Diagnosis of sexually transmitted infections (STI) using self-collected non-invasive specimens

Paramount in control of transmission of sexually transmitted infections (STIs) is their prompt recognition and appropriate treatment. In countries where definitive diagnoses are difficult, a 'syndromic approach' to management of STIs is recommended and practiced, yet many STIs have common symptoms or are asymptomatic and therefore go undetected and untreated. This is of particular concern with the recognition that HIV transmission is increased with co-existent STIs: the attributable risk for each STI varying with the prevalence within a particular population. Hence, HIV public health prevention approaches must include STI preventative strategies to be effective. Even then, microbiological screening is incorporated into STI control strategies; lack of access to appropriate services (especially in rural and remote areas), reluctance of at-risk populations to attend for treatment, fear of invasive genital examinations, and lower sensitivities of conventional diagnostic assays reduces the effectiveness of such programmes. Therefore, accurate, cost-effective, reliable diagnostic assays (preferably those which can be used in the field) are needed to impact on the incidence of the various STIs, as well as HIV. With the advent of molecular technologies, including target and signal amplification methods, diagnoses of STIs have been revolutionised and allow the use of non or minimally invasive sampling techniques, some of which are self-collected by the patient, e.g. first-void urine, cervico-vaginal lavage, low vaginal swabs, and tampons. Most studies evaluating such self-sampling with molecular diagnostic techniques have demonstrated an equivalent or superior detection of STIs as compared to conventional sampling and detection methods. These sampling methods can also be used to determine prevalence of STIs in various populations, but particularly those with difficult access to medical care. In this article, the utility of self-sampling collection devices for detection of various STIs, particularly in women, is reviewed as one step towards formulating appropriate strategies in control of STIs, and which are especially suited for remote areas.

Avaliação de campanhas de saúde com ênfase na sífilis congênita: uma revisão sistemática

Campanhas têm sido instrumentos de políticas públicas de saúde, freqüentemente utilizadas no Brasil para esclarecer, motivar ou conseguir o apoio da população e/ou dos profissionais de saúde, em ações relevantes para a saúde pública. Esta revisão procurou levantar subsídios para a avaliação de campanhas de saúde, particularizando-se as metodologias utilizadas, tendo em vista a avaliação de campanhas dirigidas ao controle da sífilis congênita. Os conjuntos de palavras-chave utilizados foram "sífilis congênita + avaliação"; "campanhas de saúde + avaliação" e, "campanha + saúde + avaliação". As bases de dados pesquisadas foram a Medline (Medical Literature Analysis and Retrieval System Online) da National Library of Medicine (EUA), a LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) e da PAHO (Pan-American Health Organization), no período de 1980 e 2003. Foram incluídos 37 artigos nessa revisão, sendo 15 referentes à sífilis congênita e avaliação e 22 à campanha de saúde e avaliação. A revisão realizada mostrou que existe um espaço a ser preenchido neste campo, principalmente no que se refere à construção metodológica. Apesar da palavra avaliação constar nesses vários artigos, a fundamentação teórica encontrada não foi totalmente condizente com as propostas apresentadas.

Forgotten but not gone: the continuing scourge of congenital syphilis

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

Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features

Syphilis is a chronic disease with a waxing and waning course, the manifestations of which have been described for centuries. It occurs worldwide, and the incidence varies significantly with geographic location. Transmission is mainly by sexual contact. The causative organism, Treponema pallidum, was first described in 1905, but because of the inability to culture the organism and the limitations of direct microscopy, serologic testing is the mainstay of laboratory diagnosis. The disease has been arbitrarily divided into several stages. The primary stage is defined by a chancre at the site of inoculation. The secondary stage is characterized by a polymorphic rash, lymphadenopathy, and other systemic manifestations. A variable asymptomatic latent period follows, which for epidemiologic purposes is divided into early (<1 year) and late (>1 year) stages. The early stages (primary, secondary, and early latent) are potentially infectious. The tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system. Congenital infection may result in protean early or late manifestations. Unlike many other bacteria causing infectious diseases, the organism remains sensitive to penicillin, and this remains the mainstay of therapy.

Congenital syphilis: still a reality in 1996

Despite the widespread use of penicillin for more than 50 years, syphilis continues to be a problematic health issue in many parts of the world. In Australia, congenital syphilis is again a significant cause of stillbirth, preterm labour and neonatal disease in some areas (including central and northern Australia). Control mechanisms based on screening, reliable treatment protocols, contact-tracing and adequate follow-up appear to be less effective than they were in the past. It is difficult to discuss such a socially stigmatizing disease when it is clear that some community groups are at high risk, and may be offended by and feel disempowered in the face of well-meaning medical debate. If congenital syphilis is to be eradicated, new approaches are required. These include public-awareness campaigns to stress the need for antenatal care in affected communities; involving the community in efforts to prevent syphilis; providing culturally appropriate services; improving notification and surveillance systems; improving the management of pregnant women who present to maternity units without prior booking; and improving the management of syphilis in pregnancy. There is a need to raise awareness that antenatal care is important not only for the mother's health but also for the wellbeing of the baby.

Serologic screening for syphilis. Rationale, cost, and realpolitik

Serologic testing for syphilis is a cornerstone of syphilis control efforts, but our objectives for doing it and the costs involved are not always recognized. Tests applied to individuals with symptoms or signs may be viewed as diagnostic tests, and tests applied to individuals with no clinical indications for testing may be viewed as screening tests. Infected individuals whom we detect through screening efforts are important, mostly from an individual and economic standpoint, because treatment will prevent the late complications of syphilis and thus avoid high medical costs. Because they are uncommonly infectious for others, however, they are relatively unimportant from a public health intervention standpoint. The prevalence of infection above which we should screen is based mostly on economic grounds, but is undetermined. We intuitively recognize such a threshold, however, when we use epidemiologic markers to restrict our efforts to groups in whom we think the yield is worth the effort (i.e., targeted [focused] screening). In deciding whether to institute or increase screening efforts for syphilis, we must consider not only the dollar costs of these efforts, but also the opportunity costs (i.e., what programs we will forgo so that we can devote our resources to the increased efforts). Similarly, because syphilis is not the only priority with which governments, health departments, and sexually transmitted disease programs must contend, any broader plan to significantly enhance syphilis control must acknowledge this reality and show the benefit, economic and otherwise, of its adoption.

Cost-effectiveness of antenatal screening for syphilis

Routine obstetric screening for all prenatal checkups is an important issue. A study was conducted to ascertain the effectiveness of an antenatal screening program for syphilis. Charts of pregnant women for a 9-year period from 1982 to 1990 at the American University of Beirut were reviewed. Demographic data and the results of screening for syphilis were collected. In a total of 23,145 patients screened (with a biological false-positive rate of 0.3%), serological evidence of Treponema pallidum infection occurred in 0.27% of patients. The outcome in infants was satisfactory in all cases where appropriate antibiotic therapy was instituted antenatally. Thus antenatal screening for syphilis in our setting is a cost-effective program.

Syphilis in pregnancy: experience from a rural aboriginal community

Syphilis in pregnancy is seldom encountered in urban Australia. This retrospective study reports on the high prevalence of syphilis and its associated complications in a group of pregnant Aboriginal women attending the Dareton Community Health Centre for antenatal care between September, 1989 and September, 1991. During this time, the centre provided antenatal care for 71 Aboriginal pregnancies and maternal syphilis was found in 20 (28%). The mean age of the women was 21.3 years (range of 14-33 years). The perinatal mortality rate was 48 per 1,000 births. All stillbirths were associated with maternal syphilis. The relative risk of stillbirth in the presence of syphilis was 4 (95% CI 2.56-6.25, p = 0.022). Prematurity was associated with maternal syphilis. The odds ratio for premature delivery was 21.5 (95% CI 2.26-2.05, p = 0.003). There was no statistical difference between the mean birth-weight and mean placental weight of term infants born to women with syphilis and women without syphilis (p = 0.35 and p = 0.31 respectively). When the placental:birth-weight ratios were considered, an apparent larger placenta was seen in association with syphilis but this was secondary to the lower birth-weights in association with prematurity. Late and poor attendance for antenatal care was a feature of all women attending this centre and not a feature associated with syphilis. The treatment and follow-up of syphilis were hindered by poor compliance.

Congenital infections and the nervous system

Despite vaccines, new antimicrobials, and improved hygienic practices, congenital infections remain an important cause of death and long-term neurologic morbidity among infants world-wide. Important agents include Toxoplasma gondii, cytomegalovirus, Treponema pallidum, herpes simplex virus types 1 and 2, and rubella virus. In addition, several other agents, such as the varicella zoster virus, human parvovirus B19, and Borrelia burgdorferi, can potentially infect the fetus and cause adverse fetal outcomes. This article provides an overview of these infectious disorders and outlines current strategies for acute treatment and long-term management.

Congenital syphilis is with us still

A baby with neonatal congenital syphilis who was born prematurely at 33-weeks' gestation with hepatosplenomegaly, ascites and respiratory distress that was evident at birth is presented.