Assessing the Chagas Disease Risk Among the Homeless Population of Houston, Texas Open Access

Abstract

Background: Chagas disease (American Trypanosomiasis) is a parasitic infection endemic to Latin America and is caused by infection with Trypanosoma cruzi. The most common route of infection is by the triatomine vector. The vector is now present in the United States exposing vulnerable populations, such as homeless individuals spending prolonged time outdoors, for potential risk of infection.

Goal: The goal of this research is to address the gap in knowledge about risk of Chagas disease among vulnerable populations in the United States and investigate the risk of Chagas disease among Houston's homeless population participating in previously identified high-risk behaviors and quantify their knowledge through quantitative questionnaires.

Methods: A quantitative questionnaire was written and administered to 212 homeless individuals in Houston, Texas to investigate demographics, health status, knowledge about Chagas disease, and risky behaviors such as sharing of needles, blood transfusions, and length of time spent outdoors. Statistical analyses were conducted to quantify the risk of Chagas disease among the homeless population of Houston.

Results: A majority of those surveyed were male (79%), African-American (43%), American-born individuals (96%) using the Emergency Department as their primary source of healthcare (74%). About 30% of respondents recognized a picture of the triatomine, and 5 individuals believed they had been bitten by the triatomine. More than a quarter of respondents identified engaging in risk behaviors, including unregulated tattoos and using needles to inject drugs. The median total length of time homeless was different for males and females surveyed. The median total time homeless for male respondents was 104 weeks (2 years) and for female respondents was 76 weeks (1.5 years). In the epidemiological model, having chest pain in the past year was a significant predictor; those who did have chest pain were less likely (OR = 0.031 95% CI 0.001, 0.828) to believe they have been bitten by the triatomine than those without chest pain.

Discussion: Based on these findings, the homeless population could be at higher risk for Chagas disease in the Houston area due to the total length of time homeless and nights sleeping outside as well as high-risk behaviors for spreading pathogens in the blood such as injection drug use and unregulated tattoos. Additional research is necessary to quantify the exact prevalence of Chagas disease among the homeless population. Education about Chagas disease transmission and reducing risky behaviors should be disseminated to homeless populations, shelter directors, and medical providers.

Table of Contents

LITERATURE REVIEW........................................................................................................................................................ 1
Research Need and Goal................................................................................................................................................... 1
Chagas Disease Transmission, Symptoms, Testing, and Treatment........................................................................................... 2
Chagas Disease in Non-Endemic Countries........................................................................................................................... 5
Domestic Transmission Cycle in Stray Dogs and Mammals in Texas.......................................................................................... 9
Human Chagas Disease in the United States........................................................................................................................ 12
Demographics of Homeless Population................................................................................................................................ 15
Healthcare Access and Usage Among Homeless Population of Houston, Texas............................................................................ 16
Risk Factors Among Homeless Populations........................................................................................................................... 18
Outdoor Exposures, Shelter Seeking Behaviors, and Risk Factors for Exposure to Vector-Borne Illness Among Homeless Populations... 20
Significance.................................................................................................................................................................... 22
INTRODUCTION................................................................................................................................................................ 24
METHODS....................................................................................................................................................................... 27
Target Population and Consent........................................................................................................................................... 27
Inclusion and Exclusion Criteria.......................................................................................................................................... 28
Study Instrument............................................................................................................................................................. 28
Data Management and Analysis.......................................................................................................................................... 29
RESULTS........................................................................................................................................................................ 31
DISCUSSION................................................................................................................................................................... 34
PUBLIC HEALTH IMPLICATIONS........................................................................................................................................... 43
TABLES AND FIGURES....................................................................................................................................................... 46
Table 1: Demographics...................................................................................................................................................... 46
Table 2: Health Characteristics........................................................................................................................................... 47
Table 3: Knowledge About Chagas Disease........................................................................................................................... 48
Table 4: Frequencies and Participation in Risk Behaviors......................................................................................................... 49
Table 5: Risk Factors Associated With Believing to Have Been Bitten by a Triatomine................................................................... 50
Table 6: Risk Factors Associated With Recognition of Triatomine Picture..................................................................................... 51
Table 7: Risk Factors Associated With Total Length Homeless................................................................................................... 52
Figure 1: Total Length of Time Homeless of Males v. Females................................................................................................... 53
Figure 2: Nights Spent Outdoors Per Week For Males and Females............................................................................................. 54
REFERENCES..................................................................................................................................................................... 55
APPENDIX........................................................................................................................................................................ 60
Survey Instrument............................................................................................................................................................. 60
IRB Approval..................................................................................................................................................................... 69

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	risk United States homeless Houston outdoors Chagas disease
Committee Chair / Thesis Advisor	Leon, Juan, Emory University
Committee Members	Murray, Kristy, National School of Tropical Medicine, Baylor College of Medicine
Partnering Agencies	University, college or educational institution (other than Emory)

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