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As infecções sexualmente transmissíveis (IST) são um problema crescente de saúde pública mundial, com maior incidência em adultos jovens e adolescentes. Estas infecções, apesar da morbilidade e mortalidade associada, são frequentemente negligenciadas ou abordadas apenas na prevenção da infecção pelo vírus da imunodeficiência humana (VIH).
Portugal é o país da Europa ocidental com a maior prevalência de infecção pelo VIH e o segundo na incidência de gravidez na adolescência. O sistema de notificação português de doenças sexualmente transmissíveis é clínico, predominando a subnotificação e a não recolha de informação que permita interpretar tendências epidemiológicas ou rastrear grupos específicos.
O estudo efectuado teve como objectivos a averiguação da prevalência de IST, pesquisa das associações entre estas e factores sócio-demográficos ou morbilidade materno-fetal e estudar a adesão dos parceiros ao tratamento, em 403 adolescentes, grávidas e não grávidas, observadas nos dois maiores centros de ginecologia-obstétricia de Lisboa, entre 2005 a 2007. A pesquisa de Chlamydia trachomatis e de Neisseria gonorrhoeae foi efectuada por reacção em cadeia da polimerase (PCR) em urinas e exsudados cervicais e a recolha de variáveis sócio-demográficas obtida por inquérito preenchido por profissional de saúde. Posteriormente, pesquisou-se também nos processos clínicos disponíveis dos recém-nascidos das adolescentes grávidas a existência de morbilidade materno-fetal.
A infecção por C. trachomatis foi diagnosticada em 10,4% das adolescentes e por N. gonorrhoeae em 4,2%, com 1,2% de coinfecção. Estas infecções foram assintomáticas, respectivamente em 60 e 53% das adolescentes. Os exsudados cervicais, apesar de uma boa concordância com as urinas, tiveram maior número de resultados positivos para estas duas bactérias.
A tricomonose foi diagnosticada em 1% das adolescentes, a hepatite B em igual percentagem e não se diagnosticou infecções pelo VIH, hepatite C ou sífilis.
A prevalência de C. trachomatis e de N. gonorrhoeae na população estudada está de acordo com as prevalências descritas em adolescentes de outros países. Estas percentagens, sobretudo as de C. trachomatis, justificam o rastreio destas IST nesta faixa etária, conforme defendido por várias entidades europeias e internacionais.
As urinas, pela sua maior facilidade de obtenção são habitualmente utilizadas para rastreio, mas poderão ter mais resultados falsos negativos por inibição da técnica de PCR, sobretudo em grávidas, como se observou no nosso estudo. A colheita do exsudado cervical tem maior sensibilidade e a sua realização é também uma oportunidade para a pesquisa de outras IST e esclarecimento de dúvidas das adolescentes.
No estudo de associações significativas destas infecções com variáveis sócio-
-demográficas salientou-se a associação entre a infecção por C. trachomatis e a maior idade dos parceiros, o que pode explicar a prevalência elevada de IST observada em adolescentes com início recente da actividade sexual e média de apenas um parceiro no último ano.
As adolescentes grávidas tiveram significativamente menor escolaridade obtida, menor uso regular do preservativo, maior desemprego e exclusão do sistema de ensino, com consequências sócio-económicas futuras para a jovem mãe e filho. Esta baixa escolaridade, consequência do marcado abandono escolar em Portugal, pode comprometer a eficácia de programas de rastreio e controlo de IST com base nas escolas. É assim importante sensibilizar os profissionais de saúde para a promoção do uso do preservativo, porque na população estudada e à semelhança dos dados nacionais, observou-se uma elevada prescrição da pílula e um reduzido uso do preservativo.
Na pesquisa de associações entre agentes de IST e a morbilidade materno-
-fetal foi possível observar que a infecção gonocócica esteve associada à morbilidade materna. Na população estudada observou-se também uma associação entre o baixo peso no nascimento e a infecção materna por N. gonorrhoeae e/ou C. trachomatis. Em contraste com as recomendações europeias ou internacionais, a infecção por C. trachomatis, a que tem maior associação à adolescência, não é notificada ou pesquisada sistematicamente em Portugal na gravidez. O estudo efectuado, com as limitações referentes à amostragem e número de adolescentes, reforça a importância da pesquisa de IST em adolescentes do sexo feminino, sobretudo em grávidas, grupo que sofre desproporcionalmente as consequências destas infecções.
Sexually transmitted infections (STI) are a public health issue, with a high incidence in adolescents and young adults and despite its associated morbidity and mortality is frequently overshadowed and neglegected in favor of the human immunodeficiency virus infection (HIV). Portugal has the highest HIV prevalence in Western Europe and is second in teenage pregnancy rates. The Portuguese STI notification system is clinical and undernotification is frequent, resulting in lack of important epidemiological data. The objectives of this thesis were to study the prevalence of STI, its associations with sociodemographic data and maternal or fetal morbidity, and to assess the efficacy of partner treatment and importance of STI screening in a group of 403 pregnant and not pregnant female adolescents, observed in the two main obstetric hospitals in Lisbon between 2005 and 2007. Polymerase chain reaction (PCR) was performed for Chlamydia trachomatis and Neisseria gonorrhoeae in cervical swabs and urine samples. Sociodemographic data was obtained by a questionnaire taken by a health professional and clinical files of the newborn babies were searched for maternal-fetal morbidity data. C. trachomatis and N. gonorrhoeae were identified in 10.4% and 4.2% of the adolescents, being respectively 60 and 53% asymptomatic, with a 1.2% rate of coinfection. Cervical swabs had more positive results, although there was a significant concordance ratio with the urine samples. Trichomonosis and hepatitis B were each diagnosed in 1% of the adolescents and Treponema pallidum , HIV or hepatitis C were not identified. The observed prevalence of C. trachomatis and N. gonorrhoeae was similar to those reported in other countries in the same age groups. As proposed by European and International health agencies, the prevalence of STI found in this study, especially of C. trachomatis, indicates the need for screening in this age group. Urine samples are easier and more feasible to obtain, but there are concerns about the loss of sensitivity due to urine PCR inhibitors, more frequent in pregnant women as it was observed in our study. Furthermore, collecting cervical swabs is also an opportunity for diagnosing other STI and for information to be given to these adolescents. When studying significant associations between STI and sociodemographic data in this population, infection with C. trachomatis was associated to older partners, what may have accounted for the high prevalence of this STI in teenagers that had their sexual life recently started and that had only one partner during the last year. Pregnant adolescents had significantly lower education levels and use of the preservative, were more frequently unemployed and out of the school system. This last fact has socioeconomic consequences for both the mother and the child and together with the high level of school dropout in Portugal can impair the efficacy of school based STI education and screening programs in populations groups like this. It is important to engage the health care professionals in the promotion of condom‘s use, since as in other national studies these are seldom used in contrast to the higher frequency of hormonal anticonceptives prescription. In relation to the associations between maternal-fetal morbidity and STI, maternal morbidity was found to be associated to gonococal infection and low birth weight to maternal infection with N. gonorrhoeae and/or C. trachomatis. This last organism is not routinely screened during pregnancy in Portugal, although this is recommended in European and International guidelines. Our study, despite its epidemiological limitations, also reinforces the importance of screening for these infections in adolescents, especially in those that are pregnant, because they suffer the heaviest burden of these STI.
Sexually transmitted infections (STI) are a public health issue, with a high incidence in adolescents and young adults and despite its associated morbidity and mortality is frequently overshadowed and neglegected in favor of the human immunodeficiency virus infection (HIV). Portugal has the highest HIV prevalence in Western Europe and is second in teenage pregnancy rates. The Portuguese STI notification system is clinical and undernotification is frequent, resulting in lack of important epidemiological data. The objectives of this thesis were to study the prevalence of STI, its associations with sociodemographic data and maternal or fetal morbidity, and to assess the efficacy of partner treatment and importance of STI screening in a group of 403 pregnant and not pregnant female adolescents, observed in the two main obstetric hospitals in Lisbon between 2005 and 2007. Polymerase chain reaction (PCR) was performed for Chlamydia trachomatis and Neisseria gonorrhoeae in cervical swabs and urine samples. Sociodemographic data was obtained by a questionnaire taken by a health professional and clinical files of the newborn babies were searched for maternal-fetal morbidity data. C. trachomatis and N. gonorrhoeae were identified in 10.4% and 4.2% of the adolescents, being respectively 60 and 53% asymptomatic, with a 1.2% rate of coinfection. Cervical swabs had more positive results, although there was a significant concordance ratio with the urine samples. Trichomonosis and hepatitis B were each diagnosed in 1% of the adolescents and Treponema pallidum , HIV or hepatitis C were not identified. The observed prevalence of C. trachomatis and N. gonorrhoeae was similar to those reported in other countries in the same age groups. As proposed by European and International health agencies, the prevalence of STI found in this study, especially of C. trachomatis, indicates the need for screening in this age group. Urine samples are easier and more feasible to obtain, but there are concerns about the loss of sensitivity due to urine PCR inhibitors, more frequent in pregnant women as it was observed in our study. Furthermore, collecting cervical swabs is also an opportunity for diagnosing other STI and for information to be given to these adolescents. When studying significant associations between STI and sociodemographic data in this population, infection with C. trachomatis was associated to older partners, what may have accounted for the high prevalence of this STI in teenagers that had their sexual life recently started and that had only one partner during the last year. Pregnant adolescents had significantly lower education levels and use of the preservative, were more frequently unemployed and out of the school system. This last fact has socioeconomic consequences for both the mother and the child and together with the high level of school dropout in Portugal can impair the efficacy of school based STI education and screening programs in populations groups like this. It is important to engage the health care professionals in the promotion of condom‘s use, since as in other national studies these are seldom used in contrast to the higher frequency of hormonal anticonceptives prescription. In relation to the associations between maternal-fetal morbidity and STI, maternal morbidity was found to be associated to gonococal infection and low birth weight to maternal infection with N. gonorrhoeae and/or C. trachomatis. This last organism is not routinely screened during pregnancy in Portugal, although this is recommended in European and International guidelines. Our study, despite its epidemiological limitations, also reinforces the importance of screening for these infections in adolescents, especially in those that are pregnant, because they suffer the heaviest burden of these STI.
Descrição
Palavras-chave
Doenças sexualmente transmitidas Adolescentes Chlamydia trachomatis Neisseria gonorrhoeae Factores sociodemográficos
Contexto Educativo
Citação
Editora
Instituto de Higiene e Medicina Tropical