Abstract

This study analyzed the prevalence of complete neonatal screening (CNS) of children aged under 2 years in Brazil and associated factors using data from the 2013 (n=4,442) and 2019 (n=5,643) national health surveys. We conducted a cross-sectional study to compare prevalence of CNS (eye, ear and heel prick tests) adopting 95% confidence intervals (95%CI) and a 5% significance level. Crude and adjusted Poisson regression was performed to estimate prevalence ratios (PR) and 95%CI to assess the association between socioeconomic, demographic and health variables and CNS. There was a statistically significant increase in CNS prevalence, from 49.2% (95%CI: 47.1-51.3) in 2013 to 67.4% (95%CI: 65.5-69.3) in 2019. However, large disparities persist across states and between sociodemographic groups. In both years, CNS prevalence was lowest among brown and black children, those from families in the three lowest income quintiles, children without health insurance, those from families registered in the Family Health Strategy and children living in the North, cities outside the state capital/metropolitan regions and rural areas. Despite the increase in prevalence of CNS, deep individual and contextual inequalities persist, posing challenges for health policies.

Key words:
Neonatal screening; Children’s health; Health inequalities

Introduction

Beginning in the 1960s in the United States (US)¹1 Mendes IC, Pinheiro DS, Rebelo ACS, Lilian CC. General Aspects of the Neonatal Screening in Brazil: a review. Rev Med Minas Gerais 2020; 30(1):e-3008., neonatal screening seeks to ensure the early identification (from birth up to 28 days of life) of disorders and/or diseases in newborns in order to define appropriate interventions and guarantee treatment and follow-up during the life cycle²2 Brasil. Portaria nº 1.130, de 5 de agosto de 2015. Institui a Política Nacional de Atenção Integral à Saúde da Criança (PNAISC) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2015; 5 ago.^,33 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018..

Health problems identified by neonatal screening include congenital cataracts (the leading cause of child blindness, affecting 3-5 per 10,000 children in the US and UK and almost double this in low- and middle-income countries⁴4 Duret A, Humphries R, Ramanujam S, Naudé ATW, Reid C, Allen LE. The infrared reflex: a potential new method for congenital cataract screening. Eye (Lond) 2019; 33(12):1865-1870.), phenylketonuria (which causes severe brain dysfunction, epilepsy and behavioral problems, with a global prevalence of 1 per 10,000 live births⁵5 Spronsen FJV, Blau N, Harding C, Burlina A, Longo N, Bosch AM. Phenylketonuria. Nat Rev Dis Primers 2021; 7(1):36.) and hearing impairment (with 34 million children under the age of 15 and 7.5 million under the age of 5 having disabling hearing loss⁶6 Neumann K, Chadha S, Tavartkiladze G, Bu X, White KR. Newborn and Infant Hearing Screening Facing Globally Growing Numbers of People Suffering from Disabling Hearing Loss. Int J Neonatal Screen 2019; 5(1):7.).

Worldwide, only one third of newborns undergo neonatal screening and various countries do not have screening programs⁷7 Therrell Jr BL, Padilla CD. Newborn screening in the developing countries. Curr Opin Pediatr 2018; 30(6):734-739.. In Latin America, coverage of neonatal screening policies in Cuba, Chile and Uruguay was more than 99% in 2015, while in Asia, South Korea and Japan have screening coverage rates of between 99% and 100%⁸8 Baggio FL. Ansbach N, Kapusta BB, Luz GS. Produção de conhecimento sobre as doenças rastreadas pela triagem neonatal no Brasil de 2008 a 2018. REAS 2020; 45:e2596.. In China, where guidelines mandate screening for phenylketonuria and congenital hypothyroidism, coverage rates are high, reaching 99% in some cities⁹9 Howson CP, Cedergren B, Giugliani R, Huhtinen P, Padilla CD, Palubiak CS, Santos MD, Schwartz IVD, Therrell BL, Umemoto A, Wang J, Zeng X, Zhao X, Zhong N, McCabe ERB. Universal newborn screening: a roadmap for action. Mol Genet Metab 2018; 124(83):177-183.. In contrast, countries like Pakistan and Indonesia have only private neonatal screening programs, with coverage rates of below 1% and 2%, respectively⁸8 Baggio FL. Ansbach N, Kapusta BB, Luz GS. Produção de conhecimento sobre as doenças rastreadas pela triagem neonatal no Brasil de 2008 a 2018. REAS 2020; 45:e2596..

In Brazil, neonatal screening was introduced late in 1992 and it was only in 2015 that a specific child health policy, the National Policy for Comprehensive Child Health Care (PNAISC), was created. The aim of the PNAISC is to promote child health through the provision of care during pregnancy and during the first nine years of life, focusing on early childhood and vulnerable populations. One of the key actions in the core area “humanized good quality pregnancy, labor, childbirth and newborn care” is neonatal screening²2 Brasil. Portaria nº 1.130, de 5 de agosto de 2015. Institui a Política Nacional de Atenção Integral à Saúde da Criança (PNAISC) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2015; 5 ago..

Since 2016, to be discharged from hospital newborn babies must have undergone the heart and eye test and should do the ear test (during the first month of life) and heel prick test (ideally between the 3rd and 5th day of life), which are all provided free of charge¹⁰10 Brasil. Portaria nº 2.068, de 21 de outubro de 2016. Institui diretriz para a organização da atenção integral e humanizada à mulher e ao recém-nascido no Alojamento Conjunto. Diário Oficial da União 2016; 24 out.. Despite these recommendations, studies in Brazil have revealed regional, socioeconomic and racial disparities in testing¹¹11 Mallmann MB, Tomasi YT, Boing AF. Neonatal screening tests in Brazil: prevalence rates and regional and socioeconomic inequalities. J Pediatr 2020; 96(4):487-494.^,1212 Marques T, Vidal SA, Braz AF, Teixeira MDLH. Perfil clínico e assistencial de crianças e adolescentes com doença falciforme no Nordeste Brasileiro. Rev Bras Saude Mater Infant 2020; 19(4):881-888.. A considerable proportion of children are not screened, and others have only partial access to testing, receiving incomplete neonatal screening. In 2019, only 2.2 million newborns from a total of 2,849,146 (77.2%) were screened by public health services in Brazil¹³13 Brasil. Ministério da Saúde (MS). Programa Nacional de Triagem Neonatal. Indicadores da triagem neonatal no Brasil [Internet]. [acessado 2022 nov 20]. Disponível em: http://portalms.saude.gov.br/acoes-e-programas/programa-nacional-da-triagem-neonatal/indicadores-da-triagem-neonatal-no-brasil.
http://portalms.saude.gov.br/acoes-e-pro... ^,1414 Brasil. Ministério da Saúde (MS). Programa Nacional de Triagem Neonatal [Internet]. [acessado 2022 nov 20]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2020/junho/mais-de-2-2-milhoes-de-recem-nascidos-fizeram-o-teste-em-2020.
https://www.gov.br/saude/pt-br/assuntos/... .

Given the sociodemographic, racial and geographic disparities in neonatal screening in Brazil and government interventions to improve access to testing, it is essential to estimate the prevalence of screening and associated characteristics in order to assess the effectiveness of the PNAISC over time¹1 Mendes IC, Pinheiro DS, Rebelo ACS, Lilian CC. General Aspects of the Neonatal Screening in Brazil: a review. Rev Med Minas Gerais 2020; 30(1):e-3008.. In this sense, data from the 2013 and 2019 national health surveys are useful because they were undertaken before and after the creation of the policy and can therefore show advances and weaknesses in neonatal screening.

This study therefore analyzed the prevalence of complete neonatal screening (CNS) of children aged under 2 years included in the 2013 and 2019 national health surveys and associated factors.

Method

We conducted a cross-sectional study using secondary data from the 2013 and 2019 national health surveys (NHSs). These data were used to identify inequalities in neonatal screening in Brazil.

The surveys were conducted by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health and Oswaldo Cruz Foundation (Fiocruz)¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315.. Both were nationwide population-based household surveys undertaken to obtain a set of validated data on lifestyle and health indicators that is representative of the Brazilian population.

The target population of the surveys was individuals living in permanent private households in Brazil. The survey questionnaire contained questions about the households and residents. One-third of the items covered specific information about a single resident randomly selected from a list of the people living in the household¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315.^,1616 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões. Rio de Janeiro: Coordenação de Trabalho e Rendimento/IBGE; 2020..

The NHS uses complex samples selected from clusters of sampling units from selected areas (individual census tracts or tract clusters called primary sampling units (PSUs) selected across all states and representing a subsample of the master sample that makes up IBGE’s Integrated Household Survey System (SIPD).

The study used three-stage cluster sampling stratified by primary sampling unit, where the secondary units were the households and the tertiary units were the randomly selected residents who responded the individual section of the questionnaire. The census tracts or tract clusters were selected using sampling with probability proportional to the size of the master samples and probability equal to proportion. The households and residents were selected using simple random sampling¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315.^,1616 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões. Rio de Janeiro: Coordenação de Trabalho e Rendimento/IBGE; 2020..

The 2013 NHS included 64,348 households, with 205,546 residents responding the individual section of the questionnaire, compared to 94,115 households and 279,382 residents in the 2019 survey. For the purposes of the present study, we only analyzed the answers to the items in module “L”, which contains questions about children living in the household aged under 2 years¹⁷17 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Proteger e cuidar da saúde de adolescentes na atenção básica. 2ª ed. Brasília: MS; 2018.. We analyzed data on 4,442 children with information on neonatal screening born between 28/07/2011 and 27/07/2013 from the 2013 NHS and 5,643 children born between 28/07/2017 and 27/07/2019 from the 2019 NHS. Further details on the survey methodology can be found in previous studies on the respective NHSs¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315.^,1616 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões. Rio de Janeiro: Coordenação de Trabalho e Rendimento/IBGE; 2020..

We used a set of socioeconomic, demographic and health variables for the analysis. The socioeconomic and demographic variables were as follows: color/race (white, brown, black, other); number of people living in the household (1, 2 and ≥3); per capita household income quintiles (1st quintile, 2nd quintile, 3rd quintile, 4th quintile, 5th quintile, where median income in the lowest and highest quintiles in 2013 and 2019 was R$ 113 and R$ 2,976 and R$ 117 and R$ 1,333, respectively); region of residence (North, Northeast, Midwest, Southeast and South); state of residence; place of residence (urban, rural); city of residence (capital, metropolitan region and outside capital/metropolitan region). The health variables were as follows: underwent the heel prick test, ear and eye tests, respectively (yes, no); has health insurance (yes, no); household registered in the Family Health Strategy (FHS) (yes, no).

The data in each neonatal screening test were aggregated to determine the number of tests performed per child in each survey. The outcome variable complete neonatal screening (CNS) refers to children who underwent all three tests mentioned above. The study was limited to these tests because the 2013 NHS did not ask about the heart test, which was only included in the questionnaire in 2019.

We estimated national and state prevalence of neonatal screening and associated 95% confidence intervals (95%CI) in both NHSs for each socioeconomic, demographic and health variable. Differences in prevalence between variables were considered statistically significant when the p-value was <0.05 with non-overlapping 95%CIs. Pearson’s chi-squared test was used to confirm these differences between the 2019 and 2013 surveys.

Crude and adjusted Poisson regression with robust variance was used to calculate prevalence ratios (PRs) and respective 95%CIs to determine the association between socioeconomic, demographic and health variables and CNS.

All analyses were performed using RStudio version 2022.2.3.492 (R Foundation for Statistical Computing, Boston, USA) and incorporated all the complex sample design features of the 2013 and 2019 surveys.

The 2013 and 2019 NHS data are available in the public domain. The 2013 and 2019 survey protocols were approved by the National Research Ethics Committee/National Health Council (reference numbers CAAE 10853812.7.0000.0008 and CAAE 11713319.7.0000.0008, respectively). All participants signed an informed consent form¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315..

Results

The findings show that there was a statistically significant increase in the overall prevalence of CNS in Brazil, from 49.2% (95%CI: 47.1-51.3) in 2013 to 67.4% in 2019 (95%CI: 65.5-69.3; p-value=0.001), and a statistically significant reduction in the prevalence of children who underwent only two, one or no tests (p-value=0.001). There was a statistically significant increase in the prevalence of CNS in 17 of the 26 states and in the Federal District (p-value<0.01). However, large disparities remained between some states, with CNS prevalence rates in the states of Amapá and Maranhão in 2019 being lower than those in São Paulo and Pará in 2013 (Figure 1).

In both the 2013 and 2019 surveys, prevalence of CNS was highest among whites, children from families in the 5th income quintile, children who had health insurance, and children living in households not registered in the FHS, urban areas, capital cities, metropolitan regions and in the South. There was a statistically significant increase in the prevalence of CNS in white and brown children across all income quintiles, regardless of whether the children had health insurance or lived in a household registered in the FHS, and across both places of residence, all types of cities, and all regions. Despite these increases, significant disparities remained in 2019. CNS prevalence rates in 2019 among brown children, children from families in the 1st income quintile, those who did not have health insurance, and children living in rural areas, outside capital cities and in the North were lower than those in 2013 among white children, children from families in the 5th income quintile, those with health insurance, and children living in urban areas, capital cities and the South and Southeast. The only variable that did not show disparities in 2019 was being registered with the FHS (Table 1).

The results of the crude analysis (Table 2) show that, in 2013, the chance of undergoing CNS was lowest among brown children, children from families in the 1st income quintile, those who did not have health insurance, children from families registered in the FHS and those living in the North, cities outside the state capital/metropolitan regions and rural areas. The same results were found for the adjusted analysis of the 2013 data and the crude analysis of the 2019 data. The only variable that showed a change in the adjusted analysis of the 2019 data was color/race, with black children having the lowest chance of undergoing CNS. The last column of Table 2 shows the consolidated data for 2013 and 2019 controlled for year effect and the other variables. The results show that the chance of undergoing CNS increased by 37% and 39% in the crude and adjusted analysis, respectively (PR: 1.37; 95%CI: 1.29-1.46 and PR: 1.39; 95%CI: 1.32-1.46) (Table 2).

When the variables were adjusted by year, the results of the crude analysis show that the chance of undergoing CNS was lowest in brown children, children from families in the four lowest income quintiles, those who did not have health insurance, children from families not registered in the FHS and those living in cities outside the state capital/metropolitan regions and rural areas. In the adjusted analysis, the variables that continued to be associated with a lower chance of undergoing CNS were being brown (PR: 0.94; 95%CI: 0.89-0.99), being from families in the 1st (PR: 0.75; 95%CI: 0.68-0.82), second (PR: 0.80; 95%CI: 0.73-0.87) and 3rd (PR: 0.88; 95%CI: 0.82-0.95) income quintiles, not having health insurance (PR: 0.83; 95%CI: 0.79-0.88) and living in cities outside the state capital/metropolitan regions (PR: 0.84; 95%CI: 0.80-0.89) and rural areas (PR: 0.81; 95%CI: 0.75-0.88). Chances were highest in children from families not registered in the FHS (PR: 1.08; 95%CI: 1.03-1.13) and children living in the Midwest (PR: 1.33; 95%CI: 1.21-1.47), Southeast (PR: 1.64; 95%CI: 1.51-1.80) and South (PR: 1.77; 95%CI: 1.61-1.94) (Table 2).

Discussion

The results reveal that there was an increase in the prevalence of CNS between 2013 and 2019, leading to a reduction in the proportion of children who underwent isolated neonatal screening tests. However, 32.6% (95%CI: 30.7-34.5) of children in the 2019 survey had not undergone CNS and only the heel prick test was almost universal (data not shown). The disparities in CNS between regions and groups highlight the challenges faced by the PNAISC in increasing prevalence rates and reducing inequalities to guarantee the right to neonatal care for all in Brazil.

Brazil stands out from other Latin America countries such as Paraguay, Guatemala and Haiti when it comes to neonatal screening. However, nations such as Argentina, Cuba, Chile and Uruguay have higher CNS coverage rates.

Asian countries such as China, South Korea and Japan have always had high coverage rates, while in Europe neonatal screening started slowly and gradually increased, first in western Europe and then in countries in the eastern bloc. Poland stands out from other countries, having had almost 100% coverage since 2004. Other countries in Asia, such as Pakistan and Indonesia, have much lower coverage rates than Brazil⁸8 Baggio FL. Ansbach N, Kapusta BB, Luz GS. Produção de conhecimento sobre as doenças rastreadas pela triagem neonatal no Brasil de 2008 a 2018. REAS 2020; 45:e2596.^,99 Howson CP, Cedergren B, Giugliani R, Huhtinen P, Padilla CD, Palubiak CS, Santos MD, Schwartz IVD, Therrell BL, Umemoto A, Wang J, Zeng X, Zhao X, Zhong N, McCabe ERB. Universal newborn screening: a roadmap for action. Mol Genet Metab 2018; 124(83):177-183.^,1818 Therrell BL, Padilla CD, Loeber JG, Kneisser I, Saadallah A,Borrajo GJ, Adams J. Current status of newborn screening worldwide: 2015. Semin Perinatol 2015; 39(3):171-187.^,1919 Greczka G, Zych M, Szyfter W, Wróbel M. Analysis of changes in the Polish universal neonatal hearing screening program over15 years. Otolaryngol Pol 2018; 72(2):13-20..

In Brazil, health care was enshrined as a right for all and duty of the state in the 1988 Federal Constitution. The creation of the country’s public health system, o Sistema Único de Saúde (SUS) or Unified Health System in the 1990s, one of the largest health systems in the world, placed Brazil in the spotlight. However, progress towards guaranteeing the right to health has been shaky²⁰20 Valle FAAL, Farah BF. A saúde de quem está em situação de rua: (in)visibilidades no acesso ao Sistema Único de Saúde. Physis 2020; 30(2):e300226., especially when it comes to vulnerable groups.

Between the 2013 and 2019 NHSs, Brazil went through a political and socioeconomic crisis that impacted all spheres of society, deepening individual and contextual inequalities. This situation aggravated barriers to access to public health services, contributed to the dismantling of institutional rights, amplified threats to the SUS, and led to increase in the number of people in poverty and vulnerable situations that persist today²⁰20 Valle FAAL, Farah BF. A saúde de quem está em situação de rua: (in)visibilidades no acesso ao Sistema Único de Saúde. Physis 2020; 30(2):e300226..

The findings of this study reveal various types of inequality. Despite a reduction in racial disparities in screening over the study period, white people have historically enjoyed proportionally better access to health services than black or brown people²¹21 Cobo B, Cruz C, Dick PC. Gender and racial inequalities in the access to and the use of Brazilian health services. Cien Saúde Colet 2021; 26(9):4021-4032.^,2222 Szwarcwald CL, Stopa SR, Damacena GN, Almeida WS, Souza Júnior PRB, Vieira MLFP, Pereira CA, Sardinha LMV, Macário EM. Changes in the pattern of health services use in Brazil between 2013 and 2019. Cien Saúde Colet 2021; 26(Supl. 1):2515-2528..

While the FHS aims to reduce socioeconomic inequalities in access to services, be a model for the expansion and reorganization of the SUS, and ensure care continuity and longitudinality²³23 Kessler M, Lima SBS, Weiller TH, Lopes LFD, Ferraz L, Eberhardt TD, Soares RSA, Trindade LL. Longitudinalidade do cuidado na atenção primária: avaliação na perspectiva dos usuários. Acta Paul Enferm 2019; 32(2):186-193., our findings show that prevalence of CNS was higher in children from families not registered in the program. These children are also from families that have higher purchasing power and health insurance. FHS coverage may therefore be a marker of unmet health needs among more vulnerable populations, who have historically been characterized by higher FHS adherence rates.

In a study by Mallmann et al.¹¹11 Mallmann MB, Tomasi YT, Boing AF. Neonatal screening tests in Brazil: prevalence rates and regional and socioeconomic inequalities. J Pediatr 2020; 96(4):487-494., prevalence of test seeking and neonatal screening was higher among children with health insurance, while Pilotto and Celeste²⁴24 Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saude Publica 2018; 34(4):e00052017. reported that the utilization of medical services is higher among this group. This factor therefore reduces barriers to access and facilitates disease prevention.

Geographical inequalities (place of residence, city and region) are related to purchasing power, quality of facilities, infrastructure and health system organization, and level of health workforce training and development¹¹11 Mallmann MB, Tomasi YT, Boing AF. Neonatal screening tests in Brazil: prevalence rates and regional and socioeconomic inequalities. J Pediatr 2020; 96(4):487-494.^,2525 Dimenstein M, Simoni ACR, Macedo JP, Nogueira N, Barbosa BCNS, Silva BIBM, Amaral Filho JB, Silva RCA, Liberato MTC, Prado CLC, Leão MVAS, Quinto BA, Soares LF. Equidade e acesso aos cuidados em saúde mental em três estados nordestinos. Cien Saúde Colet 2021; 26(5):1727-1738.. There are also differences in the organization of the health care network across all levels of care between regions, weakening health services, especially in more disadvantaged areas²⁶26 Paschoal MR, Cavalcanti HG, Ferreira MA. Análise espacial e temporal da cobertura da triagem auditiva neonatal no Brasil (2008-2015). Cien Saúde Colet 2017; 22(11):3615-3624..

Although notable progress was made in CNS over the study period, efforts to reduce inequalities in Brazil need to be intensified as they persist even after the expansion of the PNAISC. Intersectoral strategies should be developed to promote coordination and cooperation between different spheres of government, with health, finance and social service departments and agencies working together to provide well-structured services and comprehensive newborn and children’s health care¹¹11 Mallmann MB, Tomasi YT, Boing AF. Neonatal screening tests in Brazil: prevalence rates and regional and socioeconomic inequalities. J Pediatr 2020; 96(4):487-494..

In view of the positive long-term health and socioeconomic benefits of neonatal screening, it is necessary to strengthen the PNAISC by increasing investment and improving the availability of tests on the SUS.

Despite providing important findings, this study has some limitations. First, the fact that testing was self-reported by the child’s mother or guardian during the interview means that the data may be subject to recall bias, including confusing the names of the tests. Second, the NHS questionnaire does not ask about the action taken after carrying out the tests. Information on whether the family received the results of the tests or if timely appropriate treatment was provided and child referral through the health system was not available. The 2019 survey questionnaire asked about tests that were not available in 2013, meaning that for the purposes of this study screening was deemed to be complete when the child had undergone the three tests included in both surveys.

Study strengths included the use of nationally representative data for two different periods, providing a broad overview of the situation in Brazil and progress made by neonatal health policies in a country with deep and wide-ranging individual and contextual inequalities. Our findings also revealed stark disparities and the main barriers to CNS, providing important insights to inform further research and the development of strategies to expand the coverage of CNS in Brazil.

In conclusion, this study revealed an increase in the prevalence of CNS in recent years in Brazil. However, large individual and contextual disparities remain, posing challenges for the PNAISC in the pursuit of wide-scale and even CNS coverage in the country.

This study provides important findings that show the progress made by the country’s neonatal screening policy, revealing weaknesses in and opportunities to improve health policies and social and economic policies that have an impact on health.

References

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