Assignment Two: Screening for maternal syphilis

TM5541 Managing Effective Health Programmes
Assignment Two:
Screening for
maternal syphilis
Plan of an early detection activity
Samantha Leggett
SN 12494652
Word Count: 3342 (excluding in-text references, tables and footnotes)
SN: 12494652 Samantha Leggett
1. The early detection activity
2. 2.1 The problem screened for
2.2 The screening test used
3. Evidence justifying why the activity would be beneficial to the population
4. 4.1 The process required to establish an antenatal maternal syphilis screening
4.2 Running an antenatal maternal syphilis screening programme
5. Promoting a maternal syphilis screening programme to expectant mothers
6. Summary
7. Appendix A: Congenital syphilis- signs, symptoms and sequelae
8. References
SN: 12494652 Samantha Leggett
TM5541 Managing Effective Health Programmes
Assignment Two: Plan of an early detection activity
1: The early detection activity: Maternal syphilis screening as an integral component of
antenatal care across Papua New Guinea
2.1: The problem screened for: Maternal and potential congenital syphilis infection
Syphilis infection is a significant public health problem and remains a major infectious but
preventable determinant of maternal, neonatal, infant and child morbidity and mortality in
resource poor settings (Peeling & Ye, 2004; Rydzak & Goldie, 2008).
Globally, each year around 12 million people are infected with syphilis; 2 million of these
are pregnant women and 90% of all annual syphilis cases are in low income countries
(Tucker et al. 2010). Untreated infection in a woman can lead to serious cardiovascular and
neurological complications and can facilitate HIV transmission1 (Levin et al. 2007; Rydzak
& Goldie, 2008). If a pregnant woman has syphilis she may transmit the infection to the
foetus transplacentally at any point during the pregnancy causing congenital syphilis (see
Appendix A). Additionally maternal syphilis also has the potential to lead to other adverse
pregnancy outcomes such as still birth or spontaneous abortion and low birth weight
babies. (Bronzan et al. 2007; Levin et al. 2007; World Health Organization [WHO], 2009). It
is thought that between 49-67% of pregnant women with active syphilis will have adverse
Syphilis causes genital sores and these make it easier to transmit and acquire HIV infection. It is estimated that if syphilis
is present an individual is at 2-5 times higher risk of acquiring HIV via sexual exposure.
Ulcerative sexually transmitted infections that cause sores, ulcers or breaks in the skin or mucous membranes (such as
syphilis) disrupt the bodies’ natural defence barriers that provide protection against infection. Genital ulcers caused by
syphilis can bleed easily and when they come into contact with mucosa during sex increase the infectiousness of and
susceptibility to HIV (Centers for Disease Control and Prevention. (2010). Sexually transmitted Diseases: Syphilis.
Retrieved from:
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pregnancy outcomes (Bronzan et al. 2007); the earlier in pregnancy the transmission, the
worse the expected outcome if the maternal syphilis is left untreated (WHO, 2005).
The exact burden of congenital syphilis is not truly known due to inadequate surveillance
and reporting (WHO, 2009). Additionally only 68% of women in developing countries
receive ante natal care (ANC) and of these, around half do not attend until after the first
trimester-many pregnancies affected by syphilis end in miscarriage in the first or second
trimester before women are screened for syphilis (Romoren &Rahman, 2006; WHO, 2005).
However at least half a million infants are known to be born annually with congenital
syphilis and maternal syphilis results in a further half million known stillbirths and
miscarriages per year (WHO, 2007). Perinatal morbidity and mortality attributed to
syphilis infection is on par with that of HIV, tetanus and malaria which all receive greater
global public health attention (Schmid, 2004; WHO, 2008; WHO, 2009).
Foetal mortality and infant and childhood morbidity and mortality due to congenital
syphilis are preventable if infected mothers are identified and treated appropriately by the
middle of the second trimester. Routine antenatal screening and treatment to prevent
congenital syphilis has thus become the main focus of syphilis control programmes
(Peeling & Ye 2004; WHO, 2004).
2.2: The screening test used
Rapid point-of care testing using an onsite treponemal immunochromatographic
strip test.
The selection of diagnostic tools used in such programmes must take into consideration the
health and economic outcomes of variables such as: adverse pregnancy outcomes
(miscarriage, low-birth-weight, still birth, neonatal death, congenital syphilis); maternal life
expectancy; life time health costs for both mothers and their children; life expectancy gains
for children; and the availability and feasibility of resources.
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Serological tests are cited as the method of choice for prenatal screening and are asserted
to be feasible and affordable in most resource limited countries; non-treponemal tests such
as Rapid Plasma Reagin (RPR) are sensitive and simple to perform but have not historically
been readily available in primary health care settings as cold storage is required for reagins
and electricity is needed to operate a rotator. In general, non-treponemal tests can be
prone to providing pregnant women with false positive results (as much as 28%) and
ideally in this situation results would be confirmed in a laboratory using for example a
venereal disease research laboratory (VDRL) test. However, it is acknowledged that in
resource poor settings this is technologically and logistically unlikely (Peeling & Ye, 2004).
Another important drawback of using a two-step diagnostic method is the potential of loss
of patients to follow-up due to women having to return to the clinic for test results and
potential treatment. Loss to follow up represents a waste of resources, adverse clinical
outcomes due to a delay in early treatment or no treatment at all and continued
transmission of infection (Munkhuu, Liabsuetrakul, Chongsuvivatwong, McNeil, & Janchiv,
2009; WHO, 2006).
Stoner (2008) asserts that the new generation rapid point-of-care treponemal test
(immunochromatographic strip (ICS) test) offers an opportunity for the immediate
detection and treatment of infected pregnant women without the drawbacks of the other
two methods. These tests are simpler to use, interpretation does not rely on subjectivity
and they do not require electricity/refrigeration or additional equipment. A number of
researchers, in comparisons of RPR, VDRL and ICS tests have found the ICS test, used in a
one stop screen-and-treat strategy was: more effective in the prevention of congenital
syphilis; resulted in increased screening coverage; improved the rate of case detection in
women and their partners; was more cost-effective; and had the added benefit of ease of
use even in the most rudimentary conditions (Levin et al. 2007; Munkhuu et al. 2009;
Peeling & Ye. 2004; Rydzak & Goldie, 2008; Watson-Jones et al. 2005). Comparisons
between these tests are presented in table 1.
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Table 1. Comparison of suitable diagnostic tests for maternal and congenital syphilis
screening in resource poor settings
ICS Rapid Test
Ease of use
Where used
Exam room/on-site
Exam room/on-site
Exam room/on-site
Light microscope
Training Needed
Average Cost
Most RPR agents
Reagents require
Most tests are stable
require refrigeration
at room temperature
Cannot be used on
Cannot be used on
for >6 months
whole blood-serum
whole blood-serum
Test doesn’t
distinguish between
Test results
Test results
active infections and
previously treated
for reporting error
for reporting error
Uses whole blood
Extra Equipment
(Bronzan et al. 2007; Peeling & Ye, 2004; WHO, 2006)
Stoner (2008) points out that the ICS tests also have some performance limitations: the
treponemal antibody is present for many years and because of this treponemal tests are
unable to distinguish between active syphilis infection and a previously treated infection.
So, despite having had prior and adequate treatment for syphilis, a previously positive but
cured woman will have persistently positive ICS tests and without laboratory confirmation
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will always receive treatment for syphilis. The treponemal test also only presents a positive
or negative result and is also therefore unsuitable for monitoring therapy responses.
In resource constrained settings, facilities for immediate testing and treatment and the
subsequent reduction of losses to follow-up provide considerable advantages, since the
benefits of preventing serious sequelae and onward transmission of syphilis clearly
outweigh the risks and costs of over treatment (Benzaken et al. 2011; Bronzan et al. 2007;
Peeling & Ye, 2004). Rydzak and Goldie (2008) argue that unnecessary treatment increases
costs and the probability of treatment side effects in addition to potentially contributing to
antimicrobial resistance. However they point out that the net impact of overtreatment is
expected to be marginal relative to the magnitude of the benefits.
3: Evidence justifying why the activity would be beneficial to the population of Papua
New Guinea
To date, Papua New Guinea’s (PNG) performance towards achieving the Millennium
Development Goals (MDGs) has been variable, with progress made in some areas and
stagnation or even reversal in others. The WHO (2010) believe this to be due to a
combination of factors: restricted institutional frameworks; severe resource limitations
(both material and human); and many socioeconomic, cultural and political constraints.
Table 2 presents some important comparisons in local health related statistics.
Table 2: Western Pacific health statistics
Papua New
Still births per
At least one
mortality per
mortality per
1000 total
antenatal care
1000 live
1000 live
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WHO (2011)
The successful implementation of a programme to eliminate congenital syphilis would
significantly contribute to PNG’s progress towards three key health related MDGs:
MDG 4: reduce child mortality –mortality rates in children under five will be reduced as a
result of a decreased incidence of low-birth-weight babies, perinatal death and congenital
infection. Additionally mother to child transmission of HIV should be reduced.
MDG 5: improve maternal health-maternal health will be improved as a result of fewer
spontaneous abortions, and a lowered incidence of syphilis and its sequelae including the
increased risks of contracting HIV.
MDG 6: combat HIV/AIDS, malaria and other diseases-screening and treatment for syphilis
in women will help to prevent the spread of HIV (WHO 2005a; WHO, 2008)
The WHO (2010) report that in PNG the syphilis prevalence rate amongst antenatal care
attendees is 5.78%. Of the seventy seven countries reporting antenatal care attendance,
only five had a higher prevalence of syphilis amongst attendees than PNG: Central African
Republic (5.88%); Ghana (6.91%); Mozambique (6.93%); Chad (7.3%); and Madagascar
(7.7%). Frank and Duke (2000) found a syphilis prevalence of 7.1% in a small rural
Highlands centre and in the same study congenital syphilis accounted for 22% of all
neonatal deaths over a two year period; the major risk factor for death in affected babies
was low-birth-weight. Duke et al. (2002) point out that in the same setting potentially
avoidable factors accounted for 50% of childhood mortality and a lack of maternal syphilis
screening was cited amongst these variables as were a lack of antenatal care and a failure
of disease screening programmes.
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Syphilis surveillance was endorsed by the PNG Ministry of Health in 2006 and initiated in
2008. As a component of the five year HIV and syphilis surveillance plan, routine antenatal
syphilis screening is recommended for all pregnant women although the literature is
unclear regarding testing methodology (HIV & AIDS Data Hub, 2011). UNICEF (2011)
purports that syphilis screening is routinely conducted for all antenatal care attendees in
PNG however it would be wise to remain mindful of previous warnings of poor surveillance
and reporting, antenatal care attendance figures, topographical challenges, access
constraints and known resource constraints. The WHO (2007) point out that policy
guidelines are building blocks only and Hawkes, Miller, Reichenbach, Nayyar and Buse
(2004) warn that policy doesn’t automatically translate into an effective health
A considerable challenge that faces the delivery of health care services in PNG is that 86%
of the country’s population live in rural areas and access to these widely scattered
communities is often difficult, slow and expensive. Only 3% of roads are paved and many
villages can only be reached on foot or via river transportation. The nations’ capital Port
Moresby is not linked by road with the rest of the country. (WHO, 2010). These constraints
also make it difficult and costly for the population to access the services that are available
(AusAID, 2009).
Section 2.2 discusses the general benefits of a same day screen-and-treat syphilis detection
programme. In addition to this and relevant to the PNG context, the choice to use ICS tests
over other options is important in PNG if aiming to scale up syphilis screening programmes
in distant settings of high maternal syphilis prevalence and with the lowest levels of health
care service delivery. Regions for example characterised by the need for river
transportation, a lack of well equipped laboratories, a lack of electricity and refrigeration
facilities, inadequate staff training and a poor continuity of supplies (Benzaken et al. 2011).
These characteristics are typical of much of PNG.
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4: The process required to establish and run an antenatal syphilis screening
4.1 Establishing a screening programme would utilise the following steps:
1. Planning: The literature highlights the utmost importance of comprehensive
planning as the first step in implementing a screening programme in resource
limited countries. The inclusion of the national Ministry of Health (MoH),
programme decision makers and managers, health care staff and importantly,
representatives of the women and their male sexual partners who are to be offered
screening is imperative. In doing this a culturally appropriate intervention
responsive to needs can be crafted using a partnership approach. Additionally
barriers to and opportunities for turning health policy into effective practice can be
identified. Hawkes et al. (2004) assert that political support is vital for getting issues
such as congenital syphilis onto the health policy agenda and for helping to ensure
that programmes are implemented in a sustainable way.
Planning should include: a review of the evidence on disease prevalence and
associated sequelae; any previous cost-effectiveness analyses in the local setting;
lobbying for the cause, addressing sustainability issues (e.g. funding and capacity),
addressing procurement and supply issues and strengthening existing systems; how
partner notification is best to be addressed; how an integrated approach is best
achieved (i.e. linking screening to another more politically successful issue e.g.
prevention of mother-to-child transmission of HIV (PMTCT-HIV); identifying areas
of responsibility and ownership; and planning for any trial sites.
2. Training: The second stage should be comprehensive training for health personnel
to include: correct use and interpretation of the chosen ICS test; a comprehensive
understanding of maternal and neonatal syphilis and the importance of
incorporating early screening into ANC programmes; pre- and post-test counselling
skills; and documentation skills. The WHO (2007) advocate training traditional birth
attendants and traditional healers to refer women to appropriate antenatal health
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services. It is thought that this may be an important method of increasing early
attendance for antenatal care since many women consult these caregivers first.
Further, training of lay community health workers to deliver promotion of early
ANC is also advocated (Howlett, Larsh, Dobi & Mai, 2009; Tanjasiri, Sablan-Santos,
Merrill, Quitugua & Kuratani (2008).
3. Information, education and communication (IEC)2 activities should be planned. A
high visibility campaign is essential in a country such as PNG where much news
travels by word of mouth via the ‘wantok system’3. Pasick, Hiatt and Paskett (2004)
also stress the centrality of the church as a source of education and social support.
The influence of church leaders on individual’s beliefs and practices is thought to
offer great potential for positive health related behaviour change. Social networks
such as this can help women to not only initiate behaviours but also maintain them
over time (Byles, Sanson-Fisher & Redman, 1996; Tanjasiri et al. 2008). In terms of
the number and diversity of potential screening participants reached, information
aimed at communities has been found to achieve the widest scope (Pasick et al.
2004). MoH endorsement of all activities promoted must be explicit.
4. MoH endorsed manuals and technical guidelines on syphilis testing during antenatal
care must be developed and made available to all relevant health personnel.
IEC activities should include the design of a national informational and media campaign to encourage women to seek
antenatal care services early in pregnancy, to promote the benefits of early antenatal care and syphilis testing, the plan for
the rollout of the new programme. The campaign must be highly visible and could include themed posters, leaflets to be
given out in key locations such as markets, radio adverts, television adverts, newspaper adverts and reports and may also
employ the use of mobile telephone technology (UNFPA. (1999). Reproductive Health in Refugee Situations. Appendix
One: Information, Education and Communication (IEC) Programmes. Retrieved from:
The “wantok” (lit. one talk) system is PNG’s safety net, under which the extended family and clan members are obligated
to support each other. It also functions as an informal country-wide news network (UNDP. (2004). Millennium
Development Goals, Progress Report for Papua New Guinea. Retrieved from:
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5. Procurement, importation and stocking of ICS tests and other supplies.
6. Roll out of screening programme
(Garcia et al. 2007; Gloyd et al. 2007; Hawkes et al. 2004; Howlett et al. 2009; WHO, 2006;
WHO, 2007)
4.2 Running a screening programme should follow the proceeding steps:
 Ideally all pregnant women will be screened at least once as early in antenatal care
as possible integral to routine and existing antenatal/HIV-PMTCT programmes. The
test and treatment will be free.
 Group IEC activities should be carried out in the antenatal clinic each morning by
health care staff.
 The woman will receive pre-test counselling.
 If informed consent is given blood will be obtained from a finger prick for rapid ICS
testing for syphilis (+/- HIV testing).
 The woman will receive her result and post-test counselling.
 If the result is positive she will receive the appropriate treatment on the same day
as the test4.
 The woman will receive a notification card to give to her male sexual partner asking
them to attend the clinic. It is advised that the reason for visiting the clinic is not
explicitly stated on the card, but wording such as ‘there are issues regarding the
pregnancy that we wish to discuss with you’. It is thought that messages focusing on
the health of the unborn child will have a more positive effect and that this will
If penicillin allergy is not a known issue treatment is with intramuscular Benzathine Penicillin. It is inexpensive (median
cost US$0.25 per treatment), on the WHO essential drugs list and resistance is not known to be a widespread problem.
(World Health Organization. (2005). Eliminating Congenital Syphilis. Retrieved from:
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promote a higher male sexual partner attendance rate at the clinic where maternal
and congenital syphilis can be discussed with them and they can receive free
presumptive treatment should they choose (Gichangi, Fonck, Sekande-Kigondu &
Ndinya-Achola, 2000; WHO, 2007).
 The woman will also receive counselling regarding intimate partner violence (IPV)
 The health care professional will clearly and concisely document all aspects of the
consultation including counselling given, screening, treatment and partner
notification in the woman’s health record and clinic health records.
 Ongoing supervision, training and audit procedures should include: evaluating test
use and interpretation; stock management; staff rostering and cover (Kamb et al.
(2010) assert that an especially difficult barrier to surmount in many settings is
ensuring adequate human resources-not only in numbers (recruiting and retaining)
but in currency of training and practical experience); record keeping; quality control
(QC)5; and partner tracing activities.
(Garcia et al. 2007; Gloyd et al. 2007; Maggwa, Askew, Mugwe, Hagembe & Homan, 2001;
WHO, 2006; WHO, 2007)
NB Ideally all women should be screened in their first trimester and again in the third
trimester to account for later primary infection and the possibility of re-infection,
particularly if partners aren’t treated. Optimally a third test would be performed on the
woman at delivery. As a minimum, one test should be performed at the first antenatal visit
and if this doesn’t happen, then at or soon after delivery (Saloojee et al. 2004).
QC of the validity of the rapid tests is advocated as most manufacturers recommend that the rapid test kits are
transported and stored at 4-30 degrees Celsius. It is acknowledged that temperatures above 30 degrees Celsius may
sometimes be unavoidable, as in many remote locations where rapid tests are intended to be used. QC should be carried
out in a central laboratory (World Health Organization. (2006). The use of rapid syphilis tests. Retrieved from:
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5: Promoting a maternal syphilis screening programme to expectant mothers
In general, common barriers to participation in screening activities include: 1) lack of
awareness and understanding of the importance of screening; 2) not knowing the required
screening frequency; 3) not knowing how to access screening; 4) emotional barriers (fear
of the test, fear of finding disease, embarrassment, previous negative experiences); and 5)
cognitive barriers (lack of knowledge, not understanding concept of prevention) (Howlett
et al. 2009). Promoting a screening activity to a potential client should therefore aim to
address these barriers.
Ideally, as previously stated, before the antenatal clinic commences each morning and
afternoon the women waiting will be part of a group IEC activity run by the health care
staff. Information should include: the importance of early ANC and syphilis testing in
pregnancy; complications of untreated syphilis to the mother and unborn child and
children who are born with congenital syphilis; HIV-PMTCT; voluntary counselling and
testing and the promotion of condom use in pregnancy. Face to face information delivered
by health care workers plus visual media has been shown to be the most effective strategy
for increasing the uptake of screening (Byles et al. 1996).
The one-to-one dialogue between the healthcare provider and the client would then
proceed as follows:
The information related to maternal and congenital syphilis from the IEC session would be
re-iterated, emphasizing both the health and economic benefits to the woman and her
family of the early treatment and detection of maternal syphilis. Meissner et al. (2004)
emphasize that health care workers play a pivotal role in facilitating screening uptake and
highlight that messages communicating the advantages of early screening must use clear
language. Efforts should be made to address individual barriers to early screening uptake
face-to-face; counselling provides the perfect opportunity for this (Tanjasiri et al. 2008).
Since syphilis is often asymptomatic (WHO, 2007) and therefore cannot necessarily be
seen, it is important to stress the normalcy of lack of symptoms in syphilis infection and the
simplicity of testing and treatment (Tanjasiri et al. 2008). That both screening and
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treatment is rapid, on-site and free would also be emphasized-a number of studies have
shown that the lower the response cost to the client, the greater the likelihood of screening
uptake (Byles et al. 1996; Meissner et al. 2004).
At this point the client would also receive counselling regarding the event of a positive
result and the need for partner notification and treatment to gain optimal results. IPV
screening would take place and counselling given regarding the best ways to inform
partners when IPV is feared. Gichangi et al. (2000) state that women who inform their
spouse of an STI often face increased violence, divorce or loss of security. Programmes
involving partner notification should weight the benefits and risks for the woman involved.
Edwards et al. (2005) stress that adequate discussion about the risks and benefits
associated with different choices that could be made is required if client involvement is to
be secured through informed decision making.
6: Summary
In summary, maternal and congenital syphilis are a significant public health concern and
untreated, cause a high burden of morbidity and mortality, particularly in resource poor
settings. Early screening and treatment for maternal syphilis as an integral component of
antenatal care has been shown to be an effective method of combating this somewhat
neglected burden of disease. The use of new generation rapid point-of-care ICS tests
provides a simple and cost-effective method for the immediate detection and treatment of
syphilis without the drawbacks of other methods which is particularly relevant to the
Papua New Guinea context.
Evidence demonstrates that a comprehensively and inclusively planned screening
programme that is well run and consistently evaluated has the ability to significantly raise
the profile of a disease, dramatically increase screening coverage and subsequently
considerably reduce the burden of disease. Screening programmes such as this can assist
resource poor countries such as PNG improve maternal and child morbidity and mortality
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and can thus act as an aid to making real progress toward the achievement of the
Millennium Development Goals.
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7: Appendix A
Congenital Syphilis- signs, symptoms and sequelae
Congenital syphilis is caused by the bacterium Treponema pallidum which spreads from a
pregnant mother who is infected with syphilis to her unborn child via the placenta. T.
pallidum can also be contracted via the birth canal. Nearly half of all children infected with
syphilis while they are in utero will die before or shortly after birth. For the rest congenital
syphilis can be a severely disabling condition. It is possible for a baby to be born without
signs and symptoms of the disease but, if left untreated, the baby may develop serious
problems within a few weeks.
Signs and symptoms in the newborn:
 Failure to thrive
 Irritability
 Fever
 Early rash (small blisters on the palms of the hands and soles of the feet)
 Later rash (a copper coloured maculopapular rash esp. on the extremities)
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(Peihong, J., Zhiyong, L., Rengui, C., & Jian, W. (2001). Early congenital syphilis. International Journal of Dermatology, 40(3), 198-202).
 Rash of the mouth genitalia and anus
 Watery discharge from the nose
(Congenital syphilis in a newborn. Retrieved from:
 Hepatosplenomegaly
 Lymphadenopathy
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Signs, symptoms and sequelae in older infants and young children:
 Abnormal notched and peg-shaped teeth
 Clouding of the cornea
(Syphilis: congenital interstitial keratitis. Retrieved from:
 Blindness
 Poor hearing/deafness
 Gray, mucous-like patches on the anus and outer vagina
 Scarring of the skin around the mouth, genitalia and anus
 Joint swelling
 Bone pain
 ‘Saber shins’-a malformation of the tibia
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 Saddle nose deformity
 Neurological sequelae including seizures and developmental delay
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Taken from: PubMed Health. (2009). Congenital Syphilis. Retrieved from:
British Association for Sexual Health and HIV (BASHH). (2008). UK National Guidelines on
the Management of Syphilis 2008. Retrieved from:
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