In December 1943, Dr. Emmanuel Dias initiated an ambitious scientific project in
Bambuí (State of Minas Gerais, Brazil) to address the epidemiology and control of
Chagas disease11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.. Three years prior, Amilcar Martins and collaborators had described a hyperendemic
incidence of the disease in that region based on the detection of 25 acute cases and a high level of
housing infestation by Triatominae bugs11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.,44. Martins AV, Versiani OC, Tupinambá AA. Sobre 25 casos agudos de
moléstia de Chagas observados em Minas Gerais. Mem Inst Ezequiel Dias 1940;
3-4:1-66.,55. Coura JR. Síntese histórica sobre a evolução dos
conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e
Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de
Janeiro: Fiocruz Editora; 1997; p. 469-486..
At that time, the recognition of this disease was very difficult and mainly limited to acute cases
discovered by Carlos Chagas himself and Argentinian and Uruguayan researchers, namely,
Romaña, Mazza and Talice33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,55. Coura JR. Síntese histórica sobre a evolução dos
conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e
Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de
Janeiro: Fiocruz Editora; 1997; p. 469-486.. Invited by Martins, Dias and Romaña immediately visited
Bambuí and produced a historical report with a prophetical prognosis that a local center for
the study of Chagas disease would provide a tremendous improvement in the knowledge and control of
this trypanosomiasis33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,66. Dias JCP. A descoberta do foco e a instalação do Posto do IOC em Bambuí. In: Dias
JCP, editor. Dr. Emmanuel Dias (1908-1962). Rio de Janeiro: Fiocruz Editora; 2008. p.
142-147.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.. In the face of difficult circumstances,
Dias was charged by his director, Dr. Henrique Aragão, to proceed with this task11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.,33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.. In addition to
the description of other acute cases of Chagas disease, Dias's attention soon was drawn to the
innumerable chronic cases, most of which presented with severe cardiopathy, which was responsible
for premature deaths throughout the region. Within a few months, Dias wrote that it was urgently
necessary to stop the transmission of Chagas by means of a drastic reduction in the number of
domiciled vectors, an ambitious effort implemented via housing improvement, intensive health
education and the use of available insecticides and physical tools such as flame-throwers, kerosene,
caustic soda and hydrocyanic gas11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.,88. Dias E. Profilaxia da doença de Chagas. O Hospital 1957;
51:53-68.. In parallel, the chronic disease also needed to be addressed. This task required
improved diagnostic and clinical characterization, especially for cases involving heart
disease11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.,55. Coura JR. Síntese histórica sobre a evolução dos
conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e
Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de
Janeiro: Fiocruz Editora; 1997; p. 469-486.,99. Laranja FS, Dias E, Nóbrega GC, Miranda A. Chagas' disease. A
clinical, epidemiologic and pathologic study. Circulation 1956; 14:1035-1060.,1010. Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo
clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis].
[Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.. Enthusiastic and
ever determined, Dias recruited several colleagues from the Oswaldo Cruz Institute into various
aspects of the project. These colleagues included an immunologist (Julio Muniz),
pathologists (Aloisio Miranda and Magarinos Torres), an entomologist (Herman
Lent), general physicians (Genard Nóbrega) and a cardiologist (Francisco
Laranja). Additionally, José Pellegrino of Belo Horizonte was charged with assisting in
insecticide trials and experimental cardiopathy11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.. As an immediate result, various aspects of the
transmission and morbidity of Chagas disease were elucidated by means of well-planned
epidemiological investigations, which were performed among non-selected regional populations and
included serology coupled with entomology, electrocardiography and clinical data. Within a few
years, the group had obtained an efficient insecticide (Gammexane) and
elucidated the systematization of the basic clinical, epidemiologic and pathologic aspects of
chronic cardiopathy due to Chagas disease11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,55. Coura JR. Síntese histórica sobre a evolução dos
conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e
Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de
Janeiro: Fiocruz Editora; 1997; p. 469-486.,99. Laranja FS, Dias E, Nóbrega GC, Miranda A. Chagas' disease. A
clinical, epidemiologic and pathologic study. Circulation 1956; 14:1035-1060.
10. Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo
clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis].
[Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.-1111. Laranja FS, Dias E, Duarte E, Pellegrino J. Observações
clínicas e epidemiológicas sobre a moléstia de Chagas no Oeste de Minas Gerais.
O Hospital 1951; 40:137-192.. At the beginning, the Center was
installed in a modest house rented by the Institute. In 1951, a new and modern building was
constructed using state, federal and municipal resources11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
(Figure 1).
- The Emmanuel Dias Research Center in Bambuí, State of Minas Gerais, Brazil (PAEED - Posto Avançado de Pesquisas Emmanuel Dias), and its founder, Dr. Emmanuel Dias (27/07/1908-22/10/1962). Photo by João Carlos Pinto Dias: 1951.
The control activities in Bambuí had an extraordinary impact, swiftly
diminishing the incidence of acute cases and, consequently, the prevalence of infection in young
individuals11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.,1010. Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo
clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis].
[Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.,1111. Laranja FS, Dias E, Duarte E, Pellegrino J. Observações
clínicas e epidemiológicas sobre a moléstia de Chagas no Oeste de Minas Gerais.
O Hospital 1951; 40:137-192.. Convinced of an urgent need to expand the fight against
triatomine bugs, Dias initiated a fact-finding tour throughout Latin America and international
agencies in the middle of the 1950s, insisting that vector control was a feasible and undeferrable
task22. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.,33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.. At the same time, the incidence and severity of the
disease began to be recognized in several endemic areas where the epidemiological model tested in
Bambuí was implemented. By involving governors and health authorities, chiefly Mario Pinotti,
the leader of Brazilian Malariology and his friend, Dias achieved the implementation of vector
control throughout a large area of the States Minas Gerais and São Paulo. This trial was so
successful that the results stimulated the creation of the National Programme for Chagas Disease
Control11. Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em
Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor
Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
2. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.-33. Kropf SP. Doença de Chagas, Doença do Brasil: ciência,
saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora;
2009.,55. Coura JR. Síntese histórica sobre a evolução dos
conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e
Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de
Janeiro: Fiocruz Editora; 1997; p. 469-486.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.,88. Dias E. Profilaxia da doença de Chagas. O Hospital 1957;
51:53-68.. Emmanuel Dias died prematurely in 1962, although the work in Bambuí
was continued by the staff of the Institute Oswaldo Cruz and, subsequently, by the René
Rachou Center, headquartered in Belo Horizonte. In 1979, the center was rechristened Posto
Avançado de Pesquisas Emmanuel Dias (PAEED) by the president of the
Oswaldo Cruz Foundation (FIOCRUZ), Dr. Guillardo Martins Alves22. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.
1010. Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo
clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis].
[Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.. The legacy from the
pioneering first 20 years provided three basic directions: to maintain and improve vector control,
to describe the natural history of human Chagas disease (HCD) via the systematic and
longitudinal follow-up of infected individuals and to seek new options and tools for the medical
management of chronic patients. With such a perspective, a new phase of vector control was
implemented in the municipality in 1974, consisting of an epidemiological surveillance of
triatomines carried out at the municipal level and supported by extensive community participation.
In parallel, new insecticides were tested as replacements to the proscribed
Gammexane; members of the pyrethroid group were mainly used because they have
greater residual action and are less harmful to humans and the environment22. Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26
(supl II):4-8.,77. Dias JCP, Schofield CJ. The evolution of Chagas disease (American
Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz
1999; 94:103-122.,1111. Laranja FS, Dias E, Duarte E, Pellegrino J. Observações
clínicas e epidemiológicas sobre a moléstia de Chagas no Oeste de Minas Gerais.
O Hospital 1951; 40:137-192..
The dynamics of the natural foci of Panstronylus megistus, the principal species that continued to invade artificial ecotopes, was thoroughly studied in the area, as was the role of sylvatic reservoirs of this parasite, mainly synanthropic marsupials. The follow-up of hundreds of patients, involving decades of evolution, revealed the progressive character of the infection and the various risk factors related to the development of the disease. In parallel, several important issues, including social aspects, diagnosis (new serologic techniques, polymerase chain reaction (PCR) and hemocultures), heart disease management, follow-up of mortality, management of digestive forms, the occurrence of co-morbidities and the specific aspects of the disease in geriatric groups, have been studied by PAEED in recent decades1212. Matos CS, Santos JE, Dias JCP. Present situation of human Chagas disease prevalence in Bambuí municipality, Minas Gerais, Brazil. Mem Inst Oswaldo Cruz 2013; In press..
Today, as a product of continuous entomological surveillance and a decrease in the
magnitude of outbreaks of sylvatic P. megistus resulting from intense anthropic
action combined with an expansive rural exodus and the improvement of dwellings, the transmission of
HCD is virtually suspended in Bambuí. A recent investigation among a non-selected population
(1,782 individuals) showed that infected individuals beyond the fourth decade of life
could no longer be identified (a unique exception being a 34-year-old woman who never lived in
rural areas and whose mother is seropositive). A general disease prevalence of 7.74% is
restricted to individuals greater than 50 years old, with a median age of 66 years and with no
differences due to gender, in contrast with the levels of approximately 60% found in the
1950s involving all age groups1010. Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo
clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis].
[Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.
11. Laranja FS, Dias E, Duarte E, Pellegrino J. Observações
clínicas e epidemiológicas sobre a moléstia de Chagas no Oeste de Minas Gerais.
O Hospital 1951; 40:137-192.-1212. Matos CS, Santos JE, Dias JCP. Present situation of human Chagas disease
prevalence in Bambuí municipality, Minas Gerais, Brazil. Mem Inst Oswaldo Cruz 2013; In
press.. Independent of age, approximately 17.6% of the seropositive group
has the indeterminate clinical form of HCD. Chagas heart disease and chronic digestive disturbances
due to infection were found respectively in 70.6% and 53.9% of the patients The
association of heart and digestive disturbances (cardiodigestive form) represented
40.1%.
The concomitance of HCD with other chronic and degenerative diseases increases with increasing age of the patients. Genotypes TcI and TcII of the parasite are still circulating in Bambuí among vectors, reservoirs and humans. Of 58 patient hemocultures performed, 45 (77.6%) tested positive for the TcII genotype, with two cases of mixed infection by TcI and TcII1212. Matos CS, Santos JE, Dias JCP. Present situation of human Chagas disease prevalence in Bambuí municipality, Minas Gerais, Brazil. Mem Inst Oswaldo Cruz 2013; In press.,1313. Zingales B, Andrade SG, Briones MRS, Campbell DA, Chiari E, Fernandes O, et al. A new consensus for Trypanosoma cruzi intraspecific nomenclature: second revision meeting recommends TcI to TcVI. Mem Inst Oswaldo Cruz 2009; 107:1051-1054..
In such a landscape, studies of HCD in Bambuí are coming to a natural end. This historical endeavor has resulted in the publication of more than 400 scientific papers and dozens of theses over the last 70 years and has provided the continuous training of professionals and an immeasurable service to the community, the country and science. In conclusion, the entire history of this small center should be celebrated as a dream of pioneers and the realization of a beautiful struggle against an important and often neglected illness. The center's mission was fulfilled with extraordinary success.
The present moment necessitates definition of the future of PAEED. Among several options, given the long history of PAEED and the epidemiological setting of this region, the best thing to do seems to be the transformation of this research center into a Regional Service Center of Reference and Research in Cardiology, with joint leadership by the Oswaldo Cruz Foundation, the City Hall of Bambuí and the Regional Health System of the State of Minas Gerais. After several productive preliminary interactions, State of Minas Gerais and the City of Bambuí have demonstrated enthusiastic support for this proposition, and FIOCRUZ must now assess its own interest and willingness to implement this new mission.
REFERENCES
-
1Dias E. O Centro de Estudos e Profilaxia da Moléstia de Chagas em Bambuí, Estado de Minas Gerais. Notícia histórica em homenagem ao Professor Henrique Aragão. Mem Inst Oswaldo Cruz 1956; 54:309-357.
-
2Dias JCP. Cinquenta anos de Bambuí. Rev Soc Bras Med Trop 1993; 26 (supl II):4-8.
-
3Kropf SP. Doença de Chagas, Doença do Brasil: ciência, saúde e nação, 1909-1962. Rio de Janeiro: Fiocruz Editora; 2009.
-
4Martins AV, Versiani OC, Tupinambá AA. Sobre 25 casos agudos de moléstia de Chagas observados em Minas Gerais. Mem Inst Ezequiel Dias 1940; 3-4:1-66.
-
5Coura JR. Síntese histórica sobre a evolução dos conhecimentos sobre a doença de Chagas. In: Dias JCP, Coura JR, editors. Clínica e Terapêutica da doença de Chagas. Uma abordagem para o clínico geral. Rio de Janeiro: Fiocruz Editora; 1997; p. 469-486.
-
6Dias JCP. A descoberta do foco e a instalação do Posto do IOC em Bambuí. In: Dias JCP, editor. Dr. Emmanuel Dias (1908-1962). Rio de Janeiro: Fiocruz Editora; 2008. p. 142-147.
-
7Dias JCP, Schofield CJ. The evolution of Chagas disease (American Trypanosomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz 1999; 94:103-122.
-
8Dias E. Profilaxia da doença de Chagas. O Hospital 1957; 51:53-68.
-
9Laranja FS, Dias E, Nóbrega GC, Miranda A. Chagas' disease. A clinical, epidemiologic and pathologic study. Circulation 1956; 14:1035-1060.
-
10Dias JCP. Doença de Chagas em Bambuí, Minas Gerais, Brasil. Estudo clínico-epidemiológico a partir da fase aguda entre 1940 e 1982. [Thesis]. [Belo Horizonte]: Universidade Federal de Minas Gerais; 1982.
-
11Laranja FS, Dias E, Duarte E, Pellegrino J. Observações clínicas e epidemiológicas sobre a moléstia de Chagas no Oeste de Minas Gerais. O Hospital 1951; 40:137-192.
-
12Matos CS, Santos JE, Dias JCP. Present situation of human Chagas disease prevalence in Bambuí municipality, Minas Gerais, Brazil. Mem Inst Oswaldo Cruz 2013; In press.
-
13Zingales B, Andrade SG, Briones MRS, Campbell DA, Chiari E, Fernandes O, et al. A new consensus for Trypanosoma cruzi intraspecific nomenclature: second revision meeting recommends TcI to TcVI. Mem Inst Oswaldo Cruz 2009; 107:1051-1054.
Publication Dates
-
Publication in this collection
Sept-Oct 2013
History
-
Received
3 Sept 2013 -
Accepted
25 Sept 2013