The sound of silence: missing the opportunity to save lives at birth.

Editorials 158 The adverse impact of syphilis on child health has been known for over 500 years, yet the World Health Organization (WHO) only targeted congenital syphilis for elimination in 2007. 1 Syphilis in pregnancy is not rare. Far more pregnant women have syphilis than human immunodeficiency virus (HIV) infection: 1.9 million (2008) and 1.49 million (2010), respectively. 2 The fraction of pregnant women with syphilis that is detected and treated is unknown, but estimates suggest that it is less than 10%. 3 Whereas untreated maternal HIV infection is transmitted to infants in about one third of the cases, untreated maternal syphilis nearly always results in an adverse pregnancy outcome. For these reasons, syphilis is as important an infection during pregnancy as infection with HIV. It therefore makes sense to build on global efforts to prevent and treat HIV infection during pregnancy to strengthen the fight against maternal syphilis. The adverse pregnancy outcomes that can result from syphilis include fetal death, stillbirth or premature birth, low birth weight and congenital syphilis infection. The frequency of these outcomes has been poorly quantified. In a literature review published in the present issue of the Bulletin, Gomez et al. tried to generate summary estimates of syphilis-related adverse pregnancy outcomes by reviewing 3258 studies published up to December 2011. They specifically looked for studies that compared pregnancy outcomes in untreated syphilitic women and non-syphilitic women belonging to the general population. Only 6 studies, representing 1715 pregnant women with untreated syphilis and 22 515 non-syphilitic women, satisfied those criteria and were included in the analysis. Adverse birth outcomes were observed in 66.5% (range: 53.4–81.8) of the women with untreated syphilis and in 14.3% (range: 10.25–20.8) of the women without syphilis. Hence, the frequency of adverse pregnancy outcomes was 4.5 times higher in the former than in the latter group. The adverse pregnancy outcomes associated with maternal syphilis can be easily prevented, yet implementing proper measures within health systems has been difficult. 5 Laboratory-based and rapid point-of-care syphilis tests identify most maternal syphilis infections. A single dose of benzathine penicillin early in pregnancy is highly effective at preventing adverse pregnancy outcomes. 6 Testing and treatment combined cost less than one United States dollar. The problem, then, is not a lack of affordable tests or treatment, but the absence of political will. In many countries , most maternal syphilis infections remain unidentified and untreated. Cur-United Republic of …