Abstract
The present study aims to investigate how the social context contributes to the prognosis of Chagas disease (CD). This is a multilevel study that considered individual and contextual data. Individual data came from a Brazilian cohort study that followed 1,637 patients who lived in 21 municipalities to which CD is endemic, over two years. Contextual data were collected from official Brazilian government databases. The dependent variable was the occurrence of cardiovascular events in CD during the two-year follow-up, defined from the grouping of three possible combined events: death, development of atrial fibrillation, or pacemaker implantation. Analysis was performed using multilevel binary logistic regression. Among the individuals evaluated, 205 (12.5%) manifested cardiovascular events in CD during two years of follow-up. Individuals living in municipalities with a larger rural population had protection for these events (OR = 0.5; 95% CI = 0.4-0.7), while those residing in municipalities with fewer physicians per thousand inhabitants (OR = 1.6; 95% CI = 1.2-2.5) and those living in municipalities with lower Primary Health Care (PHC) coverage (OR = 1.4; 95% CI = 1.1-2.1) had higher chances of experiencing cardiovascular events. Among the individual variables, the probability of experiencing cardiovascular events was higher for individuals aged over 60 years (OR = 1.4; 95% CI = 1.01-2.2), with no stable relationship (OR = 1.4; 95% CI = 0.98-2.1), without previous treatment with Benznidazole (OR = 1.5; 95% CI = 0.98-2.9), with functional class limitation (OR = 2.0; 95% CI = 1.4-2.9), with a QRS complex duration longer than 120 ms (OR = 1.5; 95% CI = 1.1-2.3), and in individuals with high NT-proBNP levels (OR = 6.4; 95% CI = 4.3-9.6). CONCLUSION: The present study showed that the occurrence of cardiovascular events in individuals with CD is determined by individual conditions that express the severity of cardiovascular involvement. However, these individual characteristics are not isolated protagonists of this outcome, and the context in which individuals live, are also determining factors for a worse clinical prognosis.
Highlights
Chagas disease (CD) is a serious public health problem in Latin America and one of the main Brazilian medical and social problems
No studies have been identified that assessed whether unfavorable social contexts are related to the prognosis and evolution of CD, which is the purpose of our study
We evaluated 1,637 patients with CD who lived in 21 municipalities located in regions to which CD is endemic in Brazil, over a two-year period
Summary
Chagas disease (CD) is a serious public health problem in Latin America and one of the main Brazilian medical and social problems. The World Health Organization (WHO) estimates a high concentration of CD patients in Latin America, to which the disease is endemic. In Brazil it is estimated that more than 1,100,000 people are affected by CD [1], which remains a major cause of morbidity, mortality, and disability in several Latin American countries. CD was the leading cause of disability-adjusted lost years of life (DALY) among all neglected tropical diseases, and in this group as well as in general, the Brazilian state of Minas Gerais is cited as having one of the highest age-standardized DALY rates [3]. Most patients with CD remain in the “undetermined chronic form”, defined as a persistent asymptomatic infection without cardiac or gastrointestinal tract alterations [4]. Chagasic cardiomyopathy is associated with a worse prognosis, with higher mortality rates compared to other causes of heart failure [4, 6,7,8]
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