Syphilis is a bacterial infection that is mainly spread through sexual contact. Left untreated, it can have severe long-term impacts on the health of both women and men. It can also be transmitted from mothers to infants with devastating consequences for the child. When an infant gets sick in this way it is referred to as congenital syphilis. South Africa's National Institute for Communicable disease (NICD) defines it as a "severe, disabling, and often life-threatening infection seen in infants".
Back in 2004, a group of leading clinicians argued that the continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections.
They wrote that at the time over 1 million infants were born with congenital syphilis each year worldwide and that despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women.
Fast forward a decade-plus and many of these problems are still with us, although globally there are signs of improvement. A study in the journal PLoS ONE estimated that there were around 661 000 cases of congenital syphilis in 2016 - a substantial improvement on the estimated one million 12 years earlier. Disturbingly, they estimated that there were around 355 000 adverse birth outcomes due to congenital syphilis in 2016 - including 143 000 early foetal deaths and stillbirths, 61 000 neonatal deaths, 41 000 preterm or low-birth-weight births, and 109,000 infants with clinical congenital syphilis.
In South Africa, the numbers also paint a worrying picture. The latest NICD congenital syphilis surveillance report (published in February) found that in the period 1 July 2017 to 31 December 2020, there were a total of 794 clinical notifications of congenital syphilis and 11 170 RPR positive results from infants/ children < 2 years (RPR, or rapid plasma reagin, is a blood test used to screen for syphilis).
"Over this period there was a steady increase in both the number of clinical notifications and the number of RPR positive results from infants/ children," the NICD report reads. This increase is despite the National Strategic Plan for HIV, TB and STIs (2017-2022) setting out to "virtually eliminate congenital syphilis by reducing incidence to 50 or fewer cases per 100 000 live births".
Speaking at a webinar on Prevention of Mother-to-Child Transmission of Communicable Infections hosted by the National Department of Health last month, Dr Neil Moran said rates of syphilis have increased over the years and has had adverse outcomes on the foetus and on the baby. "We currently have a syphilis epidemic," he said. Moran is head of clinical obstetrics and gynaecology in the KwaZulu-Natal Department of Health.
Preventable and treatable
Senior epidemiologist at the NICD for HIV and STIs, Dr Tendesayi Kufa-Chakezha explains that congenital syphilis is a preventable and treatable condition that results from mother-to-child transmission of syphilis infection. She says when a pregnant woman gets syphilis during pregnancy or already has syphilis when she falls pregnant, there is a danger of the syphilis being passed on from the mother to the child mostly during pregnancy and sometimes during delivery unless the mother is tested for syphilis and treated.
"Treating the mother at least 30 days before delivery also results in treatment of the unborn child. If pregnant women with syphilis are not treated this can result in miscarriage, stillbirths, death of the infant soon after birth or a child with illness from syphilis and its complications," Kufa-Chakezha tells Spotlight.
Stressing the health impact of syphilis on a baby, Gauteng Department of Health spokesperson Kwara Kekana says, "The extent to which it affects the baby depends on when syphilis was acquired during pregnancy as well as when the mother received treatment for the infection before she delivers."
Babies born with congenital syphilis may have bone damage, severe anaemia, an enlarged liver, jaundice, skin rashes as well as nerve problems causing blindness or loss of hearing, she says. In severe cases, some babies may die. Congenital syphilis may present with symptoms that can among others include fever, difficulty gaining weight, and small blisters on the hand and feet. If treated early, it can be cured.
Both in adults and in children syphilis can be a complex multi-stage infection. Characterised by four different stages, it is usually highly transmitted during its first or second stages. Syphilis first shows up as a chancre (a small, painless sore) that can appear on sexual organs or inside the mouth. It is challenging to diagnose - some people may have it for years and not show any signs.
In men, signs of syphilis may include body rashes on the palms of the hands and sores on the feet. It may also include symptoms such as mild fever, fatigue, and a sore throat among others. Women may develop small skin growths, white patches in the mouth and flu-like symptoms such as tiredness, headache, joint pains and fever.
Syphilis is a bacterial infection caused by the Spirochaete bacterium Treponema Pallidum. Moran says Benzathine penicillin which is an antibiotic given by injection is the only appropriate and proven effective treatment for syphilis in pregnancy.
"It is in short supply worldwide and supply in South Africa is unreliable," he says. "Distribution and use of the drug must be carefully managed and controlled to ensure that it remains available to treat syphilis in pregnancy. Reserve the drug for this indication. Use alternatives for other indications where alternatives exist, this includes syphilis in males and outside pregnancy."
According to Kufa-Chakezha, the drug has not yet been registered by the South African Health Products Regulatory Authority. As a result, accessing the medicine requires applications to be made in terms of section 21 of the Medicines Act - a time-consuming process that involves significant paperwork.
Lack of notification
Speaking at the same webinar, Kufa-Chakezha said part of the challenge in managing congenital syphilis is a lack of notification. She said the Western Cape, KwaZulu-Natal and Gauteng submitted the highest numbers and proportions of notifications between July 2017 to 31 March 2021. The three provinces hold 89% of notifications throughout the country.
"These three provinces also have some of the highest numbers of live births in the country. For example, in 2020, the three provinces accounted for 54% of live births in a facility. The provinces have also accounted for 61% of syphilis positive results among infants under the age of two years.
This means the three provinces are over-represented among the notified congenital syphilis cases, which means they are either much better than the rest of the provinces in diagnosing and reporting cases or they have extra-ordinarily high rates of congenital syphilis. The former is more likely because these provinces do not have high rates of maternal syphilis cases," she says.
"Accurately reporting and monitoring [the] numbers of cases will allow us to determine what the impact of any changes in the measures for preventing maternal and congenital syphilis has been. Without good data, one cannot monitor adequately what the situation is. For example, what has been the impact of benzathine penicillin shortages on new congenital syphilis cases or what impact improving maternal testing will have, can be determined by an increase or decrease in cases," Kufa-Chakezha says, adding that good data is needed to evaluate progress towards meeting mother-to-child transmission targets.
We see an increase in STIs at all our medical male circumcision sites. When left untreated, an STI will ulcerate and become a thriving access point for HIV to enter the body. Uncircumcised men are far more vulnerable to STIs like herpes and syphilis. #MensHealthMonth #StandProud
- Right to Care (@righttocaresa) June 22, 2021
She further explained that there are many reasons congenital syphilis is under-reported. Some reasons include limited buy-in into the Notifiable Medical Conditions (NMC) programme, which affects all NMCs and not just congenital syphilis. Other reasons include a lack of awareness that it is a notifiable medical condition and a lack of awareness of the notification process.
According to Kufa-Chakezha there are gaps in the notification system which make it difficult for people to notify. "For example, submitting a paper notification means printing a form, manually completing the form, scanning and emailing the form to the NICD's NMC programme. All of this can take time and the lack of printed forms where facilities notify on paper can lead to under-reporting. At times, health care workers are busy with clinical work and may not get to the paperwork required for notification," she said, adding that limited data and internet connectivity where providers use the electronic NMC notification application as well as lack of awareness about who should be notified, and which babies meet criteria for notification can all lead to less reporting.
To improve notifications, Kufa-Chakezha says they are training healthcare workers on case definition (criteria for notification), the notification process and they are contacting facilities directly as the need arises, using every opportunity as a training opportunity.
Gauteng and Western Cape
Kekana says in 2018, 2019 and 2020 Gauteng recorded 461, 583 and 679 cases of congenital syphilis respectively - a steady increase in reported cases.
"Prevention of congenital syphilis relies on effective syphilis screening and treatment during pregnancy. Screening for syphilis is conducted at the first antenatal care visit and repeated at 32 to 34 weeks of pregnancy. The department aims for early identification through rapid syphilis testing, thereby adopting the test-and-treat approach. Once the patient tests positive for syphilis she is started on treatment immediately," says Kekana
She also said that procurement processes for single syphilis and dual syphilis/HIV rapid test kits are underway and that this point-of-care testing will help to start treatment immediately without having to wait for blood results from the laboratory.
In a paper in the South African Medical Journal, results of a study done at Groote Schuur Hospital (GSH) showed that of 50 symptomatic neonates, 19 (38%) died. 28 mothers (56%) were unbooked and therefore received no antenatal care. Most mothers (98%) were inadequately treated. Health worker-related failures included poor notification and partner tracing as well as failure to recheck syphilis serology after 32 weeks gestation in mothers who initially tested negative.
It was concluded that congenital syphilis in neonates admitted to the GSH neonatal unit was associated with substantial morbidity and mortality. The modifiable factors identified represent inadequate antenatal healthcare and health system failures. These factors are longstanding, highlighting the need to establish governance and audit processes, and address the continuing socio-economic and socio-cultural barriers that mothers face as a way forward in ultimately eliminating this entirely preventable disease.
Gaps in management
Due to inadequate treatment of the mother because of late antenatal care booking, Kekana says they encourage early antenatal care booking for early identification and adequate treatment before delivery. She says Gauteng is implementing the BANC Plus model (Basic Antenatal Care) which has a total of at least eight Antenatal Care visits for frequent monitoring with the opportunity to do RPR retest at 32 to 34 weeks. As for the turnaround times for blood results, they are introducing Rapid Test Kits at the point of care.
Kufa-Chakezha tells Spotlight the main gaps in managing congenital syphilis in their view are late booking and testing.
"Ideally all pregnant women should book at 12 weeks pregnancy and at least by 20 weeks. There are delays in getting mothers' test results from the laboratory and bringing positive mothers back to the clinic for treatment. This means some positive mothers are only treated when there are less than 30 days from expected delivery or they have a pre-term delivery less than 30 days after starting treatment. Infants who are not showing signs and symptoms at birth may be missed and only show up later in infancy," she says.