From the Institute of Global Health, University College London, UK
Correspondence: Sarah Hawkes, MBBS, PhD, Institute of Global Health, University College London, UK. E-mail: firstname.lastname@example.org.
Received for publication November 5, 2012, and accepted December 12, 2012.
In Ancient Greek mythology, the tragic story of Niobe (wife of Amphion and daughter-in-law of Zeus) centers on the death of her 14 (or more) children at the hands of Apollo and Artemis. According to the poet Ovid, Sipylus, one of Niobe’s sons, died along with his siblings, and their distraught mother fled to Mount Sipylus (the eponymous mountain after which her son was named), where she was turned into stone and wept unceasingly. The Weeping Rock of Mount Sipylus in present-day Turkey bears witness to this ancient tale of maternal loss.
In the 16th century, the Italian poet and physician Fracastoro adapted the name of Mount Sipylus for a shepherd character, Siphylus, in his poem about “Syphilis: The French Disease”—and thus, the first recorded (fictional) victim of syphilis was given a name. The ensuing 500 years of records of syphilis stories provides no less a tale of human suffering than many a Greek tragedy.
The article by Lago and colleagues in this issue neatly summarizes the tragic nature of the syphilis epidemic affecting Brazil and many other countries. In the study of Lago et al, 499 newborn infants had mothers with a positive syphilis serology—giving a total of 1 in every 50 babies born to a syphilis-positive mother. Brazil is not alone in recording a high prevalence of syphilis in pregnant women. The World Health Organization (WHO) estimates that annually, “1.3 million women have ‘sufficiently active’ syphilis in pregnancy to transmit perinatally.”1
The association between syphilis in the mother and adverse outcomes of pregnancy has been recorded in the medical literature for almost a century. Indeed, in 1917, William Osler2 estimated that syphilis was responsible for an astonishing 20% of all stillbirths and up to 22% of infant deaths in the United States. In the intervening decades since Osler’s estimates were published, a number of studies globally have measured and reported on the impact that maternal syphilis has on pregnancy outcomes. The estimates show a remarkable consistency—from the prepenicillin reports of Harman3 in London during the 1910s, to the more recent reports of unscreened and/or untreated pregnant women in Zambia,4 Malawi,5 and Tanzania6 in the 1980s and 1990s. Syphilis results in an adverse outcome in at least 50% of pregnancies where mothers are untreated or undertreated,7 with effects as varied as early fetal loss, stillbirth, small-for-gestational-age babies, neonatal death, or an infected infant. Studies beyond the neonatal period are relatively uncommon, although one study in Malawi did find 11% more infant deaths in the group born to mothers seropositive for syphilis, when compared with the non–syphilis-positive group.5 This relative paucity of postneonatal data has received a considerable boost with the study of Lago, which includes children up to the age of 5 years, and provides invaluable evidence of the ongoing impact of maternal syphilis on the health outcomes of some children.
Given this background, it is encouraging to note that Brazil, as reported by Lago and her colleagues, has had a plan for the elimination of congenital syphilis in place for almost 20 years. Brazil and other countries in the Pan-American Health Organisation region (particularly in the South and Central American areas) have globally led the way in highlighting both the problem and the available solutions for control (and eventual elimination) of congenital syphilis. World Health Organization, building on the PAHO expertise and experience, has, within the past month, launched an investment case for the global elimination of congenital syphilis.8
It is therefore somewhat discouraging to note the national experience as reported by Lago et al. Several features of the Brazilian experience deserve closer scrutiny: maternal prevalence of syphilis seropositivity remains high at 2%, and of the 490 women diagnosed as having with syphilis in pregnancy, 379 of their infants received a diagnosis of congenital syphilis predominantly because the mothers had not received any treatment (64% of women) or had received inadequate therapy (15%). A substantial proportion of the infants received their diagnosis mainly on account of failures of the health system to implement standard management protocols: no retesting in the third trimester, failure to prescribe treatment or prescribing inadequate treatment, lack of documentation of treatment.
The Brazilian experience contains valuable lessons for WHO as it seeks funding for the global elimination program. First, despite 7 years of an elimination goal, there was no evidence of a change in maternal prevalence over time. Screening pregnant women for syphilis is unlikely to have a significant impact on adult prevalence rates; additional intervention measures will be needed to see maternal prevalence fall.9 This is an important feature of the global program to eliminate mother-to-child transmission of HIV, the first of 4 “programmatic prongs” being primary prevention of HIV among women of childbearing age—a crucial lesson for syphilis programs. For global elimination of congenital syphilis to succeed, it will be vital for linkages to primary prevention programs to be emphasized and strengthened—otherwise, as was noted in the case of Brazil, the size of the problem will not spontaneously diminish with time.
Second, there needs to be a concerted effort to strengthen policy implementation. The WHO strategy for elimination of congenital syphilis is premised on health systems strengthening—which includes improving the quality of care women experience. The WHO estimates that globally at least one third of women are not tested for syphilis at their first visit,1 and there are no global estimates for the proportion of women retested at the time of, or close to, delivery (102 women in the Brazil study seroconverted during pregnancy). As Lago et al have further highlighted, testing (screening) rates are not equivalent to treatment rates; the failure to treat, or inadequate treatment, meted out to women screened as syphilis seropositive women accounted for most cases of congenital syphilis diagnosed (a minority, n = 31, were caused by caused by the mother’s failure “to comply with diagnosis or treatment”). These statistics are likely to be repeated in many other countries, but at a global level, we have no systematic evidence of syphilis treatment coverage rates for pregnant women.
Third, improvements in the quality of care are predicated on women actually reaching services in the first place. A substantial proportion of cases in Brazil (n = 92) were the result of a lack of any prenatal care. Access to antenatal care is a global public health success story, but still 1 in 5 pregnant women in low- and middle-income countries do not access any prenatal care services, only 55% avail the recommended 4 or more visits during their pregnancy and a third of women do not have any skilled attendants present at the time of delivery.10 These figures highlight the challenges still facing health care systems globally where lack of service access denies women their rights to recommended effective interventions to prevent syphilis transmission.
The story of congenital syphilis has certain (adapted) elements of a Greek tragedy about it: the protagonists (the pregnant women, their unborn infants) fall to disaster due to circumstances beyond their control (a nonfunctioning or inaccessible health system), and an evil event happens out of sight of the audience (syphilis, unscreened for, untreated, is transmitted from mother to child). However, neither theater nor public health are static; scripts and storylines can evolve over time, and unimaginable happy endings may now be within our grasp.
The recent global push for dual elimination of both HIV and syphilis has raised the political profile of syphilis in many parts of the world. Global commitment to improve access to reproductive health services (including prenatal care and skilled birth attendants) is improving life chances for women and their infants all over the world, and effective interventions for timely diagnosis are being made more affordable even in the poorest of countries. If we can draw on the lessons of Brazil and other countries in their fight to eliminate congenital syphilis, there is some hope that the Weeping Rock of Mount Sipylus need no longer stand as a symbol of maternal grief for a preventable tragedy.
1. Newman L, Kamb M, Hawkes S, et al.. Global estimates of syphilis in pregnancy and associated adverse outcomes in 2008: The need to improve quality and coverage of antenatal care services. PLOS Med. Forthcoming.
2. Osler W. The anti-venereal campaign. Trans Med Soc Lond 1917; 40: 290.
3. Harman NB. The influence of syphilis on the chances of progeny. BMJ 1916; 1: 196–197.
4. Hira SK, Bhat GJ, Chikamata DM, et al.. Syphilis intervention in pregnancy: Zambian demonstration project. Genitourin Med 1990; 66: 159–164.
5. McDermott J, Steketee R, Larsen S, et al.. Syphilis-associated perinatal and infant mortality in rural Malawi. Bull World Health Organ 1993; 71: 773–780.
6. Watson-Jones D, Changalucha J, Gumodoka B, et al.. Syphilis in pregnancy in Tanzania. I. Impact of maternal syphilis on outcome of pregnancy. J Infect Dis 2002; 186: 940–947.
7. Gomez GB, Kamb ML, Newman LM, et al.. The impact of syphilis on adverse pregnancy outcomes: A systematic literature review and meta-analysis. Bull WHO. Forthcoming.
9. Low N, Broutet N, Yaw Sarkodie A, et al.. Global control of sexually transmitted infections. Lancet 2006; 368: 2001–2016.
10. United Nations. The Millennium Development Goals Report 2012. New York: United Nations, 2012.