Syphilis Resurgence Puts Pregnant Women and Babies at Risk

Ricki Lewis, PhD

November 03, 2011

November 3, 2011 — Syphilis is experiencing a worldwide resurgence. The World Health Organization estimates that 2 million pregnant women contract syphilis annually, and that if untreated, 1 in 2 of these women passes the infection to her fetus.

A report published online September 27 and in the November issue of the Bulletin of the World Health Organization analyzes the situation in rural areas of Guangdong province in southern China. The 300,000 cases of syphilis reported in China in 2008 reflect a 10-fold increase in prevalence within a decade, attributed largely to transmission among female sex workers and men who have sex with men.

Syphilis can cause spontaneous abortion, stillbirth, irreversible congenital defects, and perinatal death. Treating infected pregnant women with penicillin can prevent transmission. However, access to prenatal testing for syphilis is problematic in rural areas. Studies from places as diverse as Mongolia, South Africa, Kenya, and Bolivia associate congenital syphilis with care beginning late in pregnancy, as well as with distance from a clinic.

In southern China, women in urban areas seek prenatal care at general hospitals and at women's and children's hospitals, whereas women in rural areas use hygiene stations, which provide only basic services. In the study, conducted by Li-Gang Yang, MD, and colleagues at Guangdong Provincial Center for STI Control & Prevention, China, and the London School of Hygiene and Tropical Medicine, United Kingdom, 11 of the 14 less-developed municipalities submitted surveys about syphilis testing at facilities where babies are delivered. Questions probed the number of deliveries, number of pregnant women screened at least once, and whether faster and cheaper treponemal screening or nontreponemal tests were done.

The study encompassed 109 facilities from 2006 to 2008, 76 of which were hygiene stations. In 2008, only 40 of the 109 facilities provided syphilis testing, and at these facilities, only 77% of women who gave birth had at least 1 syphilis test. At the 109 facilities, 125,645 babies were born in 2008, and 57% (71,449/125,645) of the pregnant women had at least 1 syphilis test. Of those not screened, 60.6% (32,863/54,196) had visited clinics that did not offer syphilis screening, and 39.4% (21,333/54,196) had received care at facilities that did offer screening, but did not have it done. Screening was most limited at hygiene stations, with only 11% of pregnant women screened for syphilis. For pregnant women who received their care from hygiene stations, the odds ratio of not being screened for syphilis was 10 (95% confidence interval, 4 - 25).

Very few facilities met the 2015 benchmark established by the National Syphilis Control Plan in China of 80% or more for syphilis screening in cities, and 60% in rural areas. Most (85%) of the facilities offered only nontreponemal tests. The study did not account for women who delivered at home, nor did it record gestational time of testing.

The situation in China is echoed elsewhere. In sub-Saharan Africa, for example, 38% of pregnant women are screened for syphilis, the investigators write.

"Our study of almost 500,000 pregnant women in Guangdong Province found that more than 40% of pregnant women in poor areas were missing out on a syphilis test, in most cases because health clinics lack testing facilities," states Dr. Yang in a news release. The authors also note that several programs to improve syphilis testing have begun since 2008, including the integration of "rapid tests into the national programme for prevention of mother-to-child transmission of HIV, syphilis and hepatitis B in China," states another author, Rosanna Peeling, PhD, professor of diagnostics research, London School of Hygiene and Tropical Medicine. "This timely translation of evidence to policy can serve as a model for other countries."

Support for the study was from the Guangdong Provincial Medical Science and Technology Research Funding Award, the World Health Organization Rapid Syphilis Test Project, the National STD Control Centre, and National Institutes of Health Fogarty K01 Award. The authors have disclosed no relevant financial relationships.

Bull World Health Organ. 2011:89:798-805. Full text

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