{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T17:22:08Z","timestamp":1788283328520,"version":"build-2803163510"},"reference-count":94,"publisher":"American Society of Tropical Medicine and Hygiene","license":[{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,1]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>\n                    Chagas disease, caused by\n                    <jats:italic>Trypanosoma cruzi<\/jats:italic>\n                    , poses an emerging and under recognized threat to U.S. military personnel deployed in endemic regions. Despite significant morbidity and mortality risks, the US Department of Defense (DoD) lacks comprehensive policies for Chagas disease prevention, screening, or treatment, unlike other similar infectious diseases. We conducted a comparative policy analysis of existing DoD policies on tuberculosis, HIV, and hepatitis C to inform the development of Chagas disease policy. Using an adapted Political, Administrative, Social, Technological, Economic, Legal factors (PASTEL) framework, we evaluated five policy alternatives through expert consensus scoring. Military health policies and literature were systematically reviewed to identify screening protocols, risk assessment tools, and prevention strategies. Analysis of current military screening policies revealed significant gaps in Chagas disease coverage in comparison with analogous infectious diseases. The decision matrix analysis identified an integrated Periodic Health Assessment (PHA) approach as the optimal policy alternative (weighted score 4.20\/5.0), followed by targeted risk-based screening (3.85\/5.0). Universal screening scored lowest (2.20\/5.0) due to poor cost-effectiveness and implementation challenges. The recommended approach leverages existing annual health assessment infrastructure while incorporating Chagas disease-specific risk evaluation tools. A tiered policy strategy integrating Chagas disease risk assessment into routine military health evaluations offers the most feasible approach for protecting service members. Implementation should prioritize risk-based screening, vector-control measures (e.g., insecticide-treated uniforms), and enhanced surveillance in endemic deployment areas. This framework provides an evidence-based foundation for developing comprehensive DoD Chagas disease policies.\n                  <\/jats:p>","DOI":"10.4269\/ajtmh.26-0052","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T17:09:53Z","timestamp":1788282593000},"source":"Crossref","is-referenced-by-count":0,"title":["Policy Recommendations for Chagas Disease: An Emerging Concern of Public Health Significance for the U.S. Military"],"prefix":"10.4269","author":[{"given":"Gerardo J.","family":"Pacheco","sequence":"first","affiliation":[{"name":"School of Health Administration, Texas State University, San Marcos, Texas, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose A.","family":"Betancourt","sequence":"additional","affiliation":[{"name":"School of Health Administration, Texas State University, San Marcos, Texas, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diane","family":"Dolezel","sequence":"additional","affiliation":[{"name":"Department of Health Informatics and Information Management, Texas State University, San Marcos, Texas, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley M.","family":"Beauvais","sequence":"additional","affiliation":[{"name":"School of Health Administration, Texas State University, San Marcos, Texas, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph E.","family":"Marcus","sequence":"additional","affiliation":[{"name":"Brooke Army Medical Center, Fort Sam Houston, Texas, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Lenhart","sequence":"additional","affiliation":[{"name":"Entomological Sciences Division, Public Health Command, West, Fort Sam Houston, Texas, USA;"},{"name":"Entomology Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paula S.","family":"Granados","sequence":"additional","affiliation":[{"name":"School of Public Health, San Diego State University, San Diego, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2795","reference":[{"key":"b1","article-title":"World Chagas Disease Day: Finding and Reporting Every Case.","year":"2023"},{"issue":"7","key":"b2","series-title":"Emerg Infect Dis","first-page":"1313","article-title":"Updated estimates and mapping for prevalence of Chagas disease among adults, United States","volume":"28","author":"Irish","year":"2022"},{"issue":"1","key":"b3","series-title":"Clin Microbiol Rev","first-page":"e00023-19","article-title":"Chagas disease in the United States: A public health approach","volume":"33","author":"Bern","year":"2019"},{"issue":"9","key":"b4","series-title":"Emerg Infect Dis","first-page":"1691","article-title":"Chagas disease, an endemic disease in the United States","volume":"31","author":"Beatty","year":"2025"},{"key":"b5","article-title":"About Chagas Disease.","year":"2024"},{"issue":"5","key":"b6","series-title":"Am J Trop Med Hyg","first-page":"814","article-title":"Neglected parasitic infections in the United States: Chagas disease","volume":"90","author":"Montgomery","year":"2014"},{"issue":"18","key":"b7","series-title":"JAMA","first-page":"2171","article-title":"Evaluation and treatment of Chagas disease in the United States: A systematic review","volume":"298","author":"Bern","year":"2007"},{"key":"b8","article-title":"Chagas Disease.","year":"2024"},{"issue":"1","key":"b9","series-title":"BMC Infect Dis","first-page":"743","article-title":"Assessing the effectiveness of Chagas disease education for healthcare providers in the United States","volume":"20","author":"Stigler Granados","year":"2020"},{"issue":"6","key":"b10","series-title":"Am J Trop Med Hyg","first-page":"1225","article-title":"What do we know about Chagas disease in the United States?","volume":"95","author":"Montgomery","year":"2016"},{"issue":"6","key":"b11","series-title":"Zoonoses Public Health","first-page":"491","article-title":"Autochthonous Chagas disease in the southern United States: A case report of suspected residential and military exposures","volume":"64","author":"Harris","year":"2017"},{"issue":"5","key":"b12","series-title":"Am J Trop Med Hyg","first-page":"1477","article-title":"Prevalence and seroprevalence of Trypanosoma cruzi infection in a military population in Texas","volume":"97","author":"Webber","year":"2017"},{"issue":"9","key":"b13","series-title":"Emerg Infect Dis","first-page":"1882","article-title":"Acute Chagas disease outbreak among military personnel, Colombia, 2021","volume":"29","author":"Vergara","year":"2023"},{"issue":"12","key":"b14","series-title":"PLoS Negl Trop Dis","first-page":"e0004235","article-title":"Combining public health education and disease ecology research: Using citizen science to assess Chagas disease entomological risk in Texas","volume":"9","author":"Curtis-Robles","year":"2015"},{"key":"b15","article-title":"Department of Defense HIV\/AIDS Prevention Program.","year":"2025"},{"key":"b16","article-title":"The Tuberculosis Surveillance and Control Program.","year":"2013"},{"key":"b17","article-title":"HIV\/AIDS in the Military.","author":"Mendez","year":"2023"},{"key":"b18","series-title":"SECNAV Instruction 5300.30F: Management of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection in the Navy and Marine Corps","year":"2018"},{"key":"b19","article-title":"Air Force Manual 48-105 Public Health Surveillance.","year":"2020"},{"key":"b20","series-title":"Lancet Reg Health Am","first-page":"100768","article-title":"Chagas disease in the United States: A call for increased investment and collaborative research","volume":"34","author":"Agudelo Higuita","year":"2024"},{"issue":"3","key":"b21","series-title":"Am J Trop Med Hyg","first-page":"967","article-title":"Autochthonous Chagas disease in the United States: How are people getting infected?","volume":"103","author":"Beatty","year":"2020"},{"key":"b22","article-title":"Chagas Disease.","year":"2024"},{"issue":"9","key":"b23","series-title":"J Infect Dis","first-page":"1601","article-title":"Recommendations for screening and diagnosis of Chagas disease in the United States","volume":"225","author":"Forsyth","year":"2022"},{"key":"b24","article-title":"Screening Programmes: A Short Guide.","year":"2020"},{"key":"b25","article-title":"Air Force Policy Directive 48-1.","year":"2023"},{"issue":"5","key":"b26","series-title":"MSMR","first-page":"4","article-title":"Tuberculosis trends in the U.S. Armed Forces, active component, 1998\u20132012","volume":"20","author":"Mancuso","year":"2013"},{"issue":"1","key":"b27","series-title":"Am J Public Health","first-page":"60","article-title":"Tuberculosis screening and control in the U.S. military in war and peace","volume":"107","author":"Mancuso","year":"2017"},{"key":"b28","series-title":"BUMEDINST 6224.8C: Tuberculosis Surveillance and Control Program","year":"2018"},{"key":"b29","article-title":"Federal Judge Rules Defense Department Can\u2019t Ban HIV-Positive People from Joining the Military.","author":"Kime","year":"2024"},{"key":"b30","article-title":"HIV\/AIDS in the Military.","author":"Mendez","year":"2023"},{"key":"b31","article-title":"Clinical Screening and Diagnosis for Hepatitis C.","year":"2025"},{"issue":"5","key":"b32","series-title":"MSMR","first-page":"12","article-title":"Viral hepatitis C, active component, U.S. military service members and beneficiaries, 2008\u20132016","volume":"24","author":"Stahlman","year":"2017"},{"issue":"10","key":"b33","series-title":"MSMR","first-page":"2","article-title":"Viral hepatitis C, active component, U.S. Armed Forces, 2011\u20132020","volume":"29","author":"Stahlman","year":"2022"},{"key":"b34","article-title":"Brief Report: Prevalence of Hepatitis C Virus Infections in U.S. Air Force Basic Military Trainees Who Donated Blood, 2017\u20132020.","year":"2021"},{"key":"b35","series-title":"Public Health Intelligence","first-page":"91","author":"Gilbert","year":"2016"},{"issue":"7","key":"b36","series-title":"MSMR","first-page":"15","article-title":"The evolution of military health surveillance reporting: A historical review","volume":"28","author":"Mancuso","year":"2021"},{"key":"b37","article-title":"Armed Forces Reportable Medical Events: Guidelines and Case Definitions.","year":"2022"},{"issue":"4","key":"b38","series-title":"MSMR","first-page":"13","article-title":"Four decades of HIV antibody screening in the U.S. military: A review of incidence and demographic trends, 1990\u20132024","volume":"32","author":"Aumakhan","year":"2025"},{"key":"b39","article-title":"Diagnosis of Hepatitis C Infection and Cascade of Care in the Active Component, U.S. Armed Forces, 2020.","author":"Legg","year":"2024"},{"key":"b40","series-title":"Basics of Health Care Performance Improvement: A Lean Six Sigma Approach","author":"Lighter","year":"2013"},{"key":"b41","series-title":"Health Policymaking in the United States","author":"Longest","year":"2016"},{"key":"b42","series-title":"Public Policy: Politics, Analysis, and Alternatives","volume":"26","author":"Kraft","year":"2007"},{"key":"b43","article-title":"Military Health System Strategy: Fiscal Years 2024\u20132029.","year":"2023"},{"issue":"10","key":"b44","series-title":"MSMR","first-page":"2","article-title":"Routine screening for antibodies to human immunodeficiency virus in the U.S. Armed Forces, active and reserve components, January 2019-June 2024","volume":"31","year":"2024"},{"issue":"9","key":"b45","series-title":"Open Forum Infect Dis","first-page":"ofaf522","article-title":"Outcomes in military blood donors at joint base San Antonio with reactive Trypanosoma cruzi antibody screening results","volume":"12","author":"Wells","year":"2025"},{"key":"b46","series-title":"Open Forum Infect Dis","first-page":"S120","article-title":"Follow-up evaluation of Air Force blood donors screening positive for Chagas disease","volume":"4","author":"Marcus","year":"2017"},{"key":"b47","article-title":"155,000 Military Health System Patients to be Pushed to Civilian Care Starting This Year.","author":"Kime","year":"2022"},{"key":"b1","article-title":"World Chagas Disease Day: Finding and Reporting Every Case.","year":"2023"},{"issue":"7","key":"b2","series-title":"Emerg Infect Dis","first-page":"1313","article-title":"Updated estimates and mapping for prevalence of Chagas disease among adults, United States","volume":"28","author":"Irish","year":"2022"},{"issue":"1","key":"b3","series-title":"Clin Microbiol Rev","first-page":"e00023-19","article-title":"Chagas disease in the United States: A public health approach","volume":"33","author":"Bern","year":"2019"},{"issue":"9","key":"b4","series-title":"Emerg Infect Dis","first-page":"1691","article-title":"Chagas disease, an endemic disease in the United States","volume":"31","author":"Beatty","year":"2025"},{"key":"b5","article-title":"About Chagas Disease.","year":"2024"},{"issue":"5","key":"b6","series-title":"Am J Trop Med Hyg","first-page":"814","article-title":"Neglected parasitic infections in the United States: Chagas disease","volume":"90","author":"Montgomery","year":"2014"},{"issue":"18","key":"b7","series-title":"JAMA","first-page":"2171","article-title":"Evaluation and treatment of Chagas disease in the United States: A systematic review","volume":"298","author":"Bern","year":"2007"},{"key":"b8","article-title":"Chagas Disease.","year":"2024"},{"issue":"1","key":"b9","series-title":"BMC Infect Dis","first-page":"743","article-title":"Assessing the effectiveness of Chagas disease education for healthcare providers in the United States","volume":"20","author":"Stigler Granados","year":"2020"},{"issue":"6","key":"b10","series-title":"Am J Trop Med Hyg","first-page":"1225","article-title":"What do we know about Chagas disease in the United States?","volume":"95","author":"Montgomery","year":"2016"},{"issue":"6","key":"b11","series-title":"Zoonoses Public Health","first-page":"491","article-title":"Autochthonous Chagas disease in the southern United States: A case report of suspected residential and military exposures","volume":"64","author":"Harris","year":"2017"},{"issue":"5","key":"b12","series-title":"Am J Trop Med Hyg","first-page":"1477","article-title":"Prevalence and seroprevalence of Trypanosoma cruzi infection in a military population in Texas","volume":"97","author":"Webber","year":"2017"},{"issue":"9","key":"b13","series-title":"Emerg Infect Dis","first-page":"1882","article-title":"Acute Chagas disease outbreak among military personnel, Colombia, 2021","volume":"29","author":"Vergara","year":"2023"},{"issue":"12","key":"b14","series-title":"PLoS Negl Trop Dis","first-page":"e0004235","article-title":"Combining public health education and disease ecology research: Using citizen science to assess Chagas disease entomological risk in Texas","volume":"9","author":"Curtis-Robles","year":"2015"},{"key":"b15","article-title":"Department of Defense HIV\/AIDS Prevention Program.","year":"2025"},{"key":"b16","article-title":"The Tuberculosis Surveillance and Control Program.","year":"2013"},{"key":"b17","article-title":"HIV\/AIDS in the Military.","author":"Mendez","year":"2023"},{"key":"b18","series-title":"SECNAV Instruction 5300.30F: Management of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection in the Navy and Marine Corps","year":"2018"},{"key":"b19","article-title":"Air Force Manual 48-105 Public Health Surveillance.","year":"2020"},{"key":"b20","series-title":"Lancet Reg Health Am","first-page":"100768","article-title":"Chagas disease in the United States: A call for increased investment and collaborative research","volume":"34","author":"Agudelo Higuita","year":"2024"},{"issue":"3","key":"b21","series-title":"Am J Trop Med Hyg","first-page":"967","article-title":"Autochthonous Chagas disease in the United States: How are people getting infected?","volume":"103","author":"Beatty","year":"2020"},{"key":"b22","article-title":"Chagas Disease.","year":"2024"},{"issue":"9","key":"b23","series-title":"J Infect Dis","first-page":"1601","article-title":"Recommendations for screening and diagnosis of Chagas disease in the United States","volume":"225","author":"Forsyth","year":"2022"},{"key":"b24","article-title":"Screening Programmes: A Short Guide.","year":"2020"},{"key":"b25","article-title":"Air Force Policy Directive 48-1.","year":"2023"},{"issue":"5","key":"b26","series-title":"MSMR","first-page":"4","article-title":"Tuberculosis trends in the U.S. Armed Forces, 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screening in the U.S. military: A review of incidence and demographic trends, 1990\u20132024","volume":"32","author":"Aumakhan","year":"2025"},{"key":"b39","article-title":"Diagnosis of Hepatitis C Infection and Cascade of Care in the Active Component, U.S. Armed Forces, 2020.","author":"Legg","year":"2024"},{"key":"b40","series-title":"Basics of Health Care Performance Improvement: A Lean Six Sigma Approach","author":"Lighter","year":"2013"},{"key":"b41","series-title":"Health Policymaking in the United States","author":"Longest","year":"2016"},{"key":"b42","series-title":"Public Policy: Politics, Analysis, and Alternatives","volume":"26","author":"Kraft","year":"2007"},{"key":"b43","article-title":"Military Health System Strategy: Fiscal Years 2024\u20132029.","year":"2023"},{"issue":"10","key":"b44","series-title":"MSMR","first-page":"2","article-title":"Routine screening for antibodies to human immunodeficiency virus in the U.S. Armed Forces, active and reserve components, January 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