In just five years, the cases quadrupled and the peak is in the 15-24 age group. Why the care was relaxed.
Florence Cunzolo
08/21/2019 - 7:00
- Clarín.com
- Good Life
In the Sexually Transmitted Diseases (STDs) sector of the Muñiz Hospital, they opened an Excel document on January 2 of this year in which they record all the cases of syphilis they diagnose. “We are seeing about 50 cases per month of infectious syphilis. And for each index case it is calculated that there are 10 undetected. It's outrageous, ”says Viviana Leiro, a member of the Dermatology service (where the STD clinic operates). Some arrive with chancres (the typical lesion that appears on the genitals, the anus or the mouth), others with red spots in different parts of the body, and there are those who do not manifest symptoms, but go in search of treatment because they had sexual intercourse with a infected person.
They usually receive one to two cases a day there. The day she attended Clarín , just after midmorning, the doctor had seen three.
Health professionals use adjectives to measure what is happening with syphilis. They speak of a "phenomenal" and "alarming" increase, which no longer generates surprise but does generate increasing concern.
According to Omar Sued, president of the Argentine Society of Infectious Diseases (SADI) and director of Medical Research at the Huissa Foundation, the rise “has been seen for several years in men who have sex with men, in transgender women, but also in the General population".
Red spots on the trunk, hands and soles of the feet are a typical symptom of the secondary stage of syphilis.
“Health personnel are sensitized, they perceive an increase in the entire population, especially in young people. Syphilis does not discriminate: like HIV, it is found in any social stratum ”, adds Analía Urueña, infectologist at Helios Salud, consultant until last month for Unicef and member of the Argentine Society of Vaccination and Epidemiology (SAVE).
This breadth is also accounted for by the infectologist Jorge Lattner, who divides his activity between a charming private sanatorium - where he has worked for a decade - and the public hospital. “In the last two years we have seen an increase in congenital syphilis in Otamendi, something that did not happen before and now it does. At Fernández we are putting between 10 and 15 penicillins per day -the antibiotic with which the infection is treated-, and that never happened either ”.
Less HIV, more syphilis
In Argentina, the rate of reported cases in men and women quadrupled between 2013 and 2018 (it grew by 330%: it went from 11.7 to 50.4 per 100,000 inhabitants), with a peak in the group of young people aged 15 to 24 years. In 2018, 22,428 were reported, almost 16% more than in 2017. Cases of congenital syphilis (transmitted from mother to child during pregnancy) also grow year by year.
The statistics of the Muñiz Hospital -specialized in infectious diseases- account for this frenzy of progress: in the 10 years between 1998 and 2008, 1,541 cases of early syphilis were registered (within the first year after the infection was acquired), a figure close to 1,236 diagnosed in just a third of the time , from 2014 to 2017. The annual average for that three-year period is 412. In 2018 there were 481 cases. The Excel opened at the beginning of 2019 counted 376 in mid-August, when there was still more than four months to open a new file.
What happens in Argentina is replicated worldwide. The steady decline in the number of cases in the last third of the 20th century was dramatically reversed. In Europe there is also an increase in the last decade. In 2017, the rate shot up 70% compared to 2010. And for the first time since the beginning of the millennium, the old continent registered more cases of syphilis than new HIV infections , according to a recent report by the European Center for the Prevention and Control of HIV. Diseases (ECDC).
Here is the paradox: while epidemiological data show a reduction or stabilization in new cases of HIV, in contrast other sexually transmitted infections (STIs) do not stop growing .
The absent condom
How do you explain that syphilis, which during the 15th and 16th centuries affected 15% of the European population and caused thousands of deaths, reemerges strongly -because it was never eliminated- in the 21st century, when it is well known that sexual behavior does it prevent transmission?
“The reasons that would explain this fact include changes in sexual behavior, the use of designer drugs and, above all, the reduction of protection measures in sexual relations . This change in trends has coincided with the improvement in the prognosis of people with HIV after the introduction of highly active antiretroviral treatment (ART), which seems to have led to a certain 'relaxation' in prevention measures ”, says the Bulletin on HIV, AIDS and STIs of 2018 prepared by the Ministry of Health.
“ Those under 30 and those over 50 practically do not use a condom . The minors because they did not experience the worst stage of HIV and AIDS and the elderly because they never used it and now it is difficult for them to adapt. The use of alcohol and other legal and illegal drugs also has a lot to do with it. Sometimes they come to the office with an STD, you ask them how they got it and they don't remember how, or with whom they were, or with how many, or even if they enjoyed it. And there is another fashion called chemsex , the use of potentiating drugs to be able to have sex with more than one person for several days, which although you don't see much in Argentina, it is also practiced ”, says Leiro.
From the Ricardo Gutiérrez Children's Hospital, Jaime Altcheh, pediatrician and principal investigator of Conicet, shares the diagnosis: “In the hospital we see an increase in acquired syphilis in adolescents because they do not use a condom . The fear of HIV has been lost ”. They usually go to the consultation alone, very few are accompanied by their parents. When the lesions are on the genitals, they suspect that it may be a sexually transmitted infection. But many enter for stains on the feet, others for dentistry, for injuries in the mouth.
"Are you surprised at the diagnosis of syphilis?"
"Yes," emphasizes the doctor. But since they are given the treatment and respond well, they don't worry much.
Among his patients, Urueña identifies two extremes: “ There are those who are scared and cannot believe it , because they thought that syphilis was something of the past. And there are those who had more than one episode, they come for the treatment -which in general is relatively simple- and they choose to continue having unprotected relationships ”.
"Did you use a condom?" - Leiro consultation with each new patient diagnosed. If the answer is yes, ask a little more - For oral sex?
“It is very common that a condom is not used, or is used (hopefully) in penetration, but nobody uses it for oral sex . We are seeing a lot of transmission from that practice. The lesions in the mouth are very treponemal, they have the syphilis bacteria and they are extremely infectious ”, he emphasizes.
A survey carried out in 2017 to more than 30 thousand people from 14 provinces of the country by the Argentine branch of the NGO Aids Health Foundation (AHF) showed that only 14.5% of those consulted always use it in a sexual relationship , 65 % on some occasions and 20.5% never. Meanwhile, according to the Ministry of Health, more than 98% of new HIV infections are caused by unprotected sex.
In many cases, 'relaxation' in care is not linked to knowledge (about improving HIV treatments, for example), quite the contrary. The lack of information on sexual and reproductive health is a constant in the queries received by the Casa FUSA team, a health center specialized in adolescents and young people located in the Almagro neighborhood. “ The information that young people receive is lacking . The Comprehensive Sex Education Act (ESI) is not provided in many schools. Care in relation to the body and sexual health of people is often not addressed in the family environment, so the information they may have is left to chance. ESI is essential ”, he emphasizes.
And he adds: “In the consultations, we promote the use of condoms as the only contraceptive method that prevents STDs, the only one that men with a penis can use and that does not cause any side effects on the female or male body. We hint at a more political perspective of care so that we women are the ones who can demand that our partners use condoms and correctly. Also the use of the latex field, when doing oral sex on the woman. In using the latex field on the vulva is not even thought and the health teams practically do not offer it as an option ”.
What is syphilis
Syphilis is an infection caused by the bacterium Treponema pallidum (TP), which is transmitted mainly through sexual and vertical contact (during pregnancy or childbirth). Its evolution is divided into several stages: primary, secondary, serological or latent and tertiary.
A small sore or ulcer called a chancre is its first appearance. It usually appears in the mouth, anus, penis, or vagina. "In general, it is painless and heals on its own, so that sometimes the patient does not consult -or consult and are misdiagnosed-, they do not do the correct treatment and the disease progresses, even if the lesions go away. Even without symptoms, at this stage the infection is transmitted. Obviously, when there are lesions and they are mucous, it is more infectious ”, explains Leiro.
Treatment is essential to clear the infection, even when there are no symptoms.
Treponemes can spread throughout the body through the bloodstream, which begins the most "flowery" stage of infection, the secondary stage, called "the great simulator" because it can occur in the most varied forms. "The most common is a very characteristic rash , red erythematous papules that can appear on the trunk, hands and soles of the feet," says Urueña. In addition to the cutaneous-mucosal manifestations, lymphadenopathy (swollen lymph nodes) are also characteristic of this stage. At the other extreme are the less frequent expressions. “ Because there is so much syphilis, we see both typical and atypical cases . The disease can manifest itself as pharyngitis and for anyone who does not think about it, it can go completely unnoticed ”, he says.
Among the atypical is that of Marcos, 49 years old, married with three children. No sores, no spots on his body. What he felt were severe pain in his hands and feet, to the point that it was difficult for him to step. Symptoms of a neuropathy that required a lumbar puncture to rule out neurosyphilis after the VDRL was positive in the laboratory routine. The diagnosis surprised him. He has lived with HIV for 10 years, but he thought that syphilis was something from another time. “ My case was not easy . I was hospitalized for two days, they pricked my marrow to study me. I lost 8 kilos in 15 days. You must take care. If I kept taking things for pain, I could see it more screwed up. Or not tell it. "
If the infection is not treated, the lesions - if any - disappear spontaneously and the infection remains "asleep" for a long time, only detectable through laboratory tests. Several years later the tertiary stage ensues, the symptoms of which can include difficulty in movement of the arms and legs, paralysis, numbness, blindness and heart disease . One to four untreated patients can develop neurosyphilis at any stage of the disease.
Cut the chain
"Bring me your partner."
"But I'm not talking to him anymore."
" Contact her and let her know, " the doctor replied.
The following week, on a new visit by the young man to the office, he insisted.
"Did you warn him?"
"Yes, I warned you on Facebook." She uploaded photos and wrote "I got hives, what could it be?" - the young man related before the amazed look of the professional -. It's syphilis, I'm taking care of myself, ”he wrote in a public comment.
-And what happened?
"He blocked me."
The incubation period for syphilis is between 10 and 90 days. That is why the specialists insist on each person who they diagnose that they must inform the situation to the sexual partners or contacts who have had up to three months prior to the infection , because they must also receive treatment.
Discovered by Fleming in 1928, penicillin has been used since 1943 in the treatment of syphilis (the first case treated in Argentina was in 1947). Within the first year of infection, a single dose is the treatment of choice. In pregnant women and late syphilis, three are indicated.
Chancre is the primary lesion of syphilis. It appears at the site of entry of the infection.
Congenital syphilis, the most worrying face
"Take care and test yourself" is, according to Urueña, the message that should reach the entire population.
However, protection with condoms (even in stable couples) and testing are especially important during pregnancy to avoid congenital (before birth) and perinatal (during childbirth) transmission.
The control must be carried out in the three quarters, something that many times is not fulfilled, professionals warn. To facilitate adherence, rapid testing for HIV and syphilis during prenatal control at the first level of care is gradually being implemented at the public level, within the framework of the joint strategy for the elimination of mother-to-child transmission of HIV , syphilis, hepatitis and Chagas disease (ETMI PLUS) carried out by the Ministry of Health, PAHO, UNAIDS and Unicef.
"One of the problems we have is that the woman is not always accompanied by the man in the consultation, or she is, but the man is not offered to have the test, his serology is not known ," he says.
In the exclusion of men from the consultation, social conditioning operates, says the doctor. “There are women who do not have a stable partner, or the man works all day and cannot go. There are also issues related to gender violence, abuse, machismo, lack of education, lack of work, poverty , factors that condition the male to undergo health checks, in addition to the fact that he is less likely to have check-ups.
The proportion of positivity in the tests performed on pregnant women doubled from 2013 to 2018 ( from 2% to 3.8% ). The Newsletter on AIDS and STIs also highlights one of the most worrying aspects of the problem:the number of boys and girls with congenital syphilis is growing every year.
“ The greatest severity of syphilis today is congenital . From Garrahan they refer us to the parents of the little ones who are hospitalized, ”says Leiro from El Muñiz.
Congenital syphilis can cause miscarriage (death in utero) or stillbirth (stillbirth). The risk in live births are malformations, which are being seen more and more . "They can be neurological (coupled with higher mortality), osteoarticular, ocular, auditory, respiratory disorders (pneumonitis alba), which in some cases condition life," says Urueña, a former UNICEF advisor.
At the Ricardo Gutiérrez Children's Hospital, “in the last five years we have seen an increase in cases of late congenital syphilis. They are the boys who are born healthy, who escape the controls of the maternity wards and after two or three months show symptoms - says Altcheh-. Most are doing well. But we have cases with significant kidney damage and deaths from that cause , and with significant damage at the joint level ”.
And he concludes: “This has treatment. It is not difficult to make the diagnosis, but it must be done in a timely manner ”.
ACE