Chagas disease: A Latin American health problem becoming a world health problem
Introduction
Chagas disease is an autochthonous disease of 22 countries in the continental Western Hemisphere (WHO, 1991, WHO, 2002), caused by the protozoa Trypanosoma cruzi (T. cruzi). Human infection is primarily transmitted by domestic and sylvatic insects of the subfamily Triatominae (Hemiptera, Reduviidae), the kissing bug, whose habitat in the Americas ranges from the US and Mexico in the north to Argentina and Chile in the south. T. cruzi infection may be also transmitted to humans congenitally, by blood transfusion and organ transplant and by the oral route (WHO, 1991, WHO, 2002).
Travelers, including immigrants, have been considered a potential source of introduction of diseases like Chagas disease since the early ages. This concern was as valid for plague in the XIV century as it is for Tuberculosis (Jia et al., 2008) and SARS today (Ostroff et al., 2005). From the late 1800s to the 1930s and 1940s, millions of people, predominantly from Italy, Portugal and Spain, migrated from Europe to Latin America. In general, about 10 million people migrated to Argentina and Brazil alone (Moya J., cited by Padilla and Peixoto, 2007), leaving behind poverty and political repression, while taking advantage of favorable immigration policies in the New World (Padilla and Peixoto, 2007). Between the 1960s and the 1980s, political turmoil and economic stagnation spurred migration from Latin America to developed countries. While the United States (US) was the most frequent destination, Latin Americans also migrated to Australia and Canada.
In the 1990s, the original flow of migration from Europe to Latin America reversed course, and people from Latin America moved to Europe. This migration, fueled by periodic economic recession and opportunities created by the formation of the European Union (EU), further accelerated after 2000. By 2005, there were more than 2 million people born in Latin America living in Western European countries that favored immigration of descendants to whom visas and dual citizenship rights were extended. Most were in the Southern European countries, such as Italy, Portugal and Spain (Padilla and Peixoto, 2007). In the United States, it was estimated that there were millions of Latin American immigrants (documented or undocumented) living in the US (US Census Bureau, 2000, Passel and Cohn, 2009a).
The potential for Chagas disease (American trypanosomiasis) cases to be found and/or transmitted in Canada (Schipper et al., 1980) and the US (Pearlman, 1983, Kirchhoff and Neva, 1985, Theis et al., 1987, Kirchhoff et al., 1987, Kirchhoff, 1989, Schmunis, 1991, Hagar and Rahimtoola, 1991, Wendell and Gonzaga, 1993) due to the presence of immigrants from endemic countries has been stressed since the 1980s. Therefore, it was not surprising when 2 Chagas cases in Canada and 5 in the US resulted from transfusions using infected blood that was donated by an immigrant, a native of a Chagas endemic country (Leiby, 2005). Organ transplants were another route of transmission of T. cruzi in the US (CDC, 2002, Mascola et al., 2006).
Blood and organ donation as well as congenital infection are the primary modes of infection in the destination countries of immigrants (Schmunis, 2007a, Schmunis, 2007b).
The possibility that vector transmission may occur in Europe or in other continents by autochthonous triatominae is considered remote. More feasible however, is the risk of accidental transport of domestic Latin American species of triatominae to other regions or continents (i.e. in the baggage of airline passengers) (Schofield et al., 2009). In the US, the social conditions in the rural areas are not usually adequate for the intimate contact between vectors and humans. Therefore, the probability of vector transmission is low and few autochthonous Chagas disease cases have been documented in the US (Dorn et al., 2007).
Until recently, Chagas disease cases described in Europe were considered a novelty: one case imported from Colombia in France (Brisseau et al., 1988), one from Brazil in Italy (Sztajzel et al., 1996), one from Bolivia in Switzerland (Crovato and Rebora, 1997), one case from Venezuela in Denmark (Enemark et al., 2000), one congenital case in Sweden (Pehrson et al., 1981), one infection through bone marrow transplant in Spain (Villalba et al., 1992), and 2% overall prevalence for T. cruzi in Germany among immigrants from Latin America (Frank et al., 1997). Presently, cases of T. cruzi infection are no longer rare in countries with Latin American immigrants and a call for attention was made to have Chagas disease in mind in the differential diagnosis and possible etiology of cardiomyopathies in Spain (Florian Sanz et al., 2005). The importance of Chagas disease in immigrant-receiving countries depends on the potential number of infected migrants and their infection rate for T. cruzi. Estimation of the burden of Chagas disease in immigrants from endemic countries is essential to plan preventive measures, as well as to determine the resources needed for screening and treatment of acute and chronic cases in destination countries. Chronic Chagas disease can develop after a latency period of many years in up to 30% of those infected (Prata, 2001).
This paper reviews the available information on the number of immigrants from 17 Latin American endemic countries for T. cruzi, and reports updated estimates of T. cruzi infected individuals and how many of them may need medical attention in Australia, Canada, Japan, the European Union (EU) and non-EU European countries, and the United States. We also report estimates of the expected number of congenital infections among newborn from immigrant Latin American women living in Spain.
Section snippets
Source of data
The number of Latin American immigrants in Australia and Canada in 2006 was obtained from the Australian Bureau of Statistics (2007) and Statistics Canada (2006). Data for immigrants to Japan were obtained for Brazilians and Peruvians only (General Immigration Directorate, Ministry of Justice, Japan, 2008). The number of Latin American legal immigrants in European countries other than Spain in 2005 was obtained from Padilla and Peixoto (2007). When no breakdown of the country of origin of the
Results
Table 1 summarizes the number of T. cruzi infection estimated in Australia and Canada in 2006. For Australia, it was estimated that 3.8% (3088) of 80,522 immigrants from endemic countries were infected with T. cruzi and 618 of them, would need medical follow up related to the infection. In Canada, according to the 2006 census, there were 130,455 immigrants from Mexico and Central America and 250,710 from South America, but the number of immigrants by country of origin was only available for
Discussion
Despite the difficulties and limitations of using secondary data for policy decisions, our results provide estimates of T. cruzi infection and disease cases among immigrant from disease endemic countries. These estimates depend on several assumptions. For our estimates we considered that the overall prevalence rate of T. cruzi is stable and constant by age, geographic area and socioeconomic status. This approximation may not be completely valid since there is some evidence that the prevalence
Acknowledgments
The authors thanks Ms. Carmen Chand for assistance in collecting the references; Mr. Jiro Nakamura for finding and translating the number of immigrants from South America to Japan in 2007; Dr. Stephen Ault for reviewing the manuscript; and Dr. Sondra Schlesinger, and Ms. Katherine Darling for assistance in editing the manuscript.
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