Revisiting strategies to eliminate mother-to-child transmission of syphilis.

Mother-to-child transmission of syphilis, so-called congenital syphilis, can result in adverse pregnancy outcomes such as fetal loss, stillbirth, neonatal death, preterm birth, low birthweight, and congenital anomalies. Roughly 1 million pregnant women are estimated to be infected with syphilis worldwide, with the highest prevalence in east and southern Africa. Antenatal screening and treatment with a single dose of benzathine benzylpenicillin successfully cures both maternal and congenital syphilis and prevents adverse pregnancy outcomes due to syphilis. 10 years have elapsed since the release of the WHO Strategy for the Global Elimination of Congenital Syphilis in 2007. This document called for political commitment and advocacy to address the issue of congenital syphilis through increasing access to and quality of maternal and newborn health services, increasing screening and treatment of pregnant women and their partners, and establishing surveillance, monitoring, and evaluation systems. In June, 2017, a meeting was organised by the WHO Department of Reproductive Health and Research and the Bill and Melinda Gates Foundation to review the progress that has been made in the elimination of congenital syphilis, to discuss existing tools (panel), and to identify challenges ahead. The general consensus at the meeting was that little progress has been made in the elimination of congenital syphilis over the past decade because of several challenges. Communicating the burden of congenital syphilis has been challenging because adverse health outcomes, such as stillbirth, are not always attributed to congenital syphilis. Additionally, many awareness efforts have been unsuccessful because of the stigma surrounding syphilis and the poor visibility of important advocates and stakeholders, which gives the perception that congenital syphilis is not a major public health problem. The participants acknowledged that reframing screening of syphilis in pregnancy as a matter of healthy pregnancy and healthy infants would deliver a more positive message, which could ultimately help raise awareness and garner support for the elimination of mother-to-child transmission of syphilis. Poor access to benzathine benzylpenicillin, the only recommended treatment for pregnant women with syphilis, is a major issue, with shortages reported in many parts of the world. This issue is further complicated by the absence of an easily administered paediatric formulation of benzathine benzylpenicillin, the fear of allergic reactions to the drug, and resistance to using the drug because of its intramuscular administration. The misperception that benzathine benzylpenicillin is an outdated drug that could be replaced by newer, more effective drugs (that might be orally administered) has led health-care professionals to select alternative, ineffective treatments. A penicillin allergy desensitisation protocol (in consideration for guideline development by WHO) could reduce the use of alternative treatments because of concerns related to allergic reactions. Alternative treatments to benzathine