Abstract

The aim of this article is to evaluate the conditions of Primary Care (PC) services in Brazil as regards the availability of quick tests (QTs) for early diagnoses and of Benzylpenicillin (BZP) for the treatment of pregnant women with syphilis. This was a cross-sectional study, conducted with data from PC services that participated in the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB, in Portuguese). The services where QTs were not readily available or where BZP was not available in a sufficient quantity were categorized as “inadequate”, while those where the QTs were readily available and BZP was found in sufficient quantities were categorized as “adequate”. A bivariate analysis and Odds Ratio (OR) estimates, together with their respective 95% confidence intervals (CI), were performed. The sample included 20,286 PC services from regions throughout the country. The prevalence of services with inadequate conditions for the diagnosis and treatment of syphilis was 47.7%. The Midwest region and non-capital cities presented the highest prevalence rates for PC services with inadequate conditions for the diagnosis and treatment of syphilis in pregnant women (p<0.05). Differences in the regions and locations of the PC services impact the availability of QTs and BZP.

Key words:
Syphilis congenital; Maternal and Child Health; Primary Health Care; Quality of Health Care

Introduction

Congenital syphilis, an infectious disease caused by Treponema Pallidum and transmitted vertically from the pregnant woman to the fetus, can cause an abortion, premature births, or even late sequelae that can compromise the child´s full development¹1 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapeuticas para Atenção às Pessoas com Infecções Sexualmente Transmissíveis (IST). Brasília: MS; 2020.. It is estimated that some 930,000 cases of congenital syphilis are reported yearly around the world, resulting in approximately 350,000 adverse outcomes to births, with the majority occurring in low to middle income countries²2 Organizacion Mundial de la Salud (OMS). 2018 Report on global sexually transmitted infection surveillance. Geneva: WHO; 2018.^,33 Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, Mahiané SG, Ishikawa N, Le LV, Newman-Owiredu M, Nagelkerke N, Newman L, Kamb M, Broutet N, Taylor MM. Global burden of maternal and congenital syphilis and associated adverse birth outcomes - Estimates for 2016 and progress since 2012. PLoS One 2019; 14:e0211720.. Considering the rate of high morbidity-mortality and of clinical repercussions of syphilis of the mother to the fetus¹1 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapeuticas para Atenção às Pessoas com Infecções Sexualmente Transmissíveis (IST). Brasília: MS; 2020.^,44 Ozelame JÉEP, Frota OP, Ferreira Júnior MA, Teston EF. Vulnerabilidade à sífilis gestacional e congênita: uma análise de 11 anos. Rev Enferm UERJ 2020; 28:50487., the World Health Organization (WHO) has set forth strategies to ensure the diagnosis and the treatment of pregnant women with syphilis in an attempt to reduce the rates of congenital syphilis to less than 50 cases per 1,000 live births in at least 80% of the countries worldwide by 2030²2 Organizacion Mundial de la Salud (OMS). 2018 Report on global sexually transmitted infection surveillance. Geneva: WHO; 2018..

In Brazil, the Ministry of Health has adopted strategies to improve the surveillance of syphilis in pregnant women by expanding the access to and the supply of quick tests (QTs)for diagnoses and the tracking of Sexually Transmitted Infections (STIs) in the scope of Primary Care (PC) services¹1 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapeuticas para Atenção às Pessoas com Infecções Sexualmente Transmissíveis (IST). Brasília: MS; 2020.. The QTs for the syphilis screening are of easy application and of low operational cost; they do not require a laboratory infrastructure; and they can be applied during pre-natal appointments¹1 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapeuticas para Atenção às Pessoas com Infecções Sexualmente Transmissíveis (IST). Brasília: MS; 2020.. In addition to the support provided to diagnoses, the Ministry of Health has made benzathine benzylpenicillinavailable within PC services for the treatment of pregnant women and their sexual partners, which is the only effective medicine for the prevention of the vertical transmission of syphilis⁵5 Padovani C, Oliveira RR, Pelloso SM. Sífilis na gestação: associação das características maternas e perinatais em região do sul do Brasil. Rev Lat Am Enferm 2018; 26:e3019.. The combination of support strategies for the diagnosis and treatment of syphilis during pre-natal care in the realm of Primary Health Care increases the chances of success in the treatment of congenital syphilis and reduces the exposure of the fetus to Treponema pallidum¹1 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapeuticas para Atenção às Pessoas com Infecções Sexualmente Transmissíveis (IST). Brasília: MS; 2020.^,66 Saraceni V, Pereira GFM, Silveira MF, Araujo MAL, Miranda AE. Vigilância epidemiológica da transmissão vertical da sífilis: dados de seis unidades federativas no Brasil. Rev Panam Salud Publica 2017; 41:1-8..

Despite the strategies adopted by the Ministry of Health for the improvements in the surveillance of syphilis in pregnant women, from 2009 to 2019, the rate of congenital syphilis in Brazil went from 2.1 to 9.0 cases per 1,000 live births, but showed regional differences⁷7 Brasil. Boletim Epidemiológico de Sífilis. 1ª ed. Brasília: MS; 2020.. In 2019, the rates of congenital syphilis above the national average were recorded in the South and Southeast regions, which reached 8.2 cases per 1,000 live births⁷7 Brasil. Boletim Epidemiológico de Sífilis. 1ª ed. Brasília: MS; 2020.. The increase in the number of health centers over the past 30 years in Brazil, along with the increase in the population’s coverage provided by the Family Health Strategy and PC teams, has expanded the population’s access to health services, but the regional inequalities in the healthcare structures still persist⁸8 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6):1751-1762.

9 Soares Neto JJ, Machado MH, Alves CB. O programa Mais Médicos, a infraestrutura das unidades básicas de saúde e o Índice de desenvolvimento humano municipal. Cien Saude Colet 2016; 21(9):2709-2718.^-1010 Neves TCCL, Montenegro LAA, Bittencourt SDA. Produção e registro de informações em saúde no Brasil: panorama descritivo através do PMAQ-AB. Saude Debate 2014; 38:756-770.. Considering that the progressive precarious nature of the PC services can impact the access of pregnant women who reside in the coverage area to these services¹¹11 Vieira EW, Pimenta AM, Montenegro LC, Silva TMR. Structure and location of vaccination services influence the availability of the triple viral in Brazil. Reme Rev Min Enferm 2020; 24:1-6. and that the regional inequalities in the allocation of resources and investments in the health sector¹²12 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20:S190-S198. can be compromised by both the population’s supply and access to syphilis screening, the present study aims to evaluate the conditions of PC services in Brazil as regards the availability of QTs for diagnoses and of benzathine benzylpenicillin for the treatment of syphilis in pregnant women.

Methods

This was a cross-sectional, multicenter, and nationwide study, conducted with secondary data from the PC services that participated in the third cycle of external assessments of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB, in Portuguese), from the Ministry of Health¹³13 Brasil. Ministério da Saúde (MS). Programa de Melhoria do Acesso e da Qualidade - Manual Instrutivo para as Equipes de Atenção Básica e Nasf. Brasília: MS; 2017.. The PMAQ-AB was created in 2011 in order to improve the Unified Health System (SUS, in Portuguese), aimed at expanding access to and the quality of PC¹³13 Brasil. Ministério da Saúde (MS). Programa de Melhoria do Acesso e da Qualidade - Manual Instrutivo para as Equipes de Atenção Básica e Nasf. Brasília: MS; 2017..

Data collection from the third cycle of external assessments of PMAQ-AB took place from January to December 2017, and from May to August 2018, including 30,347 PC services, corresponding to 95.36% of all PC services, located in 5,324 Brazilian municipalities (95.6%)¹³13 Brasil. Ministério da Saúde (MS). Programa de Melhoria do Acesso e da Qualidade - Manual Instrutivo para as Equipes de Atenção Básica e Nasf. Brasília: MS; 2017.. As regards regional distribution, 2,255 of the services that participated in the third cycle of external assessment of the PMAQ-AB were located in the North region, corresponding to 94.6% of the total number of services rendered in this region, as compared to 12,048 (95.6%) in the Northeast; 2,145 (96.2%) in the Midwest; 8,331 (94.7%) in the Southeast, and 4,160 (95.8%) in the South¹⁴14 Meloni DR. Estratégias organizacionais para o acesso e integralidade da assistência na atenção primária à saúde [tese]. Ribeirão Preto: Faculdade de Medicina de Ribeirão Preto; 2020..

The databank was formulated by the Ministry of Health and organized in modules: Modules I, II, and III, of which, in the present study, Module I was used for its data related to the conditions of infrastructure, materials, inputs, and medicines from Primary Health Care¹³13 Brasil. Ministério da Saúde (MS). Programa de Melhoria do Acesso e da Qualidade - Manual Instrutivo para as Equipes de Atenção Básica e Nasf. Brasília: MS; 2017.. The data from this module were collected, with a structured questionnaire applied in-person to the professional responsible for the evaluated service. Guided inspections and verification of service records were also carried out in an attempt to verify the information provided in the questionnaire. The resulting data of these two processes were organized and tabulated in Microsoft Excel 2016 and are of open access, available at: https://aps.saude.gov.br/ape/pmaq. The assessment of data consistency after data collection was conducted by the higher education institutions and partner research groups, under the coordination of the Primary Health Care Department of the Ministry of Health¹³13 Brasil. Ministério da Saúde (MS). Programa de Melhoria do Acesso e da Qualidade - Manual Instrutivo para as Equipes de Atenção Básica e Nasf. Brasília: MS; 2017..

The following questions were selected in Module I (1) Was the benzathine benzylpenicillin sufficient? (2) Was the quick test for syphilis always available?, together with the possible answers: yes/no. To answer the questions of this study, the following variable was created: “inadequate conditions for the diagnosis and treatment of syphilis”, through questions 1 and 2, in the following manner: the services that presented benzathine benzylpenicillin in sufficient quantity and available QTs for syphilis were categorized as “no”, as they presented adequate conditions of diagnosis and treatment for syphilis. The services that have available access to QTs for syphilis and/or did not have a sufficient quantity of benzathine benzylpenicillin were categorized as “yes”, as they presented inadequate conditions for diagnosis and treatment (Chart 1).

The independent variables of this study were chosen based on previous studies and according to theoretical criteria¹⁵15 Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Toledo Vianna RP. Relationship between the supply of syphilis diagnosis and treatment in primary care and incidence of gestational and congenital syphilis. Cad Saude Publica 2020; 36(3):e00074519.. The geographic and location characteristics of the PC services included in this study were: Capitals (Yes/No), States of the Federation and the Federal District, and regions (North, Northeast, South, Southeast, and Midwest).

Excluded from this study were: 1) services that did not answer Module I of the PMAQ-AB and 2) services that did not provide Benzylpenicillin. As such, 20,286 PC services were included (Figure 1).

The data from Module I of the PMAQ-AB were transferred to the Statistical Package for the Social Science (SPSS), version 20.0, and were submitted to statistical analysis. For the analysis, the Statistical Package for the Social Sciences, version 26, was used. First, the conditions for the diagnosis and treatment of syphilis in the services that participated in the PMAQ-AB were analyzed, according to geographic characteristics, considering absolute and relative frequencies. Next, a bivariate analysis was performed to show the differences between the prevalence of services with inadequate conditions for the diagnosis and/or treatment of syphilis and the independent variable by means of the Pearson Chi-squared test and 95% confidence interval (95%CI). In all of the analyses, a 5% statistical significance was adopted (p≤0.05).

Results

The sample included 20,286 PC services from five regions of Brazil, most of which were located in the Northeast Region (50.4%) and in municipalities that were not capitals of the states or the Federal District (91.3%). As regards the diagnosis and treatment of syphilis, 47.7% of the services did not have a sufficient quantity of benzathine benzylpenicillin and/or did not have readily available QTs for syphilis, with the Midwest region and the non-capital cities being responsible for the highest prevalence of PC services with inadequate conditions for the diagnosis and/or treatment of syphilis (p<0.05) (Table 1).

In the bivariate analysis, the North, Northeast, Midwest, and Southeast regions presented a higher probability of providing services with inadequate conditions for the diagnosis and treatment of syphilis than those of the South region. The Midwest stood out, showing a 1.87-fold (95%CI 1.62-1.91) greater chance of providing services with inadequate conditions when compared to the South Region (p<0.05) (Table 2). The ranking of the states with a greater percentage of services with inadequate conditions for the diagnosis and/or treatment of syphilis in Brazil is shown in Figure 2.

The states of the North region presented the chance of services with inadequate conditions for the diagnosis and/or treatment of syphilis that varied from 3.17 (95%CI 1.46-6.85) in the state of Roraima to 9.80 (95%CI 4.58-20.95) in the state of Acre (p<0.05).

In the Northeast region, all of the states presented a probability of services with inadequate conditions for the diagnosis and/or treatment of syphilis that was higher than that of the state of Sergipe, with the state of Piauí presenting a 5.07 (95%CI 3.79-6.78) chance of services with inadequate conditions for the diagnosis and/or treatment of syphilis when compared to the state of Sergipe (p<0.001).

In the South region, only the state of Paraná presented a statistically significant chance of services with inadequate conditions for the diagnosis and/or treatment of syphilis when compared to the state of Santa Catarina, corresponding to 2.46 (95%CI 2.07-2.93) (p<0.001).

When the location of PC services was evaluated, those that were not located in capital cities presented a 1.70 (95%CI 1.53-1.88) chance of inadequate conditions for the diagnosis and/or treatment of syphilis when compared to those located in capital cities (p<0.001).

Discussion

In this study, 20,286 PC services from throughout Brazil were evaluated, of which 47.7% presented inadequate conditions for the diagnosis and/or treatment of syphilis in pregnant women, with 52.3% of these located in the Midwest and 48.8% in non-capital cities.

In Brazil, the pre-natal follow-up of pregnant women is performed in PC services and the progressive precarious nature of these services can impact the diagnosis and treatment of syphilis in pregnant women¹⁵15 Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Toledo Vianna RP. Relationship between the supply of syphilis diagnosis and treatment in primary care and incidence of gestational and congenital syphilis. Cad Saude Publica 2020; 36(3):e00074519.. The increase in the number of health clinics and centers in the last 30 years, along with the increase in the population’s coverage by the Family Health Strategy and PC teams, has expanded the access of the population to these services; however, the regional inequalities of the healthcare structure still persist⁸8 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6):1751-1762.

9 Soares Neto JJ, Machado MH, Alves CB. O programa Mais Médicos, a infraestrutura das unidades básicas de saúde e o Índice de desenvolvimento humano municipal. Cien Saude Colet 2016; 21(9):2709-2718.^-1010 Neves TCCL, Montenegro LAA, Bittencourt SDA. Produção e registro de informações em saúde no Brasil: panorama descritivo através do PMAQ-AB. Saude Debate 2014; 38:756-770..

In this study, the North and Midwest regions presented a proportion of services with inadequate conditions for the diagnosis and/or treatment of syphilis that was higher than those with adequate conditions. The regional differences in the availability of the diagnosis and/or treatment of syphilis in pregnant women in PC services was pointed out by a cross-sectional study with data from cycle II of the PMAQ-AB, which analyzed the relationship among the offers of the diagnosis and/or treatment of syphilis in PCs¹⁵15 Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Toledo Vianna RP. Relationship between the supply of syphilis diagnosis and treatment in primary care and incidence of gestational and congenital syphilis. Cad Saude Publica 2020; 36(3):e00074519.. In 41.9% of the evaluated municipalities, more than 50% of the PC service teams reported the administration of benzathine benzylpenicillin, varying from 73.12% in the North to 22.71% in the Southeast. As regards the QT, most of the teams affirmed that they performed QTs for syphilis, with the lowest frequency identified in the Southeast (56.61%) and the highest in the North (83.87%)¹⁵15 Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Toledo Vianna RP. Relationship between the supply of syphilis diagnosis and treatment in primary care and incidence of gestational and congenital syphilis. Cad Saude Publica 2020; 36(3):e00074519.. These results differ from the results found by this study and which point out the South region with the highest proportion of QTs and treatment of syphilis in pregnant women among all of the regions of Brazil. This difference between the results of the studies is possibly associated with the differences of the methodological design adopted by the studies.

Although the regional and municipal inequalities of structure and access to PC services are historical and significant⁸8 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6):1751-1762.^,99 Soares Neto JJ, Machado MH, Alves CB. O programa Mais Médicos, a infraestrutura das unidades básicas de saúde e o Índice de desenvolvimento humano municipal. Cien Saude Colet 2016; 21(9):2709-2718., epidemiological studies about congenital syphilis have been limited to individual and family-related factors, associated with the rates of syphilis in pregnant women or congenital syphilis¹⁶16 Domingues RMSM, Leal MC. Incidência de sífilis congênita e fatores associados à transmissão vertical da sífilis: dados do estudo Nascer no Brasil. Cad Saude Publica 2016; 32(6):S0102-311X2016000605002.^,1717 Dallé J, Baumgarten VZ, Ramos MC, et al. Maternal syphilis and accomplishing sexual partner treatment: still a huge gap. Int J STD AIDS 2016; 28(9):876-880.. This was a cross-sectional study, conducted with data from the PMAQ-AB and from the Live Birth Information System, which evaluated the adequacy of the pre-natal care provided in Brazilian capital cities with the diagnosis of gestational syphilis and pointed out that the diagnosis of syphilis was more prevalent among pregnant women in vulnerable situations, women with a low level of education, non-whites, and teenagers¹⁸18 Benzaken AS, Pereira GFM, Cunha ARC, Souza FMA, Saraceni V. Adequacy of prenatal care, diagnosis and treatment of syphilis in pregnancy: a study with open data from Brazilian state capitals. Cad Saude Publica 2019; 36:e00057219.. As regards congenital syphilis, the proportion was seven times greater in the group that did not undergo any pre-natal care, when compared to the population as a whole¹⁸18 Benzaken AS, Pereira GFM, Cunha ARC, Souza FMA, Saraceni V. Adequacy of prenatal care, diagnosis and treatment of syphilis in pregnancy: a study with open data from Brazilian state capitals. Cad Saude Publica 2019; 36:e00057219..

In this study, most of the Brazilian states presented a high prevalence of PC services with inadequate conditions for the diagnosis and treatment of syphilis, thus hindering the early identification and opportune treatment of the pregnant women with syphilis. One study, which evaluated the relationship between the providing of the diagnosis and treatment of syphilis in PC services and the incidences of gestational and congenital syphilis, revealed that the incidence of gestational syphilis was higher in municipalities with a greater number of available QTs, highlighting the increase in the capacity to detect syphilis when the municipality had a greater access to the diagnosis⁸8 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6):1751-1762.. As regards congenital syphilis, this study observed a drop in vertical transmission among the teams with access to QTs and penicillin, demonstrating the relationship of these actions with the fall in rates of congenital syphilis in the evaluated municipalities¹⁵15 Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Toledo Vianna RP. Relationship between the supply of syphilis diagnosis and treatment in primary care and incidence of gestational and congenital syphilis. Cad Saude Publica 2020; 36(3):e00074519..

In addition to the availability of benzathine benzylpenicillin within the PC services, it is important to note the refusal on the part of health professionals to apply this medicine, alleging the lack of technical and human resources in the PC services to provide medical care in the case of anaphylactic reactions associated with benzathine benzylpenicillin. In 2017, the Federal Nursing Council authorized the application of benzathine benzylpenicillin within PC services¹⁹19 Conselho Federal de Enfermagem (COFEN). Parecer Normativo Nº 003/2017/COFEN [Internet]. 2017 [acessado 2021 out 6]. Disponível em: http://www.cofen.gov.br/parecer-normativo-no-0032017_51061.html.
http://www.cofen.gov.br/parecer-normativ... . Another reason for the non-administration of benzathine benzylpenicillin in PC services may well be related to this medicine’s lack of supply in 2014. Through a Technical Note, the Ministry of Health communicated the emergency acquisition and distribution of penicillin as of the first semester of 2016²⁰20 Brasil. Ministério da Saúde (MS). Nota Informativa no 006/2016 - GAB/DDAHV/SVS/MS [Internet]. 2016 [acessado 2021 out 6]. Disponível em: http://www.aids.gov.br/pt-br/legislacao/nota-informativa-no-0062016-gabddahvsvsms.
http://www.aids.gov.br/pt-br/legislacao/... ^,2121 Brasil. Ministério da Saúde (MS). Agenda de Ações Estratégicas para Redução da Sífilis no Brasil/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. 1ª ed. Brasília: MS; 20217., which may have impacted the availability of benzathine benzylpenicillin within the PC services at the time of the data collection from cycle III of the PMAQ-AB.

In the rural areas, the health services are often located far from the residencies of the population, which can add an additional cost for transport, make the access to the services difficult, and result in a lower demand for health services²²22 Esposti CDD, Santos-Neto ET, Oliveira AE, Travassos C, Pinheiro RS. Desigualdades sociais e geográficas no desempenho da assistência pré-natal de uma Região Metropolitana do Brasil. Cien Saude Colet 2020; 25(5):1735-1750.^,2323 Arruda NM, Maia AG, Alves LC. Inequality in access to health services between urban and rural areas in Brazil: A disaggregation of factors from 1998 to 2008. Cad Saude Publica 2018; 34(6):e00213816. Moreover, the scarcity in the supply of health services in rural areas reflects the historical inequalities in the allocation of resources earmarked for health in Brazil²³23 Arruda NM, Maia AG, Alves LC. Inequality in access to health services between urban and rural areas in Brazil: A disaggregation of factors from 1998 to 2008. Cad Saude Publica 2018; 34(6):e00213816, which runs in line with the results found in the present study, since the PC services that are not located in capital cities presented greater chances of inadequate conditions for the diagnosis and treatment of syphilis in pregnant women when compared to the services located in capital cities.

Finally, it is important to highlight the limitation inherent to the nature of the analysis of secondary data, since the available data were not collected specifically to answer the questions of this study; therefore, some variables that were not collected or are omitted from the databank could have been useful in formulating a better comprehension of the object of this study. Nevertheless, it is important to note the accuracy in the data collection from the PMAQ-AB of the Ministry of Health, the use of a nationwide database, and the large sample size in this study.

It is important to mention that the differences in the regions and locations of the PC services impact the availability of the QTs and of benzathine benzylpenicillin, which compromise the diagnosis and treatment of syphilis in pregnant women. The results of this study therefore reinforce the need for strategies to conduct the proper diagnosis and treatment of syphilis in pregnant women within PC services in an attempt to reduce the vertical transmission of syphilis.

References

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History