Preventing newborn mortality due to syphilis

Congenital syphilis had been largely ignored as a global health problem until research conducted by LSHTM put it firmly back on the international agenda, leading to the launch of a new global elimination programme.

In 2002 Deborah Watson-Jones, a clinical epidemiologist at LSHTM, published a paper which drew attention to the enormous burden of neonatal mortality due to syphilis in sub-Saharan Africa. She showed that 25% of women with syphilis delivered a stillborn baby, and 33% delivered a live but premature infant. Syphilis was responsible for 50% of all stillbirths in Northern Tanzania, where the study was done.

A second study – a comparison of birth outcomes for 1,688 women with and without syphilis who were screened in pregnancy – showed that a single dose of benzathine penicillin given before 28 weeks’ gestation prevented adverse pregnancy outcomes due to syphilis. Subsequent research showed that antenatal syphilis screening and treatment was one of the most cost effective health interventions, at $10 per healthy life year saved in Tanzania.

Further work by Watson-Jones, Philippe Mayaud and other colleagues at LSHTM showed that, although screening pregnant women for syphilis was recommended policy in Tanzania, as in most African countries, few women were screened and, among those who were screened, many of those who tested positive were not treated. A review by David Mabey, professor of communicable diseases at the School, and Rosanna Peeling, professor of diagnostics research, found that poor integration of screening programmes for syphilis and HIV in many countries meant that screening for syphilis was often overlooked, resulting in the tragedy of infants being protected from HIV, only to die of syphilis.

Soon after the publication of these studies new, point of care tests for syphilis became available, which did not require laboratory support or electricity, and gave a result in 15 minutes. Mabey and Peeling led a series of evaluations of these tests, and showed that they could give accurate results even in the most remote settings. As a result, they were made available at an affordable price to national programmes through the WHO bulk procurement programme. The Global Fund for AIDS, Tuberculosis and Malaria announced that it would fund the purchase of these tests from 2007/08.

This body of research provided the momentum for a World Health Organization initiative in 2007 to eliminate mother to child transmission of syphilis globally.

All countries taking part in this research – Brazil, Haiti, Tanzania, Uganda, Zambia, Peru and China – have now incorporated these POC tests into prenatal syphilis screening programmes.  The research has helped strengthen health services in Brazil, where it has provided a model for the provision of health services to indigenous populations, and 10 out of 29 countries in the Americas that have introduced the point-of-care tests have reported that 95% of those attending antenatal care are now screened for syphilis.

A roadmap was produced by WHO and the US Centers for Disease Control and Prevention (CDC) in 2010, and a 2012 document based on the School’s research made the economic case for syphilis screening. In March 2012 Peeling launched the Global Congenital Syphilis Partnership, hosted by the School, which has provided technical support for the use and evaluation of a new generation of point-of-care tests for HIV and syphilis.