GHENT UNIVERSITY Karoline FONCK - International Centre for ...
GHENT UNIVERSITY Karoline FONCK - International Centre for ... GHENT UNIVERSITY Karoline FONCK - International Centre for ...
One of the priorities of the Kenyan Sexually Transmitted Diseases Control Program, set up in 1987 (Forsythe 1996), was to control syphilis during pregnancy. In 1989, an evaluation of the centralized screening program in Nairobi revealed low effectiveness (Temmerman 1993). Subsequently, in 1992, a decentralized program was put in place with support from the European Commission. This program has since been extended to other locations in Kenya (Jenniskens 1995). The purpose of this study was to assess the effectiveness of this 6-year-old urban decentralized program and to formulate recommendations for future implementation. Methods The main strategy of the syphilis program in Nairobi was the implementation of a decentralized, clinic-based model for the on-site diagnosis and treatment of syphilis seroreactive pregnant women and their partners. Components of the project included: (1) laboratory support, (2) supplies and drugs, (3) training nurses in rapid plasma reagin (RPR) testing and treating seroreactive women with a single dose of 2.4 million international units of benzathin penicillin administered intramuscularly, (4) counseling, (5) partner notification, and (6) supervision and monitoring. The Macro-Value RPR card test (Becton Dickinson, Cockeysville, Md) was used for RPR testing at the peripheral level and for quality control at the central sexually transmitted disease (STD) referral clinic. The quality control consisted of a blind analysis of all RPR-positive sera and of a random selection of 1 in 10 negative samples. To analyze the program, we monitored data from the 10 primary health care clinics, quality control data from the referral laboratory, and information on costs. Results Between July 1997 and June 1998, 96% of all pregnant women (n=27,377) attending the 10 clinics were screened for syphilis. Main reasons for failure to screen were high workload and lack of electricity, although manual RPR cards were available. Overall, 928 women (3.4%) were RPR positive, and 91 % of these women were promptly treated (Table 1). The reasons for non-treatment included absence of the person in charge, unwillingness of the woman to wait for test results, and the policy of some of the clinics to treat the woman simultaneously with the partner. PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 69
Table 1: Syphilis Rapid Plasma Reagin (RPR) seroreactivity and treatment rates at 10 Mother and Child Health (MCH) Clinics in Nairobi, Kenya. Women screened RPR+ Women Treated Partners Treated MCH clinic n % n % n % n % Baba Dogo 2863 97 160 6 153 96 64 42 Dandora 4064 97 183 5 173 95 112 65 Eastleigh 1453 86 51 3 50 98 27 54 Kariobangi 2647 85 30 1 23 77 19 83 Langata 4662 100 168 4 149 89 74 50 Mathare 2793 100 78 3 78 100 40 51 Ngong Road 2749 100 75 3 58 77 44 76 Riruta 1651 90 41 2 33 80 11 11 Umoja 2458 100 90 4 80 89 41 41 Westlands 1947 100 52 3 48 92 20 20 Total 27377 96 928 3 845 91 452 452 Overall, 53% of the partners were treated. Partner notification was hampered by the quality of counseling, the casual nature of the partnerships, and a woman's risk of physical abuse when she informed her partner of the STD; hence, women might be reluctant to do so despite the counseling's focus on the well-being of the unborn child. When we performed quality control, only 69% of the RPR-positive results and 97% of the RPR-negative results were confirmed. The relatively high false-positive rate may be explained by technical constraints, high workload inadequate training, and slackening of the supervision. There is also anecdotal evidence that some centers report false-positive results on purpose in order to obtain benzathin penicillin for other uses. The costs of the program include testing, Table 2: Cost in Kenyan Shilling of the syphilis screening program treatment, quality control, yearly during a one-year period, (1 US Dollar = 60 Kenyan Shillings). No of Units Cost / Unit Total Cost refresher training, and supervision. The RPR kits 200 2000 400000 capital costs (car, rotators, and Vacutainers and needles 27377 2 54754 centrifuges) were discounted over 5 Rotators and centrifuges* 10 20000 200000 Drugs 1420 25 355000 years. The total cost of the syphilis Staff salaries** 372000 screening program for 1 year was US$ Refresher training 1 100000 100000 30,996 (1 US dollar= 60 Kenyan Car* Transport cost 1 200000 82000 shillings) (Table 2). Total 1859754 The total cost of testing and treatment Cost per pregnant woman 68 (RPR kits, Vacutainer collection tubes * Capital cost discounted over 5 years. and needles, rotators and centrifuges, ** Includes only salaries for staff involved in supervision and quality control, does not include clinic staff salaries. clinic supplies, and drugs) was US$ 18,429. Of the 27,377 women screened, 928 were RPR reactive and 845 were treated, resulting in a cost of US$ 37 per case treated. Positive results were confirmed in only 583 (69%) of the women treated. If congenital syphilis occurs in one third of babies born to syphilitic mothers and stillbirth or prematurity in another third, the PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 70
- Page 19 and 20: 2.1. OBJECTIVES 2.1.1. General obje
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- Page 51 and 52: Table 2: Healthcare-seeking behavio
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- Page 55 and 56: Men reported more extramarital affa
- Page 57 and 58: C HAPTER 5 DIAGNOSIS AND MANAGEMENT
- Page 59 and 60: discharge and abdominal pain-two co
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- Page 101 and 102: patients. The analysis revealed hig
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- Page 105 and 106: use in Kenya. In a supplement of Se
- Page 107 and 108: with intensive behavioral change in
- Page 109 and 110: C HAPTER 8 FINAL REMARKS STIs illus
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- Page 115 and 116: Fleming D and Wasserheit J. From ep
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- Page 119 and 120: Manning B, Moodley J, Ross SM. Syph
One of the priorities of the Kenyan Sexually Transmitted Diseases Control Program, set up in<br />
1987 (Forsythe 1996), was to control syphilis during pregnancy. In 1989, an evaluation of the<br />
centralized screening program in Nairobi revealed low effectiveness (Temmerman 1993).<br />
Subsequently, in 1992, a decentralized program was put in place with support from the<br />
European Commission. This program has since been extended to other locations in Kenya<br />
(Jenniskens 1995).<br />
The purpose of this study was to assess the effectiveness of this 6-year-old urban<br />
decentralized program and to <strong>for</strong>mulate recommendations <strong>for</strong> future implementation.<br />
Methods<br />
The main strategy of the syphilis program in Nairobi was the implementation of a<br />
decentralized, clinic-based model <strong>for</strong> the on-site diagnosis and treatment of syphilis<br />
seroreactive pregnant women and their partners. Components of the project included:<br />
(1) laboratory support, (2) supplies and drugs, (3) training nurses in rapid plasma reagin<br />
(RPR) testing and treating seroreactive women with a single dose of 2.4 million international<br />
units of benzathin penicillin administered intramuscularly, (4) counseling, (5) partner<br />
notification, and (6) supervision and monitoring. The Macro-Value RPR card test (Becton<br />
Dickinson, Cockeysville, Md) was used <strong>for</strong> RPR testing at the peripheral level and <strong>for</strong> quality<br />
control at the central sexually transmitted disease (STD) referral clinic. The quality control<br />
consisted of a blind analysis of all RPR-positive sera and of a random selection of 1 in 10<br />
negative samples.<br />
To analyze the program, we monitored data from the 10 primary health care clinics, quality<br />
control data from the referral laboratory, and in<strong>for</strong>mation on costs.<br />
Results<br />
Between July 1997 and June 1998, 96% of all pregnant women (n=27,377) attending the 10<br />
clinics were screened <strong>for</strong> syphilis. Main reasons <strong>for</strong> failure to screen were high workload and<br />
lack of electricity, although manual RPR cards were available. Overall, 928 women (3.4%)<br />
were RPR positive, and 91 % of these women were promptly treated (Table 1). The reasons<br />
<strong>for</strong> non-treatment included absence of the person in charge, unwillingness of the woman to<br />
wait <strong>for</strong> test results, and the policy of some of the clinics to treat the woman simultaneously<br />
with the partner.<br />
PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 69
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