Sexually Transmitted Diseases:
From the Department of Public Health, STD Prevention and Control Services Section, San Francisco, California
Correspondence: Jeffrey D. Klausner, Department of Public Health, STD Prevention and Control Services Section, San Francisco, CA. E-mail: Jeff.Klausner@sfdph.org.
Received for publication January 31, 2007, and accepted March 29, 2007.
A century after the successful development of the Wassermann test, the first blood test to identify patients with syphilis, and more than half a century after the discovery of penicillin, a cheap antibiotic exquisitely effective against Treponema pallidum, more babies continue to die worldwide of syphilis than any other single curable disease.
Currently the World Health Organization estimates that up to 1.4 million cases of congenital syphilis occur worldwide each year—more than double the United Nation’s estimates of the 530,000 children aged <15 years annually infected with HIV.1,2 Maternal infection with syphilis silences its victims early—resulting in miscarriages, stillbirths, early perinatal death, or chronic infection leading to premature death. Timely detection of maternal syphilis and treatment, however, can cure infection in both the mother and the fetus.3,4
In June 2004 the Bulletin of the World Health Organization included a special focus on several areas in the control of maternal and congenital syphilis including policy, prevention, clinical management, and country-level case studies. Perhaps the most important report identified the lack of mobilization or activism, the resistance of overburdened public health professionals to include additional programs, and the absence of political leadership as key reasons for the absence of congenital syphilis elimination efforts.5
It is disheartening that with diagnostic assays costing about $1 and single dose penicillin treatment under $2 that we have not eliminated congenital syphilis in the world today and are unlikely to in the near tomorrow. Although decades of indifference allowed AIDS to ravage women and caused tens of millions of orphans, the world’s nascent response to that devastation may bring opportunity for congenital syphilis elimination. Incorporating maternal syphilis screening into prenatal HIV testing could be the tipping point that results in an effective effort to eliminate congenital syphilis.
This special issue of Sexually Transmitted Diseases brings together some of the leading scientists and public health professionals currently involved in the elimination of congenital syphilis. Schmid et al. lay out the rationale, current epidemiology, and the global plan: (1) ensure political will; (2) increase access to antenatal care; (3) universally screen and treat pregnant women; and (4) conduct surveillance, monitoring, and evaluation. Di Mario et al. present an analysis of causes of stillbirth in developing countries. Hossain et al. sample national policies across the globe and compare them with the four-part WHO plan for congenital syphilis elimination. Gloyd et al. present a successful story of the implementation of maternal syphilis screening and treatment in Mozambique one of the earth’s most impoverished nations. Garcia et al. report from the other side of the globe and provide similar promising evidence in a very different health system in Bolivia. Diaz-Olavarrieta et al. conduct a unique gender-based analysis in a maternal syphilis control program to understand cultural barriers to implementation at the patient and partner level. Levin et al. combine experiences from both Bolivia and Mozambique to describe diagnostic testing costs with a particular focus on the rapid, point-of-care assay. Bronzan et al. describe the clinical value of the rapid point-of-care syphilis test in South Africa and finally, Blandford et al. look at the cost-effectiveness of such rapid testing.
These reports highlight the real promise of rapid point-of-care syphilis testing in the developing world and emphasize the need for further program integration whether within safe motherhood initiatives or the prevention of maternal-to-child transmission of HIV infection. They cap the scientific foundation necessary for policy leaders to implement evidence-based cost-effective programs.
How and when that research becomes action are the remaining key questions. Will it be this century or the next? Who will provide the necessary leadership to eliminate the needless suffering? While those answers are not provided in this special issue, many other answers are. More importantly perhaps within may lay the inspiration to transform that academic work into political will.
1. Schmid GP, Stoner BP, Hawkes S, Broutet N. The need and plan for global elimination of congenital syphilis. Sex Transm Dis 2007; 34 Supplement:S5–S9.
3. Walker GJ. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database Syst Rev. 2001; (3):CD001143. Review.
4. Wendel GD Jr, Sheffield JS, Hollier LM, et al. Treatment of syphilis in pregnancy and prevention of congenital syphilis. Clin Infect Dis 2002; 35(suppl 2):S200–S209.
5. Hawkes S, Miller S, Reichenbach L, et al. Antenatal syphilis control: People, programmes, policies and politics. Bull World Health Organ 2004; 82:417–423.