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Tracing an elusive killer parasite in Peru

Penn epidemiological study takes 'snapshot' of long-term chagas disease outbreak

Despite what Hollywood would have you believe, not all epidemics involve people suffering from zombie-like symptoms--some can only be uncovered through door-to-door epidemiology and advanced mathematics.

Michael Levy, PhD, assistant professor of Biostatistics and Epidemiology, at the Perelman School of Medicine, University of Pennsylvania, along with other collaborators from Penn, Johns Hopkins University, the Centers for Disease Control and Prevention, and Universidad Peruana Cayetano Heredia in Peru, are in the trenches combining tried-and-true epidemiological approaches with new statistical methods to learn more about the course of a dangerous, contagious disease epidemic. Their research was published last week in PLoS Computational Biology.

Chagas disease, primarily seen in South America, Central America, and Mexico, is the most deadly parasitic disease in the Americas. Caused by the protozoan parasite, Trypanosoma cruzi, it is spread chiefly via several species of blood-sucking triatomine insects. After an initial acute phase, the disease continues to lurk in the body and can eventually cause a variety of chronic life-threatening problems, particularly in the heart. Although there are some drugs to treat Chagas disease, they become less effective the longer a person is infected. The lack of a vaccine also means that the only effective way to control the disease is to control the disease vectors.

Because the chronic effects of Chagas disease can take decades to manifest themselves, tracking the development and progression of epidemics has been a challenging problem. In the past, Chagas disease was known mostly in rural regions, but has been spreading into more urbanized areas over the last 40 years. Levy's team has been focusing on one of those areas in the city of Arequipa, Peru.

"There is an assumption that Chagas disease is not a problem in Peru because statistics don't show that more people are dying of cardiac disease in the areas with Chagas transmission compared to the rest of the country," Levy said. "What we've shown calls into question the assumption that the particular parasite that's circulating in Arequipa is somehow less virulent. We show that there's really nothing to back that assumption."

Epicenter Regression

Levy's team has been collecting data in Peru since 2004. "We do all the fieldwork, we gather all our data, which is very much door-to-door, old-fashioned epidemiology," said Levy. That involves both entering households to search for infected insects and collecting blood samples from residents. The team's survey work led to the observation of spatial clusters of parasites in insects such that "it looked like there were isolated clusters of transmission, or 'micro-epidemics.' It was really observation, then hypothesis, then testing."

According to their findings, the Chagas parasite was introduced into the region about twenty years ago, and most infections occurred over the last ten years. Spread of the disease is being disrupted in Arequipa through insecticide application, but up to 5 percent of the population was infected before their houses were sprayed with insecticide. Levy and his colleagues conclude that the lack of chronic disease symptoms among these infected individuals could be due to the relatively short time of transmission: Most individuals may have yet to pass from the long asymptomatic period to symptomatic Chagas disease.

Inevitable Increase

The finding has crucial implications for the future management of the disease. Because the lack of late-stage Chagas disease in Arequipa is not an indication of a weakened parasite, the researchers believe that preparations should be made for a potential increase in chronic Chagas cases in coming years. As they have throughout their research, Levy's team is working in close collaboration with the Peruvian government to ensure that the warning provided by their work does not go unheeded. "Everything we do in Arequipa is with the local Ministry of Health," Levy said. "We're very much integrated with the government's Chagas disease control program. We started diagnosing people who are asymptomatic and the Ministry of Health is treating the individuals who are diagnosed to increase the probability they don't progress to later-stage disease."

Levy and his collaborators, including Eleazar Cordova-Benzaquen and Cesar Naquira in Peru, plan to expand their epicenter regression modeling techniques to study other infectious diseases, including the West Nile virus in New York City. The method can even be applied to fighting the spread of pesky insects such as bedbugs. "We're trying to work in parallel to improve control of Chagas vectors and bedbugs," he noted. "The idea is if you find a house with bedbugs, where do you go next? Same thing with the Chagas bugs. When they come back after the insecticide campaigns, you get a report and you have to figure out how to react to those reports, which are pretty scattered." Levy and his team have found a way to find patterns, and thus more predictability, in the chaos of infectious disease transmission.

This work was funded by the National Institutes of Allergy and Infectious Diseases.

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $4 billion enterprise.

Penn's Perelman School of Medicine is currently ranked #2 in U.S. News & World Report's survey of research-oriented medical schools and among the top 10 schools for primary care. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $507.6 million awarded in the 2010 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania -- recognized as one of the nation's top 10 hospitals by U.S. News & World Report; Penn Presbyterian Medical Center; and Pennsylvania Hospital – the nation's first hospital, founded in 1751. Penn Medicine also includes additional patient care facilities and services throughout the Philadelphia region.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2010, Penn Medicine provided $788 million to benefit our community.

Karen Kreeger | EurekAlert!
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