Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis

Acquired syphilis in older people in Brazil from 2010-2020

BACKGROUND

The infection caused by Treponema pallidum remains a severe public health problem, with a high prevalence in individuals over 60 years. However, research into infections such as syphilis continues to be neglected in geriatrics. This study aims to evaluate data on the detection rate of syphilis in Brazil, in individuals between 60 and 120 years, by characterizing the epidemiological profile and respective factors associated with it, in addition to performing a temporal trend analysis, from 2010 to 2020.

METHODOLOGY

Ecological, time-series study, which started with the collection of notifications from the database of the Information System on Compulsory Notification of Diseases. The epidemiological profile was characterized based on sociodemographic variables. The Statistical Package for the Social Sciences program, version 19.0, was used for incidence and prevalence analysis. The 2010 census by the Brazilian Institute of Geography and Statistics and projections for older people were considered. In the trend analysis, the Joinpoint regression model was used.

MAIN FINDINGS

There was an upward variation in the detection of syphilis in older people from 2010 to 2018, with a peak in 2018. In 2019, there was a slight reduction in the notification of cases, which was accentuated in 2020. The prevalence of the infection was equivalent to 12.84 cases for each 100,000 Brazilians, with a mean age of 68.04 years (±7.15) for those between 60 and 120 years, being higher in white and black males. The highest proportion of older people with syphilis occurred in the South and Southeast regions. However, the trend analysis showed a significant and homogeneous increase in all regions of Brazil, for both sexes and all age groups.

CONCLUSIONS

There is a tendency for an increase in cases of syphilis in older people, which reinforces the need to plan health actions to combat the disease in this population.

Syphilis in pregnancy and adverse birth outcomes: A nationwide longitudinal study in Brazil

OBJECTIVE

The present study aimed to evaluate the association between syphilis in pregnancy and low birth weight, small for gestational age, and preterm birth.

METHODS

This longitudinal study used Brazilian National Information System for livebirths (SINASC) linked to the gestational syphilis cases from Notifiable Diseases Information System (SINAN) from 2011 to 2017. Descriptive statistics and logistic regression were used to compare the birth outcomes of pregnant women with and without syphilis. The study protocol was approved by the Research Ethics Committee of the Institute of Collective Health of the Federal University of Bahia (CAAE: registration no. 18022319.4.0000.5030).

RESULTS

A total of 17 930 817 live births were included in the study. Of these, 155 214 (8.7/1000) were exposed to syphilis during pregnancy. Maternal syphilis increased the odds of low birth weight (aOR 1.88, 95% CI: 1.85-1.91), small for gestational age (aOR 1.53, 95% CI: 1.51-1.56), and preterm birth (aOR 1.35, 95% CI: 1.33-1.37). Higher odds were observed for pregnant women with VDRL titer ≥64 and untreated maternal syphilis when compared to mothers without syphilis. Analysis stratified by prenatal care showed higher odds for all adverse birth outcomes for mothers attending ≤6 prenatal appointments.

CONCLUSION

Our findings showed a strong association between gestational syphilis and adverse birth outcomes with increased odds observed among women with higher VDRL titers, lack of treatment, and fewer prenatal appointments. These results highlight the need for adequate screening and treatment for gestational syphilis during pregnancy to mitigate the risk of adverse birth outcomes.

Cerebrospinal fluid CXCL13 concentration for diagnosis and monitoring of neurosyphilis in people with HIV

OBJECTIVES

The study aimed to assess and compare cerebrospinal fluid (CSF)-CXCL13 levels in People with HIV (PWH) with suspected neurosyphilis (NS), those with syphilis but without NS, and patients without treponema infection. Additionally, it aimed to evaluate changes in CSF-CXCL13 concentrations before and after antibiotic treatment.

DESIGN

This was a prospective cohort study involving 93 PWH suspected of NS. All participants underwent lumbar puncture, with CSF-CXCL13 levels measured at baseline and during follow-up in patients diagnosed with NS.

METHODS

CSF-CXCL13 levels were quantified using ELISA. The Mann-Whitney U test was used to analyze differences between groups, while the Wilcoxon test assessed within subject changes. ROC curve analysis determined the diagnostic efficacy of CSF-CXCL13 for NS.

RESULTS

Significantly higher CSF-CXCL13 levels were observed in patients with NS compared to those with syphilis without NS and non-syphilis patients. Posttreatment, a decline in CSF-CXCL13 levels was noted in all NS cases. A CSF-CXCL13 threshold exceeding 60.0 pg/ml, in conjunction with reactive CSF-FTA-ABS, yielded a sensitivity of 88.9% and a specificity of 97.6% for NS diagnosis.

CONCLUSIONS

CSF-CXCL13 emerges as a valuable adjunctive biomarker for detecting NS in PWH, especially in cases with nonreactive CSF-VDRL. Monitoring CSF-CXCL13 levels also appears effective in evaluating therapeutic response in PWH undergoing NS treatment.

Epidemiology of Syphilis in Pregnancy and Congenital Syphilis in Brazil and the Risk or Associated Factors: Protocol for a Systematic Review

BACKGROUND

Syphilis in pregnancy and congenital syphilis are growing public health issues worldwide. Several factors can influence their occurrence in the population. Therefore, understanding the epidemiology of this condition and the factors that influence its occurrence is fundamental for decision-making by clinicians and health managers. However, so far, no systematic review has summarized and analyzed data on the incidence, prevalence, and predictors of these diseases in Brazilian cities, considering different sociocultural, demographic, economic, sanitary, and spatial-temporal characteristics presented across locations.

OBJECTIVE

We propose a systematic review protocol to gather and analyze data on the incidence, prevalence, and risk or associated factors of syphilis in pregnancy and congenital syphilis in Brazil, taking into account different local or regional contexts.

METHODS

Searches will be conducted in CINAHL, MEDLINE, LILACS, Embase, and Web of Science databases. We will include observational studies (ie, cross-sectional, longitudinal, or case-control studies), analyzing the incidence, prevalence, and risk or associated factors of syphilis in pregnancy and congenital syphilis in Brazil from primary data. The diagnosed syphilis will be assessed based on direct pathogen detection tests or through immunological, treponemal or nontreponemal tests, following Brazilian protocols for diagnosing syphilis. The studies are currently undergoing screening in the databases, and after this step, 2 reviewers will perform all identified documents. The Newcastle-Ottawa Scale and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) system will be used to assess methodological quality and quality of evidence of studies, respectively. The Kappa coefficient will assess the agreement between researchers in each study stage. Cochran Q test will assess the heterogeneity among studies. Then, a random-effects meta-analysis will be performed.

RESULTS

Results will be discussed based on subgroup analysis, which is as follows: (1) type of syphilis (in pregnancy or congenital), (2) type of study (case-control and cross-sectional studies for analysis of associated factors and longitudinal studies for risk factors), and (3) contextual factors (ie, region of country, socioeconomic and demographic characteristics, and year of study). This systematic review is expected to be completed by December 2023, and our results will be disseminated through publication in peer-reviewed journals and scientific events.

CONCLUSIONS

This systematic review aims to assist health care managers and professionals in their decision-making to control these diseases in Brazil, considering location heterogeneity. Furthermore, countries with health systems and demographic and socioeconomic contexts similar to those of Brazil may benefit from this information.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50702.

Social and individual vulnerability factors associated with syphilis among populations living on islands in the Brazilian Amazon

BACKGROUND

The repercussions of the syphilis epidemic differ according to populations. Identifying and acknowledging the differences and specificities of populations is fundamental in the design and implementation of policies aimed at assisting the groups most vulnerable to syphilis.

OBJECTIVE

To estimate the prevalence of antibodies against Treponema pallidum and associated vulnerability factors among riverside populations of a capital city in the Brazilian Amazon.

METHODS

Cross-sectional study was conducted among residents of the periurban islands in Belém, northern Brazil, from August 2020 to January 2021. The inclusion criterion was being a resident of the riverside communities of the Combú Environmental Protection Area, aged 18 years or over. The participants responded to questionnaire and were tested for syphilis using rapid test. Data were analyzed using multiple logistic regression by Minitab version 20® software.

RESULTS

Overall, a total of 325 riverine were included. Age varied from 18 to 91 years (average 40 years). Prevalence of markers for syphilis was 5.9% (95% CI: 3.3%-8.4%). The multiple regression showed that as age increases, the chances of having syphilis also increase (p = 0.001; aOR: 1.04) and riverside dwellers with more than one sexual partner in the last 6 months had more than four chances of having syphilis compared to people who had only one sexual partner (p = 0.007; aOR: 4.20).

CONCLUSION

Syphilis circulates among traditional populations in the Amazon and is associated with factors of social and individual vulnerability.

Hospitalizations for congenital syphilis in children under one year old in the state of Pará, Brazilian Amazon: ecological study

BACKGROUND

The high incidence of congenital syphilis shows flaws in the resolution of primary health care, being a predictor of greater use of hospital services, whose regional differences in access to health actions and services may be reflected in health inequalities.

OBJECTIVE

to investigate hospitalizations due to congenital syphilis in children under one year of age, in the state of Pará, Brazilian Amazon.

METHODS

an ecological study was carried out, using hospitalization, lethality and mortality rates related to congenital syphilis in children under one year of age. Temporal analysis and mapping of hospitalization flows were carried out using Joinpoint®, version 4.7.0.0, Terraview 4.2.2, Tabwin 4.1.5.

RESULTS

A total of 6,487 hospitalizations were recorded. For the ten years of the study period (2009 to 2018), the lethality rate showed a decreasing trend of - 13.5% (p = 0.01). The crude hospitalization rate showed an increasing trend of 12.8% (p < 0.000. The regression analysis demonstrated that there was a change point in the trend with a significant growth of 12.8% until 2016 (p = 0.0006). In the mortality rate the trend was stable (p = 0.56). The analysis of hospitalization care flows made it possible to identify that most hospitalizations due to congenital syphilis occurred in the municipalities of residence, but 1,378 (21.2%) had to move. Two large care gaps were highlighted in Metropolitan health regions II and III, belonging to macroregion II. The hospitalizations of residents of these regions were carried out by the assistance networks of Belém (capital) and Marituba, both of which are part of Metropolitana I. Residents of macroregions III and IV had the greatest distances traveled to access hospital care.

CONCLUSIONS

The increase in the rate of hospitalizations with an increasing trend demonstrates the impact that syphilis still causes in Brazil, not being resolved even after national government interventions in primary health care, but there was a decreasing trend in the fatality rate. The results demonstrate a heterogeneous organization of health care networks in the state's health regions and macroregions.

Diagnosis of neurosyphilis in HIV-negative patients with syphilis: development, validation, and clinical utility of a suite of machine learning models

Background

The ability to accurately identify the absolute risk of neurosyphilis diagnosis for patients with syphilis would allow preventative and therapeutic interventions to be delivered to patients at high-risk, sparing patients at low-risk from unnecessary care. We aimed to develop, validate, and evaluate the clinical utility of simplified clinical diagnostic models for neurosyphilis diagnosis in HIV-negative patients with syphilis.

Methods

We searched PubMed, China National Knowledge Infrastructure and UpToDate for publications about neurosyphilis diagnostic guidelines in English or Chinese from database inception until March 15, 2023. We developed and validated machine learning models with a uniform set of predictors based on six authoritative diagnostic guidelines across four continents to predict neurosyphilis using routinely collected data from real-world clinical practice in China and the United States (through the Dermatology Hospital of Southern Medical University in Guangzhou [659 recruited between August 2012 and March 2022, treated as Development cohort], the Beijing Youan Hospital of Capital Medical University in Beijng [480 recruited between December 2013 and April 2021, treated as External cohort 1], the Zhongshan Hospital of Xiamen University in Xiamen [493 recruited between November 2005 and November 2021, treated as External cohort 2] from China, and University of Washington School of Medicine in Seattle [16 recruited between September 2002 and April 2014, treated as External cohort 3] from United States). We included all these patients with syphilis into our analysis, and no patients were further excluded. We trained eXtreme gradient boosting (XGBoost) models to predict the diagnostic outcome of neurosyphilis according to each diagnostic guideline in two scenarios, respectively. Model performance was measured through both internal and external validation in terms of discrimination and calibration, and clinical utility was evaluated using decision curve analysis.

Findings

The final simplified clinical diagnostic models included neurological symptoms, cerebrospinal fluid (CSF) protein, CSF white blood cell, and CSF venereal disease research laboratory test/rapid plasma reagin. The models showed good calibration with rescaled Brier score of 0.99 (95% CI 0.98-1.00) and excellent discrimination (the minimum value of area under the receiver operating characteristic curve, 0.84; 95% CI 0.81-0.88) when externally validated. Decision curve analysis demonstrated that the models were useful across a range of neurosyphilis probability thresholds between 0.33 and 0.66 compared to the alternatives of managing all patients with syphilis as if they do or do not have neurosyphilis.

Interpretation

The simplified clinical diagnostic models comprised of readily available data show good performance, are generalisable across clinical settings, and have clinical utility over a broad range of probability thresholds. The models with a uniform set of predictors can simplify the sophisticated clinical diagnosis of neurosyphilis, and guide decisions on delivery of neurosyphilis health-care, ultimately, support accurate diagnosis and necessary treatment.

Funding

The Natural Science Foundation of China General Program, Health Appropriate Technology Promotion Project of Guangdong Medical Research Foundation, Department of Science and technology of Guangdong Province Xinjiang Rural Science and Technology（Special Commissioner）Project, Southern Medical University Clinical Research Nursery Garden Project, Beijing Municipal Administration of Hospitals Incubating Program.

Determinants of gestational syphilis among women attending prenatal care programs in the Brazilian Amazon

Background

There was a high proportion of pregnant women who were attending prenatal care who were not tested for syphilis or tested but not treated, among priority countries. The coverage for prenatal care visits, syphilis screening, and treatment are priority indicators for monitoring of the elimination of syphilis. The aim was to determine the factors associated with gestational syphilis among postpartum women who were in a prenatal care program in the Brazilian Amazon.

Methods

An unmatched case-control study was conducted at the hospital in Brazil. Data collection was carried out from November 2020 to July 2021 during hospitalization using a pretested structured questionnaire. The criteria for selection of cases and control followed the guidelines established by the Ministry of Health of Brazil; postpartum women with a laboratory diagnosis based on treponemal and/or nontreponemal tests, symptoms of syphilis or asymptomatic, treatment or not treated, and in a prenatal care program. Gestational syphilis cases were identified as women who tested positive for syphilis, and those who tested negative were controls, at minimally one prenatal care visit, childbirth, and/or the puerperium. The sample size encompassed 59 cases and 118 controls (1: 2 ratio of cases to controls). Data were analyzed using Minitab 20^® and BioEstat 5.3^® software. The odds ratio was calculated by multiple logistic regression.

Results

One hundred and seventy-seven postpartum women were included in the study, 59 cases and 118 controls. Among all participants, 95.5% (169) were tested for syphilis in any trimester during pregnancy and at the delivery and 4.5% (8) were tested in the maternity only, at the time childbirth and/or puerperium. The final multiple logistic regression model evidenced that cases had higher odds compared to controls if they had past history of sexually transmitted infections (AOR: 55.4; p: 0.00), difficulty talking about condom use with their sexual partner (AOR: 4.92; p: 0.01), one to six prenatal care visits (AOR: 4.93; p: 0.01), had not received a sexually transmitted infections test result in the maternity hospital (AOR: 4.09; p: 0.04), lower monthly income (AOR: 4.32; p: 0.04), or one to three miscarriages (AOR: 4.34; p: 0.01).

Conclusion

The sociodemographic, programmatic, obstetric, and sexual factors are associated with gestational syphilis among postpartum women.

Prevalence and Vulnerability Factors Associated with HIV and Syphilis in Older People from Subnormal Agglomerate, Brazilian Amazon

Background: This study aimed to estimate the prevalence of HIV and syphilis and associated factors among elderly people from subnormal agglomerations in a city in the Brazilian Amazon. Methods: An observational, cross-sectional study was carried out in a subnormal agglomerate from the Brazilian Amazon. Data collection was conducted from August 2021 to February 2022, using a structured questionnaire. Whole blood samples were collected to perform a rapid test for HIV and syphilis. People aged 50 and over were included in the study, and the sample consisted of 213 participants. The odds ratio was calculated by multiple logistic regression. Results: A total of 203 participants with a mean age of 63.5 years were considered (95% CI: 62.4; 64.6; standard deviation: 8.1; minimum age: 50 years and maximum age: 94 years). The prevalence of either HIV or syphilis was 16.4% (35/213; 95% CI: 0.11; 0.21); syphilis was 15.5% (33/213) and HIV was 1.40% (3/213). One coinfection (0.46%; 1/213) was registered. In the final multiple logistic regression, the elderly with an education level of illiterate/elementary were two times more likely to have a positive rapid test result for HIV or syphilis. Conclusions: Testing for HIV and syphilis identified that STI represented a burden on populations affected by socioeconomic inequality.

Atypical presentation of secondary syphilis: annular lesions in an elderly patient

Syphilis is a chronic bacterial sexually transmitted infectious disease caused by Treponema pallidum. Different age groups are affected by heterogeneous clinical forms of the disease. We report a case of atypical secondary syphilis in an elderly patient with diffuse annular erythematous lesions on the chest, back, upper and lower limbs diagnosed by histopathological, immunohistochemical and serological tests.