1

Introduction

Syphilis is a contagious venereal disease caused by the spirochete TREPONEMA PALLIDUM.

(WHO). It is one of the oldest diseases known to mankind. It has such diverse manifestations
that about a hundred years ago almost all clinical signs in patients presented for care were
attributed to syphilis (much as they are for tuberculosis today). Basically the presentation of
syphilis can be divided into incubation period (about 21 days), primary, secondary and tertiary
stages.

Primary syphilis is the early stage when the infection is establishing and appears in the form of
an ulcer called chancre at the site of inoculation of infection. Usually this is in the genitalia but
has also been documented on fingers, lips etc.

Secondary syphilis appears about 2-8 weeks after the chancre. The possible manifestations
are many. Although the most common presentations are on the skin and include macular,
maculopapular, papular or pustular lesions. Any body surface may be involved but palms of the
hands and soles of feet are the commonest. Sometimes papules may enlarge, to erythematous
highly infectious plaques called condyloma lata. Besides, skin inflammation of blood vessels can
lead to arteritis.

Late latent stage is that phase when a person harbors the infection as shown by tests but no
clinical symptoms are present. About 10-25% of these individuals will go on to develop tertiary
syphilis.

Tertiary syphilis is late syphilis. Its manifestations include neurological involvement, ocular
involvement, Cardiovascular Syphilis and Late Benign Syphilis (Gumma).

Epidemiology

• Age: 75% b/w age of 15-35 years and peak incidence is between the age of 25-30 years
• Sex ratio: 3 males to 2 female
• More common in colored than white
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Syphilis can be congenital or acquired. Congenital syphilis is transmitted from an infected

mother to her unborn or newborn baby. Rate of transmission is 60–100% Infection is transmitted
to the fetus at any stage of disease; during primary, secondary and tertiary syphilis. Nasal
secretions are highly infectious in congenital syphilis. Acquired syphilis is sexually transmitted
from an infected to an uninfected individual. Open moist skin lesions are infectious in congenital
and acquired syphilis.

Key Determinants of Syphilis

. In considering syphilis several socioeconomic and behavioral factors make Pakistan a high risk
country. Among these factors following are worth mentioning:

• Not following our cultural and religious values regarding sexual behavior specially pre
marital and extra marital relationships.
• Low literacy level.
• Poor reproductive health education environment.
• Large concentration of individuals with behaviors that make them extremely vulnerable
to spread of syphilis in major cities. These individuals are both male and female sex
workers.
• Men who have unprotected (without condom) sex with transgendered/female sex
workers - Unsafe sexual activity globally ranks second in 20 leading risk factors for mortality
and morbidity and a fifth of attributed mortality.1
• Drug users using syringes.
• Highly mobile occupational groups such as truck drivers. 2
• Sexually abused, mainly if one of them is already infected with syphilis.
• Male migrant.3
• Lack of prenatal care.
• Differences in gender based attitudes such as power inequalities, poor access to care.
• Pregnant women who are infected with syphilis - can transmit the infection to their fetus,
causing congenital syphilis, with serious adverse outcomes for the pregnancy in up to 80%
of cases (WHO report 200)
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Statistics of Syphilis

• Global context

 Incidence of Syphilis 2 million worldwide cases ( m/f = 1.2/1), including

3.53 million in sub-Saharan Africa. 4

 37,977 cases annually in the USA (1998)

 31,575 new cases of syphilis occurred annually in the US 2000.5
 70,000 new cases annually in America. 6
 0.29 per 100,000 in Canada 2000. 7
 613 new cases of syphilis in England and Wales 200. 8
 11,627 new cases of syphilis was notified in Australia 2002. 9

 Death Statistics for Syphilis. 10

 About 89,000 deaths from syphilis in Africa 2002

 About 1,000 deaths from syphilis in The Americas 2002
 About 43,000 deaths from syphilis in South East Asia 2002
 About 21,000 deaths from syphilis in Eastern Mediterranean 2002
 About 1,000 deaths from syphilis in Western Pacific 2002

Pre gnanacy

45%
40%
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Source : www.wrongdiagnosis.com/s/syphilis/stats.htm

ASIA : In Asian countries although prevalence is variable but it is high in different population
groups as well:

 12% sero- positivity was seen in drug-users of St-Petersburg, Russia 11, while in India
seroprevalnce among long distance truck drivers was 13.3 %, 12 but a incidence was low
in blood donors (0.22 %) 13. Among 1534 slum dwellers from Dhaka, Bangladesh,
serologic evidence of syphilis infection was found in 6%. 14. A very high seroprevalnce
(43%) among 296 male transvestites from Jakarta, Indonesia gives us the magnitude
among such high-risk group in Asian countries 15. It is estimated that 1.0% of the
population above age 15 are infected with syphilis in Malaysia. In Nepal prevalence of
syphilis is 22% among men.

Syphilis Prevalance 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 clinics 1.5

Libyan Arabs 1992 Male 19

Source www.emro.who.int/asd/pdf/Strategy_HIV-TB_06-10.pdf

PAKISTAN Syphilis is relatively uncommon among general population in contrast with much
higher prevalence in high risk group. Syphilis infection is taboo in our society there is very
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limited data available on the prevalence or incidence of syphilis infection among general
population

Syphilis Prevalence in Different Population in Pakistan (2004 -2006)

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

Source www.emro.who.int/asd/pdf/Strategy_HIV-TB_06-10.pdf

@ STI prevalence and associated factors among urban men in Pakistan ,Mir AM, Wajid A,
Reichenbach L, Khan M., Sex Transm Infect. 2009 Jun; 85(3):199-200. Epub 2009 Feb
11. Population Council,PUBMED
* http://www.rmj.org.pk/RMJ%2029 (2)%20Jul-Dec%202004/PDF/Artic%20-
%20Seroprevalence%20of%20syphilis.pdf

Existing polices and capacities: In Pakistan there is no separate policy for control of Syphilis.
It is being managed in the policy for treatment of other STIs. Pakistan was a member of ICPD
and the key goals which were embedded in the ICPD - were:
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• By 2005, 60% of primary health care should offer the widest, prevention and
management of reproductive tract infections, including sexually transmitted infections (STIs);
80% of facilities should offer such services by 2010, and all should do so by 2015. 16
• In view of this, the World Health Organization promotes national guide lines for STI..
These guidelines focus that all patients being considered for STI treatment must also be
considered for testing of Syphilis.MOH has drafted expanded response program of about
US$ 40 million with the assistance of WHO and one of the key areas is to provide improved
availability of STI services among general population.
• The National AIDS Control Programm UNICEF, UNAIDS, UNFPA have been active for
providing services in STI
• Most high risk group members seek help from the private sector – mainly general
practitioners and non medical personnel 17. Public sector STI facilities tend to provide
services mainly to clients of sex workers and others who acquire STIs from non commercial
sex.

Priorities to control and prevent syphilis infection.

• To reduce syphilis related morbidity and mortality:

• The spectrum of health consequences ranges from mild acute illness to painful lesions
and psychological morbidity. It can result in neurological, cardio vascular, bone diseases
and fetal loss in pregnancy.
• To prevent HIV infection: Syphilis case management is one of the cost effective
interventions for HIV prevention. It is scientifically proven that such prevention reduces the
incidence of HIV infection in general population specially if targeted towards high risk group.
o Evidence: - A recent study in USA of 52 HIV infected men with primary or secondary
syphilis, 58% of whom were receiving anti retroviral therapy, showed that syphilis is
associated with significant increases in plasma viral load and significant decrease in
CD+4 cell count. Syphilis treatment restored immunity to pre infection levels, findings
that under score the importance of preventing and promptly treating syphilis in HIV
infected individuals both as preventive strategy and to improve quality of care for person
living with HIV. 18
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o Evidence:- Genital ulcers (caused by syphilis) have been estimated to

increase the risk of transmission of HIV 3 to 5 folds per episode of unprotected sexual
intercourse. 19

To prevent adverse pregnancy outcome Universal institution of an effective intervention to

prevent congenital syphilis should prevent an estimated 492,000 stillbirths and perinatal deaths
per year in Africa alone. 20 In terms of cost effectiveness, in Mwanza (United Republic of
Tanzania), where the prevalence of active syphilis is 8% in pregnant women, the cost of
intervention is estimated to be US$ 1.44 per women screened, US $ 20 per woman treated, and
US $ 10.56 per disability adjusted life year saved21

Rationale: Disclosing of STI is considered to be a taboo in our society. People have self
imposed restrictions due to which they do not want to disclose that they are suffering from this
disease and therefore they are not able to get the required treatment. They cannot imagine the
complications of the disease mainly due to their lack of education and awareness about its
consequences. There is need to first take them into confidence and through interactive
discussions educate them on preventive measures while at the same time physically improve
upon the quality of care by providing medicines and by establishing good relationship with the
patients.

. Aim: To reduce syphilis related morbidity and mortality in Pakistan.

Objective: To prevent syphilis infection in district Karachi by 90% by improving the quality of
preventive and curative services in 5 years time.

After literature reviewing and setting of aim and objective produced possible interventions by
developing precede proceed model

Precede – Proceed Model

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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
Factors
Behavior
Health 70%
Promotion Community
elimination of
Enabling syphilis
Factors
Environment
Policy
Regulation
Community
Organization

Phase 6 Phase 7 Phase 8 Phase 9

Implementation Process Evaluation Impact Evaluation Outcome Evaluation

Behavioral Factors: Reduction of risk taking sexual behavior among 70%.

Behavioral Factors: Reduction of risk taking sexual behavior among 70% general population

Environmental Factors: 100% availability of effective treatment at all BHUs and RHC and
other private health sector

Pre disposing Factors

• Promoting healthy sexual behavior among 80% general population

• Change attitude for early seeking behavior 80%.
• Awareness about syphilis.

Reinforcing Factor

• 90% increase of effective response from health care provider

• 70% decrease of social taboo stigmatization regarding Syphilis

Enabling Factor

• 80% lab diagnostic facilities for syphilis

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

• 60% screening of pregnant women
• 100% community based distribution of condom to targeted population.

After analyzing the above mentioned factors I identified the following possible strategies:

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 and its
risk factors.

• 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, syphilis
infection and personal hygiene.

Community organization

• Screening test among ANC.

• Surveillance program among high risk groups at district level.

• Integrating syphilis intervention with other health programs.

• Offer counseling and confidential voluntary test for high risk groups.

• Offer effective treatment for established cases to improve the quality of life.

• Religious and faith based organizations to motivate and shape attitudes and
behaviors of the community.
• Improve surveillance and research tools
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• Case finding program

• Social hygiene program

IMPLEMENTATION PLAN

SPHYLIS 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.

Clients centered approach allows patients to discuss their needs / circumstances freely and
confidentially to receive appropriate treatment. Evidence: Client centered approach was used
in a project by population council in Sargodha district that showed positive results. (Ref:
intervention smart report 2 UNFPA) Patient, care provider council ling and interactive
communication are ideal to deliver preventive measures (Ref:, The national study of sexual and
reproductive tract infections, NACP, MOH, PMRC 2004).

Package Includes:

Training of doctors for

• Identification and respect of client.
• Improving care providers’ skills in giving education for preventive measure.
• Encouraging patients to use condoms and notification of sexual partners.
• Refresh course of doctors for case management.
Community mobilization for BCC progmm
Provision of medicines and condoms at all public hospitals and GPs clinics in high risk
groups’ areas.
Referral system will be established in all public hospitals for those patients who are not
responding to treatment given by care providers
Phase I
• Mobilize resources.
• Identification of national organizations./NGO and faith based organization
• Assessment of base line health services.
• Prepare training material to meet specific needs.
• Prepare list of care providers to be trained.
• Identification of master trainers.
• Identification of community workers and opinion leaders
Phase II
• Training of health providers – A total of fifty master trainers are needed to initiate
the process in districts.
• List of care providers will be formed with the help of EDO and they will be
informed via letters.
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• Offer training to private doctors and confirm their consent.

• Training will be done 10 batches for one month
• Integration/collaboration with other programs STD control program ANC, MCH,
FP, RH, dermatology and other existing programs
• National / local media campaign
• Education for youth in / out of school
• Community initiatives (e.g. peer education)
• Education in health facility waiting area
• Seminars at work places to increase awareness regarding high risk sexual
behavior
Phase III
• Identification of referral system.
• Regular supervisory and monitoring visits to health facilities for ensuring proper
treatment.
• Laboratory support in all public hospitals for syphilis test
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 with infection who are given care with advice of condom use.
• Proportion of patients with infection who are given care with advice /education about
prevention of reinfection.
• Proportion of patients with infection who identified their sexual partner.
• Proportion of patients with infection who are treated by the notification of sexual partner.
• Proportion of patients with infection who are cured by treatment.
• Proportion of pregnant women treated.

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
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