Orally-transmitted Chagas disease | Medicina Clínica (English Edition)

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Results from major randomized controlled clinical trials and Registry studies. (A) Randomized controlled trials. (A.1) Phase 3 placebo-controlled clinical trial for agalsidase beta (total patients randomized: 58, follow-up 6 months). Endothelial deposits in kidney biopsies.<a class="elsevierStyleCrossRef" href="#bib0280">25</a> (A.2) Phase 2 placebo-controlled clinical trial for agalsidase alfa (total patients randomized: 26, follow-up 6 months). Endothelial deposits in kidney biopsies.<a class="elsevierStyleCrossRef" href="#bib0275">24</a> (A.3) Phase 4 placebo-controlled clinical trial for agalsidase beta (total patients randomized: 82, follow-up 3 years). Severe kidney, cardiac, central nervous system events or death.<a class="elsevierStyleCrossRef" href="#bib0285">26</a> (A.4) Phase 4 head-to-head controlled clinical trial for agalsidase beta versus alfa (Canadian Fabry Disease Initiative, total patients randomized: 114, sample size calculation: >600, follow-up 8 years). Severe kidney, cardiac, central nervous system events or death (http://garrodsymposium.com/garrod2016/posters/#p104; accessed July 18, 2016). (B) Registry data. Fabry Registry, patients treated with agalsidase beta. Severe kidney, cardiac, central nervous system events or death.<a class="elsevierStyleCrossRef" href="#bib0290">27</a> Incidence of severe clinical events in first 6 months of ERT compared to next 5 years (1044 patients, follow-up 5 years). Note that as patients get 5 years older during the study, an increased incidence rate of events would be expected but the opposite was observed. S In all trials ERT was used at label dose: 0.2mg/kg/2 weeks for agalsidse alfa and 1.0mg/kg/2 weeks for agalsidase beta. * Statistically significant difference, n.a. Not available, given the nature of the study. 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PCR: polymerase chain reaction." ] ] ] "textoCompleto" => "Chagas disease (CD) is a zoonosis caused by the Trypanosoma cruzi (T. cruzi) protozoan parasite which affects between 6 and 7 million people. Initially, it was only present in Latin America, but in recent decades, due to the intensification of migration flows and to the increase in the number of people travelling, it has also been diagnosed in countries where it is not endemic.In recent years, numerous outbreaks of acute CD have been described, with a tendency to increase, caused by ingestion of tripomastigotes forms present in beverages, such as sugar cane juice and açai (Euterpe oleracea) which is a palm tree native to northern South America, in which probably wild, insect vectors were crushed during preparation or food was contaminated by their faeces.<a class="elsevierStyleCrossRef" href="#bib0270">1</a> The scientific literature has also shown survival of T. cruzi in beverages, over 24h from contamination, a time frame that allows easy oral transmission of the parasite,<a class="elsevierStyleCrossRefs" href="#bib0275">2,3</a> which manifests itself with a high mortality and a poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0285">4</a>The aim of this paper is to review the characteristics of orally-transmitted CD outbreaks, sources of infection, transmission mechanism, virulence of the transmission and of the clinical forms, and finally, diagnostic tools and prevention.Materials and methodsDesignA review of scientific studies was carried out in 3 databases: PubMed, EMBASE and Google Scholar.Search strategyFirst, searches were conducted in two databases, PubMed and EMBASE, using the following search equations: “Chagas disease” and “oral transmission,” “acute Chagas” and “oral Chagas” and “outbreaks”, “Trypanosoma cruzi” and “oral route”. No restrictions were used and all kinds of studies were considered. In addition, references from other articles found through Google Scholar were reviewed.Data extractionAfter the search, 80 studies were found, of which 47 were relevant to the objective of this study. To proceed with the selection, abstracts and, where necessary, full papers were reviewed in order to decide whether the information they contained was or was not related to the objective.Data analysisOnce analyzed, the information was divided into sub-sections, and the following data was singled out from the revised articles: authorship, journal name and year of publication, country where the study was conducted, type of study, subjects and origin, outcome variable and conclusions made.Orally-transmitted acute Chagas disease outbreaksThe highest number of orally-transmitted acute Chagas disease outbreaks has been seen in the last decade, all of which occurred in South America (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Outbreaks in BrazilIn Brazil, the first outbreak of acute CD was recorded in 1965, which affected 18 people, 6 of whom died of acute myocarditis, suspecting intake of vegetables contaminated by opossum faeces.<a class="elsevierStyleCrossRef" href="#bib0290">5</a> Between 1968 and 2005 there were a total of 437 cases of acute CD, of which 311 were linked to 62 outbreaks caused by açai ingestion.<a class="elsevierStyleCrossRef" href="#bib0295">6</a> In contrast, only in the period between 2000 and 2010, there were more than 1000 acute cases in 138 outbreaks of which 776 cases (71%) were attributed to orally-transmitted epidemics.<a class="elsevierStyleCrossRef" href="#bib0300">7</a>In 2005, an acute CD outbreak was recorded in the tourist area of Santa Caterina after the ingestion of sugar cane juice. Remains of contaminated kissing bugs or insect faeces would have been processed while grinding the cane. 25 cases were confirmed, of which one was an Italian tourist. 3 of them died.<a class="elsevierStyleCrossRefs" href="#bib0305">8,9</a> Between January and November 2006 a total of 178 cases of CD were reported in the state of Para, again being linked with consumption of açai. In the same year, in Bahia, 7 cases of acute CD transmitted by contaminated water were recorded, with 28% lethality<a class="elsevierStyleCrossRef" href="#bib0315">10</a> and 8 other cases were reported in Ceara by eating contaminated soup made with vegetables grown in a home family garden.<a class="elsevierStyleCrossRef" href="#bib0320">11</a> In January 2010, another outbreak was reported in the Brazilian Amazon region of 17 cases per consumption of açaí,<a class="elsevierStyleCrossRef" href="#bib0325">12</a> with another outbreak of similar characteristics repeating in January 2015 (in the press).Outbreaks in ColombiaAcute CD was rare in Colombia. Between 1990 and 1999 two outbreaks associated with myocarditis were detected with possible oral transmission<a class="elsevierStyleCrossRef" href="#bib0330">13</a>; and between 2002 and 2005, 10 new cases (8 confirmed by oral transmission and 2 with portal of entry) were reported.<a class="elsevierStyleCrossRef" href="#bib0335">14</a> However, in later years a notable increase was observed, so that, from 2008, more than 64 new acute cases have been detected, including micro-outbreaks and isolated cases.<a class="elsevierStyleCrossRefs" href="#bib0300">7,15–17</a>In 2008, 10 cases of acute CD were recorded, with T. cruzi found in orange juice being the source of contamination. 2 patients died of acute myocarditis and cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0340">15</a> In another outbreak caused by consumption of food contaminated with the parasite, a 27-year-old woman and her 2-year-old son died.<a class="elsevierStyleCrossRef" href="#bib0350">17</a> In 2010, 11 cases of acute CD caused by oral ingestion of food contaminated with T. cruzi were reported. The source was either triatomine bug remnants or marsupial droppings.<a class="elsevierStyleCrossRef" href="#bib0355">18</a> Another 11 acute CD cases were detected in one family due to food contamination with faeces from triatomines infected with T. cruzi in Attalea butyracea and Elaeis oleifera<a class="elsevierStyleCrossRefs" href="#bib0360">19,20</a> palms. In the outbreak occurred in the Department of Casanare, in March 2014, 40 workers of companies related to the mining sector were exposed to contaminated food.<a class="elsevierStyleCrossRef" href="#bib0370">21</a>Outbreaks in VenezuelaIn Venezuela, there had been no reported cases of oral transmission in human groups until 2007, when 103 members of a school group in the municipality of Chacao in Caracas were affected; the disease was acquired by drinking guava juice made outside the school facilities. A 5-year-old boy died in this first microepidemic.<a class="elsevierStyleCrossRef" href="#bib0375">22</a> In May 2008, 3 members of a family were diagnosed of acute T. cruzi infection, of probable oral transmission, with prolonged febrile syndrome and chills.<a class="elsevierStyleCrossRef" href="#bib0380">23</a> In April 2009, in a coastal town, there was another outbreak of acute CD (71 children and 14 adults) with the same characteristics as the 2007 one. 4 deaths were recorded, 3 children and a pregnant woman.<a class="elsevierStyleCrossRef" href="#bib0385">24</a> Another documented episode occurred again in Caracas in May 2010 where 20 people were diagnosed and a 2-year-old died.In October 2010, T. cruzi was observed in trypomastigote form in the peripheral blood of a 2-year-old girl, 16 days after admission for pneumonia. The patient developed fever, pericarditis, pleural effusion, and pericardial effusion and finally died. 5 other people from the same family were diagnosed with CD.<a class="elsevierStyleCrossRef" href="#bib0390">25</a> In March 2012, 4 construction workers who had been working in the basement of one of the Food Municipal Market's warehouses in Caracas, simultaneously manifested prolonged febrile symptoms; trypomastigote forms of T. cruzi were isolated in blood. Rats infected with T. cruzi<a class="elsevierStyleCrossRef" href="#bib0395">26</a> were later caught in the warehouse. In July 2012, an outbreak of acute CD in 5 members of the same family was recorded, 2 had acute myocarditis and one died.<a class="elsevierStyleCrossRef" href="#bib0400">27</a> In June 2013, a case of celiac disease was diagnosed in a 16-year-old with high parasitemia and febrile syndrome. Similar symptoms were also identified in 8 other people, including a pregnant woman who died. Panstrongylus geniculatus (P. geniculatus) was isolated in the house where the mango juice was made and later drunk by all individuals diagnosed.<a class="elsevierStyleCrossRef" href="#bib0405">28</a>In February 2014, another case of acute CD was diagnosed in a 16-year-old and his parents who had fever, pericardial effusion, acute myocarditis and high parasitemia; they all died. In July 2014, there was an orally-transmitted CD outbreak that affected 5 individuals of the same family, 3 of whom were hospitalized for myocarditis.<a class="elsevierStyleCrossRef" href="#bib0405">28</a> In June 2015, 12 people from the same family had CD associated with unhygienic handling of food. 2 infants and one adult died.<a class="elsevierStyleCrossRef" href="#bib0410">29</a>In Venezuela, therefore, two types of oral transmission infection have been observed: microepidemics in which the number of infected individuals is high; and small group outbreaks (households).<a class="elsevierStyleCrossRef" href="#bib0415">30</a>Outbreaks in BoliviaThe first orally-transmitted acute CD outbreak in Bolivia occurred in October 2010, due to majo (Oenocarpus bataua) consumption, a local fruit whose juice is made by crushing the same. The juice is drunk without cooking. 24 people were exposed, 16 of which developed the disease, there were no deaths. The most common signs and symptoms were fever and headache (100%) followed by vomiting, diarrhoea, splenomegaly and increases in liver enzymes.<a class="elsevierStyleCrossRef" href="#bib0420">31</a>Other outbreaksIn 2010, in French Guyana, 8 patients of the same family presented with epidemiological histories and clinical data consistent with recent T. cruzi infection due to ingestion of contaminated Oenocarpus bacaba palm juice.<a class="elsevierStyleCrossRef" href="#bib0425">32</a>Sporadic cases have been reported in Ecuador and Argentina in relation to the consumption of undercooked meat from contaminated animals.<a class="elsevierStyleCrossRefs" href="#bib0430">33,34</a>Vectors and reservoirsT. cruzi is a parasite capable of infecting dozens of species of wild and domestic mammals and is transmitted by several species of hematophagous triatomine insects.Of the 125 species of triatomine bugs described in America, the following have been linked to oral transmission: P. geniculatus and Rhodnius pallescens in Colombia,<a class="elsevierStyleCrossRef" href="#bib0345">16</a>P. geniculatus in Venezuela<a class="elsevierStyleCrossRef" href="#bib0415">30</a> and Triatoma tibiamaculata, T. sordida, T. braziliensis and P. lutzi in Brazil.<a class="elsevierStyleCrossRefs" href="#bib0305">8,35</a>The natural reservoir is constituted by armadillos, marsupials (Didelphis or opossums), rodents, coatis, ferrets, bats and wild primates besides pets like dogs, cats and even rats (Rattus rattus).As a result of the alteration of peri-urban wooded areas and increased luminosity, wild vectors and reservoirs reach residential areas and pollute the nearby palm trees and banana and fruit plantations<a class="elsevierStyleCrossRefs" href="#bib0445">36–38</a>; thus, preparing beverages from fruits cooked overnight favours exposure to infected vectors and reservoirs, attracted by the smell of these fruits and artificial lighting, this is reflected in an increase in oral transmission cases.<a class="elsevierStyleCrossRef" href="#bib0460">39</a>Other contributing factors are the increase of street vending of food and beverages, transport of contaminated fruit and vegetables and distant consumption of the same.<a class="elsevierStyleCrossRef" href="#bib0465">40</a>Type of food involvedOral transmission of T. cruzi is common during the enzootic cycle of this parasite through ingestion (by susceptible mammals) of infected vectors.<a class="elsevierStyleCrossRef" href="#bib0470">41</a> In the case of man, it occurs circumstantially by the ingestion of beverages or food contaminated with faeces or the whole infected triatomine, or fruit or vegetables sprayed with secretions from the odoriferous anal glands of infected animals. Another source of infection is the consumption of undercooked animal meat or blood from some reservoirs of the parasite such as the armadillo (Dasypus spp.)<a class="elsevierStyleCrossRefs" href="#bib0375">22,31</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Transmission usually coincides with hot weather, the busiest time for triatomines (greater mobility, hematophagy, and contamination of the environment with infected faeces) and, depending on the temperature, humidity and desiccation, T. cruzi may stay alive for a few hours or days, and at low temperatures its viability can last for weeks.Therefore, contaminated food must be kept wet or partially liquid to allow transmission of the parasite and in this sense the palm, sugar cane and fruit juices are ideal sources of transmission, because they often are cultivated, harvested and handled with the help of artificial light, in rural or peri-urban areas where triatomines are abundant.<a class="elsevierStyleCrossRef" href="#bib0430">33</a>Such is the case of acai and sugar cane juice in Brazil, palm wine and orange juice in Colombia, guava juice in Venezuela, “comou” juice in French Guyana and more recently, majo (Oenocarpus bataua) palm juice in Bolivia. The risk of infection is higher if the fresh pulp is eaten and almost null if it goes through a washer-pasteurizer process.Virulence of orally-transmitted acute Chagas diseaseThere are few significant studies on the pathophysiology of orally-transmitted acute CD, since most of the immunological knowledge we have derives from experimental studies with intraperitoneally/subcutaneously infected mice.<a class="elsevierStyleCrossRef" href="#bib0285">4</a>The first demonstrations of T. cruzi invasion and replication in the gastric mucosa were performed in mouse models (BALB/cAnNHsd) after oral ingestion of residues with 10,000–40,000 parasites. The mice were examined 2 weeks after infection, performing cuts of different organs, which allowed to determine their anatomical localization in the stomach by immunohistochemical colourations, observing intracellular amastigote forms of T. cruzi in the gastric mucosa.<a class="elsevierStyleCrossRef" href="#bib0475">42</a>The gastric epithelium invasion is mediated by proteins of metacyclic trypomastigotes that allow their adherence and penetration.<a class="elsevierStyleCrossRef" href="#bib0480">43</a> The gp82 glycoprotein is resistant to acidic pH and is able to bind to the gastric mucosa through Ca2+ ion mobilization, allowing the parasite to enter the cells.<a class="elsevierStyleCrossRefs" href="#bib0485">44–46</a> Once in the cytoplasm, it transforms into amastigote, and then into the metacyclic stage, when it is detectable in blood.<a class="elsevierStyleCrossRef" href="#bib0300">7</a> Gp30 glycoprotein also has affinity for the gastric mucosa although to a lesser extent, whereas the gp90 is widely degraded by gastric juice, therefore its expression is inversely correlated with parasite infectivity.<a class="elsevierStyleCrossRef" href="#bib0475">42</a>The gastric mucosa invasion results in a progressive gastritis and, despite the short period of replication, it induces specific immunity, involving the production of IgA and IgG.<a class="elsevierStyleCrossRef" href="#bib0500">47</a> Intraepithelial and lamina propria lymphocytes produce IFN-γ but not IL-4, suggesting the possibility that this type of route of infection does not affect the response of CD8+ T cells.<a class="elsevierStyleCrossRef" href="#bib0285">4</a>The different modulation of the local and systemic immune system influences the different expression of such outbreaks, which often emphasizes the seriousness of the clinical manifestations compared to other types of transmission route.<a class="elsevierStyleCrossRef" href="#bib0435">34</a>Penetration by the oral cavity and esophagus<a class="elsevierStyleCrossRef" href="#bib0400">27</a> has also been described, showing, at local level, facial oedema on the inside of the cheeks, paraesthesia, lingual oedema and, at systemic level, high parasitaemia, elevated serum levels of TNF, carditis and hepatitis, with high mortality rates.<a class="elsevierStyleCrossRef" href="#bib0285">4</a>Clinical manifestationsThe latency period after ingestion of contaminated food is 3–30 days (4–15 days in vector transmission and 30–112 days in transfusion transmission).<a class="elsevierStyleCrossRef" href="#bib0440">35</a> Unlike the vector route, the oral route is characterized by a large number of signs and symptoms and high mortality; probably due, not only to the more efficient penetration at gastric mucosa level, but also because greater inoculum amounts can be transmitted orally compared to those who can penetrate through the skin.The most characteristic clinical manifestation is prolonged fever, which can be associated with non-specific symptoms (prostration, diarrhoea, vomiting, headache, myalgia, skin rash, lymphadenopathy) and/or specific symptoms (acute myocarditis, acute pericarditis, acute heart failure, cardiac tamponade, pleural effusion, epigastric pain, jaundice, hematemesis, haematochezia or melena<a class="elsevierStyleCrossRef" href="#bib0430">33</a> and in some cases meningoencephalitis) or frequent (face, lower limbs or generalized oedema, cough, dyspnoea, chest pain, palpitations, arrhythmias, hepatosplenomegaly). These manifestations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) match the descriptions of acute CD outbreaks reported by several researchers in different regions of Latin America.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Diagnosis of orally-transmitted acute Chagas diseaseEpidemiological history is essential to raise the diagnosis: recent travel, intake of home-prepared food with no cooking involved, simultaneous presence of other similar cases. The clinical approach should be careful, ruling out other diseases such as visceral leishmaniosis, malaria, mononucleosis, typhoid fever, toxoplasmosis, hepatitis, hantavirus, leptospirosis, yellow fever, arbovirus (Dengue, Chikungunya, Zika) and rickettsiosis, among others.Laboratory tests include direct parasitological methods in which the parasite is observed in blood and indirect immunological methods that detect specific antibodies.<a class="elsevierStyleCrossRefs" href="#bib0300">7,28,48</a><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the diagnostic methods used in orally-transmitted acute CD outbreaks.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Among the parasitological examinations, direct examination of peripheral blood stands out, it is fast and inexpensive, specific but not always sensitive; alternatively, in the presence of symptoms for more than 30 days, concentration methods (microhematocrit, Stourt method) are used. In developing countries, thick blood film is also used, as it may also rule out malaria.Among the serological methods, indirect hemagglutination, indirect immunofluorescence and the immunosorbent assay use as antigen the whole parasite or soluble extracts; in contrast, immunochromatography and Western Blot use recombinant antigens or synthetic peptides. If the initial serology is negative, it is repeated 3 weeks later and diagnosis would be confirmed if there is seroconversion or variation of 3 serologic titres by indirect immunofluorescence.Xenodiagnosis is not a method used in Europe as it requires the vector. The molecular diagnosis by polymerase chain reaction is used only in reference centres, but allows the identification of the parasite in the acute phase before serological positivity.The use of these methodologies is reflected in the outbreaks described in the medical literature, being the direct examination, serology by indirect immunofluorescence and the enzyme immunoassay method the most commonly used tests.TreatmentSpecific treatment is standard for all modes of transmission of T. cruzi and it should be initiated as soon as possible. The goal is to cure the infection, prevent organ damage or the development of the same, and reduce the possibility of transmission (vertical, transfusion, transplantation).Benznidazole is the drug of choice (100mg tablets) and dose varies depending on age and weight. It is taken orally in 2 daily doses for 60 days (adults: 5mg/kg/day, children 5–10mg/kg/day and infants 10mg/kg/day).<a class="elsevierStyleCrossRef" href="#bib0505">48</a> The drug can be given in shorter cycles or intermittently if there is a case of intolerance.<a class="elsevierStyleCrossRef" href="#bib0510">49</a>The most common adverse reactions are skin disease, neuropathy, nausea, vomiting and diarrhoea. In mild cases, the treatment is maintained, in moderate cases, it is better to interrupt temporarily, treat the symptoms and gradually reintroduce the drug. In case of serious side effects, augesia (complete loss of taste) or marrow hypoplasia (<1%), the treatment is discontinued.<a class="elsevierStyleCrossRef" href="#bib0505">48</a>An alternative is nifurtimox (120mg tablets), whose dose also depends on the patient's age and weight, administered in 3 and 4 times daily during 90 days (adults: 8–10mg/kg/day, children: 15mg/kg/day). The most common side effects are anorexia, weight loss, psychic disorders, irritability, drowsiness, nausea, vomiting, cramps and diarrhoea. Testicular damage, ovarian toxicity and deleterious effects on adrenal, colon, oesophagus and breast tissue have also been observed.<a class="elsevierStyleCrossRef" href="#bib0515">50</a>Both drugs showed significant mutagenic effects and proved carcinogenic in some studies.<a class="elsevierStyleCrossRef" href="#bib0515">50</a> Treatment should be postponed until after the first trimester.Remission involves serological negativity which in most cases occurs up to 5 years after treatment, so the performance of serological tests (IgG) every 6 months or annually until 2 successive tests are nonreactive is recommended.<a class="elsevierStyleCrossRef" href="#bib0505">48</a>Preventing orally-transmitted acute Chagas diseaseOrally-transmitted acute CD is a preventable disease if proper measures are taken. In this sense, traveller education is essential to ensure a responsible and qualitative food consumption, which involves knowledge of the entire production chain, from source to consumption.<a class="elsevierStyleCrossRefs" href="#bib0505">48,51–53</a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the prevention measures for orally-transmitted acute CD.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>ConclusionsProper care of persons infected with T. cruzi is an essential strategy for a comprehensive control of the CD and its elimination as a public health problem. Faced with the exponential increase in cases over the past decade, it is important to have knowledge of the oral route as a mechanism of transmission of the disease, to provide adequate information to travellers, suggest measures for prevention and early diagnosis in case of epidemiological risk and/or compatible clinical symptoms, even away from vector transmission areas.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres813161" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec810523" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres813162" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec810522" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Search strategy" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Data extraction" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Data analysis" ] ] ] 5 => array:3 [ "identificador" => "sec0030" "titulo" => "Orally-transmitted acute Chagas disease outbreaks" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Outbreaks in Brazil" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Outbreaks in Colombia" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Outbreaks in Venezuela" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Outbreaks in Bolivia" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Other outbreaks" ] ] ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Vectors and reservoirs" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Type of food involved" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Virulence of orally-transmitted acute Chagas disease" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Clinical manifestations" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Diagnosis of orally-transmitted acute Chagas disease" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Treatment" ] 12 => array:2 [ "identificador" => "sec0090" "titulo" => "Preventing orally-transmitted acute Chagas disease" ] 13 => array:2 [ "identificador" => "sec0095" "titulo" => "Conclusions" ] 14 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflict of interests" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-14" "fechaAceptado" => "2016-10-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec810523" "palabras" => array:5 [ 0 => "Chagas disease" 1 => "Oral transmission" 2 => "Disease outbreaks" 3 => "Trypanosoma cruzi" 4 => "Epidemiology" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec810522" "palabras" => array:5 [ 0 => "Enfermedad de Chagas" 1 => "Transmisión oral" 2 => "Brotes" 3 => "Trypanosoma cruzi" 4 => "Epidemiología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Chagas disease is a zoonosis caused by protozoan parasite Trypanosoma cruzi, which is most frequently associated with a vectorial transmission. However, in recent years we have observed a significant increase in the oral transmission of the disease, associated mainly with the consumption of drinks made from fruit or other vegetables contaminated with triatomine faeces or secretions from infected mammals. After a latency period of 3–22 days after ingestion, the oral infection is characterized by more severe manifestations than those associated with vectorial transmission: prolonged fever, acute myocarditis with heart failure and, in some cases, meningoencephalitis. Mortality can reach up to 33% of those infected. The aim of this paper is to review this matter and to promote prevention practices." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La enfermedad de Chagas es una zoonosis causada por el parásito protozoario Trypanosoma cruzi, transmitido con mayor frecuencia por vía vectorial. En los últimos años, sin embargo, se está observando un aumento marcado de la transmisión de la enfermedad por vía oral, asociada al consumo de bebidas preparadas a base de frutas u otros vegetales contaminados con las heces de triatominos o secreciones de mamíferos infectados. Después de un período de latencia de 3-22 días, a partir de la ingestión, la infección oral se caracteriza por manifestaciones más graves que la vectorial: fiebre prolongada, miocarditis aguda con insuficiencia cardíaca y en algunos casos meningoencefalitis. La mortalidad puede llegar hasta un 33% de los infectados. El objetivo de este trabajo es realizar una revisión del fenómeno y promover prácticas de prevención." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Filigheddu MT, Górgolas M, Ramos JM. Enfermedad de Chagas de transmisión oral. Med Clin (Barc). 2017;148:125–131." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1519 "Ancho" => 2811 "Tamanyo" => 191447 ] ] "descripcion" => array:1 [ "en" => "Distribution of signs and symptoms in outbreaks of orally-transmitted acute Chagas disease." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1144 "Ancho" => 2460 "Tamanyo" => 105427 ] ] "descripcion" => array:1 [ "en" => "Diagnostic methods used in orally-transmitted acute Chagas disease outbreaks. PCR: polymerase chain reaction." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ref. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">City/state \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Area \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transmission source \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No deaths \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0430">33</a> <a class="elsevierStyleCrossRef" href="#bib0435">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1936 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Argentina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chaco \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breastmilk Inadequately cooked meat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0430">33</a> <a class="elsevierStyleCrossRef" href="#bib0435">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1936 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ecuador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Meat of wild animals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0290">5</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1965 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Teutonia, Rio Grande do Sul \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated vegetables (marsupials) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0295">6</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1988–2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Para, Amapa, Maranhao \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban/Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Açaí juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0335">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2002–2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Putumayo, Arauca, Casanare, Santander \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0310">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">St. Catarina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tourists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sugar cane juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0270">1</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pará \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reunión \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Açaí juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0315">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macaubas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Water \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (Myocarditis/respiratory failure) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0320">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceará \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vegetable soup \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0375">22</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chacao \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Students Workers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Guava juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0425">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">French Guyana \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Iracoubo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palm juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0340">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lebrija (Santander) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Orange juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0385">24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chichiriviche \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Students Workers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Guava juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0390">25</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tachira \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0355">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Antioquia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (Unclear) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0360">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Aguachica \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Periurban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0325">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rio Negro \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tourist boat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Açaí juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0420">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bolivia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Guayamerín \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Majo milk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0400">27</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Merida \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0370">21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Casanare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mining sector \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contaminated food \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0405">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mirmire \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mango juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0410">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macarena \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Family nucleus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Natural juice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (Myocarditis) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1365536.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological characteristics of orally-transmitted acute Chagas disease outbreaks." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Source of infection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col">Animals of the Didephix genus (opossum, fara) infected by Trypanosoma cruzi</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col">Insect vectors (triatomine) infected by Trypanosoma cruzi</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ingestion-acquired \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fruits or food sprayed with secretions from the odoriferous anal glands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Undercooked game meat from infected animals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Foods prepared with crushed insect vectors (cane juice) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Food contaminated with triatomine droppings \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1365535.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Forms of orally-transmitted acute Chagas disease." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acquire fruits or other foods from registered suppliers, if possible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluate food at the time of purchasing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ensure that the food has been stored in clean, waterproof containers, protected from potential contaminants and distant from light sources \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food always needs to be washed and disinfected before preparing and eating \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Utensils that come into contact with food should be made with smooth, washable, easy to clean and corrosion-resistant materials \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Protect food and kitchen areas from insects or other animals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wash vegetables especially if they are eaten raw and store in the refrigerator after having washed them, in dry plastic bags \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cooling or freezing food does not prevent the oral transmission of T. cruzi but cooking>45°, pasteurization and freeze drying does \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cook food thoroughly, especially meat. The juice should be clear, not pink, the inner part should not be included \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food ready for consumption should be protected from contamination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The vehicle used for food transport must be clean, with a cover, it should not carry animals, toxic chemicals or other contaminants \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The hands should always be washed before food ingestion \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1365537.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preventing orally-transmitted acute Chagas disease." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:53 [ 0 => array:3 [ "identificador" => "bib0270" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral transmission of Chagas disease by consumption of açaí palm fruit, Brazil" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.A. 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Orally-transmitted Chagas disease

Enfermedad de Chagas de transmisión oral

Maria Teresa Filigheddua,

Corresponding author

etafiligheddu@gmail.com

Corresponding author.

, Miguel Górgolasb,c, José Manuel Ramosd,e

a División de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain

b División de Enfermedades Infecciosas, Fundación Jiménez Díaz, Madrid, Spain

c Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain

d Servicio de Medicina Interna, Hospital General Universitario de Alicante, Alicante, Spain

e Departamento de Medicina Clínica, Universidad Miguel Hernández de Elche, Elche, Alicante, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chagas disease &#40;CD&#41; is a zoonosis caused by the <span class="elsevierStyleItalic">Trypanosoma cruzi &#40;T&#46; cruzi&#41;</span> protozoan parasite which affects between 6 and 7 million people&#46; Initially&#44; it was only present in Latin America&#44; but in recent decades&#44; due to the intensification of migration flows and to the increase in the number of people travelling&#44; it has also been diagnosed in countries where it is not endemic&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years&#44; numerous outbreaks of acute CD have been described&#44; with a tendency to increase&#44; caused by ingestion of tripomastigotes forms present in beverages&#44; such as sugar cane juice and a&#231;ai <span class="elsevierStyleItalic">&#40;Euterpe oleracea&#41;</span> which is a palm tree native to northern South America&#44; in which probably wild&#44; insect vectors were crushed during preparation or food was contaminated by their faeces&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">1</span></a> The scientific literature has also shown survival of <span class="elsevierStyleItalic">T&#46; cruzi</span> in beverages&#44; over 24<span class="elsevierStyleHsp" style=""></span>h from contamination&#44; a time frame that allows easy <span class="elsevierStyleItalic">oral</span> transmission of the parasite&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">2&#44;3</span></a> which manifests itself with a high mortality and a poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this paper is to review the characteristics of orally-transmitted CD outbreaks&#44; sources of infection&#44; transmission mechanism&#44; virulence of the transmission and of the clinical forms&#44; and finally&#44; diagnostic tools and prevention&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Materials and methods</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Design</span><p id="par0020" class="elsevierStylePara elsevierViewall">A review of scientific studies was carried out in 3 databases&#58; PubMed&#44; EMBASE and Google Scholar&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Search strategy</span><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; searches were conducted in two databases&#44; PubMed and EMBASE&#44; using the following search equations&#58; &#8220;Chagas disease&#8221; and &#8220;oral transmission&#44;&#8221; &#8220;acute Chagas&#8221; and &#8220;oral Chagas&#8221; and &#8220;outbreaks&#8221;&#44; &#8220;<span class="elsevierStyleItalic">Trypanosoma cruzi&#8221;</span> and &#8220;oral route&#8221;&#46; No restrictions were used and all kinds of studies were considered&#46; In addition&#44; references from other articles found through Google Scholar were reviewed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Data extraction</span><p id="par0030" class="elsevierStylePara elsevierViewall">After the search&#44; 80 studies were found&#44; of which 47 were relevant to the objective of this study&#46; To proceed with the selection&#44; abstracts and&#44; where necessary&#44; full papers were reviewed in order to decide whether the information they contained was or was not related to the objective&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Data analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Once analyzed&#44; the information was divided into sub-sections&#44; and the following data was singled out from the revised articles&#58; authorship&#44; journal name and year of publication&#44; country where the study was conducted&#44; type of study&#44; subjects and origin&#44; outcome variable and conclusions made&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Orally-transmitted acute Chagas disease outbreaks</span><p id="par0040" class="elsevierStylePara elsevierViewall">The highest number of orally-transmitted acute Chagas disease outbreaks has been seen in the last decade&#44; all of which occurred in South America &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Outbreaks in Brazil</span><p id="par0045" class="elsevierStylePara elsevierViewall">In Brazil&#44; the first outbreak of acute CD was recorded in 1965&#44; which affected 18 people&#44; 6 of whom died of acute myocarditis&#44; suspecting intake of vegetables contaminated by opossum faeces&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">5</span></a> Between 1968 and 2005 there were a total of 437 cases of acute CD&#44; of which 311 were linked to 62 outbreaks caused by a&#231;ai ingestion&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">6</span></a> In contrast&#44; only in the period between 2000 and 2010&#44; there were more than 1000 acute cases in 138 outbreaks of which 776 cases &#40;71&#37;&#41; were attributed to orally-transmitted epidemics&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In 2005&#44; an acute CD outbreak was recorded in the tourist area of Santa Caterina after the ingestion of sugar cane juice&#46; Remains of contaminated kissing bugs or insect faeces would have been processed while grinding the cane&#46; 25 cases were confirmed&#44; of which one was an Italian tourist&#46; 3 of them died&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">8&#44;9</span></a> Between January and November 2006 a total of 178 cases of CD were reported in the state of Para&#44; again being linked with consumption of a&#231;ai&#46; In the same year&#44; in Bahia&#44; 7 cases of acute CD transmitted by contaminated water were recorded&#44; with 28&#37; lethality<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">10</span></a> and 8 other cases were reported in Ceara by eating contaminated soup made with vegetables grown in a home family garden&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">11</span></a> In January 2010&#44; another outbreak was reported in the Brazilian Amazon region of 17 cases per consumption of a&#231;a&#237;&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">12</span></a> with another outbreak of similar characteristics repeating in January 2015 &#40;in the press&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Outbreaks in Colombia</span><p id="par0055" class="elsevierStylePara elsevierViewall">Acute CD was rare in Colombia&#46; Between 1990 and 1999 two outbreaks associated with myocarditis were detected with possible oral transmission<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">13</span></a>&#59; and between 2002 and 2005&#44; 10 new cases &#40;8 confirmed by oral transmission and 2 with portal of entry&#41; were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">14</span></a> However&#44; in later years a notable increase was observed&#44; so that&#44; from 2008&#44; more than 64 new acute cases have been detected&#44; including micro-outbreaks and isolated cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">7&#44;15&#8211;17</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In 2008&#44; 10 cases of acute CD were recorded&#44; with <span class="elsevierStyleItalic">T&#46; cruzi</span> found in orange juice being the source of contamination&#46; 2 patients died of acute myocarditis and cardiogenic shock&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">15</span></a> In another outbreak caused by consumption of food contaminated with the parasite&#44; a 27-year-old woman and her 2-year-old son died&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">17</span></a> In 2010&#44; 11 cases of acute CD caused by oral ingestion of food contaminated with <span class="elsevierStyleItalic">T&#46; cruzi</span> were reported&#46; The source was either triatomine bug remnants or marsupial droppings&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">18</span></a> Another 11 acute CD cases were detected in one family due to food contamination with faeces from triatomines infected with <span class="elsevierStyleItalic">T&#46; cruzi</span> in <span class="elsevierStyleItalic">Attalea butyracea</span> and <span class="elsevierStyleItalic">Elaeis oleifera</span><a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">19&#44;20</span></a> palms&#46; In the outbreak occurred in the Department of Casanare&#44; in March 2014&#44; 40 workers of companies related to the mining sector were exposed to contaminated food&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Outbreaks in Venezuela</span><p id="par0065" class="elsevierStylePara elsevierViewall">In Venezuela&#44; there had been no reported cases of oral transmission in human groups until 2007&#44; when 103 members of a school group in the municipality of Chacao in Caracas were affected&#59; the disease was acquired by drinking guava juice made outside the school facilities&#46; A 5-year-old boy died in this first microepidemic&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">22</span></a> In May 2008&#44; 3 members of a family were diagnosed of acute <span class="elsevierStyleItalic">T&#46; cruzi</span> infection&#44; of probable oral transmission&#44; with prolonged febrile syndrome and chills&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">23</span></a> In April 2009&#44; in a coastal town&#44; there was another outbreak of acute CD &#40;71 children and 14 adults&#41; with the same characteristics as the 2007 one&#46; 4 deaths were recorded&#44; 3 children and a pregnant woman&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">24</span></a> Another documented episode occurred again in Caracas in May 2010 where 20 people were diagnosed and a 2-year-old died&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In October 2010&#44; <span class="elsevierStyleItalic">T&#46; cruzi</span> was observed in trypomastigote form in the peripheral blood of a 2-year-old girl&#44; 16 days after admission for pneumonia&#46; The patient developed fever&#44; pericarditis&#44; pleural effusion&#44; and pericardial effusion and finally died&#46; 5 other people from the same family were diagnosed with CD&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">25</span></a> In March 2012&#44; 4 construction workers who had been working in the basement of one of the Food Municipal Market&#39;s warehouses in Caracas&#44; simultaneously manifested prolonged febrile symptoms&#59; trypomastigote forms of <span class="elsevierStyleItalic">T&#46; cruzi</span> were isolated in blood&#46; Rats infected with <span class="elsevierStyleItalic">T&#46; cruzi</span><a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">26</span></a> were later caught in the warehouse&#46; In July 2012&#44; an outbreak of acute CD in 5 members of the same family was recorded&#44; 2 had acute myocarditis and one died&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">27</span></a> In June 2013&#44; a case of celiac disease was diagnosed in a 16-year-old with high parasitemia and febrile syndrome&#46; Similar symptoms were also identified in 8 other people&#44; including a pregnant woman who died&#46; <span class="elsevierStyleItalic">Panstrongylus geniculatus &#40;P&#46; geniculatus&#41;</span> was isolated in the house where the mango juice was made and later drunk by all individuals diagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In February 2014&#44; another case of acute CD was diagnosed in a 16-year-old and his parents who had fever&#44; pericardial effusion&#44; acute myocarditis and high parasitemia&#59; they all died&#46; In July 2014&#44; there was an orally-transmitted CD outbreak that affected 5 individuals of the same family&#44; 3 of whom were hospitalized for myocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">28</span></a> In June 2015&#44; 12 people from the same family had CD associated with unhygienic handling of food&#46; 2 infants and one adult died&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">29</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In Venezuela&#44; therefore&#44; two types of oral transmission infection have been observed&#58; microepidemics in which the number of infected individuals is high&#59; and small group outbreaks &#40;households&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Outbreaks in Bolivia</span><p id="par0085" class="elsevierStylePara elsevierViewall">The first orally-transmitted acute CD outbreak in Bolivia occurred in October 2010&#44; due to majo &#40;<span class="elsevierStyleItalic">Oenocarpus bataua</span>&#41; consumption&#44; a local fruit whose juice is made by crushing the same&#46; The juice is drunk without cooking&#46; 24 people were exposed&#44; 16 of which developed the disease&#44; there were no deaths&#46; The most common signs and symptoms were fever and headache &#40;100&#37;&#41; followed by vomiting&#44; diarrhoea&#44; splenomegaly and increases in liver enzymes&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Other outbreaks</span><p id="par0090" class="elsevierStylePara elsevierViewall">In 2010&#44; in French Guyana&#44; 8 patients of the same family presented with epidemiological histories and clinical data consistent with recent <span class="elsevierStyleItalic">T&#46; cruzi</span> infection due to ingestion of contaminated <span class="elsevierStyleItalic">Oenocarpus bacaba</span> palm juice&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">32</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Sporadic cases have been reported in Ecuador and Argentina in relation to the consumption of undercooked meat from contaminated animals&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">33&#44;34</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Vectors and reservoirs</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">T&#46; cruzi</span> is a parasite capable of infecting dozens of species of wild and domestic mammals and is transmitted by several species of hematophagous triatomine insects&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Of the 125 species of triatomine bugs described in America&#44; the following have been linked to oral transmission&#58; <span class="elsevierStyleItalic">P&#46; geniculatus</span> and <span class="elsevierStyleItalic">Rhodnius pallescens</span> in Colombia&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleItalic">P&#46; geniculatus</span> in Venezuela<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">30</span></a> and <span class="elsevierStyleItalic">Triatoma tibiamaculata&#44; T&#46; sordida&#44; T&#46; braziliensis</span> and <span class="elsevierStyleItalic">P&#46; lutzi</span> in Brazil&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">8&#44;35</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The natural reservoir is constituted by armadillos&#44; marsupials &#40;<span class="elsevierStyleItalic">Didelphis</span> or opossums&#41;&#44; rodents&#44; coatis&#44; ferrets&#44; bats and wild primates besides pets like dogs&#44; cats and even rats <span class="elsevierStyleItalic">&#40;Rattus rattus&#41;</span>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As a result of the alteration of peri-urban wooded areas and increased luminosity&#44; wild vectors and reservoirs reach residential areas and pollute the nearby palm trees and banana and fruit plantations<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">36&#8211;38</span></a>&#59; thus&#44; preparing beverages from fruits cooked overnight favours exposure to infected vectors and reservoirs&#44; attracted by the smell of these fruits and artificial lighting&#44; this is reflected in an increase in oral transmission cases&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">39</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Other contributing factors are the increase of street vending of food and beverages&#44; transport of contaminated fruit and vegetables and distant consumption of the same&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Type of food involved</span><p id="par0125" class="elsevierStylePara elsevierViewall">Oral transmission of <span class="elsevierStyleItalic">T&#46; cruzi</span> is common during the enzootic cycle of this parasite through ingestion &#40;by susceptible mammals&#41; of infected vectors&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">41</span></a> In the case of man&#44; it occurs circumstantially by the ingestion of beverages or food contaminated with faeces or the whole infected triatomine&#44; or fruit or vegetables sprayed with secretions from the odoriferous anal glands of infected animals&#46; Another source of infection is the consumption of undercooked animal meat or blood from some reservoirs of the parasite such as the armadillo &#40;<span class="elsevierStyleItalic">Dasypus</span> spp&#46;&#41;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">22&#44;31</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Transmission usually coincides with hot weather&#44; the busiest time for triatomines &#40;greater mobility&#44; hematophagy&#44; and contamination of the environment with infected faeces&#41; and&#44; depending on the temperature&#44; humidity and desiccation&#44; <span class="elsevierStyleItalic">T&#46; cruzi</span> may stay alive for a few hours or days&#44; and at low temperatures its viability can last for weeks&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Therefore&#44; contaminated food must be kept wet or partially liquid to allow transmission of the parasite and in this sense the palm&#44; sugar cane and fruit juices are ideal sources of transmission&#44; because they often are cultivated&#44; harvested and handled with the help of artificial light&#44; in rural or peri-urban areas where triatomines are abundant&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">33</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Such is the case of acai and sugar cane juice in Brazil&#44; palm wine and orange juice in Colombia&#44; guava juice in Venezuela&#44; &#8220;comou&#8221; juice in French Guyana and more recently&#44; majo &#40;<span class="elsevierStyleItalic">Oenocarpus bataua</span>&#41; palm juice in Bolivia&#46; The risk of infection is higher if the fresh pulp is eaten and almost null if it goes through a washer-pasteurizer process&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Virulence of orally-transmitted acute Chagas disease</span><p id="par0145" class="elsevierStylePara elsevierViewall">There are few significant studies on the pathophysiology of orally-transmitted acute CD&#44; since most of the immunological knowledge we have derives from experimental studies with intraperitoneally&#47;subcutaneously infected mice&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The first demonstrations of <span class="elsevierStyleItalic">T&#46; cruzi</span> invasion and replication in the gastric mucosa were performed in mouse models &#40;BALB&#47;cAnNHsd&#41; after oral ingestion of residues with 10&#44;000&#8211;40&#44;000 parasites&#46; The mice were examined 2 weeks after infection&#44; performing cuts of different organs&#44; which allowed to determine their anatomical localization in the stomach by immunohistochemical colourations&#44; observing intracellular amastigote forms of <span class="elsevierStyleItalic">T&#46; cruzi</span> in the gastric mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">42</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The gastric epithelium invasion is mediated by proteins of metacyclic trypomastigotes that allow their adherence and penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">43</span></a> The gp82 glycoprotein is resistant to acidic pH and is able to bind to the gastric mucosa through Ca<span class="elsevierStyleSup">2&#43;</span> ion mobilization&#44; allowing the parasite to enter the cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">44&#8211;46</span></a> Once in the cytoplasm&#44; it transforms into amastigote&#44; and then into the metacyclic stage&#44; when it is detectable in blood&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">7</span></a> Gp30 glycoprotein also has affinity for the gastric mucosa although to a lesser extent&#44; whereas the gp90 is widely degraded by gastric juice&#44; therefore its expression is inversely correlated with parasite infectivity&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">42</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The gastric mucosa invasion results in a progressive gastritis and&#44; despite the short period of replication&#44; it induces specific immunity&#44; involving the production of IgA and IgG&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">47</span></a> Intraepithelial and lamina propria lymphocytes produce IFN-&#947; but not IL-4&#44; suggesting the possibility that this type of route of infection does not affect the response of CD8&#43; T cells&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">4</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The different modulation of the local and systemic immune system influences the different expression of such outbreaks&#44; which often emphasizes the seriousness of the clinical manifestations compared to other types of transmission route&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">34</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Penetration by the oral cavity and esophagus<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">27</span></a> has also been described&#44; showing&#44; at local level&#44; facial oedema on the inside of the cheeks&#44; paraesthesia&#44; lingual oedema and&#44; at systemic level&#44; high parasitaemia&#44; elevated serum levels of TNF&#44; carditis and hepatitis&#44; with high mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinical manifestations</span><p id="par0175" class="elsevierStylePara elsevierViewall">The latency period after ingestion of contaminated food is 3&#8211;30 days &#40;4&#8211;15 days in vector transmission and 30&#8211;112 days in transfusion transmission&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">35</span></a> Unlike the vector route&#44; the oral route is characterized by a large number of signs and symptoms and high mortality&#59; probably due&#44; not only to the more efficient penetration at gastric mucosa level&#44; but also because greater inoculum amounts can be transmitted orally compared to those who can penetrate through the skin&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The most characteristic clinical manifestation is prolonged fever&#44; which can be associated with non-specific symptoms &#40;prostration&#44; diarrhoea&#44; vomiting&#44; headache&#44; myalgia&#44; skin rash&#44; lymphadenopathy&#41; and&#47;or specific symptoms &#40;acute myocarditis&#44; acute pericarditis&#44; acute heart failure&#44; cardiac tamponade&#44; pleural effusion&#44; epigastric pain&#44; jaundice&#44; hematemesis&#44; haematochezia or melena<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">33</span></a> and in some cases meningoencephalitis&#41; or frequent &#40;face&#44; lower limbs or generalized oedema&#44; cough&#44; dyspnoea&#44; chest pain&#44; palpitations&#44; arrhythmias&#44; hepatosplenomegaly&#41;&#46; These manifestations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; match the descriptions of acute CD outbreaks reported by several researchers in different regions of Latin America&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Diagnosis of orally-transmitted acute Chagas disease</span><p id="par0185" class="elsevierStylePara elsevierViewall">Epidemiological history is essential to raise the diagnosis&#58; recent travel&#44; intake of home-prepared food with no cooking involved&#44; simultaneous presence of other similar cases&#46; The clinical approach should be careful&#44; ruling out other diseases such as visceral leishmaniosis&#44; malaria&#44; mononucleosis&#44; typhoid fever&#44; toxoplasmosis&#44; hepatitis&#44; hantavirus&#44; leptospirosis&#44; yellow fever&#44; arbovirus &#40;Dengue&#44; Chikungunya&#44; Zika&#41; and rickettsiosis&#44; among others&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Laboratory tests include direct parasitological methods in which the parasite is observed in blood and indirect immunological methods that detect specific antibodies&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">7&#44;28&#44;48</span></a><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the diagnostic methods used in orally-transmitted acute CD outbreaks&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Among the parasitological examinations&#44; direct examination of peripheral blood stands out&#44; it is fast and inexpensive&#44; specific but not always sensitive&#59; alternatively&#44; in the presence of symptoms for more than 30 days&#44; concentration methods &#40;microhematocrit&#44; Stourt method&#41; are used&#46; In developing countries&#44; thick blood film is also used&#44; as it may also rule out malaria&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Among the serological methods&#44; indirect hemagglutination&#44; indirect immunofluorescence and the immunosorbent assay use as antigen the whole parasite or soluble extracts&#59; in contrast&#44; immunochromatography and <span class="elsevierStyleItalic">Western Blot</span> use recombinant antigens or synthetic peptides&#46; If the initial serology is negative&#44; it is repeated 3 weeks later and diagnosis would be confirmed if there is seroconversion or variation of 3 serologic titres by indirect immunofluorescence&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Xenodiagnosis is not a method used in Europe as it requires the vector&#46; The molecular diagnosis by polymerase chain reaction is used only in reference centres&#44; but allows the identification of the parasite in the acute phase before serological positivity&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The use of these methodologies is reflected in the outbreaks described in the medical literature&#44; being the direct examination&#44; serology by indirect immunofluorescence and the enzyme immunoassay method the most commonly used tests&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Treatment</span><p id="par0215" class="elsevierStylePara elsevierViewall">Specific treatment is standard for all modes of transmission of <span class="elsevierStyleItalic">T&#46; cruzi</span> and it should be initiated as soon as possible&#46; The goal is to cure the infection&#44; prevent organ damage or the development of the same&#44; and reduce the possibility of transmission &#40;vertical&#44; transfusion&#44; transplantation&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Benznidazole is the drug of choice &#40;100<span class="elsevierStyleHsp" style=""></span>mg tablets&#41; and dose varies depending on age and weight&#46; It is taken orally in 2 daily doses for 60 days &#40;adults&#58; 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; children 5&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day and infants 10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">48</span></a> The drug can be given in shorter cycles or intermittently if there is a case of intolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">49</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The most common adverse reactions are skin disease&#44; neuropathy&#44; nausea&#44; vomiting and diarrhoea&#46; In mild cases&#44; the treatment is maintained&#44; in moderate cases&#44; it is better to interrupt temporarily&#44; treat the symptoms and gradually reintroduce the drug&#46; In case of serious side effects&#44; augesia &#40;complete loss of taste&#41; or marrow hypoplasia &#40;&#60;1&#37;&#41;&#44; the treatment is discontinued&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">48</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">An alternative is nifurtimox &#40;120<span class="elsevierStyleHsp" style=""></span>mg tablets&#41;&#44; whose dose also depends on the patient&#39;s age and weight&#44; administered in 3 and 4 times daily during 90 days &#40;adults&#58; 8&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; children&#58; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#46; The most common side effects are anorexia&#44; weight loss&#44; psychic disorders&#44; irritability&#44; drowsiness&#44; nausea&#44; vomiting&#44; cramps and diarrhoea&#46; Testicular damage&#44; ovarian toxicity and deleterious effects on adrenal&#44; colon&#44; oesophagus and breast tissue have also been observed&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">50</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Both drugs showed significant mutagenic effects and proved carcinogenic in some studies&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">50</span></a> Treatment should be postponed until after the first trimester&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Remission involves serological negativity which in most cases occurs up to 5 years after treatment&#44; so the performance of serological tests &#40;IgG&#41; every 6 months or annually until 2 successive tests are nonreactive is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Preventing orally-transmitted acute Chagas disease</span><p id="par0245" class="elsevierStylePara elsevierViewall">Orally-transmitted acute CD is a preventable disease if proper measures are taken&#46; In this sense&#44; traveller education is essential to ensure a responsible and qualitative food consumption&#44; which involves knowledge of the entire production chain&#44; from source to consumption&#46;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">48&#44;51&#8211;53</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the prevention measures for orally-transmitted acute CD&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0250" class="elsevierStylePara elsevierViewall">Proper care of persons infected with <span class="elsevierStyleItalic">T&#46; cruzi</span> is an essential strategy for a comprehensive control of the CD and its elimination as a public health problem&#46; Faced with the exponential increase in cases over the past decade&#44; it is important to have knowledge of the oral route as a mechanism of transmission of the disease&#44; to provide adequate information to travellers&#44; suggest measures for prevention and early diagnosis in case of epidemiological risk and&#47;or compatible clinical symptoms&#44; even away from vector transmission areas&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chagas disease is a zoonosis caused by protozoan parasite <span class="elsevierStyleItalic">Trypanosoma cruzi</span>&#44; which is most frequently associated with a vectorial transmission&#46; However&#44; in recent years we have observed a significant increase in the oral transmission of the disease&#44; associated mainly with the consumption of drinks made from fruit or other vegetables contaminated with triatomine faeces or secretions from infected mammals&#46; After a latency period of 3&#8211;22 days after ingestion&#44; the oral infection is characterized by more severe manifestations than those associated with vectorial transmission&#58; prolonged fever&#44; acute myocarditis with heart failure and&#44; in some cases&#44; meningoencephalitis&#46; Mortality can reach up to 33&#37; of those infected&#46; The aim of this paper is to review this matter and to promote prevention practices&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Chagas es una zoonosis causada por el par&#225;sito protozoario <span class="elsevierStyleItalic">Trypanosoma cruzi</span>&#44; transmitido con mayor frecuencia por v&#237;a vectorial&#46; En los &#250;ltimos a&#241;os&#44; sin embargo&#44; se est&#225; observando un aumento marcado de la transmisi&#243;n de la enfermedad por v&#237;a oral&#44; asociada al consumo de bebidas preparadas a base de frutas u otros vegetales contaminados con las heces de triatominos o secreciones de mam&#237;feros infectados&#46; Despu&#233;s de un per&#237;odo de latencia de 3-22 d&#237;as&#44; a partir de la ingesti&#243;n&#44; la infecci&#243;n oral se caracteriza por manifestaciones m&#225;s graves que la vectorial&#58; fiebre prolongada&#44; miocarditis aguda con insuficiencia card&#237;aca y en algunos casos meningoencefalitis&#46; La mortalidad puede llegar hasta un 33&#37; de los infectados&#46; El objetivo de este trabajo es realizar una revisi&#243;n del fen&#243;meno y promover pr&#225;cticas de prevenci&#243;n&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Filigheddu MT&#44; G&#243;rgolas M&#44; Ramos JM&#46; Enfermedad de Chagas de transmisi&#243;n oral&#46; Med Clin &#40;Barc&#41;&#46; 2017&#59;148&#58;125&#8211;131&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1519
            "Ancho" => 2811
            "Tamanyo" => 191447
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distribution of signs and symptoms in outbreaks of orally-transmitted acute Chagas disease&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic methods used in orally-transmitted acute Chagas disease outbreaks&#46; PCR&#58; polymerase chain reaction&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">City&#47;state&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transmission source&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No deaths&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0430">33</a><br><a class="elsevierStyleCrossRef" href="#bib0435">34</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1936&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Argentina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chaco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breastmilk<br>Inadequately cooked meat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0430">33</a><br><a class="elsevierStyleCrossRef" href="#bib0435">34</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1936&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ecuador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Meat of wild animals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0290">5</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1965&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Teutonia&#44; Rio Grande do Sul&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated vegetables &#40;marsupials&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0295">6</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1988&#8211;2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Para&#44; Amapa&#44; Maranhao&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&#47;Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#231;a&#237; juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0335">14</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2002&#8211;2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Putumayo&#44; Arauca&#44; Casanare&#44; Santander&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0310">9</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">St&#46; Catarina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tourists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sugar cane juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0270">1</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Par&#225;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reuni&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#231;a&#237; juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0315">10</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macaubas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Water&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<br>&#40;Myocarditis&#47;respiratory failure&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0320">11</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cear&#225;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vegetable soup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0375">22</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chacao&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Students<br>Workers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Guava juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0425">32</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">French Guyana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Iracoubo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palm juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0340">15</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lebrija<br>&#40;Santander&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Orange juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0385">24</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chichiriviche&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Students<br>Workers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Guava juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0390">25</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tachira&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0355">18</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antioquia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<br>&#40;Unclear&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0360">19</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aguachica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Periurban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0325">12</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rio Negro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tourist boat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#231;a&#237; juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0420">31</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bolivia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Guayamer&#237;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Majo milk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0400">27</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Merida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0370">21</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Casanare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mining sector&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contaminated food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0405">28</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mirmire&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mango juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib0410">29</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macarena&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Natural juice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<br>&#40;Myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Epidemiological characteristics of orally-transmitted acute Chagas disease outbreaks&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Source of infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col">Animals of the <span class="elsevierStyleItalic">Didephix</span> genus &#40;opossum&#44; fara&#41; infected by <span class="elsevierStyleItalic">Trypanosoma cruzi</span></th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col">Insect vectors &#40;triatomine&#41; infected by <span class="elsevierStyleItalic">Trypanosoma cruzi</span></th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ingestion-acquired&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fruits or food sprayed with secretions from the odoriferous anal glands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Undercooked game meat from infected animals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Foods prepared with crushed insect vectors &#40;cane juice&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Food contaminated with triatomine droppings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Forms of orally-transmitted acute Chagas disease&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acquire fruits or other foods from registered suppliers&#44; if possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluate food at the time of purchasing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ensure that the food has been stored in clean&#44; waterproof containers&#44; protected from potential contaminants and distant from light sources&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food always needs to be washed and disinfected before preparing and eating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Utensils that come into contact with food should be made with smooth&#44; washable&#44; easy to clean and corrosion-resistant materials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Protect food and kitchen areas from insects or other animals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wash vegetables especially if they are eaten raw and store in the refrigerator after having washed them&#44; in dry plastic bags&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cooling or freezing food does not prevent the oral transmission of <span class="elsevierStyleItalic">T&#46; cruzi</span> but cooking<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>45&#176;&#44; pasteurization and freeze drying does&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cook food thoroughly&#44; especially meat&#46; The juice should be clear&#44; not pink&#44; the inner part should not be included&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food ready for consumption should be protected from contamination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The vehicle used for food transport must be clean&#44; with a cover&#44; it should not carry animals&#44; toxic chemicals or other contaminants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The hands should always be washed before food ingestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Preventing orally-transmitted acute Chagas disease&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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