ORIGINAL ARTICLE
AMANAJÁS, Emarine Carla Almeida [1], DIAS, Claudio Alberto Gellis de Mattos [2], DENDASCK, Carla Viana [3], ARAÚJO, Maria Helena Mendonça de [4], FECURY, Amanda Alves [5]
AMANAJÁS, Emarine Carla Almeida et al. Epidemiological profile of syphilis during pregnancy in the state of Amapá, Amazon, Brazil, between 2018 and 2022. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 09, Ed. 09, Vol. 01, pp. 186-203. September 2024. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/syphilis-during-pregnancy, DOI: 10.32749/nucleodoconhecimento.com.br/health/syphilis-during-pregnancy
ABSTRACT
Syphilis is a Sexually Transmitted Infection (STI) that, during pregnancy, can cause miscarriages, fetal malformations, blindness, deafness, mental disabilities, and/or stillbirth. It is considered a key tool in evaluating the quality of prenatal care. This article aimed to outline the epidemiological profile of syphilis in pregnant women in the state of Amapá, Amazon, Brazil, between 2018 and 2022, using data from DATASUS. A total of 2,069 cases of syphilis in pregnant women were reported during the study period. There was an increase in the number of cases from 282 in 2018 to 364 in 2019. In 2020, likely due to the pandemic, the number of diagnoses decreased to 309. The year 2021 saw the highest number of cases, with a total of 594 reports, followed by 520 in 2022. Most patients were mixed-race women, had completed elementary education, and were between 20 and 39 years old. The most frequent clinical classification was primary syphilis, a period with a high likelihood of vertical transmission. Although most cases were reported in the city of Macapá, the state’s capital was the only capital in Brazil where the detection rate of syphilis in pregnant women was lower than the state average. Cases from islands in Pará, such as Afuá, Breves, and Chaves, were also reported, likely due to the proximity of these municipalities to health reference centers located in municipalities in Amapá. As a result, Amapá recorded a detection rate of syphilis in pregnant women of 36.24 in 2021 and 34.52 cases per 1,000 live births in 2022, ranking as the fourth highest in the country and the second highest in the northern region. In light of these findings, there is a need for strategies to prevent syphilis in susceptible populations, as well as for appropriate diagnosis and treatment of syphilis cases in pregnant women, thus avoiding the incidence of congenital syphilis and other complications, especially in rural areas.
Keywords: Notifiable diseases, Epidemiology, Pregnancy, Sexually transmitted infections, Syphilis.
1. INTRODUCTION
Syphilis is a Sexually Transmitted Infection (STI) caused by the bacterium Treponema pallidum, which can be transmitted through unprotected sexual intercourse with an infected person or during pregnancy or childbirth (Brazil, 2024).
It manifests through various clinical stages known as primary, secondary, and tertiary syphilis. The likelihood of transmission is higher during the first two stages, when the patient may experience anything from a single, painless sore at the site of bacterial entry (which could be the genital organs, mouth, or other skin areas) between 10 and 90 days after infection (primary syphilis) to body rashes accompanied by fever, headaches, and swollen lymph nodes throughout the body, which disappear after a few weeks, creating the false impression of recovery (secondary syphilis). Tertiary syphilis, in turn, typically presents as skin, bone, cardiovascular, or neurological lesions and, depending on the severity and immune status of the patient, can lead to death (Brazil, 2024).
The World Health Organization (WHO) estimated that in 2020, around 7.1 million people between the ages of 15 and 49 acquired syphilis worldwide. In 2016, the last year for which global estimates are available, seven out of every 1,000 pregnant women had syphilis, resulting in 143,000 stillbirths or fetal deaths, 61,000 neonatal deaths, 41,000 preterm or low-birthweight infants, and 109,000 cases of congenital syphilis (WHO, 2023), highlighting the global epidemiological significance of the disease.
In 2005, under Ordinance No. 33 of the Ministry of Health, syphilis in pregnant women was classified as a notifiable disease. Since then, there has been a steady increase in the detection rate of the disease, with 624,273 cases reported across the country from 2005 to June 2023 (Brazil, 2023).
The diagnosis of syphilis during pregnancy is a concern due to the potential to cause miscarriages, fetal malformations, blindness, deafness, mental disabilities, and/or stillbirth (Brazil, 2016). Thus, the identification of syphilis during pregnancy is an important tool for assessing the quality of prenatal care, as well as a critical indicator for the functioning and monitoring of health information systems. Proper reporting and data collection enable the planning of prevention and response strategies (Rocha et al., 2023).
2. OBJECTIVE
To outline the epidemiological profile of syphilis in pregnant women in the state of Amapá, Amazon, Brazil, between 2018 and 2022.
3. METHODS
A descriptive and retrospective study was conducted on cases of syphilis in pregnant women reported in the state of Amapá and diagnosed between 2018 and 2022. The state is located in the northern region of Brazil, within the Amazon region. It has an estimated population of 733,759 inhabitants, is composed of 16 municipalities, and covers a total area of approximately 142,470 km² (IBGE, 2023).
The other variables evaluated were: state and municipality of residence and where prenatal care was conducted, age group, clinical classification (primary, secondary, tertiary, or latent syphilis), race, and education level.
To determine the detection rate of syphilis in pregnant women, the ratio between the number of reported cases per year and the number of live births was calculated and multiplied by 1,000.
The data were obtained from the Department of Informatics of the Unified Health System (DATASUS) through the website http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinannet/cnv/sifilisgestantebr.def for determining syphilis cases in pregnant women, and http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def for obtaining live birth data. The data were then tabulated and analyzed using spreadsheets and graphs created with Microsoft Excel, part of the Microsoft Corporation’s Office package.
4. RESULTS
Between 2018 and 2022, 2,069 cases of syphilis in pregnant women were reported in the state of Amapá, with 2021 standing out with 594 cases. The majority of women were mixed-race (75.9%; n=1571) and were between 20 and 39 years old (69.4%; n=1435). Women aged 15 to 19 years accounted for 27.1% (n=560) of the total reported cases in the state (Table 1).
Patients who had completed elementary education made up 26.3% (n=545) of the total diagnosed during the period. Pregnant women with a high school diploma and those with incomplete elementary education reached similar figures, representing 24.6% (n=510) and 24.3% (n=503), respectively. Women with a university degree and illiterate women had less significant representation, accounting for 1.8% (n=37) and 0.5% (n=11), respectively. A noteworthy number of cases lacked education data in the reports, totaling 22.4% of the cases (n=463) (Table 1).
Primary syphilis was the most frequent clinical form among the patients, present in 56.1% of cases (n=1161). Clinical classification was either ignored or left blank in more than a quarter (26.9%; n=556) of the reports. Detailed data are described in Table 1.
Table 1 – Number of syphilis cases in pregnant women in Amapá between 2018 and 2022, according to the analyzed variables
A gradual increase was observed in the percentage of pregnant women with syphilis who had completed high school, rising by 8.3% from 2018 to 2022, while a decrease was noted in the percentage of patients with incomplete elementary education, along with a decline in the proportion of reports where education information was ignored (Figure 1).
Figure 1 – Percentage distribution of syphilis cases in pregnant women according to education level and year of diagnosis in Amapá, between 2018 and 2022
Unlike education level, the age group of patients diagnosed with syphilis during pregnancy did not show significant variation from 2018 to 2022 (Figure 2).
Figure 2 – Percentage distribution of syphilis cases in pregnant women according to age group and year of diagnosis in Amapá, between 2018 and 2022
Regarding race, however, a decrease was observed in the proportion of white patients over the years, with a peak of 80.3% of mixed-race patients in 2020 (Figure 3).
Figure 3 – Percentage distribution of syphilis cases in pregnant women according to race and year of diagnosis in Amapá, between 2018 and 2022.
Throughout the study period, primary syphilis was the main clinical classification among patients with syphilis during pregnancy in the state of Amapá. However, in 2018, the percentage of patients with this information ignored or left blank was 58.5% of the total cases, showing a gradual decline to 10.6% in 2022 (Figure 4).
Figure 4 – Percentage distribution of syphilis cases in pregnant women according to clinical classification and year of diagnosis in Amapá, from 2018 to 2022
When considering the Federal Unit (UF) of residence of the patients reported in the state of Amapá, it is noteworthy that 3.2% (n=67) of the patients resided in municipalities in Pará; however, less than half of the patients received prenatal care in that state. The percentage of patients without information on prenatal visits was 13% (n=270), and the percentage of patients whose prenatal care was conducted in the state of Amapá was 85.8% (n=1775). The data are described in Table 2.
Table 2 – Number of syphilis cases during pregnancy according to the Federal Unit (UF) of residence of the patient and where prenatal care was conducted, reported in Amapá between 2018 and 2022
When considering the municipality of residence of the patients, 68.3% (n=1413) resided in the municipality of Macapá, followed by the municipality of Santana with 10.8% (n=224) of the cases and the municipality of Laranjal do Jari representing 4.6% of the diagnoses (n=95). Among the patients from Pará, the majority came from the municipality of Afuá. The information regarding the distribution of the municipalities of residence of the patients diagnosed during the period is presented in Table 3.
Table 3 – Number of syphilis cases during pregnancy according to the municipality of residence of the patient, reported in Amapá between 2018 and 2022
The detection rate of syphilis in pregnant women in the state of Amapá increased by more than 100%, rising from 16.17 in 2018 to 34.52 cases per 1,000 live births in 2022, reaching its peak in 2021 with 36.24 cases per 1,000 live births. The evolution of the detection rate of syphilis during pregnancy is shown in Figure 5.
Figure 5 – Detection rate of syphilis in pregnant women (per 1,000 live births) in the state of Amapá by year of diagnosis
5. DISCUSSION
The evolution of syphilis cases during pregnancy in Amapá followed national averages, showing an increase in the number of cases until 2019. Among the total cases of syphilis, cases in pregnant women were the only ones that continued to grow during the pandemic period. A study conducted in the municipality of Ji-Paraná, Rondônia, demonstrated an increase of 245.45% in cases between 2019 and 2020 (Silva et al., 2023). Amapá, on the other hand, showed a slight decline in the number of reported cases in 2020, which may be partly explained by the suppression of notifications due to the high demand for health services and the reduction of diagnostic capacity due to the COVID-19 pandemic (Brazil, 2023).
Moreover, unlike the national average, Amapá recorded a slight decline in the absolute number of gestational syphilis cases in 2022, with a total of 520 records, while the previous year saw this number reach 594. However, it is uncertain to claim that this decrease represents an improvement in the effectiveness of prevention and treatment strategies for STIs in the state, highlighting the need for monitoring these data for a better understanding of the evolution of these numbers.
Alignment with regional trends regarding the age group of patients was observed. In the northern region of the country, between 2011 and 2021, there were 40,582 reported cases, of which 67.76% of the patients were aged between 20 and 39 years, and 28.70% were aged between 15 and 19 years. This result is likely associated with greater sexual activity during these age ranges (Itapary et al., 2023).
Mixed-race women also make up the majority of notifications in Amapá and in the northern region of the country, representing over 80% of patients diagnosed with syphilis during pregnancy (Lima et al., 2023). According to IBGE, which is responsible for studies on the population profile in Brazil, the self-declared mixed-race population is the majority in the country, especially in the northern region, indicating that the results found demonstrate a proportional relationship with the racial profile of the population (IBGE, 2023).
A study conducted in the state of Acre by Cavalcante et al. (2021) demonstrated that the majority of pregnant women diagnosed with syphilis had education levels up to elementary school, representing 47% of cases. This reality was also observed in Altamira-PA, where 36.20% of cases were patients with incomplete elementary education (Colaça, 2021), and in Marabá, which is considered the municipality with the highest incidence rate in the state of Pará, where education up to elementary school represented 53% of the patients (Martins et al., 2020). Both studies relate and associate lower education levels with greater difficulties in accessing information about STIs and their prevention methods, as well as prenatal care, which subjects them to unfavorable outcomes such as prematurity and congenital syphilis.
Despite the similar percentages observed in this study for the period from 2018 to 2022 as a whole, there is a notable change in the proportion of education levels over the years, where women with complete high school became the majority of those diagnosed in 2021 and 2022. This result not only indicates an increase in the education level of the population (IBGE, 2024) but also raises concerns about the growing number of cases regardless of education, which may reflect negligence in STI prevention methods across the population.
The percentage of notifications with education information ignored or left blank, although showing a slight decrease, is still relatively high, averaging 22.4% of responses during the study period, reaching over 28% in 2020. Tracking the sociodemographic profile of a population affected by a disease is essential to identify the most susceptible individuals and, therefore, to create effective prevention and control strategies. Therefore, it is crucial to emphasize the importance of the complete and accurate filling out of notification forms to provide the maximum amount of reliable information and ensure better support for health surveillance agencies.
In this context, there was a decrease in the proportion of ignored or blank responses regarding the clinical classification of gestational syphilis, which favors a better epidemiological understanding of the disease studied and may be related to improvements in the diagnostic clarification of syphilis cases in the state.
A study conducted in the state of Goiás by Oliveira et al. (2021) also demonstrates that primary syphilis is the main clinical classification observed in 34.1% of diagnosed patients. Another study carried out in Bahia by Soares and Aquino (2021) also reported that 39.9% of cases were classified as primary syphilis during pregnancy.
Although this data suggests early diagnosis of the disease, it also highlights the increased risk of fetal infection, emphasizing the importance of appropriate treatment for both the patient and the partner. In 2022, Amapá was the second state with the highest percentage of prescriptions for alternative therapeutic regimens other than penicillin, according to the protocols recommended by the Ministry of Health, indicating a higher likelihood of vertical transmission of the infection (Brasil, 2023).
In the present study, it was shown that a small portion of the cases of syphilis in pregnant women identified in the state of Amapá were from patients residing in municipalities of the state of Pará, primarily Afuá, Chaves, and Breves. This may be explained by the closer proximity of these municipalities to reference health centers located in Amapá than to those in their own state. However, it is important to accurately identify and record these cases, given that the division and decentralization of resources in the Unified Health System (Sistema Único de Saúde) is partially based on the population size of municipalities and states (Ugá et al., 2003).
Furthermore, a study conducted by Nemer et al. (2021) demonstrated a significant correlation between inadequate prenatal care and patients from islands in Pará such as Afuá, Breves, and Chaves, highlighting the difficulties this rural population faces in accessing health services, as well as the inadequacy of local services and the lack of qualified professionals.
Another study also indicated that, despite the northern region having a high rate of prenatal care, most cases of congenital syphilis were diagnosed only after delivery. This indicates not only misinterpretations regarding tests and diagnoses but also a potential underreporting of syphilis during pregnancy (Almeida et al., 2020).
This evidence can also be observed in the state of Amapá. Although the capital, Macapá, presents the highest absolute number of cases, the Epidemiological Bulletin on Syphilis published by the Ministry of Health in 2023 highlights Macapá as the only capital in the country maintaining a syphilis detection rate during pregnancy lower than the total for the state. This reveals the need to strengthen epidemiological strategies for the diagnosis, treatment, and prevention of syphilis and other sexually transmitted infections (STIs) within the state.
Brazil has been experiencing a gradual increase in the syphilis detection rate in pregnant women for over 20 years. Between 2011 and 2017, the increase was from 2.2 to 16.9 cases per 1,000 live births, representing a 660% increase, which corroborates the identification of syphilis in pregnancy as a serious public health problem and highlights significant flaws in Brazilian prenatal care (Santos et al., 2020). In 2022, this indicator reached a rate of 32.4 cases per 1,000 live births (Brasil, 2023).
In the present study, it was found that the syphilis detection rate in Amapá increased from 16.17 in 2018 to 34.52 cases per 1,000 live births in 2022. In 2021, this number reached a rate of 36.24 per 1,000 live births. These data position the state of Amapá as the second state in the northern region with the highest syphilis detection rate and the fourth highest in Brazil (Brasil, 2023).
Despite Brazil having well-established, regulated, and standardized clinical protocols, the incidence of syphilis during pregnancy remains substantially high and alarming due to various economic, cultural, and social factors that hinder adequate prevention and treatment (Pinto et al., 2022).
6. CONCLUSIONS
The increasing number of syphilis cases during pregnancy can be considered a reflection of the care and assistance provided to the population. Throughout the COVID-19 pandemic, there was a high demand for health services across the country, which may have influenced a decrease in the capacity for prevention, diagnosis, and health promotion in other areas.
Although there was a decrease in the number of registered syphilis cases in Amapá in 2022, it is still early to claim that there has been an improvement in syphilis prevention strategies in the state. It is suggested that such studies be encouraged in the region to serve as a foundation for new research and to aid public agencies in decision-making.
Preventing syphilis is essential for public health, as these infections can cause severe health consequences, including small sores, body rashes, fever, and headaches, as well as skin, bone, cardiovascular, and neurological lesions. In pregnant women, it can lead to miscarriages, fetal malformations, blindness, deafness, mental disabilities, and/or death at birth.
Investment in prevention strategies such as sexual education, the use of condoms, and access to health services and regular testing is crucial to reducing the transmission of this disease. These measures also demonstrate an effective way to improve quality of life and reduce long-term treatment costs.
Epidemiological studies are fundamental for public health, as they allow the identification of patterns of disease occurrence and their risk factors in the population. Through these studies, it is possible to understand the dynamics of disease spread, evaluate the effectiveness of preventive and therapeutic interventions, and guide evidence-based health policies. This can assist in identifying vulnerable groups, monitoring outbreaks and epidemics, and promoting prevention strategies that can significantly reduce morbidity and mortality. The data obtained from this study are essential for the planning and allocation of health resources, contributing to a more efficient and equitable health system.
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NOTE
The authors used the AI ChatGPT-4 for grammatical verification and correction of the text. However, all searches for content and quality classification of the articles were conducted independently.
[1] Resident in Gynecology and Obstetrics. Graduated in Medicine from the Federal University of Amapá (UNIFAP). ORCID: https://orcid.org/0009-0007-9198-7398. Currículo Lattes: http://lattes.cnpq.br/4547211920436518.
[2] Doctor in Theory and Research of Behavior (UFPA). Master’s degree in Neurosciences and Cell Biology. ORCID: https://orcid.org/0000-0003-0840-6307. Currículo Lattes: http://lattes.cnpq.br/8303202339219096.
[3] PhD in Communication and Semiotics from the Pontifical Catholic University of São Paulo (PUC/SP). PhD in Psychology and Clinical Psychoanalysis. Master’s degree in Religious Studies from Mackenzie Presbyterian University. Master’s degree in Clinical Psychoanalysis. Bachelor’s degree in Biological Sciences. Bachelor’s degree in Theology. Has been working for over 15 years with Scientific Methodology (Research Method) in guiding scientific production for Master’s and Doctoral students. Specialist in Market Research and research focused on the health area. ORCID: https://orcid.org/0000-0003-2952-4337. Lattes: https://lattes.cnpq.br/2008995647080248.
[4] Master’s degree in Health Sciences Education. ORCID: https://orcid.org/0000-0003-2952-4337. Currículo Lattes: https://lattes.cnpq.br/2008995647080248.
[5] Advisor. PhD in Tropical Diseases. Master’s in Tropical Diseases. Specialization in Microbiology. ORCID: https://orcid.org/0000-0001-5128-8903. Currículo Lattes: http://lattes.cnpq.br/9314252766209613.
Material received: August 8, 2024.
Material approved by peers: August 28, 2024.
Edited material approved by authors: September 9, 2024.
