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Book Review: Centro de Referência e Treinamento DST/AIDS-SP. Coordenadoria de Controle de Doença, Secretaria de Estado da Saúde de São Paulo. Guia de bolso para o manejo de sífilis em gestante e sífilis congênita, 2a edição. São Paulo: [s.n.], 2016. Disponível em: http://www.saude.campinas.sp.gov.br/doencas/sifilis/guiadebolsodasifilis_2edicao2016.pdf . 116 p.

Isabela Colem Castelo Borges
Universidade Federal de São João Del Rey - Campus Centro-Oeste Dona Lindu/CCO
isabelacolen@gmail.com
Carla Jorge Machado
Universidade Federal de Minas Gerais – Faculdade de Medicina
carlajmachado@gmail.com

Abstract

This manuscript critically reviews the following guideline: Guia de bolso para o manejo de sífilis em gestante e sífilis congênita, do Centro de Referência e Treinamento DST/AIDS-SP

Key words: syphilis, congenital; syphilis, handbooks, guidleines as topic, practice guidelines as topic


Syphilis infection during pregnancy is a serious public health problem, and it is related to congenital syphilis. Congenital syphilis, in most cases, is associated with pregnant women who do not screen for syphilis, and/or who are not treated properly or who have not been treated. Thus, detection and management of syphilis in pregnancy is important.1

In September 2017, the ‘Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais’ launched, through \'Nota Informativa No. 2-SEI/2017-. DIAHV/ SVS/MS\' 2, new criteria for definition of congenital, acquired and pregnant syphilis, in line with the recommendations of the Pan American Health Organization (PAHO) and the World Health Organization.

To consider the occurrence of syphilis in pregnant women, the following situations were defined: women who were not treated and had a positive test result for at least one type of test, treponemic or not, positive during pregnancy, but also at the baby birth and puerperium; symptomatic women who had at least one test positive (treponemic or not) during the same period; and women who were treated, but presented both reagent tests, also in the same period. In case of congenital syphilis, different criteria are defined for newborns, younger than thirteen years and results of biopsies and necropsies. Among changes made in these criteria that were proposed by \'Nota Informativa No. 2\' 2 are: absence of consideration of the mother\'s sexual partner\'s treatment to define inadequate treatment, need to perform at least two dilutions for non-treponemal test and, finally, the possibility of obtaining nasal secretion material or skin lesion for laboratory evaluation2

For epidemiological analysis of congenital syphilis and in pregnant women in Brazil, a reference document is the \'Boletim Epidemiológico da Sífilis\', de 2017. According to this bulletin, the incidence rates of congenital syphilis and syphilis in pregnant women increased about three times between 2010 and 2016, and the increase from 2015 to 2016 was, respectively, 4.7% and 14.7%. Among the cases, approximately 51.6% of pregnant women with syphilis were in the 20-29 age group in 2005/2007, and in 2016, 53.6% of the women did not have completed high school.

The disease is responsible for causing signs of bone, neurological and cardiovascular complications in mothers, and, in babies, is responsible for causing premature birth, pneumonia and malformation. Syphilis in pregnancy is growing in Brazil and needs to be precisely notified for the proper design of governmental actions. Considering that syphilis is a 100% preventable condition, with the appropriate measures to pregnant women 3, the need to identify and notify the disease, as well as to have knowledge about the care of affected mothers and children, is clear.

Important material that can help medical doctors and other health professionals is the \'Guia de Bolso para Manejo da Sífilis em Gestantes e Sífilis Congênita\', published in 2016, by the \'Coordenadoria de Controle de Doenças de São Paulo\' 4. The content of the ‘Guia’ addresses the issue in a complete and comprehensive manner, ranging from the definition disease cases to clinical and laboratory diagnosis, treatment, referral and epidemiological surveillance. Syphilis requires attention: clinical signs vary according to disease stages; the diagnosis does not include specific serological tests, which, in addition to varying degrees, react with different precision according to the stage of syphilis and, like any other disease, treatment varies according to variables such as: the patient having lost doses, being allergic to the medication or being infected by another disease - especially HIV. Therefore, syphilis requires a high technical, academic and scientific knowledge for its correct management, being only one of the diseases that health professionals need to be familiar, especially in their undergraduate and specialization courses, which brings value to ‘Guia’ as a reference material.

As discussed, syphilis has several forms of diagnosis, drug dosage and manifestation, and each case has its specific manegement. The flowcharts and charts presented in ‘Guia’ become valuable tools: syphilis evolution scheme, which shows the reactivity of serological tests and the chance of vertical transmission; clinical manifestations of the disease in phases, describing the type of lesion, location, among other aspects; flowcharts of attention to pregnant woman; flowchart of newborn care. By placing the information, usually technical and operational, in a graphical way, the text load of the ‘Guia’ is relieved, and the reader\'s understanding becomes easier, and even a better mental organization of the content takes place. These resources, however, could be used more frequently to replace certain texts, since it is a pocket guide, a name that suggests that each subject is written in a concise way. In the case of the topic that deals with the follow-up and control of the cure of newborns with congenital syphilis or exposed to maternal syphilis, for example, information is repeated in the diagram that follows the text.

While some sections might have been more synthetic - another example being the explanatory note of inadequate treatment for maternal syphilis, repeated less than fifteen pages later - the topic of Laboratory Diagnostic Aspects (item 1.2.2) could have been deepened. Treponemal tests, that is, those that react according to specific antibodies to Treponema pallidum and non-treponemal tests, are presented, with the latter being used for monitoring the treatment, since the former can be reagents throughout life, even after infection has ceased. The way these non-treponemal tests work could have been explained, which would contribute to a better understanding of the difference between the two types of tests and also why the chances of false-positive in non-treponemal tests are only mentioned in ‘Guia’. In addition, it is indicated that the rapid test should be the first to be performed as a screening procedure, but, among the subsequent tests, that is, of confirmation or follow-up, it is only reported whether or not they are treponemic, without indicating whether FTA-Abs or ELISA should be used. Thus, despite the sensitivity and specificity of each test being shown in the table, it was not clear which test of each type is the most appropriate for recurrent use and what should be the criteria of choice in each situation, or whether they should be used in combination.

Despite the mentioned issues, the \'Guia de Bolso para Manejo da Sífilis em Gestantes e Sífilis Congênita\' is undoubtedly very well written and structured. In fact, guides, usually based on clinical guidelines, can improve the quality of clinical decisions, offering explicit recommendations to physicians who are not sure how to proceed, and thus help promote up-to-date practices and improve consistency of care 5. Therein lies the greatest virtue of having available guides such as this one, which is also available in the internet.

Finally, the questions at the end of the two sessions deal with more complex cases: the concern to put them in ‘Guia’ shows the intention of the the technical staff who wrote the guide, in addition to making the reading more dynamic, to elucidate any issues that may appear in the day to day of a reference center in infectology. Also, ‘Guia’ is an initiative of the \'Secretaria de Estado da Saúde de São Paulo\', which is in line with the ‘Agenda de Ações Estratégicas para Redução da Sífilis no Brasil’ 6, which replaced, in 2017, the ‘Agenda de Ações Estratégicas para Redução da Sífilis Congênita no Brasil’. Finally, the publication of a new edition is suggested, given the fact that some of its concepts have become out of date with the changes made by \'Nota Informativa No. 2’ 2.


Referências

1- Padovani C, Oliveira RR, Pelloso SM. Sífilis na gestação: associação das características maternas e perinatais em região do sul do Brasil. Rev Latino-am Enfermagem 2018; 26, e3019. Epub 09 de agosto de 2018. Disponível em: https://dx.doi.org/10.1590/1518-8345.2305.3019
2- SEI/MS. Nota informativa Nº 2-SEI/2017-. DIAHV/SVS/MS. Altera os Critérios de Definição de Caso para notificação de Sífilis Adquirida, Sífilis em Gestante e Sífilis Congênita. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Agravos/Sifilis-Ges/Nota_Informativa_Sifilis.pdf
3- Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico - Sífilis. Brasília: Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais – DIAVH/SVS/MS, 2017. Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/novembro/13/BE-2017-038-Boletim-Sifilis-11-2017-publicacao-.pdf (44 p.)
4- Centro de Referência e Treinamento DST/AIDS-SP. Coordenadoria de Controle de Doença, Secretaria de Estado da Saúde de São Paulo. Guia de bolso para o manejo de sífilis em gestante e sífilis congênita, 2a edição. São Paulo: [s.n.], 2016. Disponível em: http://www.saude.campinas.sp.gov.br/doencas/sifilis/guiadebolsodasifilis_2edicao2016.pdf (116 p.)
5- Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999; 318(7182): 527-30.
6- Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Agenda de Ações Estratégicas para Redução da Sífilis no Brasil. Brasília : Ministério da Saúde, 2017. Disponível em: http://www.aids.gov.br/pt-br/pub/2017/agenda-de-acoes-estrategicas-para-reducao-da-sifilis-no-brasil