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===Non-endemic countries=== Though Chagas is traditionally considered a disease of rural Latin America, international migration has dispersed those with the disease to numerous non-endemic countries, primarily in North America and Europe.<ref name="WHO2019"/><ref name=Lidani2019/> As of 2020, approximately 300,000 infected people are living in the United States,<ref name="mmwr">{{Cite journal |vauthors=Turabelidze G, Vasudevan A, Rojas-Moreno C, et al |date=2020 |title=Autochthonous Chagas Disease — Missouri, 2018 |journal=MMWR. Morbidity and Mortality Weekly Report |volume=69 |issue=7 |doi=10.15585/mmwr.mm6907a4 |issn=0149-2195 |pages=193–195 |pmid=32078594 |pmc=7043387 }}</ref> and in 2018 it was estimated that 30,000 to 40,000 people in the United States had Chagas cardiomyopathy.<ref name="Nunes2018"/> The vast majority of cases in the United States occur in [[Immigration to the United States#Contemporary immigration|immigrants from Latin America]],<ref name="Nunes2018"/><ref name="Bern2019"/> but local transmission is possible. Eleven triatomine species are native to the United States, and some southern states have persistent cycles of disease transmission between insect vectors and animal reservoirs,<ref name="Molina2018"/><ref name="Bern2019"/> which include woodrats, possums, [[raccoon]]s, armadillos and [[skunk]]s.<ref name="Montgomery2014">{{cite journal|vauthors=Montgomery SP, Starr MC, Cantey PT, Edwards MS, Meymandi SK|title=Neglected Parasitic Infections in the United States: Chagas Disease|journal=Am J Trop Med Hyg|volume=90|issue=5|year=2014|pages=814–818|doi=10.4269/ajtmh.13-0726|pmid=24808250|pmc=4015570}}</ref> However, locally acquired infection is very rare: only 28 cases were documented from 1955 to 2015.<ref name="Molina2018"/><ref name="mmwr"/> As of 2013, the cost of treatment in the United States was estimated to be US$900 million annually (global cost $7 billion), which included hospitalization and medical devices such as pacemakers.<ref name=econ>{{cite journal|vauthors=Lee BY, Bacon KM, Bottazzi ME, Hotez PJ |title=Global economic burden of Chagas disease: a computational simulation model|journal=The Lancet Infectious Diseases|date=April 2013|volume=13|issue=4|pages=342–8|doi=10.1016/S1473-3099(13)70002-1|pmc=3763184 |pmid=23395248}}</ref> Chagas disease affected approximately 68,000 to 123,000 people in Europe as of 2019.<ref name="Alonso2019">{{cite book|vauthors=Alonso-Padilla J, Pinazo MJ, Gascón J|title=Chagas Disease |editor=Marcelo Altcheh J, Freilij H|url=https://books.google.com/books?id=WpyuDwAAQBAJ|series=Birkhäuser Advances in Infectious Diseases|date=9 September 2019|publisher=Springer Nature|location=Switzerland|isbn=978-3-030-00054-7|pages=111–123|chapter=Chagas Disease in Europe|issn=2504-3811|doi=10.1007/978-3-030-00054-7_5|s2cid=203406723}}</ref> Spain, which has a high rate of immigration from Latin America, has the highest prevalence of the disease. It is estimated that 50,000 to 70,000 people in Spain are living with Chagas disease, accounting for the majority of European cases.<ref name="Velasco2020"/> The prevalence varies widely within European countries due to differing immigration patterns.<ref name="Alonso2019"/> Italy has the second highest prevalence, followed by the Netherlands, the United Kingdom, and Germany.<ref name="Velasco2020">{{cite journal |vauthors=Velasco M, Gimeno-Feliú LA, Molina I, et al |title=Screening for Trypanosoma cruzi infection in immigrants and refugees: Systematic review and recommendations from the Spanish Society of Infectious Diseases and Clinical Microbiology |journal=Euro Surveill. |volume=25 |issue=8 |date=February 2020 |pmid=32127121 |doi=10.2807/1560-7917.ES.2020.25.8.1900393 |type= Review|pmc=7055039 }}</ref>
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