Towards Chagas disease elimination: Neonatal screening for congenital transmission in rural communities

Abstract

Chagas disease is a neglected tropical disease that continues to affect populations living in extreme poverty in Latin America. After successful vector control programs, congenital transmission remains as a challenge to disease elimination. We used the PRECEDE-PROCEED planning model to develop strategies for neonatal screening of congenital Chagas disease in rural communities of Guatemala. These communities have persistent high triatomine infestations and low access to healthcare. We used mixed methods with multiple stakeholders to identify and address maternal-infant health behaviors through semi-structured interviews, participatory group meetings, archival reviews and a cross-sectional survey in high risk communities. From December 2015 to April 2016, we jointly developed a strategy to illustratively advertise newborn screening at the Health Center. The strategy included socioculturally appropriate promotional and educational material, in collaboration with midwives, nurses and nongovernmental organizations. By March 2016, eight of 228 (3.9%) pregnant women had been diagnosed with T. cruzi at the Health Center. Up to this date, no neonatal screening had been performed. By August 2016, seven of eight newborns born to Chagas seropositive women had been parasitologically screened at the Health Center, according to international standards. Thus, we implemented a successful community-based neonatal screening strategy to promote congenital Chagas disease healthcare in a rural setting. The success of the health promotion strategies developed will depend on local access to maternal-infant services, integration with detection of other congenital diseases and reliance on community participation in problem and solution definition.

Fig 1. Map of study site location.

Comapa municipality and health center location in the department of Jutiapa, Guatemala, relative to Mexico, Honduras, Belize (BZ) and El Salvador (ES). The map was developed using QGis 2.14 with publicly available administrative boundaries.

Fig 2. Promotional poster “Midwives preventing Chagas”.

The poster was developed through participatory activities with midwives to show the steps to promote congenital Chagas disease screening.

Fig 3. Promotional poster titled “Health Center Preventing Chagas”.

The workflow and poster were developed through participatory activities with Health Center personnel to promote screening for early detection of congenital Chagas disease at the HC. The workflow shows two parallel arrows for the same newborn heel prick blood sample. The blood sample for buffy coat separation in capillary tube is taken simultaneously with the blood sample preserved in nucleic acid preservation cards (FTA) for PCR analysis. The arrow connecting the PCR result with the capillary result indicates confirmation of the microscopy, to optimize the parasitological screening method at the Health Center. Children born to positive mothers, but that are not screened within two weeks of birth, should be brought to the Health Center at ten months for antibody rapid test only.

Fig 4. Increased childbirths assisted by health services at Comapa´s Health Center over time.

We recorded the number of deliveries within and outside of health services (HS) for children <1 year of age or 1–5 years of age at the time of the health access survey in 2015. Reports were for children born to women living in 18 communities of Comapa with persistent triatomine infestation (n = 490).

Fig 5. Banner used at Comapa´s Health Center maternity ward to promote congenital Chagas disease screening.

An educational flip-chart was developed together with the banner to communicate Chagas disease risk factors, diagnosis and treatment services at the Health Center.