syphilis session

1.15pm - 1.25pm Antenatal care and syphilis treatment access critical for congenital syphilis prevention, Australia 2016 - 2021 and WA 2019 - 2021 (This session encompasses data from the following two abstracts)

Donna Mak (Communicable Disease Control Directorate, WA Dept of Health) 

 

Lessons learned from public health review of congenital syphilis cases in WA.

Donna Mak (Communicable Disease Control Directorate, WA Dept of Health), Carolien Giele (Surveillance and Disease Control Program, Communicable Disease Control Directorate, WA Dept of Health), Stephen Boccaletti (Communicable Disease Control Directorate, WA Dept of Health)

Background/aims: Congenital syphilis (CS) can result in babies being still-born or with serious sequelae. This can be prevented if pregnant people are tested for syphilis and treated promptly. Congenital syphilis notifications in WA increased from three in the 10-year period 2008 to 2017 to 18 cases in the 8-year period 2018 to 2023. Public health reviews of every CS and near-miss case (baby born to an infected mother who did NOT receive treatment more than 30 days before delivery but did not contract congenital syphilis) commenced in 2019 to identify health system gaps/issues that can be addressed to prevent future cases. Lessons learned from these reviews will be shared during this presentation.

Methods: We reviewed minutes and recommendations from public health reviews of CS and near-miss cases from 2019 to 2023. Qualitative thematic analysis identified common themes contributing to syphilis transmission from mother to baby.

Results: Seventeen CS and four near-miss cases notified between 2019 and 2023 were reviewed. Common themes identified as contributing to CS or, for near-miss cases, risk of CS, included:

• Complex social issues, e g. homelessness, alcohol and other substance misuse, domestic violence, sexual assault, geographic mobility and fear of government services involvement, that impacted on a woman’s access to antenatal care

• Healthcare workforce being unaware of current antenatal syphilis testing recommendations

• Inability of antenatal care to meet patients’ needs

which contributed to lack of, infrequent or inadequate antenatal care and/or syphilis tests.

Future actions

WA Health and partners promote the importance of antenatal syphilis testing to healthcare staff via professional development, and to the general public via the Healthysexual campaign (including busback posters) and monitor the completeness of antenatal syphilis testing via mandatory reporting.

Conclusions: Prevention of CS requires the delivery of holistic, flexible, culturally responsive antenatal care by adequately-resourced, knowledgeable staff.

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Antenatal care access critical for congenital syphilis prevention, Australia 2016 - 2021

Donna Mak (Communicable Disease Control Directorate, WA Dept of Health), Alison Chew (Australian National University, Australian Government Department of Health and Aged Care), James Ward (University of Queensland), Lorraine Anderson (Kimberley Aboriginal Medical Services Ltd)

Background/aims: Congenital syphilis, most commonly caused by trans-placental transmission of Treponema pallidum infection from mother to fetus, can result in stillbirth or life-long, serious disabilities. From 2013 to 2022, infectious and congenital syphilis rates in Australia increased 3.2 and 2.2 fold, respectively. This study aims to describe gaps in congenital syphilis prevention in Australia.

Methods: Mixed methods including: a descriptive analysis of gestational syphilis cases; a case-control study; and qualitative analysis of archival and grey literature. The case-control study identified mothers who did not receive adequate treatment for gestational syphilis (cases) and those who did (controls) using national and jurisdictional surveillance databases from January 2016 to December 2021. Cases were matched to controls by age, Aboriginal or Torres Strait Islander status and remoteness area, and their demographic and clinical care characteristics compared.

Results: 53/688 syphilis notifications known to have gestational syphilis resulted in a congenital syphilis outcome. Data completeness for the ‘pregnancy status’ variable was poor overall, and few jurisdictions collected detailed data on clinical care. On multivariable analysis, first presentation for antenatal care after the first trimester (aOR 54.9 95%CI 7.9 - 380, p <0.001), diagnosis on clinical presentation (aOR 9.9, 95%CI 1.5 – 65.1, p = 0.02) and diagnosis in a hospital (aOR 13.9, 95%CI 1.4 - 136, p = 0.02) were associated with inadequate treatment for gestational syphilis. Qualitative analysis identified access to antenatal care for mothers with complex social situations as an important factor.

Conclusion and future actions: Given infectious and congenital syphilis rates are increasing in Australia, it is important to improve completeness of reporting and data availability for women with gestational syphilis. Investing in programs that overcome barriers to antenatal care for women at high risk of congenital syphilis is critical for its prevention.

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1.25pm - 1.35pm WA Syphilis Outbreak Response Group – Partnership Model

Kim Gates (Aboriginal Health Council WA), Lisa Bastian (Sexual Health and Bloodborne Virus Program, WA Dept of Health), Paul Armstrong (Communicable Disease Control Directorate, WA Dept of Health)

Background: The Western Australian Syphilis Outbreak Response Group (WASORG) was formed in 2018 and is responsible for coordinating the statewide response to the increasing notifications of infectious syphilis in WA and prevention of congenital syphilis. Aim: The aim of the WASORG is to control the outbreak of syphilis among communities in WA using partnership strategies that, wherever possible, are applicable to the sustainable control measures for sexually transmitted infections and promotion of sexual health in WA communities. Approach: The group is co-chaired, in partnership, by the Aboriginal Health Council of WA and WA Department of Health. Membership is made up of government and Aboriginal Community-Controlled Health Services (ACCHS) from across the state. All regions have activated Syphilis Outbreak Response Teams responsible for the implementation of region-specific initiatives and work in partnership with local ACCHS and service providers. Outcomes: Through consultation with over 100 stakeholders, the WASORG has developed a WA Syphilis Outbreak Response Action Plan 2023-2025 to guide activities. The WASORG have activated the following initiatives to prevent infectious and congenital syphilis:

• Established a state-wide syphilis patient management system REDCap

• Updated antenatal syphilis screening guidelines and systems to monitor adherence

• Established a syphilis point-of-care testing program

• Development of an online syphilis training module

• Congenital syphilis public health reviews

• Development of Structured Administration Supply Arrangement to allow Registered Nurses and Aboriginal Health Practitioners to administer syphilis treatment.

Available data suggests that at a state level, the rate of increase of syphilis notifications has slowed over the past two years. However, congenital syphilis has not been eliminated and syphilis notifications continue to disproportionately impact vulnerable populations. The efforts of WASORG  will need to continue for some time yet. Conclusion: The partnerships between government and ACCHS through WASORG plays an integral role in the implementation of initiatives to prevent syphilis in WA.

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1.35pm - 1.45pm Achieving syphilis outbreak control: The Syphilis Response Team's Service Delivery Model for High Risk Populations

Rosie Jack (Metropolitan Communicable Disease Control, Syphilis Response Team), Suzanne McEvoy (Metropolitan Communicable Disease Control) 

Background: Syphilis is increasingly affecting hard-to-reach populations including people experiencing homelessness, intravenous drug users, culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander people. Testing, treatment and contact tracing are vital for outbreak control. Traditionally, phone calls and letters are used to contact cases and sexual contacts. This is more challenging  for people who do not have phones or fixed addresses. Methods: The Syphilis Response Team (SRT) was established in 2022 within Metropolitan Communicable Disease Control and covers metropolitan Perth (~2.1 million). The team includes two nurses, part-time doctors, Aboriginal health liaison officers (AHLOs), an epidemiologist and project officer. Innovative approaches have been adopted to reach people including;
- Home and outreach visits (e.g. shelters, parks, court appearances).
- Offering Point of Care Testing and collection of blood for syphilis serology at time of outreach.

- Facilitation of treatment for cases and contacts via a clinic or by an SRT nurse at time of outreach.
- Regular database checks for latest contact details or health service attendance.
- Collaboration with stakeholders, including maintenance of a “Be on the Lookout” list.

Results: Outreach enables face-to-face engagement about syphilis, testing and treatment. An explanatory letter can be given, and actions can include on-the-spot testing and treatment. The AHLOs assist with locating and approaching individuals in a culturally safe way. Many people have been successfully notified, tested, and treated where previously they may have been ‘lost to follow up’. Accordingly, the number of syphilis infections in these groups stabilised last year. Future actions: In addition to current initiatives, we will explore using social media to:
- Improve public knowledge and awareness of the outbreak, and
- Support contact tracing.

Conclusions: High-quality public health follow up for hard-to-reach populations requires flexible and innovative delivery. This is central to outbreak control.

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1.45pm - 1.55pm Evaluation of the Western Australian Syphilis Point-of-Care testing program

Stephen Boccaletti (WA Dept of Health), Tenneille Wisby (WA Dept of Health), Matthew Bacon (WA Dept of Health)

Background: The WA-Health funded Syphilis Point-of-Care (PoC) testing program was established in July 2020, allowing syphilis PoC testing to be available to up to 24 health services. The program comprises a quality framework, training and PoC testing materials, all of which are funded by WA Health’s Communicable Disease Control Directorate (CDCD). CDCD conducted a mixed methods process and impact evaluation of the WA Syphilis PoC testing program. Methods: Data analysed included data reported by all participating services over the lifetime of the program (31), as part of enrolment conditions (from July 2020 to September 2022), and those collected from a survey distributed to all 21 participating services in November 2022. The survey included questions about PoC test usage, benefits, barriers, and enablers. Responses were analysed using thematic analysis. Results: During the evaluation period, syphilis PoC tests for were used for 2,122 patients, with 112 reactive test results. Eleven services responded to the survey (52% response rate). Thematic analysis identified seven themes: testing at-risk populations; immediate results and treatment; extra work; training; embedding syphilis PoC testing in routine work; staff champions; and opportunistic testing. Top performing services activated patient testing promptly (within 2 months of registering) and used 51% of tests provided for patient testing, compared to poorer performing services, who used 14% of tests for patient testing and needed over 18 months to start-up. Services which used PoC testing effectively also who had staff champions motivating colleagues and embedded PoC testing into clinic processes. Future actions and conclusion: There was wide variation between services in uptake of PoCT. Sustainable use of PoCT was observed in services that had PoCT staff champion and had embedded PoCT into their clinic processes. The CDCD have begun implementing changes in the program to increase patient testing and reduce burden of PoC testing of services.

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1.55pm - 2.05pm Syphilis diagnosis and management in pregnancy: a public health perspective towards eliminating congenital syphilis

Grace Phua (Metropolitan Communicable Disease Control), Hannah Vogt (Metropolitan Disease Control), Caroline McMahon (Metropolitan Communicable Disease Control), Suzanne McEvoy (Metropolitan Communicable Disease Control)

Background: The syphilis outbreak in Perth has been increasingly affecting women of reproductive age. There has been a concomitant increase in cases of syphilis diagnosed in pregnancy, and cases of congenital syphilis. The Syphilis Response Team (SRT) at Metropolitan Communicable Disease Control works towards eliminating congenital syphilis through increased follow-up of pregnant women diagnosed with syphilis, inter-agency collaboration to facilitate appropriate management of at-risk neonates, and education about syphilis screening in pregnancy. Methods: The SRT coordinate a program in which pregnant women diagnosed with syphilis receive management informed by specialist and inter-agency consultation. This includes the development of neonatal management plans to guide testing of mothers and neonates at the time of birth, and treatment for the neonates. Records are detailed in a REDCap database. The SRT also offer education to primary care settings, antenatal units and emergency departments. Results: In the years 2021-2023, 115 pregnancies were managed under the SRT and 85 neonatal management plans produced. There were no cases of congenital syphilis among neonates of women monitored in the program. Analysis of REDCap records reveal that diagnoses of syphilis have been made in the third trimester, adding evidence to changes in recommendations that now include syphilis screening at 28- and 36-weeks’ gestation. In 2023, over 100 education sessions were delivered to primary care providers, antenatal units, emergency departments and other settings to highlight the importance of syphilis screening in pregnancy. Future actions: Unfortunately, cases of congenital syphilis do occur in women not known to have syphilis while pregnant, generally due to lack of testing. The SRT is developing a plain language resource about syphilis testing in pregnancy for consumers. Conclusions: Increased screening in pregnancy, dedicated follow-up of pregnant women diagnosed with syphilis and inter-agency consultation are effective means towards eliminating congenital syphilis.

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2.05pm - 2.15pm Increasing Aboriginal women’s engagement with antenatal care to prevent congenital syphilis in Western Australia: Stories of success and lessons learned

Belinda D'Costa (Curtin University), Amanda Sibosado (University of Queensland), Roanna Lobo (Curtin University)

Background/aims: Endemic across many Western Australian (WA) regions, syphilis is a sexually transmitted infection that disproportionally impacts Aboriginal peoples. In 2022, the syphilis notification rate for Aboriginal peoples was more than five times higher than the rate reported for non-Aboriginal people. Untreated syphilis can have a range of adverse outcomes, including for pregnant women, congenital syphilis. Congenital syphilis is preventable if screening and treatment occur during antenatal/postnatal care. The aims of this research were two-fold: to identify effective approaches for engaging Aboriginal women in syphilis testing during antenatal/postnatal care; and to capture the experiences of Aboriginal women engaging in antenatal/postnatal care services. Methods: A cultural lens was applied to this research project, informed by a lengthy consultation process, to ensure culturally safe and appropriate research practices. The project adopted a strengths-based, qualitative methodology, which involved one-to-one yarns with Aboriginal women aged 16-39 years who were pregnant or had a child aged three years or younger, along with interviews with health professionals involved in antenatal care delivery. Conducted between 2021 and 2023, participants were purposefully recruited from WA regions affected by the syphilis epidemic. Results and future action: Trust was identified as the principal factor influencing the successful engagement of Aboriginal women in antenatal/postnatal care. Strategies for establishing trust and the implications of trusting patient-practitioner relationships were revealed. The findings informed the development of five action areas key to the improved and sustained engagement of Aboriginal women in antenatal/postnatal care: relationship building; workforce development; service integration; partnerships and collaboration; and community capacity. Conclusions: The research findings are a valuable advocacy tool for culturally appropriate antenatal/postnatal care delivery for Aboriginal women. A commitment to the five action areas have value beyond the prevention of congenital syphilis, it could also facilitate improved outcomes across the spectrum of maternal and infant health.

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2.15pm - 2.25pm Developing resources for syphilis testing in pregnancy

Joanne O'Dea (Metropolitan Communicable Disease Control), Suzanne McEvoy (Metropolitan Communicable Disease Control) 

Background: The syphilis outbreak in Perth has resulted in several initiatives. First, increased frequency of screening for syphilis in pregnancy (to three tests). Second, Metropolitan Communicable Disease Control (MCDC) established a Syphilis in Pregnancy Committee for the public health management of women diagnosed with syphilis during, or up to one year prior to, their pregnancy. Coordinated by a midwife, it involves maternity services and health organisations in Perth to facilitate testing, treatment and contact tracing. Third, when a case of congenital syphilis is diagnosed, a congenital syphilis review is undertaken to identify opportunities for improvement. Through these initiatives, a need for a resource about testing for syphilis in pregnancy (including the revised protocol) was identified. Aims: To develop plain language resources to explain syphilis, the importance of testing in pregnancy, the pathway for those diagnosed with syphilis, and congenital syphilis. Methods: Two resources were developed in three stages. The Syphilis Response, Aboriginal Health and Communications teams developed an initial draft. This was disseminated to external stakeholders, particularly obstetric/midwifery, neonatal, infectious disease, and sexual health clinicians. Finally, a structured questionnaire was used to obtain feedback from consumers and other stakeholders working with community. An iterative revision process was undertaken guided by the Syphilis Response team. Results: A 15-page ‘Syphilis testing in pregnancy’ booklet and one-page ‘Congenital syphilis’ flyer were developed. Future actions: MCDC will disseminate the resources to maternity services and through general practice, using printed and electronic means. An evaluation is planned. Opportunities to use other modalities will be explored, including on TVs in waiting rooms. Conclusions: The syphilis testing in pregnancy resource and congenital syphilis flyer are evidence-based resources developed in partnership with clinicians and consumers. The resources will deliver time-critical information about syphilis testing to pregnant consumers and reminds treating clinicians about the revised testing protocol.

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2.25pm - 2.45pm Q&A session