Gaps in the congenital syphilis prevention cascade: qualitative findings from Kern County, California

Notification rates for syphilis in women of reproductive age and congenital syphilis in Australia, 2011-2021: a retrospective cohort analysis of national notifications data

OBJECTIVES

To estimate notification rates for infectious syphilis in women of reproductive age and congenital syphilis in Australia.

STUDY DESIGN

Retrospective cohort study; analysis of national infectious syphilis and enhanced congenital syphilis surveillance data.

SETTING, PARTICIPANTS

Women aged 15-44 years diagnosed with infectious syphilis, and babies with congenital syphilis, Australia, 2011-2021.

MAIN OUTCOME MEASURES

Numbers and rates of infectious syphilis notifications, by Indigenous status and age group; numbers and rates of congenital syphilis, by Indigenous status of the infant; antenatal care history for mothers of infants born with congenital syphilis.

RESULTS

During 2011-2021, 5011 cases of infectious syphilis in women aged 15-44 years were notified. The notification rate for Aboriginal and Torres Strait Islander women rose from 56 (95% confidence interval [CI], 45-65) cases per 100 000 in 2011 to 227 (95% CI, 206-248) cases per 100 000 population in 2021; for non-Indigenous women, it rose from 1.1 (95% CI, 0.8-1.4) to 9.2 (95% CI, 8.4-10.1) cases per 100 000 population. The notification rate was higher for Aboriginal and Torres Strait Islander women than for non-Indigenous women (incidence rate ratio [IRR], 23.1; 95% CI, 19.7-27.1), lower for 15-24- (IRR, 0.7; 95% CI, 0.6-0.9) and 35-44-year-old women (IRR, 0.6; 95% CI, 0.5-0.7) than for 25-34-year-old women, and higher in remote regions than in major cities (IRR, 2.7; 95% CI, 2.2-3.8). During 2011-2021, 74 cases of congenital syphilis were notified, the annual number increasing from six in 2011 to a peak of 17 in 2020; the rate was consistently higher among Aboriginal and Torres Strait Islander infants than among non-Indigenous infants (2021: 38.3 v 2.1 per 100 000 live births). The mothers of 32 infants with congenital syphilis (43%) had not received antenatal care.

CONCLUSIONS

The number of infectious syphilis notifications for women of reproductive age increased in Australia during 2011-2021, as did the number of cases of congenital syphilis. To avert congenital syphilis, antenatal screening of pregnant women, followed by prompt treatment for infectious syphilis when diagnosed, needs to be improved.

Provider-Reported Barriers in Sexual Health Care Services for Women With Upstream Barriers: The Case of Syphilis and Congenital Syphilis in Southern Colorado, 2022

BACKGROUND

Syphilis and congenital syphilis rates have increased sharply in Colorado in the past 5 years. Congenital syphilis is passed during pregnancy in utero and can cause lifelong physical, developmental, and neurologic problems for the child, or can lead to miscarriage, stillbirth, or early infant death. Congenital syphilis is easily prevented if the mother receives timely testing, treatment, and prenatal care. Providers can play a key role in preventing congenital syphilis for women with social vulnerabilities, who have a higher likelihood of syphilis and/or congenital syphilis infection.

METHODS

We surveyed 23 and interviewed 4 health care providers in southern Colorado in 2022 to record their experiences in providing sexual health care services. We asked providers with direct care experience about perceived barriers in effectively treating syphilis.

RESULTS

The most significant barriers reported in the survey were the cost of treatment (26%) and the loss to follow-up (22%). Interviews revealed further challenges, including discretionary testing procedures, delays in screening results, treatment referral issues, and stigma around substance use and sexual activity.

CONCLUSIONS

Elevated syphilis and congenital syphilis rates pose significant public health challenges. Coordinated interventions are necessary to effectively reduce the transmission of syphilis and congenital syphilis among women with upstream barriers. Potential care solutions include expanding rapid, point-of care testing and treatment options, supporting bicillin delivery or web-based inventory systems, offering anti-stigma training for providers, offering mental and behavioral health resources at providers' clinics, and expanding partnerships with syringe access programs.

Gaps in the prevention of mother-to-child transmission of syphilis: a review of reported cases, South Africa, January 2020-June 2022

INTRODUCTION

Congenital syphilis (CS) is preventable through timely antenatal care (ANC), syphilis screening and treatment among pregnant women. Robust CS surveillance can identify gaps in this prevention cascade. We reviewed CS cases reported to the South African notifiable medical conditions surveillance system (NMCSS) from January 2020 to June 2022.

METHODS

CS cases are reported using a case notification form (CNF) containing limited infant demographic and clinical characteristics. During January 2020-June 2022, healthcare workers supplemented CNFs with a case investigation form (CIF) containing maternal and infant testing and treatment information. We describe CS cases with/without a matching CIF and gaps in the CS prevention cascade among those with clinical information.

FINDINGS

During January 2020-June 2022, 938 CS cases were reported to the NMCSS with a median age of 1 day (interquartile range: 0-5). Nine percent were diagnosed based on clinical signs and symptoms only. During January 2020-June 2022, 667 CIFs were reported with 51% (343) successfully matched to a CNF. Only 57% of mothers of infants with a matching CIF had an ANC booking visit (entry into ANC). Overall, 87% of mothers were tested for syphilis increasing to 98% among mothers with an ANC booking visit. Median time between first syphilis test and delivery was 16 days overall increasing to 82 days among mothers with an ANC booking visit.

DISCUSSION

Only 37% of CS cases had accompanying clinical information to support evaluation of the prevention cascade. Mothers with an ANC booking visit had increased syphilis screening and time before delivery to allow for adequate treatment.

Educational intervention improves knowledge and adherence to treatment amongst puerperal women with syphilis: randomized clinical trial

BACKGROUND

Gestational syphilis requires early detection and proper treatment to prevent negative maternal-fetal outcomes. This study aimed to evaluate the effectiveness of an educational intervention on treatment adherence and knowledge about syphilis in postpartum women with positive Treponema pallidum results.

METHODS

A randomized, parallel, and open clinical trial was conducted with 64 postpartum women who tested positive for T. pallidum, assigned to two groups (1:1 ratio). The Intervention Group (IG) received an educational intervention on syphilis, including an explanatory leaflet and hands-on demonstrations, along with standard guidelines. The Control Group (CG) received standard guidelines alone. Pre-test and post-test assessments were conducted to measure knowledge and treatment adherence. Statistical analyses included descriptive and inferential methods, assessing group homogeneity using the Chi-square or Fishers exact test. The interventions effectiveness was determined using relative risk, and pre- and post-test scores were compared using the independent t test.

RESULTS

The post-test revealed improvements in knowledge scores for general knowledge, treatment, and prevention domains (p < .05). The IG demonstrated an increase in post-test knowledge scores (p = .001), with association between post-test scores and treatment adherence (p = .001).

CONCLUSION

The educational intervention on syphilis improved knowledge and treatment adherence in postpartum women with syphilis.

Congenital syphilis in Switzerland: a marker of inequality? A mini-review

Syphilis remains a global public health problem, with growing incidence in most regions of the world, particularly among women of childbearing age. This alarming trend has led to an increase in cases of congenital syphilis, resulting in devastating consequences. While the implementation of measures by the World Health Organization (WHO) and various governments has contributed to a decline in the global incidence of congenital syphilis, many countries are facing an escalating crisis, as incidence continues to rise. This mini-review aims to provide an overview of the current state of this disease in different parts of the world, focusing on the most affected populations and highlighting congenital syphilis as a marker of vulnerability. It also focuses on Switzerland, a country with a robust economy, to identify shortcomings in the healthcare system that contribute to the persistence of congenital syphilis, even though the infection is easily detectable and treatable. In conclusion, this mini-review highlights the persistent risk of congenital syphilis worldwide, regardless of country prevalence or economic status, and underscores the need for sustained efforts to reach underserved women, emphasizing the vital role of comprehensive training for healthcare professionals.

Congenital Syphilis Epidemiology, Prevention, and Management in the United States: A 2022 Update

Congenital syphilis (CS) has dramatically increased in the United States (US) in the past decade despite the widespread availability of penicillin. Once considered an infection on the verge of elimination, CS has re-emerged as a familiar neonatal pathogen in US hospitals. This rise in cases has prompted the evaluation of potential causes and updates in prevention and management guidelines. Following a structured narrative approach, we reviewed CS data reports, peer-reviewed research articles, and updated management guidelines from state health departments over the past two decades. Our main search criteria centered on the treatment and prevention of CS, with a focus on prenatal health disparities. We identified geographical regions reporting disproportionate rates of CS, examined state laws regarding maternal syphilis testing, and evaluated potential reasons for the recent rise in cases. This article examines the current epidemiology, screening, and management recommendations for perinatal and CS in the US. It also reviews pathogenesis and clinical features in perinatal and pediatric populations. Finally, it highlights the likely contributing factors to increased CS rates and identifies areas for future research. Dramatically rising CS cases in certain regions and racial groups reflect gaps in the prevention, timely diagnosis, treatment, and management of perinatal syphilis and CS. Healthcare providers attending to mothers and children should recognize the re-emergence of this pathogen and be familiar with new screening and management guidelines. Increased federal funding for targeted interventions and research that address vulnerable populations is critical to curbing the re-emergence of this infection.

Examining associations in congenital syphilis infection and socioeconomic factors between California's small-to-medium and large metro counties

OBJECTIVE

To investigate differences in congenital syphilis (CS) infection between California's small-to-medium and large metropolitan counties and the socioeconomic mechanisms behind these differences.

STUDY DESIGN

County-level data from 2019 and 2020 on CS infection and other socioeconomic covariates were obtained from the California Department of Public Health and the United States Census Bureau. Counties were stratified into small-to-medium or large metropolitan counties by the National Center for Health Statistics Urban-Rural Classification Scheme and analyzed using simple and multiple Poisson regression models.

RESULTS

California's small-to-medium metropolitan counties reported significantly higher rates of CS incidence, female poverty, and uninsured females, and significantly lower rates of English-language speaking ability and female education level compared to large metropolitan counties. CS infection was significantly associated with female poverty and education level.

CONCLUSION

Rates of CS infection in the California counties are more dependent on socioeconomic indicators than county classification itself.

New trends in congenital syphilis: epidemiology, testing in pregnancy, and management

PURPOSE OF REVIEW

In light of alarming increases in the incidence of congenital syphilis in many middle and higher income countries across the globe, this review summarizes recent changes in the epidemiology of syphilis, highlights recommended changes to testing in pregnancy and provides an update for the management of syphilis infection in pregnancy (SIP) and of the infant born to a mother with SIP.

RECENT FINDINGS

The re-emergence of congenital syphilis is a result of increasing infectious syphilis in women of childbearing age, which is in turn a result of increasing syphilis in the general population particularly in Indigenous and marginalized populations. Potential reasons for the increase include changing sexual practices and increased travel and migration, as well as factors that limit healthcare access, particularly access to antenatal care and limited awareness and education amongst mothers and maternity services. A single antenatal test for syphilis is insufficient; more frequent testing in pregnancy is necessary even for women deemed to be low risk. The management of SIP and of the newborn is complex and guidelines should be readily available with clear recommendations.

SUMMARY

Congenital syphilis is preventable. The current crisis calls for a global and national multipronged, co-ordinated approach involving public health and hospital systems which includes education of individuals and healthcare workers, availability of updated guidelines for prevention and treatment, prioritization of antenatal testing, assurance of accessible and prompt treatment and appropriate assessment and follow-up of infants.