The Need and Plan for Global Elimination of Congenital Syphilis

Treponema pallidum genetic diversity and its implications for targeted vaccine development: A cross-sectional study of early syphilis cases in Southwestern Colombia

BACKGROUND

Venereal syphilis, caused by the spirochete Treponema pallidum subsp. pallidum (TPA), is surging worldwide, underscoring the need for a vaccine with global efficacy. Vaccine development requires an understanding of syphilis epidemiology and clinical presentation as well as genomic characterization of TPA strains circulating within at-risk populations. The aim of this study was to describe the clinical, demographic, and molecular features of early syphilis cases in Cali, Colombia.

METHODS AND FINDINGS

We conducted a cross-sectional study to identify individuals with early syphilis (ES) in Cali, Colombia through a city-wide network of public health centers, private sector HIV clinics and laboratory databases from public health institutions. Whole blood (WB), skin biopsies (SB), and genital and oral lesion swabs were obtained for measurement of treponemal burdens by polA quantitative polymerase chain reaction (qPCR) and for whole-genome sequencing (WGS). Among 1,966 individuals screened, 128 participants met enrollment criteria: 112 (87%) with secondary (SS), 15 (12%) with primary (PS) and one with early latent syphilis; 66/128 (52%) self-reported as heterosexual, while 48 (38%) were men who have sex with men (MSM). Genital ulcer swabs had the highest polA copy numbers (67 copies/μl) by qPCR with a positivity rate (PR) of 73%, while SS lesions had 42 polA copies/μl with PR of 62%. WB polA positivity was more frequent in SS than PS (42% vs 7%, respectively; p = 0.009). Isolation of TPA from WB by rabbit infectivity testing (RIT) was achieved in 5 (56%) of 9 ES WB samples tested. WGS from 33 Cali patient samples, along with 10 other genomic sequences from South America (9 from Peru, 1 from Argentina) used as comparators, confirmed that SS14 was the predominant clade, and that half of all samples had mutations associated with macrolide (i.e., azithromycin) resistance. Variability in the outer membrane protein (OMP) and vaccine candidate BamA (TP0326) was mapped onto the protein's predicted structure from AlphaFold. Despite the presence of mutations in several extracellular loops (ECLs), ECL4, an immunodominant loop and proven opsonic target, was highly conserved in this group of Colombian and South American TPA isolates.

CONCLUSIONS

This study offers new insights into the sociodemographic and clinical features of venereal syphilis in a highly endemic area of Colombia and illustrates how genomic sequencing of regionally prevalent TPA strains can inform vaccine development.

Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis

INTRODUCTION

Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation.

METHODS

Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts.

RESULTS

A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control.

CONCLUSION

Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts' views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.

Barriers to optimal management of syphilis in pregnancy and congenital syphilis in south-east Queensland: a qualitative investigation

BACKGROUND

Australia, like many high-income countries, is experiencing a resurgence of infectious syphilis in pregnancy and congenital syphilis. Evaluations of public health notifications and clinical records suggest that healthcare systems may not be providing optimal care to women and their neonates. This study aims to explore the barriers to optimal management of syphilis in pregnancy and congenital syphilis to identify key areas for improvement.

METHODS

Between 2021 and 2022, 34 healthcare workers (HCW) practicing in south-east Queensland (SEQ) Australia were recruited to complete semi-structured interviews regarding their perceptions towards management of syphilis in pregnancy and congenital syphilis. Interviews were analysed thematically.

RESULTS

Thematic analysis identified four themes related to the management of syphilis in pregnancy. These included poor communication between disciplines, services, and teams from delivery through to management and post-delivery, lack of formal internal and external referral pathways, unclear and often complex maternal and congenital syphilis management procedures, and limited HCW knowledge of infectious syphilis in pregnancy and congenital syphilis.

CONCLUSION

As congenital syphilis numbers continue to rise in SEQ, it is imperative that healthcare systems and HCWs identify and address gaps in the provision of health care.

Identification of a Potential Vaccine against Treponema pallidum Using Subtractive Proteomics and Reverse-Vaccinology Approaches

Syphilis, a sexually transmitted infection, is a deadly disease caused by Treponema pallidum. It is a Gram-negative spirochete that can infect nearly every organ of the human body. It can be transmitted both sexually and perinatally. Since syphilis is the second most fatal sexually transmitted disease after AIDS, an efficient vaccine candidate is needed to establish long-term protection against infections by T. pallidum. This study used reverse-vaccinology-based immunoinformatic pathway subtractive proteomics to find the best antigenic proteins for multi-epitope vaccine production. Six essential virulent and antigenic proteins were identified, including the membrane lipoprotein TpN32 (UniProt ID: O07950), DNA translocase FtsK (UniProt ID: O83964), Protein Soj homolog (UniProt ID: O83296), site-determining protein (UniProt ID: F7IVD2), ABC transporter, ATP-binding protein (UniProt ID: O83930), and Sugar ABC superfamily ATP-binding cassette transporter, ABC protein (UniProt ID: O83782). We found that the multiepitope subunit vaccine consisting of 4 CTL, 4 HTL, and 11 B-cell epitopes mixed with the adjuvant TLR-2 agonist ESAT6 has potent antigenic characteristics and does not induce an allergic response. Before being docked at Toll-like receptors 2 and 4, the developed vaccine was modeled, improved, and validated. Docking studies revealed significant binding interactions, whereas molecular dynamics simulations demonstrated its stability. Furthermore, the immune system simulation indicated significant and long-lasting immunological responses. The vaccine was then reverse-transcribed into a DNA sequence and cloned into the pET28a (+) vector to validate translational activity as well as the microbial production process. The vaccine developed in this study requires further scientific consensus before it can be used against T. pallidum to confirm its safety and efficacy.

Assessment of recombinant antigens Tp0100 and Tp1016 of Treponema pallidum for serological diagnosis of syphilis

Objective

To discover novel serodiagnostic candidates for the serological diagnosis of syphilis.

Methods

Two recombinant Treponema pallidum proteins Tp0100 and Tp1016 were expressed, purified, and identified by Western Blotting. A total of 600 clinical serum samples were tested with the Tp0100‐based ELISA, the Tp1016‐based ELISA, and the commercial LICA Syphilis TP kit (ChIVD, Beijing, China). The sensitivities were determined by testing 340 samples from individuals with clinically diagnosed primary, secondary, latent, and tertiary syphilis. The specificities were determined by screening 260 samples from healthy controls and individuals with potentially cross‐reactive infections, including leptospirosis, Lyme disease, hepatitis B, tuberculosis, rheumatoid arthritis, systemic lupus erythematosus. Kappa (κ) values were applied to compare the agreement between clinical syphilis diagnosis and the Tp0100‐based ELISA, the Tp1016‐based ELISA, or the LICA Syphilis TP test.

Results

Using clinical syphilis diagnosis as the gold standard, Tp0100 exhibited an overall sensitivity of 95.6% and specificity of 98.1% for testing IgG antibody while Tp1016 demonstrated only an overall sensitivity of 75.0% and specificity of 79.6%. In contrast, the LICA Syphilis TP test revealed an overall sensitivity of 97.6% and specificity of 96.2%. In addition, the overall percent agreement and corresponding κ values were 96.7% (95% CI 95.6%–97.8%) and 0.93 for the Tp0100‐based ELISA, 77.0% (95% CI 74.3%–79.7%) and 0.54 for the Tp1016‐based ELISA, and 97.0% (95% CI 96.0%–98.0%) and 0.94 for the LICA Syphilis TP test, respectively.

Conclusion

The recombinant T. pallidum protein Tp0100 shows promise as a novel diagnostic antigen in the serological tests for syphilis.

A rare case of early congenital syphilis with patent ductus arteriosus: The continuing curse for generations

A 19-year-old female with untreated syphilis (venereal disease research laboratory test reactive) delivered a female child at 34 weeks with low birth weight, intrauterine growth retardation, respiratory distress, and bilateral pedal edema. One week later, the baby was found to be having pansystolic murmur confirmed by ECHO as patent ductus arteriosus. At 2 weeks, the baby developed maculopapular rash; hepatomegaly; and swelling of the shoulder, knee, ankle, wrist, and medial end of the clavicle. Both parents and baby were rapid plasma reagin test. X-ray showed Wimberger's sign at the upper end of the tibia. A diagnosis of congenital syphilis was made. The baby became asymptomatic after giving injection benzylpenicillin for 10 days.

Congenital syphilis in Argentina: Experience in a pediatric hospital

In spite of being preventable, Congenital syphilis (CS) is still an important, and growing health problem worldwide. Fetal infection can be particularly aggressive, but newborns can be asymptomatic at birth and, if left untreated, develop systemic compromise afterwards with poor prognosis. We analyzed 61 CS diagnosis cases between 1987-2019 presenting at the Buenos Aires Children' Hospital. The distribution of cases showed a bimodal curve, with a peak in 1992-1993 and in 2014-2017. Median age at diagnosis was 2 months (IQ 1-6 months). The main clinical findings were: bone alterations (59%); hepatosplenomegaly (54.1%); anemia (62.8%); skin lesions (42.6%) and renal compromise (33.3%). Cerebrospinal fluid (CSF) was abnormal in 5 patients, normal in 45 and was not available for 11 patients. Remarkably, spinal lumbar puncture did not modify therapeutic decisions in any case. Between mothers, only 46% have been tested for syphilis during pregnancy and 60.5% patients had non-treponemal titers equal to or less than fourfold the maternal titer. Intravenous penicillin G was prescribed for all except one patient, who received ceftriaxone with good therapeutic response. During follow-up, 1.6% infants died, 6.5% had persistent kidney disorders and 1.6% showed bone sequelae damage. RPR titers decreased after treatment, reaching negative seroconversion in 43% subjects at a median of 26.4 months. Low adherence to follow up was observed due to inherent vulnerable and low-income population characteristics in our cohort. Our results highlight a rising tendency in cases referred for CS in our population with high morbidity related to delayed diagnosis. A good therapeutic response was observed. CS requires a greater effort from the health system to adequately screen for this disease during pregnancy, and to detect cases earlier, to provide an adequate diagnosis and treatment.

Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews

BACKGROUND

Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections.

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women.

METHODS

We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence.

MAIN RESULTS

We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined.

AUTHORS' CONCLUSIONS

While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.

Prevalence, associated factors and clinical features of congenital syphilis among newborns in Mbarara hospital, Uganda

Background

While congenital syphilis is a significant public health problem that can cause severe disabilities, little is known about the situation in Uganda. We describe prevalence, associated factors and clinical presentation of congenital syphilis in Mbarara, Uganda.

Methods

A cross sectional study was carried out among mother- newborn dyads from the postnatal ward of Mbarara Regional Referral Hospital (MRRH). After obtaining informed consent, a structured questionnaire was used to capture data on risk factors for congenital syphilis. A finger prick was performed on the mothers for Treponema Pallidum Haemagglutination Assay (TPHA). If TPHA was positive, a venous blood sample was collected from the mother to confirm active infection using Rapid Plasma Reagin (RPR). Venous blood was drawn from a newborn if the mother tested positive by TPHA and RPR. A newborn with RPR titres 4 times higher than the mother was considered to have congenital syphilis. We fit logistic regression models to determine factors associated with congenital syphilis.

Results

Between June and September 2015, we enrolled 2500 mothers and 2502 newborns. Prevalence of syphilis was 3.8% (95% CI 3.1–4.6) among newborn infants and 4.1% (95% CI 3.4–5.0) among their mothers. Maternal age <25 years, past history of genital ulcer, a past history of abnormal vaginal discharge, and not receiving treatment of at least one of genital ulcer, genital itching, lower abdominal pain and abnormal vaginal discharge in the current pregnancy were the risk factors associated with congenital syphilis. The most common clinical feature was hepatosplenomegaly.

Conclusions

We found higher-than-expected syphilis sero-prevalence rates in a high risk population of postnatal mothers and their newborns in Uganda. Bridge populations for syphilis may include mothers not tested during pregnancy, who are usually married and not treated. In accordance with our results, the national policy for syphilis control in Uganda should be strengthened to include universal syphilis screening amongst mother-newborn pairs in postnatal clinics with subsequent partner notification.

It Is Complicated: The Medico-Social Journey of an Undocumented Pregnant Adolescent

Adolescent pregnancies are a global health problem with over 16 million children born to this age group globally. Adolescent females also represent almost half of all adolescent global migrants. Adolescent pregnancy by itself is associated with poor health care access and morbidities; the additional risk of social insecurity in the case of undocumented adolescent migrants leads to higher risks for the mother and newborn. According to the CDC, adolescents comprise half of all new sexually transmitted diseases (STDs) including reported primary and secondary syphilis. Our case highlights the relationship between social insecurity for the undocumented adolescent migrant and excess risks for preventable mother-to-child transmission of communicable diseases. In formulating preventive measures and policies for the recent rise in sexually transmitted maternal diseases with resultant congenital infections, there is need for health care systems and providers to familiarize themselves with advocacy and other useful resources that will promote health care access for undocumented and other vulnerable adolescents. Additionally, local providers who work in areas with a large population of immigrant adolescents should utilize the untapped resources of these adolescents to develop youth community advocacy projects that link adolescents to health resources, including reproductive health.

A clinical audit of maternal syphilis in a regional hospital in KwaZulu-Natal, South Africa

Background

Despite the availability of screening guidelines and effective treatment for maternal syphilis (MS), its prevalence remains high and is re-emerging in many parts of the world. This might be because of varying screening tests and algorithms for the laboratory diagnosis and treatment of syphilis. In addition, HIV co-infection may compromise the elimination of MS. The present study is a clinical audit of the prevalence of MS in KwaZulu-Natal, South Africa, using the 'Traditional Algorithm' screening.

Methods

This was a retrospective audit in which data on syphilis testing were obtained over a 1-year period (2016) at a large regional hospital in South Africa. The standard screening test at the study site was the non-treponemal antigen, rapid plasma reagin (RPR). Data on the prevalence of MS and comorbidity with HIV infection were analysed.

Results

There were 10 680 deliveries in the study period of which 118 were RPR reactive, giving an MS prevalence of 1.1%. MS occurred predominantly in the age groups < 18 and > 35 years (p = 0.001). The prevalence of HIV infection was 41.2% (n = 4451). Seventy-two (61.0%) had both HIV and MS infection, whilst 46 (39.0%) had discordant results (p = 0.001).

Conclusion

We report an increase in the prevalence of MS compared to previous South African National Antenatal Syphilis Surveillance studies. This may be because of the prozone effect caused by HIV infection on the sensitivity of the RPR. We propose a change in MS screening, using a Rapid DUO (Dual HIV and syphilis point of care test) and Reverse Algorithm for screening that could improve the sensitivity, detection and management of both diseases.

Congenital Syphilis as a Measure of Maternal and Child Healthcare, Brazil

Syphilis is a sexually transmitted infection that has direct adverse effects on maternal and infant health through vertical Treponema pallidum transmission during early pregnancy. We evaluated congenital syphilis as a predictor of the quality of basic maternal and child healthcare in Brazil during 2010–2015. We investigated case rates and correlations with epidemiologic and socioeconomic indicators. We observed rising congenital syphilis incidence rates and increasing syphilis-associated perinatal and infant mortality rates in all regions. Case rates were highest in the Northeast, Southeast, and South, and congenital syphilis infant mortality rates were highest in the Northeast and Southeast. We observed correlations between congenital syphilis rates and infant death, spontaneous abortion (miscarriage), and stillbirth rates. We also noted correlations between rates of stillbirth caused by syphilis and inadequate prenatal care. Our study suggests gaps in basic healthcare for pregnant women and indicates the urgent need for measures to increase early diagnosis and appropriate treatment.

Prevalence and factors associated with HIV and syphilis infection among children aged 0-36 months in Kilimanjaro, Tanzania: a community-based cross-sectional study

Background

Childhood mortality is high in sub-Saharan Africa. Mother-to-child transmission (MTCT) of HIV and congenital syphilis are among significant causes. Dual elimination of these two infections is one of the international goals. Community-based studies on the burden of HIV and syphilis among children will contribute to fine-tuning the interventions to achieve the elimination goal. This study aims to describe the prevalence of HIV and syphilis among children aged 0–36 months and associated factors in northern Tanzania.

Methods

This was a community-based cross-sectional study, which was conducted in all the seven districts of Kilimanjaro region. Multistage sampling was used, and a total of 2452 children aged 0 to 36 months and their primary caretakers were enrolled. Interviews were conducted with the mother/caretaker, and dried blood samples were collected from the children and processed for laboratory diagnosis of HIV and syphilis. HIV ELISA was first performed on all the samples. Positive samples of children < 18 months were confirmed using PCR.

Results

The prevalence of HIV among 2452 children aged 0–36 months was 1.7% (n = 42). There was a significant difference in the distribution of HIV by age of the child, maternal antenatal attendance, and breastfeeding history.

The prevalence of syphilis was 0.4% (n = 10). Five of the children were more than 1 year old. All children with a positive test for syphilis were from Moshi rural district, and their mothers consumed alcohol. No child was co-infected with HIV and syphilis.

Conclusions

Though the prevalence of the two infections was low, detecting syphilis in children suggests a missed opportunity in screening women during pregnancy. The region may be on track with the goal to achieve dual elimination of mother-to-child transmitted HIV and syphilis. However, efforts are needed to reduce missed opportunities for screening women for syphilis and HIV early in pregnancy and retesting at 3rd trimester/delivery. Strategies to improve testing for HIV-exposed children are needed.

Prevalence of Syphilis among Pregnant Women in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

OBJECTIVE

Syphilis is one of the most imperative STIs, caused by the spirochete Treponema pallidum. During pregnancy it is associated with disastrous health outcomes in the newborn. In sub-Saharan Africa, study findings on the prevalence of syphilis among pregnant women are highly dispersed and inconsistent. The aim of the current review is to conduct a systematic review and meta-analysis of syphilis in sub-Saharan Africa among pregnant women.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Databases including MEDLINE, PubMed, Cochrane Library, Google Scholar, and HINARI and reference lists of previous prevalence studies were systematically searched for relevant literature from January 1999 to November 2018. Results were presented in forest plot, tables, and figures. Random-effects model was used for the meta-analysis. For the purpose of this review, a case of syphilis was defined as positive treponemal or nontreponemal tests among pregnant women.

DATA EXTRACTION

Our search gave a total of 262 citations from all searched databases. Of these, 44 studies fulfilling the inclusion criteria and comprising 175,546 subjects were finally included.

RESULTS

The pooled prevalence of syphilis among pregnant women in sub-Saharan Africa was 2.9% (95%CI: 2.4%-3.4%). East and Southern African regions had a higher syphilis prevalence among pregnant women (3.2%, 95% CI: 2.3%-4.2% and 3.6%, 95%CI: 2.0%-5.1%, respectively) than the sub-Saharan African pooled prevalence. The prevalence of syphilis among pregnant women in most parts of the region seemed to have decreased over the past 20 years except for the East African region. However, prevalence did not significantly differ by region and time period.

CONCLUSION

This review showed a high prevalence of syphilis in sub-Saharan Africa among pregnant women. The evidence suggests strengthening the screening program during pregnancy as part of the care package during antenatal care visits. Programs focusing on primary prevention of syphilis in women should also be strengthened.

Congenital Syphilis: A Discussion of Epidemiology, Diagnosis, Management, and Nurses' Role in Early Identification and Treatment

BACKGROUND

Syphilis is caused by the spirochete bacterium Treponema pallidum. Syphilis left untreated, or inadequately treated during pregnancy, can result in congenital syphilis (CS). Congenital syphilis can lead to severe sequelae or fetal, neonatal, or infant death.

PURPOSE

To discuss the epidemiological trends, pathophysiology, diagnosis, and management of CS; the implications of CS upon the infant; as well as the importance of the nurse's role in the prompt identification of CS and the timely interventions needed to minimize sequelae.

METHODS

A literature search was completed using ProQuest, CINAHL, Google Scholar, and PubMed. Articles published within the past 10 years were included.

FINDINGS

Epidemiological trends of CS in the United States indicate that maternal syphilis infection and CS are on the rise. Risk factors include ethnicity, socioeconomic status, access to prenatal care, and sexual behaviors, as well as compliance with prenatal syphilis screening by prenatal providers. Risks of CS to the developing fetus begin at approximately 14 weeks. Timely treatment is necessary to minimize or eliminate mortality and morbidity.

IMPLICATIONS FOR PRACTICE

Evidence-based, interprofessional strategies, which promote a collaborative perinatal/neonatal preventative approach to care of the pregnant female, are indicated to reverse the increasing incidence of CS within the United States. Strategies prioritizing early identification and treatment of at-risk neonates are necessary to reduce/eliminate the devastating long-term consequences of CS upon this vulnerable population.

IMPLICATIONS FOR RESEARCH

The paucity of research, which focuses on CS, is most likely due to ethical concerns related to infants as research participants and provides an opportunity for future research. Future research could focus on factors that focus on maternal-fetal/maternal-child transmission of CS.

Features of syphilis seropositive pregnant women raising alarms in Hungary, 2013-2016

OBJECTIVES

The incidence of syphilis has been on the rise in Hungary over the last decades. We aimed to assess the syphilis seroprevalence in pregnant women during 2013-2016. The secondary aims were to describe seropositivity by age and gestational age, to estimate infectivity rates in different age groups, and to compare the efficacy of mandatory prenatal screening versus individual venereological testing in revealing syphilis.

STUDY DESIGN

During the above mentioned period the reactive serum samples (N = 527) of 49,965 pregnant women undergoing routine screening were submitted for syphilis verification to the Bacterial STI Reference Laboratory, National Center for Epidemiology, Budapest, Hungary. The confirmation process included titrated RPR and TPHA tests performed simultaneously. The tested women were considered seronegative if both tests gave negative results. When any of these tests proved indeterminate or positive, anti-Treponema pallidum IgG and IgM ELISA tests were performed. Patients confirmed for the presence for specific IgG were judged seropositive. Further evaluation of potential infectivity of seropositive patients was carried out on RPR reactivity.

RESULTS

Syphilis seropositivity was detected in overall 2.9‰ (N = 148) of the cases. RPR-negative cases, i.e. past infections were confirmed in 36% (53/148); weak-reactive RPR (titres≤8) cases, i. e. past/early acute infections in 37% (55/148); strong-reactive RPR (titres>8) cases suggesting recent syphilis in 27% (40/148). Half of the infectious syphilis cases (20/40) belonged to the 15-24 age group. The gestational age at screening was available of 123 seropositive women, out of whom 27 (22%) were diagnosed late, in the third trimester. Nineteen (13%) out of all seropositives were detected via individual venereological testing before/instead of general prenatal screening.

CONCLUSIONS

The majority of infected pregnants may remain undetected due to the lack of mandatory general prenatal screening. The seropositivity for syphilis in pregnancy of 2.9/1000, of which one quarter were recent and infectious, the late diagnosis of syphilis in one in five, and the low pick-up rate of individualised instead of generalized screening are alarming signals and call for more effective prevention strategies, focusing on the most vulnerable adolescents, as well as on the first trimester of pregnancy.

Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study

Summary

Background

In 2007, WHO launched a global initiative for the elimination of mother-to-child transmission of syphilis (congenital syphilis). An important aspect of the initiative is strengthening surveillance to monitor progress towards elimination. In 2008, using a health systems model with country data inputs, WHO estimated that 1 4 million maternal syphilis infections caused 520 000 adverse pregnancy outcomes. To assess progress, we updated the 2008 estimates and estimated the 2012 global prevalence and cases of maternal and congenital syphilis.

Methods

We used a health systems model approved by the Child Health Epidemiology Reference Group. WHO and UN databases provided inputs on livebirths, antenatal care coverage, and syphilis testing, seropositivity, and treatment in antenatal care. For 2012 estimates, we used data collected between 2009 and 2012. We updated the 2008 estimates using data collected between 2000 and 2008, compared these with 2012 estimates using data collected between 2009 and 2012, and performed subanalyses to validate results.

Findings

In 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes including 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low weight births, and 102 000 infected infants worldwide. Nearly 80% of adverse outcomes (274 000) occurred in women who received antenatal care at least once. Comparing the updated 2008 estimates with the 2012 estimates, maternal syphilis decreased by 38% (from 1 488 394 cases in 2008 to 927 936 cases in 2012) and congenital syphilis decreased by 39% (from 576 784 to 350 915). India represented 65% of the decrease. Analysis excluding India still showed an 18% decrease in maternal and congenital cases of syphilis worldwide.

Interpretation

Maternal and congenital syphilis decreased worldwide from 2008 to 2012, which suggests progress towards the elimination of mother-to-child transmission of syphilis. Nonetheless, maternal syphilis caused substantial adverse pregnancy outcomes, even in women receiving antenatal care. Improved access to quality antenatal care, including syphilis testing and treatment, and robust data are all important for achieving the elimination of mother-to-child transmission of syphilis.

Funding

The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction in WHO, and the US Centers for Disease Control and Prevention.

Congenital syphilis with bone lesion: case report

The authors report a case of congenital syphilis in a newborn with a bone lesion, resulting in left ankle periostitis.

Syphilis

Treponema pallidum subspecies pallidum (T. pallidum) causes syphilis via sexual exposure or via vertical transmission during pregnancy. T. pallidum is renowned for its invasiveness and immune-evasiveness; its clinical manifestations result from local inflammatory responses to replicating spirochaetes and often imitate those of other diseases. The spirochaete has a long latent period during which individuals have no signs or symptoms but can remain infectious. Despite the availability of simple diagnostic tests and the effectiveness of treatment with a single dose of long-acting penicillin, syphilis is re-emerging as a global public health problem, particularly among men who have sex with men (MSM) in high-income and middle-income countries. Syphilis also causes several hundred thousand stillbirths and neonatal deaths every year in developing nations. Although several low-income countries have achieved WHO targets for the elimination of congenital syphilis, an alarming increase in the prevalence of syphilis in HIV-infected MSM serves as a strong reminder of the tenacity of T. pallidum as a pathogen. Strong advocacy and community involvement are needed to ensure that syphilis is given a high priority on the global health agenda. More investment is needed in research on the interaction between HIV and syphilis in MSM as well as into improved diagnostics, a better test of cure, intensified public health measures and, ultimately, a vaccine.

Identification of Tp0751 (Pallilysin) as a Treponema pallidum Vascular Adhesin by Heterologous Expression in the Lyme disease Spirochete

Treponema pallidum subsp. pallidum, the causative agent of syphilis, is a highly invasive spirochete pathogen that uses the vasculature to disseminate throughout the body. Identification of bacterial factors promoting dissemination is crucial for syphilis vaccine development. An important step in dissemination is bacterial adhesion to blood vessel surfaces, a process mediated by bacterial proteins that can withstand forces imposed on adhesive bonds by blood flow (vascular adhesins). The study of T. pallidum vascular adhesins is hindered by the uncultivable nature of this pathogen. We overcame these limitations by expressing T. pallidum adhesin Tp0751 (pallilysin) in an adhesion-attenuated strain of the cultivable spirochete Borrelia burgdorferi. Under fluid shear stress representative of conditions in postcapillary venules, Tp0751 restored bacterial-vascular interactions to levels similar to those observed for infectious B. burgdorferi and a gain-of-function strain expressing B. burgdorferi vascular adhesin BBK32. The strength and stability of Tp0751- and BBK32-dependent endothelial interactions under physiological shear stress were similar, although the mechanisms stabilizing these interactions were distinct. Tp0751 expression also permitted bacteria to interact with postcapillary venules in live mice as effectively as BBK32-expressing strains. These results demonstrate that Tp0751 can function as a vascular adhesin.

Vigilância epidemiológica da transmissão vertical da sífilis: dados de seis unidades federativas no Brasil

Objetivo. Descrever o perfil epidemiológico dos casos notificados de sífilis em gestantes e sífilis congênita nos estados brasileiros do Amazonas, Ceará, Espírito Santo, Rio de Janeiro e Rio Grande do Sul e no Distrito Federal a partir de dados do Sistema Nacional de Agravos de Notificação (SINAN).

Métodos. Estudo descritivo incluindo avaliação ecológica e transversal. Foram utilizados dados do SINAN Net. Foram calculadas a taxa de detecção de sífilis em gestantes e a taxa de incidência de sífilis congênita por 1 000 nascidos vivos. Para identificar as gestantes notificadas com sífilis com desfecho de sífilis congênita, as duas bases do SINAN foram relacionadas por meio do software RecLink. Como os dados eram de representatividade regional, as comparações foram feitas entre as unidades da federação, e não com a soma dos casos.

Resultados A taxa de detecção de sífilis em gestantes cresceu entre 21% (Amazonas) e 75% (Rio de Janeiro). A incidência de sífilis congênita seguiu o mesmo perfil de incremento, variando de 35,6% no Distrito Federal a 639,9% no Rio Grande do Sul, com redução de 0,7% no Amazonas. A realização de pré-natal nas mulheres com desfecho de sífilis congênita variou de 67,3% no Amazonas a 83,3% no Distrito Federal. Das gestantes com sífilis, 43% tiveram desfecho notificado de sífilis congênita. Nas gestantes com sífilis e desfecho de sífilis congênita, o diagnóstico materno ocorreu durante o pré-natal em 74% e no parto em 18%. Em 8% das mulheres ignorava-se o momento do diagnóstico.

Conclusão. O incremento nas taxas de detecção de sífilis pode ter resultado do aumento na notificação. O monitoramento constante em gestantes é essencial para a eliminação desses agravos.

Syphilis during pregnancy: a preventable threat to maternal-fetal health

Syphilis remains the most common congenital infection worldwide and has tremendous consequences for the mother and her developing fetus if left untreated. Recently, there has been an increase in the number of congenital syphilis cases in the United States. Thus, recognition and appropriate treatment of reproductive-age women must be a priority. Testing should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients. There are 2 diagnostic algorithms available and physicians should be aware of which algorithm is utilized by their testing laboratory. Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV. Serofast syphilis can occur in patients with previous adequate treatment but persistent low nontreponemal titers (<1:8). Syphilis can infect the fetus in all stages of the disease regardless of trimester and can sometimes be detected with ultrasound >20 weeks. The most common findings include hepatomegaly and placentomegaly, but also elevated peak systolic velocity in the middle cerebral artery (indicative of fetal anemia), ascites, and hydrops fetalis. Pregnancies with ultrasound abnormalities are at higher risk of compromise during syphilotherapy as well as fetal treatment failure. Thus, we recommend a pretreatment ultrasound in viable pregnancies when feasible. The only recommended treatment during pregnancy is benzathine penicillin G and it should be administered according to maternal stage of infection per Centers for Disease Control and Prevention guidelines. Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis. The Jarisch-Herxheimer reaction occurs in up to 44% of gravidas and can cause contractions, fetal heart rate abnormalities, and even stillbirth in the most severely affected pregnancies. We recommend all viable pregnancies receive the first dose of benzathine penicillin G in a labor and delivery department under continuous fetal monitoring for at least 24 hours. Thereafter, the remaining benzathine penicillin G doses can be given in an outpatient setting. The rate of maternal titer decline is not tied to pregnancy outcomes. Therefore, after adequate syphilotherapy, maternal titers should be checked monthly to ensure they are not increasing four-fold, as this may indicate reinfection or treatment failure.

Diagnostic value of recombinant Tp0821 protein in serodiagnosis for syphilis

Syphilis is a multistage sexually transmitted disease that remains a serious public health concern worldwide. The coexistence of Treponema pallidum with other closely related members of spirochaeta, such as Leptospira spp. and Borrelia burgdorferi, has complicated the serodiagnosis due to cross-reactive antigens. In this study, recombinant Tp0821 protein was expressed in Escherichia coli and purified by metal affinity chromatography. Then enzyme-linked immunosorbent assays (ELISAs) based on Tp0821 for the detection of specific antibodies were established. The relative positive rates of the IgM ELISA and the IgG ELISA were found to be 91·0 and 98·3%, respectively, when screening 578 syphilis specimens. The specificities were 94·3 and 100%, respectively, when cross-checking with serum samples obtained from 30 patients with Lyme disease, five patients with leptospirosis, and 52 uninfected controls. In addition, relative positive rates and specificities of Tp0821 for human sera were all 100% in Western blotting. When compared to the syphilis diagnostic tests commonly used in clinical settings, we found that the results of Tp0821-based ELISAs correlated well with the results of the treponemal tests, specifically the T. pallidum particle agglutination (TP-PA) test and the chemiluminescent immunoassay (CIA). Thus, these findings identify Tp0821 as a novel serodiagnostic candidate for syphilis.

SIGNIFICANCE AND IMPACT OF THE STUDY

In this study, we expressed and purified the Treponema pallidum protein Tp0821 and developed Tp0821-based enzyme-linked immunosorbent assays (ELISAs) for the detection of specific antibodies. The serodiagnostic performance of the recombinant protein was then evaluated. When compared to the results of syphilis diagnostic tests commonly used in clinical settings, we found that the reactivities of syphilitic sera with the recombinant antigen correlated well with the results of the treponemal tests, specifically the T. pallidum particle agglutination (TP-PA) test and the chemiluminescent immunoassay (CIA). Thus, the recombinant protein shows promise as a new diagnostic antigen in the ELISAs.

Syphilis: Re-emergence of an old foe

Syphilis is caused by infection with Treponema pallidum subsp. pallidum, a not-yet-cultivable spiral-shaped bacterium that is usually transmitted by sexual contact with an infected partner or by an infected pregnant woman to her fetus. There is no vaccine to prevent syphilis. Diagnosis and treatment of infected individuals and their contacts is key to syphilis control programs that also include sex education and promotion of condom use to prevent infection. Untreated syphilis can progress through four stages: primary (chancre, regional lymphadenopathy), secondary (disseminated skin eruptions, generalized lymphadenopathy), latent (decreased re-occurrence of secondary stage manifestations, absence of symptoms), and tertiary (gummas, cardiovascular syphilis and late neurological symptoms). The primary and secondary stages are the most infectious. WHO estimates that each year 11 million new cases of syphilis occur globally among adults aged 15-49 years. Syphilis has re-emerged in several regions including North America, Western Europe, China and Australia. Host-associated factors that drive the re-emergence and spread of syphilis include high-risk sexual activity, migration and travel, and economic and social changes that limit access to health care. Early, uncomplicated syphilis is curable with a single intramuscular injection of benzathine penicillin G (BPG), the first line drug for all stages of syphilis. Emergence of macrolide-resistant T. pallidum has essentially precluded the empirical use of azithromycin as a second-line drug for treatment of syphilis. Virulence attributes of T. pallidum are poorly understood. Genomic and proteomic studies have provided some new information concerning how this spirochete may evade host defense mechanisms to persist for long periods in the host.

Utility of immunochromatographic assay as a rapid point of care test for screening of antenatal syphilis

BACKGROUND AND OBJECTIVES

Syphilis is one of the most common preventable causes of adverse effects during pregnancy. Antenatal screening prevents the delay between diagnosis and treatment there by reducing the risk of congenital syphilis. The objective of this study was to evaluate the utility of an immunochromatographic assay as a point of care test for antenatal screening of syphilis.

MATERIALS AND METHODS

Sera of 200 antenatal mothers were evaluated for serodiagnosis of syphilis by the venereal disease research laboratory (VDRL), Treponema pallidum hemagglutination assay (TPHA) and SD BIOLINE Syphilis 3.0 test. The performance of SD BIOLINE Syphilis 3.0 test was compared with VDRL as screening assay and TPHA as a confirmatory test.

RESULTS

The antenatal prevalence of syphilis was found to be 2% by both VDRL and TPHA. The sensitivity, specificity, positive predictive value, and the negative predictive value of SD BIOLINE Syphilis 3.0 test were 75%, 100%, 100%, and 99.45%, respectively.

CONCLUSIONS

Antenatal screening and treatment of maternal syphilis are cost-effective health interventions even under the low prevalence of infection. SD BIOLINE Syphilis 3.0 test, although having less sensitivity than the existing testing strategy, can have a tremendous impact on the disease burden if used prudently for the screening of antenatal mothers in peripheral health settings.

Recent change in congenital syphilis in Korea: Retrospective 10 year study

BACKGROUND

This study was conducted to evaluate recent clinical and anthropologic features of neonates with reactive serology for syphilis and their mothers from three institutions in Korea over an 11-year-period.

METHOD

The medical records of 20 neonates with reactive serology for syphilis and their mothers at three centers (Kyung Hee University Hospital, Kyung Hee University Hospital at Gangdong, and Korea Electric Power Corporation Hospital) seen between January 2000 and December 2010 were reviewed retrospectively.

RESULTS

Among 20 mothers, 16 (80%) were native Korean and four (20%) were foreign-born immigrants. Two mothers (10%) were unmarried. The annual distribution of cases was three (15%) in 2000, one each (5%) in 2005 and 2006, respectively, two each (10%) in 2007 and 2008, respectively, six (30%) in 2009, and five (25%) in 2010. Just over half (55%) occurred across 2009 and 2010. All neonates, by definition, were diagnosed with presumptive congenital syphilis (CS). Among the neonates, four had positive cerebrospinal fluid venereal disease research laboratory test, and three exhibited symptoms and signs.

CONCLUSIONS

In three centers in Seoul, Korea, the observed number of CS cases was higher in 2009 and 2010 than in previous years. This finding is consistent with a trend toward increasing prevalence of international marriage and suggests that more meticulous screening of CS is needed.

Evaluation of FlaB1, FlaB2, FlaB3, and Tp0463 of Treponema pallidum for serodiagnosis of syphilis

Syphilis is a multistage disease caused by the invasive spirochete Treponema pallidum subsp. pallidum, and accurate diagnosis is important for the prevention and treatment of syphilis. Here, to identify appropriate diagnostic antigens for serodiagnosis of syphilis, 6 recombinant proteins were expressed in Escherichia coli and purified, including flagellins (FlaB1 [Tp0868], FlaB2 [Tp0792], and FlaB3 [Tp0870]), Tp0463, Tp0751, and Tp1038. The sensitivities were determined by screening sera from individuals with primary (n=82), secondary (n=115), latent (n=105), and congenital (n=65) syphilis. The specificities were determined by screening sera from uninfected controls (n=30) and potentially cross-reactive infections including Lyme disease (n=30), leptospirosis (n=5), and hepatitis B (n=30). Our data showed that FlaB1, FlaB2, FlaB3, Tp0463, and Tp1038 exhibited higher overall sensitivities and specificities for detecting IgG antibody, with 95.4% and 98.9%, 92.6% and 95.8%, 95.1% and 95.8%, 92.6% and 97.9%, and 95.9% and 98.9%, respectively. In contrast, Tp0751 demonstrated only an overall sensitivity of 39.2%. For comparison, the sensitivity and specificity of Architect Syphilis TP were determined to be 98.1% and 93.7%, respectively. In addition, FlaB1, FlaB2, FlaB3, and Tp0463 demonstrated excellent performance for detecting IgM antibody in primary and congenital syphilis, with sensitivities of 76.8% and 83.1%, 72.0% and 87.7%, 74.4% and 89.2%, and 64.6% and 75.3%, respectively. These results indicate that FlaB1, FlaB2, FlaB3, and Tp0463 could be as novel diagnostic candidates for serodiagnosis of syphilis.

Development of a novel protein biochip enabling validation of immunological assays and detection of serum IgG and IgM antibodies against Treponema pallidum pathogens in the patients with syphilis

In this study, we developed a novel protein biochip methodology that was characterized by dithiobis (succinimidyl undecanoate) (DSU) and specialized for detection of serum IgG and IgM antibodies against Treponema pallidum pathogens in the patients with syphilis, respectively. The biochips were validated by a dimension of atomic force microscope (AFM). The visualized detection limit of IgG antibody on the biochip was 0.39μg/ml. Finally, 286 serum samples from the patients with syphilis were simultaneously tested on the rTpN15-17-47 coated biochips. The results were evaluated in comparison with the assays of T. pallidum particle agglutination (TPPA) and the toluidine red unheated serum test (TRUST). The result demonstrated that the relative positive rate in the 286 patients by biochip was 99.0%, similar to that by TPPA (97.9%, P>0.05) and higher than that by TRUST, (76.2%, P<0.01). The detection specificities were 100% for the biochip and the TPPA and 97.0% for the TRUST. Thus, the protein biochip would provide a useful platform not only for enabling concurrent detection of the infectious antibodies directed against T. pallidum on a larger scale, but also for monitoring therapy modality of the disease.

Investments in sexually transmitted infection research, 1997-2013: a systematic analysis of funding awarded to UK institutions

Background

We report the first study that analyses public and philanthropic investments awarded to UK institutions for research related to sexually transmitted infections (STIs).

Methods

We systematically searched award data from the major funders for information on all infectious disease research funding awarded in 1997–2013. The STI–related projects were identified and categorised by pathogen, disease and type of science along the research pipeline from preclinical to translational research.

Findings

We identified 7393 infection–related awards with total investment of GBP 3.5 billion. Of these, 1238 awards (16.7%) covering funding of GBP 719.1 million (20.5%) were for STI research. HIV as an STI received GBP 465 million across 719 studies; non–HIV STIs received GBP 139 million across 378 studies. The Medical Research Council provided greatest investment (GBP 193 million for HIV, GBP 45 million for non–HIV STIs). Preclinical awards totalled GBP 233 million (37.1%), whilst translational research received GBP 286 million (39.7%). Substantial proportions of HIV investment addressed global health research (GBP 265 million), vaccinology (GBP 110 million) and therapeutics (GBP 202 million). For other STIs, investments focused on diagnostics (GBP 45 million) and global health (GBP 27 million). Human Papilloma Virus research received GBP 58 million and chlamydia GBP 24 million. Funding for non–HIV STIs has declined in the three most recent years of this data set.

Conclusions

The investment for HIV research awarded to UK institutions correlates with the high global burden, but other STIs are relatively neglected, including gonorrhoea and syphilis. Future STI funding should be better aligned with burden while addressing the emerging risk of antimicrobial resistance in Neisseria gonorrhoeae and outbreaks of other pathogens.

Implementation of Point-of-Care Diagnostics Leads to Variable Uptake of Syphilis, Anemia and CD4+ T-Cell Count Testing in Rural Maternal and Child Health Clinics

INTRODUCTION

Anemia, syphilis and HIV are high burden diseases among pregnant women in sub-Saharan Africa. A quasi-experimental study was conducted in four health facilities in Southern Mozambique to evaluate the effect of point-of-care technologies for hemoglobin quantification, syphilis testing and CD4+ T-cell enumeration performed within maternal and child health services on testing and treatment coverage, and assessing acceptability by health workers.

METHODS

Demographic and testing data on women attending first antenatal care services were extracted from existing records, before (2011; n = 865) and after (2012; n = 808) introduction of point-of-care testing. Study outcomes per health facility were compared using z-tests (categorical variables) and Wilcoxon rank-sum test (continuous variables), while inverse variance weights were used to adjust for possible cluster effects in the pooled analysis. A structured acceptability-assessment interview was conducted with health workers before (n = 22) and after (n = 19).

RESULTS

After implementation of point-of-care testing, there was no significant change in uptake of overall hemoglobin screening (67.9% to 83.0%; p = 0.229), syphilis screening (80.8% to 87.0%; p = 0.282) and CD4+ T-cell testing (84.9% to 83.5%; p = 0.930). Initiation of antiretroviral therapy for treatment eligible women was similar in the weighted analysis before and after, with variability among the sites. Time from HIV diagnosis to treatment initiation decreased (median of 44 days to 17 days; p<0.0001). A generally good acceptability for point-of-care testing was seen among health workers.

CONCLUSIONS

Point-of-care CD4+ T-cell enumeration resulted in a decreased time to initiation of antiretroviral therapy among treatment eligible women, without significant increase in testing coverage. Overall hemoglobin and syphilis screening increased. Despite the perception that point-of-care technologies increase access to health services, the variability in results indicate the potential for detrimental effects in some settings. Local context needs to be considered and services restructured to accommodate innovative technologies in order to improve service delivery to expectant mothers.

Introduction of Syphilis Point-of-Care Tests, from Pilot Study to National Programme Implementation in Zambia: A Qualitative Study of Healthcare Workers' Perspectives on Testing, Training and Quality Assurance

Syphilis affects 1.4 million pregnant women globally each year. Maternal syphilis causes congenital syphilis in over half of affected pregnancies, leading to early foetal loss, pregnancy complications, stillbirth and neonatal death. Syphilis is under-diagnosed in pregnant women. Point-of-care rapid syphilis tests (RST) allow for same-day treatment and address logistical barriers to testing encountered with standard Rapid Plasma Reagin testing. Recent literature emphasises successful introduction of new health technologies requires healthcare worker (HCW) acceptance, effective training, quality monitoring and robust health systems. Following a successful pilot, the Zambian Ministry of Health (MoH) adopted RST into policy, integrating them into prevention of mother-to-child transmission of HIV clinics in four underserved Zambian districts. We compare HCW experiences, including challenges encountered in scaling up from a highly supported NGO-led pilot to a large-scale MoH-led national programme. Questionnaires were administered through structured interviews of 16 HCWs in two pilot districts and 24 HCWs in two different rollout districts. Supplementary data were gathered via stakeholder interviews, clinic registers and supervisory visits. Using a conceptual framework adapted from health technology literature, we explored RST acceptance and usability. Quantitative data were analysed using descriptive statistics. Key themes in qualitative data were explored using template analysis. Overall, HCWs accepted RST as learnable, suitable, effective tools to improve antenatal services, which were usable in diverse clinical settings. Changes in training, supervision and quality monitoring models between pilot and rollout may have influenced rollout HCW acceptance and compromised testing quality. While quality monitoring was integrated into national policy and training, implementation was limited during rollout despite financial support and mentorship. We illustrate that new health technology pilot research can rapidly translate into policy change and scale-up. However, training, supervision and quality assurance models should be reviewed and strengthened as rollout of the Zambian RST programme continues.

Current standards for diagnosis of syphilis: comparing the russian and foreign guidelines (part I)

Despite the abundance of existing laboratory methods the diagnosis of syphilis still faces many challenges. Though direct detection of T. pallidum plays an important role in early manifest forms of the disease, serological tests remain the mainstay of diagnosis. Traditional syphilis screening algorithm based on nontreponemal tests with subsequent confirmation using treponemal tests is a standard worldwide. Recently, the ability to automate the treponemal tests promotes the increasingly widespread implementation of reverse algorithm when these tests are used for syphilis screening. None of the current serological algorithms are able to reliably differentiate between active and previously treated syphilis, which causes uncertainty in the management of patients. There is no «gold standard» for the diagnosis of neurosyphilis, ocular, auricular and visceral syphilis. The interpretation of serological tests in children born to seropositive mothers is also complicated. Diagnosis of congenital syphilis in newborns and, consequently, the prescription of antibiotic therapy often depends on assessment of the adequacy of maternal treatment during pregnancy, which leads to subjective decisions. This article provides a comparative analysis of the «Federal guidelines for the management of patients with syphilis» and their foreign analogues, discusses significant peculiarities of these guidelines and reviews current concerns and controversies in syphilis diagnosis.

Gestational syphilis and stillbirth in Latin America and the Caribbean

OBJECTIVE

To measure the association between gestational syphilis and stillbirth in Latin America and the Caribbean.

METHODS

In a retrospective study, data on stillbirth and gestational syphilis extracted from the Sistema Informático Perinatal database were analyzed for deliveries in 11 countries between January 1, 2009, and December 31, 2012. Potential confounders were examined, and binary logistic regression analysis was performed to assess the association between gestational syphilis and stillbirth.

RESULTS

Among 368 151 deliveries, 3875 (1.1%) were by women with a positive syphilis test, and 1461 (0.4%) were stillbirths. Among the stillbirths, 29 (2.0%) were delivered by women with a positive syphilis test. After controlling for country, congenital anomalies, gestational age at labor, maternal age, and previous stillbirth, gestational syphilis was significantly associated with stillbirth (odds ratio 1.88, 95% confidence interval 1.25-2.83; P=0.002).

CONCLUSION

Gestational syphilis contributes to stillbirth in Latin America and the Caribbean. Interventions targeting gestational syphilis are highly cost-effective and should be implemented across the region.

Strategies of testing for syphilis during pregnancy

BACKGROUND

Each year about two million pregnant women are infected with preventable syphilis infection, mostly in developing countries. Despite the expansion of antenatal syphilis screening programmes over the past few decades, syphilis continues to be a major public health concern in developing countries. Point-of-care syphilis testing may be a useful strategy to substantially prevent syphilis-associated perinatal mortality and other negative consequences in resource-poor settings. However, the evidence on effectiveness has been generated mostly from observational study designs or has been reported as a mixed-intervention effect.

OBJECTIVES

To assess the effectiveness of antenatal syphilis screening in improving the uptake of screening tests and treatment, and reducing perinatal mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and the reference lists of retrieved studies.

SELECTION CRITERIA

Randomised (individual and cluster) controlled trials comparing different screening tests conducted during routine antenatal check-ups versus no screening test. Cross-over trials and quasi-randomised experimental study designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy.

MAIN RESULTS

We included two cluster-randomised controlled trials (three reports). Both trials assessed point-of-care syphilis testing with conventional testing methods and together involved a total of 8493 pregnant women. Data from these trials were not amenable to meta-analysis as the measure of effectiveness was assessed in a non-comparable way.One trial randomised 14 antenatal clinics (including 7700 pregnant women) and was carried out at in Ulaanbaatar, Mongolia. The trial assessed one-stop syphilis testing using a rapid treponemal test, and was judged to have unclear methods of random sequence generation, allocation concealment, selective reporting, and other bias and low risk of bias for incomplete outcome data. Blinding was not reported and was assessed as high risk. The point-of-care testing provided screening, test results and treatment within the same day. The trial appears to have adjusted their results to account for clustering. We entered the data into RevMan using the generic inverse variance method. The incidence of congenital syphilis was lower in the clusters receiving on-site screening (adjusted odds ratio (AOR) 0.09, 95% confidence interval (CI) 0.01 to 0.71) and the proportion of women tested for syphilis was higher in the clusters receiving on-site screening at both the first antenatal visit and at the third trimester visit (OR 989.80, 95% CI 16.27 to 60233.05; OR 617.88, 95% CI 13.44 to 28399.01). Adequate treatment and partner treatment was higher with the on-site screening (AOR 10.44, 95% CI 1.00 to 108.99; AOR 18.17, 95% CI 3.23 to 101.20) and more syphilis cases were detected at first and third trimester visits with the on-site screening (AOR 2.45, 95% CI 1.44 to 4.18; AOR 6.27, 95% CI 1.47 to 26.69). Perinatal mortality, incidence of HIV/AIDS, obstacles in uptake of screening, any other adverse effects, or healthcare resource usage were not reported in this trial.The second trial divided clinics into seven matched pairs (including 7618 pregnant women, although results were only presented for the positive cases (793 women)), and within each pair one clinic was randomised to receive the on-site screening and the other to continue routine laboratory testing. The trial was conducted in primary healthcare clinics in KwaZulu-Natal, South Africa. Random sequence generation were judged to be at low risk of bias, but allocation concealment and incomplete outcome data were judged to be high risk. Other bias and selective reporting bias remain unclear. Blinding was not reported and was assessed as high risk of bias. This trial assessed the primary outcome of this review (perinatal mortality) and the secondary outcomes (adverse outcomes; adequate treatment; syphilis prevalence) in the subset of women (793 women) who tested positive for syphilis. Only one outcome, adequate treatment, was adjusted to account for cluster design. However, not enough information was provided to include this in an analysis using the generic inverse variance method. Where possible, results have therefore been presented in forest plots (perinatal mortality; adequate treatment), as if the data are from a parallel randomised controlled trial. These results should therefore be interpreted with caution.The trial reported on perinatal mortality in women with positive test results and showed that on-site screening using a rapid plasma reagin test had no clear evidence of an effect on perinatal mortality reduction (odds ratio (OR) 0.63; 95% CI 0.27 to 1.48; 18/549 (3.3%) versus 8/157 (5.1%)). After loss to follow up, 396/618 (64.1%) women with positive test results received adequate treatment (two or more doses of 2.4 mega units of benzathine penicillin) in the intervention cluster versus 120/175 (68.6%) in the control (OR 0.82; 95% CI 0.57 to 1.17). It was not possible to include any other data on reported outcomes in forest plots (adverse outcomes; syphilis prevalence). Incidence of congenital syphilis, proportion of women test for syphilis, incidence of HIV/AIDS, obstacles in uptake of screening, partner treatment, or healthcare resource usage were not reported in this trial.

AUTHORS' CONCLUSIONS

This review included evidence from two cluster-randomised trials at high or unclear risk of bias for most of the 'Risk of bias' domains. Data were not combined in meta-analysis because the trials used non-comparable measures of effectiveness.Point-of-care syphilis testing showed some promising results for syphilis detection and treatment rates and for use in different settings. In Mongolia point-of-care testing was found to be effective in increasing the proportion of pregnant women tested for syphilis and treatment provided, reducing congenital syphilis, and improving access to treatment for both women and their partners. In contrast, in rural South Africa, among women with positive test results, there was no clear evidence of an effect of point-of-care syphilis testing in increasing adequate syphilis treatment rates, and reducing perinatal mortality, but point-of-care testing was found to reduce delay in seeking treatment.More trials are therefore warranted to determine the effectiveness of available testing strategies for improving syphilis-associated adverse outcomes in pregnant women and neonates, especially in high-risk regions.

Global mortality from conditions with skin manifestations

BACKGROUND

Global Burden of Disease Study is a research database containing systematically compiled information from vital statistics and epidemiologic literature to inform research, public policy, and resource allocation.

OBJECTIVE

We sought to compare mortality among conditions with skin manifestations in 50 developed and 137 developing countries from 1990 to 2010.

METHODS

This was a cross-sectional study to calculate mean age-standardized mortality (per 100,000 persons) across countries for 10 disease categories with skin manifestations. We compared differences in mortality from these disorders by time period (year 1990 vs year 2010) and by developing versus developed country status.

RESULTS

Melanoma death rates were 5.6 and 4.7 times greater in developed compared with developing countries in 1990 and 2010, respectively. Measles death rates in 1990 and 2010 were 345 and 197 times greater in developing countries, and corresponding syphilis death rates were 33 and 45 times greater.

LIMITATIONS

Inability to adjust for patient-, provider-, and geographic-level confounders may limit the accuracy and generalizability of these results.

CONCLUSION

The mortality burden from skin-related conditions differs between developing and developed countries, with the greatest differences observed for melanoma, measles, and syphilis. These results may help prioritize and optimize efforts to prevent and treat these disorders.

Preconception care: preventing and treating infections

Introduction

Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.

Conclusion

Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.

Current trends in congenital syphilis

In many parts of the world particularly sub-Saharan Africa, congenital syphilis is a significant public health problem. Though it is rare in most affluent countries there has been a slight resurgence recently in several European countries. The diagnosis of suspected cases and management of congenital syphilis may be confusing and the potential for severe disability is high when cases are missed. The cornerstone of congenital syphilis control is antenatal screening and treatment of mothers with penicillin and in affluent countries it should be strengthened among those at high risk. In developing countries antenatal care screening needs to be strengthened by implementing point-of-care decentralised screening and treatment, also alternative novel approaches to control congenital syphilis should be looked at and utilized. International health agencies and political parties should take steps urgently to support focused approaches to tackling the problem of continuing congenital syphilis.

Syphilis in the modern era: an update for physicians

Syphilis is a complex, systemic disease caused by the spirochete Treponema pallidum. Syphilis is most commonly transmitted sexually or congenitally and can involve nearly every organ system. Its clinical progression involves several well-characterized stages: an incubation period, a primary stage, a secondary stage, a latent stage, and a late or tertiary stage. Syphilis during pregnancy is a leading cause of perinatal mortality in sub-Saharan Africa and can cause spontaneous abortion, stillbirth, prematurity, low birth weight, or congenital syphilis. Penicillin is highly effective against syphilis and remains the treatment of choice. This article reviews the epidemiology, clinical features, diagnostic approach, treatment, and prevention of syphilis.

State of the art syphilis diagnostics: rapid point-of-care tests

Syphilis remains an important and entirely preventable cause of stillbirth and neonatal mortality. More than 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby, 33% will deliver a live 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. Until recently access to screening in low- and middle-income countries has been limited, since screening tests have been laboratory based, requiring equipment, electricity and trained laboratory staff. Now a number of rapid, cheap, simple and accurate screening tests are available and can give a result in 15-20 min, enabling those who require treatment to be treated at their first visit.

Evaluation of the recombinant protein TpF1 of Treponema pallidum for serodiagnosis of syphilis

Syphilis is a chronic infection caused by Treponema pallidum subsp. pallidum, and diagnosis with sensitive and specific methods is a challenging process that is important for its prevention and treatment. In the present study, we established a recombinant protein TpF1-based indirect immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) and a Western blot assay for human and rabbit sera. The 20-kDa recombinant protein TpF1 was detected by Western blotting performed with sera from rabbits immunized with recombinant TpF1 and infected with the T. pallidum Nichols strain and T. pallidum clinical isolates but was not detected by Western blotting with sera from uninfected rabbits. The sensitivity of the recombinant protein was determined by screening sera from individuals with primary, secondary, latent, and congenital syphilis (n = 82). The specificity of the recombinant protein was determined by screening sera from uninfected controls (n = 30) and individuals with potentially cross-reactive infections, including Lyme disease (n = 30) and leptospirosis (n = 5). The sensitivities of TpF1-based ELISAs were 93.3%, 100%, 100%, and 100% for primary, secondary, latent, and congenital syphilis, respectively, and the specificities were all 100% for sera from uninfected controls and individuals with potentially cross-reactive infections. In Western blot assays, the sensitivities and specificities of TpF1 for human sera were all 100%. The reactivities of TpF1 with syphilitic sera were proportional to the titers of the T. pallidum particle agglutination (TPPA) assay. These data indicate that the recombinant protein TpF1 is a highly immunogenic protein in human and rabbit infections and a promising marker for the screening of syphilis.

Rapid diagnostic tests for neurological infections in central Africa

Infections are a leading cause of life-threatening neuropathology worldwide. In central African countries affected by endemic diseases such as human African trypanosomiasis, tuberculosis, HIV/AIDS, and schistosomiasis, delayed diagnosis and treatment often lead to avoidable death or severe sequelae. Confirmatory microbiological and parasitological tests are essential because clinical features of most neurological infections are not specific, brain imaging is seldom feasible, and treatment regimens are often prolonged or toxic. Recognition of this diagnostic bottleneck has yielded major investment in application of advances in biotechnology to clinical microbiology in the past decade. We review the neurological pathogens for which rapid diagnostic tests are most urgently needed in central Africa, detail the state of development of putative rapid diagnostic tests for each, and describe key technical and operational challenges to their development and implementation. Promising field-suitable rapid diagnostic tests exist for the diagnosis of human African trypanosomiasis and cryptococcal meningoencephalitis. For other infections-eg, syphilis and schistosomiasis-highly accurate field-validated rapid diagnostic tests are available, but their role in diagnosis of disease with neurological involvement is still unclear. For others-eg, tuberculosis-advances in research have not yet yielded validated tests for diagnosis of neurological disease.

Incidence of congenital syphilis in Brazil and its relationship with the Family Health Strategy

OBJECTIVE

To estimate the incidence of congenital syphilis and identify its relationship with Family Health Strategy coverage.

METHODS

An observational ecological study was carried out with both descriptive and analytical components, by two different approaches: one that explores a temporal series (2003 to 2008) and one that focuses on the 2008 data. The secondary data (epidemiological, demographic, and socioeconomic) were obtained from the Department of Informatics of the Unified Health System and the Brazilian Institute of Geography and Statistics. Analysis of the possible effects of the implementation of the Family Health Strategy on the prevention of congenital syphilis was performed on selected subgroups of counties according to two approaches: a) the variation of the average annual rate of incidence of congenital syphilis in different strata of Family Health Program coverage between 2003 and 2008 and the calculation of the simple linear regression coefficient; and b) a negative binomial regression analysis of data from 2008 to control for confounding factors.

RESULTS

Increasingly trends of congenital syphilis notification in Brazil reflect social inequalities in the distribution of cases. The incidence of congenital syphilis was lower in the counties with high Family Health Strategy coverage; however, after controlling for the co-variables, such an effect might be attributed to the coverage of prenatal care and the demographic characteristics of the counties where the implementation of the Strategy was a priority.

CONCLUSIONS

Despite the increase in prenatal care coverage, the actions implemented still exhibit low effectiveness in the prevention of congenital syphilis. Prenatal care performed by Family Health Strategy teams did not control syphilis better than the prenatal care performed within the context of other models of assistance.

Early antenatal care: does it make a difference to outcomes of pregnancy associated with syphilis? A systematic review and meta-analysis

OBJECTIVE

Despite an increase in the proportion of women who access antenatal care, mother-to-child transmission of syphilis continues to be a consequence of undiagnosed, untreated, or inadequately treated maternal syphilis. We reviewed evidence on the optimal timing of antenatal interventions to prevent mother-to-child transmission of syphilis and its associated adverse outcomes.

DESIGN

Systematic review and meta-analysis of published literature. English-language articles were included if they (1) reported the gestational age at which the mother was screened or tested for syphilis; (2) reported on pregnancy outcome. No publication date limits were set.

RESULTS

We identified a total of 1,199 publications, of which 84 were selected for further review and five were included. All showed a lower prevalence of any adverse outcome among women who received an intervention (to include screening and treatment) in the first and second trimesters of pregnancy compared to the third trimester. The overall odds ratio for any adverse outcome was 2.24 (95% CI 1.28, 3.93). All sub-analyses by type of outcome presented important heterogeneity between studies, except for those studies reporting an infected infant (odds ratio 2.92, 95% CI 0.66, 12.87; I(2) = 48.2%, p = 0.165).

CONCLUSIONS

Our review has shown that the timing of antenatal care interventions makes a significant difference in the risk of having an adverse outcome due to syphilis. Women who sought care in the first two trimesters of their pregnancy, and received the appropriate intervention, were more likely to have a healthy infant, compared to women screened and treated in the third trimester. Encouraging ALL pregnant women to seek care in the first two trimesters of their pregnancy should be a priority for health programmes. For interventions to be effective within these health programmes, health systems and community engagement programmes need to be strengthened to enable pregnant women to seek antenatal care early.