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Abstract Background International travel and migration have been related with an increase of imported malaria cases. There has been considerable immigration to Barcelona from low-income countries (LIC) in recent years. The objective is to describe the epidemiology and to determine the trends of the disease in Barcelona. Methods Analysis of the cases notified among city residents between 1989 and 2005. Patients were classified as: tourists, voluntary workers, resident immigrants (visiting friends and relatives, VFR) and recently arrived immigrants. An analysis was conducted using the chi2 test and comparison of means. As a measure of association we calculated the Relative Risk (RR) and Odds Ratio (OR) with a Confidence Interval of 95% (CI) and carried out a trends analysis. Results Of the total of 1,579 imported cases notified, 997 (63.1%) lived in Barcelona city, and 55.1% were male. The mean age of patients was 32.7 years. The incidence increased from 2.4 cases/100,000 in 1989 to 3.5 cases/100,000 in 2005 (RR 1.46 CI:1.36–1.55). This increase was not statistically significant (trends analysis, p = 0.36). In terms of reason for travelling, 40.7% were VFR, 33.6% tourists, 12.1% voluntary workers and 13.6% were recently arrived immigrants. The most frequent species found was Plasmodium falciparum (71.3%), mainly in visitors to Africa (OR = 2.3, CI = 1.7–3.2). The vast majority (82.2%) had had some contact with Africa (35.9% with Equatorial Guinea, a Spanish ex-colony) and 96.6% had not completed chemoprophylaxis. Six deaths were observed, all tourists who had travelled to Africa and not taken chemoprophylaxis (3.9% fatality rate). Conclusion Over the period studied there is an increase in malaria incidence, however the trend is not statistically significant. Lack of chemoprophylaxis compliance and the association between Africa and P. falciparum are very clear in the imported cases. Most of the patients with malaria did not take chemoprophylaxis.

Background: Most paediatric tuberculosis (TB) cases in low-TB-incidence countries involve children born to migrant families. This may be partially explained by trips to their countries of origin for visiting friends and relatives (VFR). We aimed to estimate the risk of latent TB infection (LTBI) and TB in children VFR., Methods: We conducted a prospective multicentric observational study in Catalonia (Spain) from June 2017 to December 2019. We enrolled children aged < 15 years with a negative tuberculin skin test (TST) at baseline and at least one parent from a high-TB-incidence country, and who had travelled to their parent's birth country for ≥21 days. TST and QuantiFERON-TB Gold Plus (QFT-Plus) were performed within 8-12 weeks post-return. LTBI was defined as a TST ≥5 mm and/or a positive QFT-Plus., Results: Five hundred children completed the study, equivalent to 78.2 person-years of follow-up (PYFU). Thirteen children (2.6%) were diagnosed with LTBI (16.6/per100 PYFU, 95%CI = 8.8-28.5), including two cases (0.4%) of TB (2.5/per100 PYFU, 95%CI = 0.3-9.3). LTBI incidence rates remained high after excluding BCG-vaccinated children (9.7/per100 PYFU, 95%CI = 3.9-20.0). Household tobacco smoke exposure was associated with LTBI (aOR = 3.9, 95%CI = 1.1-13.3)., Conclusions: The risk of LTBI in children VFR in high-TB-incidence countries may equal, or perhaps even exceed, the infection risk of the native population. The primary associated risk factor was the presence of smokers in the household. Furthermore, the incidence rate of active TB largely surpassed that of the countries visited. Children VFR in high-TB-incidence countries should be targeted for diagnostic and preventive interventions., (© International Society of Travel Medicine 2024. Published by Oxford University Press.)

Research has shown that multidimensional approaches to Chagas disease (CD), integrating its biomedical and psycho-socio-cultural components, are successful in enhancing early access to diagnosis, treatment and sustainable follow-up.For the first time, a consulate was selected for a community-based CD detection campaign. Two different strategies were designed, implemented and compared between 2021 and 2022 at the Consulate General of Bolivia and a reference health facility in Barcelona open to all Bolivians in Catalonia.Strategy 1 consisted in CD awareness-raising activities before referring those interested to the reference facility for infectious disease screening. Strategy 2 offered additional in-situ serological CD screening. Most of the 307 participants were Bolivian women residents in Barcelona. In strategy 1, 73 people (35.8% of those who were offered the test) were screened and 19.2% of them were diagnosed with CD. Additionally, 53,4% completed their vaccination schedules and 28.8% were treated for other parasitic infections (strongyloidiasis, giardiasis, eosinophilia, syphilis). In strategy 2, 103 people were screened in-situ (100% of those who were offered the test) and 13.5% received a CD diagnosis. 21,4% completed their vaccination schedule at the reference health facility and 2,9% were referred for iron deficiency anemia, strongyloidiasis or chronic hepatitis C.The fact that the screening took place in an official workplace of representatives of their own country, together with the presence of community-based participants fueled trust and increased CD understanding. Each of the strategies assessed had different benefits. Opportunities for systematic integration for CD based on community action in consulates may enhance early access to diagnosis, care and disease prevention., (© 2023. The Author(s).)

In high-income countries, migrant populations have a greater epidemiological vulnerability: increased exposure to infectious diseases, difficulties in diagnosis, case follow-up and contact tracing, and obstacles following preventive measures related to cultural and administrative barriers. This study aims to describe the implementation of a community-based program to address these challenges. The target population is the migrant native population from North Africa, South Asia, Sub-Saharan Africa, Eastern Europe, and Latin America resident in Catalonia during 2023. Implementation phases include the identification of the perceived needs, search, recruitment and capacity building of 16 community health workers, and the development of a computer software. From January to June 2023, 117 community-based interventions have been implemented, reaching 677 people: 73 community case and contacts management interventions, 17 community in-situ screenings (reaching 247 people) and 27 culturally adapted health awareness and education actions (reaching 358 people). The program addresses the following infectious diseases: tuberculosis, Chagas disease, hepatitis C, typhoid, scabies, hepatitis B, mumps and tinea capitis. The implementation of a community-based model may be key to improving surveillance communicable diseases, promoting an equitable and comprehensive epidemiological surveillance system.

Objectives: To perform a budget impact analysis of the HepC link test-and-treat strategy in which community health agents offer hepatitis C virus (HCV) testing, diagnosis and treatment to the Pakistani population living in Catalonia compared with the current practice of the Catalan health system (without targeted screening programmes)., Methods: We estimated the population of adult Pakistani migrants registered at the primary care centres in Catalonia by means of the Information System for the Development of Research in Primary Care (n=37 972 in 2019, Barcelona health area). This cohort was followed for a time period of 10 years after HCV diagnosis (2019-2028). The statistical significance of the differences observed in the anti-HCV positivity rate between screened and non-screened was confirmed (α=0.05). The budget impact was calculated from the perspective of the Catalan Department of Health. Sensitivity analyses included different levels of participation in HepC link : pessimistic, optimistic and maximum., Results: The HepC link scenario screened a higher percentage of individuals (69.8%) compared with the current scenario of HCV care (39.7%). Viraemia was lower in the HepC link scenario compared with the current scenario (1.7% vs 2.5%, respectively). The budget impact of the HepC link scenario was €884 244.42 in 10 years., Conclusions: Scaling up the HepC link strategy to the whole Catalan territory infers a high budget impact for the Department of Health and allows increasing the detection of viraemia (+17.8%) among Pakistani migrants ≥18 years. To achieve a sustainable elimination of HCV by improving screening and treatment rates, there is room for improvement at two levels. First, taking advantage of the fact that 68.08% of the Pakistani population had visited their primary care physicians to reinforce targeted screening in primary care. Second, to use HepC link at the community level to reach individuals with reluctance to use healthcare services., Competing Interests: Competing interests: EM received lecture fees from Gilead Sciences and Abbvie, and research grants from Gilead Sciences. VS received travel sponsorship to attend scientific meetings from Gilead Sciences. MB received fees and research grants from Abbvie, Janssen and Gilead Sciences. The rest of authors have no conflict to declare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Mongolia has one of the highest viral hepatitis infection (B, C, and D) rates in the world. The aims of this study were to increase awareness of this disease and promote viral hepatitis screening in the Mongolian community living in Spain. Through a native community worker, Mongolian adults were invited to a community program consisting of an educational activity, an epidemiological questionnaire, and rapid point-of-care testing for hepatitis B and C. In those testing positive, blood extraction was performed to determine serological and virological parameters. In total, 280 Mongolians were invited to the program and 222 (79%) attended the event: 139 were women (63%), mean age was 42 years, and 78 (35%) had viral hepatitis risk factors. Testing found 13 (5.8%) anti-HCV-positive individuals, 1 with detectable HCV RNA (0.5%), 8 HBsAg-positive (3.6%), and 7 with detectable HBV DNA (3.1%). One additional individual had HBV/HCV co-infection with detectable HBV DNA and HCV RNA. Two subjects had hepatitis B/D co-infection (0.9%). The knowledge questionnaire showed a 1.64/8-point (20.5%) increase in correct answers after the educational activity. In summary, a viral hepatitis community program was feasible and widely accepted. It increased awareness of this condition in the Mongolian community in Spain and led to linkage to care in 22 participants, 50% of whom were unaware of their infection.

Background and Aims: Pakistani migrants in Catalonia, Spain, could have high hepatitis C virus (HCV) prevalence. The aims of the HepClink study were (i) to implement and assess the quality of a micro-elimination strategy based on a community intervention and (ii) to obtain data from primary care (PC) registries as a baseline comparator., Methods: The community intervention targeted Pakistani adults and consisted of education, screening and simplified access to treatment. Quality indicators were calculated (effectiveness, impact and acceptability). The testing rate, the prevalence of HCV antibodies and HCV-RNA were compared with those observed in the Pakistani population accessing PC in the previous year., Results: A total of 505 participants were recruited through the community intervention (64.6% men, median 37 years) vs those accessing PC (N = 25 455, 70.9% men, median 38 years). Among study participants, 35.1% did not know about HCV and 9.7% had been previously tested. The testing rate in the community intervention was 99.4% vs 50.7% in PC. Prevalence was 4.6% vs 7.1% (p = .008) for HCV antibodies and 1.4% (3/6 new diagnoses) vs 2.4% (p = .183) for HCV-RNA. Among the six viremic patients, three began treatment within the intervention and two through the usual circuit and all completed the full course., Conclusions: This novel community intervention was well accepted and effective at reaching a Pakistani migrant population with a low-level knowledge of HCV and largely not tested before. The observed prevalence and the high unawareness of their HCV status justify a targeted screening in this group both in the community and in PC., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

It is well documented that Chagas disease (CD) can pose a public health problem to countries. As one of the World Health Organization Neglected Tropical Diseases undoubtedly calls for comprehensive healthcare, transcending a restricted biomedical approach. After more than a century since their discovery, in 1909, people affected by CD are still frequently marginalised and/or neglected. The aim of this article is to tell the story of their activism, highlighting key historical experiences and successful initiatives, from 1909 to 2019. The first association was created in 1987, in the city of Recife, Brazil. So far, thirty associations have been reported on five continents. They were created as independent non-profit civil society organisations and run democratically by affected people. Among the common associations' objectives, we notably find: increase the visibility of the affected; make their voice heard; build bridges between patients, health system professionals, public health officials, policy makers and the academic and scientific communities. The International Federation of Associations of People Affected by CD - FINDECHAGAS, created in 2010 with the input of the Americas, Europe and the Western Pacific, counts as one of the main responses to the globalisation of CD. Despite all the obstacles and difficulties encountered, the Federation has thrived, grown, and matured. As a result of this mobilisation along with the support of many national and international partners, in May 2019 the 72nd World Health Assembly decided to establish World Chagas Disease Day, on 14 April. The associative movement has increased the understanding of the challenges related to the disease and breaks the silence around Chagas disease, improving surveillance, and sustaining engagement towards the United Nations 2030 agenda.

Chagas is a complex, multidimensional phenomenon in which political, economic, environmental, biomedical, epidemiological, psychological, and sociocultural factors intersect. Nonetheless, the hegemonic conceptualisation has long envisioned Chagas as primarily a biomedical question, while ignoring or downplaying the other dimensions, and this limited view has reinforced the disease's long neglect. Integrating the multiple dimensions of the problem into a coherent approach adapted to field realities and needs represents an immense challenge, but the payoff is more effective and sustainable experiences, with higher social awareness, increased case detection and follow-up, improved adherence to care, and integrated participation of various actors from multiple action levels. Information, Education, and Communication (IEC) initiatives have great potential for impact in the implementation of multidimensional programs of prevention and control successfully customised to the diverse and complex contexts where Chagas disease persists.

Background: As a Neglected Tropical Disease associated with Latin America, Chagas Disease (CD) is little known in non-endemic territories of the Americas, Europe and Western Pacific, making its control challenging, with limited detection rates, healthcare access and consequent epidemiological silence. This is reinforced by its biomedical characteristics-it is usually asymptomatic-and the fact that it mostly affects people with low social and financial resources. Because CD is mainly a chronic infection, which principally causes a cardiomyopathy and can also cause a prothrombotic status, it increases the risk of contracting severe COVID-19., Methods: In order to get an accurate picture of CD and COVID-19 overlapping and co-infection, this operational research draws on community-based experience and participative-action-research components. It was conducted during the Bolivian elections in Barcelona on a representative sample of that community., Results: The results show that 55% of the people interviewed had already undergone a previous T. cruzi infection screening-among which 81% were diagnosed in Catalonia and 19% in Bolivia. The prevalence of T. cruzi infection was 18.3% (with 3.3% of discordant results), the SARS-CoV-2 22.3% and the coinfection rate, 6%. The benefits of an integrated approach for COVID-19 and CD were shown, since it only took an average of 25% of additional time per patient and undoubtedly empowered the patients about the co-infection, its detection and care. Finally, the rapid diagnostic test used for COVID-19 showed a sensitivity of 89.5%., Conclusions: This research addresses CD and its co-infection, through an innovative way, an opportunity of systematic integration, during the COVID-19 pandemic., (© 2022. The Author(s).)

Introduction: Chagas disease presents bio-psycho-social and cultural determinants for infected patients, their family members, close friends, and society. For this reason, diagnosis and treatment require an active approach and an integral focus, so that we can prevent the disease from creating stigma and exclusion, as is actively promoting access to diagnosis, medical attention and social integration., Methodology: The study was conducted in the Metropolitan Area of Barcelona (Catalonia, Spain) from 2004 to 2017. After an increased detection rates of CHD in our region, the process of construction of community strategies started (2004-2013). Different community interventions with informational, educational, and communication components were designed, developed, implemented, and evaluated. The results of the evaluation helped to determine which intervention should be prioritized: 1) workshop; 2) community event; 3) in situ screening. Afterwards, those strategies were implemented (2014-2017)., Results: Each of the three strategies resulted in a different level of coverage, or number of people reached. The in situ screening interventions reached the highest coverage (956 persons, 58.98%).Clear differences exist (p-value<0.001) between the three strategies regarding the percentage of screenings and diagnoses carried out. The largest number was in the in situ screening intervention, with a total of 830 persons screened despite the greatest number of diagnoses was among the workshop participants (33 persons, 20.75% of those screened). The prevalence of infection found is similar among the three strategies, ranging from 16.63% to 22.32% of the screened patients (p-value = 0.325)., Conclusions: The results of the study show that community interventions seem to be necessary to improve access to diagnosis and treatment of CHD in the area of Barcelona. They also show which strategy is the most appropriate based on the detected needs of the community, the proposed objectives of the intervention, and the given socio-temporal context., Competing Interests: NO authors have competing interests.

Objective: The World Health Organization estimates that 257 million people suffer from chronic infection by the hepatitis B (HB) virus. It is common for diagnosis to be delayed or never given at all. In Spain, immigrants that come from endemic areas present a prevalence of infection of around 8%. In the year 2015, this study was begun with the aiml of improving accessibility to hepatitis B diagnoses in immigrant communities., Methods: A descriptive qualitative study was carried out, based on participatory action research (IAP). It was divided into two cycles: in the first cycle, after forming a motor group (GIAP), a participatory community assessment (DCP) was performed with the population, through a descriptive-interpretative qualitative study (ECDI) with 3 focal groups (n=17). A narrative analysis was then performed of thematic content. In the second cycle, two collaborative workshops (coworking) were held to create an educational tool (HEPARJOC) and to co-create an action plan (PDA). As a pilot test, the PDA was put into practice through eight workshops (n=56). A knowledge questionnaire was used to compare the median number of correct responses before and after the workshop, using the t of Student for paired data., Results: A GIAP was formed with 8 members of different sectors and community spaces. In the DCP it was observed that there was a lack of knowledge about different aspects of hepatitis B. Visual, interactive materials were proposed as educational tools, and "HEPARJOC" was created as the final product. In the pilot test of the PDA, the median of correct responses to the knowledge questionnaire about HB was 7.7 (DE=3) before the workshop, and 10.6 (DE=0.2) afterward. The improvement of the median was 2.9 points (IC 95% 2.2-3.6), which is statistically significant (p<0.001). 30 people sought screening (53.6% of participants), and 23 of those people were screened (41% of participants)., Conclusions: "HEPARJOC-ACTUA" is a strategy that could contribute to transforming knowledge and improving accessibility to hepatitis B diagnosis in immigrant communities. Key words: Infectious diseases, hepatitis B, community health, community health agents, health education, participatory action research, immigration. Key words: Infectious.

Chagas disease (CHD) has become a challenge in Spain due to the high prevalence of immigrants coming from endemic areas. One of the main difficulties for its control and elimination is its underdiagnosis. The identification and integral treatment of CHD are key to increasing rates of diagnosis, overcoming psycho-social barriers and avoiding CHD progression. Community interventions with in situ screening have proven to be a useful tool in detecting CHD among those with difficulties accessing health services. To determine the underdiagnosis rate of the population most susceptible to CHD among those attending two different Bolivian cultural events celebrated in Barcelona; to describe the sociodemographic characteristics of the people screened; and to analyse the results of the screening. The community interventions were carried out at two Bolivian cultural events held in Barcelona in 2017. Participants were recruited through community health agents. A questionnaire was given to determine the participants' prior knowledge of CHD. In situ screening was offered to those who had not previously been screened. Those who did not wish to be screened were asked for the reason behind their decision. Results were gathered in a database and statistical analyses were performed using STATA v14. 635 interviews were carried out. 95% of the subjects reported prior knowledge of CHD. 271 subjects were screened: 71.2% women and 28.8% men, of whom 87.8% were of Bolivian origin. The prevalence of CHD was 8.9%. Community health interventions with in situ screening are essential to facilitating access to diagnosis.

With the objective of providing an insightful analysis of Chagas disease in the world, the authors share their collective reflections about the current situation of this public health problem in: rural environments of Latin America; urban environments of endemic and non-endemic areas everywhere; and, at a global level. A perspective based on the 'Democracy and Health Promotion' axis allowed the development of an innovative update about Chagas disease as a model of a complex socio-environmental health problem, with a key set of elements that goes beyond biomedical aspects. The authors created a dialogue between the fundamental elements of the Curitiba Statement on Health Promotion and Equity and crucial aspects of a reflection on the reality of Chagas disease today that at the same time challenges the different actors involved. With that reference, the call to promote a 'critical analysis of viabilities and opportunities for action, considering the potentialities and barriers imposed by the complexity of social movements in the present context of recedes and the loss of rights' was emphasized repeatedly. Finally, on the occasion of the recent creation of the Technical Group on Information, Education and Communication to control Chagas disease, WHO Department of Control of Neglected Tropical Diseases, the authors share reflections to propose an inclusive and transformative approach of health promotion-what we hope is a new horizon for people affected, directly and indirectly, by Chagas disease., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Setting: Tuberculosis (TB) control requires the proper identification and treatment of affected patients and investigation of their contacts. In certain vulnerable immigrant groups, however, these tasks may be hindered due to their ethnic and sociocultural characteristics. Objective: To analyse the results of a community programme designed to locate hard-to-reach immigrants with TB. Design: Descriptive study of all cases diagnosed with confirmed TB referred to the Public and Community Health team of the Drassanes International Health Unit in Barcelona during 2012-2014 due to difficulties in tracing these patients. Both cases and contacts were categorised based on their World Health Organization region of origin. The sociodemographic characteristics of each group and the community interventions carried out during the tracing period are described. Results: A total of 122 cases and 316 contacts were detected. As a result of community-based strategies, 73% of the initial cases completed treatment; 3.8% of the contacts were diagnosed with TB, 91.7% of whom were treated appropriately; 17.1% contacts had latent infection, 79.3% of whom completed chemoprophylaxis. Conclusions: Intervention strategies with a community approach for follow-up and control of TB in certain immigrant communities seem to be effective., Competing Interests: Conflicts of interest: none declared.

The Catalonian Expert Patient Programme on Chagas disease is a initiative, which is part of the Chronic Disease Programme. It aims to boost responsibility of patients for their own health and to promote self-care. The programme is based on nine sessions conducted by an expert patient. Evaluation was focusing in: habits and lifestyle/self-care, knowledge of disease, perception of health, self-esteem, participant satisfaction, and compliance with medical follow-up visits. Eighteen participants initiated the programme and 15 completed it. The participants were Bolivians. The 66.7 % of them had been diagnosed with chagas disease in Spain. The 100 % mentioned that they would participate in this activity again and would recommend it to family and friends. The knowledge about disease improve after sessions. The method used in the programme could serve as a key strategy in the field of comprehensive care for individuals with this disease.

Objectives: Identifying pregnant women infected with Trypanosoma cruzi is one of the major challenges for preventing and controlling Chagas disease (CD) in non-endemic countries. The aim of this paper was to perform a policy evaluation of the current practices of congenital Chagas disease (CCD) control in non-endemic countries and to propose specific targets for enhanced interventions to tackle this emerging health problem outside the endemic areas of Latin America., Methods: We conducted a mixed method review of CCD policy strategies by searching the literature in the PubMed, Google Scholar and the World Health Organization (WHO) databases using the key terms 'CCD', 'paediatric Chagas disease' and 'non-endemic countries'; as free text and combined as one phrase to increase the search sensitivity. Reviews, recommendations, guidelines and control/surveillance programme reports were included., Results: Of 427 CCD papers identified in non-endemic countries, 44 matched the inclusion. Although local programmes were launched in different countries with large numbers of Latin American immigrants, there were considerable disparities in terms of the programmes' distribution, delivery, integration and appropriated CCD control strategies. Moreover, Catalonia, Spain is the only region/country with an established systematic monitoring of CCD in pregnant women from Latin American countries., Conclusions: Given the worldwide dissemination of CD, the nature of its vertical transmission, and the gaps of the current strategies in non-endemic countries, there is an urgent need to standardise, expand and reinforce the control measures against CCD transmission., (© 2016 John Wiley & Sons Ltd.)

Background: Chagas disease (CD) is endemic in countries of continental Latin America. Congenital transmission is a major concern worldwide. In 2010, the Public Health Agency of Catalonia (ASPCAT) launched a screening protocol for Trypanosoma cruzi infection in pregnant women and their newborns. In 2012, ASPCAT detected appropriate follow-up of pregnant women but incomplete information about their offspring., Methods: The PROSICS community health team carried out active surveillance and community health action in target populations. These activities included active case searches, group awareness workshops and visualization campaigns as well as investigation of all lost children born from pregnant women with CD and their families., Results: Overall, 42/179 (23.5%) cases were included in the study: 35/42 (83.3%) children were born in Hospitalet de Llobregat (Catalonia, Spain); 4/42 (16.7%) were born in Latin America; two were miscarried and one was stillborn. The mean age of pregnant women was 31.3 years (SD 5.52; range: 21-44): 90.5% were Bolivian, of whom 74% were diagnosed with CD during pregnancy. Of the 35 newborns, 31 were recovered by community health action; 12/31 were correctly controlled at Hospitalet de Llobregat and 19/31 were controlled at a primary health centre. Of these 19 (73.7%) cases, 14 were not tested for CD by family paediatricians and were recovered by the PROSICS community health team. Finally, two (6.9%) of the 29 newborns tested with serology were positive., Conclusions: It is essential to implement active surveillance, education and information activities at paediatric primary care and community levels to avoid the loss of CD-infected mothers and their newborns. Training sessions addressed to paediatricians and other involved health professionals would consolidate surveillance and care reference circuits, improving the control of congenital CD.

Background: Current therapeutic options for Chagas' disease are limited to benznidazole and nifurtimox, which have been associated with low cure rates in the chronic stage of the disease and which have considerable toxicity. Posaconazole has shown trypanocidal activity in murine models., Methods: We performed a prospective, randomized clinical trial to assess the efficacy and safety of posaconazole as compared with the efficacy and safety of benznidazole in adults with chronic Trypanosoma cruzi infection. We randomly assigned patients to receive posaconazole at a dose of 400 mg twice daily (high-dose posaconazole), posaconazole at a dose of 100 mg twice daily (low-dose posaconazole), or benznidazole at a dose of 150 mg twice daily; all the study drugs were administered for 60 days. We assessed antiparasitic activity by testing for the presence of T. cruzi DNA, using real-time polymerase-chain-reaction (rt-PCR) assays, during the treatment period and 10 months after the end of treatment. Posaconazole absorption was assessed on day 14., Results: The intention-to-treat population included 78 patients. During the treatment period, all the patients tested negative for T. cruzi DNA on rt-PCR assay beyond day 14, except for 2 patients in the low-dose posaconazole group who tested positive on day 60. During the follow-up period, in the intention-to-treat analysis, 92% of the patients receiving low-dose posaconazole and 81% receiving high-dose posaconazole, as compared with 38% receiving benznidazole, tested positive for T. cruzi DNA on rt-PCR assay (P<0.01 for the comparison of the benznidazole group with either posaconazole group); in the per-protocol analysis, 90% of the patients receiving low-dose posaconazole and 80% of those receiving high-dose posaconazole, as compared with 6% receiving benznidazole, tested positive on rt-PCR assay (P<0.001 for the comparison of the benznidazole group with either posaconazole group). In the benznidazole group, treatment was discontinued in 5 patients because of severe cutaneous reactions; in the posaconazole groups, 4 patients had aminotransferase levels that were more than 3 times the upper limit of the normal range, but there were no discontinuations of treatment., Conclusions: Posaconazole showed antitrypanosomal activity in patients with chronic Chagas' disease. However, significantly more patients in the posaconazole groups than in the benznidazole group had treatment failure during follow-up. (Funded by the Ministry of Health, Spain; CHAGASAZOL ClinicalTrials.gov number, NCT01162967.).

Objectives: To describe and compare levels of knowledge about HIV/AIDS and condom use in the immigrant population., Method: We performed a cross-sectional study by means of a semi-structured questionnaire and face-to face interviews in 238 Latin American and Maghrebi users of medical centers in the Barcelona and North Barcelona-Maresme health areas. The questionnaire included sociodemographic variables and questions on sexual behavior and general knowledge about HIV/AIDS, transmission mechanisms, and means of prevention. A logistic regression model was used to identify the determinants of 'inadequate knowledge of HIV/AIDS'., Results: A total of 53.8% of interviewees had inadequate knowledge of HIV/AIDS. Univariate analysis showed inadequate knowledge to be associated with being from the Maghreb, not living in Barcelona, being without work and not having educational qualifications. Multivariate analysis revealed that the only variables significantly associated with inadequate knowledge were being from the Maghreb as opposed to being from Latin America (OR=4.99; 95% CI: 2.74-5.10) and being unemployed as opposed to being employed (OR=2.59; 95% IC: 1.42-4.73). Condoms were seen as an effective prevention method, but 42.1% of interviewees did not use them in occasional relationships., Conclusions: Knowledge of routes of HIV transmission should be improved and mistaken ideas about infection should be eliminated among Latin American and Maghrebi immigrants. The immigrant population is a vulnerable group that ought to be prioritized to promote prevention programs adapted to its linguistic and cultural specificities.

Background: Chagas disease is no longer limited to Latin America and is becoming frequent in industrialised countries in Europe and United States., Methods: A descriptive study of Latin American immigrants in Barcelona attending two centres for imported diseases during a period of 3 years. The main outcome was the identification of Trypanosoma cruzi-infected individuals in a non-endemic country and the characterization of their clinical and epidemiological features., Results: A total of 489 Latin American patients participated in the study. Forty-one percent were infected by T. cruzi, and the most frequent country of origin was Bolivia. All T. cruzi infected patients were in chronic stages of infection. 19% of cases had cardiac disorders and 9% had digestive disorders., Conclusions: A high percentage of participants in this study were infected by T. cruzi and various factors were found to be associated to the infection. It is important to improve clinical and epidemiological knowledge of T. cruzi infection in non-endemic countries and to develop appropriate screening and treatment protocols in these settings.

Background: International travel and migration have been related with an increase of imported malaria cases. There has been considerable immigration to Barcelona from low-income countries (LIC) in recent years. The objective is to describe the epidemiology and to determine the trends of the disease in Barcelona., Methods: Analysis of the cases notified among city residents between 1989 and 2005. Patients were classified as: tourists, voluntary workers, resident immigrants (visiting friends and relatives, VFR) and recently arrived immigrants. An analysis was conducted using the chi2 test and comparison of means. As a measure of association we calculated the Relative Risk (RR) and Odds Ratio (OR) with a Confidence Interval of 95% (CI) and carried out a trends analysis., Results: Of the total of 1,579 imported cases notified, 997 (63.1%) lived in Barcelona city, and 55.1% were male. The mean age of patients was 32.7 years. The incidence increased from 2.4 cases/100,000 in 1989 to 3.5 cases/100,000 in 2005 (RR 1.46 CI:1.36-1.55). This increase was not statistically significant (trends analysis, p = 0.36). In terms of reason for travelling, 40.7% were VFR, 33.6% tourists, 12.1% voluntary workers and 13.6% were recently arrived immigrants. The most frequent species found was Plasmodium falciparum (71.3%), mainly in visitors to Africa (OR = 2.3, CI = 1.7-3.2). The vast majority (82.2%) had had some contact with Africa (35.9% with Equatorial Guinea, a Spanish ex-colony) and 96.6% had not completed chemoprophylaxis. Six deaths were observed, all tourists who had travelled to Africa and not taken chemoprophylaxis (3.9% fatality rate)., Conclusion: Over the period studied there is an increase in malaria incidence, however the trend is not statistically significant. Lack of chemoprophylaxis compliance and the association between Africa and P. falciparum are very clear in the imported cases. Most of the patients with malaria did not take chemoprophylaxis.

Chagas' disease, or American trypanosomiasis, is a parasitic zoonosis found only in the Americas. Under natural conditions, Trypanosoma cruzi is transmitted by insects belonging to different species of Triatoma. However, several routes of transmission that do not involve insect vectors have also been described, such as transmission via blood products or transplantation of infected organs, and vertical transmission. At present, the number of people infected with Chagas' disease worldwide is estimated to be about 10-12 million. The process of urbanization in Latin America and migratory population movements from endemic countries have led to the disease being diagnosed in non-endemic areas. It is estimated that 20-30% of individuals infected with T. cruzi will develop symptomatic heart disease at some point during their lives. The specific differential characteristics of chronic chagasic cardiopathy, lack of knowledge of the disease among many healthcare workers, and the fact that arrhythmia or sudden death is frequently the first manifestation of disease all make it essential that diagnostic and therapeutic protocols for the disease are developed and disseminated. The aim should be to improve patient care by increasing understanding of the condition by physicians and other healthcare professionals who may be involved in its detection and treatment.

For geographical and historical reasons, Spain is receiving an increasing number of immigrants. The aim of this study was to evaluate some epidemiological aspects and the main public health issues of communicable diseases in Barcelona's immigrant population. From 2001 to 2004, a population of immigrants from tropical, subtropical regions and Eastern Europe was attended to in our centre. Each patient was offered a complete screening for tropical and common diseases. The prevalence and demographical characteristics of eight diseases with a potential risk of transmission in our setting were studied: latent and active tuberculosis, syphilis, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), Chagas disease, Giardia intestinalis and Entamoeba histolytica/Entamoeba dispar. In all, 2464 immigrants mainly from sub-Saharan Africa were seen. Among the patients who underwent the screening, 46.5% had a positive tuberculin skin test (>or=10 mm), incidence of active tuberculosis was 324.7/100,000 immigrants in the period of the study, 6.4% had a positive syphilis serology, 7.7% had a positive HBsAg, 3.1% had a positive serology for HCV and 2.8% were HIV positive, 41 patients from Latin America with risk factors for American Trypanosomiasis were screened for Chagas disease by immunofluorescence assay and 34% had a positive result; 5.4% of stools parasitological tests were positive for G. intestinalis; 4.2% for E. histolytica/E. dispar. Communicable diseases in immigrant population could lead to emerging and re-emerging infections in the European Union with important issues for public health. European countries may have to establish guidelines for screening of infectious diseases in immigrants from low-income countries.

The aim of this study was to develop a real-time PCR technique to detect Trypanosoma cruzi DNA in blood of chagasic patients. Analytical sensitivity of the real-time PCR was assessed by two-fold serial dilutions of T. cruzi epimastigotes in seronegative blood (7.8 down to 0.06 epimastigotes/mL). Clinical sensitivity was tested in 38 blood samples from adult chronic chagasic patients and 1 blood sample from a child with an acute congenital infection. Specificity was assessed with 100 seronegative subjects from endemic areas, 24 seronegative subjects from non-endemic area and 20 patients with Leishmania infantum-visceral leishmaniosis. Real-time PCR was designed to amplify a fragment of 166 bp in the satellite DNA of T. cruzi. As internal control of amplification human RNase P gene was coamplified, and uracil-N-glycosylase (UNG) was added to the reaction to avoid false positives due to PCR contamination. Samples were also analysed by a previously described nested PCR (N-PCR) that amplifies the same DNA region as the real-time PCR. Sensitivity of the real-time PCR was 0.8 parasites/mL (50% positive hit rate) and 2 parasites/mL (95% positive hit rate). None of the seronegative samples was positive by real-time PCR, resulting in 100% specificity. Sixteen out of 39 patients were positive by real-time PCR (41%). Concordance of results with the N-PCR was 90%. In conclusion, real-time PCR provides an optimal alternative to N-PCR, with similar sensitivity and higher throughput, and could help determine ongoing parasitaemia in chagasic patients.

Chagas' disease, or American trypanosomiasis, is a parasitic zoonosis found only in the Americas. Under natural conditions, Trypanosoma cruzi is transmitted by insects belonging to different species of Triatoma. However, several routes of transmission that do not involve insect vectors have also been described, such as transmission via blood products or transplantation of infected organs, and vertical transmission. At present, the number of people infected with Chagas' disease worldwide is estimated to be about 10-12 million. The process of urbanization in Latin America and migratory population movements from endemic countries have led to the disease being diagnosed in non-endemic areas. It is estimated that 20-30% of individuals infected with T. cruzi will develop symptomatic heart disease at some point during their lives. The specific differential characteristics of chronic chagasic cardiopathy, lack of knowledge of the disease among many healthcare workers, and the fact that arrhythmia or sudden death is frequently the first manifestation of disease all make it essential that diagnostic and therapeutic protocols for the disease are developed and disseminated. The aim should be to improve patient care by increasing understanding of the condition by physicians and other healthcare professionals who may be involved in its detection and treatment.

Objective: To analyze the prevalence of latent tuberculosis infection in immigrants., Method: A review was performed of patients less than 35 years old who were seen in an imported disease unit in Barcelona (Spain)., Results: A total of 837 tuberculin tests were performed, 728 were read and 351 (48.2%) cases of latent tuberculosis infection were detected. Older patients and those from Africa showed the highest prevalence., Conclusions: Immigrants in our setting present a high prevalence of latent tuberculosis infection. Few patients follow all the indications, making it necessary to improve strategies directed toward screening and diagnosis, as well as prescription and compliance with preventive treatment.

Background: Given the increasing flux of immigrant population from high-risk areas to our country, the need of screening for loasis arises, despite systematic screening being a debated and poorly evaluated practice to which there is no protocol. This study is aimed at identifying the population to which loasis screening would be most appropriate, by drawing a comparison among four alternatives., Methods: Case and control group study, involving 30 cases (all those who came to our unit for treatment and who tested positive for Loa Loa in a microfilariae in the blood detection test) and 90 control cases (three controls per case from among the subjects having tested negative for microfiliariae in the blood chosen at random without any pairing criteria)., Results: Of the 1,638 subjects on whom the microfilariae blood test was performed, 30 tested positive (1.8%; 1.2-2.6%). Of these 30 cases of loasis, 76.7% (23; 57.7-90.1%) had eosinophilia (OR 8.8; 3.3-23.1; p<0.0001) and 30.0% (9; 14.7-49.4%) compatible clinical symptoms (OR 2.8; 1.0-7.5; p=0.04). If we were to apply the screening test to the entire immigrant population coming from endemic areas, we would have to perform 54.6 tests to detect one case. If we were to perform the test on patients showing eosinophilia and/or compatible clinical symptoms, we would have to perform a smaller number of tests for every case detected (NNS=29; IC=21-48), but there would be 16.7% (5; 5.7-34.7%) false negatives., Conclusions: Conducting a screening test with determination of microfiliariae in the blood on the immigrant population coming from Central and West Africa, independently of the presence of eosinophilia or compatible clinical symptoms, would be indicated, provided that the necessary resources are available.

Background: Plasmodium vivax is the second most common species among malaria patients diagnosed in Europe, but epidemiological and clinical data on imported P. vivax malaria are limited. The TropNetEurop surveillance network has monitored the importation of vivax malaria into Europe since 1999., Objectives: To present epidemiological and clinical data on imported P. vivax malaria collected at European level., Material and Methods: Data of primary cases of P. vivax malaria reported between January 1999 and September 2003 were analysed, focusing on disease frequency, patient characteristics, place of infection, course of disease, treatment and differences between network-member countries., Results: Within the surveillance period 4,801 cases of imported malaria were reported. 618 (12.9%) were attributed to P. vivax. European travellers and immigrants were the largest patient groups, but their proportion varied among the reporting countries. The main regions of infection in descending order were the Indian subcontinent, Indonesia, South America and Western and Eastern Africa, as a group accounting for more than 60% of the cases. Regular use of malaria chemoprophylaxis was reported by 118 patients. With 86 (inter-quartile range 41-158) versus 31 days (inter-quartile range 4-133) the median symptom onset was significantly delayed in patients with chemoprophylaxis (p < 0.0001). Common complaints were fever, headache, fatigue, and musculo-skeletal symptoms. All patients survived and severe clinical complications were rare. Hospitalization was provided for 60% and primaquine treatment administered to 83.8% of the patients, but frequencies varied strongly among reporting countries., Conclusions: TropNetEurop data can contribute to the harmonization of European treatment policies.

Setting: In January 2001, approximately 600 immigrants held a sit-down and hunger strike in several churches in Barcelona to force the Spanish government to comply with demands to regulate their immigration status. Following the diagnosis of a case of smear-positive pulmonary tuberculosis (TB) in one of the immigrants, we performed a large contact investigation., Objectives: To describe contact investigation procedures used in this setting and to evaluate contact investigation results., Methods: Demographic variables were collected, and tuberculin skin tests (TST) and chest radiograph examinations were performed. Odds ratios (OR) with 95% confidence intervals (CI) were calculated and logistic regression was used for multivariate analyses., Results: A total of 541 TSTs were performed. Of these, 86% were read and 40.5% yielded a positive reaction with an induration >14 mm. In a multivariate analysis, the risk of presenting a TST induration >14 mm was found to be three times higher among those aged >35 years compared to those <24 years (OR 3.40; 95%CI 1.76-6.59), and for immigrants from Bangladesh (OR 3.14; 95%CI 1.16-6.10) and Pakistan (OR 2.04; 95%CI 1.11-3.73) compared to those from India. A total of 314 chest radiographs examinations were performed and three additional cases of TB were identified, yielding a TB prevalence of 0.7%., Conclusions: By focusing efforts and conducting targeted TB screening in this high-risk population, it was possible to complete the intervention in only 3 days. A high prevalence of TB infection and TB disease was found.

Tuberculosis is a prehistoric American human disease. This paper reviews the literature and discusses hypotheses for origins and epidemiological patterns of prehistoric tuberculosis. From the last decades, 24 papers about prehistoric tuberculosis were published and 133 cases were reviewed. In South America most are isolated case studies, contrary to North America where more skeletal series were analyzed. Disease was usually located at the deserts of Chile and Peru, Central Plains in USA, and Lake Ontario in Canada. Skeletal remains represent most of the cases, but 16 mummies have also been described. Thirty individuals had lung disease, 19 of them diagnosed by the ribs. More then 100 individuals had osseous tuberculosis and 26 also had it in other organs. As today, transmission of the infection and establishment of the disease were favored by cultural and life-style changes such as sedentarization, crowding, undernutrition, use of dark and insulated houses, and by the frequency of interpersonal contacts. The papers confirm that despite previous perceptions, tuberculosis seems to have occurred in America for millennia. It only had epidemiological expression when special conditions favored its expansion. Occurring as epidemic bursts or low endemic disease, it had differential impact on groups or social segments in America for at least two millennia.