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==Epidemiology== [[File:Chagas2011Map.jpg|thumb|upright=1.4|alt=A world map. South America and Mexico are red, the United States is yellow, and Canada, Japan, Australia, the United Kingdom, Scandinavia, Romania, and most of Western Europe is blue.|Epidemiology of Chagas disease circa 2011: red is endemic countries where spread is through vectors; yellow is endemic countries where spread is occasionally through vectors; blue is non-endemic countries where spread is through blood transfusions and migration.<ref>{{cite journal | vauthors = Liu Q, Zhou XN | title = Preventing the transmission of American trypanosomiasis and its spread into non-endemic countries | journal = Infectious Diseases of Poverty | volume = 4 | pages = 60 | date = December 2015 | pmid = 26715535 | doi = 10.1186/s40249-015-0092-7 | pmc = 4693433 | doi-access = free }}</ref>]] [[File:2016 Chagas Disease DALYs.svg|thumb|upright=1.4|alt=See description.|[[Disability-adjusted life years]] due to Chagas disease in 2016. Grey indicates no data. Otherwise, colors get increasingly dark red for each order of magnitude increase in DALY burden: 0, white. Up to 1,000 DALYs, yellow. 1,001 to 10,000 DALYs, orange. 10,001 to 100,000 DALYs, light red. Greater than 100,000 DALYs, dark red.<ref name="WHO2016">{{cite web|author=World Health Organization|title=Disease burden and mortality estimates|url=https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html|access-date=27 April 2020|archive-url=https://web.archive.org/web/20200210135939/https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html|archive-date=10 February 2020}}</ref>]] <!--Impact--> In 2019, an estimated 6.5 million people worldwide had Chagas disease, with approximately 173,000 new infections and 9,490 deaths each year.<ref name="GBD2019">{{cite web|date=2020|title=Global Health Metrics: Chagas disease—Level 3 cause|work=[[The Lancet]]|url=https://www.thelancet.com/pb-assets/Lancet/gbd/summaries/diseases/chagas-disease.pdf|archiveurl=https://web.archive.org/web/20220318033609/https://www.thelancet.com/pb-assets/Lancet/gbd/summaries/diseases/chagas-disease.pdf |archivedate=18 March 2022|url-status=live}}</ref> The disease resulted in a global annual economic burden estimated at US$7.2 billion in 2013, 86% of which is borne by endemic countries.<ref name=Lidani2019/><ref name=econ/> Chagas disease results in the loss of over 800,000 [[disability-adjusted life years]] each year.<ref name="Molina2018"/> <!--Endemic areas--> The endemic area of Chagas disease stretches from the southern United States to northern Chile and Argentina, with Bolivia (6.1%), Argentina (3.6%), and Paraguay (2.1%) exhibiting the highest prevalence of the disease.<ref name="Molina2018">{{cite journal|vauthors=Pérez-Molina JA, Molina I|title=Chagas disease|journal=The Lancet|volume=391|issue=10115|year=2018|pages=82–94|issn=0140-6736|doi=10.1016/S0140-6736(17)31612-4|pmid=28673423|s2cid=4514617}}</ref> Within continental Latin America, Chagas disease is endemic to 21 countries: Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, French Guiana, Guatemala, Guyana, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Uruguay, and Venezuela.<ref name="WHO2019"/><ref name="Molina2018"/> In endemic areas, due largely to vector control efforts and screening of blood donations, annual infections and deaths have fallen by 67% and more than 73% respectively from their peaks in the 1980s to 2010.<ref name="Molina2018"/><ref name=Moncayo2017>{{cite book|title=American Trypanosomiasis – Chagas Disease |edition=2 |date=2017 |chapter=Current epidemiological trends of Chagas disease in Latin America and future challenges: epidemiology, surveillance, and health policies |vauthors=Moncayo A, Silveria AC |doi=10.1016/B978-0-12-801029-7.00004-6 |publisher=Elsevier |pages=59–88}}</ref> Transmission by insect vector and blood transfusion has been completely interrupted in Uruguay (1997), Chile (1999), and Brazil (2006),<ref name=Moncayo2017/> and in Argentina, vectorial transmission had been interrupted in 13 of the 19 endemic provinces as of 2001.<ref name=TDR1>{{cite press release|url=https://www.who.int/tdrold/publications/tdrnews/news65/chagas.htm |title=The Southern Cone Initiative: an update |work=Special Programme for Research and Training in Tropical Diseases (TDR) |publisher=WHO |year=2004 |access-date=29 August 2008 |url-status=dead |archive-url=https://web.archive.org/web/20090922232932/http://www.who.int/tdrold/publications/tdrnews/news65/chagas.htm |archive-date=22 September 2009 }}</ref> During Venezuela's [[Crisis in Venezuela|humanitarian crisis]], vectorial transmission has begun occurring in areas where it had previously been interrupted, and Chagas disease [[seroprevalence]] rates have increased.<ref name=Grillet2019>{{cite journal |vauthors=Grillet ME, Hernández-Villena JV, Llewellyn MS, et al |title=Venezuela's humanitarian crisis, resurgence of vector-borne diseases, and implications for spillover in the region |journal=Lancet Infect Dis |volume=19 |issue=5 |pages=e149–e161 |date=May 2019 |pmid=30799251 |doi=10.1016/S1473-3099(18)30757-6 |s2cid=73475841 |type= Review|url=http://eprints.gla.ac.uk/180750/7/180750.pdf }}</ref> Transmission rates have also risen in the [[Gran Chaco]] region due to insecticide resistance and in the [[Amazon basin]] due to oral transmission.<ref name="Molina2018"/> While the rate of vector-transmitted Chagas disease has declined throughout most of Latin America, the rate of orally transmitted disease has risen, possibly due to increasing urbanization and [[deforestation]] bringing people into closer contact with triatomines and altering the distribution of triatomine species.<ref name="Robertson2016"/><ref name="Alarcon2019">{{cite book|vauthors=Alarcón de Noya B, Noya Gonzáles O|title=Chagas Disease |editor=Marcelo Altcheh J, Freilij H|series=Birkhäuser Advances in Infectious Diseases|date=9 September 2019|publisher=Springer Nature|location=Switzerland|isbn=978-3-030-00054-7|pages=[https://books.google.com/books?id=WpyuDwAAQBAJ&q=Orally+Transmitted+Chagas+Disease 225–241]|chapter=Orally Transmitted Chagas Disease: Biology, Epidemiology, and Clinical Aspects of a Foodborne Infection|doi=10.1007/978-3-030-00054-7_11|s2cid=239445211|issn=2504-3811}}</ref><ref name="Hotez2017">{{cite journal|vauthors=Hotez PJ, Basáñez MG, Acosta-Serrano A, Grillet ME|title=Venezuela and its rising vector-borne neglected diseases|journal=PLOS Neglected Tropical Diseases|volume=11|issue=6|year=2017|pages=e0005423|issn=1935-2735|doi=10.1371/journal.pntd.0005423|pmid=28662038|pmc=5490936 |doi-access=free }}</ref> Orally transmitted Chagas disease is of particular concern in Venezuela, where 16 outbreaks have been recorded between 2007 and 2018.<ref name="Grillet2019">{{cite journal |vauthors=Grillet ME, Hernández-Villena JV, Llewellyn MS, et al |title=Venezuela's humanitarian crisis, resurgence of vector-borne diseases, and implications for spillover in the region |journal=Lancet Infect Dis |volume=19 |issue=5 |pages=e149–e161 |date=May 2019 |pmid=30799251 |doi=10.1016/S1473-3099(18)30757-6 |s2cid=73475841 |type= Review|url=http://eprints.gla.ac.uk/180750/7/180750.pdf }}</ref> Chagas exists in two different ecological zones. In the [[Southern Cone]] region, the main vector lives in and around human homes. In Central America and Mexico, the main vector species lives both inside dwellings and in uninhabited areas. In both zones, Chagas occurs almost exclusively in rural areas, where {{nowrap|''T. cruzi''}} also circulates in wild and domestic animals.<ref name=NatRev>{{cite journal |vauthors=Morel CM, Lazdins J |title=Chagas disease |journal=Nat Rev Microbiol |volume=1 |issue=1 |pages=14–5 |date=October 2003 |pmid=15040175 |doi=10.1038/nrmicro735|s2cid=29869370 |doi-access=free }}</ref> {{nowrap|''T. cruzi''}} commonly infects more than 100 species of mammals across Latin America including [[opossum]]s (''Didelphis'' spp.),<ref name="Wilkowsky-2022">{{cite web | vauthors=Wilkowsky SE| title=Trypanosomiasis in Animals - Circulatory System | website=[[Merck Veterinary Manual]] | date=2022-03-09 | url=http://www.merckvetmanual.com/circulatory-system/blood-parasites/trypanosomiasis-in-animals?autoredirectid=17926 | access-date=28 March 2022|archiveurl=https://web.archive.org/web/20220328212043/https://www.merckvetmanual.com/circulatory-system/blood-parasites/trypanosomiasis-in-animals?autoredirectid=17926|archivedate=28 March 2022|url-status=live}}</ref> [[armadillo]]s, [[marmoset]]s, [[bat]]s, various [[rodent]]s<ref name="Telleria-Tibayrenc-2010">{{cite book|veditors=Telleria J, Tibayrenc M|title=American Trypanosomiasis |url=https://archive.org/details/americantrypanos00tiba|url-access=limited|chapter=11 - Domestic and Wild Mammalian Reservoirs |vauthors=Jansen AM, ((Roque ALR)) |publisher=Elsevier |doi=10.1016/B978-0-12-384876-5.00011-3 |date=2010 |pages=249–276 |isbn=978-0-123-84876-5}}</ref> and [[dog]]s<ref name="Wilkowsky-2022" /> all of which can be infected by the vectors or orally by eating triatomine bugs and other infected animals.<ref name="Telleria-Tibayrenc-2010" /><ref name="Wilkowsky-2022" /> For [[entomophagy|entomophagous]] animals this is a common mode.<ref name="Wilkowsky-2022" /> ''Didelphis'' spp. are unique in that they do not require the triatomine for transmission, completing the life cycle through their own urine and feces.<ref name="Wilkowsky-2022" /> Veterinary transmission also occurs through [[vertical transmission]] through the placenta, [[veterinary blood transfusion|blood transfusion]] and [[veterinary organ transplant|organ transplant]]s.<ref name="Wilkowsky-2022" /> ===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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