ARTICLE
Analysis of congenital syphilis cases notification in a reference hospital of Niterói, Rio de Janeiro State, from 2008 to 2015

INTRODUCTION

Congenital syphilis (CS) is an important potentially avoidable cause of fetal death and other adverse perinatal consequences. Its incidence is especially higher in the less developed regions of the world^(1,2,3).

It is a sexually transmitted infection caused by the Treponema pallidum bacterium, and can be vertically transmitted from mother to fetus during pregnancy⁽⁴⁾. Syphilis is asymptomatic in many women, and screening pregnant women is essential⁽⁵⁾.

Since penicillin was introduced for clinical use in 1943, the number of cases was progressively reduced, reaching not worth considering levels. However, a resurgence of the disease was observed during the last years, not only in under developing countries, but also in the developed ones⁽⁶⁾. Pregnant women are more often infected with syphilis than with HIV⁽⁷⁾.

The Pan American Health Organization (PAHO) estimates that, every year, approximately 300,000 pregnant women with syphilis in Latin America received no treatment for this disease during prenatal period, and two-thirds of cases in pregnant women result from CS⁽⁸⁾.

Early diagnosis and accurate syphilis treatment of pregnant women and their partners are simple and effective measures in order to prevent CS^(9,10). However, a series of social, political, economic and individual factors can make difficult for these population to access these measures, which contributes to the incidence of cases in the more vulnerable one⁽¹⁰⁾.

For the purpose of epidemiological surveillance and banishment of CS in Brazil, the disease became a compulsory notification through the federal government Instruction 542 of December 22, 1986⁽⁷⁾. Obligatory notification and investigation include all detected cases, involving stillborn and miscarriage caused by syphilis. However, such notifications are still below the national reality⁽¹¹⁾.

OBJECTIVE

Analyze the notification reports of CS and quantify the number of cases in Hospital Universitário Antônio Pedro (HUAP) of Universidade Federal Fluminense, located in the municipality of Niterói, in the state of Rio de Janeiro.

METHODS

This is a temporal retrospective study on the frequency of CS notifications in newborns assisted at HUAP maternity, located in Niterói, Rio de Janeiro, from 2008 to 2015, with about 4,000 deliveries.

A data survey was carried out on 56 filed Compulsory Notification of Infection Diseases of the Notification Information System (Sistema de Informação de Agravos de Notificação – SINAN) during the period mentioned.

The following variables were analyzed: gender of the neonate; maternal age; prenatal location; time of syphilis diagnosis in pregnant women; neonate and mother non-treponemal tests results; treatment of the mother, the partner and the neonate; radiological changes in the long bones’ tests; signs and symptoms; and place of birth of the newborn.

A database in Epi Info software was developed for the registration and the analysis of the information collected in the Notification reports.

The present study has been approved by the Ethics and Research Committee of the Universidade Federal Fluminense.

RESULTS

Four notifications were excluded from the total of 56 (4/56/7,14%) due to the lack of relevant information in the variables analyzed, such as partner treatment, evolution of the case, maternal and neonate non-treponemal test result, long bone X-rays result and presence of signs and symptoms. All reports were available in the Epidemiological Surveillance Department of HUAP, although these files did not contain enough information for the analysis of the problem.

The study considered 52 reports from 2008 to 2015, after the exclusion of 4 Notifications of SINAN.

Only 9 notifications (9/52/17.37%) were completely filled out; the items “education” and “mother’s occupation” were not informed in the remaining reports.

A reduction in the number of notifications from 2008 to 2012 (8 cases reduced to 1, 0 reported cases in 2011) was observed, despite coinciding with a period of increase in births’ number at the Hospital Universitário (389 deliveries in 2008 and 521 in 2012), followed by an increase of notifications from 2013 (9 cases). The largest number of reported cases occurred in 2014 (26.9%: 14); however, there is a gradual reduction in births in the period (640 births in 2013, 522 in 2014, and 422 in 2015) (Table 1).

Table 1

Number of deliveries x cases per year (2008 to 2015).

*HUAP: Hospital Universitário Antônio Pedro.

Concerning maternal data: age ranged from 14 to 40 years old, 6 pregnant women (11.5%) were between 14 and 18 years old, 25 (48.1%) were between 19 and 25 years (34.6%), 18 were between 26 and 40 years, and 3 of them had (5.8%) unknown age. With regard to prenatal care, 10 pregnant women (19.2%) were assisted in HUAP, 34 (65.4%) were treated at other health units, and 8 (15.4%) were not assisted. The diagnosis of maternal syphilis occurred during the prenatal period in 37 (71.0%) cases, during childbirth in 12 (23.0%) cases and after delivery in 3 ones (6.0%).

The result of the non-treponemal testing of pregnant women during childbirth was reagent in 46 cases (88.4%), non-reagent in 2 (4.0%) and ignored in 4 (7.6%). As for treatment, 28 pregnant women (53.8%) were correctly treated and 24 (46.2%) were inappropriately treated (Table 2).

Table 2

Epidemiologic analysis of maternal data.

HUAP: Hospital Universitário Antônio Pedro; VDRL: Venereal Disease Research Laboratory.

Regarding the partner treatment, it was observed that 11 of them (21.1%) were treated and 41 (78.9%) of them were not (Table 3).

Table 3

Comparative analysis of data across prenatal locations.

HUAP: Hospital Universitário Antônio Pedro.

Concerning the data of newborns: it was noted that 26 (50.0%) of them were male and 26 (50.0%) were female, 42 (80.8%) were born in HUAP and 10 (19.2%) in other health units. As for the result of the non-treponemal test, it was reagent in 43 newborns (82.5%), non-reagent in 6 (11.5%), and 3 (6.0%) of them were not tested. Three (5.8%) neonates did not receive treatment (due to miscarriages and stillbirths), 1 (1.9%) unknown information, 48 (92.3%) were treated properly, and 44 (91.7%) of these used crystalline penicillin and 4 (8.3%) penicillin G procaine; penicillin G benzathine was not used in any neonate (Table 4). After verifying the presence of signs and symptoms, it was observed that 36 newborns (69.5%) were asymptomatic, 7 (13.4%) manifested icterus and 3 (5.7%) osteochondrosis, 2 (3.8%) of them had skin lesions, 2 (3.8%) had splenomegaly, 1 (1.9%) of them had anemia, and 1 (1.9%) of them had bloody mucus rhinitis. Regarding long bone X-rays, 5 new-borns (9.6%) showed changes, 36 (69.0%) did not show alterations, 4 (8.0%) were not submitted to X-rays, and results were unknown for 7 (13.4%) of them (Table 5).

Table 4

Epidemiologic analysis of neonate data.

HUAP: Hospital Universitário Antônio Pedro; VDRL: Venereal Disease Research Laboratory.

Table 5

Analysis of neonates’ signs and symptoms.

In relation to the evolution of cases, 46 newborns (88.5%) remained alive, 3 (5.8%) were stillborn, 2 (3.8%) evolved to death, and 1 (1.9%) resulted in abortion due to the disease in question.

DISCUSSION

In Brazil, from 1998 to 2014, 104,853 cases of CS in children under one year of age were notified to SINAN, most of them located in the Southeast and Northeast. There has been a progressive increase in the incidence rate of the disease in the last 10 years: in 2004 the infection rate was of 1.7 case for every 1,000 live births. In 2013, this rate reached 4.7 cases, i.e., an increase in 100% ⁽¹²⁾.

The present study also observed a growth of the notification cases in the last years, but it could not determine the reason of the reduction of cases notified from 2008 to 2012, which shows rates of 0.00% (2011) and 0.19% (2012). This fact does not match the reality of the city of Niterói, since there were cases of morbidity reductions in the studied years. The numbers concerning HUAP represent 9.0% of the total reported cases for that city.

The increasing number of these notifications does not occur only in Brazil, but all over the world, since syphilis affects 12 million people annually, and 90.0% of these new adult cases occur in developing countries. In Brazil, we estimate that the prevalence of syphilis in pregnant women varies between 1.4 and 2.8%, with a vertical transmission rate of 25.0%⁽¹³⁾.

Since the consequences of CS are extremely serious, such as miscarriage, stillbirth, premature birth, low weight, blindness, deafness, mental retardation, hydrocephalus, the adequate prenatal care is of vital importance to the early diagnosis of maternal syphilis and its proper treatment^{(4,11,12,13,14,15)}.

The present study also observed that, although most mothers have received prenatal care, this treatment was not considered fully effective, since the disease and many of its serious consequences were diagnosed, though not avoided. It should be noted that most of these pregnant women are from the city of Niterói, which has a Human Development Index (HDI) of 0.837 — the highest HDI in the state of Rio de Janeiro —, and a Family Health Strategy (FHS) that ranged from 25.8 to 26.1% of the population involved, in 2008 and 2014, respectively^(16,17).

The Centers for Disease Control and Prevention (CDCP) of the United States of America recommends serological screening in early pregnancy. In populations in which the prevalence of syphilis is high or in high-risk patients, screening should be repeated in the third quarter and at the time of delivery.^(14,18,19) According to the Ministry of Health of Brazil, screening should be carried out in the first prenatal appointment, preferentially in the first trimester of pregnancy, in the beginning of the third trimester (28 weeks) and at the time of delivery, regardless of previous examinations’ results^(20,21). In some populations, syphilis detection at the time of delivery is quite common, especially if the woman was not properly assisted during the prenatal period^(14,18,19). In cases studied in HUAP, 23.0% (12 cases) of diagnosis at the time of delivery were observed, showing the need for an improvement in the monitoring of pregnant women, since 50.0% of them (6 pregnant women) were not assisted during prenatal care in HUAP and 50.0% (6 pregnant women) did not receive prenatal care.

The effectiveness of treatment and the manifestations of CS are dependent on many variables, including maternal syphilis stage, gestational age at time of infection, fetal infection severity (degree of maternal spirocheatemia), adequacy and timing of maternal treatment and fetal immune response⁽²²⁾.

The therapeutic failure is usually associated with the use of inadequate doses of penicillin to the clinical stage, when treatment is done in the later stages of pregnancy, with the disuse of penicillin or when the partner is not treated, and pregnant women is considered inappropriately treated^(5,18).

The present study evidences therapeutic failure, since most partners did not receive any treatment (41/52/78.9%) and a relevant amount of pregnant women were inadequately treated (24/52/46.2%), including those held in prenatal HUAP. It is essential that pregnant women with syphilis are orientated regarding the illness and its serious consequences, and the importance of an adequate treatment. It is also of utmost importance the inclusion of the partner’s treatment, once that despite the correct treatment of women during pregnancy, they may suffer reinfection and then perpetuate the risk of new cases of CS⁽¹⁵⁾.

The study showed another very serious character affecting a significant portion of the population of the metropolitan region II of Niterói, which covers the cities of Niterói, Itaboraí, Maricá, Rio Bonito, São Gonçalo, Silva Jardim, and Tanguá: the occurrence of a disturbing rate (11.5%) of the worst outcomes caused by the disease — abortion, stillbirths and neonatal death. During this period the occurrence of 40 cases of miscarriage and 29 stillbirths by the disease was observed in Niterói⁽²³⁾. These cases and their mentioned consequences, reported in HUAP, correspond to 2.5 and 10.3%, respectively, of cases occurred throughout the municipality.

CONCLUSION

The notification and the completion of the records need to be improved, as only a few forms were completely filled out and some did not contain enough data for a minimal analysis. An adequate completion is fundamental to identify gaps in the monitoring of pregnant women and their partners, aiming to reduce the incidence of the disease.

It is also possible to verify that prenatal of pregnant women in the region assisted by HUAP has to be analyzed, as a considerable number of these women were diagnosed with maternal syphilis during the prenatal period and the Congenital Syphilis (CS) and its consequences were not avoided. Such data is extremely alarming and shows the need for improvements in maternal health care.

It is necessary that all hospital teams become aware of the relevance of this assistance in order to create more accurate mechanisms to control the CS notifications, and carry out specific training for the involved people, such as doctors and nurses. The use of the information derived from the surveillance can benefit and help the actions of health care programs and improve the rate of CS.