International Journal of Public Health ORIGINAL ARTICLE published: 30 November 2022 doi: 10.3389/ijph.2022.1605386 Opportunistic Community Screening of Chronic Chagas Disease Using a Rapid Diagnosis Test in Pharmacies in Barcelona (Catalonia, Spain): Study Protocol and Pilot Phase Results Aroa Silgado 1, Pau Bosch-Nicolau 2,3, Adrián Sánchez-Montalvá 2,3*, Ariadna Cervià 4, Jordi Gomez-i-Prat 2, Guillermo Bagaria 4, Cristina Rodriguez 4, Lidia Goterris 1, Núria Serre-Delcor 2,3, Inés Oliveira-Souto 2,3, Fernando Salvador 2,3, Israel Molina 2,3 and Elena Sulleiro 1,3 on behalf of Chagas-farmacias study group 1 Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain, 2Department of Infectious Diseases, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain, 3Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain, 4Official College of Pharmacists of Barcelona, Barcelona, Spain Edited by: Jean Tenena Coulibaly, Objectives: This study aimed to report the protocol and results from the pilot phase of an Félix Houphouët-Boigny University, opportunistic CP-based CD screening program in Barcelona, Spain. Côte d’Ivoire Reviewed by: Methods: Three strategies according to recruitment approach were designed: passive, Rufin Kouassi Assare, active and active-community. The study process consisted of signing the informed Félix Houphouët-Boigny University, Côte d’Ivoire consent form, recording the patient’s data in a web-based database system, and *Correspondence: performing the rapid test and blood collection on dry paper. Adrián Sánchez-Montalvá adrian.sanchez.montalva@gmail.com Results: Nineteen pharmacies participated and 64 patients were included during the pilot This Original Article is part of the IJPH phase of the study. The rapid diagnostic test (RDT) was positive in 2/64 (3.13%) cases. Of Special Issue: “Neglected Tropical the 49 DBS samples that arrived at the laboratory, 22 (45%) were collected incorrectly. Diseases During the COVID- 19 Pandemic.” After quantitative and qualitative assessment of the program, the dry paper sample and passive strategy were ruled out. Received: 08 September 2022 Accepted: 14 November 2022 Conclusion: DBS sampling and the passive strategy are not suitable for CD screening in Published: 30 November 2022 community pharmacies. There is a need to expand the number of participating pharmacies Citation: and individuals to determine whether conducting a RDT in community pharmacies is an Silgado A, Bosch-Nicolau P, effective screening method to increase access to CD diagnosis in a non-endemic area. Sánchez-Montalvá A, Cervià A, Gomez-i-Prat J, Bagaria G, Keywords: Chagas disease, opportunistic screening, community pharmacies, rapid test, dried blood Rodriguez C, Goterris L, Serre-Delcor N, Oliveira-Souto I, Salvador F, Molina I and Sulleiro E INTRODUCTION (2022) Opportunistic Community Screening of Chronic Chagas Disease Chagas disease (CD), a life-threatening disease caused by the protozoan Trypanosoma cruzi, affects between Using a Rapid Diagnosis Test in 6 and 7 million people worldwide (1). It is estimated that nearly 10,000 deaths per year are directly caused by Pharmacies in Barcelona (Catalonia, Spain): Study Protocol and Pilot CD, with an estimated global cost of 8 billion dollars per year in lost productivity and health costs (2). Phase Results. Although endemic in Latin America, the number of CD cases reported in non-endemic countries has Int J Public Health 67:1605386. increased due to population movements (3). In Europe, Spain has the highest number of people infected by doi: 10.3389/ijph.2022.1605386 T. cruzi, with an estimated 52,000 cases; however, approximately 70% remain undiagnosed (4). Int J Public Health | Owned by SSPH+ | Published by Frontiers 1 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies In the absence of the vector, CD can be transmitted via vertical organizations: College of Pharmacists of Barcelona, Vall transmission, blood transfusion and organ transplantation (5). d’Hebron University Hospital (HUVH), International Health Accordingly, health authorities in Spain have implemented Program of the Catalan Health Institute and XarChagas different measures to control CD transmission: screening in program. The pilot phase was performed from November blood banks is mandatory (Royal Decree 1088/2005) and some 2019 to May 2021, at which time the strengths, weaknesses, Spanish regions established CD screening protocols in pregnant opportunities, and threats (SWOT) analysis and relevant women from Latin America, such as Valencia (in 2008) (6), modifications to the final study protocol were made. Galicia (in 2008) (7) and Catalonia (in 2015) (8). However, no The screening study was carried out in three districts of screening program to control CD in the general Latin American Barcelona city (Figure 1) with a large population of Latin population is implemented in Spain and CD diagnosis relies on American migrants, according to the data of the last census in the general physician’s decision. Unfortunately, time constraints Barcelona (19): Nou Barris, Sants-Montjuïc and Horta-Guinardó. and the healthcare workers’ poor knowledge of CD, inefficiencies Participating pharmacies (N = 19) were selected based on in the diagnosis and referral process flows, together with barriers different factors, including proactivity, experience in other to health system access and stigmatization, limit the current screening programs (HIV and/or colorectal cancer), biological strategy to diagnose people with CD (9). To overcome these waste management training and certification, commitment to barriers, community-based activities for screening and case data protection procedures and facilities that ensure a detection allow us to identify at-risk individuals and thus limit comfortable and safe participant experience. potential associated complications through early detection and appropriate treatment (10). Opportunistic Screening Strategies The vast majority of CD patients living in non-endemic areas Three different strategies were used to approach the target are in the chronic stage of the disease (11). Diagnosis of this phase population: 1) passive, 2) active and 3) active-community is by means of serological tests (12); for mass-screening surveys, a actions (Table 1). All participating CPs displayed posters rapid, sensitive and easy to perform and interpret point of care offering CD screening at the entrance of the pharmacy, diagnostic test would be valuable (13). Rapid diagnostic tests easily visible from the outside. In addition, informative (RDTs) to detect antibodies against T. cruzi have been developed leaflets were placed on the counter of the CP. Both posters (14). Additionally, Dried Blood Spots (DBS) from finger-prick and leaflets informed that the participant had the opportunity blood can be safely collected, stored at room temperature and sent to take a free, rapid test to diagnose CD. In addition, the leaflets under conventional courier conditions (15). contained basic information about CD and reasons to be Community pharmacies (CPs) are a private healthcare screened. Iconographic material was specially designed with resource that work in an integrated and coordinated manner the help of people affected with CD using a consensus in the management of health processes of the population. CPs are decision-making process with the aim of drawing the valuable assets for screening strategies due to territorial balance, attention of the Latin American population (Supplementary consumer confidence, capillarity and social cohesion, File S1). professionalism and qualification, and their dense and i) Passive: implemented in Nou Barris, pharmacists had a wait- interconnected network (16). Previous screening initiatives and-see attitude to recruit the target population, in this case the involving CPs have been carried out in Spain for other participant would request the RDT. ii) Active: implemented in pathologies, such as opportunistic, under request, HIV Horta-Guinardó, pharmacists had a proactive attitude, where screening programs and systematic colorectal cancer screening they explained and offered the RDT to Latin American programs, with positive results (17, 18). To our knowledge, no consumers. iii) Active-community: implemented in those CD screening program has been carried out in community pharmacies located in the Sants-Montjuïc district. The pharmacies. iconographic material and the active attitude of the pharmacist This study aimed to describe the protocol and results from the were supplemented by the participation of community agents, pilot phase of an opportunistic CD screening program at CPs in who were tasked with conducting workshops/informative Barcelona (Catalonia, Spain). sessions in Latin American cultural associations and social meetings to encourage participation. METHODS Pharmacist Training Pharmacists received training in CD and RDT performance by Stakeholders, Target Population and Study completing a 3 h course imparted by physicians, microbiologists Design and community agents. This course explained general aspects of This was an opportunistic CD screening intervention performed CD (including epidemiology, diagnosis and treatment); how to in CPs for people aged 18 or over, who are originally from one of use and interpret the RDT; how to collect DBS samples; the use of the 21 endemic countries for CD, have been in an endemic area the information system tools; as well as how to approach the for more than 1 month or have a mother originally from an participant. In this sense, an “Expert Patient” (Latin American endemic country, even if the participant was born here. This community worker) trained the pharmacist in techniques to project was financed by the Fundació Marató TV3 (project identify and approach Latin American consumers number 20182610) and supported by different referent (Supplementary File S2). Int J Public Health | Owned by SSPH+ | Published by Frontiers 2 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies FIGURE 1 | Distribution of the 19 pharmacies that participated in the pilot phase in the city of Barcelona. (Barcelona, Spain. 2019–2021). Modified from: https:// www.instamaps.cat/ TABLE 1 | Characteristics of the three strategies presented in the CD screening program. (Barcelona, Spain. 2019–2021). Passive Active Active-community Informative leaflets √a √ √ Posters √ √ √ Pharmacist offers rapid diagnosis tests xb √ √ Involvement of community agents X x √ a Included in the strataegy. b Not included in the strategy. Participating pharmacies were invited to complete a brief Dissemination and Communication anonymous survey with general questions about CD before Different collaborating entities were contacted to inform them of and after the training. This survey consisted of 18 questions the implementation of the screening program, such as the health divided into four specific areas (epidemiology, transmission, centers in the selected neighborhoods, the department of health clinical presentation and diagnosis/treatment). Moreover, of the Government of Catalonia, and different community another brief anonymous satisfaction survey was performed to organizations. evaluate the training course. During the project, online stakeholder meetings were scheduled every 3 months or sooner under request from any Monitoring Plan stakeholder. A mailing list and a group in an instant message app During the study, pharmacies received a personal visit from the were created for rapid communication. training personnel (including a physician, a microbiologist, and a community health agent) to review the process, answer questions Information System Tools and Database and correct any protocol deviations. To this end, a monitoring A web-based database platform was designed to record patient system was developed that included a guide for visiting and information, results obtained from the RDT and analysis of the monitoring pharmacies (Standard Operational Procedure DBS samples. This platform had personal authentication, search Monitoring Guideline). In addition to the on-site monitoring, function, user privilege management and remote control. pharmacies, lying in the last quartile according to the number of The Official College of Pharmacists Information System patients recruited, were telephoned and interviewed by an centralized all information related to the processing and investigator regarding the hurdles hindering project tracing of the RDT kits and DBS samples of the pharmacies implementation. and the microbiology laboratory of the HUVH. Int J Public Health | Owned by SSPH+ | Published by Frontiers 3 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies FIGURE 2 | Flow diagram depicting the testing algorithm performed at the pharmacy. (Barcelona, Spain. 2019–2021). CRF, case report form; RDT, Rapid Diagnostic Test; DBS, Dried Blood Spot; HUVH, Vall d’Hebron University Hospital. Study Procedures Laboratory Procedures (RDT and DBS Serology) Screening Methods A previous analytical study was carried out to determine the The pharmacist’s role, regardless of the strategy, was to check sensitivity and specificity of the chosen rapid test, as well as for the exclusion/inclusion criteria, inform about the importance of analysis of the DBS samples via a serological technique (20). screening for CD, and explain the project’s objective, procedure, possible results and referral interventions. If the ™ The Trypanosoma Detect Rapid Test (InBios International, Inc., Seattle, WA) was selected for the rapid test in community participant agreed, he/she signed two copies of the informed pharmacies and performed according to manufacturer’s consent form; one copy is kept in the investigator file in the CP instructions. Briefly, one finger-prick blood drop is added to the and the other is given to the participant. Later, the participant test strip in the absorbent area, and then three or four drops of buffer answered a short survey about sociodemographic characteristics solution are added to the same area. The results are read after 10 min. and CD risk factors, relatives with the disease and previous testing Regarding DBS samples, between two or three additional history. Then, the RDT is performed using a blood drop from a drops of blood from the same finger-prick were used to fill finger-prick. All the procedures were free of charge for the one 8-mm-diameter circle on Whatman filter paper card patient. In addition to the rapid test, DBS samples were obtained from finger-prick blood on filter-paper cards. ™ (Whatman 903 Specimen Collection Paper; GE Healthcare Ltd., Cardiff, United Kingdom). This procedure was repeated When the RDT result was negative, a specific information to fill a minimum of two circles. If the first finger-prick was not sheet was given to the participant. Additionally, he/she was enough to fill the two required circles, the participant was asked informed, using plain language, of the test’s yield, including about the possibility of making a second finger-prick. sensitivity and specificity, and was advised to consult their Paper cards were dried at room temperature and then placed primary healthcare physician for the corresponding analyses. in a plastic bag with an anti-humidity sachet. All DBS samples On the other hand, if the RDT was positive, pharmacists were labeled with a code generated at the time of patient data informed the patient about the need for a confirmatory test in entry to ensure sample traceability. In accordance with the a referral hospital. Upon acceptance, the pharmacist could, at that pharmaceutical distribution system, DBS samples were time, schedule an appointment at the HUVH Tropical Medicine delivered monthly to the microbiology laboratory of the Unit for the participant (Figure 2). HUVH for serological analysis. Int J Public Health | Owned by SSPH+ | Published by Frontiers 4 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies number of correct answers after having completed the course (Figure 3). The satisfaction survey completed by the participating pharmacists included aspects related to organization, training activity, teaching staff and overall evaluation. The scoring scale ranged from 1 to 4 (4 being very positive). The specific aspects and overall median were between 3 and 4 (data not shown). Results From the Pilot Phase and SWOT Assessment FIGURE 3 | Percentage of correct answers by category before and after In the pilot phase of the study, a total of 19 pharmacies were the training course. (Barcelona, Spain. 2019–2021). The questions were included: seven for the passive strategy, six for the active strategy grouped into category: questions 1 and 2 on epidemiology, questions 3 to 7 on transmission, questions 8 to 12 on pathology, and questions 13 to and six for the active-community strategy. A total of 64 patients 18 on diagnosis and treatment. were included, of which 46 (71.9%) were women, and the median age was 40 years (Inter Quartile Range, 32.75-53). The main countries of origin of the participants were Bolivia DBSs were processed for analysis with the Elecsys Chagas (18/64; 28.1%), Ecuador (16/64; 25%) and Peru (12/64; 18.8%). assay (Roche Diagnostics, Manheim, Germany) for the Participants entered the program via communication from determination of anti-T. cruzi immunoglobulin G. pharmacy staff (29/64; 45.3%), observation of the material in the pharmacy (27/64; 42.2%) and, to a lesser extent, through an Community Survey acquaintance or family member (2/64; 3.1%) or information During March and July 2021, a survey of the target population from community agents (1/64; 1.6%). In five cases (7.8%) this was carried out to provide information regarding the acceptance information was not registered. The RDT was positive in 2/64 of CD screening in CPs. This survey was conducted in the Sants- (3.1%) cases. The characteristics of these two cases are resumed Montjuïc district, coinciding with the involvement of community in Table 2. agents in the project’s active strategy. Participants were asked Of the 64 patients included, a DBS sample was collected in 49 whether they would want to be diagnosed for CD in pharmacies (76.56%) cases. Thirteen samples (13/49; 26.5%) were and to find out the reasons if not. Oral consent was requested inadequately collected and could not be processed. Of the before beginning the survey. No personal data was recorded for remaining 36 DBS samples processed for serological analysis, this study. 26/36 (72.22%) were negative, 1/36 (2.78%) was positive and 9/36 (25%) were classified as invalid, which means that a reading error Ethics was obtained in the technique. This CD screening program follows the Public Health laws and Due to the low number of patients recruited, a qualitative the Organic Law on Data Protection. Review Board approvals study of the acceptance of the project by potential participants were obtained from the Ethics Committee ofthe Vall d’Hebron was performed in a Latin American population recruited from Research Institute (PR(AG)230/2018), according to the principles public places, such as the Bolivian consulate. Of the 94 people expressed in the Declaration of Helsinki. Informed consent was surveyed, 27/94 (28.7%) answered that they considered a obtained from all the participants prior to performance of the community pharmacy a suitable facility for CD diagnosis, RDT. Patients were not involved in developing the research while 28/94 (29.8%) preferred to be diagnosed in healthcare question, design or implementation of this analysis. centers. However, the majority of participants (39/94; 41.5%) answered that they did not want to be tested for CD. Statistical Analysis After completion of the pilot experience, a SWOT analysis was Qualitative variables were expressed as absolute frequencies and applied to improve aspects of the project (Figure 4). percentages. Quantitative variables were described as mean or median and standard deviation or interquartile range according to normal distribution. Statistical analyses were done using SPSS Statistics v22.0 (SPSS Inc., Chicago, IL). TABLE 2 | Characteristics of the two patients with a positive RDT result. (Barcelona, Spain. 2019–2021). Patient code RESULTS 1 6 Pharmacist’s Training Country of origin Age Bolivia 43 Uruguay 54 Thirty-eight pharmacists attended the training course and Gender Female Male completed the knowledge survey before and after receiving the Serology by DBS Reactive Non-Reactive training. All question categories showed an increase in the Conventional serology Positive Negative Int J Public Health | Owned by SSPH+ | Published by Frontiers 5 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies FIGURE 4 | Strengths, weaknesses, opportunities, and threats analysis of the pilot study (Barcelona, Spain. 2019–2021). CD, Chagas disease. DISCUSSION pharmacists are recommended to communicate using clear language, without stereotypes and with scientific rigor. The under-diagnosis of people infected by T. cruzi responds to a Likewise, they must respect the views and knowledge of the complex matrix of interrelated factors, mainly attributed to the participants. To this end, the figure of the “expert patient,” as lack of knowledge of the infection and its transmission, fear and well as iconographic materials, were essential for the stigma, and a long asymptomatic phase (10). These factors implementation of this program. The involvement of complicate access to a diagnosis and, consequently, to community agents was intended to reduce the reluctance to treatment and clinical follow-up care (10). In situ screening participate and increase community engagement with the interventions facilitate access to diagnostic tests and increase project. Therefore, their participation was aimed at eliminating accessibility to potentially CD-affected people (21). the social stigma surrounding CD. In the knowledge survey conducted on pharmacists before the The SWOT analysis of the pilot phase highlighted several course, the categories of “diagnosis and treatment” and strengths of this program, such as coordination by experienced “epidemiology” had the lowest percentage of correct answers. staff and training of pharmacists, as well as the free testing The work of (9), concluded that many physicians outside offered. However, several challenges were identified, including endemic areas have limited or no knowledge about CD and its the reluctance to know their CD status and the lack of acceptance implications. It is important to emphasize these aspects since, of positive RDT results. although the vector is not present in Spain, there are other routes The study was designed to compare three screening strategies of transmission that are particularly relevant for the transmission with the hypothesis that pharmacist and community engagement of CD in non-endemic areas, especially congenital transmission would increase the number of patients screened. After the results and via organ transplants and blood products (5). from the pilot phase, and according to the participants and A poor understanding of CD is one of the most important pharmacists’ opinions, the passive strategy was dropped. barriers to screening people susceptible to T. cruzi infection, The COVID-19 pandemic has, in many ways, disrupted the especially a lack of accurate information about the disease, daily lives of people in affected countries, especially regarding including the myth that CD is a synonym for death (22). social dynamics (25). Countries applied different measures to try Moreover, CD diagnosis produces a range of reactions in to limit the spread of the virus; in Spain, different states of alarm individuals, from skepticism to fear or anxiety (23). Therefore, were decreed over time with perimeter closures, quarantines, a careful approach must be made when offering opportunistic curfews... as well as the adoption of sanitary measures, such as screening to Latin American participants. To this end, our project safety distance, reduced personal contact... Moreover, pharmacies included the collaboration of a CD “expert patient” with first- have seen an increase in the services offered as a result of the hand experience in the disease, who helped design the pandemic, such as antigen and serological tests. This fact may participant-centered approach and management plan, as well explain, in part, the low recruitment speed observed in this pilot as the communication and dissemination plan (21, 24). phase of the project. Pharmacists were trained in the misconceptions and fears Rapid diagnostic tests reduce the turnaround time, and with a associated with CD. When dealing with the at-risk population, proper referral procedure, reduce losses to follow-up (26). RDTs Int J Public Health | Owned by SSPH+ | Published by Frontiers 6 November 2022 | Volume 67 | Article 1605386 Silgado et al. Chagas Disease Screening in Pharmacies are easily implemented at the community level, but the sensitivity Genis, Enrique Javier Gonzalez, Paula Hernandez, Francesca reported is not high enough to be used as the sole screening Iglesias, Antoni Saus, J. Antoni Soriano, Aina Surroca, technique. Based on this fact, in the present study, a strategy was Marcelo Gabriel Sykuler, Guillermo Vallejo, David Xuriguera. selected based on the combination of the RDT with a serology test using DBS, which can reach a sensitivity up to 97% (20). In 15/64 (23.44%) of the cases it was not possible to collect the ETHICS STATEMENT DBS sample for serology analysis. This may be due to the fact that, although finger pricking seems to be a simple act, the fact of The studies involving human participants were reviewed and having to repeat it in order to obtain the DBS sample may be a approved by Ethics Committee of the Vall d’Hebron Research reason for participants to refuse. In addition, although in 49 cases Institute. The patients/participants provided their written it was possible to collect DBS samples, 13 of them were collected informed consent to participate in this study. improperly (either both circles were not full or only one circle was impregnated). Unfortunately, after the pilot phase, the project steering committee decided to remove this procedure as it was AUTHOR CONTRIBUTIONS considered to hinder the logistics of the screening process. Similarly, in non-endemic countries, the choice of using Conceptualization: AS-M and IO-S. Data curation and RDTs for screening should be followed by confirmation of investigation: AS, PB-N, AS-M, AC, JG, GB, CR, LG, NS-D, the results in a reference laboratory (27). Challenges related IO-S, FS, IM, and ES. Methodology: AS, AS-M, IO-S, AC, JG, GB, to the follow-up of patients by specialized units, especially in and CR. Writing—original draft: AS and PB-N. Writing—review those with a positive RDT, can be a real problem that can hinder and editing: AS, PB-N, AS-M, AC, JG, GB, CR, LG, NS-D, IO-S, the effectiveness and success of the screening program. In order FS, IM, and ES. Supervision: AS-M. Funding acquisition: IO-S. to try to lose as few patients as possible between screening and All authors contributed to the article and approved the submitted subsequent clinical follow-up, the pharmacy booked an version. appointment for diagnosis in the referral center. Participants not attending the scheduled visit were contacted by phone or e-mail to offer them a new visit. FUNDING During the pilot phase, two participants had a positive result on the RDT. Both attended the subsequent visit at the referral unit This work has been supported by the Fundació la Marató TV3 at HUVH, indicating that acquiring the appointment at the (project number 481/U/2018). pharmacy is a successful method to avoid the risk of losing the patient. The positive RDT result of patient 6 was not confirmed neither by serology from DBS and serum samples. CONFLICT OF INTEREST On the other hand, participants with negative results were carefully explained the meaning of the result and encouraged The authors declare that they do not have any conflicts of interest. to perform the diagnosis at his/her primary care center. Implementation of screening actions for CD, coupled with early management of the disease, is a cost-effective strategy (28); ACKNOWLEDGMENTS however, cost assessment prior to the large-scale implementation of any strategy is essential for planning and refining procedures The authors thank Helena Kruyer for her assistance with the and investment efforts (29). English. To conclude, DBS sampling and the passive strategy are not suitable for CD screening in community pharmacies. There is a need to expand the number of participating pharmacies and SUPPLEMENTARY MATERIAL individuals to determine whether conducting a RDT in community pharmacies is an effective screening method to The Supplementary Material for this article can be found online at: increase access to CD diagnosis in a non-endemic area. https://www.ssph-journal.org/articles/10.3389/ijph.2022.1605386/ full#supplementary-material Supplementary Figure S1 | Iconographic material used in this program (in CHAGAS-FARMACIA STUDY GROUP Spanish). (A) Poster displayed at the entrance of the pharmacy, visible from the outside. (B) Leaflets with brief information about Chagas disease. (Barcelona, Spain. Francisca Aranzana, Conxita Alsina, Judith Barcelo, Begoña 2019–2021). Barenys, Jose M. Bellart, Montserrat Brio, Pere Casanovas, Supplementary Figure S2 | Guidelines for approaching people from countries Bibiana de Dou, Eva Falco, Eduard Fernandez-Rajal, Gloria endemic for Chagas disease. 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