congenital Syphilis

Has Sri Lanka achieved elimination?

lil/consyp/2007 1

THE TARGET FOR VALIDATING EMTCT OF

SYPHILIS IS:

INCIDENCE OF CONGENITAL SYPHILIS ≤ 50 CASES

PER 100,000 LIVE BIRTHS.

by 2015 – 0.5 congenital syphilis cases per 1000 livebirths

lil/consyp/2007 2

Congenital syphilis Case definition

lil/consyp/2007 3

Strategy for ECS in Sri Lanka

CaseDefinition 1 Congenital syphilis is defined as a live born infant with clinical evidence

of (one major and two minor criteria) and confirmed by serologic evidence of syphilis to a mother with confirmed syphilis

Major criteria

• Swelling of joints

• Bullous skin lesions

• snuffles

Minor criteria • Hepatosplenomegaly

• Jaundice

• Anaemia

• Radiological changes in long bones

lil/consyp/2007 4

Case definition 2

• Congenital syphilis is defined as a live born asymptomatic infant born to a mother with confirmed syphilis and any one of the following: – Reactive non-treponemal test which is four fold

higher than mother at delivery

– A reactive syphilis specific IgM antibody test

– Rising non treponemal titre in the baby

– Persistently reactive treponemal test in the infant beyond 4 months of age

lil/consyp/2007 5

An incidence case

• An infant who falls in to either case definition 1 or 2

lil/consyp/2007 6

Case definition 3 – for programmatic purposes

• Congenital syphilis is defined as a live born asymptomatic infant, still birth or foetal loss to a mother with syphilis where;

• Mother was treated <4 weeks prior to delivery or

• Mother was untreated, partially treated, treatment status unknown

or

• Mother treated with non penicillin regimen

lil/consyp/2007 7

year 2012

• Reported number of congenital syphilis - 12

• Criteria fulfilled cases congenital syphilis – 5

• the reported pregnancies in the same year was 365,000.

• In Sri Lanka the rate of CS is around 0.03 per 1000 births

• Target for ECS – 0.5 per 1000 live births

lil/consyp/2007 8

Has Sri Lanka achieved elimination of congenital syphilis?

lil/consyp/2007 9

Anti VD campaign was formally established in 1951

Specific Objectives:

• To establish a model VD clinic in Colombo.

• To develop VD services in major outstations.

• To establish syphilis serological tests for expectant mothers.

• Provide serological testing in main outstations.

lil/consyp/2007 10

Universal screening of Antenatal clinic attendees for syphilis started

in 1954

lil/consyp/2007 11

What is the current situation with antenatal Syphilis screening?

Antenatal screening for syphilis

• is a routine procedure in the country

• Over 98% of the pregnant women are tested for syphilis (2010).

• The prevalence of syphilis among antenatal mothers is maintained at a low level of 0.02% during 2010.

lil/consyp/2007 13

Initiative to eliminate congenital syphilis was launched in 2010

Prevention of congenital syphilis has been a public health priority in Sri

Lanka.

lil/consyp/2007 14

DEVELOPED NATIONAL POLICY AND STRATEGY FOR ELIMINATION OF CONGENITAL SYPHILIS IN SRI LANKA.

lil/consyp/2007 15

• Secretary Health issued a circular regarding the programme for elimination of congenital syphilis to provincial health authorities.

lil/consyp/2007 16

Two strategies

• increasing access to and quality of maternal and newborn health services

• Screening pregnant women and treating seropositive women and their partners and newborns

lil/consyp/2007 17

Two strategies were included in the antenatal management package

of the Family Health Bureau.

lil/consyp/2007 18

Elimination of Congenital Syphilis Programme in Sri Lanka

• based on the integrated model of Maternal and Child Health and STI services together with prevention of mother to child transmission of HIV programmes

lil/consyp/2007 19

Can Sri Lanka qualify for validation for elimination of

congenital syphilis?

lil/consyp/2007 20

Global minimum required process indicators for validation

HIV

Impact indicators

Mother-to-child transmission HIV case rate of ≤ 50 new paediatric HIV infections per 100,000 live births

Mother-to-child transmission of HIV of <5% in breastfeeding populations OR

Mother-to-child transmission of HIV of <2% in non-breastfeeding populations

Process indicators

Antenatal care (ANC) coverage (1 visit) of ≥95%

Coverage of HIV testing of pregnant women at first ANC visit of ≥95%

Anti-retroviral (ARV) coverage of HIV-positive pregnant women of ≥90%

Congenital Syphilis

Impact indicator

Incidence of congenital syphilis ≤ 50 cases per 100,000 live births

Process indicators

Antenatal care (ANC) coverage (1 visit) of ≥95%

Coverage of syphilis testing of pregnant women at first ANC visit of ≥95%

Treatment of syphilis seropositive pregnant women ≥95%

Positive syphilis serology in pregnant women (no target)

lil/consyp/2007 21

Qualifying requirements for validation

• Countries must meet the following global minimum criteria

• National level evidence of

– achievement of the EMTCT validation process indicator targets for 2 years

and

– achievement of validation impact indicator targets for one year

• Evidence that ECS has been achieved in at least one of the lowest performing district

• Existence of adequate validation standard national monitoring and surveillance system from both public and private sectors

lil/consyp/2007 22

Sri Lanka needs to prove that there is

• reduction of syphilis among pregnant women through prevention of syphilis in women in reproductive age, including pregnant women and their partners.

• timely identification and appropriate treatment of pregnant women infected with syphilis, their male partners and infants.

lil/consyp/2007 23

Infectious Syphilis rate per 100,000 population

(Sri Lanka) Infectious Syphilis rate per 100,000

01234567

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

years

Rate

per

100,0

00

The global minimum required process indicators for validation

• ANC coverage one visit >95%

• Coverage of syphilis testing of pregnant women at first ANC visit of >95%

• Treatment of syphilis seropositive pregnant women >95%

• Positive syphilis serology in pregnant women (no target)

lil/consyp/2007 26

Antenatal care (ANC) coverage (1 visit) of ≥95% Rationale: • Elimination targets for MTCT of HIV and syphilis testing

coverage cannot be attained unless ANC services are universal or nearly universal.

• If high ANC coverage is not attained, many of the pregnant women at greatest risk for HIV and syphilis infection will not receive critical services to prevent MTCT of HIV and syphilis.

lil/consyp/2007 27

lil/consyp/2007 28

2007 2008 2009 2010

Total Live Births reported 320507 326865 313628 310247

Stillbirths 2739 2859 2383 2415

Stillbirth rate (per 1000 live births) 8.5 8.7 7.6 7.8

Institutional births 318693 326155 313148 309638

Institutional births % 99.4 99.8 99.8 99.8

Skilled attendance at Birth 319178 326504 313403 309839

Skilled attendance at Birth % 99.6 99.9 99.9 99.9

Pregnant Mothers Registered by PHM 404138 397527 380884 382418

Pregnant Mothers Registered before 8 Wks 221652 244078 251304 267083

Pregnant Mothers Registered before 8 Wks % 54.8 61.4 66.0 69.8

Pregnant Mothers Registered between 8-12 Wks 138456 113261 95185 86388

Pregnant Mothers Registered between 8-12 Wks % 34.3 28.5 25.0 22.6

Pregnant Mothers Registered before 12 Wks % 89.1 89.9 91.0 92.4

Mothers tested for VDRL (at Delivery) 294539 307213 307063 297957

Number reported as reactive 139 210 158 217

Number of CS cases 2 8 5 6

CS cases per 1000 live births 0.01 0.02 0.02 0.02

96%

Coverage of HIV and/or syphilis testing of pregnant women at first ANC visit of ≥95%

Rationale: • Near-universal testing of HIV and syphilis in early

pregnancy is necessary to identify women who can benefit from services to prevent MTCT

and • is the entry point for providing treatment and

preventive services.

lil/consyp/2007 29

• In the year 2012, government STD clinics have screened 194,513 pregnant women for syphilis with 60.6% coverage through government facilities. However, when combined with the private sector services the coverage is 96%. (data from FHB)

lil/consyp/2007 30

Need improvements in data collection

• Form 509 of MCH services – gives data on number tested for VDRL and the number VDRL reactive

• VDRL data available at MCH services do not indicate time or POA at which the samples were collected

• or number confirmed as having syphilis.

• Therefore it is difficult to assess early ANC testing services and the coverage of services offered to confirmed syphilis cases.

lil/consyp/2007 31

Treatment of syphilis seropositive pregnant women of ≥95%

Rationale:

• Early treatment of seropositive women with at least one dose of intramuscular benzathine penicillin is sufficient to prevent or cure syphilis in the majority of infants.

lil/consyp/2007 32

Management of pregnant females with positive VDRL results

Primary health care

Ante-natal clinic

Hospital ante-

natal clinic

STD Clinic

Confirmatory test +ve

Management of baby

•Screening of baby

•Coordinated Mx with

paediatrician

•Prophylactic Penicillin

•Follow up

Management of mother

•Treat with penicillin

•Partner tracing and Mx

•Coordinated Mx with VOG

•Follow up

Pregnancy with syphilis 2012 No: STD clinic No of pregnant patient

with Syphilis

No of patient were treated before 36 weeks of POA

1. Ampara 2 2

1. Anuradhapura 1 0

1. Badulla 3 3

1. Balapitiya 0 0

1. Batticaloa 0 0

1. Chillaw 0 0

1. Colombo 12 11

1. Gampaha 4 4

1. Hambantota 4 3

1. Jaffna 0 0

1. Kalubowila 2 2

1. Kalutara 2 2

1. Kalmunai 0 0

1. Kandy 1 1

1. Kegalle 1 1

1. Kurunegalle 5 5

1. Mahamodara 3 3

1. Mannar 0 0

1. Matale No MO

1. Matara - -

1. Monaragala No MO

1. Negambo 1 1

1. NuwaraEliya 3 3

1. Polonnaruwa - -

1. Ragama 1 1

1. Rathnapura - -

1. Trincomalee - -

1. Vavuniya 3 3

1. Wathupitiwala 1 1

Total 49 46

lil/consyp/2007 34

• 49 pregnant women have been diagnosed as having syphilis (0.03%) at STD clinics and 46 have been managed before 36 weeks at STD clinics islandwide (93.8%). (data from NSACP)

lil/consyp/2007 35

STD clinic data

• show that all pregnant mothers who are referred to STD clinics are adequately managed to eliminate congenital syphilis.

• The mechanism is not in place to assess whether all sero-positives are referred to STD clinics.

• No feedback from the STD clinic to the MCH services regarding pregnant females with syphilis.

lil/consyp/2007 36

Need improvements in the referral system

• Do we need to see all VDRL reactive pregnant women at the STD clinic?

• Current practice - all ANC VDRL positive samples are

tested for TPPA at STD clinic laboratory

• Inform MOH only TPPA positive reports – gives

number of confirmed cases to fill form 509

• Need to refer only TPPA positive pregnant women to STD clinic

lil/consyp/2007 37

Syphilis Data from private sector

?Included in 509 (if the pregnant woman is registered at the area MOH

clinic)

lil/consyp/2007 38

To qualify for validation

• Further there should be evidence that ECS has been achieved in at least one of the lowest performing district in the country.

Vavuniya district –

• Number ANC registered – 3514

• Number tested for VDRL – 3514

• Number diagnosed with syphilis – 3

• Number treated before 36 weeks - 3

lil/consyp/2007 39

Need to Improve data collection

• A quarterly return on STI and pregnancy, preferably according to the MOH area, needs to be developed by the STD clinic and sent to the MCH services in the area and to the NSACP.

• MOH should seek support of the area MO, STD clinic, when completing form 509 which gives data on STI among pregnant women.

lil/consyp/2007 40

Impact indicator

incidence of congenital syphilis <0.5 cases per 1000 live births.

lil/consyp/2007 41

Lack of adverse pregnancy outcome/ still birth data is a concern.

It would be supportive if there is evidence to prove that foetal wastage is not related to syphilis.

Women with adverse pregnancy outcomes should be

tested for VDRL.

lil/consyp/2007 42

Sri Lanka has almost reached targets given in process indicators

• Sri Lanka has very high rates of early registration of pregnancies by community midwives.

• Antenatal care coverage one visit >95%

• Coverage of syphilis testing of pregnant women >95%

• Treatment of syphilis seropositive pregnant women >95%.

• Screening of pregnant women in north show that incidence of syphilis is low.

lil/consyp/2007 43

Need data

• Number of women screened for syphilis – form 509 – MCH services (?first ANC visit)

• Number of women having confirmed syphilis - ? – MCH services (Need to improve form 509 – instead of number VDRL reactive, should say number confirmed positive)

• Number of pregnant women treated for syphilis – ? - STD clinic (need to include data on pregnancy and STI in quarterly return from STD clinics)

• Number of babies with congenital syphilis – quarterly return STD clinic

lil/consyp/2007 44

Need to consider improvements to

Initiate the validation process When the minimum qualifying

requirements have been met, Sri Lanka can apply to initiate the process for

validation of ECS.

lil/consyp/2007 45

If successful by 2015

Sri Lanka will be the first country in the region to

eliminate congenital syphilis

lil/consyp/2007 46

The end

lil/consyp/2007 47