Situaţia epidemiologică a sifilisului în Republica Moldova rămâne tensionată, incidenţa sifilisului dobândit fiind net superioară, comparativ cu media
europeană. Totodată, numărul cazurilor de sifilis congenital este unul mic pe parcursul mai multor ani. Astfel, principalii indicatori de impact, care
caracterizează eficienţa sistemului sanitar în acest domeniu, rata sifilisului congenital şi ponderea mortinatalităţii atribuită sifilisului, sunt cu mult sub
pragul de eliminare a sifilisului congenital propus de Organizaţia Mondială a Sănătăţii (OMS). Pe parcursul anilor de referinţă, 2012-2015, rata sifilisului
congenital a fost sub nivelul de 0,3/1000 nou-născuţi vii, iar ponderea mortinatalităţii, atribuită sifilisului – sub 1,5%. Menţinerea indicatorilor de impact
menţionaţi, de rând cu cei de proces, sub pragul OMS, pe parcursul anilor respectivi, a permis înaintarea solicitării de validare externă OMS a eliminării
transmiterii materno-fetale a sifilisului în Republica Moldova

Beţiu, Mircea

Emeţ, Iulia

Institutional Repository in Medical Sciences of Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova

82Curierul medical, Iunie 2016, Vol. 59, No 3Th e trend of syphilis in the Republic of Moldova shows an evident decline in evolution: from the beginning of sur-vey in 1950 till present days.  In 1950 aft er the 2nd World War the incidence of syphilis amounted 9 to 104.2 per 100 000 population mainly because of migration of the people as well as destruction of the health network.  In middle 1950s and 1960s was registered the lowest incidence of syphilis from 12.9 in 1958 to 5.5 in 1962. In 1970s a small peak was ob-served – 59.2 in 1978.  In mid 1980s the incidence was low – 7.1 in 1988. Aft er the collapse of the Soviet Union, due to the low socioeconomic income of people and a high migration rate, the number of reported cases of syphilis per 100000 population (incidence) increased signifi cantly, achieving its highest level in 1996 – 200,7 per 100 000 population.  In 2000s incidence of syphilis began to decrease from 155 in 2000 to 63.5 in 2010 [2, 3].  Th is downward pattern has been maintained during last three years: 64.6 per 100 000 popu-lation in 2012, 63.7 in 2013, 52.2 in 2014 and 53,8 in 2015 correspondingly (fi g.1).Fig. 1.  Reported incidence of syphilis in the Republic of Moldova, 1953-2015.The national level results on elimination of mother-to-child transmission of syphilis: main impact indicators*Mircea BEŢIU, Iulia EMEŢDepartment of Dermatovenerology, Nicolae Testemitsanu State University of Medicine and PharmacyChisinau, the Republic of Moldova*Corresponding author: mircea.betiu@usmf.mdRezultatele la nivel naţional privind eliminarea transmiterii materno-fetale a sifilisului: principalii indicatori de impactRezumatSituaţia epidemiologică a sifilisului în Republica Moldova rămâne tensionată, incidenţa sifilisului dobândit fiind net superioară, comparativ cu media europeană.  Totodată, numărul cazurilor de sifilis congenital este unul mic pe parcursul mai multor ani.  Astfel, principalii indicatori de impact, care caracterizează eficienţa sistemului sanitar în acest domeniu, rata sifilisului congenital şi ponderea mortinatalităţii atribuită sifilisului, sunt cu mult sub pragul de eliminare a sifilisului congenital propus de Organizaţia Mondială a Sănătăţii (OMS).  Pe parcursul anilor de referinţă, 2012-2015, rata sifilisului congenital a fost sub nivelul de 0,3/1000 nou-născuţi vii, iar ponderea mortinatalităţii, atribuită sifilisului – sub 1,5%.  Menţinerea indicatorilor de impact menţionaţi, de rând cu cei de proces, sub pragul OMS, pe parcursul anilor respectivi, a permis înaintarea solicitării de validare externă OMS a eliminării transmiterii materno-fetale a sifilisului în Republica Moldova.Cuvinte-cheie: sifilis dobândit, sifilis congenital, eliminarea transmiterii materno-fetale, indicatori de impact.Epidemiological situation of syphilis in the Republic of MoldovaDuring 2012-2015, according to the data provided by Th e National Center of Health Management, proportion of reported cases of syphilis was higher in men (56.3%/54.3%/ 55.8%/55.1%), than in women (43.7%/45.7%/44.2%/44.9). In males recent forms of syphilis have predominated (55.9% in 2012, 53.8% in 2013 and 55.4% in 2014), therein symp-tomatic patients in 2012 accounted for a half of cases, in 2013-2014 evolution of the disease showed a downward pat-tern in cases with symptoms (50.8% in 2012, 47.2% in 2013 and 44.3% in 2014). Latent cases in turn demonstrated an upward trend (48.6% in 2012, 51.8% in 2013 and 54.9% in 2014). In women recent forms of syphilis ranged 43.5% in 2012, 45.2% in 2013 and 43.8% in 2014. Symptomatic pa-tients formed 35.8% in 2012, 31.9% in 2013 and 31.5% in 2014, with latent syphilis representing 63.6% in 2012, 66.9% in 2013 and 67.7% in 2014 (fi g. 2-3). Fig. 2.  Distribution of recent forms of syphilis by sex, 2012-2014.Distribution of syphilis between diff erent age and gender groups in 2009-2015 showed a non-uniform pattern (tab. 1).Th e Integrated Bio-Behavioral Survey (2012-2013) has outlined syphilis prevalence among high-risk populations (fi g. 4), including:· Injecting Drug User (IDU) (man or woman who in-jected any type of drugs at least once during the last 12 months).MATERIALELE CONGRESULUI V NAŢIONAL DE DERMATOLOGIE CU PARTICIPARE INTERNAŢIONALĂ· Sex worker (CSW) (female who off ered sex in exchange for money or drugs at least once during the last 12 months).· Man who has Sex with Man (MSM) (male who had at least one homosexual contact with males within the last 6 months).Fig. 4.  Serologic prevalence of syphilis among high-risk populations.Th e syphilis prevalence among IDU shows an upward prevalence in Chisinau from 4.2% in 2009 to 12.7% in 2012, at the same time a downward pattern is seen in Balti with 2.7% in 2009 and 0.7% in 2012 (tab. 2).Th e prevalence of syphilis between CSW from Chisinau has increased signifi cantly during 2010-2013 and ranged 8.9% in 2010 and 20.5% in 2013[2, 4]. In Balti city a vice ver-sa data can be observed, as follows: 7.4% in 2010 and 2.4% in 2013 (tab. 3).Table 2Syphilis prevalence among key populations at higher risk (IDU)2009 2012TPHA TPHAChisinau Balti Chisinau BaltiIDU 4.2% 2.7% IDU 12.7% 0.7%Table 3 Syphilis prevalence among key populations at higher risk (CSW)2010 2013TPHA TPHAChisinau Balti Chisinau BaltiCSW 8.9% 7.4% CSW 20.5% 2.4%Rate of the disease among MSM from Chisinau has grown from 12% in 2010 to 14.6% in 2013, and dramatically increased in Balti ranging 0.4% in 2010 and 5.4% in 2013 (tab. 4).Table 4Syphilis prevalence among key populations at higher risk (MSM)2010 2013TPHA TPHAChisinau Balti Chisinau BaltiMSM 12% 0.4% MSM 14.6% 5.4%Case reporting released in last four years showed the highest syphilis incidence in capital of the country Chisinau, where it constituted 77.3 in 2012, 85.9 in 2013, 61.8 in 2014 and 62.18 in 2015 accordingly [1,5,7]. Th e 2nd place was re-ferred to the central region (77.1/68.2/56.5/56.48), the 3rd – Fig. 3.  Proportion of early, symptomatic and latent forms of syphilis by sex.Table 1Distribution of patients with syphilis by age and sex, 2009-2015YearsTotal 0-14years 15-24 years 25-49 years 50+ yearsMales Females Males Females Males Females Males Females Males Ffemales2009 1277 1124 7 16 419 546 704 490 147 722010 1296 1147 13 16 409 568 725 477 149 862011 1209 982 8 11 378 442 698 453 125 762012 1231 993 8 12 390 458 702 429 131 942013 1173 1030 10 11 319 430 691 485 153 1042014 958 819 8 17 263 356 546 355 141 912015 1022 834 15 19 259 338 600 398 148 798384Curierul medical, Iunie 2016, Vol. 59, No 3to the southern region (63.4/70.4/63.4/63.18), the 4th – to the northern region (40.2/37.6/30.0/29.89) and the last one – to ATU Gagauzia (28.5/23.5/26.0/25.95), (fi g. 5).Fig. 5.  Syphilis incidence by geographical distribution, 2012-2015.Syphilis in pregnant women and live birth congenital syphilisTh e trend of syphilis among pregnant women pointed out an upward pattern initially. It ranged from 132 in 2006 to 190 in 2013[8,11]. During the last 2 years the number of seropositive pregnant women remains stable with 154 cases in 2014 and 153 in 2015. Th e same has been registered for congenital syphilis live births (5 in 2012, 9 in 2013, 7 in 2014 and 9 in 2015), (fi g. 6).Table 5Prevalence of syphilis among pregnant womenYearsNumber of syphilis cases in pregnant womenPregnancies detectedPrevalence (%)2012 142 42918 0.33%2013 190 45392 0.42%2014 154 45804 0.34%2015 153 45924 0.33%To estimate the prevalence of syphilis, the nominator was the number of pregnant women testing positive for syphi-lis, and the denominator – the number of pregnancies de-tected in the respective period. As a result, the prevalence of syphilis among pregnant women in 2012 was 0.33% (142/42918×100), in 2013 was 0.42% (190/45392×100), in 2014 – 0.34% (154/45804×100) and in 2015 – 0.33% (153/45924x100), (tab. 5).Th e prevalence of syphilis in pregnant women in the 15-24 year group is greater than in 25+ ages (tab. 6).Table 6Prevalence of syphilis in pregnant women of different age groupsYears 2012 2013 2014 2015No. of cases of syphilis in pregnant women142 190 154 153No. of pregnancies in respec-tive year42918 45392 45804 45924Prevalence 0.33% 0.42% 0.34% 0.33%Age 15-24 yearsNo. of cases of syphilis in pregnant women102 110 100 90No. of pregnancies in respec-tive year42918 45392 45804 45924Prevalence 0.23% 0.24% 0.22% 0.20%Age 25+ yearsNo. of cases of syphilis in pregnant women40 80 54 63No. of pregnancies in respec-tive year42918 45392 45804 45924Prevalence 0.09% 0.18% 0.12% 0.14%Fig. 6.  Timeline of syphilis in pregnant women and congenital syphilis cases (live births).88Curierul medical, Iunie 2016, Vol. 59, No 3Stillbirths and stillbirth attributable to syphilis; congenital syphilis rateAccording to the ICD-10 defi nitions of the fetal death in perinatal period a stillbirth or fetal death is a death of a fetus before its expulsion or complete extraction from the body of the mother, independent of the duration of the pregnancy. Th e death is indicated by the fact that immediately aft er la-bor the fetus doesn’t breathe or show any other sign of life, such as heartbeat, pulse in the umbilical cord, or eff ective movements of the voluntary muscles. A fetal death certifi -cate is used for every fetus with a birth weight of 500 grams or more, or with 22 weeks or more of gestation.WHO indicates as the major causes of stillbirth are of fol-lowing conditions:· childbirth complications· maternal infections in pregnancy· maternal disorders (especially hypertension and diabetes)· fetal growth restriction· congenital abnormalities.Almost half of stillbirths happen when woman is in labor and the most straightforward cause is intrauterine hypoxia. Obstetricians from every regional hospital fi ll the case history of birth. In the case of fetal death, the case history shows that the fetus was born dead and an additional record is made in register of fetal deaths. Each case of stillbirth is examined via autopsy and all fi ndings are included in patient’s case history. Th e information is sent immediately to the Family Medicine Center to which mother belongs. Th e woman and her rela-tives are informed of it at a visit subsequent to the loss.Once a year obstetric services from the whole Republic send reports (form32A-san) to the national level, where data about health care in labor are described, inclusively still-birth. In this way defi nitive data about fetal death are col-lected, kept and published.In fact, the surveillance starts in pregnancy, from the moment the latter has been detected and a pregnant woman receives a “pregnant woman’s card”, an offi  cial document. It includes the fi ndings of prenatal checkups as well as results of VDRL and HIV tests for the woman and her sexual part-ner. Pregnant women bring this card to each checkup visit, to hospital admissions during the pregnancy and when ad-mitted to delivery. All physicians admitted to the woman’s care are required to write on her card, providing feedback to the family doctor or any specialist involved. In case when a fetal death happens the acting medical team makes an analy-sis and comprehensive assessment of the mother’s clinical, epidemiological, and serological history, with emphasis on possible risks, causes and conditions which led to the still-birth. Aft er the birth, the card remains archived as part of the hospital’s case history [11, 13].In the last four years stillbirth rate in the Republic of Moldova showed a stable pattern: it made up 6.6 per 1000 live births in 2012 (267 cases of stillbirth per 40322 neo-nates), 6.8 per 1000 live births in 2013 (270 cases of stillbirth per 39726 neonates), 5.8 per 1000 live births in 2014 (241 cases of stillbirth per 41446 neonates) and 5.8 per live births in 2015 correspondingly (243 cases of stillbirth per 41404 neonates), (fi g. 7).Fig. 7.  Stillbirth rate, 2012-2015.At the same time the reported number of stillbirths at-tributable to syphilis is as follows: 2012 – 2 (0,7%) cases; 2013 – 2 (0,7%) cases, 2014 – 0 cases and in 2015 – 3 (1,2%) cases; data were taken from Annual Report regarding par-turients’ and nursing women care service, No 32a [9,10,11], 2012-2015 (fi g. 8).Overall, the number of congenital syphilis cases for the reporting period, including stillbirth attributable to mother syphilis and live birth congenital syphilis cases, was adduced below: in 2012 – 7; 2013 – 11; 2014 – 7 cases and in 2015 – Fig. 8.  Stillbirths attributable to mother syphilis (%), 2012-2015.Fig. 9.  Rate of congenital syphilis per 1000 live births per year, 2012-2015.MATERIALELE CONGRESULUI V NAŢIONAL DE DERMATOLOGIE CU PARTICIPARE INTERNAŢIONALĂ12 cases[9,10,11]. Th us, the calculation of congenital syphilis rate was made as follows: 0.17 (7 cases per 40055 live births) in 2012; 0.27 (11 cases per 39456 live births) in 2013; 0.17 (7 cases per 41205 live births) in 2014; 0.29 (12 cases per 41161 live births) in 2015 (fi g. 9).ConclusionsTh e national level results on elimination of mother-to-child transmission (EMTCT) of syphilis in the Republic Moldova revealed a consistent and stable control within the last years 2012-2015 of the main impact indicators, as fol-lows: rate of congenital below 0,3/1000 live births and still-birth attributable to mother syphilis below 1,5%, both being much lower than WHO threshold  indicators – 0,5/1000 live births and 5%, respectively.  Th us, the national counterparts are ready for the WHO validation of syphilis EMTCT in the Republic of Moldova.Key words: aquired syphilis, congenital syhilis, elimina-tion of mother-to-child transmission, impact indicators.References1. Statistical Yearbook of the Republic of Moldova, 2012-2015 (http://www.statistica.md/pageview.php?l=en&id=2193&idc=263).2. Integrated Bio-Behavioral Study in key populations at higher risk. Key indicators 2012-2013. pdf (http://cnms.md/ro/rapoarte).3. Mid-term progress report on National Reproductive Health Strategy 2006-2015 (http://www.old.ms.md/_files/11785-Raport_evaluare_eng.pdf).4. Republic of Moldova progress report on HIV/AIDS 2014 (http://www.unaids.org/sites/default/files/country/documents//MDA_narrative_re-port_2014.pd.5. Strengthening of STI surveillance in the Republic of Moldova, Report on a WHO mission, 11-15 March 2013 (http://www.whohub-zagreb.org/uploads/strengthening-of-sti-surveillance.pdf).6. Ministry of Health Ordinance No 68 of 31.01.2015 regarding approval of National Guidelines of STI Management. (http://old.ms.gov.md/public/info/Ghid/ghiduri/ ghid/ghidnationalinfectiitransmiteresexuala/).7. Republic of Moldova Health System Review, Health Systems in Tran-sition, vol.14, no.7, 2012. (http://www.euro.who.int/__data/assets/pdf_file/0006/178053/HiT-Moldova.pdf?ua=1).8. Neonatal Congenital Syphilis Clinical Standardized Protocol (http://old.ms.gov.md/_files/14930-Protocol%2520clinic%2520standardizat%2520%2520 Sifilisul%2520congenital.pdf).9. Annual Report regarding sexually transmitted diseases, No 32a –săn, 2012-2015 (http://www.cnms.md/).10. Annual Report regarding pregnancy care service, no. 32 –săn , 2012-2015 (http://www.cnms.md/).11. Annual Report regarding parturients’ and nursing women care service, No. 32a–săn , 2012-2015 (http://www.cnms.md/).12. Global guidance on criteria and processes for validation: elimina-tion of mother-to-child transmission (EMTCT) of HIV and syphilis, WHO, 2014 (http://www.who.int/reproductivehealth/publications/rtis/9789241505888/en/).13. National Programme on Prevention and Control of HIV/AIDS and STI 2011–2015 (http://aids.md/aids/index.php?cmd=item&id=250).Sifilis primar, asociat cu gonoree şi trihomoniază, la un copilpreşcolar – caz clinic*Vasile STURZA, Iulia EMEŢ, Rodica CHITIC, Nina FIODOROVACatedra Dermatovenerologie, Universitatea de Stat de Medicină şi Farmacie “Nicolae Testemiţanu”Chişinău, Republica Moldova*Autor corespondent: vasile.sturza@usmf.mdGeneralităţi. Se prezintă cazul unui copil de 7 ani, sex masculin, din mediul rural, internat în spitalul Dermatologie şi Maladii Comunicabile, în 2014, fiind depistat cu sifilis primar recent al pielii şi mucoaselor, ca urmare a unui contact sexual al pacientei de 15 ani.Obiectiv. Au fost observate următoarele semne clinice: ulceraţii pe glandul penian de 1-2 cm în diametru, rotunde, contur regulat, culoare roşie-cărămizie, margini elevate, suprafaţă netedă, dur-elastice la palpare; câteva eroziuni pe foiţa internă a prepuţiului, de 3-6 mm, bine conturate, acoperite cu depuneri purulente; parafimoză; eliminări abundente din canalul uretral, galben-verzui, cu miros fetid; limfadenită inghinală bilaterală; papulo-vezicule pe trunchi, fese, coapse şi membre, multiple, mici, situate „în perechi”, unele fiind centrate de pustule şi cruste.  Diagnosticul clinic s-a confirmat cu cel paraclinic, depistându-se Tr. pallidum, Neisseria gonorrhoeae, Trichomonas vaginalis din materialul recoltat şi testele serologice pozitive (RMP 4+, TPHA 4+).  S-a stabilit următorul diagnostic: sifilis primar (şancru dur de tip ulceros şi eroziv; parafimoză); adenopatie inghinală bilaterală; scabie asociată cu piodermie acută; infecţie gonococică (uretrită acută); trichomoniază urogenitală.  S-a indicat tratament general: benzilpenicilină - 1 mln. un. i/m, câte 400.000 un., de 6 ori în zi, 14 zile; benzatin-benzilpenicilină 2,4 mln. un. i/m; metronidazol 125 mg - de 2 ori în zi, 10 zile.  Tratamentul topic a inclus: comprese umede cu sol. NaCl 10%; coloranţi anilinici, Baneocină ung., Sulf precipitat ung. 15%.Concluzii: Cazul este pus în discuţie pentru raritatea infecţiilor transmise sexual la copiii preşcolari.Cuvinte-cheie: sifilis, gonoree, trichomoniază, copil, caz rar.89

Rezultatele la nivel naţional privind eliminarea transmiterii materno-fetale a sifilisului: principalii indicatori de impact

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Rezultatele la nivel naţional privind eliminarea transmiterii materno-fetale a sifilisului: principalii indicatori de impact

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