Sustained health systems strengthening holds the key to prevention of mother-to-child transmission of syphilis

Half a million still-births annually are due to syphilis in pregnancy – deaths that could be averted by means of a single dose of penicillin.  An important project, reported in PLoS Medicine by Mabey, Peeling et al., to introduce point-of-care syphilis tests (POCTs) at ante-natal clinics (ANCs) in six countries, has resulted in all six countries adopting a policy to recommend POCTs; it has also influenced two of those countries, Brazil and China, to make syphilis testing for pregnant women a major public health priority (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001233).

The past failure to address the problem of mother-to-child transmission is nothing to do with the efficacy of the intervention or its cost-effectiveness.  A recent systematic review, covered by this blog, indicates an odds ratio of 0.46 for reduced perinatal death and of 0.42 for reduced still birth (https://blogs.bmj.com/sti/2011/06/29/screening-for-syphilis-in-pregnancy-evidence-for-the-effectiveness-of-doing-something/?preview=true&preview_id=407&preview_nonce=8747e0989c).  The cost effectiveness of ante-natal screening is strongly endorsed by Terris-Prestholt, Ndeki et al. (2003) (http://sti.bmj.com/content/82/suppl_5/v38.abstract?sid=82a53292-0a5a-46d1-a01d-9cf6bbade9ae).  In the past an important obstacle to testing in low and middle income countries (LMICs) may have been the absence of a medical laboratory infrastructure.  But cheap and effective POCTs now offer a means to conduct screening in ANCs, which are attended by most pregnant women even in limited resource settings.  The relative merits of four POCT devices are compared by Mabey, Galban, et al. (2006) (http://sti.bmj.com/content/82/suppl_5/v26.abstract?sid=87c460fb-7f2f-49e6-b978-8720b427de3f).  You will find technical description of a POCT in this blog (https://blogs.bmj.com/sti/2011/10/02/what-fluidics-engineering-can-do-to-prevent-vertical-hivsyphilis-transmission-in-low-resource-settings/?preview=true&preview_id=495&preview_nonce=99cf925437).

So what are the obstacles to POCT deployment?

Mabey, Peeling et al. focus on the training and organizational challenges to deployment of POCTs in LMICs.  From the research angle, their project is a piece of “implementation research”.  What they set out to evaluate in their paper is the way in which the project meets the challenges of: 1. training the health care workers to implement the tests; 2. maintaining the quality of tests through a quality assurance program; 3. ensuring the continuity of supply chains for material and staff.  At the outset, design and location of the project were agreed with local authorities and stakeholders; next, training was offered not only to health-workers (HCWs) but to supervisors – and in the latter case the training included the assessment and training of HCWs, stock management etc.;  the project was then allowed to run.

What emerged in one area (Tanzania),was, interestingly, a 65% drop over the first six months in the percentage of ANCs passing the quality assurance controls due to high staff turn-over: but, subsequently, with the HWC training mechanism kicking in, there was a return to 100% levels of proficiency.  Also interesting was the initial resistance of laboratory staff in another area (Peru) to the idea of HWCs doing the work of laboratory technicians, though this was finally overcome.

In due course detailed papers will be published on the data from each of the countries involved: Brazil, China, Peru, Zambia, Uganda and Tanzania.  The published paper stresses the power and value of implementation research, and its potential application to other areas (e.g. HIV).  An implication of this approach is the significance of obstacles to improved health care delivery represented by the structural and organizational considerations.  The secret of obtaining better outcomes for prevention of mother-to-child transmission and other interventions may, therefore, lie in sustained health systems strengthening .

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