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Serological screening for Chagas disease in an endemic region of Northern Minas Gerais, Brazil: the SaMi-Trop project

ABSTRACT

Chagas disease (CD) is still a neglected disease. Infected individuals are diagnosed late, being treated in worse clinical conditions. Thus, this study aimed to analyze the prevalence and the factors associated with new confirmed cases of CD identified by serological screening in an endemic region of Minas Gerais State, Brazil. This is an analytical cross-sectional study with data from a project of the Research Center in Tropical Medicine of Sao Paulo- Minas Gerais (SaMi-Trop) conducted in two municipalities. Data collection included a questionnaire with closed questions, a venous blood collection and an ELISA serological test for CD. A total of 2,038 individuals with no previous diagnosis of CD participated in the study. The result of the serological test for CD was adopted as the dependent variable. The independent variables addressed personal issues, health conditions and lifetime housing. A descriptive analysis of individual variables was performed. Subsequently, a bivariate analysis was performed using the Pearson’s chi-square test. Households sheltering individuals positive for CD were georeferenced, and the analysis of spatial distribution was performed using the quartic function to estimate the density of the nucleus. Among the participants, 188 (9.2 %) were positive for CD. The profile of participants with CD was associated with place of residence, age, relative/family member with CD and living conditions. It is noteworthy that there are still patients with CD who are unaware of their diagnosis in both, rural and urban areas.

Chagas disease; Serologic tests; Spatial analysis

INTRODUCTION

Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is a neglected disease11. Pinheiro E, Brum-Soares L, Reis R, Cubides JC. Chagas disease: review of needs, neglect, and obstacles to treatment access in Latin America. Rev Soc Bras Med Trop 2017;50:296-300.. It still constitutes a major social and public health problem in endemic countries, and represents an emerging health problem in non-endemic countries22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.,33. Nunes MC, Dones W, Morillo CA, Encina JJ, Ribeiro AL. Chagas disease: an overview of clinical and epidemiological aspects. J Am Coll Cardiol. 2013;62:767-76.. In both places of occurrence, there is inexperience of health professionals44. Ferreira AM, Sabino EC, Moreira HF, Cardoso CS, Oliveira CD, Ribeiro AL, et al. Avaliação do conhecimento acerca do manejo clínico de portadores da doença de Chagas em região endêmica no Brasil. Rev APS. 2018;21:345-54.,55. Stimpert KK, Montgomery SP. Physician awareness of Chagas disease, USA. Emerg Infect Dis. 2010;16:871-2. and a high rate of underdiagnosis22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.,55. Stimpert KK, Montgomery SP. Physician awareness of Chagas disease, USA. Emerg Infect Dis. 2010;16:871-2.

6. Basile L, Jansa JM, Carlier Y, Salamanca DD, Angheben A, Bartoloni A, et al. Chagas disease in european countries: the challenge of a surveillance system. Euro Surveill. 2011;16:19968.
-77. Cortez J, Ramos E, Valente C, Seixas J, Vieira A. A expressão global da doença de Chagas: oportunidades emergentes e impacto em Portugal. Acta Med Port. 2012;25:332-9..

It is estimated that 6 to 7 million people are infected worldwide88. World Health Organization. Chagas disease (also known as American trypanosomiasis). [cited 2021 Aug 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/chagas-disease-(american-trypanosomiasis)
https://www.who.int/news-room/fact-sheet...
. In Brazil, it was estimated that between 1.3 and 3.2 million people would be infected with T. cruzi in 202022. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.. However, the country does not have data on the prevalence of chronic CD. Although the notification of chronic cases of CD became mandatory in 202099. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 264, de 17 de fevereiro de 2020. Altera a Portaria de Consolidação nº 4/GM/MS, de 28 de setembro de 2017, para incluir a doença de Chagas crônica, na Lista Nacional de Notificação Compulsória de doenças, agravos e eventos de saúde pública nos serviços de saúde públicos e privados em todo o território nacional. Diário Oficial da União, Brasília, 19 fev. 2020. Seção 1:97. [cited 2021 Aug 3]. Available from: https://www.in.gov.br/en/web/dou/-/portaria-n-264-de-17-de-fevereiro-de-2020-244043656
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, the CD control program is disjointed and its actions are discontinuous1010. Silveira AC. El impacto de la descentralización de los sistemas de salud em la prevención y control de la enfermedad de Chagas: el caso del Brasil. In: Yadón ZE, Gurtler RE, Tobar F, Medici AC, editores. Descentralización y manejo del control de enfermidades transmisibles en América Latina. Buenos Aires: OPS; 2006. p.203-14..

From 2009 to 2018, 45,863 deaths were recorded in Brazil as a result of CD1111. Brasil. Ministério da Saúde. DATASUS: informações de saúde (TABNET): estatísticas vitais. [cited 2021 Aug 3]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt1
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. Of these, 11,343 (24.7 %) were registered in the Brazilian Minas Gerais State, and the highest number of deaths, 2,300 or 20.2 %, were reported by the Northern health macro-region1111. Brasil. Ministério da Saúde. DATASUS: informações de saúde (TABNET): estatísticas vitais. [cited 2021 Aug 3]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt1
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. Although much of Northern Minas Gerais has been identified as an area of high risk for vector transmission of CD or of reestablished home transmission1212. Galvão C, organizador. Vetores da doença de Chagas no Brasil. Curitiba: Sociedade Brasileira de Zoologia; 2014., there is no investigation of CD in the prenatal care routine1313. São Paulo. Secretaria da Saúde. Coordenadoria de Planejamento em Saúde. Assessoria Técnica em Saúde da Mulher. Atenção a gestante e a puérpera no SUS-SP: manual técnico do pré-natal e puerpério. São Paulo: Secretaria da Sáude; 2010. [cited 2021 Aug 3]. Available from: http://www.saude.sp.gov.br/resources/ses/perfil/gestor/destaques/atencao-a-gestante-e-a-puerpera-no-sus-sp/manual-tecnico-do-pre-natal-e-puerperio/manual_tecnicoii.pdf
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and many infected people are unaware of their condition1414. Pecoul B, Batista C, Stobbaerts E, Ribeiro I, Vilasanjuan R, Gascon J, et al. The BENEFIT trial: where do we go from here ? PLoS Negl Trop Dis. 2016; 10:e0004343..

The late diagnosis of CD makes infected people arrive in worse clinical conditions to the health system, favoring the evolution of the disease, decreasing the quality of life of infected individuals, increasing their morbidity and mortality and causing a significant economic loss1515. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Doença de Chagas aguda no Brasil: série histórica de 2000 a 2013. Bol Epidemiol. 2015;46:1-9. [cited 2021 Aug 3]. Available from: https://antigo.saude.gov.br/images/pdf/2015/agosto/03/2014-020.pdf
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16. Araújo SM, Andó MH, Cassarotti DJ, Mota DC, Borges SM, Gomes ML. Programa ACHEI: Atenção ao Chagásico com Educação Integral no município de Maringá e Região Noroeste do Paraná, Brasil. Rev Soc Bras Med Trop. 2000;33:565-72.
-1717 Franco-Paredes C, Von A, Hidron A, Rodríguez-Morales AJ, Tellez I, Barragán M, et al. Chagas disease : an impediment in achieving the Millennium Development Goals in Latin America. BMC Int Health Hum Rights. 2007;7:7.. The absence of accessible diagnostic methods and the lack of specific information on CD by health professionals, leaves infected individuals unidentified, and therefore, untreated44. Ferreira AM, Sabino EC, Moreira HF, Cardoso CS, Oliveira CD, Ribeiro AL, et al. Avaliação do conhecimento acerca do manejo clínico de portadores da doença de Chagas em região endêmica no Brasil. Rev APS. 2018;21:345-54.,1818. Balouz V, Aguero F, Buscaglia CA. Chagas disease diagnostic applications: present knowledge and future steps. Adv Parasitol. 2017;97:1-45.. This reality mainly affects vulnerable populations1313. São Paulo. Secretaria da Saúde. Coordenadoria de Planejamento em Saúde. Assessoria Técnica em Saúde da Mulher. Atenção a gestante e a puérpera no SUS-SP: manual técnico do pré-natal e puerpério. São Paulo: Secretaria da Sáude; 2010. [cited 2021 Aug 3]. Available from: http://www.saude.sp.gov.br/resources/ses/perfil/gestor/destaques/atencao-a-gestante-e-a-puerpera-no-sus-sp/manual-tecnico-do-pre-natal-e-puerperio/manual_tecnicoii.pdf
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. An early diagnosis allows the access to an appropriate treatment, minimizing complications of the disease, and lowering the corresponding mortality22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.. In addition, it is recommended that the diagnosis be made in all suspected cases22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86..

Thus, this study aimed to analyze the prevalence and the factors associated with new confirmed cases of CD identified by serological screening in an endemic region of Minas Gerais State, Brazil.

MATERIALS AND METHODS

Ethical approval

This study was approved by the Ethics Committee of the State University of Montes Claros (CEP/UNIMONTES Nº 3.502.440/2018). All participants agreed to participate in this study and signed the Informed Consent Form.

Study design

This is a cross-sectional analytical study with data from a project performed at the Center for Research in Tropical Medicine of Sao Paulo-Minas Gerais (Centro de Pesquisa em Medicina Tropical de Sao Paulo-Minas Gerais - SaMi-Trop). This multicenter project is carried out by researchers from four Brazilian public universities in the States of Minas Gerais and Sao Paulo, Brazil. Its purpose is to develop and conduct research projects on CD.

Study area

This study was conducted in two municipalities in the Northern region of the Brazilian State of Minas Gerais: Espinosa (Latitude: 15°56’55” South; Longitude 44°51’52” West) and Sao Francisco (Latitude:15°56’41” South; Longitude: 44°51’14” West). The territorial extension of Espinosa is 1,884.23 km2 and of Sao Francisco is 3,312.27 km2. The population of Espinosa comprises 31,113 inhabitants and of Sao Francisco 53,8281919. Programa das Nações Unidas para o Desenvolvimento. Fundação João Pinheiro. Instituto de Pesquisa Econômica Aplicada. Atlas de desenvolvimento humano no Brasil. [cited 2021 Aug 3]. Available from: https://atlasbrasil.org.br/
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. Both municipalities have high coverages of the Family Health Strategy (FHS) and more than 98% of the population depends on the Primary Health Care (PHC) offered by the Public Health System (Sistema Unico de Saude - SUS)2020. Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Sistema de nota técnica do DESF. [cited 2021 Aug 3]. Available from: https://sisaps.saude.gov.br/notatecnica/frmListaMunic.php
https://sisaps.saude.gov.br/notatecnica/...
.

Sample

Individuals over the age of 18 and belonging to the FHS coverage area were invited. The sample was defined in a non-probabilistic way. The exclusion criterion was: individuals with a previous diagnosis of CD.

A total of 2,056 individuals participated in the stage of sample collection. However, for this study, 18 individuals who reported having been diagnosed with CD were excluded from the analysis, thus 2,038 were eligible.

Data collection

A meeting was held with the managers and nurses responsible for the FHS of the respective municipalities in order to inform them on the planned intervention and request their consent to carry out the study. After their acceptance, the municipalities made available an accessible FHS unit to carry out the data collection. Nurses passed on the information to the community health workers (CHW). Then, upon a scheduled date, the CHW invited the community to participate in the study and informed that more than one family member could participate.

The data collection took place between February and November 2019, and included a questionnaire with closed questions and one collection of venous blood. The questionnaire was applied to the participants with the questions addressing personal information, health and housing conditions during their lives.

Serological screening

The collected venous blood samples were centrifuged the resulting serum was stored at -20 °C and subsequently sent in dry ice to the Institute of Tropical Medicine of the University of Sao Paulo (IMT-USP), where two enzyme linked immune sorbent assays (ELISA) tests were performed in duplicate, using commercial kits (Chagatest, Wiener Lab, Rosario, Argentina, and Trypanosoma cruzi IgG, Euroimmun, Lübeck, Germany) according to the manufacturer’s instructions. To confirm the serological diagnosis, it was necessary to obtain concordant results in at least two serological tests of different methodological principles or antigenic preparations22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86..

Individuals identified with CD who authorized the notification of their condition, and those with inconclusive serology, were included in the flow of the Brazilian unified health system for the continuity of their health care and treatment of CD.

Variables

The results of the ELISA tests were adopted as the outcome (dependent variable), dichotomized into two categories (negative/inconclusive vs. positive). The independent variables were composed by city, age, gender, relative/family member with CD, knowledge on triatomine insects, have lived in an area with triatomine insects, have lived in a wooden/wattle and daub/adobe house. The age was calculated based on the date of birth of the participants and categorized as: up to 35 years, from 36 to 55 years, from 56 to 75 and 76 years or more.

Statistical analysis

The descriptive analysis of individual variables was performed, estimating absolute (n) and relative (%) frequencies for the categorical variables and calculating the central tendency and dispersion measures for the numerical variables. Subsequently, a bivariate analysis was performed using the Pearson’s chi-square test, considering only the associations that maintained a significance level of up to 5 % (p < 0.05). The statistical software Statistical Package for the Social Sciences (SPSS) V.19 (SPSS Inc., IBM, Armonk, New York, USA) was used to carry out the analyzes conducted in this study.

The households that sheltered individuals serological positive for CD were georeferenced on site using a Global Positioning System (GPS) navigation device (Garmin Etrex® Garmin Ltd., Olathe, USA). In the Qgis 3.4® program (version 3.4 Madeira, QGIS Development Team), the spatial distribution analysis of the residences was carried out using the quartic function of the kernel density estimation (KDE)2121. Gatrell AC, Bailey TC, Diggle PJ, Rowlingson BS. Spatial point pattern analysis and its application in geographical epidemiology. Trans Inst Br Geogr. 1996;21:256-74., considering a bandwidth of 500 m. KDE is a non-parametric function that estimates probable occurrence values based on the density of upcoming events.

RESULTS

A total of 2,038 individuals participated in this study, of which 188 (9.2 %) were serologically positive, 48 (2.6%) were inconclusive and 1,850 (90.8 %) were negative for CD. The inconclusive tests were repeated when these individuals were entered into the SUS, but for logistical and ethical reasons, we did not have access to these results. Among the participants, the majority live in the city of Sao Francisco, are female (63.5%), have a mean age of 48.18 years (± 15.43), with a minimum age of 18 and a maximum of 94 years. They reported to be related to people with CD (50.8%), not having been bitten by triatomine insects (60.3 %), having lived in an area with triatomine insects (87.1 %), and having lived in a wooden/wattle and daub/adobe house (72.2 %) (Table 1).

Table 1
Descriptive and bivariate analysis of the diagnoses of Chagas disease (n = 2,038).

Among the individuals diagnosed with CD, the mean age was 56.19 (± 9.02) years with a minimum of 35 and a maximum of 86 years old. The majority of individuals with a diagnosis of CD lived in the city of Espinosa (12%), while the majority of respondents lived in the city of Sao Francisco. When analyzing the distribution of positive diagnoses in the cities studied (Figure 1, Table 2), it was observed that 75 % of positive cases live in the rural area of Espinosa and 55 % live in the urban area of Sao Francisco.

Figure 1
Spatial distribution of cases diagnosed with Chagas disease in 2019, in the municipalities of Espinosa and Sao Francisco, Minas Gerais State (n = 2,038).

Table 2
Description of the place of residence of the individuals participating in the study (n = 2,038).

In the bivariate analysis, it was observed that the characteristics that were statistically associated with positive diagnoses were age, having a family member with CD, have been bitten by the triatomine insect, have lived in an area with triatomine insects, and have lived in a wooden/wattle and daub/adobe house (Table 1).

The individual variables that were statistically associated with the outcome were age, being related to people with CD, having been bitten by the triatomine insect, having lived in an area with triatomine insects, and have lived in a wooden house/wattle and daub/adobe.

DISCUSSION

The present study observed that the number of positive cases screened by serology corroborates the number of positive cases estimated by the high-risk population of the Clinical Protocol and Therapeutic Guideline for Chagas Disease (PCDT)2222. Brasil. Ministério da Saúde. Comissão Nacional de Incorporação de Tecnologias no SUS. Protocolo clínico e diretrizes terapêuticas: doença de Chagas. Brasília: Ministério da Saúde; 2018. [cited 2021 Aug 3]. Available from: http://conitec.gov.br/images/Consultas/Relatorios/2018/Relatorio_PCDT_DoencaChagas_CP42_2018.pdf
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With the increase in migration and progressive changes in the rural economy, the epidemiological patterns of CD have been modified, with a transition from acute rural to chronic urban disease2323. World Health Organization. Chagas disease (American trypanosomiasis). [cited 2021 Aug 3]. Available from: https://www.who.int/news-room/q-a-detail/chagas-disease
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. In Minas Gerais State, it was observed that between 2001 and 2006, 84 cases of acute CD were reported, with 58% of the cases of acute CD being registered in the urban area2424. Pereira CM, Azevedo AP, Marinho SS, Prince KA, Gonçalves JT, Costa MR, et al. Perfil clínico e epidemiológico da doença de Chagas aguda no estado de Minas Gerais. Rev Aten Saude. 2017;15:49-54., a significant data, since for decades CD was restricted to rural areas and was strongly marked by poverty22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.. However, our study shows that it is not possible to generalize the epidemiological patterns of CD, as the municipality of Sao Francisco presented an urban pattern, but the municipality of Espinosa presented a rural pattern. CD is still recognized as a neglected disease, which mainly affects vulnerable populations in need of public policies that promote access to health care11. Pinheiro E, Brum-Soares L, Reis R, Cubides JC. Chagas disease: review of needs, neglect, and obstacles to treatment access in Latin America. Rev Soc Bras Med Trop 2017;50:296-300..

Regarding the age, our study corroborates the results of others2525. Vizzoni AG, Varela MC, Sangenis LH, Hasslocher-Moreno AM, Brasil PE, Saraiva RM. Ageing with Chagas disease: an overview of an urban Brazilian cohort in Rio de Janeiro. Parasit Vectors. 2018;11:354.,2626. Matos CS, Santos Júnior JE, Medeiros FA, Furtado E, Dias JC. Current situation and perspectives regarding human Chagas disease in midwestern of the state of Minas Gerais, Brazil. Mem Inst Oswaldo Cruz. 2014;109:374-8. who observed a greater relationship between positive serology and older people, suggesting that the infection by T. cruzi has happened in the past. From the 1950s to the mid-1990s, campaigns to prevent CD were intensified, and since then, vector transmission has suffered a significant decrease. As a consequence, it is possible that the positive individuals in the study became infected in a period prior to the campaigns to combat CD22. Dias JC, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saude. 2016;25:7-86.,2626. Matos CS, Santos Júnior JE, Medeiros FA, Furtado E, Dias JC. Current situation and perspectives regarding human Chagas disease in midwestern of the state of Minas Gerais, Brazil. Mem Inst Oswaldo Cruz. 2014;109:374-8.,2727. Glass IR, Santos AD, Varjão AE, Costa IS, Correia D, Silva AM. Clinical and epidemiological characteristics of Chagas disease in an endemic area of Sergipe State, Brazil. Rev Soc Bras Med Trop. 2018;51:660-4.. Another factor to consider would be the lack of adequate training of PHC professionals during their under graduation studies as well as their professional lives, leading to the failure to consider the suspicion of CD in their patients44. Ferreira AM, Sabino EC, Moreira HF, Cardoso CS, Oliveira CD, Ribeiro AL, et al. Avaliação do conhecimento acerca do manejo clínico de portadores da doença de Chagas em região endêmica no Brasil. Rev APS. 2018;21:345-54., making the early diagnosis and treatment unfeasible.

Having a relative/family member with CD was associated with a positive diagnosis. Other studies have also observed a history of CD in the families of diagnosed patients2828. Gontijo ED, Rocha MO, Oliveira UT. Perfil clínico-epidemiológico de chagásicos atendidos em ambulatório de referência e proposição de modelo de atenção ao chagásico na perspectiva do SUS. Rev Soc Bras Med Trop. 1996;29:101-8.,2929. Bozelli CE, Araújo SM, Guilherme AL, Gomes ML. Perfil clínico-epidemiológico de pacientes com doença de Chagas no Hospital Universitário de Maringá, Paraná, Brasil. Cad Saude Publica. 2006;22:1027-34.. The authors hypothesized that these infections occurred through vector transmission, due to their region of birth, being in the rural area or in an endemic area, and the presence of triatomine insects in the households2828. Gontijo ED, Rocha MO, Oliveira UT. Perfil clínico-epidemiológico de chagásicos atendidos em ambulatório de referência e proposição de modelo de atenção ao chagásico na perspectiva do SUS. Rev Soc Bras Med Trop. 1996;29:101-8.,2929. Bozelli CE, Araújo SM, Guilherme AL, Gomes ML. Perfil clínico-epidemiológico de pacientes com doença de Chagas no Hospital Universitário de Maringá, Paraná, Brasil. Cad Saude Publica. 2006;22:1027-34.. This demonstrates the relevance of medical care to the entire family group. In addition, another possibility of infection is through congenital transmission1212. Galvão C, organizador. Vetores da doença de Chagas no Brasil. Curitiba: Sociedade Brasileira de Zoologia; 2014.. A systematic review with meta-analysis carried out in Brazil, in 2014, reported a congenital transmission rate ranging from 0 to 5.2%3030. Martins-Melo FR, Lima MS, Ramos Jr AN, Alencar CH, Heukelbach J. Prevalence of Chagas disease in pregnant women and congenital transmission of Trypanosoma cruzi in Brazil : a systematic review and meta-analysis. Trop Med Int Health. 2014;19:943-57.. The WHO recommends that all pregnant women be subjected to serology to T. cruzi3131. Organização Pan-Americana da Saúde. Organização Mundial da Saúde. Enfermedad de Chagas en las Américas: una revisión de la situación actual de salud pública y su visión para el futuro: informe: conclusiones y recomendaciones, Washington D.C., mayo 3 y 4 de 2018. [cited 2021 Aug 3]. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=14399:enfermedad-chagas-en-americas-revision-de-situacion-vision-futuro&Itemid=72315⟨=en
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, but this has not yet been achieved, and CD continues to be neglected and excluded from the prenatal care examinations1313. São Paulo. Secretaria da Saúde. Coordenadoria de Planejamento em Saúde. Assessoria Técnica em Saúde da Mulher. Atenção a gestante e a puérpera no SUS-SP: manual técnico do pré-natal e puerpério. São Paulo: Secretaria da Sáude; 2010. [cited 2021 Aug 3]. Available from: http://www.saude.sp.gov.br/resources/ses/perfil/gestor/destaques/atencao-a-gestante-e-a-puerpera-no-sus-sp/manual-tecnico-do-pre-natal-e-puerperio/manual_tecnicoii.pdf
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.

Having previous contact with the CD vector through a triatomine bite was associated with a positive diagnosis. In 2006, Brazil was certified for the interruption of the transmission of CD by its main vector, and also made progress in the transfusion screening3232. Silveira AC. Os novos desafios e perspectivas futuras do controle. Rev Soc Bras Med Trop. 2011;44 Suppl 2:122-4.. Even in the face of these achievements, an alert is essential, as it is still possible to find residual foci in the Brazilian territory capable of reintroducing the main vector of CD3232. Silveira AC. Os novos desafios e perspectivas futuras do controle. Rev Soc Bras Med Trop. 2011;44 Suppl 2:122-4.. Bearing in mind that the studied municipalities are currently located in areas at risk of transmission of CD due to the presence of the vector, we cannot rule out the possibility of vector transmission in the individuals participating in the study, therefore continuous epidemiological surveillance actions are necessary1212. Galvão C, organizador. Vetores da doença de Chagas no Brasil. Curitiba: Sociedade Brasileira de Zoologia; 2014.. The CD control program is in the epidemiological surveillance phase, where the population has a fundamental role, but many people do not have knowledge on the management and identification of the vector, making this type of control vulnerable3333. Santos CV, Bedin C, Wilhelms TS, Villela MM. Assessment of the housing improvement program for Chagas disease control in the Northwestern municipalities of Rio Grande do Sul, Brazil. Rev Soc Bras Med Trop. 2016;49:572-8.,3434. De Urioste-Stone SM, Pennington PM, Pellecer E, Aguilar TM, Samayoa G, Perdomo HD, et al. Development of a community-based intervention for the control of Chagas disease based on peridomestic animal management: an eco-bio-social perspective. Trans R Soc Trop Med Hyg. 2015;109:159-67.. A study carried out in Diamantina (Minas Gerais State) demonstrated that the population’s knowledge on the identification of the CD vector is indispensable for the correct referral of insects to the control service. In areas where people had sufficient knowledge to identify the vector, entomological surveillance actions were more assiduous3535. Dias JV, Queiroz DR, Diotaiuti L, Pires HH. Knowledge of triatomine insects and of the Chagas disease among people from localities which have different levels of vector infestations. Cien Saude Colet. 2016;21:2293-304.. This indicates the need to carry out health education activities, because, through alerting and bringing knowledge, it is possible to achieve an effective control.

Living in a wooden, wattle and daub, or adobe house at some point in life was related to positive serology. Housing characteristics have already been reported to be significantly associated with domestic infestation of the CD vector3636. Gaspe MS, Provecho YM, Cardinal MV, Fernández MP, Gürtler RE. Ecological and sociodemographic determinants of house infestation by Triatoma infestans in indigenous communities of the Argentine Chaco. PLoS Negl Trop Dis. 2015;9: e0003614.. Houses built with wood, wattle and daub, or adobe have refuges that are ideal shelters for vector infestation, thus making their residents a food source, increasing the chances of infection by T. cruzi3636. Gaspe MS, Provecho YM, Cardinal MV, Fernández MP, Gürtler RE. Ecological and sociodemographic determinants of house infestation by Triatoma infestans in indigenous communities of the Argentine Chaco. PLoS Negl Trop Dis. 2015;9: e0003614.. Despite the Federal Government’s incentive aimed to improve the civil construction in endemic regions of Brazil3737. Brasil. Fundação Nacional de Saúde. Elaboração de projeto de melhoria habitacional para o controle da doença de chagas. Brasília: Funasa; 2013. [cited 2021 Aug 3]. Available from: http://www.funasa.gov.br/documents/20182/34758/elab_proj_melh_hab_cont_doen_chagas_2.pdf/4b57c475-5812-43e0-9ad3-ed4ebf150070
http://www.funasa.gov.br/documents/20182...
, it is still possible to find precarious households in rural communities in the country. Adequate housing infrastructure generates positive impacts on health in general, thus the improvement of households is an important factor for vector control, as a long-term strategy3737. Brasil. Fundação Nacional de Saúde. Elaboração de projeto de melhoria habitacional para o controle da doença de chagas. Brasília: Funasa; 2013. [cited 2021 Aug 3]. Available from: http://www.funasa.gov.br/documents/20182/34758/elab_proj_melh_hab_cont_doen_chagas_2.pdf/4b57c475-5812-43e0-9ad3-ed4ebf150070
http://www.funasa.gov.br/documents/20182...
.

In the development of this study, some limitations were observed, among them the cross-sectional design, which does not allow establishing causal relationships. IN addition, there is a limitation of temporality, as it is not possible to verify when these people were infected. However, this type of design allows to characterize the population and identify risk groups. One of the strengths of our study was the high detection rate of patients with CD who were unaware of their condition. The low visibility of these individuals in the society is notorious and our study shows the deficit in coping with CD along with the PHC, which is the closest health resource for the population. Although a PCDT for CD was instituted in 2018 by the Ministry of Health, there is still no specific line of care for chronic CD patients2222. Brasil. Ministério da Saúde. Comissão Nacional de Incorporação de Tecnologias no SUS. Protocolo clínico e diretrizes terapêuticas: doença de Chagas. Brasília: Ministério da Saúde; 2018. [cited 2021 Aug 3]. Available from: http://conitec.gov.br/images/Consultas/Relatorios/2018/Relatorio_PCDT_DoencaChagas_CP42_2018.pdf
http://conitec.gov.br/images/Consultas/R...
. CD continues to be neglected even one hundred years after its discovery, demonstrating the importance of actively searching for new CD carriers in an endemic region.

CONCLUSION

The profile of participants with positive CD serology identified in this study is associated with place of residence, age, family and life conditions. Our study demonstrates that in both, rural and urban areas, there are still people with CD who are unaware of their diagnosis. CD remains a major challenge for the SUS, thus it is necessary that the PHC together with the epidemiological surveillance establish effective protocols for the screening and management of CD.

ACKNOWLEDGMENTS

We thank the SaMi-Trop project team, the patients in this study and the National Institutes of Health (NIH).

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    » http://www.funasa.gov.br/documents/20182/34758/elab_proj_melh_hab_cont_doen_chagas_2.pdf/4b57c475-5812-43e0-9ad3-ed4ebf150070
  • FUNDING: National Institutes of Health (NIH) (P50 AI098461-02).

Publication Dates

  • Publication in this collection
    03 Sept 2021
  • Date of issue
    2021

History

  • Received
    6 Apr 2021
  • Accepted
    3 Aug 2021
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