Fernando Abad-Franch

Chagas disease in the Amazon Region

The risk that Chagas disease becomes established as a major endemic threat in Amazonia (the worlds largest tropical biome, today inhabited by over 30 million people) relates to a complex set of interacting biological and social determinants. These include intense immigration from endemic areas (possibly introducing parasites and vectors), extensive landscape transformation with uncontrolled deforestation, and the great diversity of wild Trypanosoma cruzi reservoir hosts and vectors (25 species in nine genera), which maintain intense sylvatic transmission cycles. Invasion of houses by adventitious vectors (with infection rates > 60%) is common, and focal adaptation of native triatomines to artificial structures has been reported. Both acute (approximately 500) and chronic cases of autochthonous human Chagas disease have been documented beyond doubt in the region. Continuous, low-intensity transmission seems to occur throughout the Amazon, and generates a hypoendemic pattern with seropositivity rates of approximately 1-3%. Discrete foci also exist in which transmission is more intense (e.g., in localized outbreaks probably linked to oral transmission) and prevalence rates higher. Early detection-treatment of acute cases is crucial for avoiding further dispersion of endemic transmission of Chagas disease in Amazonia, and will require the involvement of malaria control and primary health care systems. Comprehensive eco-epidemiological research, including prevalence surveys or the characterization of transmission dynamics in different ecological settings, is still needed. The International Initiative for Chagas Disease Surveillance and Prevention in the Amazon provides the framework for building up the political and scientific cooperation networks required to confront the challenge of preventing Chagas disease in Amazonia.

Phylogeography and Genetic Variation of Triatoma dimidiata, the Main Chagas Disease Vector in Central America, and Its Position within the Genus Triatoma

Background Among Chagas disease triatomine vectors, the largest genus, Triatoma, includes species of high public health interest. Triatoma dimidiata, the main vector throughout Central America and up to Ecuador, presents extensive phenotypic, genotypic, and behavioral diversity in sylvatic, peridomestic and domestic habitats, and non-domiciliated populations acting as reinfestation sources. DNA sequence analyses, phylogenetic reconstruction methods, and genetic variation approaches are combined to investigate the haplotype profiling, genetic polymorphism, phylogeography, and evolutionary trends of T. dimidiata and its closest relatives within Triatoma. This is the largest interpopulational analysis performed on a triatomine species so far. Methodology and Findings Triatomines from Mexico, Guatemala, Honduras, Nicaragua, Panama, Cuba, Colombia, Ecuador, and Brazil were used. Triatoma dimidiata populations follow different evolutionary divergences in which geographical isolation appears to have had an important influence. A southern Mexican–northern Guatemalan ancestral form gave rise to two main clades. One clade remained confined to the Yucatan peninsula and northern parts of Chiapas State, Guatemala, and Honduras, with extant descendants deserving specific status. Within the second clade, extant subspecies diversity was shaped by adaptive radiation derived from Guatemalan ancestral populations. Central American populations correspond to subspecies T. d. dimidiata. A southern spread into Panama and Colombia gave the T. d. capitata forms, and a northwestern spread rising from Guatemala into Mexico gave the T. d. maculipennis forms. Triatoma hegneri appears as a subspecific insular form. Conclusions The comparison with very numerous Triatoma species allows us to reach highly supported conclusions not only about T. dimidiata, but also on different, important Triatoma species groupings and their evolution. The very large intraspecific genetic variability found in T. dimidiata sensu lato has never been detected in a triatomine species before. The distinction between the five different taxa furnishes a new frame for future analyses of the different vector transmission capacities and epidemiological characteristics of Chagas disease. Results indicate that T. dimidiata will offer problems for control, although dwelling insecticide spraying might be successful against introduced populations in Ecuador.

Sex bias in infectious disease epidemiology: patterns and processes.

Background Infectious disease incidence is often male-biased. Two main hypotheses have been proposed to explain this observation. The physiological hypothesis (PH) emphasizes differences in sex hormones and genetic architecture, while the behavioral hypothesis (BH) stresses gender-related differences in exposure. Surprisingly, the population-level predictions of these hypotheses are yet to be thoroughly tested in humans. Methods and Findings For ten major pathogens, we tested PH and BH predictions about incidence and exposure-prevalence patterns. Compulsory-notification records (Brazil, 2006–2009) were used to estimate age-stratified ♂:♀ incidence rate ratios for the general population and across selected sociological contrasts. Exposure-prevalence odds ratios were derived from 82 published surveys. We estimated summary effect-size measures using random-effects models; our analyses encompass ∼0.5 million cases of disease or exposure. We found that, after puberty, disease incidence is male-biased in cutaneous and visceral leishmaniasis, schistosomiasis, pulmonary tuberculosis, leptospirosis, meningococcal meningitis, and hepatitis A. Severe dengue is female-biased, and no clear pattern is evident for typhoid fever. In leprosy, milder tuberculoid forms are female-biased, whereas more severe lepromatous forms are male-biased. For most diseases, male bias emerges also during infancy, when behavior is unbiased but sex steroid levels transiently rise. Behavioral factors likely modulate male–female differences in some diseases (the leishmaniases, tuberculosis, leptospirosis, or schistosomiasis) and age classes; however, average exposure-prevalence is significantly sex-biased only for Schistosoma and Leptospira. Conclusions Our results closely match some key PH predictions and contradict some crucial BH predictions, suggesting that gender-specific behavior plays an overall secondary role in generating sex bias. Physiological differences, including the crosstalk between sex hormones and immune effectors, thus emerge as the main candidate drivers of gender differences in infectious disease susceptibility.

Trapping Triatominae in Silvatic Habitats

Large-scale trials of a trapping system designed to collect silvatic Triatominae are reported. Live-baited adhesive traps were tested in various ecosystems and different triatomine habitats (arboreal and terrestrial). The trials were always successful, with a rate of positive habitats generally over 20% and reaching 48.4% for palm trees of the Amazon basin. Eleven species of Triatominae belonging to the three genera of public health importance (Triatoma, Rhodnius and Panstrongylus) were captured. This trapping system provides an effective way to detect the presence of triatomines in terrestrial and arboreal silvatic habitats and represents a promising tool for ecological studies. Various lines of research are contemplated to improve the performance of this trapping system.

Ecology, evolution, and the long-term surveillance of vector-borne Chagas disease: a multi-scale appraisal of the tribe Rhodniini (Triatominae).

Chagas disease incidence has sharply declined over the last decade. Long-term disease control will, however, require extensive, longitudinal surveillance systems capable of detecting (and dealing with) reinvasion-reinfestation of insecticide-treated dwellings by non-domiciliated triatomines. Sound surveillance design calls for reliable data on vector ecology, and these data must cover different spatial scales. We conducted a multi-scale assessment of ecological and evolutionary trends in members of the tribe Rhodniini, including (i) a macroscale analysis of Rhodniini species richness and composition patterns across the Americas, and (ii) a detailed, mesoscale case-study of ecological and behavioural trends in Rhodnius neglectus and R. nasutus. Our macroscale overview provides some comprehensive insights about key mechanisms/processes probably underlying ecological and genetic diversification in the Rhodniini. These insights translate into a series of testable hypotheses about current species distributions and their likely causes. At the landscape scale, we used geometric morphometrics to identify dubious specimens as either R. neglectus or R. nasutus (two near-sibling species), and studied palm tree populations of these two vector taxa in five geographical areas. The data suggest that deforestation and the associated loss of habitat and host diversity might increase the frequency of vector-human contact (and perhaps Trypanosoma cruzi infection rates in vectors). Surveillance in central-northeastern Brazil should prioritise deforested landscapes where large palm trees (e.g., Attalea, Mauritia, Copernicia, Acrocomia or Syagrus) occur near houses. We anticipate that, by helping define the distribution patterns and ecological preferences of each species, multi-scale research will significantly strengthen vector surveillance systems across Latin America.

Biogeography of Triatominae (Hemiptera: Reduviidae) in Ecuador: implications for the design of control strategies

Chagas disease control strategies strongly depend on the triatomine vector species involved in Trypanosoma cruzi transmission within each area. Here we report the results of the identification of specimens belonging to various species of Triatominae captured in Ecuador (15 species from 17 provinces) and deposited in the entomological collections of the Catholic University of Ecuador (Quito), Instituto Oswaldo Cruz (Brazil), the Natural History Museum London (UK), the London School of Hygiene and Tropical Medicine (UK), the National Institute of Hygiene (Quito), and the Vozandes Hospital (Quito). A critical review of published information and new field records are presented. We analysed these data in relation to the life zones where triatomines occur (11 life zones, excluding those over 2,200 m altitude), and provide biogeographical maps for each species. These records are discussed in terms of epidemiological significance and design of control strategies. Findings relevant to the control of the main vector species are emphasised. Different lines of evidence suggest that Triatoma dimidiata is not native to Ecuador-Peru, and that synanthropic populations of Rhodnius ecuadoriensis in southern Ecuador-northern Peru might be isolated from their sylvatic conspecifics. Local eradication of T. dimidiata and these R. ecuadoriensis populations might therefore be attainable. However, the presence of a wide variety of native species indicates the necessity for a strong longitudinal surveillance system.

Biogeography and evolution of Amazonian triatomines (Heteroptera: Reduviidae): implications for Chagas disease surveillance in humid forest ecoregions.

An ecological-evolutionary classification of Amazonian triatomines is proposed based on a revision of their main contemporary biogeographical patterns. Truly Amazonian triatomines include the Rhodniini, the Cavernicolini, and perhaps Eratyrus and some Bolboderini. The tribe Rhodniini comprises two major lineages (pictipes and robustus). The former gave rise to trans-Andean (pallescens) and Amazonian (pictipes) species groups, while the latter diversified within Amazonia (robustus group) and radiated to neighbouring ecoregions (Orinoco, Cerrado-Caatinga-Chaco, and Atlantic Forest). Three widely distributed Panstrongylus species probably occupied Amazonia secondarily, while a few Triatoma species include Amazonian populations that occur only in the fringes of the region. T. maculata probably represents a vicariant subset isolated from its parental lineage in the Caatinga-Cerrado system when moist forests closed a dry trans-Amazonian corridor. These diverse Amazonian triatomines display different degrees of synanthropism, defining a behavioural gradient from household invasion by adult triatomines to the stable colonisation of artificial structures. Anthropogenic ecological disturbance (driven by deforestation) is probably crucial in the onset of the process, but the fact that only a small fraction of species effectively colonises artificial environments suggests a role for evolution at the end of the gradient. Domestic infestation foci are restricted to drier subregions within Amazonia; thus, populations adapted to extremely humid rainforest microclimates may have limited chances of successfully colonising the slightly drier artificial microenvironments. These observations suggest several research avenues, from the use of climate data to map risk areas to the assessment of the synanthropic potential of individual vector species.

Nuclear rDNA ITS-2 sequences reveal polyphyly of Panstrongylus species (Hemiptera: Reduviidae: Triatominae), vectors of Trypanosoma cruzi.

Panstrongylus species are widely distributed throughout the Americas, where they act as vectors of Trypanosoma cruzi, agent of Chagas disease. Their intraspecific relationships, taxonomic position and phylogeny in relation to other Triatomini were explored using ribosomal DNA (rDNA) internal transcribed spacer 2 (ITS-2) sequence polymorphisms and maximum parsimony, distance and maximum likelihood analyses of 10 populations representing six species of the genus (P. megistus, P. geniculatus, P. rufotuberculatus, P. lignarius, P. herreri and P. chinai). At the subspecific level, P. megistus appeared more homogeneous than P. rufotuberculatus and P. geniculatus (both with broader distribution). Several dinucleotide microsatellites were detected in the sequences of given species. Many of these microsatellites (GC, TA, GT and AT) showed different number of repeats in different populations and thus, may be very useful for population differentiation and dynamics analyses in future studies. The sequences of P. lignarius (considered sylvatic) and P. herreri (a major disease vector in Peru) were identical, suggesting that these species should be synonymised. Intrageneric analysis showed a clear separation of P. rufotuberculatus, with closest relationships between P. geniculatus and P. chinai, and P. megistus occupying a separate branch. Genetic distances between Panstrongylus species (0.11585-0.22131) were higher than those between Panstrongylus and other Triatomini (16 species from central and North America and South America) (0.08617-0.11039). The distance between P. megistus and P. lignarius/herreri (0.22131) was the largest so far recorded in the tribe. The pronounced differences in length and nucleotide composition suggest a relatively old divergence of Panstrongylus species. P. rufotuberculatus was closer to Mesoamerican Triatoma, Meccus and Dipetalogaster species than to other Panstrongylus. All Panstrongylus clustered with the Mesoamerican clade; P. rufotuberculatus clustered with the phyllosoma complex and T. dimidiata, with D. maxima and T. barberi in a basal position. The rest of Panstrongylus appeared paraphyletically in the tree. This is evidence suggesting polyphyly within the genus Panstrongylus, whose species may be related to the ancestors giving rise to central and North American Triatomini.

Epidemiology of Chagas Disease in Ecuador. A Brief Review

Chagas disease is a complex public health problem that has been underestimated in Ecuador. Here we review the relevant published information, and present unpublished and new data that help to understand the current Chagas disease epidemiological situation and its evolution in the country. Three main characteristics have been identified: (i) persistence of Trypanosoma cruzi transmission in already known foci; (ii) a marked endemicity in some urban areas of Guayaquil; and (iii) the transformation of new Amazon foci into truly endemic areas. The situation in other suspect areas remains uncertain. Five Triatominae species have been implicated in the transmission of T. cruzi to people in Ecuador (Triatoma dimidiata, Rhodnius ecuadoriensis, R. pictipes, R. robustus and Panstrongylus geniculatus), but some others may also play a role in some areas (P. rufotuberculatus, P. howardi, T. carrioni and P. chinai). Other Triatominae reported seem to have little or no epidemiological relevance (T. venosa, T. dispar, Eratyrus mucronatus, E. cuspidatus, P. lignarius and Cavernicola pilosa). High frequency of acute cases and severe chronic disease has been observed. Although cardiomyopathy is more frequent, serious digestive disease is also present. It is estimated that around 120,000-200,000 people may be infected. 2.2 to 3.8 million people are estimated to live under transmission risk conditions.

Field ecology of sylvatic Rhodnius populations (Heteroptera, Triatominae): risk factors for palm tree infestation in western Ecuador.

Most Rhodnius species (Triatominae) are primarily associated with palm trees. They maintain enzootic Trypanosoma cruzi transmission and are responsible for human infection (causing Chagas disease) through the Neotropics. Assessing whether individual palm traits (ecological and/or botanical) may increase the risk of palm infestation by triatomines is relevant in areas where bugs invade houses flying from peridomestic palms. We developed a novel fieldwork approach with that objective, and applied it to study infestation by sylvatic Rhodnius ecuadoriensis in 110 tagua palms (Phytelephas aequatorialis). Palm infestation (23% overall) was non‐randomly distributed in our sample. Palms located in anthropic landscapes were frequently infested (>27%, n = 92), whereas no bugs were collected from palms surveyed within forest remnants (n = 18; P = 0.01). The presence of abundant decaying vegetable matter (P = 0.001) and (to a lesser extent) epiphytic plants (P = 0.049) on palm crowns and stems increased the probability of infestation and was positively correlated with the apparent density of bug colonies (R2 = 0.68). A trend towards higher infestation rates in male palms (34%vs. 18%) could relate to female palm management (removal of infrutescences and vegetable debris) in areas where palm seeds are harvested. An outline of ‘risk palm ecotopes’ and environmental management‐based strategies for the control of peridomestic, palm tree‐living vector populations are proposed.