INTRODUCTION

Adolescence is considered a multidimensional phenomenon, with physiological, social, behavioral and psychological changes. The risk behaviors to which adolescents are exposed constitute a challenge for Public Health, due to the repercussions that can originate in the psychosocial, individual and family spheres ¹ .

There are multiple factors related to sexual behavior that point to adolescents as a risk group for Sexually Transmitted Infections (STIs). The most frequently mentioned factors are: early sexual initiation, irregular and infrequent use of condoms, multiple sexual partners, feelings of omnipotence and little involvement with preventive aspects ² .

Among the STIs, syphilis has challenged humanity for centuries. Caused by Treponema pallidum, it is characterized by being a chronic infectious disease of systemic nature, exclusive to humans and transmitted predominantly through sexual and vertical transmission ³ . When syphilis affects women during pregnancy and is not diagnosed and treated early, it can be transmitted transplacentally, which constitutes an important and potentially preventable cause of fetal death and other adverse perinatal outcomes ⁴ .

Global data revealed that in 2008, 1.5 million pregnant women were infected with Treponema Pallidum ⁵ . In 2017, the Pan American Health Organization (PAHO) indicated that new cases of congenital syphilis had doubled since 2010 ⁶ , representing a major challenge for global public health.

In Brazil, there has been an increase in cases of syphilis in pregnant women. Between 2007 and 2016, approximately 180,000 cases were reported, showing a 573% increase in the number of notifications, rising 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 to 19 years. During this period, the number of reported cases of syphilis in pregnant adolescents increased by 822%, rising from 1,245 cases in 2007 to 10,230 in 2016 ⁷ .

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 the social, demographic and epidemiological characteristics of syphilis in pregnant adolescents living in Pernambuco, in order to understand its trend and distribution that may support the planning, decision-making and evaluation of prevention and control actions.

METHODS

A cross-sectional study was conducted using secondary data from the Notifiable Diseases Information System (SINAN) of the Health Department of the State of Pernambuco. The population consisted of pregnant women aged 10 to 19 years, residing in the state and reported as cases of gestational syphilis between 2007 and 2016.

The variables selected for analysis were classified as: a) sociodemographic (gestational trimester, age group, race/color, education level and municipality of residence); b) clinical and epidemiological (clinical classification, non-treponemal and treponemal tests performed during prenatal care, prescribed treatment regimen, treated partner and reason for partner’s non-treatment). Regarding the variables of treponemal and non-treponemal tests performed during prenatal care, prescribed treatment and partner’s treatment, when filled in as unknown or not filled in (blank), they were considered as tests and treatments not performed.

The database was analyzed using the Epi-info 7.0 statistical package to describe the social, demographic, and epidemiological characteristics of pregnant adolescents reported with syphilis. The incidence rates were calculated based on the number of live births from the Live Birth Information System (SINASC) available in DATASUS. The project was approved by the Research Ethics Committee of the University of Pernambuco under opinion No. 2,545,932.

RESULTS

During the period from 2007 to 2016, 1,494 cases of syphilis were reported in pregnant adolescents living in the state of Pernambuco. In the same period, 305,099 live births (LB) were recorded from mothers in this same age group, which represents an incidence rate of syphilis in pregnant adolescents of 4.9 cases for every 1,000 LB. There was a growing increase in notifications, going 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 condition for this age group in the period was 149 (±79 SD) cases, representing an average annual incidence coefficient of 4.9 (±2.9 SD).

Regarding sociodemographic characteristics (Table 1), cases occurred predominantly in adolescents in the 2nd trimester of pregnancy (41.7%), aged between 15 and 19 years (95.0%), brown race/skin color (70.0%) and with incomplete 5th to 8th grade of elementary school (EF) (42.2%). The distribution of residences by health regions showed more cases in region I (52.1%), more specifically in the cities of Recife, Olinda and Jaboatao dos Guararapes, followed by health regions IV (Caruaru) and VIII (Petrolina) with 13.7% and 5.7%, respectively.

Considering the clinical and epidemiological characteristics (Table 2), the cases were predominantly classified as primary syphilis (68.7%). The majority underwent the non-treponemal test during prenatal care (93.2%), and the result was reactive in 92.8% of the tests performed. A little over half of the registered cases underwent the treponemal test during prenatal care (54.1%), and the result was reactive in 51.8%.

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

DISCUSSION

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

Regarding the increase in the detection of cases during the period studied, surveillance data from Brazil show that the country has been experiencing an increase in the number of syphilis cases reported in pregnant adolescents in recent years. According to the epidemiological bulletin released in 2017, between 2007 and 2016, 46,395 cases of syphilis were reported in pregnant adolescents, of which 94.5% were in the 15-19 age group. The number of registered cases increased by 821.7%, from 1,245 cases reported in the initial year to 10,230 cases in the final year ⁷ .

The findings of the present study regarding the most prevalent age group are corroborated by national data and by the results of a descriptive study carried out in Palmas-TO, during the period from 2007 to 2014, in which 171 cases of syphilis were reported in pregnant women, of which 20.5% were in adolescence ⁸ . The increase in notifications of syphilis in pregnant adolescents was also evidenced in Minas Gerais, increasing from 32 in 2007 to 734 cases in 2015, corresponding to 26.4% of the total notifications ⁹ .

It is known that prenatal care plays a fundamental role in the early diagnosis of syphilis in pregnant women, and quality of care and early detection are essential. In adolescents, there are cases in which the pregnancy is not planned, resulting in a late search for care. In this study, most cases occurred in a late period, between the second and third trimester of pregnancy, a result similar to the study carried out in Fortaleza-CE, in which 43.4% and 41.7% of the reported cases occurred in the second and third trimester of pregnancy, respectively ¹⁰ . In Minas Gerais, the late period was even more evident, since 43.6% of the reports occurred in the 3rd trimester of pregnancy and 26.2% in the 2nd trimester ⁹ , which may suggest late diagnosis or infection during the gestational period.

The low level of education found in this study may be related to the lack of knowledge about good health practices, contributing to the non-performance of serological screening ² , and is also similar in the research on the epidemiological profile of adolescents living in Recife-PE reported with AIDS, of which 42.8% had incomplete elementary school ¹¹ . Still on the subject of education, a study conducted in the state of Rio de Janeiro showed that 44.4% of adolescents aged 15 to 19 who vertically transmitted syphilis had incomplete 5th to 8th grade of elementary school ¹² , with education being a contributing factor to the occurrence of congenital syphilis. The predominantly brown race/color was also corroborated by other studies ^8,9,12 .

Regarding the municipality of residence, it was shown that the most populous regions with a predominantly urban area presented the highest number of notifications, namely Health Region I (Recife), followed by Health Region IV (Caruaru). On the other hand, the incidence rates made it possible to verify that in Health Region XII (Goiana), although it is less populous, the infection manifested itself more frequently when compared to Health Region IV.

The probability of congenital syphilis occurring is influenced by the stage of syphilis in the mother and the duration of fetal exposure, being greater when the pregnant woman has primary or secondary syphilis ³ , highlighting the importance of early identification and treatment. Although characterized by the appearance of the initial lesion, the hard chancre, usually single and painless, may be located in areas not visible to the woman ³ .

The results obtained differed from those of Fortaleza-CE, since 28.6% of the cases presented clinical evidence of tertiary syphilis ¹⁰ , while in the present study the most recorded clinical evidence was primary syphilis. In contrast, the studies carried out in Palmas-TO and Goiás obtained similar results to this one, with 36.8% and 40.3% of the cases with clinical evidence of primary syphilis ⁸¹³ .

Regarding the diagnosis, it can be performed through immunological tests divided into non-treponemal and treponemal. Non-treponemal tests detect antibodies not specific for Treponema pallidum , such as VDRL, and are used as a screening to determine whether a sample is reactive or not, as well as to monitor the response to treatment. Meanwhile, treponemal tests, such as rapid tests, detect antibodies specific for T. pallidum antigens ³ .

In the present study, the vast majority of adolescents underwent non-treponemal testing during prenatal care, which resulted in positive results. The small percentage of prenatal treponemal testing can be explained by the fact that only in 2012 was Ordinance No. 77 of January 12 published, which provides for the implementation of rapid tests in primary care for the detection of HIV and syphilis, as well as for other diseases, within the scope of prenatal care for pregnant women and their sexual partners ¹⁴ .

Treatment for syphilis is phase-dependent, determined by symptoms and serological profile. The drug of first choice is Benzathine Penicillin G, with the dose varying according to the stage of the disease ³ . Most adolescents in the study were prescribed Benzathine Penicillin G 7,200,000 IU. Considering that in most of the reported cases the clinical evidence presented was primary syphilis, whose appropriate treatment consists of Penicillin G benzathine 2,400,000 IU ³ , it can be inferred that there was a failure in the management of the infection in pregnant adolescents.

The results were similar to the study carried out in Fortaleza-CE, since 62.9% of the cases were treated with Penicillin G benzathine 7,200,000 IU and only 28.6% presented clinical evidence of tertiary syphilis ⁹ . In Minas Gerais these data are also corroborated, considering that only 5.1% of the cases presented clinical evidence of tertiary syphilis and that 34.5% were treated with Penicillin G benzathine 7,200,000 IU ⁹ .

Regarding the treatment of syphilis, it is essential that the partner be treated at the same time as the pregnant woman to avoid reinfection and consequent vertical transmission. In Pernambuco, a small percentage of the sexual partners of adolescents were treated, with the following main justifications for not receiving treatment: lack of contact with the pregnant adolescent and the partner’s failure to appear, despite being summoned.

The first reason highlights the absence of a steady partner, which is characteristic of the period of adolescence when there is a search for experimentation and changing partners. The second reason mentioned above may be associated with cultural issues in which the disease is considered a sign of fragility, reducing adherence to treatment, as well as the lack of mechanisms that can contribute to the integration of the partner during pregnancy.

Studies show that the treatment of the partner is still an issue that needs to be worked on. In studies conducted in Palmas ⁸ and Goiás ¹³The data obtained were not different, since 29.8% and 53.6% of the partners, respectively, were not treated. In Fortaleza-CE, 2008-2010, the records of untreated and ignored partners corresponded to 62.9% of the notifications ⁹ .

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

CONCLUSION

A progressive increase in the notification and incidence rate of syphilis cases in pregnant adolescents living in Pernambuco was observed. The results demonstrate that there is a predominance of cases in the second trimester of pregnancy, in the age group of 15 to 19 years, of mixed race/color, with low education and living in the metropolitan region of Recife. The majority presented primary syphilis as clinical classification, for which non-treponemal and treponemal tests were performed during prenatal care. In addition, there was low coverage of concomitant treatment of sexual partners.

The implementation of public policies aimed at adolescence is of great importance for the prevention of new cases of syphilis in pregnant adolescents. It is during this period that sexual life begins and risk 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, are essential to ensure early diagnosis, timely treatment and prevention of vertical transmission.

Given the magnitude of the problem, considering that sexual activity is beginning at an increasingly early age, it is even more necessary to understand the health situation through the distribution and trends of reported cases, in order to contribute to planning, formulating health policies, making decisions and evaluating prevention and control actions.