Chagas: A Bug That Gives More Than Kisses

It is definitely feeling like summertime here in America, specifically Texas, where I live. This week, the high temperature reaches 100 degrees Fahrenheit multiple times. During these kinds of summer days, I find myself spending a lot of time outdoors recreationally exploring water holes and hiking. With all the outdoor time, I’ve also come across so many different types of bugs and contemplated how many of these bugs can cause vector-borne infectious diseases. There is one disease in particular that has been at the front of my mind after attending an insightful conference over diseases in nature last month – Chagas disease.

Chagas disease is caused by a parasite called Trypanosoma cruzi and transmitted to people and animals by insects called Triatomines, or more commonly known as “kissing bugs.” Uniquely, these vectors are only found in the Americas (mainly Latin America). The vector, or insect, can infect a person or animal when it takes a blood meal bite near a wound, mouth, eye or other mucus membrane and then deposits feces near the bite. If the human or animal rubs the infected feces into their eye or mucus membrane then the parasite will begin its life cycle, multiply and cause disease.

Chagas disease is tricky to diagnose because it causes mild to no symptoms at all and can go from an acute stage to a relatively quiet chronic stage. Fever and swelling near the bite is common in those that experience symptoms in the acute stage. In some very rare cases, people can experience inflammation of the heart or brain. After the acute stage, most will enter the chronic stage of Chagas disease. Most people will never have any other problems associated with the disease at this point. However, 20-30% can develop life-threatening medical problems associated with the chronic disease including heart rhythm abnormalities, a heart that does not pump correctly, or a dilated esophagus or colon that can cause issues with eating or passing stool. Antiparasitic treatment is recommended for all cases under the age of 50 that have not developed medical problems from the chronic stage. This treatment is typically through the drug nifurtimox or benznidazole.

Chagas diseases does not only affect humans. Dogs have been found to be significantly impacted as well if they ingest bugs or are passed the disease congenitally from their mother. Symptoms in dogs include: fever, loss of appetite, lethargy, swollen lymph nodes, liver or spleen. Many owners don’t notice these symptoms because they are similar to other diseases and resolve over time. If a dog develops a chronic infection, they can develop deadly heart disease which can result in heart failure or sudden death. Unfortunately, there is no medication that has been found to be effective for treating Chagas in dogs and no vaccine against the disease in dogs or humans.

The disease has gotten much attention in the news and public health realm as of recently. CDC deemed it a “neglected tropical disease” and has devoted time to learning more about the disease and its impact. The public health burden of the disease in the United States is uncertain because many states are not required by law to keep track of the number of confirmed cases. As immigration increases in America, specifically from Latin America to the U.S., we are seeing increasing numbers of Chagas reports. In Texas, a research group from A&M that studies kissing bugs extensively has even created a collaborative project where citizens can send in bugs to have identified and be counted for. This study emphasizes the importance of “citizen science” – where the community can contribute to the advancement of scientific research through their participation in the study by sending in insects. They even have provided an interactive map on their website that shows where kissing bugs have been submitted from in the state of Texas.

If you’re interested in seeing a picture of a kissing bug, check out this link from the Texas A&M research site. The photos are taken by Dr. Gabriel Hamer and show the kissing bugs that can be found in Texas as well as the ones found across the United States.

If you live in the Americas, keep your eyes peeled for these bugs this summer and know when to seek care. This article by USA today, hits on some places that the bug can be found including: under porches, cement, in between rock, wood or brush and in outdoor dog houses or chicken coops. If you do come across these bugs and are interested in submitting them to the Texas A&M research team, check out this link. They have a few FAQ’s and reminders on how to handle the bug. Happy summer and bug swatting season!

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MS: An Unpredictable Disease That Needs More Attention

What would you do if you had symptoms of extreme fatigue, blurred vision, loss of balance, slurred speech, tremors, problems with memory and concentration, or paralysis that occurred sporadically throughout your life and potentially worsened over time? It is a crazy and debilitating thing to think of, but this is what people with multiple sclerosis deal with every day. Multiple sclerosis (MS) is a chronic neurological disease of the central disease system (brain, spinal cord and optic nerves) and is thought to be a disease in which the immune system incorrectly attacks its own healthy tissue. Over 2.3 million people are affected by MS across the globe, but because symptoms can be invisible or difficult to diagnose, the National Multiple Sclerosis Society predicts there are many more cases than accounted for.

This past month I volunteered at the MS150 – a two day, 150 mile bike ride from Houston to Austin that fundraises for the National MS Society. Anyone that races has a four hundred dollar minimum to raise towards MS. This year, they were able to raise over $10 million dollars total towards helping the National MS Society bring hope to those affected. I had heard of this race and organization in the past, but had never really pursued looking further into it. This year I decided to cheer on a fellow friend racing in it and learn a little more about MS while I was there. I was so glad I did. It was such an uplifting experience with everyone gathered and racing for a common cause. It really made me consider if there’s anything similar being done – information sharing, raising money, learning about the disease – in other countries. The U.S. is lucky to have resources to coordinate these kinds of events, but they are not the only people affected by the disease.

MS does not know country borders or only affect populations in certain nations. It is a disease that affects those across the globe. Global prevalence of MS showed greater numbers in higher income countries (>60 people per 100,000) than lower income countries (ranging from 0-20 people per 100,000) from a study done by the Global Atlas in 2013. However, these numbers could be skewed from showing the whole picture due to less lower income countries adequately diagnosing and reporting the disease. Another study, the global burden of disease study, or GBD, conducted in 1990 estimated the incidence, prevalence, duration and mortality for more than 500 different diseases and injuries. Neurological diseases, like MS, were measured in disability-adjusted life years, or DALYs. These measure the impact of a disease such as MS, on a person’s healthy lifespan. If the impact is one DALY, then it can be thought of as losing one year of healthy life free from disease and disability. This study revealed that noncommunicable diseases, including neuropsychiatric diseases like MS, had a notable impact on the health burden in all parts of the world. MS was predicted to have an increasing number of total DALYs from 2005 (1,510,000 DALYs) to 2030 (1,648,000 DALYs). This was measured out of a total of 92 million DALYs contributed by neurological disorders in 2005 and a predicted 103 million DALYs in 2030. Although the burden of MS seems small in the group of neurological disorders, it is predicted to increase and continue to make an impact.

Luckily, scientists today are researching and testing different theories to try and pinpoint the unknown cause of multiple sclerosis. A recent study published this past week points to gene expression of what’s called TOX. TOX contributes to the development of lymphocytes that attack foreign threats in the body. However, when this TOX is activated in CD8+ T lymphocytes, the lymphocytes can not hear signals from the brain telling them that the neurons they want to attack are actually healthy and not a threat. They instead attack the brain cells and eventually lead to the development of MS. This discovery is an exciting first step in understanding MS better and how to prevent it from impacting so many.

However, we are not all scientists. So what can we do to help those with MS or other noncommunicable diseases across the globe? We can start with learning, understanding and speaking out about the burden that noncommunicable diseases like MS have on our communities. In the 2013 Atlas of MS survey, it was found that there were 4.7 neurologists per 100,000 people in high income countries compared to 0.04 per 100,000 people in low income countries. The range of MS nurses was also similar and many low income countries reported having zero nurses with these specific skills and expertise. The number of MRI machines also closely matched this trend, with lower income countries having less machines available to them. Low and middle income countries unfortunately have the double burden of communicable and noncommunicable diseases. It is easy to spend so much time on infectious and communicable diseases because we see “easier fixes” to the problem such as providing vaccines, adequate hand hygiene education, and access to clean water initiatives. However, diseases like MS, while trickier to tackle, should be kept in the forefront of our minds.

The World Health Organization has an awesome chapter from a book called, “Neurological Disorders: Public Health Challenges” that hits home this point about resources (both financially and the public health workforce) being needed to help those with neurological disorders alongside communicable disease resources. It aims to provide a basis for decision making at global, regional and national levels so that resources are available for both realms of public health challenges. I believe if we’re acknowledging and advocating that noncommunicable diseases are also of public health importance – we can slowly chip away at the multitude of different global health challenges we are faced with everyday. I’ll end with a quick link to the World Health Organization’s page titled 10 facts on noncommunicable diseases. Check it out and see if there’s something new you can learn today!

Conference Reflections: Emergency Preparedness & International Health – Different Fields, Same Goals

Last week I was given the opportunity to attend the Preparedness Summit in Atlanta. This conference is the first and longest running national conference that discusses and revolves around the world of public health preparedness (think: natural disasters, medical countermeasures, flu, Zika and Ebola responses, biological threats and much more). There were many different opportunities to learn about preparedness activities including plenaries, small discussions, learning sessions and networking with local, state and federal partners. It was overwhelming, but in a good way!

As an epidemiologist, I have some experience and background in public health preparedness activities, but my main interests and time have always been spent with infectious diseases and global health initiatives. When I worked for the state health department, I actually was on a team that was half epidemiologists and half preparedness staff and we continually supported each other’s activities. Those experiences helped me with preparedness lingo and acronyms used during the conference so that things didn’t go completely over my head. However, I would not consider myself a preparedness expert by any means and soaked up as much as I could from the various sessions I attended.

One of the most exciting activities from the week was visiting the Emergency Operations Center (EOC) at the Centers for Disease Control and Prevention (CDC). This EOC is the center that gets activated in a public health emergency and where experts gather and get ready to respond. The main room of the EOC is spacious, with many computers, television screens and telephones set up and ready to be filled with points of contacts from different divisions and organizations. When there’s not an emergency response going on (like on our tour), it’s actually pretty quiet. However, staff are still on call working to monitor information and sift through potential threats. During a response, I’m sure the place is bustling with people, calls, information sharing and meetings. It was a neat experience to be in the center communication hub where past emergency responses like Hurricane Katrina in 2005 or the 2014 Ebola outbreaks took place.

I did some research after attending the summit and found that the EOC has become an integral part of meeting the goals of the “Global Health Security Agenda (GHSA)”. This agenda is focused on “accelerating progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Over 50 countries have joined in partnership with the U.S. to meet this objective and the CDC aims to activate the EOC and respond within 2 hours of any mandated public health emergency. There’s even a fellowship offered by the CDC called the “Public Health Emergency Management Fellowship” that provides an opportunity for public health workers to learn and train over a four-month course then go back to their respective countries and create their own local EOCs. Emergency management experts can also be sent to these countries and help guide and train responders in their own environment if needed.

This post-tour research made me start thinking about the importance of the EOC and preparedness in relation to international health. Public health threats (like pandemic flu, Zika, Ebola) of any degree can happen at any time at the local, state, national, or international level. Bill Gates recently spoke out about the necessity of being prepared for public health threats such as these at the Massachusetts Medical Society 2018. He stressed how unprepared we are for the next epidemic and the world’s need for a “global approach” with “better tools, an early detection system, and a global response system”. Gates’ is most likely alluding to the poor handling of the Ebola outbreaks in the recent past. These are a perfect example of why the field of preparedness is so important to global health. During Ebola, public health response was “too late” and there were too many “deaths that could have been prevented”. There were many disagreements among global health leaders over things like travel bans, how to handle public panic and how to best respond. The aftereffects of the outbreak point to the integral link between a strong preparedness field and international health that was lacking. Gates’ argues that we weren’t prepared to handle prior outbreaks, but we are capable and should spend time and money on planning and preparing for similar epidemics in the future.

Overall, these events – the conference, EOC tour and recent news and outbreaks – have helped hit home that these different public health fields, although working in slightly different capacities, are really aligned and influential on each other. Ultimately, preparedness and global health are working to reach the same goals of keeping our planet safe and healthy and we must first be prepared for any global threat in order to achieve these goals. Today, I feel refreshed in my perspective of the field and inspired and hopeful of future preparedness efforts. I no longer feel that preparedness and international health belong in the different boxes or divisions I’ve created in my mind, but as two parts to the same path.

I challenge other public health workers to also think about the important link between preparedness and global health and advocate for changes that strengthen this partnership. The Preparedness Summit conference is a great starting place and I encourage all fields of public health workers to look into it! I truly believe the more you learn, the more you see how everything is connected and the better you are able to achieve your public health goals … and maybe find some new teammates from other fields to help you along your journey, too.