Malaria - Haiti
Hurricane Katrina - Southeast United States
Chagas Disease Outbreak - Brazil, Santa Catarina

Malaria — Haiti
November 11, 2005

The following was submitted to ProMed.

Archive Number 20051111.3292
Published Date 11-NOV-2005
Subject PRO/EDR> Malaria - Haiti, Canada ex Haiti
MALARIA - HAITI, CANADA EX HAITI
********************************
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Date: 8 Nov 2005
From: David O. Freedman <dfreedman@geomed.dom.uab.edu>
Source: GeoSentinel [edited] <http://www.istm.org/geosentinel/main.html>

GeoSentinel, the global surveillance program of the International Society of Travel Medicine, has been informed by our sites and collaborators that here have been 2 deaths in the past 5 days.

Both were in foreign citizens usually resident in Haiti not taking any malaria chemoprophylaxis. Both had spent the weekend of 17 Oct 2005 in the Côte des Arcadins area on the gulf side of the island. Slide diagnosis of one case has been confirmed in Canada, where one patient died after becoming ill while visiting there. CDC in the US is providing technical assistance with the specimens in the 2nd case, which had been slide-diagnosed after evacuation to a US hospital.

Both patients had rapidly fulminant disease with DIC very consistent with malaria, but this naturally raised the concern about other etiologies in the expatriate community in Haiti. Falciparum malaria is known to be endemic in Haiti, and these cases serve as a reminder of the perils of forgoing malaria prophylaxis.
--
David O. Freedman, MD
University of Alabama
for GeoSentinel

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Hurricane Katrina — Southeast United States
September 4, 2005

CDC has nice guidelines for travelers and aid workers to link to:

http://www.cdc.gov/travel/other/hurricane/guidance_hp_travelers.htm
http://www.bt.cdc.gov/disasters/hurricanes/infectiousdisease.asp

We would ask any GeoSentinel sites that see Katrina-related illness in refugees in their home city or because they are involved in relief or evacuee efforts to inform GeoSentinel <geosentinel@geosentinel.org> as soon as feasible, keeping in mind any obligations to first inform appropriate publich health authorities.

So far there are really not too many health issues despite a lot of dire predictions earlier in the press.

Those wanting to give money can try:
http://www.washingtonpost.com/wp-dyn/content/article/2005/08/31/AR2005083101758.html

Those wanting to volunteer should visit:
http://www.ama-assn.org/ama/pub/category/15474.html

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Chagas Disease Outbreak — Brazil, Santa Catarina
March 27, 2005

Please be on the lookout or any illnesses in returning travelers consistent with this exposure and inform us immediately if any suspicions. <geosentinel@geosentinel.org>

From: [TRAVELMED] Chagas disease - Santa Catarina

1. Santa Catarina is very important touristic State in South of Brazil with many gorgeous beachs and very well prepared to welcome tourists
2. Sugar cane juice, also known as "garapa" is a very common beavarage all over the country and it is made by crushing the cane.. The triatomineo (vector - "bug")may have been crushed along this process or the cane was contaminated with infected "bug's faeces"
3. There have been so far 25 confirmed cases (aroud 14 suspicious and symptomatic) and 6 deaths. There may have been more than 50,000 possible exposures (wihic includes international travellers)
4. All cases are apparently related to drinking "garapa" in cities of upper north beachs of the State ( To name all the suspicious cities: Itapoá, Garuva, Joinville, Araquari, São Francisco do Sul, Balneário Barra do Sul, Barra Velha, Piçarras, Penha, Navegantes, Itajaí, Balneário Camboriú,Camboriú e Itapema). All are closely related to the Federal road named BR 101
5. There 2 papers refering previous outbreaks of Chagas disease associated with oral route of transmission (year - city State; 1968 - Teutonia RS; 1991 - Catolé do Rocha PB) with the biggest one presenting 26 confirmed cases
6. Incubation period seems to be around 7-28 days and main signs and symptons - High Fever for more than 5 days; myalgia; headache; orbital swelling; hepatosplenomegaly.....
7. Treatment with either benzonidazol or nifurtimox must be provided ASAP for all acute cases, specially symptomatic ones. Cure rates are around 70%

Several of you have asked about diagnosis of Chagas in those who were potentially exposed in this outbreak in Brazil.  The US CDC is willing to accept specimens from GeoSentinel Sites submitted via the DPDX website as described below.

The bottom line is that it may take some time for serologic tests to become positive after an acute exposure and that at this time there is insufficient data on the performance of PCR in such cases to make definitive statements about its use.

Important distinctions to consider when reading the information below:

• Acute stage vs. latent/chronic stages of infection
• Parasitologic vs. serologic diagnosis
• Tests for "screening" large numbers of persons (e.g., blood donors, in some countries) vs. tests for "confirming the diagnosis" (for individual potential cases of infection and/or because a "screening" test was "positive")
• Testing by "local" laboratories vs. "reference" laboratories with specialized expertise related to diagnosing T. cruzi infection.

Caveat:

We purposefully did not include details below about particular tests/methods (e.g., particular serologic and PCR techniques), in part because the "performance" of a particular type of test often is highly variable and affected by many factors.

Diagnosis of T. cruzi infection:

ACUTE STAGE -- "look" for the parasite ... but the immune response might not yet be detectable:

Diagnosis typically relies on detection of circulating organisms ... by:

• microscopic examination of a fresh blood specimen/buffy coat or stained blood smear
• hemoculture
• xenodiagnosis (of note, CDC does not offer such testing)

In some circumstances, the use of investigational molecular tools (e.g., PCR) may be helpful (e.g., to detect low levels of parasite DNA after a "recognized" exposure, before the parasite is detectable by the above methods).

Antibodies to T. cruzi antigens typically are not detectable for at least several weeks, sometimes several months, after the relevant exposure.  Therefore, the results of serologic testing may be negative during the acute stage of infection.

LATENT (indeterminate) and CHRONIC STAGES -- the immune response usually is detectable; the parasite -- although still present -- may be "hard to find":

Diagnosis typically relies on serologic testing.

Although the results of hemoculture and/or xenodiagnosis may be positive during the latent/chronic stages of infection, the level of parasitemia often is too low for parasites to be reliably detected with conventional parasitologic techiques.  Investigational molecular tools (see above) may be more sensitive for detecting low-level parasitemia and therefore be useful in some circumstances.

Links to web sites:

• CDC/DPD's "main menu page" about Chagas disease:
    This site provides links to:
  • a fact sheet written for lay persons. (Of note, the comment that "blood is not screened for Chagas" is true in the United States but does not apply to all countries.)
  • the "DPDx" (see below) section about Chagas disease.
• "DPDx," the Division of Parasitic Diseases' (DPD) telediagnosis service
• Section of DPDx that provides information for clinicians and laboratorians about sending specimens or images to CDC/DPD
• Persons with specific questions about diagnosis of Chagas disease may address their inquiries to: dpdx@cdc.gov
• World Health Organization's "main menu page" about Chagas disease
• Pan American Health Organization's "main menu page" about Chagas disease

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