H5N1

MMWR: Factors contributing to congenital syphilis cases — New York City, 2010–2016

MMWR has published Factors Contributing to Congenital Syphilis Cases — New York City, 2010–2016. The summary:

What is already known about this topic?  

Cases of congenital syphilis are increasing in the United States and often represent missed opportunities for prevention.  

What is added by this report?  

During 2010–2016, 578 New York City women with syphilis infection were noted to be pregnant, and in 510 (88.2%) pregnancies congenital syphilis did not occur. In the majority of the 68 congenital syphilis cases, maternal syphilis diagnosis occurred too late to prevent congenital syphilis. 

What are the implications for public health practice? 

Provider and public health systems play a critical role in preventing congenital syphilis through screening and treating pregnant women for syphilis; these systems need to be maintained and strengthened.

Infectious diseases kill 2,198 in China in December

Via the National Health and Family Planning Commission: Infectious diseases kill 2,198 in China in December.

A total of 2,198 people died as a result of infectious diseases on the Chinese mainland in December 2017, official data showed. 

According to the National Health and Family Planning Commission, there were 699,850 cases of infectious diseases reported on the mainland in December.  

One person died from plague while no cases of cholera were reported in December. 

Plague and cholera are classified as Class A infectious diseases, the most serious classification on China's Law on the Prevention and Treatment of Infectious Diseases. 

A total of 294,397 cases were classified as Class B infectious diseases, resulting in 2,187 deaths. Viral hepatitis, tuberculosis, syphilis, gonorrhoea as well as scarlet fever accounted for 93 percent of these cases. 

Category C diseases caused 10 deaths in December. Infectious diarrhea, influenza, foot and mouth disease were the most prevalent in this category, accounting for 93 percent of cases. 

Infectious disease screening in asylum seekers: Range, coverage and economic evaluation in Germany, 2015

Via Eurosurveillance: Infectious disease screening in asylum seekers: range, coverage and economic evaluation in Germany, 2015. Excerpt from the discussion section:

This study analysed the compulsory medical screening of asylum seekers in Germany and provided estimates of the coverage and costs relative to expected yields. By listing and comparing state-level policies, we generated a comprehensive nation-wide overview of the content of screening programmes. 

Our study reveals substantial heterogeneity with respect to the range of compulsory screening tests stipulated by state policies and illustrates how this affects the proportion of asylum seekers screened as a consequence of the quota-based allocation system. The heterogeneity in screening policies leads to different economic impacts with respect to the distribution of the costs of receiving asylum seekers; federal states with the same level of economic strength mobilise different amounts of resources per asylum seeker for medical screening implementation. 

A high number and proportion of newly arrived asylum seekers were affected by compulsory screening for STIs (hepatitis B, syphilis or HIV) and stool examinations, in addition to the mandatory chest X-ray performed in asylum seekers ≥ 16 years of age. This resulted in total costs for Germany of more than 10 million EUR in 2015, a conservative, lower-bound estimate assuming full reimbursement according to statutory insurance fees. 

The sensitivity analysis showed that the total costs at the upper-bound using private fees could be up to 30% higher, which further argues in favour of the introduction of electronic health cards for asylum seekers and their integration into the regular healthcare system in Germany. 

We found high costs of medical screening relative to expected yields, raising questions on the cost-effectiveness of screening for some of the pathogens or diseases. By far the highest cost per identified case with respect to the initial screening test was found for Shigella spp. (> 80,000 EUR), followed by Salmonella spp. and TB (each > 5,000 EUR), syphilis (> 1,000 EUR), as well as HIV (> 700 EUR) and hepatitis B infections (> 600 EUR). 

Considering the co-existing private fee arrangements for conducting the medical screenings, the benefits of screening relative to programme costs are likely to be even lower, especially for infections with HIV, hepatitis B and enteropathogens.

Sexually transmitted infections: Challenges ahead

Via The Lancet Infectious Diseases, a report by The Lancet Infectious Diseases Commission: Sexually transmitted infections: challenges ahead. The summary:

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. 

In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. 

The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. 

Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. 

STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. 

Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. 

Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

China: Infectious diseases in the decade after SARS

Via The Lancet Infectious Diseases: Epidemiological features of and changes in incidence of infectious diseases in China in the first decade after the SARS outbreak: an observational trend study. The summary:

Background 

The model of infectious disease prevention and control changed significantly in China after the outbreak in 2003 of severe acute respiratory syndrome (SARS), but trends and epidemiological features of infectious diseases are rarely studied. In this study, we aimed to assess specific incidence and mortality trends of 45 notifiable infectious diseases from 2004 to 2013 in China and to investigate the overall effectiveness of current prevention and control strategies.  

Methods 

Incidence and mortality data for 45 notifiable infectious diseases were extracted from a Chinese public health science data centre from 2004 to 2013, which covers 31 provinces in mainland China. We estimated the annual percentage change in incidence of each infectious disease using joinpoint regression.  

Findings 

Between January, 2004, and December, 2013, 54 984 661 cases of 45 infectious diseases were reported (average yearly incidence 417·98 per 100 000). The infectious diseases with the highest yearly incidence were hand, foot, and mouth disease (114·48 per 100 000), hepatitis B (81·57 per 100 000), and tuberculosis (80·33 per 100 000). 132 681 deaths were reported among the 54 984 661 cases (average yearly mortality 1·01 deaths per 100 000; average case fatality 2·4 per 1000). 

Overall yearly incidence of infectious disease was higher among males than females and was highest among children younger than 10 years. Overall yearly mortality was higher among males than females older than 20 years and highest among individuals older than 80 years. Average yearly incidence rose from 300·54 per 100 000 in 2004 to 483·63 per 100 000 in 2013 (annual percentage change 5·9%); hydatid disease (echinococcosis), hepatitis C, and syphilis showed the fastest growth. The overall increasing trend changed after 2009, and the annual percentage change in incidence of infectious disease in 2009–13 (2·3%) was significantly lower than in 2004–08 (6·2%).  

Interpretation 

Although the overall incidence of infectious diseases was increasing from 2004, the rate levelled off after 2009. Effective prevention and control strategies are needed for diseases with the highest incidence—including hand, foot, and mouth disease, hepatitis B, and tuberculosis—and those with the fastest rates of increase (including hydatid disease, hepatitis C, and syphilis).

ECDC on antenatal screening in Europe

ECDC has published Antenatal screening in Europe: how to avoid mother-to-child transmission of infections. Excerpt:

Each year, more than five million live births are recorded in the European Union. Almost as many pregnant women are screened for infections – namely for HIV, syphilis, hepatitis B and rubella susceptibility – in order to prevent possible mother-to-child transmission (MTCT). However, children are still being born with these infections in the EU/EEA. For example, 424 congenital syphilis infections and 274 HIV infections were reported in children born between 2010 and 2014.   

In its evidence-based guidance, ECDC aims to help Member States to strengthen antenatal screening in the general population and in particular among vulnerable groups for MTCT. The guidance looks at which elements of a national antenatal screening programme for infections influence effectiveness, and which are the specific approaches to be used for reaching the vulnerable groups in order to increase the uptake of prenatal care and reduce mother-to-child transmission. The guidance is accompanied by two technical reports of literature reviews.   

Among the main proposals for effective antenatal screening are: 

• Testing for HIV, syphilis and hepatitis B during the first trimester of pregnancy. 

• Repeat testing offer during the third trimester for pregnant women at increased risk of infection and/or for those who previously refused testing. 

• Testing at delivery to women who had not previously been tested. 

• For HIV and syphilis in particular, a universal approach should be considered for the antenatal screening, which means voluntary testing for all pregnant women with an opt-out possibility.   

To improve the uptake of antenatal testing among vulnerable groups like migrant women or women at higher risk for infections due to injecting drug use or those engaging in high risk sexual practices, several options may be considered. This includes addressing communication barriers regarding language, literacy levels, or individual or cultural specifics, and improving access to antenatal care through outreach services and informal networks can help.

Canada: Risky behaviour not the only cause of syphilis outbreaks, new study proposes

Via CBC News British Columbia: Risky behaviour not only cause of syphilis outbreaks, new study proposes. Excerpt:

A new study from B.C. researchers is proposing a biological reason behind the "astounding" increase in syphilis cases, saying high-risk sexual behaviour doesn't explain the outbreaks that are happening. 

Syphilis outbreaks have been on the rise worldwide, including B.C. and many other locations in Canada — primarily among men who have sex with men, many of whom are taking antiretroviral drugs to treat HIV, the study states.  

Past research has speculated new, highly effective HIV treatments had encouraged more high-risk sexual behaviour. 

However, the study's lead author said that didn't make sense as a sole explanation,  because other sexually-transmitted disease such as chlamydia and gonorrhea weren't rising as quickly.  

"That led me to believe there must be something else going on," said Michael Rekert, clinical professor in the University of B.C.'s School of Population and Public Health, in a news release.

The study, published this week in the journal Sexually Transmitted Infections, proposes another possible cause — that the HIV therapy itself may make patients more vulnerable to syphilis. 

"What we are hypothesizing is there is an additional reason, besides behaviour, for why we are seeing this increase in syphilis cases," said Caroline Cameron, a University of Victoria microbiologist and co-author of the study.  

In B.C. for example, from 2005 to 2014, syphilis cases rose 90.6 per cent, much more than chlamydia (39.9 per cent) and gonorrhea (63.8 per cent). 

Biology vs. behaviour 

The paper hasn't demonstrated HIV therapy has this effect on syphilis but examines the case for it. 

One part of that is looking at the microbiology: whether there's a plausible biological mechanism for the HIV treatment, known as highly active anti-retroviral therapy, or HAART, to affect how the body responds to syphilis. 

"What we're hypothesizing is it's altering the immune response ... in a way that is increasing susceptibility to the pathogen," said Cameron. "It warrants further study." 

The authors are clear: HAART drugs are life-saving for people with HIV and shouldn't be stopped even if they make someone more vulnerable to syphilis.  

But it's important to explore the connection, with laboratory tests and other work, said Cameron.

Germany: Increased incidence of syphilis in MSM

Via Eurosurveillance: Increased incidence of syphilis is men who have sex with men and risk management strategies, Germany, 2015. The abstract:

In Germany, the number of reported syphilis cases increased between 11% and 22% per year between 2010 and 2014. We analysed syphilis surveillance data and data of four behavioural surveys on men who have sex with men (MSM) in Germany (2003, 2007, 2010, 2013) to assess if this rise is ongoing and to find possible explanations for it. 

Syphilis notifications increased in 2015 by 19% to a total of 6,834. This was mainly due to increasing notifications in MSM of all age groups in larger German cities. Data from the behavioural surveys on MSM in Germany showed a simultaneous increase of selective condom use as HIV-status-bases risk management strategy and the number of syphilis cases. MSM diagnosed with HIV reported condomless anal intercourse with non-steady partners more frequently than MSM not diagnosed with HIV or untested for HIV, but the latter also reported higher frequencies of this behaviour in the more recent surveys. 

Transmission in HIV-positive MSM probably plays an important, but not exclusive role, for the syphilis dynamics in Germany. A risk adapted routine screening for sexually active MSM and potentially innovative approaches to increase early screening and treatment of syphilis such as internet counselling, home sampling, home testing and broadening venue-based (rapid) testing, should be critically evaluated to effectively reduce syphilis infections.

Canada: University of Victoria researcher close to developing syphilis vaccine

Via The Globe and Mail: University of Victoria researcher close to developing syphilis vaccine.

A University of Victoria researcher says she and a colleague are close to developing a vaccine for syphilis, a disease that has reached its highest rates in B.C. in 30 years. 

Microbiologist Caroline Cameron and Sheila Lukehart, a professor in the University of Washington’s department of global health, have received a nearly $3-million grant from the U.S. National Institute of Allergy and Infectious Diseases at the National Institutes of Health. The grant will help fund preclinical trials. 

Dr. Cameron has studied the sexually-transmitted infection for two decades and runs the only lab in Canada that researches how the pathogen that causes it spreads throughout the body. Dr. Lukehart’s research focuses on the initial stage of the disease: preventing the formation of a chancre that is unique to syphilis. 

 “If we combine in a vaccine cocktail her protein that prevents the lesion from forming and my protein, which prevents the organism from spreading in the body, then we should be able to combat what causes the disease,” Dr. Cameron said. 

The grant, which will cover a four-year period of research, will allow the two to test on animals the effectiveness, optimal dose and longevity of the vaccine cocktail. 

“We’re hoping at the end of that period to be at a point where we will have a great idea of whether this will be it, or we have to tweak it,” Dr. Cameron said. 

Almost 400 cases of infectious syphilis have been reported in B.C. in the first half of 2016, said Jason Wong, a physician epidemiologist with the B.C. Centre for Disease Control. This is about 25 per cent higher than the same period last year, though a projection would put the year-end total at about 4 per cent higher than last year’s total of 761 cases. 

Of last year’s total, almost 500 cases were reported in the Vancouver Coastal Health (VCH) region – more than double the number of cases reported a decade ago – prompting the health authority to initiate a formal outbreak response early this year. 

Dr. Wong said there are various possible factors as to why numbers have climbed year-over-year since about 2010, one being increased awareness and testing. 

“We do know that testing volumes have gone up – more people are testing for syphilis, and testing for syphilis more regularly – so one reason for the increase may be that we’re able to catch more of it,” he said.

Thailand eliminates mother-to-child transmission of HIV and syphilis

Via The Lancet: Thailand eliminates mother-to-child transmission of HIV and syphilis. The summary:

On June 7, 2016, WHO certified that Thailand had eliminated mother-to-child transmission of HIV and syphilis, becoming only the second non-Organisation for Economic Co-operation and Development country after Cuba to achieve these goals. WHO also validated Belarus for eliminating mother-to-child transmission of both HIV and syphilis on June 8. 

This is not only a public health success story for Thailand, but also an affirmation of how internationally agreed aspirational goals—from WHO's Health for All by 2000 campaign and the UN's 2001 Declaration of Commitment on HIV/AIDS to the Millennium Development Goals and the Sustainable Development Goals—can help health ministries to mobilise political will, public funds, and committed implementation.