Prevalence of factors associated with positive Venereal Disease Research Laboratory in parturient women in Northeast, Brazil

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1 Prevalence of factors associated with positive Venereal Disease Research Laboratory in parturient women in Northeast, Brazil Positive VDRL in parturient women in Northeast, Brazil Silvio Carlos Rocha de Freitas Health Secretary of the Municipality of Fortaleza, Ceará. Rua Assunção, 283, Centro, CEP , Fortaleza, Ceará, Brazil. Maria Alix Leite Araújo Professor of Health Collective Master s Degree Course in the University of Fortaleza - UNIFOR. Av. Washington Soares, 1321, Edson Queiróz, CEP , Fortaleza, Ceará, Brazil. mleite@unifor.br Heber José de Moura Professor of Administration Master s Degree Course in the University of Fortaleza UNIFOR. Av. Washington Soares, 1321, Edson Queiróz, CEP , Fortaleza, Ceará, Brazil. heberm@unifor.br Ana Paula Soares Gondim - Professor of Collective Health Master s Degree Course in the University of Fortaleza UNIFOR. Av. Washington Soares, 1321, Bairro Edson Queiróz, CEP , Fortaleza, Ceará, Brazil. anapaulasgondim@unifor.br Raimunda Magalhães da Silva - Professor of Collective Health Master s Degree Course in the University of Fortaleza UNIFOR. Av. Washington Soares, 1321, Bairro Edson Queiróz, CEP , Fortaleza, Ceará, Brazil. rmsilva@unifor.br Corresponding author: Maria Alix Leite Araújo Professor of Health Collective Master s Degree Course. Av. Washington Soares, 1321, Edson Queiróz, CEP , Fortaleza, Ceará, Brazil. e- mail: mleite@unifor.br

2 Background Objective To analyze the prevalence and factors associated with positive Venereal Disease Research Laboratory (VDRL) test in parturient women admitted to public maternity hospitals in Northeast, Brazil. Methods A cross-sectional study was conducted from June to September, 2010 using a questionnaire and complementary information collected from medical records and prenatal cards. The sample of 320 parturient women was calculated using the number of births at the hospitals in 2009, the prevalence of syphilis in pregnant women of 2.3%, margin of error of 2% and a 95%confidence interval. Results The prevalence of positive VDRL found was 5.3%. Most of the women with positive results had studied for less than nine years, initiated sexual activity at the age of 19 or younger, had more than one sexual partner and didn t live with the partner. The multiple logistic regression analysis revealed that the following factors were associated with a positive VDRL: a previous diagnosis of syphilis (OR = ; IC95% = ; p < ) and the use of illegal drugs (OR = 51.47; IC95% = ; p=0.002). Conclusion It is extremely necessary to perform the VDRL test with all women whenever it s possible, before pregnancy, and perform a special work with those who use illegal drugs. Additionally, other internal and external services should be included in women s health care. Key words: Syphilis, parturient, prevalence, associated factors Background

3 The congenital syphilis (CS) is still an ongoing public health concern, although intervention protocols have been implemented in several countries. 1 The worldwide prevalence of syphilis during pregnancy ranges from 0.11 in Korea to 8.40 in South Africa. 2 In Brazil, the global prevalence is 2.6, ranging from 1.0 in Goiânia to 4.4 in Rio de Janeiro and 2.3 in Fortaleza city (the capital of the state of Ceará). 3 From June, 2005 to June, 2010 a rate of 29,544 cases of syphilis in pregnant women was registered. 4 Between the year 2005 and June, 2010 we registered 27,865 cases of CS. The analysis of records from the year 2000 to 2010 found that 75.5% had received prenatal care and only 55.4% were diagnosed with syphilis during pregnancy. 4 In 2009, the detection rate for congenital syphilis ranged from 0.2 to 5.8 per 1000 live births among Brazilian States. 4 Even considering the health records failures in Brazil, these data show the low quality of prenatal care. When syphilis in pregnant women is not properly treated, it may cause abortion, neonatal and fetal death, preterm birth, intrauterine growth retardation, and long-term harm to the baby s health. 5-6 The persistence of the disease punctuates the need for international and national efforts for an effective implementation of necessary measures, once its control may contribute to the reduction of infant mortality, which is one of the Millennium Development Goals. 7 The universal screening for syphilis in pregnant women through the nontreponemal and Veneral Diseases Research Laboratory (VDRL) tests, as well as a high quality prenatal care are some of the most important strategies recommended by the World Health Organization (WHO) 2 and by the Ministry of Health of Brazil 8 for the elimination of CS as a public health problem. In Brazil, it is recommended the performance of three VDRL tests in pregnant women: two of them during prenatal and another one during in childbirth. The diagnosis of Syphilis is confirmed using treponemal tests. The high cost of such tests and the limited numbers of laboratories either hinder their frequent use in healthcare services or delay their results, hampering the performance of therapeutic and educative interventions to prevent vertical transmission. Thus, the Ministry of Health recommends the treatment of all pregnant women with positive VDRL, regardless of the titration, provided there s no history of previous proper treatment. 9 It is evident that the recommendation for the treatment of positive VDRL cases without a confirmatory test can cause an overtreatment of pregnant women. It s worth saying that this is not a specific test and it may present false-positive results 10. For that reason, they are best recommended for a post-therapeutic follow-up. The ideal procedure would be to ensure a timely confirmatory test. Thus, regarding the urgent need to ensure prevention and control of congenital syphilis and considering that VDRL is the test used in healthcare services to treat pregnant women and prevent vertical transmission, this study aimed to analyze factors associated with positive VDRL results in parturient women attending public maternity hospitals in a city in Northeast Brazil. Methods

4 This is a cross-sectional study with parturient women attending public maternity hospitals of Fortaleza city, Ceará, Brazil, performed from June to September, These hospitals are part of the Brazilian National Healthcare System (SUS) and offer secondary and tertiary care. They are linked to the municipal and state health secretariats and a university. Fortaleza city is divided into six Regional Executive Boards (REB) and has around 2 500,000 inhabitants with 888,966 (35.5%) women of reproductive age among them. 11 The healthcare services offered by SUS include a hierarchized network of 1712 healthcare units, including public and private services and blood banks. The study population was made up of parturient women who were at the hospitals lodging. All the women who performed the VDRL test at the time of their admission for the delivery were included. The sample calculation used 22,232 childbirths from women assisted by SUS, a prevalence of 2.3% of syphilis in pregnant women in Fortaleza 3, a 2% sampling error and a 95% confidence interval. The minimum sample size was made up of 214 pregnant women and it was stratified considering the total number of childbirths performed in each maternity hospital in the year The sampling fraction was calculated using f = n/n and to obtain the number of elements to be observed in each hospital it was used n 1 = f. N 1 /N. 12 Data collection was done randomly through a survey with the parturient women and complementary information was obtained through hospitals records, admission forms and prenatal cards. Undergraduate nursing students were properly trained to visit the hospitals and apply the survey and also obtain complementary information. The VDRL test was done with all parturient women at the time of their admission for the delivery even if it had been done during prenatal, following what it is recommended by the Ministry of Health. 9 The tests were done in all the hospitals where the childbirth occurred using the flocculation reaction test. 13 The study analyzed socio-demographic variables: origin, age, schooling, family income, self-reported ethnicity, occupation (working or studying), and living with a partner; Behavioral: initiation of sexual activity, number of sexual partners, history of forced sex or sex for money, use of alcohol and/or illegal drugs; Individual and partner s risk factors: history of syphilis before pregnancy, occurrence of genital injury, imprisoned partner, partner diagnosed with syphilis, partner using illegal drugs; Institutional: prenatal care (at least one consultation), number of consultations, gestational age at the initiation of prenatal care, VDRL test in prenatal care during the 1 st and 3 rd trimesters. The participants were asked about any signs or symptoms of genital injury and previous treatment for syphilis. The data were stored using the Statistical Package SPSS (Statistical Package for the Social Sciences), version 18. It was performed a descriptive statistical analysis using frequency distribution for the qualitative variables and central tendency and spread measures for the quantitative variables. To analyze the relation between the variables and risk factors for syphilis it was performed a bivariate analysis using Pearson s Chisquare test and Fischer s Exact Test with a significance level of 5% and a 95% confidence interval. The multivariate logistic regression analysis was done in the statistical package STATA, version 11.0.

5 The current study was approved by the Research Ethics Committee from two of the maternity hospitals that participated in it (117/09). The access to information from medical records and admission forms occurred after having the depositary sign a form. The directors of the maternity hospitals signed a document authorizing the authors to conduct the research and all the parturient women signed the Informed Consent Form. With regards to the women under 18 years of age, the people who were in charge of them signed the form. The parturient women started the treatment with benzathinebenzylpenicillin in the maternity hospitals and their partners were summoned and referred to a primary healthcare unit for follow-up care. Results During the study, 350 parturient women were admitted to the seven public maternity hospitals of Fortaleza. Among these, 320 participated in the research and 30 were excluded (23 who were admitted due to abortion, five for not having the VDRL test at the admission and two who refused to sign the Informed Consent Form.) Positive VDRL was found in 17 women (5.3%) and among them, 12 (70.1%) already knew the result during prenatal care. Ten women (83.3%) reported receiving at least one dose of benzathinebenzylpenicillin ( UI) and no one could say the total of doses administered. Besides that, 174 (54.3%) women were in the age group from years old, 179 (56.0%) have studied for less than nine years, 251 (78.4) had a family income of less than two minimum wages and 271 (84.7%) reported their ethnicity as white. The study also found that 308 women (96.2%) attended at least one prenatal consultation. Of all these women, 253 (82.1%) attended the consultation in primary healthcare. Among the ones who received prenatal care, 242 (78.6%) had at least one VDRL test and among them, 89 (28.8%) had it during the first trimester and 86 (27.9%) in the third trimester while 63 (20.5%) did it in the first and third trimesters and 66 (21.4%) didn t have any VDRL tests. Table 1 shows the parturient women s socio-demographic and behavioural variables with the number positive VDRL cases. The rate of positive VDRL was higher among the women from Fortaleza (7.1%), who studied for less than nine years (7.5%), initiated sexual activity at the age of 19 or less (90.0%), who had a previous diagnosis of syphilis (70.0%), more than one sexual partner in life (7.1%), who didn t live with the partner (9.3%), used illegal drugs (27.8%), had sex for money (18.2%) and who had a partner who used illegal drugs and had diagnosis of syphilis (58.8% and 58.8%, respectively). The study also found that 18 women (5.6%) used some kind of drugs (marijuana and/or cocaine and/or crack, 84 (26.3% reported their partners used illegal drugs and 217 (67.8%) reported having previous genital complaints. It s worth saying that no one reported using injectable drugs or its use by their partners. Statistically significant relation was found in the following variables: Origin (p=0.029), number of sexual partners in life (0.026), previous diagnosis of syphilis

6 (p<0.001), living with the partner (p=0.024), use of illegal drugs (p<0.001), partner who uses illegal drugs (p<0.001) and partner with diagnosis of syphilis (p<0.001) (Table 1). It s worth saying that 134 (46.5%) parturient women initiated sexual life at the age of 15 or less and among them, 14/17 (10.4%) had a positive VDRL in childbirth (82.3% of the total of positive cases). Table 2 shows an analysis of institutional factors associated with positive VDRL. Not receiving prenatal care was the only variable that presented a statistically significant relation (p<0.0001). Table 3 shows the adjusted and non-adjusted multiple logistic regression of the variables. The non-adjusted analysis showed that the following variables have a statistically significant positive association with the positive VDRL: women from Fortaleza (OR=7.08; CI95%= ; p=0.029), who had more than one sexual partner in life (OR=7.30; CI95%= ; p=0.026), had a previous diagnosis of syphilis (OR=2.31; CI95%= ; p<0.0001), didn t live with the partner (OR=2.98; CI95%= p=0.024), used illegal drugs (p<0.001; OR=4.42; CI95%= ), having a partner who uses illegal drugs (p<0.001; OR=4.42; CI95%= ) and those whose partners had diagnosis of syphilis (OR=142.85; CI95%= ; p<0.001). The adjusted analysis showed that the following variables remained associated with positive VDRL: women who had a previous diagnosis of syphilis (OR=621.77; CI95%= ; p<0.0001) and who used illegal drugs (OR=51.47; CI95%= ; p=0.002). Discussion The 5.3% prevalence found in the parturient women s VDRL tests was significantly high when compared to other studies conducted in Brazil 3,14 and throughout the world, since these studies performed confirmatory tests. Due to the difficulty in the access to confirmatory tests, the VDRL is the test used in healthcare routine. Furthermore, it has a high sensitivity, low cost and a fast treatment response. 8 In Brazil, it is recommended the performance of three tests in pregnant women: two during prenatal and one in childbirth. Regarding factors associated with positive VDRL, it was found a positive association with previous diagnosis of syphilis and use of illegal drugs. A study conducted with parturient women in Vitória city, Espírito Santo, didn t find a positive association with these variables in the multiple regression design. 18 Other studies 15,19 show that low socio-economic level, use of drugs (crack cocaine and cocaine), having sex for money or drugs, lack of prenatal care and STD symptoms are found to be factors associated with syphilis. The high rate of positive VDRL cases found in women from Fortaleza city was expected, considering that the care for pregnant women from other cities usually occurs due to the need for a more qualified care that is available in the reference maternity hospitals. Most of the parturient women had their first sexual relation when they were less than 15 years of age and all the women with positive VDRL initiated their sexual activities when they were 19 or younger. This shows that the early initiation of sexual

7 activity may favor the exposure to STD. It is necessary to improve healthcare service in order to expand and prioritize its access by the young population. These findings show the importance of intensifying the health policy for adolescents with more actions against STD and precocious pregnancy, which are markers of vulnerability in this age group. It is true that the initiation of sexual activity occurs earlier as time goes by and that it exposes youngsters to STD due to the unawareness of the vulnerability conditions, changing of sexual partners because of an unstable and immature relationship and also the non-use of condoms, especially when they consider trusting the partner A relevant percentage of women who were diagnosed with positive VDRL during prenatal reported receiving at least one dose of benzathinebenzypenicillin. However, they didn t know how many doses were administered, highlighting the low quality of health care that cannot be assessed considering only the number of consultations performed. The quality of health care spans the valorization of pregnant women s counseling, especially of those who have diseases which the transmission to the baby can be avoided, such as syphilis and HIV. In fact, health professionals value this action when it concerns women with HIV but not the ones with syphilis. This study calls the attention to the number of pregnant women that didn t have any VDRL tests during the prenatal period, confirming the finding of another study conducted in Brazil about the failures in health services regarding the adoption of measures to prevent and control vertical transmission of syphilis The findings highlight a poor prenatal care showing the urgent need for a better system, especially in primary care. Studies show that the early capture and reception of pregnant women as well as the correct and timely detection and treatment for syphilis, especially in their sexual partners, are challenges that must be considered by healthcare services It is necessary, therefore, that public policy makers rethink prenatal care in all levels of health care, as well as actions for education and prevention of syphilis and, consequently, congenital syphilis in pregnant women. References 1. Broutet N, Hossain M, Hawkes S. The Elimination of Congenital Syphilis: A Comparison of the Proposed World Health Organization Action Plan for the

8 Elimination of Congenital Syphilis With Existing National Maternal and Congenital Syphilis Policies. Sex Transm Dis 2007; 34: S22-S World Health Organization: The Global elimination of congenital syphilis: rationale and strategy for action. Geneva; Brasil. Ministério da Saúde: DST: Prevalências e frequências relativas de doenças sexualmente transmissíveis em populações selecionadas de seis capitais brasileiras, ed. Brasília, DF; (Série G: Estatística e Informação em Saúde). 4. Brasil. Ministério da Saúde. Boletim epidemiológico: AIDS/DST. Ano VII. Brasília, DF; 2009/ Nascimento MI, Cunha AA, Guimarães EV, et al. Gestações complicadas por sífilis materna e óbito fetal. Rev Bras Ginecol Obstet 2012; 34(2): Hawkes S, Miller ST, Reichenbach L, et al: Antenatal syphilis control: people, programs, policies and politics. Bull World Health Organ 2004; 82: Nações Unidas: Declaração do Milênio. Cimeira do Milénio: 6-8 de Setembro de 2000; Nova Iorque; Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e Aids. Protocolo para a prevenção de transmissão vertical de HIV e sífilis: manual de bolso. Brasília, DF; (Série B: Textos Básicos de Saúde). 9. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e Aids. Diretrizes para o Controle da sífilis Congênita. Brasília, DF; (Série Manuais nº 62). 10. Abarzúa C F, Belmar J C, Rioseco R A, et al: Pesquisa de sífilis congénita al momento del parto: Suero materno o sangue do cordón?. Rev Chil Infect 2008; 25: Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativa populacional de Ministério do Planejamento, Orçamento e Gestão. Fortaleza; Torres TZG, Magnanini MMF, Luiz RR, Amostragem. In Epidemiologia. 2. ed. Editado por Roberto A Medronho, São Paulo: Atheneu; 2009: Ferreira AW. Diagnóstico Laboratorial das Principais Doenças Infecciosas e auto-imunes. 2 ed. Rio de Janeiro: Editora Guanabara Koogan; 2001.

9 14. Machado Filho ACM, Sardinha JFJ, Ponte RL, et al: Prevalência de infecção por HIV, HTLV, VHB e de sífilis e clamídia em gestantes numa unidade de saúde terciária na Amazônia ocidental brasileira. Rev Bras Ginecol Obstet 2010; 32: Romoren M, Rahman M. Syphilis screening in the antenatal care: a crosssectional study from Botswana. BMC International Health and Human Rights. 2006; 6:[5p.]. {doi: / x-6-8} 16. Yahya-Malima KI, Evjen-Olsen B, Matee MI, et al. HIV-1, HSV-2 and syphilis among pregnant women in a rural area of Tanzania: Prevalence and risk factors. BMC Infectious Diseases 2008; 8:[8 p.]. {doi: / } 17. Msuya SE, Uriyo J, Hussain A, et al: Prevalence of sexually transmitted infections among pregnant women with Known HIV status in northen Tanzania. Reproductive Health 2009; 6:[8p.]. {doi: / } 18. Miranda AE, Rosetti Filho E, Trindade CR, et al. Prevalência de Sífilis e HIV utilizando testes rápidos em parturientes atendidas nas maternidades públicas de Vitória, Estado do Espírito Santo. Rev Soc Bras Med Trop 2009; 42: Soares LS, Mesquita AMTS, Cavalcante FGT, et al: Sexually transmited infections in female population in rural Northeast Brazil: prevalence, morbidity and risk factors. Tropical Medicine and International Health 2003; 8: Doreto DT, Vieira EM. O conhecimento sobre doenças sexualmente transmissíveis entre adolescentes de baixa renda em Ribeirão Preto, São Paulo, Brasil. Cad Saúde Publica 2007; 23: Guimarães EA, Witter GP. Gravidez na adolescência: conhecimentos e prevenção entre jovens. Bol Acad Paul Psicol 2007; 27: Rodrigues CS, Guimarães MDG, César CG. Oportunidades perdidas na prevenção da sífilis congênita e da transmissão vertical do HIV. Rev Saúde Pública 2008; 42: Campos ALA, Araújo MAL, Melo SP, et al: Epidemiologia da sífilis gestacional em Fortaleza, Ceará, Brasil: um agravo sem controle. Cad Saúde Pública 2010; 26: Figueiró-Filho EA, Senefonte FRA, Lopes AHA, et al: Frequency of HIV-1, rubella, syphilis, toxoplasmosis, cytomegalovirus, simple herpes virus, hepatitis B, hepatitis C, Chagas disease and HTLV I/II infection in pregnant women of State of Mato Grosso do Sul. Rev Soc Bras Med Trop 2007; 40:

10 Authors contribution Maria Alix Leite Araujo developed the project, analyzed and interpreted data, and helped in the final review of the article. Silvio Carlos Rocha de Freitas developed the project, collected, analyzed and interpreted data.

11 Heber José de Moura performed the statistical treatment, analyzed data and helped in the final review of the article. Ana Paula Soares Gondim analized and interpreted data and helped in the final review of the article. Raimunda Magalhães da Silva analyzed and interpreted data and helped in the final review of the article. All authors read and approved the final manuscript. Acknowledgements We are very grateful to the team of the health unit of the maternity in Fortaleza for their effort to development of this work and the nursery undergraduate students of the University of Fortaleza UNIFOR. In addition, we would also like to thank Flaviano da Silva Santos for English translation and review and language editing of the manuscript.

12 Table 1. Socio-demographic and behavioral factors associated with positive VDRL in parturient women admitted to public maternity hospitals. Fortaleza, Ceará Variables n (%) Positive VDRL p value (%) Origin Fortaleza 226 (70.6) 7.1 Countryside 94 (29.4) 1.1 Age (years) (21.2) 4.4 > (78.8) 5.6 Schooling (years of study) (54.4) 7.5 > (45.6) 2.7 Family income (minimum wages)* (82.3) 4.4 > 2 54 (17.7) 7.4 Occupation (working/studying) Yes 130 (40.6) 5.4 No 190 (59.4) 5.3 Initiation of sexual activity (years) (90.0) 5.9 > (10.0) - No. of sexual partners in life (30.0) 1.0 > (70.0) 7.1 Previous diagnosis of syphilis < Yes 20 (6.3) 70.0 No 300 (93.7) 1.0 Living with partner Yes 212 (66.2) 3.3 No 108 (33.8) 9.3 Use ilegal drugs < Yes 18 (5.6) 27.8 No 302 (94.4) 4.0 Partner uses ilegal drugs < Yes 84 (26.3) 58.8 No/Ignored 236 (73.8) 41.2 Partner with a diagnosis of syphilis < Yes 13 (4.1) 58.8 No/ know 307 (95.9) 41.2 *Current minimum wage R$ Figure 1

13 Table 2. Analysis of institutional factors associated with positive VDRL inparturient women admitted to public maternity hospitals. Fortaleza Ceará, Variables Parturients n (%) Positive VDRL (%) Received prenatal care* Yes 308 (96.2) 3.9 No 12 (3.8) 41.7 No. of prenatal consultations** 113 (37.9) 1.8 > (62.1) 4.9 Initiation of prenatal (weeks) < (36.4) (63.6) 5.1 VDRL during prenatal (at least one) Yes 242 (78.6) 3.3 No 66 (21.4) 6.1 VDRL inthe 1 st and 3 rd gestational trimesters Yes 63 (20.5) 6.3 No 245 (79.5) 3.3 *p<0.001 **n=298 due to lack of registration in the prenatal card. Figure 2

14 Table 3.Non-adjusted and adjusted analysis of variables associated with positive VDRL in parturient women admitted to public maternity hospitals. Fortaleza, Ceará, Var iables Nonadjusted CI 95% p Adjusted CI 95% P Odds Odds Being from Fortaleza More than one sexual partner in life Previous diagnosis of syphilis < <0.001 Not living with the partner Use of illegal drugs < Having sex for benefits Partner uses ilegal drugs Partner diagnosed with syphilis <0.001 Figure 3