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Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Mar 26, 2015

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Chagas disease in Spain: Experience from a reference laboratory Teresa Grate Servicio de Parasitologa Centro Nacional de Microbiologa Second WHO consultation: Development of a WHO reference panel for the control of Chagas diagnostic tests Geneva, 27 28 January 2009 Slide 2 General Role of the Parasitology Lab Parasitology Lab and Chagas disease in Spain Experience from a Parasitology Reference Laboratory Slide 3 National Microbiology Centre Parasitic diseases AUTOCTHONOUS Leishmaniasis Toxoplasmosis Cryptosporidiasis Giardiasis Amebiasis Fasciolosis Hydatidosis Anisakiasis Toxocariosis Trichinellosis IMPORTED Malaria Other Leishmaniasis Chagas disease Sleeping sickness Cysticercosis Schistosomiasis Filariasis/Oncho Intestinal parasites Slide 4 The Parasitology Lab works with Spanish hospitals and blood donor centers on Chagas disease diagnosis Slide 5 Other Activities related with T. cruzi diagnosis Chagas Test evaluation - In house tests - Commercial tests Control sample preparation - Serum of characterized patients - DNA from parasite strains - Blood spiked with parasites Training microbiologists in - Microhaemotocrit - PCR - Serological result interpretation Slide 6 Microscopic examination Xenodiagnosis IFAT ELISA PCR Commercial assays (rapid tests) Implementation of T. cruzi Diagnostic Tools in Parasitology Lab in Parasitology Lab Real time PCR Culture Slide 7 Evaluation of serological tests: In house ELISA and 3 serum panels Slide 8 Diagnostic index Panel 1Panel 2Panel 3 %CI 95% % Sensitivity8565to1009791to100 to100 Specificity100 to1009896to100 to100 PPV100 to1009485to100 to100 NPV8873to1009997to100 to100 Evaluation of serological tests: In house ELISA and 3 serum panels Slide 9 Panel 1: Sera from Bolivian individuals with positive or negative xenodiagnosis Panel 2: Sera from population with positive or negative T. cruzi IFAT. Healthy individuals from endemic and non-endemic areas Panel 3: Sera of anti-T. cruzi Specific Panel and healthy individuals from endemic and non-endemic areas Anti-T. cruzi Specific Sera Panel (QPanel, Sao Paulo-Brazil, http://www.panel.com.br) was kindly provided by Dra. Elena Franco http://www.panel.com.br Characteristics of serum samples of the 3 panels used in the evaluation of the In house ELISA Slide 10 Evaluation of serological tests: Commercial ELISAs Slide 11 Characteristics of serum samples used in the evaluation of commercial tests Slide 12 Evaluation of Commercial ELISAs: Sensitivity Slide 13 a The specificity was calculated into account results of healthy control b The specificity was calculated into account results of healthy control and other pathologies. Evaluation of Commercial ELISAs: Specificity Slide 14 Molecular diagnosis of T. cruzi kDNA-PCR kDNA-PCR modified (121-122 / HUF-REV) Britto et al 1993; Cruz et al 2002; Walsh et al 1991; Dorn et al 1997; Gomes et al 1998; Wincker et al 1994; Rubio et al 2002 Control assay of limit detection Samples of population at-risk Slide 15 Diagnostic sensitivity and specificity PCR PositiveNegativeTotal Acute patients 110 Chronic patients 471295766 Seronegative subjects 01227 Total 4821522 2004 Diagnostic index in chronic phaseCI (95%) Sensitivity61.55865 Specificity10099.96100 Positive predictive value10099.89100 Negative predictive value80.6278.682.64 Molecular diagnosis of T. cruzi Slide 16 Chagas disease cases in Spain IMPORTED Immigration from endemic area Long stays in endemic area AUTOCTHONOUS Blood transfusion Congenital transmission Organ transplant Laboratory accidents Slide 17 Latin American population in Spain On December 2008: > 1.8 million Slide 18 Year of detection Year of Donation N of recipients N of infected Ref. 1992?1?1Villalba et al., 1992 Reports of Transfusional Chagas cases in Spain 2005200411 Fores et al., 2007; Flores-Chavez et al., 2008 20072005-200792 Perez et al., 2008; CNM 20061994-2003101 Abalo et al., 2007, CNM National Haemovigilance System 2008200411 Ibarra et al., 2008, CNM Slide 19 Madrid recipient Corua recipient Mlaga recipient 1 Mlaga recipient 2 Pas Vasco recipient OriginSpanish MoroccanSpanish Age275533574 Clinical status before transfusion Leukemia Hepatic transplant Bone marrow aplasia Choroid plexus papilloma Cardiac surgery Phase of Chagas disease and symptoms Acute FUO Multiorga nic failure Chronic Asympto matic Acute FUO Chronic Right bundle branch block Chronic Asympto matic TreatmentYes Follow up After treatment Fatal dead person S (+) PCR (-) S (-) PCR (-) S (+) PCR (-) S (+) PCR (-) Transfusional Chagas Cases Slide 20 Characteristics of Infected donors: A Corua MadridMalaga Pas Vasco OriginBoliviaBrazilBolivia SexMaleFemaleMale Age625853 ELISA2.32.22.3 IFAT> 1/160 PCRPN/PP TreatmentNoYes Permanenc e in Spain 42 years1 year3 years Malaga Madrid A Corua Pas Vasco Slide 21 NewbornsPositive PCR 20021 20033 200421* 20054 200612 2007783 2008915 Total1919 Congenital Chagas disease Transmission index: ~ 4,5% * Post mortem diagnosis Newborns examined during 2002 - 2008 In Spain 990 000 women of childbearing age Bolivia: 132 421 women Argentina: 94 794 women Slide 22 Alvar J. 1983 Laboratorio 76(456): 645-648 Laboratory Accidents and Chagas disease Slide 23 Chagas disease cases in Spain IMPORTED Immigration from endemic area Long stays in endemic area AUTOCTHONOUS Blood transfusion Congenital transmission Organ transplant Laboratory accidents Slide 24 Chagas disease in blood donors at- risk C. T. Cruz Roja de Madrid Prevalence %1,23 C.C. de Sangre y Tejidos de Asturias 0,13 Asturias Madrid Slide 25 Madrid Asturias Profile of immigrant population 2006: 17 000 immigrant 2008: 20 000 immigrant 2006: 400 000 immigrant 2008: 500 000 immigrant Slide 26 Prevalence in blood donors at-risk (2002-2006) PNPrevalence % Nicaragua1166.25 Colombia17760.13 Venezuela12490.40 Ecuador19080.11 Peru22580.78 Bolivia3720318.23 Brazil22210.90 End. Zone32071.45 Non End. Zone13070.33 ND32451.22 Spain12770.36 P = Seropositive N = Seronegative ???? Slide 27 Seroprevalence in population at-risk: 24% 1144 Chagasic patients Slide 28 Distribution of cases in Spain Slide 29 Origin of seropositive population Slide 30 Conclusions Panel of Reference - Positive samples by different serological tests, and - Positive samples from chagasic individuals with parasitological, epidemiological and clinical evaluation. Number of positive sera/panel - 3 serum samples for kit manufacturers - 100 serum samples for evaluation of tests - 3 serum samples for quality control. Chagas in Spain - Imported and autochonous types. - Bolivian group, mainly from Santa Cruz region, shows the highest seropositivity rates and represents the highest risk for T. cruzi infection transmission. Slide 31 UNIDAD LEISHMANIA Y CHAGAS Carmen Caavate Javier Nieto Mercedes Rodriguez Israel Cruz Elena Bodas Marta Hernndez Rubn Gonzlez Emilia Garca Carmen Chicharro Mara Flores Thank you Slide 32 Organ transplant and lab incident Months Years Transfusional and congenital Chagas Acute Chronic phase Immigration and long stays in endemic area Chagas disease in Spain AUTOCTHONOUS IMPORTED ???? Slide 33 Level of anti-T. cruzi IgG in samples of patients with positive PCR Acute case 1 (Madrid recipient) Acute case 2 (Mlaga recipient)