Congenital Syphilis Resurgent

Syphilis is resurgent in many parts of the world. Even in those countries where rates have fallen focal outbreaks still occur. Congenital syphilis is an inevitable consequence of undetected and untreated syphilis in a pregnant woman. Universal screening in pregnancy, even if the positive yield from the test is low, remains the keystone to congenital syphilis prevention. Programmatic attention to testing, treating, education, and contact tracing in pregnancy and subsequent late trimester retesting of high-risk women will lower congenital infection rates. Any slip in this meticulous process inevitably leads to resurgence of congenital syphilis.

Universal antenatal screening for syphilis: is it still justified economically?

OBJECTIVE

Because universal prenatal screening for syphilis has recently been called into question, we documented the development of syphilis in Austria and analysed the effectiveness of current antenatal syphilis screening practices.

METHODS

The development of syphilis in Austria and Vienna was determined based on the data published by the Austrian Bureau of National Statistics (Statistik Austria) and the Vienna Health Authority (Gesundheitsamt Wien, MA15), respectively. The data obtained for Vienna were then compared with those for the remaining eight federal provinces. Also, we retrospectively analysed a total of 34,312 sera obtained between 1988 and 1999 from women screened for syphilis at delivery at the laboratory of the Department of Dermatology, University of Vienna. Serological screening was done with both the Venereal Disease Research Laboratory (VDRL) and the Treponema pallidum haemagglutination (TPHA) assays. Finally, we determined the number of cases of congenital syphilis diagnosed in Vienna between 1988 and 1999.

RESULTS

In the past 10 years, the annual number of reported syphilis cases has remained fairly constant. In 1999 and 2000, there were 8.1 and 11.0 notifications of syphilis per 100,000 inhabitants in the capital Vienna, compared with 0.7 and 0.9 in the remaining provinces with a mainly rural character. At delivery, there were 96 cases of maternal syphilis that were both TPHA- and fluorescent treponemal absorption (FTA-ABS)-reactive, corresponding to a seroprevalence of 2.8 per 1000 births. Only 24 of the TPHA-reactive sera were VDRL-reactive. In Vienna, there were three stillbirth deliveries due to congenital syphilis and six cases of confirmed congenitally syphilis between 1988 and 1999.

CONCLUSION

Universal syphilis screening may no longer be justified economically. The usefulness of VDRL-based syphilis screening should be reassessed. The screening focus should shift to regions with a high seroprevalence of syphilis. Universal syphilis screening does not appear warranted.

Congenital Syphilis

BACKGROUND

Behavioral and socioeconomic factors create considerable obstacles to the elimination of congenital syphilis. A clear understanding of maternal risk factors is important to define interventions in every community.

GOAL

The goal of this study was to investigate maternal risk factors for congenital syphilis.

STUDY DESIGN

We conducted a case-control and descriptive analysis of 3 groups of live born infants and their mothers consisting of: group I (cases of congenital syphilis), group II (neonates without congenital syphilis whose mothers had been adequately treated for syphilis), and group III (random sample of newborn infants whose mothers have not had syphilis). Data were prospectively collected from personal interview and antenatal records.

RESULTS

In the case-control study, including groups I and III, the maternal characteristics independently associated with congenital syphilis in the logistic regression were monthly per capita income under 30 US dollars (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.1-7.4), single status (OR, 2.8; 95% CI, 1.1-7.8), and less than 6 prenatal visits (OR, 3.2; 95% CI, 1.3-8.1). Comparison between groups I and II (only mothers who have had syphilis) showed a strong protective association of prenatal care with congenital syphilis (OR, 0.05; 95% CI, 0.00-0.39). Additional analysis identified 2 separate profiles of maternal characteristics, one consisting of low socioeconomic status and the other of risk behaviors. Some women who had syphilis before or during pregnancy received adequate prenatal care and delivered infants without congenital syphilis. Most of these women had high-risk behaviors but they were, in general, less poor, older, and more educated than mothers of infants with congenital syphilis.

CONCLUSIONS

Risk behaviors and low socioeconomic characteristics constituted 2 separate maternal profiles associated with congenital syphilis. Socioeconomic risk factors interfered more with prenatal care. To become more effective, the strategies for prevention of congenital syphilis should be targeted to each maternal profile.

Avaliação da efetividade das campanhas para eliminação da sífilis congênita na redução da morbi-mortalidade perinatal: Município do Rio de Janeiro, 1999-2000

O aumento da incidência da sífilis congênita no Município do Rio de Janeiro levou a Secretaria Municipal de Saúde a realizar as campanhas para a sua eliminação nos anos de 1999 e 2000, com o objetivo de dar visibilidade à doença e capacitar os profissionais de saúde no manejo do agravo. Neste estudo realizou-se uma avaliação da efetividade das campanhas, servindo-se do seguimento das mulheres grávidas identificadas com sífilis durante as campanhas, pelos sistemas de informação em saúde (SINASC, SIM e SINAN) utilizando-se da comparação deste grupo a um grupo controle de gestantes não envolvidas na campanha. Foi possível evidenciar uma redução significativa da morbidade e mortalidade perinatais nos filhos das mulheres atendidas pelas campanhas, demonstrando que as ações da rotina de pré-natal nas unidades municipais não estavam conseguindo resolver o problema. Foi baixo o número de casos de sífilis congênita encontrado no SINAN em relação aos casos reconhecidos por intermédio das campanhas, demonstrando uma subnotificação importante.

RPR test for serological survey of rabbit syphilis in companion rabbits

Since the RPR (rapid plasma regain) test was found to be useful for the diagnosis of rabbit syphilis, serological survey by this test has been carried out in Japanese companion rabbits. A hundred virgin household rabbits kept alone and without signs and history of syphilis were examined by RPR test from April 2001 to March 2002, in Tokyo, Japan. The test was positive in 35 cases and negative in 65 cases. RPR negative rabbits should be selected for breeding to prevent the spread of rabbit syphilis in companion rabbits in Japan.

Treatment of syphilis in pregnancy and prevention of congenital syphilis

Studies about the management of syphilis during pregnancy were reviewed. They lacked uniformity in diagnostic criteria and study design. Currently recommended doses of benzathine penicillin G are effective in preventing congenital syphilis in most settings, although studies are needed regarding increased dosing regimens. Azithromycin and ceftriaxone offer potential alternatives for penicillin-allergic women, but insufficient data on efficacy limit their use in pregnancy. Ultrasonography provides a noninvasive means to examine pregnant women for signs of fetal syphilis, and abnormal findings indicate a risk for obstetric complications and fetal treatment failure. Ultrasonography should precede antepartum treatment during the latter half of pregnancy to gauge severity of fetal infection. However, optimal management of the affected fetus has not been established; collaborative management with a specialist is recommended. Antepartum screening remains a critical component of congenital syphilis prevention, even in the era of syphilis elimination.

Forgotten but not gone: the continuing scourge of congenital syphilis

Much attention is being given to the prevention of HIV infection in babies through transmission from the mother. By contrast, regrettably little concern is raised about the increasing numbers of babies born with congenital syphilis. In affluent countries congenital syphilis is very rare, but in many poor countries, including the newly independent countries of eastern Europe and the former Soviet Union, the numbers are high and increasing. In much of sub-Saharan Africa, around 10% of pregnant women are affected by syphilis. The prevention of congenital syphilis is more cost-effective than the prevention of mother-to-child transmission of HIV. The control of congenital syphilis could indirectly have a beneficial effect on the HIV epidemic by reducing susceptibility to infection. Although the procedure to prevent congenital syphilis through antenatal screening and treatment is well established, implementation of effective programmes in resource-poor settings has proved very difficult. A new and focused approach to tackling congenital syphilis is needed. It should combine different mixes of interventions, such as mass treatment, focused screening, and universal screening, according to the local epidemiology and available resources. A task-force approach to defining the most appropriate interventions together with support for some research should be a priority for support under the Global Health Fund.

A case study of antenatal syphilis screening in South Africa: successes and challenges

BACKGROUND

To evaluate the process of providing routine syphilis screening to antenatal care (ANC) clients at primary healthcare clinics in KwaZulu-Natal Province, South Africa.

GOAL

To document the program performance and make recommendations for improving the current program and informing proposals for on-site testing.

STUDY DESIGN

Nine health facilities were recruited for the study. The methodology used for this case study included: Key informant interviews, inventory, focus group discussions with clients, client flow analysis, exit interviews with clients and observations of consultations.

RESULTS

All 51 women attending their first ANC visit had a blood sample taken for a syphilis rapid plasma reagin (RPR) test. Unreliable transport resulted in an average 4 weeks turnaround time to get RPR test results back to clinics. Due to late presentation in the pregnancy for their first ANC visit, 15% would have been unable to complete their treatment before delivery if they had been found positive. Health providers gave minimal information and/or counseling on syphilis, neither did they stress the importance of treatment of positive clients and their partners. There was no strategy to track positive clients who had not been treated or their partners. Providers were unclear on whether partners should be tested before treatment.

CONCLUSION

Although testing was readily available, most of the constraints were centered round logistics of ensuring treatment of women and their partners. These issues must be addressed by sexually transmitted infection managers and policymakers.

Congenital syphilis--United States, 2000

In 1998, CDC initiated intensive efforts to eliminate syphilis from the United States. The following year, the National Syphilis Elimination Plan was launched with the goal of reducing primary and secondary (P&S) syphilis in adults to <0.4 cases per 100,000 population. A decrease in syphilis among women of reproductive age usually is followed by reductions in congenital syphilis (CS) rates. CS occurs when the spirochete Treponema pallidum is transmitted from a pregnant woman with syphilis to her fetus. Untreated syphilis during pregnancy may lead to stillbirth, neonatal death, and infant disorders such as deafness, neurologic impairment, and bone deformities. One of the national health objectives for 2000 was to reduce the rate of CS to <40 cases per 100,000 live-born infants. To evaluate progress toward this goal, the CS rate for 2000 was compared with the rate for 1997, the year before syphilis elimination efforts began. This report summarizes 1997-2000 CS surveillance data, which indicate that CS rates have decreased substantially among most racial/ethnic minority populations and that the elimination of CS in the United States is feasible because of the limited number of cases and highly focal distribution. To increase the percentage of women at risk who receive screening for syphilis during pregnancy, collaborative efforts are needed among health-care providers, health insurers, policymakers, and the public.

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital

BACKGROUND

Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem.

GOALS

To identify missed opportunities for congenital syphilis prevention during prenatal care.

STUDY DESIGN

Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA).

RESULTS

The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01).

CONCLUSION

Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

Antibiotics for syphilis diagnosed during pregnancy

BACKGROUND

Congenital syphilis is an increasing problem in many developing countries and in the transitional economies of Eastern Europe and the former Soviet Union. In several countries this increase has been aggravated by HIV/AIDS. While the effectiveness of penicillin in the treatment of syphilis in pregnant women and the prevention of congenital syphilis was established shortly after the introduction of penicillin in the 1940s, there is uncertainty about the optimal treatment regimens.

OBJECTIVES

To identify the most effective antibiotic treatment regimen (in terms of dose, length of course and mode of administration) of syphilis with and without concomitant infection with HIV for pregnant women infected with syphilis.

SEARCH STRATEGY

MEDLINE 1966 to March 2000; EMBASE 1974 to March 2000, the Cochrane Controlled Trials Register (last searched March 2001), the Cochrane Pregnancy and Childbirth group trials register (last searched March 2001) and the references of traditional reviews were searched. Experts in specialist units were contacted.

SELECTION CRITERIA

It was planned that any trial in which an attempt is made to allocate treatment for syphilis during pregnancy by a random or quasi-random method would be included in this review.

DATA COLLECTION AND ANALYSIS

Information was extracted using a data extraction sheet and this included entry criteria, the source of controls, and whether the authors stratified by the stage of pregnancy when the diagnosis of syphilis was made.

MAIN RESULTS

Twenty six studies met the criteria for detailed scrutiny. However, none of these met the pre-determined criteria for comparative groups and none included comparisons between randomly allocated groups of pregnant women.

REVIEWER'S CONCLUSIONS

While there is no doubt that penicillin is effective in the treatment of syphilis in pregnancy and the prevention of congenital syphilis, uncertainty remains about what are the optimal treatment regimens. Further studies are needed to evaluate treatment failure cases with currently recommended regimens and this should include an assessment of the role of HIV infection in cases of prenatal syphilis treatment failure. The effectiveness of various antibiotic regimens for the treatment of primary and secondary syphilis in pregnant women need to be assessed using randomised controlled trials which compare them with existing recommendations.

Maternal and congenital syphilis in Bolivia, 1996: prevalence and risk factors

OBJECTIVES

The present study was carried out in seven maternity hospitals to determine the prevalence of maternal syphilis at the time of delivery and the associated risk factors, to conduct a pilot project of rapid syphilis testing in hospital laboratories, to assure the quality of syphilis testing, and to determine the rate of congenital syphilis in infants born to women with syphilis at the time of delivery--all of which would provide baseline data for a national prevention programme in Bolivia.

METHODS

All women delivering either live-born or stillborn infants in the seven participating hospitals in and around La Paz, El Alto, and Cochabamba between June and November 1996 were eligible for enrolment in the study.

FINDINGS

A total of 61 out of 1428 mothers (4.3%) of live-born infants and 11 out of 43 mothers (26%) of stillborn infants were found to have syphilis at delivery. Multivariate analysis showed that women with live-born infants who had less than secondary-level education, who did not watch television during the week before delivery (this was used as an indicator of socioeconomic status), who had a previous history of syphilis, or who had more than one partner during the pregnancy were at increased risk of syphilis. While 76% of the study population had received prenatal care, only 17% had syphilis testing carried out during the pregnancy; 91% of serum samples that were reactive to rapid plasma reagin (RPR) tests were also reactive to fluorescent treponemal antibody-absorption (FTA-ABS) testing. There was 96% agreement between the results from local hospital laboratories and national reference laboratories in their testing of RPR reactivity of serum samples. Congenital syphilis infection was confirmed by laboratory tests in 15% of 66 infants born to women with positive RPR and FTA-ABS testing.

CONCLUSION

These results indicate that a congenital syphilis prevention programme in Bolivia could substantially reduce adverse infant outcomes due to this disease.

Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis

OBJECTIVE

Antenatal screening for syphilis is well established in the United Kingdom. The prevalence of syphilis is now very low, prompting the question as to whether this screening programme is still necessary. This paper aims at identifying possible screening strategy options for the programme and comparing their effectiveness and cost effectiveness.

METHODS

The cost of the screening programme in the United Kingdom was estimated. This was based on the cost of screening tests, treatment, and follow up of infected women and their infants. This information was obtained from laboratories, antenatal clinics, and genitourinary medicine clinics. Epidemiological data from a survey of women treated for syphilis in pregnancy were analysed to identify groups at increased risk of syphilis. Strategic options for the screening programme were then identified. The effectiveness, number needed to treat, and cost effectiveness of these options were compared.

RESULTS

Antenatal screening in the United Kingdom detected at least 40 pregnant women who need treatment for syphilis every year. This means that 18602 women are screened for every woman detected who needs treatment for syphilis. The marginal annual cost of this screening programme in the United Kingdom is 672366 pounds sterling. This is equivalent to 90p per woman screened, or 16670 pounds sterling to detect one woman who needs treatment for syphilis. The screening programme could be targeted geographically at pregnant women in the Thames regions. This option has the potential to save 482185 pounds sterling. Other strategic options are to target pregnant women in non-white ethnic groups, or those born outside the United Kingdom. These targeted options would each detect between 70% and 77% of women needing treatment for syphilis. These options could potentially save 592938 pounds sterling and 562691 pounds sterling respectively.

CONCLUSIONS

Targeting or stopping the screening programme would save relatively little money. Although selectively screening groups by country of birth or by ethnic group could detect at least 70% of cases, this would be politically and practically difficult. Targeting by region would facts and the changing international epidemiology of syphilis lead us to recommend that the current universal antenatal screening for syphilis should continue.

[Congenital syphilis: need for adequate antenatal care]

Congenital syphilis is well-known and treatable with penicillin. Diagnosis in the neonate and young child may be difficult and consequently morbidity and mortality can be high. Prevention in children is of utmost importance and can be achieved by proper antenatal care and adequate follow-up of pregnant women. This includes identification of pregnant women at risk for contracting syphilis. The case presented demonstrates this need.

[Positive results from serologic screening for syphilis in pregnancy in the Amsterdam region, 1991-1995]

OBJECTIVE

To evaluate the results of screening of pregnant women for syphilis in the region of Amsterdam, the Netherlands.

DESIGN

Descriptive study and cost-benefit analysis.

METHODS

In the period 1991-1995, physicians and midwives from the Amsterdam region sent serum samples of pregnant women to the Regional Public Health Laboratory of the Municipal Health Service (GG & GD) to be screened for syphilis. All physicians who had sent in specimens with a positive result of the Treponema pallidum haemagglutination assay (TPHA) and a confirming test result were asked, in the year of the screening, by telephone or in writing, what diagnosis they had made in the woman in question. Collection of these data was handled by the social nursing staffs of the outpatient clinics for sexually transmitted diseases in Amsterdam. The costs of laboratory tests and follow-up of the children were compared with the positive effects of special treatment and education avoided by antibiotic treatment.

RESULTS

54,344 serum samples were sent in. In the city of Amsterdam the coverage was 87.4%. In 81 women (0.15%) all the serological tests for syphilis were positive. From this group, 37 women had already been treated and 24 women were treated as a result of this screening programme (most of them had a foreign nationality), 10 for early syphilis and 14 for syphilis of unknown duration, preventing the birth of an estimated five to six children with congenital syphilis. The cost-benefit ratio was 1:15.

CONCLUSION

Continuation of screening for syphilis during pregnancy in the Amsterdam region remains useful.

[Syphilis in addicted pregnant women: better care through more awareness and contract between organizations involved]

Three women, aged 21, 20 and 30 years, were cocaine users and pregnant. There had been no prenatal monitoring until they reported with uterine contractions. Blood of the first two women was then tested; serology revealed active syphilis infections: their children had died in utero. The blood of the third woman had been tested as part of a street project; it revealed an active syphilitic infection but she could not be found for treatment. After delivery, the child showed withdrawal symptoms. The first and third women and the child of the third woman were treated with benzylpenicillin. The system for screening and treating drug-addicted pregnant women should be intensified.

An epidemic of congenital syphilis in Jefferson County, Texas, 1994-1995: inadequate prenatal syphilis testing after an outbreak in adults

OBJECTIVES

After a syphilis epidemic in Jefferson County, Texas, in 1993 and 1994, congenital syphilis prevalence and risk factors were determined and local prenatal syphilis screening practices were assessed.

METHODS

Medical records were reviewed, pregnant women with syphilis were interviewed, and prenatal care providers were surveyed.

RESULTS

Of 91 women, 59 (65%) had infants with congenital syphilis. Among African Americans, the prevalence per 1000 live births was 24.1 in 1994 and 17.9 in 1995. Of the 50 women with at least 2 prenatal care visits who had infants with congenital syphilis, 15 (30%) had received inadequate testing. Only 16% of 31 providers obtained an early third-trimester syphilis test on all patients.

CONCLUSIONS

Inadequate prenatal testing contributed to this outbreak of congenital syphilis.

Problems in physician's classification and reporting of congenital syphilis

The diagnosis of congenital syphilis (CS) in newborns can only be made through a review of the mothers' testing and treatment history and through the infants' clinical and laboratory findings. We describe difficulties in the classification of CS by physicians and the health department during a recent syphilis epidemic. The records of infants identified as potential cases of CS by laboratory testing, discharge diagnosis, or health department records were reviewed by epidemiologists. The reasons for concordance and discordance in classification between the physician and the epidemiologist were determined. Congenital syphilis was identified in 126 infants. Seventeen cases were discordant and 12 cases concordant but the physician's classification was for incorrect reasons. Misclassification occurred because physicians lacked data known to the health department (n=7), health departments lacked data known to the physician (n=1), and physicians misinterpreted the case definition for CS (n=21). Suggestions for improving the diagnosis and reporting of CS are included.