Manifestation of congenital syphilis in a newborn’s feet. Picture: Supplied
Despite syphilis being a treatable sexually transmitted disease — which untreated pregnant mothers pass on to their infants as congenital syphilis, South Africa has reported 1 739 congenital syphilis cases translating to a rate of 198 per 100 000 live births — well above the global target of 50 per 100 000 live births.
This is according to a recent report by the National Institute for Communicable Diseases (NICD) titled – Congenital Syphilis in South Africa: 2023 Annual Surveillance Report.
Congenital syphilis is a severe, disabling, and often life-threatening infection seen in infants whose mothers were infected with syphilis caused by treponema pallidum and not fully treated during pregnancy. The infection can pass through the placenta to the unborn infant during pregnancy or natural birth.
The NICD revealed that KwaZulu-Natal, Gauteng, Western Cape, and Eastern Cape recorded the highest clinical notifications, accounting for 89.9%. KZN alone accounts for 46% of clinical notifications — with the eThekwini metro having the highest cases.
“In the absence of treatment, 50–90% of pregnant women with syphilis will transmit the infection to their unborn child, resulting in adverse pregnancy or birth outcomes such as stillbirths, preterm or low birthweight deliveries, and associated complications, early neonatal deaths, and congenital infections,” the NICD said in the report.
Congenital syphilis symptoms can manifest early in a newborn (within three months) or late (after two years).
“Pregnant women living with HIV and co-infected with syphilis are more likely to transmit HIV to their unborn babies compared to pregnant women living with HIV but without syphilis. Screening and testing pregnant women for syphilis remains the cornerstone of the elimination of the mother-to-child transmissions (MTCTs) plan,” revealed the report.
To improve case detection, treatment, and reporting, it was highlighted that there is a need to train and re-train healthcare providers at primary care facilities, district, regional, and tertiary hospitals on the clinical signs and symptoms of maternal and congenital syphilis, and the notification procedures.
Dr Radhika Singh, the head of the Neonatal unit at King Edward Hospital, and a Paediatrics and Child Health lecturer at the University of KwaZulu-Natal, said when parents notice congenital syphilis symptoms, they should take the child immediately to a local clinic or hospital, and they as parents should also check their syphilis status.
“The best option to treat manifestations of congenital syphilis in both early and late stages is intravenous benzyl penicillin for 10 days or intramuscular procaine penicillin,” Singh said.
When congenital syphilis is discovered late, it can cause permanent damage to the bones, ears, eyes, nervous system, and heart which is irreversible, she said.
Dr Singh added that while the child is undergoing congenital syphilis medical treatment, parents should report any complications that may arise.
“If a child is treated in the early phase, they can lead a normal life after treatment. The most important steps for prevention are to get tested during pregnancy in the first and third trimester and at delivery, practising safe sex, avoiding unintended pregnancies, and checking for HIV infection as well,” she said.
The report noted that although there was an increase in notifications over the year, there is likely under-reporting of cases in some facilities and districts.
“To estimate the completeness of reporting or notifications, the NICD, in collaboration with the national and provincial departments of Health, needs to conduct a facility-based evaluation or assessment at selected hospitals to identify congenital syphilis cases in a given period and match identified cases to the Notifiable Medical Conditions (NMC) line list.
“Findings of this assessment would be useful to estimate the extent of under-reporting and the nature of the selection bias introduced by under-reporting,” read the report.
To assess gaps and challenges faced by the country concerning the elimination of congenital syphilis, analysis of patient data to determine clinical characteristics that are over-represented among cases is a prerequisite.
“Identifying such characteristics will help the National Department of Health to design targeted interventions to maximise prevention, detection, and treatment of maternal and congenital syphilis.”
The mother-to-child transmissions plan was launched by the World Health Organization in 2007, and it requires that countries ensure that 95% of pregnant women attend antenatal care, ideally before 20 weeks, and that 95% of those who attend antenatal care are screened and tested for syphilis, and that 95% of pregnant women who have syphilis are treated with benzathine penicillin.
“Countries will be considered to have eliminated congenital syphilis when they have a case rate that is less than 50 cases per 100 000 live births in the presence of a robust surveillance system.
“South Africa has been screening for antenatal syphilis since the late 1990s and has included congenital syphilis on the national Notifiable Medical Conditions (NMC) platform since 2017 to monitor progress toward eliminating mother-to-child transmission.
“Healthcare workers are required to report congenital syphilis cases within seven days, with additional surveillance through (rapid plasma reagin) RPR-positive results in children under two,” the NICD said in the report.
The rapid plasma reagin test is a type of rapid diagnostic test that looks for non-specific antibodies in the blood of the patient that may indicate an infection by syphilis.
“In July 2023, a combined case notification and investigation form was introduced for more efficient case reporting and classification. This report presents trends in congenital syphilis notifications and RPR-positive results for 2023,” said the NICD.
gcwalisile.khanyile@inl.co.za