The management of Maternal and Congenital syphilis

Syphilis is a sexually and vertically transmitted infectious disease caused by the bacterium Treponema Pallidum. Syphilis causes substantial illness globally, in particular, maternal syphilis (MS) is associated with considerable adverse pregnancy outcomes including stillbirths, preterm labor, low birth weight babies, neonatal deaths, and congenital syphilis [1].

Global estimates of MS have increased in the last decade and one such estimate indicates that there were 988,000 infected pregnant women and 355,000 adverse birth outcomes in 2006 [2]. The global burden of syphilis infections mainly impacts the African continent [1-3].  In sub-Saharan Africa, 2.7% of all pregnant women are infected with syphilis [2,3]. A recent report [2019] of the annual HIV and Syphilis antenatal surveillance study in South Africa (SA) established that the syphilis rate was 2.1%, a rise from the previous year’s report [4].

Despite measures such as the WHO initiative to improve syphilis screening, testing, and adequate treatment of pregnant women and their babies to reduce the frequency of congenital syphilis, rates of this disease remain high and are increasing in some countries [1,3]. In 2017, congenital syphilis resulted in 305,000 perinatal deaths worldwide [5]. 

In the African continent, screening of MS at antenatal clinics is low (47%), only 76% of cases of MS received treatment and lastly, Africa has the highest global rate of congenital syphilis (119 per 100,000 births) [ 6,7]. These high rates of congenital syphilis in Africa are probably due to the fact that, many women only seek antenatal care late in their pregnancy, may have incomplete treatment or there may have been difficulties in obtaining the results of tests timeously or the lack of follow-up of the mother and baby following birth. It is reported that babies born to women infected with syphilis who are asymptomatic at birth may develop symptoms such as skin rashes, hepatomegaly, and central nervous pathology later [1-8]. Therefore, a follow-up of infected women and their babies is essential [1-8].  Another factor that may account for the high rates of congenital syphilis is that pregnant women can become infected in any trimester of pregnancy, resulting in some women becoming infected after having had a negative test. Therefore, it is recommended that repeat testing be done in the third trimester and the treatment completed 28 days prior to childbirth [8].  The National Department of Health of SA has produced clinical guidelines for screening, testing, and treatment for syphilis, and these are provided to all health facilities [3]. In addition, there are publications on syphilis rates from regional and tertiary health facilities [3]. However, there is limited data on syphilis screening at community clinics in poor rural areas of SA. Recently there has been a report of a study done at a community clinic on the outskirts of Durban, in the eThekwini health district [5]. This study only reported the frequency of MS and did not comment on gaps in clinical management and the incidence of congenital syphilis [5].  A report from a tertiary neonatal unit in Cape Town, found that there is high morbidity and mortality associated with symptomatic congenital syphilis indicating that there are gaps in the quality of care in the clinical management of maternal and newborn syphilis [6]. It is possible that there is a disconnect in the dyad management as the mother is managed by staff nurses, midwives, and doctors, while the baby is handed over to the pediatricians and communication becomes a structural problem.

References: 

1.         Korenromp EL, Rowley J, Alonso M, et al. Global outcomes: estimates for 2016 and progress since 2012. PLoS One 2019;14: e0211720

2.         World Health Organization. The Global Elimination of Congenital Syphilis. Rationale and at   Strategy for Action. WHO. Available on-line at: https//www.int/publications/i/item/the-global-elimination-of-congenita-syphilis-rationale-strategy-for-action (accessed June 2 burden of maternal and congenital syphilis and associated adverse birth, 2022)

3.         WHO. Global guidelines on syphilis screening and /treatment for pregnant women-World Health Organization;2017.https/www.who.int/reproductive health... screening and treat-guidelines/en/. Accessed June 2022

4.         National Department of Health of South Africa. The 2019 National Antenatal HIV and Syphilis Sentinal Survey (ANCHSS) Key Findings. 30th April 2021.   NDOH. Pretoria.

5.         Hoque H, Hoque ME, van Hall, Buckus S,. Prevalence, incidence and seroconversion of HIV and syphilis infections in pregnant women of South Africa. S Afr J  Infect Dis 2021: 36(1) ; 296 -299.

6.         Pillay S, Tooke LJ, Symptomatic congenital syphilis in a tertiary neonatal unit in Cape Town,  South Africa: High mortality and morbidity in a preventable disease. S Afr Med J 2019;109(9):.doi.org/107196/SAMJ.2019v.10919.13817652-658

7.         Pattinson, R. C. and Moodley, J. ‘Saving Mothers 2014-2016: Seventh triennial report on confidential enquiries into maternal deaths in South Africa: Short report’, Department of Health. 2018.doi: 10.2337/dc14-S014. 

8.        Center for Disease and Prevention Control, NCBDDD April 2021.  Congenital Diseases. https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/quick-reference-handbook/congenital-syphilis.html. Accessed June 2022

Introduce a technology that helps patients and healthcare workers to work together to improve maternal and neonatal health by implementing a notification system vis SMS on patient and healthcare worker mobiles. 

The automated SMS will notify patients to take their medication at a specific time daily, notify them 24 hours prior to their next clinic visit about it, and in turn, notify the healthcare worker about the patients who will be coming the next day for their regular check-ups. This SMS system will not require any internet connection or incur extra costs to the patient or the healthcare worker because some areas do not have internet coverage and most patients will not be able to afford the SMS if payment was required. 

All data will be collected by the study leader and solutions will be carried out by all members of the team. The study leader will visit all the primary health clinics in the areas of interest to collect information on all patients with syphilis from medical records, their screening methods, diagnosis, and management. The healthcare workers will also be requested to fill out a questionnaire on their methods for the management of patients with syphilis. Clinic management will be requested to provide the guidelines that are in place for the management of syphilis at their clinic. The methods provided by the healthcare worker will be compared to the guidelines provided by management and the outcomes thereof. New protocols and recommendations will be provided to improve the management of maternal and congenital syphilis and a follow-up visit will be made to monitor the management and the outcomes of patients who received the new protocols and guidelines. 

Education and regular training of healthcare workers on the management of maternal syphilis will be initiated to ensure that proper care is given to the patients. Patients will also be informed and educated about the disease, management, self-care, and prevention methods.

We will also investigate whether the clinic provides any emotional and mental support to all patients with syphilis and recommend a counselor to each clinic.

This solution serves to improve maternal and neonatal health, primary healthcare services, healthcare workers' knowledge, and skills, patient self-care and love, patients' confidence, knowledge, and care for others. Employment rates will also improve as this project intends to appoint a counselor at each clinic to provide emotional and mental support.  

My team consists of 5 members;

1. Study Leader- Dr. Olive Khaliq, Ph.D. in  medical sciences with specialization in obstetrics and gynecology research

2. Emeritus Professor Jack Moodley, specialized gynecologist and renounced researcher in Women's Health and HIV.

3. Dr. Nomakhuwa Tabane- A general pediatrician and Head of the Department, expert in neonatal health and management of diseases

4. Dr. Ahmed Jassen- A neonatologist and expert in the management of infants and with syphilis

5. Dr. Thandeka Khumalo- A specialized gynecologist and district specialist 

We are requesting financial support in making this project possible as this has a long-term implication for primary health services in South Africa. The health care system is currently threatened by a lack of infrastructure, proper equipment, and services to the community. This project may not be able to solve all the issues but will make a difference in the lives of the community

South Africa has a health system that is divided into Primary, Secondary, and Tertiary levels of care. The Primary level is divided into primary health clinics (PHC)and District Hospitals. The latter is staffed by medical doctors (not specialists), nurses, and midwives. In Addition, district hospitals accept referrals from the lowest level of healthcare (the PHC) staffed mainly by nurses and sometimes visited by doctors from the District hospitals.

The current problems: In terms of research, data collection is often retrospective and doesn't focus on 1 specific problem. In fact, it does not include the whole system viz, staffing issues, including administration, nursing, medical doctors, specialists, and generalists,  problems related to equipment functioning, and repairs; shortages in medical supplies (drugs), and alternative medicine. Most importantly, research is solely focused on the patient and their outcome, no research is ever done on the management of the patent by staff. Data is often collected and published but no follow-ups are to determine improvement are done. 

We plan to provide improvement of measurement methods, leverage current systems, and collect information on a common condition that is highly detectable, preventable, and treatable by an evaluation of clinical management of maternal syphilis. Identifying, and provision of information by health professionals to the patient and or family/ partner. 

Follow-up- visits, records, and systems to trace patients who return for follow-up visits, treatments, the use of clinical protocols, methods reporting failures in the system by healthcare workers, and systems at the hospitals that are developed to monitor whether the correct procedures are done and how often. Our system will also include mother and baby investigations at birth and postpartum to ensure treatment is taken and used properly.

Assessments on whether treatment of the condition identified (in this case maternal syphilis and associated sexually transmitted infections such as HIV are not only identified but treated and managed adequately. 

We intend to involve the Health System via the condition "syphilis in pregnancy" by including the Administration and Senior Nursing staff to evaluate the presence of clinical guidelines, adherence to the guidelines, whether the outcomes are recorded, follow-ups are done, and what is done in cases where management of the condition fails. 

Staff training will be implemented at community health clinics on the management of syphilis in pregnancy and in infants, and patient awareness campaigns will be strongly advised. An appointment of a professional counselor at these clinics will be introduced to support all syphilis and HIV-positive patients. Feedback by physical reporting with the administration on findings and improvement 6 months later will be done. To ensure that progress is made, the administrator will be required to provide information on patient files to assess the management of syphilis. A system will be employed to ensure sufficient availability of medical supplies and regular communication with District hospitals in cases where referrals are required. The Department of Health will be urged to employ a person assigned to control supplies and ensure that items are available at all times. e.g. presence of rapid testing kits, the presence of antibiotics for the treatment, and referral patterns of positive mothers and babies. 

This should work towards improving maternal and fetal management in primary healthcare facilities in South Africa and perhaps other surrounding countries.

The main goal is to reduce maternal and fetal morbidity and mortality in LMICs.

The goal for the next year is to improve maternal and congenital syphilis treatment by:

-Employing unusual proxy data sources to inform primary healthcare performance improvement

-Promote interactions with the healthcare workers on the management, continuation of training and education  on syphilis and  associated sexually transmitted diseases 

-Feedback by physical contact with the administration on findings and the need to modify protocols if necessary.

Depending on the success rate of our plan of action next year, 

In the next five years,  we intend to employ the above-mentioned system to manage chronic illnesses such as hypertension, diabetes, and HIV in primary health care clinics to improve the management of these diseases by both healthcare workers and patients. 

Patients with chronic illness require close and monitoring as they are susceptible to other bacterial and viral infections. We intend on drawing up protocols for regular screening of other infections while ensuring proper management of existing illnesses. Workshops will take place on a weekly bases on a different day each week to ensure that all patients attend whereby brief lectures and discussions will take place and patients will be taught and informed about their existing conditions, how to manage them at home, how to identify serious symptoms and when to contact the doctor. A counselor will be placed at each clinic to provide emotional support to all patients. 

To ensure that the patient is compliant with their treatment and clinic check-ups, a system will be introduced whereby an automated notification will be sent to the patient via their mobile and to the nursing staff's email or mobile a day before the patient's next visit. In this way, the healthcare worker can re-visit the patient file to prepare for the next day's visit. In addition, the patient will also receive a scheduled plan on the time to take their medication and this will be included in their mobile device to provide notifications on taking their medications, to warrant adherence and compliance to treatment.  

Prior to employing a new system of protocols and guidelines, information on the patients for the last two years will be collected, and healthcare workers and clinic managers will be required to fill out a questionnaire on the current protocols and guidelines followed to manage maternal and congenital syphilis. From this, gaps will be identified and new protocols will be created to improve the existing guidelines and protocols. A new notification system will be employed on patient mobile devices to ensure compliance and adherence to medication and clinic visits. Automated emails and or sms will be created to notify the healthcare workers on the patient's next visit. Six months after the new methods have been implemented, a clinical audit will be done by viewing the medical records of newly managed patients and their outcomes. These will be compared to those of patients managed before the implementation of the new method. 

Currently, LMICs face the highest maternal and neonatal morbidity and mortality due to several factors that require a lot of time to overcome. Nonetheless, the solution we have in place is simple, quick, and easy to achieve. One of the main reasons why we have the highest maternal and neonatal morbidity and mortality is clinical governance, negligence and delays to visit the clinic, not being compliant and adherent to treatment, and emotional instability. This solution will bring improve services provided to patients and increase nursing skills in terms of disease management as regular training of staff will be advised. Patient self-awareness and a fundamental understanding of their condition will improve the way they manage themselves outside the clinic and their perceptions of the illness will change positively. 

The SMS technology will be used to empower my solution as these do not require internet service to operate. Most areas in LMICs are deprived of internet coverage but cell phone reception is available.

A notification system vis SMS will be used to ensure patient compliance and adherence to medication and to prevent missed clinic visits. The nursing staff at community clinical are overburdened and understaffed. They are, therefore, unable to remember each patient's next visit and their condition. The SMS system will bring a change to the situation because the nursing staff will be notified about the patient and they can then go through their medical file the day before for proper assistance the next day. 

The project has four members and will take place in two provinces in South Africa. One study will be in the Free state province where I, as the PI, will be in charge of collecting data and the other will be the in KwaZulu-Natal province where a district specialist will be in charge of data collection.

A data sheet that includes all patient demographic and clinical data will be used to collect information from the medical records of all patients with maternal syphilis, and the management and outcome of the patients will also be recorded. Following this, the nurses and midwives on site will be requested to fill out a questionnaire about their methods of maternal and congenital management, these will be tested against guidelines provided by the clinic manager and the information recorded in the medical files. 

There are 5 members in the group, two males and 3 females. The members stem from different cultures of different geographical regions in South Africa. All members have contributed equally to the success of the solution. In this team, the leader is a Ph.D. graduate researcher (female) while the other 3 are professional clinicians with the required expertise to reach the required goal. The geographical locations aimed at are two different Provinces with different cultures languages and religions. However, this project intends to include all the diverse groups situated in the different provinces to bring equal change in services provided and to reach one and the same goal.

The members of the team have mutual interests which are to improve maternal and neonatal health in South Africa. There are no conflicts of interest among the members and there is understanding and respect among them.

Healthcare workers-Regular training and education on the management of Maternal and Congenital syphilis will be introduced in all primary healthcare clinics.

Patient Support- Workshops will be held on a weekly basis (different days each week) to educate patients about syphilis, and other sexually transmitted diseases. Patients will learn about self-care and management of syphilis and prevention. A counselor will also be appointed at each community clinic to provide emotional support to all patients who need it.

Notification system- An SMS system will be activated on each patient's mobile device to automatically notify them to take their medication and to remind them about their next hospital visit. The healthcare workers will also receive an automated SMS about the patients who will be revisiting the clinic. This notification will help prepare each patient accordingly.

New protocols-If the guidelines currently practiced do not improve the health of the patients, new protocols will be created to ensure proper management and new guidelines will be added to existing ones for a better outcome.

Funding from grant opportunities such as the Bill Gates Foundation will be applied to support the business model explained in the previous question. 

Funding will be required to cover transport costs to all the community clinics, provide consumables for data collection, and implement the SMS technology for all the patients and healthcare workers cost-free. 

As this is a newly designed project, no funding has been applied for except for the current application. However, other studies that we are actively involved with, where the chief goal is improving maternal and neonatal health have successfully received funding from the South African Medical Council and the National Research Funding.