https://orcid.org/0000-0001-8888-2957
Figures
Abstract
Introduction
Chagas Disease (CD) remains a persistent public health problem in Brazil, particularly in historically hyperendemic regions such as northern Minas Gerais. Despite the sustained burden of transmission and chronic disease, access to specialized care for CD continues to be limited. This study aimed to describe the clinical and epidemiological profile of patients attending a newly established specialized CD outpatient clinic and to contextualize its role within the regional hyperendemic scenario.
Methods
A descriptive cross-sectional assessment was conducted using routinely collected clinical information from medical records of patients who attended the service between October 2022 and September 2024. Data extraction combined review of paper and electronic records with verification through on-site clinical documentation.
Results
Over the two-year period, the clinic experienced a substantial increase in demand. In the first year, 274 patients received care, whereas in the second year this number rose to 657—an increase of 239.7%. Overall, 931 patients attended the service. The majority of patients were female, with a mean age of 58 (± 11.1) years, and had the indeterminate form of CD (47.2%). A total of 630 patients (68.5%) underwent etiological treatment for the disease. Among these, 309 received prescriptions directly from the outpatient clinic, and 208 out of them (67.3%) experienced adverse drug reactions. The clinic provides care for the northern macro-region of Minas Gerais, encompassing 86 municipalities: 45 (52%) of these referred patients during the study period. Referral patterns highlighted contrasting municipal profiles: Montes Claros was the largest source of patients.
Conclusion
The findings demonstrate the growing demand for specialized CD care and underscore the importance of dedicated services in regions where primary care lacks structured clinical pathways for CD management. The clinic offers not only access to etiological treatment and longitudinal follow-up but also a reproducible model for expanding equitable care for neglected diseases in other endemic settings.
Author summary
Chagas Disease remains a significant public health problem in northern Minas Gerais, Brazil, a region where access to specialized healthcare services is still limited. To address this gap, a specialized Chagas Disease outpatient clinic was recently implemented. In this study, we describe the clinical and epidemiological profile of patients treated at this clinic. We analyzed medical records of patients treated between October 2022 and September 2024. During this period, 931 patients were treated, with a substantial increase in demand between the first and second years of operation. Patients came from more than half of the municipalities in the northern macro-region of Minas Gerais, highlighting the broad geographic reach of the service. Our findings demonstrate a high and growing demand for specialized Chagas Disease care and emphasize the importance of dedicated outpatient services to improve access to diagnosis, treatment, and clinical follow-up. This outpatient clinic represents a potentially scalable and replicable model for strengthening care for Chagas Disease in other endemic regions.
Citation: Fernandes LF, Teixeira Fernandes GR, Sabino EC, Leite SF, Cardoso MD, Torres Bonfim Rocha AJ, et al. (2026) Chagas Disease in northern Minas Gerais: Clinical and epidemiological features of patients at a pioneering specialized outpatient service. PLoS Negl Trop Dis 20(7): e0014488. https://doi.org/10.1371/journal.pntd.0014488
Editor: Deborah Bittencourt Mothé Fraga, Fundacao Oswaldo Cruz, BRAZIL
Received: January 14, 2026; Accepted: June 22, 2026; Published: July 6, 2026
Copyright: © 2026 Fernandes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: There are ethical restrictions on sharing a set of de-identified data, as it contains sensitive patient data belonging to the healthcare service. For local ethical approval, the ethics committee requested a confidentiality agreement. Therefore, the database will be made available to anyone who also makes this commitment. The data can be requested from the Ethics Committee of the State University of Montes Claros (comite.etica@unimontes.br). full citation of where the data can be found: title- Avaliação de saúde dos usuários do Ambulatório de Doença de Chagas do Hospital Universitário Clemente de Faria. CAAE: 77807124.8.0000.5146.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Chagas Disease (CD), caused by Trypanosoma cruzi, is recognized by the World Health Organization (WHO) as one of the thirteen most neglected tropical diseases and remains a major public health concern across Latin America [1]. In Brazil, CD is considered not only a biomedical issue but also one of the country’s most pressing socio-medical challenges [2].
The disease is potentially lethal: up to 42% of patients may develop Chronic Chagas Cardiomyopathy (CCC), often decades after the initial infection [3]. This highlights the urgent need for systematic medical attention. Yet, limited awareness and insufficient training on CD and CCC among healthcare professionals frequently result in inadequate follow-up, management, and treatment [4–6]. A national review of ten years of mortality data reported around 5,000 deaths attributable to CD, underscoring its persistent burden [7].
The state of Minas Gerais represents one of the country’s most relevant endemic regions [8]. It accounts for the highest number of CD-related deaths nationwide and ranks among the three Brazilian states with the greatest vulnerability to chronic CD [9]. Within the state, the North of Minas region is particularly critical: it reports nearly half of all chronic cases in Minas Gerais and presents the second-highest CD Vulnerability Index (CDVI) at both state and national levels [10,11]. Current prevalence estimates remain strikingly high, reaching up to 9.2% in some areas, nearly five times the state average of 2.1% [12,13].
In the absence of a national policy to structure care for CD patients, primary healthcare (PHC) has carried the responsibility of managing these individuals without the support of an organized referral network [12]. Physicians working in endemic regions have highlighted critical challenges: insufficient training for CD management, uncertainties regarding antiparasitic treatment in the chronic phase, limited access to specialized outpatient care, and the tendency of patients to underestimate the disease, delaying care-seeking [5,14,15].
Until 2022, the northern macro-region of Minas Gerais, encompassing 86 municipalities, lacked any specialized outpatient service for CD within the Brazilian Unified Health System (SUS). Given the strong link between CD and social vulnerability, implementing a structured model of care has the potential to reduce long-standing health inequities for patients, their families, and communities, while addressing the broader neglect of this disease.
In response, a specialized outpatient clinic for CD was established to serve as a regional referral center, providing diagnosis, follow-up, and treatment for patients across the macro-region. The present study aims to describe the clinical and epidemiological profile of patients attending this pioneering service, while situating it within the hyperendemic context of northern Minas Gerais.
Methods
Ethic statement
The study was approved by the Ethics Committee of the State University of Montes Claros (approval no. 7.076.797) and conducted in accordance with Resolution 466/2012 of the Brazilian National Health Council. As this study used secondary data, a waiver of informed consent was requested.
We conducted a descriptive cross-sectional study based on medical records of patients attending the CD outpatient clinic over a two-year period (October 2022–September 2024). Information was extracted from both paper-based and electronic records provided by the service administration and complemented by on-site professional documentation. The CD outpatient clinic serves the northern macro-region of Minas Gerais, an endemic area encompassing 86 municipalities. The dataset generated is available at the SciELO Data repository.
Clinical care at the clinic follows standardized operating procedures covering patient referral, diagnosis, treatment, and follow-up. Referral from primary healthcare (PHC) is mandatory to ensure continuity of care. Patients are required to present two positive serological tests based on different diagnostic methods, in accordance with the national Clinical Protocol and Therapeutic Guidelines (PCDT) for CD [14], and notification in the national E-SUS system, as CD has been a compulsory notifiable disease in Brazil since 2018. At the clinic, patients undergo specialist consultations (infectious disease and cardiology), vital sign assessment, epidemiological interview, and nursing consultation.
Variables analyzed were grouped into sociodemographic and clinical characteristics. Sociodemographic variables included sex (female vs. male), age, self-reported skin color (white, yellow, mixed-race, or Black), and membership in traditional communities. Clinical variables included: family history of prior CD screening, clinical form of CD (cardiac, digestive, cardiodigestive, or indeterminate), mean age by clinical form, hypertension, diabetes, history of stroke, presence of pacemaker, obtained from reports provided by the patients, (any minor or major change is considered to be altered), left ventricular ejection fraction, and body mass index (BMI) [16]. Among the group of patients treated at the outpatient clinic, the variables related to drug reactions were collected.
For the classification of cardiac involvement, a 12-lead ECG was used, applying the criteria established in the Brazilian Society of Cardiology guidelines [16]. The digestive form was defined by evidence of megaesophagus and/or megacolon detected through plain radiography or digestive endoscopy. Patients classified as indeterminate were those in the chronic phase of CD without specific clinical syndromes, with normal ECG, chest X-ray, and esophageal and colonic studies [17].
We also recorded medication classes used, including antihypertensives, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE inhibitors/ARB), diuretics, antiarrhythmics, alpha/beta-blockers, statins, hypoglycemic agents, antidepressants, anticoagulants, calcium channel blockers, vasodilators, and angiotensin receptor–neprilysin inhibitor (ARNI).
In the outpatient clinic, a standardized template is used to collect patient information, except for medical progress notes, which facilitates standardization and, consequently, improves data quality. The researchers responsible for data collection were previously trained and calibrated regarding data extraction procedures. In cases where the information found in the records did not follow the expected standard or raised interpretative uncertainties, the records were reviewed and discussed jointly by all authors to ensure greater consistency and reliability of the collected data.
To assess contextual factors, we used the Chagas Disease Vulnerability Index (CDVI) [18] and the 2010 Municipal Human Development Index (MHDI) [19]. The CDVI, developed by the Brazilian Ministry of Health in 2022, identifies areas with greater potential morbidity and mortality from chronic CD in association with healthcare access barriers. It comprises three sub-indices: (i) epidemiological indicators directly related to chronic CD; (ii) indicators of conditions arising from disease progression; and (iii) indicators of healthcare access. Scores range from 0 to 1, with higher values indicating greater vulnerability. The MHDI is the geometric mean of income, education, and life expectancy indices, categorized as low, medium, high, or very high.
Descriptive analyses were performed for all individual variables, with absolute and relative frequencies reported. For age, we also calculated mean and standard deviation. Missing data were treated as losses in the analysis. Spearman’s correlation was applied to assess the relationship between the number of clinic visits per municipality and both CDVI and MHDI scores. Analyses were conducted using Predictive Analytics Software (PASW/SPSS) version 18.0.
Results
The CD outpatient clinic was established in October 2022 at the Tancredo Neves Specialty Center (CAETAN), affiliated with the Clemente de Faria University Hospital of the State University of Montes Claros (Unimontes). Its implementation was driven by researchers from the SaMi-Trop project, representing a social return from research on CD conducted in the region since 2014 [20]. The initiative involved a partnership between Unimontes, its university hospital, the Minas Gerais State Health Department, and the Municipal Health Department of Montes Claros. The service was formally approved during a bipartite inter-management committee (CIB) meeting with participation from all municipalities in the region, where patient referral and care flows were defined.
For the care of patients with CD, a standard operating procedure was developed for scheduling, diagnosis, treatment and management. At the scheduling, three documents are required. 1) a referral from primary health care, aimed at maintaining the patient’s linkage with this level of care; 2) two positive serological tests using different diagnostic methods, as recommend by the PCDT [14]; 3) a recorded compulsory notification form. After the initial visit, the necessary complementary tests are requested to assess the clinical form and progression of CD. The scheduling of follow-up visits is determined according to the patient’s access to these tests within the health system, as appointment booking is managed by primary health care, which may influence the interval between visits.
Over the two-year evaluation period, a steady increase in service utilization was observed. In the first year, 274 patients with CD were seen, while in the second year this number more than doubled (+239.7%), reaching 657 patients (Fig 1). The clinic provides care for the northern macro-region of Minas Gerais, comprising 86 municipalities. During the study period, 45 (52%) municipalities referred patients for care (Fig 2).
Minas Gerais. Brazil, 2023-2024.
Minas Gerais, Brazil, 2023-2024. Cartographic elaboration: Ana Clara de Jesus Santos (2025). Sources: municipal and state boundaries (IBGE, 2023). Geographic coordinate system, datum SIRGAS 2000. Source: Malha municipal e unidades federativas do Brasil (shapefile), disponibilizadas pelo IBGE (2023). Available:https://www.ibge.gov.br/geociencias/organizacao-do-territorio/malhas-territoriais/15774-malhas.html.
Among them 931 patients attended over the two-year period, the majority (64%) were female, with a mean age of 58 (± 11.1) years and self-reported Brown skin color. Among the medical records evaluated in this study, information was obtained regarding treatment with BZN, whether prior at some point in life or conducted in an outpatient setting. Among the patients evaluated, 630 (68.5%) had received benznidazole treatment at some point in their lives, with a mean treatment duration of 59 days (±24.1; range: 1–180 days). Most were female, with a mean age of 60.8 (± 12.8) years and self-reported Brown skin color. Among treated patients with clinical form data available, the indeterminate form was most frequent (n = 260; 51.7%) (Table 1). It was observed that 94 (14.9%) patients completed at least 30 days of treatment, and 402 (63,8%) completed 60 days of treatment, as recommended by the PCDT.
For treatment prescription, the outpatient clinic follows the criteria established by the PCDT, which include patients under 50 years of age with the indeterminate form of the disease or mild cardiac involvement. However, for individuals over 50 years, the benefit is considered more uncertain, therefore, the decision regarding treatment is shared between doctor and patient [14].
Of the 630 patients who had received benznidazole treatment at some point in their lives, 309 were treated at the outpatient clinic evaluated in this study (Fig 3). Of these, 252 (81.6%) completed the prescribed treatment and 208 (67.3%) patients experienced adverse drug reactions. Treatment discontinuation was more frequent among older patients and those experiencing adverse drug reactions, particularly neurological events (Table 2).
Minas Gerais, Brazil, 2023–2024.
To minimize treatment discontinuation due to adverse drug reactions, the clinic implemented a follow-up protocol. Patients were carefully counseled on potential side effects, received weekly telephone follow-up, and were managed promptly with symptomatic treatment or temporary treatment interruption when necessary. Scheduled follow-up visits were conducted at 30 days and at the end of treatment, including clinical evaluation and laboratory monitoring with complete blood count, renal function tests, and assessment of liver enzymes [14].
Medication use was evaluated, by therapeutic class, among patients seen in the outpatient clinic, showing antihypertensives as the most frequently prescribed (Fig 4). Notably, patients often used more than one class concurrently.
Minas Gerais, Brazil, 2023-2024. *inhibitor/angiotensin receptor blocker (ACE inhibitors/ARB). *angiotensin receptor–neprilysin inhibitor (ARNI).
Among referring municipalities, Montes Claros had the highest number of patients, despite being among those with the lowest CDVI and the highest Municipal Human Development Index (MHDI). Conversely, São Francisco stood out as the second largest source of referrals, despite ranking among the 11 municipalities with the highest CDVI and among the 14 with the lowest MHDI (Table 3). Correlation between the number of referrals and CDVI (r = 0.022; p = 0.885) or MHDI (r = 0.007; p = 0.966) was weak.
Discussion
This study describes the clinical and epidemiological profile of patients with Chagas Disease (CD) attended at the first specialized outpatient clinic within the SUS in a hyperendemic region of Brazil. The growing number of referrals over the two-year period highlights the urgent need for this service. In total, 931 patients were evaluated, coming from 45 municipalities.
The implementation of a specialized outpatient clinic for CD is aligned with SUS policy, which emphasizes equity in health not only in terms of generalized access but also in addressing the real endemic needs of specific populations. In this case, the service responds to the demands of a population that has long remained invisible within the health system, lacking systematic registration in primary healthcare and without structured follow-up. These patients generate a considerable burden for the public health system and remain largely underserved by the private sector [21].
Descriptions of specialized care models for Chagas Disease are scarce in the literature. In Guatemala, the implementation of a care model supported by the Drugs for Neglected Diseases (DNDi) enabled the integration of a specialized clinic into the local health network, offering comprehensive care, including etiological treatment and longitudinal clinical follow-up. This model prioritized women of reproductive age and pregnant women, who accounted for more than 76% of the treatments provided [22]. In Brazil, particularly in Minas Gerais, region characterized by high vulnerability to the disease [18], no records were identified in the literature, nor in national health facility databases, describing the existence of structured specialized services for the management of CD [23]. In this context, the present outpatient clinic represents a pioneering initiative, as it implements and describes a care model in an endemic region. Nonetheless, the consolidation and ampliation of such models remain subject to significant challenges. The principal challenges include the lack of qualified human resources, gaps in integration across different levels of care, including coordination between healthcare service delivery and epidemiological surveillance, and limited structural funding [24].
The estimated population of the northern region of Minas Gerais is nearly 1.7 million [25], with recent studies suggesting a CD prevalence of up to 9.2% [12], equivalent to approximately 150,000 carriers. Given the clinic’s current monthly capacity of around 50 patients, it is clear that the service is still far from meeting the total demand, particularly considering the need for periodic follow-up visits. Moreover, only about half of the municipalities in the macro-region referred patients during the study period, suggesting persistent inequalities in local health service management, logistical barriers, or limited awareness of the specialized service. Therefore, the growing demand confirms a substantial hidden burden of CD, with the clinic addressing only a fraction of the need.
The sociodemographic characteristics of the patients are consistent with prior studies. The majority were women, which may reflect the tendency of women to seek healthcare more frequently than men, particularly for preventive services [26]. The mean age of 58 years reflects a cohort that was exposed to transmission before the establishment of effective vector control measures in the 1970s [27]. However, the fact that the youngest patient is only 4 years old may suggest congenital or even vector-borne transmission [13]. The predominance of black and mixed-race patients, along with the presence of quilombola communities, reinforces the disproportionate burden of CD on socially vulnerable populations [28,29].
With respect to clinical forms, the indeterminate and cardiac forms predominated, consistent with prior epidemiological descriptions [16], highlighting the importance of systematic monitoring. Hypertension was the most frequent comorbidity, compounding the clinical complexity of this population [3].
Etiological treatment with benznidazole was prescribed to 68.5% of patients, yet nearly half of them received treatment only after referral to the outpatient clinic, underscoring the limitations of primary care in initiating therapy. In Brazil, benznidazole (BZN) is currently the only available drug for the treatment of CD, and guidelines recommend that therapy should be initiated at the primary care level. In practice, however, this is not consistently implemented. Almost half of the patients who received treatment did so only after being referred to a specialized outpatient clinic. Importantly, most patients had already been diagnosed with CD, and according to national guidelines [14], could have been identified and treated earlier. These findings suggest a relevant gap between recommendations and routine practice, which limits timely access to treatment for many patients.
The treatment with benznidazole is associated with a high rate of adverse drug reactions (44.1%- 95% CI 37.2–51.2) and of treatment discontinuations (11.4%-95% CI 8.5–14.5) [30]. The clinic’s structured protocol for monitoring treatment proved crucial in minimizing treatment abandonment.
A key innovative feature of this service is the structured follow-up protocol for benznidazole treatment, combining patient education, weekly calls, prompt clinical management, and scheduled visits. This low-cost, patient-centered adherence strategy not only improved treatment completion but also helped reduce structural inequities by securing effective care for socially vulnerable groups.
This study also has limitations. The reliance on compulsory notification through primary healthcare as a prerequisite for referral may have contributed to underreporting and left many patients uncounted and untreated. Furthermore, only 52% of municipalities referred patients, reflecting uneven health service organization and awareness across the region.
The specialized CD outpatient clinic described here highlights the need for dedicated services for neglected diseases. In the absence of systematic clinical pathways in primary care, such services are essential for providing comprehensive patient care. Their importance lies not only in facilitating etiological treatment but also in expanding follow-up and promoting equity in healthcare delivery for a historically neglected disease. As the first large-scale documented experience of its kind in that hyperendemic region, it offers a replicable framework for other endemic regions, providing both a pioneering local solution and an internationally relevant model for neglected diseases.
Acknowledgments
The authors acknowledge the SaMi-Trop project researchers, who are funded by the National Institutes of Health (NIH) Grant number 1UIAI168383, for their initiative in establishing the Chagas Disease outpatient clinic, in partnership with the Northern Minas Gerais Regional Health Superintendence, the State University of Montes Claros, and the Clemente de Faria University Hospital, as well as the participating municipalities that contributed to strengthening the service. Ester Cerdeira Sabino and Mayra Domingues Cardoso are National Council for Scientific and Technological Development CNPq scholarship recipients. Ana Clara de Jesus Santos and Ana Beatriz Cardoso Sena are a scholarship recipient from the Coordination for the Improvement of Higher Education Personnel (CAPES).
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