Simple, low cost interventions to increase the coverage of screening and treatment of syphilis during pregnancy could prevent more than half of newborn deaths and stillbirths related to the disease, which is responsible for nearly 500 000 perinatal deaths every year in sub-Saharan Africa alone. The findings, published Online First in The Lancet Infectious Diseases, show that syphilis remains a major cause of infant death in many low-income and middle-income countries and that antenatal syphilis screening is one of the most cost-effective health interventions for preventing adverse pregnancy outcomes and improving newborn and child survival.
More than 2 million pregnant women are infected with syphilis every year. Screening of pregnant women for syphilis is recommended in nearly all countries but is not widely implemented, and fewer than one in eight pregnant women is screened. Without screening and treatment, up to 69% of women will experience an adverse pregnancy outcome such as stillbirth, low birthweight, or disability of an infant. Yet adverse outcomes caused by syphilis are entirely preventable.*
In this study, Sarah Hawkes from University College London, London, UK and colleagues reviewed the evidence for the effectiveness of interventions to increase syphilis testing and treatment rates, and improve pregnancy outcomes. The meta-analysis included ten studies and over 41 000 women and showed that interventions that include offering decentralised, same-day testing and treatment could reduce perinatal deaths by 54%, stillbirths by 58%, as well as reducing congenital syphilis (an infected live-born infant).
The authors say: "This review adds to the observational evidence of the benefits of single interventions such as penicillin for the treatment of diagnosed syphilis in pregnancy and of the diagnostic efficacy of rapid point-of-care tests. We showed the levels of benefit that could be achieved at a population level, when single interventions are combined and delivered as a comprehensive programme."
They conclude: "This study suggests that the resources needed to roll out programmes for antenatal screening will be a worthwhile investment for reduction of adverse pregnancy outcomes and improvement of neonatal and child survival."
In a Comment, David Mabey and Rosanna W Peeling from London School of Hygiene and Tropical Medicine, London, UK point out: "The perception among many public health experts, programme managers, and policy makers that syphilis has disappeared has probably been the greatest barrier to preventing syphilis deaths in babies. If you don't test for it you don't find it, which reinforces the impression that it is no longer an issue."
They add: "If all pregnant women were screened, and those who tested positive were treated with one dose of benzathine penicillin before 28 weeks' gestation, no stillbirths or neonatal deaths would be due to syphilis."
Dr Sarah Hawkes, University College London, London, UK. T) +44(0)203 1083 845 or +44(0)779 067 5947 (mobile) E) s.hawkes@ucl.ac.uk
Professor Nicola Low, University of Bern, Bern, Switzerland. T) +41 31 631 3092 E) low@ispm.unibe.ch
Dr Nathalie Broutet, World Health Organisation, Geneva, Switzerland. T) +41 22 791 33 36 E) broutetn@who.int
Dr David Mabey, London School of Hygiene and Tropical Medicine, London, UK. E) david.mabey@lshtm.ac.uk
Via Rebecca Ladbury, Press Office, London School of Hygiene and Tropical Medicine, London, UK. T) +44 07941 224975 (mobile)
Notes to Editors: *Based on this evidence, the World Health Organization (WHO) has been advocating and supporting countries to eliminate congenital syphilis by strengthening access to universal screening for syphilis in all pregnant women and providing adequate treatment if positive (http://www.who.int/reproductivehealth/topics/rtis/syphilis/en/). In addition, a global effort led by WHO is aiming to strengthen the dual elimination of mother-to-child-transmission of HIV and syphilis in the context of antenatal care services.
Journal
The Lancet Infectious Diseases