Use o In e up ed Time Se ies Analysis in
Unde s anding he Cou se o he Congeni al Syphilis
Epidemic in B azil
Ra ael Pin o,
a,b,c,
*Rica do Valen im,
a,b
Ly ene Fe nandes da Sil a,
a
Gus a o Fon ou a de Souza,
b,c
Thaísa G
ois Fa ias de Mou a San os Lima,
b,d
Ca los Albe o Pe ei a de Oli ei a,
b,e
Ma quiony Ma ques dos San os,
a,b
Ang
elica Espinosa Mi anda,
d,
Alie e Cunha-Oli ei a,
g,h
Vi ekanandan Kuma ,
i
and Ri a A un
j
a
Fede al Uni e si y o Rio G ande do No e, Na al, RN, B azil
b
Labo a o y o Technological Inno a ion in Heal h (LAIS), Na al, RN, B azil
c
Fede al Ins i u e o Rio G ande do No e, Na al, RN, B azil
d
Minis y o Heal h, B asília, DF, B azil
e
S a e Uni e si y o Rio de Janei o, Rio de Janei o, RJ, B azil
Fede al Uni e si y o Espí i o San o, ES, B azil
g
Heal h Sciences Resea ch Uni : Nu sing (UICISA: E) and Nu sing School o Coimb a (ESEn C), Coimb a, Po ugal
h
Cen e o In e disciplina y S udies o he 20 h Cen u y (CEIS20), Uni e si y o Coimb a, Coimb a, Po ugal
i
A habasca Uni e si y, A habasca, Canada
j
Ha a d School o Public Heal h, Ha a d Uni e si y, Bos on, MA, USA
Summa y
Backg ound To igh agains he ising incidence o syphilis, he B azilian Minis y o Heal h (MoH) launched he
“Syphilis No!” P ojec (SNP), wi h speci ic esou ces unded by a pa liamen a y amendmen . Then, in 2018, a
na ional apid esponse s a ed o be implemen ed on he B azilian Uni ied Heal h Sys em (SUS, Sis ema 
Unico de
Sa
ude) in wo s a egic lines (1) o ein o ce SUS's uni e sal ac ions and (2) o implemen speci ic ones o 100
municipali ies chosen by he MoH as p io i ies o syphilis congeni al esponse. In 2015, such locali ies ep esen ed
6895% o congeni al syphilis cases in B azil. In his con ex , SNP has implemen ed ac ions o s eng hen epidemio-
logical su eillance o acqui ed syphilis and congeni al syphilis by ins i u ing an in eg a ed and collabo a i e
esponse h ough heal h se ices ne wo ks and ein o cing in e s a e ela ions.
Me hods A quasi-expe imen al s udy using ime se ies analysis was conduc ed o assess immedia e impac s and
changes o he end in na ional congeni al syphilis be o e and a e he p ojec , om Sep embe 2016 o Decembe
2019. Da a we e assessed conside ing a es o congeni al syphilis pe 1,000 li e bi hs in all p io i y municipali ies
(n=100) co e ed by he p ojec and in non-p io i y municipali ies (n=5,470) om all i e mac o- egions o B azil.
Findings P io i y municipali ies showed a g ea e educ ion (change in end) in compa ison o non-p io i y. The
linea eg ession model e ealed end changes a e he in e en ion, wi h bo h g oups o municipali ies showing a
d op in he a e age mon hly numbe o cases pe 1,000 li e bi hs, wi h a educ ion o -0¢21 (CI 95% -0¢33 o -0¢09;
p=0¢0011) in p io i y municipali ies and o -0¢10 (CI 95% -0.19 o -0.02; p=0¢0216) in non-p io i y municipali ies.
In e p e a ion The s udy using ITS p o ides impo an e idence on he di ec ion, iming, and magni ude o he
e ec s o in e en ions in oduced as pa o he SNP on congeni al syphilis in B azil. Ou esul s sugges ha he
Syphilis No! P ojec in luenced he ends o congeni al syphilis in B azil om 2018, wi h highe educ ions
achie ed in he p io i y municipali ies.
Funding The esea ch is unded by a g an o he Syphilis No! P ojec om B azilian Minis y o Heal h (P ojec
Numbe : 54/2017). The unde s had no ole in s udy design, analysis, decision o publish, o p epa a ion o he man-
usc ip .
Copy igh Ó2021 The Au ho (s). Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND
license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/)
Keywo ds: public heal h; policy; in e up ed ime se ies; segmen ed eg ession analysis; no i iable disease; syphilis
*Co esponding au ho .
E-mail add ess: [email p o ec ed] (R. Pin o).
The Lance Regional
Heal h - Ame icas
2022;7: 100163
Published online 27
Decembe 2021
h ps://doi.o g/10.1016/j.
lana.2021.100163
www. helance .com Vol 7 Mon h Ma ch, 2022 1
A icles
In oduc ion
Congeni al syphilis (mo he - o-child ansmission o
e ical ansmission o syphilis o syphilis) causes dam-
age o he e us i he mo he ’s in ec ion is no de ec ed
and p ope ly ea ed du ing p egnancy. The Wo ld
Heal h O ganiza ion (WHO) es ima es ha each yea
930,000 p egnan women ha e p obable ac i e syphilis
wo ldwide each yea . I esul s in app oxima ely
350,000 ad e se bi h ou comes, including 143,000
ea ly e al dea hs/s illbi hs, 62,000 neona al dea hs,
44,000 p ema u e/low-bi hweigh babies, and
102,000 in ec ed in an s.
1,2
The Pan Ame ican Heal h O ganiza ion (PAHO)
Membe S a es, suppo ed by WHO, in 2010 app o ed
he S a egy and Plan o Ac ion o he Elimina ion o
Mo he - o-Child T ansmission o HIV and Congeni al
Syphilis. The s a egy was se o educe he incidence o
congeni al syphilis o ≤0¢5 cases pe 1,000 li e bi hs
by 2015.
3
None heless, B azil did no each he congeni-
al syphilis elimina ion goal, which led a esu gence o
acqui ed syphilis, syphilis in p egnan women and con-
geni al syphilis ac oss he coun y. In 2010, 6,949 cases
o congeni al syphilis we e epo ed o he B azilian
Minis y o Heal h (2¢4/1,000 li e bi hs), whe eas, in
2015, his case coun inc eased o 19,647 (6¢5/1,000 li e
bi hs) accoun ing o a g ow h a e o 170¢83%.
4
To igh he syphilis epidemic in B azil, in Oc obe o
2016, he Minis y o Heal h (MoH) issued he S a egic
Ac ions Agenda o Reducing Syphilis in B azil.
5
This
agenda es ablished a lis o p io i ies aimed in collabo a-
ion wi h PAHO and o he ins i u ions such as uni e si-
ies, in e na ional agencies, and s a e and municipal
ep esen a i es. Fu he mo e, such agenda p omp ed a
pa liamen a y amendmen wi h speci ic esou ces o
implemen a na ional apid esponse in B azil’s Uni ied
Heal h Sys em (SUS, Sis ema 
Unico de Sa
ude).
The B azilian Minis y o Heal h in i ed s a e and
municipal heal h manage s o igh syphilis h ough he
“Syphilis No!” P ojec — ha included he “Applied
Resea ch o In elligen In eg a ion Aimed a S eng h-
ening Heal hca e Ne wo ks o Rapid Response o
Syphilis”— o educe acqui ed syphilis, syphilis in p eg-
nan women, and congeni al syphilis by expanding co -
e age o diagnosis ( h ough apid es ing), and imely
and p ope ea men o p egnan women and sexual
pa ne s in p ena al ca e, childbi h, o abo ion si ua-
ions. Th ough he P ojec , he syphilis epidemic has
been aced up h ough wo s a egic lines: (1) ein o c-
ing uni e sal ac ions o SUS and (2) implemen ing spe-
ci ic ones o 100 municipali ies chosen by he MoH as
p io i ies o syphilis congeni al esponse, as in 2015
hey ep esen ed 68¢95% o he numbe o congeni al
syphilis cases in B azil.
The uni e sal line o in e en ion included acqui ing
and dis ibu ing es ing and ea men supplies (c ys al-
line and benza hine penicillin), enhancing he STI labo-
a o ies ne wo k and he si ua ion ooms o
epidemiological su eillance, educommunica ion s a e-
gies,
6
social in e en ions, and awa eness campaigns
pe o med o ace syphilis in ha pe iod. A he same
ime, ins i u ional suppo was g an ed o he p io i y
municipali ies, whe e Resea ch and In e en ion Sup-
po e s (RIS) ca ied ou speci ic wo k wi h local heal h
manage s. Hence, his wo k p o ided echnical coope a-
ion o s eng hen p e en ion ac ions aimed a educing
he e ical ansmission o syphilis, such as imple-
men ing commi ees ocused on in es iga ing syphilis
Resea ch in Con ex
E idence be o e his s udy
We sea ched PubMed o a icles published up o Oc 1,
2021, using he e ms "syphilis" AND (" empo al analysis"
OR " ime se ies" OR " eg ession me hods") AND "public
heal h", wi h no language es ic ions. Ou sea ch iden i-
fied six s udies. Fou o hem epo analysis o syphilis
da a in B azil om a ime se ies pe spec i e, wi h di e -
en se ings, showing he syphilis incidence a es inc eas-
ing om 2007 o 2016 and he challenge o he B azilian
Minis y o Heal h o educe he h ee o ms o syphilis
(in p egnancy, congeni al and acqui ed). Apa om
hese s udies, China epo ed ha syphilis incidence a es
ha e inc eased h ee- old om 2005 o 2012 and ime
se ies analysis was an e ec i e ool o modelling he his-
o ical and u u e incidence.
Added alue o his s udy
We used in e up ed ime se ies o examine ends
be o e and a e he in oduc ion o a public in e en-
ion p ojec in B azil in o de o educe acqui ed syphilis,
syphilis in p egnan women, and congeni al syphilis by
expanding co e age o diagnosis ( h ough apid es -
ing), and imely and app op ia e ea men o p egnan
women and sexual pa ne s in p ena al ca e, childbi h,
o abo ion si ua ions. Da a we e assessed conside ing
a es o congeni al syphilis pe 1,000 li e bi hs in all p i-
o i y municipali ies (n=100) co e ed by he p ojec and
in non-p io i y municipali ies (n=5,470) om all fi e
mac o- egions o B azil.
Ou in e up ed ime se ies da a indica e changes in
ends owa ds educ ion o s abiliza ion in almos all
egions (No h, No heas , Sou h, and Sou heas ). This
e ec may be a ibu ed o he p ojec 's uni e sal
ac ions, ha is, gene al in e en ions ha we e
designed and implemen ed in all B azilian s a es and
municipali ies.
Implica ion o all he a ailable e idence
In ecen yea s (2010-2019) i is he fi s ime we can see
a change in he cou se o congeni al syphilis in B azil.
The e ec s o he in e en ion a he na ional le el
e eals s a is ically significan end changes in mon hly
a es o congeni al syphilis in B azil and shows a e a -
ia ions by egion.
A icles
2 www. helance .com Vol 7 Mon h Ma ch, 2022
cases and ein o cing local planning o esponse on he
p ojec 's axis, among o he s. The de ails o he p ojec
in e en ions and ele an imelines a e p esen ed in
Appendix (Figu es A1 o A5).
The pu pose o his s udy is o use in e up ed ime
se ies o es ima e in e en ion e ec s o e ime by com-
pa ing a es o congeni al syphilis pe 1,000 li e bi hs
in he p io i y municipali ies (n=100) co e ed by he
Syphilis No! P ojec and in non-p io i y municipali ies
(n=5,470) in he i e mac o- egions o B azil: No h,
No heas , Sou h, Sou heas , and Midwes .
Me hods
Conside ing ha a andomized con olled ial (RCT) is
in easible o be pe o med in his s udy, we used a
quasi-expe imen al esea ch design wi h in e up ed
ime se ies (ITS) analysis. Such design enables compa i-
sons in popula ion heal h ou comes be o e, du ing and
a e an in e en ion wi hin a clea ly de ined span.
7
ITS
is a good app oach o e alua ing longi udinal e ec s o
heal h in e en ions.
8,9
Besides, i can be used as a s a-
is ical me hod o es ima ing in e en ion e ec s o a
policy change on an ou come o in e es .
10
The ITS
design and he use o segmen ed eg ession analysis
enables e alua ion o immedia e impac and slope asso-
cia ed wi h a policy in e en ion while con olling he
o e all end in he a e o he ou come o in e es .
10
This s udy was pe o med h ough a mul idimen-
sional, lexible, and adap i e amewo k aimed a disco -
e y and empo al analysis o public heal h in e en ions.
I was implemen ed using he He mes sys em,
11,12
which manages a comple e da a li e cycle
13
by 1) acqui -
ing da a om se e al ex e nal sou ces in di e en o -
ma s; 2) cleaning da a o s anda diza ion and e o
emo al; 3) ans o ming i in o speci ic models; 4) pub-
lishing a dashboa d; 5) p ese ing da a as a s uc u ed
da abase.
Use o da a sou ces
The He mes sys em was used o collec congeni al syph-
ilis da a om he No i iable Diseases In o ma ion Sys-
em (SINAN, Sis ema de In o ma¸c~
ao de Ag a os de
No i ica¸c~
ao), p o ided by he B azilian MoH. These da a
ep esen he o al numbe o no i ied cases pe munici-
pali y, gi en by mon h and yea . The i al eco ds o li e
bi hs by municipali y o each yea , we e e ie ed
om he Heal h In o ma ics Depa men o he B azil-
ian Minis y o Heal h (DATASUS) and used calcula e
mon hly a e age li e pe municipali y pe yea . He mes
de i ed he a es o congeni al syphilis cases by di iding
mon hly cases pe municipali y by li e bi hs.
P io i y s non-p io i y municipali ies
B azil has 5,570 municipali ies sp ead o e i e
mac o- egions—No h, No heas , Sou h, Sou heas
and Midwes . Mon hly a es pe municipali y we e
used o ca ego ise municipali ies in o p io i y and
non-p io i y.
The MoH classi ied he p ojec as a ool wi h wo
lines o inducing esponse on syphilis: uni e sal and
speci ic ac ions. Thus, p io i y municipali ies (n=100)
we e de ined on popula ion and epidemiological c i e-
ia, namely: he 27 capi als, in addi ion o municipali ies
in me opoli an egions wi h mo e han 100,000 inhab-
i an s ha had, in 2015, he highes a es o bo h con-
geni al syphilis incidence in child en unde one yea o
age and pe ina al mo ali y. The p io i y municipali ies
ep esen ed 68¢95% o he o al congeni al syphilis
cases in B azil. O he municipali ies (n=5,470) we e ca -
ego ised as non-p io i y. Appendix (Figu e A6) p o ides
geog aphic, demog aphic and socio-economic cha ac e -
is ics o he i e egions and p esen s he geog aphic
loca ion o 100 p io i y and 5,470 non-p io i y munici-
pali ies.
The p io i y municipali ies ecei ed suppo and
echnical coope a ion om he p ojec 's ne wo k o
Resea ch and In e en ion Suppo e s. Thei wo k
ocused on he municipali ies'needs wi hin he axis o
he p ojec , as i was moni o ed h ough he “LUES”
pla o m,
14
made a ailable by he p ojec . The suppo -
e s en e ed on he “LUES” pla o m all o hei echnical
coope a ion ac i i ies o heal h eams and local manag-
e s o p io i y municipali ies on a mon hly basis o sup-
po ing ac ions o p e en mo he - o-child ansmission
(MTCT) o syphilis.
S a is ical analysis
A quasi-expe imen al design was applied o analyze he
ime se ies da a using a segmen ed linea eg ession
model in he R so wa e, adap ed o exchange da a wi h
He mes in o de o assess he immedia e impac and
change in end o na ional congeni al syphilis a es p e
and pos he SNP in e en ion. Wha is mo e, May o
2018 was conside ed he in e en ion s a ime poin
o implemen ing he Syphilis No! P ojec . Appendix
p o ides R code used in his analysis.
Da a mus be collec ed egula ly o e ime and a
equally spaced in e als o pe o m a segmen ed eg es-
sion analysis.
9,15
To a oid any bias ela ed o he Co id-
19 pandemic, Decembe o 2019 was de ined as he end
da e o he da a collec ion, o aling 20 mon hs p e-
in e en ion (Sep/2016 o Ap /2018) and 20 mon hs
pos -in e en ion (May/2018 o Dec/2019).
A linea ela ionship be ween ime and he ou come
wi hin each segmen was assumed, conside ing seg-
men ed eg ession models i a leas squa es eg ession
line o each segmen o he independen a iable
( ime), p<0¢05 was conside ed s a is ically signi ican .
Thus, he nex s ep in he analysis was o es ima e he
magni ude o he in e en ion and es he s a is ical sig-
ni icance o immedia e impac and end a es.
A icles
www. helance .com Vol 7 Mon h Ma ch, 2022 3
The eg ession model used o i hese da a is
s aigh o wa d. ou come
=b
0
+b
1
* + b
2
*
p io i y
+b
3
* p io i y
*i+b
4
* pos -in e en ion
+b
5
*( -T
I
) * pos -in e en ion
+b
6
* pos -in e en ion
*
p io i y
+b
7
* pos -in e en ion
* * p io i y
+e
Whe e b
0
is he baseline ou come o he non-p io -
i y g oup; b
1
is he p e-exis ing end in he ou come o
in e es o he p io i y non-g oup; b
2
is he baseline di -
e ence be ween non-p io i y and p io i y g oups; b
3
is
he di e ence in end be ween non-p io i y and p io i y
g oup be o e in e en ion; b
4
is he immedia e impac
in he p io i y g oup; b
5
is he end change in he p io -
i y g oup; b
6
is he di e ence in he immedia e impac
change be ween he non-p io i y and p io i y a e in e -
en ion, and b
7
is he di e ence in end change
be ween he non-p io i y and p io i y g oup a e in e -
en ion. P io i y a iable is coded 1 o p io i y and 0 o
non-p io i y. The a iable is only an inc emen ha
coun s up om 1 o 40 o e he en i e pe iod. The pos -
in e en ion a iable was se o be 0 be o e he in e en-
ion and 1 a e . T
I
is cons an ha ep esen s he in e -
en ion momen , in his case is equal o 20. Figu e 1
ep esen s he model, including he immedia e impac
and end change.
O dina y Leas Squa es (OLS) eg ession analysis
assumes ha e o e ms associa ed wi h each obse a-
ion a e unco ela ed. Co ec ly inspec ing au oco ela-
ion e ms can a oid unde es ima ed s anda d e o s
and o e es ima ed signi icance o he e ec s o an in e -
en ion.
15
In he case o his s udy, a Du bin-Wa son
es was used o in es iga e he p esence o au oco ela-
ion, in addi ion o esidual plo s, Au o Co ela ion
Func ion (ACF) plo s, and pa ial-ACF plo s. Au oco e-
la ion was no de ec ed in he s a is ical es s.
R-squa ed is a s a is ical measu e o how close he da a
a e o he i ed eg ession line. I is also known as he coe -
icien o de e mina ion o he coe icien o mul iple de e -
mina ion o mul iple eg ession. I was used in his
esea ch’s model o de e mine how close he da a a e o
he model and how i is p esen ed in he esul s. R-squa ed
is a alue be ween 0 and 1, whe e 0 indica es ha he
model explains none o he a iabili y o he esponse da a
a ound i s mean, and 1 indica es ha he model explains
all he a iabili y o he esponse da a a ound i s mean.
Ou lie s a e ex eme alues ha do no seem o i in
he ime se ies. I he ou lie e lec s an an icipa o y o
sho - e m his o y e ec , he da a poin can be explici ly
modeled. Al e na i ely, i he ou lie is an unambiguous
clea consequence o he in e en ion, i can be ea ed
as a egula da a poin o e alua e i s impac . A p elimi-
na y analysis was pe o med, and a single ou lie was
iden i ied in he Midwes egion a e he in e en ion
(July 2018). The Mo ing A e age (MA) me hod was
used o smoo h he da a o he pu pose o explaining
empo al ends. The MA used was o o de h ee,
which p o ides only a smoo hing wi h he wo mon hs
(be o e and a e ) he calcula ed obse a ion. A e his
p ocess, no ou lie emained.
The eg ession models ob ained o each g oup (p i-
o i y and non-p io i y municipali ies), using da a om
he p e- and pos -in e en ion pe iods (May 2018), we e
compa ed wi h he coun e ac ual o he pos -in e en-
ion pe iod conside ing he end obse ed be o e he
in e en ion. The coun e ac ual enables a compa ison
be ween he obse ed change and wha would ha e hap-
pened had he in e en ion no aken place. The eg es-
sion model pa ame e s we e ob ained by poin and
in e al es ima ion using 95% o con idence.
Figu e 1. In e up ed ime-se ies pa ame e ized as a segmen ed eg ession model, including he immedia e impac and end
change. The solid lines ep esen he obse ed alues, and do ed lines indica e he coun e ac ual o he pos -in e en ion pe iod.
A icles
4 www. helance .com Vol 7 Mon h Ma ch, 2022
Role o he unding sou ce
The unde s had no ole in s udy design, da a collec ion,
da a analysis, in e p e a ion, decision o publish, o
p epa a ion o he manusc ip .
Resul s
Resul s o he ime se ies analysis compa ing a es o
congeni al syphilis pe 1,000 li e bi hs in he p io i y
municipali ies and non-p io i y municipali ies a e p e-
sen ed in Table 1 and Figu es 2 o 7. The ed do s ep e-
sen he mon hly a es o cases in p io i y
municipali ies and he blue do s in non-p io i y ones.
The con inuous lines indica e he eg ession models
ob ained o each g oup (p io i y and non-p io i y),
using da a om he p e- and pos -in e en ion pe iods
(May 2018). Mo eo e , he do ed lines indica e he
coun e ac ual o he pos -in e en ion pe iod using
he da a end obse ed be o e he in e en ion. Table 2
p esen s his compa ison conside ing he las mon h o
he analyzed pe iod (20 h mon h, Decembe o 2019).
These esul s desc ibe he in e en ion e ec s in
de ail o each egion, sepa a ely. Tha is because i cap-
u es he egionalized in luence o he Uni ied Heal h
Sys em go e nance—which is in e ede a i e, wi h clea
a ibu ions a local, s a e, and ede al le els. In his
sense, as P ima y Heal h Ca e (PHC) is a esponsibili y
o municipali ies, e idence ha he SNP e ec s can a y
ac oss egions can be cap u ed.
Fo he No h egion o B azil, in Figu e 2 and Table 1
(column 2), o bo h p io i y and non-p io i y municipali-
ies, he e was a educ ion in he mon hly a e o congeni-
al syphilis cases in he pos -in e en ion pe iod. The
mon hly a e age educ ion was -1¢77 cases pe 1,000 li e
bi hs in p io i y municipali ies and -009 pe 1,000 li e
bi hs in non-p io i y municipali ies, as shown in Table 1.
In addi ion, he es ima ed linea eg ession models o
each si ua ion show changes in he mon hly a e age
ends, wi h a -0¢05 educ ion in he p io i y municipali ies
and a -0¢07 educ ion o he non-p io i y ones.
The coun e ac ual p esen ed in Table 2 shows ha
o he p io i y municipali ies he model es ima ed
18¢08 cases pe 1,000 li e bi hs a he end o he 20 h
mon h wi hou in e en ion. In compa ison, wi h in e -
en ion, 13¢73 cases we e obse ed o he same ime
poin , indica ing a decline o 24¢09%. In he non-p io -
i y municipali ies, he model es ima ed 5¢11 mon hly
cases pe 1,000 li e bi hs in he 20 h mon h. The
obse ed alue wi h he in e en ion was 3¢63 pe 1,000
li e bi hs, which ep esen s a all o 28¢97%.
Figu e 3 and Table 1 (column 3) display he esul s o
he No heas egion, whe e an inc easing o 2¢23 cases
pe 1,000 li e bi hs in immedia e impac can be obse ed
pos -in e en ion in p io i y loca ions. The e was also a
0¢34 educ ion in cases o non-p io i y municipali ies. A
change in end can be obse ed o bo h g oups. Non-p i-
o i y municipali ies e e sed he upwa d end wi h a
mon hly slope o -0¢11 cases pe 1,000 li e bi hs. Mean-
while, p io i y municipali ies showed a slope o -0¢64
cases pe housand li e bi hs pos in e en ion.
Rega ding he coun e ac ual (Table 2) o his
egion, a he end o he span analyzed in p io i y
municipali ies and wi hou in e en ion, he model es i-
ma ed 28¢11 cases pe 1,000 li e bi hs, compa ed o
15¢75 cases obse ed a e in e en ion (a d op o
43¢95% o his g oup). In non-p io i y municipali ies,
he model es ima ed 5¢33 cases in he las mon h o da a
collec ion, while he ac ual alue wi h he in e en ion
was 3¢63 pe 1,000 li e bi hs, a decline o 31¢79%.
As ep esen ed in Figu e 4 and Table 1 (column 4),
p io i y municipali ies in he Sou h egion showed a
sha p d op o -1¢76 mon hly cases pe 1,000 li e bi hs,
and a end change o -0¢28 mon hly cases pe 1,000
li e bi hs. Con e sely, in he non-p io i y municipali-
ies he e was an inc ease o 0¢48 in mon hly cases pe
1,000 li e bi hs and a mino end change o -0¢04
mon hly cases pe 1,000 li e bi hs.
The model es ima ed 26¢13 cases pe 1,000 li e
bi hs i no in e en ion had aken place in he p io i y
municipali ies om he Sou h egion. The ac ual alue
wi h in e en ion, was 18¢42 cases pe 1,000 li e bi hs,
ep esen ing a decline o 29¢48%. A sligh dec ease o
4¢27% was obse ed o non-p io i y municipali ies
wi h an es ima ed 5¢82 coun e ac ual cases and 5¢57
ac ual cases pe 1,000 li e bi hs.
The non-p io i y municipali ies in he Sou heas
egion (Figu e 5 and Table 1, column 5) wen h ough
an inc ease o 0¢13 mon hly cases pe 1,000 li e bi hs
and a change in end wi h a dec ease o -0¢16 mon hly
cases. Whe eas he p io i y municipali ies expe ienced a
-1¢11 educ ion in mon hly cases and sligh ly declining
end o -0¢02 mon hly cases.
The coun e ac ual o his egion p ojec ed an es i-
ma ed 20¢84 cases pe 1,000 li e bi hs in p io i y munici-
pali ies (Table 2) in he absence o in e en ion. Howe e ,
a educ ion o 21¢21% o 16¢42 cases pe 1,000 li e bi hs
was obse ed. In he Sou heas egions’s non-p io i y
municipali ies, he coun e ac ual was 8¢70 cases agains
5¢85 ac ual cases pe 1,000 li e bi hs, wi h a 32¢69%
educ ionin hepos -in e en ionpe iod.
In he Midwes egion (Figu e 6 and Table 1, column
6), he e was a educ ion o -0¢47 mon hly cases in he
p io i y municipali ies ollowing he in e en ions, bu
an inc ease o 0¢87 mon hly cases in he non-p io i y
municipali ies. The e was a e e sal o he end in he
p io i y municipali ies om 0¢09 mon hly cases pe
1,000 li e bi hs p e-in e en ion o -0¢07 pos in e en-
ions. Con e sely, in non-p io i y loca ions, he e was a
e e sal o he end in he opposi e di ec ion. In his
manne , a downwa d end o -0¢02 mon hly cases
be o e in e en ion changed o 0¢00 in he pos -in e -
en ion pe iod.
The coun e ac ual o he pos -in e en ion pe iod
in p io i y municipali ies was 12¢52 cases pe 1,000 li e
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No h No heas Sou h Sou heas Midwes B azil
alue
(CI 95%)
p- alue alue
(CI 95%)
p- alue alue (CI 95%) p- alue alue (CI 95%) p- alue alue (CI 95%) p- alue alue (CI 95%) p- alue
P e-In e en ion
In e cep 1¢45
(0¢71 o 2¢19)
<0¢001 2¢45
(1¢51 o 3¢39)
<0¢001 4¢65
(3¢49 o 5¢82)
<0¢001 4¢45
(3¢61 o 5¢30)
<0¢001 2¢54
(1¢71 o 3¢37)
<0¢001 3¢44
(2¢71 o 4¢17)
<0¢001
Di e en ial
be ween g oups
11¢39
(10¢35 o 12¢44)
<0¢001 15¢58
(14¢25 o 16¢91)
<0¢001 15¢04
(13¢39 o 16¢68)
<0¢001 8¢38
(7¢18 o 9¢58)
<0¢001 6¢87
(5¢70 o 8¢04)
<0¢001 10¢96
(9¢92 o 12¢00)
<0¢001
T end in p io i y
g oup
0¢04
(-0¢05 o 0¢13)
0¢393 0¢18
(0¢07 o 0¢29)
0¢002 0¢13
(-0¢01 o 0¢27)
0¢062 0¢09
(-0¢01 o 0¢19)
0¢077 0¢09
(-0¢01 o 0¢19)
0¢063 0¢11
(0¢03 o 0¢20)
0¢011
T end in non-p io -
i y g oup
0¢09
(0¢03 o 0¢16)
0¢004 0¢07
(0¢00 o 0¢15)
0¢062 0¢03
(-0¢07 o 0¢13)
0¢539 0¢11
(0¢04 o 0¢18)
0¢003 -0¢02
(-0¢08 o 0¢05)
0¢665 0¢08
(0¢01 o 0¢14)
0¢017
Pos -In e en ion
Immedia e impac
in p io i y g oup
-1¢77
(-3¢20 o -0¢34)
0¢016 2¢23
(0¢42 o 4¢05)
0¢016 -1¢76
(-4¢00 o 0¢49)
0¢123 -1¢11
(-2¢75 o 0¢53)
0¢181 -0¢47
(-2¢07 o 1¢13)
0¢560 -0¢36
(-1¢77 o 1¢06)
0¢618
Immedia e impac
in non-p io i y
g oup
-0¢09
(-1¢10 o 0¢92)
0¢865 0¢34
(-0¢94 o 1¢62)
0¢598 0¢48
(-1¢11 o 2¢07)
0¢548 0¢13
(-1¢03 o 1¢29)
0¢822 0¢87
(-0¢26 o 2¢00)
0¢131 0¢28
(-0¢72 o 1¢28)
0¢583
Change in end in
p io i y g oup
-0¢05
(-0¢18 o 0¢07)
0¢407 -0¢64
(-0¢80 o -0¢48)
<0¢001 -0¢28
(-0¢48 o -0¢09)
0¢005 -0¢02
(-0¢16 o 0¢13)
0¢827 -0¢07
(-0¢21 o 0¢06)
0¢291 -0¢21
(-0¢33 o -0¢09)
0¢001
Change in end in
non-p io i y
g oup
-0¢07
(-0¢16 o 0¢01)
0¢099 -0¢11
(-0¢22 o 0¢00)
0¢058 -0¢04
(-0¢18 o 0¢10)
0¢579 -0¢16
(-0¢26 o -0¢06)
0¢003 0¢00
(-0¢09 o 0¢10)
0¢949 -0¢10
(-0¢19 o -0¢02)
0¢021
R
2
0¢9816 0¢9877 0¢9767 0¢9691 0¢9590 0¢9848
Table 1: Resul s o he ime se ies analysis compa ing a es o congeni al syphilis pe 1,000 li e bi hs be ween p io i y and non-p io i y municipali ies.
6 www. helance .com Vol 7 Mon h Ma ch, 2022
A icles
bi hs a he end o he pe iod (Table 2), compa ed o
16¢42 ac ual cases, which ep esen s a all o 21¢21%. By
con as , he compa ison be ween he coun e ac ual
(1¢94) and ac ual (2¢86) cases pe 1,000 li e bi hs o
he non-p io i y municipali ies e ealed a 47¢86%
inc ease.
The combined analysis o he na ional da a e eals a
decline in he immedia e impac o congeni al syphilis
pos -in e en ion, wi h an a e age mon hly educ ion o
-0¢36 cases pe 1,000 li e bi hs in he p io i y munici-
pali ies. Con e sely, he e was an inc ease o 0¢28 cases
pe 1,000 li e bi hs in non-p io i y municipali ies. In
he linea eg ession model, examina ion o he ends
o bo h g oups ollowing he in e en ion, e eals a
dec ease in he g ow h o he a e age numbe o cases
pe 1,000 li e bi hs. Hence, he e was a educ ion o
-0¢21 in p io i y municipali ies and o -0¢10 in non-p io -
i y ones, as depic ed in Figu e 7 and Table 1 (column 7).
Figu e 2. Changes in congeni al syphilis a es in he No h egion 20 mon hs be o e and a e he in e en ion.
Figu e 3. Changes in congeni al syphilis a es in he No heas egion 20 mon hs be o e and a e he in e en ion.
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Fo p io i y municipali ies, he combined analysis
also indica es a educ ion o 28¢79% in he numbe o
cases in he las mon h o he analyzed pe iod (Table 2)
when compa ed he coun e ac ual o 21¢93 wi h he
ac ual numbe o 15¢61 cases pe 1,000 li e bi hs. In
he non-p io i y municipali ies, he e was a d op o
26¢20%. Acco dingly, i wen om 6¢34 coun e ac ual
cases o 4¢68 ac ual cases pe 1,000 li e bi hs.
As o congeni al syphilis in p io i y and non-p i-
o i y municipali ies, he mos ema kable di e en-
ces we e ound in he No heas (15¢58 pe 1,000
li e bi hs) and Sou h (15¢04 pe 1,000 li e bi hs)
egions, ollowed by he No h (11¢39 cases pe
1,000 li e bi hs), Sou heas (8¢38 cases pe 1,000
li e bi hs) and Midwes (6¢87 cases pe 1,000 li e
bi hs).
Figu e 4. Changes in congeni al syphilis a es in he Sou h egion 20 mon hs be o e and a e he in e en ion.
Figu e 5. Changes in congeni al syphilis a es in he Sou heas egion 20 mon hs be o e and a e he in e en ion.
8 www. helance .com Vol 7 Mon h Ma ch, 2022
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Discussion
The indings indica e a s a is ically signi ican educ ion in
he end o congeni al syphilis cases in B azil in he 20
mon hs ollowing he Syphilis No! P ojec in e en ions.
Addi ionally, he esul s e eal ha p io i y municipali ies
expe ienced a mo e signi ican educ ion in congeni al
syphilis cases when compa ed o o he B azilian munici-
pali ies wi h a g ea e educ ion in he end.
Fo p io i y municipali ies, he p ojec ’s impac on
changing he cou se o congeni al syphilis ends was
mo e e iden . Unlike he o he ou B azilian egions,
he mos signi ican change in he g ow h end was
obse ed in he No heas , which showed a sha p d op.
Fu he mo e, dec easing pos -in e en ion ends we e
obse ed in he No heas and Sou h egions. Mean-
while, he e was s abiliza ion o he end in he No h.
Figu e 6. Changes in congeni al syphilis a es in he Midwes egion 20 mon hs be o e and a e he in e en ion.
Figu e 7. Changes in congeni al syphilis a es in B azil 20 mon hs be o e and a e he in e en ion.
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