Chapter 3Infectious Diseases Related To Travel
Trypanosomiasis, American (Chagas Disease)
Alicia I. Hidron, Carlos Franco-Paredes
American trypanosomiasis is caused by the protozoan parasite, Trypanosoma cruzi.
MODE OF TRANSMISSION
Infection occurs through vectorborne transmission in endemic countries via the feces of the triatomine insect (reduviid bug), which may be inadvertently inoculated into the skin or the mucosa of the eyes, nose, or mouth when the insect’s bite is scratched and rubbed. Infection may also be transmitted through blood transfusion or organ transplantation, from mother to infant, by consuming contaminated food or beverages (including fruit juices), and through occupational exposure in laboratory workers.
Approximately 7.6 million people have Chagas disease, according to the most recent estimates. The disease is endemic in Mexico and Central and South America. Rare cases of Chagas disease attributed to local vectorborne transmission have been reported in the United States, but it is more commonly found in nonendemic areas as a result of immigration. In fact, Chagas disease is considered a globalized disease because of immigration from endemic to nonendemic zones; it has been identified through blood banks or other screening programs.
No cases have been documented of Chagas disease acquired during travel; the risk of acquiring Chagas disease while traveling is assumed to be extremely low. Travelers could be at risk for Chagas disease if staying in poor-quality housing (for example, mud walls with cracks) in endemic areas. Chagas disease could be acquired through blood transfusion in areas with poor screening or by consuming contaminated food or beverages.
The acute phase of Chagas disease lasts up to 90 days, followed by asymptomatic chronic infection, usually undetectable by parasitologic methods. Most infected people never develop symptoms but remain infected throughout their lives. People with chronic infection but without signs or symptoms are considered to have the indeterminate form of Chagas disease. This is the most common clinical presentation in nonendemic areas where patients are incidentally diagnosed through blood donation. Those who develop acute illness will do so 1 week or more after exposure. A chagoma may develop, which is an area of edema and erythema at the site of infection; the classic picture is the Romaña sign, which presents as edema of the eyelid and ocular tissues when the entry site was the conjunctiva. Approximately 20%–30% of infected patients will develop manifestations of chronic Chagas disease, usually involving the heart. Clinical signs include conduction system abnormalities, ventricular arrhythmias, and in late-stage disease, congestive cardiomyopathy. Less commonly, chronic gastrointestinal problems may ensue when Chagas causes megaesophagus or megacolon. Reactivation disease can occur in immunocompromised patients.
Diagnosis requires consideration of both test results and patient exposure history. During the acute phase, parasites may be detectable in fresh preparations of buffy coat or stained peripheral blood specimens. After the acute phase, diagnosis relies on the use of 2 or more different serologic tests (most commonly, ELISA and the immunofluorescent antibody test). Infected people should be evaluated for symptoms and signs of cardiac and gastrointestinal disease.
Clinicians should consult with an infectious disease or tropical medicine specialist to diagnose and treat Chagas disease. Antitrypanosomal drug treatment is always recommended for acute, early congenital, and reactivated T. cruzi infection and for chronic T. cruzi infection in children up to 18 years old. In adults, treatment is usually recommended, based on recent data suggesting that a course of antitrypanosomal treatment delays progression of cardiomyopathy and decreases mortality.
In the United States, the only source of the antitrypanosomal drugs, benznidazole and nifurtimox, is through CDC. The drugs are not licensed in the United States and are provided only under investigational new drug protocols. Clinicians should contact the CDC’s Parasitic Diseases public inquiries line (404-718-4745), the CDC Drug Service (404-639-3670), or outside business hours, the CDC Emergency Operations Center (770-488-7100). CDC also provides guidance on diagnostic testing and clinical evaluation.
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available. Preventive measures include insecticide spraying of sleeping quarters or infested houses. Travelers who cannot avoid camping, sleeping outdoors, or sleeping in poorly constructed houses in endemic areas should use insecticide-impregnated bed nets and tuck in the edges to provide a physical barrier to the vectors. Compliance with food and water precautions in endemic areas is also recommended to prevent the extremely rare occurrence of foodborne Chagas disease. Blood transfusion and organ transplantation should be avoided in travelers visiting or living in endemic countries, if at all possible, unless urgently or emergently required (see Chapter 2, Medical Tourism).
- Bern C, Montgomery SP, Herwaldt BL, Rassi A Jr, Marin-Neto JA, Dantas RO, et al. Evaluation and treatment of Chagas disease in the United States: a systematic review. JAMA. 2007 Nov 14;298(18):2171–81.
- CDC. Chagas disease after organ transplantation—United States, 2001. MMWR Morb Mortal Wkly Rep. 2002 Mar 15;51(10):210–2.
- Dias JC. The indeterminate form of human chronic Chagas’ disease A clinical epidemiological review. Rev Soc Bras Med Trop. 1989 Jul–Sep;22(3):147–56.
- Dorn PL, Perniciaro L, Yabsley MJ, Roellig DM, Balsamo G, Diaz J, et al. Autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerg Infect Dis. 2007 Apr;13(4):605–7.
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- ProMED-mail. Trypanosomiasis, foodborne—Brazil (Santa Catarina). 2005 [updated Mar 27]. Available from: http://www.promedmail.org.
- Rassi A Jr, Rassi A, Little WC. Chagas’ heart disease. Clin Cardiol. 2000 Dec;23(12):883–9.
- Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010 Apr 17;375(9723):1388–402.
- Schmunis GA. Epidemiology of Chagas disease in non-endemic countries: the role of international migration. Mem Inst Oswaldo Cruz. 2007 Oct 30;102 Suppl 1:75–85.
- Schmunis GA, Cruz JR. Safety of the blood supply in Latin America. Clin Microbiol Rev. 2005 Jan;18(1): 12–29.
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