1665. The Cascade of Care for the Strong Hearts Chagas Disease Screening and Treatment Program in East Boston, Massachusetts

Abstract

BackgroundOver 300,000 people in the United States are infected with Trypanosoma cruzi, the parasite that causes Chagas disease. Less than 1% of those people have received antitrypanosomal therapy. We report findings of an ongoing project to address Chagas disease in East Boston, including the epidemiology and cascade of care for this disease.MethodsProviders at the East Boston Neighborhood Health Center were offered continuing medical education sessions on Chagas disease by the Strong Hearts project. One-time screening for Chagas disease is recommended for all patients <50 years old who had lived in Mexico, South or Central America for ≥6 months at the provider’s discretion. Screening is performed by a commercial laboratory using the Hemagen ELISA; confirmatory testing is performed at CDC. Patients with confirmed positive serology are referred to the Center for Infectious Diseases (ID) at Boston Medical Center for evaluation and treatment. We compared the prevalence of Chagas disease by age, sex and national origin. We then used a conditional numerator and fixed denominator to construct the cascade of care, with the stages defined as referred to ID care, evaluation in ID, initiation of treatment and completion of antitrypanosomal therapy. We used chi-squared tests to compare proportions.ResultsFrom March 21, 2017 to April 17, 2019, 5,125 patients were screened. 50 (0.97%) were confirmed to have T. cruzi infection, among them 3 pregnant women. There were no differences in the prevalence of T. cruzi infection by sex (M = 22/1870 [1.18%], F = 28/3305 [0.85%], P = 0.245) but prevalence increased from 0/190 (0%) in those <20 years old to 11/1083 (1.02%) in 40–49 year olds (P = 0.001). The 3 infants of infected mothers were screened. The cascade of care for Strong Hearts is displayed in Figure 1.ConclusionChagas disease prevalence in at-risk communities in Boston is substantial. 20% of patients with T. cruzi infection identified in this program have completed treatment to date. Most infected patients were referred for evaluation, but substantial drop-off occurred at each of the next 3 steps of the cascade. Confronting barriers at each of these steps is a crucial component of efforts to address this neglected disease. Disclosures All authors: No reported disclosures.

Recognition and screening for Chagas disease in the USA

“…The current dropout rate between diagnosis and treatment can be as high as 80% based on a study in the northeastern USA. 36 In that study, of 50 patients who tested positive, only 20% finished a course of benznidazole therapy. Community involvement in the creation of self-awareness materials for CD can increase the number of patients seeking to be screened for the disease.…”

“… 1 In a primary care sample in East Boston, 5125 immigrants were screened, with an overall seroprevalence of 0.97%. 36 Finally, in a community-based seroprevalence study in the metropolitan Washington DC area, 3.8% of 1500 immigrants tested positive for T. cruzi infection, with 2% of Central American and 23% of South American participants testing positive. 37 …”

Chagas Disease in the United States: A Perspective on Diagnostic Testing Limitations and Next Steps

“…This test is difficult to obtain in the United States outside of the CDC (Gilman, personal communication). The practice of using a high-sensitivity initial test followed by a high-specificity confirmatory test could be to optimize diagnostic accuracy for chronic Chagas disease in low-prevalence settings, such as the United States (where programs in Boston 23,24 and Los Angeles cities 25 have found a prevalence of 0.9-1.2% among Latinx immigrants).…”

Chagas cardiomyopathy in Boston, Massachusetts: Identifying disease and improving management after community and hospital-based screening

“…Based on other successful US Chagas disease screening programs, the Strong Hearts project integrated Chagas screening into primary care at East Boston Neighborhood Health Center (EBNHC) in 2017 [ 16 , 17 ]. They demonstrated a 0.97% screening positivity rate at EBNHC, similar to other published Chagas screening program results [ 17 , 18 ].…”

“…Based on other successful US Chagas disease screening programs, the Strong Hearts project integrated Chagas screening into primary care at East Boston Neighborhood Health Center (EBNHC) in 2017 [ 16 , 17 ]. They demonstrated a 0.97% screening positivity rate at EBNHC, similar to other published Chagas screening program results [ 17 , 18 ]. Referrals from EBNHC to the Boston Medical Center (BMC) Center for Infectious Disease (CID), as well as efforts to promote screening across the BMC hospital system, have identified a large cohort of patients living with Chagas disease in Boston.…”