Educational Workshop EW10: Emerging parasites arranged with ESGCP (ESCMID Study Group for Clinical Parasitology) Convenor: Eskild Petersen (Arhus, DK) Faculty: Joaquim Gascon (Barcelona, ES) Edoardo Pozzi (Rome, IT) Eskild Petersen (Arhus, DK) Peter Deplazes (Zurich, CH) Gascon –Chagas‘ disease Chagas Disease Joaquim Gascon Centre Salut Internacional Hospital Clínic de Barcelona Helsinki, May 2009 LYFE CYCLE Chagas is a zoonotic disease Endemic to LatinAmerica The vector and the parasite The triatomine. Domestic and peridomestic environments in rural dwellings and domestic animals From: Carlomagno M, et al. 1989 The parasite. Two major groups: T.cruzi I (widespread but the only form north of the Amazon region) T.cruzi II (Southamerica. Associated with digestive tract lesions). Both groups associated with cardiac lesions 3 Gascon –Chagas‘ disease Ó TRANSMISI N Routes of transmission . Vectorial transmission (triatomine bite) . Vertical transmission (pregnancy, delivery) . Transfusion or trasplants. Oral transmission through contaminated food/beverages Phases of Chagas Disease Subacute cases Acute Form deaths 5-10% (<50% symptomatic) 2-3% Indeterminate Form (no symptoms, and no pathologic changes detected by ECG, Rx, esofagogram or barium enema) 60% of infected people Digestive Chronic Cardiac Chronic Form Chronic Forms Form 10-20% 20- 30% CHRONIC FORMS OF CHAGAS Cardiac Chronic Form Digestive Chronic Form (fibrosing cardiopathy and (loss of neurons in the gut and inflammatory lesions) inflammatory lesions) Dilated miocardiopathy Megaesophagus congestive failure Megacolon Rhythm disturbances Other megaviscera Thromboembolism. 4 Gascon –Chagas‘ disease T.cruzi Infection prevalence in Latin-american pregnant women in Barcelona* *2 Maternities : HCB & H. St. J. de Deu Fac Farm UB COUNTRY N (total: 1350) POSITIVE SAMPLES (%) BOLIVIA 166 42 (27.5%) ARGENTINA 90 2 (1.1%) PERU 204 1 (0.58%) ECUADOR 435 0 COLOMBIA 137 1 (0.73%) CHILE 36 0 Screening URUGUAY 32 0 Lab test PARAGUAY 32 0 ELISAr (Biokit) VENEZUELA 33 0 TOTAL 1350 46 (3.4%) 3 + newborn (7.3%) Muñoz J. et al, Clin Infect Dis, in press Results of the study in the Blood Banks in Catalonia* *BSTC / Fac Farm UB / HCB Serological Prevalence In latinamerican blood donors: 10/1524 (0.66%) 6/10 were bolivians (10% of 59 bolivian donors) In spanish travellers / migrants / expatriates living >1 month in endemic areas 1/ 250 (0.42%) Piron M. et al. Transfusion 2008 5 Gascon –Chagas‘ disease Chagas Disease in Barcelona *HCB / UMTISI Drassanes. / Fac Farm UB April/07 Studies in Specialized Imported Diseases Centers, Barcelona - 171/458 (37%) infected by T.cruzi (Bolivia: 86%) (4.6% were blood donors in Barcelona). Clinical features: 23% ECG alterations (N= 39). 1 sudden death. 1 in the cardiac trasplant programme 8% with GI tract pathology (N=14) 6 immunodepressed patients Muñoz J. et al, Acta Tropica in press EUROPEAN CASES OF CHAGAS DISEASE May / 08 • Italy: 22 cases - 1 acute case (traveller) - 1 reactivation - 2 chronic cardiac forms - 1 chronic digestive form • France: 18 cases (Paris) - 7 chronic cardiac forms - 1 acute case • Germany / UK / Portugal: no cases reported (or anecdotic) • Sweden 2-4 cases/year reported Switzerland: 28 cases • Spain: >500 cases Estimated cases of Chagas in Europe From: Guerri-Guttenberg RA. Eur H J, 2008 6 Gascon –Chagas‘ disease Latinamerican immigration by country in Spain 2008 ESTIMATED Nº of ESTIMATED T.cruzi ESTIMATED INFECTED COUNTRIES MIGRANTS PREVALENCE MIGRANTS ARGENTINA 287,760 4,13% 11,882 BOLIVIA 238,605 6,75% - 15% 16,106 –35,791 BRASIL 140,942 1,02% 1,436 CHILE 66,270 0,99% 653 COLOMBIA 326,459 0,96% 3,121 ECUADOR 451,072 1,74% 7,844 MEXICO 42,413 1,03% 436 PARAGUAY 68,234 2,54% 1,735 PERU 160.603 0,69% 1,102 URUGUAY 86,601 0,66% 568 VENEZUELA 142,709 1,16% 1,654 TOTAL 2,090,000 47,738 –67,423 DIAGNOSIS OF CHAGAS DISEASE Acute cases: Parasitological tests Thick blood film Strout Microhematocrit (newborns) Hemoculture Molecular test PCR Chronic / Indeterminate forms: Serology (two tests with different antigens) ELISA, IHA, IFI TREATMENT Benznidazol and Nifurtimox are the only drugs currently availables for Chagas disease . treatment Both have a poor profile for side effects (~ 10% severe) - cutaneous (rash, urticaria, pruritis) - polineuritis - gastrointestinal disturbances High efficacy in acute cases, but the efficacy declines with the duration of infection 7 Gascon –Chagas‘ disease CONCLUSIONS What does Europe need? To better evaluate the emergence of Chagas disease in the Continent -prevalence -burden of disease To implement public health policies to prevent/control Chagas transmission - blood transfusion - organ transplantation - mother-to-child CONCLUSIONS The European health care community has the opportunity to contribute to the general knowledge of Chagas disease and to promote research in this field. 8 Summary Trichinella infection and trichinellosis E. Pozio (Rome, IT) Nematode worms belonging to the genus Trichinella are the etiological agent of a zoonosis named trichinellosis. These parasites are widespread in wildlife on all continents but Antarctica, and in domestic pigs of many countries. Infections occur in humans where cultural food practices include dishes based on raw or undercooked meat and meat products of different animal origins (e.g. pork, horse, game); thus, cultural factors such as traditional dishes based on raw or undercooked meat play an important role in the epidemiology of the disease. When a population uniquely consumes well-cooked meat, trichinellosis cases are lacking or very scarce despite persistent wildlife transmission. Human trichinellosis has been documented in 55 (27.8%) countries around the world. In several of these countries, however, trichinellosis affects only ethnic minorities because the native inhabitants do not consume uncooked meat or meat of some animal species. Trichinella sp. infection has been documented in domestic animals (mainly pigs) and in wildlife of 43 (21.9%) and 66 (33.3%) countries, respectively. At present, eight species and four genotypes are recognised in the genus Trichinella. The parasites are perpetuated in life-cycles with carnivorous and omnivorous animals representing the most important reservoir. All species can develop in mammals, but T. pseudospiralis can also develop in birds, and two species also occur in crocodiles and monitor lizards. No morphological differences exist between species and genotypes, and they are most reliably distinguished by biochemical or molecular analyses. A peculiarity of the cycle of these worms is the development of two generations in the same host. The average yearly incidence of the clinical disease in humans worldwide is probably close to 10,000 cases with a mortality rate of about 0.2%; however, the number of infections is underreported in many countries due to the lack of appropriate serological tests and a lack of knowledge of the disease on the part of physicians. Trichinellosis usually begins with a sensation of general discomfort and headache, increasing fever, chills and sometimes diarrhoea and/or abdominal pain. Pyrexia, eyelid or facial oedema and myalgia represent the principal syndrome of the acute stage, which can be complicated by myocarditis, thromboembolic disease and encephalitis. The clinical signs and symptoms are directly related to the parasitic cycle in the human host. 9 10 Pozio - Trichinellosis Trichinellosis Edoardo Pozio Community Reference Laboratory for Parasites Istituto Superiore di Sanità Rome, Italy 19th ECCMID, Helsinki, Finland 16-19 May, 2009 What is trichinellosis? •It is a zoonotic disease caused by nematode worms of the genus Trichinella •Humans acquire the infection by the consumption of raw or semi-raw meat or meat derived products of pig, horse or game Introduction to the Trichinella world • What is Trichinella – a genus of nematode worms (round worms), which infect vertebrates including humans 100 mm – these parasites were discovered by Owen in U.K. in 1835 – etiological agent of a serious human disease named trichinellosis – they show a cosmopolitan distribution 11 Pozio - Trichinellosis The life cycle Taxonomy of the genus Trichinella • Non-encapsulated • Encapsulated species species – T. pseudospiralis – T. spiralis – T. papuae – T. nativa, – T. zimbabwensis Trichinella T6 Trichinella T12 – T. britovi, Trichinella T8 – T. murrelli, Trichinella T9 – T. nelsoni World map of Trichinella spiralis 12 Pozio - Trichinellosis Geographical distribution of encapsulated species of Trichinella transmitted by a sylvatic cycle T12 Geographical distribution of non-encapsulated species of Trichinella World distribution of Trichinella and trichinellosis • Human trichinellosis has been documented in 55 (27.8%) countries • Trichinella sp. infection has been documented in: – domestic animals (mainly pigs) of 43 (21.9%) countries – in wildlife of 66 (33.3%) countries 13 Pozio - Trichinellosis Trichinella spp. – four species are circulating in Europe: • T. britovi is the most widespread species in Europe; it has been detected in 23 MS, but not in Cyprus, Ireland, Malta and United Kingdom • T. spiralis has been detected in 16 of 27 MS (Austria, Bulgaria, Estonia, Finland, France, Germany, Hungary, Ireland, Poland, Latvia, Lithuania, Slovak rep., Romania, Spain, Sweden and United Kingdom) • T. nativa has been detected in Estonia, Finland, Latvia, Lithuania and Sweden • T. pseudospiralis in Bulgaria, Denmark, Finland, France, Germany, Hungary, Italy, Slovak Rep and Sweden Distribution of T. britovi and T. spiralis