YOU ARE DOWNLOADING DOCUMENT

Please tick the box to continue:

Transcript
Page 1: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Chagas disease in Spain:Chagas disease in Spain:Experience from Experience from

a reference laboratorya reference laboratory

Teresa GárateTeresa GárateServicio de ParasitologíaServicio de Parasitología

Centro Nacional de Centro Nacional de MicrobiologíaMicrobiología

Second WHO consultation: Development Second WHO consultation: Development of a WHO reference panel for the of a WHO reference panel for the control of Chagas diagnostic testscontrol of Chagas diagnostic tests

Geneva, 27 – 28 January 2009Geneva, 27 – 28 January 2009

Page 2: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

General Role of the Parasitology Lab

Parasitology Lab and Chagas’ disease in Spain

Experience from a Experience from a Parasitology Reference Parasitology Reference

LaboratoryLaboratory

Page 3: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

National National Microbiology Microbiology

Centre Centre

Parasitic diseasesParasitic diseasesAUTOCTHONOUS

Leishmaniasis

Toxoplasmosis

Cryptosporidiasis

Giardiasis

Amebiasis

Fasciolosis

Hydatidosis

Anisakiasis

Toxocariosis

Trichinellosis

IMPORTED

Malaria

Other Leishmaniasis

Chagas disease

Sleeping sickness

Cysticercosis

Schistosomiasis

Filariasis/Oncho

Intestinal parasites

Page 4: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

The Parasitology Lab works with Spanish The Parasitology Lab works with Spanish hospitals and blood donor centers on Chagas hospitals and blood donor centers on Chagas

disease diagnosisdisease diagnosis

Page 5: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Other Activities related with Other Activities related with T. T. cruzicruzi diagnosisdiagnosis

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

Page 6: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Microscopic examination

Xenodiagnosis

IFAT

ELISA

PCR

Commercial assays

(rapid tests)

Implementation of Implementation of T. cruziT. cruzi Diagnostic ToolsDiagnostic Tools in Parasitology Labin Parasitology Lab

Real time PCR

Culture

Page 7: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Evaluation of serological Evaluation of serological tests:tests:

In house In house ELISAELISA and 3 serum and 3 serum panelspanels

0.0

0.5

1.0

1.5

2.0

2.5

3.0

DO

405

nm

Panel 1 Panel 2 Panel 3

Positive IFAT Negative IFAT

Chagasic Healthy Chagasic Healthy Chagasic Healthy(n = 13) (n = 15) (n =31) (n = 115) (n = 38) (n = 30)

Positive 11 0 30 2 38 0

Negative 2 15 1 113 0 30

Panel 2 Panel 3ELISA in

house

Panel 1

Page 8: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Diagnostic index

Panel 1 Panel 2 Panel 3

% CI 95% % CI 95% % CI 95%

Sensitivity 85 65 to 100 97 91 to 100 100 100 to 100

Specificity 100 100 to 100 98 96 to 100 100 100 to 100

PPV 100 100 to 100 94 85 to 100 100 100 to 100

NPV 88 73 to 100 99 97 to 100 100 100 to 100

Evaluation of serological Evaluation of serological tests:tests:

In house In house ELISAELISA and 3 and 3 serum panelsserum panels

Page 9: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

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

Characteristics of serum samples of Characteristics of serum samples of the 3 panels used in the evaluation the 3 panels used in the evaluation

of the In house of the In house ELISAELISA

Page 10: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

CHAGAS HEALTHYVI SCERAL

LEI SHMANI ASI S

BLK Chagas test 25/25 (100%) 1/10 (10%) 5/9 (56%)

Biokit ELI SA 25/25 (100%) 1/10 (10%) 3/9 (33%)

I D-PaGI A 30/31 (97%) 1D/23 (4%) 4D/52 (8%)

BLK Chagas test

Biokit ELI SA I D-Pagia

Sensitivity 100 100 97

Specificity 90 90 96

PPV 96 96 97

NPV 100 100 96

Evaluation of Evaluation of serological tests:serological tests:Commercial Commercial ELISAsELISAs

Page 11: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

38

Non Chagasic 2

28

Spain 22

Bolivia 19

Brazil 20

Argentina 14

Ecuador 20

30

30

Characteristics of SeraNº of sera

Panel 1 (QPanel, Brasil)

Chagasic

Chagasic patients diagnosed in Spain

Healthy individuals

Malaria

Panel 2 (Parasitology, CNM, ISCIII)

Panel 3 (Parasitology, CNM, ISCIII)

Visceral leishmaniasis

Characteristics of serum samples Characteristics of serum samples used in the evaluation of used in the evaluation of

commercial testscommercial tests

Page 12: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Evaluation of Commercial Evaluation of Commercial ELISAs: ELISAs: SensitivitySensitivity

(CI 95%)

IFAT-CNM 65 (66) 98.5 (95.5 - 100)

ELISA-CNM 66 (66) 100 (100 - 100)

Certest 66 (66) 100 (100 - 100)

Ortho 66 (66) 100 (100 - 100)

BLK 41 (42) 97.6 (93.0 - 100)

Biokit 66 (66) 100 (100 - 100)

ID-PaGIA2 61 (66) 92.4 (86 - 98.8)

ID-PaGIA3 65 (66) 98.5 (95.5 - 100)

ICT Operon 61 (66) 92.4 (86.0 - 98.8)

SensitivityChagasic

Nº of positive (total sera)

Page 13: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

a The specificity was calculated into account results of healthy controlb The specificity was calculated into account results of healthy control and other pathologies.

Evaluation of Commercial Evaluation of Commercial ELISAs: ELISAs:

SpecificitySpecificity

(CI 95%) (CI 95%)

IFAT-CNM 0 (97) 100 (100 - 100) 23 (60) 85.4 (79.8 - 90.9)

ELISA-CNM 0 (97) 100 (100 - 100) 18 (60) 88.6 (83.6 - 93.5)

Certest 0 (97) 100 (100 - 100) 25 (60) 84.2 (78.4 - 89.8)

Ortho 0 (97) 100 (100 - 100) 18 (60) 88.6 (83.6 - 93.5)

BLK 0 (74) 100 (100 - 100) 13 (60) 90.3 (85.3 - 95.3)

Biokit 1 (97) 99 (97 - 100) 7 (60) 94.9 (91.5 - 98.3)

ID-PaGIA2 1 (97) 99 (97 - 100) 1 (60) 98.7 (97.0 - 100)

ID-PaGIA3 2 (97) 98 (95 - 100) 2 (60) 97.5 (95.0 - 99.9)

ICT Operon 2 (97) 98 (95 - 100) 10 (60) 92.4 (88.2 - 96.5)

Other pathologiesSpecificity 2b

Nº of positive (total sera)

Nº of positive(total sera)

Non ChagasicSpecificity 1a

Page 14: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Molecular diagnosis of Molecular diagnosis of T. T. cruzicruzi

kDNA-PCRkDNA-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 Control assay of limit detectiondetection

Samples of population Samples of population at-riskat-risk

Page 15: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Diagnostic sensitivity and specificityDiagnostic sensitivity and specificity

PCR Positive Negative Total

Acute patients 11 0 11

Chronic patients 471 295 766

Seronegative subjects 0 1227 1227

Total 482 1522 2004

Diagnostic index in chronic phase CI (95%)

Sensitivity 61.5 58 65

Specificity 100 99.96 100

Positive predictive value 100 99.89 100

Negative predictive value 80.62 78.6 82.64

Molecular diagnosis of Molecular diagnosis of T. T. cruzicruzi

Page 16: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Chagas disease cases in Chagas disease cases in SpainSpain

IMPORTED

Immigration from endemic area

Long stays in endemic area

AUTOCTHONOUSAUTOCTHONOUS

Blood transfusion

Congenital transmission

Organ transplant

Laboratory accidents

Page 17: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Latin American population Latin American population in Spainin Spain

On December 2008: > 1.8 million415535

284043236048

196946123173119209

669506140761069

48939268

EcuadorColombia

BoliviaArgentina

PeruBrazil

ParaguayUruguay

VenezuelaChile

Rest of SA

Page 18: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Year of Year of detectiondetection

Year of Year of DonationDonation

N º of N º of recipientsrecipients

Nº of Nº of infectedinfected Ref.Ref.

1992 ? 1? 1 Villalba et al., 1992

Reports of Transfusional Reports of Transfusional Chagas cases in SpainChagas cases in Spain

2005 2004 1 1Fores et al., 2007; Flores-Chavez et al., 2008

2007 2005-2007 9 2 Perez et al., 2008; CNM

2006 1994-2003 10 1 Abalo et al., 2007, CNM

National Haemovigilance System

2008 2004 1 1 Ibarra et al., 2008, CNM

Page 19: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Madrid recipient

Coruña recipient

Málaga recipient 1

Málaga recipient 2

País Vasco

recipient

Origin Spanish Spanish Spanish Moroccan Spanish

Age 27 55 33 57 4

Clinical status before transfusion

Leukemia Hepatic transplant

Bone marrow aplasia

Choroid plexus

papilloma

Cardiac surgery

Phase of Chagas disease and symptoms

AcuteFUO

Multiorganic failure

ChronicAsympto

matic

AcuteFUO

ChronicRight bundle branch block

ChronicAsympto

matic

Treatment Yes Yes Yes Yes Yes

Follow upAfter treatment

Fatal dead

person

S (+) PCR (-)

S (-) PCR (-)

S (+) PCR (-)

S (+) PCR (-)

Transfusional Chagas Transfusional Chagas CasesCases

Page 20: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Characteristics Characteristics of Infected of Infected

donors:donors:

A CoruñaA Coruña MadridMadrid MalagaMalaga País VascoPaís Vasco

OriginOrigin Bolivia Brazil Bolivia Bolivia

SexSex Male Female Male Male

AgeAge 62 58 53

ELISAELISA 2.3 2.2 2.3

IFATIFAT > 1/160 > 1/160 > 1/160

PCRPCR PP N/PN/P PP

TreatmentTreatment No Yes Yes

PermanencPermanence in Spaine in Spain 42 years 1 year 3 years

Malaga

Madrid

A CoruñaPaís Vasco

Page 21: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Newborns Positive PCR

2002 1

2003 3

2004 2 1*

2005 4

2006 12

2007 78 3

2008 91 5

Total 191 9

Congenital Chagas Congenital Chagas diseasedisease

Transmission index: ~ 4,5%* Post mortem diagnosis

Newborns examined during 2002 - 2008

In Spain ≈ 990 000 women of childbearing ageBolivia: 132 421 women

Argentina: 94 794 women

Page 22: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Alvar J. 1983 Laboratorio 76(456): 645-648

Laboratory Accidents Laboratory Accidents and Chagas diseaseand Chagas disease

Page 23: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Chagas disease cases in Chagas disease cases in SpainSpain

IMPORTED

Immigration from endemic area

Long stays in endemic area

AUTOCTHONOUSAUTOCTHONOUS

Blood transfusion

Congenital transmission

Organ transplant

Laboratory accidents

Page 24: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Chagas disease in Chagas disease in blood donors at- risk blood donors at- risk

C. T. Cruz Roja de Madrid

Prevalence % 1,23

2890

779500

1250

2000

2750

361 4

0

100

200

2002-2006 2003-2006 2006-2008

357

C.C. de Sangre y Tejidos de Asturias

0,13

2890

779500

1250

2000

2750

361 4

0

100

200

2002-2006 2003-2006 2006-2008

357

Asturias

Madrid

Page 25: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

14581164906

4306832975

2516913474

1084089978476

3958

0 30000 60000 90000 120000 150000

EcuadorColombia

PeruBolivia

ArgentinaBrazil

VenezuelaParaguay

ChileUruguay

Madrid

43582721

19031886

915549

435373370

310

0 1000 2000 3000 4000 5000

EcuadorColombiaArgentina

BrazilVenezuelaParaguayUruguay

PeruChile

Bolivia

Asturias

MadridMadrid

AsturiasAsturias

Profile of immigrant populationProfile of immigrant population

2006: ≈ 17 000 2006: ≈ 17 000 immigrantimmigrant2008: ≈ 20 000 immigrant2008: ≈ 20 000 immigrant

2006: ≈ 400 000 2006: ≈ 400 000 immigrantimmigrant2008: ≈ 500 000 immigrant2008: ≈ 500 000 immigrant

Page 26: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Prevalence in blood Prevalence in blood donors at-risk (2002-donors at-risk (2002-

2006)2006) P N Prevalence %

Nicaragua 1 16 6.25Colombia 1 776 0.13Venezuela 1 249 0.40Ecuador 1 908 0.11Peru 2 258 0.78Bolivia 37 203 18.23Brazil 2 221 0.90End. Zone 3 207 1.45Non End. Zone 1 307 0.33ND 3 245 1.22Spain 1 277 0.36

P = SeropositiveN = Seronegative

??

Page 27: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

6 5 27 40 75 131219

285398

476

815

1137

1 0 2 7 3 6 26 46 90138

361464

0

200

400

600

800

1000

1200

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

SERONEGATIVE SEROPOSITIVE

SeroprevalenceSeroprevalence in in population at-risk: population at-risk:

24%24%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Prevalence % 14 0 7 15 4 4 11 14 18 22 31 29

≈ 1144 Chagasic patients

Page 28: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

1

379

150

10

4

16

571

1

5

1

2

4

7

1

16

35

3

3

10

7

528

40

5

28

4

40

3

11

1 59

22

1

3

1

15

Distribution of cases Distribution of cases in Spainin Spain

2289

528

0

500

1000

1500

2000

2500

Seronegative Seropositive

MadridPrevalence

19 %

598

79

0

200

400

600

800

Seronegative Seropositive

AlicantePrevalence

12 %

173

150

50

100

150

200

Seronegative Seropositive

Almeria

Prevalence8 %

Page 29: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

0%1%2%3%4%5%

ARG

ENTI

NA

BOLI

VIA

BRA

ZIL

CHIL

EPA

RAG

UAY

URU

GU

AYCO

LOM

BIA

ECU

AD

OR

PERU

VEN

EZU

ELA

GU

ATEM

ALA

HO

ND

URA

SN

ICA

RAG

UA

SALV

AD

OR

MEX

ICO

SPA

IN

60%

80%

100%

Origin of seropositive Origin of seropositive populationpopulation

Page 30: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

ConclusionsConclusions 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.

Page 31: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

UNIDAD LEISHMANIA Y CHAGASUNIDAD LEISHMANIA Y CHAGASCarmen CañavateCarmen CañavateJavier NietoJavier NietoMercedes RodriguezMercedes RodriguezIsrael CruzIsrael CruzElena BodasElena BodasMarta HernándezMarta HernándezRubén GonzálezRubén GonzálezEmilia GarcíaEmilia GarcíaCarmen ChicharroCarmen ChicharroMaría FloresMaría Flores

Thank youThank you

Page 32: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

Organ transplant and

lab incident

Months Years

Transfusional and congenital

Chagas

Acute Chronic phase

Immigration and long stays in endemic area

Chagas disease in Chagas disease in SpainSpainAUTOCTHONOUSAUTOCTHONOUS

IMPORTEDIMPORTED

??

Page 33: Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:

0

1

2

3

4

5

6

DO/CO

Level of anti-Level of anti-T. cruzi T. cruzi IgGIgG in in samples of patients with samples of patients with

positive positive PCRPCR

Acute case 1(Madrid recipient)

Acute case 2(Málaga recipient)


Related Documents