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Revista da Sociedade Brasileira de Medicina Tropical

versão impressa ISSN 0037-8682versão On-line ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.52  Uberaba  2019  Epub 25-Abr-2019

http://dx.doi.org/10.1590/0037-8682-0026-2018 

Short Communication

Descriptive analysis of syphilis cases reported in Mato Grosso do Sul, Brazil identifies failure in treatment

José Victor Bortolotto Bampi1 

Maisa Estopa Correa1 

Graciela Mendonça dos Santos Bet1  2 

Silvana Beutinger Marchioro1 

Simone Simionatto1 
http://orcid.org/0000-0003-2367-0915

1Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, MS, Brasil.

22Hospital Universitário de Dourados, Universidade Federal da Grande Dourados, Dourados, MS, Brasil.


Abstract

INTRODUCTION:

Syphilis infection remains an alarming public health problem worldwide.

METHODS:

This study analyzed syphilis cases listed in the Information System on Diseases of Compulsory Declaration (SINAN) of Mato Grosso do Sul state in Brazil between January 2013 and December 2014.

RESULTS:

Most of the evaluated syphilis cases would have been preventable through public education, particularly congenital syphilis in children of previously diagnosed mothers and infection by untreated sexual partners.

CONCLUSIONS:

The incidence rate of syphilis could be reduced by improving prevention through counselling on the risk of infection, improving access to condoms, and increasing the frequency of diagnostic tests.

Keywords: Treponema pallidum; SINAN; Mato Grosso do Sul; Descriptive analysis; Syphilis

Syphilis, a chronic multistage disease caused by the spirochete Treponema pallidum subspecies pallidum, is usual transmitted by sexual contact or through the placenta during pregnancy1. Syphilis infection remains a serious public health problem worldwide, with a global prevalence of an estimated 36 million cases and an annual incidence of 12 million cases. According to the World Health Organization (WHO), pregnant women with active syphilis will suffer stillbirth or the neonates contract the infection or die in the perinatal period in half of these cases2. Syphilis is among the five most reported infectious diseases worldwide and is the most frequently reported sexually transmitted infection (STI) in Brazil. Sexually transmitted infections in the adult population are estimated at 937,000 cases per year, with a prevalence of 2.6% (range: 1.0% to 4.4%). Because gestational syphilis is often not treated properly, it is a major cause of stillbirth with approximately 2.65 million cases attributed to this disease every year3. The infection results in the formation of lesions that occur particularly in the genital area. Syphilis may also facilitate the transmission of human immunodeficiency virus (HIV) and appears to increase the risk of contracting HIV by up to 4 times4.

Brazil has reached an alarming transmission rate of syphilis in the susceptible population, with 21,382 cases in pregnant women and 13,705 cases in children <1 year of age reported in 2013 by the Information System on Diseases of Compulsory Declaration (SINAN), a public health notification system. In this report, the Midwest region had one of the highest syphilis rates in pregnant women in the country (8.5 cases in 1,000 live births)5 and within this region, the state of Mato Grosso do Sul had the most cases in 2015 (21.9 cases in 1,000 live births)2. Although cases of congenital, gestational, and acquired syphilis have been reported in Brazil since 1986, 2005, and 2010, respectively, few studies have evaluated these notifications in recent years. Therefore, the aim of this study was to describe the epidemiological profile of reported syphilis cases in the adult population of Mato Grosso do Sul state. The results of this study will support the implementation of public health strategies to control this infectious disease.

Mato Grosso do Sul is a state with 2.5 million inhabitants in the Western central region of Brazil that borders with Paraguay and Bolivia. The state has implemented 547 basic health facilities that serve 735,479 inhabitants. Data pertaining to syphilis notification documented between January 2013 and December 2014 in the SINAN of Mato Grosso do Sul was assessed in this retrospective, observational study. Variables collected included age, race, sex, level of education, treatment of patients and partners, serological tests and tests on the liquor (treponemic/non-treponemic), clinical classification, diagnosis of maternal syphilis, case evolution, and clinical manifestations such as changes in the long bones observed by radiology, osteochondritis, cutaneous lesions, jaundice, anemia, splenomegaly, hepatomegaly, and pseudoparalysis. Extracted data was transferred to Excel sheets (Microsoft, Redmond, WA, USA) and analyzed with the Statistical Analysis System (SAS) version 9.2 software (SAS Institute, Cary, NC, USA) using a simple frequency procedure of the reported syphilis cases. The incidence rate of acquired syphilis cases was calculated using population estimates reported for this period by the Fundação Instituto Brasileiro de Geografia e Estatística (IBGE).

In the study period, 2,207 cases of acquired syphilis, 1,497 cases of gestational syphilis and 417 cases of congenital syphilis were reported in the state of Mato Grosso do Sul. The incidence rate of acquired syphilis was 88 cases/100,000 inhabitants, representing 2.4% of all patients reported nationwide2. Of these patients, 36% were older than 40 years, 59% were men, 39% were of mixed race, and 45% were only educated up to primary school (Table 1). Unfortunately, certain clinical characteristics of these patients such as duration of treatment, sexual behavior, and socio-demographics, could not be evaluated because this information had not been provided with the notification.

TABLE 1: Demographic characteristics of patients with acquired syphilis reported between January 2013 and December 2014. 

Variables Cases %
Number of syphilis 2,207
Gender
Male 1,311 59
Female 895 40
Undefined 1 0.05
Race
White 574 26
Black 98 4
Asian 19 1
Mixed 851 39
Indigenous 34 1
Data missing 631 29
Age
≤19 214 9
20-29 688 31
30-39 481 22
≥40 806 36
Data missing 18 0.8
Schooling
Illiterate 23 1
Primary 990 45
Secondary 88 4
Data missing 1,106 50

Out of 1,497 patients with gestational syphilis, 48% were between 20 and 29 years old, 51% were of mixed race, and 71% had only completed primary education. The disease was diagnosed during the primary stage in 36% of these cases, followed by 22% in the tertiary stage and 11% in the latent stage. Nonetheless, only 71% of these patients were properly treated with 7.2 million IU of penicillin G and only 50% of the sexual partners received concurrent treatment (Table 2). Of the patients with congenital syphilis, 52% were boys, with most babies and their mothers being of mixed race (47%/62%). Treponemal and non-treponemal tests were conducted at birth in 37% and 77% of the newborns, respectively. Nonetheless, only 58% of infected newborns had a mother with a confirmed syphilis diagnosis. The most common clinical signs in newborns were jaundice (9%), anemia (3.6%), and changes in the long bones observed in radiological exams (2.64%). Less than 1% of these patients died from syphilis (Table 3).

TABLE 2: Demographic characteristics of patients with gestational syphilis reported between January 2013 and December 2014. 

Variables Cases %
Total cases 1,497
Race
White 470 31
Black 78 5
Asian 12 1
Mixed 775 51
Indigenous 101 6
Data missing 81 5
Age
≤19 401 26
20-29 733 48
30-39 345 22
≥40 37 2
Data missing 1 0.06
Schooling
Illiterate 17 1
Primary 1,083 71
Secondary 23 1
Data missing 394 26
Treponemic test reagent
Reagent 1,115 73
Unrealized 236 15
Data missing 166 12
Non-treponemic test
Reagent 1,163 77
Non-reagent 106 7
Not performed 172 11
Data missing 76 5
Clinical classification
Primary 518 34
Secondary 68 5
Tertiary 316 21
Latent 158 10
Data missing 457 30
Treatment
Penicillin G 2.400.000UI 289 19
Penicillin G 4.800.000UI 28 1
Penicillin G 7.200.000UI 1,054 70
Another antibiotic 20 1
Not treated 72 5
Data missing 54 4
Sexual partner treatment
Treated 756 50
Not treated 528 35
Data missing 233 15

TABLE 3: Demographic characteristics of patients with congenital syphilis reported between January 2013 and December 2014. 

Variables Cases %
Number 417
Gender
Male 218 52
Female 190 45
Undefined 9 2
Race Son/Mother
White 154/101 37/24
Black 7/17 1/4
Asian 1/0 0.2/0
Mixed 195/260 47/62
Indigenous 21/28 5/7
Data missing 39/11 9/2
Diagnosis of maternal syphilis 245 58
Treponemal confirmatory test at birth 156 37
Non-treponemal test at birth 328 77
Non-treponemal test Blood/Liquor
Reagent 295/8 71/1.9
Non-reagent 62/110 15/26
Not performed 39/231 9/55
Data missing 21/68 5/16
Clinical manifestations
Changes in long bones (radiological tests) 11 2.6
Osteochondritis 5 1.2
Cutaneous lesions 9 2.1
Jaundice 40 9
Anemia 15 3
Splenomegaly 5 1.2
Hepatomegaly 8 1.9
Pseudoparalysis 2 0.48
Case evolution
Alive 355 85
Death by syphilis 4 0.96
Death by another cause 6 1.4
Abortion 4 0.96
Stillborn 13 3
Data missing 35 8

The “great imitator” syphilis is still a serious concern for the sexually active population in the Midwest region of Brazil. In this retrospective, observational study, data from 2,207 adult patients with acquired syphilis, 1,497 women with gestational syphilis, and 417 children with congenital syphilis were collected. Our study showed an increase in gestational syphilis by 1,265 cases in the assessed region within the last decade6. A similar increase has been reported for other states but Mato Grosso do Sul had the highest incidence rate (16.7 cases/1,000 live births).2

Although the guidelines from the Brazilian Ministry of Health recommend a medical follow-up of the sexual partners of STI patients of the preceding 3 months7, half of the partners of pregnant women with syphilis were not treated according to our findings. This could potentially result in re-infections and additional cases of latent syphilis and demonstrates the inadequacy of public health programs. Furthermore, 58% of mothers whose sons were born with congenital syphilis had been diagnosed with gestational syphilis. This may indicate either a lack of appropriate treatment of the mother or a failure of the employed treatment regimen and the prenatal follow-up. In addition, social and behavioral risk factors may be associated with gestational syphilis and therefore more studies are needed to identify the reasons for the failure to control syphilis in pregnant women.

There is clear evidence that intra-uterine transmission to children and the ensuing adverse outcomes could be avoided by simple and cheap interventions performed by any physician at a primary care clinic8,9. Furthermore, 90% of the treated mothers received penicillin G, thereby decreasing the chance of adverse outcomes for the fetus. Our results also revealed that patients with acquired and gestational syphilis (45% and 71% respectively) had a low level of education which has been linked to unprotected sexual practices in previous studies10,11. Of note, teenagers tend to have the first sexual experience during the years at primary school12, indicating the need for sexual education in primary school. These observations are corroborated by similar reports on low educational levels and required treatment of sexual partners among syphilis patients in Olinda (Pernambuco state)13, Belo Horizonte (Minas Gerais state)14, and Sumaré (São Paulo state)15. Preventive interventions and sexual education on potential risks of transmission associated with sexual practices would encourage this population to practice safer sexual behaviors.

We assessed syphilis notifications of 2 years only which prevented statistical analysis of the data obtained in this study. Despite this, data on patients with acquired syphilis missing in the SINAN files such as serological tests and socio-demographic characteristics could be identified. The results of our study highlight the shortcomings of the basic health system and point to a substantial revision of practices to manage and prevent syphilis and other STIs. These may include counseling for risk reduction, increased access to condoms, and frequent testing for syphilis, particularly targeting socioeconomic groups that are at higher risk.

In conclusion, this study revealed a substantial increase in new syphilis cases in this part of Brazil. Furthermore, our results demonstrate that most cases of congenital syphilis could be avoided by effective treatment of the pregnant mother and her partner. Thus, public health strategies to prevent and manage syphilis infections need to be reviewed and improved.

Ethical Considerations

This study was approved by the research ethics committee of the Universidade Federal da Grande Dourados, Dourados, MS (Study number 1.372.627).

Acknowledgements

We are grateful to the Department of Health of Mato Grosso do Sul and the administrators of SINAN for their cooperation in providing the data.

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Financial Support: This work was partially supported by the National Council for Scientific and Technological Development (CNPq grant 440245/2018-4), Fundação de Apoio ao Desenvolvimento do Ensino, Ciência e Tecnologia do Estado de Mato Grosso do Sul (FUNDECT grants 092/2015 and 041/2017), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, grant 001) and Universidade Federal da Grande Dourados (UFGD). M.E.C. received a scholarship from FUNDECT and J.V.B.B. from the CNPq. The funding agencies had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Recebido: 09 de Fevereiro de 2018; Aceito: 29 de Novembro de 2018

Corresponding author: Simone Simionatto. E-mail:simonesimionatto@ufgd.edu.br

Conflict of Interest: There were no conflicts of interest.

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