Congenital and maternal syphilis in the capital of Brazil

Introduction: This study aimed to describe the epidemiology of congenital and maternal syphilis in the Brazilian Federal District in 2010. Methods: A retrospective descriptive study was conducted on the basis of the cases recorded in the System of Notifi able Disease Information. Results: The study population comprised 133 cases of congenital syphilis; of these, 116 (52.6%) mothers received prenatal care, and 70 (60.4%) were diagnosed with syphilis during pregnancy. Only 1 mother was adequately treated, and 100 (75.2%) of the pregnant women’s partners did not undergo treatment for syphilis. Conclusions: Although mothers attended prenatal care, not all were diagnosed during pregnancy or received adequate treatment for syphilis, as their partners did not undergo treatment for syphilis.

In developing nations, maternal syphilis and, consequently, congenital syphilis continue to be a public health problem, affecting approximately 10-15% of pregnant women (1) .
In the Federal District (DF), which is one of the 27 units of the Federative Republic of Brazil, the number of cases and detection coeffi cients continued to increase between the years of 2007 (n=70; detection coeffi cient = 1.6/1,000) and 2009 (n=117; detection coeffi cient = 2.6/1,000), despite surveillance and disease control measures (3) .
The aim of this study was to describe the epidemiological characteristics of congenital and maternal syphilis cases diagnosed in the DF in 2010.
In this retrospective, observational study, data from 137 of children and their mothers with syphilis were collected from the System of Notifi able Disease Information of the Federal District (Sistema de Informação de Agravos de Notifi cação/ Distrito Federal -SINAN/DF) and the Live Birth Information System (Sistema de Informações de Nascidos Vivos -SINASC) between October 2013 and March 2014.The study area is located in the Midwestern region of Brazil that has an area of 5.779,999km², a demographic density of 444.07 individuals per km 2 , and a population of 2,570,160 (4) inhabitants.The Federal District has 15 Regional Health Units and 106 establishments of Public Health (5) .
Collected variables included the federated unit of residence, child's sex, clinical manifestations of syphilis in newborns (jaundice, anemia, splenomegaly, osteochondritis, mucus bloody rhinitis, hepatomegaly, skin lesions, and pseudoparalysis), age, race, and diagnostic features of mother and child; treatment information (adequate, inadequate) for the mother, child, and partner; mother's occupation and educational level; and prenatal care.The neonatal treatment was evaluated by comparing the regimen registered in the SINAN/DF to the recommended regimen for congenital syphilis from the Ministry of Health of Brazil (MoH).For this analysis, stillbirths, abortions, and deaths were excluded, representing 119 neonates.Age was calculated in days by subtracting the date of the neonate from the date of diagnosis.Stillbirths and deaths were also excluded for Nontreponemal tests analysis, totalizing 124 cases.
To calculate the congenital syphilis detection rate among infants under 1 year of age in the DF, the following formula was used (2) : number of children less than 1 year of age diagnosed with congenital syphilis while living in the DF and recorded in the SINAN/DF in 2010/number of live births registered in the SINASC in 2010 while living in the DF × 1,000.The coeffi cient of specifi c mortality from congenital syphilis was calculated using the following formula (2) : number of deaths and stillbirths due to congenital syphilis registered in the SINAN/DF in 2010/number of live births registered in the SINASC in 2010 while living in the DF × 1,000.The software package Epi Info TM 7.1.5(https://www.cdc.gov/epiinfo/html/downloads.htm)was used for data processing and analysis, and data tables were constructed in Microsoft® Excel 2010 (Microsoft Corp, Redmond, WA, USA).A total of 137 children with congenital syphilis were reported in 2010; 4 of these patients had inconsistents records, and they were excluded, resulting in 133 children.The congenital syphilis detection rate among DF residents was 2.0/1,000 live births, and the coeffi cient of specifi c mortality from congenital syphilis was 0.1 deaths/1,000 live births.
Characteristics of the maternal syphilis cases, including sex, skin color, age, diagnosis, and treatment are shown in Table 2. Of the 133 mothers of children with congenital syphilis, the highest rates (per 1,000 live births) were observed in mothers who were black skinned (11.3/1,000 live births) or ≥40 years old (4.0/1,000 live births).Most of the mothers had less than 9 years of education (28.6%, n=38), and the majority (54.9%, n=73) were homemakers.Prenatal consultations occurred in 87.2% (n=116) of the mothers, and 52.6% (n=70) received confi rmed diagnoses in the prenatal period.Another 12.8% (n=17) did not undergo diagnostic tests, or the information was ignored even if they had undergone prenatal consultations.Treatment was inadequate for 88% of the mothers (n=117), and 75.2% (n=100) of their partners had not received treatment.
The coefficient of specific mortality from congenital syphilis, which was lower in the DF than in other states in Brazil (2) , might suggest underreporting.
Similar to other studies, child and maternal factors that are considered to increase the risk and vulnerability for congenital syphilis, such as black or brown skin color, low socioeconomic status, and maternal age between 20 and 30 years (6) , were observed in the present study (6) (7) (8) .Greater efforts should be undertaken to minimize inequalities for these vulnerable populations through strategies that enable greater access to health services.
Clinical manifestations in newborns are usually delayed, potentially occurring months or years later (9) .The high frequency of asymptomatic cases at birth in the present study supports the use of a surveillance system to identify more cases based on laboratory results.Furthermore, not all of the cases that were identifi ed were treated in accordance with the MoH recommendations for the treatment of newborns with congenital syphilis (1) .The therapeutic regimens for newborns depend on the clinical, laboratory, and radiographic fi ndings and range from a single application to up to 10 daily doses of penicillin (1) (8) .

Rev Soc Bras Med Trop 48(2):216-219, Mar-Apr, 2015
The MoH recommends a minimum of six prenatal care consultations (10) .In the present study, prenatal assistance was provided to most of the mothers, at a similar frequency to other studies (6) (7) .However, this fact did not ensure early maternal diagnosis, ensure adequate treatment of the pregnant women and their partners, or prevent abortions, deaths, and stillbirths caused by congenital syphilis.The incidence of syphilis is considered an important indicator of the quality and accessibility of prenatal care (9) (10) (11) Several studies have examined factors affecting the quality of prenatal assistance (9) (12) (13) like access of health care service.These factors should be monitored, with appropriate interventions to prevent congenital syphilis.
Early maternal diagnosis remains the most effective strategy to prevent congenital syphilis (14) , because transplacental transmission of Treponema pallidum can be prevented more effectively.Serological tests remain the method of choice for maternal diagnosis (2) (10) , and prenatal visits provide the perfect opportunity to conduct these tests.We observed a high proportion of positive nontreponemal tests during delivery, which suggests that the health care system in the DF is following the recommendation to perform rapid tests for maternal syphilis during labor.Nevertheless, it is necessary to improve the system for syphilis diagnosis during prenatal care for pregnant women and their sexual partners.Treatment that begins at the end of pregnancy doesn´t allow enough time to cease treatment in the required time to prevent vertical transmission to the newborn, fetal death, and prematurity (15) .
In addition, the proportion of inadequately treated mothers was higher in the present study than in previous studies (6) (14) , and more than 90% of the partners in our study were inadequately treated, untreated, or the information was ignored.When partners are left untreated or are inadequately treated, the risk of vertical transmission increases as a consequence of the re exposure of pregnant women to the infectious agent (15) .In our country, the partner's visit to the Health Unit depends on the pregnant woman; therefore, it is necessary for the mother to be properly educated regarding the importance of treatment.As the mothers were also inadequately treated, it is assumed that the information provided and prenatal approach were insuffi cient to sensitize the mothers, which could hardly be expected to sensitize their partners.A more active approach is expected from health services in the education of partners because relying exclusively on one member of the couple can undermine prevention strategies.
Limitations of the study include its descriptive design and the lack of comparison groups; therefore, analysis of potential causal relationships between the risk factors and outcomes could not be conducted.It is also possible that cases are underreported to the surveillance system.Restricting the sample to the DF also limits the ability to generalize the results.
Efforts must be undertaken by public health authorities to improve the quality of prenatal care, including the allocation of suffi cient human resources and investment in training and continuing education for the counseling of pregnant women and their partners.The infrastructure and service organizations should also be reassessed.Several sectors are responsible for

Muricy
CL and Pinto Júnior VL -Congenital and maternal syphilis in the capital of Brazil