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Epidemiological Surveillance of Birth Defects Compatible
with Thalidomide Embryopathy in Brazil
Fernanda Sales Luiz Vianna
1,2
, Jorge S. Lopez-Camelo
3,4
,Ju
´lio Ce
´sar Louguercio Leite
1
, Maria Teresa
Vieira Sanseverino
1
, Maria da Grac¸a Dutra
5
, Eduardo E. Castilla
4,5
,Lavı
´nia Schu
¨ler-Faccini
1,2
*
1INAGEMP (Instituto Nacional de Gene
´tica Me
´dica Populacional) at Teratogen Information Service, Medical Genetics Service, Hospital de Clı
´nicas de Porto Alegre, Porto
Alegre, Brazil, 2INAGEMP at Genetics Department, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 3INAGEMP at ECLAMC (Latin-American Collaborative
Study of Congenital Malformations) in IMBICE: Instituto Multidisciplinario de Biologia Celular, La Plata, Argentina, 4INAGEMP at ECLAMC in CEMIC: Centro de Educacio
´n
Me
´dica e Investigacio
´nClı
´nica, Buenos Aires, Argentina, 5INAGEMP at ECLAMC in Laborato
´rio de Epidemiologia de Malformac¸o
˜es Conge
ˆnitas, Instituto Oswaldo Cruz,
FIOCRUZ, Rio de Janeiro, Brazil
Abstract
The thalidomide tragedy of the 1960s resulted in thousands of children being born with severe limb reduction defects
(LRD), among other malformations. In Brazil, there are still babies born with thalidomide embryopathy (TE) because of
leprosy prevalence, availability of thalidomide, and deficiencies in the control of drug dispensation. Our objective was to
implement a system of proactive surveillance to identify birth defects compatible with TE. Along one year, newborns with
LRD were assessed in the Brazilian hospitals participating in the Latin-American Collaborative Study of Congenital
Malformations (ECLAMC). A phenotype of LRD called thalidomide embryopathy phenotype (TEP) was established for
surveillance. Children with TEP born between the years 2000–2008 were monitored, and during the 2007–2008 period we
clinically investigated in greater detail all cases with TEP (proactive period). The period from 1982 to 1999 was defined as the
baseline period for the cumulative sum statistics. The frequency of TEP during the surveillance period, at 3.10/10,000 births
(CI 95%: 2.50–3.70), was significantly higher than that observed in the baseline period (1.92/10,000 births; CI 95%: 1.60–2.20),
and not uniformly distributed across different Brazilian regions. During the proactive surveillance (2007–2008), two cases of
suspected TE were identified, although the two mothers had denied the use of the drug during pregnancy. Our results
suggest that TEP has probably increased in recent years, which coincides with the period of greater thalidomide availability.
Our proactive surveillance identified two newborns with suspected TE, proving to be a sensitive tool to detect TE. The high
frequency of leprosy and the large use of thalidomide reinforce the need for a continuous monitoring of TEP across Brazil.
Citation: Vianna FSL, Lopez-Camelo JS, Leite JCL, Sanseverino MTV, Dutra MdG, et al. (2011) Epidemiological Surveillance of Birth Defects Compatible with
Thalidomide Embryopathy in Brazil. PLoS ONE 6(7): e21735. doi:10.1371/journal.pone.0021735
Editor: Julian Little, University of Ottawa, Canada
Received January 18, 2011; Accepted June 8, 2011; Published July 6, 2011
Copyright: ß2011 Vianna et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Funding was provided by INCT (National Institute of Science and Technology), National Council of Research (CNPq), Process nr 573993/2008-4. The
funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: lavinia.faccini@ufrgs.br
Introduction
Thalidomide was first synthesized in 1954 in Western
Germany and introduced to the market in 1956. Subsequently
it was licensed in a further 46 countries worldwide, including
Brazil [1,2]. Limited studies inanimalshadsuggestedthat
thalidomide was not toxic, which indicated it was a safe sedative
when compared to barbiturates [3]. However, a great number of
babies with congenital defects, especially limb reduction, were
born at the beginning of the 1960s, something that was
promptly detected by ‘‘alert practitioners’’ [4,5,6]. These
malformations were characterized by defects in the development
of the long bones of the limbs, with hands and feet varying
between normal and rudimentary. Besides limb reduction
defects (LRD), associated malformations were also documented,
such as anotia, microtia, anophthalmia, and microphthalmia, as
well as cardiac, genitourinary and gastrointestinal anomalies [7].
At the end of 1961 [5,6] Lenz in Germany, and McBride in
Australia [4] suggested a possible correlation between these
congenital defects and the use of thalidomide during pregnancy.
The drug was removed from the market in Germany and in
several other countries between 1961 and 1962, by which time
some 10,000 child victims of thalidomide had already been born
worldwide [2].
A few years later, Sheskin in 1965 [8] reported the effectiveness
of thalidomide in the treatment of erythema nodosum leprosum
(ENL), an inflammatory condition resulting from leprosy. He
prescribed this drug to a leprosy patient as a sedative, and
observed the complete improvement of symptoms and skin lesions
within three days. The proven efficacy of the drug for this
indication [9] increased the general interest in the drug’s
therapeutic potential for other conditions, especially after its
anti-inflammatory, immunomodulating and anti-angiogenic pro-
prieties were recognized [10,11,12].
Based on the knowledge of these properties, several clinical trials
set out to demonstrate the effectiveness of the drug for the
treatment of various medical conditions. In 1998, thalidomide was
approved by the US FDA for the treatment of ENL and later, in
2006, for the treatment of multiple myeloma, under strict
restrictions to prevent exposure in utero [13]. Presently, the use of
thalidomide is approved in many countries for the treatment
mainly of ENL, skin diseases, and several types of cancer.
PLoS ONE | www.plosone.org 1 July 2011 | Volume 6 | Issue 7 | e21735
In Brazil, thalidomide has always been available in the regions
with endemic leprosy. In 1965 Brazil approved its use for the
treatment of ENL [14]. This continuous commercialization plus its
high use due to the prevalence of leprosy and inefficient drug
control measures gave way to the appearance of new cases of
thalidomide embryopathy (TE) between the 1970s and 1990s [15].
Following these reports, a more restrictive regulation was created
for thalidomide use and prescription in Brazil [16]. Nevertheless,
three new individuals with thalidomide syndrome were reported
after that [17].
Besides being employed in the treatment of ENL since 1965,
thalidomide has been available for use in Brazil since the end of
the 1990s for the treatment of multiple myeloma, graft-versus-host
reaction, systemic lupus erythematosus, and ulcerations related to
the acquired immunodeficiency syndrome (AIDS), among other
diseases, as long as the purpose of prescription in these situations is
duly documented. Leprosy is definitely the main disease to which
thalidomide has been prescribed. Brazil, with a population of 190
million inhabitants is one of the leading countries in number of
leprosy cases the world, with an overall estimated prevalence of 5/
10,000. However, regional prevalences are quite dissimilar,
ranging from less than 1/10,000 in South Brazil to 7/10,000 in
North and Northeast [18].
The drug is not commercially available being distributed only
through specific programs of the Ministry of Health, and
dispensed following explicit and rigid rules. However, the recent
discovery of babies with thalidomide embryopathy (TE) [17] raises
questions as to the effectiveness of the restricted distribution system
with respect to prevention of pregnancy exposures. Thus, the
objective of the present study was to perform a proactive
surveillance of thalidomide embryopathy phenotype (TEP) using
an established system for monitoring birth defects in Latin
America.
Results
During the baseline period (1982–1999), of the 793,177 births
examined 152 newborns presented TEP. The BPR observed was
1.92/10,000 births (CI 95%: 1.60–2.20), and no significant difference
between geographical regions was detected (Table 1).
During the surveillance period (2000–2008), of 352,037 births
assessed, 109 newborns fitted our definition of TEP, which generated
a BPR of 3.10/10,000 births (CI 95%: 2.50–3.70) (Table 2). Overall,
BPR was higher than that observed for the baseline period. Among
the regions assessed, the southeast presented the highest BPR in the
surveillance period (Tables 1 and 2). On the other hand, the south
region presented the lowest BPR compared to other regions during
the surveillance period, being similar during baseline and surveillance
periods (Table 1 and 2).
It is noteworthy also that during the surveillance period the
overall Brazilian frequency of LRD (8.50, CI 95%: 7.50–9.80) was
significantly higher than that registered by ECLAMC hospitals in
other Latin American countries (6.83, CI 95%: 6.40–7.30; data
not shown).
Cumulative Sum Analysis (CUSUM)
During the surveillance period (2000–2008), increases in the
frequencies of TEP were observed in all Brazilian geographical
regions (Figure 1), but only in the southeast and northeast regions
were the alarms confirmed.
Proactive Surveillance
After detailed clinical evaluation (photographs, radiographs and
a structured questionnaire) of the 96 babies born with LRD during
the proactive surveillance period (March 2007 to February 2008),
16 neonates were classified as affected by TEP. Of these, seven
cases were considered inconclusive because of lack of information
and seven were incompatibles. Thus, two infants had phenotypes
suggestive of thalidomide use during pregnancy and had not
received a diagnosis of any other type of syndrome. However, the
use of thalidomide was not confirmed by their mothers when
specifically questioned. These two cases are described in detail
below. For the second year of surveillance clinical evaluation is not
yet complete.
Case 1. Female born in July 2007 in the northeast of Brazil;
birth weight 2,360 g. The mother was 29 years old with no family
history of malformations and with no pregnancy exposure. Upper
limbs: bilateral intercalary defect; absent left humerus, hypoplastic
radius and ulna; hypoplastic left hand with two rudimentary digits;
hypoplastic right radius and ulna, hypoplastic hand with two
rudimentary fingers; both lower limbs normal. Besides the LRD,
this newborn presented unilateral cleft lip. The electrocardiogram
was normal.
Case 2. Male born in October 2007, in the same hospital as case
1; birth weight 2,405 g. The third son of a 34-year-old mother with
no family history of malformations or genetic diseases; his mother had
no exposure to thalidomide during pregnancy. Tetramelic amelia,
bilateral microtia, elongated nose root, moderate retromicrognathia,
and left cryptorchidism. Electrocardiogram was normal.
Discussion
Generic thalidomide is produced in Brazil by just one
laboratory, under supervision of the Ministry of Health. Around
four million tablets of thalidomide are distributed yearly, by
specific government programs, mostly for the treatment of ENL.
Until 2010, there was no information about the exact destination
of these tablets. This lack of information can be accountable for
the recent occurrence of cases of thalidomide syndrome. From
2011, a new legislation for thalidomide dispensing was imple-
mented in Brazil with a strong control of to whom this drug is
being prescribed [27]. However, we know that in Brazil around
24,000 cases of multibacilar leprosy are yearly diagnosed. From
these, 30% to 50% will present ENL. From this estimation,
approximately 10,000 individuals are possible users of thalido-
mide.
The assessment of TEP during the baseline period enabled the
establishment of a Brazilian BPR for phenotypes compatible with
this syndrome, permitting the detection of increases in the
frequency of TEP through the CUSUM methodology.
There are no references with which to compare the rates of a
sentinel phenotype as described here; however, during the
surveillance period, increases in the BPRs of TEP were observed,
Table 1. Number of newborns with TEP and BPR in the
period of 1982–1999 by Poisson distribution.
Region TEP Births BPR CI 95%
Northeast 22 155,784 1.41 0.90–2.10
Southeast 94 423,261 2.22 1.80–2.80
South 36 214,132 1.68 1.20–2.30
Total 152 793,177 1.92 1.60–2.20
Footnote: TEP: thalidomide embryopathy phenotype; BPR: birth prevalence
rate; BPR per ten thousand births.
doi:10.1371/journal.pone.0021735.t001
Thalidomide Embryopathy Surveillance in Brazil
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corroborating the thalidomide distribution pattern from 2000. The
differences observed in the TEP rate between the different regions
of Brazil are in accordance with the distribution of leprosy across
the country [20]. In the south region, TEP was less frequent than
in other regions, and so was leprosy prevalence. Furthermore, no
differences between the two periods were detected. The southeast
region presented the highest BPR, although this result may have
been biased by data collected in specialized maternities belonging
to ECLAMC, which have a higher rate of birth defects, especially
from cases referred to them after prenatal diagnosis. The alarms
detected in the CUSUM analysis followed the same pattern.
This significant increase in the frequency of LRD could have been
biased by the improvement in prenatal diagnosis and derivation of
those cases with fetal anomalies to referral hospitals participants of
ECLAMC. Excluding tertiary hospitals in both periods, the increased
rate of TEP is not observed (baseline period: 1.59, 95% CI :1.30–
1.87; period of surveillance: 2.18, 95% CI 1.64–2.71).
Our proactive surveillance led to the identification of two cases
compatible with TE, although maternal use of thalidomide could
not be proven. However, the availability of this information often
depends on individual conditions, such as maternal memory and
fear of social prejudice due to of the use of a medication that is
contraindicated during pregnancy. Moreover, there is the
possibility of self-medication, which is a habitual behavior among
the Brazilian population and lies behind the unadvised use of
several drugs during pregnancy. This is a problem observed not
only with thalidomide but also with other drugs with teratogenic
potential. In three recent clinically characteristic cases of
embryopathy recorded in Brazil [17], maternal interview was
negative for the use of thalidomide.
Table 2. Number of newborns with TEP and BPR, per year and geographical region, in the period of 2000–2008 by Poisson
distribution.
Brazil Northeast Southeast South
Year TEP Births BPR CI 95% TEP Births BPR CI 95% TEP Births BPR CI 95% TEP Births BPR CI 95%
2000 11 40104 2.74 1.40–4.90 -- -- 6 12047 5.00 1.80–10.80 5 28057 1.80 0.60–4.20
2001 10 38742 2.50 1.20–4.70 0 5088 0.00 0.00–10.2 8 11876 6.74 2.90–13.30 2 21778 0.92 0.10–3.30
2002 10 40231 2.49 1.20–4.60 0 6617 0.00 0.00–7.8 8 12197 6.56 280–12.80 2 21417 0.93 0.10–3.40
2003 10 42061 2.38 1.10–4.40 0 10171 0.00 0.00–4.90 4 11466 3.50 0.90–8.90 6 20424 2.94 1.10–6.40
2004 11 42581 2.58 1.30–4.60 2 9733 2.10 0.20–7.40 5 11316 4.42 1.40–10.30 3 21532 1.40 0.30–4.10
2005 16 37518 4.26 2.40–6.90 7 10196 6.90 2.80–14.10 5 10909 4.60 1.50–10.70 5 16413 3.05 1.00–7.10
2006 15 38298 3.92 2.20–6.50 6 9341 6.42 2.30–14.00 4 13021 3.10 0.80–7.90 5 15936 3.24 1.00–7.30
2007 16 38281 4.18 2.40–6.80 2 8627 2.32 0.30–8.40 13 14658 8.90 4.70–13.20 1 14996 0.70 0.10–3.70
2008 10 34221 2.92 1.40–5.40 5 8920 5.60 1.80–13.10 3 13192 2.30 0.50–6.60 2 12109 1.65 0.20–6.00
Total 109 352037 3.10 2.50–3.70 22 68693 3.20 2.00–4.80 56 110682 5.10* 3.80–6.80 31 172662 1.80* 1.20–2.50
Footnote: TEP: thalidomide embryopathy phenotype; BPR: birth prevalence rate; CI 95%: confidence interval of 95%.
*p,0.05.
-: year without monitoring by ECLAMC. BPR per 10 thousand births.
doi:10.1371/journal.pone.0021735.t002
Figure 1. CUSUM analysis done for thalidomide embryopathy phenotype for southeast (black line), northeast (red line), and south
(blue line) Brazilian regions. Parameters: Southeast region (K = 0.8 H = 10 ARL = 518 OOCARL = 44.4); northeast region (K = 0.4 H = 5.6 ARL = 473
OOCARL = 44.2); and south region (K = 1 H = 8 ARL = 462.1 OOCARL = 36.4).
doi:10.1371/journal.pone.0021735.g001
Thalidomide Embryopathy Surveillance in Brazil
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It is important to point out that thalidomide is not the only
etiological factor for the phenotypes that we included as suggestive
of TE. Syndromes whose characteristics are similar to those of TE
include: Roberts syndrome, Holt-Oram syndrome, Fanconi’s
pancytopenia, radial aplasia-thrombocytopenia (TAR), among
others syndromes, as well and Femur-Fibula-Ulna complex [1,7],
besides unspecified developmental conditions.
One limitation of the present surveillance is that the main
endemic areas of leprosy in Brazil are located in rural regions,
especially in the north and center-west regions, where many births
take place outside hospital settings and where coverage and
monitoring by ECLAMC is not present. In any case, the percentage
of coverage of births is also a limiting factor in surveillance systems.
Yang et al. [22] evaluated the ability of monitoring systems to
detect TE alarms and suggested that the surveillance of all LRD is
insufficient for the detection of this type of embryopathy. They
support the notion that an impracticable surveillance time would
be necessary when the rate of exposure to thalidomide is very low,
even when monitoring bilateral intercalary and preaxial defects (or
only intercalary, which are the defects most frequently associated
with TE). In the present study, however, local accessibility to
thalidomide was high, and we proposed the cumulative sum
methodology (CUSUM) for the detection of increases in the
frequency of alarms, since it is a method which is faster at
detecting changes in prevalences than the Poisson methodology
[22]. The TE surveillance system presented herein is highly
sensitive because all the LRD described in the syndrome are
included, but the system has low specificity because it groups
different types of LRD not related to TE. This bias was controlled
by the direct assessment of all the TEP reported cases.
We believe that the surveillance protocol presented here is
feasible and sensitive to immediately detect new cases of
thalidomide embryopathy cases. This surveillance will be main-
tained at population level in Brazil through official birth certificates
registry, which includes mandatory description of birth defects.
The present paper should be considered as an alert toward the
prevention of an announced tragedy mainly in developing
countries. It also points the necessity to develop more precise
and controlled national systems that permit to identify and to
prevent the abuse observed in prescription of drugs widely known
as teratogens as well as the necessity to improve the diagnosis
procedures in children with complex limb anomalies.
Methods
Ethics Statement
The surveillance was carried out on the data generated by
ECLAMC (The Latin-American Collaborative Study of Congen-
ital Malformations). ECLAMC is a program for the clinical and
epidemiological investigation of risk factors in the etiology of
congenital anomalies in Latin-American hospitals, using a case-
control methodological approach already described elsewhere
[19]. ECLAMC has been performing quarterly surveillance of TE
since 1982. Participation of all Brazilian institutions active in the
ECLAMC network was approved by their local ethics committees,
and included the signing of a consent term for the publication of
data. This investigation was approved by the ethics committee of
CEMIC (Centro de Educacio´n Me´dica e Investigaciones Clı
´nicas),
Buenos Aires, Argentina (IRB-000001745, IORG-0001315).
Baseline Period and Surveillance
Two periods were examined: a baseline period (1982–1999) and
a surveillance period (2000–2008); from 2007 onwards we
clinically investigated in closer detail all TEP cases (proactive
surveillance).
During all periods, 56 Brazilian hospitals were included in the
analysis covering 1,145,214 births, representing 23.52% of
4,868,490 births in ECLAMC surveilled from nine different
Countries in Latin America.
We analyzed the frequency of variation within hospitals by
comparing the frequency during the surveillance period with the
frequency of the baseline period within each hospital. For this, we
calculated the observed and expected and used the Z test
according to the Poisson distribution.
The period between the years 1982 and 1999 was established as
a baseline period for TEP surveillance since the availability of
thalidomide is suspected to have increased after 2000 due to the
expansion in clinical indications for its prescription authorized
by the Brazilian Health Ministry. Geographical regions were
considered too, taking into account the differential prevalence of
leprosy in Brazil [20]. The Poisson distribution, with a confidence
interval of 95% was used to estimate birth prevalence rate (BPR).
The CUSUM methodology [21] was used to detect possible
increases in TEP frequency after 2000. CUSUM has already been
widely used for birth defects surveillance [22,23,24], being able to
detect variations of TEP from the BPR of the baseline period by
the sum of differences between the number of cases occurring
during the surveillance period and a reference value obtained from
the baseline period. The false alarm rate was set to one in 500
months (average run length (ARL) = 500).
Detailed clinical proactive surveillance was conducted from
March 2007 to February 2008 with records of newborns from 33
Brazilian hospitals participating in ECLAMC. All newborns with
limb reduction defects were assessed and classified according to the
type of limb defect and compatibility with TEP.
Thalidomide Embryopathy Phenotype (TEP)
Newborns with preaxial and bilateral intercalary LRD came
into this category, as these are already well established in the
literature as TE sentinel phenotypes [15,22]. Also, individuals that
presented amelia were included, since it is a defect frequently
observed in TE [25]. However, defects were included regardless of
laterality, since this is information that can be lost during
registration. This surveillance sentinel phenotype was called TEP.
The following LRD classification, adapted from [26], was
adopted:
NAmelia: complete absence of one or more limbs;
NDefect of intercalary transverse limb reduction: absence or
severe hypoplasia of proximal limb parts (humerus, femur,
radius, ulna, tibia, and fibula, also in combination) with
normal or approximately normal hands and feet. This group
included phocomelia.
NDefect of preaxial longitudinal limb reduction: total or partial
absence of thumbs, first metacarpus or radius; or hallux, first
metatarsus, and tibia;
Limb defects that did not fit into any of these classifications were
not included in the analysis.
Whenever TEP was identified, photographs and radiographs
were requested, and a detailed maternal interview was conducted
with the aim of investigating a possible exposure to thalidomide,
including questions such as the use of medications during
pregnancy, family history of congenital abnormalities, abortion
attempt, and a diagnosis (in herself or in a close relative) of leprosy
or other disease for which thalidomide use is approved in Brazil.
Thalidomide Embryopathy Surveillance in Brazil
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All newborns with TEP were also assessed according to
compatibility with TE based on the following criteria:
NPresence or absence of congenital defects described in the
literature relating to TE.
NPresence or absence of another known etiological syndrome
that shows the same defects.
Maternal history of thalidomide use or of another associated risk
factor: patient or close relative affected by leprosy, or another
disease for which thalidomide has been employed: multiple
myeloma, AIDS, lupus, graft-host reaction.
Acknowledgments
We are indebted to these following persons that helped us to identify and to
follow the patients studied here: Rosa Castalia and Expedito Luna (from
Brazilian Ministry of Health), Claudia Maximino (ABPST - Brazilian
Association of the Thalidomide Victims), Artur Custodio de Sousa
(Morhan – Movement for Reintegration of People affected by Leprosy,
Brazil), Beatriz B Silva and Maria Auxiliadora Villar (ECLAMC -
American Collaborative Study of Congenital Malformations).
Author Contributions
Conceived and designed the experiments: LSF FSLV EEC JSLC MGD.
Performed the experiments: FSLV JCLL MGD MTVS. Analyzed the
data: LSF JSLC JCLL MTVS MGD.
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PLoS ONE | www.plosone.org 5 July 2011 | Volume 6 | Issue 7 | e21735
