ISSN: 1981-8963 DOI: 10.5205/reuol.2265-25464-1-LE.0612201214

Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical…

ORIGINAL ARTICLE

SYPHILIS IN PREGNANCIES AND VERTICAL TRANSMISSION AS A PUBLIC HEALTH PROBLEM SÍFILIS EM GESTAÇÕES E TRANSMISSÃO VERTICAL COMO PROBLEMA DE SAÚDE PÚBLICA SÍFILIS EN EMBARAZOS Y TRANSMISIÓN VERTICAL COMO PROBLEMA DE SALUD PÚBLICA Marisa Dias Rolan Loureiro1, Rivaldo Venâncio da Cunha2, Maria Lúcia Ivo3, Elenir Rose Jardim Cury Pontes4, Márcia Maria Ferrairo Janini Dal Fabbro5, Marcos Antonio Ferreira Júnior6

ABSTRACT Objective: describe the frequency of infection with treponema pallidum in pregnancies and its vertical transmission. Method: this is a cross-sectional study with laboratory screening results regarding 228,196 pregnancies using the recombinant ELISA technique by elution in , , from 2003 to 2008. The research was approved by the Ethics Committee of Universidade Federal de Mato Grosso do Sul (UFMS), under the Protocol 660/2009. Results: the total number of positive results detected for syphilis in pregnancies was 5,043, corresponding to 2.2% of cases. Within the study period, prenatal screening for disease detection reached the average of 95.42% of pregnancies. Conclusion: the microregions with higher frequency of syphilis in pregnant women are located in bordering zones, indigenous poles, and areas with high tourist traffic. Although the coverage index for the diagnosis of syphilis in pregnancy is close to 100% in the state, it’s not enough to ensure an improved quality of care for the pregnant woman with this disease. Descriptors: Syphilis; Pregnancies; Prenatal Screening. RESUMO Objetivo: descrever a frequência da infecção por treponema pallidum em gestações e sua transmissão vertical. Método: trata-se de estudo transversal com resultados de triagem laboratorial referentes a 228.196 gestações pela técnica ELISA recombinante por eluição em Mato Grosso do Sul, de 2003 a 2008. A pesquisa foi aprovada pelo Comitê de Ética da Universidade Federal de Mato Grosso do Sul (UFMS), sob o Protocolo n. 660/2009. Resultados: foi detectado o total de 5.043 resultados positivos de sífilis em gestações, correspondendo a 2,2% dos casos. No período de estudo, a triagem pré-natal para detecção da doença alcançou a média de 95,42% das gestações. Conclusão: as microrregiões com maior frequência de sífilis em gestantes estão localizadas em zonas de fronteira, polos indígenas e áreas de grande movimento turístico. Embora o índice de cobertura para o diagnóstico de sífilis na gestação esteja próximo de 100% no estado, ele não é suficiente para garantir a melhoria da qualidade da atenção à gestante com essa doença. Descritores: Sífilis; Gestações; Triagem Pré-Natal. RESUMEN Objetivo: describir la frecuencia de la infección por treponema pallidum en embarazos y su transmisión vertical. Método: esto es un estudio transversal con resultados de tamizaje de laboratorio relativos a 228.196 embarazos por la técnica ELISA recombinante por elución en Mato Grosso do Sul, de 2003 hasta 2008. La investigación fue aprobada por el Comité de Ética de la Universidade Federal de Mato Grosso do Sul (UFMS), bajo el Protocolo 660/2009. Resultados: fue detectado el total de 5.043 resultados positivos de sífilis en embarazos, lo que corresponde al 2,2% de los casos. En el periodo de estudio, el tamizaje prenatal para detección de enfermedad alcanzó la media de 95,42% de los embarazos. Conclusión: las microrregiones con mayor frecuencia de sífilis en mujeres embarazadas están ubicadas en zonas fronterizas, polos indígenas y áreas de mucho tránsito turístico. Aunque el índice de cobertura para el diagnóstico de sífilis en el embarazo esté cerca del 100% en el estado, ello no es suficiente para garantizar una mejor calidad de la atención a la mujer embarazada con esa enfermedad. Descriptores: Sífilis; Embarazos; Tamizaje Prenatal. 1Nurse, Ph.D Professor at the Nursing Department of Federal University Mato Grosso do Sul/UFMS. (MS), Brazil. Email: [email protected]; 2Infectious disease physician, Post-Ph.D Professor at Dr. Helio Mandetta School of Medicine of UFMS, as well as at the Graduate Program in Health and Development in the Central-West Region and at the Graduate Program in Infectious and Parasitic Diseases. Campo Grande (MS), Brazil. Email: [email protected]; 3Nurse, Ph.D Professor at the Nursing Department and at the Graduate Program in Health and Development in the Central-West Region of Dr. Helio Mandetta School of Medicine of UFMS. Campo Grande (MS), Brazil. Email: [email protected]; 4Dentist, Ph.D Professor at the Center for Biological and Health Sciences, as well as at the Graduate Program in Health and Development in the Central-West Region and at the Graduate Program in Infectious and Parasitic Diseases of Dr. Helio Mandetta School of Medicine of UFMS. Campo Grande (MS), Brazil. Email: [email protected]; 5Infectious disease physician, State Health Secretary of Campo Grande, Mato Grosso do Sul/Brazil, and Researcher at the Institute for Researches, Teaching, and Diagnoses of the Association of Parents and Friends/IPED/APAE. Campo Grande (MS), Brazil. Email: [email protected]; 6Nurse, Ph.D Professor at the Nursing Department from the Center of Health Sciences of Federal University Rio Grande do Norte/UFRN. Natal (RN), Brazil. Email: [email protected]

Study developed from the thesis << Infection with treponema pallidum in pregnancies and its vertical transmission in Mato Grosso do Sul within the period from 2003 to 2008 >>, presented to the Multi-Institutional Graduate Program in Health Sciences of Universidade Federal de Mato Grosso do Sul (UFMS)/Universidade Federal de Goias (UFG)/Universidade de Brasilia (UnB). Campo Grande-MS/Goiania-GO/Brasilia/DF/Brazil. 2009. English/Portuguese J Nurs UFPE on line. 2012 Dec;6(12):2971-9 2971 ISSN: 1981-8963 DOI: 10.5205/reuol.2265-25464-1-LE.0612201214

Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical…

estimated about 50,000 pregnant women with INTRODUCTION syphilis and 12,000 live births with congenital Known since the 15th century, syphilis, syphilis, besides a vertical transmission rate of almost 600 years later, is still regarded as a 25%, which ranges from 1.9% in the Northeast 7-9 major public health problem worldwide, Region to 1.3% in the Central-West Region. although the discovery of penicillin, in 1940, Congenital syphilis is the disease that, and the improvement of health care have led perhaps, best represents the deficiencies in to a sharp decline in its incidence, both in the access and use of health services, especially acquired and congenital forms — up to the among the most disadvantaged people, as it’s point that one predicted total eradication of a preventable cause of perinatal the disease by the end of the 20th century. morbimortality, with the possibility of early From 1960 and more sharply after 1980, diagnosis and effective treatment during the incidence of syphilis took an ascending pregnancy. This form of the disease path in general population, given a lower constitutes one of the most sensitive awareness on the preventive measures, indicators to assess the quality of health care something which came along with the use of services, and the Ministry of Health oral contraceptives, abuse in injecting drug recommends monitoring its rate as an 10 use, a greater sexual promiscuity, a neglect of indicator of primary health care in towns. health care authorities, a poor structural Given the fact that the incidence of organization of health care services, failures sexually transmitted diseases in pregnant in the training of professionals from health women enhances the risk of vertical care areas, and non-compulsory notification, transmission to the newborn infant and taking factors which allowed an intensification of the into account the poor information on health disease.1-4 care for pregnant women during the prenatal Syphilis is conceptualized as a sexually period in Mato Grosso do Sul, this study aims transmitted disease, although it can be to describe the frequency of infection with transmitted by transfusion of contaminated treponema pallidum in pregnancies and its blood or through contact with mucocutaneous vertical transmission. lesions rich in treponemes. Vertical METHOD transmission of treponema pallidum (TPPA) can occur transplacentally at any time during This cross-sectional study was developed pregnancy, being directly related to maternal with secondary data, relating to all results of treponemia. In pregnant women with early laboratory screening tests of pregnant women untreated syphilis, the vertical transmission from the 78 towns of Mato Grosso do Sul, rate ranges from 70% to 100% and in the late Brazil, enrolled in the State Program for untreated syphilis it ranges from 30% to 40%, Pregnant Women Protection from the Institute and it’s possible to occur abortions, stillbirths, for Researches, Teaching, and Diagnoses of or perinatal deaths in about 40% of infected the Association of Parents and Friends of 2,5 children. Exceptional Children (PEPG/APAE/IPED), with In underdeveloped countries, syphilis and the period from January 2003 to December its congenital form never ceased to be a 2008. public health problem, affecting 10% to 15% of PEPG/IPED/APAE recommends the pregnant women, according to data from the laboratory screening test for syphilis diagnosis 6 World Health Organization (WHO). The through recombinant ELISA technique (Q- disease also presents a high prevalence and PREVEN Sifilis Total  DBS) by elution. Blood incidence in rich countries, such as the USA, samples are obtained through finger prick and Australia, and European nations. absorbed into six discs of filter paper S&S 903 In Brazil, gestational syphilis is still to perform the test. Regarding screened cases observed in a significant proportion of women, of infection with TPPA, new samples of blood something which has favored a relevant are requested, obtained through peripheral occurrence of congenital syphilis. Although venipuncture, from which the serum is the Ministry of Health launched in 1993 the extracted and confirmatory tests are Project for the Elimination of Congenital performed through the recombinant ELISA Syphilis, aiming to reduce its incidence to 1 (EIAgen TMPA Screen Recombinant Kit) and case or less per 1,000 live births, the VDRL test techniques. government targets weren’t met, as shown by The variables selected for the study were: the fact that in 2004, among mothers from 15 syphilis cases in pregnant women by health to 49 years in all regions of the country, a care microregion and by hometown. prevalence rate of 1.6% was found; one

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Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical…

Data were tabulated in the Microsoft Excel Table 1 shows the percentages of screened software, version 2003, pertinent statistical pregnancies and the number and frequency of tests with percentages were applied, to check positive results. whether there was a statistically significant Within the study period, 228,916 laboratory association between the study variables, and tests were performed to detect syphilis in 2 the chi-square test ( ) was applied, at a 5% pregnant women, among which 5,043 had a significance level. positive result, corresponding to 2.2% (2.1- The study was approved with regard to its 2.3%, a 95% coverage index) of all screened methodological and ethical aspects by the pregnancies. Research Ethics Committee of Universidade The coverage index ranged from 90% to 99% Federal de Mato Grosso do Sul, under the within the period from 2003 to 2008, and the Protocol 660/2009. average in the years studied was 95.42%. Since 2006, coverage came close to 100% RESULTS (Table 1).

Table 1. Distribution of syphilis cases in pregnant women and coverage index, per year. Mato Grosso do Sul, 2003 to 2008. Year Screenings Cases Case/screening ratio (%) Coverage index (%)1 2003 34,989 353 1.01 89.66 2004 38,471 905 2.35 93.11 2005 39,204 1,149 2.93 95.47 2006 39,118 1,004 2.57 98.72 2007 37,064 807 2.18 96.79 2008 40,070 825 2.06 98.79 Total 228,916 5,043 2.20 95.42 Note: In 2004, VDRL laboratory test was replaced by recombinant ELISA, which has greater sensitivity and specificity and facilitates screening, as it’s automated. Calculated having live births and screening tests as the bases.

Despite the decrease which occurred in geographical microregions (Table 2). There 2006 and 2007, there was an upward trend in was a statistically significant difference in the the proportion of screened cases (p < 0.001; case/screening ratio among microregions (p < 2 for trend). 0.001; 2 test). Mato Grosso do Sul is divided by the State Health Department into 11 heterogeneous

Table 2. Distribution of syphilis cases in pregnant women, by health care microregion. Mato Grosso do Sul, 2003 to 2008. Microregion Screenings Cases Case/screening ratio (%) Ponta Pora 27,854 1,510 5.42 Corumba 12,497 420 3.34 Navirai 14,085 372 2.63 Jardim 7,771 202 2.60 Aquidauana 14,939 287 1.91 Dourados 28,209 468 1.66 Campo Grande 82,020 1,286 1.57 Paranaiba 8,992 134 1.49 Tres Lagoas 14,542 189 1.30 8,329 89 1.07 9,678 86 0.89 Total 228,916 5,043 2.20

Regarding the ratios shown (Table 2), one The town of Ladario showed a higher highlights the Ponta Pora microregion (5.42%), case/screening ratio when compared to followed by the Corumba (3.34%), Navirai Corumba (p = 0.008; 2 test), with 4.34% and (2.63%), and Jardim (2.60%) microregions. The 3.18%, respectively (Table 3). lowest percentage was that of the Nova There was a statistically significant Andradina microregion (0.89%). difference in the case/screening ratio among There was a statistically significant the towns of the Jardim microregion (p < difference among the towns of the Ponta Pora 0.001; 2 test). The towns above the microregion (p < 0.001; 2 test). The towns of microregion average were micro Jardim and (10.94%) and Coronel Sapucaia , with 3.37% and 3.40%, (5.90%) were above the average calculated for respectively (Table 3). the microregion (Table 3).

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Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical…

Table 3. Distribution of syphilis frequency in pregnant women in the Ponta Pora, Corumba, Jardim, and Navirai microregions, by town. Mato Grosso do Sul, 2003 to 2008. Towns Screenings Cases Case/screening ratio (%) Ponta Pora Microregion Amambai 5,432 594 10.94 Coronel Sapucaia 2,442 144 5.90 Paranhos 2,371 117 4.93 Ponta Pora 8,786 376 4.28 Antonio Joao 1,389 58 4.18 Aral Moreira 912 35 3.84 Bela Vista 2,684 99 3.69 Tacuru 1,396 52 3.72 1,791 27 1.51 Caracol 651 8 1.23 Corumba Microregion Ladario 1,911 83 4.34 Corumba 10,586 337 3.18 Jardim Microregion Jardim 2,817 95 3.37 Porto Murtinho 1,646 56 3.40 1,213 21 1.73 Bonito 2,095 30 1.43 Navirai Microregion Japora 963 59 6,13 2,157 100 4.64 Mundo Novo 2,420 89 3.68 Eldorado 1,331 31 2.33 Navirai 4,839 73 1.51 557 6 1.08 Itaquirai 1,679 14 0.83

One found out a statistically significant Despite the high coverage of prenatal care difference among the towns in the Navirai in the country, above 85% and with a ratio of region (p < 0.001; 2 test). The towns where five prenatal care consultations per delivery the case/screening ratio was higher than the within the Unified Health System (SUS), the microregion average were Japora, Iguatemi, quality of care for the pregnant woman falls and Mundo Novo, with 6.13%, 4.64%, and short of needs. The National Policy on 3.68%, respectively (Table 3). Obstetric and Neonatal Care provides for examinations for syphilis, although sometimes DISCUSSION one verifies a failure to comply with the recommended routine and other times one The average coverage ratio (screenings verifies treatment mismanagement, without with regard to live births) found in this study partner treatment.8,12 was 95.42%. On the other hand, 500 congenital syphilis cases were notified to the Regarding the diagnosis of syphilis in a Brazilian Information System for Notifiable pregnant woman, it’s regarded as late if nd rd Diseases (SINAN) between 2003 and 2008. performed on the 2 and 3 trimesters. In this period, deleterious effects can already The Ministry of Health, based on the have occurred to the fetus, due to the higher proposition of the WHO, recommends, for maternal treponemia. reducing vertical transmission of the infection with TPPA, that testing should be performed Even if proper treatment is performed in during the 1st and 3rd trimester of pregnancy the pregnant woman up to 30 days before and at delivery. However, there’re marked delivery, the fetus will be regarded as a differences in compliance with these congenital syphilis case. protocols, due to heterogeneity of regions in Early diagnosis of maternal infection is still the country with regard to their development the best way to prevent vertical transmission stages and access to specific health care of the disease. Even with completion of services (prenatal and laboratory tests).11,12 treatment during pregnancy, fetal infection A study carried out in Niteroi, Rio de can still occur in 14% of cases. These rates can Janeiro, Brazil, revealed that 60% of pregnant vary according to the infection stage. Even if women attended prenatal care. One third of the pregnant woman is properly treated, pregnant women, therefore, arrive at the congenital syphilis can occur, although this is 11 maternity hospital without serologic result for a rare event in these cases. syphilis. The later the diagnosis and treatment In a study on attendance to prenatal care, of maternal infection, the greater the it was found that 55.6% of pregnant women difficulty for completing the treatment within surveyed underwent VDRL test and that 13.9% the time required, in order to achieve repeated it, something which demonstrates prevention of vertical transmission.11 the low importance attributed to prevention of congenital syphilis. The authors consider

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Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical… that this behavior may be a result of lack of STDs are among the five leading causes of knowledge or forgetfulness on the part of search for health services, and they may health professionals with regard to the need cause congenital malformations and other to track syphilis during prenatal care.2 complications, besides abortion and death, According to the current protocol, the events whose occurrence rises at least 10 disease diagnosis and proper treatment for times in cases of HIV infection. Syphilis the pregnant woman and her partner during constitutes an associated factor for the prenatal care make it possible to eliminate acquisition of other STDs, particularly viral congenital syphilis as a public health problem, diseases, such as herpes simplex type 2 and 20 i.e. reducing its occurrence up to 1 case per hepatitis B. 1,000 live births.12 A prospective study carried out from May However, access to diagnosis alone isn’t 1996 to October 2001 in Campo Grande, Mato enough to ensure an improved quality of care Grosso do Sul, Brazil, with 76 pregnant women for the pregnant woman with HIV, AIDS, with a mean age of 24 years infected with HIV 21 and/or syphilis. Conformation to an organized revealed 9.2% of coinfection with syphilis. In network through the definition of another study carried out with 35,512 responsibilities between the health care levels pregnant women in Mato Grosso do Sul, from within SUS is inherent to testing, ensuring 2002 to 2003, one observed a 0.8% frequency access for pregnant women, parturients, and of syphilitic infection, much higher than HIV 22 newborn infants to the latest HIV and TPPA infection, which was 0.2%. infection diagnostic, control, and According to the National STD/AIDS management technologies.13 Program, among the diseases which can be This study revealed a frequency of 2.2% transmitted during the gravidic-puerperal (2.1-2.3%, a 95% coverage index) of syphilis cycle, syphilis presents one of the highest cases with regard to the analyzed transmission rates, with an estimate of 13,23 pregnancies. The study whose results came 937,000 cases. closer to this, although with a lower In 1993, the Ministry of Health proposed percentage, was that carried out in Caxias do the elimination of congenital syphilis by 2000, Sul, Rio Grande do Sul, Brazil,14 which and it recommends screening for disease in identified, among 8,009 births, 150 women pregnancy having non-treponemal serological (1.87%) with syphilis. On the other hand, this diagnosis (VDRL) as a strategy to be favored.9 result differs from another which estimated Currently, vertical transmission of HIV and that the average prevalence of syphilis in syphilis is still a challenge in public health pregnant Brazilian women is 3% to 4%, varying which needs to be faced by health policies in 9 according to region. These rates are higher Brazil. To achieve advances in this prevention, than the prevalence of 1.6% estimated by the there’s a need to improve the conditions of 12,15 Ministry of Health. care for the pregnant woman with HIV or In the United States, the prevalence rates syphilis, as well as for her newborn child, of syphilis for adults in general within the especially in the case of people living in the period from 2003 to 2007 were, successively, countryside.12,22,24 12.1%, 11.6%, 11.5%, 12.5%, and 13.9% per The Ponta Pora microregion had the highest 16 100,000 individuals. It’s believed that the frequency in the state (5.42%), followed by increase in these rates may be related to drug the Corumba (3.34%), Navirai (2.63%), and use, sexual promiscuity, and return of soldiers Jardim (2.60%) microregions (Table 2). The from conflict regions. Among developing town of Amambai is the leader, with 10.94% of countries, surveys by WHO estimate that confirmed cases of syphilis in pregnant about 10% to 15% of pregnant women have women, followed by others with high 11,17 syphilis. percentages: Japora (6.13%), Coronel In the analysis of syphilis status in African Sapucaia (5.90%), Paranhos (4.93%), Iguatemi countries, one observes that it’s still an (4.64%), Ladario (4.34%), Ponta Pora (4.28%), important cause of morbidity and mortality and Antonio Joao (4.18%) (Table 3). These during pregnancy. In the Sub-Saharan Africa, percentages are higher than the state (2.2%) every year, about 1.6 million pregnant women and national (1.6%) ones.12,15 with syphilis remain undiagnosed, favoring The frequencies of gestational syphilis by 18,19 vertical transmission of this infection. An microregion obtained in this study were high. emphasis should be given to these countries, To discuss these findings, one should take into where the epidemic of HIV infection has account aspects such as the geographical decimated the population. location of Mato Grosso do Sul, with 78 towns in the Brazilian Central-West Region, whose

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Loureiro MDR, Cunha RV da, Ivo ML et al. Syphilis in pregnancies and vertical… capital city is Campo Grande. Having an area system is influenced by the closeness to the of 358,159 km², it’s limited to the west by international boundary, receiving an extra Bolivia and Paraguay (open boundary), to the flow of users which raises the demand for north by Mato Grosso, to the south by assistance. Once in Brazil “health is a right for Paraguay and Parana, and to the east by Sao all and a duty for the State”,26 foreign Paulo, Minas Gerais, and Goias. In 2007, it had individuals usually cross the border to seek 2,265,021 inhabitants (6.42 inhab./km²), care by SUS. A survey carried out by the presenting a multiethnic and multicultural National Council of Municipal Health population composition in the bordering areas Departments along with municipal health which allow a migrant influx of. The state is secretaries corroborates this occurrence, also the second in Brazil with regard to the showing that 75% of towns provide assistance number of Amerindian inhabitants (63,000 in from SUS to the demand from foreigners. This 2008).25 Due to its strategic geographical survey also informs that about 100 deliveries position, it has detachments from the three of Paraguayan women are performed in Ponta armed forces. Moreover, it’s an emerging Pora each year.29 state with regard to tourism, agribusiness, and Corumba exerts a strong attraction in the industries, particularly the sugarcane region of the Bolivian border, favoring the industry. flow of migrants and tourists by land, air, and By analyzing syphilis in pregnant women, water ways. Ladario is located 5 km far from it’s observed that all cases are located in this town, and, like Amambai, Bela Vista, bordering zones (with Bolivia and Paraguay). Jardim, Ponta Pora, and Porto Murtinho, it has It’s understood as a bordering zone, according a large contingent of conscripted men to the 1988 Brazilian Constitution, every area (Brazilian army and navy). Therefore, they’re comprising 150 km perpendicular to the towns with transient population migrations. limiting line of the Brazilian territory.26 Population moves put in contact groups In short, the borderline is a zone or area vulnerable to the occurrence of STDs, which presents two basic characteristics with especially syphilis and HIV, with the regard to the health/disease processes emergence of new cases in remote locations. established there: a) it’s the point of entry or Thus, such diseases can be “exported” from exit of people and goods which allows the Brazil to neighboring countries or “imported” 28 exchange and dissemination of pathogens from bordering countries. between countries; and b) an area or zone According to the Brazilian STD/AIDS with particular characteristics, where Program Coordination, in bordering towns, inhabitants from the neighboring countries foreigners and Brazilians living in neighboring experience the effects of closeness, countries use, to ensure access to health care generating particular behaviors.27 services, an address from a Brazilian town. Regarding the composition of population Moreover, the search for health care services living in the bordering areas, one finds a high outside one’s hometown or referral to frequency of foreign migrants (2.5%) when reference centers may be justified by the compared to the national average (0.6%). In poor quality of local services. Such facts Mato Grosso do Sul, in the towns of Sete change morbidity indicators in these bordering Quedas, Paranhos, and Coronel Sapucaia, the or countryside areas, and they can cause 30 foreign migrants account for 9.9%, 6.4%, and undernotification of cases. 4.5% of the population, respectively.28 The Amerindian population from Mato The concept of twin towns deserves Grosso do Sul is made up of 13 indigenous attention here. They are two towns located ethnic groups, which inhabit 72 villages face to face on opposite sides of an located in 31 towns, among which 15 are international boundary, forming a conurbation regarded as indigenous poles: Iguatemi, or not, with varying levels of interaction.27 Amambai, Caarapo, Eldorado, Japora, Sete Seven towns investigated are regarded as twin Quedas, Antonio Joao, Bela Vista, Ponta Pora, towns with Paraguay: Bela Vista, Ponta Pora, Juti, Laguna Carapa, Bonito, Bodoquena, and 25 Coronel Sapucaia, Paranhos, Porto Murtinho, Miranda. Out of these 15, 11 belong to the and Mundo Novo. On the border with Bolivia, microregions with higher frequency of syphilis there’s the town of Corumbá. The flow of in pregnant women and they’re located in legal or illegal immigrants and tourists in bordering zones, a location which allows the these locations is high, setting a daily flow influx of other population groups, creating risk between towns.27 situations to indigenous persons due to their vulnerability, especially with regard to the The boundaries can influence the behavior spread of epidemics, a context comprising of their populations. The very health care STDs. English/Portuguese J Nurs UFPE on line. 2012 Dec;6(12):2971-9 2976 ISSN: 1981-8963 DOI: 10.5205/reuol.2265-25464-1-LE.0612201214

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Taking into account the aspects mentioned, prevenção da sífilis congênita. Rev Para Med it’s still a challenge for managers to provide [serial on the internet]. 2006 Jan-Mar [cited indigenous women with access to a prenatal 2012 Feb 10];20(1):47-51. Available from: service, on one hand because of cultural http://scielo.iec.pa.gov.br/pdf/rpm/v20n1/v characteristics and on the other due to the 20n1a08.pdf. difficulties for disseminating information, 3. Saraceni V, Domingues RMSM, Vellozo V, implement prevention strategies, know the Lauria LM, Dias MAB, Ratto KMN, et al. serostatus, and treat STDs, aiming to ensure Vigilância da sífilis na gravidez. Epidemiol maternal health and achieve a decrease in Serv Saúde [serial on the internet]. 2007 Apr- 31 vertical transmission. Jun [cited 2012 May 3];16(2):103-11. Available The associations between all these factors from: identified in the state may explain the http://scielo.iec.pa.gov.br/pdf/ess/v16n2/v1 phenomenon of high rate of syphilis in 6n2a05.pdf. pregnant women, especially in the Ponta Pora 4. Milanez H, Amaral E. Por que ainda não and Corumba microregions. These facts make conseguimos controlar o problema da sífilis prenatal care a challenge for health em gestantes e recém-nascidos? Rev Bras managers, given the difficulties to implement Ginecol Obstet [serial on the internet]. 2008 it in such a heterogeneous geographical Jul [cited 2012 Aug 2];30(7):325-7. Available location. from: http://www.scielo.br/pdf/rbgo/v30n7/a01v3 CONCLUSION 0n7.pdf. Vertical transmission of syphilis remains a 5. Paz LC, Pereira GF, Pinto VM, Medeiros public health challenge which needs to be MGPF, Matida LH, Saraceni V, et al. Nova faced by health care policies in Brazil, definição de casos de sífilis congênita para constituting one of the most sensitive fins de vigilância epidemiológica no Brasil, indicators for assessing the quality of health 2004. Rev Bras Enferm [serial on the care services, especially the quality of internet]. 2005 July-Aug [cited 2012 May prenatal care. 13];58(4):486-7. Available from: The microregions with higher frequency of http://www.scielo.br/pdf/reben/v58n4/a21v syphilis in pregnant women are bordering 58n4.pdf. zones, indigenous poles, and areas with high 6. Brasil. Sífilis congênita. Brasília (DF): tourist traffic. Although the coverage index Ministério da Saúde; 2001. for diagnosis of syphilis in pregnancies is close 7. Rodrigues C, Guimarães MD. Positividade to 100% in the state, it’s not enough to ensure para sífilis em puérperas: ainda um desafio an improved quality of care for the pregnant para o Brasil. Rev Panam Salud Pública [serial woman with this disease. on the internet]. 2004 Sep [cited 2012 Feb The authors recommend that managers 13];16(3):168-75. Available from: from the three spheres of SUS in these http://www.scielosp.org/pdf/rpsp/v16n3/230 microregions take into account their 86.pdf. specificities, ensuring accessibility of 8. Saraceni V, Leal MC, Hartz ZMA. Avaliação pregnant women, sexual partners, and de campanhas de saúde com ênfase na sífilis newborn infants to diagnosis, control, and congênita: uma revisão sistemática. Rev Bras management of infection with treponema Saúde Mater Infant [serial on the internet]. pallidum, through the effective 2005 July-Sep [cited 2012 Mar 28];5(3):263-73. implementation of the Stork Network, Available from: fulfilling the goal of eradicating syphilis by http://www.scielo.br/pdf/rbsmi/v5n3/a02v5n 2015. 3.pdf. REFERENCES 9. Donalísio MR, Freire JB, Mendes ET. Investigação da sífilis congênita na 1. Vieira A. Contribuição ao estudo microrregião de Sumaré, Estado de São Paulo, epidemiológico de sífilis congênita no Brasil  desvelando a fragilidade do cuidado à município de Carapicuíba-SP: ainda uma mulher gestante e ao recém-nascido. realidade em 2002. DST J Bras Doenças Sex Epidemiol Serv Saúde [serial on the internet]. Transm [serial on the internet]. 2005 Jan 2007 July-Sep [cited 2012 Jan 18];16(3):165- [cited 2012 Mar 20];17(1):10-7. Available 73. Available from: from: http://www.dst.uff.br/revista17-1- http://scielo.iec.pa.gov.br/pdf/ess/v16n3/v1 2005/contribuicaoaoestudo.pdf. 6n3a03.pdf. 2. Araujo EC, Costa KC, Silva R, Azevedo VNG, 10. Sá RAM, Bornia RBG, Cunha AA, Oliveira Lima FAS. Importância do pré-natal na CA, Rocha GPG, Giordano EB. Sífilis e English/Portuguese J Nurs UFPE on line. 2012 Dec;6(12):2971-9 2977 ISSN: 1981-8963 DOI: 10.5205/reuol.2265-25464-1-LE.0612201214

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Sources of funding: No Conflict of interest: No Date of first submission: 2012/02/09 Last received: 2012/11/11 Accepted: 2012/11/12 Publishing: 2012/12/01 Corresponding Address Marcos Antonio Ferreira Júnior Universidade Federal do Rio Grande do Norte  Departamento de Enfermagem Av. Senador Salgado Filho, s/n  Campus Lagoa Nova CEP: 59072-970  Natal (RN), Brazil

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