Brief Communication
Public Health
Kasmera 49(2):e49234108, Julio-Diciembre, 2021
P-ISSN
0075-5222 E-ISSN 2477-9628
https://doi.org/10.5281/zenodo.5515407
Congenital Syphilis in Ecuador is a still unsolved
problem?
La sífilis
congénita en Ecuador ¿un problema aún sin resolver?
González-Andrade Fabricio (Corresponding author). https://orcid.org/0000-0002-2091-9095.
Universidad San Francisco de Quito. Colegio Ciencias de la Salud. Quito.
Ecuador. Universidad Central del Ecuador. Facultad de Ciencias Médicas. Unidad
de Medicina Traslacional. Quito. Ecuador. Dirección Postal: UnitIquique
N14-121 y Sodiro-Itchimbía, Sector El Dorado, 170403,
Quito. Ecuador. Telèfono: +593-9-984536414. E-mail: fabriciogonzaleza@gmail.com
Aguinaga-Romero Gabriela. https://orcid.org/0000-0002-6274-2195.
Universidad San Francisco de Quito. Colegio Ciencias de la Salud. Quito.
Ecuador. E-mail: gabrielaaguinaga@yahoo.com
Carrero Yenddy. https://orcid.org/0000-0003-4050-4468.
Universidad Técnica de Ambato. Facultad de Ciencias de la Salud. Carrera de
Medicina. Ambato-Tungurahua. Ecuador. E-mail: yenddycarrero@yahoo.es
Ocaña Carolina. https://orcid.org/0000-0003-2432-9401.
Universidad Central del Ecuador. Facultad de Ciencias Médicas. Unidad de
Medicina Traslacional. Quito. Ecuador. E-mail: macaro.1791@gmail.com
Abstract
Congenital syphilis represents a public health problem.
Despite the increases in prenatal care coverage, the actions implemented still
show low effectiveness in their prevention. An epidemiological, observational,
cross-sectional study is presented, in which data were obtained from the
National Institute of Statistics and Censuses (INEC) with the purpose of
establishing the current situation of congenital syphilis in Ecuador, taking
into consideration the data throughout the last years. According to the
registries, no cases of late syphilis have been reported for 6 years. The
reports prior to 2004 are irregular, the data recorded from 2005 on are more
reliable due to the mean and standard deviation data. There is a slight
downward trend from 2003 to 2011 showing an increase of 200 reported cases in
2013. No detailed data was found as of 2016. Congenital syphilis still
prevails, with a slightly higher prevalence in men, although the ratio (male /
female) is kept at 1: 1. Since 2005 there is no significant variation. A
downward slope is evident, but the mean values would indicate a plateau during
the last 7 years. This fact will determine a blockage of the expected decrease
in the number of cases. There is no proper official data record. The prevalence
in Ecuador for the year 2019 shows 320 reported cases, but it remains
stationary, with Guayas being the most affected province. The prevention,
control and monitoring guidelines must be reviewed by the health authorities.
Keywords: syphilis, congenital, epidemiology, disease prevention.
Resumen
Palabras claves: sífilis,
sífilis congénita, epidemiología, prevención de enfermedades.
Recibido: 01/10/2020 | Aceptado: 30/05/2021 | Publicado: 20/09/2021
How to Cite: González-Andrade F, Aguinaga-Romero G, Carrero Y, Ocaña C. Congenital Syphilis in Ecuador is a still unsolved
problem? Kasmera. 2021;49(2):e49234108. doi: 10.5281/zenodo.5515407
Introduction
Congenital syphilis (CS) is still a major
public health problem, according to World Health Organization WHO (1). Researchers estimate that congenital syphilis
is a complicating factor in about 1 million pregnancies every year worldwide.
CS has a largely contributed toward infant death and has been responsible for
305,000 perinatal deaths worldwide annually (2).
While the prevalence of CS remains low in most
developed countries, it has been a subtle remerging of the disease in some
European countries including Spain, and South America. For 2006 in Latin
America was overall reported 8.423 cases of CS, more than 164.000 children were
born with CS in Latin American and Caribbean countries since 2007. By 2013 the
overall reported cases were 13.831, Colombia reports 287.3 cases per 100,000
live births, Venezuela 4.6 cases per 100,000 live births, Argentina 99 cases
per 100,000 live births, Honduras 14.7 cases per 100,000 live births, Cuba
reports less than 2.4 by per 100,00 live births and Brazil 388.4 per 100,000
live births (3).
Despite the increase in prenatal care coverage
in Ecuador, the actions implemented exhibit low effectiveness in its prevention
(4). This disease without treatment, it is lethal (5). The disease can manifest according to
severity, such as late abortion, stillbirth, and low birth weight. The first
manifestations of syphilis in the neonatal period include aseptic meningitis,
seizure, rash, and neonatal death. It can also manifest as a latent infection
leading to subsequent sequel (6). Syphilis is a systemic an exclusive human sexually, sanguineous, and
perinatal transmitted disease caused by the spirochete Treponema pallidum (7,8).
CS´s transmission occurs transplacentally
at any time during gestation. The risk of transmission to the fetus depends on
the stage of maternal infection. Usually, the longer before the pregnancy
occurred the primary infection, the more benign the result regarding the rate
and severity of infection. Untreated primary or secondary syphilis in pregnancy
results in a 25% risk of stillborn, a 14% risk of neonatal death, a 41% risk of
giving birth to a live but infected infant and only a 20% chance of giving
birth to a healthy, uninfected infant (9). Cohort studies have been consistent in finding that substantial
proportions (40 to 81%) of syphilis-exposed fetuses are severely affected, with
stillbirth neonatal death being the most significant consequences (10).
However, fetal compromise is generally not
manifested until later in the second or third trimesters with maturation of the
fetal immune system (11). As syphilis remains an easily treatable disease, most cases of CS are
seen in women who did not receive proper prenatal care or receive improper
treatment. Treatment of early maternal syphilis at least 30 days before
delivery is the most important factor influencing the risk of congenital
infection. Seventy to 100 percent of infants born to untreated mothers will be
infected compared to 1 to 2 percent of those born to women adequately treated
during pregnancy (12).
WHO estimates most maternal syphilis infections
are untreated and of sufficiently high-titer (RPR≥1:
However, infection rates are shown also among
women, especially pregnant women. This group needs special attention due to the
importance for the incidence and the prevalence of congenital syphilis. Active
syphilis in pregnant women presents fetal or perinatal death and serious
neonatal infection. CS elimination as a public health problem will be achieved
through reduction on prevalence of syphilis of pregnant women and reducing
mother to child transmission of syphilis (17). The economic burden associated with the
treatment of CS affects not only families, but society. The hospitalization
cost for an infant affected by CS is as much as 7 times higher, and the length
of hospital stay is approximately 8 days longer than for a healthy infant.
These cost increase estimates do not include post discharge medical expenses
related to late CS. In comparison,
prenatal screening offers a long-term cost-benefit for public health entities (18).
In this paper, it analyzes the prevalence of
the disease in Ecuador through the time, to set the evolution and the situation
of the same, and its implications to reduce child mortality through reductions
in perinatal deaths and low-birth-weight infants.
Methods
Study design: epidemiological,
observational, and cross-sectional study.
Data source: National Census and
Statistics Institute (INEC) of Ecuador. Data was obtained from
birth, annual reports, death reports and hospital bed occupation, during the
years 2000 to 2016. The statistics are of national, urban, rural, regional,
provincial, cantonal, and parochial coverage. The information was collected in
all the establishments that provide hospitalization at the national level and
the patients diagnosed according to the clinical and laboratory parameters were
taken into consideration.
Specific methods: it used an information
collection sheet, to gather all information required.
Statistical analysis: data collection,
analysis and evaluation were collected in an Excel database to be analyzed with
the SPSS© software version 22, licensed; appropriate descriptive statistics
were used for the analysis.
Avoided biases: it was verified that
all the information was complete; the information was always collected by the
same operator.
Limitations: being a purely descriptive work based on databases, there were
limitations such as, for example, validating the cases individually with the
patient directly to confirm the diagnosis, it could not fully establish if
there were cases of re-admissions even when each of the cases was verified
through clinical records, and there is a general sub-registry in the country
that could vary the study.
Ethical criteria: no approval was
required. All procedures performed in studies involving human participants were
in accordance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards (19).
Result
It analyzed 2701 cases corresponding to
Congenital Syphilis (CS), Early Syphilis (ES), Late Syphilis (LS) and other
types of Syphilis (OS) according to the ICD 10, during the years 2000 to 2016.
The annual average of cases reported with CS was 124.12 (SD 42.41), ES 11.41
(SD 8.10), LS 10.47 (SD 12.50), and finally, OS 12.88 (SD 6.49). Distribution
of cases of CS between 2000 and 2003 shows an increase of 43.38 cases per year
with an average of 167.5 cases reported in four years, similar to the period
2012 to 2016 with an average of 150.8 cases per year and an increase of 26.68
cases during that period. The highest rate of reported cases of CS was 59.45
cases per 100,000 live births in 2013 (Table 1).
The provinces of Pichincha and Guayas show most reported cases to be provinces
of national reference; however, the province of Los Rios also reports a
significant increase with 31 cases of CS in 2002, with an average of 19 cases
per year compared with other provinces. Some data indicate that during the
years 2017 and 2018 of every 293,139 and 291.39 live births, 261 and 129 cases
were diagnosed, respectively (data not revealed).
Table 1. Syphilis infection
prevalence in Ecuador (2000-2016)
|
Year |
Congenital Syphilis |
Early Syphilis |
Late
Syphilis |
Other Syphilis |
Total |
||||||||
|
N |
% |
Rate |
n |
% |
Rate |
n |
% |
Rate |
N |
% |
Rate |
||
|
2016 |
117 |
55.18 |
36.70 |
14 |
6.60 |
4.39 |
13 |
5.38 |
4.00 |
6 |
2.83 |
1.88 |
150 |
|
2015 |
140 |
66.03 |
43.92 |
26 |
12.26 |
8.15 |
29 |
12.01 |
8.92 |
8 |
3.77 |
2.50 |
203 |
|
2014 |
155 |
73.11 |
48.63 |
27 |
12.74 |
8.47 |
0 |
0.00 |
0.00 |
30 |
14.15 |
9.41 |
212 |
|
2013 |
193 |
80.08 |
59.45 |
24 |
9.96 |
7.39 |
9 |
3.73 |
2.77 |
15 |
6.22 |
4.62 |
241 |
|
2012 |
149 |
81.87 |
43.17 |
16 |
8.79 |
4.64 |
12 |
6.59 |
3.48 |
5 |
2.75 |
1.45 |
182 |
|
2011 |
72 |
77.42 |
20.70 |
6 |
6.45 |
1.73 |
0 |
0.00 |
0.00 |
15 |
16.13 |
4.31 |
93 |
|
2010 |
87 |
86.14 |
24.75 |
8 |
7.92 |
2.28 |
0 |
0.00 |
0.00 |
6 |
5.94 |
1.71 |
101 |
|
2009 |
84 |
80.77 |
23.25 |
7 |
6.73 |
1.94 |
0 |
0.00 |
0.00 |
13 |
12.50 |
3.60 |
104 |
|
2008 |
118 |
83.69 |
31.92 |
5 |
3.55 |
1.35 |
0 |
0.00 |
0.00 |
18 |
12.77 |
4.87 |
141 |
|
2007 |
74 |
72.55 |
20.02 |
6 |
5.88 |
1.62 |
0 |
0.00 |
0.00 |
22 |
21.57 |
5.95 |
102 |
|
2006 |
71 |
78.89 |
20.60 |
8 |
8.89 |
2.32 |
0 |
0.00 |
0.00 |
11 |
12.22 |
3.19 |
90 |
|
2005 |
81 |
73.64 |
25.34 |
9 |
8.18 |
2.82 |
13 |
11.82 |
4.07 |
7 |
6.36 |
2.19 |
110 |
|
2004 |
99 |
55.62 |
32.39 |
19 |
10.67 |
6.22 |
46 |
25.84 |
15.05 |
14 |
7.87 |
4.58 |
178 |
|
2003 |
192 |
83.12 |
57.68 |
9 |
3.90 |
2.70 |
15 |
6.49 |
4.51 |
15 |
6.49 |
4.51 |
231 |
|
2002 |
157 |
83.07 |
49.91 |
3 |
1.59 |
0.95 |
20 |
10.58 |
6.36 |
9 |
4.76 |
2.86 |
189 |
|
2001 |
172 |
88.21 |
51.69 |
4 |
2.05 |
1.20 |
10 |
5.13 |
3.01 |
9 |
4.62 |
2.70 |
195 |
|
2000 |
149 |
83.24 |
43.10 |
3 |
1.68 |
0.87 |
11 |
6.15 |
3.18 |
16 |
8.94 |
4.63 |
179 |
|
Mean |
SD |
|
Mean |
SD |
|
Mean |
SD |
Mean |
SD |
Mean |
|||
|
124.12 |
42.41 |
|
11.41 |
8.10 |
|
10.47 |
12.50 |
12.88 |
6.49 |
158.88 |
|||
Rate calculated by
100.000 live births
Data source: INEC
Overall prevalence in
male reported was 50.45% and female 49.54%.
SD: standard deviation
The global
predominance of syphilis is attributed to the male population. In general,
statistics within CS syphilis group men appear with greater prevalence.
Nevertheless, this is not decisive. There is the need to observe data during
the years 2001, 2004, 2005, 2010 and 2011. During those years female prevalence
is shown (Table
2). Some records indicate that during 2017, 69
cases of congenital syphilis were diagnosed in males and 60 in females, while
in 2018 the figure increased to 142 cases of congenital syphilis in males and
119 in females.
Table 2. Sex distribution of Syphilis in Ecuador (2000-2016)
|
|
Congenital Syphilis |
Early Syphilis |
Late
Syphilis |
Other Syphilis |
||||||||
|
|
Men n=
(%) |
Women
n= (%) |
Total |
Men n=
(%) |
Women
n= (%) |
Total |
Men n=
(%) |
Women
n= (%) |
Total |
Men n=
(%) |
Women
n= (%) |
Total |
|
Total |
958 (51.70) |
895 (48.30) |
1853 |
81 (52.60) |
73 (47.40) |
154 |
62 (44.93) |
76 (55.07) |
138 |
112 (52.58) |
101 (47.42) |
213 |
|
Mean |
64.35 |
59.76 |
124.11 |
5.40 |
4.87 |
10.27 |
4.13 |
5.07 |
9.2 |
7.467 |
6.73 |
14.2 |
|
SD |
23.73 |
20.14 |
45.10 |
3.79 |
4.47 |
7.61 |
5.04 |
7.41 |
12.32 |
4.44 |
3.61 |
7.08 |
Regarding the prevalence first years of registry (2000 to 2003) shows cases as higher as the end of the baseline (2012 to 2016) (Figure 1).
Figure1. Cases distribution by year
Discussion
Prevalence of CS is higher over the rest of
groups showed early, late, and other forms of syphilis. This fact was due to
lack of prevention around those years in Ecuador. Records presented in year
2008 have a peak that should be analyzed considering the way of registry.
Presence of false positive could be questioned due to new diagnostic technics.
There should be special attention to the fact data was reviewed over 12 years,
2000 to 2016. This range of time could have higher dispersion of cases number.
Statistics analysis of the mean values compared with standard deviation data
supports greater reliability of registry from year 2005 (Figure 1).
Since 2006 and forward no report of late
syphilis was made. That finding could mean progression of the illness has been
stopped giving those records are persistent. That would be ideal, but there is
the possibility the cases have been registered somewhere else like other
syphilis. In that scenario it would not show diminished prevalence. Other
syphilis refers to all survival people who have had illness control. Those
people have regular follow up by health personnel. It has not been established
if cases presented belong just to people who have been born in Ecuador or come
from another country. This is a circumstance that must be presented because of
recent immigration to Ecuador (20).
The global predominance of syphilis is
attributed to the male population, however the female population stood out in
other years. This finding reproduces the analysis of late syphilis until 2005.
Considering the previous discussion on reliability, no one can be made.
Categorical statement about a higher prevalence. In general terms, although the
number of cases in men is higher, the ratio is almost 1: 1 for both sexes (21). Prevalence in Ecuador regarding to
male/female ratio is about the same as published by other countries. In Colombia,
in 2020, 777 cases of congenital syphilis were registered, representing an
increase of 19% compared to the previous year, with 192 cases of patients from
or residents of Venezuela (22). In 2018 in Peru the incidence of congenital
syphilis ranged from 0.3 to 0.5 cases per 1000 live births (23); in 2019, an incidence of congenital syphilis
(including stillbirths) was reported at 0.5 cases or less per 1000 live births,
however there are no detailed official data available in recent years.
Most common cause of CS is a deficiency of
pregnancy control. Even in largest
cities some women do not access to an adequate medical control during
pregnancy. Those who get attention not always have the number of medical controls
required (24). There is educational factor involved also related with a low impact in
the strategies to accomplish the standards of care. Venereal Disease Research
Laboratory (VDRL) is not always performed during pregnancy (25).
The number of cases has an irregular tendency
downward. However, analysis made covers 12 years of reports with shortcoming
about information and registry. If only statistically reliably data is
considered, variation from year 2005 is not significant. It maintains a slight
slope declined but media values presented would indicate a plateau during last
7 years. Considerations previously explained should be taken for year 2008
data. The data obtained confirm the proposed plateau on syphilis in Ecuador.
Despite the fact that the absolute number of cases has presented an annual rate
of decrease in prevalence, it has not undergone such a change in recent years (26).
This determines a blockage on expected descent
of cases. Real effectiveness of existing prevention and treatment of congenital
syphilis programs is questionable. Possibly, there is not yet adequate follow
up of all pregnant women. Perhaps, follow up by health professionals is still
deficient (27). Reasons to explain the unchanged prevalence during specially the last
8 years are initially due to lack of adequate registry of data (28). There are still some ethnic groups as Native
Amerindians, poverty, and lack of enough education, to whom information
regarding sexual education and pregnancy control is still insufficient (29). Other problem is the health promotion is not
well understood. To assure prevention, there is a need of better planning and
management in public health. Physicians, nurses, medical students, and people
related to health system should be involved. Authorities should have a program
and monitor its effectiveness (30).
There are many physicians who still gather only
at the main hospitals. If the goal to lower cases of syphilis is based on
prevention the work remaining will not be at the hospital only. There should be
emphasis to go out, educate and make sure it has had an impact on target
population. Coordination will be expected from health authorities (31). CS registry requires background research,
clinical abilities to detect characteristic signs and symptoms and adequate
diagnosis tests opportunely (32).
Cases reported and presented by the INEC are
official. Data is approved by the Ecuadorian government. It was possible to
find archives from year 2000 giving that previous information is not complete.
Archives in some cases have been eliminated from the virtual database. Although
there is some information published in other papers even in Ecuador, only
records part of national reference has been taken in consideration for this paper.
The rate of CS in the United States reached a low of 8.4 cases per 100.000 live
births in 2012 compared with our study Ecuador CS rate was 43.17 cases per
100.000 live births for the same year. In Ecuador, there have been reports on
the number of cases in different publications. There are some variations in the
numbers presented here. Causes to find some cases which do not coincide with
different sources researched can be explained by and inadequate registry of
cases or misreport in official sources. Nonetheless, data maintain stated
distribution. It is due to this reason analysis don´t vary overall, albeit it
could show variations from the statistical point of view (33).
In September 2010, WHO member countries in the
region of the Americas approved the Strategy a Plan of Action for Elimination
of Mother-to-Child Transmission of HIV and Congenital Syphilis in the Americas
(resolution 50/12. 50 Directive Council Meeting); the proposed goals until 2015
were (i) to reduce HIV maternal-to-child transmission
to 2% or less (ii) to reduce the incidence of pediatric HIV cases to 0.3 or
less per 1000 live births; and (iii) to reduce congenital syphilis incidence
including stillbirths) to 0.5 or less per 1000 live births until 2015 (34).
In 2007 the WHO launched a global initiative
for the elimination of CS. Furtherly. WHO estimated that in countries with high
antenatal syphilis burden allowed to focus efforts in strengthening existing
maternal and child health systems infrastructure, an small investment could
substantially reduce this global perinatal scourge.
Elimination of CS requires a combined commitment of governments and other
partners to mount an effective and sustained response (35,36).
WHO has outlined a strategic plan of action for
the global elimination of CS is a public health problem.
The four-pillar strategy for elimination CS is ensure advocacy and sustained
political commitment for a successful health initiative, increase access to,
and quality of maternal and newborn health services, screen and treat pregnant
women and partners, and establish surveillance, monitoring, and evaluation
systems (37).
The global initiative emphasizes that congenital
syphilis elimination can contribute directly to three of the Millennium
Development Goals by reducing child mortality through reductions in perinatal
deaths and low-birth-weight infants; improving maternal health through
reductions in late fetal losses and stillbirths and through a decreased burden
of syphilis in pregnant women, and combating HIV/AIDS, malaria and other
diseases through combined systematic screening for HIV and syphilis in
pregnancy with an emphasis on strengthening antenatal and postpartum health
systems (12).
Unfortunately, Ecuador is far of this reality.
Several barriers currently exist that limit maternal syphilis screening and
treatment efforts (38). Promote maternal syphilis screening and treatment as part of basic
antenatal health services its mandatory (39). In addition, promotes strategies such as
incorporating integrated professional training and curricula for health care
providers or integrating data systems monitoring (40) it will support to build capacities and it
will improve antenatal outcomes.
Current
prevalence of CS in Ecuador shows a slight drop, but it is still stationary.
Prevention, control and follow up guidelines must be reviewed by health
authorities in Ecuador. Standard of care must be known by patients and health
personnel. Ecuador will probably not reach the millennium development goals if
syphilis remains stationary.
Acknowledgements
The authors are
grateful to the researchers and health authorities that support this initiative.
Conflict of
Relations and Activities
The authors
declare not to present conflicts of interest and relationships during the
conduct of the study.
Funding
The
research was carried out with the researchers' own funds; therefore, it was
self-financed.
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Authors' Contribution
GAF, ARG, CY and OC:
conceptualization,
methodology, validation, formal analysis, investigation, resources, data
curation, drafting-preparation of the original draft, writing-review and
editing, visualization, supervision, planning and execution, project
administration, funding acquisition
©2021. Los Autores. Kasmera.
Publicación del Departamento de Enfermedades Infecciosas y Tropicales de la
Facultad de Medicina. Universidad del Zulia. Maracaibo-Venezuela. Este
es un artículo de acceso abierto distribuido bajo los términos de la licencia
Creative Commons atribución no comercial (https://creativecommons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial,
distribución y reproducción sin restricciones en cualquier medio, siempre y
cuando la obra original sea debidamente citada.