• 1.

    Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Periago MR, 2008. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis 2: e300.

    • Search Google Scholar
    • Export Citation
  • 2.

    Franco-Paredes C, Von A, Hidron A, Rodríguez-Morales AJ, Tellez I, Barragán M, Jones D, Náquira CG, Mendez J, 2007. Chagas disease: an impediment in achieving the millennium development goals in Latin America. BMC Int Health Hum Rights 7: 7.

    • Search Google Scholar
    • Export Citation
  • 3.

    World Health Organization, 2015. Chagas disease in Latin America: an epidemiological update based on 2010 estimates. Wkly Epidemiol Rec 90: 3343.

    • Search Google Scholar
    • Export Citation
  • 4.

    Centers for Disease Control and Prevention, 2012. Congenital transmission of Chagas disease–Virginia, 2010. MMWR Morb Mortal Wkly Rep 61: 477479.

    • Search Google Scholar
    • Export Citation
  • 5.

    Torrico F, Alonso-Vega C, Suarez E, Rodriguez P, Torrico M-C, Dramaix M, Truyens C, Carlier Y, 2004. Maternal Trypanosoma cruzi infection, pregnancy outcome, morbidity, and mortality of congenitally infected and non-infected newborns in Bolivia. Am J Trop Med Hyg 70: 201209.

    • Search Google Scholar
    • Export Citation
  • 6.

    Parra-Henao G, Amioka E, Franco-Paredes C, Colborn KL, Henao-Martínez AF, 2018. Heart failure symptoms and ecological factors as predictors of Chagas disease among indigenous communities in the Sierra Nevada de Santa Marta, Colombia. J Card Fail 24: 864866.

    • Search Google Scholar
    • Export Citation
  • 7.

    Tuite AR, Thomas-Bachli A, Acosta H, Bhatia D, Huber C, Petrasek K, Watts A, Yong JHE, Bogoch II, Khan K, 2018. Infectious disease implications of large-scale migration of Venezuelan nationals. J Trav Med 25. https://doi.org/10.1093/jtm/tay077.

    • Search Google Scholar
    • Export Citation
  • 8.

    Gómez Ochoa SA, 2018. Increasing cases of HIV/AIDS in the northern region of the Colombia-Venezuela border: the impact of high scale migration in recent years. Trav Med Infect Dis 25: 1617.

    • Search Google Scholar
    • Export Citation
  • 9.

    Dib JC, 2011. Enfermedad de Chagas en las Comunidades Indígenas de la Sierra Nevada de Santa Marta. Bogota, Colombia: Organización Panamericana de la Salud OPS/OMS Colombia.

    • Search Google Scholar
    • Export Citation
  • 10.

    Cucunubá ZM et al. 2014. Primer consenso colombiano sobre Chagas congénito y orientación clínica a mujeres en edad fértil con diagnóstico de Chagas. Infectio 18: 5065.

    • Search Google Scholar
    • Export Citation
  • 11.

    Colombia SINdSd, 2018. Boletín Epidemiológico Semanal. Semana 32. Available at: https://www.ins.gov.co/buscador-eventos/BoletinEpidemiologico/2018%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2032.pdf. Accessed January 31, 2019.

    • Search Google Scholar
    • Export Citation
  • 12.

    Russomando G, de Tomassone MM, de Guillen I, Acosta N, Vera N, Almiron M, Candia N, Calcena MF, Figueredo A, 1998. Treatment of congenital Chagas’ disease diagnosed and followed up by the polymerase chain reaction. Am J Trop Med Hyg 59: 487491.

    • Search Google Scholar
    • Export Citation
  • 13.

    Altcheh J, Biancardi M, Lapeña A, Ballering G, Freilij H, 2005. Congenital Chagas disease: experience in the Hospital de Niños, Ricardo Gutiérrez, Buenos Aires, Argentina [article in Spanish]. Rev Soc Bras Med Trop 38 (Suppl 2): 4145.

    • Search Google Scholar
    • Export Citation
  • 14.

    Picado A, Cruz I, Redard-Jacot M, Schijman AG, Torrico F, Sosa-Estani S, Katz Z, Ndung'u JM, 2018. The burden of congenital Chagas disease and implementation of molecular diagnostic tools in Latin America. BMJ Glob Health 3: e001069.

    • Search Google Scholar
    • Export Citation
  • 15.

    Henao-Martínez AF, Colborn K, Parra-Henao G, 2017. Overcoming research barriers in Chagas disease-designing effective implementation science. Parasitol Res 116: 3544.

    • Search Google Scholar
    • Export Citation
  • 16.

    Weidmann M et al. 2018. Development of mobile laboratory for viral hemorrhagic fever detection in Africa. J Infect Dis 218: 16221630.

  • 17.

    Noazin S et al. 2018. Trypomastigote excretory secretory antigen blot is associated with Trypanosoma cruzi load and detects congenital T. cruzi infection in neonates, using anti–shed acute phase antigen immunoglobulin M. J Infect Dis 219: 609618.

    • Search Google Scholar
    • Export Citation
  • 18.

    Alvarez MG, Vigliano C, Lococo B, Bertocchi G, Viotti R, 2017. Prevention of congenital Chagas disease by benznidazole treatment in reproductive-age women. An observational study. Acta Trop 174: 149152.

    • Search Google Scholar
    • Export Citation
  • 19.

    Dumonteil E, Herrera C, Buekens P, 2019. A therapeutic preconceptional vaccine against Chagas disease: a novel indication that could reduce congenital transmission and accelerate vaccine development. PLoS Negl Trop Dis 13: e0006985.

    • Search Google Scholar
    • Export Citation
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In Search of Congenital Chagas Disease in the Sierra Nevada de Santa Marta, Colombia

Gabriel Parra-HenaoCentro de Investigación en Salud para el Trópico (CIST), Universidad Cooperativa de Colombia, Santa Marta, Colombia;

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Horacio OliverosCentro de Investigación en Salud para el Trópico (CIST), Universidad Cooperativa de Colombia, Santa Marta, Colombia;

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Peter J. HotezDepartment of Pediatrics, Texas Children’s Hospital Center for Vaccine Development, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas;
Department of Biology, Baylor University, Waco, Texas;

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Gabriel MotoaDivision of Infectious Diseases, University of Colorado Denver, School of Medicine, Aurora, Colorado;

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Carlos Franco-ParedesDivision of Infectious Diseases, University of Colorado Denver, School of Medicine, Aurora, Colorado;
Hospital Infantil de México, Federico Gómez, México City, México

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Andrés F. Henao-MartínezDivision of Infectious Diseases, University of Colorado Denver, School of Medicine, Aurora, Colorado;

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Chagas disease remains a major impediment to sustainable socioeconomic development in Latin America. Transplacental transmission explains the persistence of transmission in urban areas, in non-endemic regions, and in areas with an established interrupted vectorial transmission. One of every five cases of congenital Chagas disease in the world occurs in Colombia and Venezuela. The massive migration of impoverished populations from neighboring Venezuela has worsened the situation creating a humanitarian crisis in Northeastern Colombia, including the Sierra Nevada de Santa Marta. The prevalence of Chagas infection among pregnant women in these areas is higher than the national average, and the public health resources are insufficient. This perspective discusses the associated increased morbidity and mortality of congenital Chagas in this region, where stigmatization contributes to the impression among health authorities and the general population that it affects indigenous communities only. The monitoring and control of congenital Chagas disease in the Sierra Nevada of Santa Marta is a public health necessity that demands urgent and effective interventions.

In Colombia, Venezuela, and other Latin American countries, the burden associated with neglected tropical diseases and other infectious diseases of poverty is on the rise.1 In this region, Chagas disease remains a major impediment to achieve sustainable socioeconomic development.2 According to the WHO, approximately 438,000 and 193,000 people are living with Chagas disease in Colombia and Venezuela, respectively.3 Together, these two nations combined represent the fourth largest region in the world in terms of Chagas disease cases, behind Argentina, Brazil, and Mexico. In addition to the critical role of vector-borne transmission in Colombia and Venezuela, Trypanosoma cruzi infects fetuses in utero via a vertical transmission (transplacentally).4,5 According to the WHO, in 2010, Colombia and Venezuela accounted for approximately 20% of the world’s cases of congenital Chagas disease, although these two nations account for about 11% of the total number of people living with Chagas disease.3

In contrast to its exotic and majestic natural landscape, the Sierra Nevada de Santa Marta (SNSM) is one the most impoverished areas in Colombia, which expands to three departments in Northeastern Colombia: Magdalena, La Guajira, and Cesar. The SNSM is home to many Native American indigenous groups including the Arhuacos, Arzario, and Koguis. This underserved area in Colombia lacks sufficient public health resources to care for these historically disenfranchised and segregated indigenous groups. It is not a coincidence that Chagas disease is a highly prevalent neglected infection among these populations, leading to a cycle of destitution.6 Presently, there is limited access to medical care and a limited deployment of preventive and therapeutic resources and interventions to reduce the burden of Chagas disease in this region. More recently, there are important concerns that the burden of Chagas disease among indigenous groups in the SNSM is worsening, given the increasing population influx from disenfranchised Venezuelan populations caused by the ongoing humanitarian crisis in this neighboring country.7,8 In addition to the poor infrastructure and poor living conditions in this area, there is a high prevalence of T. cruzi infection among triatomine vectors fueling increasing transmission. Among local triatomine vectors (Rhodnius prolixus and Triatoma dimidiata), the infection index for T. cruzi is on average 20%.9

Previous work in several localities in Colombia revealed a prevalence of Chagas infection among pregnant women between 2% and 4%.10 We have previously identified a prevalence of 47% of Chagas disease among indigenous tribes in SNSM, and many of them have not received effective antiparasitic therapy.6 We can, therefore, infer that in this region, there is a high rate of congenital transmission of T. cruzi.

Congenital Chagas infection may lead to stillbirth, preterm birth, polyhydramnios, low birth weight, and severe disease, including hepatosplenomegaly, meningoencephalitis, and respiratory insufficiency, similar to manifestations of the toxoplasmosis, other agents, rubella, cytomegalovirus infection, and herpes simplex virus infection syndrome.4,5 Mortality associated with congenital Chagas disease ranges from 2% to 13%.5 The neonatal and perinatal mortality in the region—16.2 deaths per 1,000 live birth—is significantly higher than the national average.11 The local health department has reported that polyhydramnios is present in 20% of neonatal deaths. Although we lack specific data on the specific etiologies of polyhydramnios and death, we can assume that congenital T. cruzi infection may be a potential contributor to death in these cases. The transplacental transmission also explains the persistence of parasitic transmission in urban areas, in non-endemic regions, and in selected areas where there has been an interruption of vectorial transmission.10 Furthermore, there are no available drugs considered safe to treat Chagas disease during pregnancy. However, parasitological cure rates after treatment in infants are high (> 90%), and side effects develop less frequently than in older adults.12,13 Therefore, there is a pressing need to elucidate the current epidemiology of congenital Chagas disease and to implement surveillance and control activities in this region of Colombia.

Early diagnosis and treatment of Chagas disease among infants and women of childbearing age are high priorities. Diagnosis and treatment guidelines of congenital Chagas disease in Colombia recommend the use of blood smear techniques for diagnosis in newborns compared with older individuals. Alternatively, they recommend for clinicians to use serology-based or molecular testing after the first 8 months of life.10 PCR-based technologies are an attractive option, but increased costs, reliability, and lack of standardization remain significant concerns.14 Likewise, effective clinical strategies and algorithms, which are easy to implement, detect, and prevent congenital Chagas disease, are lacking.15 Despite these limitations, the opportunities to develop low-cost, accessible, and effective technologies for early diagnosis and treatment of congenital Chagas disease are promising. Mobile laboratories16 and electronic technology can aid in the increasing need for better screening and diagnosis of preventable infectious diseases affecting the most vulnerable populations. New serologic methods such as IgM trypomastigote excretory secretory antigen blot had favorable results in improving congenital infection detection in an infant cohort in Bolivia.17 Benznidazole treatment or vaccine development among reproductive-age women could be an important approach to reduce congenital Chagas disease.18,19 There is also an unprecedented need for cost-effective, easy-to-implement, point-of-care diagnostics for this parasitic infection.

Chagas disease remains a neglected disease in SNSM, where local data are limited, and stigmatization contributes to the impression among health authorities and the general population that it affects indigenous communities only. Designing and implementing pilot programs for monitoring and control of congenital Chagas disease in the region of the SNSM is a public health necessity that demands urgent and effective interventions.

REFERENCES

  • 1.

    Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Periago MR, 2008. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis 2: e300.

    • Search Google Scholar
    • Export Citation
  • 2.

    Franco-Paredes C, Von A, Hidron A, Rodríguez-Morales AJ, Tellez I, Barragán M, Jones D, Náquira CG, Mendez J, 2007. Chagas disease: an impediment in achieving the millennium development goals in Latin America. BMC Int Health Hum Rights 7: 7.

    • Search Google Scholar
    • Export Citation
  • 3.

    World Health Organization, 2015. Chagas disease in Latin America: an epidemiological update based on 2010 estimates. Wkly Epidemiol Rec 90: 3343.

    • Search Google Scholar
    • Export Citation
  • 4.

    Centers for Disease Control and Prevention, 2012. Congenital transmission of Chagas disease–Virginia, 2010. MMWR Morb Mortal Wkly Rep 61: 477479.

    • Search Google Scholar
    • Export Citation
  • 5.

    Torrico F, Alonso-Vega C, Suarez E, Rodriguez P, Torrico M-C, Dramaix M, Truyens C, Carlier Y, 2004. Maternal Trypanosoma cruzi infection, pregnancy outcome, morbidity, and mortality of congenitally infected and non-infected newborns in Bolivia. Am J Trop Med Hyg 70: 201209.

    • Search Google Scholar
    • Export Citation
  • 6.

    Parra-Henao G, Amioka E, Franco-Paredes C, Colborn KL, Henao-Martínez AF, 2018. Heart failure symptoms and ecological factors as predictors of Chagas disease among indigenous communities in the Sierra Nevada de Santa Marta, Colombia. J Card Fail 24: 864866.

    • Search Google Scholar
    • Export Citation
  • 7.

    Tuite AR, Thomas-Bachli A, Acosta H, Bhatia D, Huber C, Petrasek K, Watts A, Yong JHE, Bogoch II, Khan K, 2018. Infectious disease implications of large-scale migration of Venezuelan nationals. J Trav Med 25. https://doi.org/10.1093/jtm/tay077.

    • Search Google Scholar
    • Export Citation
  • 8.

    Gómez Ochoa SA, 2018. Increasing cases of HIV/AIDS in the northern region of the Colombia-Venezuela border: the impact of high scale migration in recent years. Trav Med Infect Dis 25: 1617.

    • Search Google Scholar
    • Export Citation
  • 9.

    Dib JC, 2011. Enfermedad de Chagas en las Comunidades Indígenas de la Sierra Nevada de Santa Marta. Bogota, Colombia: Organización Panamericana de la Salud OPS/OMS Colombia.

    • Search Google Scholar
    • Export Citation
  • 10.

    Cucunubá ZM et al. 2014. Primer consenso colombiano sobre Chagas congénito y orientación clínica a mujeres en edad fértil con diagnóstico de Chagas. Infectio 18: 5065.

    • Search Google Scholar
    • Export Citation
  • 11.

    Colombia SINdSd, 2018. Boletín Epidemiológico Semanal. Semana 32. Available at: https://www.ins.gov.co/buscador-eventos/BoletinEpidemiologico/2018%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2032.pdf. Accessed January 31, 2019.

    • Search Google Scholar
    • Export Citation
  • 12.

    Russomando G, de Tomassone MM, de Guillen I, Acosta N, Vera N, Almiron M, Candia N, Calcena MF, Figueredo A, 1998. Treatment of congenital Chagas’ disease diagnosed and followed up by the polymerase chain reaction. Am J Trop Med Hyg 59: 487491.

    • Search Google Scholar
    • Export Citation
  • 13.

    Altcheh J, Biancardi M, Lapeña A, Ballering G, Freilij H, 2005. Congenital Chagas disease: experience in the Hospital de Niños, Ricardo Gutiérrez, Buenos Aires, Argentina [article in Spanish]. Rev Soc Bras Med Trop 38 (Suppl 2): 4145.

    • Search Google Scholar
    • Export Citation
  • 14.

    Picado A, Cruz I, Redard-Jacot M, Schijman AG, Torrico F, Sosa-Estani S, Katz Z, Ndung'u JM, 2018. The burden of congenital Chagas disease and implementation of molecular diagnostic tools in Latin America. BMJ Glob Health 3: e001069.

    • Search Google Scholar
    • Export Citation
  • 15.

    Henao-Martínez AF, Colborn K, Parra-Henao G, 2017. Overcoming research barriers in Chagas disease-designing effective implementation science. Parasitol Res 116: 3544.

    • Search Google Scholar
    • Export Citation
  • 16.

    Weidmann M et al. 2018. Development of mobile laboratory for viral hemorrhagic fever detection in Africa. J Infect Dis 218: 16221630.

  • 17.

    Noazin S et al. 2018. Trypomastigote excretory secretory antigen blot is associated with Trypanosoma cruzi load and detects congenital T. cruzi infection in neonates, using anti–shed acute phase antigen immunoglobulin M. J Infect Dis 219: 609618.

    • Search Google Scholar
    • Export Citation
  • 18.

    Alvarez MG, Vigliano C, Lococo B, Bertocchi G, Viotti R, 2017. Prevention of congenital Chagas disease by benznidazole treatment in reproductive-age women. An observational study. Acta Trop 174: 149152.

    • Search Google Scholar
    • Export Citation
  • 19.

    Dumonteil E, Herrera C, Buekens P, 2019. A therapeutic preconceptional vaccine against Chagas disease: a novel indication that could reduce congenital transmission and accelerate vaccine development. PLoS Negl Trop Dis 13: e0006985.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to Gabriel Parra-Henao, Carretera Troncal del Caribe, Km 3 Sector Mamatoco, Santa Marta, Colombia. E-mail: gabriel.parrah@ucc.edu.co

Disclosure: P. J. H. has a patent WO2017160849A1 issued, and is the lead investigator and potentially a patent holder on a therapeutic vaccine against Chagas disease which is in development.

Financial support: A. F. H.-M. reports personal fees from Bayer and grants from Sanofi, outside the submitted work.

Authors’ addresses: Gabriel Parra-Henao and Horacio Oliveros, Centro de Investigación en Salud para el Trópico (CIST), Universidad Cooperativa de Colombia, Santa Marta, Colombia, E-mails: gparrahenao@gmail.com and horacio_oliveros@hotmail.com. Peter J. Hotez, Faculty of Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, E-mail: hotez@bcm.edu. Gabriel Motoa, Carlos Franco-Paredes, and Andrés F. Henao-Martínez, Division of Infectious Diseases, Faculty of Medicine, University of Colorado Denver, Aurora, CO, E-mails: gabrielmotoa@gmail.com, carlos.franco-paredes@ucdenver.edu, and andres.henaomartinez@ucdenver.edu.

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