Estimating the uptake of maternal syphilis screening and other antenatal interventions before and after national rollout of syphilis point-of-care testing in Ghana

Interventions in maternal syphilis care globally: A scoping review

Infectious and Congenital Syphilis rates continue to rise globally. Current recommendations for syphilis screening and treatment may be insufficient, and there is a pressing need for improved programs and services to address the increase in cases. A scoping review was conducted to examine approaches to maternal syphilis screening and treatment. Theoretical underpinnings and the key characteristics of these interventions were studied to identify gaps in the existing literature to guide future research. Developing a modified version of the socio-ecological model to guide data analysis, we included 33 academic studies spanning 31 years, covering a range of interventions, programs, and policies globally. We highlight key facets of interventions aligning with the five levels of the modified model that include: individual, interpersonal, institutional, community and policy. In this review, we provide valuable insights into the characteristics and principles of maternal syphilis screening and treatment interventions.

Availability, stock levels and usage of In-vitro diagnostics in the Bono region, Ghana: A cross-sectional study

BACKGROUND

Point-of-care (POC) diagnostic tests play essential roles in diagnosis, surveillance, and disease management in health settings. Nevertheless, implementation challenges may hamper POC test accessibility. This study evaluated the availability and stock levels of the World Health Organization (WHO) prequalified existing in-vitro diagnostics (IVDs) for use in health facilities without laboratories.

AIM

To evaluate the availability, stock levels, and usage of POC diagnostic tests.

SETTING

Bono Region, Ghana.

METHODS

This cross-sectional survey involved 102 randomly selected Community Health-based and Planning Services (CHPS), 12 district health depots, and a regional medical depot. Using a survey tool, data were collected on clinic staffing, availability and stock levels of tests, and funding sources. STATA 17 was employed for data analysis.

RESULTS

Majority (37.3%) of the respondents were community health nurses, with 4.4 mean years of work experience and 38 working hours per week. Of the 18 existing WHO prequalified POC tests for use at facilities without laboratories, 10 (56%), 2 (11%) and 0 (0%) were found at CHPS, regional, and district depots, respectively. Majority (183 out of 301) stock levels were low. Of the 10 available tests found, 7 scored 111 (36%) of 'high use'. Supply chain management compliance was 5 (31%) out of 16. All CHPS received government funding with 25.5% of them receiving additional donor or internally generated funding.

CONCLUSION

This study found poor supply chain management compliance, and low availability of POC tests in the Bono Region of Ghana.Contribution: The study outlines POC tests availability and usage in low-resourced setting.

Facilitators and barriers to point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review

BACKGROUND

Sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) are predominantly managed by syndromic management. However, most STIs are asymptomatic. These untreated STIs cause individual morbidity, and lead to high STI prevalences. There is increasing interest in the use of point-of-care tests (POCTs) for STIs in LMICs, which could facilitate same day testing and treatment. To best utilise these tests, we must understand the facilitators and barriers to their implementation. The aim of this review is to explore how point-of-care testing for STIs has been implemented into healthcare systems in LMIC and the facilitators and barriers to doing so.

METHODS

A scoping review was conducted by searching MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, the Cochrane Library, and ProQuest Dissertations and Theses for studies published between 1st January 1998 and 5th June 2020. Abstracts and full articles were screened independently by two reviewers. Studies were considered for inclusion if they assessed the acceptability, feasibility, facilitators, or barriers to implementation of point-of-care testing for chlamydia, gonorrhoea, trichomoniasis or syphilis in LMICs. Thematic analysis was used to analyse and present the facilitators and barriers to point-of-care STI testing.

RESULTS

The literature search revealed 82 articles suitable for inclusion; 44 (53.7%) from sub-Saharan Africa; 21 (25.6%) from Latin American and the Caribbean; 10 (12.2%) from East Asia and the Pacific; 6 (7.3%) from South Asia; and one (1.2%) multi-regional study. Thematic analysis revealed seven overarching themes related to the implementation of POCTs in LMICs, namely (i) Ideal test characteristics, (ii) Client factors, (iii) Healthcare provision factors, (iv) Policy, infrastructure and health system factors, (v) Training, audit, and feedback, (vi) Reaching new testing environments, and (vii) Dual testing.

CONCLUSION

Implementation of POCTs in LMICs is complex, with many of the barriers due to wider health system weakness. In addition to pressing for broader structural change to facilitate basic healthcare delivery, these themes may also be used as a basis on which to develop future interventions. The literature was heavily skewed towards syphilis testing, and so more research needs to be conducted assessing chlamydia, gonorrhoea, and trichomoniasis testing, as well as home or self-testing.

Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries

Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.

A review of the process of knowledge transfer and use of evidence in reproductive and child health in Ghana

Background

The paper carries out a situational analysis to examine the production, dissemination and utilisation of reproductive and child health-related evidence to inform policy formulation in Ghana’s health sector.

Methods

The study used Wald’s model of knowledge production, transfer and utilisation as a conceptual model to collect relevant data via interviews and administration of questionnaire to a network of persons who either previously or currently hold policy-relevant positions in Ghana’s health sector. Additional data was also gathered through a scoping review of the knowledge transfer and research utilisation literature, existing reproductive and child health policies, protocols and guidelines and information available on the websites of relevant institutions in Ghana’s health sector.

Results

The findings of the study suggest that the health sector in Ghana has major strengths (strong knowledge production capacity, a positive environment for the promotion of evidence-informed policy) and opportunities (access to major donors who have the resources to fund good quality research and access to both local and international networks for collaborative research). What remains a challenge, however, is the absence of a robust institutional-wide mechanism for collating research needs and communicating these to researchers, communicating research findings in forms that are friendlier to policy-makers and the inability to incorporate funding for research into the budget of the health sector.

Conclusion

The study concludes, admonishing the Ministry of Health and its agencies to leverage on the existing strengths and opportunities to address the identified challenges.

Rollout of rapid point of care tests for antenatal syphilis screening in Ghana: healthcare provider perspectives and experiences

BACKGROUND

Effective implementation of rapid point of care tests (POCTs) for antenatal syphilis screening especially in settings where antenatal care attendance is high, can significantly increase screening coverage and treatment uptake. The operational challenges of introducing rapid syphilis POCTs at scale needs to be investigated. This study explores healthcare providers' experiences and challenges in antenatal syphilis screening following the national rollout of rapid syphilis POCTs in Ghana.

METHODS

Prior to the main study, we undertook a desk review of key syphilis policy documents, and conducted key stakeholder interviews and a baseline survey of syphilis screening practices. Antenatal syphilis screening had been poorly implemented mainly due to inadequate technical and logistic support, and lack of monitoring and supervision. For the main research, semi-structured interviews were conducted with 51 purposively selected healthcare staff involved in antenatal syphilis screening in 15 health facilities in three regions, representative of all levels of healthcare in Ghana and two regional programme coordinators, at least four months after the rollout. The interviews were supplemented with an audit of the conduct of antenatal care, syphilis-related supplies and other maternal and newborn interventions. Qualitative data were coded and analysed using Nvivo software.

RESULTS

Syphilis screening with rapid POCTs was integrated into antenatal care in almost all (13/15) the facilities surveyed. Testing and treatment were offered free of charge to pregnant women, their partners and babies. In most facilities, midwives were performing syphilis tests together with HIV tests. Operational challenges included: inadequate training and lack of refresher training, lack of clear testing guidelines, clear channels of communication, supervision, and guidance on treatment and referral procedures, frequent stockouts of, or expired test kits, staff overload, and poor documentation of test results and treatment.

CONCLUSION

Although syphilis screening with rapid syphilis POCTs was integrated into antenatal care, key challenges, particularly around supply chain and supervision, need to be addressed to improve and sustain such a programme.

Cost-effectiveness of maternal GBS immunization in low-income sub-Saharan Africa

BACKGROUND

A maternal group B streptococcal (GBS) vaccine could prevent neonatal sepsis and meningitis. Its cost-effectiveness in low-income sub-Saharan Africa, a high burden region, is unknown.

METHODS

We used a decision tree model, with Markov nodes to project infants' lifetimes, to compare maternal immunization delivered through routine antenatal care with no immunization. 37 countries were clustered on the basis of economic and health resources and past public health performance. Vaccine efficacy for covered serotypes was ranged from 50% to 90%. The model projected EOGBS (early-onset) and LOGBS (late-onset) cases and deaths, disability-adjusted life years (DALYs), healthcare costs (2014 US$), and cost-effectiveness for a representative country in each of the four clusters: Guinea-Bissau, Uganda, Nigeria, and Ghana. Maximum vaccination costs/dose were estimated to meet two cost-effectiveness benchmarks, 0.5 GDP and GDP per capita/DALY, for ranges of disease incidence (reported and adjusted for under-reporting) and vaccine efficacy.

RESULTS

At coverage equal to the proportion of pregnant women with≥4 antenatal visits (ANC4) and serotype-specific vaccine efficacy of 70%, maternal GBS immunization would prevent one-third of GBS cases and deaths in Uganda and Nigeria, where ANC4 is 50%, 42-43% in Guinea-Bissau (ANC4=65%), and 55-57% in Ghana (ANC4=87%). At a vaccination cost of $7/dose, maternal immunization would cost $320-$350/DALY averted in Guinea-Bissau, Nigeria, and Ghana, less than half these countries' GDP per capita. In Uganda, which has the lowest case fatality ratios, the cost would be $573/DALY. If the vaccine prevents a small proportion of stillbirths, it would be even more cost-effective. Vaccination cost/dose, disease incidence, and case fatality were key drivers of cost/DALY in sensitivity analyses.

CONCLUSION

Maternal GBS immunization could be a cost-effective intervention in low-income sub-Saharan Africa, with cost-effectiveness ratios similar to other recently introduced vaccines. The vaccination cost at which introduction is cost-effective depends on disease incidence and vaccine efficacy. Clinical Trial registry name and registration number: Not applicable.

The introduction of syphilis point of care tests in resource limited settings

INTRODUCTION

Syphilis remains an important and preventable cause of stillbirth and neonatal mortality. About 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby and 33% a low birth weight baby with an increased chance of dying in the first month of life. Adverse pregnancy outcomes due to syphilis can be prevented by screening pregnant women, and treating those who test positive with a single dose of penicillin before 28 weeks' gestation. Areas covered: This manuscript covers the impact of syphilis on pregnancy outcome, the diagnosis of syphilis, with a special focus on point of care (POC) tests, and challenges to the introduction of POC tests, and their potential impact on the control and prevention of syphilis in resource limited settings. Expert commentary: POC tests for syphilis are available which meet the ASSURED criteria, and could make syphilis screening accessible to all women anywhere in the world who attend an antenatal clinic. High quality dual POC tests for HIV and syphilis could ensure that well-funded programmes for the prevention of mother to child transmission of HIV can contribute towards increased coverage of antenatal syphilis screening, and prevent more than 300,000 adverse pregnancy outcomes due to syphilis annually. Alongside investment to increase availability of syphilis POC tests, operational research is needed to understand how best to improve screening of pregnant women and to translate test availability into improved pregnancy outcomes.

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.