Addressing a serious public health issue in Bangladesh

Many sexually transmitted diseases (STDs) can have serious complications when left untreated, but it is simple to prevent and can be cured with the right treatment

Sexually transmitted diseases (STDs) include more than 35 infectious organisms that are transmitted primarily through sexual activity. STDs can lead to harmful medical conditions, including poor reproductive outcomes and increased risk of HIV infection. Syphilis is an STD that can have very serious complications when left untreated, but it’s easy to prevent and can be cured with the right treatment.

Syphilis remains a significant public health problem in Bangladesh. Syphilis rates are increasing among women and men throughout Bangladesh. Untreated syphilis can cause severe medical issues. Efforts are needed to create new tools to detect and treat syphilis, increase testing, control the further spread of syphilis, and improve electronic medical records in order to improve patient outcomes.

Syphilis is a sexually transmitted disease that can have very serious complications when left untreated, but it is simple to prevent and can be cured with the right treatment. Penicillin has been used to treat syphilis since 1943 and remains the best drug for treating the infection.

When not adequately treated, syphilis can lead to visual impairment, hearing loss, stroke, and other neurological problems. Syphilis infection can also increase a person’s risk for getting HIV or giving it to others. All syphilis cases are to be reported to the public health agency so that it can take action to find and treat exposed persons. This prevents others from becoming infected and also prevents the adverse health outcomes of untreated syphilis.

Recent data show that syphilis rates are on the rise. Rates of primary and secondary (P&S) syphilis—the most infectious stages of the disease—increased while rates have increased among both men and women; and other men who have sex with men (MSM). Likewise, increases in congenital syphilis (CS) have paralleled the national increase in P&S syphilis among women of reproductive age. CS, which can cause miscarriage, stillbirth, early infant death, or severe illness in those infants who survive, increased each year.

A pregnant woman with untreated syphilis can infect her fetus through the bloodstream during any stage of syphilis.

Bangladesh needs new tools for syphilis prevention and control to supplement those in use since the 1940s.

Fortunately, penicillin still works to treat syphilis. However, it is the only known antibiotic to treat syphilis during pregnancy. So for pregnant women with a severe allergy to penicillin, or when there is a drug shortage, there are no alternative treatment regimens to turn. The rest of our treatment and prevention tools are outdated.

The most commonly used tests do not confirm syphilis on the spot. Instead, they require at least two sequential antibody tests in blood, rather than directly detecting the presence of syphilis-causing bacteria.

These tests are cumbersome and may lead to treatment delays. Results can be hard to interpret. Existing tests cannot diagnose an early infection.

There is a critical need for modernized test development. For example, if we could look at the proteins or at genetics-based technologies, test results would be fast and specific.  

Treatment options need to be expanded, especially for pregnant women, congenital syphilis, ocular syphilis, and neurosyphilis. Research is also needed to better identify the stage of disease and determine appropriate management of syphilis, factors associated with the development of neurosyphilis and ocular syphilis, and treatment for syphilis disease in individuals living with HIV.

There is no syphilis vaccine, despite early work demonstrating that vaccination could potentially protect from syphilis disease. Additionally, very few biomedical scientists have entered the field, and in the 21st century many clinicians are not familiar with the appropriate diagnosis and management of syphilis. A pregnant woman with untreated syphilis can infect her fetus through the bloodstream at any stage of syphilis. Up to 40 percent of babies born to women with untreated syphilis may be stillborn or die from the infection as a newborn. Infants born with congenital syphilis might have health problems, including skin rashes, yellowing of the skin or whites of the eyes (jaundice), enlarged liver and spleen, or severe anemia. Untreated babies that survive the newborn period can develop problems later on, such as developmental delays and bone and joint abnormalities.

The resurgence of congenital syphilis points to missed opportunities for prevention. One quarter of congenital syphilis cases are due to a lack of prenatal care.  But even among those receiving some prenatal care, the detection and treatment of maternal syphilis often occur too late to prevent congenital syphilis of women who gave birth to an infant with congenital syphilis were not tested in time to be treated to prevent congenital syphilis.

Syphilis screening needs to increase among men who have sex with men (MSM). The current situation is stark— reported syphilis among MSM increasing day by day. Addressing syphilis among men is challenging. Syphilis epidemics vary by geography, race/ethnicity, age, and HIV serostatus Syphilis prevention has historically relied on partner notification to interrupt disease transmission, which has been difficult to scale up to levels that would reduce new infections at an MSM population level.

Dramatic improvements in access to and effectiveness of HIV treatment have resulted in changes in sexual behaviour and social norms that may reduce the risk of HIV but have little impact on syphilis risk reduction, such as treatment as prevention, pre-exposure prophylaxis (PrEP), seroadaptive behaviours, and reduced reliance on condoms.

To reduce the numbers of women and their babies who are infected with syphilis, the government should work to improve congenital syphilis data through an enhanced congenital syphilis surveillance system to capture stillbirths, infant morbidity, and cases prevented; investigate all congenital syphilis cases in states to identify missed opportunities and improve services; develop tools and evaluate high-impact prevention services, such as syphilis screening; timely treatment; partner services; and linkage to contraceptive counseling, behavioural health, and pregnancy case management programmes; develop congenital syphilis prevention guidelines for health care providers and health departments; identify and share best practices, such as infant morbidity review boards, assessment approaches to identify missed opportunities, and implementation of system level changes; and support health care providers to implement recommended syphilis screening and treatment of pregnant women and women of reproductive age through

training, guidelines, tools, and resources.

 To reverse this increasing trend of syphilis among MSM, the government also should work to harmonize STD/HIV screening recommendations and prevention messages related to sexual health services for MSM; support health care providers to implement recommended STD screening, treatment, and through training, guidelines, tools, and resources; improve syphilis surveillance among homosexual, bisexual, and other MSM; conduct epidemiologic studies to better understand factors associated with syphilis adverse outcomes, such as neurosyphilis and ocular syphilis, and transmission networks; and identify and share best practices.

Syphilis is treatable, but the medicine used to treat the disease has been in use for 75 years. There is no rapid test for syphilis, so individuals must undergo a blood test and wait days for the results.

The writer is former Head, Department of Medical Sociology , Institute of Epidemiology, Disease Control & Research (IEDCR)

Dhaka, Bangladesh

E-mail: [email protected]

 

Addressing a serious public health issue in Bangladesh

Many sexually transmitted diseases (STDs) can have serious complications when left untreated, but it is simple to prevent and can be cured with the right treatment

Sexually transmitted diseases (STDs) include more than 35 infectious organisms that are transmitted primarily through sexual activity. STDs can lead to harmful medical conditions, including poor reproductive outcomes and increased risk of HIV infection. Syphilis is an STD that can have very serious complications when left untreated, but its easy to prevent and can be cured with the right treatment. Syphilis remains a significant public health problem in Bangladesh. Syphilis rates are increasing among women and men throughout Bangladesh. Untreated syphilis can cause severe medical issues. Efforts are needed to create new tools to detect and treat syphilis, increase testing, control the further spread of syphilis, and improve electronic medical records in order to improve patient outcomes. Syphilis is a sexually transmitted disease that can have very serious complications when left untreated, but it is simple to prevent and can be cured with the right treatment. Penicillin has been used to treat syphilis since 1943 and remains the best drug for treating the infection. When not adequately treated, syphilis can lead to visual impairment, hearing loss, stroke, and other neurological problems. Syphilis infection can also increase a persons risk for getting HIV or giving it to others. All syphilis cases are to be reported to the public health agency so that it can take action to find and treat exposed persons. This prevents others from becoming infected and also prevents the adverse health outcomes of untreated syphilis. Recent data show that syphilis rates are on the rise. Rates of primary and secondary (PS) syphilisthe most infectious stages of the diseaseincreased while rates have increased among both men and women; and other men who have sex with men (MSM). Likewise, increases in congenital syphilis (CS) have paralleled the national increase in PS syphilis among women of reproductive age. CS, which can cause miscarriage, stillbirth, early infant death, or severe illness in those infants who survive, increased each year. A pregnant woman with untreated syphilis can infect her fetus through the bloodstream during any stage of syphilis. Bangladesh needs new tools for syphilis prevention and control to supplement those in use since the 1940s. Fortunately, penicillin still works to treat syphilis. However, it is the only known antibiotic to treat syphilis during pregnancy. So for pregnant women with a severe allergy to penicillin, or when there is a drug shortage, there are no alternative treatment regimens to turn. The rest of our treatment and prevention tools are outdated. The most commonly used tests do not confirm syphilis on the spot. Instead, they require at least two sequential antibody tests in blood, rather than directly detecting the presence of syphilis-causing bacteria. These tests are cumbersome and may lead to treatment delays. Results can be hard to interpret. Existing tests cannot diagnose an early infection. There is a critical need for modernized test development. For example, if we could look at the proteins or at genetics-based technologies, test results would be fast and specific. Treatment options need to be expanded, especially for pregnant women, congenital syphilis, ocular syphilis, and neurosyphilis. Research is also needed to better identify the stage of disease and determine appropriate management of syphilis, factors associated with the development of neurosyphilis and ocular syphilis, and treatment for syphilis disease in individuals living with HIV. There is no syphilis vaccine, despite early work demonstrating that vaccination could potentially protect from syphilis disease. Additionally, very few biomedical scientists have entered the field, and in the 21st century many clinicians are not familiar with the appropriate diagnosis and management of syphilis. A pregnant woman with untreated syphilis can infect her fetus through the bloodstream at any stage of syphilis. Up to 40 percent of babies born to women with untreated syphilis may be stillborn or die from the infection as a newborn. Infants born with congenital syphilis might have health problems, including skin rashes, yellowing of the skin or whites of the eyes (jaundice), enlarged liver and spleen, or severe anemia. Untreated babies that survive the newborn period can develop problems later on, such as developmental delays and bone and joint abnormalities. The resurgence of congenital syphilis points to missed opportunities for prevention. One quarter of congenital syphilis cases are due to a lack of prenatal care. But even among those receiving some prenatal care, the detection and treatment of maternal syphilis often occur too late to prevent congenital syphilis of women who gave birth to an infant with congenital syphilis were not tested in time to be treated to prevent congenital syphilis. Syphilis screening needs to increase among men who have sex with men (MSM). The current situation is stark reported syphilis among MSM increasing day by day. Addressing syphilis among men is challenging. Syphilis epidemics vary by geography, race/ethnicity, age, and HIV serostatus Syphilis prevention has historically relied on partner notification to interrupt disease transmission, which has been difficult to scale up to levels that would reduce new infections at an MSM population level. Dramatic improvements in access to and effectiveness of HIV treatment have resulted in changes in sexual behaviour and social norms that may reduce the risk of HIV but have little impact on syphilis risk reduction, such as treatment as prevention, pre-exposure prophylaxis (PrEP), seroadaptive behaviours, and reduced reliance on condoms. To reduce the numbers of women and their babies who are infected with syphilis, the government should work to improve congenital syphilis data through an enhanced congenital syphilis surveillance system to capture stillbirths, infant morbidity, and cases prevented; investigate all congenital syphilis cases in states to identify missed opportunities and improve services; develop tools and evaluate high-impact prevention services, such as syphilis screening; timely treatment; partner services; and linkage to contraceptive counseling, behavioural health, and pregnancy case management programmes; develop congenital syphilis prevention guidelines for health care providers and health departments; identify and share best practices, such as infant morbidity review boards, assessment approaches to identify missed opportunities, and implementation of system level changes; and support health care providers to implement recommended syphilis screening and treatment of pregnant women and women of reproductive age through training, guidelines, tools, and resources. To reverse this increasing trend of syphilis among MSM, the government also should work to harmonize STD/HIV screening recommendations and prevention messages related to sexual health services for MSM; support health care providers to implement recommended STD screening, treatment, and through training, guidelines, tools, and resources; improve syphilis surveillance among homosexual, bisexual, and other MSM; conduct epidemiologic studies to better understand factors associated with syphilis adverse outcomes, such as neurosyphilis and ocular syphilis, and transmission networks; and identify and share best practices. Syphilis is treatable, but the medicine used to treat the disease has been in use for 75 years. There is no rapid test for syphilis, so individuals must undergo a blood test and wait days for the results. The writer is former Head, Department of Medical Sociology , Institute of Epidemiology, Disease Control Research (IEDCR) Dhaka, Bangladesh E-mail: [email protected]