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Brief report
Relevance of screening for Chagas and viral hepatitis in Bolivian migrants
Relevancia del cribado de Chagas y hepatitis vírica en emigrantes bolivianos
Irene Losada Galvána,
Corresponding author
irene.losada@isglobal.org

Corresponding author.
, Giuseppe Gariupb, Aina Casellasa, Carme Subiràa, Natalia Rodríguez-Valeroa, María Jesús Pinazoa
a ISGlobal, Hospital Clínic – Universitat de Barcelona, Barcelona, Spain
b Internal Medicine, Hospital Clinic, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Global migratory movements in recent decades imply new challenges for health professionals and policy makers&#46; One of the diseases that best illustrates this challenge is Chagas disease &#40;CD&#41;&#44; caused by chronic infection by <span class="elsevierStyleItalic">Trypanosoma cruzi</span> parasite&#46; Arround 6&#8211;7 million people worldwide are infected with <span class="elsevierStyleItalic">T&#46;cruzi</span>&#44; mainly in Latin America &#40;LA&#41;&#44; where it causes more than 10000 deaths per year&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> It is estimated that 120&#44;000 people are infected in Europe&#44; 50&#44;000 of them in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The relevance of conducting Chagas disease screening in LA migrants is based on its potential for transmission &#40;through blood transfusion&#44; organ transplantation or mother to child&#41; and its potential progression to cardiac&#44; digestive or neurological complications in 35&#8211;45&#37; of those infected&#46; <span class="elsevierStyleItalic">Strongyloides stercoralis</span>&#44; highly prevalent in LA countries is commonly asymptomatic&#44; but can develop into a lethal disease in the context of immunosuppression&#46; <span class="elsevierStyleItalic">T&#46; cruzi</span> infection is associated with a two-fold increase in the odds of strongyloidiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Around 257 million persons live with chronic Hepatitis B Virus &#40;HBV&#41; infection&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> It is usually asymptomatic&#44; but 20&#8211;30&#37; will develop complications including liver cirrhosis and hepatocellular carcinoma&#46; There is a broad consensus on the pertinence of screening for hepatitis B in people from countries with prevalence greater than 2&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> In contrast&#44; prevalence of chronic infection with hepatitis C virus &#40;HCV&#41; is higher in Spain compared to LA countries&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Considering the scarcity of data of these entities in LA migrants&#44; our study aims to assess the burden of these diseases in LA migrants attending our center&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This retrospective observational study was performed at the International Health department in Hospital Clinic of Barcelona&#46; We reviewed medical records from patients at risk of <span class="elsevierStyleItalic">T&#46; cruzi</span> infection attending our unit between February 2012 and April 2015&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first visit consists of an interview collecting epidemiological information and relevant medical history&#46; A physical examination is performed and diagnostic tests are requested according to current screening guidelines&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Screening of Chagas was performed with a chemiluminescent microparticle immunoassay &#40;ARCHITECT Chagas&#174;&#44; Abbott&#41;&#46; A positive result was confirmed with a conventional ELISA with recombinant antigens &#40;CHAGAS ELISA IgG&#43;IgM&#44; Vircell&#41;&#46; <span class="elsevierStyleItalic">S&#46; stercoralis</span> infection was screened by a one-step sandwich-format immunoassay for detection of IgG-class antibodies &#40;Strongyloides ELISA&#44; SciMedx&#41;&#46; Detection of hepatitis B virus antigens &#40;HBsAgII&#44; HBc Total&#44; antiHBs 2&#44; Advia Centaur&#41; were used to assess HBV status&#46; Chronic HCV infection was detected using antibodies against hepatitis C &#40;HCV&#44; Advia Centaur&#41;&#46; Screening of HIV was made by a chemiluminometric immunoassay of antigen binding microparticles &#40;HIV 1&#47;O&#47;2 Enhanced Assay&#44; Avia Centaur&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data were presented as frequencies and median &#40;interquartile range&#44; IQR&#41; for discrete and continuous variables&#44; respectively&#46; Proportions were compared using Chi-squared test or Fisher&#39;s exact test if the application conditions of the former where not met&#46; Medians were compared between groups using Wilcoxon Rank Sum test&#46; Significance was set at 0&#46;05&#46; The analysis was carried out using Stata 15 &#40;StataCorp&#46; 2017&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study was approved by the ethics committee for medical research of Hospital Clinic Barcelona with reference number HCB&#47;2018&#47;0521&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Over the study period&#44; 565 individuals were screened for <span class="elsevierStyleItalic">T&#46; cruzi</span> and other infectious diseases&#46; Bolivian patients accounted for 87&#37; of the study population&#46; Demographic characteristics and risk factors for <span class="elsevierStyleItalic">T&#46; cruzi</span> infection are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Chagas disease</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">T&#46; cruzi</span> was positive in 273 participants &#40;48&#37;&#41; of the screened individuals&#46; Out of 80 patients whose mothers had confirmed positive serology for <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; 32 &#40;40&#37;&#59; 95&#37;CI&#58; 29&#8211;52&#37;&#41; were also positive for <span class="elsevierStyleItalic">T&#46; cruzi&#46; T&#46;cruzi</span> positivity in relation to other infectious diseases is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Hepatitis B virus</span><p id="par0045" class="elsevierStylePara elsevierViewall">There was a 7&#37; prevalence of positive serology for HBV &#40;either by chronic or immune by past infection&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; with one case &#40;0&#46;2&#37;&#41; of chronic HBV&#46; The remaining 93&#37; had a negative serology for HBV or were immune by vaccination&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hepatitis C virus</span><p id="par0050" class="elsevierStylePara elsevierViewall">There was one positive result from a patient who was also positive for <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; but negative for HBV and HIV&#46; This patient was initially screened for HCV in 2014 with a negative result and had not traveled ever since&#46; Acute HCV infection &#40;genotype 1a&#41; acquired in Spain between February and March 2016 was suspected&#46; Elastography showed no fibrosis and was successfully treated with Sofosbuvir&#47;Ledipasvir in 2017&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095"><span class="elsevierStyleItalic">Strongyloides stercoralis</span></span><p id="par0055" class="elsevierStylePara elsevierViewall">A serologic test and&#47;or stool sample for parasite examination was obtained in 71&#37; of the study population&#44; with an overall prevalence of 16&#37;&#46; This prevalence of <span class="elsevierStyleItalic">S&#46; stercoralis</span> infection was significantly higher in patients who were also positive for <span class="elsevierStyleItalic">T&#46; cruzi&#46;</span></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The aim of this study was to describe the prevalence of different infectious diseases in Bolivian and other LA migrants attending a referral International Health service in order to establish more accurate screening protocols according to international recommendations&#46; Bolivian origin of most of our patients limits the generalization of the results to the LA community as a whole&#44; but provides with a robust source of information about the Bolivian community in our context&#46; A relevant finding was a high prevalence &#40;48&#37;&#41; for <span class="elsevierStyleItalic">T&#46; cruzi</span> infection&#46; This could be explained by the fact that most patients came from highly endemic areas in Bolivia with an expected prevalence of 18&#37; and the results might be influenced by community and family clusters that share risk factors for CD&#46; In light of these results and others in other non-endemic countries&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> we cannot stress enough the need for standardized screening programs for <span class="elsevierStyleItalic">T&#46; cruzi</span> in LA migrants&#46; An early <span class="elsevierStyleItalic">T&#46; cruzi</span> diagnosis allows the individual evaluation and adequacy of the support treatment according to the clinical stage&#44; especially of women of childbearing age since it reduces the likelihood of congenital transmission&#46; In addition&#44; there are studies in favor of the cost-effectiveness of screening for Chagas disease in this context&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> In agreement with previous work&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> we found a high prevalence of <span class="elsevierStyleBold">Strongyloidiasis</span> and an association with <span class="elsevierStyleItalic">T&#46; cruzi</span> infection&#46; This is probably explained by shared risk factors between both entities&#46; This further supports maintaining a combined screening strategy&#46; Our results show very low chronic <span class="elsevierStyleBold">hepatitis B virus</span> prevalence &#40;0&#46;2&#37;&#41;&#44; although up to 7&#37; of the screened population was immune by past infection&#46; This prevalence would not justify a systematic screening program&#44; since the most accepted threshold is 2&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a> Moreover&#44; no complete serological information was available for almost one third of patients&#44; which constitutes one of the main limitations of the study&#46; In any case&#44; this scenario of young and healthy patients is common in countries that host migrant population&#46; It is the basis on which estimates of the necessary screening can be made&#44; in the absence of reliable epidemiological data from the countries of origin&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Due to the negative gradient of the prevalence of <span class="elsevierStyleBold">hepatitis C virus</span> in Spain with respect to Bolivia&#44; the systematic screening of this disease in the absence of other risk factors would not be granted&#46; However&#44; HCV serology is sometimes performed when requesting other serologies&#44; such as HBV or HIV in young people who are sexually active due to the risk of acquisition in the host country&#46; Our results confirm the relevance of this strategy in both the prevalence of HCV and HIV&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">This work supports the relevance of the screening of <span class="elsevierStyleItalic">T&#46;cruzi</span> and <span class="elsevierStyleItalic">S&#46; stercoralis</span> in Bolivians&#46; According to available evidence&#44; the systematic screening of HCV and HIV is not recommended&#44; with the exception of making at least one determination in sexually active persons&#46; On the other hand&#44; this work questions the relevance of systematic HBV screening in Bolivian migrants given its low prevalence&#46; Epidemiological studies are urgently needed to clarify the situation of HBV in Bolivia in order to direct efforts both inside and outside its borders&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">The team is supported by the <span class="elsevierStyleGrantSponsor" id="gs1">Agencia de Gesti&#243; d&#8217;Ajuts Universitaris i de Recerca &#40;AGAUR&#41;</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">2016SGR924</span>&#41; and by the <span class="elsevierStyleGrantSponsor" id="gs2">Tropical Disease Cooperative Research Network &#40;RICET&#41;</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">RD16&#47;0027&#47;0004</span>&#41;&#46; We acknowledge support from the Spanish Ministry of Science and Innovation through the &#8220;Centro de Excelencia Severo Ochoa 2019-2023&#8221; Program &#40;CEX2018-000806-S&#41;&#44; and support from the Generalitat de Catalunya through the CERCA Program&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Given the scarcity of data regarding prevalence of various infectious diseases in Latin-American countries&#44; our study aims to assess the burden of <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; HIV and viral hepatitis in Latin-American migrants&#44; with a focus on Bolivian migrants&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective observational study of 565 screening evaluations in adults &#40;&#8805;18 years&#41; carried out at our International Healthcare referral service in Barcelona&#46; We reviewed structured clinical records and microbiological results of patients attended between February 2012 and April 2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The median age was 35 years and 74&#37; were women&#46; Of the population screened&#44; 87&#37; were of Bolivian origin&#46; We found a 48&#37; prevalence of <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; 16&#37; of <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; 0&#46;2&#37; of HIV&#44; 0&#46;2&#37; HBV and 0&#46;2&#37; HCV&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">These results support the relevance of screening for <span class="elsevierStyleItalic">T&#46; cruzi</span> and <span class="elsevierStyleItalic">S&#46; stercoralis</span> in Bolivian migrants but challenge the pertinence of systematic screening for HBV in this population&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dada la escasez de datos con relaci&#243;n a la prevalencia de diversas enfermedades infecciosas en los pa&#237;ses iberoamericanos&#44; el objetivo de nuestro estudio fue evaluar la carga de <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; VIH y hepatitis v&#237;rica en los emigrantes iberoamericanos&#44; con especial atenci&#243;n en los emigrantes bolivianos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de 565 cribados en adultos &#40;&#8805; 18 a&#241;os&#41; realizado en nuestro servicio de Servicio de Salud Internacional en Barcelona&#46; Revisamos los registros cl&#237;nicos estructurados y los resultados microbiol&#243;gicos de los pacientes asistidos entre febrero de 2012 y abril de 2015&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 35 a&#241;os y el 74&#37; fueron mujeres&#46; El origen boliviano represent&#243; el 87&#37; de la poblaci&#243;n cribada&#46; Encontramos una prevalencia de 48&#37; de <span class="elsevierStyleItalic">T&#46; cruzi</span>&#44; 16&#37; de <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; 0&#44;2&#37; de VIH&#44; 0&#44;2&#37; de VHB y 0&#44;2&#37; de VHC&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estos resultados respaldan la relevancia del cribado de <span class="elsevierStyleItalic">T&#46; cruzi</span> y <span class="elsevierStyleItalic">S&#46; stercoralis</span> en migrantes bolivianos&#44; aunque cuestiona la pertinencia del cribado sistem&#225;tico de VHB en esta poblaci&#243;n&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;4&#46;4&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immune by vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;6&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;10&#46;5&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Indeterminate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#46;6&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Incomplete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63 &#40;24&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;33&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141 &#40;28&#46;5&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">259 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">236 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">495 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">HCV</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">234 &#40;100&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">223 &#40;99&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">457 &#40;99&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;4891<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;2&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">234 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">224 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">458 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Strongyloides stercoralis</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178 &#40;87&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">152 &#40;76&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">330 &#40;82&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0123<span class="elsevierStyleSup">b</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;11&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;21&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65 &#40;16&#46;2&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Indeterminate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;1&#46;5&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">203 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">198 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">401 &#40;100&#46;0&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2659624.png"
              ]
            ]
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          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025"><span class="elsevierStyleItalic">n</span> &#40;Column percentage&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Fisher&#39;s exact test&#46;</p> <p class="elsevierStyleNotepara" id="npar0035">HIV&#58; Human immunodeficiency virus&#59; HAV&#58; hepatitis A virus&#59; HCV&#58; hepatitis C virus&#46; HBV&#58; hepatitis B virus&#58; Negative&#58; HBsAg&#8722;&#44; HBsAb&#8722;&#44; HBcAb&#8722;&#59; Positive&#58; HBsAg&#43;&#59; Immune by past infection&#58; HBsAg&#8722;&#44; HBsAb&#43;&#44; HBcAb&#43;&#59; Immune by vaccination&#58; HBsAg&#8722;&#44; HBsAb&#43;&#44; HBcAb&#8722;&#59; Indeterminate&#58; HBsAg&#8722;&#44; HBsAb&#8722;&#44; HBcAb&#43;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Other infectious diseases by <span class="elsevierStyleItalic">T&#46; cruzi</span> results&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:9 [
            0 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; Chagas disease &#40;American trypanosomiasis&#41;&#46; Geneva&#59; 2017&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of chagas disease in latin-american migrants living in europe&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Requena-M&#233;ndez"
                            1 => "E&#46; Aldasoro"
                            2 => "E&#46; de Lazzari"
                            3 => "E&#46; Sicuri"
                            4 => "M&#46; Brown"
                            5 => "D&#46;A&#46;J&#46; Moore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pntd.0004151"
                      "Revista" => array:4 [
                        "tituloSerie" => "PLoS Negl Trop Dis"
                        "fecha" => "2015"
                        "volumen" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26516764"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High prevalence of S&#44; Stercoralis infection among patients with Chagas disease&#58; a retrospective case-control study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Puerta-Alcalde"
                            1 => "J&#46; Gomez-Junyent"
                            2 => "A&#46; Requena-Mendez"
                            3 => "M&#46;J&#46; Pinazo"
                            4 => "M&#46;J&#46; &#193;lvarez-Mart&#237;nez"
                            5 => "N&#46; Rodr&#237;guez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pntd.0006369"
                      "Revista" => array:4 [
                        "tituloSerie" => "PLoS Negl Trop Dis"
                        "fecha" => "2018"
                        "volumen" => "12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29734337"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; Global Hepatitis Report&#46; Geneva&#59; 2017&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
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ISSN: 23870206
Original language: English
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