In a decade, Brazil failed to report at least 45,000 cases of gestational syphilis, which increases the risk of vertical transmission of the disease, premature births and baby deaths.
The unprecedented estimate comes from a study published in the September edition of The Lancet Regional Health – Americas based on a statistical model that considers sociodemographic factors, indicators of access to health services and variables related to the quality of data available to evaluate records between 2007 and 2018. In relation to the total number of cases registered in the period, the underreporting rate was 13%.
The model also allowed the identification of regional disparities. The highest underreporting rates were found in the Northeast and North regions, led by Roraima, with 30%. In the South, as well as in part of the Southeast and Midwest, the states did not exceed 10%. The lowest level was detected in São Paulo, 3.59%.
For the researchers, the results show that there are flaws in the care provided to pregnant women and that the incidence and detection of gestational syphilis are associated with socioeconomic conditions and access to health services, such as adequate prenatal care.
“We are not able to adequately monitor pregnant women, catch them at the beginning of pregnancy, subject them to all the necessary tests and even guide them on how to avoid syphilis and other diseases”, says Maria Yury Ichihara, vice-coordinator of Cidacs (Center for Data and Knowledge Integration for Health), from Fiocruz Bahia, and co-coordinator of the project that gave rise to the article.
In her opinion, the bottlenecks still persist today and may have even increased. “Even though the detection system has improved, under-registration must have worsened, because there was disarticulation and disinvestment in the SUS during the period.”
Data from the Ministry of Health in fact show an increase in the number of diagnoses of all types of syphilis. In the case of pregnancy, in 2018, the detection rate was 21.5 per thousand live births and increased to 27.1 in 2021.
On the other hand, data from Previne Brasil, the federal government’s primary health care financing program, indicate that the targets for adequate prenatal care in the SUS were not met in 65% of municipalities in 2021.
One of the indicators is testing for syphilis and HIV. In 2021, just over half (57%) of pregnant women who received prenatal care in primary care took the test. In the second four months of 2023, the index was 73%. This gap is one of the factors that influence underreporting.
Even if it remains latent in the early stages, the disease can lead to skin, bone, cardiovascular and neurological damage. The consequences are the same for acquired syphilis.
Other effects are pregnancy losses, stillbirth and transmission from pregnant women to babies, called vertical transmission. “Among children born with congenital syphilis, many have changes in hearing or vision, curvature of the tibia bones, enlargement of the liver and spleen. These are children who can be born with many health problems, including neurological ones”, explains the doctor public health worker Roberta de Almeida Soares. Only part of these conditions is reversible.
For the specialist, the increase in diagnoses can be understood as an opportunity to carry out adequate treatment for pregnant women. But she recognizes that underreporting exists in both the public and private systems and adds to the challenges faced in reducing the incidence of the disease.
In terms of prevention, there is a lack of sexual education and awareness at home, at school and in health services about the importance of using condoms to avoid STIs (sexually transmitted infections). In the IBGE National Health Survey, 59% of Brazilians over 18 years of age said they did not use condoms during sexual relations. The data is from 2019.
For experts, there are still other challenges. Even with guidance, many pregnant women are unable to talk to their partners about condom use. Faced with a diagnosis, there are cases in which they are accused of cheating, especially if syphilis is in a latent phase in the partner.
The consequence is difficulty in treating partnerships, which exposes pregnant women to reinfection and fetuses to congenital syphilis.
“The non-treatment of partners is a big problem and an even more precarious point when it comes to under-registration. The study [do Cidacs] identified only one survey on filling [dos dados sobre o tratamento dos parceiros]which found less than 30% completeness?”, says Carmen Simone Grilo Diniz, professor at the Faculty of Public Health at USP.
One solution, according to her, would be to reinforce the partner’s prenatal strategy, which has been part of the National Policy for Comprehensive Men’s Health Care (PNAISH) since 2011. In August, the Ministry of Health launched the second edition of the Prenatal Guide -Partner Christmas for healthcare professionals. Even though she views the measure favorably, she states that it is necessary to include educational and health promotion activities in the budgets.
For Soares, from Unifesp, education and continuing training measures for professionals are also important to keep them up to date with best practices and protocols, keeping them able to act in the face of the complexity of syphilis cases.
This report was produced during Folha’s 8th Training Program in Science and Health Journalism, which has the support of the Serrapilheira Institute, the Roche Laboratory and the Sociedade Beneficente Israelita Brasileira Albert Einstein