In spite been discovered centuries ago, syphilis remains a sexually transmitted infectious disease of major public health impact given the high prevalence found in Brazil and worldwide. The laboratory detection, with subsequent treatment of this disease, can reduce vertical contamination rates among adults and reduce sequelae from its clinical manifestations.
To determine the prevalence of syphilis, as well the gestational and congenital forms of syphilis, and associated factors among patients attending the laboratory of Health Foundation of Vitória da Conquista (FSVC).
A retrospective cross-sectional study, using secondary data obtained from the system of notification for syphilis, from FSVC laboratory from July 2012 to July 2013, following the ordinance criteria nº 3242 of 2011.
134 patients were identified with positive diagnostic tests for syphilis among the 6,699 patients that were tested, revealing a global prevalence of 2%. The prevalence of congenital syphilis was 2.84 and 2.24% for gestational syphilis. It stands out among the positive ones that 19.4% of the patients were aged less or equal to one year old, 37.3% were pregnant women and the vast majority (94%) of them lived in urban areas. 47% of the patients had venereal disease research laboratory (VDRL) titers up to 1:4. Among those patients with primary positive test, 94% got positive results from the confirmatory test. Between newborns that tested positive for syphilis, 60% had titers up to 1:2.
The prevalence rates are high considering the parameters established by World Health Organization (WHO) and are capable of representing burden for the population. However, they point out good chances of screening the county from the disease, which is an essential step in addressing this serious infection to the Public Health.
A sífilis continua sendo uma doença infecciosa sexualmente transmissível de grande impacto para a Saúde Pública, dadas as elevadas prevalências encontradas no Brasil e no mundo, apesar de ter sido descoberta há séculos. Sua detecção laboratorial, com posterior tratamento, pode reduzir as taxas de contaminação vertical entre adultos, além de reduzir sequelas de suas manifestações clínicas.
Determinar a prevalência de sífilis, incluindo as formas gestacional e congênita, e fatores associados em pacientes atendidos no laboratório da Fundação de Saúde de Vitória da Conquista (FSVC).
Estudo de corte transversal retrospectivo realizado com dados secundários obtidos do sistema de laudos e norteado pela planilha de notificação para sífilis do laboratório da FSVC no período de julho de 2012 a julho de 2013, obedecendo aos critérios da Portaria nº 3.242, de 2011.
Foram identificados 134 pacientes com provas diagnósticas positivas para sífilis entre 6.699 pacientes testados, revelando uma prevalência global de 2%. A prevalência da sífilis congênita foi de 2,84% e a de sífilis gestacional de 2,24%. Destaca-se entre os positivos que 19,4% dos pacientes tinham idade igual ou inferior a um ano, 37,3% eram gestantes, 94% residiam na zona urbana e 47% tinham títulos de (VDRL) de até 1:4. Desses pacientes com teste primário positivo, 94% tiveram positividade no teste confirmatório. Entre recém-nascidos positivos, 60% tinham títulos de até 1:2.
As prevalências encontradas estão elevadas levando em consideração os parâmetros estabelecidos pela Organização Mundial da Saúde (OMS) e são capazes de representar ônus para população. No entanto, apontam boa capacidade de triagem do município frente a doença, o que é um passo essencial para a Saúde Pública combater esta grave infecção.
Syphilis is a sexually transmitted infectious disease of major impact on public health. According to the World Health Organization (WHO), in 1999, it was estimated 12 million new cases in the world, with the highest incidence seen in developing countries1. In Brazil, WHO estimates already indicated, in 1999, more than 937,000 cases of syphilis per year1. However, since that became a reportable disease (for cases of congenital syphilis in 1986, gestational syphilis from 2005 and acquired syphilis from 2011) until 2012 there were more than 137,000 cases2. In Bahia, according to the Superintendência de Vigilância e Proteção da Saúde (SUVISA - Office of Surveillance and Health Protection), from 2007 to 2013, there were more than 7,000 cases of syphilis, in which the city of Vitória da Conquista appears with 476 cases3.
The etiologic agent of syphilis is a bacterium called
The natural course of infection may be symptomatic divided into three stages: primary, secondary and tertiary syphilis; and two asymptomatic phases: the early and late latent syphilis. Clinical manifestations occur depending on the stage of the disease6.
Syphilis in pregnant women can lead to the vertical transmission of the disease at any time during pregnancy, especially when the infection is recent, since
There is a worldwide concern about the control of syphilis, especially in adults. In 2008, WHO drew a target aiming at the eradication of congenital syphilis by the year 2015 and proposed the expansion of access to maternal and child health services, increased detection, treatment and control of the disease, as well as the implementation prevention and counseling activities. Another plan was the reduction of prevalence rates of the disease to levels below 1%, which, according to WHO, does not represent a burden for the population8.
The acquired form of syphilis occurs primarily in adults and may lead to the tertiary stage of the disease. A person may be evolving symptomatic of the primary phase to tertiary or can be asymptomatic carriers of the infection and, after several years developing cardiovascular syphilis, neurosyphilis, among other complications9.
The diagnosis of syphilis can be performed easily, following recommendations of the Administrative Rule nº 3,242 of the Brazilian Ministry of Health, from December 2011, which established the laboratory flowchart for the diagnosis of syphilis10.
Whatever the methodology, the early diagnosis of syphilis can contribute to the reduction of injuries related to the clinical manifestations of the untreated disease, since the treatment is easily accessible and has low cost. Moreover, it can also break the chain of transmission of the disease.
To determine the prevalence of syphilis, including the gestational and the congenital forms, and associated factors in patients treated in the laboratory of the Fundação de Saúde de Vitória da Conquista (FSVC - Vitória da Conquista's Health Foundation).
This is a retrospective study of secondary data obtained from the notification system for FSVC Lab syphilis from July 2012 to July 2013.
The FSVC currently manages the largest public health laboratory of the interior of Bahia and figure as the major test maker of the Sistema Único de Saúde (SUS - Unified Health System) in the city and region serving both the needs of patients admitted to the Municipal Hospital of the city of Esaú Matos (maternal and child regional reference) as the patients of the ambulatory net of Vitória da Conquista and region with an average of 55 thousand tests per month. According to the Vitória da Conquista' scheduling system, the laboratory of FSVC is responsible for supplying about 85% of the exams through the city by SUS.
The laboratory of FSVC performs the diagnosis starting from the non treponemal test - venereal disease research laboratory (VDRL) for screening, following with treponemic immunoassay (IC) in case of reagent in any capacity in the screening test. When there is disagreement between the results of the two methods the samples are forwarded to the Care and Life Support Center (CAAV), in that city, where hemagglutination is the methodology of choice for confirmation of results by the
Data collection was done in the period between 05 and 15 September 2013, from the verification of positive cases for syphilis indicated in the notification sheet. Then proceeded to access the registration form of the patients with the laboratory report system of FSVC (COMPLAB(r), version 6.9.4) in order to obtain information such as age, sex, pregnancy state and county of origin.
For the purpose of calculation of prevalence of congenital and gestational syphilis it was necessary to obtain, by Serviço de Arquivo Médico Estatístico (SAME - Statistical Medical File Service) of FSVC, data on the number of live births and the number of pregnant women attended by the Health Foundation Hospital of Vitória da Conquista - reference in maternal and child care and conducting the highest number of deliveries by SUS in Vitória da Conquista and region.
The data were transported to Microsoft Office Excel 2007 spreadsheet and then analyzed using the statistical package
The data collection was initiated only after signing a confidentiality agreement by researchers delivered to the Teaching and Research of FSVC and after approval by the Research Ethics Committee of the Multidisciplinary Institute of Health (CEP/IMS-CAT) under the nº 442 012, on August 30, 2013 (CAAE: 20541813.3.0000.5556).
Among the 6,699 patients who were tested for syphilis in the laboratory of FSVC from July 2012 to July 2013, 134 were classified as positive, taking into account the Administrative Rule nº 3242, from 2011, resulting in a prevalence of syphilis of 2%. Of these, the majority, 25.39% (n = 34), were aged between 20 and 29 years. He drew attention to the presence of 19.4% (n = 26) of individuals aged less than one year, and its absolute majority represented by newborns (n = 25). Regarding the distribution by gender, 65.7% (n = 88) were female, and 50 of them were pregnant at the time of diagnosis, and 15.7% (n = 21), male. Most individuals studied 94% (n = 126) were from the urban area of Vitória da Conquista.
In relation to gestational syphilis and congenital syphilis, prevalence rates were, respectively, 2.24 and 2.84%.
Aunspecified sex newborn.
aunspecified sex newborn; VDRL: venereal disease research laboratory
Among pregnant women involved in the study, there was a more heterogeneous distribution with respect to VDRL titers; however, the majority of 60% (n = 30) showed a title of 1:4.
It was found in this study that all the cases of positive VDRL were subjected to confirmation.
atwo individuals that should be tested and were not; bone individual that should be tested and was not; cone individual that should not be tested; VDRL: venereal disease research laboratory; IC: immunochromatography; TPHA:
In this study, there was a prevalence of 2% for syphilis among patients tested by the laboratory of FSVC. Similar studies with representative samples are still not found in the country, to the point that systematic survey conducted in November 2013 using the bases of PubMed, SciELO and MEDLINE not found any similar study. Probably the fact that the notification of acquired syphilis cases only became mandatory from of Administrative Rule nº 104, from January 2011. However, comparing the prevalence of this study with studies in restricted population groups, it was found that it was smaller. In a study of women from 12 to 63 years in the state of Alagoas, Brazil, there was a prevalence of 2.6%11, and others held with adults in a university hospital in Rio de Janeiro, Brazil, there was a prevalence of 2.7%12.
For gestational syphilis the prevalence was 2.24% and is, therefore, higher than the values found in studies such as the Sentinel-blind study in 200613, who found 1.1% - a monitoring study of rates prevalence of syphilis in pregnant women in Brazil. It was also higher than the ones found in studies by Guimaraes and Roberts14, Codes
At first sight, it is important to note that the prevalence found in this study are concerning, taking into account the goals set by the WHO to combat and eradicate syphilis in the world and when compared to others prevalences already found in other studies. In further analysis these prevalence values may perhaps be justified in part by the fact that the laboratory of FSVC attends almost all of the municipal SUS demand, including a public hospital in maternal and child reference. The literature points out that low socioeconomic status brings numerous risk factors for infection with
The literature has shown that one of the major problems for the purposes of diseases prevalence calculations lies in the underreporting23. The present study has as one of its strengths information assurance of all positives for syphilis because, since July 2012, the laboratory of FSVC has been performing the notification of all diagnosed cases of syphilis and its main goal is the generation of indicators able to develop policies that aim at the reduction of syphilis cases in the city.
In this study, it was important the fact that the vast majority of the population was living in the city of the municipality, consistent with study in Sobral (CE), Brazil, from 2006 to 201024. Regarding the stratification of patients by age, there was a wide distribution between the groups, revealing an agreement with studies that showed higher prevalence in groups of 20 to 29 years old24,25,26. Another important fact is that over 50% of patients with positive results were pregnant women or newborns. In pregnant women the infection with
The laboratory screening for syphilis has low cost28 and does not require sophisticated or widely-equipped laboratories. Depends primarily on the existence of a health network well-structured and imbued in reducing the prevalence of this disease. The laboratory of FSVC screened in a year 6,699 individuals for syphilis, including pregnant women, newborns and individuals in the general population. This number represents the screening of about 3% of the population assisted by the SUS in the city, which shows an enlargement of the service to population, contributing to the reduction of cases of syphilis and perhaps it is why the prevalence rates are higher when compared to the previous studies and the ones that did not meet the requirements of the Administrative Rule nº 3242, of 2011.
Still, it is essential to continue the surveillance of disease and seek to broaden the actions in the diagnosis and treatment in order to see fewer cases, which will help to reduce the prevalence to levels that can not pose a burden for the population (below 1%)29.
When analyzing the results of confirmatory tests for syphilis in patients with positive VDRL it was observed that in a few cases there had differences between screening and confirmatory test, which could probably be justified in the first instance, by another disease, not syphilis, but which manages production of antiphospholipid antibodies as the VDRL test is not specific and can be present in the reagent of autoimmune diseases, viral, bacterial or parasitic infections30. In these cases, the TPHA test performed proved consistent with the initial treponemal, which determines the used tests have good sensitivity and specificity and may be part of the laboratory tests31.
Although the literature says that only observing the VDRL it can be classified as congenital syphilis when the baby bonds are greater or equal to the mother32, it is important to note that most newborns treated at FSVC with positive VDRL have lower titles to the mother, which does not exclude the diagnosis of congenital syphilis. In addition, performing treponemic test in these individuals there was a confirmation of positivity, which can be justified by two situations: either in fact be congenital syphilis, or represent the presence of mother's passive antibodies that have experienced treatment for syphilis33; in these cases, appropriate classification should be performed using antitreponemics IgM tests.
It must be considered in the present study a limitation, which is the fact that it was not made as a survey with proportional population calculating interest groups, such as pregnant women, newborns and the general population, coupled to an interview with several socioeconomic, lifestyle, health condition variables, with which it would be possible to do further analysis. Moreover, the number of patients screened and observed within the one year sample period constitutes a significant population for evaluation of the distribution group (pregnant women, neonates, and the general population) since FSVC not only meets ambulatory but all health facilities assisted by the SUS and its prenatal programs, including high risk, and attend a hospital maternal and child reference where is held the largest number of deliveries by SUS in Vitória da Conquista region.
Another important issue is the fact that this is the first study to show the prevalence and control of syphilis in the county, and the chosen period coincides with the moment of greatest surveillance for reporting of cases of the disease in the city.
Finally, it should be noted that this work could serve as developer of future studies of population surveys that can make causal associations and estimate more accurately the prevalence of syphilis, in order to reinforce the importance of the implementation and maintenance of public policies for the reducing the prevalence to levels that no longer will represent a burden on the population29.
Prevalence rates are high taking into account the parameters established by WHO and are able to represent burden for the population. However, they point out good capacity of the municipality for screening when facing the disease, which is an essential step for public health to combat this serious infection.
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