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.
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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: 201–209.
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: 864–866.
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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.
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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: 609–618.
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: 149–152.
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.