The real infectious disease problem in Brazil isn’t actually Zika, it’s syphilis

Shortages of penicillin have made pregnancy a high risk in Brazil.
Shortages of penicillin have made pregnancy a high risk in Brazil.
Image: Ueslei Marcelino/Reuters
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Everyone knows Brazil is currently suffering a Zika outbreak. But the real public health hazard there might be something no one’s talking about: the numbers of pregnant women infected with syphilis—and the newborn babies dying because of it—is silently growing year after year.

In 2016, the government forecasts 41,762 new syphilis infections among pregnant women—49 times higher than that reported a decade ago. And those numbers might even be underselling the problem; Brazilian health authorities estimate half of all cases go unreported. The sexually transmitted infection is beginning to spread at epidemic rates thanks to a troubling rise in unprotected sex, and has been exacerbated by shortages of the one medication that can stop syphilis in its tracks.

* 2014-2016 numbers are estimates

Syphilis is caused by the bacterium Treponema pallidum, typically spread through unprotected sex. When left untreated, it can invade the central nervous system and lead to serious complications, including psychotic symptoms, dementia and parkinsonism. Like the Zika virus, syphilis is linked to birth defects; when a woman with syphilis becomes pregnant, her baby is at risk for severe brain damage, blindness, deafness, and deformities.

But syphilis is actually far deadlier than Zika; one in every 10 infected pregnancies ends in fetal or infant death. In 2013 alone, the disease led to 1,160 infant deaths in Brazil—and the numbers for 2016 are almost certainly much worse, considering the rising rates of syphilis overall. Already, congenital syphilis has infected 22,518 babies this year. As bad as it is, microcephaly, a condition linked to Zika that causes severe brain defects, has been identified in just 1,806 babies and caused the death of 122 newborns.

And yet, “people don’t see syphilis as a serious disease [like] HIV and Zika,” says Jorge Senise, infectologist at Federal University of Sao Paulo. One reason is that in adults, syphilis can be a silent disease for years. It causes painless symptoms—a sore on the penis in men, and a sore inside the vagina or at the cervix in women—that disappear after a few weeks. Some people can go infected for years without knowing it, but women who are not treated can pass on the disease for their babies once they get pregnant.

While there is still no cure for Zika, syphilis can be easily treated with a shot of penicillin. But for the past two years, there’s been a shortage of penicillin in Brazilian hospitals because pharmaceutical companies in the country have been unable to get enough of the key active ingredient: benzathine benzylpenicillin. Typically, Brazilian drug companies purchase the active ingredient, and then formulate it and produce the the intramuscular injection sold in the local market.

Since 2014, however, five out of the six private Brazilian drug manufacturers formulating penicillin for the local market had suspended production indefinitely or temporarily, according to Anvisa, Brazil’s National Health Surveillance Agency. According to Anvisa, the shortage is in part due to the fact that the Chinese manufacturer North China Pharmaceutical Group Semisyntech, a primary supplier of benzathine benzylpenicillin to Brazilian drugmakers, failed its last site visit, and therefore lost its license. The agency says the next site visit will come some time this month.

In January this year, 17 of Brazil’s 27 states said their penicillin supply was insufficient. The government responded by announcing an emergency purchase of 2.7 million bottles of benzathine benzylpenicillin—700,000 bottles from Teuto, the one Brazilian pharma company still producing the drug at the time, and the rest from from the Pan American Health Organization. (Earlier this year, Eurofarma, one of Brazil’s major pharmaceutical companies, announced it had restarted producing benzathine benzylpenicillin, bringing the number of local drugmakers actively manufacturing the drug to two.) Around 30 percent of the bottles purchased in January were distributed throughout the states while the remainder has been saved as safety stock, “as the country faces an outbreak of syphilis,” said Adele Benzaken, director of Brazil’s Ministry of Health Department for STIs, AIDS and Viral Hepatitis.

Anvisa requires pharmaceutical companies to register their suppliers with the agency as a way to control the quality and safety of the ingredients used on essential medicines. But in July, Anvisa decided to relax the rules for those companies producing the penicillin, exempting them from registering their suppliers of benzathine benzylpenicillin until next year. With no registration, it will be harder to assess the materials and processes employed on the medicines’ production, and it will be more difficult to maintain quality control. But given the current situation, Anvisa decided those risks are worth taking.

Even a subpar penicillin is likely better than the alternatives, like azithromycin, ceftriaxone, and doxycycline, that have been used during the shortage. These substitutes were designed to treat other infections—azithromycin, for example, is very effective against gonorrhea—but are insufficient in managing syphilis, says Rosana Camargo, a doctor member of Brazil’s Society of Infectology. “A shortage means less people treated, higher incidence of the disease, and worse outcomes in the long term as later forms of syphilis are much harder to treat. Guaranteeing access to the right drug is paramount.”

The other key to stifling the syphilis outbreak is tackling the escalation of unprotected sex. Senise, at the Federal University of Sao Paulo, says Brazilians don’t typically bother with condoms. “This is related to a lack of awareness of sexually transmitted infections in general,” he says. Improvements in HIV treatment have also given many people a false sense of security when to STIs. The other issue, Senise says, is that female condoms are hard to obtain in Brazil, and in heterosexual couples, that puts much of the onus on men to make the effort to provide protection against infection. “It’s hard to tell women they should have protected sex when the decision of wearing the condom is on their male partners,” Says Senise.

Brazil’s Ministry of Health says it has launched a country-wide initiative to address the syphilis outbreak, increased the number of quick tests in public hospitals, and improved the information given to health professionals on diagnosing and treating syphilis, but the number of people infected keeps on growing.

Experts say it may be necessary to battle syphilis with the same armory employed to fight Zika. Recently, Brazilian lawmakers approved a R$420 million ($130m) budget to battle the mosquito-transmitted virus and deployed the country’s armed forces to visit residences and inform Brazilians about the disease. The government has not disclosed how much it is spending to combat syphilis; antenatal screening for the infection is covered under the R$270.6 million ($84m) Stork Network program, designed to address the entirety of pregnant women’s health, but within the program, there is no specific budget for syphilis.

The most troubling aspect of the burgeoning epidemic, says Camargo, is that though syphilis can be fatal, it is “easier to control than the Zika virus. It is more simple to control a bacteria to which there are medicines than a mosquito.” Considering that this is a treatable disease, she says, and it’s terribly sad that the rate of babies infected—and dying—in Brazil is devastatingly high.