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INTRODUCTION
The World Health Organization (WHO) points out that about 930,000 pregnant women acquire syphilis in the world every year. Of these pregnancies, approximately 38% progress to unfavorable birth outcomes, including 143,000 stillbirths, 102,000 infants with congenital syphilis (CS), 62,000 neonatal deaths, 44,000 premature or low birth weight infants1. Estimates from the Pan American Health Organization (PAHO) pointed to 22,800 cases of CS in Latin America and the Caribbean in 2015, which indicates a rate of 1.7 cases per 1,000 live births.
In Brazil, until 2018, there was a significant increase in the rates of children with CS and a beginning of a decrease in incidence rates from 2019 onwards. In 2020, the country had a CS detection rate of 7.7 cases per 1,000 live births and a CS mortality coefficient of 6.5 per 100,000 live births. Some of the factors that may be related to these results are the increased coverage and availability of rapid tests, unprotected sex and the resistance of primary care professionals to administer penicillin2, weakening access to treatment.
In 2020, most of the CS records came from the Southeast region (44.5%), followed by the Northeast of Brazil (28.2%), accounting for 72.7% of the total records in Brazil. Regarding deaths from congenital syphilis in children under one year of age, the North region had the highest mortality rate, resulting in approximately 10.2 cases per 100,000 live births, followed by the Southeast (7.3%) and Mid-West (6.2%)3.
The increase in CS cases should not be evaluated considering only social and economic indicators, but should use data such as the quality of information passed on in prenatal care to pregnant women and partners. Another important factor is the working conditions that provide appropriate tools for satisfactory prenatal care, providing the necessary conditions for the correct registration of cases and the clinical management of syphilis in pregnant women, preventing vertical transmission4,5.
The epidemiological scenario is an elementary instrument for surveillance, as it configures a triggering tool in the “information-decision-action” process. Health information not only describes epidemiological scenarios, but also evaluates services, directs implementations, conducts, evaluates and monitors health care models, as well as disease control. For this purpose, it is essential to have technical knowledge and professionals qualified to program, conduct and monitor the processes related to the collection, notification, processing, evaluation, presentation and dissemination of data, in addition to the production of information6.
The list that determines the harms and diseases of compulsory notification, determined by law, has been the main source of data and information for epidemiological surveillance, ensuring the mandatory registration, periodicity and dissemination of information. The constant qualification of the epidemiological surveillance system, supported by parameters of utility, timeliness of registration and quality, portrays substantial tools for the programming, monitoring, operationalization and analysis of health actions, promoting their improvements and pointing out activities that lead to more knowledge regarding the diseases as a solution7.
In order to improve the system and bring reliable, complete and consistent information, every database must be regularly evaluated, thus serving as a subsidy in decision-making by health managers. The more qualified the database, the greater its capacity to support the construction of effective public policies4.
Continuous updating followed by the qualification of the database of the Notifiable Diseases Information System (SINAN, as per its Portuguese acronym) is essential for monitoring the epidemiological scenarios of the diseases and conditions contained in the system. Data with irregularities, from incomplete records or with frequently ignored variables, inconsistencies between fields and duplication of records, among other setbacks verified at the municipal, state or federal levels, indicate the need for an analysis of the quality of the collected information8.
The current study aimed to evaluate the quality of data from the epidemiological surveillance system for congenital syphilis in Natal, Rio Grande do Norte State, Brazil, from 2017 to 2021, according to the Updated Guidelines for Evaluating Public Health Surveillance Systems, belonging to the Centers for Diseases Control and Prevention9.
METHODS
Study design
This is an evaluative study with secondary data regarding the notifications of cases of congenital syphilis in the municipality of Natal.
Study location and period
The municipality of Natal, capital of Rio Grande do Norte (RN), is located in the Northeast region of Brazil. According to the Brazilian Institute of Geography and Statistics (2019), the city occupies a territorial area of 167.4 km2, divided into 36 neighborhoods, distributed in 5 health districts, all included in the study. It has a demographic density of 4,805.24 inhabitants/km2 and a population estimate of 884,122 inhabitants in 2019. Data collection took place from January 1, 2017 to December 31, 2021.
Study population and eligibility criteria
All cases of congenital syphilis registered in the Notifiable Diseases Information System (SINAN) and all deaths, miscarriages and stillbirths due to congenital syphilis in the municipality of Natal were included. In order to identify fetal and infant deaths recorded in the Mortality Information System (SIM, as per its Portuguese acronym), records that had congenital syphilis as the underlying or associated cause were selected (codes in the range A50 to A50.9 of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems of the International Health Code (ICD-10)10. The extraction and compilation of data for the study took place from March to June 2022.
In order to evaluate the syphilis system, the Updated Guidelines for Evaluating Public Health Surveillance Systems, belonging to the Centers for Diseases Control and Prevention, is a document produced to promote the best use of the resources offered by public health systems, through the design of the evaluation of databases, ensuring that diseases and health conditions are monitored efficiently and effectively9.
Data collection
In order to study the completeness of the data, the following variables were selected: neighborhood, mother’s education, prenatal care during this pregnancy, diagnosis period of maternal syphilis, non-treponemal test at delivery/curettage, mother’s treatment regimen, partner(s) treated concurrently with the pregnant woman, non-treponemal test – peripheral blood, treponemal test (after 18 months), non-treponemal test – cerebrospinal fluid, changes in cerebrospinal fluid, radiological diagnosis of the child, treatment regimen of the child and progression of the case. Variables that were not filled in, filled in with “unknown” or with invalid values, were considered incomplete.
Data analysis
The completeness values were categorized based on the parameters of a study that evaluated the completeness of the data from the Notifiable Diseases Information System (SINAN) on congenital syphilis4. The parameters were adapted by defining them as: very poor (< 50%), poor (50 - 69.9%), regular (70 - 89.9%), good (90 - 94.9%) and excellent (≥ 95%).
Regarding the consistency of the data, the following variables were studied: (1) death from congenital syphilis, death from other causes, miscarriage or stillbirth – cases that had these progressions without the presence of information on the date of occurrence were checked; (2) non-treponemal reactive test of the mother at delivery/curettage and the field of the titration filled in; (3) non-treponemal test of the reactive child and the field of the titration filled in; (4) non-treponemal reactive test (cerebrospinal fluid) and the field of the titration filled in; (5) symptomatic clinical diagnosis – the presence of signs and symptoms was verified; (6) the criterion for defining a case of congenital syphilis was met in accordance with the Clinical Protocol and Therapeutic Guidelines (PCDT, as per its Portuguese acronym)11. The adopted parameters were the same as those used for the completeness evaluation.
The speed of data recording was calculated using the time interval, in days, between the date of diagnosis and the date of notification of the case, and (II) between the date of notification and the date of entering the form into SINAN. An agile system for syphilis is considered when (I) 90% of the cases are notified within seven days from the beginning of the diagnosis and when (II) the data are entered into the SINAN within 30 days after the notification of the case9,12. In order to evaluate the degree of representativeness of the system, the records of deaths, miscarriages and stillbirths in SINAN were compared with mortality data from the Mortality Information System (SIM) using the Spearman’s correlation test. According to this comparison, it was possible to evaluate representativeness according to the occurrence of the description of events in multiple data sources.
RESULTS
Between 2017 and 2021, 1,575 cases of congenital syphilis were reported in the municipality of Natal. In all the years evaluated, the predominant age group of the mother was from 20 to 39 years old and the race was brown. The mothers’ education profile is incomplete Elementary School and the period of maternal diagnosis reveals that most of them were diagnosed during prenatal care (table 1).
Table 1 : Characterization of cases of congenital syphilis in the Natal Notification Information System, Rio Grande do Norte, 2017 to 2021 (n = 1,575)
| Variables | Year of notification | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | ||||||
| n | % | n | % | n | % | n | % | n | % | |
| Mother’s age group | ||||||||||
| 0-9 years | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 |
| 10-19 years | 68 | 23.86 | 74 | 24.83 | 74 | 20.56 | 45 | 15.31 | 64 | 18.93 |
| 20-39 years | 202 | 70.88 | 212 | 71.14 | 264 | 73.33 | 234 | 79.59 | 257 | 76.04 |
| 40-59 years | 07 | 2.46 | 06 | 2.01 | 05 | 1.39 | 11 | 3.74 | 10 | 2.96 |
| > 60 years | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 |
| Ignored | 08 | 2.81 | 06 | 2.01 | 17 | 4.72 | 04 | 1.36 | 07 | 2.07 |
| Mother’s race/skin color | ||||||||||
| White | 52 | 18.25 | 69 | 23.15 | 93 | 25.83 | 74 | 25.17 | 69 | 20.41 |
| Black | 13 | 4.56 | 16 | 5.37 | 11 | 3.06 | 16 | 5.44 | 19 | 5.62 |
| Yellow | 01 | 0.35 | 01 | 0.34 | 00 | 0.00 | 00 | 0.00 | 00 | 0.00 |
| Brown | 186 | 65.26 | 202 | 67.79 | 233 | 64.72 | 189 | 64.29 | 221 | 65.38 |
| Indigenous | 00 | 0.00 | 00 | 0.00 | 01 | 0.28 | 00 | 0.00 | 00 | 0.00 |
| Ignored | 33 | 11.58 | 10 | 3.36 | 22 | 6.01 | 15 | 5.10 | 29 | 8.58 |
| Education | ||||||||||
| Illiterate | 01 | 0.35 | 02 | 0.67 | 04 | 1.11 | 00 | 00 | 03 | 0.89 |
| 1st to 4th grade of incomplete Elementary School | 20 | 7.02 | 17 | 5.70 | 18 | 5.00 | 11 | 3.74 | 04 | 1.18 |
| 4th grade of incomplete Elementary School | 08 | 2.81 | 08 | 2.68 | 11 | 3.06 | 11 | 3.74 | 08 | 2.37 |
| 5th to 8th grade of incomplete Elementary School | 111 | 38.95 | 118 | 39.60 | 138 | 38.33 | 114 | 38.78 | 130 | 38.46 |
| Complete Elementary School | 12 | 4.21 | 24 | 8.05 | 14 | 3.89 | 23 | 7.82 | 32 | 9.47 |
| Incomplete High School | 39 | 13.68 | 51 | 17.11 | 56 | 15.56 | 44 | 14.97 | 53 | 15.68 |
| Complete High School | 34 | 11.93 | 46 | 15.44 | 63 | 17.50 | 52 | 17.69 | 51 | 18.09 |
| Incomplete Higher Education | 03 | 1.05 | 02 | 0.67 | 06 | 1.67 | 05 | 1.70 | 04 | 1.18 |
| Complete Higher Education | 00 | 0.00 | 01 | 0.34 | 04 | 1.11 | 00 | 0.00 | 05 | 1.48 |
| Ignored | 57 | 20.00 | 29 | 9.73 | 46 | 12.77 | 34 | 11.56 | 48 | 14.20 |
| Diagnosis of maternal syphilis | ||||||||||
| During prenatal care | 160 | 56.14 | 165 | 55.37 | 252 | 70.00 | 198 | 67.35 | 203 | 60.95 |
| At the time of delivery/curettage | 109 | 38.25 | 121 | 40.60 | 96 | 26.67 | 82 | 27.89 | 113 | 33.43 |
| After delivery | 07 | 2.46 | 09 | 3.02 | 06 | 1.67 | 08 | 2.72 | 14 | 4.14 |
| Not performed | 00 | 0.00 | 00 | 0.00 | 02 | 0.56 | 02 | 0.68 | 02 | 0.59 |
| Ignored | 09 | 3.16 | 03 | 1.01 | 04 | 1.11 | 04 | 1.36 | 03 | 0.89 |
Source: Prepared by the authors, 2024.
In Natal, 63.1% (65) of the health facilities are decentralized to the Notifiable Diseases Information System (SINAN), that is, they have autonomy to collect, monitor and close cases in their establishments, while the other 36.9% (38) depend on the health district to consolidate the information in the epidemiological surveillance system for congenital syphilis.
The variables: non-treponemal test reactive of the mother at delivery/curettage, reactive non-treponemal test of the child (peripheral blood), reactive treponemal test (cerebrospinal fluid) and their respective fields of titrations filled in, were considered consistent, with a percentage above 95% in the period. The clinical variable and the presence of described signs and symptoms were considered excellent in the period from 2017 to 2020; in 2021, it showed a good category. On the other hand, the variables “death from congenital syphilis”, “death from other causes”, “miscarriage or stillbirth” with the field “date” filled in was consistent only in 2017; in the other analyzed years, it showed a result classified as very poor. Regarding the case definition, the variable was regular in relation to the used categorization (table 2).
Table 2 : Percentage of consistency of the variables selected in the Notifiable Diseases Information System, Natal, Rio Grande do Norte, 2017 to 2021. (n = 1,575)
| Variables | Consistency (%) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | ||||||
| n = 285 | % | n = 298 | % | n = 360 | % | n = 294 | % | n = 338 | % | |
| Definition of a case of congenital syphilis treated | 251/285 | 88.07 | 261/298 | 87.58 | 289/360 | 80.27 | 244/294 | 82.99 | 261/338 | 77.21 |
| Reactive non-treponemal test of the mother at delivery/curettage – Title | 266/266 | 100.00 | 276/276 | 100.00 | 335/335 | 100.00 | 276/276 | 100.00 | 306/306 | 100.00 |
| Reactive non-treponemal test of the child (peripheral blood) – Title | 219/219 | 100.00 | 250/250 | 100.00 | 313/314 | 99.68 | 262/262 | 100.00 | 283/283 | 100.00 |
| Reactive non-treponemal test (cerebrospinal fluid) – Title | 03/03 | 100.00 | 00/00 | 100.00 | 00/00 | 100.00 | 01/01 | 100.00 | 02/02 | 100.00 |
| Symptomatic clinical diagnosis – Presence of signs and symptoms | 45/47 | 95.74 | 22/23 | 95.65 | 28/29 | 96.55 | 27/27 | 100.00 | 18/19 | 94.73 |
| Case progression: death from congenital syphilis, death from other causes, miscarriage or stillbirth – Date of death | 02/02 | 100 | 00/13 | 0.00 | 02/11 | 6.06 | 02/08 | 25.00 | 05/15 | 33.33 |
Source: Prepared by the authors, 2024.
Completeness was high in all years for the following fields: neighborhood, prenatal care during pregnancy, diagnosis period of maternal syphilis, non-treponemal test at delivery/curettage and case progression (>95%), and discharge from the period from 2017 to 2020 from the fields of non-treponemal test – child’s peripheral blood, treponemal test (after 18 months), and child’s treatment regimen. The treatment regimen was classified as good in 2017 and 2018, but showed improvement, providing excellent completeness. The fields of non-treponemal (cerebrospinal fluid) tests and radiological diagnosis of the child were mostly classified as good. For the variables “education”, “partner(s) treated concurrently with the pregnant woman” and “changes in cerebrospinal fluid”, completeness was regular (table 3).
Table 3 : Completeness of the selected variables on congenital syphilis in the Notifiable Diseases Information System, Natal, Rio Grande do Norte, 2017 to 2021. (n = 1,575)
| Variables | Completude | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | ||||||
| n = 285 | % | n = 298 | % | n = 360 | % | n = 294 | % | n = 338 | % | |
| Mother’s details | ||||||||||
| Neighborhood | 284 | 99.65 | 298 | 100.00 | 359 | 99.72 | 292 | 99.32 | 337 | 99.70 |
| Education | 230 | 80.70 | 269 | 90.27 | 311 | 86.39 | 263 | 89.46 | 286 | 84.62 |
| Performed prenatal care during this pregnancy | 278 | 97.54 | 288 | 96.64 | 352 | 97.78 | 287 | 97.62 | 327 | 96.75 |
| Diagnosis period of maternal syphilis | 277 | 97.19 | 295 | 98.99 | 357 | 99.17 | 292 | 99.32 | 336 | 99.41 |
| Non-treponemal test at delivery/curettage | 280 | 98.25 | 293 | 98.32 | 354 | 98.33 | 289 | 98.30 | 335 | 99.11 |
| Treponemal test at delivery/curettage | 235 | 82.46 | 250 | 83.89 | 336 | 93.33 | 282 | 95.92 | 330 | 97.63 |
| Treatment regimen | 268 | 94.04 | 279 | 93.62 | 352 | 97.78 | 287 | 97.62 | 330 | 97.63 |
| Partner(s) treated concurrently with pregnant woman | 220 | 77.19 | 262 | 87.92 | 341 | 94.72 | 277 | 94.22 | 291 | 86.09 |
| Child’s data | ||||||||||
| Non-treponemal test – Peripheral Blood | 275 | 96.49 | 294 | 98.66 | 354 | 98.33 | 293 | 99.66 | 318 | 94.08 |
| Treponemal test (after 18 months) | 280 | 98.25 | 293 | 98.32 | 354 | 98.33 | 280 | 95.24 | 320 | 94.67 |
| Non-treponemal test - cerebrospinal fluid | 269 | 94.39 | 269 | 90.27 | 326 | 90.56 | 276 | 93.88 | 294 | 86.98 |
| Changes in cerebrospinal fluid | 256 | 89.92 | 258 | 86.58 | 321 | 89.17 | 274 | 93.20 | 289 | 85.50 |
| Radiological diagnosis of the child: altered examination of the long bones | 246 | 86.32 | 261 | 87.58 | 329 | 91.39 | 279 | 94.90 | 310 | 91.72 |
| Treatment regimen | 277 | 97.19 | 294 | 98.66 | 357 | 99.17 | 291 | 98.98 | 320 | 94.67 |
| Case progression | 282 | 98.95 | 298 | 100 | 360 | 100 | 281 | 95.58 | 337 | 99.70 |
Source: Prepared by the authors, 2024.
The system was considered late in the detection of cases, as the mean numbers of days between the day of diagnosis and the date of notification were 20.16 in 2017, 11.31 in 2018, 11.14 in 2019, 12.86 in 2020 and 47.00 in 2021, with a median of four in 2017 and three in the other years. It is observed that there has been an improvement in the delay between the date of notification and the date of entry over the years, where the mean number of days between the date of notification and the date of entry has reduced considerably in the time series (Table 4), with means of 30.59 in 2017, 14.13 in 2018, 6.58 in 2019, 7.86 in 2020 and 8.00 in 2021. The median was eight in 2017, four in 2018 and three in the following years.
Table 4 : Summary-measures of the interval (in days) between the date of diagnosis, notification and entry of cases of congenital syphilis in the Notifiable Diseases Information System, Natal, Rio Grande do Norte, 2017 to 2021. (n = 1,575)
| Summary-measures | Year of notification | ||||
|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | |
| Interval (in days) between diagnosis and notification | |||||
| Mean | 20.16 | 11.31 | 11.14 | 12.86 | 47.00 |
| Standard deviation | 51.96 | 41.09 | 29.76 | 70.66 | 173.70 |
| Minimum | 00 | 00 | 00 | 00 | 00 |
| Maximum | 540 | 400 | 311 | 1027 | 1386 |
| Median | 04 | 03 | 03 | 03 | 03 |
| Percentile 25 | 02 | 02 | 01 | 01 | 01 |
| Percentile 75 | 16 | 06 | 06 | 05 | 06 |
| Interval (in days) between notification and entry | |||||
| Mean | 30.59 | 14.13 | 6.58 | 7.86 | 8.00 |
| Standard deviation | 80.02 | 46.82 | 13.47 | 11.09 | 14.90 |
| Minimum | 00 | 00 | 00 | 00 | 00 |
| Maximum | 379 | 592 | 178 | 75 | 177 |
| Median | 08 | 04 | 03 | 03 | 03 |
| Percentile 25 | 02 | 01 | 01 | 00 | 00 |
| Percentile 75 | 22 | 10 | 07 | 13 | 11 |
Source: Prepared by the authors, 2024.
The representativeness of deaths from congenital syphilis, miscarriages and stillbirths in SINAN was evident when comparing them with the number of deaths recorded in the Mortality Information System, which showed a moderate correlation (r = 0.65) (table 5).
Table 5 : Number of deaths with mention of congenital syphilis in the Mortality Information System (SIM) and in the Notifiable Diseases Information System (SINAN), Natal, Rio Grande do Norte, 2017 to 2021
| Month | 2017 | 2018 | 2019 | 2020 | 2021 | Sperman’s Correlation | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| SIM | SINAN | SIM | SINAN | SIM | SINAN | SIM | SINAN | SIM | SINAN | ||
| Jan | 00 | 00 | 01 | 02 | 01 | 01 | 02 | 01 | 00 | 00 | rho = 0,650 p value ≤ 0,001 |
| Feb | 00 | 00 | 02 | 04 | 00 | 00 | 01 | 01 | 01 | 01 | |
| Mar | 01 | 01 | 00 | 00 | 01 | 01 | 00 | 00 | 03 | 02 | |
| Apr | 00 | 00 | 00 | 02 | 02 | 02 | 00 | 00 | 01 | 01 | |
| May | 00 | 00 | 00 | 00 | 00 | 00 | 00 | 00 | 01 | 01 | |
| Jun | 01 | 01 | 00 | 00 | 00 | 00 | 00 | 01 | 00 | 00 | |
| Jul | 00 | 00 | 01 | 02 | 01 | 01 | 01 | 00 | 00 | 00 | |
| Aug | 00 | 00 | 00 | 00 | 01 | 03 | 00 | 01 | 01 | 01 | |
| Sep | 00 | 00 | 02 | 00 | 01 | 01 | 00 | 01 | 02 | 02 | |
| Oct | 00 | 00 | 02 | 03 | 01 | 01 | 01 | 00 | 00 | 01 | |
| Nov | 00 | 00 | 00 | 00 | 00 | 00 | 02 | 03 | 00 | 02 | |
| Dec | 00 | 00 | 00 | 00 | 01 | 01 | 00 | 00 | 00 | 04 | |
Source: Prepared by the authors, 2024.
DISCUSSION
Overall completeness ranged from 92.5% to 96.2% and consistency ranged from 80.4% to 97.3%. The system was considered late for the interval between diagnosis and notification, with a mean of 11.14 to 47 days, and agile in entries, with a mean of 8 to 30.59 days. It was considered moderately representative due to its correlation with the number of deaths obtained in SINAN and SIM.
Among the various factors that may be related to the decrease in the number of cases and the incidence rate of Congenital Syphilis (CS), one can cite the advance in the improvement of notifications, caused by the decentralization of SINAN in the main health facilities in the municipality over the years, increasing the consistency of data and reducing the number of duplicate records, increased coverage and supply of rapid tests and the need to perform the non-treponemal test at the time of delivery13,14.
The issue reinforces the need for health services, especially Primary Health Care (PHC), to carry out the early detection of pregnant women, as well as the offer of syphilis screening tests at an opportune time, enabling pregnant women to receive information and guidance for the prevention of syphilis and the treatment of the infection in a timely manner in their unit15.
Considered a notifiable disease since 198616, CS has as its registration system the Notifiable Diseases Information System (SINAN), which, despite its performance weaknesses, operationalization of notifications in relation to the periodicity of updating, timeliness, data insertion and setbacks in relation to data processing, is still the main system used to evaluate the behavior of the disease and whether the information collected in this system is consistent and timely16.
The profile of mothers of children with congenital syphilis in the municipality corroborates the national scenario. Mothers aged between 20 and 39 years, brown, with a low level of education, most of whom had prenatal care, were diagnosed during prenatal care, but had inadequate treatment15,17. The surveillance system for congenital syphilis showed good quality of completeness, timeliness in the entries and can be considered moderately representative.
Data quality reflects the completeness, agility in recording and consistency (validity) of data recorded by a Public Health surveillance system18. The variables “neighborhood”, “prenatal care during this pregnancy”, “diagnosis period of maternal syphilis”, “non-treponemal test at delivery/curettage” and “case progression” had completeness classified as excellent in all periods. In turn, the variables “mother’s treatment regimen”, “non-treponemal test – peripheral blood”, “treponemal test after 18 months” and “child’s treatment regimen” had excellent completeness in most years.
When compared to other regions of Brazil, the municipality of Natal has a higher quality of completeness. The high quality of the evaluated data refers to the relationship between efficiency in filling in the data and improvement of the work routine, decentralization of notifying units and continuing education. This can generate a greater awareness of the importance of data completeness16. Another important resource is the “Syphilis No!” project in the territory since 2018, where it was seen that both the completeness and consistency between the number of cases of pregnant syphilis (PS) and congenital syphilis (CS) were balanced, unlike previous years, where the number of CS cases was higher than that of GS.
In São Gonçalo, metropolitan region II of Rio de Janeiro, as an example, a study carried out to evaluate congenital syphilis defined most of the evaluated fields as excellent; however, variables such as maternal education, occupation, quantitative VDRL in the child, quantitative VDRL in cerebrospinal fluid and alterations in the X-ray of long bones did not obtain satisfactory results17. Porto Alegre-RS showed results similar to those of São Gonçalo19.
Regarding the consistency of the data, SINAN in Natal was regular. Studies on the surveillance system in Natal pointed out underreporting of the field “date of death” and notifications in disagreement with the case definition criteria of the Ministry of Health, as the main reported inconsistencies. Such factors may occur because the system is local and not online, making it difficult to feedback the data, when qualification is necessary.
The inconsistencies observed in the date of death of the notifications showed the same national pattern in other diseases, such as AIDS in adults and children, which may be a limiting factor in their use in the evaluation of the time interval between notification and the date of death20. Another relevant point may be the choice of professionals to diagnose the case to be treated in maternity hospitals, with fear that the patient will not return to primary care to continue treatment, registering cases that do not comply with the definition of a CS case.
Regarding the variables “clinical diagnosis” and “the presence of described signs and symptoms”, they were considered excellent in the period from 2017 to 2020; in 2021, it showed a good category. The downgrading of the category at this point may also be related to professionals who choose to diagnose even without presenting the case description established by the Brazilian protocol, considering the guarantee of treatment, especially when evaluating the impacts and direction of clinical management that the Covid-19 pandemic caused, anticipating treatment and recommending the least possible displacement to contain the expansion of the virus.
Regarding the evaluation of the consistency of the other criteria, the excellent results can be attributed to the agility in obtaining laboratory results, quality of the clinical examination and good completion of the forms, verified by the good completeness of the fields.
The surveillance system for syphilis was considered timely in entering and late in detecting cases. According to the Department of Health Surveillance of the municipality, this fact is due to the lack of sufficient human resources to identify these diagnoses and notify them in the official SINAN file, to later be entered into the system, a routine already optimized by the typists of the municipal health network. With regard to opportunity, a study carried out in Iran identified that this transfer of data, referring to another problem, was carried out within 19 days. This was due to the greater integration of systems and improvement of places and working conditions12, a limiting factor in the country because SINAN is a local system that does not allow integration between other health systems.
The representativeness of deaths, miscarriages and stillbirths from congenital syphilis in SINAN was evidenced when compared with the number of deaths registered in the Mortality Information System (SIM), which showed a moderate correlation (r = 0.65). This data indicates that in relation to SIM, SINAN offers similar data, showing similar scenarios when evaluated together. Although there are some bottlenecks, such as the lack of feedback in SINAN and delays in typing death certificates, it was possible to consider the system representative in the municipality of Natal.
In turn, in Recife-PE, studies on congenital syphilis point to an unfavorable scenario of underreporting in SINAN. About 80.9% of the local SIM records were not identified in SINAN21. From this perspective, even if the underreporting of the data in these systems has not been evaluated, they can be evaluated as representative12.
Nevertheless, this study has limitations. The first is the low number of evaluations of the epidemiological surveillance system for syphilis in other regions of the country, making it difficult to compare our results with other realities, thus limiting the discussion to a few regions of Brazil, making it necessary to compare the results of other diseases. The second limiting factor is that the evaluation does not foresee the difficulties inherent to the development of the routine by the team, only the weaknesses of the system, being an important element to broadly evaluate not only the system, but also the surveillance process, through the users. Although this first limitation has been addressed, the production of the current study can also be considered fundamental to identify the fragility of the system in a global way, giving the opportunity for future studies to deepen this theme.
CONCLUSION
The surveillance system for congenital syphilis in the city of Natal was considered complete, consistent and moderately representative, bringing the importance of a surveillance system that allows the production of an epidemiological scenario, the referral of interventional and strategic actions, as well as the production of new public health policies.
As improvements to the surveillance system, it is essential that the Notifiable Diseases Information System (SINAN)21 be updated to an online version, in addition to creating configurations that allow systematic and periodic evaluations, as well as qualified monitoring of the case with additional information to the used form. Another relevant factor is the need to implement the vertical transmission committee of syphilis in the municipality of Natal, in order to further improve the analysis of the profiles and the opportunity for intervention and improvement in work processes.
In this context, it is possible to highlight the need for evaluations, such as these for health services, so that surveillance continues to improve, thus being able to incorporate into its routine more and more robust tools with great impact on the quality of the service provided not only to the municipality, but also to the surrounding municipalities. The importance of the research is emphasized not only for the municipality, but for dissemination in the scientific community, so that new system evaluations can be made, which can show the potential of epidemiological surveillance.
