congenital Syphilis
Has Sri Lanka achieved elimination?
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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
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Congenital syphilis Case definition
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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
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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
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An incidence case • An infant who falls in to either case definition 1 or 2
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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
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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
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Has Sri Lanka achieved elimination of congenital syphilis?
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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.
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Universal screening of Antenatal clinic attendees for syphilis started in 1954
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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.
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Initiative to eliminate congenital syphilis was launched in 2010 Prevention of congenital syphilis has been a public health priority in Sri Lanka.
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DEVELOPED NATIONAL POLICY AND STRATEGY FOR ELIMINATION OF CONGENITAL SYPHILIS IN SRI LANKA. lil/consyp/2007
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â&#x20AC;˘ Secretary Health issued a circular regarding the programme for elimination of congenital syphilis to provincial health authorities.
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Two strategies â&#x20AC;˘ increasing access to and quality of maternal and newborn health services â&#x20AC;˘ Screening pregnant women and treating seropositive women and their partners and newborns
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Two strategies were included in the antenatal management package of the Family Health Bureau.
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Elimination of Congenital Syphilis Programme in Sri Lanka
â&#x20AC;˘ based on the integrated model of Maternal and Child Health and STI services together with prevention of mother to child transmission of HIV programmes
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Can Sri Lanka qualify for validation for elimination of congenital syphilis?
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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
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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
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Sri Lanka needs to prove that there is â&#x20AC;˘ reduction of syphilis among pregnant women through prevention of syphilis in women in reproductive age, including pregnant women and their partners. â&#x20AC;˘ timely identification and appropriate treatment of pregnant women infected with syphilis, their male partners and infants. lil/consyp/2007
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7 6 5 4 3 2 1 0
19 81 19 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01
Rate per 100,000
Infectious Syphilis rate per 100,000 population (Sri Lanka) Infectious Syphilis rate per 100,000
years
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
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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.
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Total Live Births reported Stillbirths Stillbirth rate (per 1000 live births) Institutional births Institutional births % Skilled attendance at Birth Skilled attendance at Birth % Pregnant Mothers Registered by PHM Pregnant Mothers Registered before 8 Wks Pregnant Mothers Registered before 8 Wks % Pregnant Mothers Registered between 8-12 Wks Pregnant Mothers Registered between 8-12 Wks % Pregnant Mothers Registered before 12 Wks % Mothers tested for VDRL (at Delivery) Number reported as reactive Number of CS cases CS cases per 1000 live births
2007 320507 2739 8.5 318693 99.4 319178 99.6 404138 221652 54.8 138456 34.3 89.1 294539 139 2 0.01
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2008 326865 2859 8.7 326155 99.8 326504 99.9 397527 244078 61.4 113261 28.5 89.9 307213 210 8 0.02
2009 313628 2383 7.6 313148 99.8 313403 99.9 380884 251304 66.0 95185 25.0 91.0 307063 158 5 0.02
2010 310247 2415 7.8 309638 99.8 309839 99.9 382418 267083 69.8 86388 22.6 92.4 297957 217 6 0.02
96%
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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.
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â&#x20AC;˘ 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)
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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
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Treatment of syphilis seropositive pregnant women of â&#x2030;Ľ95% Rationale: â&#x20AC;˘ 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.
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Management of pregnant females with positive VDRL results Hospital antenatal clinic
Primary health care Ante-natal clinic
Confirmatory test +ve
STD Clinic
Management of mother •Treat with penicillin •Partner tracing and Mx •Coordinated Mx with VOG •Follow up
Management of baby •Screening of baby •Coordinated Mx with paediatrician •Prophylactic Penicillin •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
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
-
-
No MO
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â&#x20AC;˘ 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)
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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
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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
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Syphilis Data from private sector ?Included in 509 (if the pregnant woman is registered at the area MOH clinic)
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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 • Number tested for VDRL • Number diagnosed with syphilis • Number treated before 36 weeks
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– 3514 – 3514 –3 -3
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Need to Improve data collection â&#x20AC;˘ 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. â&#x20AC;˘ 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
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Impact indicator
incidence of congenital syphilis <0.5 cases per 1000 live births. lil/consyp/2007
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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.
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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
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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
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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
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If successful by 2015
Sri Lanka will be the first country in the region to eliminate congenital syphilis lil/consyp/2007
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The end
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