Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 2 - Apr/Jun - 2019

Original Article Imprimir 

Páginas 47 a 56


Syphilis in adolescent pregnant women from Pernambuco

Sífilis en adolescentes embarazadas de Pernambuco

Sífilis em gestantes adolescentes de Pernambuco

Autores: Rebeca Bezerra Bonfim de Oliveira1; Alisse Maria Chaves de Lima Peixoto2; Mirian Domingos Cardoso3

1. Resident in Collective Health by the Medical Sciences College at Pernambuco University (UPE); Graduated in Nursing by the College of Nossa Senhora das Graças (FENSG) at the Pernambuco University (UPE). Recife, PE, Brazil
2. Mastering in Hebiatry by the Dentistry College of Pernambuco. Graduated in Nursing. Pernambuco University (UPE). Recife, PE, Brazil
3. Doctorate in Public Health by the Federal University of Minas Gerais. Adjunct Professor of the Nursing College of Nossa Senhora das Graças. Pernambuco University (UPE). Recife, PE, Brazil

Correspondência:
Rebeca Bezerra Bonfim de Oliveira
Universidade de Pernambuco (UPE)
Av. Gov. Agamenon Magalhães - Santo Amaro
Recife - PE, Brasil. CEP: 50100-010
(rebecabonfim2@gmail.com)

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Keywords: Adolescent; Syphilis; Sexually Transmitted Diseases.
Palabra Clave: Adolescente; Sífilis; Enfermedades Sexualmente Transmisibles.
Descritores: Adolescente; Sífilis; Doenças Sexualmente Transmissíveis.

Abstract:
OBJECTIVE: Describe the social, demographic and epidemiological characteristics of syphilis among pregnant women living in Pernambuco.
METHODS: Cross-sectional study with secondary data from the Information System of Notification Diseases (SINAN) of the State of Pernambuco. The population was composed of pregnant women aged 10 to 19 years, reported as gestational syphilis in the period from 2007 to 2016. The database was analyzed in the Epi-info 7.0 statistical package. The project was approved by the research ethics committee of the University of Pernambuco.
RESULTS: During the period from 2007 to 2014, 1,494 cases of syphilis were reported in adolescent pregnant women. There was an increase in notifications, from 71 (CI = 2.1) in 2007 to 289 (CI = 10.7) in 2016. Cases occurred predominantly in adolescents aged 15 to 19 years (95%), in the second trimester of gestation (41.7%), with brown skin color brown (70%) and with incomplete grades from 5o. to 8o. year (42.2%). The majority of the cases were classified as primary syphilis (68.7%), with treatment using Penicillin G benzathine 7,200,000 UI (38.3%).
CONCLUSION: There was a progressive increase in the notification and the incidence rate of syphilis cases in pregnant teenagers living in Pernambuco.

Resumen:
OBJETIVO: Describir las características sociales, demográficas y epidemiológicas de la sífilis en gestantes adolescentes residentes en Pernambuco.
MÉTODOS: Estudio transversal con datos secundarios del Sistema de Información de Agravios de Notificación (SINAN) del Estado de Pernambuco. La población fue compuesta por gestantes entre 10 y 19 años, notificadas como caso de sífilis gestacional en el periodo de 2007 a 2016. El banco de datos fue analizado en el paquete estadístico Epi-info 7.0. El proyecto fue aprobado por el comité de ética en pesquisa de la Universidad de Pernambuco.
RESULTADOS: Durante el periodo de 2007 a 2016 fueron notificados 1.494 casos de sífilis en gestantes adolescentes. Se observó un aumento de las notificaciones de cerca de 71 casos (CI=2,1) en 2007, para 289 (CI=10,7) en 2016. Los casos ocurrieron predominantemente en las adolescentes con la franja etaria entre 15 a 19 años (95%), en el 2º trimestre de gestación (41,7%), raza/color parda (70%) y con 5ª a 8ª serie incompleta de enseñanza fundamental (EF) (42,2%). La mayoría de los casos fue clasificada como sífilis primaria (68,7%), teniendo como tratamiento prescrito la Penicilina G benzatina 7.200.000UI (38,3%).
CONCLUSIÓN: Hubo un crecimiento progresivo en la notificación y en la tasa de incidencia de casos de sífilis en gestantes adolescentes residentes en Pernambuco.

Resumo:
OBJETIVO: Descrever as características sociais, demográficas e epidemiológicas da sífilis em gestantes adolescentes residentes em Pernambuco.
MÉTODOS: Estudo transversal com dados secundários do Sistema de Informação de Agravos de Notificação (SINAN) do Estado de Pernambuco. A população foi composta por gestantes entre 10 a 19 anos, notificadas como caso de sífilis gestacional no período de 2007 a 2016. O banco de dados foi analisado no pacote estatístico Epi-info 7.0. O projeto foi aprovado pelo comitê de ética em pesquisa da Universidade de Pernambuco.
RESULTADOS: Durante o período de 2007 a 2016 foram notificados 1.494 casos de sífilis em gestantes adolescentes. Observou-se um aumento das notificações, de cerca de 71 casos (CI=2,1) em 2007 para 289 (CI=10,7) em 2016. Os casos ocorreram predominantemente nas adolescentes com a faixa etária entre 15 a 19 anos (95%), no 2º trimestre de gestação (41,7%), raça/cor parda (70%) e com 5ª à 8ª série incompleta do ensino fundamental (EF) (42,2%). A maioria dos casos foi classificada como sífilis primária (68,7%), tendo como tratamento prescrito a Penicilina G benzatina 7.200.000UI (38,3%).
CONCLUSÃO: Houve um crescimento progressivo na notificação e na taxa de incidência de casos de sífilis em gestante adolescente residentes em Pernambuco.

INTRODUCTION

Adolescence is considered a multidimensional phenomenon, with physiological, social, behavioral and psychological changes. The risk behavior to which the adolescent is exposed is a challenge for Public Health, due to the repercussions that may originate in the psychosocial, individual and family context1.

There are multiple factors related to sexual conduct that indicate the adolescent as a risk group for Sexually Transmitted Infections (STIs). The most common factors are: Early sexual onset, irregular and infrequent use of condoms, multiple sexual partners, feelings of omnipotence and little involvement with the preventive aspects2.

Among STIs, syphilis has been challenging humanity for centuries. Caused by Treponema pallidum, it is characterized by being a chronic infectious disease of a systemic character, exclusive to humans and transmitted predominantly by sexual and vertical routes3. When syphilis affects women during pregnancy who are not diagnosed and treated early, it can be transmitted via placenta, which is an important and potentially preventable cause of fetal death and other adverse perinatal outcomes4.

Worldwide data revealed that in 2008, 1.5 million pregnant women were infected with Treponema Pallidum5. In 2017, the Pan American Health Organization (PAHO) indicated that new cases of congenital syphilis have doubled since 20106, posing a major challenge to global public health.

In Brazil, there has been an increase in syphilis cases in pregnant women. In the period from 2007 to 2016, approximately 180 thousand cases were reported, showing a 573% increase in the number of notifications, from 6,530 cases in 2007 to 37,414 cases registered in 2016. Of the total cases registered from 2007 to 2016, 25.8 % occurred in adolescents aged 10-19 years. During this period, the number of syphilis cases reported in adolescent pregnant women increased by 822%, from 1,245 cases in 2007 to 10,230 in 20167.

Considering the high magnitude of the syphilis problem and that adolescents constitute a group of high vulnerability to STIs, as well as the existence of few studies in the literature focused on gestational syphilis in adolescence, this study aimed to describe social, demographic and social characteristics. of syphilis in adolescent pregnant women living in Pernambuco, for the purpose of knowing its tendency and distribution that may support the planning, decision making and evaluation of prevention and control actions.


METHODS

A cross-sectional study was conducted with secondary data from the Notification Disease Information System (SINAN) of the Pernambuco State Department of Health. The population consisted of pregnant women aged 10 to 19 years, resident in the state and reported as a case of gestational syphilis from 2007 to 2016.

The variables selected for analysis were classified as: a) sociodemographic (gestational trimester, age group, race/color, education and municipality of residence); b) clinical and epidemiological (clinical classification, nontreponemal and treponemal test performed prenatally, prescribed treatment regimen, partner treated and reason for non-treatment of partner). Regarding the prenatal treponemal and nontreponemal test variables, prescribed treatment, and partner treatment, when filled in as ignored or unfilled (blank), were considered as unrealized tests and treatments.

The database was analyzed in the Epi-info 7.0 statistical package to describe the social, demographic and epidemiological characteristics of adolescent pregnant women notified with syphilis. Incidence coefficients were calculated based on the number of live births from the Live Birth Information System (SINASC) available from DATASUS. The project was approved by the Research Ethics Committee of the University of Pernambuco under Opinion No. 2.545.932.


RESULTS

From 2007 to 2016, 1,494 cases of syphilis were reported in adolescent pregnant women living in the state of Pernambuco. In this same period, 305,099 live births (NV) of mothers in this same age group were recorded, which represents an incidence coefficient of syphilis in adolescent pregnant women of 4.9 cases per 1,000 NV. There was a growing increase in notifications, from 71 cases (CI = 2.1) in 2007 to 289 (CI = 10.7) in 2016 (Figures 1 and 2), corresponding to an increase of 407%. The average notification rate of the injury for this age group in the period was 149 (± 79 SD) cases, representing an average annual incidence coefficient of 4.9 (± 2.9 SD).


Figure 1. Number of cases of syphilis in adolescent pregnant women living in Pernambuco, reported from 2007 to 2016.


Figure 2. Incidence coefficient of syphilis cases in adolescent pregnant women living in Pernambuco, reported from 2007 to 2016, by 1.000 NV.



Regarding sociodemographic characteristics (Table 1), the cases occurred predominantly in adolescents in the second trimester of pregnancy (41.7%), aged 15-19 years (95.0%), race/brown (70 , 0%) and with 5th to 8th grade incomplete elementary school (PE) (42.2%). The distribution of residences by health regions showed more cases in regional I (52.1%), more specifically in the municipalities of Recife, Olinda and Jaboatão dos Guararapes, followed by regional IV (Caruaru) and VIII (Petrolina) with 13.7% and 5.7%, respectively.




Considering the clinical and epidemiological characteristics (Table 2), the cases presented predominantly as clinical classification the primary syphilis (68.7%). Most performed the non-treponemal prenatal test (93.2%), whose result was reactive in 92.8% of the tests performed. A little more than half of the registered cases performed the prenatal treponemal test (54.1%), with 51.8% reactive result.




The treatment prescribed for most cases was Penicillin G Benzathine 7,200,000UI (38.3%). Regarding the treatment of the adolescent sexual partnership, a small percentage referred to the concomitant treatment to the pregnant woman (21.7%) and, in more than half of the registered cases, this field was incomplete, making data analysis difficult. Among untreated partners, the main reason for non-treatment was the absence of contact with the pregnant woman (22.2%).


DISCUSSION

During the period from 2007 to 2016, 1,494 cases of syphilis were reported in adolescent pregnant women living in Pernambuco, which shows a significant increase from 71 in 2007 to 289 in 2016, and occurred predominantly in the 15-19 age group years.

Regarding the growth in case detection in the studied period, surveillance data from Brazil show that the country is experiencing a period of increase in the registration of syphilis cases in adolescent pregnant women in recent years. According to the epidemiological bulletin released in 2017, from 2007 to 2016, 46,395 cases of syphilis in pregnant women were reported, of which 94.5% were aged 15-19 years. The number of registered cases grew by 821.7%, from 1,245 reported cases in the initial year to 10,230 cases in the final year7.

The findings of the present study in relation to the most prevalent age group are corroborated by national data and the results of a descriptive study conducted in Palmas-TO, from 2007 to 2014, in which 171 cases of syphilis in pregnant women were reported, which 20.5% were in adolescence8. The growth of syphilis notifications in adolescent pregnant women was also evidenced in Minas Gerais, increasing from 32 in 2007 to 734 cases in 2015, corresponding to 26.4% of the total notifications9.

Prenatal care is known to play a fundamental role in the early diagnosis of syphilis in pregnant women, and the quality of care and early uptake are indispensable. In adolescents, there are cases where pregnancy is unplanned, resulting in a late seeking care. In this study, most cases occurred late, between the second and third trimester of pregnancy, a result similar to the study conducted in Fortaleza-CE, where 43.4% and 41.7% of reported cases occurred in the second and third trimester of pregnancy, respectively10. In Minas Gerais, the late period was even more evident, as 43.6% of the notifications occurred in the 3rd trimester of pregnancy and 26.2% in the 2nd trimester9, which may suggest late diagnosis or infection during the gestational period.

The low education found in this study may be related to the lack of knowledge about good health practices, contributing to the non-performance of serological screening2, and also similar to the research on epidemiological profile of adolescents living in Recife-PE notified with AIDS, of which 42, 8% had incomplete elementary school11. Still on schooling, a study conducted in the state of Rio de Janeiro showed that 44.4% of 15 to 19 year olds who transmitted syphilis vertically had incomplete 5th to 8th grade elementary school12, with schooling a contributing factor to the occurrence of congenital syphilis. The predominantly brown race/color was also corroborated with other studies8,9,12.

Regarding the municipality of residence, it was evidenced that the most populated regional areas with a mostly urban zone had the highest number of notifications, being the I Regional Health (Recife), followed by the IV Regional Health (Caruaru). In contrast, the incidence rates made it possible to verify that in the XII Regional Health (Goiana), although less populous, the infection was more frequent when compared to the IV Regional Health.

The likelihood of congenital syphilis is influenced by the stage of syphilis in the mother and the duration of fetal exposure, being higher when the pregnant woman has primary or secondary syphilis3, highlighting the importance of early identification and treatment. Despite being characterized by the appearance of the initial lesion, hard cancer, usually unique and painless, may be located in areas not visible to women3.

The results differed from Fortaleza-CE, since 28.6% of the cases presented as clinical evidence tertiary syphilis10, while in the present study the most common clinical evidence was primary syphilis. In contrast, studies performed in Palmas-TO and Goiás obtained similar results, with 36.8% and 40.3% of cases with clinical evidence for primary syphilis813.

On diagnosis, it can be performed through immunological tests divided into non-treponemal and treponemal. Non-treponemal tests detect antibodies that are not specific to Treponema pallidum, such as VDRL, and are used as a screen to determine whether a sample is reactive or not, as well as to monitor treatment response. While treponemal tests, such as rapid tests, detect antibodies specific for T. pallidum3 antigens.

In the present study, the vast majority of adolescents underwent a nontreponemal prenatal test, the result of which was reactive. The small percentage of prenatal treponemal tests can be justified by the fact that only in 2012 was published the Ordinance No. 77 of January 12, which provides for rapid testing in primary care for the detection of HIV and syphilis, as well as for other diseases, in the context of prenatal care for pregnant women and their sexual partnerships14.

Syphilis treatment is phase dependent, determined by symptoms and serological profile. The drug of choice is Penicillin G Benzatin, with the dose varying according to the stage of the disease3. For most adolescents in the study, Penicillin G benzathine 7,200,000 IU was prescribed. Considering that in most of the reported cases the clinical evidence presented was primary syphilis, whose appropriate treatment consists of benzathine Penicillin G 2,400,000UI3, it can be inferred that there was a failure in the management of infection in adolescent pregnant women.

The results were similar to the study conducted in Fortaleza-CE, as 62.9% of the cases were treated with Penicillin G Benzatin 7,200,000 IU and only 28.6% presented tertiary syphilis as clinical evidence9. In Minas Gerais these data are also corroborated, considering that only 5.1% of the cases presented as clinical evidence tertiary syphilis and 34.5% were treated with Penicillin G Benzatin 7,200,000 IU9.

Also regarding the treatment of syphilis, it is essential that the partner be treated concomitantly with the pregnant woman to avoid reinfection and the consequent vertical transmission. In Pernambuco, a small percentage of adolescent sexual partners were treated, presenting as main justifications for non-treatment: the lack of contact with the pregnant woman and the non-attendance of the partner, despite the call.

The first reason shows the absence of a fixed partner, being characteristic of the period of adolescence in which there is the search for experimentation and the exchange of partners. While the second reason above may be associated with cultural issues that the disease is considered a sign of fragility, reducing adherence to treatment, as well as the lack of mechanisms that may contribute to the integration of the partner with the pregnancy period.

Studies show that partner treatment is still a point that needs to be worked out. In the studies conducted in Palmas8 and Goiás13, the data obtained were not different, as 29.8% and 53.6% of the partners, respectively, were not treated. In Fortaleza-CE, 2008-2010, the records of untranslated and ignored partners corresponded to 62.9% of notifications9.

Regarding the limitations of this study, we can mention those related to research conducted with secondary data, which relate to the quality of the records, due to the incompleteness of fields considered important for knowledge and data analysis.


CONCLUSION

There was a progressive increase in the notification and incidence rate of syphilis cases in adolescent pregnant women living in Pernambuco. The results show that there is a predominance of cases in the second trimester of pregnancy, aged 15-19 years, of race/brown color, with low education and living in the metropolitan region of Recife. Most had primary syphilis as clinical classification, which was performed with a non-treponemal and treponemal test in the prenatal period. In addition, there was low coverage of concomitant sexual partnership treatment.

The performance of public policies aimed at adolescence is of great importance for the prevention of new cases of syphilis in adolescent pregnant women. It is during this period that the onset of sexual life occurs and risky behavior tends to contribute to the vulnerability of adolescents to sexually transmitted infections. Knowledge about sexual and reproductive health, as well as quality prenatal care, is indispensable for ensuring early diagnosis, timely treatment and prevention of vertical transmission.

Given the magnitude of the problem, considering that the onset of sexual activity is increasingly early, it is even more necessary to know the health reality through the distribution and trend of reported cases, in order to contribute to the planning, formulation of policies, decision-making and evaluation of prevention and control actions.


REFERENCES

1. Fonseca MS, Melchiori LE. Gravidez e maternidade na adolescência. In: Valle TGM, Melchiori LE. orgs. Saúde e desenvolvimento humano [online]. Pág.134. São Paulo: Editora UNESP; São Paulo: Cultura Acadêmica, 2010.

2. Costa MSO, Santos BC, Souza KEP, Cruz NLA, Santana MC, Nascimento OC.HIV/Aids e sífilis entre gestantes adolescentes e adultas jovens: fatores de exposição e risco dos atendimentos de um programa de DST/HIV/Aids na rede pública de saúde/SUS, Bahia, Brasil. Revista Baiana de Saúde Pública jan./jun 2011;35(supl.1):179-195.

3. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para prevenção da transmissão vertical de HIV, sífilis e hepatites virais. Brasília-DF, 2017.

4. Nascimento MID, Cunha ADA, Guimarães EV, Alvarez FS, Oliveira SRDSM, Villas Boas EL. Gestações complicadas por sífilis materna e óbito fetal. Revista Brasileira de ginecologia e obstetrícia fev. 2012;34(2): 56-62.

5. World health organization. Investment case for eliminating mother-to-child transmission of syphilis. Promoting better maternal and child health and stronger health systems, 2012.

6. Pan American Health Organization. Elimination of mother-to-child transmission of HIV and syphilis in the Americas. Update 2016. Washington, D.C.: PAHO; 2017.

7. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico- Sífilis 2017;47(35). ISSN online 2358-9450.

8. Cavalcante PAM, Pereira RBL, Castro JGD. Sífilis gestacional e congênita em Palmas, Tocantins, 2007-2014. Epidemiol. Serv. Saude abr-jun 2017; 26(2):255-264.

9. Alves PIC.Evolução temporal e caracterização dos casos de sífilis congênita e em gestante, Minas Gerais, 2007 a 2015. [dissertação]. Uberaba-MG: Universidade Federal do Triângulo Mineiro; 2017.

10. Cardoso ARP, Araújo MAL, Cavalcante MS, Frota MA, Melo SP. Análise dos casos de sífilis gestacional e congênita nos anos de 2008 a 2010 em Fortaleza, Ceará, Brasil. Ciência & Saúde Coletiva 2018; 23(2):563-574.

11. Pagani MV. Sífilis gestacional e congênita no estado do rio de janeiro 2007-2014: análise comparativa entre adolescentes e adultas [dissertação]. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira: Rio de Janeiro - RJ; 2017.

12. Cardoso MD, Peixoto AMC, Rolim ACMA. Perfil epidemiológico de adolescentes residentes em Recife - PE, notificados como caso de Sida no período de 2007 a 2015. Adolesc Saude. 2017;14(3):7-15.

13. Rezende EM, Barbosa NB. A sífilis congênita como indicador da assistência de pré-natal no estado de Goiás. Rev. APS. abr/jun 2015; 18(2): 220 - 232.

14. Ministério da Saúde. Portaria nº 77, de 12 de janeiro de 2012. Dispõe sobre a realização de testes rápidos, na atenção básica, para a detecção de HIV e sífilis, assim como testes rápidos para outros agravos, no âmbito da atenção pré-natal para gestantes e suas parcerias sexuais.
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