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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.19 no.57 Murcia ene. 2020  Epub 16-Mar-2020

https://dx.doi.org/eglobal.19.1.358351 

Originals

Syphilis in pregnant and congenital: epidemiological profile and prevalence

Giordana Maronezzi da Silva1  3  , Giovanna Brichi Pesce1  2  , Débora Cristina Martins1  3  , Cacilda Maria do Prado4  , Carlos Alexandre Molena Fernandes1  2 

1State University of Maringá – UEM. Brazil.

2State University of Paraná - UNESPAR. Brazil.

3Municipal Health Authority of Apucarana. Brazil.

416th Apucarana Regional Health. Brazil.

ABSTRACT

Objective

To describe the epidemiological profile through sociodemographic, obstetric and partner characteristics of the notified cases of syphilis in pregnant women in the period of 2012 to 2016.

Methods

This is a cross-sectional and descriptive study conducted at the 16th Apucarana Health Region of the State of Paraná through the compulsory notification sheets for syphilis in pregnant women and congenital syphilis inserted in the Notification System of Diseases and Diseases (SINAN).

Results

It was recorded 257 cases of syphilis in pregnant women and 119 cases of congenital syphilis. The prevalent rate of syphilis was 0,97% and the incidence rate of congenital syphilis was 4,73%. Women with congenital syphilis (SG) and congenital syphilis (SC) were mostly white, young, with low schooling and living in urban areas. Untreated partners accounted for 40,8% and 47.05% of the mothers were considered with inadequate treatment. Among live births (NS) with SC, 69.7% did not undergo TT at 18 months and 81.5% did not do TNT in CSF.

Conclusion

The health system must be reorganized ensuring the follow-up and follow-up of both the pregnant and the newborn.

Key words: Epidemiological profile; Pregnancy; Congenital Syphilis

INTRODUCTION

Caused by the spirochete Treponema pallidum, syphilis is a systemic, chronic and often asymptomatic disease. It can be transmitted through sexual and maternal-fetal routes, being called acquired and congenital. Acquired syphilis is subdivided into recent if the disease progression time is less than one year (primary, secondary and recent latent) and if more than one year of infection, as late (late and tertiary latent). CS is classified as recent when it appears until the second year of life and late when it appears after the second year of life1.

Fetal infection usually occurs between the 16th and the 28th weeks of gestation, being that the vertical transmission rate of Treponemapalidum in untreated women ranges from 70 to 100%, considering the primary and secondary phase of the disease. In the case of untreated pregnant women, the disease can trigger spontaneous abortion, stillbirth or perinatal death in about 40% of infected children2.

Every year in Latin America and the Caribbean, it is estimated that between 166,000 and 344,000 children are born with CS. Syphilis affects one million pregnant women a year worldwide, leading to more than 300,000 fetal and neonatal deaths and putting more than 200,000 children at risk of premature death. It is also noteworthy that 66% of all adverse outcomes occurred in women who had been treated by prenatal care3.

In 2009, the Pan American Health Organization (PAHO) and the United Nations Children's Fund (UNICEF) launched theRegional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean. This regional initiative in 2010 was articulated with the Global Plan to eliminate new HIV infections and syphilis among children by 2015 and keep their mothers alive4.

The Ministry of Health epidemiological bulletin on syphilis in 2015 showed that in Brazil in 2004 the infection rate was 1.7 cases per 1,000 live births and in 2013 this rate increased to 4.7, i.e. an increase of more 100% in less than ten years. Following these rates, the infant mortality rate from syphilis has also increased over the past ten years in Brazil, from 2.2 deaths per 100,000 live births in 2004 to 5.5 in 20135. In 2016, in Brazil, 87,593 cases of acquired syphilis, 37,436 cases of syphilis in pregnant women and 20,474 cases of congenital syphilis were reported, totaling 185 deaths6.

Congenital syphilis and syphilis in pregnant women have been compulsorily reported in Brazil since 1986 and 2005, respectively. Information on abortions, stillbirths and live births with congenital syphilis should be entered into the Sistema de Informação de Agravos de Notificação (SINAN), monitoring these infections through SINAN is of fundamental importance for the elimination of syphilis as it provides support for strategy planning and definition of the necessary interventions7.

Considering the high incidence of this disease, effective and low cost treatment, the easy access to diagnosis, the impact of this disease on public health and the need for its control, with the purpose of to describe the epidemiological profile through the sociodemographic, obstetric and partner characteristics of the reported cases of PS and CS from 2012 to 2016 in the 16ª Regional de Saúde de Apucarana in the state of Paraná, Brazil. Seeking to identify possible failures in the care provided to pregnant women so that strategies can be drawn up with the team that performs care to improve the quality of health services offered.

MATERIAL AND METHOD

This is a cross-sectional and descriptive study conducted at the 16ª Regional de Saúde de Apucarana, composed of 17 municipalities: Apucarana, Arapongas, BomSucesso, Borrazópolis, California, Cambira, Faxinal, Grandes Rios, Jandaia do Sul, Kaloré, Marilândia do Sul , Marumbi, Mauá da Serra, Rio Bom, Sabaúdia, São Pedro do Ivaí, which is located in the northern region of the state of Paraná, with a population of 346,963,000 inhabitants. Paraná is located in the southern region of Brazil and has a territorial area of 199,307,939 Km2, population of 10,444,526 inhabitants, with per capita household monthly nominal income of R $ 1,398.00, Human Development Index (HDI) of 0.749 ranking fifth in the country8.

It were included all cases of PS and CS registered in SINAN in the years 2012 to 2016, which met the case definition criteria confirmed according to the Ministry of Health.

The characteristics studied according to the information from the syphilis notification form in pregnant and congenital:

  1. Maternal socio-demographic:

    • - age (in years: 10 to 14; 15 to 19; 20 to 34; 35 to 49).

    • - race / skin color (White; Black; Asian; Hispanic; American Indian).

    • -schooling: illiterate; 1st to 4th incomplete grades of Elementary School; 4th grade complete of Elementary School; 5th to 8th grade incomplete of Elementary School; complete Elementary School; Incomplete High School; complete High School; Incomplete Higher Education; Complete Higher Education; ignored).

  2. Prenatal care: (yes; no; ignored / blank).

  3. Obstetric and treatment:

    • - time of maternal diagnosis (1st, 2nd, 3rd trimester or gestational age ignored).

    • - clinical classification of the disease (primary; secondary; tertiary; latent; ignored / blank).

    • - treponemal test (reactive; unreactive; unfulfilled; ignored / blank).

    • - non-treponemal test (reactive; unreactive; unfulfilled).

    • - prescribed treatment regimen for pregnant women (benzathine penicillin G 2,400,000 IU; benzathine penicillin G 4,800,000 IU; benzathine penicillin G 7,200,000 IU; other regimen; not done; ignored / blank).

    • - Partner treatment (yes; no; ignored / blank).

  4. Clinics and laboratories of the newborn:

    • - VDRL (venereal disease research laboratory) titration in peripheral blood (reagent; nonreactive; not performed; ignored / blank).

    • - VDRL titration in fluid (reagent; non-reagent; not performed; ignored / blank).

    • - alteration of long bone examination (yes; no; not performed; ignored / blank).

    • - case evolution (alive; death from congenital syphilis; death from other causes; abortion; stillbirth).

Compulsory reporting forms consist of a standardized form with sociodemographic and clinical information completed by health professionals. Data tabulation was performed by Tabwin 32. Microsoft Excel 2010 software was used for data entry and analysis.

To calculate the prevalence of PS we used the total number of notifications during the period from 2012 to 2016 divided by the total number of pregnancies of the same year and multiplied by 100. The number of pregnancies was obtained by summing the number of live births and stillborn in the period, excluding abortions.

The GS detection rate was obtained by the ratio of the number of cases detected in a given year of notification, by the number of live births in the same place and year multiplied by 1,0006.

The incidence of CSwas calculated by the total number of cases reported in the study period by the number of live births in the same period, multiplied by 1,0006.

The number of live births was obtained from the Sistema de Informação Sobre Nascidos Vivos(SINASC).

The study used exclusively secondary data from official databases, which are in the public domain and there is not possibility of identification of the individuals involved, therefore, there are not ethical implications regarding the approach of human beings. However, it sought to follow all principles of confidentiality of information recommended by Resolution no. 466/2012 of the National Health Council.

RESULTS

In the 16ª Regional de Saúdedo Paraná, between 2007 and 2016, 257 cases of PS and 119 cases of CS were reported from 2012 to 2016.

The prevalence rate of PS in the period from 2012 to 2016 was 0.97% and the incidence rate of CS from 2012 to 2016 was 4.73%. There was a considerable increase in the prevalence rate of PS from 0.10% to 1.78%. The year 2016 had the highest number of PS (n = 89; 34.6%), with the detection rate of PS went from 1.04 in 2012 to 17.9 in 2016 for every 1,000 live births.

Regarding the age group of pregnant women with syphilis, 61.8% (n = 159) were between 20 and 34 years old (Chart 1). Belonged to the white race 65.3% of pregnant women (n = 168) and had incomplete education from 5th to 8th grade 23.3% of pregnant women (n = 60). It is important to note that 25.6% of the notified form contained this data as ignored / blank. 91.8% (n = 236) of the pregnant women lived in the urban area, 6.61% (n = 17) in the rural and peri-urban 1.55% (n = 4). (Chart 1)

Chart 1. Distribution of syphilis prevalence and detection rates in pregnant women and the incidence rate of congenital syphilis in 16ª Regional de Saúde do Paraná, 2012-2016. 

As regards the clinical classification of the disease 49.8% (n = 128) were classified as primary syphilis, 10.1% as secondary syphilis (n = 26), 7% (n = 18) as tertiary and 1.55% (n = 4) as latent. Ignored / white totaled 31.5% (n = 81). Benzathine penicillin G 2,400,000 IU was prescribed for 32.2% (n = 33) of pregnant women, the benzathine penicillin G 4,800,000 IU scheme for 9.72% (n = 25) of pregnant women, 35.7% (n = 92), 7,200,000 IU benzathine penicillin G (n = 92), another regimen at 5.83% (n = 15) and untreated at 9.72% (n = 25). (Chart 1)

They had reactive TNT 94.1% (n = 242) of pregnant women, 1.55% (n = 4) nonreactive and 3.89% (n = 10) did not perform it. With reactive TT 48.6% (n = 125), unreactive 5.44% (n = 14), did not perform TT 33% (n = 85) and ignored 12.8% (n = 33). (Chart 1)

Untreated partners totaled 40.8% (n = 105), ignored treatment 21% (n = 54) and those who received treatment 38.1% (n = 98). As a reason for non-treatment of the partner 42.8% (n = 110) reported this field as ignored, 28.7% (n = 74) as other reasons, 14% (n = 36) of the partners had no further contact with the pregnant woman, partner with non-reactive serology 6.61% (n = 17), 5.05% (n = 13) of partners were called, but did not attend for treatment, 1.94% (n = 5) of partners were not called for treatment by the health unit, 0.77 % (n = 2) were called by the health unit, but refused treatment. (Chart 1)

The annual detection rate of CS rose from 0.41 in 2012 to 6.65 in 2016 for every 1,000 live births. Mothers who have filled the criteria for congenital syphilis, 78.1% (n = 93) were white, 67.22% (n = 80) were between the ages of 20 and 34 years old, 39.49% (n = 47) were incomplete or complete high school, and 24.36% (n = 29) had this information ignored in the notifications and 96.6% (n = 115) lived in urban areas.

They performed prenatal care 91.5% (n = 109) of the mothers, being that 83.19% (n = 99) were diagnosed with syphilis during prenatal care. TNT at delivery / curettage was performed in 88.23% (n = 105) of women and treponemal confirmatory testing was not performed at delivery in 68.06% (n = 81) of pregnant women.

As regards maternal treatment, 47.05% (n = 56) of the mothers were considered with inadequate treatment and 14.28% (n = 17) did not receive treatment. Sexual partnerships of 50.42% (n = 60) of pregnant women were not treated concomitantly.

Among live births with CS, 95.7% (n = 114) had TNT in the reactive peripheral blood, 69.7% (n = 83) did not perform TT at 18 months and 81.5% (n = 97) did not have TNT in fluid. Long bone x-ray was not performed in 78.1% (n = 93) of the newborns, 73.9% (n = 88) had a final diagnosis as a recent congenital syphilis, 31% (n = 37) were treated with another regimen not recommended according to the Ministry of Health protocol, 97.4% (n = 116) of the newborns remained alive, 1.6% died due to another cause and 0.84% had the evolution ignored in the notification.

Chart 2. Distribution of pregnant women with syphilis (n = 247) according to sociodemographic, obstetric and partner variables, reported by SINAN in16ª Regional de Saúde do Paraná, 2012-2016. 

a)SINAN: Sistema de Informação de Agravos de Notificação

b)FTA-ABS: fluorescent treponemal antibody absorption test

c)VDRL: venereal disease research laboratory

d)UI: International Units

DISCUSSION

It was observed that there was an increase in the prevalence of PS and increasing incidence of CS in the 16ª Regional de Saúde do Paraná, as observed in other regions of the country9)(10 and the world9)(10)(11)(12)(13)(14)(15. The women with syphilis are mostly white, young and with low education and live in the urban area. The detection rate of PS in Brazil, from 2010 to 2016 increased about three times, from 3.5 to 12.4 cases per 1,000 live births6, a result similar to that found in this study where the detection rate of PS in the period from 2012 to 2016 went from 1,040 to 17.96 per 1,000 live births. (Chart 1)

Most pregnant women were diagnosed in the first trimester of pregnancy, which demonstrates that prenatal care has been catching this pregnant woman early and that accessibility to the diagnosis of syphilis during pregnancy was advocated according to a decree established by the Ministry of Health in 201116. The considerable increase in PS diagnosis over time can be attributed to the considerable expansion in the offer of rapid HIV and syphilis tests with the implementation of the RedeCegonha in 20114.

Approximately half of the pregnant women were clinically classified as primary syphilis characterized by ulceration or erosion at the bacterial entry site (vulva, vagina, cervix), usually unique, painless, with a hardened base and clean bottom, rich in treponemas, accompanied by or not of inguinal lymphadenopathy. This stage can last between two to six weeks and disappear spontaneously17.

The treatment prescribed to more than one third of these pregnant women is recommended for latent, late or latent syphilis, with an ignored duration in which there is no clinical sign or symptom and tertiary syphilis that is considered rare and when it manifests itself as inflammation and tissue destruction of the nervous and cardiovascular system17. From these data we can observe that the treatment does not match the clinical phase of the disease, which reflects the difficulty of health professionals in making the diagnosis according to the clinical phase and prescribing the appropriate treatment. In a study conducted in Rio de Janeiro with prenatal professionals from the public health service network, several barriers related to knowledge and familiarity with care protocols, difficulties in addressing sexually transmitted infections, user issues and organizational context were found. Professionals with more access to training and technical manuals performed better18. Another study conducted in Bolivia, health professionals relate as barriers the elimination of syphilis transmission, lack of information and the short time available with pregnant women during prenatal consultation14.

Almost all of these women had a confirmed diagnosis of syphilis and underwent reactive TNT. TT was reactive in less than half of pregnant women, which shows that these women did not have access to the two types of tests necessary for the diagnosis of PS, as recommended by the Ministry of Health protocol4.

More than a third of partners were untreated, similar results in several studies10)(15)(19 and had the reason for non-treatment as information ignored in the notifications, was observed failed assistance given once sexual partners should perform immunological tests and be treated with syphilis at the same time in case of doubt in the follow-up4.

The record of care provided and the results found constitute an effective communication tool between health teams and allow the planning, continuity of care and evaluation of services provided to clients. In addition to subsidize information for legal activities, research, education and other related activities20.

In the last 10 years, in Brazil, there has been a progressive increase in the incidence rate of CS, from 2 cases per 1,000 live births to 6.8 cases per 1,000 live births in 20166. In the 16ª Regional de Saúde de Apucarana, an increase in the incidence rate of CS was observed by 16 times from 2012 to 2016, from 0.41 to 6.65 cases per 1,000 live births. (Chart 1). This result is far from the goal of elimination of CS proposed by WHO in 2008 for Latin America and the Caribbean and incorporated by the Ministry of Health of 0.5 cases or less for every 1,000 live births by 20154,19. The schooling of these mothers was mostly reported as ignored information and in the reported cases, the highest percentage was of mothers with complete high school, almost all reside in urban areas.

More than half of the mothers were between the ages of 20 and 34 years old and belonged to the white race, that is, they are young, white mothers with more than three years of education, characteristics that exclude them from risk factors that would classify them as being of intermediate risk1.

Almost all pregnant women had prenatal care and more than two thirds of these were diagnosed during gestational follow-up, as found in other studies 7)(14)(7, which demonstrates the fragility in health services that serve this public regarding accompaniment, follow-up and control of syphilis in pregnant women. As for testing, TNT with reactive result was found in most pregnant women, while TT was not performed in more than half of pregnant women, which is contrary to the protocols created by the Ministry of Health and shows another possible failure in follow-up of these patients4)(16.

Approximately half of the pregnant women with syphilis who had their newborns notified with CS received inadequate treatment and did not have their sexual partners treated, which was observed in several other studies conducted in different locations in Brazil10)(11)(14)(17. Sexual partnerships should be called up to the health service for guidance, clinical and laboratory evaluation, and treatment when needed. If sexual partnerships do not meet this call, the prescription for treatment should be sent by the pregnant woman. The activities related to the diagnosis, follow-up and control of the disease in the sexual partner are still poorly structured and the lack of this service is noticeable in the transmission of CS12.

Chart 3. Sociodemographic and clinical characteristics of mothers of live births with congenital syphilis (n = 119) notified by SINAN in 16ª Regional de Saúde do Paraná, 2012-2016. 

a)SINAN: Sistema de Informação de Agravos de Notificação

Chart 4. Diagnostic characteristics of congenital syphilis cases (n = 119) reported by SINAN in the 16ª Regional de Saúde do Paraná, 2012. 

The information Note No. 2-SEI / 2017- DIAHV / SVS / MS, for epidemiological surveillance purposes, does not consider the treatment of mother's sexual partnership as a case definition criterion for CS6.

As regards the follow-up of the newborn with CS, almost all of them obtained TNT reagent in peripheral blood, while TNT in fluid and long bone x-ray were not performed in more than two thirds of these newborns, which points to failure in providing care in a hospital environment, since the following tests are required to define the diagnosis of CS: blood sample (blood count, liver profile and electrolytes); neurological evaluation (cerebrospinal fluid puncture: cells, proteins, treponemal and non-treponemal tests); long-bone X-ray; ophthalmological and audiological evaluation16.

TT for syphilis should be performed at 18 months for follow-up and control of congenital syphilis cure16)(21; however, more than two thirds of children notified with CS did not undergo this exam.

It was obtained as the final diagnosis of recent congenital syphilis was more than two thirds of these children and approximately one third of these children were treated with another regimen, that is, a different treatment from the one proposed by the Ministry of Health in the current protocols. The vast majority of these children remained alive, with 2 deaths due to causes other than CS.

CONCLUSION

The results of this study show an increase in the detection rates of PS and CS, and these women are mostly white, young, with low education and residents in urban areas. The diagnosis was largely made prenatally, which shows that these pregnant women are being assisted, but not effectively, because the treatment does not match the clinical classification. Other failures in care are noticeable in the data, such as not performing both types of tests (treponemal and non-treponemal) and not treating sexual partnerships. Regarding the care provided in a hospital environment, failures were identified such as failure to perform the treponemal cerebrospinal fluid and long-bone x-ray tests, which are essential for the diagnosis of congenital syphilis. There was also failure to follow up this child at 18 months. The health system must be reorganized to ensure the follow-up and monitoring of both pregnant women and newborns and health professionals should be sensitized as to the consequences of failures in the care provided to the mother-child binomial so that Brazil can compliance with congenital syphilis elimination goals set by the World Health Organization.

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Received: January 15, 2019; Accepted: February 15, 2019

Giordana Maronezzi da Silva: giordanamaronezzi@hotmail.com

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