Elsevier

Acta Tropica

Volume 156, April 2016, Pages 68-78
Acta Tropica

A global systematic review of Chagas disease prevalence among migrants

https://doi.org/10.1016/j.actatropica.2016.01.002Get rights and content

Highlights

Abstract

Human migration has been identified as a potential factor for increased Chagas disease risk and has transformed the disease from a Latin American problem to a global one. We conducted a systematic review of the scientific literature between 2004–2014 in order to: summarize recent seroprevalence estimates of Chagas disease among Latin American migrants, in both endemic and non-endemic settings; compare seroprevalence estimates in migrants to countrywide prevalence estimates; and identify risk factors for Chagas disease among migrants. A total of 320 studies were screened and 23 studies were included. We found evidence that the prevalence of Chagas disease is higher than expected in some migrant groups and that reliance on blood donor screening prevalence estimates underestimates the burden of disease. Overall there is a dearth of high quality epidemiologic studies on the prevalence of Chagas disease in migrants, especially among intra-regional migrants within Latin America. Given that this zoonotic disease cannot likely be eradicated, improved surveillance and reporting is vital to continuing control efforts. More accurate health surveillance of both Latin American migrants and the Chagas disease burden will help countries appropriately scale up their response to this chronic disease. Overall, improved estimates of Chagas disease among migrants would likely serve to highlight the real need for better screening, diagnostics, and treatment of individuals living with the disease.

Introduction

One of the current challenges in combating Chagas disease (American trypanosomiasis) is that human migration is changing the distribution of disease in both endemic and non-endemic countries (Gascon et al., 2010, Pinazo and Gascon, 2015). This shift is so great that Chagas disease is now co-classified as both a re-emerging infection and a neglected tropical disease (Hotez et al., 2008, Mackey and Liang, 2012, Mackey et al., 2014; World Health Organization, 2013). Human migration represents both a risk for the re-emergence of new infections in countries with the vector and for the expansion of the geographical distribution of chronic Chagas cases to non-endemic countries.

Caused by the protozoan parasite Trypanosoma cruzi (T. cruzi), Chagas disease results in the largest burden of disease in disability-adjusted-life-years of any parasitic disease in the Americas (Lee et al., 2013; World Health Organization, 2012). Depending on the region, 20–30% of patients chronically infected with Chagas disease go on to develop cardiac and/or gastrointestinal damage and an estimated 10,000 people will die from Chagas each year (World Health Organization, 2010). The morbidity and mortality associated with Chagas disease results in a staggering annual global economic burden of US$7.2 billion (Lee et al., 2013).

The main mode of transmission of T. cruzi to humans is vector borne, which occurs only in the Americas. Traditionally considered a disease of poverty, risk of Chagas disease has been associated with housing in rural areas, of poor construction quality (e.g., palm roof, cracks in the walls), and with domestic pets and livestock in or near the house (Enger et al., 2004, Molina-Garza et al., 2014, Ramsey et al., 2005, World Health Organization, 2002). Coordinated efforts by endemic countries in the 1990's were instrumental in shrinking the domestic vector infestation and thus the population at risk for Chagas disease (Coura and Dias, 2016; Dias and Schofield, 1999, Dias et al., 2002).

Despite the success of spraying campaigns, the disease persists through its alternate transmission mechanisms, primarily congenital and blood transfusion, and to a lesser extent oral ingestion (Alarcon de Noya et al., 2010, Carlier et al., 2015, Coura, 2015; Rassi Jr. et al., 2010). Multiple transmission mechanisms, coupled with the chronic, often asymptomatic nature of the disease and lack of effective and accessible treatment for patients means the burden of disease continues to remain high (Pan American Health Organization, 2014).

Within Latin America, migration into urban areas and an increase in urban poverty has transformed this once rural disease to an urban disease as well (Briceno-Leon and Galvan, 2007). There are an estimated 127 million people living below the poverty line in urban and peri-urban communities in Latin America (Ault, 2007) and sub-standard housing conditions within these urban settings have facilitated the domiciliation of triatomines (Gürtler, 2009, Levy et al., 2006, Medrano-Mercado et al., 2008). A 2013 review of qualitative research on socio-cultural aspects of Chagas disease found that changes in land use may both drive human migration and provide new homes for the vector (Ventura-Garcia et al., 2013). For example, in Peru it was found that human settlement patterns created shantytowns with favorable conditions for triatomines and seasonal agricultural workers may have carried the vector to communities through their work (Bayer et al., 2009). Agricultural workers may be at greater personal risk through exposure to the vector during outdoor labor (Ventura-Garcia et al., 2013, World Health Organization, 2010).

Migration has also changed the distribution of Chagas disease from a health problem only in Latin America, to a global one. As of 2013 there were an estimated 36.7 million people who had migrated out of Latin America and the Caribbean and were residing elsewhere in the world, predominantly in North America (United Nations Department of Economic and Social Affairs, 2013b).

Generally, migrants are at greater risk of infectious diseases because of the existing poverty driving them to migrate and the social and economic inequalities they often face once relocating (Cabieses et al., 2013, Carballo and Nerukar, 2001). A 2013 review of qualitative research uncovered migration as a socio-structural risk factor for Chagas disease (Ventura-Garcia et al., 2013). After migrating, structural barriers to diagnosis and treatment include cost, language, lack of insurance, fear of deportation (in the case of undocumented migrants), and stigma against migrants (Bayer et al., 2009, Jackson et al., 2012, Minneman et al., 2012, Ventura-Garcia et al., 2013).

Current prevalence estimates of Chagas disease in non-endemic countries are largely extrapolations of countrywide prevalence from endemic birth countries multiplied by the proportion of immigrants from that country (Basile et al., 2011, Bern and Montgomery, 2009, Gascon et al., 2010, Schmunis, 2007). While country prevalence estimates provide a good starting point for estimating the burden among migrant populations, there are some substantial drawbacks. First, regional variations in migration rates and Chagas disease burden may be masked by the use of a single prevalence estimate for an endemic country. Secondly, these estimates do not take into account characteristics specific to migrants, who tend to be demographically different from the average person in any given country of origin (Weeks, 2015). Migrants often come from rural areas, have a different age profile (i.e., are younger), and are of a different socioeconomic status than the general population (Bern and Montgomery, 2009).

Determining accurate prevalence estimates of Chagas disease among migrants may enable health systems to more precisely gauge the true burden of disease and target populations most at risk. Further, given the heterogeneity of Chagas disease distribution within countries, there remain questions as to whether migrants are at heightened personal risk for this disease.

Therefore the purpose of this review was to: summarize current seroprevalence estimates of Chagas disease among Latin American migrants, in both endemic and non-endemic settings and compare seroprevalence estimates in migrants to countrywide prevalence estimates. We also report on risk factors for Chagas disease among migrants.

Section snippets

Methods

We conducted a systematic review of the literature from January 2004 to July 2014 using the PubMed and Scopus databases. We also searched relevant grey literature from international and governmental organizations, including the Pan American Health Organization (PAHO), World Health Organization (WHO), and the U.S. Centers for Disease Control and Prevention. Search terms included combinations of the following keywords: (1) Chagas; American trypanosomiasis; or T. cruzi; (2) migra*; mobil*;

Description of included and excluded studies

After duplicates were removed, the initial search identified a total of 311 original articles and an additional 9 references were identified through other sources. Of these records, 246 did not meet initial inclusion criteria (Fig. 1). A total of 74 articles were included for full text review and 23 met the inclusion criteria for the final analysis. Among the excluded articles: 5 did not contain original prevalence estimates; 18 had selection bias (i.e., tropical disease hospital sample or

Discussion

An estimated 94–96% of migrants living with Chagas disease in non-endemic areas are unaware of their disease (Basile et al., 2011). Underestimating the burden of disease among Latin American migrants likely means a continued lack of priority for a neglected disease and migrant health generally.

We found a trend that the prevalence of Chagas disease in migrant groups, when stratified by birth country, was generally higher than endemic countrywide estimates of prevalence. In non-endemic countries,

Conclusions

Our findings from this literature review, along with recent work by others to establish more accurate prevalence estimates in Europe, are that Chagas disease estimates among migrants are generally poor (Requena-Mendez et al., 2015). No longer only a disease of Latin America, control of Chagas disease now requires the joint collaboration of endemic and non-endemic countries.

Despite challenges, the benefit of better estimates and surveillance are manifold and include improved distribution of

Acknowledgements

Erin Conners was supported by a UC MEXUS dissertation research grant titled “The Potential Role of Migration in Chagas Disease Expansion” and the University of California, San Diego, Center for AIDS Research (CFAR), an NIH-funded program (P30 AI036214), which is supported by the following NIH Institutes and Centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA, NIGMS, and NIDDK.

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