key: cord-0839077-e86hzyo4 authors: Tilli, Marta; Olliaro, Piero; Gobbi, Federico; Bisoffi, Zeno; Bartoloni, Alessandro; Zammarchi, Lorenzo title: Neglected tropical diseases in non-endemic countries in the era of COVID-19 pandemic: the great forgotten date: 2020-09-24 journal: J Travel Med DOI: 10.1093/jtm/taaa179 sha: 6726bae37680ffa62dbe31ff9e8ab5f05692496d doc_id: 839077 cord_uid: e86hzyo4 In non-endemic countries, the access to healthcare for migrants and other patients with NTDs may be hampered by new barriers linked to the COVID-19 pandemic. Low awareness of health care professionals on the opportunistic potential of some NTDs may lead to unfavorable outcome of COVID-19 patients treated with immunomodulatory drugs. pandemic has created more medical neglect and inequalities worldwide, healthcare delayed and health needs unattended, even in the most advanced health systems, for both chronic and acute conditions. 2 It will take time to appreciate the fuller, long-term effect on public health. What we are seeing are both direct and indirect consequences of measures adopted to tackle the pandemic, and it is little surprise that the typical NTDs are being hit hardest in endemic countries, through a combination of newer (discontinuation of preventive chemotherapy campaigns recommended by the World Health Organization to reduce the risk of SARS-CoV-2 spreading) 1 , and longer-term factors (such as conflicts, embargoes, and social opposition to mass distribution and vaccination programs); a recent paper underlines the major threat of syndemic malaria, NTDs and COVID-19 in low and middleincome countries. 3 In recent years also high-income temperate countries have seen an increase in imported NTD cases -mainly linked to migration, but also to international travels and commerce and to climate changes. 4,5 Schistosomiasis, strongyloidiasis, and Chagas disease are among the most relevant imported NTDs and migrants are those at highest risk for NTDs. 4 In addition, some There are also potential concerns with some of the COVID-19 treatments. Several immunomodulatory drugs have been proposed and used to control the so-called "cytokine storm", and WHO has recently issued a guideline for the use of corticosteroids in COVID-19. 11 The impact of this immunomodulatory therapy on the reactivation of latent infections is poorly known. NTDs such as strongyloidiasis, Chagas disease, and leishmaniasis are often overlooked unlike other infections such as viral hepatitis, HIV and tuberculosis. Although we know that each of these infections may act as an opportunistic disease in all immunosuppressed patients with potentially severe and even fatal manifestations often difficult to identify since the symptoms may be aspecific. Strongyloidiasis is the most concerning disease since even low-dose corticosteroids may induce a S. stercoralis hyperinfection and dissemination with very high fatality rate. 12 All migrants from highly-endemic countries and elderly patients from the endemic foci in temperate areas should be screened for strongyloidiasis using a combination of serology and direct detection on stool through parasitological or molecular methods or presumptively treated with ivermectin when testing is unavailable or delayed and when treatment with steroids is imminent. 12 Concerning Chagas disease and leishmaniasis it seems unlikely that short courses of immunomodulatory drug could increase the risk of a severe reactivation. However, a serological screening in all COVID-19 patients at risk for Chagas disease (such as patients born in continental Latin American or from a continental Latin American mother) seeking medical attention would be useful. Chagas disease underdiagnosis surpasses 94% in nonendemic setting, so testing people at risk would help identify affected subjects and link them to care. 11 Moreover people with Chagas disease could have unidentified cardiac problems which could complicate the course of COVID-19 requiring a more strict follow-up. Concerning leishmaniasis, clinical monitoring of patients currently living or exposed in the past in endemic areas who undergo immunosuppressive treatment is advisable to early detect manifestation such as unexplained prolonged fever, cytopoenia, and muco-cutaneous lesions. In conclusions NTDs are diseases of poverty, sustained by social inequalities, whether in endemic or non-endemic, high-income countries where the most frequently affected subjects are migrants and to a less extent, international travelers and autochthonous subjects in delimited enclaves. COVID-19 can cause more neglect for NTDs affected patients but may also represent an opportunity to screen at risk subjects seeking medical attention in this period for some of these diseases. It is important to raise awareness of health care professionals managing COVID-19 patients about strongyloidiasis and other potentially opportunistic NTDs in order to implement adequate management strategies. It is also important to resume screening programs for NTDs for refugees/migrants, when suspended for COVID-19, and to strengthen diagnostic and treatment capacities in areas that are underserved. As health systems learn how better to cope with COVID-19, let's be reminded that NTDs, though rare in the general population, are disproportionally present in disadvantaged pockets of our populations in high-income countries. 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