Prevalence of Chagas disease in pregnant women and incidence of congenital transmission in Santa Cruz de la Sierra, Bolivia.

Congenital transmission of Chagas disease stand out as a major public health problem since the vector control was performed in all endemic areas and has shown its effectiveness. An epidemiological study was performed in three maternity hospitals of the city of Santa Cruz de la Sierra, Bolivia from 2006 to 2008. The serological screening for Trypanosoma cruzi infection was carried out in 15,767 pregnant women. Chagas infection was detected in 3725 women (23.6%), who gave birth to 125 newborns infected by T. cruzi at birth, representing an incidence of 790 per 100,000 births during a period of 16 months and a vertical transmission rate by 3.4%. There was a significant difference between hospitals that might be explained by socio-economic origins of mothers and diagnostic constraints.

[Screening for congenital infection by Trypanosoma cruzi in France]. / Le dépistage de l'infection congénitale par Trypanosoma cruzi en France métropolitaine.

The importance of congenital transmission of Chagas' disease increases with its emergence in communities infected with Trypanosoma cruzi, but where vector transmission has never existed or is fully controlled through vector control campaigns. In both endemic and non-endemic areas, the rates of mother-to-child transmission (MTCT) could be the same, by 5%, generating a constant source of new cases of the disease. Risk factors for vertical transmission are not fully elucidated, but the effectiveness of the adaptive immune response and the genetic susceptibility of both the mother and the child are suspected. Besides the risk of miscarriage or premature birth, neonatal infection by T. cruzi causes an acute form of Chagas disease, which may be accompanied by a severe infectious syndrome that can causes death if not treated early. This form of the disease is a real public health priority because it is frequent, severe, identifiable and curable. Indeed, almost all newborns diagnosed and treated before the end of their first year of life will be definitely cured. In all non-endemic areas, detection of cases of congenital Chagas disease is hampered by a very low prevalence of the disease in the general population of pregnant women, the lack of symptoms in most infected women and the disregard of these problems from health personnel in charge of monitoring pregnancy. Secondary prevention firstly consists in identifying infected women (with history of exposure and positive serology for Chagas disease) and secondly to look for the parasite in newborns from infected mothers. No primary prevention is indeed possible during pregnancy, since the only two drugs are toxic and possibly teratogenic. However, after birth, treatment could be offered to all infected women in order to prevent late complications of the disease and to make an attempt at breaking the chain of MTCT in future pregnancies.

Congenital Chagas disease: diagnostic and clinical aspects in an area without vectorial transmission, Bermejo, Bolivia.

The authors carried out a 1-year study of a population of pregnant women delivering at Bermejo hospital, South Bolivia. In this area, vectorial transmission of Trypanosoma cruzi is negligible and women infect themselves during displacements in close endemic areas. The prevalence of T. cruzi in 508 pregnant women, diagnosed by several serological tests, was 33.9%. In eight infants, we observed T. cruzi in the umbilical cord (congenital transmission rate of 5.2%). The means of birth weights, lengths and hemoglobin rates were similar in the children from both seronegative and seropositive women, and in children infected or not by T. cruzi. This study could confirm a less severity of the congenital disease of Chagas in the absence of re-infestation of the mother during pregnancy. Serological screening of pregnant women by rapid diagnostic tests and examination of babies born from seropositive mothers by microhematocrit method at birth is a suitable strategy to detect and prevent congenital Chagas disease in non-endemic areas.

Risk factors and consequences of congenital Chagas disease in Yacuiba, south Bolivia.

OBJECTIVE: To determine the risk factors of congenital Chagas disease and the consequences of the disease in newborns. METHODS: Study of 2712 pregnant women and 2742 newborns in Yacuiba, south Bolivia. Chagas infection was determined serologically in mothers and parasitologically in newborns. Consequences of congenital Chagas disease were assessed clinically. RESULTS: The prevalence of Chagas disease in pregnant women was 42.2%. Congenital transmission was estimated at 6% of infected mothers leading to an incidence rate of 2.6% among newborns. Main risk factors of congenital transmission were mothers' seropositivity and maternal Trypanosoma cruzi parasitaemia. Parity was higher in infected than in non-infected mothers, but it was not associated with the risk of congenital transmission. The rate of congenital infection was significantly higher in newborns from multiple pregnancies than in singletons. However, we did not observe statistically significant consequences of Chagas disease in newborns from single pregnancies or among twins. CONCLUSIONS: The main risk factors for congenital transmission were infection and parasitaemia of mothers. Consequences of the disease seemed mild in newborns from single pregnancies and perhaps more important in multiple births.

Evidence of congenital transmission of Trypanosoma cruzi in a vector-free area of Bolivia.

A seroprevalence survey of Trypanosoma cruzi was carried out in two areas of South Bolivia. Triatoma infestans, the main vector of Tryp. cruzi, was abundant in the first area, but absent in the second one. Titration of Tryp. cruzi antibodies was carried out in children aged 6-24 months and their mothers. The seroprevalence of Chagas' disease was significantly higher in the area with the vector, but also high in the second area. Chagas' infection in children under 2 years old could be linked to congenital transmission of parasites during pregnancy and/or delivery, despite active vector control in both areas.

[Anopheles and malaria transmission in Ambohimena, a village in the Occidental fringe of Madagascar Highlands]. / Les anophèles et la transmission du paludisme à Ambohimena, village de la marge occidentale des Hautes-Terres malgaches.

The anopheline vectors and malaria transmission were investigated in the Middle West of Madagascar, in the village of Ambohimena (at the altitude of 940 meters) during two years (August 1996 to July 1998). This village is located outside the vector control area, where yearly DDT house spraying campaigns have been conducted between 1993 and 1998. Collection of mosquitoes was mainly based on all night man billing collections (650 man-nights), pyrethrum spray catches (224 bedrooms) and direct collections in outdoor resting places (140 toilets, 61 pigsties, 33 holes, 19 sheds, 79 sisal hedges, 70 cart shelters). Blood fed anophelines allowed analysis of the origin of blood with an ELISA method. Presence of circum-sporozoite protein was assessed with another ELISA method. The total number of collected anophelines was 14,280. Two malaria vectors were identified: Anopheles funestus Giles, 1900 and An. arabiensis Patton, 1902. An. funestus was the most abundant mosquito, especially during the hot rainy season. Two peaks of abundance were observed (in December and April). Endophagic rate (for mosquitoes aggressive for man) of 35.3%, an endophilic rate (for resting mosquitoes) of 78.0% and an anthropophilic rate (for indoor resting mosquitoes) of 64.0% were calculated. The average parity rate was relatively low (61.2%). The Plasmodium falciparum immunological sporozoite rate was 0.20%. An. funestus presented a higher vectorial capacity during the first round of rice cultivation (January) than during the second round (April-May). An. arabiensis was mostly abundant in December and January at the beginning of the rainy season. This species was exophagic (endophagic rate = 27.5%) and zoophilic (anthropophilic rate = 7.8%). The sporozoitic index was determined as zero (number of examined mosquitoes = 871). In this village, An. arabiensis presented only marginal importance for malaria transmission. Malaria transmission occurred from December to April. Annual entomological inoculation rate, only due to An. funestus, was 8.96 during the first year, and 3.17 during the second year. In this area where transmission is moderately stable, we suggest an extension of vector imagocidal control activities up to the western fringes of the Highlands.

Malaria prevention during pregnancy in unstable transmission areas: the highlands of Madagascar.

Malaria transmission in Madagascar is highly variable from one region to the next, and the consequences of the disease on pregnant women and their foetuses are not fully documented. In midwestern Madagascar, the high-transmission lowlands in the west of the country meet the central plateaux, where malaria is unstable because of the high altitude and annual indoor spraying of DDT since 1993. We studied five of the region's main maternity clinics. We began by interviewing sample groups of women of childbearing age living within the vicinity of each clinic. This enabled us to determine the extent to which they had accessed and made use of available maternal health services during pregnancy and delivery, and, hence, to estimate the feasibility of boosting the prophylaxis. We then spent a whole year (from June 1996 to May 1997) observing deliveries at the five clinics in order to gauge the prevalence of placental infection and its consequences on birthweight in various transmission situations. Although only between 2 and 15% of the women said that they had taken prophylaxis during their previous pregnancy, the vast majority had benefited from preventive care: 97% had attended an antenatal visit on at least one occasion and 84% had had the assistance of medical or paramedical staff during delivery, even when their homes were situated relatively far away from the clinic (76%). In total, we observed 1637 deliveries with a mean placental malaria prevalence rate of 8.1%. Individual prevalence rates, however, were found to differ significantly between the maternity clinics situated in the east (minimum 2.1%) and west (maximum 26.2%) of the region. There were also marked variations in line with the seasonal fluctuations in entomological transmission. On the whole, a greater percentage of low birthweights (LBWs) was recorded at the lowland clinics than at the highland ones (17.1% vs. 9.7%), possibly because of the higher malaria infection rate in low altitude areas. On the other hand, the relative risk of LBW linked to placental infection was far greater in the highlands [4.9 (3.3-7.3)] than in the lowlands [1.9 (1.2-3.0)]. Although the rate of placental malaria among women inhabiting the country's central plateaux may be low, it means that transmission--and, hence, the risk of LBW because of placental infection--still persists in spite of the indoor DDT spraying programme. For maximum efficacy, we recommend a combination of vector control (extended to lower altitude areas outside the current OPID zone) and preventive care--i.e. individual chemoprophylaxis--for all highland women during pregnancy.

[The campaign against malaria in central western Madagascar: comparison of the efficacy of lambda-cyhalothrin and DDT house spraying. I--Entomological study]. / Lutte contre le paludisme dans le moyen-ouest de Madagascar: comparaison de l'efficacité de la lambda-cyhalothrine et du DDT en aspersions intra-domiciliaires. I--Etude entomologique.

For malaria vector control in Madagascar, the efficacy of lambda-cyhalothrin 10% wettable powder (ICON 10 WP) was compared with DDT 75% WP for house-spraying. This evaluation was conducted from November 1997 to September 1998 in highland villages of Vakinankaratra Region, at the fringe of the malaria epidemic zone, outside the zone covered by routine DDT house-spraying (Opération de pulvérisation intro-domiciliaire de DDT: OPID zone). Treatments were compared by house-spraying in four areas: 1) application of DDT 2g ai/m2 and 2) lambda-cyhalothrin 30 mg ai/m2 in previously unsprayed villages; 3) no intervention (control); 4) OPID 5th cycle of DDT 2g ai/m2. The prevalent vector Anopheles funestus almost disappeared from both the DDT and ICON sprayed areas, whereas in the unsprayed (control) area An. funeslus density went up to 60 females per room in April and there were two seasonal peaks of malaria transmission in January and March (see following paper). In the area sprayed with ICON, the parous rate of An. funestus decreased from 47% pre-spray to 39% six months post-spraying, while the parous rate increased in DDT-sprayed area (from 57% pre-spray to 64% six months post-spray). Bioassays of An. funestus on treated walls, six months post-spray, gave mortality rates of 100% on DDT and 90% on ICON. Conversely, ICON appeared to be more effective than DDT on thatched roofs (66% versus 100%, respectively, six months post-spray). In areas sprayed with DDT or ICON the density of An. arabiensis were little affected. This study demonstrated that, under equivalent conditions, both DDT and lambda-cyhalothrin were effective in reducing malaria transmission on the western fringes of the malaria epidemic zone of the malagasy highlands, with a residual effect lasting at least for six months. Lambda-cyhalothrin appeared to be more effective than DDT in reducing the longevity of malaria vectors. In addition to efficacy, the choice of insecticide for malaria vector control should take into account their acceptability by human populations and their toxicity and persistence in the environment.

[The campaign against malaria in central western Madagascar: comparison of lambda-cyhalothrin and DDT house spraying. II--Parasitological and clinical study]. / Lutte contre le paludisme dans le moyen-ouest de Madagascar: comparaison de l'efficacité de la lambda-cyhalothrine et du DDT en aspersions intra-domiciliaires. II--Etude parasitologique et clinique.

For malaria vector control in Madagascar, 10 WP (lambda-cyhalothrin 10% wettable powder) was compared with DDT 75% WP for house-spraying, from November 1997 to September 1998. This study was implemented at the fringe of the malaria epidemic zone, in villages on western slopes of the central highlands, outside the area covered for the past five years by routine DDT house-spraying (OPID). Four types of treatment were compared in different areas: 1) DDT 2 g ai/m2 and 2) lambda-cyhalothrin 30 mg ai/m2 in previously unsprayed villages, 3) no intervention (control); 4) yearly DDT spraying (OPID fifth cycle). To investigate the malariological impact of spraying, cross-sectional surveys of the village populations were performed in each study area at intervals of two months, before and after spraying. In the newly sprayed areas, from December to June, malaria indices decreased by 62% in the ICON area and 44% in the DDT area, whereas in the unsprayed village malaria increased by 32% during the same season. There was a similar decrease in the number of gametocyte carriers in the newly sprayed areas. Active malaria case detection among febrile individuals was performed fortnightly in each village outside the OPID area. Results showed decreased malaria incidence from February (two months post-spraying) in the sprayed villages, despite the rainy season, whereas in the unsprayed area the decline occurred only after the main transmission season. This study demonstrated that, parasitologically as well as entomologically, house-spraying with residual insecticide (DDT or ICON) was an effective method for controlling malaria on the western fringes of the Madagascar highlands epidemic zone. Both products were effective, but ICON had slightly better impact than DDT, i.e. more reduction of malaria indices and of vector longevity, less irritancy of mosquitoes. For best results in this area of transition between stable and unstable malaria, we recommend earlier annual spraying (as soon as November) and extension of the OPID barrier towards western and northern slopes of the Plateau.

[Intestinal schistosomiasis from Schistosoma mansoni in Madagascar: extent and center of the endemic]. / La schistosomose intestinale à Schistosoma mansoni à Madagascar: extension et focalisation de l'endémie.

Schistosoma mansoni and S. haematobium affect respectively 2 million and 500,000 persons in Madagascar. Over the past decade, S. mansoni has spread in the central Highlands of Madagascar, essentially throughout the mid-west and Antananarivo plain. To understand this recent change in the epidemiology of S. mansoni, we examined the relationship between its spatial distribution and several host factors, including labour migration, urbanization and water development projects. In the Highlands, the disease in distribution could be superimposed on the potential expansion areas of snail distribution defined in 1958. However, the distribution is not homogeneous, as for example the road between Betafo and Mandoto (South West of Antananarivo). This focal pattern described in other African countries is unique to the central Highlands of Madagascar. Rice cultivation is the main economic activity and is associated with intense water contact. The focal distribution may be related to an environmental adaptation of host-parasite interaction depending on behavioural patterns, water and soil chemistry and incompatibility between Biomphalaria pfeifferi and S. mansoni. It is also possible that these focal patterns precede homogeneous endemicity, as along the road Itasy-Tsiroanomandidy (west Antananarivo). Major water development carried out in this migration area led to a rapid endemization of the disease. In Befato-Mandoto, where soil management is more restricted, schistosomiasis due to S. mansoni seems to have been established in some foci where epidemiologic conditions are favourable (for example, traditional irrigation canals). In contrast, the spread of S. mansoni in the Antananarivo plain closely follows the settlement of an infected rural population. Epidemiologic surveys conducted on school children in the Antananarivo suburbs, where sanitary conditions are poor, showed a prevalence of 25%. Human migration linked to development projects and urbanization seems to be the principal factor associated with the spread of schistosomiasis in the mid-west area and Antananarivo plain. In the Highlands, the preferential exposure of adult labour migrants has contributed to the widening of the endemic area.

High amounts of genetic differentiation between populations of the malaria vector Anopheles arabiensis from West Africa and eastern outer islands.

Polymorphism at nine microsatellite loci was examined to assess the level of genetic differentiation between four Anopheles arabiensis populations from Senegal, the high plateau of Madagascar, and Reunion and Mauritius islands. Eight of nine loci showed great polymorphism (2-16 alleles/locus) and significant genetic differentiation was revealed between all four populations by F- and R-statistics, with Fst estimates ranging from 0.080 to 0.215 and equivalent Rst values ranging between 0.022 and 0.300. These high amounts of genetic differentiation are discussed in relation to geographic distance including large bodies of water, and history of mosquito settlement, and insecticide use on the islands. The results suggest that historical events of drift rather than mutation are probably the forces generating genetic divergence between these populations, with homogenization of the gene pool by migration being drastically restricted across the ocean.

[Epidemiologic study of the main human intestinal nematodes in the middle west of Madagascar]. / Etude épidémiologique des principales nématodoses intestinales humaines dans le Moyen-ouest de Madagascar.

An epidemiological study of human intestinal helminthiasis was conducted during July and August 1995, in the middle west of Madagascar, with 4571 adults and children ranging from six months to 90 years, in 61 communities between Betafo and Miandrivazo. Faecal examination utilising the MIF concentration method revealed that ascariasis was the dominant nematodosis in the middle west with high prevalences in the high-altitude communities. Ascaris lumbricoides prevalences increase among children and women. Interesting more than 50% of the pattern, ascariasis is a public health problem and its association with infant malnutrition is statistically significant. Hookworm infection prevalence is higher in low-altitude communities, it increases among adults. The Trichuris trichiura prevalences were lower than the prevalences of ascariasis and hookworm infection in all of the communities. Important variations of the prevalences of intestinal helminthiasis are observed essentially in relation with climatic conditions.

[Demonstration of two twin species A and B of the Aedes detritus (Haliday, 1833) complex from the Atlantic coast of France]. / Mise en évidence des deux espèces jumelles A et B du complexe Aedes detritus (Haliday, 1833) sur le littoral atlantique français.

The electrophoretic analysis of five natural populations of Aedes detritus has shown that the two sibling species A and B of the complex, described in 1977 in an other geographical area by Pasteur et al., cohabit on Atlantic coastline in France.