title: Increased mortality attributed to Chagas disease: a systematic review and meta-analysis.
abstract: BACKGROUND
  The clinical outcomes associated with Chagas disease remain poorly understood. In addition to the burden of morbidity, the burden of mortality due to Trypanosoma cruzi infection can be substantial, yet its quantification has eluded rigorous scrutiny. This is partly due to considerable heterogeneity between studies, which can influence the resulting estimates. There is a pressing need for accurate estimates of mortality due to Chagas disease that can be used to improve mathematical modelling, burden of disease evaluations, and cost-effectiveness studies.
  
  
  METHODS
  A systematic literature review was conducted to select observational studies comparing mortality in populations with and without a diagnosis of Chagas disease using the PubMed, MEDLINE, EMBASE, Web of Science and LILACS databases, without restrictions on language or date of publication. The primary outcome of interest was mortality (as all-cause mortality, sudden cardiac death, heart transplant or cardiovascular deaths). Data were analysed using a random-effects model to obtain the relative risk (RR) of mortality, the attributable risk percent (ARP), and the annual mortality rates (AMR). The statistic I(2) (proportion of variance in the meta-analysis due to study heterogeneity) was calculated. Sensitivity analyses and publication bias test were also conducted.
  
  
  RESULTS
  Twenty five studies were selected for quantitative analysis, providing data on 10,638 patients, 53,346 patient-years of follow-up, and 2739 events. Pooled estimates revealed that Chagas disease patients have significantly higher AMR compared with non-Chagas disease patients (0.18 versus 0.10; RR = 1.74, 95% CI 1.49-2.03). Substantial heterogeneity was found among studies (I(2) = 67.3%). The ARP above background mortality was 42.5%. Through a sub-analysis patients were classified by clinical group (severe, moderate, asymptomatic). While RR did not differ significantly between clinical groups, important differences in AMR were found: AMR = 0.43 in Chagas vs. 0.29 in non-Chagas patients (RR = 1.40, 95% CI 1.21-1.62) in the severe group; AMR = 0.16 (Chagas) vs. 0.08 (non-Chagas) (RR = 2.10, 95% CI 1.52-2.91) in the moderate group, and AMR = 0.02 vs. 0.01 (RR = 1.42, 95% CI 1.14-1.77) in the asymptomatic group. Meta-regression showed no evidence of study-level covariates on the effect size. Publication bias was not statistically significant (Egger's test p=0.08).
  
  
  CONCLUSIONS
  The results indicate a statistically significant excess of mortality due to Chagas disease that is shared among both symptomatic and asymptomatic populations.
authors.affiliation: London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's campus), Imperial College London, Norfolk Place, London, W2 1PG, United Kingdom. zcucunuba@gmail.com.|Grupo de Parasitología - RED CHAGAS, Instituto Nacional de Salud, Bogotá, Colombia. zcucunuba@gmail.com.
authors.forename: Zulma M
authors.initials: ZM
authors.lastname: Cucunubá
authors.affiliation: London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's campus), Imperial College London, Norfolk Place, London, W2 1PG, United Kingdom. omolade.okuwoga14@imperial.ac.uk.
authors.forename: Omolade
authors.initials: O
authors.lastname: Okuwoga
authors.affiliation: London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's campus), Imperial College London, Norfolk Place, London, W2 1PG, United Kingdom. m.basanez@imperial.ac.uk.
authors.forename: María-Gloria
authors.initials: MG
authors.lastname: Basáñez
authors.affiliation: London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's campus), Imperial College London, Norfolk Place, London, W2 1PG, United Kingdom. p.nouvellet@imperial.ac.uk.|Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's campus), Imperial College London, London, UK. p.nouvellet@imperial.ac.uk.
authors.forename: Pierre
authors.initials: P
authors.lastname: Nouvellet
mesh_terms: D000818:Animals; D014355:Chagas Disease / Q000401:mortality*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D012307:Risk Factors; D014349:Trypanosoma cruzi / Q000502:physiology*
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