Congenital syphilis in Marabá (State of Pará, Brazil): epidemiological analysis of a decade

Congenital syphilis (CS) is a systemic infect contagious disease, sexually transmitted, easily diagnosed, with effective and low cost treatment. Thus, the existence of a paradox is detached, once infectious diseases of greater complexity have already been controlled. In its congenital form, syphilis in Brazil constitutes a sentry event of high magnitude that presents unfavorable indicators in terms of its control. In the State of Pará, Marabá is the municipality with the highest number of cases in the past years. The aimed of this study was describing a clinical-epidemiological profile of congenital syphilis in Marabá, from 2006 to 2015. This was a descriptive, retrospective and documental study which analyzed secondary data from SINAN/SMS/SVS/DATASUS/Marabá/PA. Between 2006 and 2015, 323 cases of CS were notified in Marabá. The incidence of congenital syphilis of 6.5 cases per 1,000 live births from 20062015 is 6.5 the Ministry of Health goal; from 2012 to 2015 the rates were 8, 9.8, 26.3 and 11.3/1,000, respectively. Most pregnant women performed prenatal (88.6%), was between 20 and 24 years old (62.2%), 26.6% did not finish Middle School. Most partners, 67.5%, of the pregnants diagnosed with did not perform treatment; in 55% of cases, the maternal syphilis diagnosis happened during labor/curettage. Congenital syphilis in Marabá overcame the highest incidence in 2014, with 26.3 cases per 1,000 live births. This great value in 2014 may be a result of the campaign “It’s possible to born without syphilis in Pará”, released by the Secretary of State for Health of Pará at the end of 2013, since in periods of huge campaigns there is an increase of notifications, due to easier access to the diagnosis of the disease. In the year of 2015, an incidence of 11.3 cases per 1,000 live births was observed, this abrupt decrease, compared to 2014, corroborates with the influence of the campaigns in the detection of new cases. The cases of congenital syphilis notified in the Municipality of Marabá demonstrated failures in the prenatal service, particularly in the time of verification of gestational syphilis and in the treatment of the partners. Received


Introduction
The sexually transmitted infections (STIs) represent a global concern because of the increasing number of cases per year (Donalísio et al., 2007). According to World Health Organization (WHO), that are about 12 millions of new cases per year, and syphilis represents a huge number of them (OMS, 2008). The syphilis is a systemic, infectious and contagious disease, sexually transmitted, with easy diagnosis, effective and inexpensive treatment. Thereby, points to the existence of a paradox, seeing that more complex contagious diseases were already control (Matthes et al., 2010).
The syphilis etiologic agent is the Treponema pallidum bacteria and the evolution of the illness has three stages: primary, secondary and tertiary, and between the two final stages occurs latency period that can last years, with absence of symptoms (WHO, 2008).
In newborns, congenital syphilis (CS) can be distinct in two stages: early and late. The early-stage happens when the sings of the disease appear until the first two years old. The late-stage happens when the symptoms appear after the second year of life. Biggest part of the live births doesn't have symptoms, however the adversities observed in those newborns include cutaneous lesion, low weight, hepatic/ splenomegaly, prematurity, respiratory distress, etc. The Ministry of Health recommended treatment includes the administration of penicillin G (crystal or procaine) and the therapeutic system changes according to the clinical conditions. The diagnosis in newborns should be done by the serology Venereal Disease Research Laboratory (VDRL), radiograph of long bones and blood and cerebrospinal fluid analysis (Brasil, 2008).
Among all the diseases that can be transmitted during the pregnancypuerperal cycle, the syphilis has the higher infections rates. Spontaneous abort, stillborn fetus or perinatal death are present in 40% of the children infected by non-treat mothers (Brasil, 2006).
The occurrence of CS demonstrates deficits in the prevention of syphilis in the public health system, mainly in the prenatal care. The serology diagnosis with VDRL of the pregnant must be requested in the 1º and 3º trimesters of pregnancy. The treatment is Epidemiology of congenital syphilis in Marabá (State of Pará, Brazil) 185 Braz. J. Biol. Sci., 2018, v. 5, No. 9, p. 183-193. done with penicillin and the therapeutic scheme is defined according to the clinical evaluation (Brasil, 2010 (Sespa, 2015).
Those indicators can be a reflection of the low quality of the prenatal care and the short importance that the health professionals give to the early diagnosis and treatment of syphilis. Stressed that the prevention of the disease is simple and unexpressive, the treatment of a child with CS is long and onerous (Damasceno et al., 2014). The treatment of the pregnant women, which should be done during the pregnancy, is also faulty, despite is available for free in Brazil's Unified Health System (Sistema Único de Saúde). Social vulnerabilities and inequality in access to health care are pointed as substantial coefficients to the prevalence of CS (Cunha and Merchan-Hamann, 2015). Brazil is a signatory of the global agreement that intended the control and eradication of syphilis until 2015. In this accordance, the incidence of congenital syphilis should be less than 0.5 cases by 1,000 newborns per year until 2015 (Brasil, 2015).
According to the numbers presented to Brazil, to State of Pará and the Municipality of Marabá, is important an epidemiological study about CS that intend to identify probable causes of the increasing in the incidence, failures that cause the vertical transmission of syphilis and to propose measures that help in the prevention, assistance and vigilance of that disease. Thus, this study may assist the Municipal Health Secretary of Marabá (Secretaria de Saúde de Marabá) in the better targeting of the congenital syphilis prevention campaigns.
The aimed of this study was provide an epidemiological study of the notified cases of congenital syphilis in the Municipality of Marabá, State of Pará, between in the period of 2006 to 2015, through the recorded data in three health information systems (SINAN, SIM and SINASC) and data from Municipal Health Secretary of Marabá.  (Brasil, 2012), that provides the guidelines to research that involves humans.

Results
During Jan. 01, 2006, andDec. 31, 2015, 323 cases of congenital syphilis (CS) were notified in Marabá, including the early and late mode and abortions caused by syphilis. The lower incidence was registered in 2006, and the highest, in 2014. The CS incidence is shown in Figure 1.   (Sespa) in the end of 2013, called "It's possible to born without syphilis in Pará" (É possível nascer no Pará sem sífilis), whereas periods of huge campaigns occurs rising in the notifications, because the greater ease in the disease's diagnosis. In 2015, that was an incidence of 11.3 per 1,000 live births and that abrupt reduction regarding 2014 corroborates with the influence of campaigns in the diagnosis of new cases (Sespa, 2013). Despite the decrease of notified cases, the CS incidence in 2015 was 11.3, a number far from the recommend by Pan American Health Organization (PAHO) and United Nations Children's Fund (UNICEF), an incidence of 0.5 cases per 1,000 live births until 2015 (Brasil, 2015).
According to the section of Epidemiological Surveillance of Marabá, many factors are responsible for the high incidence of congenital syphilis in the municipality, among them the lack of clarification of the pregnants/mothers about syphilis, a low demand by the prenatal care and the low attendance of partners, what unfeasible the effective control of this disease. According to Milanez (2016), the main problem to the control of syphilis during pregnancy is in the precarious training of health professionals, who give little importance to the disease and show difficulty to interpret lab results. The failure in the partners' treatment also is a factor to the permanency of the disease, as well as the ineffective pregnants' treatment (Milanez, 2016).
During the data analysis, the number of pregnant women who accomplish the prenatal (88.6%) overcame those who did not or those who that variable was unknown. Despite this, the number of women whose children had CS and that did not do prenatal developed, going to 1 notified case in 2011 to 22 cases in 2015. A hospital-based cohort study performed by Domingues et al. (2014), verified that North region had the second worse prenatal coverage in Brazil, a factor that may be related to cultural and socioeconomic hurdles, once the less attended groups were indigenous and low income women. Almeida (2012) verified that in State of Ceará, Northeast Brazil, about 70% of pregnant women performed prenatal and among those who did not, the main reason was unconcern, described by the pregnants in many forms: lack of time or companion, undesirable pregnancy, never had done prenatal, etc.
In 55% of cases, the diagnosis of maternal syphilis occurs during labor/curettage, a factor that dissents of the verified in Macapá (State of Amapá), where the most diagnosis occurs during prenatal (36.8%) or after delivery (35.8%) (Francisco, 2014). Lima et al. (2016) ascertain that most (62.1%) syphilis during pregnancy diagnosis were performed in prenatal. In 2015 the Municipality of Marabá showed a decrease in the number of mothers who diagnosed syphilis during prenatal, what is worrisome because this health service provides the ideal time to the diagnosis and treatment of various diseases, in addition to health promotion to the mother and the unborn. The nonaccomplished of VDRL during prenatal -pointed by the number of mothers who had the syphilis diagnosis during labor/curettage -it's contrary to the Ministry of Health, that recommend the accomplishment of two VDRL tests during pregnancy, one in the first trimester and other in the third one . Must consider that most pregnant women infected by T. pallidum are in the latency period of the disease, with absence of symptoms, being a responsibility of the health professionals require for the VDRL (Milanez, 2016).
The treponemal test is a significant factor to the syphilis diagnosis in false-positive or false-negative cases, what can happen in non-treponemal tests (Brasil, 2006). Among the pregnants/mothers who did the treponemal test, 67.0% presented reactive result and in 16.5% of cases, this test was not performed. This data is compatible with Teixeira et al. (2015).
Most of the partners (67.5%) of the pregnant women with syphilis did not perform treatment and the second most (20.6%) had this information unknown in the notification record. The number of unknowns went from zero in 2012 to 76 in 2015, increasing more than the number of partners who got treatment. Lima et al. (2017) and Souza et al. (2016) presented similar congenital syphilis data in Sobral (State of Ceará) and in Brazil, respectively. Those numbers go against gainsay of Teixeira et al. (2015) in Chapadão do Sul (State of Minas Gerais), where 50% of partners were treated with the pregnant and, among those who did not be treated, the reason was unknown. The undone partner treatment is one of the main obstacles to the of syphilis elimination because it provides reinfection of the pregnants. Studies indicates that the difficulty of partners to get involve in treatment can be related to the misunderstanding of what the disease will cause in the mother and the unborn's life or to the fact that the public health service concerns to congenital syphilis have not specific initiatives to the male public Mesquita et al., 2012).
Most of the newborns (76.0%) whose mothers had syphilis got the diagnosis of early CS, with only one case of late CS, what agrees with the epidemiology of CS in Macapá (Francisco, 2014). The smaller number of cases of late CS is probably related to the penicillin therapy, that is capable to provide a less aggressive form of the disease (Flores, 2011).
Majority of cases, 96.3%, have not neonatal death, what concurs with the CS epidemiological profile describes in current literature (Domingues and Leal, 2016;Rojas et al., 2015). The aborts for syphilis are frequently related to neurosyphilis or bone injuries, variables often ignored in the notification records (Saraceni and Leal, 2016). Researchers pointed those notifications of deaths caused CS may do not correspond with reality since little is known about the evolution of the newborn's condition after discharge (Rojas et al., 2015).
In 37.2% of cases, the neonates diagnosed with syphilis were treated with penicillin G crystal, in a therapeutic scheme of 100,000 to 150,000 Ul kg/day during 10 days. The penicillin G benzathine -administrated in the absence of symptoms and clinical, laboratorial, radiological and serological alterations -were prescribed in 23.4% of cases. Although the treatment were not performed in 15.0% of cases only, it's important to inquire the reasons that lead to this situation, because the nonaccomplished of the treatment in up to three months can cause severe damage to the child (Flores, 2011).
Regarding mothers' schooling, most (26.6%) did not finish fifth through eighth grade of Middle School, what agrees with Francisco (2014) in a study of the epidemiological profile of syphilis during pregnancy in Macapá. The low level of instruction is usually associate with low socioeconomic class, what expose the pregnant/mother to social Braz. J. Biol. Sci., 2018, v. 5, No. 9, p. 183-193. risk factors, as unemployment, chaotic urbanization and inequality (Flores, 2011;Souza and Benito, 2016). In 2015, the number of pregnant women who had finished High School overcame those who hadn't, what shows a change in the congenital syphilis epidemiological profile in Marabá. Such fact is concerning since this part of the population should have greater knowledge about Sexually Transmitted Infections (Souza and Benito, 2016). The number of unknown education developed, going from none in 2012 to 13 in 2015, a detrimental factor to the Epidemiological Surveillance and an evidence of health professionals potential default.
Most pregnants with syphilis were between 20 to 34 years old, totalizing 62.2% of notified cases. That goes against Teixeira et al. (2015) in an analysis of syphilis during pregnancy data in Chapadão do Sul (State of Mato Grosso do Sul), where most women that presented syphilis during pregnancy were 15 to 25 years old. The data found agrees with the age profile of syphilis during pregnancy in Aracaju (State of Sergipe), Fortaleza and in the State of Ceará (Almeida, 2012;Santos et al., 2016). This age range is the most fertile and with the higher numbers of gestations, what agrees with what was found in this study.
The central issue in this study was the discrepancy between the data present by the Municipal Health Secretary of Marabá and those recorded in SINAN, since those registered in a municipality level were higher than those that were available in DATASUS.  (Flores, 2011). Researchers indicate that the control of syphilis in the country still precarious, obtained less success than the control of AIDS (Acquired Immunodeficiency Syndrom). The necessary approach to that would be in a better training to the health professionals and more information and education about the disease for the population (Ramos Junior et al., 2007). In a study with mothers of child who were born with congenital syphilis, Lima et al. (2016) estimate that the low schooling and the little information provide by the health professionals about the riskiness of the T. pallidum infection were determinants to the little adhesion to treatment or incorrect treatment (Lima et al., 2016).
The presented data verified that the accomplishment of prenatal in Marabá pointed for a low resolubility of the Basic Attention concerning to women health and should be investigated, once the achievement of prenatal is usually associate with a small number of congenital syphilis cases. The nonachievement of partners' treatment pointed to the necessity of training to the Marabá Basic Attention health professionals, focused on the importance of request VDRL during prenatal, the presence of the partner and the correct fill of the syphilis notification form. Moreover, the low level of education of the pregnants/mothers indicates that improvements in the quality of life can act in a good way to decrease CS, although the educational profile change in 2015 suggests that the more educated pregnants/mothers may have not satisfactory health education and did not know the severity of CS. The data from this study can help in the elaboration of public health campaigns against syphilis and congenital syphilis that had greater accuracy, directed for the more vulnerable population groups and adjustments of the prenatal failures.

Conclusions
The findings in this study show that congenital syphilis still a huge problem in the public health of Marabá. The average incidence rates were above the national established parameter. Thus, correct notification (if it is a better quality in the notification, the numbers of cases will be closer of the real), investigation of cases, adequate treatment, implementation of measures to prevent new cases of congenital syphilis will contribute to the decrease of cases towards the elimination of this disease in Marabá.