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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:

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Presentation on theme: "Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation:"— Presentation transcript:

1 Chagas disease in Spain: Experience from a reference laboratory Teresa Gárate Servicio de Parasitología Centro Nacional de Microbiología Second WHO consultation: Development of a WHO reference panel for the control of Chagas diagnostic tests Geneva, 27 – 28 January 2009

2 General Role of the Parasitology Lab Parasitology Lab and Chagas disease in Spain Experience from a Parasitology Reference Laboratory

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

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

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

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

7 Evaluation of serological tests: In house ELISA and 3 serum panels

8 Diagnostic index Panel 1Panel 2Panel 3 %CI 95% % Sensitivity8565to to100 to100 Specificity100 to to100 to100 PPV100 to to100 to100 NPV8873to to100 to100 Evaluation of serological tests: In house ELISA and 3 serum panels

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, was kindly provided by Dra. Elena Franco Characteristics of serum samples of the 3 panels used in the evaluation of the In house ELISA

10 Evaluation of serological tests: Commercial ELISAs

11 Characteristics of serum samples used in the evaluation of commercial tests

12 Evaluation of Commercial ELISAs: Sensitivity

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

14 Molecular diagnosis of T. cruzi kDNA-PCR kDNA-PCR modified ( / 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

15 Diagnostic sensitivity and specificity PCR PositiveNegativeTotal Acute patients 110 Chronic patients Seronegative subjects Total Diagnostic index in chronic phaseCI (95%) Sensitivity Specificity Positive predictive value Negative predictive value Molecular diagnosis of T. cruzi

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

17 Latin American population in Spain On December 2008: > 1.8 million

18 Year of detection Year of Donation N º of recipients Nº of infected Ref. 1992?1?1Villalba et al., 1992 Reports of Transfusional Chagas cases in Spain Fores et al., 2007; Flores-Chavez et al., Perez et al., 2008; CNM Abalo et al., 2007, CNM National Haemovigilance System Ibarra et al., 2008, CNM

19 Madrid recipient Coruña recipient Málaga recipient 1 Málaga recipient 2 País Vasco recipient OriginSpanish MoroccanSpanish Age 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

20 Characteristics of Infected donors: A Coruña MadridMalaga País Vasco OriginBoliviaBrazilBolivia SexMaleFemaleMale Age ELISA IFAT> 1/160 PCRPN/PP TreatmentNoYes Permanenc e in Spain 42 years1 year3 years Malaga Madrid A Coruña País Vasco

21 NewbornsPositive PCR * Total1919 Congenital Chagas disease Transmission index: ~ 4,5% * Post mortem diagnosis Newborns examined during In Spain women of childbearing age Bolivia: women Argentina: women

22 Alvar J Laboratorio 76(456): Laboratory Accidents and Chagas disease

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

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

25 Madrid Asturias Profile of immigrant population 2006: immigrant 2008: immigrant 2006: immigrant 2008: immigrant

26 Prevalence in blood donors at-risk ( ) PNPrevalence % Nicaragua Colombia Venezuela Ecuador Peru Bolivia Brazil End. Zone Non End. Zone ND Spain P = Seropositive N = Seronegative ????

27 Seroprevalence in population at-risk: 24% 1144 Chagasic patients

28 Distribution of cases in Spain

29 Origin of seropositive population

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 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.

31 UNIDAD LEISHMANIA Y CHAGAS Carmen Cañavate Javier Nieto Mercedes Rodriguez Israel Cruz Elena Bodas Marta Hernández Rubén González Emilia García Carmen Chicharro María Flores Thank you

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 ????

33 Level of anti-T. cruzi IgG in samples of patients with positive PCR Acute case 1 (Madrid recipient) Acute case 2 (Málaga recipient)


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