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PubMed2005

Misclassification of the stages of syphilis: implications for surveillance.

SHORT SUMMARY: Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested. BACKGROUND: Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions. OBJECTIVE: Assess validity of reported syphilis stages. METHODS: Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions. RESULTS: Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age < or =35 and nontreponemal test titer > or =32) was often misinterpreted to mean "not known." Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers. CONCLUSIONS: The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

Adult↗
PubMed2006

Correlates of syphilis seroreactivity among pregnant women: the HIVNET 024 Trial in Malawi, Tanzania, and Zambia.

OBJECTIVES: The objectives of this cross-sectional study were to determine correlates of syphilis seroprevalence among HIV-infected and -uninfected antenatal attendees in an African multisite clinical trial, and to improve strategies for maternal syphilis prevention. RESULTS: A total of 2,270 (86%) women were HIV-infected and 366 (14%) were HIV-uninfected. One hundred seventy-five (6.6%) were syphilis-seropositive (7.3% among HIV-infected and 2.6% HIV-uninfected women). Statistically significant correlates included geographic site (odds ratio [OR] = 4.5, Blantyre; OR = 3.2, Lilongwe; OR = 9.0, Lusaka vs. Dar es Salaam referent); HIV infection (OR = 3.3); age 20 to 24 years (OR = 2.5); being divorced, widowed, or separated (OR = 2.9); genital ulcer treatment in the last year (OR = 2.9); history of stillbirth (OR = 2.8, one stillbirth; OR = 4.3, 2-5 stillbirths); and history of preterm delivery (OR = 2.7, one preterm delivery). CONCLUSION: Many women without identified risk factors were syphilis-seropositive. Younger HIV-infected women were at highest risk. Universal integrated antenatal HIV and syphilis screening and treatment is essential in sub-Saharan African settings.

Adolescent↗
PubMed2007

Demonstrating public health at work: a demonstration project of congenital syphilis prevention efforts in Bolivia.

OBJECTIVES: We introduced syphilis immunochromatic strip (ICS) tests into antenatal care (ANC) settings in Bolivia and evaluated feasibility, patient and provider acceptability, and introduction costs. We conducted complementary studies on related topics, strengthened quality of care, and aided the response to sensitive aspects of maternal/congenital syphilis control (e.g., partner notification). GOAL: The goal of this study was to discuss our experience working with Bolivian stakeholders to document potential public health benefits of syphilis ICS test introduction in ANC settings. STUDY DESIGN: We trained public health personnel and offered the Abbott Determine Rapid Syphilis TP test in 4 urban maternity hospitals and 37 rural clinics. RESULTS: Using the ICS test, 11,618 women were tested for syphilis; 5% had positive results and 93.2% received treatment. Women and health personnel found the test acceptable and introduction costs were not prohibitive. CONCLUSIONS: Based on these findings, by mid-2006, the Bolivian Ministry of Health will offer the ICS tests in rural ANC settings.

Adult↗
PubMed1980

Antibodies in secondary syphilis against five of forty Reiter treponeme antigens.

More than forty water-soluble antigens were found in the Reiter treponeme by crossed immunoelectrophoresis, using isolated and concentrated Ig from immunized rabbits. Five antigens reacted with antibodies in sera from selected patients with secondary syphilis, all having strong reactions in traditional tests for syphilis. No antibodies were found in selected healthy controls nonreactive in traditional syphilis tests. The five antigens represent available and potentially valuable antigens for development of new diagnostic syphilis tests. One of the antigens probably represents the axial filament. The findings open new possibilities for precise immunochemical studies of treponemes and of the immunology of syphilis.

Antibodies, Bacterial↗
PubMed1987

Evaluation of the Bio-EnzaBead test for syphilis.

The sensitivity and specificity of the Bio-EnzaBead test for syphilis and the fluorescent treponemal antibody-absorption (FTA-ABS) test were determined by examining 262 serum samples, including 202 serum samples from patients with confirmed syphilis in various stages. Overall correlation with patient history was 95.8% with both tests. False-negative Bio-EnzaBead tests occurred in 9 of 86 (10.5%) cases of late-latent syphilis (greater than 2 years) and in 1 of 38 (2.6%) cases for which the stage of disease could not be determined. False-negative FTA-ABS tests occurred in 5 of 86 (5.8%) cases of late-latent syphilis (greater than 2 years) and in 2 of 38 (5.3%) cases for which the stage of disease could not be determined. One false-positive test occurred with Bio-EnzaBead, and the cause could not be determined. The reproducibility of the Bio-EnzaBead test was excellent when spectrophotometric readings were calibrated against either air or substrate blanks. The Bio-EnzaBead test for syphilis is a suitable alternative to the FTA-ABS test.

Enzyme-Linked Immunosorbent Assay↗
PubMed2006

Is serological testing a reliable tool in laboratory diagnosis of syphilis? Meta-analysis of eight external quality control surveys performed by the german infection serology proficiency testing program.

The accuracy of diagnostic tests is critical for successful control of epidemic outbreaks of syphilis. The reliability of syphilis serology in the nonspecialist laboratory has always been questioned, but actual data dealing with this issue are sparse. Here, the results of eight proficiency testing sentinel surveys for diagnostic laboratories in Germany between 2000 and 2003 were analyzed. Screening tests such as Treponema pallidum hemagglutination assay (mean accuracy, 91.4% [qualitative], 75.4% [quantitative]), Treponema pallidum particle agglutination assay (mean accuracy, 98.1% [qualitative], 82.9% [quantitative]), and enzyme-linked immunosorbent assays (ELISAs) (mean qualitative accuracy, 95%) were more reliable than Venereal Disease Research Laboratory (VDRL) testing (mean accuracy, 89.6% [qualitative], 71.1% [quantitative]), the fluorescent treponemal antibody absorption test (FTA-ABS) (mean accuracy, 88% [qualitative], 65.8% [quantitative]), and immunoblot assays (mean qualitative accuracy, 87.3%). Clearly, immunoglobulin M (IgM) tests were more difficult to manage than IgG tests. False-negative results for samples that have been unambiguously determined to be IgM and anti-lipoid antibody positive accounted for 4.7% of results in the IgM ELISA, 6.9% in the VDRL test, 18.5% in the IgM FTA-ABS, and 23.0% in the IgM immunoblot assay. For negative samples, the mean percentage of false-positive results was 4.1% in the VDRL test, 5.4% in the IgM ELISA, 0.7% in the IgM FTA-ABS, and 1.4% in the IgM immunoblot assay. On average, 18.3% of participants misclassified samples from patients with active syphilis as past infection without indicating the need for further treatment. Moreover, 10.2% of laboratories wrongly reported serological evidence for active infection in samples from patients with past syphilis or in sera from seronegative blood donors. Consequently, the continuous participation of laboratories in proficiency testing and further standardization of tests is strongly recommended to achieve better quality of syphilis serology.

Antibodies, Bacterial↗
PubMed1989

Rheumatoid factor in congenital syphilis.

The rheumatoid factor (RF) latex test was evaluated as a test for congenital syphilis. High risk newborns of mothers with untreated or inadequately treated syphilis were studied. The asymptomatic infants were followed up for between 3 and 4 months (or longer if the VDRL test was positive). The overall performance of the RF latex test was better than that of the other tests studied, even though the sensitivity was 46.7%. The specificity and positive predictive value of the test were 100% whilst the negative predictive value was 86.4%. The test was negative in all 84 controls studied. Although a negative RF latex test cannot be used to exclude congenital syphilis in an asymptomatic infant, a positive test in the presence of maternal syphilis should lead one to strongly suspect congenital syphilis.

Humans↗
PubMed1995

Serological screening for sexually transmitted infections in pregnancy: is there any value in re-screening for HIV and syphilis at the time of delivery?

OBJECTIVE: The aim of this study was to assess the prevalence of syphilis, human immunodeficiency virus (HIV), and hepatitis B virus (HBV) infections in women at the time of delivery, and to determine the seroconversion rates for syphilis and HIV infections from initial booking visit to delivery. SETTING: The labour ward of a typical tertiary hospital in a developing country and serving an indigent African population. METHOD: Four hundred and eighteen women presenting in labour were randomly selected and informed consent obtained for serological testing for syphilis and HBV infections in umbilical cord blood samples. The specimens were then given a study number, the gestational ages recorded and anonymously tested for HIV infection. RESULTS: Of the 191 women who had antenatal care, 13 (6.8%) were HIV antibody positive at the initial "booking" visit. An additional 4 were found to be HIV antibody positive at the time of delivery resulting in a seroconversion rate of 2.2%. The seroconversion rate for syphilis at the time of delivery was 2.7%. Hepatitis B surface antigens were detected in only 2 women, one of whom was antigen positive. CONCLUSION: The high seroconversion rates for both syphilis and HIV infection in pregnancy justifies re-screening for these conditions in endemic areas such as ours.

Delivery, Obstetric↗
PubMedDate not supplied

A preliminary evaluation of a prototype western blot confirmatory test kit for syphilis.

A prototype Western blot kit was evaluated as a confirmatory test for syphilis using 131 sera characterized by other serological tests for syphilis. There were 114 treponemal sera (including 94 cases of early syphilis, 83 of which were untreated) and 17 non-treponemal problem sera (11 gave false positive reactions on screening with the TmpA recombinant antigen enzyme immunoassay (EIA), 3 gave false positive fluorescent treponemal antibody absorbed (FTA-abs) tests, and 3 false positive Captia Syphilis G EIA results). Based on the manufacturer's criteria of reactivity in multiple bands for designating a positive result the Western blot test gave a sensitivity of 99.1% (113/114) and a specificity of 88.2% (15/17) when indeterminate reactions were scored positive and 98.2% (112/114) and 100% (17/17) when indeterminate reactions were scored negative. Sensitivity was high in both treated and untreated infection. Corresponding sensitivities for the TPHA and FTA-abs when equivocal reactions were scored negative were 97.5% (111/114) and 99.1% (113/114). The high sensitivity of the FTA-abs in this study is probably due to the large number of untreated primary infections. Our results with the Western blot, confirm earlier studies using 'in-house' test systems and, support a role for a commercial Western blot test in the confirmatory diagnosis of syphilis. Further studies are required to confirm the high specificity and sensitivity of the kit in a larger series including a wider variety of non-treponemal cases as well as patients with untreated and treated infection.

Blotting, Western↗
PubMed2000

Epidemiology of syphilis in Bulgaria, 1990-1998.

There have been great political, social and economic changes in Bulgaria since 1990 with higher incidences of syphilis when compared with the previously controlled morbidity of syphilis. There has been a 7-fold increase in 1998 compared with 1990. The male/female ratio remained the same 1.2:1. A higher number of cases was reported in cities than in villages and small towns, 80.68% in 1990; 73.4% in 1998. The number of employed patients with syphilis has decreased during the years--from 75.5% in 1990 to 44% in 1998, with a corresponding increase in syphilis in the unemployed. The age group at highest risk is 20-24 years, 28.7% in 1991; 24% in 1998. The least affected group are those older than 55--the incidence being 6.34% in 1990; 2.6% in 1997 and 4% in 1998. The prevalence of the different stages of early infection remained the same. The incidence of congenital syphilis increased from 1 in 1990 and 1991 to 21 in 1996, 29 in 1997 and 35 in 1998.

Adult↗
PubMed1996

Adequately Treated Remote Syphilis Does Not Augment CNS HIV-1 Expression.

OBJECTIVE: The co-occurence of human immunodeficiency virus (HIV) infection and syphilis may accelerate the course of both infections. We investigated whether remote syphilis infection augmented the activation of central nervous system (CNS) HIV infection and increased the frequency of cerebrospinal fluid (CSF) abnormalities. METHODS: The subjects consist of HIV seropositive men who had CSF as part of prospective neurological studies performed at the Johns Hopkins University. Prior syphilis infection was determined by measuring serum FTA-ABS. All subjects had received adequate treatment for syphilis with negative RPR's or RPR's &le; 1:8 and completed a full neurological examination and underwent lumbar punctures for analysis of cerebrospinal fluid. A range of CSF tests were performed including HIV culture, p24 antigen, &beta;2 microglobulin (&beta;2M) and CSF/albumin ratios. RESULTS: The FTA positive group was significantly older (p = .005), more advanced in HIV clinical staging (p = .04), had more minor neurological symptoms (p = .03), and was more likely to be on antiretroviral therapy (p = .03). No differences between FTA positive and FTA negative groups were observed either in the frequency of CFS anbormalities or the mean CSF values. CONCLUSIONS: Based on these findings, it appears that adequately treated remote syphilis does not augment HIV-1 expression within the CNS.

Cerebrospinal Fluid↗
PubMed1999

Pituitary gland gumma in congenital syphilis after failed maternal treatment: a case report.

A preterm, very low birth weight infant was born to a mother with early latent syphilis who was treated 10 days and 3 days before delivery with 2.4 mU of benzathine penicillin. The infant had clinical, laboratory, and radiographic abnormalities consistent with congenital syphilis, ie, a Venereal Disease Research Laboratory test titer that was fourfold greater than was the maternal titer, hepatosplenomegaly, abnormal liver function tests, pneumonitis, osteochondritis of the long bones, and cerebrospinal fluid (CSF) examination showing a reactive Venereal Disease Research Laboratory test, pleocytosis, and elevated protein content. The infant died on the third day of life, and an autopsy revealed an evolving gumma of the anterior pituitary. Immunoglobulin M immunoblotting of serum and CSF was positive, and polymerase chain reaction detected Treponema pallidum DNA in endotracheal aspirate and CSF. This case highlights the pathologic abnormalities observed in congenital syphilis and focuses on the rare finding of an evolving anterior pituitary gumma. Furthermore, it documents the failure of maternal syphilis treatment during the last 4 weeks of pregnancy to cure fetal infection and supports the recommendation that all infants born to mothers with syphilis treated during the last 4 weeks of pregnancy should receive penicillin therapy.

Female↗
PubMed2001

An outbreak of syphilis in Alabama prisons: correctional health policy and communicable disease control.

OBJECTIVES: After syphilis outbreaks were reported at 3 Alabama State men's prisons in early 1999, we conducted an investigation to evaluate risk factors for syphilis infection and describe patterns of syphilis transmission. METHODS: We reviewed medical, patient interview, and prison transfer records and documented sexual networks. Presumptive source cases were identified. Odds of exposure to unscreened jail populations and transfer from other prisons were calculated for case patients at 1 prison. RESULTS: Thirty-nine case patients with early syphilis were identified from 3 prisons. Recent jail exposure (odds ratio [OR] = 8.0, 95% confidence interval [CI] = 0.3, 158.7, P = .14) and prison transfer (OR = 32.0, 95% CI = 1.6, 1668.1, P < .01) were associated with being a source case patient. CONCLUSIONS: Probable sources of syphilis introduction into and transmission within prisons included mixing of prisoners with unscreened jail populations, transfer of infected inmates between prisons, and multiple concurrent sexual partnerships. Reducing sexual transmission of disease in correctional settings is a public health priority and will require innovative prevention strategies.

AIDS Serodiagnosis↗
PubMed1996

Congenital syphilis: still a reality in 1996.

Despite the widespread use of penicillin for more than 50 years, syphilis continues to be a problematic health issue in many parts of the world. In Australia, congenital syphilis is again a significant cause of stillbirth, preterm labour and neonatal disease in some areas (including central and northern Australia). Control mechanisms based on screening, reliable treatment protocols, contact-tracing and adequate follow-up appear to be less effective than they were in the past. It is difficult to discuss such a socially stigmatizing disease when it is clear that some community groups are at high risk, and may be offended by and feel disempowered in the face of well-meaning medical debate. If congenital syphilis is to be eradicated, new approaches are required. These include public-awareness campaigns to stress the need for antenatal care in affected communities; involving the community in efforts to prevent syphilis; providing culturally appropriate services; improving notification and surveillance systems; improving the management of pregnant women who present to maternity units without prior booking; and improving the management of syphilis in pregnancy. There is a need to raise awareness that antenatal care is important not only for the mother's health but also for the wellbeing of the baby.

Australia↗
PubMed1999

Declining syphilis prevalence in pregnant women in Nairobi since 1995: another success story in the STD field?

Untreated maternal syphilis during pregnancy will cause adverse pregnancy outcomes in more than 60% of the infected women. In Nairobi, Kenya, the prevalence of syphilis in pregnant women of 2.9% in 1989, showed a rise to 6.5% in 1993, parallel to an increase of HIV-1 prevalence rates. Since the early 1990s, decentralized STD/HIV prevention and control programmes, including a specific syphilis control programme, were developed in the public health facilities of Nairobi. Since 1992 the prevalence of syphilis in pregnant women has been monitored. This paper reports the findings of 81,311 pregnant women between 1994 and 1997. A total of 4244 women (5.3%) tested positive with prevalence rates of 7.2% (95% CI: 6.7-7.7) in 1994, 7.3% (95% CI: 6.9-7.7) in 1995, 4.5% (95% CI: 4.3-4.8) in 1996 and 3.8% (95% CI: 3.6-4.0) in 1997. In conclusion, a marked decline in syphilis seroprevalence in pregnant women in Nairobi was observed since 1995-96 (P<0.0001, Chi-square test for trend) in contrast to upward trends reported between 1990 and 1994-95 in the same population.

Female↗
PubMed1999

Congenital syphilis--United States, 1998.

Congenital syphilis (CS) occurs when the spirochete Treponema pallidum is transmitted from a pregnant woman with syphilis to her fetus. A multiorgan infection, CS may result in a neurologic or musculoskeletal handicap or death in the fetus when not properly treated. Trends in CS rates in women of childbearing age follow by approximately 1 year the rates of primary and secondary syphilis. The last national syphilis epidemic, which was followed by a CS epidemic, occurred during the late 1980s and early 1990s. The syphilis rate began to decline in 1991; the CS rate began to decline in 1992. To evaluate CS epidemiology since this decline, CDC analyzed 1998 CS notifiable disease data and assessed rate changes during 1992-1998. This report summarizes the results, which indicate that the CS rate declined 78.2% from 1992 to 1998, and that rates remained disproportionately high in the southeastern United States and among minority racial/ethnic populations.

Adolescent↗
PubMed1999

[Increase of early syphilis in a red light district in Rotterdam (1995-1997) and preventive treatment].

The number of cases of syphilis in Rotterdam has increased dramatically since 1995. The prevalence of early syphilis in 1997 was highest among street prostitutes (16%). Some prostitutes could not be reached for further evaluation and treatment, probably due to their addiction to hard drugs. Prophylactic treatment for syphilis was given to most street prostitutes in a cruising zone during a screening programme for sexually transmitted diseases (STD) in January 1997. Since then, STD checkups were performed regularly in the cruising zone. The prevalence of early syphilis in the cruising zone dropped to 1.3% in 1998. The total number of reported cases of syphilis in Rotterdam also decreased sharply in 1998.

Adult↗
PubMed2000

[Syphilis and pregnancy. Prenatal control, seroprevalence and false biological positives].

Syphilis may be transmitted vertically, especially if the mother is in an early stage with a high bloodstream treponema concentration, although it may also be transmitted to a lesser degree in late latency, when non-treponemic serology may become negative spontaneously with persistence of treponemic serology. The prenatal control for syphilis is routinely carried out by means of a non-treponemic reaction such as VDRL or rapid plasma reagin (RPR) which, when positive, should be confirmed by treponemic techniques such as fluorescent treponemal antibody absorption (FTA-abs) and/or hemagglutination (MHA-Tp). Prevalence of syphilis should be defined on the basis of positive treponemic reactions. To define the seroprevalence and the validity of these control guidelines, 1,056 pregnant women attending the Hospital de Clínicas for their initial control were evaluated by means of serological treponemic and non-treponemic methods. Serological results disclosed 4 distinct groups. Group 1 (n = 17 or 1.61%) presented both types of reactive tests, while Group II (n = 22 or 2.08%) only presented reactive treponemic tests, and both groups were seroreactive for syphilis. Group III (n = 7 or 0.66%) only showed reactive non-treponemic tests, which were considered biological false-positive (BFP) reactions. Five of them were reactive for antiphospholipid antibodies. Group IV (n = 1,010 or 95.65%) fell to present serological evidence of syphilis. To conclude: 1) global seroprevalence in this population was 3.69%; 2) since 2.08% of pregnant seroreactive mothers had not been detected by routine screening, it would be advisable to perform simultaneous treponemic and non-treponemic techniques for prenatal control. 3) This methodology should identify the BFP tests in the same screening.

Argentina↗