1887
Surveillance Open Access
Like 1

Abstract

Background

Chagas disease is endemic in Latin America and affects 8 million people worldwide. In 2010, Catalonia introduced systematic public health surveillance to detect and treat congenital Chagas disease.

Aim

The objective was to evaluate the health outcomes of the congenital Chagas disease screening programme during the first 6 years (2010–2015) after its introduction in Catalonia.

Methods

In a surveillance system, we screened pregnant women and newborns and other children of positive mothers, and treated Chagas-positive newborns and children. Diagnosis was confirmed for pregnant women and children with two positive serological tests and for newborns with microhaematocrit and/or PCR at birth or serology at age 9 months.

Results

From 2010 to 2015, the estimated screening coverage rate increased from 68.4% to 88.6%. In this period, 33,469 pregnant women were tested for and 937 positive cases were diagnosed. The overall prevalence was 2.8 cases per 100 pregnancies per year (15.8 in Bolivian women). We followed 82.8% of newborns until serological testing at age 9–12 months and 28 were diagnosed with Chagas disease (congenital transmission rate: 4.17%). Of 518 siblings, 178 (34.3%) were tested and 14 (7.8%) were positive for . Having other children with Chagas disease and the heart clinical form of Chagas disease were maternal risk factors associated with congenital infection (p < 0.05).

Conclusion

The increased screening coverage rate indicates consolidation of the programme in Catalonia. The rate of Chagas disease congenital transmission in Catalonia is in accordance with the range in non-endemic countries.

Loading

Article metrics loading...

/content/10.2807/1560-7917.ES.2019.24.26.19-00011
2019-06-27
2024-11-21
http://instance.metastore.ingenta.com/content/10.2807/1560-7917.ES.2019.24.26.19-00011
Loading
Loading full text...

Full text loading...

/deliver/fulltext/eurosurveillance/24/26/eurosurv-24-26-4.html?itemId=/content/10.2807/1560-7917.ES.2019.24.26.19-00011&mimeType=html&fmt=ahah

References

  1. WHO Expert Committee. Control of Chagas disease. World Health Organ Tech Rep Ser. 2002;905:i-vi, 1-109, back cover. PMID: 12092045 
  2. Silveira AC, Rojas de Arias A, Segura E, Guillén G, Russomando G, Schenone H, et al. El control de la enfermedad de Chagas en los países del Cono Sur de América. Historia de una iniciativa internacional 1991/2001. [The control of Chagas disease in the countries of the Southern Cone of America. History of an international initiative 1991/2001]. Washington: Pan American Health Organization; 2002. Spanish. Available from: http://www1.paho.org/spanish/ad/dpc/cd/dch-historia-incosur.PDF
  3. Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010;375(9723):1388-402.  https://doi.org/10.1016/S0140-6736(10)60061-X  PMID: 20399979 
  4. Prata A. Clinical and epidemiological aspects of Chagas disease. Lancet Infect Dis. 2001;1(2):92-100.  https://doi.org/10.1016/S1473-3099(01)00065-2  PMID: 11871482 
  5. Pinazo MJ, Lacima G, Elizalde JI, Posada EJ, Gimeno F, Aldasoro E, et al. Characterization of digestive involvement in patients with chronic T. cruzi infection in Barcelona, Spain. PLoS Negl Trop Dis. 2014;8(8):e3105.  https://doi.org/10.1371/journal.pntd.0003105  PMID: 25144648 
  6. Muñoz J, Gómez i Prat J, Gállego M, Gimeno F, Treviño B, López-Chejade P, et al. Clinical profile of Trypanosoma cruzi infection in a non-endemic setting: immigration and Chagas disease in Barcelona (Spain). Acta Trop. 2009;111(1):51-5.  https://doi.org/10.1016/j.actatropica.2009.02.005  PMID: 19426663 
  7. Schmunis GA, Yadon ZE. Chagas disease: a Latin American health problem becoming a world health problem. Acta Trop. 2010;115(1-2):14-21.  https://doi.org/10.1016/j.actatropica.2009.11.003  PMID: 19932071 
  8. Basile L, Jansa JM, Carlier Y, Salamanca DD, Angheben A, Bartoloni A, et al. Chagas disease in European countries: the challenge of a surveillance system. Euro Surveill. 2011;16(37):19968. PMID: 21944556 
  9. Requena-Méndez A, Aldasoro E, de Lazzari E, Sicuri E, Brown M, Moore DA, et al. Prevalence of Chagas disease in Latin-American migrants living in Europe: a systematic review and meta-analysis. PLoS Negl Trop Dis. 2015;9(2):e0003540.  https://doi.org/10.1371/journal.pntd.0003540  PMID: 25680190 
  10. Howard EJ, Xiong X, Carlier Y, Sosa-Estani S, Buekens P. Frequency of the congenital transmission of Trypanosoma cruzi: a systematic review and meta-analysis. BJOG. 2014;121(1):22-33.  https://doi.org/10.1111/1471-0528.12396  PMID: 23924273 
  11. Requena-Méndez A, Albajar-Viñas P, Angheben A, Chiodini P, Gascón J, Muñoz J, et al. Health policies to control Chagas disease transmission in European countries. PLoS Negl Trop Dis. 2014;8(10):e3245.  https://doi.org/10.1371/journal.pntd.0003245  PMID: 25357193 
  12. Oliveira I, Torrico F, Muñoz J, Gascon J. Congenital transmission of Chagas disease: a clinical approach. Expert Rev Anti Infect Ther. 2010;8(8):945-56.  https://doi.org/10.1586/eri.10.74  PMID: 20695749 
  13. Carlier Y, Torrico F, Sosa-Estani S, Russomando G, Luquetti A, Freilij H, et al. Congenital Chagas disease: recommendations for diagnosis, treatment and control of newborns, siblings and pregnant women. PLoS Negl Trop Dis. 2011;5(10):e1250.  https://doi.org/10.1371/journal.pntd.0001250  PMID: 22039554 
  14. Jackson Y, Angheben A, Carrilero Fernandez B, Jansa i Lopez del Vallado JM, Jannin JG, Albajar-Viñas P. [Management of Chagas disease in Europe. Experiences and challenges in Spain, Switzerland and Italy]. Bull Soc Pathol Exot. 2009;102(5):326-9. French. PMID: 20131427 
  15. Ministry of Health. Real Decreto 1088/2005, de 16 de septiembre, por el que se establecen los requisitos técnicos y condiciones mínimas de la hemodonación y de los centros y servicios de transfusión. [Royal decree 1088/2005 of September 16 which establishes the technical requirements and minimum conditions of blood donation and of transfusion centres and services]. Madrid: Ministeri de Sanitat y Consum; 2005:31288-304. Spanish. Available from: http://www.boe.es/boe/dias/2005/09/20/pdfs/A31288-31304.pdf
  16. Basile L, Oliveira I, Ciruela P, Plasencia AWorking Group For Developing The Catalonian Screening Programme For Congenital Transmission Of Chagas Disease. The current screening programme for congenital transmission of Chagas disease in Catalonia, Spain. Euro Surveill. 2011;16(38):19972.  https://doi.org/10.2807/ese.16.38.19972-en  PMID: 21958532 
  17. Sicuri E, Muñoz J, Pinazo MJ, Posada E, Sanchez J, Alonso PL, et al. Economic evaluation of Chagas disease screening of pregnant Latin American women and of their infants in a non endemic area. Acta Trop. 2011;118(2):110-7.  https://doi.org/10.1016/j.actatropica.2011.02.012  PMID: 21396345 
  18. Organització Mundial de la Salut. Chagas disease in Latin America: an epidemiological update based on 2010 estimates. Wkly Epidemiol Rec. 2015;90(6):33-43.  https://doi.org/10.2147/IBPC.S70402  PMID: 25671846 
  19. Soriano-Arandes A, Angheben A, Serre-Delcor N, Treviño-Maruri B, Gómez I Prat J, Jackson Y. Control and management of congenital Chagas disease in Europe and other non-endemic countries: current policies and practices. Trop Med Int Health. 2016;21(5):590-6.  https://doi.org/10.1111/tmi.12687  PMID: 26932338 
  20. Autonomous government of Catalonia. Protocol for screening and diagnosing Chagas disease in pregnant Latin American women and their newborns. Barcelona: Generalitat de Catalunya; 2010. Available from: https://scientiasalut.gencat.cat/bitstream/handle/11351/1173/protocol_cribratge_diagnostic_malaltia_chagas_embarassades_2010_ang.pdf
  21. A Bayón Rueda, R Borrás Salvador, E Calabuig Muñoz, MT Fraile Fariña, MJ Giménez Martí, E Montesinos Sanchis, Elena, et al. Enfermedad de Chagas importada: protocolo de actuación en la Comunitat Valenciana. [Imported Chagas Disease. Protocol of actions in the Valencian Community]. Valencia: Conselleria de Sanitat. Generalitat Valenciana; 2009. Spanish. Available from: http://publicaciones.san.gva.es/publicaciones/documentos/V-5243-2008.pdf
  22. Autonomous Government of Galicia. Protocolo de cribado da enfermidade de Chagas en mulleres embarazadas. [Chagas disease screening protocol in pregnant women]. Santiago de Compostela: Xunta de Galicia; 2014. Spanish. Available from: https://www.sergas.es/Asistencia-sanitaria/Protocolo-de-cribado-da-enfermidade-de-chagas-en-mulleres-embarazadas-Actualizacion-2014
  23. Bartoloni A, Strohmeyer M, Mantella A, Zammarchi L, Trotta M, Rossolini GM, et al. Programma regionale per la prevenzione e il controllo della malattia di Chagas congenita: indicazioni per l’assistenza in gravidanza. [Regional program for the prevention and control of congenital Chagas disease: indications for assistance during pregnancy]. Firenze: Regione Toscana; 2012. Italian. Available from: http://www.regione.toscana.it/documents/10180/13329059/Allegato+parere+n.+46-2015+Prev+e+conrollo+malattia+di+Chagas.pdf/6e153700-0d7b-4d70-b098-faba975c6de8?version=1.0
  24. Martinez de Tejada B, Jackson Y, Paccolat C, Irion OGroupe Chagas Congénital Genéve. [Congenital Chagas disease in Geneva: diagnostic and clinical aspects]. Rev Med Suisse. 2009;5(222):2091-2, 2094-6. French. PMID: 19947451 
  25. Rodari P, Angheben A, Gennati G, Trezzi L, Bargiggia G, Maino M, et al. Congenital Chagas disease in a non-endemic area: Results from a control programme in Bergamo province, Northern Italy. Travel Med Infect Dis. 2018;25:31-4.  https://doi.org/10.1016/j.tmaid.2018.04.011  PMID: 29680285 
  26. Merino FJ, Martínez-Ruiz R, Olabarrieta I, Merino P, García-Bujalance S, Gastañaga T, et al. [Control of Chagas disease in pregnant Latin-American women and her children]. Rev Esp Quimioter. 2013;26(3):253-60. Spanish. PMID: 24080893 
  27. Institut d’Estadística de Catalunya. [Statistical Institute of Catalonia]. Població estrangera resident a Catalunya segons la seva nacionalitat 2016. [Foreign population resident in Catalonia by nationality]. Barcelona: Generalitat de Catalunya. [Accessed: 13/06/2019]. Catalan. Available from: http://www.idescat.cat/poblacioestrangera/
  28. Agència de Salut Pública de Catalunya. [Public Health Agency of Catalonia]. Xifres i dades de salut maternoinfantil 2018. [Figures and data on maternal and child health 2018]. Barcelona: Generalitat de Catalunya. [Accessed: 13 Jun 2019]. Catalan. Available from: http://salutpublica.gencat.cat/ca/ambits/promocio_salut/Embaras-part-i-puerperi/Xifres-i-dades/
  29. Subdirecció general de vigilància i resposta a emergencies en salut pública, Agència de Salut Pública de Catalunya. [Deputy director of public health surveillance and response to emergencies, Public Health Agency of Catalonia]. Centres collaboradors del Programa de prevenció i control de la malaltia de Chagas congènita a Catalunya. [Collaborating Centers of the Congenital Chagas disease Screening Program in Catalonia]. Barcelona: Generalitat de Catalunya; 2019. Catalan. Available from: http://canalsalut.gencat.cat/web/.content/_A-Z/C/chagas/arxius/llistatcentres.pdf
  30. Departament de Salut. [Department of Health]. Decret 203/2015, de 15 de setembre, pel qual es crea la Xarxa de Vigilància Epidemiológica i es regulen els sistemes de notificació de malalties de declaració obligatòria i brots epidémics. [Decree 203/2015, of September 15, which creates the Epidemiological Surveillance Network and regulates the reporting systems for compulsory declaration diseases and epidemic outbreaks]. Barcelona: Generalitat de Catalunya; 2015. Catalan. Available from: http://dogc.gencat.cat/ca/pdogc_canals_interns/pdogc_resultats_fitxa/?action=fitxa&documentId=702922&language=ca_ES
  31. Jané M, Vidal MJ, Tomas Z, Maresma M, Mayoral LK. Indicators of perinatal health in Catalonia 2016. Executive Report. Barcelona: Sub-directorate General for Epidemiological Surveillance and Public Health Emergency Response. Secretariat for Public Health; 2018. Available from: http://canalsalut.gencat.cat/web/.content/_Professionals/Vigilancia_epidemiologica/documents/arxius/Perinatal_Indicator_Catalonia_2016.pdf
  32. Firth D. Bias reduction of maximum likelihood estimates. Biometrika. 1993;80(1):27-38.  https://doi.org/10.1093/biomet/80.1.27 
  33. Muñoz J, Coll O, Juncosa T, Vergés M, del Pino M, Fumado V, et al. Prevalence and vertical transmission of Trypanosoma cruzi infection among pregnant Latin American women attending 2 maternity clinics in Barcelona, Spain. Clin Infect Dis. 2009;48(12):1736-40.  https://doi.org/10.1086/599223  PMID: 19438393 
  34. Otero S, Sulleiro E, Molina I, Espiau M, Suy A, Martín-Nalda A, et al. Congenital transmission of Trypanosoma cruzi in non-endemic areas: evaluation of a screening program in a tertiary care hospital in Barcelona, Spain. Am J Trop Med Hyg. 2012;87(5):832-6.  https://doi.org/10.4269/ajtmh.2012.12-0152  PMID: 22987653 
  35. Alonso-Vega C, Billot C, Torrico F. Achievements and challenges upon the implementation of a program for national control of congenital Chagas in Bolivia: results 2004-2009. PLoS Negl Trop Dis. 2013;7(7):e2304.  https://doi.org/10.1371/journal.pntd.0002304  PMID: 23875039 
  36. Barona-Vilar C, Giménez-Martí MJ, Fraile T, González-Steinbauer C, Parada C, Gil-Brusola A, et al. Prevalence of Trypanosoma cruzi infection in pregnant Latin American women and congenital transmission rate in a non-endemic area: the experience of the Valencian Health Programme (Spain). Epidemiol Infect. 2012;140(10):1896-903.  https://doi.org/10.1017/S0950268811002482  PMID: 22129521 
  37. Avila Arzanegui O, Liendo Arenaza P, Martinez Indart L, Martinez Astorkiza T, Pocheville Guruceta MI, Egurbide Arberas MV. [Prevalence of Trypanosoma cruzi infection and vertical transmission in Latin-American pregnant women in a health area of Biscay.] Enferm Infecc Microbiol Clin. 2013;31(4):210-6. Spanish.  https://doi.org/10.1016/j.eimc.2012.01.029  PMID: 22621813 
  38. Flores-Chavez MD, Merino FJ, Garcia-Bujalance S, Martin-Rabadan P, Merino P, Garcia-Bermejo I, et al. Surveillance of Chagas disease in pregnant women in Madrid, Spain, from 2008 to 2010. Euro Surveill. 2011;16(38):19974.  https://doi.org/10.2807/ese.16.38.19974-en  PMID: 21958533 
  39. Muñoz-Vilches MJ, Salas J, Cabezas T, Metz D, Vázquez J, Soriano MJ. [Chagas screening in pregnant Latin-American women. Experience in Poniente Almeriense (Almeria, Spain)]. Enferm Infecc Microbiol Clin. 2012;30(7):380-2. Spanish.  https://doi.org/10.1016/j.eimc.2011.11.012  PMID: 22277372 
  40. Ramos JM, Milla A, Rodríguez JC, López-Chejade P, Flóres M, Rodríguez JM, et al. Chagas disease in Latin American pregnant immigrants: experience in a non-endemic country. Arch Gynecol Obstet. 2012;285(4):919-23.  https://doi.org/10.1007/s00404-011-2081-9  PMID: 21927962 
  41. Russomando G, Almirón M, Candia N, Franco L, Sánchez Z, de Guillen I. [Implementation and evaluation of a locally sustainable system of prenatal diagnosis to detect cases of congenital Chagas disease in endemic areas of Paraguay]. Rev Soc Bras Med Trop. 2005;38(Suppl 2):49-54. Spanish. PMID: 16482814 
  42. Kolliker-Frers RA, Insua I, Razzitte G, Capani F. Chagas disease prevalence in pregnant women: migration and risk of congenital transmission. J Infect Dev Ctries. 2016;10(9):895-901.  https://doi.org/10.3855/jidc.7118  PMID: 27694720 
  43. Castellanos-Domínguez YZ, Cucunubá ZM, Orozco LC, Valencia-Hernández CA, León CM, Florez AC, et al. Risk factors associated with Chagas disease in pregnant women in Santander, a highly endemic Colombian area. Trop Med Int Health. 2016;21(1):140-8.  https://doi.org/10.1111/tmi.12634  PMID: 26578246 
  44. Apt W, Zulantay I, Arnello M, Oddó D, González S, Rodríguez J, et al. Congenital infection by Trypanosoma cruzi in an endemic area of Chile: a multidisciplinary study. Trans R Soc Trop Med Hyg. 2013;107(2):98-104.  https://doi.org/10.1093/trstmh/trs013  PMID: 23222947 
  45. Carrera Vargas C, Narváez AO, Muzzio Aroca J, Shiguango G, Robles LM, Herrera C, et al. Seroprevalence of Trypanosoma cruzi infection in schoolchildren and in pregnant women from an Amazonian region in Orellana Province, Ecuador. Am J Trop Med Hyg. 2015;93(4):774-8.  https://doi.org/10.4269/ajtmh.14-0807  PMID: 26283751 
  46. Martins-Melo FR, Lima M da S, Ramos ANJ Jr, Alencar CH, Heukelbach J. Prevalence of Chagas disease in pregnant women and congenital transmission of Trypanosoma cruzi in Brazil: a systematic review and meta-analysis. Trop Med Int Health. 2014;19(8):943-57.  https://doi.org/10.1111/tmi.12328  PMID: 24815954 
  47. Howard EJ, Xiong X, Carlier Y, Sosa-Estani S, Buekens P. Frequency of the congenital transmission of Trypanosoma cruzi: a systematic review and meta-analysis. BJOG. 2014;121(1):22-33.  https://doi.org/10.1111/1471-0528.12396  PMID: 23924273 
  48. Salas Clavijo NA, Postigo JR, Schneider D, Santalla JA, Brutus L, Chippaux J-P. Prevalence of Chagas disease in pregnant women and incidence of congenital transmission in Santa Cruz de la Sierra, Bolivia. Acta Trop. 2012;124(1):87-91.  https://doi.org/10.1016/j.actatropica.2012.06.012  PMID: 22772023 
  49. Torrico F, Alonso-Vega C, Suarez E, Rodriguez P, Torrico M-C, Dramaix M, et al. Maternal Trypanosoma cruzi infection, pregnancy outcome, morbidity, and mortality of congenitally infected and non-infected newborns in Bolivia. Am J Trop Med Hyg. 2004;70(2):201-9.  https://doi.org/10.4269/ajtmh.2004.70.201  PMID: 14993634 
  50. Luquetti AO, Tavares SB, Siriano LR, Oliveira RA, Campos DE, de Morais CA, et al. Congenital transmission of Trypanosoma cruzi in central Brazil. A study of 1,211 individuals born to infected mothers. Mem Inst Oswaldo Cruz. 2015;110(3):369-76.  https://doi.org/10.1590/0074-02760140410  PMID: 25993506 
  51. Rodriguez-Guerineau L, Posfay-Barbe KM, Monsonis-Cabedo M, Juncosa-Morros T, Diana A, Wyler-Lazarevic CA, et al. Pediatric Chagas disease in Europe: 45 cases from Spain and Switzerland. Pediatr Infect Dis J. 2014;33(5):458-62.  https://doi.org/10.1097/INF.0000000000000139  PMID: 24153010 
  52. Russomando G, Cousiño B, Sanchez Z, Franco LX, Nara EM, Chena L, et al. Chagas disease: national survey of seroprevalence in children under five years of age conducted in 2008. Mem Inst Oswaldo Cruz. 2017;112(5):348-53.  https://doi.org/10.1590/0074-02760160407  PMID: 28443980 
  53. Fumadó V, Juncosa T, Posada E, Fisa R, Gállego M, Gascón J. [Paediatric Chagas in a non-endemic area.] Enferm Infecc Microbiol Clin. 2014;32(5):293-6. Spanish.  https://doi.org/10.1016/j.eimc.2013.04.024  PMID: 24491481 
  54. Virreira M, Torrico F, Truyens C, Alonso-Vega C, Solano M, Carlier Y, et al. Comparison of polymerase chain reaction methods for reliable and easy detection of congenital Trypanosoma cruzi infection. Am J Trop Med Hyg. 2003;68(5):574-82.  https://doi.org/10.4269/ajtmh.2003.68.574  PMID: 12812349 
  55. Schijman AG, Bisio M, Orellana L, Sued M, Duffy T, Mejia Jaramillo AM, et al. International study to evaluate PCR methods for detection of Trypanosoma cruzi DNA in blood samples from Chagas disease patients. PLoS Negl Trop Dis. 2011;5(1):e931.  https://doi.org/10.1371/journal.pntd.0000931  PMID: 21264349 
  56. Bua J, Volta BJ, Perrone AE, Scollo K, Velázquez EB, Ruiz AM, et al. How to improve the early diagnosis of Trypanosoma cruzi infection: relationship between validated conventional diagnosis and quantitative DNA amplification in congenitally infected children. PLoS Negl Trop Dis. 2013;7(10):e2476.  https://doi.org/10.1371/journal.pntd.0002476  PMID: 24147166 
  57. Abras A, Muñoz C, Ballart C, Berenguer P, Llovet T, Herrero M, et al. Towards a new strategy for diagnosis of congenital Trypanosoma cruzi infection. J Clin Microbiol. 2017;55(5):1396-407.  https://doi.org/10.1128/JCM.02248-16  PMID: 28202792 
  58. Volta BJ, Perrone AE, Rivero R, Scollo K, Bustos PL, Bua J. Some limitations for early diagnosis of congenital Chagas infection by PCR. Pediatrics. 2018;141(Suppl 5):S451-5.  https://doi.org/10.1542/peds.2016-3719  PMID: 29610170 
  59. Schijman AG, Altcheh J, Burgos JM, Biancardi M, Bisio M, Levin MJ, et al. Aetiological treatment of congenital Chagas’ disease diagnosed and monitored by the polymerase chain reaction. J Antimicrob Chemother. 2003;52(3):441-9.  https://doi.org/10.1093/jac/dkg338  PMID: 12917253 
  60. Álvarez MG, Vigliano C, Lococo B, Bertocchi G, Viotti R. Prevention of congenital Chagas disease by Benznidazole treatment in reproductive-age women. An observational study. Acta Trop. 2017;174:149-52.  https://doi.org/10.1016/j.actatropica.2017.07.004  PMID: 28720492 
  61. Fabbro DL, Danesi E, Olivera V, Codebó MO, Denner S, Heredia C, et al. Trypanocide treatment of women infected with Trypanosoma cruzi and its effect on preventing congenital Chagas. PLoS Negl Trop Dis. 2014;8(11):e3312.  https://doi.org/10.1371/journal.pntd.0003312  PMID: 25411847 
  62. Murcia L, Simón M, Carrilero B, Roig M, Segovia M. Treatment of infected women of childbearing age prevents congenital Trypanosoma cruzi infection by eliminating the parasitemia detected by PCR. J Infect Dis. 2017;215(9):1452-8.  https://doi.org/10.1093/infdis/jix087  PMID: 28201741 
  63. Soriano-Arandes A, Basile L, Ouaarab H, Clavería I, Gómez i Prat J, Cabezos J, et al. Controlling congenital and paediatric chagas disease through a community health approach with active surveillance and promotion of paediatric awareness. BMC Public Health. 2014;14(1):1201.  https://doi.org/10.1186/1471-2458-14-1201  PMID: 25416081 
/content/10.2807/1560-7917.ES.2019.24.26.19-00011
Loading

Data & Media loading...

Submit comment
Close
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error