MJA: Congenital syphilis: still a reality in 1996

2: Action plan for prevention of congenital syphilis

Raise awareness of need for antenatal care in affected communities

In our experience, women who had a stillbirth or a baby with congenital syphilis were not aware that lack of appropriate antenatal care could threaten the life or health of their baby. Effective campaigns that raise public awareness of problems associated with lack of adequate antenatal care must be seen as a priority.

Provide culturally appropriate services

Public antenatal care programs should be examined at the local level, with community input, to see whether they truly meet the needs of those most at risk, and the services should be continually evaluated -- these are matters of high priority.

Involve the community in efforts to prevent syphilis

There must be more community involvement in efforts to prevent syphilis. ¹ A study in New York City showed that only 34% of the mothers who delivered congenitally syphilitic infants had received any antenatal care. ²² In recent cases in northern Australia, some of the mothers of infants with congenital syphilis had never presented for antenatal care. ⁶ We must address the fears in young women that prevent them seeking antenatal care, establish a rapport with communities where there is a high prevalence of syphilis, and together, in a genuine partnership, rethink our approach.

Improve notification and surveillance systems

Developing a widely accepted case definition for congenital syphilis, and an improved national notification system, is obviously important to any control activity. Difficulty in achieving consensus between State and Territory health departments should not be allowed to jeopardise this vital public health measure.

Healthcare professionals involved in pregnancy care (particularly in regions with high prevalence) should be educated about the importance of notification and of proper treatment and follow-up protocols -- this must be made a public health priority.

Screen unbooked pregnant women for syphilis

Pregnant women presenting to a maternity unit without prior booking must be screened for syphilis, so that the result can be made available while they are still in the unit, and treatment can be provided if a positive diagnosis is made; similarly, their newborn infants should never be discharged from care until the mother's syphilis status is known. ²³

Ensure appropriate management of pregnant women with syphilis

Any pregnant woman with positive specific treponemal test results should be considered infected and offered treatment, unless a clear history of adequate treatment and subsequent sequential decline of serological titres is available. A minimum standard of care must include:

Appropriate antibiotic therapy

Careful screening for other STDs

Referral of partner(s) to a sexual health service for diagnosis, treatment and contact-tracing

Instructions to refrain from sexual activity during treatment

Regular follow-up of RPR or VDRL to ensure that titres steadily decline to low levels.

It must be recognised that treatment failures do occur despite apparently satisfactory treatment protocols, and careful specialist review and follow-up of the newborn is mandatory.

Employ new techniques for diagnosis if appropriate

The diagnosis of congenital syphilis remains difficult. ²⁴ More accurate diagnosis, particularly in the infants of mothers who have been inadequately treated in pregnancy, will come with the wider use of new techniques (e.g., western blot supplementing fluorescent treponemal antibody-absorption [FTA-ABS] IgM tests on serum, and polymerase chain reaction [PCR] tests on cerebrospinal fluid), ²⁵ although it is uncertain how useful this new technology will be in remote Australia.

However, every effort should be made to make a definitive diagnosis of syphilis in stillbirths -- PCR testing on fetal and placental tissue is likely to considerably assist this process in the near future.