SYPHILIS ON THE RISE

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Syphilis on the Rise: Arizona’s Race to Prevention

Courtney M. Berman
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Courtney M. Berman is a graduate student in the Edson College of Nursing and Health
Innovation at Arizona State University. Courtney was previously a labor and delivery nurse and
currently works for the State of Arizona as a medical management specialist within the Arizona
Health Care Cost Containment System (AHCCCS).
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Courtney M. Berman,
Edson College of Nursing and Health Innovation, Arizona State University, 550 N. 3rd Street,
Phoenix, AZ 85004 email: cmberman@asu.edu.

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ACKNOWLEDGEMENTS

I want to extend my deepest appreciation to my DNP faculty mentor, Dr. Patricia Janicek
DNP, WHNP-BC. Your guidance and encouragement throughout my education and this project
have been instrumental in my success academically. I would also like to thank Dr. Sara Salek,
MD, for openly discussing public health concerns in Arizona with me. The conversations we had
ignited a passion within me and led to the creation of this project. Additionally, I would like to
thank my site champion, Dr. Heather Reed, MD. Your enthusiasm for providing quality patient
care is unmatched and inspiring; thank you for welcoming this project into your organization.
None of this would have been possible without the unconditional support, encouragement, and
love from my family. I am incredibly lucky to have you all in my corner and cannot thank you
enough.

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Abstract

Congenital syphilis (CS) is on the rise nationally; in 2020, Arizona became ranked number one
in the nation for CS rates and continued to have the highest rates for three years (Arizona
Department of Health Services [AzDHS], 2023). Pregnant women are tested for syphilis twice
during pregnancy and once at the time of delivery, yet infants continue to be born with CS at
alarming rates (Centers for Disease Control and Prevention [CDC], 2023). CS leads to many
complications, including neonatal and fetal demise. A literature review revealed it is common for
a pregnant person to have an episodic hospital visit to an obstetrical (OB) triage unit during their
pregnancy. The goal of this project is to screen non-laboring OB triage patients through a new
protocol that is aimed at testing for syphilis in those who report limited to no prenatal care.
Participation is offered to OB providers and is voluntary. The project includes a pre-education
questionnaire, a provider education session followed by a post-education questionnaire, along
with a three-month follow-up questionnaire. The questionnaires examined the providers’
knowledge, attitude, and behavior towards syphilis and the new protocol. Data analysis was
completed by the use of descriptive statistics using these data points. Additionally, qualitative
answers were studied for recurrent themes. The project results support the use of provider
education sessions for the introduction of the new protocol and should be considered as a
strategy to continue combating the high CS rates locally and nationally.

Keywords: Congenital Syphilis, prenatal care, provider education, syphilis

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Syphilis on the Rise: Arizona’s Race to Prevention
Syphilis is a preventable sexually transmitted infection (STI), but somehow this infection
continues to be transmitted from one person to another. Recently, there has been a rise in syphilis
rates affecting people around the world. Nationally, Arizona has become a top location for
congenital syphilis rates; infants are dying due to a completely preventable illness.
Problem Statement
Many people seek prenatal care starting from the time they identify they are pregnant.
However, there are many barriers that may prevent a pregnant woman from establishing care
during her pregnancy; known barriers that prevent adequate prenatal care include those
experiencing housing instability, substance use disorder, and/or a history of previous
incarceration (Kimball et al., 2020). A combination of these factors with other social
determinants of health could lead a person to have little to no prenatal care visits throughout their
pregnancy. With the recent rise in syphilis, there have been increasingly high rates of CS among
pregnant people with little to no prenatal care. CS is a condition in an infant that is caused by the
vertical transmission of syphilis; when a mother has syphilis and does not receive or complete
the full course of treatment while pregnant, it is then transferred through blood to the fetus
(Hackley & Kriebs, 2016).
In 2015, syphilis cases started to rise but the CS rates were low across the state of
Arizona (AzDHS, 2018). In 2020, Arizona was ranked number six in the nation for primary and
secondary syphilis rates, with a total of 1,454 new cases (CDC, 2022a). Even though syphilis is
treatable, Arizona had high rates of vertical transmission; this ultimately ranked the state number
one in the country for CS (CDC, 2022a). In 2020, Arizona had 120 infants diagnosed with CS,
resulting in 12 infant deaths; in 2021, there were 181 infants with CS and 14 deaths (AzDHS,

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2024). Proceed to 2023 and there were 2,750 cases of syphilis in females, 213 babies born with
CS, and 21 infant deaths (AzDHS, 2024). In Arizona, infant deaths due to CS more than doubled
within one year.
When looking at specific counties, Pima County had a total of 27 syphilis cases that
involved pregnancy throughout 2020; recent data shows that as of October 2021, Pima County
had 25 cases of syphilis that involved pregnancy (Pima County, 2022). Maricopa County is also
on the rise; data from 2018 noted that syphilis rates more than doubled within a year (Maricopa
County, n.d.). Overall, AzDHS (2024) reports there has been a 449% increase in cases in the last
eight years.
The United States has emphasized controlling the increasing rates of syphilis and other
preventable infections through the Sexually Transmitted Infections National Strategic Plan [U.S.
Department of Health and Human Services (HHS), 2021]. At the state level, AzDHS has
provided a $300,000 grant that is aimed at increasing syphilis screening for men and women up
to 34 years old (Affirm Sexual and Reproductive Health for All [Affirm], 2023). The CDC
recommends that all pregnant women be screened for syphilis at their first prenatal visit, their
28-week gestational visit, and then again at the time of delivery (CDC, 2021). These initiatives
play an important role in supporting the screening guidelines outlined by the CDC.
Purpose and Rationale
As infants continue to be diagnosed with CS at an alarming rate and fetal demises
continue to increase, it is becoming clear that there is a disconnect between prenatal screening
and treatment. Vertical transmission of syphilis is preventable when women are tested and
provided with the correct treatment promptly. The purpose of this project is to implement a

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provider education session about a new OB triage syphilis screening protocol in effort to prevent
vertical transmission and decrease the rates of fetal demise due to CS.
Background and Significance
In the 1920s, syphilis was on the rise in the United States. Information regarding the short
and long-term effects of the infection was lacking; this led to what is known as the Tuskegee
Study (Barrett, 2019). The study began in 1932 and led to the discovery of penicillin as the
standard of care for the treatment of syphilis in the 1940s. Participants were not given sufficient
doses of the medication to clear the infection, which contributed to the spread of syphilis and
became the cause of death for many of the study participants (Barrett, 2019). The Tuskegee
Study is well known for its lack of ethical considerations; elements of the research were leaked
to the Associates’ Press and the United States Government and the Department of Health,
Education, and Welfare got involved. Multiple concerns were brought forward by an Ad Hoc
Advisory Panel; on November 16, 1972, the Assistant Secretary of Health, Merlin K. DuVal,
notified the CDC that the study should be terminated (Barrett, 2019). In the history of medical
research and ethical standards, the Tuskegee Study is regarded as a pivotal event.
Fast-forward to the current time, penicillin G is still the preferred medication for syphilis
treatment and is the only treatment for a pregnant woman (CDC, 2021). The most common test
for determining whether an individual is infected with syphilis is a serum rapid plasma reagin
(RPR) test (Satyaputra et al., 2021). It is important to perform multiple tests throughout
pregnancy since it takes two weeks for an RPR to become reactive, also known as positive. A
reactive RPR would warrant treatment for the mother to prevent vertical transmission to her fetus
(Satyaputra et al., 2021). If a woman tests positive for syphilis and has a penicillin allergy, it is

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the standard to provide desensitization therapy so that she can receive a treatment that will
penetrate the placenta and provide the antibiotic to her fetus (CDC, 2021).
The increasing prevalence of congenital syphilis is alarming. In the STI national strategic
plan, multiple goals are outlined over five years. One of the primary objectives is to reduce STI
rates, which include syphilis, as quickly as possible (HHS, 2019). A major goal of the plan is to
improve health outcomes for those with current infections and to prevent new infections from
occurring.
Population
The increasing rate of CS in Arizona must be spearheaded by targeting the infectious
process at the beginning. To prevent CS within a fetus or infant, pregnant people must be
screened and treated for syphilis. Therefore, pregnant people, and those of childbearing age, are
the target population to prevent CS. It is important to put an emphasis on those who experience
homelessness, are diagnosed with substance use disorder, do not have health insurance, have
been incarcerated, are late to or lack prenatal care, have multiple sex partners, or live in a rural or
low socioeconomic area (CDC, 2022c; Chan et al., 2021).
Current State
The current healthcare delivery system in Arizona has proven that it is unable to prevent
syphilis transmission between partners, as well as between a pregnant person and their fetus. In
Arizona, the law states that a provider must screen for syphilis at the first prenatal visit,
regardless of when that occurs during the pregnancy (Maricopa County, n.d.). In 2021, 8.9% of
live births in Arizona were to mothers with little to no prenatal care; it is unclear if any of the
people were screened or treated for syphilis during their pregnancy (March of Dimes, 2023).
That same year, 18.6% of live births were born to people who did not receive adequate prenatal

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care, which makes it very possible that the pregnant person missed their syphilis testing and, or
treatment.
In addition to the lack of prenatal care, Arizona lacks sex education. Currently, there is a
requirement for parents to provide consent for their child to participate in sexual health courses,
but there is no mandate to provide sex education within Arizona school systems (Sex Education
Collaborative, n.d.). The lack of education surrounding the prevention of STIs in combination
with students who do not have parental consent to participate can have a major impact on the
spread of STIs.
Desired Outcome
When testing pregnant people for syphilis throughout their pregnancy, the desired
outcome is to identify positive syphilis cases and provide treatment, thus preventing the fetus
from contracting syphilis. The project objective is to increase early diagnosis of syphilis with the
intent to impact the implementation of treatment for the desired outcome, which is to prevent
vertical transmission. Decreasing CS rates to zero is an outcome that can be achieved, and
Arizona has previously experienced this in the past.
Once a pregnant person has a positive RPR, their partner(s) must be tested and treated to
prevent further transmission of this infection. By treating the pregnant person and their partner,
there is an effort made at decreasing overall transmission and improving rates of vertical
transmission, poor health outcomes, and infant death.
Internal Evidence
A large tertiary care teaching hospital in the desert southwest was identified as a center
with an influx of limited prenatal care population. Stakeholders expressed concerns with the high
rates of syphilis and CS in the state of Arizona and the possible association with the high rates

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and no prenatal care. There was concern that obstetric (OB) triage visits were not being utilized
as an opportunity to test these patients for syphilis. Implementing a screening process specific to
syphilis for non-laboring pregnant people who present to OB triage could have a large influence
on combating Arizona’s rates of CS.
The southwestern United States is vast with many areas lacking healthcare providers and
hospitals. Due to the lack of resources, many individuals are transferred to larger facilities for
treatment. The chosen site for this project is an OB triage unit at a level-one trauma hospital in
southern Arizona. The Obstetric staff have noticed a rise in syphilis rates among pregnant
patients and report an increase in CS cases. This hospital has over 600 beds that include an adult
and pediatric ED, a labor and delivery unit, and a neonatal intensive care unit (NICU) among
many other specialties. The OB triage has four private rooms, and the labor and delivery unit has
two operating rooms, three post-anesthesia-care-unit (PACU) beds, and 12 private inpatient
rooms. This facility serves multiple ethnicities, including Caucasian, Hispanic, and/or Native
American, with approximately 50% of patients being female (The United States Census Bureau,
2022).
In the past, this region did not have any cases of CS; as of 2015, Arizona is one of the
states with the highest rates of syphilis transmission (AzDHS, 2023). There has been discussion
between the obstetric and pediatric departments regarding this increase; the rise in CS cases these
departments have seen individually has brought the departments together to address risk factors,
testing, and treatment. Each department is aware of the implications that untreated syphilis can
have on their patients and is invested in decreasing syphilis rates in their community. The
hospital and the associated organization stakeholders have become aware of this rise as well;
they have set a goal to make a healthier community by providing evidence-based care to improve

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the community’s health with the assistance of health care providers, health departments, and
insurance companies. If syphilis-positive pregnant people are treated for the infection promptly,
theoretically, the number of infants born with CS and consequential fetal deaths due to untreated
syphilis will decrease.
PICO Question
In pregnant women at risk for syphilis, how does a provider-centered information tool,
compared to current practice, impact partner notification, transmission, and congenital syphilis
rates?
Search Strategy
A comprehensive review of the current evidence was conducted. The three databases
used to identify the research studies were CINHAL, PubMed, and SCOPUS. These databases
were selected for their relevancy to the topic of syphilis and partner notification.
Keyword Selection
The search addressed portions of the PICO question with specific terms. The following
terms were used to identify the population, intervention, and outcome: pregnant, pregnant
women, pregnant female, female, sexually active female, syphilis, congenital syphilis, sexually
transmitted infections, high-risk factors, late prenatal care, no prenatal care, OB triage,
screening, screening tool, testing, prevention, treatment, provider notification, partner, and
partner notification. MeSH terms were connected as Boolean terms to provide a broad range of
research that could be paired down. Specific studies were examined by adding the search terms
qualitative, quantitative, and randomized control trial (RCT).

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Initial and Final Search Yields
An initial search of PubMed using key terms prevention, CS, and RCT; which yielded one
result. Mesh terms were added and the key terms were made less specific to widen the search.
This search yielded 32 results; further search terms surrounding STIs and specific populations
were added. Filters were then added to further limit the search. Additional searches yielded three
to 43 results.
The initial search of CINHAL provided rather straightforward results. The initial search
yielded 157 results by the use of a Boolean phrase, syphilis AND partner notification. The search
was then altered by adding a limitation of studies published from 2018 to the present which
yielded 38 studies.
The database search using SCOPUS resulted in an initial 145 results when syphilis,
partner AND notification, and treatment were used. This search was entered a second time and
the search engine split up the word notification. This created NOT as a connecting Boolean term
and “ification” as a search term; the error resulted in 563 studies. Multiple variations were
created with MeSH terms; the final search used the words quantitative and congenital syphilis
prevention, which yielded seven studies.
Limitations, Inclusion, and Exclusion Criteria
Limitations were added to narrow the search criteria to exclude studies that are over five
years old and outside of the United States. The use of filters was used for the inclusion of studies
that have female participants, are randomized control trials, and have free access to the full
publication.
The research articles from each database were carefully examined and 12 studies were
selected. These studies were chosen for a thorough review that is aimed at answering the PICOT

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question. Of the chosen articles, three are randomized control studies, one of which is doubleblinded, six retrospective reviews, and one cohort study. Two qualitative studies were selected,
two that are a narrative review, and one that follows the random-effects logistic regression
model.
Critical Appraisal and Synthesis of Evidence
The studies chosen for review were subjected to the rapid clinical appraisal (RCA)
checklist (Melnyk & Fineout-Overholt, 2019). Of the 12 studies, 10 of them were found to be
quantitative studies, and these were reviewed through the RCA checklist. By using this method,
the quality of evidence was easily identified. The checklist gives a level of evidence (LoE) score,
that correlates to the strength of the presented material (Melnyk & Fineout-Overholt, 2019).
Eight of the 10 articles have an LoE of two; this means that the research was well designed, and
is most likely from a RCT. The two qualitative studies utilized the RCT checklist, however they
yielded lower LoE due to the subjective nature of the studies.
Discussion
The research found regarding syphilis rates among pregnant women and their partners
were very widespread. Each study had valid points, such as fear of pain during treatment as a
barrier to completing care, however, this was not mentioned across many studies. Multiple
studies listed similar high-risk demographic factors that are associated with the diagnosis of
syphilis, such as substance use, previous incarceration, multiple sex partners, and housing
instability. Pregnant women are a group that is difficult to approve research and implement
studies on, and this could contribute to gaps within the research. To stop the surge of CS, it is
important that people receive sexual health education so that they can prevent the transmission of
STIs from the start. Until this form of education is implemented, it is vital for providers to ensure

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patients are screened for STIs at routine intervals, tested for syphilis during pregnancy by
following standard recommendations combined with their clinical judgment, and incorporate
partners into the notification and treatment process.
Theory/Theoretical Framework Application
The theory of health belief is applicable when addressing high syphilis and CS rates. The
health belief model (HBM) allows for the patient’s perception to be combined with action
(Champion & Skinner, 2008). When one has a syphilis-positive lab result, their perception is
taken into account, do they feel treatment is necessary, do they think something negative will
result if they do not complete or receive treatment? As the person processes the diagnosis, they
follow the HBM (see Appendix B, Figure B1) to its final step of if they would act to follow
health recommendations (Champion & Skinner, 2008).
Implementation Framework
The model for improvement (MFI) is a framework that can be used to address increasing
rates of syphilis (Institute for Healthcare Improvement [IHI], 2022). The MFI asks three
questions that guide the researcher. The first question aims to identify what the goal of the
project is; in this case, the overall goal is to prevent vertical transmission of syphilis. The next
question asks how the researcher will know there is an improvement (IHI, 2022). Theoretically,
there will be an improvement as rates of treatment in syphilis-positive pregnant people increase
and CS rates decline. The last question is formulated to address any changes that could be made
to positively impact improvement rates (IHI, 2022).
The MFI framework also has a guide on how to create and implement a change; it is
called the Plan-Do-Study-Act (PDSA) (IHI, 2022). The planning phase includes examining an
issue and identifying a potential intervention. Throughout the planning phase, it was determined

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that in order to test and treat pregnant people for syphilis who lack prenatal care, it would be
important to identify this population during an episodic ED or OB triage visit.
To implement an intervention, Lewin’s Change Theory provides a three-step process
(Lewin, 1951). The first step is called “unfreezing.” This is where project planning occurs; this
includes the material creation of protocols, questionnaires, recruitment flyers, and data collection
tools. The second step is the “change” portion; during this step, the intervention is presented and
implemented (Lewin, 1951). The final step is “refreezing.” While in the refreezing step, data is
analyzed to identify the intervention’s impact.
Implications for Practice Change
When combining the HBM with the MFI and Lewin’s Change Theory, the process of
creating and implementing an intervention will be well thought out, and improving patient
outcomes is bound to happen. By starting with planning from the PDSA portion of the MFI, one
could choose to follow the guidance from the research that encourages continuing to screen and
treat patients for syphilis (IHI, 2022). To make an impact on syphilis rates, there is an aspect that
relies on the provider’s ability to recognize high-risk factors that are associated with syphilis. In
OB triage, a high-risk syphilis screening tool can be used to identify pregnant people who are at
a greater risk for contracting syphilis. The health care provider can then use the screening tool as
a reason to order syphilis testing. By ordering testing on people who screen positive, there is an
effort being made by the health care team to address unknown syphilis cases, provide treatment,
and prevent vertical transmission.

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Methods

Ethical Considerations
During project creation, ethics and protection for human subjects were constantly
considered. The project itself will not collect any personal health information (PHI) on patients
and participants in the project. The project proposal with all supporting documents was
submitted to the hospital organization’s Research Determination Committee (RDC) and
approved on November 14, 2023. After approval from the RDC, the project proposal was
submitted to Arizona State University’s Institutional Review Board (IRB); approval for project
implementation was granted on December 5, 2023.
Population and Setting
The target population for this project is the OB-GYN resident and fellow physicians
practicing at the selected site. Participants include consenting medical providers who are
employed by the hospital and work in the labor and delivery unit. Providers include maternalfetal-medicine fellow physicians and OB-GYN resident physicians. The providers who
participate in the weekly OB-GYN education days will be eligible to participate; the
implementation education session will take in the same room the weekly education is provided.
The anticipated participant volume is 20 healthcare providers. Excluded participants are people
who are not healthcare providers and do not hold prescriptive authority. No patients, minors,
adults who are unable to consent, prisoners, economically or educationally disadvantaged
individuals, or pregnant patients will be included in this project.
Project Description
The project will be implemented following the steps described in Lewin’s Change Theory
(Lewin, 1951). The following steps will be followed:

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Unfreezing:
1. On November 15, 2023, the DNP student will spend approximately one hour posting the
recruitment flyer in areas where providers for OB triage frequently spend time, including,
but not limited to the following (see Appendix B, Figure B3)
a. OB call rooms, provider break rooms, charting areas, and workspaces
2. On December 20, 2023, at 9 am in hospital 5th floor education room, during the
scheduled OB education session, the DNP student will read the consent to participate
script (see Appendix B, Figure B4). This script will be provided on paper for participants
to read prior to completing step three
3. Distribute the pre-education questionnaire on paper with pens and provide 5 minutes for
completion (see Appendix B, Figure B5). DNP student to collect completed or blank
questionnaires via a drop box that will be passed around the room
Change:
1. Education session:
a. Immediately following the collection of the pre-education questionnaire, in the
same room, the education session will begin, taking approximately 15 minutes
i. Distribute a copy of the protocol to all participants and those attending the
education session (see Appendix B, Figure B1)
ii. Presentation (see Appendix B, Figure B7)
b. Distribute the Post-intervention questionnaire, and provide 5 minutes for
completion (see Appendix B, Figure B8)
c. Collection of completed or blank post-education questionnaires via a drop box

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2. Return three months later during the scheduled OB education session in the 5th floor
education room for the 3-month follow-up questionnaire completion and collection (see
Appendix B, Figure B9)
a. Re-introduction by DNP student, reminder on subject ID number for data
collection correlation.
b. DNP student to read the consent to participate script
c. Distribute the 3-month follow-up questionnaire with pens. Provide 5 minutes for
completion
d. Thank each participant individually as questionnaires are returned to the drop box
e. DNP student to place surveys in a designated folder and locked cabinet.
3. Refreeze (Post-Intervention):
a. Data collection and comparison
Data Collection
Data will be entered into a spreadsheet created specific to this project (see Appendix B,
Figure B10). Descriptive statistics will be completed by inputting the quantitative data collected
into Intellectus Statistics (2023) software. Review of the qualitative questionnaire answers will
be conducted and common themes will be identified and reported by the DNP student. Results
and final presentation will be shared and available to the site’s OB-GYN department and Arizona
State University.
Budget and Funding
The DNP student will prepare all materials and provide all materials used for the
education session. The budget for all supplies needed is to not exceed $250. This will include
paper and printing costs for recruitment material, protocol handouts, and questionnaires. In

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addition, pens, light snacks, beverage options, and necessary utensils will be provided. There is
no additional funding or donations for this project.
Results
All of the data collected was intended to assess the impact of the education session in
relation to the participant’s knowledge, attitudes, and behaviors for syphilis testing in pregnant
patients. Intellectus Statistics (2023) software was used to store, manage, and analyze data sets.
Demographics
The participants were all OB-GYN resident physicians employed at the project site (n = 8). A
majority of the sample were between the ages of 24 to 27 and 32 to 35 (n = 4, 50%). The
remaining sample were between the ages of 28 to 31 years old (n = 3, 38%) and 35 to 39 years
old (n = 1, 13%). Age demographics can be found in Table 1.
Table 1
Frequency Table for Age
Variable
Age
24-27
28-31
32-35
35-39

n

%

2
3
2
1

25.00
37.50
25.00
12.50

Descriptive Statistics
Questionnaires were analyzed through the use of descriptive statistics, specifically
reviewing the overall competency and each domain in relation to the education session. The precompetency syphilis screening average score was 17.12 (SD= 2.75); the scores range from 14 to
21 points. The post-competency syphilis screening average score was 17.75 (SD= 2.71); the
scores range from 14 to 21 points. The 3-month follow-up competency syphilis screening

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average score was 19 (SD= 2.51); the scores range from 16 to 23 points. The competency
statistics can be found in Table 2.
Table 2
Competency Statistics
Variable
M SD n Min Max
Pre-competency syphilis screening 17.12 2.75 8 14.00 21.00
Post-competency syphilis screening 17.75 2.71 8 14.00 21.00
F/U-competency syphilis screening 19.00 2.51 8 16.00 23.00
The different domains assessed were knowledge, attitudes, and behavior. The preknowledge had an average score of 1.88 (SD = 0.35); the scores range from 1 to 2 points. The
post-knowledge had an average score of 2.12 (SD = 0.83); the scores range from 1 to 3 points.
The follow-up knowledge had an average score of 2.00 (SD = 0.53); the scores range from 1 to 3
points. The pre-attitudes had an average score of 9.50 (SD = 1.41); the scores range from 8 to 12
points. The post-attitudes had an average score of 10.12 (SD = 1.55); the scores range from 8 to
12 points. The follow-up-attitudes had an average score of 10.62 (SD = 1.30); the scores range
from 8 to 12 points. The pre-behavior had an average of 5.75 (SD = 1.75); the scores range from
3 to 8 points. The post-behavior had an average score of 5.50 (SD = 1.60); the scores range from
4 to 8 points. The follow-up behavior had an average score of 6.38 (SD = 1.30); the scores range
from 4 to 8 points. The domain summary statistics can be found in Table 3.

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Table 3
Summary Statistics: Knowledge, Attitudes, and Behavior
Variable
Knowledge
Pre-knowledge
Post-knowledge
F/U-knowledge

SD n Min

Max

1.88 0.35 8 1.00
2.12 0.83 8 1.00
2.00 0.53 8 1.00

2.00
3.00
3.00

M

Attitudes
Pre-attitude
Post-attitude
F/U-attitude

10.12 1.55 8 8.00 12.00
10.62 1.30 8 8.00 12.00

Behavior
Pre-behavior
Post-behavior
F/U-behavior

5.75 1.75 8 3.00
5.50 1.60 8 4.00
6.38 1.30 8 4.00

9.50 1.41 8 8.00 12.00

8.00
8.00
8.00

Qualitative Results
The post-education and 3-month follow-up questionnaire included written questions that
were analyzed for the presence of common themes and the use of the proposed protocol. A
majority of participants chose to not answer the written questions. However, those who did
provide answers expressed appreciation for the use of informative statistics in the education
session, and over half of the participants felt the protocol was clear and easy to follow.
Clinical Significance
Participants overall competency scores increased from the pre-education questionnaire
through the 3-month follow-up questionnaire. It is important to note the slight knowledge
regression between the post-education questionnaire and the 3-month follow-up. Nonetheless,
the competency scores increased and the standard deviations decreased, which indicates the
education session was clinically significant.

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Project Impact and Sustainability
Organizations often use education sessions to introduce a new workflow to their staff;
however, it is not always known if the education ended in a practice change. An organization can
attempt to change workflows and implement new protocols, but without thoughtful
implementation, the proposed changes may never make it into standard practice. The creation of
this protocol was brought to life because healthcare providers in Arizona have seen the increase
in CS rates first-hand; they want to be able to influence the CS rates through their practice. This
project allows the organization to determine if the education session for implementation of the
protocol was beneficial for the providers, thus influencing patient plans of care and aiding in the
decrease of CS.
A key component to creating a sustainable change is to methodically implement the
desired change; this project follows the steps outlined by Adelman and Taylor (2003) to maintain
sustainability. Hospital systems often use education sessions as way to inform their staff of new
policies, protocols, and processes. The data analysis highlights the positive impact this form of
protocol dissemination had on the OB-GYN resident participants. Combining this educational
influence with the potential for positive patient outcomes, provider-education sessions should be
considered as a sustainable change.
Discussion
Limitations and Barriers
Although the data reflects a successful quality improvement change project, a thorough
reflection of the project identified challenges. The first limitation is that the education session
focused on the introduction of the protocol and did not incorporate its use into the standard
workflow. This protocol has the potential to make a large impact and would have benefited from

SYPHILIS ON THE RISE

22

incorporating it into the OB triage standard workflow. Placing more emphasis on the workflow
would ensure that the providers screened all non-laboring OB triage patients for the need for
syphilis testing.
A barrier that impacted the timely implementation of the project involved communication
issues throughout the site organization. The DNP student is not employed by the site and
identifying the correct persons within the RDC was extremely difficult. The staff on the labor
and delivery unit, including the nurse manager and medical director, were not aware of the RDC
and how to go about submitting a project for approval. The project was intended to begin in the
fall of 2023 but was not approved until December 5, 2023. During the project, the site champion
was inaccessible. This challenged the completion of the project as they were responsible for
coordinating and confirming the dates of the education sessions and 3-month follow-up with the
DNP student. Consequently, the 3-month follow-up was delayed by three weeks. Effective
communication is an essential element for project implementation; in this instance,
communication has been identified as a systemwide barrier. This is concerning as the rates of CS
continue to rise in Arizona. The protocol was created with the intent to be utilized and spread
throughout the multiple hospitals in the organization.
To evaluate the use of the protocol, it was requested to obtain data relating to syphilis
testing orders placed in OB triage and the associated results before and after implementation of
the new protocol. The project site created a barrier to having comprehensive data to review by
denying the evaluation of the site’s testing rates and the. Despite attempts to gain approval for
this data set, analysis of the use of the protocol through ordered tests was unable to be assessed.

SYPHILIS ON THE RISE

23

Implications and Future Recommendations
The main implication of this project is that healthcare providers can impact CS rates.
Increasing providers’ knowledge, attitudes, and behavior towards syphilis testing in OB triage
implies that syphilis testing in non-laboring pregnant patients will increase. Therefore treatment
rates during pregnancy will increase and CS rates will improve. Literature supports the use of
provider-based education sessions as an effective way to implement change. The questionnaire
results imply that the education presented to the participants was a successful way of
communicating change, however, there is room for improvement. Given that there was a
knowledge decline at the 3-month follow-up, there is a need for knowledge reinforcement. The
organization could implement a biannual provider-education session to provide updates on
statistics, national and local initiatives, changes in practice guidelines, and reinforce the use of
the protocol. Many providers besides OB-GYN residents service OB triage, such as OB-GYN
attendings, maternal-fetal-medicine fellows, ED residents, family practice providers, and nurses.
Nurses play an essential role in OB triage. By educating the nurses and increasing their
knowledge of syphilis and CS rates the community is facing, they can encourage provider use of
the protocol and impact testing rates. In addition to nurses, nurse managers have a significant
role within a hospital unit’s education, reinforcing protocols, and monitoring protocol
compliance. Consideration to include the different disciplines in project development and future
education sessions should be made to expand the use of the protocol and reach more patients.
To successfully implement this project in the future, it is essential to create a realistic
timeline and communicate the expectations from the beginning. The timeline should include
expected dates for the RDC application review and the anticipated date for project approval.
Should the RDC request changes to the project, it would be advantageous to have an alternate

SYPHILIS ON THE RISE

24

timeline that accounts for delays in project approval. Dates, times, and room locations for all
events included in the project should be agreed upon between the site champion and the DNP
student prior to the implementation date. After project completion, a results dissemination
presentation was offered to the site champion, participants of the project, and OB-GYN-related
employees. The project heavily relied on the site champion for scheduling and implementation
and the presentation was denied; this could be due to the site champion having many roles with
the hospital and associated clinic. The presentation was emailed to the site champion with the
ability to disperse it to the department. Openly communicating the results throughout the
department and the organization could reinforce the use of this protocol. The future use of the
protocol is dependent on the support of the site champion and the OB-GYN providers. The
project would benefit from the addition of a site champion who is more administrative; this way
communication and decisions for the project timeline and dissemination of the results would not
rely on clinical staff.
The final recommendation is for provider compliance to be evaluated through monitored
use of the protocol and site testing rates. Compliance is valuable and necessary information when
evaluating the protocol's impact. Providers could become more motivated to implement the
protocol into their standard practice if compliance was a measurable outcome. To accomplish
this, the creation of a reminder, or flag, within the electronic medical record could be used to
monitor protocol use.
Conclusion
The OB triage has become a common place for pregnant people to seek and receive care.
For many patients who do not receive ample prenatal care, episodic hospital visits are common
and present an opportunity for routine care and testing, which is often overlooked in this setting.

SYPHILIS ON THE RISE

25

It is critical for healthcare providers, of all disciplines, to utilize episodic hospital visits as a
point-of-care opportunity. When the organization implements provider education sessions to
inform the healthcare team of public health concerns their community is facing, they align
themselves with national and local health initiatives. By addressing the identified limitations and
barriers, and monitoring the future use of the protocol, there is the potential to impact local CS
rates greatly. This project provides a foundation for a necessary quality improvement change and
is a starting point to include healthcare providers in transforming the health of pregnant women
and their fetus’ in an unconventional way.

SYPHILIS ON THE RISE

26
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Appendix A

Table A1
Evaluation Table for Quantitative Studies
Citation

Theoretical/
Conceptual
Framework

Design/ Method/

Evaluation and Synthesis Tables
Sample/Setting

Variables

Purpose

Measurement/

Data Analysis

Instrumentation

Results/
Findings

Level of Evidence;
Application to
practice/
Generalization

Adachi et al.,
(2018),
Combined
evaluation of
sexually
transmitted
infections in
HIV-infected
pregnant
women and
infant HIV
transmission

Country:
Netherlands

None listed.
Presumed
Health
Promotion
Model

Design:
Retrospective
cohort study
Purpose: To
determine if there
is a correlation of
+STIs and HIV in
maternal
transmission in
mother-infant pairs

N= 1684
mother-infant
pairs

Demographics:
53.4% had
specimens
available for
maternal CT,
NG, TP, and
infant CMV
testing.
86.2% were
from Brazil,

IV1: maternalinfant pair
DV1: Maternal
HIV +
DV2: Maternal
HIV and STI +
DV3: infant
HIV + MTCT
-DV3a: MCTC
of one STI
-DV3b: MCTC
of two STIs

Tools: Chart reviews
and urine testing

Validity/Reliability:
Large sample size with
excluded criteria
applied to different
aspects of the research,
therefore increased
validity.

Statistical
Tests Used:
Kruskal-Wallis
test & Chisquare test

DV1: 69.8%
were HIV+
mothers.
DV2: 30.2% of
HIV + mothers
had a coinfection.

DV3: 9.1% HIV+
infants
-DV3a: MCTC of
one STI: 10.8%
-DV3b: MCTC of
two STIs: 23.8%

Level of Evidence:
Level 3
Strengths:
Participants wide
geographical range,
strong correlations
represented in data
results
Weakness:
Population was not
representative of
parent study.
Unable to test for all
STIs, such as
bacterial vaginosis

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Funding:
National
Institute of
Child Health
and Human
Development
(NICHD)
Bias: No
conflict
reported.

34
Argentina, and
the U.S.
13.8% were
from South
Africa.
26.5: Mean
maternal age
69.4% had PNC.
Reports of
Substances
during
pregnancy:
36.5% alcohol,
37 % tobacco, &
9.8% illegal
substances

4.8% had
stillbirths.

Setting: Samples
were from labor

-DV3c:MCTC
of three or
more STIs
DV4: Infant
HIV- with STI
MTCT
-DV4a: MCTC
of one STI
-DV4b: MCTC
of two STIs
-DV4c:MCTC
of three or
more STIs
Definitions:
CMV
Cytomegalovir
us

-DV3c: MCTC of
three or more
STIs: 12.5%

DV4: 90.9% of
infants
-DV4a: MCTC of
one STI: 89.2%
-DV4b: MCTC of
two STIs: 76.2%

and herpes simplex
virus.
Feasibility: Very
feasible as the
recommendation is
to follow PNC
appointments/scree
nings
Application: Able to
generalize to the
public

-DV4c: MCTC of
three or more
STIs: 87.5%

CT Chlamydia
trachomatis
MTCT
maternal to
child
transmission

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

35
and delivery
units in Brazil,
Argentina, and
the U.S.

NG Neisseria
Gonorrhoeae
TP Treponema
pallidum

Exclusion: 47%
of the
participants due
to not having
testing results
available. Any
testing that was
indeterminate
was rerun two
times, if still
indeterminant,
the sample was
removed.

Attrition:
Not mentioned.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Almeida et al.,
(2021). Syphilis
in pregnancy,
factors
associated with
congenital
syphilis and
newborn
conditions at
birth.

Country:
Brazil

None listed.
Presumed
Health
Promotion
Model

36
Design:
Retrospective
cohort study
Purpose: to
investigate factors
associated with the
occurrence of
congenital syphilis
in pregnant women
with syphilis

N= 158 pregnant
women with
syphilis during
pregnancy

Demographics:
71% of women
with syphilis
were white, had
nine or more
years of
schooling and
performed
unpaid work.
96.8% had
prenatal care.

Funding:
Federal Council
of Nursing and
the
Coordination
for the
Improvement
of Higher

IV1: 74 +CS
cases (46.8%)
DV1:
Inadequate
maternal
treatment
DV2: Late
maternal
treatment
DV3: Lack of
partner
treatment
Definitions:
N/A

Tools: Software
Statistical Package for
the Social Sciences

Validity/Reliability: n/a

Statistical
Tests Used:
Wald test.

DV1: 17.9% of
examined CS
cases.

DV2: 3.2% of
examined CS
cases.

DV3: 39.0% of
examined CS
cases.

Level of Evidence:
Level 2
Strengths:
reinforces the need
for syphilis + people
to complete
treatment. Large
collection of +CS
patients which
research is lacking.
Weakness: Unclear
what the screening
and testing
guidelines were for
the participants
when they had PNC.
Feasibility:

Setting:
-Botucatu, Brazil
-8 traditional
health clinics, 12
family health
clinics, and 2
labor and

Feasible, however if
this is a major
changes to have
women increase
their PNC visits,
then there could be
a strain on providers
in this particular
area.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

37

Education
Personnel

delivery
locations.

Application:
Generalization to
other populations is
applicable, as CS
needs to be
prevented.

Exclusion:
Bias: None
listed.

Not mentioned.
Attrition:

No conflict
reported.

Biswas et al.,
(2018).
Characteristics
associated with
delivery of an

Not mentioned.

None Listed.

Design:
Retrospective chart
review

N= 2498 women

IV1: Women
with positive
syphilis test
during
pregnancy or

Tools: Birth records and
chart reviews

Statistical
Tests Used: χ2
tests and

DV1: 134 (17%)
gave birth to a
CS positive
infant

Level of Evidence:
Level 2
Strengths: Ability to
determine shared

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
infant with
congenital
syphilis and
missed
opportunities
for
prevention—
California, 2012
to 2014

Country:
United State

Funding:
None Declared

38
Purpose: To
identify
characteristics
among women
who were syphilispositive, delivered
and infant with or
without CS, and
missed
opportunities for
care and/or
prevention among
syphilis-positive
pregnant women

Demographics:
Age: 15-45 years
old

Setting: Birth
records from the
California

Exclusion:
-Women who
refused to
answer or
missed a
question
-Non-pregnant
syphilis cases

Bias:
None declared

-Syphilis-positive
stillbirths

time of
delivery
DV1: Delivery
of a CS
positive infant
DV2: Delivery
of an infant
without
diagnosis of CS
Definitions:
CS Congenital
Syphilis

Validity/Reliability:
Statewide data, and a
large sample size with
many syphilis-positive
cases

Fisher exact
tests

DV2: 293 (69%)
deliveries were
not diagnosed
CS

demographic
information that are
high-risk factors for
syphilis-positive
pregnancies.
Specifically women
who have been paid
or received money
and/or drugs for
sex,
methamphetamine
or cocaine use, and
previous
incarceration in the
last 12-months
Weakness: Women
who had syphilis
during pregnancy or
at time of delivery,
with the delivery of
a still birth were
excluded.
Feasibility: feasible
to complete since
data points have
been identified
from this study

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

39
-Women
diagnosed with
late syphilis

Application:
Applicable to review
in each State that is
experiencing an
increase in syphilis
and CS cases

Attrition: not
identified

Dunseth et al.,
(2017),
Traditional
versus reverse
syphilis
algorithms: A
comparison at a
large academic
medical center

Country:
United States
Funding:

None listed.
Presumed
Health
Promotion
Model

Design: Six-year
Retrospective
Study
Purpose:
To examine the
switch from
traditional
serologic syphilis
testing (RPR) to
reverse testing
models by using
syphilis IgG as a
screening test.

N= 23,065
Traditional:
(n=12,612)
Reverse:
(n= 10,453)

Demographics:
Traditional:
Average age
35.6 years
Male to female
ratio is 0.35.

IV1: Syphilis
screening
DV1: RPR
screening
DV2: Syphilis
IgG testing on
a Bioplex 2200
analyzer
Definitions:
Syphilis- a
sexually
transmitted
infection
Treponema
pallidum- the
organism that

Tools:
Chart reviews, lab and
specimen materials
including the Bioplex
2200

Validity/Reliability:
Large sample size, but
low rates of positive
syphilis cases.

Statistical
Tests Used:
Chi-square
analysis

DV1: 93 patients
(0.7% of total)
had a reactive
RPR. 53 patients
(0.4% of total)
were confirmed
+ with TP-PA. 29
of these patient
had no
documentation
of a prior
infection. 25 of
these patients
received
treatment; the
other 24 had
documentation
of previous

Level of Evidence:
Level 3
Strengths:
Large sample sizes
with no exclusions.
RPR & IgG testing
yields similar & high
sensitivity rates.
Retrospective
review provides
strong evidence for
disease processes
that have latency
periods.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
None
mentioned.
Bias:
No conflict
reported.

40
Obstetrical
Department:
47.8% of screens

causes a
syphilis
infection.

Non-obstetrical
and outpatient
clinics: 41.3% of
screens

Rapid plasma
regain (RPR)nontreponemal
test that
screens for
syphilis.

Inpatient units:
9.9% of screens
ED: 1.0% of
screens

Reverse:
Average age
35.6

Treponema
pallidum
particle
agglutination
assay (TP-PA)when an

Male to female
ratio is 0.37.

is positive,
this a
confirmatory
test for
syphilis.

Obstetrical
department:
49.3% of screens

Syphilis
Immunoglobul
in G (IgG)-

years

infection with
treatment. Only
5 of the 24
patients
received
treatment.

DV2: 13 patients
(0.1% of total)
screened
equivocal with
syphilis IgG
values. 110
patients who
screened
positive; of
those, 44
confirmed
positive with a
reactive RPR; all
positive patients
received
treatment.

Weakness: Was
tested in an area of
the U.S with low
syphilis rates,
therefore there was
not many samples
to compare.
Feasibility: Easy to
replicate, presumed
low cost as this was
made from a chart
review with
statistical analysis.

Provider Education
will be a large factor
in the ease of
application.

Application: Results
are between the
two variables are
very close,
application of
testing via one
variable or the

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

41
Non-obstetrical
and outpatient
clinics: 41.2% of
screens
Inpatient units:
8.7% of screens
ED: 0.8% of
screens

serum testing
showing an
immune
response to
syphilis
infection.

Results: Syphilis
IgG is just as
sensitive as
screening with
an RPR. If early
syphilis is not a
factor being
when examining
results, the
sensitivity of
both the IgG and
RPR are 100%.

other is dependent
on the institution,
budget, policies,
and provider
preference.
However, it should
be easy to apply the
chosen method
testing.

Setting:
University of
Iowa hospitals,
clinics, and an
academic
medical center

Exclusion:
None.
Attrition:
Not mentioned.
Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

Estrada et al.,
(2019),
Tolerability of
IM penicillin G
benzathine
diluted or not
with local
anesthetics, or
different gauge
needles for
syphilis
treatment: a
randomized
clinical trial.

Country:

None Listed.
Presumed
the Health
Promotion
Model

42

Design:
randomized,
double-blind
clinical trial

Purpose:
To determine if
anesthetics and/or
needle gauge size
impacts pain
associated with IM
injections of PGB.

N= 108

Demographics:
94.4% male,
41.7% have HIV,
and the mean
age is 36.6
years.

Setting: Centro
Sanitario
Sandoval and
Hospital Clinico
San Carlos

Spain

Funding: no
external

Exclusion:
Under 18 years
of age, no
diagnosis of
syphilis,
diagnosis of

IV1: IM
injection of
PGB 2400,00
IU diluted with
6mL of sterile
water.

Tools: Serum testing,
PGB, MV, 19G long
needles, and 21G short
needles, injection
supplies, and a visual
pain scale.

DV1: PGB with
a 19G long
needle
DV2: PGB
diluted with
0.5 mL MV 1%
with a 19G
long needle.
DV3: PGB
without
anesthetic and
with the use of
a 21G short
needle.
DV4: PGB
diluted with
0.5 mL MV 1%

Validity/Reliability: all
participants received
and injection and
provided real time pain
results feedback

Statistical
Tests Used:
multiple linear
mixed model
performed by
STATA 12.0
software.

DV1: n=25
average pain
rating 5.56

DV2: n=27
average pain
rating 2.92

DV3: n=28
average pain
rating 5.06

DV4: n=27
average pain
rating 3.36

Level of Evidence:
Level 1
Strengths:
Double-blinded
study; the person
administering the
medication along
with the
patient/participant
were unaware of
group assignments.

Weakness:
Largely a young
male population.
Feasibility: Feasible
as the injection of
PGB recommended
treatment. Including
an anesthetic is low
cost and provides
patient comfort.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
funding
identified

Bias:
Estrada, V. is a
member of the
editorial board
for BMC
Infectious
Diseases. No
other conflicts
identified.

43
secondary,
latent, or
tertiary syphilis.
Patients with
any sensory
perception
diagnosis or
cognitive
impairment
unable to
understand or
evaluate the
visual analog
score on pain.
Patients with
previous
penicillin allergy.

Attrition: none
identified.

with a 21G
short needle.
Definitions: GGauge, needle
width IUInternational
Unit of
measurement
mL- milliliters,
Unit of fluid
measurement
MVMepivacaine
hydrochloride,
an anesthetic
medication
PGB- Penicillin
G Benzathine,
an antibiotic
medication
used to treat
syphilis

Application:
Generalizable to the
public

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Folke et al.,
(2022), An
evaluation of
digital partner
notification tool
engagement
and impact for
patients
diagnosed with
gonorrhea and
syphilis.

Country:
United States
and London,
England

Funding:
UnLtd & 4iP
grant number
APP1/1/12055,
Guy's & St
Thomas' Charity
grant G101010,

None listed.
Presumed
Health
Promotion
Model

44
Design:
Retrospective
Review
Partner notification
data from 2019
were extracted
from a cloud
database that
records the activity
of health care
providers using
dPNt. Each partner
informed by SMS
or email is
allocated a unique
partner code that is
associated with the
index patient who
notified them.

N= 5715

Demographics:
Primarily
Caucasian males
that engage in
sexual activities
with other
males.

IV1: Partner
verified as
tested after
PN.
DV1: Partners
who tested
before PN.
DV2: Partners
who selfidentify with
the use of
dNPt.

Age ranging
from late
teenage years to
early 80’s.

DV3: partners
verified in
clinic using
dNPt.

Purpose:

Setting:

To support PN in
syphilis-positive
patients; Ultimately
to encourage
testing and
treatment.

Combination of
23 clinics in the
United States
and United
Kingdom

Definitions:
dPNt- A digital
PN tool
PN- Partner
Notification

Tools:
dPNt software

Validity/Reliability:
Large sample size, many
clinics involved.

Statistical
Tests Used:
Hierarchical
logistic
regression
model

DV1: not
statistically
significant

DV2: not
statistically
significant

DV3: 0.67

Level of Evidence:
Level 2
Strengths: Allows
for anonymous PN,
applies to other STIs
besides syphilis and
multiple diagnosis,
the number of
partners who were
screened and tested
for syphilis
increased by 23%.

Weakness: The
need for a digital
communication
device that is
compatible with
dPNt.

Feasibility: Overall
feasible- there is a
cost for the
program to
integrate into the
EHRs and Clinics,

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Public Health
England HIV
Prevention
Innovation
Fund grant 092
BSP 2459,
Comic Relief /
MAC AIDS
Fund, HIV in the
UK: Think
digital grant
2778545 and
SXT Health CIC
customers in
2019.

45

Exclusion:
Negative STI
results

Attrition: Not
mentioned

along with training
HCPs.

Application: Can
easily be
generalized to many
populations,
especially young
adults who are
sexually active.

Bias:
MenonJohansson is
the Founder &
Director of SXT
Health CIC.
Thomas Folke
declares no
conflicts of
interest.
Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

Mmeji, O. et al.,
(2015).
Discordant
syphilis
immunoassays
in pregnancy:
perinatal
outcomes and
implications for
clinical
management.

Country: United
States

Funding: NIH
training grant
(T32AI065388)
from the
National
Institute of
Allergy and
Infectious

None Listed.

46

Design:
Retrospective
review

Purpose:
To examine reverse
sequence
algorithm with
negative RPR
syphilis testing and
associated birth
outcomes

N= 194

IV1: + CIA and
- RPR women
DV1: + TP-PA
DV2: - TP-PA

Demographics:
Pregnant
women 18 years
and older with a
positive CIA test
and a negative
RPR, with known
birth outcomes

Setting: Kaiser
Permanente
Northern
California

Exclusion:

Definitions:
CIAchemiluminesc
ence
immunoassay
TP-PATreponema
pallidum
particle
agglutination
assay

Tools: Lab test
materials for CIA and
RPR testing, maternal
and infant medical
charts for review

Stata version 12
(StataCorp, College
Station, Texas) and SAS
version 9.2

Validity/Reliability:
Unknown

Statistical
Tests Used: χ2
or Fisher’s
exact test, and
Student t test
was used for
continuous
variables.

DV1: 38 women
with 4%
resulting with a
+ RPR in
subsequent
testing

DV2: 77 women
with 1% having
a +CIA and +RPR
in subsequent
testing

Level of Evidence:
Level 2

Strengths:
Uncovered the CIA
test is not reliable
on its own.

Weakness: No
strong correlation
identified
More than half of
the women had
false + CIA test
results
1/3 of infant followup charts were not
obtained
No control group

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Diseases, and
the CDC (grant
number
H25PS00137901).

Bias:
No reported
conflicts

47
Women with a
positive RPR test
before CIA
testing
Pregnant
women under
the age of 18
Attrition: Not
identified

Feasibility: Patients
could incur
unnecessary lab
costs

Application: Not
recommended as
there are many false
positive results for
the CIA testing, this
could lead to
overtreatment with
antibiotic or
undertreatment of
syphilis for
patient/provider
pairs who doubt the
result. Should not
be generalized to
areas with highsyphilis rates.

Obure et al.,
None Listed. Design: cluster
N= 2214
IV1: Testing
Tools: SAS software,
Statistical
DV1: 0.28%
Level of Evidence:
(2017), A
randomized
pregnant
Microsoft Excel
Tests Used:
tested positive
Level 2
Presumed
Single
RDT
(N=
comparative
controlled study
women for
for HIV and 2.8%
Cost analysis
Strengths: Large
the Health
1048)
analysis of costs
syphilis and
tested positive
sample size.
Purpose:
of single and
HIV
for syphilis. Of
dual rapid HIV
those who
Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
and syphilis
diagnostics:
results from a
randomized
controlled trial
in Colombia

Promotion
Model

48
To determine if
single RDT for
syphilis is more
cost effective than
dual RDT for
syphilis and HIV.

Dual RDT
(N=1166)

DV1: Single
RDT for
syphilis and
HIV

Demographics:

DV2: Dual RDT
for syphilis
and HIV
together

Country:

Pregnant
women living in
Colombia.

Columbia

Setting:

Funding:

4 hospitals and 8
health centers in
Columbia

The Bill and
Melinda Gates
Foundation and
PATH through
the Dual
Testing to
Eliminate
Congenital
Syphilis project
and the
UNDP/UNFPA/
WHO/World
Bank Special
Programme of

Exclusion:
None identified.

Attrition:

Definitions:
RDT- Rapid
Diagnostic
Test

Validity/Reliability: The
convenience of dual
RDTs may have
impacted the type of
test chosen.

tested positive
for syphilis 83%
received timely
treatment.

100% of syphilis +
cases in the dual
RDT group received
treatment on time.

Average total
cost U.S.
$1847.99

Weakness:

DV2: 0.42%
tested positive
for HIV and 1.7%
tested positive
for syphilis;
100% of the
women who
tested positive
for syphilis
received timely
treatment.

Costs for the dual
RDT is more
expensive.
Feasibility: Clinic
and patient
preference based

Application: Easy to
generalize to other
populations as the
testing had high
treatment rates.

Average total
cost: U.S.
$3074.43

None identified.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

49

Research
Development
and Research
Training in
Human
Reproduction

Bias:
No conflict
reported.

Parkes-Ratanshi
et al., (2020),
Low male
partner
attendance
after syphilis
screening in
pregnant
women leads to
worse birth
outcomes: The
syphilis
treatment of
partners (stop)

None Listed.
Presumed
the Health
Promotion
Model

Design:
Randomized
controlled trial

N= 17,130
pregnant
women

Purpose:
To determine what
is the best way to
contact partners of
pregnant women
with syphilis to
increase the
number of partners
screeded and
treated.

N= 442 women
enrolled

Demographics:
Women with a
+ pregnancy test
& treponemal

IV1: - PN slip
given pregnant
woman with
positive
syphilis
screening.
DV1: Text
message
notification
with PN slip.
DV2: Phone
calls from the

Tools: PN slips, access
to send text messages,
and telephones

Validity/Reliability: n/a

Statistical
Tests Used:
Chi-square
test,
multivariable
logistic
regression
model

IV1: 7.4% did not
give the PN slip
to their partner.

Level of Evidence:
Level 2

DV1: 33.1%
follow up.

Strengths:
Identifying and
treating syphilis in
the pregnant
women.

DV2: 32.6%
follow up.

Preventing
congenital syphilis
and associated poor
outcomes.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
randomized
control trial.

Country:
Uganda

Funding:
Foundation for
the National
Institutes of
Health
Bias:
Receives grant
funding
through the
Infectious
Diseases
Institute from
Janssen, the
Pharmaceutical
s Company of
Johnson and
Johnson.

50
antibody rapid
POCT were
offered study
inclusion.

clinic staff
with PN slip.

Other inclusion
criteria were age
>18 years or 1417 years and
being a mature
and
emancipated
minor, having a
known sexual
partner, having
access to a cell
phone, and
being willing and
able to use and
receive SMS or
phone calls.

STI- sexually
transmitted
infections

Average age- 25

Definitions:

DALYDisability
Adjusted Life
Years
HCP- Health
care provider
PN- Partner
notification
IDI- Infectious
Diseases
Institute
POCT- pointof-care tests

Setting:

ANCantenatal
clinic/care

Weakness:
Small enrollment
compared to overall
sample size.
Unclear if every
partner who tested
positive received
treatment;
therefore, not able
to prevent
congenital syphilis
as a whole.
DV1 and DV2 were
not shown to be a
better option.
Feasibility:
Low cost to
implement
reminder text
messages and
phone calls if
statistically
appropriate as an
intervention.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

51
Antenatal clinic
in Kampala,
Uganda

Exclusion:
Illiteracy,
inability to use a
mobile phone,
confirmed
neurosyphilis,
not interested,
or is not
pregnant.

MOH- Ministry
of Health

Application:
Can be generalized
to large population
and applied to other
STIs and screening
tests.

Attrition:
71 women who
do not access to
telephones.

55 women due
to partner

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

52
attending the
ANC visit.

33 women due
to various
reasons.

Wu et al.,
(2021),
Addressing the
crisis of
congenital
syphilis: Key
findings from
an evaluation of
the
management of
syphilis in
pregnancy and
the newborn in
South-East
Queensland

None listed.
Presumed
Health
Promotion
Model

Design:
Retrospective
Review

N= 30

IV1: Syphilis +
pregnant
women

Purpose: To
evaluate the
management of
syphilis in pregnant
women and their
newborns and
compare the three
most commonly
used guidelines
available between
2016 to 2018.

Demographics:

DV1:
Guidelines
from the
Australasian
Society of
Infectious
Diseases

Syphilis +
pregnant
women, median
age of 27, and
50% of
participants
have had 2-4
pregnancies.

DV2:
Guidelines
from the
Communicable
Diseases

Tools: Data collected
from the Queensland
Perinatal Data
Collection

Validity/Reliability:
Reliance on public
health documentation
for syphilis staging, and
incomplete records
from four deliveries at
private hospitals

Statistical
Tests Used:
Not
mentioned

DV1: Not
specifically
addressed.

DV2: Not
specifically
addressed.

DV3: 73% of
women
completed the
CDC
recommended

Level of Evidence:
Level 2
Strengths:
Reinforces
treatment through
IM injection

Weakness: does not
discuss the different
guidelines and how
they compare to
each other.
Feasibility: Feasible
as it should not
inquire more costs

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Country:
Australia
Funding:
Queensland
Sexual Health
Research Fund

53
Average age27.9

Network
Australia

Setting:
Southeast
Queensland

DV3:
Guidelines
from the U.S.
Centers for
Disease
Control and
Prevention

Exclusion:

Definitions:

False- positive
serological
result,
documentation
of previous
appropriate
syphilis
treatment not
requiring further
treatment in
pregnancy or
termination of
pregnancy for
unrelated
reasons.

N/A

Bias:
No conflict
reported.

treatment
course

as women should be
tested during
pregnancy.

Application: Easily
applied to practice
as CDC guidelines
are the current
standard of care for
syphilis treatment.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

54

Attrition:
Not mentioned.

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

55

Table A2
Evaluation Table for Qualitative Studies
Citation

Theory/
Conceptual
Framework

Design/ Method/
Sampling

Sample/ Setting

Major Themes
Studied/
Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/ Themes

Level/ Quality of
Evidence; Decision
for/ Application to
practice;
Generalization

Nakku-Joloba et
al., (2019),
Perspectives on
male partner
notification and
treatment for
syphilis among
antenatal
women and
their partners in
Kampala and
Wakiso districts,
Uganda

Country:
Uganda

None Listed.
Presumed
narrative
research
framework.

Design: Narrative
Review
Method:
Recruitment of
participants in the
Syphilis Treatment
of Partners (STOP)
Trial
Purpose: to
understand factors
influencing male
partners to seek
treatment after
syphilis notification
by their pregnant
partners.

Sample: (n= 54)

Demographics:
-24 women, 30
male partners
with a mean age
of 32.
-87% were
married.
- 48% are selfemployed.
-57.4% had
secondary
education.

Individual
research
questions not
discussed.

Definitions:
STOP Syphilis
Treatment of
Partners Trial

Data Collection:
In-depth
interviews that
were audio
recorded,
transcribed, and
analyzed using the
thematic
approach.
Interviews
followed a guide
and were
conducted in
Luganda.

Data
Dependability:

Examination
of interview
quotes to
identify
common
themes
across
genders.

Notification of
male partners by
pregnant women
treated for
syphilis was low
due to individual
characteristics.

(1) Men reported
fear of finding out
HIV status as a
reason for not
returning after
partner
notification.

Level of Evidence:
Level 3
Strengths: Emphasis
on accurate
language and
translation. Allowed
for participants to
expand their
answers to
questions, allowing
for more data
collection.
Weakness: Needs
more information
on the fear of
domestic violence
impacting

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

Funding:
The Foundation
for the National
Institutes of
Health.

56
-63% of female
participants
reported that they
sometimes
experienced
domestic violence.

Setting:
Bias:
None.

Infectious
Diseases Institute
Clinic in Mulago
Attrition:
None listed.

-Medical and
social scientists
with experience in
qualitative
research and
fluent in English
and Luganda.
-Standardized
interview guide
was developed
and a Professional
translator was
used.
-Interviewers were
fluent Luganda
and English
speakers.

(2) Lack of
knowledge of
syphilis as a
disease

(3) Fears of
domestic
violence.

(4) Male fears of
injection/treatme
nt pain, cost of
treatment, and
lack of trust in
health care
system.

notification and
treatment.
Feasibility:
Implementing the
interviews in
different areas of
the world is feasible.
Proper translation
will be needed in
different areas.

Application: Can be
generalized to other
clinics to collect
information.

(5) Males report
limited resources
of care, long wait
times in clinic for
treatment

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

57
*Improved public
awareness about
syphilis is needed

Park et al.,
(2022), Gaps in
the congenital
syphilis
prevention
cascade:
Qualitative
findings from
Kern County,
California

Country:
United States.

Funding:
March of Dimes
and the Centers
for Disease

None Listed.
Presumed
narrative
research
framework

Design: Five focus
groups, and ten
interviews with
prenatal care (PNC)
providers

Method: Focus
groups and
interviews were
recorded,
transcribed, and
analyzed
Purpose: To identify
facilitators and
barriers that are
contributing to
increased CS rates.

Sample: (n= 52)
Focus groups n=42
PNC provider
interviews n=10

Demographics:

Focus groups:
18 years and
older, receiving
PNC or early
postnatal care in
Kern County, a
resident of Kern
County for at least
six months,
currently

Individual
research
questions not
discussed.

Definitions:
PNC- prenatal
care
providersclinicians who
provide care
to pregnant
women.

Data Collection:
semi-structured
guides with openended questions

Data
Dependability:
n/a

State type
used.
Content
analysis,
interpretatio
n of patterns
and themes
recorded
data.

(1) Barriers to
accessing care:
long wait times,
geographic
location,
transportation
and insurance
issues.

(2) social,
economic and
cultural barriersunemployment,
homelessness, to
unmet linguistic
needs including
culturally
competent PNC

Level of Evidence:
Level 6
Strengths: Use of
the CS prevention
cascade to identify
themes in areas
with high CS rates
Weakness: Small
sample size that
cannot be
generalized to other
populations, and
not all participants
had had infants
born with CS.
Feasibility:
Feasible, relatively
low cost and
incentive gift cards

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE
Control and
Prevention
(CDC)

Participants
received a $25
gift card and
prenatal care
providers
received a $50
gift card funded
by Tulane and
the University
of California,
San Diego
(UCSD).

Bias:
No conflict
reported.

58
pregnant or
delivered an
infant less than
12 months prior,
considered as
“high-risk” for CS,
has a phone or
another way of
being contacted,
and is able to
consent to the
study.

(3) Contributing
factors: substance
use and intimate
partner /
domestic violence

may not be
necessary,
especially for
provider interviews.

Application: results
cannot be
generalized as the
sample population
was small.

PNC Providers:
PNC providers
who work in Kern,
County and have
been in their
position for six
months or more,
identified as
possessing
knowledge about
the healthcare
setting and
dynamics relevant

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

SYPHILIS ON THE RISE

59
to CS and
pregnant women
in the region,
currently working
with high-risk
pregnant women,
has a phone or
another way of
being contacted
and is able to
consent to the
study.

Setting: Kern
County, California

Attrition: Not
indicated

Key: ANC antenatal clinic/care, CDC U.S. Centers for Disease Control and Prevention, CIA Chemiluminescence Immunoassay, CMV Cytomegalovirus, CS Congenital Syphilis, CT
Chlamydia trachomatis, DALY Disability Adjusted Life Years, dPNt digital Partner Notification tool, DV Dependent Variable, ED Emergency Department, G Gauge, HCP Health
care provider, HIV Human Immunodeficiency Virus, IDI Infectious Diseases Institute, IgG Immunoglobulin, IM Intramuscular, Institutional Review Boards, IU International Unit, IV
Independent Variable, mL milliliters, MOH Ministry of Health, MTCT Maternal to Child Transmission, MV Mepivacaine hydrochloride, NG Neisseria Gonorrhoeae, GNICHD
National Institute of Child Health and Human Development, PGB Penicillin G Benzathine, PN Partner Notification, PNC Prenatal Care, POCT point-of-care test, RDT Rapid
Diagnostic Test, RPR Rapid Plasma Reagin, STI Sexually Transmitted Infection, STOP Syphilis Treatment of Partners Trial, TP Treponema pallidum, TP-PA Treponema pallidum
particle agglutination assay, UCSD University of California San Diego

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Table A3
Synthesis Table

Study

60

Adachi et al.,
2018

Almeida et
al., 2021

Biswas et al.,
2018

Dunseth et
al., 2017

Estrada et
al., 2019

Folke et al.,
2022

Mmeje et al.
2015

NakkuJoloba et
al., 2019

Obure et
al., 2017

Park et al.,
2022

ParkesRatanshi et
al., 2020

Wu et al.,
2021

Design

Retrospective
cohort study

Retrospective
cohort study

Retrospective
Review

Six-year
Retrospective
Study

Randomized
double-blind
clinical trial

Retrospective
Review

Retrospective
Review

Narrativ
e Review

Cluster
randomize
d
controlled
study

Five focus
groups,
and ten
interviews
with PNC
providers

Randomized
controlled
trial

Retrospecti
ve Review

LOE

II

II

II

III

I

II

II

II

II

VI

II

II

n subjects

1,684

158

2498

23,065

108

5,715

194

54

2,214

52

17,130

30

M-Age

26.5

-

-

35.6

36.6

-

-

32

-

-

25

27.9

-

-

-

-

94.4%

-

-

55.5%

-

-

-

-

OP clinic

-

+

-

+

+

+

-

+

+

+

+

-

Hospital

+

+

+

+

-

-

+

-

+

-

-

-

U.S.

-

-

+

+

-

+

+

-

-

+

-

-

Other Country

+

+

-

-

+

+

-

+

+

-

+

+

(Author,
year)

Sample

% of males
Setting

Intervention

Key: dPNt digital Partner Notification tool, Dx Diagnosis, HIV Human Immunodeficiency Virus, LOE Level of Evidence, MTCT Maternal to Child Transmission n number, OP Outpatient, PN Partner
Notification, Pn Pain, PNC Prenatal Care, PNS Partner Notification Slip, SMS text message, Tx Treatment, U.S. United States

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Study
(Author,
year)

Adachi et al.,
2018

61

Almeida et
al., 2021

Biswas et al.,
2018

Dunseth et
al., 2017

Change in
serum testing

↔

PN tools

dPNt

Estrada et
al., 2019

Folke et al.,
2022

Mmeje et al.
2015

NakkuJoloba et
al., 2019

Obure et
al., 2017

Park et al.,
2022

ParkesRatanshi et
al., 2020

Wu et al.,
2021

SMS & PNS

Outcomes
and Themes
Correlation
between HIV+
and syphilis+

+

Reinforces
need for
screening and
Tx

+

Fear
associated
with pain or
dx

+

+

+

+

+

+

+ (Pn)

+

+

+

+

n/a

+

+

n/a

+

+ (Pn)
+ (Dx)

Key: dPNt digital Partner Notification tool, Dx Diagnosis, HIV Human Immunodeficiency Virus, LOE Level of Evidence, MTCT Maternal to Child Transmission n number, OP Outpatient, PN Partner
Notification, Pn Pain, PNC Prenatal Care, PNS Partner Notification Slip, SMS text message, Tx Treatment, U.S. United States

SYPHILIS ON THE RISE

62
Appendix B

Models, Frameworks and Project Materials
Figure B1
Health Belief Model

The HBM is used to understand the patient’s perspective and what leads them to completing
screening, testing, and/or treatment.

(Champion & Skinner, 2008)

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Figure B2
Model for Improvement

The MFI was idnetifed as a framework to implement changes with the intent decrease CS rates.

(IHI, 2022)

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Figure B2
Recruitment Material

64

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Figure B4
Voluntary Consent Script

65

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Figure B5
Pre- Education Questionnaire

66

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Figure B6
OB Triage Syphilis Protocol

68

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Figure B7
Education Session Presentation

69

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Figure B8
Post-Education Questionnaire

75

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Figure B9
3 Month Follow-up Questionnaire

78

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Figure B10
Data Collection Sheets

81