Educational intervention in Primary Care for the prevention of congenital syphilis

ABSTRACT Objectives: to evaluate the efficiency of educational interventions related to the knowledge of health care professionals of Primary Care and to verify the impact on the vertical transmission rates of congenital syphilis. Method: a quasi-experimental study conducted in the city of Londrina, Paraná, between 2013 and 2015. An educational intervention on diagnosis, treatment and notification was carried out with 102 professionals with knowledge measurement before and after the intervention. Incidence and mortality data from congenital syphilis were taken from the system for notifiable diseases (SINAN) and the Mortality Information System (SIM). Excel tabulation and statistical analysis was done in the Statistical Package for Social Sciences, version 2.1. A descriptive and inferential analysis was performed. Results: the mean number of correct responses increased from 53% to 74.3% after the intervention (p < 0.01). The adherence to professional training was 92.6%. There was a significant reduction in the vertical transmission rate of syphilis from 75% in 2013 to 40.2% in 2015. In 2014 and 2015 there were no records of infant mortality from this condition. Conclusion: the educational intervention significantly increased the knowledge of health professionals about syphilis and collaborated to reduce the rate of vertical transmission of the disease.


Introduction
According to the World Health Organization (WHO), in 2008, 1.4 million pregnant women worldwide were infected with syphilis, of which 80% had attended prenatal care. In that same year, about one fifth (20%) of these pregnant women did not attend the referral service to receive adequate prenatal care (1) .
Syphilis is a notifiable disease, which when transmitted intrauterus causes congenital syphilis presents up to 40% mortality rate. In untreated pregnant women the transmission is 70 to 100%, in the primary and secondary stages of maternal disease (2) .
In view of these points, regarding the reemergence of syphilis in the general population and its range encompassing maternal and child health, as well as the difficulties encountered by epidemiological surveillance in overcoming the biomedical model, the fragmentation of care (3) and the use of health policies established at the global and national levels, there is a need for strategic regional studies to enable intervention measures that are more effective and based on local reality.
The Brazilian National Health System (SUS) recommends preventing the occurrence of this sentinel event (4) and provides free diagnosis and treatment for the population, with emphasis on public policies aimed at pregnant women and their sexual partners. However, there is an increasing number of cases of congenital syphilis (1) , fetal deaths, abortions and several irreversible sequelae for newborns (2) from this preventable infection.
The objective of this study was to evaluate the efficiency of the educational proposal in the knowledge of health professionals about syphilis.

Material and Method
Ethical aspects: the study was preceded by the approval of the Research Ethics Committee (CEP) of Unifesp (nº 520.189) and the signing of the free and informed consent form by the professionals included in the research.
Design, place and period: a quasi-experimental study with a "before and after" design carried out in the

Detail of the intervention, study variables and data analysis
The theme of the adequate use of the protocols

Results
The results related to the characterization of health professionals who participated in the permanent education workshops, and became facilitators in the Basic Health Units (UBS), are presented in Table 1   The number of people who answered the questionnaire after the intervention was lower (n = 85) to the number of participants who responded before (n = 102). The average successes were 53% before the intervention and reached 74,3% after (p < 0,001).
Regarding the notification, Table 3  With regards to mortality, Table 4 shows the number of fetal and infant deaths due to this condition.    the reality of other Brazilian municipalities (2,(6)(7)(8)(9) , showing that the health professionals presented insufficient technical qualification to face the problem of syphilis in prenatal care (10)(11)(12)(13)(14)(15) .
To ensure agility in the diagnosis of syphilis, in its confirmation, and in accounting for the number of VDRL tests performed in prenatal care -an important indicator that measures the quality of care (16)(17)(18)  Faced with this reality, it is understood that permanent education actions and changes in the work process must have a planned continuity (18) , because their www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2017;25:e2845 punctual action informs and updates the professionals, but the change of conduct in practice needs monitoring and correction of errors as learning, not punishment, reinforcing self-analysis and self-management activities of the health teams (19)(20) .
Although prenatal care is recognized as a very important area for the prevention of vertical transmission of syphilis (21) , directly influencing the quality indexes that affect the health of the pregnant woman and the fetus and / or newborn (10,22) , about 30% of the professionals were unaware of the need to initiate immediate treatment of the pregnant women and to call in their sexual partners through positive VDRL before the intervention. Only for this question did the increase in correct responses after training not significantly improve participants' knowledge. In Fortaleza-CE*, half of the interviewed professionals stated that they would request the VDRL for the partner and would only deal with the result (13) . A similar study carried out in Recife-PE* showed a value of 38% for the same index (20) , closer to the one found in Londrina. The data corroborate those pointed out in a similar survey carried in Rio de Janeiro-RJ*, in which approximately 40% of medical professionals and nurses reported having difficulty discussing syphilis with sexual partners (9) .
The lack of recruitment and orientation of the partners and the difficulty of the health professionals in using the recommended therapeutic scheme for these cases -concomitant with the pregnant women -has been evidenced in several studies (9,(15)(16) , leading to the understanding that this protocol standard has not yet been fully assimilated, causing errors at the time of care and provoking inadequate treatments that reflect in the elevation of cases of congenital syphilis (20) .
Another recent problem is the national shortage of penicillin due to the lack of specific raw material for its production in the world market. In 2015, the MS regarding Treponema pallidum (23) .
It is emphasized that this situation results in Regarding the notification, although the significant increase of adequate responses after the intervention, the percentage of correct answers was considered low since it did not reach 30%. This is added to the difficulty in identifying gestational and congenital syphilis as notifiable diseases (13) and the incorporation of the notification of acquired syphilis to the work routines, fundamental for the disruption of the chain of transmission and control of the disease (21) . The search for the eradication of syphilis has been a great challenge for health professionals, health authorities and society at large over the years, and precisely for this reason this concept needs to be better addressed in health services (15) .
In addition, misconceptions about the correct treatment of syphilis according to staging of the disease (6,9,13) , as well as in conducting VDRL titration for control of the treatment, as well as recruitment of sexual partners for testing, counseling and appropriate treatment, point out that the de-structuring of the work process favors the occurrence of many missed opportunities for diagnosis and intervention that would enable the prevention of vertical transmission (4,7) .
In addition, the index of erroneous responses in this study to questions about the syndromic approach was 40%, a scenario also found in Rio de Janeiro-RJ when 47% of professionals reported having some difficulty in the practice of adequate syphilis management (7) .
Other studies conducted in Brazil (6,21) , in China (17) , in Switzerland (12) and in the United States of America (11) reinforced the same flaws and the reappearance of congenital syphilis today.
It is emphasized that vertical transmission causes serious consequences to these newborn infants, due to the failures in primary prevention (13)(14) , which have sequelae (largely irreversible), as well as prematurity (7,10) and put a burden on the health system (20)(21) .  In this study, evidence of underreporting is highlighted, when between 2007 and 2009 cases of congenital syphilis exceeded the cases detected in pregnant women. These data reflect the reality of the various states of Brazil (21) and from other countries such as Mongolia and South Africa (24) . However, there was an Due to the fact that it is a quasi-experimental study, it can be considered a methodological limitation the absence of a control and follow-up group. These options were consciously made, considering that all health professionals who attended syphilis diagnosis and management workshops adhered to the project and were closely monitored by regional health managers who provided support throughout the ongoing education process, which still continues. Other researches used the same method and concluded that skill development after training is statistically significant when compared to the control group and that skills are largely maintained six months after training (14,25) .

Conclusion
The educational intervention interfered in improving the early detection of gestational syphilis and led to a reduction in the vertical transmission rate, as well as may have contributed to eliminating syphilis-specific mortality in children under one year in 2014 and 2015.