ORIGINAL ARTICLE
Prevention of vertical transmission in the “Syphilis No!” Project: a study on the specificities of the investigation committees/space in the North Region of Brazil

RESULTS

Within the scope of the 100 priority municipalities, the “Syphilis No” project implemented in 2018 a support and research network composed of 52 professionals, including researchers, selected by public notice from LAIS/UFRN, which, in turn, were distributed in 72 of these municipalities under the supervision of the MS, in partnership with the coordination of their technical cooperation peers at UFRN and cooperation of local health managers^2,18. Among the criteria for selecting supporters, experience within the Unified Health System in surveillance and comprehensive care was included, and among their attributions in the project were the development of studies and research aimed at fighting syphilis, in addition to interfederal technical cooperation for the deployment/implementation of municipal/regional syphilis VT investigation committees^13,17.

In the introductory course for initial training of supporters, which took place from March 19 to 23, 2018, in Natal (RN), one of the topics covered was implemented vertical transmission committees, which sought to identify gaps and needs for the project’s performance¹⁸.

After starting the actions of the “Syphilis No” project in the areas of the North region, it was identified that in the eight priority municipalities there was some CIVT strategy for PVTS, namely: five of them with the syphilis CIVT at the municipal level in their initial training when the project was implemented, and three state syphilis CIVTs and three state monitoring groups in the “Syphilis No” project, also undergoing initial training from the project implementation. In the project’s local monitoring group, one was in initial training from the start of the project’ and seven had entered into operation without a regular defined agenda or were permanently operating with a defined activity schedule, see Chart 1. These last two groups were promoted by the “Syphilis No” project as a space for discussing actions in the area, including PVTS.

Chart 1 -

Status of operation of the Municipal and State Committees for the Investigation of Vertical Transmission of Syphilis and the State and Local Moinitoring Groups of the Rapid Response to Syphilis Project, North Region, second half of 2020. (n = 8 municipalities).

With the completion of the support action in the areas, in December 2020, the peers of the “Syphilis No” project were created, namely, MS, LAIS/UFRN and the Center for Studies in Collective Health, a feedback form on the actions of the supporters, which was sent via FormLUES to strategic players who followed the development of the project in priority municipalities, and the importance of the strategy in strengthening the implementation of CIVTs for PVTS could be seen. It was asked “Does the supporter support the deployment and operation of an investigation committee for the prevention of mother-to-child transmission of HIV and syphilis?” and of the 43 who collaborated with the research, 29, 67.4% of the sample, answered ALWAYS, and of the 7 strategic players who answered about the North region, 6, or 85.7% of this region, marked that the supporter ALWAYS supported the deployment and operation of CIVT for PVTS. On the question “Does the supporter encourage training and support the operation of the Local Monitoring Group (GAL)?”, 27, 62.8% of the sample, marked ALWAYS, and 3, 42.8% of employees in the North region responded the same.

In addition, of the 63 papers presented at the I CONEPS, ten (15.9%) of the experience reports were on the theme of investigation of syphilis VT, see Annex 1.

With the purpose of enhancing and strengthening the establishment and permanent functioning of the CIVTs for syphilis, hepatitis and HIV/AIDS, from July 2019 to February 2020, there were nine rounds of videoconferences, see Chart 2, in the priority municipalities of the North region of the “Syphilis No” project. In the meetings, it was possible to reflect on the role of CIVTs in PVTS in the context of comprehensive care and surveillance.

Chart 2 -

Relationship of videoconferences in municipalities and states: Potentialize and Strengthen the Establishment and Permanent Functioning of two CIVTs for Syphilis, Hepatite and HIV/AIDS, North region, 2019-2020.

Among the participants of the agendas were representatives of the MS and the supervisor and supporters of “Syphilis No” in the North region and strategic players from the municipalities and states of the referred region (STI/HIV-AIDS Coordination, Viral Hepatitis Coordination, Surveillance Coordination, Coordination of Primary Care [Women’s/Children’s/Men’s Health], Testing and Counseling Center reference, maternity reference, Qualineo and ÁpiceOn reference and president of CIVTs).

During the videoconferences, difficulties were identified for the establishment and strengthening of VT investigation spaces, which meet the main constraints for the sustainability of syphilis VT investigation committees or spaces in the North region, namely: lack of periodic agendas for the space that carries out VT investigations; change in the state’s organizational chart; lack of adequacy of the investigation form for the local reality; lack of a medical professional in the working space that conducts VT investigations to assist in case discussions; and turnover and insufficiency of human resources. The latter, later on, was also considered an advance towards the makeup of the CIVT or investigation space, as it was identified that in some municipalities, there was an indication of permanent members after rounds of videoconferences.

During the agendas, among the advances found in CIVTs or in the space conducting VT investigations, the beginning of investigations by e-SUS records, the performance of data analysis to identify the number of cases of children exposed per macro-area, the investigation through home visits, the support of a member of the maternity hospital in the composition of the space and advances in the organization of VT investigation spaces, which is now subdivided by (HIV, syphilis and hepatitis).

Another advance reported by the areas was the expansion of the establishment and permanent operation of different spaces for the investigation of syphilis VT or the inclusion of the theme of VT investigation in existing spaces. From this perspective, spaces were created such as the committee itself, technical group, working group, conducting or monitoring group, and the investigation agenda for syphilis VT was included in pre-existing groups, such as the maternal and child mortality committee.

Looking at the power of CIVTs or spaces for investigation of PVTS in the agendas on CIVT in priority municipalities in the North region listed by the “Syphilis No” project, flaws in the Health Care Network (HCN) and necessary qualifications were also pointed out, which could be identified through the investigations carried out, making clear the role of CIVT or investigation spaces for the rapid response to syphilis.

In the context of lost opportunities for PVTS, the following were observed: low coverage of Primary Health Care (PHC) in the territory, lack of diagnosis, inadequate diagnosis and treatment, lack of monitoring and follow-up of cases, prenatal card filled inadequately, lack of integration between services, lack of guidance offered to users, lack of partner treatment, non-active search for positive pregnant women and lack of rapid testing for syphilis in the third trimester.

For congenital syphilis, notification is mandatory; but even so, among the failures identified in the HCN was underreporting, that is, not carrying out the notification of the case. But there was also inadequate notification, for example, duplication in the notification of pregnant women with syphilis, by PHC or the maternity ward or the hospital.

It was also observed that there are hospitals and maternity hospitals that do not screen pregnant women who had a diagnosis and treatment performed in the prenatal period, which is related to the lack of proper filling out of the child and pregnant woman’s booklet.

Other flaws pointed out were related to the lack of offer of qualification for the professionals and the impasses regarding the transfer of the CIVT recommendations to the HCN.

Returning to the role of the CIVT as capable of pointing out intervention measures for the network and contributing to the qualification of care and surveillance, after the municipalities in the North region identified the flaws of the HCN and found their way to PVTS. During the meetings, the following qualifications were also pointed out, including: organization of the area’s database, qualification of completion of the notification form, expansion of screening for rapid testing and offer of mass testing with extended hours in PHC, conducting an active search for pregnant women and partners, offering groups for pregnant women and partners during prenatal care, partner treatment, construction of flowcharts and line of care for comprehensive care for syphilis, monitoring of cases of congenital syphilis and exposed children in PHC, qualification of newborn assessment - born to avoid undue and inadequate notification, fluorescent treponemal antibody absorption test offered in PHC (in this case, previously offered only in the private network) and continuing education for the network’s professionals.

DISCUSSION

In the survey carried out in 2016 with the State and Municipal Coordinations (Capitals) of STI/AIDS on the diagnosis of CIVT for syphilis and HIV, it was found that in 48% of the states there was no process of implementing committees and only 11% reported having a committee deployed. In the municipalities, 41% did not have committees and only 26 and 7% reported having committees in place and in the implementation phase, respectively¹⁹.

Corroborating the data on advances in functioning spaces for VT investigation from the implementation of the “Syphilis No” project, according to the SVS Epidemiological Bulletin of the MS on the “Rapid Response to Syphilis: a situational analysis of the institutional support strategy”, VT investigations were highlighted as priority strategies, as there was an evolution in the implementation of the municipal CIVT, state CIVT, State Group, Local Group and Working Group linked to the project theme in the priority municipalities defined by the project “Syphilis No”² (Figure 2).

Figure 2 -

Percentage distribution of territorial operation of municipal and state committees of investigation of vertical transmission and state group, local group, and working group linked to the Rapid Response to Syphilis Project, February 2020 (n = 72 municipalities).

The strategic players who participated in the videoconferences in the North region with the purpose of strengthening the establishment and permanent functioning of the CIVT for Syphilis/Hepatitis and HIV/AIDS were listed in the recommendation of the MS, which indicates that the CIVT brings together government institutions, managers, health workers, class councils, members of academia and members of organized civil society³, because to reduce the incidence of syphilis VT, these entities must know the magnitude of the problem and have access to and knowledge of local information to carry out the planning and monitoring of the necessary interventions through the outcomes that have occurred and been investigated²⁰.

The difficulties in establishing the VT investigation space underlined in the videoconference rounds with the North region converge with the study of other authors who identified that the high number of states and municipalities that did not have committees was related to the difficulty of bringing members together, lack of human resources and issues related to the formation of a technical group, such as the committee not being legitimized by regulation¹⁹.

In addition, authors bring out other variables, such as the unavailability of transport for local visits and the lack of authorization for technicians to investigate cases¹⁹.

The research with the North region dealt with here resulted in the fact that some places use pre-existing spaces to carry out the investigation of cases, such as the maternal and infant mortality committee. This type of committee was recommended by the MS as a public policy strategy for maternal and child health with support from the Pan American Health Organization and the United Nations Children’s Fund in the 1980s²¹. The space has the objective of analyzing maternal and infant mortality and carrying out activities that qualify the care network through the causes and determinants identified in the investigations carried out, to prevent the occurrence of avoidable diseases^21,22, which goes against what is recommended by the MS for the CIVT as strategic for PVTS³.

The identification of cases of exposed children by macro area was one of the advances made by CIVTs or spaces that carry out the investigation of VT for syphilis in the North region, and authors argue that the recognition of country by macro area is positive to identify the segment of the population and direct the distribution of public health resources²³, here for comprehensive care of PVTS.

In the context of lost opportunities in PVTS, national and international studies have shown failures related to inadequate or no care provided during pregnancy^{24,25,26,27,28,29}. Among these lost opportunities are the lack of proper diagnosis and treatment, the non-performance of the partner’s treatment, and the lack of follow-up and tracking of cases²⁹.

The MS recommends that testing for syphilis should be performed in pregnant women at least in the first prenatal visit and at the beginning of the third trimester. If there is a history of exposure to risk or sexual violence, it is also recommended to perform the test at admission for childbirth³⁰. This point is necessary to guarantee diagnosis and timely treatment during pregnancy.

In Brazil, in 2019, 83.1% of mothers of children with congenital syphilis received prenatal care; however, only 58.6% were diagnosed with syphilis during pregnancy³¹.

In a study conducted in 2012, “Birth in Brazil: a national survey on labor and birth”, also on pregnant women with syphilis in public and private health services, with a sample of the five regions of Brazil, it was observed that women living in the North region were among the group that had the lowest coverage of prenatal care, as well as the lowest records of results from the first serology²⁸.

In the study “Birth in Brazil”, 98.7% of the mothers in the research sample had prenatal care and 96% reported receiving the prenatal monitoring card, but only 71.6% presented the card at admission to the delivery and, of the cards analyzed, 89% had a record of the first serology and 41.1% the result of the second²⁸.

At the meeting of experts that took place in March 2021 on “Maternity and territory: successful experiences in preventing VT”, it was pointed out that one of the ways to integrate PHC with other sectors, such as maternity hospitals and surveillance, is through the CIVT. This is considered to enhance the PVTS at the federal, state and municipal level and is an essential strategy to propose recommendations for the HCN regarding the creation of care flows²⁹.

Finally, authors point out that the guidelines on VT prevention are essential for the reduction of VT, requiring professional training and strengthening of surveillance and care²⁴.

CONCLUSION

To respond to the recommendations of the MS and public policies and agendas, the implementation of the “Sífilis Não” or “Syphilis No” project showed potential for the establishment of committees and spaces for VT investigation in the project’s priority municipalities. In addition, this work presented conditions for the sustainability of VT investigation committees or spaces in the North region, as well as addressing the role of investigation spaces in the rapid response to syphilis in being able to identify flaws in the HCN and to propose intervention and improvement measures for care and surveillance.

It is recommended that further studies be carried out to address the theme of CITV or syphilis VT investigation spaces to identify the situation, potential, challenges and obstacles of these spaces in their constitution, implementation, operation and return to the HCN in view of the technical-scientific and social relevance for PTVS with regard to the reduction of congenital syphilis and, consequently, infant mortality.