Syphilis among pregnant women
Export Indicator
Percentage of women accessing antenatal care services who were tested for syphilis, tested positive and treated
What it measures
A. Coverage of syphilis testing in women attending antenatal care services
B. Percentage of pregnant women attending antenatal clinics with a positive (reactive) syphilis serology
C. Percentage of antenatal care attendees during a specified period with a positive syphilis serology who were treated adequately
Rationale
A. Testing pregnant women for syphilis early in pregnancy is important for their health and that of the fetus. This contributes to monitoring the quality of antenatal care services and services to prevent HIV among pregnant women. It is also a process indicator for assessing the validation of eliminating the mother-to-child transmission of syphilis.
B. Syphilis infection in antenatal care attendees can be used to guide programmes for preventing sexually transmitted infections and may provide early warning of potential changes in HIV transmission in the general population.
C. Treating antenatal care attendees who test positive for syphilis directly measures the programme for eliminating the mother-to-child transmission of syphilis and efforts to strengthen primary HIV prevention. It is also a process indicator for validating the elimination of mother-to-child transmission of syphilis.
Numerator
A. Number of women attending antenatal care services who were tested for syphilis
B. Number of women attending antenatal care services who tested positive for syphilis
C. Number of antenatal care attendees with a positive syphilis test who received at least one dose of benzathine penicillin 2.4 mU intramuscularly
Denominator
A. Number of women attending antenatal care services
B. Number of antenatal care attendees who were tested for syphilis
C. Number of antenatal care attendees who tested positive for syphilis
Calculation
Numerator/denominator (for A, B and C, respectively)
Method of measurement
A. All pregnant women should be tested (screened) for syphilis at their first antenatal care visit. Ideally, countries will report on testing at any visit as well as at the first visit. Countries unable to distinguish the first visit from testing at any visit should still report data on this indicator but ensure that it is clearly reported as data for any visit. This indicator should be measured annually.
Screening may include either nontreponemal tests that measure reaginic antibody (such as Venereal Disease Research Laboratory (VDRL)) or rapid plasma reagin (RPR)) or treponemal tests that measure treponemal antibody (such as Treponema pallidum haemagglutination assay (TPHA), Treponema pallidum particle agglutination assay (TPPA), enzyme immunoassay or rapid treponemal tests). For this indicator, having either type of test is sufficient, although being tested with both is preferred. Indicate in the comments section what test type is generally used in your country. The type of test is factored into the analysis of the data.
Ideally, national programme records aggregated from health-facility data should be used. However, if such data are not available, data from sentinel surveillance or special studies can be reported if they are deemed representative of the national situation. Specify the source and coverage of your data (such as national programme data from all 12 provinces) in the comments section.
B. Syphilis positivity can be measured using either nontreponemal tests (for example, RPR or VDRL) or treponemal tests (TPHA, TPPA, enzyme immunoassay or a variety of available rapid tests) or, ideally, a combination of both. A reactive nontreponemal test, especially if the titre is high, suggests active infection, whereas positivity with a treponemal test indicates any previous infection even if treated successfully. For the purposes of this indicator (intended to measure seropositivity), reporting positivity based on a single test result is acceptable. If both treponemal and nontreponemal test results on an individual person are available, then syphilis positivity should be defined as having positive results in both tests.
The rapid treponemal test has enabled testing in settings without laboratory capacity, greatly increasing the number of women who can be tested and treated for syphilis in pregnancy. Data should be collected annually. It is important to report what test type is generally used in your country. The type of test is factored into data analysis.
The following sources of data may be used: national programme records aggregated from health-facility data, sentinel surveillance or special surveys, using serological tests to detect reaginic and/or treponemal antibody. In the comments section, specify the source and coverage of your data: for example, sentinel surveillance of all antenatal care attendees in two of 10 provinces. Further, specify what test type is generally used in your country to define positivity in pregnant women: for example, nontreponemal (RPR or VDRL), treponemal (rapid tests or TPPA), people positive on both or unknown.
Countries are encouraged to use unique identifiers or registries that separate first and subsequent tests so that the data reflect the true prevalence or incidence of syphilis rather than test positivity.
Since most countries have data from a variety of test types, subanalysis (disaggregation) among women 15–24 years old may increase the likelihood that test positivity reflects recent infection.
C. Data should be collected annually. Seropositivity on either a treponemal or nontreponemal test is sufficient to be considered positive for syphilis for this indicator.
Ideally, national programme records aggregated from health-facility data should be used. However, if national programme data are not available, data from sentinel surveillance or special studies can be reported if they are deemed representative of the national situation. Specify the source and coverage of your data (such as national programme data from all 12 provinces) in the comments section.
Measurement frequency
Data should be recorded daily and reported quarterly to the national or subnational level. They should also be consolidated annually and reported to WHO.
Disaggregation
A. Tested at any visit, tested at first visit
B. Age (15–24 and 25+ years)
C. None
Additional information requested
Comment on whether the data you are providing are routine programme data deemed to be representative of the entire country and what test type was used to define positivity among antenatal care attendees: for example, non-treponemal, treponemal, people positive on both or mixed or unknown.
Strengths and weaknesses
A. Countries may also monitor the week of pregnancy in which each woman is tested. Preventing congenital syphilis requires testing early in pregnancy, since stillbirth may occur in the second trimester. Knowing that women are being tested late in pregnancy will indicate that women are not accessing antenatal care early or that testing is not occurring early in pregnancy.
Programmes that separately test pregnant women for syphilis and for HIV should work together to enhance the effectiveness of their work.
Global. Examine trends over time to assess progress towards target levels of testing coverage required for eliminating mother-to-child transmission of syphilis. Knowledge of testing policies and practices should be used to interpret trends in coverage. Data on testing pregnant women who attend antenatal care services can later be combined with data on antenatal care attendance to estimate the overall coverage of syphilis testing
among pregnant women.
Local. Data can be used to identify clinics not fully implementing national policy.
B. Data on syphilis positivity among pregnant women are available in most countries through routine health-system reporting.
Differences in the test type used or changes in testing practices may affect data. Knowledge of testing practices within the country (such as the proportion of treponemal versus non-treponemal testing used) should be used to interpret disease trends.
Global and regional. Estimate the perinatal mortality and morbidity caused by syphilis that could be averted with effective programmes to eliminate the mother-to-child transmission of syphilis. Identify areas with the greatest need for comprehensive congenital syphilis prevention interventions. Data are used to estimate syphilis incidence and prevalence.
Local. Follow trends over time to assess changes in the burden of disease and the needs of programmes for preventing sexually transmitted infections. Data are used to estimate the incidence and prevalence of syphilis.
All levels. Compare data on trends in syphilis and HIV to look for early warning of increased risk of HIV transmission
C. Data on treating syphilis among antenatal care attendees are often routinely monitored in health facilities.
Collecting treatment data may require collaboration with maternal and child health programmes to ensure that such data are available at the national level.
For the purposes of this indicator, documentation of a single dose of penicillin is sufficient. Treating a pregnant woman positive for syphilis with a single injection of 2.4 mU of benzathine penicillin before 24 weeks of gestational age is sufficient to prevent syphilis from being transmitted mother to infant. However, three injections at weekly intervals are recommended to treat latent syphilis and prevent tertiary syphilis in the mother.
Global, regional and local. Estimate the effectiveness of the programme in reducing syphilis-associated perinatal morbidity and mortality.
Local. Identify areas that need assistance to implement programmes or additional resources.
All levels. Knowledge of treatment policies and practices should be used to interpret trends in treatment.
Further information
National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators. Geneva: World Health Organization; 2008 (http://www.who.int/reproductivehealth/publications/monitoring/9789241596...).
Methods for surveillance and monitoring of congenital syphilis elimination within existing systems. Geneva: World Health Organization; 2011 (http://www.who.int/reproductivehealth/publications/rtis/9789241503020/en).
Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/handle/10665/112858).