Congenital syphilis: global trends

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1 Sex, Sores, Science and Surveillance: Syphilis in the 21 st Century (UO20) Congenital syphilis: global trends Adriana R. Cruz A. Associate professor Universidad del Valle Research associate CIDEIM Cali, Colombia

2 DISCLOSURES None

3 OBJECTIVES Review global epidemiological trends with emphasis in Latin America and the Caribbean Discuss health systems barriers that lead to CS and potential solutions Describe emerging control strategies

4 INTRODUCTION

5 Congenital Syphilis Early infection in pregnant mother: 20-50% Prematurity 20% Perinatal death 40-50% Congenital syphilis 20% Infected infant 0-20% Healthy child Infected mother Pregnant Pregnant mother Infection Wicher, Wicher, CID 2001 ShafiiT et al, CS Chapter, Holmes KK STDs 2013

6 Congenital Syphilis Rash Hepatomegaly Splenomegaly Anemia Jaundice Snuffles Abnormal bones Pseudoparalysis

7 Castillo-Loaiza S, et al. Pemphigus syphilticus, a case report. Under review.

8 EPIDEMIOLOGY

9 EPIDEMIOLOGY: World wide Global syphilis: 6 million new cases per year / 18 million prevalent cases Gestational syphilis : GS complications: early fetal deaths and stillbirths neonatal deaths preterm or low weight births infected infants WHO Global health sector strategy on STI 2016 Whijesooriya NS, Rochat R, Kamb M, et al, Lancet 2012

10 ADVERSE PREGNANCY OUTCOMES Whijesooriya NS, Rochat R, Kamb M, et al, Lancet 2012

EPIDEMIOLOGY: USA P&S syphilis rate increase: 27.3% 2014-2015 55.6% 2011-2015 10.5 8.4 12.

11 EPIDEMIOLOGY: USA P&S syphilis rate increase: 27.3% % CS 6% % : West: 18.5/ South: 14.4/

12 EPIDEMIOLOGY: Latin America CS cases/ 1000 LB Courtesy Freddy Tinajeros

13 EPIDEMIOLOGY: Colombia Cruz AR, et al. STD 2013

14 HEALTH SYSTEM BARRIERS AND POTENTIAL SOLUTIONS

15 Syphilis Prevention of Mother-to-Child- Transmission (PMTCT) Among the most cost-effective public health interventions in existence Peeling R and Mabey D. Lancet % of syphilis adverse outcomes occur in women who receive ANC at least once! CS prevention would impact 7.7% of all stillbirths. CS should be deemed to be unacceptable even in the weakest health systems Lawn JE, Blencowe H, Waiswa P, et al. Lancet 2016 Whijesooriya NS, Rochat R, Kamb M, et al, Lancet 2012

16 PREVENTION BARRIERS & INTERVENTIONS The Global Elimination of CS Rationale and Strategy for Action, WHO 2006 Schmid G. WHO bulletin. 2004

17 What may happen with an infected pregnant mom in developing countries:

18 Strategies shoot for diagnosis and treatment in the same day:

19 Point-of-Care Tests Rogozinska E, et al. BJOG 2016 Mabey D, et al. PLoS Med 2012

20 2017

21 BP EFFECTIVENESS AND SAFETY One single dose of benzathine penicillin can prevent CS Watson-Jones D et al. JID 2002 Benzathine penicilline is safe for preventing CS 0-3 cases of anaphylaxis / treated Risk of treating GS to prevent CS appears very low and does not outweight its benefits. Galvao TF, Silva MT, Serruya S, Newman LM, Klausner JD et al PLoS One 2013

22 BPG SHORTAGE?? 2015: anecdotal reports of BPG shortage 114 territories were explored, 95 had evaluable information 39 (41%) territories reported shortage 10 countries indicated use of alternative treatments which DO NOT CROSS the placenta Low cost: $0.2USD / 2.4m IU for an injectable drug, that needs to be manufactured under sterile conditions. Nurse-Findlay S et al. PLoS Med 2017 In 2016, BPG was recognized by the World Health Assembly as an essential medicine at high risk for stock-out

23 GLOBAL STRATEGIES

24 Millenium Development Goals: by 2015

Global Health Sector Strategy on STI 2016-2021 - WHO Milestones for 2020: 70% of countries having at least 95% of pregnant

25 Global Health Sector Strategy on STI WHO Milestones for 2020: 70% of countries having at least 95% of pregnant women screened for Syphilis + 95% of seropositive pregnant women treated with at least one dose of IM benzathine penicillin

26 WHERE ARE WE NOW? 2010: PAHO: EMTCT of HIV and Syphilis 2016: Plan of Action for the Prevention and Control of HIV and STI : EMTCT Plus, which embraces the principles and lines of action of the Strategy for Universal Access to Health and Universal Health Coverage.

27 GOOD NEWS! Congratulations!

28 Do you want to help? BASTA is an informal collaboration of key partners interested in eliminating mother-to-child transmission (MTCT) of syphilis. Created by WHO and CDC approximately 10 years ago, BASTA presently has over 100 members working around the world in ministries of health, bilaterals, NGOs, academic centres, professional organizations and civil society BASTA has been instrumental in developing an investment case, identifying priority research topics, and fostering collaborative efforts to eliminate MTCT of syphilis

29 SYPHILIS VACCINE

30 WHY A SYPHILIS VACCINE? Despite the effectiveness of penicillin treatment and continued sensitivity of TP to this antibiotic, syphilis prevention and control has not been successful. Modeling studies have shown that a syphilis vaccine: Reduces syphilis prevalence better than expanded treatment interventions Has significant impact on HIV prevention Champredon D, Cameron C. et al. Epidemiol Infect Lithgow KV, Hof R, Cameron C. et al. Nature 2017

31 IS IT POSSIBLE TO DEVELOP A SYPHILIS VACCINE? Proof of principle for syphilis vaccination: Miller demonstrated sterilizing immunity in rabbits following immunization with intact γ-irradiated Tp Miller JN. J. Immunology 1973

32 WHERE ARE WE WITH A SYPHILIS VACCINE? Lithgow KV, Hof R, Cameron C. et al. Nature 2017

33 WHERE ARE WE WITH A SYPHILIS VACCINE? Lithgow KV, Hof R, Cameron C. et al. Nature 2017

34 KEY NOTES Syphilis is prevalent world wide CS accounts for 7% of all still births CS is 100% preventable Same day diagnosis + treatment is encouraged POC tests + single dose BP WHO Global Health Sector Strategy on STI includes GS and CS as a priority New efforts in syphilis vaccine studies

35 THANK YOU! De Alejandra Quintero Sinisterra - foto para presidencia, CC BY 2.0,

transmission (MTCT) of

transmission (MTCT) of Training Course in Sexual and Reproductive Health Research 2013 Module: Principles and Practice of Sexually Transmitted Infections Prevention and Care Dual elimination of mother-to-child transmission (MTCT)