The Western Region of the Brazilian Federal District has a population of half million people, of which 7000 women become pregnant every year. As in many parts of the world, syphilis is a major public health challenge in the Region: in 2021 there were 1654 congenital syphilis cases for every 100 000 live births. This is 33 times higher than the WHO target of 50 cases per 100 000 live births to reach the elimination of vertical transmission, also known as mother-to-child-transmission, of syphilis as a public health problem.
In 2021 an assessment revealed that whilst antenatal care (ANC) was high with 48% of women having at least 6 visits (1), only 68% of pregnant women attending ANC were tested for syphilis and only 46% of those diagnosed with syphilis received adequate treatment (2) (figure 1). The global targets for testing and treatment coverage are both ≥95%.
Figure 1. Progress in the cascade of care of syphilis in pregnancy of 2021 and 2023
/global-hiv-hepatitis-and-stis-programmes-(hhs)/progress-in-the-cascade-of-care-of-syphilis-in-pregnancy-of-2021-and-2023.png?sfvrsn=2702b954_6)
In response to these challenges, managers, health workers and the epidemiological surveillance team joined forces and developed a comprehensive local action plan to tackle congenital syphilis. The successful implementation of the plan decreased the congenital syphilis rate by 37% in only 2 years, from 1654 to 1042 per 100 000 live births.
"Everyone was determined to improve the quality of care and reach elimination standards, despite the Region's high social vulnerabilities and determinants of health, such as poverty and high rates of violence," said André Luiz de Queiroz, Superintendent of the Western Health Region of the Federal District.
The action plan aims to improve governance and increase the quality of ANC services at the primary health care and maternity wards, driven by effective person-centred data monitoring. Thus, an easy-to-use digital tool was deployed to track, in real-time, every pregnant woman who initiated ANC. One of the features of the tool is the recording of syphilis testing, test results and treatment history, including non-treponemal tests titres to evaluate treatment success. It also identifies those who need to re-engage in care, and soon will track sexual partners' testing.
The plan also includes other critical actions, such as:
- adding to the tasks of the existing Primary Health Care Committee the role of overseeing the continuum of care of all pregnant women in ANC in addition to investigating every congenital syphilis case to correct failures in the provision of services;
- engaging the local laboratory personnel to ensure expedited testing and prompt return of results, as well as to help the surveillance team to identify and correct underreporting or misreporting of maternal syphilis cases;
- training health workers providing easy-to-use standard operation procedures and information on the latest national clinical protocols and therapeutic guidelines so syphilis can be diagnosed and treated at the primary level of care;
- offering free-of-charge rapid testing and treatment for syphilis, in addition to HIV and viral hepatitis B and C, to everyone using health services, regardless of pregnancy status, as well as providing free condoms and lubricant gel;
- offering the same package of services at the local vaccination program mobile clinic to decrease stigma and discrimination related to STI testing; and
- strengthening the referral system for infants exposed to syphilis.
In recognition of this progress, the Western Region of the Federal District was awarded the Silver Seal towards the elimination of vertical transmission of syphilis by the Federal District and the Silver Medal of Good Practices by the Brazilian Ministry of Health for the elimination of mother-to-child transmission of HIV.
"This Brazilian experience can serve as an example and inspiration for other countries facing similar challenges, especially regarding maternal and congenital syphilis. It demonstrates how political will, data-driven strategic management and a committed health workforce can make tangible improvements to people's lives." said Dr Meg Doherty, Director of WHO Global HIV, Hepatitis and Sexually Transmitted Infections Programmes.
