INTRODUCTION

Syphilis is an infectious disease caused by a spirochete bacterium, named Treponema pallidum, transmitted mainly by sexual contact, which presents a variety of clinical manifestations with chronic evolution, and may be asymptomatic in some stages.^1,2

In congenital syphilis (CS) transmission of treponemas often occurs transplacentally, and may occur during childbirth³. About 80% of pregnancies, in which the mother has syphilis, have adverse outcomes such as prematurity, low birth weight, congenital infection and fetal and neonatal death. Hutchinson’s triad, composed of dental malformations, interstitial keratitis and sensorineural deafness, caused by damage to the VIII cranial nerve, constitute the CS triad⁴.

In recent years, there has been an increase in CS cases in the five regions of Brazil, highlighting the Northeast and Southeast regions with the highest number of cases, recording rates ranging from 2.7 to 6.9/1000 live births⁵. The continuous growth of CS cases is associated with the challenge of timely diagnosis and follow-up of cases, although it is a preventable and treatable disease⁶.

Timely and adequate care is one of the barriers to vertical transmission of syphilis. Therefore, one of the main risk factors for CS is inadequate prenatal care, which should be tracked from the first consultations and provide early and immediate treatment for pregnant women and partner, as determined by the Ministry of Health recommendations⁶.

Existing inequalities in access to health, whether regional or social, in addition to other failures resulting from poor care, such as inadequate information provided by the health care team, misinterpretation of syphilis tests and non-recognition of maternal signs of syphilis contribute to CS persisting across the country⁷. Thus, CS is a public health problem, in which case control is directly related to the quality of health services offered to pregnant women⁸.

Therefore, improvements in the implementation of health services for pregnant women with syphilis can be monitored through the frequent analysis of CS cases. Therefore, this study aims to describe the epidemiological profile of CS in northeastern Brazil.

METHODS

This is a retrospective, descriptive and quantitative study, carried out from secondary data from the Notifiable Diseases Information System (SINAN - Sistema de Informação de Agravos de Notificação), from the website of the Department of Informatics of the Unified Health System (DATASUS - Sistema de Informação de Agravos de Notificação). The Northeast Region of Brazil was adopted as the study site, as it has the largest number of states (Alagoas, Ceará, Maranhão, Paraíba, Pernambuco, Piauí, Rio Grande do Norte and Sergipe) in relation to other Brazilian regions, with an approximate area of 1.5 million km. and 57 million inhabitants⁹ .

The population consisted of all confirmed CS cases in children under one year of age, from 2014 to 2018. This time frame was adopted, as this period is fully available for analysis in DATASUS.

Data collection took place in August 2020, by one of the authors of the study. Then, they were grouped in Microsoft Excel., in which descriptive statistical analysis (absolute and relative frequency) was performed. It is noteworthy that the incidence rate and gross mortality coefficient per year are already calculated in DATASUS.

The variables considered were: number of cases and deaths from CS in children under one year of age; syphilis cases by state and year of diagnosis; child’s age group; classification of the final diagnosis; age group, race and maternal education; prenatal care; maternal treatment scheme; and performing the partner’s treatment.

This study was not submitted to the Institutional Review Board, as it uses secondary data, available on a public platform and online. Despite this, the ethical principles of Resolutions 466, of December 12, 2012, and 510, of April 7, 2016, of the National Health Council, of the Ministry of Health of Brazil, were respected.

RESULTS

In the time frame from 2014 to 2018, there was a prevalence of cases in the state of Pernambuco (25.2%), with a gradual increase in incidence, followed by Bahia (20.0%) and Ceará (19.0%) (Table 1).

In 2018, there was a significant increase in CS with a rate of 9.6 cases per 1,000 live births, when compared to previous years, accompanied by the increasing number of deaths, reaching the gross mortality rate of 9.4 per 100,000 live births in the same period (Table 2).

In all years analyzed, there was a predominance of early CS. Maternal age ranged from 20 to 29 years (52.0%), and education between incomplete 5^th and 8^th grades (31.3%) and mixed color/race (77.1%). It was verified that women underwent prenatal follow-up (79.8%), with inadequate maternal treatment regimen (59.2%) as well as without treatment of their partner (59.5%) (Table 3).

DISCUSSION

The Pan American Health Organization (PAHO), with support from the World Health Organization (WHO), approved the strategy and action plan for the elimination of mother-to-child transmission of syphilis. The establishment of this strategy in 2010 aimed to reduce the incidence of CS to less than 0.5 cases per 1,000 live births by 2015.^10,11

In Brazil, the CS incidence rate diverges from PAHO’s goals. This situation is observed with an increase of 3.8 times in CS incidence, jumping from 2.4 in 2010 to 9.0/1,000 live births in 2018. The increase in incidence is justified as a result of greater screening of syphilis.¹² Despite this, the number of deaths from CS has increased in recent years, as observed in the present research.

In this study, despite fluctuations, all states in the Northeast region had high rates of CS, with a predominance of cases in Pernambuco, over the years. To control the mother-to-child transmission of syphilis, it is necessary to improve the access and quality of prenatal care, promote syphilis testing in the pregnant woman’s first appointment, ensure adequate and immediate treatment of the pregnant woman and partner¹, training of health professionals health to carry out screening and early identification of cases¹³. Furthermore, the data suggest a variety of factors that may be related to vertical transmission, such as maternal, socioeconomic and prenatal care indicators.

Therefore, it is necessary to consider the particularities of each municipality in order to provide actions to cope with CS.¹⁴ Public policies in the Northeast region should be encouraged, with the intensification of geographic planning and the construction of maps that highlight the regions that need more effective control, including other sexually transmitted infections (STIs) and prevalent pathologies based on improvements in public health.¹⁵

With regard to the diagnosis of CS, there was a predominance of neonates younger than seven days old, corresponding to 93.6% of cases. This finding is consistent with other studies that identified a predominance of the diagnosis in the first days of life.^16,17

Syphilis infection prevailed in young, mixed-race pregnant women who had completed high school, results similar to previous studies.^16,18Younger women are at the beginning of their sexual lives, which can lead to early, unprotected, multiple-partner sex and a high number of STIs.¹² In this sense, it is important to implement actions that encourage safe sex practices to prevent unwanted pregnancies and prevent STI transmission.¹⁷ Furthermore, a study shows that the aforementioned sociodemographic characteristics are predominant in pregnant women with syphilis.¹⁶

Despite the pregnant women undergoing prenatal care, their and their partner’s treatment scheme was inadequate. Previous studies carried out in Maranhão¹⁶ and Minas Gerais¹⁸obtained similar results. Inadequate treatment and non-performance of the partner’s treatment, associated with infection in young pregnant women and with low education are determinants to prevent vertical transmission¹⁶. Until timely and solid actions are taken, syphilis will remain a health problem with adverse consequences to the maternal-fetal cycle,¹⁰ which denotes a deficiency in the public health system and the need to improve the quality of prenatal care¹.

Appropriate treatment is possible with penicillin G benzathine, a safe and effective option during pregnancy provided by the Unified Health System (Sistema Único de Saúde). Moreover, sexual partnerships of pregnant women with syphilis must be treated regardless of laboratory confirmation.¹⁹ The inadequate treatment of mothers and their partners reveals the fragility, while highlighting the importance of proper diagnosis and monitoring of pregnant women during prenatal care as well as greater attention in the child’s first year of life²⁰.

By 2030, the elimination of CS as a public health problem will depend on the control of syphilis in the general population and on the treatment of partnerships of pregnant women with syphilis identified in the prenatal period.¹⁰ It is considered that the efforts of primary care can contribute to the decline in vertical transmission of syphilis, as it serves as a gateway, increasing proximity to patients.²⁰Furthermore, the partner’s participation should be encouraged from the prenatal period, as it promotes the strengthening of the bond between the couple and with newborns. ²¹

The limitation of the study is related to the method used, since, due to the use of secondary data from official sources, there is the possibility of underreporting and incomplete information, given by failures in filling in the data.

There is an increase in CS every year in the Northeast region, accompanied by inadequate treatment of pregnant women and their partners in the prenatal period. This highlights the importance of new approaches, with the purpose of training health professionals, especially in primary care, for prevention, screening and effective treatment of syphilis in pregnant women in order to reduce CS cases. Studies that investigate the difficulties of pregnant women and partners with syphilis in adherence to prenatal care are recommended, as well as the weaknesses of health care for the screening and effective treatment of gestational syphilis.

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