Syphilis in Brazil: Time of COVID-19

Background: Sexually transmitted infections, such as syphilis, even though they have treatment, represent an important public health problem. In view of the pandemic brought about by the new coronavirus worldwide, changes in the incidence of syphilis in Brazil and in the state of Goiás were noticed. Methods: this is a descriptive, exploratory and retrospective observational study with integrative and systematic analysis. A search was carried out at the SUS IT Department (DATA-SUS), through the TABNET application. Results: the study identified the evolution of cases of acquired, gestational and congenital syphilis in Brazil and in the State of Goias. We can see a gradual increase over the years until 2018, but a slight decrease in 2019 and a significant reduction in 2020. Conclusion: we cannot conclude that social distancing reduced the disease transmission rate, since underreporting of cases can only be proven in a few years, when the number of visits to specialized clinics and the performance of diagnostic tests normalize.


INTRODUCTION
Sexually transmitted infections (STIs), such as syphilis, represent a serious public health problem in the world, especially in developing countries (Machado et al., 2021).
Despite the existence of inexpensive and effective antibiotic treatment regimens, syphilis continues to have a profound impact on the reproductive, sexual and psychological health of the population (Kidd et al., 2018;Luo et al., 2021).
Syphilis is an infectious disease caused by the bacterium Treponema pallidum, which can be transmitted from person to person, through sexual contact or during pregnancy (vertical transmission). In the absence of adequate treatment, syphilis can progress to different stages, resulting in irreversible cardiovascular or neurological complications (Lasagabastera and Guerra, 2019).
The natural history of syphilis alternates in periods with different clinical, immunological and histopathological characteristics (primary, secondary and tertiary syphilis), which can be interspersed with latency periods, when there are no signs or symptoms (Gaspar et al., 2019). Primary syphilis is characterized by the appearance of lesions in genitals, called inguinal cancer or lymphadenopathy, which are usually painless and resolve spontaneously. The secondary phase is characterized by a maculopapular rash on the shoulders, arm, chest, or back and a gray papillomatous lesion in the perianal area, called condyloma lata. Tertiary syphilis, on the other hand, is characterized by destructive visceral, cardiovascular or neurological disorders, as well as severe skin lesions that affect untreated patients (Gaspar et al., 2019;Peeling et al., 2017).
Congenital syphilis is the infection of the fetus by Treponema pallidum that occurs via the transplacental hematogenous route, when the pregnant woman was infected and did not correctly treat the infection. In this case, the disease can occur regardless of the stage of pregnancy or clinical stage of the disease in the mother (Domingues et al., 2021).
In December 2019, an outbreak of pneumonia began in Wuhan, China, prompting an etiological and epidemiological investigation carried out by the Chinese Center for Disease Control and Prevention (CDC). As a result of this investigation, it was discovered that the etiology of this pneumonia was one of the viruses belonging to the Coronaviridae family, of the order Nidovirales, called the new coronavirus of 2019 (2019-nCoV) (Lu et al., 2020;Zhou et al., 2020).
The new coronavirus was later named SARS-CoV-2, due to its high similarity to SARS-CoV, which was identified in 2002 as the etiologic agent of an epidemic of severe acute respiratory syndrome. Severe acute respiratory syndrome caused by the new coronavirus was then called COVID-19 (Coronavirus 19 Disease) (Huang et al., 2020;Lima et al., 2020). The rapid spread of the new virus across continents led the World Health Organization (WHO) to declare a pandemic. Since then, there has been a significant increase in human infections on all continents, which has led to the need for preventive measures such as the use of masks and social distancing (Nussbaumer-Streit et al., 2020).
The feeling of panic and fear of being exposed to the new coronavirus can make some people fail to pay proper attention to other infections or diseases that deserve serious care, such as syphilis. Thus, this paper aims to describe the incidence of syphilis in Brazil and the Goias State in the last 10 years and its relationship with the social distance caused by the pandemic.

METHODS
This is a descriptive, exploratory and retrospective observational study with integrative and systematic analysis. A search was carried out on secondary data in the public domain and unrestricted access available at the SUS IT Department (DATA-SUS), through the TABNET application, referring to cases of syphilis reported in Brazil and in the state of Goias in the last 10 years.

Epidemiological Surveillance
Strengthening epidemiological surveillance, government management, communication and education help to reduce the incidence of comorbidities. The integration of these sectors is the main objective of the Ministry of Health in the fight against syphilis in the country (Brasil, 2017).

The Notifiable Diseases Information System (SINAN) is a data collection system
where it is possible to transmit and disseminate data collected by the government through the epidemiological surveillance system. This system uses the internet as a way to make data more accessible to users in any part of the country, in addition to facilitating its feeding and avoiding duplication of data. SINAN collects important information in order to assist in the development of public policies to promote and protect the health of the population (Laguardia et al., 2004).
The information department of the Unified Health System (DATA-SUS) started its research and information in 1991. This body is managed by the Strategic and Participatory Management Secretariat of the Ministry of Health, with the purpose of collecting, processing and disseminating data on the health. The information collected by this department is available on TABNET.
When analyzing the distribution of cases of acquired syphilis according to sex, we conclude that, regardless of the year in question, the incidence is higher in men both nationally and in the State of Goiás. In all years analyzed, the number of confirmed cases secondary or tertiary congenital syphilis is lower than the other clinical classifications.
Regarding gestational age, the number of cases in the third trimester was higher between 2010 and 2014 across the country, but as of 2015 notification in the first trimester was higher (Tables 1 and 2    The notification of cases of congenital syphilis is greater in newborns (up to 7 days) and tends to decrease with increasing age, probably due to the proximity to birth and the proper perinatal exams. Furthermore, the recent diagnosis of congenital syphilis is extremely superior to the number of late diagnosis (Table 1). Both observations are relevant and should be highlighted, since early diagnosis is crucial for advance treatment of the disease in order to minimize future sequelae and prevent unfavorable pregnancy outcomes for mother and child (Damasceno et al., 2014). The notification of abortion and stillbirth because of syphilis increased between 2010 and 2018, but it decreased significantly in 2020. These cases represent a total of 7% of the notifications of congenital syphilis cases in the country and 5% in Goias. This fact can be justified by the lack adequate treatment of pregnant women, since we can observe that 55% of pregnant women underwent inadequate treatment throughout the country and 57% in the state of Goias (Table 1 and 2).

Congenital syphilis -final diagnosis
When carrying out a cross-sectional study at the Dona Regina Reference Hospital, located in Palmas-TO, Konka & Lago17 reported that in 2004 there were five fetal losses and 23 live births with congenital syphilis, of which 87% had weight greater than 2. 5 kg.
One child presented clinical symptoms with septicemia, but the others did not show changes on physical examination. Five newborns were submitted to complementary evaluation, one of which showed CSF alteration and one alteration on long bone X-ray.

Time Of COVID-19
When we observe the evolution of cases of acquired, gestational and congenital syphilis in Brazil (Table 1) and in the State of Goias (Table 2), we can see a gradual increase until 2018, but a slight decrease in 2019 and a significant reduction in 2020.
The increase in the notification of cases between 2010 and 2018 can be explained by the increase in syphilis detection rates, which may have been driven by the organization of health services and awareness of professionals (Saraceni et al., 2017). On the other hand, we can relate the pandemic we experienced in the last year to the reduction in the incidence of syphilis in 2020, since this disease is contagious and social distance has significantly reduced human contact. Thus, we can infer that quarantine was beneficial not only to reduce the spread of Corona virus, but probably other pathogens as well. However, it should be noted that it is not possible to show whether this reduction in the number of cases is because of a reduction in contagion or just an underreporting, caused by a decrease in testing, a reduction in the demand for medical care, and a decrease in the frequency of screening campaigns. If we have gone through underreporting, in the coming years we will see a significant increase in the number of cases.
The same was observed by Crane et al. (2021) in the United States of America, which informed a 20% reduction in reporting chlamydia, 3% gonorrhea, but a 5.5% increase in syphilis cases in the first 40 weeks of the pandemic. However, after 40 weeks an 18% reduction in the occurrence of chlamydia and 7% of syphilis was observed.
However, like us, the authors reported that it is not possible to determine whether there was a reduction in contagion or just an underreporting. The authors suggest that measures should be taken to encourage home testing.
A survey conducted in Rhode Island (USA) analyzed the number of visits to the main clinic in the province dedicated to the care of sexually transmitted infections (STI's) during the pandemic, divided into 3 periods: (1) pre-COVID-19 (September 1st, 2019 to February 29, 2020); (2) evolution (March 1st, 2020to April 11, 2020and (3) plateau (April 12, 2020 to May 13, 2020). The researchers observed that during the evolution phase there was a reduction by 55 % in the total number of visits, 60% in screening and 62% in the number of consultations for treatment compared to the pre-COVID-19 phase. In the plateau phase, this decrease was even more significant, as they observed a reduction of 84% in the total number of clinical visits, 100% in screening visits and 77% in treatment. To solve the problem, the clinic resorted to telemedicine, but they did not provide screening tests by this modality (Tao et al., 2021).
A study carried out in New York, USA, between April 20 and July 8, 2020beginning of social distancing -, with a sample of 108 patients who sought the team for preventive routine follow-up and filled in all the data online, reported that, among the 87 Another factor that must be taken into account is the way people relate, which has been changing more and more. Before the pandemic, the number of encounters caused by apps such as Tinder or Match Group only increased, but the pandemic may have influenced the number of users. With that in mind, Lozic (2021) analyzed these applications and concluded that the number of Match Group users increased by 5.9% in the third quarter of 2019 and 7.3% in the same period in 2020, while the Tinder grew by 9.6% in the third quarter of 2019 and 6.5% in 2020. Despite this, researchers report that the trend of users is variable depending on the situation with the pandemic, however, the number of users of the Tinder continues to grow, despite being a digressive growth.
Despite going against what is expected about measures of social distancing, this fact can be justified by the need that individuals felt to make new friends and keep busy.
An online survey conducted in the UK found that of the 868 individuals who responded to questions about sexual practice during self-isolation/social distancing, 39.9% reported having sexual activity at least once a week. In addition, they described some variables dependent on this fact, such as being male, being young, being married or in a stable relationship, consuming alcohol and being isolated for a greater number of days (Jacob et al., 2020). Thus, we can observe that the fact of being married or in a stable relationship is a dependent variable for sexual practice can reduce the spread of STIs.

CONSIDERATIONS
The self-isolation/social distancing caused by the pandemic triggered a reduction in the number of notifications of syphilis cases throughout Brazil, as observed in another study carried out in the USA. However, we cannot conclude that social distancing reduced the disease transmission rate, since underreporting of cases can only be proven in a few years, when the number of visits to specialized clinics and the performance of diagnostic tests normalize.
More studies are suggested that relate the reporting of cases of syphilis and other sexually transmitted infections with the years 2020 and 2021. In addition to studies that analyze the effect of the pandemic on changes in the behavior of individuals regarding the rigor in choosing partners.