to serological results.

Table 2.

Distribution of knowledge variables about Chagas disease among Bolivian immigrants from two health care centers in Palma (Majorca) October 2011-March 2012.

Variables  Total  Serology + N (%)  Serology - N (%) 
The disease is produced by an insect bite
Yes  196 (91.6)  42 (95.5)  154 (90.6)  0.30 
No  18 (8.4)  2 (4.5)  16 (9.4)   
The disease is not very frequent in Spain
Yes  159 (84.1)  34 (89.5)  125 (82.8)  0.31 
No  30 (15.9)  4 (10.5)  26 (17.2)   
It is spread by transfusion
Yes  164 (87.7)  36 (94.7)  128 (85.9)  0.13 
No  23 (12.3)  2 (5.3)  21 (14.1)   
It is spread by pregnancy
Yes  163 (87.6)  29 (78.4)  134 (89.9)  0.056 
No  23 (12.4)  8 (21.6)  15 (10.1)   
         
It is spread by organ donation         
Yes  64 (37.6)  16 (48.6)  48 (35.0)  0.15 
No  106 (62.4)  17 (51.5)  89 (65.0)   
It is spread through skin
Yes  40 (20.1)  7 (19.4)  33 (20.2)  0.91 
No  159 (79.9)  33 (80.6)  130 (79.8)   
It is spread through sexual contact
Yes  83 (48.8)  11 (40.7)  72 (50.3)  0.36 
No  87 (51.2)  16 (59.3)  71 (49.7)   
An infected subject can be asymptomatic
Yes  140 (71.8)  26 (70.3)  114 (72.2)  0.81 
No  55 (28.2)  11 (29.7)  44 (27.8)   
Chagas can affect the heart
Yes  182 (94.8)  37 (92.5)  145 (95.4)  0.46 
No  10 (5.2)  3 (7.5)  7 (4.6)   
Chagas can affect the esophagus
Yes  104 (78.8)  19 (73.3)  85 (80.2)  0.42 
No  28 (21.2)  7 (26.9)  21 (19.8)   
Chagas can affect the intestine
Yes  105 (76.6)  20 (66.7)  85 (79.4)  0.14 
No  32 (23.4)  10 (33.3)  22 (20.6)   
Discussion

Our study shows that 19.1% of the Bolivian immigrants living in Majorca are infected with T. cruzi, and that a high percentage present risk factors associated with Chagas disease. This study uses a community-based approach in order to provide a fair estimate of Chagas prevalence. The practical difficulties associated with random sampling from a community sample frame resulted in a less optimal estimate of the disease presence in this population.

This high prevalence matches the results found in other Spanish studies9,10. For instance, Roca et al. found a prevalence of 16.53% among Bolivians compared with a 2.87% in the total Latin American studied population.9 In Switzerland prevalence among Bolivian population was of 26.6%, whereas the global one was of 12%.11

Some authors point out that the heterogeneity in prevalence estimation varies according to the studied immigrant origin and the recruiting scenario. Thus, patients recruited in primary care would present lower prevalence than that found in reference centers12,13.

Our results are also similar to those of other studies, when referring to the relationship of risk factors and positive serology. Risk factors not associated with positive serology prevalence in the study, were time out of Bolivia and origin region, probably because most subjects came from high incidence regions. Our sample was very similar to the one of Jackson et al,11 regarding age but in contrast, we did not find differences by age. We did find higher prevalence in women compared with other studies9,11.

The persons interviewed have a high knowledge level about Chagas disease. Few studies have explored this subject among Latin American population.9 These results could be due to the Bolivian Programs that aim sensitizing and informing the population.

Despite the high estimated prevalence of Chagas disease observed, it is difficult to conclude that Bolivian subjects living in our country, could globally profit from population screening of the disease, as no benefits of this procedure have been reported to date. A detailed assessment of the cost-benefit of implementing a population screening should be carried out, even when there is not yet an absolute indication about the need of treating all patients in the chronic indeterminate phase.14 In Spain, T. cruzi screening is highly established in blood or high risk organ donors. However, protocol performance in pregnant and childbearing age women, and newborns is more optional. Thus, a national consensus to apply protocols in these women is necessary.15

The strongest point in our study refers to the random subject selection from the Health Card population data base of two health centers. This could lead to a prevalence estimate of Chagas disease in a non selected Bolivian population as compared with health care attendees or refugees. However, there could be a biased estimation of prevalence if Bolivian population registered in other health centers or non participation are related with T. cruzi risk factors, such as origin region.

In conclusion, a high prevalence of Chagas disease in the Bolivian population has been observed, especially in those that presented the common risk factors. Due to the high T. cruzi infection frequency in population from Bolivian origin compared with those coming from other Latin American countries, the screening in this group should be considered to avoid the transmission and progression of the disease.

What is known about the topic?

Spain is estimated to be one of the non-endemic countries with the highest prevalence of Chagas disease, and the European country with the highest number of cases. Studies to learn the real magnitude of the disease in non-endemic countries are required, as most of the reviewed works are not population based.

What does this study add to the literature?

This population based study shows that 19.1% of the Bolivian immigrants living in Mallorca are infected with Trypanosoma cruzi, and that a higher percentage present risk factors associated with Chagas disease. We believe that there is a need to involve primary and hospital care professionals in the awareness, monitoring and management of a disease that is still cornered to the drawer of ignorance.

Editor in charge

Pere Godoy.

Authorship contributions

P. Favila Escobio, J. Ribas and M.G. Morillo conceived the study. All authors participate in the study design, supervised by M. Esteva. P. Favila Escobio and M.G. Morillo managed financial support from Médicos del Mundo. J. Ribas arranged collaborations with microbiology service of Hospital Son Espases. P. Favila Escobio, J. Ribas, M.G. Morillo, G. Rodríguez-Ramírez and J. Vicens-Ferrer participated in different aspects of the field work and presentations in the health centers and hospitals. Authors wrote the different sections of the paper and M. Esteva coordinated the final version of the manuscript.

Funding

This study was partially financed by Médicos del Mundo.

Conflicts of interest

None.

Acknowledgements

The authors would like to thank Médicos del Mundo for their support in contacting patients and financing serology tests. Also to the health centers admission personnel and nurses for their collaboration in managing appointments and blood tests. Our sincere gratitude to María D. Flores (Instituto Carlos III) and to the microbiologists of the Hospital Son Espases for their technical assistance and collaboration and to Stephen Kelly for his writing assistance.

References
[1]
World Health Organization (WHO). Chagas disease: control and elimination. A63/20. 63rd World Health Assembly. Geneva, 18-22 May 2009. Disponible en: http://www.who.int/neglected_diseases/mediacentre/WHA_63.20_Eng.pdf
[2]
A. Moncayo, A.C. Silveira
Epidemiological trends for Chagas disease in Latin America and future challenges in epidemiology, surveillance and health policy
Mem Inst Oswaldo Cruz., 104 (2009), pp. 17-30
[3]
G.A. Schmunis
Epidemiology of Chagas disease in non endemic countries: the role of international migration
Mem Inst Oswaldo Cruz., 102 (2007), pp. 75-85
[4]
L. Basile, J.M. Jansà, Y. Carlier
Chagas disease in European countries: the challenge of a surveillance system
Euro Surveill., 1 (2011), pp. 6
[5]
Instituto Nacional de Estadística. Revisión del padrón municipal 2011. Población extranjera por país de nacionalidad, edad (grupos quinquenales) y sexo. (Accessed February 20, 2013.) Available at: http://www.ine.es/jaxi/menu.do?type=pcaxis&file=pcaxis&path=%2Ft20%2Fe245%2Fp04%2F%2Fa2011.
[6]
J. Gascón, C. Bern, M.J. Pinazo
Chagas disease in Spain, the United States and other non-endemic countries
[7]
C.L. Sánchez-Camargo, P. Albajar-Viñas, P.P. Wilkins
Comparative evaluation of 11 commercialized rapid diagnostic tests for detecting Trypanosoma cruzi antibodies in serum banks in areas of endemicity and nonendemicity
J Clin Microbiol., 52 (2014), pp. 2506-2512 http://dx.doi.org/10.1128/JCM.00144-14
[8]
M. Florez-Chávez, I. Cruz, M. Rodríguez
Comparación de técnicas serológicas convencionales y no convencionales para el diagnóstico de la enfermedad de Chagas importada en España
Enferm Infecc Microbiol Clin., 28 (2010), pp. 284-293 http://dx.doi.org/10.1016/j.eimc.2009.07.005
[9]
C. Roca, M.J. Pinazo, P. López-Chejade, The Chagas-Clot Research Group
Chagas disease among the Latin American adult population attending in a primary care center in Barcelona, Spain
Plos Negl Trop Dis., 5 (2011), pp. e1135 http://dx.doi.org/10.1371/journal.pntd.0001135
[10]
A. Irueta Isusi, M. Jarque Moyano, P. Redondo Ruiz
Enfermedad de Chagas importada: una alarma en Europa en su justa medida
Aten Primaria., 44 (2012), pp. 115-116 http://dx.doi.org/10.1016/j.aprim.2010.12.008
[11]
Y. Jackson, F. Chappuis
Chagas disease in Switzerland: history and challenges
Euro Surveill., 16 (2011),
[12]
M.D. Flores-Chávez, F.J. Merino, S. García-Bujalance
Transfusional Chagas disease: parasitological and serological monitoring of an infected recipient and blood donor
Clin Infect Dis., 46 (2008), pp. 44-47
[13]
C. Barona-Villar, M.J. Giménez Martí, T. Fraile
Prevalence of Trypanosoma cruzi infection in pregnant Latin American women and congenital transmission rate in a non-endemic area: the experience of the Valencian Health Programme (Spain)
Epidemiol Infect., 1 (2011), pp. 1-8
[14]
A.J. Rodríguez-Morales, J.A. Benítez, I. Téllez
Chagas disease screening among Latin American immigrants in non-endemic settings
Trav Med Infec Dis., 6 (2008), pp. 162-163
[15]
E. Sicuri, J. Muñoz, M.J. Pinazo
Economic evaluation of Chagas disease screening of pregnant Latin American women and of their infants in a non endemic area
Copyright © 2014. SESPAS
Idiomas
Gaceta Sanitaria

Suscríbase al Newsletter

Opciones de artículo
Herramientas
es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?