The sexual route is not a means of transmission of Trypanosoma cruzi.

The sexual route is not a means of transmission of Trypanosoma cruzi. In our environment, since the transmitting vector is not found, the most important means of transmission is the vertical route from mother to child. The woman was already infected by the parasite when she arrived in Spain, it may be correct to suggest that her siblings have a T. cruzi serology test because of the risk that her mother may have transmitted the infection vertically to all her siblings. Likewise, having had two pregnancies in these years of stay in Spain, it should be suggested that her children also be tested for the probable vertical transmission.

The sexual route is not a means of transmission of Trypanosoma cruzi. In our environment, since the transmitting vector is not found, the most important means of transmission is the vertical route from mother to child. The woman was already infected by the parasite when she arrived in Spain, it may be correct to suggest that her siblings have a T. cruzi serology test because of the risk that her mother may have transmitted the infection vertically to all her siblings. Likewise, having had two pregnancies in these years of stay in Spain, it should be suggested that her children also be tested for the [HIDDEN].

A 35-year-old Bolivian woman, 3 months pregnant, who has been living in Spain for 10 years with her partner, who is Spanish and has never traveled to Latin America. The woman has two other children with her partner, born in Spain, and a brother who lives in Bolivia and another in Spain. During her pregnancy she has been diagnosed with Trypanosoma cruzi infection. Which of the following is WRONG?

Recommend that their children have a T. cruzi serology because of the risk of transplacental transmission.

Inform the patient of the risk of T. cruzi transmission and the attitude to be taken during pregnancy, delivery and postpartum.

Recommend that her husband have T. cruzi serology because of the risk of having sexually transmitted the disease to her.

Recommend that her siblings have T. cruzi serology because of the risk of vectorial transmission.

[Prevalence of Trypanosoma cruzi infection and vertical transmission in Latin-American pregnant women in a health area of Biscay].

To estimate the prevalence of Trypanosoma cruzi infection, the epidemiological factors associated with it, and the risk of maternal-foetal transmission in pregnant women from endemic areas seen in the catchment area of Cruces Hospital (Basque Country, Spain). Descriptive study. Diagnosis of T. cruzi infection in pregnant women and neonates by performing serological tests and parasitological diagnosis using PCR. Epidemiological survey and multivariate analysis to identify the risk factors associated with T. cruzi infection. A total of 158 women participated in the study between December 2008 and January 2010, with mean age of 28.5 (±5.3). Nineteen (12%) pregnant mothers were seropositive, of whom 16 (84.2%) came from Bolivia, with a prevalence, in this group, of 22.2%. Independent epidemiological risk factors associated with T. cruzi infection were a history of living in mud houses (OR: 4.62; 95%IC: 1.54-13.87; P=.006) and knowledge of the vector (OR: 9.07; 95%IC: 1.91-43.11; P=.006). There was one newborn infected, which assumed a congenital transmission rate of 5.8% On the basis of the high prevalence of T. cruzi infection detected in Latin-American pregnant women and the risk of vertical transmission, a screening program would be recommended, which would be fundamentally based on the identification of geographic origin and epidemiological variables.

[Seroprevalence and vertical transmission of Chagas disease in a cohort of Latin-american pregnant women in a tertiary hospital in Madrid].

Chagas disease, caused by Trypanosoma cruzi (T. cruzi), is endemic in Latin-America and is emerging in Spain due to immigration. The vertical transmission rate is around 5%. A routine prenatal screening with serology of all pregnant women from endemic areas is recommended to identify infected newborns, allowing early treatment and cure. The aim of this study was to estimate the prevalence of positive Chagas serology in a cohort of pregnant women from Latin-America and its vertical transmission. An observational, prospective, follow-up study was conducted on women with positive serology to T. cruzi, as well as their newborns, from January 2013 to April 2015. Congenital Chagas was ruled out using a PCR technique at birth and at 1 month, and with serology at 9-12 months old. A child was considered infected when PCR was positive, and uninfected when PCR was negative, and/or it had a negative serology. Screening was performed on 1244 pregnant women from Latin-America, and there were positive results in 40 (prevalence 3.2%, 95% CI: 2.4-4.4%), with 85% of them from Bolivia. There was only one infected newborn (rate of vertical transmission 2.8% (95% CI: 0-15%)), who had a positive PCR at birth. Relative studies enabled an 8-year-old sister with an asymptomatic disease to be diagnosed and treated. Both were treated successfully with benznidazole (later the PCR and serology were negative). Screening during pregnancy in Latin-American women helped to detect those with Chagas disease. The rate of vertical transmission was 2.8%, in keeping with literature. Screening led to the detection and treatment of previously unidentified familial cases.

Surveillance of Chagas disease in pregnant women in Madrid, Spain, from 2008 to 2010.

One of the most important modes of transmission of Trypanosoma cruzi infection in areas where it is not endemic is vertical transmission: from mother to child. The objective of this report is to assess the efficacy of different programmes of serological screening to monitor infection with T. cruzi in pregnant Latin American women living in Madrid (Spain). To achieve this, a retrospective study was undertaken from January 2008 to December 2010 in seven hospitals in the Autonomous Community of Madrid. Serological screening programmes were classified in two main strategies: a selective one (pregnant women from Bolivia) and a universal one (pregnant women from Latin America). A total of 3,839 pregnant women were tested and the overall prevalence was 3.96%. The rate of congenital transmission was 2.6%. The current monitoring programmes have variable coverage ranging between 26% (selective screening) and 100% (universal screening). Monitoring of pregnant women from Latin America only reaches full coverage if universal screening of pregnant women is carried out at any moment of pregnancy, including at delivery. A common national regulation is necessary in order to ensure homogenous implementation of screening.

[Control of Chagas disease in pregnant Latin-American women and her children].

Chagas disease is a chronic and systemic infection caused by Trypanosoma cruzi. According to estimates from WHO, 10 million people are affected by this parasite. In the last years, birthrate among the immigrant women from Latin America settled in the Comunidad Autónoma de Madrid has been increasing, and as T. cruzi can be transmitted from mother to child, in fact 11 cases of congenital Chagas disease have been confirmed. Therefore, the aim of this paper is encouraging improvements in the coverage of the anti-T. cruzi antibodies detection in pregnant women from endemic areas. By this strategy, an active search for infected pregnant women and early detection of her infected newborns could be conducted, and then an early specific treatment could be administrated. Thus, there could be an important contribution to the control of Chagas disease in non-endemic area.

Trypanosoma cruzi-infected pregnant women without vector exposure have higher parasitemia levels: implications for congenital transmission risk.

Congenital transmission is a major source of new Trypanosoma cruzi infections, and as vector and blood bank control continue to improve, the proportion due to congenital infection will grow. A major unanswered question is why reported transmission rates from T. cruzi-infected mothers vary so widely among study populations. Women with high parasite loads during pregnancy are more likely to transmit to their infants, but the factors that govern maternal parasite load are largely unknown. Better understanding of these factors could enable prioritization of screening programs to target women most at risk of transmission to their infants. We screened pregnant women presenting for delivery in a large urban hospital in Bolivia and followed infants of infected women for congenital Chagas disease. Of 596 women screened, 128 (21.5%) had confirmed T. cruzi infection; transmission occurred from 15 (11.7%) infected women to their infants. Parasite loads were significantly higher among women who transmitted compared to those who did not. Congenital transmission occurred from 31.3% (9/29), 15.4% (4/26) and 0% (0/62) of women with high, moderate and low parasite load, respectively (χx2 for trend 18.2; p<0.0001). Twin births were associated with higher transmission risk and higher maternal parasite loads. Infected women without reported vector exposure had significantly higher parasite loads than those who had lived in an infested house (median 26.4 vs 0 parasites/mL; p<0.001) with an inverse relationship between years of living in an infested house and parasite load. We hypothesize that sustained vector-borne parasite exposure and repeated superinfection by T. cruzi may act as an immune booster, allowing women to maintain effective control of the parasite despite the down-regulation of late pregnancy.

[Control of congenital transmission of Trypanosoma cruzi in Argentina].

The vertical transmission of Trypanosoma cruzi has been augmenting its relative importance as vector and transfusion-mediated transmission routes have been, and continue to be, increasingly controlled. The vertical transmission of T. cruzi cannot be prevented; but early detection and treatment of congenital infection achieve cure rates close to 100%. In Argentina, the Subprogram of Control of Pregnant Women examined 58,196 women from 13 provinces in 1997 and found a 9% seropositivity to T. cruzi. In spite of such high maternal prevalence rates of T. cruzi, only a small proportion of live newborns to infected mothers acquires the infection. The probability of vertical transmission was 1.9% (range: 0.1% to 3.5%) in surveys carried out in the '70s, and 2.5% (range: 0.7% to 10.4%) in others conducted in the '70-'80s. Other more recent studies in Argentina estimated the probability of transmission in 2.6%-6.7%, but studies from Paraguay estimated 10.5% by PCR or serodiagnosis. The microhematocrit technique is the recommended parasitologic method to detect congenital infection. Routine serodiagnosis that detects IgG against T. cruzi is only helpful after the newborn reaches 6 months of age. Detection of specific IgM using recombinant antigens and PCR constitute excellent alternatives, but their feasibility from operational and cost-effective viewpoints in affected endemic areas remains to be considered. In a longitudinal project carried out in Maternidad Nuestra Señora de la Merced in the city of Tucumán between 1992-1994, the majority of congenital cases were asymptomatic. They were diagnosed through the microhematocrit technique, but a number of cases could only be detected later as a result of the parasitological and/or serological follow-up. Of a total of 32 newborns infected with T. cruzi who were treated with nifurtimox or benznidazole, 30 had a negative microhematocrit and serodiagnosis between 6 months and 2 years post-treatment. The magnitude of congenital transmission, and its associated morbidity and mortalidad, largely justify the efforts needed to detect T. cruzi infection in the mothers and newborns. This project demonstrated that the transmission of T. cruzi can be successfully controlled at a provincial scale through a specific program inserted in the primary health care system or at the first level of attention. The congenital transmission of T. cruzi clearly represents a public health problem in areas that in the past were of active transmission, even years after being under entomologic surveillance.

Seroprevalence of Trypanosoma cruzi in pregnant women in Midwest Brazil: an evaluation of congenital transmission.

Chagas disease (CD) is caused by the protozoan Trypanosoma cruzi and it is mainly acquired through the vector route, however, blood transfusion and congenital transmission are implicated in the spread of the illness worldwide. The congenital route can occur at any stage of pregnancy and its frequency varies. In the Federal District, in Brazil, the frequency of T. cruzi infection in pregnant women and their offspring has not been updated. Thus, the aim of this study was to estimate the prevalence of T. cruzi infection in pregnant women and the rate of congenital transmission in the Federal District. A cross-sectional study was conducted to estimate the seroprevalence of T. cruzi from 2014 to 2016 in the population of pregnant women attended by the public health service throughout the Federal District and a descriptive cohort for the evaluation of congenital transmission. During the study, prenatal data of 98,895 women were consulted and pregnant women registered in 2016, presenting with positive T. cruzi serology, were part of the descriptive cohort. The estimated prevalence of T. cruzi infection in the three years was 0.19% and the congenital transmission rate was 1/40 (2.5%). Our results have shown that, although the main routes of transmission of CD have been interrupted, there is still a risk of congenital transmission in the Federal District. This present study highlights the need for the continuous implementation of a screening program for pregnant women and timely treatment of infected newborns and children.

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).

This study describes the results of the health programme implemented in the Valencian Community (Spain) to achieve an early diagnosis of Chagas disease in pregnant Latin American women and their newborns. During 2009 and 2010, 1975 women living in the health districts of three university hospitals were enrolled via midwives or at the time of delivery. Diagnosis of disease was performed using two serological tests with different antigens. Congenital infection was diagnosed by parasitological, molecular or serological methods from blood samples obtained at birth or in subsequent controls. The overall seroprevalence of Chagas infection in pregnant women from 16 different endemic countries was 11·4%. Infection was higher in those from countries in the Gran Chaco Region (Bolivia, 34·1%; Paraguay, 7·4%; Argentina, 5·3%). Eight newborn infants from Bolivian mothers had congenital Chagas which represents a vertical transmission rate of 3·7%. In conclusion, this work supports the benefits of offering an early diagnosis to pregnant women and newborns during routine prenatal healthcare.

Congenital Chagas disease: diagnostic and clinical aspects in an area without vectorial transmission, Bermejo, Bolivia.

The authors carried out a 1-year study of a population of pregnant women delivering at Bermejo hospital, South Bolivia. In this area, vectorial transmission of Trypanosoma cruzi is negligible and women infect themselves during displacements in close endemic areas. The prevalence of T. cruzi in 508 pregnant women, diagnosed by several serological tests, was 33.9%. In eight infants, we observed T. cruzi in the umbilical cord (congenital transmission rate of 5.2%). The means of birth weights, lengths and hemoglobin rates were similar in the children from both seronegative and seropositive women, and in children infected or not by T. cruzi. This study could confirm a less severity of the congenital disease of Chagas in the absence of re-infestation of the mother during pregnancy. Serological screening of pregnant women by rapid diagnostic tests and examination of babies born from seropositive mothers by microhematocrit method at birth is a suitable strategy to detect and prevent congenital Chagas disease in non-endemic areas.

Chagas disease in Latin American pregnant immigrants: experience in a non-endemic country.

Chagas disease is a systemic chronic parasitic infection by Trypanosoma cruzi endemic in Latin America. Migration of women of childbearing age from Latin America to developed countries may spread the disease to non-endemic areas through vertical transmission. Prospective study of seroprevalence of T. cruzi infection in immigrant Latin American pregnant women during a 5-year period (from 2006 to 2010) in Spain. Seven out of 545 participants were seropositive for T. cruzi [prevalence 1.28%, 95% confidence interval (CI) 0.06-2.56]. Four (57%) were from Bolivia and three (43.%) from Paraguay. The seroprevalence in pregnant women from Bolivia was 10.26% (95% CI 4.06-23.58) and in participants from Paraguay was 6.52% (95% CI 2.24-17.5). No congenital transmission occurred. Seroprevalence of T. cruzi infection in Latin American pregnant women coming from Bolivia and Paraguay is high. Those women should be screened for T. cruzi to control mother-to-child transmission in non-endemic areas.

Seroprevalence of Trypanosoma cruzi infection in at-risk blood donors in Catalonia (Spain).

The increasing arrival of Latin Americans to Europe and, particularly, to Spain has led to the appearance of new pathologies, such as Chagas disease, a zoonotic infection endemic to rural areas of Central and South America. In the absence of the triatomid vector, one of the main modes of transmission of Chagas disease in nonendemic regions is through blood transfusion. The Catalonian Blood Bank has implemented a screening program for Chagas disease in at-risk blood donors and has performed a study to determine the seroprevalence of Trypanosoma cruzi infection in the donor population. The two commercial tests used in all samples were the ID-PaGIA Chagas antibody test (DiaMed) and the bioelisa Chagas assay (Biokit). Overall seroprevalence was 0.62 percent, with 11 donors confirmed positive among the 1770 at-risk donors studied; the highest rate (10.2%) was in Bolivian donors. Interestingly, 1 of the 11 positive donors was a Spaniard who had resided various years in a Chagas disease endemic area. Furthermore, 1 of the positive donors presented detectable parasitemia. The results of this study emphasize the need for T. cruzi screening in at-risk blood donors in nonendemic countries. An important finding is the relevance of including in the at-risk category persons who have resided in, but were not necessarily born in, an endemic region. If T. cruzi screening is not routinely performed in all donations, it remains highly dependent on proper identification of at-risk donors during the predonation interview.

Extended screening of Trypanosoma cruzi among the offspring of infected women. Barcelona North metropolitan area, Catalonia (Spain), 2005-2016.

To date, very little data is available on the extensive, familiar, serological screening of Trypanosoma cruzi from infected-index cases. As it is a parasite with possibility of mother-to-child fetal transmission, the study of the offspring of chronically infected women has a special relevance. An observational study using a capture-recapture method that evaluates the offspring serological status of women diagnosed with T. cruzi infection (positive serology) in the northern metropolitan area of Barcelona during 2005-2016. A total of 238 women with positive serology for T. cruzi were identified. Of these, 117 (49.2%) could be localized. Their offspring summarized 300 individuals, of which 192 (64%) had serology records, with 23 positive for T. cruzi (11.98%; CI95%: 8.1-17.3). Among the 53 children born within the study area, 5 (9.8%, CI95%: 4.2-20.9) cases of vertical transmission were recorded. All children born as of 2010 (the starting year of mother screening) had serological outputs. Offspring of T. cruzi-seropositive women showed a high rate of seropositivity. The prevalence of vertical transmission is also remarkably high but comparable to that obtained in other European studies. The main source of loss was non-accessible women. It is reasonable to formaly include extensive, familiar, serological assessment in Chagas screening guidelines. In order to avoid losses, any eventual screening should be implemented at the time of the maternal diagnosis.

[The prevalence of Chagas' disease in puerperal women and congenital transmission in an endemic area of Peru].

To determine the prevalence of antibodies against Trypanosoma cruzi in puerperal women and to assess possible congenital transmission of Chagas' disease in the department of Arequipa, Peru, where the disease is endemic. Women who had given birth between December 2001 and July 2002 in three hospitals (two urban and one rural) and four health centers (three rural and one urban) of the department of Arequipa, Peru, were studied. The serological study included screening all the puerperal women in order to detect antibodies against T. cruzi through indirect immunofluorescence (IIF), with confirmatory testing done with enzyme-linked immunosorbent assay (ELISA) testing and the titration of immunoglobulin G (IgG) antibodies by IIF. IIF tests to screen for immunoglobulin M (IgM) antibodies were done with the seropositive women and their newborns, and infection was evaluated through xenodiagnosis (evaluated at 30 and 60 days) and the direct micromethod of Freilij et al. The results were analyzed in terms of the presence of the vector and of cases of Chagas' disease in the places where the puerperal women had been born and where they were living. Two neonatologists clinically evaluated the newborns in order to detect abnormalities and signs of congenital Chagas' disease. The overall prevalence of Chagas' disease in the 3 000 puerperal women studied was 0.73%. Prevalence was highest in two health centers located in rural areas (2.2% in El Pedregal and 4.1% in La Joya) (P=0.018). The disease was associated with previous direct contact with the vector (P<0.05) and with having been born in an area considered endemic (P<0.01). Four (20%) of the 20 seropositive puerperal women were also positive by xenodiagnosis. However, none of the women was aware of her infectious carrier state, and none showed the characteristic symptoms or signs of acute or chronic Chagas' disease. IgM antibodies were not detected in any of the puerperal women. One neonate (whose mother did not have evidence of parasitemia) presented an IgM titer of 1/8, but in later controls neither IgM nor IgG antibodies were detected. Parasites were not detected in the blood of the neonates by either of the two testing methods used. Of the 20 neonates evaluated, one presented microcephaly and hepatosplenomegaly; although the child had specific IgG antibodies against T. cruzi at birth, the antibodies were not present at the age of two months. The growth and development of the other 19 newborns were normal. The prevalence of Chagas' disease in puerperal women of the department of Arequipa, Peru, is low. No cases of intrauterine congenital transmission were found. We recommend carrying out studies on prenatal detection that evaluate more mothers and in which women who give birth at home also participate.

Chagas disease screening in pregnant Latin American women: Adherence to a systematic screening protocol in a non-endemic country.

Chagas disease (CD) is a chronic parasitic disease caused by Trypanosoma cruzi and is endemic to continental Latin America. In Spain, the main transmission route is congenital. We aimed to assess adherence to regional recommendations of universal screening for CD during pregnancy in Latin American women in the province of Alicante from 2014 to 2018. Retrospective quality study using two data sources: 1) delivery records of Latin American women that gave birth in the 10 public hospitals of Alicante between January 2014 and December 2018; and 2) records of Chagas serologies carried out in those centers between May 2013 and December 2018. There were 3026 deliveries in Latin American women during the study period; 1178 (38.9%) underwent CD serology. Screening adherence ranged from 17.2% to 59.3% in the different health departments and was higher in Bolivian women (48.3%). Twenty-six deliveries (2.2%) had a positive screening; CD was confirmed in 23 (2%) deliveries of 21 women. Bolivians had the highest seroprevalence (21/112; 18.7%), followed by Colombians (1/333; 0.3%) and Ecuadorians (1/348; 0.3%). Of 21 CD-positive women (19 Bolivians, 1 Colombian, 1 Ecuadorian), infection was already known in 12 (57.1%), and 9 (42.9%) had already been treated. Only 1 of the 12 untreated women (8.3%) was treated postpartum. Follow-up started in 20 of the 23 (87.0%) neonates but was completed only in 11 (47.8%); no cases of congenital transmission were detected. Among the 1848 unscreened deliveries, we estimate 43 undiagnosed cases of CD and 1 to 2 undetected cases of congenital transmission. Adherence to recommendations of systematic screening for CD in Latin American pregnant women in Alicante can be improved. Strategies to strengthen treatment of postpartum women and monitoring of exposed newborns are needed. Currently, there may be undetected cases of congenital transmission in our province.

Maternal fetal transmission of Trypanosoma cruzi: a problem of public health little studied in Mexico.

The first case of neonatal Chagas was reported in Mexico in 1998, but there have been no studies since then. Therefore, we investigated the rates of congenital infection of Trypanosoma cruzi by examining the seroprevalence among 1448 pregnant women in Oaxaca, Jalisco and Mexico City. We performed ELISAs to screen for recombinant and total antigens in mothers, and examined the frequency of congenital T. cruzi transmission by PCR with cord blood and antibody testing in children when they reached two years old. Our results showed that the prevalence of infection in pregnant women was 7.32% (106/1448) overall, and 4.4% (35/794) in Oaxaca, 12.02% (67/557) in Jalisco and 4.12% (4/97) in the Mexico City. In Oaxaca, T. cruzi infection was detected by PCR in 20% (7/35) of infants born to seroreactive mothers and 11.9% (8/67) in Jalisco. No infections were identified in infants from the Mexico City. From these only eleven serological follow up their children are agree to take blood. Therefore, the maternal-fetal overall transmission rate was 4.08% (4/98) in Oaxaca and 9.1% (3/33) in Jalisco 1.5% (1/65) children with positive serology were given specific treatment Chagas. In conclusion, these are the first reports of the rates of congenital Chagas disease in Mexico. The seroprevalence was higher in mothers from Jalisco, and could be related to that there is not the periodic fumigation of the transmitting vector performed in that state. The high rates of maternal-fetal transmission found in Oaxaca could be related to the differences of pathogenicity of trypanosome. No association between both the rate of congenital transmission and the gynecologic anthropometric data was observed.

[Endemic level of congenital Trypanosoma cruzi infection in the areas of maternal residence and the development of congenital Chagas disease in Bolivia].

In Bolivia, the prevalence of infection by T. cruzi in women in fertile age can vary between 20 and 60%. The present study made in the Maternity Germin Urquidi of Cochabamba - Bolivia, it has demonstrated, that 19.9% of the mothers who go to this hospitable center to be taken care of in the childbirth, they are carrying of the infection and that 4,6% of them, they are going to transmit, by transplacentaria route, the infection to its babies. Of the 71 children born with congenital Chagas, only 47,8 % present/display some type of alteration or of development(Apgar to 1 minute low, BPN, prematuridad, pathological dismadurez) or signs (SDR, hepatomegalia, esplenomegalia, neurological signs, cardiomegalia, anasarca, petequias). When investigating the effect of the differences in the vectorial density (low, medium and high) of the zone of maternal residence, on the transmission of the infection of the mother infected to the fetus, we concluded that the rate of transmission of the congenital infection of T. cruzi is not modified by the level of endemicidad of the zone of maternal residence. By another infected new born sides whose mothers reside in zones of high endemicidad present/display, most frequently and of significant way, Apgar to 1 minute < to 7, low weight when being born and prematuridad or an association of these alterations with respiratory syndrome of distress or anasarca, when one compares them with new born of resident mothers in the zones of loss or medium endemicidad, mortality in this group is greater. These results suggest calls to account it of the mothers, in areas of high endemicidad, she is associate with a serious increase in the risk of Disease of newborn severe and mortal congenital Chagas in.

Mother-to-Child Transmission of Trypanosoma cruzi.

Among the world's most neglected tropical diseases, Chagas disease is vector-borne and caused by Trypanosoma cruzi. T cruzi infection is endemic to South and Central America as well as Mexico. Due to population migration, T cruzi is increasingly becoming a public health problem in nonendemic settings. Success with vector control strategies has led to a relative increase in the burden attributable to congenital transmission of T cruzi. In endemic settings, approximately 5% of infected pregnant women transmit to their offspring. Congenital T cruzi infection is generally asymptomatic and parasitological and serological testing is required for diagnosis. This review highlights research gaps with a focus on (1) improving screening, diagnostic, and treatment options and (2) designing epidemiologic studies to understand risk factors for congenital T cruzi.

The current screening programme for congenital transmission of Chagas disease in Catalonia, Spain.

Due to considerable numbers of migrants from Chagas disease-endemic countries living in Catalonia, the Catalonian Health Department has recently implemented a screening programme for preventing congenital transmission, targeting Latin American pregnant women who attend antenatal consultations. Diagnosis of Trypanosoma cruzi infection in women is based on two positive serological tests. Screening of newborns from mothers with positive serology is based on a parasitological test during the first 48 hours of life and/or conventional serological analysis at the age of nine months. If either of these tests is positive, treatment with benznidazole is started following the World Health Organization's recommendations. The epidemiological surveillance of the programme is based on the Microbiological Reporting System of Catalonia, a well established network of laboratories. Once a positive case is reported, the responsible physician is asked to complete a structured epidemiological questionnaire. Clinical and demographic data are registered in the Voluntary Case Registry of Chagas Disease, a database administered by the Catalonian Health Department. It is expected that this programme will improve the understanding of the real burden of Chagas disease in the region. Furthermore, this initiative could encourage the implementation of similar programmes in other regions of Spain and even in other European countries.

Congenital transmission of Trypanosoma cruzi in Europe (Spain): a case report.

Here we report a documented case of congenital transmission of Trypanosoma cruzi from a Bolivian mother with chronic Chagas disease living in Spain. The serology and blood nested polymerase chain reaction (PCR) were positive for the mother, and amastigote forms were observed in histopathological study of the placenta and umbilical cord. Direct examination, culture, and nested PCR were positive in the blood of the neonate. At the age of 8 days, the neonate began treatment with 5-7.5 mg/kg/day of benznidazol, which was continued for 60 days. Direct examination, blood culture, and nested PCR were negative to T. cruzi 20 days after the start of treatment and remained negative 4 and 7 months thereafter. Serological tests were negative at 4 months. To detect congenital infection and initiate early treatment of infected newborns, protocols are required to detect Chagas disease in pregnant women who migrate from endemic to non-endemic areas.

Chagas disease in pregnancy: a non-endemic problem in a globalized world.

Chagas disease, caused by the Trypanosoma cruzi infection, is an endemic cause of morbidity and mortality in Latin America. Infection during pregnancy may increase the risk for adverse maternal-foetal outcome. Review of significant articles regarding maternal-foetal T. cruzi infection in free-vector non-endemic regions. Vertical transmission, even in vector-free world regions, occurs in 1 out of 20 seropositive mothers. T. cruzi infection increases the risk of miscarriage, preterm birth and neonatal infection which may cause infant death or severe sequelae. Prevention of T. cruzi vertical transmission is not feasible, although early diagnosis allows appropriate treatment of newborns with a 100% efficacy. The present document will recall the importance of T. cruzi mother-to-child transmission and maternal-foetal consequences in non-endemic areas. It is highly recommended that infected pregnant women in non-endemic regions be accurately assessed.

Chagas disease (American trypanosomiasis) in Mexico: an update.

Chagas disease is a parasitic infection caused by the protozoan Trypanosoma cruzi, a flagellated organism that is transmitted mainly to humans through the infected feces of triatomine kissing bugs (vector transmission in endemic areas) or by transfusion of infected blood, donations of infected organ, or transmission from an infected mother to her child at birth. Chagas disease was first described in 1909 by the Brazilian physician Carlos Chagas, and due to the parasite's distribution throughout North, Central and South America, the disease is commonly known as American trypanosomiasis. However, this disease is now present in non-endemic countries such as Canada, the United States of America, and several countries in Europe (principally Spain). Moreover, Chagas disease was recently designated by the World Health Organization as one of the main neglected tropical diseases. The aim of this review is to summarize the research efforts recently described in studies conducted in Mexico on Chagas disease. In this country, there are no existing vector control programs. In addition, there is no consensus on the diagnostic methods for acute and chronic Chagas disease in maternity wards and blood banks, and trypanocidal therapy is not administered to chronic patients. The actual prevalence of the disease is unknown because no official reporting of cases is performed. Therefore, the number of people infected by different routes of transmission (vector, congenital, blood transfusion, organ transplantation, or oral) is unknown. We believe that by promoting education about Chagas disease in schools starting at the basic elementary level and including reinforcement at higher education levels will ensure that the Mexican population would be aware of this health problem and that the control measures adopted will have more acceptance and success. We hope that this review sensitizes the relevant authorities and that the appropriate measures to reduce the risk of infection by T. cruzi are undertaken to provide the Mexican people a better quality of life.

Serological and parasitological screening of Trypanosoma cruzi infection in mothers and newborns living in two Chagasic areas of Mexico.

Maternal-fetal transmission of Trypanosoma cruzi generally occurs in 2-12% of pregnant infected mothers. This transmission form has been poorly studied in Mexico where only one case of congenital infection published in 1998 has been reported. We screened 145 mothers and their delivered babies in two hospitals of endemic regions in Mexico (states of Chiapas and Veracruz) searching for anti-T. cruzi antibodies and circulating parasites by hemoculture and PCR. In Poza Rica, Veracruz, 3/85 (3.5%) mothers were seropositive for T. cruzi infection and in Palenque, Chiapas, 3/60 (5%) cases. In total 6/145 (4.1%) were seropositive subjects. Although cord blood samples of delivered babies from seropositive mothers have IgG anti-T. cruzi antibodies, none presented PCR and positive hemoculture. Although a high relative seroprevalence of T. cruzi infection in pregnant women was detected, no case of vertical transmission was recognized. Undoubtedly, further studies of large samples are necessary to evaluate maternal transmission risk in Mexico.

[Screening for congenital infection by Trypanosoma cruzi in France].

The importance of congenital transmission of Chagas' disease increases with its emergence in communities infected with Trypanosoma cruzi, but where vector transmission has never existed or is fully controlled through vector control campaigns. In both endemic and non-endemic areas, the rates of mother-to-child transmission (MTCT) could be the same, by 5%, generating a constant source of new cases of the disease. Risk factors for vertical transmission are not fully elucidated, but the effectiveness of the adaptive immune response and the genetic susceptibility of both the mother and the child are suspected. Besides the risk of miscarriage or premature birth, neonatal infection by T. cruzi causes an acute form of Chagas disease, which may be accompanied by a severe infectious syndrome that can causes death if not treated early. This form of the disease is a real public health priority because it is frequent, severe, identifiable and curable. Indeed, almost all newborns diagnosed and treated before the end of their first year of life will be definitely cured. In all non-endemic areas, detection of cases of congenital Chagas disease is hampered by a very low prevalence of the disease in the general population of pregnant women, the lack of symptoms in most infected women and the disregard of these problems from health personnel in charge of monitoring pregnancy. Secondary prevention firstly consists in identifying infected women (with history of exposure and positive serology for Chagas disease) and secondly to look for the parasite in newborns from infected mothers. No primary prevention is indeed possible during pregnancy, since the only two drugs are toxic and possibly teratogenic. However, after birth, treatment could be offered to all infected women in order to prevent late complications of the disease and to make an attempt at breaking the chain of MTCT in future pregnancies.

Chagas disease

T. cruzi can be transmitted independent of the triatomine bug during blood transfusion, following organ transplantation, or across the placenta during pregnancy. Transfusion with the blood of an infected donor infects the recipient 10–25% of the time. To prevent this, blood donations are screened for in many countries with endemic Chagas disease, as well as the United States. Similarly, transplantation of solid organs from an infected donor can transmit to the recipient. This is especially true for heart transplant, which transmits T. cruzi 75–100% of the time, and less so for transplantation of the liver (0–29%) or a kidney (0–19%). An infected mother can pass to her child through the placenta; this occurs in up to 15% of births by infected mothers. As of 2019, 22.5% of new infections occurred through congenital transmission. Pathophysiology

Trypanosoma cruzi infection in Latin American pregnant women living outside endemic countries and frequency of congenital transmission: a systematic review and meta-analysis.

Chagas disease, as a consequence of globalization and immigration, is no more restricted to Central and Latin America. Therefore, congenital transmission represents a growing public health concern in non-endemic countries. The aim of this study was to assess the prevalence of Trypanosoma cruzi infection in pregnant Latin American (LA) women living outside endemic countries and the rate of congenital transmission. Data were extracted from studies indexed in PubMed, Scopus, Embase, Lilacs and SciELO databases without language restriction. Two investigators independently collected data on study characteristics, diagnosis, prevalence of infection in pregnant women and congenital infection rate. The data were pooled using a random effects model. The search identified 1078 articles of which 29 were eligible regarding prevalence of T. cruzi infection among pregnant women and 1795 articles of which 32 were eligible regarding the congenital transmission rate. The estimated pooled prevalence of T. cruzi infection in LA pregnant women was 4.2% [95% confidence interval (CI): 3.0-5.5]. The prevalence of T. cruzi infection in pregnant women from Bolivia was 15.5% (95% CI: 11.7-19.7) and 0.5% (95% CI: 0.2-0.89) for those coming from all other LA countries. The estimated global rate of congenital transmission was 3.5% (95% CI: 2.5-4.5); excluding poor-quality studies, the rate of congenital transmission was 3.8% (95% CI: 2.4-5.1). Prevalence of Chagas disease among LA pregnant women living outside endemic countries is high, particularly in Bolivian women. The rate of vertical transmission of T. cruzi infection is similar to the rate reported in South and Central American countries.

Family cluster of Chagas disease among Bolivian immigrants in Italy: High rate of maternal-fetal transmission.

Chagas disease (CD) or American trypanosomiasis is a neglected anthropozoonosis caused by Trypanosoma cruzi that affects 6-8 million people worldwide (mainly in Latin America), 30-40% of whom develop cardiac or digestive complications. Once confined to endemic areas of Latin America, CD has more recently become a global disease as a result of migration flows from endemic to non-endemic regions, particularly in northern America and Europe. Congenital transmission is a particular challenge as it may be sustained for multiple generations and perpetuate the infection even in non-endemic countries. Subjects were identified during a cross-sectional survey of CD among Latin American people living in Milan, Italy. Serology was carried out using tests based on either a lysate and a recombinant antigen of Trypanosoma cruzi. They were also tested by a conventional Polymerase Chain Reaction (PCR) targeting the 330 bp variable region of the T. cruzi kinetoplast minicircle genome and a commercial real-time PCR. We here describe a Bolivian family cluster with seven affected people with at least two autochthonous congenital T. cruzi infection which was identified during the course of a CD screening programme. We also review the epidemiology, diagnosis and control of congenital CD, with particular emphasis on the challenges facing the control and management of such a complex and still largely hidden disease. Our experience confirms the need to screen for CD all family members once a case is diagnosed and shows the possible high rate of congenital CD also in non-endemic areas.

Risk factors and primary prevention of congenital Chagas disease in a nonendemic country.

In this longitudinal cohort study we evaluated the congenital transmission of Chagas disease (CD) in a nonendemic area. The aim of this work was to analyze the predictive value of a Trypanosoma cruzi-positive polymerase chain reaction (PCR) result in pregnant women for the diagnosis of vertical transmission and to evaluate the use of PCR as a tool for early detection of infection. The offspring of 59 seropositive pregnant mothers were followed up. The parasitological status of mothers was studied by PCR in a total of 64 pregnancies; 10 of these women had received treatment before pregnancy. Sixty-five infants (including a pair of twins) were monitored at 0, 6, 9, and 12 months of age by PCR and serology. In cases of congenital transmission, hemoculture and parasite lineage typing were performed. Nine infants had acquired CD congenitally. This represents a transmission rate of 13.8% among seropositive mothers (9 infected newborns of 65 total live births). All infants were infected with T. cruzi discrete typing unit V strain. A statistically significant correlation was found between T. cruzi vertical transmission and a positive PCR result during pregnancy (31%; 9 infected newborns in 29 live births). No infected infants were detected among 10 mothers who were treated before they became pregnant, compared with 16.4% (9 of 55 live births) among untreated mothers. PCR is a useful tool for the detection of congenital CD, and the treatment of infected women of childbearing age seems to be useful for preventing vertical transmission.

Chagas disease

Other modes of transmission have been targeted by Chagas disease prevention programs. Treating -infected mothers during pregnancy reduces the risk of congenital transmission of the infection. To this end, many countries in Latin America have implemented routine screening of pregnant women and infants for infection, and the World Health Organization recommends screening all children born to infected mothers to prevent congenital infection from developing into chronic disease. Similarly to blood transfusions, many countries with endemic Chagas disease screen organs for transplantation with serological tests. There is no vaccine against Chagas disease. Several experimental vaccines have been tested in animals infected with and were able to reduce parasite numbers in the blood and heart, but no vaccine candidates had undergone clinical trials in humans as of 2016. Management

Chagas disease in pregnancy.

Chagas disease is a tropical disease now making its appearance in the United States as more immigration from Latin America occurs. Pregnant women with chronic infection with Trypanosoma cruzi may present with cardiac or gastrointestinal symptoms and transmit the infection to their fetuses. A 32-year-old Mexican woman presented with cardiac symptoms at 16 weeks' gestation. She was found to have a left anterior hemiblock on her electrocardiogram. Her indirect immunofluorescent antibody titer for T cruzi was positive at greater than 1:2048. Subsequently, she had a normal pregnancy and delivery. The infant's T cruzi immunofluorescent antibody titer was 1:256 at birth and had not declined at his 6-week follow-up. Obstetric care providers in the United States need to be familiar with American trypanosomiasis because it may present during pregnancy. Serious maternal disease is possible, and perinatal transmission may be seen in 2-10% of cases.

[Cost effectiveness study of a control program of congenital Chagas disease in Bolivia].

Cost effectiveness analysis of Chagas' vertical transmission control program in Bolivia: Today, Bolivia is the most concerned country in America by Chagas disease: Trypanosoma cruzi infection affects 20% of whole population, around 1800000 inhabitants, and mother-to-child transmission is around 5%, from 1.6 to 9.8%. Direct and indirect costs derived from disease complications and death, from birth to adulthood, add up around US$ 21 millions per year for 2,718 infected new-borns. This cost falls on individual, family and society, when the nation is struggling in a depressed economy. On the other side, an effective control program could detect and treat all cases with an investment of US$ 123 per infected new-born, or US$ 1.2 per new-born in Bolivia. Indirect benefits, apart of suffering relieve and improving of life quality, are related with Chagas vector control program, increasing the demand thanks to increasing risk awareness and also induced demand testing all pregnant women in endemic areas. So the conclusion is that such investment is profitable.

Chagas disease among the Latin American adult population attending in a primary care center in Barcelona, Spain.

The epidemiology of Chagas disease, until recently confined to areas of continental Latin America, has undergone considerable changes in recent decades due to migration to other parts of the world, including Spain. We studied the prevalence of Chagas disease in Latin American patients treated at a health center in Barcelona and evaluated its clinical phase. We make some recommendations for screening for the disease. We performed an observational, cross-sectional prevalence study by means of an immunochromatographic test screening of all continental Latin American patients over the age of 14 years visiting the health centre from October 2007 to October 2009. The diagnosis was confirmed by serological methods: conventional in-house ELISA (cELISA), a commercial kit (rELISA) and ELISA using T cruzi lysate (Ortho-Clinical Diagnostics) (oELISA). Of 766 patients studied, 22 were diagnosed with T. cruzi infection, showing a prevalence of 2.87% (95% CI, 1.6-4.12%). Of the infected patients, 45.45% men and 54.55% women, 21 were from Bolivia, showing a prevalence in the Bolivian subgroup (n=127) of 16.53% (95% CI, 9.6-23.39%). ALL THE INFECTED PATIENTS WERE IN A CHRONIC PHASE OF CHAGAS DISEASE: 81% with the indeterminate form, 9.5% with the cardiac form and 9.5% with the cardiodigestive form. All patients infected with T. cruzi had heard of Chagas disease in their country of origin, 82% knew someone affected, and 77% had a significant history of living in adobe houses in rural areas. We found a high prevalence of T. cruzi infection in immigrants from Bolivia. Detection of T. cruzi-infected persons by screening programs in non-endemic countries would control non-vectorial transmission and would benefit the persons affected, public health and national health systems.

Prevalence of Chagas disease in pregnant women and incidence of congenital transmission in Santa Cruz de la Sierra, Bolivia.

Congenital transmission of Chagas disease stand out as a major public health problem since the vector control was performed in all endemic areas and has shown its effectiveness. An epidemiological study was performed in three maternity hospitals of the city of Santa Cruz de la Sierra, Bolivia from 2006 to 2008. The serological screening for Trypanosoma cruzi infection was carried out in 15,767 pregnant women. Chagas infection was detected in 3725 women (23.6%), who gave birth to 125 newborns infected by T. cruzi at birth, representing an incidence of 790 per 100,000 births during a period of 16 months and a vertical transmission rate by 3.4%. There was a significant difference between hospitals that might be explained by socio-economic origins of mothers and diagnostic constraints.