Abstract

Objective:

to describe congenital anomalies (CA) among live births of mothers resident in Tangará da Serra, MT, Brazil, during the period 2006-2016.

Methods:

this was a descriptive study, using Brazilian Live Birth Information System (SINASC) data.

Results:

out of 15,689 births, 77 were registered with CA (prevalence of 4.9/1,000); there was an 80.7% increase of recorded CA in 2016, accounting for 10.3/1,000 live births, including five cases of microcephaly; CA prevalence was higher among children born to women aged over 35 years (prevalence ratio [PR] =1.91; confidence interval [95%CI] 1.01;3.60), preterm (PR=2.22; 95%CI 1.26;3.92) and low birth weight infants (PR=3.21; 95%CI 1.86;5.54).

Conclusion:

low CA prevalence was found, possibly related to under-recording at birth; the increase observed in 2016 may be related to the Zika epidemic causing microcephaly, as well as greater attention by health professionals in relation to CA during this public health emergency.

Keywords:
Congenital Anomalies; Live Birth; Information Systems; Public Health Surveillance; Zika Virus Infection; Microcephaly

Introduction

Congenital anomalies (CA) are developmental disorders of prenatal origin present at birth, and may be structural (physical deformities), functional (neuromotor alterations) or metabolic (for example, inborn errors of metabolism, phenylketonuria, among other). Their causes may be genetic, environmental, or multifactorial.¹1. Mazzu-Nascimento T, Melo DG, Morbioli GG, Carrilho E, Vianna FSL, Silva AA, et al. Teratogens: a public health issue - a Brazilian overview. Genet Mol Biol. 2017 Apr-Jun;40(2):387-97.^,22. Ramos AP, Oliveira MND, Cardoso JP. Prevalência de malformações congênitas em recém-nascidos em hospital da rede pública. Rev Saúde Com. 2008 jan-jun;4(1):27-42. In most cases, their etiology remains unknown and environmental causes (teratogens) are still little studied, especially in developing countries like Brazil.¹1. Mazzu-Nascimento T, Melo DG, Morbioli GG, Carrilho E, Vianna FSL, Silva AA, et al. Teratogens: a public health issue - a Brazilian overview. Genet Mol Biol. 2017 Apr-Jun;40(2):387-97.^,33. Organização Mundial da Saúde. CID-10: classificações internacionais em português. São Paulo: Editora da Universidade de São Paulo; 2014. It is estimated that congenital anomalies are present in 2 to 3% of live births, and can reach 5% if alterations diagnosed later, such as cardiac, renal and pulmonary anomalies, are taken into account.²2. Ramos AP, Oliveira MND, Cardoso JP. Prevalência de malformações congênitas em recém-nascidos em hospital da rede pública. Rev Saúde Com. 2008 jan-jun;4(1):27-42. Between 1980 and 2007, there was a large proportional reduction of secondary infant deaths due to infectious and respiratory causes, while CA remained stable, these being the second cause of infant mortality in Brazil.¹1. Mazzu-Nascimento T, Melo DG, Morbioli GG, Carrilho E, Vianna FSL, Silva AA, et al. Teratogens: a public health issue - a Brazilian overview. Genet Mol Biol. 2017 Apr-Jun;40(2):387-97.^,44. Victora CG, Aquino EM, Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011 May;377(9780):1863-76. A similar phenomenon was described in another Latin American country, Chile, between 2001 and 2010.⁵5. Canals A, Cavada G, Nazer J. Factores de riesgo de ocurrencia y gravedad de malformaciones congénitas. Rev Méd Chile. 2017 nov;142(11):1431-9.

The Brazilian Live Birth Information System (SINASC) was established in 1990 by the Brazilian Ministry of Health with the goal of providing data on live births retrieved from Statements of Live Birth (SLB).⁶6. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.^,77. Marinho F, Araujo VEM, Porto DL, Ferreira HL, Coelho MRS, Lecca RCR, et al. Microcephaly in Brazil: prevalence and characterization of cases from the Information System on Live Births (Sinasc), 2000-2015. Epidemiol Serv Saúde. 2016 Oct-Dec;25(4):701-12. With effect from 1999, a field was included on the SLB form for registering CA and coded according to the 10^th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10).³3. Organização Mundial da Saúde. CID-10: classificações internacionais em português. São Paulo: Editora da Universidade de São Paulo; 2014. This makes SINASC an important instrument for CA monitoring in Brazil.⁸8. Luquetti DV, Koifman RJ. Quality of birth defect reporting in the Brazilian Information System on Live Births (SINASC): a comparative study of 2004 and 2007. Cad Saúde Pública. 2010 Sep;26(9):1756-65.

With the national emergency caused by the Zika virus and its association with microcephaly,⁹9. Schuler-Faccini L, Ribeiro EM, Feitosa IML, Horovitz DG, Cavalcanti DP, Pessoa A, et al. Possible association between zika virus infection and microcephaly - Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016 Jan;65(3):59-62. the epidemiological surveillance service of the municipality of Tangará da Serra, Mato Grosso, Brazil, realized the importance of recording live birth head circumference and length at birth (data until then absent from the SLB form) and made it compulsory for all local maternity hospitals to record this information manually with effect from 2016. In 2017, the initiative was extended throughout the national territory in response to a Ministry of Health recommendation.

In seeking to understand the behavior of congenital anomalies in Tangará da Serra over the last ten years (2006-2016), both prior to the emergence of congenital Zika virus syndrome (CZS) as well as during the occurrence of CZS with continuous virus transmission, the objective of this study was to describe congenital anomalies (CA) among live births to mothers resident in Tangará da Serra, MT, Brazil, during the period 2006-2016.

Methods

This was a descriptive study, using SLB and SINASC data referring to the period between 1 January 2006 and 31 December 2016, consulted in the second half of 2017. We included all live births resident in the municipality of Tangará da Serra, located in the Southwestern region of Mato Grosso state, 240km from Cuiabá, the state capital. In 2017, Tangará da Serrra had a population of 98,828 inhabitants, with an annual average of 1,445 live births. Tangará da Serra is the main city of its microregion and the sixth largest city in Mato Grosso state, accounting for approximately 3% of the state’s population.¹⁰10. Instituto Brasileiro de Geografia e Estatística. IBGE cidades: Tangará da Serra - MT [Internet]. 2017 [citado 2018 jun 5]. Disponível em: Disponível em: https://cidades.ibge.gov.br/brasil/mt/tangara-da-serra/panorama
https://cidades.ibge.gov.br/brasil/mt/ta... The city has a total of 211 public and private health establishments registered on the National Database of Health Care Facilities (CNES). These establishments include four hospitals with three maternity units.¹¹11. Ministério da Saúde (BR). Cadastro Nacional de Estabelecimento de Saúde (CNES). Tabnet: Brasil [Internet]. 2017 [citado 2018 jun 5]. Disponível em: Disponível em: http://cnes.datasus.gov.br/
http://cnes.datasus.gov.br/...

We included all live births between 1 January 2006 and 31 December 2016, based on SINASC data retrieved on 1 September 2017. SINASC is organized on the basis of Statement of Live Birth (SLB) records filled in by healthcare professionals. For the purpose of our analysis, the following SLB variables were selected:

Congenital anomalies are recorded in a special field on the SLB form. This field allows one or more congenital anomalies to be recorded. Each diagnosis should be informed both on the SLB form and on SINASC. Physicians are responsible for diagnosing defects and/or anomalies, as well as for informing the person who fills in and/or inputs the corresponding ICD-103 codes on the SLB Recording this information in hospitals can be hampered by inadequate workflow, especially when different people collect and fill in SLB data. For this reason it is recommended that the SLB form is filled in by just one person before the mother is discharged. In the case of congenital defects diagnosed after the issuance of the SLB, or when laboratory confirmation of diagnosis is late, it is possible to register the data as an exception and add the information to the SINASC database.

The statistical analysis was performed using Stata version13.0.12 Initially, the annual numbers of live births with any congenital anomaly (isolated or multiple) and their prevalence per 1,000 live births were analyzed. As such, we estimated CA prevalence (per 1,000 live births) by type, according to ICD-10, for the entire period from 2006 to 2016, whereby the numerator was the number of live births for each CA type/group and the denominator was the total number of live births in the period. Prevalence ratios (PR) and their respective 95% confidence intervals (95%CI), were calculated according to sociodemographic characteristics, child delivery characteristics and live birth characteristics.

The study was carried out within the scope of the Epidemiological Surveillance actions of the municipality of Tangará da Serra. Only secondary data were used, with no direct or indirect identification of people. As it followed the ethical standards set out in National Health Council (CNS) Resolution No. 466 of 12 December 2012 and Resolution No. 510, of 7 April 2016, the study project was not submitted to a Research Ethics Committee.

Results

15,689 live births to mothers resident in the municipality of Tangará da Serra between 2006 and 2016 were analyzed. Of these, 77 had some form of CA identified before hospital discharge, representing CA prevalence of 4.9/1,000 live births.

Figure 1 shows total CA prevalence between 2006 and 2016. It is noteworthy that in the decade between 2006 and 2015, the records remained stable, although there was an increase of 80.7% in CA prevalence between 2015 and 2016 (5.7/1,000) (10.3/1,000).

There were a total of 90 anomalies, since seven live births had more than one anomaly. Musculoskeletal system CA (27/90) were the most frequent, followed by nervous system CA (23/90), digestive system CA (12/90), cleft lip and palate CA (6/90) and chromosomal CA (4/90). Among musculoskeletal system CA, the most recorded diagnoses were 'clubfoot' (7/27) and polydactyly (5/27). Of the 23 records of nervous system CA, the most common diagnosis was microcephaly with six records - five of in the year 2016 alone, followed by hydrocephalus (5/23), anencephaly (3/23), spina bifida (2/23) and encephalocele (2/23) (Table 1).

Table 2 presents the distribution of live births with CA by type of anomaly and year of birth, including the ten most frequent CA in the period. From 2006 to 2015, only one case of microcephaly was recorded in the municipality, while the following year, 2016, no fewer than five cases were notified and all of them were severe cases.

Regarding maternal and live birth characteristics, CA prevalence ratios were greater among children born to women over the age of 35 years, in relation to those aged under 35 years (PR=1.91; 95% CI 1.01;3.60), as well as among preterm children, in comparison with those who were born at term (PR=2.22; 95% CI 1.26;3.92), and those with birth weight less than 2,500g (PR=3.21; 95% CI 1.86;5.54) (Table 3).

Discussion

Annual CA prevalence recorded on SINASC between 2006 and 2016 in a municipality in the state of Mato Grosso in the Brazilian Midwest was evaluated retrospectively. There was a Zika virus outbreak in this municipality at the end of 2015 and beginning of 2016. Zika virus (ZIKV)infection is known to be teratogenic in humans and the epidemic heightened the importance of establishing protocols for CA surveillance in developing countries. The World Health Organization (WHO) recommends as responsibility of each country the establishment of protocols and regulations for CA surveillance.¹³13. World Health Organization. Centers for Disease Control and Prevention. Birth defects surveillance: a manual for programme managers [Internet]. Geneva: World Health Organization; 2014 [citado 2018 jun 5]. 126 p. Available in: Available in: http://apps.who.int/iris/bitstream/handle/10665/110223/9789241548724_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handl... CA are responsible for 276,000 early neonatal deaths from congenital anomaly worldwide each year.¹⁴14. Organización Mundial de la Salud. Anomalías congénitas. Nota descriptiva n° 370 [Internet]. 2015 [cited 2016 Oct 21]. Disponible: Disponible: http://www.who.int/es/news-room/fact-sheets/detail/congenital-anomalies
http://www.who.int/es/news-room/fact-she...

In Europe, the European Surveillance of Congenital Anomalies (EUROCAT) was created in 1979. It is a network of population records for epidemiological surveillance of CA with 23 member countries.¹⁵15. European surveillance of congenital anomalies. EUROCAT special report: geographic inequalities in public health indicators related to congenital anomalies [Internet]. Northern Ireland: European surveillance of congenital anomalies; 2014 [cited 2018 jun 5]. 31 p. Available in: Available in: http://www.eurocat-network.eu/content/Special-Report-Geographical-Inequalities.pdf
http://www.eurocat-network.eu/content/Sp...

In the Americas, there are records of CA in several countries such as Argentina, Brazil, Canada, Chile, Colombia, Costa Rica, Mexico and Uruguay, in addition to the Latin-American Collaborative Study of Congenital Malformations (ECLAMC), which involves hospitals in several countries in South America. In the United States, state-level tracking is mandatory and hospital services notify data on CA births and fetal deaths using a standardized form. The majority of these data are reported to higher authorities, such as the International Clearinghouse for Birth Defects and Monitoring Systems (ICBDMS), responsible for international surveillance.¹⁶16. International Clearinghouse for Birth Defects and Monitoring Systems. Addressess and staff [Internet]. 2017 [cited 2018 Jun 5]. Available in: Available in: http://www.icbdsr.org/members-address-and-staff/
http://www.icbdsr.org/members-address-an...

In Brazil, notification has been compulsory since 1999 and is done by filling out the SLB form. This data is available on SINASC and allows the tracking of CA.⁶6. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.^,77. Marinho F, Araujo VEM, Porto DL, Ferreira HL, Coelho MRS, Lecca RCR, et al. Microcephaly in Brazil: prevalence and characterization of cases from the Information System on Live Births (Sinasc), 2000-2015. Epidemiol Serv Saúde. 2016 Oct-Dec;25(4):701-12.

In Mato Grosso State, SINASC coverage between the years 2000 and 2012 was 94.9%. This was considered satisfactory and had an increasing trend¹⁷17. Stevanato JM, Gaíva MAM, Silva AMC. Coverage trends of the Information System on Live Births in Mato Grosso, Brazil, 2000 to 2012. Epidemiol Serv Saude. 2017 Apr-Jun;26(2):265-74. above the Brazilian average of 92%.⁴4. Victora CG, Aquino EM, Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011 May;377(9780):1863-76.

CA frequency is estimated to be 2% to 3% of live births. ECLAMC registers 2.73% of CA live births in Latin America, while in European countries covered by the EUROCAT network, this average is 9.5/1,000 live births and 0.9/1,000 perinatal deaths. These differences between frequencies in Latin America and in Europe are due, to a large extent, to elective interruption of pregnancy (elective abortions) owing to fetal anomalies. When the records include these anomalies, the CA frequency reaches 2% in European countries.²2. Ramos AP, Oliveira MND, Cardoso JP. Prevalência de malformações congênitas em recém-nascidos em hospital da rede pública. Rev Saúde Com. 2008 jan-jun;4(1):27-42.^,1414. Organización Mundial de la Salud. Anomalías congénitas. Nota descriptiva n° 370 [Internet]. 2015 [cited 2016 Oct 21]. Disponible: Disponible: http://www.who.int/es/news-room/fact-sheets/detail/congenital-anomalies
http://www.who.int/es/news-room/fact-she...

Some 2.9 million live births are registered annually in Brazil and it is expected that approximately 90,000 have some kind of CA, taking estimated prevalence of 3% for the human species.⁶6. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8. However, studies based on SINASC data for the municipalities of Rio de Janeiro and São Paulo showed live birth CA frequency of 1.7% and 1.6%, respectively, these rates being higher than those found in our study.⁶6. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.^,1818. Costa CM, Gama SG, Leal MC. Congenital malformations in Rio de Janeiro, Brazil: prevalence and associated factors. Cad Saúde Pública. 2006 Nov;22(11):2423-31. Maringá-PR and Vale do Paraíba-SP share similar data, having 0.7% and 0.76% live birth ACs, respectively, this being close to the findings of our study, 0.7.¹⁹19. Melo WA, Zurita RCM, Uchimura TT, Marcon SS. Anomalias congênitas: fatores associados à idade materna em município sul brasileiro, 2000 a 2007. Rev Eletr Enf. 2010 jan-mar;12(1):73-82.^,2020. Pinto CO, Nascimento LFC. Estudo de prevalência de defeitos congênitos no Vale do Paraíba Paulista. Rev Paul Pediatr. 2007 set;25(3):233-9. The issue of CA underreporting on SLB forms has been investigated by Luquetti and Koifmann⁸8. Luquetti DV, Koifman RJ. Quality of birth defect reporting in the Brazilian Information System on Live Births (SINASC): a comparative study of 2004 and 2007. Cad Saúde Pública. 2010 Sep;26(9):1756-65. in eight hospitals in João Pessoa-PB, Salvador-BAa, São Paulo and Campinas-SP, Belo Horizonte-MG, and Florianópolis and Joinville-SC.⁸8. Luquetti DV, Koifman RJ. Quality of birth defect reporting in the Brazilian Information System on Live Births (SINASC): a comparative study of 2004 and 2007. Cad Saúde Pública. 2010 Sep;26(9):1756-65. In their work, which used ECLAMC as its gold standard, the authors found that CA was underreported on SINASC in these hospitals by at least 40% in 2004 and 2007. Costa et al. (2008)¹⁸18. Costa CM, Gama SG, Leal MC. Congenital malformations in Rio de Janeiro, Brazil: prevalence and associated factors. Cad Saúde Pública. 2006 Nov;22(11):2423-31. also performed a study comparing SINASC data with hospital records of live births in the state of Rio de Janeiro in 2004 and found variability of concordance between SINASC data and hospital records, depending on the type of CA, with the highest CA concordance rates being found for the musculoskeletal system.

In Tangará da Serra underreporting can be attributed in particular to the lack of detection of CA in internal organs, such as congenital cardiopathies²¹21. Pinto-Júnior VC, Branco KMPC, Cavalcante RC, Carvalho-Junior W, Lima JRC, et al. Epidemiology of congenital heart disease in Brazil. Rev Bras Cir Cardiovasc. 2015 Mar-Apr;30(2 ):219-24. or other CA the clinical characteristics of which are less visible at birth.²²22. Nhoncanse GC, Germano CMR, Avó LRS, Melo DG. Maternal and perinatal aspects of birth defects: a case-control study. Rev Paul Pediatr. 2014 Mar;32(1):24-31. The predominance of congenital anomalies of the musculoskeletal system may be related to the inclusion of frequent anomalies, such as 'clubfoot' and polydactyly, in addition to the majority of musculoskeletal system anomalies being easily visible at birth.²2. Ramos AP, Oliveira MND, Cardoso JP. Prevalência de malformações congênitas em recém-nascidos em hospital da rede pública. Rev Saúde Com. 2008 jan-jun;4(1):27-42.^,66. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.

There was a sharp increase in CA in 2016, with the occurrence of five live births of children with microcephaly, compared to only one case recorded in all the previous years. This result could have arisen from more records being made following the incorporation of head circumference measurement on SLB. However, the five cases reported were severe microcephaly cases, which were clinically observable, even without the aid of a tape measure. Subsequently, these five cases were all evaluated and recorded as being compatible with congenital Zika syndrome. This assessment is concomitant with the occurrence of the ZIKV infection outbreak in the municipality, between the end of 2015 and the beginning of 2016. In Brazil, microcephaly cases remained stable from 2000 to 2014, with prevalence of 2/10,000 live births, changing significantly with effect from 2015, with 54.6/10,000 live births.⁷7. Marinho F, Araujo VEM, Porto DL, Ferreira HL, Coelho MRS, Lecca RCR, et al. Microcephaly in Brazil: prevalence and characterization of cases from the Information System on Live Births (Sinasc), 2000-2015. Epidemiol Serv Saúde. 2016 Oct-Dec;25(4):701-12. Part of this increase is attributed to the adoption of broader microcephaly inclusion criteria, such as head circumference of between -2 and -3 Z-Scores In addition, head circumference measurement is often subject to bias, either because of measurement errors, or because measurement is taken before the child completes 24 hours of life.²³23. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Orientações integradas de vigilância e atenção à saúde no âmbito da Emergência de Saúde Pública de Importância Nacional: procedimentos para o monitoramento das alterações no crescimento e desenvolvimento a partir da gestação até a primeira infância, relacionadas à infecção pelo vírus Zika e outras etiologias infeciosas dentro da capacidade operacional do SUS [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2018 jun 5]. 158 p. Disponível em: Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2016/dezembro/12/orientacoes-integradas-vigilancia-atencao.pdf
http://portalarquivos.saude.gov.br/image... Notwithstanding such obliquities, the use of SINASC data was fundamental for the confirmation of an abnormal and sudden increase in microcephaly cases in Northeast Brazil at the end of 2015.⁷7. Marinho F, Araujo VEM, Porto DL, Ferreira HL, Coelho MRS, Lecca RCR, et al. Microcephaly in Brazil: prevalence and characterization of cases from the Information System on Live Births (Sinasc), 2000-2015. Epidemiol Serv Saúde. 2016 Oct-Dec;25(4):701-12. In Mato Grosso state as a whole, between epidemiological weeks 45/2015 and 35/2017, the state registered 386 notifications of microcephaly cases, of which 19% were confirmed as cases of congenital Zika syndrome.²⁴24. Secretaria Estadual de Saúde (MT). Casos acumulativos até a Semana Epidemiológica 35/2017 - Monitoramento dos casos com alterações relacionadas ao Zika vírus e outras etiologias infecciosas em Mato Grosso - Semana Epidemiológica (SE) 35. Bol Epidemiol. 2017;(31):1-7.

In our study, CA prevalence was greater among live births to mothers aged more than 35 years old. This is an expected effect, since maternal age is the main risk factor for chromosomal abnormalities.²2. Ramos AP, Oliveira MND, Cardoso JP. Prevalência de malformações congênitas em recém-nascidos em hospital da rede pública. Rev Saúde Com. 2008 jan-jun;4(1):27-42.^,66. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.^,1717. Stevanato JM, Gaíva MAM, Silva AMC. Coverage trends of the Information System on Live Births in Mato Grosso, Brazil, 2000 to 2012. Epidemiol Serv Saude. 2017 Apr-Jun;26(2):265-74. It is also important to note that three cases of gastroschisis were recorded, this being an anomaly more frequent in children of younger mothers. Moreover there appears to be a global time trend of increasing CA with effect from 1980 as confirmed in North American records.²⁵25. St Louis AM, Kim K, Browne ML, Liu G, Liberman RF, Nembhard WN, et al. Prevalence trends of selected major birth defects: a multi-state population-based retrospective study, United States, 1999 to 2007. Birth Defects Res. 2017 Nov;109(18):1442-50. Weighing less than 2,500g and prematurity were also factors associated with congenital anomalies. This was to be expected as congenital defects are frequently associated with these outcomes.³3. Organização Mundial da Saúde. CID-10: classificações internacionais em português. São Paulo: Editora da Universidade de São Paulo; 2014.^,66. Cosme HW, Lima LS, Barbosa LG. Prevalence of congenital anomalies and their associated factors in newborns in the city of São Paulo from 2010 to 2014. Rev Paul Pediatr. 2017 jan-mar;35(1):33-8.^,88. Luquetti DV, Koifman RJ. Quality of birth defect reporting in the Brazilian Information System on Live Births (SINASC): a comparative study of 2004 and 2007. Cad Saúde Pública. 2010 Sep;26(9):1756-65.

As additional limitations of the present study, we highlight the incomplete filling in of the SLB form and the unavailability of complementary exams in prenatal care for early diagnosis of CA.

Considering the lack of studies about CA in Brazil, mainly in Midwest region, the results presented by this research can contribute to the planning of Public Health actions, as well as to directing and deepening discussions regarding the scaling up of actions as part of the public policies on CA and all actors involved in this process: family, friends, professionals and society in general. Standing out among these actions is the importance of training and raising the awareness of health professionals regarding the filling in of the SLB form, since the data they provide on CA, once they have been included on SINASC, constitute an important tool for the detection of alterations in temporal or spatial frequencies of congenital anomalies, such as the occurrence of microcephaly owing to maternal infection by the virus.

Acknowledgments

We thank the epidemiological surveillance team of the Municipal Health Department of Tangará da Serra: Zulema Salete Dengo Nuernberg, Maria Ozana Ferreira da Silva and Gisele Barbosa da Silva.

References

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