SYPHILIS

IN GENERAL POPULATION
by
Dr Kauser Hanif
Roll # 11
HSA
DEFINITION

Syphilis is a contagious venereal disease

caused by the spirochete TREPONEMA
PALLIDUM.
WHO
Historical Background
 It is one of the oldest diseases known to mankind
which swept through Europe in a devastating
epidemic during the late 15th century, is now
readily treated with antibiotics.
 Incidence rose sharply the end of world war 1but
steadily declined in two decades
 Since 1945 the rate has further declined and at
present at the lowest level ever recorded
SYPHILIS
 It is known as the great imitator because it

mimics so many other diseases,

 Syphilis infection ranges from skin
eruptions to complications involving the
heart and nervous system
 A curable and preventable disease
Stages
 Primary syphilis appears in the form of
an ulcer called chancre at the site of
inoculation of infection.
 Secondary syphilis include macular,
maculopapular, papular lesions to
erythematous highly infectious plaques
called condyloma lata
 Late latent shown by tests but no clinical
symptoms
 Tertiary syphilis manifestations
include ocular cardiovascular and
neurological involvement.
Epidemiology
 Age: 75%b/w age of 15-35 years Peak 25-30 years
 Sex ratio: 3 males to 2 female
 More common in colored than white
 Congenital
 Rate of transmission is 80%
 transmitted to the fetus at any stage of disease through
blood.
 Acquired
 Sexually transmitted from an infected to an uninfected
individual by direct: physical contact with lesion through
skin and mucosa
 Directly into blood stream in transfusion infection
.
Key Determinants

 Low literacy level.

 Poor reproductive health education
environment.
 Male and female sex workers suffering with
the disease.
 Differences in gender based attitudes such
as power inequalities, poor access to care
Highly mobile occupational groups (truckers
Key Determinants
 Neglect to abide by cultural and religious norms
regarding sexual behavior.
 Male and female sex workers suffering with the
disease
 Unprotected sex with Tran-gendered/female sex
workers - ranks second in 20 leading risk factors
 Sexually abused
 Migrants
 Lack of prenatal care.
PERCENTAGE OF SYPHILIS AMONG
STD

31.4
SYPHILIS
STD

68.4
INCIDENCE OF SYPHILIS
 PREVALANCE IN DIFFERENT PARTS
OF ASIA
India among truck drivers 33%

Bangladesh slum 6%

Indonesia- hijras 43%

Malaysia – above age15 1.0%

Nepal-men 22%
Prevalence in Different Population
in Countries of EMRO
Country Year Population Syphilis %

Egypt 2001 FSW 5.8

MSW 7.5
IDU 1.3
MALE 5.6

Yemen 2002 Out patient clinics1.5

Libyan Arabs 1992 Male 19

Death Statistics for Syphilis In
2002.

 About 89,000 deaths in Africa

 About 1,000 deaths in The America
 About 43,000 deaths in South East Asia
 About 21,000 deaths in Eastern Mediterranean
 About 1,000 deaths in Western Pacific
 P re g n an acy o u t co me in syp h illis in fe ctio n

45% 40%
40%
35%
30% 25%
percentages

25%
20%
14%
15%
10%
5%
0%
S till b irth N e o n a ta l m o rta lity P e rin a ta l m o rta lity
P re gna nc y O utc om e s
SITUATION IN PAKISTAN

 Data availability among general

population is limited because
disclosing of this infection is
considered a taboo in our society
 SITUATION IN PAKISTAN

Syphilis prevalance in different population in

Pakistan

60
60 ANC
urban men
50
healthy adults
40 transgendered khi/lhr

30 FSW -LHR
FSW -Hyderabad
20 16.4
13.8 FSW - Khi
11.5
9.4 IDU
10 6.4 6.9
0.4 1.3 0.67 Truckers-LHR
0
%AGE Truckers-KHI
Existing polices and capacities
 Integration /collaboration b/w STD and other
program
 Goal of ICPD
By 2005, 60% of primary health care should offer the
widest, prevention and management of reproductive
tract infections, including sexually transmitted
infections (STIs)
By 2010, 80% of facilities should offer such services
By 2015, 100% facilities should do so.
 WHO guidelines - Patients being considered for STI
treatment must also be considered for testing of
Syphilis
 Expanded response program provide (US$ 40 million)
-.
 National AIDS Control Program UNICEF, UNAIDS,
UNFPA have been active for providing services in STI
WHY SYPHILIS IS NOT
CONTROLLED

 Care seeking –not willing

 Syphilis testing - uncommon.
 Partner notification b/c of secrecy - rare.
 Condom promotion for safe sex - uncommon.
Priorities to control syphilis
infection.
 To reduce syphilis related morbidity and
mortality
 To prevent HIV infection
 To prevent adverse pregnancy outcome
Population whose behavior need to be
analyzed for possible interventions

 Sex workers and their clients

 Mobile population
 Homosexuals who have multiple same sex
partners.
 Bisexual men.
 Women and men who experience gender
based violence.
 Sexually abused Children, young people and
orphans
Transmission Dynamics of Syphilis Infection at
the Population Level

General Population

Bridge Population

Core
Group
Facts

In Pakistan, the July 1996 edition of AIDS Analysis

 Asia reported that:

 20% of men in one rural area have male-to-male sex

 40% of men living in a Karachi squatter settlement had
male-to-male sex
 72% of truck drivers in central Karachi had sex with
other males, while 76% had sex with female sex
workers
Rationale

 Disclosing of infection- taboo in our society.

 People do not want to disclose the disease.
 Unable to get treatment.
 Complications of the disease are beyond their
imagination.
 Need to take them into confidence
 Educate them on preventive measures through
interactive discussions
 Physically improve quality care by providing
medicines and by establishing good relationship
with the patients.
 Aim

To reduce syphilis related morbidity and

mortality in Pakistan
Objectives

 To prevent syphilis infection in district

Karachi by 90% by improving the quality of
preventive and curative services in 3 years
time.
 Precede – Proceed Model

Phase 5 Phase 4 Phase 3 Phase 2 Phase 1

Administrative Educational and Behavioral and Epidemiological Social
& policy assessment ecological environmental assessment Assessment
assessment assessment

Predisposing
Factors
Direct
Health
Education Indirect
Reinforcing Behavior
Factors
Health 90% elimination
Promotion Community
of syphilis
Enabling
Environment
Policy Factors
Regulation
Organization Community

Phase 7 Phase 8 Phase 9

Phase 6
Process Impact Outcome
Implementation
Evaluation Evaluation Evaluation
Pre disposing Factors
 Promoting healthy sexual behavior among 80% general

population
 Change attitude for early seeking behavior 60%.

 Awareness about syphilis.

Reinforcing Factor
 70% increase of effective response from health care provider

 70% decrease of social taboo / stigmatization regarding Syphilis

Enabling Factor
 50% lab diagnostic facilities for syphilis

 100% provision of medicine for syphilis at all health sectors

 60% screening of pregnant women

 90% distribution of condom to targeted population.

Direct Communication
 Promoting religious and cultural values and practices regarding sexual behaviors
through interactive sessions.
 Media campaign, distribution of IEC material on complication of syphilis.
 Interactive sessions with high risk individuals on risk reduction of infection such as
consistent and correct use of condom.
Indirect Communication
 Training of HCP for syphilis diagnoses and treatment.
 BCC program to raise awareness and education on reproductive health, and
personal hygiene.
Community organization
 Screening test among ANC.
 Surveillance program among high risk groups
 Integrating syphilis intervention with other health programs.
 Offer counseling and confidential voluntary test for high risk groups..
 Religious and faith based organizations to motivate and shape attitudes and
behaviors of the community.
 Involve political and opinion leader in advocating preventive and care of syphilis
infection.
 condom promotion
 comprehensive program for effective treatment
 Improve surveillance and research tools
 Case finding program
 Social hygiene program
SPHYLLIS CONTROL
PROGRAMME
 It covers a wide range of activities centered
on improving the quality of health care given
for management of syphilis and BCC by
using client centered approach.
 Evidence
Client centered approach showed positive results Sargodha district.

Patient, care provider counseling and interactive communication are

ideal to deliver preventive measures
Target Population

 Doctors from public health sectors

 Private doctors practicing in high risk areas
 Gynecologists, skin specialists and urologists in
public sector.
 Other non traditional healers in high risk areas
 High risk group
Package Includes

 Care providers’ counseling to reduce high risk

behaviors.
 Improving patients’ awareness regarding
complications.
 Correct diagnosis and management of case
 Tracing and treating sexual contacts of the patient.
 Promoting use of condoms in all sexually active
patients
Training Objectives

 Identification and respect of client.

 Improving care providers’ skills.
 Encouraging patients to use condoms and
notification of sexual partners.
 Refresh doctors course for case management.
 Provision of medicines and condoms at all public
hospitals and GPs clinics in high risk groups’ areas.
Phase I

 Mobilize resources.
 Identify national organizations.
 Assess base line health services.
 Preparation of training material to meet specific
needs.
 Forming list of care providers with the help of EDO
and informing them in writing
 Offering training to private doctors and confirming
their consent
 Identify master trainers. gynecologist, urologist psychologist
dermatologists and doctors having specialization in STI management
 Phase II
 Training of health providers
 One month training in batches of 10
Phase III
 Identification of referral system.
 Regular supervisory and monitoring visits
 Laboratory support in all public hospital.
 Regular supply of effective drugs
Phase IV
 Integration/collaboration with other programs STD

control program ANC, MCH, FP, RH, dermatology

and other existing programs
 National / local media campaigns

Education for youth in / out of school

Community initiatives (e.g. peer education)
 Education in health facility waiting area

 Work place education programs

Evaluation

 Established strong program for evaluation

which will be greatly facilitated by good
information as to what works and what does
not.
 It is done by analyzing the indicators
Indicators
Proportion of patients who
 Are given care with advice /education about un safe sexual behavior.
 Are given care with advice of condom use.
 Identified their sexual partner
 .ARE diagnosed by lab test
 Are treated by the notification of sexual partner.
 Are cured by treatment
 Are referred to specialist.

Proportion of pregnant women

 Are tested
 Are treated.

No. of lab test done

No of medicine supplied by separate distribution
No of lab facilities provided
GANTT CHART
Conclusion
 In considering syphilis several social economics and behavioral
factors make Pakistan a high risk country .
 Because of the mode of spread and the popular stigma attached
to infection with syphilis the administrative approach to this
disease must be somewhat altered from that conventionally
followed for other infections.
 It is therefore necessary to bring about the functional integration
of other services such as NGOs and other faith organizations for
achieving better outcome.
 Proper treatment will cure the disease, but in late syphilis,
damage already done to body organs cannot be reversed.so
increase the awareness for early treatment