As the sun clears the fog on a Tuesday morning Sandra (not her real name), readies herself for her antenatal clinic at the Ngara Health Centre where she has been seen for the last three months.
It is at the same facility that she found out she had a condition that would have put her child at risk had it not been identified as early as it was – syphilis.
Syphilis is a bacterial disease that was once at the brink of eradication, but which is now becoming a cause for concern among health workers who are in a mad rush to ensure it is done away with, especially among pregnant women.
Two decades ago, syphilis infection rates were so low that public health officials believed eradication was on the horizon, however, it is raging once again despite the availability of effective treatments and reliable prevention strategies.
It is quickly becoming one of the most common sexually transmitted infections globally, with approximately six million new cases each year, and the second most common cause of stillbirth in the world.
In its Global Health Sector Strategy on Sexually Transmitted Infections 2016–2021, the World Health Organization (WHO) states that syphilis in pregnancy leads to over 300,000 foetal and neonatal deaths each year, and places an additional 215,000 infants at increased risk of early death.
Syphilis infections
The global health body estimates that two million syphilis infections occur among pregnant women annually, with 65 per cent of cases being spread through sexual contact.
The disease starts as a painless sore, typically on the genitals, rectum or mouth. According to WHO, it spreads from person to person via skin or mucous membrane contact. Without treatment, syphilis can severely damage the heart, brain or other organs, and can be life-threatening.
It can be passed on through sex without a condom, sharing needles and injecting equipment and from mother-to-child during pregnancy. The latter is the major cause for concern, and in an effort to try and close the gap, WHO released a policy brief recommending that countries offer a single finger-prick rapid diagnostic test that screens for HIV and syphilis simultaneously.
This is the simple test that Sandra took. Because it can be carried out in health facilities, she was shortly after informed that she had syphilis.
However, because the dual test does not differentiate between active or past syphilis infection, a past syphilis infection may still produce a positive result. For this reason, the WHO recommends that any woman testing positive for syphilis be prescribed benzathine penicillin then referred for further testing for a confirmatory diagnosis.
If a pregnant woman who is infected does not receive early and effective treatment, she can transmit the infection to her unborn infant. This is known as congenital syphilis, which is often fatal. It can also cause low birth weight, prematurity, and other deformities.
The Centers for Disease Control and Prevention (CDC) states that having syphilis can also make it more likely you will deliver your baby too early or stillborn.
“An infected baby may be born without signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies can have health problems such as cataracts, deafness, or seizures, and can die,” states the CDC.
Preventable
Dr Simon Kigondu, the secretary-general of the Kenya Medical Association and a gynaecologist in Murang’a County adds states that congenital syphilis is easily preventable and treatable.
“The risk of adverse outcomes to the foetus is minimal if a pregnant woman receives testing and adequate treatment with benzathine penicillin early in pregnancy, ideally before the second trimester,” he says.
He notes that there are some things health workers look at that can lead to suspicion of syphilis among pregnant women, like recurrent miscarriages during the second trimester. When these are overlooked and a woman delivers a child with syphilis then the baby could end up deformed, have milestone delays, experience brain convulsions if it goes to the brain, have rushes, and have a big liver and spleen, among other complications
The outcomes for congenital syphilis are why the medics attending to Sandra advised her to take the test when she attended her first antenatal clinic. Being a single woman, she attended the clinic alone and took the Venereal Disease Research Laboratory (VDRL) test. She says she was confused when the health worker attending to her told her that she would have to take another test.
Dr Kigondu explains that the reason why a person who tests positive on the VDRL test has to take another test is because VDRL is only used for screening and can give a false positive. He adds that the test is used because of its simplicity, sensitivity and low cost. A second test is taken to confirm whether the syphilis is active.
“When we have a patient with suspected syphilis, it is advisable to perform the testreponemal haemagglutination (TPHA) test, which is a diagnostic test,” he says. The TPHA test confirmed Sandra’s worst fears; she had syphilis. She did not know how and when she had contracted the virus and was asked to contact her partner and have him tested fas well.
“I do not know where I may have contracted it and I could not confirm whether it was the father of the child who gave it to me. So I just called him and told him to go get tested,” she says.
She became worried when the doctor told her that after initial infection, the syphilis bacteria can remain inactive in the body for decades before becoming active again. She only got some sense of relief when he added that early syphilis can be cured, sometimes with a single injection of penicillin. Where she contracted syphilis from is something that lingers in her mind, says Sandra, as she wonders how she got a disease she had never heard of before.
“I just do not know how I got it. When I inquired about the symptoms I found it hard to believe I had the virus yet I have none of the symptoms the doctor mentioned,” says Sandra.
Dr Kigondu says the answer is simple: “Many people with syphilis won’t notice any symptoms for years, so, if you think there’s a chance you could have syphilis, don’t wait for symptoms to develop, just go for a test. Without treatment a syphilis infection develops through different stages and can become more serious, spreading to other parts of the body.”
Syphilis, Dr Kigondu explains, has four stages of clinical presentation, starting with the primary phase characterised by a cut or wound (chancre) at the site of entry that is painless and relatively clean.
“At this stage, it may go unnoticed for the patient but if left untreated it persists for about five weeks and then heals spontaneously,” he says.
Secondary stage
Next is the secondary stage, in which the bacteria spreads widely throughout the body about three to six weeks after the appearance of the ulcer. The CDC notes that common symptoms of secondary syphilis include skin rashes, itch (mainly on the palms and soles), generalised lymphadenopathy and mucosal ulceration, among others. All manifestations of secondary syphilis resolve with or without treatment.
The latent stage is asymptomatic, after resolution of the clinical manifestations seen in secondary syphilis. However, during this stage the patients have a positive syphilis serology test.
The last stage is tertiary syphilis, which can affect different organs, including the heart, blood vessels, brain (neurosyphilis) and the eyes (ocular syphilis). Neurosyphilis may present with severe headaches, difficulty in coordinating muscular movements, paralysis and numbness. Ocular syphilis, which can be associated with neurosyphilis, may lead to decreased visual acuity, including permanent blindness. Both ocular syphilis and neurosyphilis can occur at any stage of syphilis.
There are four different forms of neurosyphilis, with the most common being asymptomatic other forms are general paresis, meningovascular and tabes dorsalis.
General paresis is a problem with mental function due to damage to the brain from untreated syphilis that attacks the brain and nervous system. It often begins about 10 to 30 years after infection.
Meningovascular or syphilitic meningitis is a potential complication whose symptoms usually first occur in the early stages of infection. The CDC states that syphilitic meningitis may be asymptomatic at first, or there may be symptoms similar to those of other forms of meningitis. These symptoms can go unnoticed or be mistaken for another illnesses, such as the flu. If left untreated, it can progress and resurface years or even decades later with more serious symptoms such as stroke, paralysis, or heart disease.
Complication
Although rare, tabes dorsalis is a complication of untreated syphilis that involves muscle weakness and abnormal sensations. It is also a complication of late stage syphilis infection.
In July, WHO stated that there are unacceptably high global prevalence levels of syphilis, especially among men who have sex with men, which “underscores the need to advance stalled progress toward eliminating syphilis as a public health threat by 2030”. WHO has set ambitious targets to reduce the incidence of syphilis by 90 per cent by 2030, but the global response has been slow.
“While there have been modest reductions in congenital syphilis as a result of the scale-up of interventions in antenatal care, such as syphilis screening and treatment for pregnant women, there is an urgent need to galvanize momentum and better serve other priority populations disproportionately impacted by the disease, “WHO says in a newsletter.
In Kenya, syphilis is often grouped with other sexually transmitted diseases such as HIV, chlamydia and gonorrhoea, resulting in little information on the disease.
A study conducted by the National AIDS and STI Control Programme (Nascop) found that among people who inject drugs, STI prevalence was higher than that of the general population. The study shows that chlamydia ranked highest at 4.2 per cent, followed by syphilis (1.7 per cent) and gonorrhoea (1.5 percent).
HIV acquisition
A study conducted by researchers from Kenyatta University, Ministry of Health and Unicef states that syphilis also facilitates HIV acquisition. The researchers say that Kenya’s commitment to reduce mother to child transmission of HIV and syphilis to below 5 per cent requires the country to improve syphilis screening and testing. This is because for years, the Kenya syphilis testing did not catch up with HIV testing at the first antenatal clinic.
The researchers found that out of 289,875 women who visited their first antenatal clinic in October to December 2016, 277,196 (95.6 per cent) were tested for HIV and 12,161 (4.3 per cent) tested HIV. Those screened for syphilis were 211,546 (72.9 per cent) out of which 2,396 (1.1 per cent) women tested positive.
Between October to December 2017, a total of 336,512 women made antenatal clinic visists, 306,573 (91.1 per cent) them tested for HIV and 15,056 (4.9 per cent) turned positive while 262,567 (78 per cent) were tested for syphilis and 3,072 (1.2 per cent) were positive.
In period in 2018, 336,687 women visited antenatal clinics and 298,598 (88.9 per cent) were tested for HIV, with16, 5805 (6 per cent) turning positive while 307,842 (91 per cent) tested for syphilis and 3,464 (1.1 per cent) tested positive.
The study was conducted in an effort to find out the extent of adherence to syphilis testing among pregnant women so as to establish if Kenya could achieve its plan to eliminate mother-to-child transmission of HIV and syphilis by 2022.
Kenya introduced the HIV and syphilis test kit used in antenatal clinics in March 2018.
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