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Clinical Research in Infectious Diseases

Research Article

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Prevalence and Challenges Associated with Syphilis Screening among Pregnant Women in Dodoma, Tanzania

Kaunara A. Azizi, Tanzania Food and Nutrition Centre, 22 Barack Obama Road, P. O. Box 977, Dar es Salaam, Tanzania, Tel: 255 717 935 154; Email; Submitted: 16 July 2016 Accepted: 28 October 2016 Published: 01 November 2016 ISSN: 2379-0636 Copyright © 2016 Azizi et al. OPEN ACCESS

Kaunara A. Azizi1*, Filemon Tenu2, and Sia E. Msuya3,4 1

Tanzania Food and Nutrition Centre, Tanzania Amani Medical Research Centre, Tanzania 3 Department of Community Medicine, Kilimanjaro Christian Medical University College,Tanzania 4 Department of Community Health, KCMC Hospital, Tanzania

Keywords

2

• Syphilis • Pregnancy • Screening • Challenges • Tanzania

Abstract Objective: The present study was conducted to assess the prevalence of syphilis and screening challenges among pregnant women coming for delivery at Dodoma Regional Hospital. Methods: A review of antenatal/ labor records for deliveries that were conducted from January to December 2010 (n=10,462) at Dodoma Regional Hospital was done to obtain the proportion of women who were not tested for syphilis. A crosssectional study was also carried among 125 pregnant women coming for delivery at the hospital April-May 2011 to collect information on syphilis testing and on facilities where women attended for antenatal care but not tested. Questionnaires were used to obtain relevant information during face to face interviews. Interviews were also conducted with health providers (laboratory staff and heads of RCH clinics) where syphilis testing was not performed to get their views on barriers for syphilis screening. Results: Among the 10, 462 reviewed records of women presenting for delivery in 2010 at Dodoma Regional Hospital, 1120 (11%) were not tested for syphilis at the time of admission to the labour ward. Of the remaining 9,432, seventy one were positive for syphilis, giving a prevalence of 0.8%.Among the 125 interviewed women at admission to the labor ward, 43 (34%) were not screened for syphilis during pregnancy compared to only 3% who were not screened for HIV. The key challenge for syphilis screening reported by health providers was the frequent stock out of rapid syphilis screening tests (Bioline syphilis test). Conclusion and recommendations: A high proportion of pregnant women (34%) coming for delivery were not scrrened for syphilis in Dodoma. Screening for syphilis is cost-effective even when prevalence is 0.1% as recommended by the WHO, hence the health managers of respective clinics should make sure the facilities are getting syphilis testing kits in smooth manner like the HIV kits.

ABBREVIATIONS ANC: Antenantal Care; NACP: National Aids Control Programm; PMCTC: Prevention of Mother to Child Transmission; RCH: Reproductive Child Health; RPR: Rapid Plasma Reagin; STI: Sexually Transmitted Infections

INTRODUCTION

Syphilis remains a major public health problem despite several efforts in treatment and managements [1].Syphilis may

be transmitted from mother to foetus during gestation resulting in congenital syphilis [2]. The bacteria Treponema pallidum usually crosses the placenta after the first trimester and the risk of transmission to the foetus depends partly on the stage of the mother’s infection. Risk decrease with the duration of the mother’s infection but is still significant into the latent period [3,4]. If left untreated, maternal syphilis can have adverse pregnancy outcome including stillbirth, low birth weight, preterm delivery and disease in the new born or early foetus death [5-7].

Cite this article: Azizi KA, Tenu F, Msuya SE (2016) Prevalence and Challenges Associated with Syphilis Screening among Pregnant Women in Dodoma, Tanzania. Clin Res Infect Dis 3(4): 1040.

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Studies in Africa shows an estimates of syphilis seroreactivity among women attending antenatal clinics ranges from 1-15 % [1,8,9]. Of the estimated 19.9 million pregnant women per year in sub-Saharan Africa countries,14.5 million (73%) receive antenantal care but only 5.5 million (38) have access to syphilis screening [10]. In Tanzania only 37% of women accessing antenantal care (ANC) services are tested for syphilis [11]. In many Sub-Saharan African countries guidelines recommend that serological test for syphilis should be done to pregnant women at a time of first prenatal visit and additional test should be done during the third trimester in women suspected at increased risk. In most African countries syphilis screening in pregnant women is a national health policy, but few screening programs achieve universal coverage for testing, mainly due to either logistical or financial constraints [2,12,13]. Tanzania is amongst several countries that recommend single dose benzathine penicillin for the treatment of pregnant women with syphilis as a national policy. In theory, women can thus be tested and treated on the same day if on-site syphilis screening at the ANC is operational [14]. However only 37% of pregnant women were screened for syphilis in 2009 [11]. Reasons for failure to screen despite the policy are not clear.

This study thus aimed to asses proportion of pregnant women screened for syphilis in Dodoma urban, Dodoma. Investigation of bottle necks associated with syphilis screening were also carried out.

METHODS

Study setting The study was conducted at Dodoma Regional Hospital, Dodoma Tanzania. Dodoma Regional Hospital is located in Dodoma region situated in central Tanzania. Dodoma region lies at 40 to 70 latitude South and 350 to 370 longitude East and cover an area of 41,310 km2. According to the 2012 Tanzania national cencus, Dodoma region has a population of 2,083,588 and annual population growth rate of 2.1%. Administratively, the region is divided into 5 districts namely, Dodoma urban, Bahi, Chamwino, Kondoa, Mpwapwa and Kongwa. Each district is futher divided into divisions, wards and villages.

Study design and data collection

We conducted a cross sectional study among women coming for delivery at Dodoma Regional Hospital from April to May 2011. Data was collected in three ways; First; questionnaires with both closed and open ended questions were administered to pregnant women coming for delivery in April and May 2011. All pregnant women coming for delivery and meet inclusion criteria were invited to participate. Informed written consent was sought from every participant prior to participation in the study. Consenting participant undertook interview in Swahili using pretested questionnaires.

Face to face interviews with pregnant women collected information on women’s social demographic characteristics, reproductive and obstetric history of previous and current pregnancy, history of syphilis screening in current pregnancy, and on challenges associated with syphilis screening including Clin Res Infect Dis 3(4): 1040 (2016)

turnaround time of results and difficult with antenatal screening for syphilis. Knowledge on syphilis was also assessed by evaluating their response to questions on transmission, prevention and complication of syphilis. Second; Record review of the antenatal records regarding syphilis sreening was done. The research team reviewed the antenatal/ labour records of women who had delivered from January 2010 to December 2010 to identify eligible participants for the study. Third; Interviews with laboratory personnel and heads of reproductive child health (RCH) of Makole and Aga Khan health facilities was done. They were asked on facilitators and barriers for syphilis screening at their respective facilities.

Ethical clearance

Ethical approval was obtained from KCMU-College Research Ethical Committee. In addition the research team obtained permission to conduct the research from the Dodoma regional hospital authorities. Written informed concent was obtained from all study participants.

Data processing and analysis

Data were cleaned and checked for completeness and consistency before analysis. Analysis was done by using Statistical Package for Social Sciences (SPSS) software version 17.0 (SPSS Inc. Chicago USA). Descriptive stastistics (mean, standard deviation, proportion) was used to summarise the data.

RESULTS

I: Prevalence of syphilis screening during pregnancy and associated factors among interviewed women Characteristics of the women: A total of 125 pregnant women participated in the study. Respondents’ age ranged between 18 and 48 with the mean age of 25.37 (SD, ± 6.4). Majority were not employed (91%), were married (86%), with none or primary education (68%), (Table 1). Of the 125 women, 47% were prime gravida and only 19% (n=24) reported to have started antenatal care at first trimester as recommended, while 9% (n=11) started attending during the third semister. Eighteen women(27%) had a history of pregnancy ending with still birth and 7 (11%) had history of neonatal death (Table 1). Proportion of women screened for syphilis screening during pregnancy: Among the 125 study participants, 34% (43) were not screenedfor syphilis in their current pregnancy, (Table 2). Of the 43 who were not screened, 23 (18%) reported that they were not screened and 20(16%) were not sure if they were screened or not. In comparison to HIV testing, only 3% (5) were not tested. Most of the 43 women who were not screened were attending for antenatal care atlocalhealth facilities.

Factors associated with syphilis screening during pregnancy: Table (3) shows association between syphilis screening and several demographic and knowledge factors. None of the investigated factors like age, level of education, employment, marital status and gravida of the study participants has statically

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Table 1: Socio-demographic and reproductive health characteristics of the 125 participants. Variable N (Percent) Age (years) 15-24 67 (54) 25-49 58 (46) Marital status Married 108 (86) Single 17 (14) Education level None 18 (14) Primary 67 (54) Secondary and above 40 (32) Employed (receive salary) No 114 (91) Yes 11 (9) Income activity for unemployed (N= 114) Business woman 32 (28) Farmer 26 (23) No activity 49 (43) Others 7 (6) Gravida First 59 (47) 2nd or higher 66 (53) History of stillbirth (N=66) No 48 (73) Yes 18 (27) History of neonatal death (N = 66) 59 (89) No 7 (11) Yes

significant association with syphilis screening (P>0.05). Majority of the 125 women (81%) were aware of syphilis. However 51% (63) did not have knowledge on syphilis transimission and 74% (91) had inadequate knowledge on complication of syphilis.

II: Results from record review on proportion of women screened for syphilis at Dodoma Rgeional

Hospital January – December 2010: A total number of 10, 462 pregnant women attended for delivery at Dodoma Regional Hospital in 2010. Among these 1,120 (11%) were not tested for syphilis. Of the remaining 9,342 who were tested for Syphilis, 71 were positive. The prevalence of syphilis was found to be 0.8%. III: Challenges associated with Syphilis screening as reported by health care providers at health facilities

According to Tanzanian focused antenatal care guideline, syphilis along with HIV, hemoglobin and blood grouping is supposed to be checked at first visit during pregnancy. We interviewed health providers in the two health facilities to get their views on facilitating and barriers for syphilis screening. National policy of free care for pregnant women and use of rapid tests with ability to give results within 30 minutes were enablers of syphilis screening (Table 4). Frequent stockouts of syphilis screening tests was the major obstacle identified in Dodoma urban district. One of the clinic reported not having reagents from January 2011 when the interviews were conducted in April 2011. Clin Res Infect Dis 3(4): 1040 (2016)

From the women challenges reported were; some pregnant women (31%) reported that syphilis screening was not available on-site where they attended for antenatal care so they had to go to another site for screening. Sometimes the limited number of health providers compared to the population of pregnant women was a barrier even though the tests were available.

DISCUSSION

Prevalence of Syphilis among pregnant women The overall prevalence of Syphilis among pregnant women in Dodoma was 0.8%. The prevalence of Syphilis in this study is similar to the prevalence found among pregnant women in Kilimanajaro 0.9%, women in general population 0.2% and among bar workers in Moshi urban 1.1% [15,16]. The prevalence is however lower compared to studies done in Kagera [17] that reported prevalence was 7.3% and in Mwanza where the prevalence of 7% was recorded [14]. This difference in prevalence within the same country has been reported in several studies, showing the need for each region to know its local data on prevalence and predictors of syphilis infection. Despite the low prevalence observed in Dodoma of 0.8%, given the negative consequence of syphilis in pregnancy, the WHO is recommeding screening is still cost-effective even at prevalence of 0.1% among pregnant women. This study found that women in Dodoma start ANC very late, the majority at or after 24 weeks the time which is critical in preventing adverse pregnancy outcomes. The efforts therefore is to encourage pregnant women to attend earlier so that they can be screened and given treatment as early Table 2: Syphilis screening in current and previous pregnancy among 125 participants. Screened or checked for following Yes (%) In current pregnancy? Blood pressure Yes No Don’t know Urine for protein Yes No Don’t know Haemoglobin Yes No Don’t know HIV Yes No Don’t know

Syphilis Yes No Don’t know Previous pregnancy (N= 66) HIV (Yes) Syphilis (Yes)

101 (81) 21 (17) 3 (2) 99 (80) 25 (19) 1 (1) 108 (87) 14 (11) 3 (2) 120 (97) 5 (3) 0 (0) 82 (66) 23 (18) 20 (16) 47 (69) 38 (58)

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Table 3: Crude and adjusted odd ratios showing factors associated with syphilis screening in Dodoma region. Variables 

Age in years 25 or less Above 25

Crude OR

p-value

1

-

1.39  

Marital status

Married

1

Single

1.30

Education level

Never attended school

1

Primary

Secondary

Yes

Yes

-

2.13

 

 

-

1

3.98

0.97

-

1

0.136  

-

0.956 -

0.79  

-

0.28 -

-

5.73  

-

3.39 -

0.001

2.91

60.27

6.13

0.032

1.17

32.10

2.04

0.486

0.27

15.14

2.80

Ever heard of syphilis

-

0.43

2.99

-

13.24

1

No

-

 

-

32.78

0.17

History of stillbirth

-

0.642

0.65

1

-

95% C. I. lower upper

2.77

1

Unemployed

 

p-value

0.000

 

Employment status

Employed

0.399

-

Adjusted OR

9.53

11.00

College/University

95% C. I. lower upper

1

0.001  

-

0.098 -

0.047 -

2.71  

-

0.02 -

1.01 -

44.58

7.82

 

 

-

1

1.39

0.28

-

1

7.74

4.11

-

1

0.018  

-

0.265 -

0.030 -

1.42  

-

0.03 -

1.14 -

43.01  

-

2.60 -

14.80 -

No

0.23

0.002

0.09

0.59

0.28

0.040

0.08

0.95

Yes

1

-

-

-

1

-

-

-

Know complications of syphilis No

0.34

0.030

0.13

0.90

Table 4: Facilitating and barriers of syphilis screening: reports of the health care providers. Facilitating

0.26

0.039

0.07

0.94

Barriers

Laboratory personnel: Laboratory personnel: • Free service for clients • Run out of test kits • Use rapid test (Syphilis Bioline) so results within 20 minutes Head, RCH clinic: Head, RCH clinic: • In this clinic the laboratory run out of syphilis • Free service testing frequently • Drug for treatment (Benzathine penicillin) is • No other challenge available the whole year Aga Khan clinic Laboratory personnel: Laboratory personnel: • Free tests for clients • None • Use rapid diagnostic syphilis • Have kits and reagents Head, RCH clinic: Head, RCH clinic: • Free service • None • Drug for treatment is available • Laboratory is functioning *Multiple answers were possible Abbreviations: RCH: Reproductive Child Health Makole clinic

as possible to prevent negative effects of syphilis in pregnancy like stillbirths and congenital transmission.

Proportion of pregnant women not tested for syphilis

It is recommended that essential screening investigation should be done during pregnant mother’s first day to the Clin Res Infect Dis 3(4): 1040 (2016)

antenantal clinic. These includes Blood presssure , Rhesus group, Haemoglobin level, Urine dipstick for protein and glucose, Syphilis serology using a rapid test, Blood examination for malaria parasites and HIV serology following principles of voluntary counseling and testing [18]. In this study, while only 66% of the women reported to be screened for syphilis, 97%

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were tested for HIV, 87% were checked for Haemoglobin level, 81% had Blood pressure measured, and 80% had Urine screened for proteins. This shows that a high proportion of pregnant women (34%) were not screened for syphilis compared to the other essential screening investigations. A study in Mwanza by Watson-Jones et al, showed similar high rates of lack of screening for syphilis. In that study out of 2,256 ANC attenders eligible for syphilis screening only 970 (43%) were documented as receiving an RPR test [14]. In Tanzania with estimated 1.77 million pregnancies per year, only 37% of pregnant women are tested for syphilis[11]. Maternal syphilis has been shown to attribute to 51% of stillbirths and 24% of preterm births in Tanzania [14]. Given 34% - 63% of pregnant women are not screened, then syphilis must contribute substantially to high perinatal mortality seen in the country. Program managers and leaders will need to address this challenge of neglect to screen syphilis because 97% of the same pregnant women were screened for HIV.

Syphilis screening is shown to be at least as cost effective as PMTCT and more cost effective than many widely implemented interventions. There is urgent need for scaling up syphilis screening and treatment in high prevalence areas. The cost effective of screening interventions is highly dependent on disease prevalence. In combination, PMTCT and syphilis screening and treatment interventions may achieve economies of scope and thus improved efficiency [19].

Challenges associated with syphilis screening

A major barrier to antenantal syphilis screening found in this study was stock out of rapid tests i.e. Syphilis Bioline. A 20142015 service provision assessment survey found that only third of Tanzanian health facilities had viable syphilis rapid diagnostic test kits available. Private-for-profit and faith-based facilities were more likely to have syphilis tests than other health facilities [20]. Drugs for syphilis treatment were available in all the clinics. It is puzzling to understand this neglect because HIV is screened using the same rapid tests, and the clinics reported they had never run out of the HIV testing kits. If supply and logistics for ordering the kits is the same, how comes there is no reaction from the leaders when syphilis is out of stock. In Nigeria Oliff et al, found that many ANC health providers didn’t know the negative consequence of untreated maternal syphilis, thus most gave syphilis screening a low priority [21]. There is a need to change this attitude of neglecting syphilis screening among both the providers and health managers. Low knowledge of syphilis transmission and complications among the pregnant women may be a barrier. While many pregnant women had knowledge about HIV and expect to be tested for HIV during pregnancy, few are even aware syphilis screening is offered. Eighteen percent of the women who were not tested in this pregnancy were not even aware what syphilis meant. There is a need to increase community awareness on syphilis and importance of screening during pregnancy, just like the efforts for HIV.

CONCLUSION AND RECOMMENDATIONS

About three in every ten pregnant women coming for delivery were not screened for. Stockout of test kits and inadequate Clin Res Infect Dis 3(4): 1040 (2016)

syphilis knowledge were identified as barriers for screening. Screening for syphilis is cost-effective even when prevalence is 0.1% as recommended by the WHO. Early testing and treatiment of syphilis can prevent substantial prenatal morbidity and mortality. The health managers of respective clinics and the district medical officers should make sure the facilities are getting syphilis testing kits in smooth manner like the HIV kits. Futher investigations should be carried out especially in other parts of the country to adopt preventive and control strategies to reduce trend of Syphilis.

AUTHORS CONTRIBUTIONS

KAA: Participated in design the study, performed data collection and wrote the manuscript. SEM: Lead the design of the study, supervised the study and provided major inputs in the manuscript writing. FT: Performed data analysis and reviewed the manuscript.

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Cite this article Azizi KA, Tenu F, Msuya SE (2016) Prevalence and Challenges Associated with Syphilis Screening among Pregnant Women in Dodoma, Tanzania. Clin Res Infect Dis 3(4): 1040.

Clin Res Infect Dis 3(4): 1040 (2016)

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