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UDC 616.971-084
ORGANIZATIONAL ASPECTS OF SYPHILIS PREVENTION
E.G.Grigorieva
Yaroslav-the-Wise Novgorod State University, geg-eg@mail.ru
The analysis of current status, major trends and dynamics of the spread of syphilis in the Russian Federation has been carried out. Considerable analysis of causes of epidemiological situation, main principles affecting spread of infection in Pskov region has been conducted. Analysis of strategies and main tends in work of medical personnel for prevention of congenital syphilis is presented. Keywords: syphilis, pregnant women, syphilis, newborns, congenital syphilis, prevention, nurse personnel, standards, algorithms
Проведен анализ современного состояния, основных направлений и динамики распространения сифилиса в РФ. Уделено значительное место анализу причин эпидемиологической ситуации по данной инфекции, отмечены основные принципы, влияющие на его распространение и в Псковской области. Дан анализ стратегий и основных направлений работы медицинского персонала по профилактике врожденного сифилиса.
Ключевые слова: сифилис, беременные, больные сифилисом, новорожденные, врожденный сифилис,
профилактика, среднее медицинское звено, стандарты, алгоритмы
matovenereologists and health care [3,7]. Since 1991 the incidence of syphilis has increased steadily and reached its highest-ever level in 1997 — 277.7 per 10000. The total syphilis morbidity has exceeded level of 1990 in 51
Relevance
The incidence of syphilis both in Russia and abroad is one of the most urgent social problems to der-
times, congenital syphilis — in 47 times [7]. Prevalence of medical and social risk factors in different population groups [1,2,4] increased in the current social and economic conditions in Russia; the reason is that due to social instability of population restoration of the so-called social diseases which include sexually transmitted diseases occurred.
Syphilis is most common among young, sexually active women of reproductive age [2,6], and it undoubtedly gives push to epidemic of congenital syphilis. Morbidity of child and adolescent population composes great social problem. During the period from 1993 to 1997 incidence of teenagers by syphilis increased in 7.1 times [8].
Analysis of epidemiological situation of syphilis in Pskov region for the period from 1996 to 2009 as in Russia was tense and contradictory. The highest morbidity rate per 100000 was registered in 1996 (376.7 per 100 000) with its decrease to 2009 (46.4 per 100 000). Tendency to gradual reduction of morbidity, which has been preserved to this day, has been noted since 1997.
Throughout the analyzed period structure of syphilis has been changing. Against the background of considerable reduction of total syphilis morbidity the cases of latent (early) syphilis has become often in Russia from 1998 to 2009. During the observation period contingent of patients with latent syphilis increased from 24.7% to 73.7% (p < 0.01) of the total number of newly registered patients with syphilis.
Large proportion of latent forms of syphilis (73.7%) of the total registered syphilis in Pskov region testifies negative dynamics associated with the poor implementation of preventive measures in the region. This situation promote to development of «reservoir of infection» which requires the expansion of prevention measures.
Analysis of epidemiological situation in Pskov region for 14 years has shown that after decrease in the total incidence of syphilis, increase of the proportion of pregnant women among women with syphilis has been registered. Measured undertaken by government to improve the demographic situation impact on increasing the number of pregnant women, whose share has grown in 3.6 times in 2009 (23,145 pregnant — 14.7% of total female population) compared with 1996 (6351 pregnant — 60.7% of total female population). Number of pregnancies increased on 27.4% (p < 0.05), while the proportion of pregnant women among women with syphilis has progressively increased from 3.8% to 30.9% (p > 0.05). The share of pregnant women with syphilis among women of fertile age was 40.7%, which reflected in appearance of cases of congenital syphilis.
Outpatient health care with a focus on prevention measures is considered as priority for further development of health protection and promotion considering economic situation in industry. Nurse participating plays substantial role in development of prevention, collaboration in various programs at the municipal level, at enterprises, schools and others [5,9]. According to the federal target program «Prevention and control of socially significant diseases (2007-2011)», one of the priorities of state policy in the health sector is to reduce morbidity of
socially significant diseases, improvement and implementation of methods for their prevention.
In connection with the abovementioned it is interesting to study the organizational aspects of prevention of syphilis in various age groups.
Materials and methods
Standards (algorithms) of organizational and preventive measures for congenital syphilis at different stages of medical care of patients conducted by nurse personnel has been considered in this research.
Medical standards are considered in research as the structural, organizational and productive aimed to providing with prevention at different stages of medical care and prevention of congenital syphilis.
Standards of medical care for patients with congenital syphilis in Russia approved by order of Ministry of Health, Social Development 18.12.2006 №860 and function now. These standards define delivery of specialized care, namely diagnosis, treatment and care, with no unified requirements for the implementation of prevention before and after treatment. In this regard we have developed standards for the prevention of congenital syphilis for the nurse personnel who are divided into groups of delivery of care and possible prevention of syphilis.
Results
We have developed methodology forms (algorithms) of organizational and preventive measures for congenital syphilis at various stages of medical care of patients: before pregnancy, during pregnancy and after pregnancy.
1. General algorithm for prevention of vertical transmission of syphilis:
Stage I
1.1. Detection of syphilis among pregnant women in prenatal clinic.
1.2. Reporting the diagnosis to dermatovenerologic dispensary (DVD): nurse asks to come to doctor’s office, tells about disease, its consequences, and explains about treatment, prevention for newborn.
1.3. Cooperative pregnancy follow-up prenatal clinic and DVD.
1.4. Administration of specific and prophylactic treatment in DVD.
1.5. Carrying out of specific and prophylactic treatment in DVD.
Stage II
2.1. Admission to hospital.
2.2. Prevention for women in maternity hospital (treatment, care).
2.3. Prevention for newborn in maternity hospital (treatment, care).
Stage III
3.1. Release of mother and newborn from hospital.
3.2. Continued treatment of the mother in DVD.
3.3. Transfer of newborn baby in hospital.
Stage IV
4.1. Preventive medical examination of mother (attendance for serological tests), nurse from DVD makes appointment to doctor.
2. Algorithm for prevention of vertical transmission of syphilis during pregnancy:
— during first appointment to prenatal clinic concerning pregnancy women take tests for detection of infection, in this case — syphilis (ELISA). If serological analysis is positive, emergency notification goes to dermatovenerologic dispensary.
If serologic test is negative, prenatal clinics reports about pregnant women to DVD and pediatric services:
—women with positive serological test in prenatal clinic make repeatedly serological test (examination) in dermatovenerologic dispensary. If positive test question of retention or termination of pregnancy should be solved (woman is explained the possible consequences of further treatment, medical check-up);
— if woman agrees, specific treatment (treatment of syphilis in women) and prophylactic from 20th weeks of gestation (treatment of child) are administered. If specific treatment is late, preventive treatment should follow immediately (regardless of gestational age);
— during treatment woman is observed in prenatal clinic and dermatovenerologic dispensary and then sent to labor.
3. Algorithm of health care for newborns from mothers with positive serological tests and diagnosis of syphilis during pregnancy:
— neonatal serologic test is performed after receiving specific treatment (umbilical cord blood is taken for blood test, because large molecules of antibodies does not penetrate healthy placenta; the formation of tre-ponemospecific IgM-antibodies in the baby's blood indicates the presence of infection in the newborn [181]. IgM may be produced in fetus body to the maternal IgG, so the results of serological studies should be evaluated in the dynamics and more than three times: at birth from umbilical vein, in 7-10 days and after specific therapy in 20-28 days);
— reporting to dermatovenerologic dispensary about birth of child from mother with syphilis, consulting dermatologist at hospital, administration of treatment;
— release of mother and child from the hospital; child with positive serological tests is transferred to children's hospital for further treatment of syphilis, and woman is treated in dermatovenerologic dispensary (if possible inpatient treatment);
— after treatment child is provided with follow-up care (clinical and serological control) in dermatovene-
rologic dispensary and at pediatricians. Removal from the dispensary observation is performed by dermatologist.
Conclusion
Developed standards for nursing care for prevention of congenital syphilis significantly improved detection of syphilis in early stages and thereby reduce the detectability on late terms of pregnancy (up to 0.2%). Involving nurse personnel to preventive measures has reduced the economic costs of medical examinations of pregnant women (up to 8279.91 rub.). Efficiency of developed methodological forms at different stages of medical care of patients is confirmed by decreased syphilis in pregnant women (on 85.9%) and congenital syphilis (on 0.3%). Studied medical and social aspects have enabled improvements in relationship between inter-agency and various health care facilities for prevention of syphilis among the population and to streamline system of dispensary observation of patients with syphilis.
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