Human Trypanosoma cruzi infection in the Argentinean Chaco: risk factors and identification of households with infected children for treatment.

BACKGROUND: Chagas disease is a neglected tropical disease (NTD). Cost-effective strategies for large-scale implementation of diagnosis and etiological treatment are urgently needed to comply with NTD control goals. We determined the seroprevalence of Trypanosoma cruzi infection and associated risk factors in a well-defined rural population of Pampa del Indio municipality including creole and indigenous (Qom) households and developed two indices to identify houses harboring infected children. METHODS: We serodiagnosed and administered a questionnaire to 1337 residents (48.2% of the listed population) in two sections of the municipality (named Areas II and IV) 6-9 years after deploying sustained vector control interventions. Multiple logistic regression models were used to evaluate the relationship between human infection and a priori selected predictors. Two risk indices were constructed based on environmental and serostatus variables, and we used spatial analysis to test whether households harboring T. cruzi-seropositive children were randomly distributed. RESULTS: The global seroprevalence of T. cruzi infection was 24.8%. Human infection was positively and significantly associated with exposure time to triatomines, the household number of seropositive co-inhabitants, maternal seropositivity for T. cruzi, recent residence at the current house and the presence of suitable walls for triatomine colonization in the domicile. The pre-intervention mean annual force of infection (FOI) was 1.23 per 100 person-years. Creoles from Area IV exhibited the highest seroprevalence and FOI; Qom people from both areas displayed intermediate ones and creoles from Area II the lowest. Three hotspots of infected children were spatially associated with hotspots of triatomine abundance at baseline and persistent house infestation. No child born after vector control interventions was T. cruzi seropositive except for one putative transplacental case. Two simple risk indices (based on self-reported inhabiting an infested house and suitable walls for triatomines or maternal serostatus) identified 97.3-98.6% of the households with at least one T. cruzi-seropositive child. CONCLUSIONS: We showed strong heterogeneity in the seroprevalence of T. cruzi infection within and between ethnic groups inhabiting neighboring rural areas. Developed indices can be used for household risk stratification and to improve access of rural residents to serodiagnosis and treatment and may be easily transferred to primary healthcare personnel.

Assessing antibody decline after chemotherapy of early chronic Chagas disease patients.

BACKGROUND: Chagas disease remains a significant public health problem in Latin America. There are only two chemotherapy drugs, nifurtimox and benznidazole, and both may have severe side effects. After complete chemotherapy of acute cases, seropositive diagnosis may revert to negative. However, there are no definitive parasitological or serological biomarkers of cure. METHODS: Following a pilot study with seven Bolivian migrants to Spain, we tested 71 serum samples from chronic patients (mean age 12.6 years) inhabiting the Argentine Chaco region. Benznidazole chemotherapy (5-8 mg/kg day, twice daily for 60 days) was administered during 2011-2016. Subsequently, pre-and post-chemotherapy serum samples were analysed in pairs by IgG1 and IgG ELISA using two different antigens and Chagas Sero K-SeT rapid diagnostic tests (RDT). Molecular diagnosis by kDNA-PCR was applied to post-treatment samples. RESULTS: Pilot data demonstrated IgG1 antibody decline in three of seven patients from Bolivia 1 year post-treatment. All Argentine patients in 2017 (averaging 5 years post-treatment), except one, were positive by conventional serology. All were kDNA-PCR-negative. Most (91.5%) pre-treatment samples were positive by the Chagas Sero K-SeT RDT, confirming the predominance of TcII/V/VI. IgG1 and IgG of Argentine patients showed significant decline in antibody titres post-chemotherapy, with either lysate (IgG, P = 0.0001, IgG1, P = 0.0001) or TcII/V/VI peptide antigen (IgG, P = 0.0001, IgG1, P = 0.0001). IgG1 decline was more discriminative than IgG. Antibody decline after treatment was also detected by the RDT. Incomplete treatment was associated with high IgG1 post-treatment titres against lysate (P = 0.013), as were IgG post-treatment titres to TcII/V/VI peptide (P = 0.0001). High pre-treatment IgG1 with lysate was associated with Qom ethnicity (P = 0.045). No associations were found between gender, age, body mass index and pre- or post-treatment antibody titres. CONCLUSIONS: We show that following chemotherapy of early chronic Chagas disease, significant decline in IgG1 antibody suggests cure, whereas sustained or increased IgG1 is a potential indicator of treatment failure. Due to restricted sensitivity, IgG1 should not be used as a diagnostic marker but has promise, with further development, as a biomarker of cure. We show that following chemotherapy of early chronic Chagas disease, a significant decline in IgG1 antibody suggests cure, whereas sustained or increased IgG1 is a potential indicator of treatment failure. Due to restricted sensitivity, IgG1 should not be used as a diagnostic marker but has promise, with further development, as a biomarker of cure.

Human infectiousness and parasite load in chronic patients seropositive for Trypanosoma cruzi in a rural area of the Argentine Chaco.

A key parameter in the transmission of vector-borne infections, including Chagas disease, is the ability of the different host species to transmit the parasite to the vector (infectiousness). Here, we determined infectiousness to the vector of Trypanosoma cruzi-seropositive humans examined by artificial xenodiagnosis (XD), established its relationship with T. cruzi DNA levels (a surrogate of intensity of parasitemia) quantified by real-time PCR (qPCR), and assessed whether infectiousness was associated with the body mass index (BMI), age, ethnic background and parasite genotype. XD was performed to 117 T. cruzi-seropositive residents from Pampa del Indio and parasite load was quantified in 81 of them. Using optical microscopy (OM) 33.6% of the seropositive people tested were infectious and this fraction nearly doubled (66.0%) when XD triatomines were examined by kDNA-PCR. The mean infectiousness (defined as the percentage of all infected triatomines detected by OM at any time point among the total number of insects examined by OM 30 days post-feeding) was 5.2%, and the mean parasite load was 0.51 parasite equivalents per ml. Infectiousness to the vector was associated negatively with age and BMI, and positively with the detection of parasitemia by kDNA-PCR, and parasite load by qPCR in bivariate analysis. Patients with a positive XD by OM exhibited a significantly higher mean parasite load. Using multiple regression, infectiousness was associated with parasite load (positively) and with the household presence of T. infestans and Qom ethnic group (negatively); no significant association was observed with age or its interaction with ethnicity. We did not find significant associations between identified DTUs and infectiousness or parasite load. Infectiousness was aggregated: 18% of the people examined by XD generated 80% of the infected triatomines. Detecting and treating the super-infectious fraction of the infected human would disproportionally impact on domestic transmission risks. Nonetheless, treatment of all eligible infected people who meet the inclusion criteria regardless of their parasitemia should be ensured to improve their prognosis.

Impacts of residual insecticide spraying on the abundance and habitat occupancy of Triatoma sordida and co-occurrence with Triatoma infestans: A three-year follow-up in northeastern Argentina.

Triatoma infestans, the main vector in the Gran Chaco region, may competitively displace other sympatric species such as Triatoma sordida. We conducted a three-year longitudinal study of site- and house-level infestation and abundance of triatomine bugs before and after an area-wide insecticide spraying campaign followed by sustained vector surveillance in a well-defined rural section of the Argentine Chaco encompassing 368-411 houses. Here, we tested whether insecticide applications targeting and virtually suppressing T. infestans reduced the abundance of T. sordida and modified its habitat occupancies, and whether their joint spatial distribution was random, aggregated or uniform, and varied over time. Systematic timed-manual searches of 18,031 sites yielded 2,226 T. sordida over seven postintervention surveys. Triatoma sordida failed to colonize human sleeping quarters after interventions, and its prime and secondary habitats remained virtually unmodified. Residual insecticide spraying and seasonality best described variations in the house-level abundance of T. sordida as determined using a generalized estimating equation model. Two-species foci occurred in 3.2% of sites ever positive for any species. The habitat-adjusted relative odds of catching one species was 10.8 times greater when the other species was present, with no evidence of heterogeneity among ORs, suggesting no antagonistic interactions throughout the follow-up. The spatial occurrence of both species was significantly aggregated within 300-500 m before and after interventions, and was random at broader spatial scales. The habitat occupancies of T. sordida may be used as a proxy for potential infestation with T. infestans and to guide targeted vector control actions.

Habitat-Specific Occupancy and a Metapopulation Model of Triatoma sordida (Hemiptera: Reduviidae), a Secondary Vector of Chagas Disease, in Northeastern Argentina.

Triatoma sordida Stål (Hemiptera: Reduviidae), a secondary vector of Trypanosoma cruzi Chagas (Kinetoplastida: Trypanosomatidae), occasionally colonizes human sleeping quarters in Paraguay, Bolivia, and Brazil, whereas only sylvatic and peridomestic populations are found in Argentina. We carried out a cross-sectional survey of house infestation in a well-defined rural area of northeastern Argentina to identify the key habitats of T. sordida; describe its spatial distribution in an apparently undisturbed setting under no recent insecticide treatment and use metapopulation theory to investigate these spatially structured populations. Timed-manual searches in 2,177 georeferenced sites from 368 houses yielded T. sordida in 78 sites (house infestation prevalence, 19.9%). Most triatomines occurred in chicken nests, chicken coops, and trees where chickens roosted (prime habitats). Goat or sheep corrals and pig corrals had a lower fraction of occupied sites (occupancies) and abundance. Both occupancy and catch increased with increasing refuge availability according to multimodel inference with model averaging. The majority of suitable habitats were unoccupied despite their proximity to occupied sites. The site-specific occurrence of T. sordida and Triatoma infestans Klug (Hemiptera: Reduviidae) was positively and homogeneously associated over ecotopes, showing no evidence of interspecific interference. An incidence function metapopulation model (including intersite distances and vector carrying capacity) predicted a fivefold greater occupancy relative to the observed pattern, suggesting the latter represented a transient state. T. sordida failed to colonize human sleeping quarters, thrived in peridomestic habitats occupied by chickens, and had a limited occupancy likely related to a poor colonizing ability and the relative instability of its prime habitats.

Trypanosoma cruzi infection in Triatoma sordida before and after community-wide residual insecticide spraying in the Argentinean Chaco.

Triatoma sordida is a secondary vector of Trypanosoma cruzi in the Gran Chaco and Cerrado eco-regions where it frequently infests peridomestic and domestic habitats. In a well-defined area of the humid Argentine Chaco, very few T. sordida were found infected when examined by optical microscopic examination (OM). In order to further assess the role of T. sordida and the relative magnitude of subpatent bug infections, we examined the insects for T. cruzi infection, parasite Discrete Typing Units (DTUs) and bloodmeal sources using various molecular techniques. Among 205 bugs with a negative or no OM-based diagnosis, the prevalence of infection determined by kDNA-PCR was nearly the same in bugs captured before (6.3%) and 4 months after insecticide spraying (6.4%). On average, these estimates were sixfold higher than the prevalence of infection based on OM (1.1%). Only TcI was identified, a DTU typically associated with opossums and rodents. Chickens and turkeys were the only bloodmeal sources identified in the infected specimens and the main local hosts at the bugs' capture sites. As birds are refractory to T. cruzi infection, further studies are needed to identify the infectious bloodmeal hosts. The persistent finding of infected T. sordida after community-wide insecticide spraying highlights the need of sustained vector surveillance to effectively prevent T. cruzi transmission in the domestic and peridomestic habitats.

The peri-urban interface and house infestation with Triatoma infestans in the Argentine Chaco: an underreported process?

Peri-urban infestations with triatomine bugs, their sources and their dynamics have rarely been investigated. Here, we corroborated the reported occurrence of Triatoma infestans in a peri-urban area and in neighbouring rural houses in Pampa del Indio, in the Argentine Chaco, and identified its putative sources using spatial analysis and demographic questionnaires. Peri-urban householders reported that 10% of their premises had triatomines, whereas T. infestans was collected by timed manual searches or community-based surveillance in only nine (3%) houses. Trypanosoma cruzi-infected T. infestans and Triatoma sordida were collected indoors only in peri-urban houses and were infected with TcV and TcI, respectively. The triatomines fed on chickens, cats and humans. Peri-urban infestations were most frequent in a squatter settlement and particularly within the recently built mud houses of rural immigrants, with large-sized households, more dogs and cats and more crowding. Several of the observed infestations were most likely associated with passive bug transport from other sources and with active bug dispersal from neighbouring foci. Thus, the households in the squatter settlement were at a greater risk of bug invasion and colonisation. In sum, the incipient process of domestic colonisation and transmission, along with persistent rural-to-urban migratory flows and unplanned urbanisation, indicate the need for active vector surveillance and control actions at the peri-urban interface of the Gran Chaco.

The peri-urban interface and house infestation with Triatoma infestans in the Argentine Chaco: an underreported process?

Peri-urban infestations with triatomine bugs, their sources and their dynamics have rarely been investigated. Here, we corroborated the reported occurrence of Triatoma infestans in a peri-urban area and in neighbouring rural houses in Pampa del Indio, in the Argentine Chaco, and identified its putative sources using spatial analysis and demographic questionnaires. Peri-urban householders reported that 10% of their premises had triatomines, whereas T. infestans was collected by timed manual searches or community-based surveillance in only nine (3%) houses. Trypanosoma cruzi-infected T. infestans and Triatoma sordida were collected indoors only in peri-urban houses and were infected with TcV and TcI, respectively. The triatomines fed on chickens, cats and humans. Peri-urban infestations were most frequent in a squatter settlement and particularly within the recently built mud houses of rural immigrants, with large-sized households, more dogs and cats and more crowding. Several of the observed infestations were most likely associated with passive bug transport from other sources and with active bug dispersal from neighbouring foci. Thus, the households in the squatter settlement were at a greater risk of bug invasion and colonisation. In sum, the incipient process of domestic colonisation and transmission, along with persistent rural-to-urban migratory flows and unplanned urbanisation, indicate the need for active vector surveillance and control actions at the peri-urban interface of the Gran Chaco.

Heterogeneities in the ecoepidemiology of Trypanosoma cruzi infection in rural communities of the Argentinean Chaco.

We conducted a cross-sectional survey of Trypanosoma cruzi infection of Triatoma infestans as well as dogs and cats in 327 households from a well-defined rural area in northeastern Argentina to test whether the household distribution of infection differed between local ethnic groups (Tobas and Creoles) and identify risk factors for host infection. Overall prevalence of infection of bugs (27.2%; 95% confidence interval = 25.3-29.3%), dogs (26.0%; 95% confidence interval = 23.3-30.1%), and cats examined (28.7%; 95% confidence interval = 20.2-39.0%) was similar. A multimodel inference approach showed that infection in dogs was associated strongly with the intensity and duration of local exposure to infected bugs and moderately with household ethnic background. Overall, Toba households were at a substantially greater risk of infection than Creole households. The strong heterogeneities in the distribution of bug, dog, and cat infections at household, village, and ethnic group levels may be used for targeted vector and disease control.

The role of sigmodontine rodents as sylvatic hosts of Trypanosoma cruzi in the Argentinean Chaco.

The role of rodents in the sylvatic transmission of Trypanosoma cruzi has seldom been investigated using parasitological and molecular methods. We assessed the occurrence of T. cruzi in wild small rodents from Pampa del Indio, in the Argentinean Chaco, and identified the taxonomic status of positive rodents by sequencing a fragment of cytochrome b gene (cytb) and performing BLAST searches and phylogenetic analyses. A total of 176 Sigmodontinae rodents was captured in six surveys using 5425 trap-nights in a wide range of sylvatic habitats between 2009 and 2011. Host infection was determined by xenodiagnosis and by polymerase chain reaction amplification of the hyper-variable region of kinetoplast DNA minicircles of T. cruzi (kDNA-PCR) from blood samples. None of the 176 rodents examined was xenodiagnosis-positive. The prevalence of infection determined by kDNA-PCR from blood samples was 16.2% (95% confidence interval, 10.1-21.9%). Half of the infections detected by kDNA-PCR were confirmed by nuclear satellite DNA-PCR or by kDNA-PCR of the rectal contents of xenodiagnostic bugs. The 24 positive specimens were assigned to eight species, providing the first records of T. cruzi in Akodon montensis, Akodon toba, Graomys chacoensis, and Oligoryzomys chacoensis. The occurrence of T. cruzi infection in Oligoryzomys nigripes, Calomys callosus, Necromys lasiurus and Oecomys sp. (most probably Oecomys mamorae) from the Gran Chaco is also reported for the first time. Although sigmodontine rodents were frequently infected, the intensity of bug rectal infection with T. cruzi was below the detection limit of xenodiagnosis (subpatent infectiousness to bugs), indicating they had a low reservoir host competence.

Intensified surveillance and insecticide-based control of the Chagas disease vector Triatoma infestans in the Argentinean Chaco.

BACKGROUND: The elimination of Triatoma infestans, the main Chagas disease vector in the Gran Chaco region, remains elusive. We implemented an intensified control strategy based on full-coverage pyrethroid spraying, followed by frequent vector surveillance and immediate selective insecticide treatment of detected foci in a well-defined rural area in northeastern Argentina with moderate pyrethroid resistance. We assessed long-term impacts, and identified factors and procedures affecting spray effectiveness. METHODS AND FINDINGS: After initial control interventions, timed-manual searches were performed by skilled personnel in 4,053 sites of 353-411 houses inspected every 4-7 months over a 35-month period. Residual insecticide spraying was less effective than expected throughout the three-year period, mainly because of the occurrence of moderate pyrethroid resistance and the limited effectiveness of selective treatment of infested sites only. After initial interventions, peridomestic infestation prevalence always exceeded domestic infestation, and timed-manual searches consistently outperformed householders' bug detection, except in domiciles. Most of the infestations occurred in houses infested at baseline, and were restricted to four main ecotopes. Houses with an early persistent infestation were spatially aggregated up to a distance of 2.5 km. An Akaike-based multi-model inference approach showed that new site-level infestations increased substantially with the local availability of appropriate refugia for triatomine bugs, and with proximity to the nearest site found infested at one or two preceding surveys. CONCLUSIONS AND SIGNIFICANCE: Current vector control procedures have limited effectiveness in the Gran Chaco. Selective insecticide sprays must include all sites within the infested house compound. The suppression of T. infestans in rural areas with moderate pyrethroid resistance requires increased efforts and appropriate management actions. In addition to careful, systematic insecticide applications, housing improvement and development policies that improve material conditions of rural villagers and reduce habitat suitability for bugs will contribute substantially to sustainable vector and disease control in the Gran Chaco.

New sylvatic hosts of Trypanosoma cruzi and their reservoir competence in the humid Chaco of Argentina: a longitudinal study.

A four-year longitudinal study of the structure of sylvatic transmission cycles of Trypanosoma cruzi, reservoir host competence and parasite discrete typing units was conducted in a disturbed rural area of the humid Chaco in Argentina. Among 190 mammals examined by xenodiagnosis and polymerase chain reaction amplification, the composite prevalence of infection was substantially higher in Dasypus novemcinctus armadillos (57.7%) and Didelphis albiventris opossums (38.1%) than in Euphractus sexcinctus (20.0%), Tolypeutes matacus (12.5%), and Chaetophractus vellerosus (6.3%) armadillos. Trypanosoma cruzi was detected for the first time in Thylamys pusilla small opossums and in two unidentified small rodents. Infection was spatially aggregated only in armadillos. All Didelphis were infected with T. cruzi I and all armadillo species were infected with T. cruzi III, implying two distinct sylvatic cycles with no inputs from the domestic cycle. Dasypus armadillos and Didelphis opossums were much more infectious to vectors than other armadillos, small opossums, or rodents.

Unexpected failures to control Chagas Disease vectors with pyrethroid spraying in northern Argentina.

Effectiveness of the elimination efforts against Triatoma infestans (Klug) in South America through residual application of pyrethroid insecticides has been highly variable in the Gran Chaco region. We investigated apparent vector control failures after a standard community-wide spraying with deltamethrin SC in a rural area of northeastern Argentina encompassing 353 houses. Insecticide spraying reduced house infestation less than expected: from 49.5% at baseline to 12.3 and 6.7% at 4 and 8 mo postspraying, respectively. Persistent infestations were detected in 28.4% of houses, and numerous colonies with late-stage bugs were recorded after the interventions. Laboratory bioassays showed reduced susceptibility to pyrethroids in the local bug populations. Eleven of 14 bug populations showed reduced mortality in diagnostic dose assays (range, 35 +/- 5% to 97 +/- 8%) whereas the remainder had 100% mortality. A fully enclosed residual bug population in a large chicken coop survived four pyrethroid sprays, including two double-dose applications, and was finally suppressed with malathion. The estimated resistance ratio of this bug population was 7.17 (range, 4.47-11.50). Our field data combined with laboratory bioassays and a residual foci experiment demonstrate that the initial failure to suppress T. infestans was mainly because of the unexpected occurrence of reduced susceptibility to deltamethrin in an area last treated with pyrethroid insecticides 12 yr earlier. Our results underline the need for close monitoring of the impact of insecticide spraying to provide early warning of possible problems because of enhanced resistance or tolerance and determine appropriate responses.

Factors affecting infestation by Triatoma infestans in a rural area of the humid Chaco in Argentina: a multi-model inference approach.

BACKGROUND: Transmission of Trypanosoma cruzi by Triatoma infestans remains a major public health problem in the Gran Chaco ecoregion, where understanding of the determinants of house infestation is limited. We conducted a cross-sectional study to model factors affecting bug presence and abundance at sites within house compounds in a well-defined rural area in the humid Argentine Chaco. METHODOLOGY/PRINCIPAL FINDINGS: Triatoma infestans bugs were found in 45.9% of 327 inhabited house compounds but only in 7.4% of the 2,584 sites inspected systematically on these compounds, even though the last insecticide spraying campaign was conducted 12 years before. Infested sites were significantly aggregated at distances of 0.8-2.5 km. The most frequently infested ecotopes were domiciles, kitchens, storerooms, chicken coops and nests; corrals were rarely infested. Domiciles with mud walls and roofs of thatch or corrugated tarred cardboard were more often infested (32.2%) than domiciles with brick-and-cement walls and corrugated metal-sheet roofs (15.1%). A multi-model inference approach using Akaike's information criterion was applied to assess the relative importance of each variable by running all possible (17,406) models resulting from all combinations of variables. Availability of refuges for bugs, construction with tarred cardboard, and host abundance (humans, dogs, cats, and poultry) per site were positively associated with infestation and abundance, whereas reported insecticide use showed a negative association. Ethnic background (Creole or Toba) adjusted for other factors showed little or no association. CONCLUSIONS/SIGNIFICANCE: Promotion and effective implementation of housing improvement (including key peridomestic structures) combined with appropriate insecticide use and host management practices are needed to eliminate infestations. Fewer refuges are likely to result in fewer residual foci after insecticide spraying, and will facilitate community-based vector surveillance. A more integrated perspective that considers simultaneously social, economic and biological processes at local and regional scales is needed to attain effective, sustainable vector and disease control.