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  • One hundred counties and districts of cities in thirteen cities of Jiangsu province were involved in this study. To carry out this evaluation, county/district level public health bureaus collected data through existing information systems and field surveys in 2015. In order to ensure the authenticity and accuracy of the data, county (district) self-assessment, municipal review and provincial inspection work were launched. For this study, we collected de-identified surveillance data on reported cases of syphilis in 2015 as well as de-identified survey data on population awareness of syphilis. In this study, original data were obtained through disease-monitoring systems in Jiangsu province to calculate 9 variables, including: The proportion of first-detected patients in HIV counseling testing clinics and first-methadone users in methadone maintenance treatment clinics who received free testing for syphilis: = Numbers of first−detected patients and first− methadone users getting free testing for syphilisTotal numbers of first−detected patients in HIV testing clinics counseling and first− methadone users in methadone maintenance treatment clinics in 2015;The proportion of first-detected patients and first-methadone users with positive syphilis tests who were referred to a STD clinic for syphilis professional treatment in HIV counseling and testing clinics and methadone maintenance treatment clinics: = Numbers of first−detected patients and first− methadone users with positive syphilis having been referred for specialized follow−up treatmentFirst−detected patients and first−methadone users with positive syphilis in HIV counseling and testing clinics and methadone maintenance treatment clinics in 2015;The proportion of pregnant women at public medical institutions who received free syphilis testing at least once during pregnancy: = Numbers of pregnant women getting free testing for syphilis at least once time during pregnancy in public medical institutionsPregnant women in 2015;The proportion of syphilis-positive pregnant women at public medical institutions who received standard diagnostic and treatment services: =  Numbers of syphilis positive women accepting standard diagnostic and treatment servicesSyphilis positive pregnant women in public medical institutions in 2015;The proportion of live babies born to syphilis-positive mothers who received standard syphilis diagnostic and treatment services: =  Numbers of babies accepting standard diagnostic and treatment servicesAlive babies born to syphilis−positive mothers in 2015;The proportion of syphilis-positive mothers with one-year-old babies who accepted syphilis follow-up for their child during its first year of life: =  Numbers of babies accepting follow−up in the first year of lifeOne−years−old babies born to syphilis−positive mothers in 2015;The diagnostic accuracy rate of syphilis cases reported by medical institution: we considered each syphilis case as correctly diagnosis if the patient had records of positive tests for both a treponema pallidum serum test and a non-treponema pallidum serum test: =Syphilis cases diagnosed accurateSample syphilis cases reported by surveyed medical institution in 2015;The annual growth rate in incidence of all cases of syphilis from 2010 to 2015(%): =  The reported incidence rate of all cases of syphilis in 2015The reported incidence rate of all cases of syphilis in 20106×100−100The compound annual growth rate in incidence of primary and secondary syphilis from 2010 to 2015(%): =  The compound incidence rate of primary and secondary syphilis in 2015The compound incidence rate of primary and secondary syphilis in 20106×100−100;The annual growth rate in incidence of congenital syphilis from 2010 to 2015(%) =  The reported incidence rate of congenital syphilis in 2015The reported incidence rate of congenital syphilis in 20106×100−100. The National Center for STD Control, China CDC created a questionnaire exam of 322 items on syphilis prevention, treatment and testing to evaluate the knowledge of technical staff/medical personnel (S1 Table). In each county (district), the local center for disease control and prevention (CDC), a maternity and child health care hospital, and the three medical institutions with the largest number of reported syphilis cases during 2015 were recruited. At each institution, 3 syphilis prevention and control staff, 3 syphilis testers and 3 syphilis clinicians were given the exam. For any category with fewer than 3 participants, all individuals within that group were given the exam. Participants required a score of 85% or higher to pass the exam. The National Center for STD Control, China CDC created a survey with eight questions on knowledge of syphilis prevention intended for residents (S2 Table). This survey was conducted among urban and rural residents in each city. In order to ensure adequate representation of survey participants, the survey was administered to 200 urban residents aged 15 to 49, 150 rural residents aged 15 to 49, 100 rural-to-urban migrants over age 18, 650 commercial female sex workers over age 18, and 300 MSM over age 18. Participants who correctly answered six or more questions were considered proficient in knowledge of syphilis prevention. Provider-initiated syphilis testing and counseling (PISTC) services: Three hospitals in each county with the highest number of reported syphilis cases during 2015 were included in this survey (S3 Table). To calculate this, we used the following formula designed by China CDC: PISTC proportion = the number of dermatology outpatients who were tested for syphilis in the fourth quarter / (the number of dermatology outpatients in fourth quarter×3%). To get the denominator, the total number of dermatology outpatients from the fourth quarter of 2015 in each selected hospital was collected. The numbers of patients being tested for syphilis in the fourth quarter of 2015 at the selected hospitals were also collected and used as nominator. Investigation on standard treatment of syphilis: Long-acting penicillin is widely regarded as the best treatment for syphilis [12–13], and a long-acting penicillin prescription was considered to be the standard treatment in this study. The top three hospitals for syphilis cases in each county (district) in 2015 were included in this study (S4 Table). We randomly selected 30 syphilis treatment prescriptions from each hospital and counted the number of prescriptions for long-acting penicillin. Since some patients with syphilis are allergic to penicillin, the Chinese CDC used 0.75 as a correction factor to account for patients with penicillin allergies. The standard treatment ratio was calculated as follows: Standard treatment ratio (%) = (long-acting penicillin prescriptions/0.75) / sample syphilis treatment prescriptions×100%. Data were analyzed using SAS 9.3. We analyzed binary data and stratified data using the CMH-x2 test (Cochran-Mantel-Haenszel chi-squared test). We also examined the trends in reported incidence rate of syphilis from 2010 to 2015. Spatial analysis was integrated using geographic information system software (GIS 10).
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