Prolaps Uteri

Investment case for
eliminating mother-to-child
transmission of syphilis
Promoting better
maternal and child health
and stronger health systems
initiative for the global elimination of congenital syphilis

Investment case for eliminating
mother-to-child transmission of syphilis
Promoting better maternal and child health and stronger health systems
WHO Library Cataloguing-in-Publication Data
Investment case for eliminating mother-to-child transmission of syphilis: promoting better maternal and
child health and stronger health systems.
1.Syphilis – transmission. 2.Syphilis – prevention and control. 3.Syphilis, Congenital. 4.Infectious Disease
Transmission, Vertical. 5.Infant, Newborn, Diseases. I.World Health Organization.
ISBN 978 92 4 150434 8 (NLM classification: WC 161)
© World Health Organization 2012
All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.
who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]).
Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial
distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/
licensing/copyright_form/en/index.html).
The designations employed and the presentation of the material in this publication do not imply the expres-
sion of any opinion whatsoever on the part of the World Health Organization concerning the legal status
of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are en-
dorsed or recommended by the World Health Organization in preference to others of a similar nature that are
not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial
capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information con-
tained in this publication. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the
reader. In no event shall the World Health Organization be liable for damages arising from its use.
Printed by the WHO Document Production Services, Geneva, Switzerland
ii
Contents
Acknowledgements v
Abbreviations and acronyms vi
Executive summary 1
1. The case for investment 2

1.1 Mother-to-child transmission of syphilis: a continuing public health burden 2
1.2 Addressing syphilis in pregnant women: a feasible solution 3
1.3 Why now is the time to invest in elimination of mother-to-child transmission of syphilis 3
1.4 Why the problem persists 5
1.5 The strong economic case for syphilis elimination 6
1.6 Who should invest in the elimination of mother-to-child transmission of syphilis? 8
1.7 How much and what sort of investment is needed? 9
2. Details of the initiative: objectives, activities and stakeholders 10

2.1 Choosing 10 intensified support countries 10
2.2 Activities 11
2.3 Key initiative partners 15
2.4 Management structure 16
3. The strength of this initiative 19

3.1 Leveraging existing investments in maternal and child health 19
3.2 Supporting country-level impact through global coordination 19
3.3 Investing in surveillance, monitoring and evaluation 20
3.4 Implementing knowledge and best practices 21
References 23
Appendix 1: economic analysis and disability-adjusted life years calculations 26
Appendix 2: proposed budget for the initiative for the global elimination of
mother-to-child transmission of syphilis 28
Appendix 3: list of tools available for country-level activities 29

Advocacy and programme tools 29
Clinical guidelines 29
Appendix 4: Battling Syphilis – a Team Approach (BASTA) participant affiliations 30
iii
Investment case for eliminating mother-to-child transmission of syphilis
iv
Acknowledgements
The Department of Reproductive Health and Research (RHR) would like to thank all those who helped
to elaborate this document and who provided critical review and input. This document was written by
Sarah Hawkes (University College London) working with a primary development team including Nathalie
Broutet (WHO), Mary Kamb (US Centers for Disease Control and Prevention, (CDC)), and Lori Newman
(WHO). The economic and burden of disease estimates at the core of this document were contributed by
Jim Kahn (University of California San Francisco), Gabriela Gomez (Amsterdam Institute for Global Health
and Development), Aliya Jiwani (University of California San Francisco), and Harrell Chesson (CDC). WHO is
also grateful for the input of the WHO regional focal points: Iyanthi Abeyewikreme, Monica Alonso, Hamida
Khattabi, Lali Khotenashvili, Khadi Mbaye, Massimo Ghidinelli, and Teodora Wi.
This document was developed using a broad consultative process with external partners and the WHO
secretariat, regional offices, and member states. From 2007 through 2009, a series of technical consultations
were held to ensure that broad stakeholder input was obtained. The early and ongoing contributions
of Deborah Atherly (PATH), Jeff Klausner (University of California San Francisco), Akjemal Magtymova
(WHO), Jennifer Mark (CDC), Pablo Montoya (Health Alliance International), George Rutherford (University
of California San Francisco), Bruce Shackman (Cornell University), Johannes Van Dam (Family Health
International) and Ken Wind-Anderson (WHO), were very helpful in identifying document goals and
approaches. Additionally, the contributions from consultation participants are gratefully acknowledged:
Ian Askew (Population Council), Ron Ballard (CDC), Frida Behets (University of North Carolina), Stu Berman
(CDC), Jan Bradley (EngenderHealth), Kent Buse (Overseas Development Institute), Flavia Bustreo (WHO),
Xiang-Sheng Chen (China National STD Control Center), Wing-sie Cheng (UNICEF), Inam Chitsike (WHO),
Simon Cousens (London School of Hygiene and Tropical Medicine), John Douglas (CDC), Peter Fajans (WHO),
Vincent Fauveau (UNFPA), Dan Fitzgerald (Cornell University), Antonio Gerbase (WHO), Patricia Garcia
(Universidad Peruana Cayetano Heredia), Sandy Garcia (Population Council), Stephen Gloyd (Health Alliance
International), David Gold (Global Health Strategies), Patricia Gomez (JHPIEGO), Catherine Goodman (London
School of Hygiene and Tropical Medicine), Cathy Grooms (CDC), Catherine Hankins (UNAIDS), Kara Hanson
(London School of Hygiene and Tropical Medicine), Fraser Hore (Peacepath Consulting), Dale Huntington
(WHO), Yojiro Ishit (Japan International Cooperation Agency), Monir Islam (WHO), Troy Jacobs (USAID), Wendy
Johnson (Health Alliance International), Lily Kak (USAID), Eve Lackritz (CDC), Stefano Lazzari (Global Fund),
Dede Leydorf (WHO), Craig Lissner (WHO), Ying-Ru Lo (WHO), Leah Lane Lowe (CDC Foundation), Chewe Luo
(UNICEF), Sandra MacDonagh (United Kingdom Department for International Development), Tasneem Malik
(CDC), Viviana Mangiaterra (WHO), Eva Margolies-Seiler (CDC), Jose Carlos Martines (WHO), Matthews Mathai
(WHO), Bayalag Munkhuu (Mongolia State Research Centre), Olive Nakakeeto (independent consultant),
Francis Ndowa (WHO), Kevin O’Reilly (WHO), Jos Perriens (WHO), Rosanna Peeling (London School of Hygiene
and Tropical Medicine), Razia Pendse (WHO) , Amy Pulver (CDC), Julie Rogers (CDC Foundation), Martha Roper
(WHO), Caroline Ryan (U.S. Office of Global AIDS Coordination), Lale Say (WHO), Robert Scherpbier (WHO),
George Schmid (WHO), Nathan Shaffer (CDC), Anuraj Shankar (WHO), Dorothy Shawn (FIGO), Elisa Sicuri
(London School of Hygiene and Tropical Medicine), R.J. Simonds (CDC), Tin Tin Sint (WHO), Mike St. Louis
(CDC), Bradley Stoner (Washington University St. Louis), Celine Taboy (CDC), Marleen Temmerman (University
of Ghent), Feiko Ter Kuile (Liverpool School of Tropical Medicine), Ye Tun (CDC), and Peter Vickerman (London
School of Hygiene and Tropical Medicine).
WHO acknowledges the financial support for this work from the Special Programme of Research,
Development and Research Training in Human Reproduction (HRP), the U.S. Centers for Disease Control and
Prevention, and UNFPA.
v
Abbreviations and acronyms

ANC antenatal care
BASTA Battling Against Syphilis – a Team Approach
CDC Centers for Disease Control and Prevention (USA)
DALY disability-adjusted life year
DSTDP Division of STD Prevention
MCA WHO Department of Maternal, Child and Adolescent Health
MCH maternal and child health
MDG millennium development goal
MTCT mother-to-child transmission (of syphilis and/or HIV)
NGO nongovernmental organization
PAHO Pan American Health Organization
PGT programme guidance tool
PMTCT prevention of mother-to-child transmission (of HIV)
RHR WHO Department of Reproductive Health and Research
RPR rapid plasma reagin
RTI reproductive tract infection
STI sexually transmitted infection
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USA United States of America
VDRL venereal disease research laboratory
WHO World Health Organization
vi
Executive summary
Nearly 1.5 million pregnant women are infected This investment case outlines why and how an
with probable active syphilis each year, and investment of US$17 million over 4 years can:
approximately half of infected pregnant women who
are untreated, will experience adverse outcomes • reduce adverse outcomes of syphilis in
due to syphilis, such as early fetal loss and stillbirth, pregnancy by 2015 through intensified support
to 12 high-burden countries, and develop a
neonatal death, low-birth-weight infants, and infants
stronger global network to eliminate MTCT of
with clinical evidence of infection. It is estimated that syphilis in other countries;
in 2008, syphilis in pregnancy contributed to 305 000
• strengthen sexual and reproductive health
stillbirths and fetal and neonatal deaths, and an
services, as well as maternal and child health
additional 215 000 infants at increased risk of dying services, to ensure dual elimination of MTCT of
from low birth weight, prematurity or complications HIV and syphilis;
of infection related to syphilis.
• improve collaboration among, and capacity
of, stakeholders engaged in activities aimed at
Mother-to-child transmission (MTCT) of syphilis reducing the overall burden of adult syphilis.
(commonly referred to as “congenital syphilis”) is
Through a series of national, regional and
relatively simple to eliminate and it is inexpensive
international consultations, it is clear that a number
to detect and treat, making it a possible “easy win”
of countries are committed to syphilis elimination.
in terms of cost, feasibility and speed of scale-up.
These countries have established ANC, prevention
Investing in screening and treatment for syphilis
of MTCT of HIV, and other programmes, which are
in pregnant women ranks as one of the most
funded through various sources. Countries have
cost-effective antenatal interventions. Screening
asked for technical support to prioritize and scale
all pregnant women, using simple and low-cost
up interventions for MTCT of syphilis in a way
technologies, is feasible, even in low-resource
that builds upon existing investments in maternal
settings. Syphilis is easily cured with penicillin, and
and child health services. The investment case
MTCT of syphilis is easily prevented when pregnant
is not intended to provide resources for routine
mothers with syphilis infection are identified
programme management and operations at the
early and treated promptly. Penicillin is off patent,
country level, but rather to assist countries in
widely available, on the World Health Organization
identifying how to incorporate antenatal syphilis
(WHO) list of essential medicines and, above all,
testing and treatment into routine national health
inexpensive.
plans and expenditure for ANC.
Moreover, a number of factors make this the ideal

Despite its devastating impact, MTCT of syphilis
time to invest, specifically: the strong political
is preventable and curable. And now – more than
will on the part of many governments in high-
ever before – is the right time to address it with a
burden countries to support the Global strategy
coordinated, strategic global initiative. Investment
for women’s and children’s health; the resources
in the elimination of MTCT of syphilis will contribute
and attention being devoted to achieving the
significantly to improved maternal and child health
Millennium Development Goals (MDGs), particularly
around the world, including achievement of MDGs
HIV, reproductive, maternal, newborn and child
4, 5 and 6, while also strengthening underlying
health objectives (MDGs 4, 5 and 6); the push for
health systems.
dual elimination of MTCT of HIV and syphilis; the
increased availability and use of antenatal care (ANC)
in many countries; and technological advances in
screening for syphilis in low-resource settings.
1
1. The case for investment
1.1 Mother-to-child transmission of

This document uses the term mother-to-child
syphilis: a continuing public health
transmission (MTCT) of syphilis throughout,
burden
but it should be noted that most of the related
An estimated 11 million people acquire new syphilis
literature to date uses the term congenital
infections annually (1). This is despite the fact that a
syphilis. The term MTCT is preferred, as it
successful test for syphilis has been available since
better reflects the range of adverse outcomes
the early 1900s and effective treatment (penicillin)
that occur when syphilis is transmitted from
has been widely available since the 1940s.
mother to child. MTCT of syphilis is any adverse
outcome in a fetus or neonate associated
In 2009, there were approximately 2.6 million
with syphilis infection in a pregnant woman.
stillbirths and an additional 3.1 million infants died
Adverse outcomes include early fetal loss,
with in the first month of life (2, 3). In 2004, the
stillbirth, neonatal death, prematurity, low
World Health Organization (WHO) global burden of
birth weight and clinical evidence of syphilis in
disease estimate of deaths due to syphilis among
a neonate.
children aged 0–4 years was approximately 64 000
deaths, or 0.6% of all deaths in children aged under
5 years (4). However, it is widely felt that syphilis Untreated maternal syphilis results in MTCT of
is underdiagnosed as a cause of death in death syphilis (see text box) in over half of affected
registries and verbal autopsies, and estimates in pregnancies (see Table 1.1). A recent meta-analysis
some developing countries have suggested that of syphilis-associated pregnancy outcomes found a
mother-to-child transmission (MTCT) of syphilis profound impact: stillbirth and late fetal loss in 21%
contributes to up to one quarter of all stillbirths and and neonatal death in 9% of untreated infections (7).
11% of neonatal deaths (4–6). Additionally, untreated maternal syphilis contributes
Table 1.1
Estimated proportion of adverse outcomes in untreated pregnancies affected by syphilis, and number
of adverse outcomes in 2008 taking into account existing servicesa
Outcome Estimated % Estimated number of
of adverse outcomes in adverse outcomes in 2008
untreated pregnancies
affected by syphilis
Early fetal loss/stillbirth 21 215 000
Neonatal death 9 90 000
Prematurity or low birth weight 6 65 000
Clinical evidence of syphilis in newborn 16 150 000
Any adverse outcome 52 520 000
a Adverse outcomes estimates = % of pregnancies affected in syphilis seropositive women minus the % of pregnancies affected in
syphilis seronegative women. This methodology thus accounts for background morbidity and mortality not attributable to syphilis.
2
to serious neonatal complications such as sufficient laboratory capacity and minimal quality-
premature and low-birth-weight infants (6%) and control processes. With a combination of these
infants with clinical evidence of syphilis (16%) – two diagnostic options, programmes can achieve
who are then at higher risk of ill health. Estimates universal access to syphilis screening in pregnant
for 2008 suggest that globally there are nearly women. If syphilis is diagnosed early and treated
1.5 million pregnant women infected with probable promptly, penicillin is highly effective in treating
active syphilis each year (8). Although there is wide maternal infection and preventing MTCT of syphilis
variation in antenatal care (ANC) practices globally, (11). Penicillin is off patent, widely available, on the
the vast majority of pregnant women with syphilis WHO list of essential medicines (12) and, above
are not identified and treated early enough to avoid all, inexpensive. Moreover, Treponema pallidum,
the adverse effects of infection on their pregnancy. the bacterium causing syphilis, has not developed
Thus, assuming that 30–70% (depending on region) resistance to penicillin.
of all pregnant women with syphilis were tested
and treated early enough to avert an adverse 1.3 Why now is the time to invest
outcome, in 2008 there were an estimated 520 000 in elimination of mother-to-child
pregnancies and neonates adversely affected by transmission of syphilis
syphilis, including 215 000 early fetal losses and More than ever before, elimination of MTCT of
stillbirths and 90 000 neonatal deaths. syphilis as a public health problem is feasible,
achievable and affordable.
1.2 Addressing syphilis in pregnant
women: a feasible solution
The Millennium Development Goal
Adverse pregnancy outcomes caused by untreated “window of opportunity”
maternal syphilis are preventable and curable, and As we near the 2015 deadline for achieving
interventions to improve screening and treatment the Millennium Development Goals (MDGs),
for syphilis in pregnancy can substantially reduce there is increased global commitment and
the current global burden of preventable perinatal attention to improving child and maternal health
mortality and morbidity (9) Detection and treatment (MDGs 4 and 5). This paves the way for tackling
of syphilis has been identified as being one of the MTCT of syphilis as an important contributor to
most effective and cost-effective interventions maternal and infant morbidity and mortality.
to prevent stillbirths and neonatal deaths (10).
Screening all pregnant women, using simple and
low-cost technologies, is feasible, even in low- Elimination of MTCT of syphilis will contribute
resource settings. to MDGs 4 (reduce child mortality), 5 (improve
maternal health) and 6 (combat HIV/AIDS,
malaria and other diseases).
All pregnant women should be tested for
syphilis, not just those perceived as being
“high risk”. Addressing MTCT of syphilis through an initiative
that strengthens ANC services as well as existing
infrastructure and programmes can contribute to
New point-of-care tests, which can use whole-blood reductions in other preventable infections affecting
samples from a finger prick, provide results and pregnancy, including perinatal malaria, maternal
allow for treatment at a single visit. They can be and neonatal tetanus, and HIV transmission to
used in all health-care settings, even in the face of neonates, and can improve maternal health. This
limited electricity, refrigeration or skilled laboratory will bolster efforts to achieve MDGs 4, 5 and 6
staff. Existing tests (rapid plasma reagin (RPR) (combat HIV/AIDS, malaria and other diseases), as
or venereal disease research laboratory (VDRL)) highlighted in the 2009 United Nations (UN) MDG
can also be used successfully in settings with report (13).
3
MDG 4: reduce child mortality conditions during pregnancy. Through the initiative
Infant and child mortality have declined globally, outlined in this document, maternal health will
but the pace of progress is uneven. In 2010, an be improved as a result of earlier ANC and fewer
estimated 8 million children died before their spontaneous abortions and stillbirths. In addition,
fifth birthday – mainly from preventable causes. the simultaneous implementation of interventions
MTCT of syphilis is a preventable cause of low birth to eliminate MTCT of syphilis, and efforts to control
weight, neonatal death, stillbirth and congenital sexually transmitted infections (STIs) in the general
infection (3). The UN MDG report states that “many adult population, will also reduce the incidence and
countries, particularly in sub-Saharan Africa and prevalence of syphilis in pregnant women.
southern Asia, have made little or no progress at all
[towards MDG 4]” (13) (see Box 1.1). An emphasis MDG 6: combat HIV/AIDS, malaria and other
on strengthening health systems to provide ANC, diseases
which includes screening for MTCT of syphilis, will It is estimated that women account for about half
help to address this public health tragedy. of all people living with HIV infection, and that
the vast majority of HIV-infected women live in
MDG 5: improve maternal health developing countries. Given the common mode of
ANC is a core component of comprehensive sexual transmission, coinfection of HIV and syphilis
maternal health care. The UN MDG report is not uncommon. Syphilis infection is a recognized
emphasizes that “many health problems among cofactor for increased risk of HIV transmission and
pregnant women are preventable, detectable acquisition, and maternal syphilis infection has even
or treatable through visits with trained health been associated with increased risk of MTCT of HIV
workers before birth” (13). In all regions, progress (15, 16).
has been made on ensuring that more women
reach and receive at least one ANC visit in their WHO recognizes that HIV services should be
pregnancy – thus providing more opportunities integrated within a package of core interventions for
for women to be screened for syphilis and other maternal, newborn and child health that includes
Box 1.1
Avoiding HIV but dying of syphilis
An HIV-positive mother in Haiti successfully completes therapy for prevention of mother-to-child-

transmission (PMTCT) of HIV, but her baby dies at 3 weeks from congenital syphilis [mother-to-child
transmission of syphilis]. This is not an isolated case.
Large investments in PMTCT of HIV have been one of the big successes of recent years. But too many of
the babies born HIV free tragically die of syphilis. This is despite the fact that it is feasible and cheap to
add screening for syphilis to existing antenatal and PMTCT programmes.
Even in countries with clear policy recommendations on syphilis screening, congenital syphilis still
poses a major threat to both women and infants. For example, only about one third of women attend-
ing antenatal clinics in 22 sub-Saharan African countries were reported to have been tested for syphilis,
despite 17 of these countries having explicit policy recommendations mandating syphilis screening.
This shows a clear disconnect between policy and implementation.
There is an opportunity for policy-makers and the donor community to recognize the importance of
integration of programmes at the local level, and to capitalize on new opportunities to enhance health
systems.
A concerted effort can avert the tragedy of babies avoiding HIV but dying of syphilis, and help to real-
ize the goal to reduce childhood mortality.
Source: Peeling R et al. Avoiding HIV and dying of syphilis. The Lancet, 2004, 364:1561–1563 (14).
4
syphilis screening and care (17). Systematic screening More availability and utilization of antenatal
of women for syphilis in programmes for PMTCT of care than ever before
HIV will allow mothers and infants to be tested and, The relatively high utilization of ANC by pregnant
where necessary, treated for both HIV infection and women in many countries makes this service
syphilis, thereby reducing fetal and infant deaths. an ideal venue to implement population-based
Treating maternal syphilis infections also improves interventions. Although women often delay seeking
maternal and neonatal health. Moreover, the Joint care until later in pregnancy, an estimated 82% of
United Nations Programme on HIV/AIDS (UNAIDS) pregnant women have at least one ANC visit (24).
recognizes testing and treatment of syphilis in
pregnant women as an indicator of quality ANC An important component of the initiative proposed
services in the context of HIV prevention (18). in this investment case will be to promote
sufficiently early ANC, which maximizes the benefits
of maternal syphilis screening when universally
Global momentum to eliminate new HIV
provided to women at low or no cost, as part of
infections among children
an integrated service package of proven-effective
The global call to eliminate new HIV infections
antenatal interventions. Early ANC also improves
among children by 2015 and keep their mothers
the effectiveness of other antenatal interventions,
alive specifically notes the importance of HIV
including prevention of HIV and malaria.
programmes working together with maternal,
newborn and child health programmes to lead to
improved health outcomes (17, 19). Three WHO Important technological advances
regions (Region of the Americas, South-East Asia Existing screening for syphilis (i.e. RPR testing) is
Region, and Western Pacific Region) have launched simple and cheap, but requires a basic laboratory
elimination of MTCT of HIV as a dual elimination capacity and quality control that may not be
initiative with MTCT of syphilis, and the African available at many antenatal facilities, particularly in
Region includes elimination of MTCT of syphilis remote settings or in resource-poor settings with
within its strategy for elimination of MTCT of HIV limited infrastructure. However, syphilis screening
(20–22). Such dual-elimination initiatives strive to has evolved over the past 10 years. On-site
promote synergies for overall strengthening of the diagnosis of syphilis and prompt treatment of
perinatal health-system platform. women who screen positive is increasingly possible,
even in remote settings, with rapid point-of-care
diagnostics. These new diagnostics allow syphilis-
Elimination of mother-to-child transmission
of syphilis supports the global strategy for infected women to be diagnosed and treated in a
women’s and children’s health single antenatal visit. Extensive research has helped
With just a short amount of time left to achieve greatly in our understanding of more effective
the MDGs, the UN Secretary-General launched the diagnostic tools, algorithms and approaches in
Global strategy for women’s and children’s health specific settings, and has ensured availability of
(23). This strategy calls for all partners to unite to high-performing point-of-care syphilis tests to low-
enhance financing, strengthen policy and improve and middle-income countries at affordable prices
service delivery of proven interventions. As a (i.e. at less than US$1 per test).
result, many countries have committed to improve
coordination around maternal and neonatal 1.4 Why the problem persists
health issues and create platforms for integration. In theory, it is easy and cheap to prevent and
Bringing ministries of health and partners together treat MTCT of syphilis. In practice, however, there
to provide universal coverage of antenatal syphilis have been a number of barriers to elimination.
screening, and ensuring treatment of all pregnant Chief among these is a general lack of awareness
women with syphilis, is a specific example of an of the true impact of MTCT of syphilis and the
activity called for within the global strategy. extent of the problem. Without diagnostic testing,
5
syphilis-associated fetal loss and stillbirth, neonatal 1.5 The strong economic case for
deaths and premature births are not recognized as syphilis elimination
being caused by syphilis or as being preventable.
Lack of awareness about the true toll of maternal Economic costs of mother-to-child
syphilis is a significant barrier at all levels – in
transmission of syphilis
The direct medical costs of MTCT of syphilis
communities, among service providers and
are substantial, because of the infection’s high
programme managers, and among policy-makers
prevalence and high rate of complications.
and decision-makers (25). In many countries, a
However, the true economic burden of any disease,
lack of clarity regarding roles, responsibilities and
including syphilis, includes more than just direct
accountability for measures to control MTCT of
medical costs. It involves indirect costs, such as lost
syphilis is a problem, since efforts involve both STI
productivity, and other non-medical costs, such as
and maternal and child health (MCH) programmes.
special educational needs and the emotional impact
In addition, many existing ANC programmes do not
of having a disabled child, which are extremely
have the information, training and technology they
difficult to quantify.
need to incorporate maternal syphilis screening and
treatment into their health-care systems.
Although the full economic cost of MTCT of syphilis
has not been definitively determined, available
Other key barriers are outlined in Table 1.2.
estimates of the direct medical costs can provide a
glimpse of the true cost to individuals, families and
Table 1.2
Barriers to the elimination of mother-to-child transmission of syphilis
Setting Barriers
In local communities • The problem is not seen as important
• Women do not seek ANC early enough or at all, or do not seek care
from trained providers
• Stigma associated with STIs
• Costs associated with detection and treatment, whether direct,
indirect, opportunity related or stigma related
Among health-care service • Lack of awareness of or training in the appropriate intervention
providers
• Lack of commodities appropriate to the setting
• Insufficient logistical support for the intervention
• No financial incentives to screen for syphilis (especially among private
providers)
Among programme managers • Syphilis accorded a low priority compared with other health problems
• Lack of resources for effective interventions
• Lack of clarity regarding roles, responsibilities and accountability
• Poor planning, coordination and monitoring of programmes
Among policy-makers and • Lack of awareness of true disease burden
decision-makers
• Lack of awareness of the cost effectiveness of the intervention
• Little external pressure to adopt or implement policies
• Few apparent political rewards for action
6
health systems. For example, in the United States be prevented or treated through improving current
of America (USA), the hospital cost per newborn ANC programmes. For each ill-health outcome, the
infant with congenital syphilis (MTCT of syphilis) economic cost and the health burden (in actual
was estimated to be almost US$5000 higher than numbers of cases, deaths and DALYs) are presented.
the cost per uninfected infant (26). In South Africa, These estimates are based on current levels of
hospital-based treatment of congenital syphilis programme coverage – which is higher for some
(MTCT of syphilis) was estimated at US$638 per programmes (e.g. neonatal tetanus) than others (e.g.
case (27). Globally, the annual direct medical costs MTCT of syphilis). Because different conditions cause
of addressing the adverse outcomes associated with different types of outcomes, and estimates are not
syphilis in pregnant women are calculated to be available for all potential outcomes (e.g. stillbirth
US$309 million (see Table 1.3). associated with HIV), death estimates are not
directly comparable.
MTCT of syphilis, tetanus, malaria,

hypertension and HIV are all important Cost effectiveness of syphilis-elimination
contributors to disease burden in pregnant programmes
women. We have conducted ananalysis of the additional
cost, health impact and cost-effectiveness of
implementing syphilis programmes in existing ANC
Although the direct medical costs of MTCT of
screening programmes in eight different country
syphilis are estimated to be lower than those of
case scenarios, which vary in terms of syphilis
some other perinatal infections, such as vertically
testing and treatment coverage (high (70%) or low
transmitted HIV (estimated to be US$3520 million),
(20%)), syphilis ANC prevalence (high (3%) or low
the current global burden of disease attributable to
(0.5%)), and country cost of health services (high
MTCT of syphilis as measured in disability-adjusted
or low). For each of the eight different country
years (DALYs) is enormous, at approximately
scenarios, the cost analysis assesses the cost of
3.6 million. A DALY is a time-based measure of the
the intervention (i.e. implementing testing and
burden of disease that combines years of life lost
treatment of syphilis in pregnancy), while the
due to premature mortality with the time lived in
health-impact analysis estimates the health benefits
a state of less than full health. Table 1.3 outlines
of the intervention in terms of DALYs averted.
several conditions affecting pregnancy that could
Table 1.3
Disease burden in pregnant women, associated perinatal deaths, DALYs and direct medical costs for
syphilis, tetanus, malaria, hypertension and HIV
Clinical cases Deaths DALYs Direct medical
costs (US$)
Syphilis 1 360 000 pregnant 305 000 fetal, stillbirth, 3.6 milliona 309 millionb
women (8) neonatal (8)
Tetanus 187 000 children 187 000 children aged 5.1 million (28) No data available
aged 0–4 years (28) 0–4 yearsc (27)
Malaria No data available 563 300 children aged No data available No data available
<5 years (29)
Hypertension No data available 71 000 maternal (28) 1.9 million (28) No data available
HIV 440 000 new infec- 440 000 new infections 6.2 million (31) 3520 million (31)
tions in children (30) in children
a DALYS for syphilis also include low-birth-weight and syphilis-infected infants.
b Assumes a 50:50 share of less- and more-expensive country settings.
c Tetanus deaths include the age group 0–4 years (excludes stillbirths); expert opinion is that 90% of deaths are neonatal.
7
Table 1.4
Estimated net cost (in US$) over 4 years, number of DALYs averted over 4 years and cost per DALY
averted for eight country scenarios varying by burden of disease, syphilis testing and treatment
coverage, and health-care costsa
Country Prevalence Proportion of Health- Net cost (savings) of Number Cost per
scenario of syphilis all pregnant care cost intervention (4 years) of DALYs DALY
in pregnant women structure (cost of intervention averted averted,
women tested and minus disease costs (4 years) US$
treated averted), US$
A High Low Low (1 943 017) 106 042 Cost savingb
B High Low High (12 261 250) 106 042 Cost saving
C High High Low (765 563) 39 155 Cost saving
D High High High (4 587 778) 39 155 Cost saving
E Low Low Low 1 736 807 17 678 98.25
F Low Low High 543 472 17 678 30.74
G Low High Low 593 188 6527 90.88
H Low High High 140 282 6527 21.49
a Classifications used for this exercise are: prevalence of syphilis = high (3%) or low (0.5%), proportion of all pregnant women
tested and treated = high (70%) or low (20%), health-care cost structure = high (1) or low (0.25), based on WHO CHOICE (CHoosing
Interventions that are Cost Effective) data (32).
b The cost per DALY averted ratio is not calculated when the intervention is “cost saving” – i.e. reduces DALYs and saves money.
The cost-effectiveness analysis combines this gross domestic product per capita in any country,
information into an estimate of the “cost per DALY the WHO criterion for “very cost effective”.
averted”, taking into account the medical costs
saved by the intervention. An intervention is said to 1.6 Who should invest in the
be “cost-saving” if it pays for itself in terms of offset elimination of mother-to-child
medical costs. In such instances, the cost per DALY transmission of syphilis?
averted is <US$0. The key inputs and results are Efforts to improve maternal and child health, and
presented in Table 1.4 for each of the eight different specifically to eliminate MTCT of syphilis, can be
country case scenarios, and described in greater considered to constitute a global public good,
detail in Appendix 1. Although the data presented defined as multicountry policies, programmes
are calculated as a ratio per 1 million pregnancies, and initiatives having a positive impact on health
the results should scale (i.e. the costs and the health that extends beyond the borders of any specific
outcomes would change similarly for smaller or country (33). However, even with widespread
larger populations), thus leaving the cost per DALY consensus around the financial and social benefits
unchanged for countries of different sizes. of procuring a global public good, achieving these
benefits requires the involvement and commitment
of a wide range of actors and stakeholders.
The costs of controlling MTCT of syphilis are
outweighed by the money saved in nearly all
• Those interested in reducing neonatal and
scenarios.
infant mortality should invest because
untreated maternal syphilis contributes to nearly
a quarter of a million stillbirths each year – an
We found that controlling MTCT of syphilis would
especially high proportion of all stillbirths in
be a “cost-saving” intervention in four of the eight
developing countries. In addition, in 2008, MTCT
country scenarios examined – i.e. the intervention of syphilis contributed to approximately 90 000
will “pay for itself” in offset medical costs. In the neonatal deaths, 65 000 low-birth-weight or
other four scenarios, the cost per DALY averted is premature babies and 150 000 babies born with
between US$20 and US$100, far below the annual syphilis infection – almost all preventable.
8
• Those interested in promoting maternal health 1.7 How much and what sort of
should invest because improving screening investment is needed?
in ANC is an opportunity to identify women at
risk of pregnancy complications and adverse We are seeking an investment of US$17 million
outcomes of pregnancy. over 4 years (see budget in Appendix 2), which will
facilitate the implementation of the initiative to
• Those interested in reducing STIs should invest
because this initiative will reduce the overall eliminate MTCT of syphilis in up to 12 “intensified
burden of STIs. It will also increase countries’ support” countries (see Fig. 1.1). We estimate that
abilities to identify pregnant women with this level of implementation will reduce cases of
syphilis, which can facilitate partner notification, MTCT of syphilis by 80% in these countries by the
thus strengthening overall syphilis control in end of 2015. In 2008, the estimated burden of
high-burden countries.
disease in the proposed 12 countries accounted
• Those interested in HIV should invest because for 33% of the global burden of pregnancies and
integration of syphilis screening with HIV neonates affected by syphilis. The funding will
screening in pregnancy is a low-cost intervention
also enable WHO to provide technical support at a
that contributes to dual elimination of MTCT of
HIV and syphilis and makes HIV services more global and regional level to other countries working
comprehensive. towards the elimination of MTCT of syphilis (“general
support” countries).
• Those interested in strengthening health
services to deliver integrated sexual and
reproductive health care should invest because
this initiative represents a vital step towards
integration of STI prevention and care into
maternal health services.
Fig. 1.1
Reported syphilis prevalence for 2010 (2009 for Indonesia) in intensified support countries for the
investment case for eliminating mother-to-child transmission of syphilisa
China 0.4%
Myanmar 0.7%
Honduras 1.5%
Papua New Guinea
4.8%
Ghana 3.4%
United Republic
of Tanzania 2.8%
Central African Republic
10.0% Indonesia 1.2%
Madagascar 6.0%
Zambia 5.3% Mozambique 5.7%
Uruguay 1.3%
a
Source: Data for Papua New Guinea are from the National Department of Health, STI, HIV and AIDS Surveillance Unit: The 2010 STI, HIV
and AIDS Annual Surveillance Report. Data for Indonesia available at: http://www.who.int/hiv/pub/2010progressreport/en/index.html.
Data for all other countries available at: http://www.who.int/hiv/pub/progress_report2011/en/.
9
2. Details of the initiative: objectives, activities and

stakeholders
The overall goal of the initiative is global elimination • reduce adverse outcomes of pregnancy due to
of MTCT of syphilis as a public health problem (34). MTCT of syphilis through intensified support
The specific goals of this elimination effort are to in 12 focus countries by 2015: achieved by
scaling up early maternal syphilis screening
prevent transmission of syphilis from mother to
for all pregnant women and ensuring prompt
child through ensuring that: treatment for women with positive tests;
• at least 90% of pregnant women are screened for • strengthen sexual and reproductive health
syphilis; services, including family planning, maternal
and child health services: this will involve
• at least 90% of pregnant women who are ensuring that activities aimed at elimination
positive for syphilis are treated appropriately. of MTCT of syphilis are integrated into existing
Given the difficulties in diagnosing and reporting health systems, commodities distribution and
monitoring and evaluation systems;
MTCT of syphilis consistently throughout the
world, a specific global target for a case rate • promote collaboration among different
for MTCT of syphilis has not been set. However, stakeholders working to reduce the overall
the burden of syphilis: this will include building
countries and regions are encouraged to identify
on synergies and forging partnerships among
country- or region-specific goals and targets different groups and agencies that address adult
to measure the impact of elimination efforts. syphilis.
The Region of the Americas, South-East Asia
To realize these objectives, specific activities will be
Region, and Western Pacific Region have defined
carried out in 12 intensified support countries and at
elimination of congenital syphilis (MTCT of syphilis)
regional and global levels. In addition, the support
as corresponding to an incidence of 0.5 cases or
network created by the investment case will provide
fewer per 1000 births (including stillbirths) (21, 22).
general support to other high-burden countries
However, this specific threshold was established for
requesting technical assistance to eliminate MTCT of
these regions and may not be appropriate for the
syphilis.
rest of the world.
2.1 Choosing 12 intensified support

Elimination can be achieved by strengthening
countries
reproductive and sexual health programmes to
ensure: The 12 intensified support countries were selected
by the WHO regional offices from among those
• the unmet need for family planning is met, thus countries with available data demonstrating a
helping women to avoid unintended pregnancy; high burden of disease. In addition, selection of
• early ANC, including syphilis screening for all countries was determined by level of interest and
pregnant women, and prompt treatment of commitment to implementation of the 4-year
those infected; plan through improved maternal and child health
• treatment of all sexual partners of infected services. The full selection criteria included:
women, promotion of condom use during
pregnancy and counselling of all women on how • demonstrable burden of syphilis in pregnancy or
to prevent infection; its adverse consequences;
• all neonates born to syphilis-positive mothers • interest in integration of initiative activities into
are given penicillin as presumptive treatment. existing national maternal and child health
frameworks;
There are three primary objectives for the
• commitment to attaining high coverage of ANC
investment case:
services;
10
• initiation of collection of indicators for national newborn and child health services that support
and global monitoring, including some form of elimination of MTCT of syphilis, in addition to
stillbirth surveillance; other perinatal and maternal health outcomes;
• designation of at least one person to coordinate
and monitor congenital syphilis (MTCT of 3. monitoring and evaluation of interventions
syphilis) activities; related to MTCT of syphilis through
• desire by regional offices to strive for subregional strengthened existing systems, within each of
diversity and representativeness. the countries as well as at global and regional
All of the countries selected for intensified support levels.
have made significant investments in establishing
effective ANC programmes, and their participation Activity stream 1: gathering evidence to guide
in the initiative should strengthen these investments best practice
over the medium and long term. Much about MTCT of syphilis is well understood,
but additional evidence in certain areas –
It is recognized that many of the countries with particularly practical operational research – is
the highest burden of disease may not have data needed to strengthen the implementation and
available and that data on burden of disease effectiveness of country plans for eliminating
change over time. However, other countries will the condition. Proposed research areas are not
receive general support through the network stand-alone activities, but exist to strengthen the
established with the funding of the investment implementation of feasible, high-quality, cost-
case, in particular for monitoring and evaluation. In effective and sustainable interventions to eliminate
addition, once activities in the 12 intensified support MTCT of syphilis.
countries are under way, a phased approach to
supporting other high-burden countries in future Table 2.1 outlines some of the areas of research
phases of the investment case will be discussed and necessary to support the implementation and
developed. evaluation of interventions to eliminate MTCT of
syphilis, which is a vital element of the initiative.
2.2 Activities Each country has its own need for filling evidence
While the initiative is designed to bring about a gaps; therefore, research priorities will be set locally
major reduction in cases of MTCT of syphilis in 12 – and may be drawn from this indicative list, or
intensified support countries, investment case funds from elsewhere. It is expected that countries will
are not primarily intended for routine programme also leverage additional funds to support evidence
expenses. Instead, investment case funds are sought gathering locally.
to provide assistance with integrating syphilis
interventions into existing programmes, and Activity stream 2: building capacity for the
ensuring and sustaining the effectiveness of these development and implementation of national
interventions. To this end, funding for the initiative plans
will be devoted to three activity streams: While each country has its own unique issues
regarding elimination of MTCT of syphilis, this
1. gathering evidence to assess the current initiative will help national health ministries to
situation and needs in each country in relation identify the best means to address issues specific
to MTCT of syphilis, to determine the most to their country, and will promote clarification of
effective approach to elimination; the roles and responsibilities within the context of
existing programmes.
2. building capacity for the development and
implementation of national plans to scale
up the coverage and quality of maternal,
11
Table 2.1
Key research areas for efforts for elimination of mother-to-child transmission of syphilis
Evidence needed Where can evidence be gathered?
Who is at risk of syphilis in pregnancy? Country- and subnational-level re-
Aim of research – to understand epidemiological and demo- search – primary data collection
graphic features associated with the risk of syphilis in pregnancy
What is the impact of syphilis in pregnancy? Multicountry studies, possibly linking

Aim of research – to further explore the impact of MTCT of syphi- to existing national surveys
lis (particularly stillbirths, neonatal and infant deaths) in a wider Modelling studies at global/national
variety of settings (e.g. extent of infant death (>28 days) related levels
to maternal syphilis, impact of stillbirth in low-income settings)
What are the most effective models for delivering the interven- Country-level studies of health systems
tion?
Aim of research – to identify different models for delivering
syphilis screening and treatment for pregnant women, e.g. how
to increase early ANC attendance; how to engage communities in
increasing ANC attendance
What are the resource requirements for delivering the inter- Country-level studies focusing on the
vention? level of service delivery
Aim of research – to quantify levels of resources (human, finan-
cial, logistic, policy) needed to achieve elimination in different
settings. What additional data are needed to support inclusion
of MTCT of syphilis as a contributor to infant mortality for major
global initiatives?
How can the effectiveness of screening and treatment be im- Country-level studies of health systems
proved? and on the level of service delivery
Aim of research – to maximize the potential of interventions
(screening and treatment) in different settings. Also, to address
issues such as the best methods of partner services, timing of
screening/treatment, algorithms for use of enzyme-linked im-
munoassay tests, increasing availability of penicillin at lower-level
facilities, etc.
Monitoring and evaluation issues Studies at country, regional and global

Aim of research – to identify feasible and appropriate indicators levels
for monitoring and evaluation at multiple levels (e.g. use of still-
birth as an impact measure). How to interpret data with increased
use of treponemal rapid testing. What are appropriate criteria for
certification and maintenance of elimination?
What is the evidence for integrated interventions? Country-level studies; literature reviews
Aim of the research – to understand the benefits and risks of in-
tegrated screening efforts (e.g. with PMTCT or malaria prevention
in pregnancy). What is the field performance of dual HIV/syphilis
point-of-care tests?
12
Intensified support countries will receive technical to support implementation of the country plans
support to develop their own national plans (see Appendix 3). The tools and technical support
through the following processes: provided by the initiative partners can assist
countries to set their own priorities for syphilis
• consultations between WHO regional offices and elimination and improvement of ANC. The process
country ministries of health to gauge interest in is intended to increase the likelihood that all
each country (in process);
stakeholders will buy into the priorities set for the
• regional-level meetings involving participants initiative, thereby strengthening sustainability and
from interested countries (already held in some
the potential for success.
regions);
• country development of plans and strategies Intensified support countries will be asked to
for elimination of MTCT of syphilis, with global make a commitment to ensuring that their existing
and regional support, assistance and capacity
workforce involved with maternal, newborn and
building, to:
child health systems will carry out the country plans
−− strengthen and expand coverage of early for the elimination of MTCT of syphilis. Furthermore,
maternal screening and prompt treatment of
over the course of the 4 years of funding, we will
individuals who test positive;
work with intensified support countries to obtain
−− integrate global indicators of elimination
future funding or justify the reallocation of existing
of MTCT of syphilis into existing maternal,
health-care budgets to ensure the sustainability of
newborn and child health monitoring and
evaluation systems (in process). the intervention.
Countries are encouraged to identify opportunities

to develop integrated plans or plans that take Activity stream 3: monitoring and evaluation
other programmes into account, such as the dual Monitoring and evaluation are critical components
initiatives in the three WHO regions to eliminate of the initiative at multiple levels. At national,
MTCT of HIV and syphilis (see Section 1.3) (21, 22). subnational and local levels, the collected data will
Once plans have been developed, each country be used to ensure that programmes have sufficient
will be encouraged and supported to follow a coverage and quality to meet the initiative’s
step-by-step approach to implementation, such as goal, and that key subpopulations are targeted
that based on WHO’s programme guidance tool for appropriately. It will also serve as vital evidence for
reproductive tract infection (RTI)/STI programmes advocacy and resource mobilization around the
(PGT) (see Box 2.1) (35). The PGT, along with a elimination of MTCT of syphilis, which can ensure
number of other guidelines and tools, are available programme continuity and sustainability.
Box 2.1
Programme guidance tool for reproductive tract infection/sexually transmitted infection programmes
The PGT facilitates an action-oriented process that can be used by decision-makers to set goals and
directions and to prioritize interventions for addressing the problem of RTIs, including STIs. It takes
into account the full range of contextual factors that can influence the ability of a health system to set
priorities and deliver effective interventions, recognizing that appropriate decisions about policy and
programme development should not only be based on disease epidemiology. The PGT recognizes the
importance of relationships between the community, service clients, the service-delivery system, and
the mix of interventions and services provided, taking into account how these interactions are influ-
enced by the broader sociocultural, economic and political context.
The PGT approach consists of 10 steps. The first eight steps amount to a strategic assessment of the
current situation, on the basis of which strategic recommendations can be made. In step 9, the strate-
gic recommendations are implemented, and in step 10, those recommendations found to be effective
are implemented on an expanded scale.
13
At the regional level, monitoring and evaluation should be integrated into existing data-
data will enable countries with similar policy- and monitoring systems;
systems-level issues (e.g. distribution; health • regular collection and analysis of monitoring
services coverage; surveillance and data systems; reports at all levels, with prompt feedback to
maternal, newborn and child health programme programmes;
integration) to learn from each other. • development of sustainable mechanisms for
providing ongoing support for in-country
At the global level, impact indicators will be used to monitoring and evaluation of the adverse
monitor global programme impact, while the tools outcomes of pregnancy that result from syphilis
infection.
developed and lessons learnt through this initiative
will contribute to scale-up in other countries in the
Indicators and targets for the elimination of
future. mother-to-child transmission of syphilis
Extensive consultations with a wide range of
A broad range of activities are planned to monitor
stakeholders have identified a limited number of
and evaluate the initiative, including:
indicators and targets to measure progress towards
the goal of eliminating MTCT of syphilis, which can
• global collaboration with stakeholders to assist
be feasibly incorporated into existing maternal,
initiative partners in defining how indicators
should be measured; newborn and child health data systems (36). These
include core indicators from WHO-recommended
• development of tools to assist with collection
of high-quality data, analysis that provides indicators for measuring universal access to
informative data to guide the programme, and reproductive health, as well as universal access to
dissemination of findings; HIV interventions; impact indicators (congenital
• regional consultations to define criteria and syphilis rates and the proportion of stillbirths
processes for validation of elimination of MTCT attributable to syphilis in the mother); and a
of both syphilis and HIV; summary process indicator to estimate overall
• national-level collaborative efforts to programme effectiveness. Furthermore, additional
adapt existing national indicators to WHO indicators may be necessary at the global, regional
recommendations where possible, outline and national level, to provide a more comprehensive
definitive plans for monitoring and evaluation of picture of initiative progress. Indicators are
MTCT of syphilis, and determine how indicators summarized in Box 2.2.
Box 2.2
Indicators for the elimination of mother-to-child transmission of syphilis
Core process indicators – routine

Testing of ANC attendees for syphilis at first visit (global target >90% by 2015)
Positive syphilis serology in pregnant women (country-specific target)
Treatment of syphilis-seropositive pregnant women (global target >90% by 2015)
Additional indicators – as able

Congenital syphilis rate (country- or region-specific target)
Estimated proportion of all syphilis-infected pregnant women who receive treatment by 24 weeks’
gestation (proposed target > 80%)
Proportion of stillbirths attributable to syphilis in the mother (proposed target <2%)
14
2.3 Key initiative partners Staff of the Department of HIV/AIDS collaborate

with other UN agencies, ministries of health,
National-level country teams development agencies, NGOs, health-services
In-country activities for intensified support providers, health-care institutions, people living with
countries will be led by a programme coordinator HIV and other partners. The aim is to strengthen
working with a country team, made up of key all aspects of the health sector, in order to deliver
stakeholders such as representatives from involved much-needed HIV services. WHO provides technical
health programmes (maternal and child health, support and develops evidence-based norms and
STI/HIV etc.), WHO country offices, representatives standards to help transform the goal of universal
of civil society, representatives of primary access to HIV care into a reality. An important
stakeholder groups, donors, multilaterals, bilaterals, aspect of universal access to HIV is to strengthen
nongovernmental organizations (NGOs), research and expand health systems, including those for
investigators and communications specialists. prevention and treatment of MTCT of syphilis.
The World Health Organization WHO will manage the technical, programmatic and
The WHO Department of Reproductive Health resource-building functions of the initiative. It will
and Research (RHR), with the assistance of the also appoint seven full-time staff at the global and
Departments of Maternal, Child and Adolescent regional level: a programme director, a laboratory
Health (MCA) and HIV/AIDS, will coordinate quality assurance/procurement officer, an advocacy/
global leadership and implementation of the communications/fundraising officer, an assistant/
initiative, provide technical support, and promote fiscal programme officer and three regional officers.
improvement of the evidence base for interventions. Funds channelled through WHO would also be
In addition, WHO regional advisers covering one or used at the global, regional and country levels to
more of the areas of STI, HIV, reproductive health promote advocacy, strengthen policy, develop
and MCH will provide similar functions at the guidelines, scale up programmes, and support
regional level. essential research to support elimination of MTCT
of syphilis. Funds channelled through WHO are not
The mission of RHR is to help people to lead intended for routine programme costs.
healthy sexual and reproductive lives. In pursuit
of this mission, the department endeavours to United Nations agency partners
strengthen the capacity of countries to enable The United Nations Population Fund (UNFPA) is an
people to promote and protect their own sexual and international development agency that promotes
reproductive health and that of their partners, and the right of every woman, man and child to enjoy
to have access to, and receive, high-quality sexual a life of health and equal opportunity. UNFPA
and reproductive health services when needed. supports countries in using population data for
policies and programmes to reduce poverty and to
MCA works to strengthen WHO capacity to support ensure that every pregnancy is wanted, every birth
countries’ efforts to improve maternal, newborn is safe, every young person is free of HIV/AIDS, and
and child health and reduce maternal, perinatal every girl and woman is treated with dignity and
and child mortality. The department aims to respect. For the initiative for the elimination of MTCT
reinforce advocacy, technical support, monitoring of syphilis, UNFPA plans to support introductory
and evaluation, and partnerships in countries, to activities, implementation and upscaling, as well
ensure that WHO can provide the most up-to-date as capacity building and logistics management. In
information and guidance on maternal, newborn addition, UNFPA can facilitate pooled procurement
and child health, including issues related to MTCT of and support countries to integrate adequate
syphilis. programmes in their national budget.
15
The United Nations Children’s Fund (UNICEF), is the provide technical support for the surveillance,
leading UN agency tasked to advocate for children. monitoring and evaluation framework for the global
The heart of UNICEF’s work is in the field. Each initiative, as well as quality assurance of laboratory
country office carries out UNICEF’s mission through and health services.
a unique programme of cooperation developed
with the host government. Regional offices guide
Battling Against Syphilis – a Team Approach
this work and provide technical assistance to (BASTA)
country offices as needed. For the initiative for the An informal collaboration of key partners interested
elimination of MTCT of syphilis, UNICEF plans to in eliminating MTCT of syphilis was created by WHO
support implementation and scale-up, as well as and CDC approximately 5 years ago, called “BASTA”:
logistics and supplies. Battling Against Syphilis – a Team Approach. There
are over 100 BASTA collaborators, who share ideas
The Joint United Nations Programme on HIV/AIDS and information on efforts to eliminate MTCT of
(UNAIDS) is an innovative joint venture of the UN syphilis. BASTA collaborators work around the world
family, bringing together the efforts and resources in bilaterals, NGOs, academic centres, professional
of 10 UN system organizations in the AIDS response, organizations and civil society (see Appendix 4).
to help the world prevent new HIV infections, care BASTA has been instrumental in the development of
for people living with HIV, and mitigate the impact the investment case and research agenda outlined
of the epidemic. The UNAIDS Secretariat works on in this document, and has promoted and supported
the ground in more than 80 countries worldwide. collaborative efforts, including dissemination
Coherent action on AIDS by the UN system is of information (publications, symposium, etc.),
coordinated in countries through the UN theme development of tools, research in key areas,
groups, and the joint programmes on AIDS. For the provision of technical expertise to countries, and
initiative for the elimination of MTCT of syphilis, integration of elimination of MTCT of syphilis into
UNAIDS plans to support advocacy on HIV-infected their respective work agendas.
women, and linkages between HIV programmes, STI
control programmes and sexual and reproductive In March 2012, several BASTA collaborators created
health programmes. the Global Congenital Syphilis Partnership, hosted
in the London School of Hygiene and Tropical
United States of America Centers for Disease Medicine. WHO looks forward to collaborating with
Control and Prevention the newly formed partnership, in particular to:
The Centers for Disease Control and Prevention
(CDC) is the agency of the Department of Health • heighten public and professional awareness, and
and Human Services in the USA that focuses on sense of urgency, on maternal syphilis and MTCT
of infection;
public health and prevention. With a mission of
collaborating to create the expertise, information • mobilize global commitment and action to scale
up knowledge transfer and capacity building to
and tools that people and communities need to
accelerate the elimination of MTCT of syphilis;
protect their health, CDC works with global partners
on specific global goals, including public health • optimize the use of available tools in the fight
against MTCT of syphilis, and enhance delivery
programmes aimed at reducing infant mortality.
of syphilis diagnosis and treatment, especially in
The Division of STD [Sexually Transmitted Disease]
pregnant women.
Prevention (DSTDP) in the National Center for
HIV, Viral Hepatitis, STD and TB Prevention is
CDC’s component agency supporting the global
2.4 Management structure
elimination of MTCT of syphilis. In the initiative WHO will coordinate the activities of each of the
for the elimination of MTCT of syphilis, DSTDP will main partners involved in the initiative, as well
16
as donor inputs and reporting requirements, and The core team will be composed of the WHO
a global fundraising and advocacy campaign. programme director, the regional programme
Initiative partners will also be responsible officers (who will represent the intensified support
for disseminating outputs (e.g. at national country teams), the advocacy/communication/
and international meetings), updating and fundraising officer, the laboratory quality assurance
reviewing existing guidelines, and disseminating and procurement officer, and the financial
recommendations to both intensified and general management/administrative officer. The core team
support countries. will report to the steering committee. The steering
committee will be composed of the core team, as
These activities will be undertaken through a close well as representatives of key UN partner agencies
collaboration between staff at global and regional and other partners. The core team and the steering
levels who are dedicated to work on this elimination committee will need to be financially and logistically
initiative, as well as staff working for allied supported to achieve their mandates.
programmes that are fundamental to the success
of the initiative (e.g. staff working on maternal child The role of the core team is to ensure coordination
health, and those working on STI control and HIV at all levels, in both intensified and general support
programmes). countries:
Fig. 2.1 is a graphical representation of the overall • the programme director, based at WHO
management structure for implementing the headquarters, will act on behalf of the steering
committee to oversee the core team. This person
initiative. The roles and responsibilities of the major
will have primary responsibility for programme
players are described next. implementation, coordination of the programme
and with partners, and achievement of
Fig. 2.1
Management structure of the initiative for the global elimination of mother-to-child transmission of
syphilis
STEERING COMMITTEE
CORE TEAM
WHO programme director
BASTA
UN
Advocacy, Financial and
partner Laboratory quality
Regional communication management and other
agencies programme officers assurance and administrative
and fundraising procurement officer partners
officer officer
Intensified support Intensified support

country teams country teams
17
objectives. In addition, the programme director • a financial and administrative officer will be
will oversee operational research, monitoring hired and deployed at WHO headquarters. Her/
and evaluation activities; his primary responsibilities will be to lead the
financial management technical group, develop
• regional officers will be placed in three of the
a fiscal reporting system that will be used by all
WHO regions to aid in full implementation
funds’ recipients, and track all funds held and
of activities, and to promote the initiative to
deployed in the field for specific activities;
intensified and general support countries in their
region. These regional officers will also serve as The role of the steering committee will be to:
technical officers, responsible for monitoring and
evaluation for their region. The regional officers • determine the overall strategic plan for the
will help to coordinate activities across the range global initiative;
of programmes involved in delivering the goals
of the initiative (ANC, STI control, prevention of • direct policy and guide the overall trajectory of
MTCT of HIV, etc.). the initiative;
• an advocacy, communication and fundraising • review narrative and financial reports;

officer will be hired and deployed at • be responsible for the overall accountability of
WHO headquarters to lead an advocacy/ the resources;
communication/fundraising technical group.
• champion the global elimination initiative in the
This person will have primary responsibility
international arena;
for advocacy, donor coordination, and
communication. This officer will provide • review and approve the annual programme
fundraising and strategic guidance to fund of work to ensure that activities in intensified
and launch the initiative, and ensure active support countries are in line with the vision and
communication between the core team, the goals;
steering committee and other partners;
• review, discuss and provide input on funding
• a laboratory quality assurance and proposals;
procurement officer will be hired and deployed
• support intensified-support-country-level
at WHO headquarters to work closely with
programme coordinators to develop national
the WHO Essential Medicines Programme
plans;
Department to develop and support global,
regional and national laboratory quality • coordinate overall monitoring and evaluation;
assurance systems, support the steps necessary • review annual programme results and overall
for prequalification of diagnostics, and work to progress towards achievement of the global
improve the stability of procurement of essential elimination initiative.
diagnostics and medications by countries;
18
3. The strength of this initiative
3.1 Leveraging existing investments in • health-system initiatives to promote integrated

maternal and child health comprehensive sexual and reproductive health
care.
This initiative will build on investments in maternal
and child health services that have already been In addition, it is recognized that the elimination of
made by governments and donors in developing MTCT of syphilis is likely to be more achievable if
countries. It works through, and therefore inevitably syphilis screening and treatment activities are also
strengthens, national health systems, particularly included in the existing health initiatives (such as
antenatal and other reproductive and sexual health- elimination of MTCT of HIV). Therefore, combining
care programmes. syphilis interventions with basic ANC programmes
as well as prevention of MTCT programmes makes
Today, over three quarters of all pregnant women medical, economic and political sense (37).
receive at least one ANC visit (24). This is an
indication that programmes and infrastructure exist Recent efforts by WHO have simplified ANC and
in many countries, and that there is widespread provided norms to encourage health-care workers
awareness and acceptance of ANC by pregnant to emphasize a few essential components of care
women. (38, 39). This initiative will build on these norms and
provide support for health-services evaluation that
This initiative will help to maximize the ability of can jump-start feasible and efficient management
these existing programmes to improve maternal and data-collection systems around integrated ANC.
health and reduce infant mortality. It will harness It will also build capacity that supports all ANC –
new technological developments and strengthen even beyond elimination of MTCT of syphilis.
existing services to promote early ANC for all
pregnant women and ensure that they receive 3.2 Supporting country-level impact
testing (and, where indicated) treatment for syphilis through global coordination
at their first antenatal clinic visit. We support a The initiative outlined in this investment case does
simple, integrated and effective ANC approach that seek a limited amount of funding for country-
can provide sustainable services within the broad level programme implementation. Countries
context of strengthening primary health care, while identified for intensified support – which all have
concentrating on this prevalent, high-burden and a high burden of MTCT of syphilis – will already be
neglected disease. committed to syphilis elimination and have ANC
programmes in place, backed by other sources
The focus on early access to services and the quality of funding. They also may already be receiving
of comprehensive ANC will strengthen synergistic substantial financial support for HIV, tuberculosis
efforts to reduce the burdens of HIV, malaria, and malaria prevention (e.g. The Global Fund to
tetanus, parasites and accompanying anaemia, as Fight AIDS, Tuberculosis and Malaria). It is hoped
well as MTCT of syphilis. As such, it will promote that the funding for country-level programme
synergies by supporting: implementation from this initiative can be used to
integrate components of elimination of MTCT of
• ongoing community mobilization programmes syphilis into existing ministry of health programmes
(to encourage women to seek and access ANC
to ensure sustainable and strengthened health
early in pregnancy);
systems.
• existing efforts to improve the quality of ANC;
19
Through a series of global, regional and national Adverse pregnancy outcomes are the critical
consultations, countries have indicated that they public health problem associated with maternal
need technical assistance to learn how to integrate syphilis infection. The congenital syphilis case
and scale up syphilis screening and treatment rate is the most widely recognized measure of the
into existing programmes and to monitor these impact of elimination efforts. Unfortunately, global
interventions. Countries have also indicated a need surveillance of MTCT of syphilis is challenging, since
to bring more attention to the burden of MTCT of there is no single test or combination of laboratory
syphilis at all levels, which will help to prioritize the tests to definitively diagnose an infected infant. As a
issue on national and international health agendas. result, a case definition for congenital syphilis must
rely on clinical history and examination. Thus, case
To this end, the initiative will mobilize regional and definitions vary widely by country, and a globally
global stakeholders into a network that can deliver accepted surveillance case definition is still under
rapid, targeted technical assistance to intensified development.
support countries to work alongside national
counterparts to fully and effectively integrate Maternal syphilis infection also contributes
syphilis interventions into existing ANC and PMTCT substantially to rates of stillbirth, though this
of HIV programmes. This initiative will also dedicate outcome is often underreported in many settings.
human and financial resources at the regional and Nonetheless, despite the current lack of universal
global levels, to work with national colleagues measuring of stillbirth rates, we are proposing this
to monitor the scale-up of country-level syphilis- as a potentially sensitive and specific measure of the
elimination interventions. Although prioritization of impact of elimination of MTCT of syphilis efforts.
resources will be aimed at the intensified support Promoting the monitoring and measurement of
countries, it is anticipated that the network created stillbirth rates will not only allow us to assess the
by the investment case will also be able to provide impact of this initiative, it will also help support
general support for other countries as needed. and strengthen reproductive health surveillance
programmes more generally.
3.3 Investing in surveillance,
monitoring and evaluation In addition, discussions at a regional and global
Previous WHO/CDC technical consultations have level are under way to identify criteria and processes
recommended the development of a monitoring for validation of elimination. Given that there are
system based upon already-established national several countries that may actually have eliminated
systems for ANC. Such an approach supports MTCT of syphilis already, establishment of such a
overall health-systems infrastructure and a quality process is critical for recognizing this achievement,
package of antenatal and perinatal preventive as well as is providing recommendations on how
services. Through these consultations, a list of the to maintain elimination. In addition, validation may
critical benchmarks was proposed for appropriate be an important motivator to engage countries
local programmes within each country, with in elimination, and encourage countries to go
annual measurement recommended. Some have the last distance to provide services for even the
already been tried out in local settings; others need most difficult-to-reach populations. The validation
further evaluation for feasibility. Investment in process is being undertaken jointly with the global
this initiative will support local and national-level programme to eliminate MTCT of HIV, given the
research needed to solidify the critical programme commonalities of the initiatives and programme
benchmarks that will be adopted globally. platforms.
20
3.4 Implementing knowledge and best costing, too, for example (42). The next step for
practices the South-East Asia and Western Pacific Regions,
however, is to identify resources to work with
This investment case represents a new direction for
countries to establish integrated policies and ensure
WHO and its partners in their goal of eliminating
clinical guidelines and monitoring systems support
MTCT of syphilis, but it also builds upon many years
these policies. The African Region is currently
of experience and evidence gathering. In recent
developing a regional framework for elimination
years, several state-of-the-art reviews on maternal
of MTCT of HIV, which includes the strengthening
and congenital syphilis (MTCT of syphilis) have been
of related MCH services such as the elimination of
published to highlight the problem and advocate
MTCT of syphilis (22).
action for its elimination (40). These reviews provide
empirical evidence of the burden of MTCT of
In all of these regions, scaling-up of use of point-
syphilis globally and information on experiences of
of-care rapid testing has been identified as critical
programmes attempting to intervene and address
for expanding testing to pregnant women seen
this burden.
in peripheral health settings. All regions have
also expressed the need to establish criteria and
At regional level, some longstanding efforts
a process for validation of elimination that is
to eliminate MTCT of syphilis have made great
integrated with that for MTCT of HIV. Thus, it is
progress, but still need assistance to reach the last
crucial that WHO works closely with the regions to
distance. For example, the Pan American Health
facilitate interregional collaboration and establish
Organization (PAHO) has developed several tools to
credible, sustainable processes for validation of
assist countries with development of policy, clinical
elimination globally and regionally.
guidance, and monitoring and evaluation (41).
See also Box 3.1. However, PAHO needs additional
There is also much work being done in the area of
support to provide technical assistance to countries
improving best practices for syphilis testing. WHO
and strengthen monitoring and evaluation systems.
and other partners also support the elimination of
In the WHO South-East Asia and Western Pacific
MTCT of syphilis through work on improved rapid
Regions, the Asia Pacific Task Force (which includes
syphilis diagnostic tests applicable for resource-
WHO, UNAIDS, UNICEF and UNFPA) has also
limited settings, including development of rapid
made great strides in outlining a strategy for dual
point-of-care tests that use whole blood (e.g. finger
elimination of MTCT of HIV and syphilis, including
prick) samples that can be used by health-care
indicators for monitoring and evaluation, and a
Box 3.1
PAHO Regional Initiative to Eliminate Vertical Transmission of HIV and Syphilis
Since 1995 PAHO has strived to eliminate MTCT of syphilis in the Americas. In 2009, PAHO countries,
in collaboration with WHO, UNICEF and others, agreed to a goal of dual elimination MTCT of HIV and
congenital syphilis (MTCT of syphilis) by 2015.
The PAHO initiative aims to reduce MTCT of HIV to 2% or less and reduce congenital syphilis (including
stillbirths) to 0.5 cases per 1000 live births or fewer. In addition, the regional initiative seeks to ensure
that at least 95% of pregnant women receive early ANC that includes screening for both HIV and
syphilis.
The initiative intends to attain these goals through scaling up services for primary prevention of HIV
and syphilis and strengthening of health systems for maternal and child health services, surveillance,
monitoring and evaluation.
21
providers at the lowest level of health care. However,

the syphilis point-of-care tests currently available
commercially are treponemal, meaning that they
can only measure a lifetime history of syphilis
exposure. Thus, additional support is needed for
WHO to encourage development and field testing
of nontreponemal tests to measure current syphilis
infection, as well as bundled diagnostics that allow
concomitant testing for syphilis, HIV, hepatitis B,
etc. The development of such tests is critical for
minimizing the burden of primary care health
workers to provide quality, integrated care.
These are just a few examples of the efforts and

advances that this initiative will build upon and
help to advance. Now – more than ever before – is
the right time to address MTCT of syphilis with
a large-scale, global initiative. Investment today
will contribute significantly to maternal and child
health improvements around the world, including
achievement of the MDGs.
22
References
1. Prevalence and incidence of selected sexually 11. Blencowe H et al. Lives Saved Tool supplement
transmitted infections, Chlamydia trachomatis, detection and treatment of syphilis in
Neisseria gonorrhoeae, syphilis and Trichomonas pregnancy to reduce syphilis related stillbirths
vaginalis: methods and results used by WHO to and neonatal mortality. BMC Public Health 2011,
generate 2005 estimates. Geneva, World Health 11(Suppl 3):S9.
Organization, 2011 (http://whqlibdoc.who.int/
12. Priority medicines for mothers and children 2011.
publications/2011/9789241502450_eng.pdf,
Geneva, World Health Organization, 2011
accessed 20 August 2012).
(http://www.who.int/medicines/publications/
2. Cousens S et al. National, regional, and emp_mar2011.1/en/index.html, accessed 29
worldwide estimates of stillbirth rates in 2009 August 2012).
with trends since 1995: a systematic analysis.
13. The Millennium Development Goals report
The Lancet, 2011, 377:1219–1330.
2009. New York, United Nations, 2009 (http://
3. UNICEF, WHO, The World Bank, UNPD. Levels www.un.org/millenniumgoals/pdf/MDG%20
and trends in child mortality report 2011. New Report%202009%20ENG.pdf, accessed 20
York, United Nations Children’s Fund, 2011 August 2012).
(http://www.healthynewbornnetwork.org/
14. Peeling R et al. Avoiding HIV and dying of
sites/default/files/resources/Child_Mortality_
syphilis. The Lancet, 2004, 364:1561–1563.
Report_2011_Final.pdf, accessed 20 August
2012). 15. Fleming DT, Wasserheit JN. From
epidemiological synergy to public health policy
4. World Health Organization. Regional burden of
and practice: the contribution of other sexually
disease estimates for 2004. (http://www.who.int/
transmitted diseases to sexual transmission of
healthinfo/global_burden_disease/estimates_
HIV infection. Sexually Transmitted Infections,
regional/en/index.html, accessed 20 August
1999, 75:3–17.
2012).
16. Mwapasa V et al. Maternal syphilis infection is
5. Goldberg RL, Thompson C. The infectious origins
associated with increased risk of mother-to-
of stillbirth. American Journal of Obstetrics and
child transmission of HIV in Malawi. AIDS, 2006,
Gynecology, 2003, 189:861–873.
20:1869–1877.
6. Finelli L et al. Congenital syphilis. Bulletin of
17. Global health sector strategy on HIV/AIDS 2011–
the World Health Organization, 1998, 76(Suppl.
2015. Geneva, World Health Organization, 2011
2):126–128.
(http://www.who.int/hiv/pub/hiv_strategy/en/
7. Gomez G et al. Untreated maternal syphilis and index.html, accessed 20 August 2012).
adverse outcomes of pregnancy: a systematic
18. Joint action for results: UNAIDS outcome
review and meta-analysis. Bulletin of the World
framework, 2009–2011. Geneva, UNAIDS,
Health Organization, 2013, 91(3):217-223.
2009 (http://data.unaids.org/pub/
8. Newman L et al. Global estimates of syphilis in BaseDocument/2010/jc1713_joint_action_
pregnancy and associated adverse outcomes: en.pdf, accessed 20 August 2012).
analysis of multinational antenatal surveillance
19. Countdown to zero: global plan for the elimination
data. PLOS Medicine, 2013,10(2):e1001396.
of new HIV infections among children by 2015
9. Hawkes S et al. Effectiveness of interventions to and keeping their mothers alive. Geneva,
improve screening for syphilis in pregnancy: a UNAIDS, 2011 (http://www.unaids.org/en/
systematic review and meta-analysis. The Lancet media/unaids/contentassets/documents/
Infectious Diseases, 2011, 11:684–691. unaidspublication/2011/20110609_JC2137_
Global-Plan-Elimination-HIV-Children_en.pdf,
10. Bhutta Z et al. Stillbirths: what difference can
we make and at what cost? The Lancet, 2011,
377:1523–1538.
23
20. Regional initiative for the elimination of vertical 29. World malaria report, 2011. Geneva, World
transmission of HIV and congenital syphilis Health Organization, 2011 (http://www.who.
in Latin America and the Caribbean: regional int/malaria/world_malaria_report_2011/
monitoring strategy [in Spanish]. Montevideo, WMR2011_noprofiles_lowres.pdf, accessed 20
Pan American Health Organization, 2010 (http:// August 2012).
new.paho.org/clap/index.php?option=com_con
30. UNAIDS. 2009 AIDS epidemic update. Geneva,
tent&task=view&id=104&Itemid=234, accessed
UNAIDS/WHO, 2009 (http://www.unaids.org/en/
20 August 2012).
media/unaids/contentassets/dataimport/pub/
21. UNAIDS, UNICEF, UNFPA, WHO. Elimination of report/2009/jc1700_epi_update_2009_en.pdf,
new paediatric HIV infections and congenital accessed 20 August 2012).
syphilis in Asia-Pacific, 2011–2015: conceptual
31. Marseille E et al. The cost-effectiveness of home-
framework, monitoring and evaluation guide.
based provision of antiretroviral therapy in rural
Bangkok, UNICEF, 2011 (http://aidsdatahub.org/
Uganda. Applied Health Economics and Health
en/regional-profiles/pptct, accessed 20 August
Policy, 2009, 7:229–243.
2012).
32. World Health Organization. CHOosing
22. WHO, UNICEF, AIDS. Strategic framework for the
Interventions that are Cost Effective (WHO-
elimination of new HIV infections among children
CHOICE) (http://www.who.int/choice/en/,
in Africa by 2015 and keeping their mothers alive.
In press.
33. Global public goods for health - the report
23. United Nations Secretary-General Ban Ki-moon.
of working group 2 of the commission on
Global strategy for women’s and children’s health.
macroeconomics and health. Geneva, World
New York, United Nations, 2010 (http://www.
Health Organization, 2002 (http://www.
everywomaneverychild.org/images/content/
earth.columbia.edu/sitefiles/file/Sachs%20
files/global_strategy/full/20100914_gswch_
Writing/2002/UNPublications_2002_
en.pdf, accessed 20 August 2012).
FinancingGlobalPublicGoods_2002.PDF,
24. Countdown to 2015. Tracking progress in accessed 20 August 2012).
maternal, newborn, and child survival: the 2008
34. The global elimination of congenital syphilis:
report. Geneva, World Health Organization, 2008
rationale and strategy for action. Geneva, World
(http://www.who.int/making_pregnancy_safer/
Health Organization, 2007 (http://whqlibdoc.
documents/9789280642841/en/index.html,
who.int/publications/2007/9789241595858_
eng.pdf, accessed 20 August 2012).
25. Hawkes S et al. Antenatal syphilis control:
35. A strategic approach to strengthening control
people, programmes, policies and politics.
of reproductive tract and sexually transmitted
Bulletin of the World Health Organization, 2004,
infections: use of the programme guidance tool.
82:417–423.
26. Bateman DA et al. The hospital cost of (http://www.who.int/reproductivehealth/
congenital syphilis. Journal of Pediatrics, 1997, publications/rtis/9789241598569/en/index.
130:752–758. html, accessed 20 August 2012).
27. Blandford JM et al. Cost-effectiveness of on- 36. WHO, CDC. Methods for surveillance and
site antenatal screening to prevent congenital monitoring of congenital syphilis elimination
syphilis in rural Eastern Cape Province, Republic within existing systems. Geneva, World
of South Africa. Sexually Transmitted Diseases, Health Organization, 2011 (http://www.
2007, 34:S61–S66. who.int/reproductivehealth/publications/
rtis/9789241503020/en/index.html, accessed 29
28. Lopez AD et al. Global burden of disease and risk
August 2012).
factors. New York/Washington, Oxford University
Press/The World Bank, 2006 (http://www.dcp2. 37. Schmid G. Economic and programmatic aspects
org/pubs/GBD, accessed 20 August 2012). of congenital syphilis prevention. Bulletin of the
World Health Organization, 2004, 82:402–409.
24
38. Pregnancy, childbirth, postpartum, and newborn

care: a guide for essential practice. Geneva,
World Health Organization, 2006 (http://
www.who.int/making_pregnancy_safer/
documents/924159084x/en/index.html,
39. Standards for maternal and neonatal care.
(http://www.who.int/making_pregnancy_safer/
documents/a91272/en/index.html, accessed 20
August 2012).
40. World Health Organization. Eliminating
congenital syphilis (http://www.who.int/
reproductivehealth/topics/rtis/syphilis/en/
index.html, accessed 29 August 2012).
41. Pan American Health Organization and
World Health Organization. Mother-to-child
transmission of HIV and syphilis (http://new.paho.
org/hq/index.php?option=com_content&view
=category&layout=blog&id=987&Itemid=904,
42. Elimination of parent-to-child transmission.
Cost analysis of elimination (http://www.
eptctasiapacific.org/funding-resource-needs,
43. Rydzak CE, Goldie SJ. Cost-effectiveness of rapid
point-of-care prenatal syphilis screening in sub-
Saharan Africa. Sexually Transmitted Diseases,
2008, 35:775–784.
44. Lopez AD et al., eds. Global burden of disease
and risk factors , disease control priorities project.
Washington, DC, World Bank, 2006.
44. Chesson HW et al. The estimated direct medical
cost of sexually transmitted diseases among
American youth, 2000. Perspectives on Sexual
and Reproductive Health, 2004, 36:11–19.
25
Appendix 1: economic analysis and disability-adjusted life

years calculations
Methods We assumed, based on published evidence,
that treatment was 90% effective, that coverage
We conducted an illustrative analysis of the 4-year
depends on the current proportion tested and
cost, health impact, and cost-effectiveness of
treated: 70–95% of women are in antenatal care
syphilis programmes in eight hypothetical country
(ANC), of whom 80–90% are tested, and 90–95%
case scenarios. These country scenarios vary in
of test-positive women are treated. The adverse
terms of current syphilis testing and treatment
outcomes averted were stillbirth/early fetal losses,
coverage of all pregnant women (high (70%) or low
20.9%; early neonatal deaths, 9.3%; prematurity
(20%)), syphilis ANC prevalence (high (3%) or low
or low birth weight, 5.8%; and infants with clinical
(0.5%)), and country cost of health services (high or
evidence of syphilis, 15.5%. These rates derived from
low, based on WHO CHOICE (Choosing Interventions
a systematic search and abstraction of studies of
that are Cost Effective) unit cost data).
untreated syphilis.
The cost analysis assessed the cost of the
We also assumed that treating syphilis reduced
intervention – implementing expanded testing
the horizontal spread of syphilis and had a modest
and treatment of syphilis in pregnancy. The health-
(20%) effect in reducing the effect of syphilis
impact analysis translated increased testing and
as a cofactor for transmission of HIV. The DALYs
treatment into adverse outcomes averted, and the
averted per adverse event averted were derived
associated averted disability adjusted life years
from estimates in the Global burden of disease (44).
(DALYs). The cost-effectiveness analysis adjusted for
All long-term outcomes were discounted, but
offsetting savings due to averted adverse outcomes,
the analysis did not discount over the 4 years of
and if there was still a net cost, that cost was divided
initiative implementation. Further details (including
by the DALYs averted. The key inputs, assumptions
sensitivity analyses) are available in a technical
and rationale for the calculations of the costs and
supplement on request.
DALYS results are presented in Table A.1.
Our key cost assumption concerned the cost of

Results
implementing testing and treatment. This was We found that controlling mother-to-child
derived from several sources. Key commodity prices transmission (MTCT) of syphilis appears to save
(e.g. rapid plasma reagin (RPR) tests and penicillin more than it costs in four of the eight country
doses) were determined from the World Health scenarios we examined. The initiative was cost
Organization (WHO) bulk procurement system, with saving in these four countries, even when excluding
allowances for delivery costs. The costs of labour the benefits of reducing the horizontal spread of
and of adverse outcomes were derived from an syphilis, and excluding syphilis-attributable HIV.
analysis using South Africa costs (43). The overall Results by scenario are presented Table 1.4.
cost of testing was US$1.83–2.30 per woman and
of treatment with three doses of penicillin was
US$3.72–3.79.
26
Table A.1
Inputs and assumptions for illustrative analysis of the 4-year cost, health impact, and cost-effectiveness
of syphilis programmes in 8 hypothetical country case scenarios
Parameter Value or rangea Source/notes
Adverse event rate
Stillbirth/early fetal loss 0.209 Synthesis of research findings (Table 1.1)
Early neonatal death 0.093 Synthesis of research findings (Table 1.1)
Infected infant 0.155 Synthesis of research findings (Table 1.1)
Prematurity or low birth weight 0.058 Synthesis of research findings (Table 1.1)
Costs, US$
Stillbirth / spontaneous abortion (0)–(1) Per Rydzak and Goldie 2008 (43), delivery
of healthy infant = US$58
Perinatal death 893–3571 Per Rydzak and Goldie, 2008 (43), adjust-
ed per WHO CHOICE inpatient unit costs
Infected infant 182–243 Per Blandford et al, 2007 (27), and Rydzak
and Goldie, 2008 (43), includes adjust-
ment for 30% discovery rate, adjusted per
WHO CHOICE outpatient unit costs
Prematurity or low birth weight 366–1464 Per Rydzak and Goldie, 2008 (43), adjust-
ed per WHO CHOICE inpatient unit costs
Primary syphilis 15 Estimate based on single visit, test, peni-
cillin
Secondary and early latent syphilis 15 Same as primary
Late latent and tertiary syphilis 500–2000 Based on Chesson et al, 2004 (45) esti-
mates for USA,, adjusted for lower price
and lower incidental treatment in devel-
oping countries and WHO CHOICE inpa-
tient unit costs
HIV infection 6500 (28)
Syphilis test, test + labour/supplies 1.83–2.30 Based on WHO Bulk Procurement esti-
mates (WHO, unpublished data, 2012)
Course of benzathine benzylpenicillin (3 3.72–3.79 Based on WHO Bulk Procurement esti-
doses) mates (WHO, unpublished data, 2012)
a
Values in parentheses indicate negative values.
27
Appendix 2: proposed budget for the initiative for the global

elimination of mother-to-child transmission of syphilis
5-year budget summary in US$ Year 1 Year 2 Year 3 Year 4 4-year total
Global support
1 P5, programme director, Geneva 330 000 330 000 330 000 330 000 1 320 000
1 P4, laboratory quality assurance 285 000 285 000 285 000 285 000 1 140 000
and procurement officer, Geneva
1 P3, advocacy, communications, 230 000 230 000 230 000 230 000 920 000
and fundraising officer, Geneva
1 G5, financial and administrative 170 000 170 000 170 000 170 000 680 000
officer, Geneva
Advocacy efforts 50 000 50 000 50 000 50 000 200 000
Technical and strategic support to 100 000 100 000 100 000 100 000 400 000
regions and countries
International meetings 150 000 150 000 150 000 150 000 600 000
Subtotal global support 1 315 000 1 315 000 1 315 000 1 315 000 5 260 000
Regional support
1 P3, regional officer 230 000 230 000 230 000 230 000 920 000
Technical and strategic support to 150 000 150 000 150 000 150 000 600 000
countries
Regional meetings 120 000 120 000 120 000 120 000 480 000
Subtotal regional support 960 000 960 000 960 000 960 000 3 840 000
Country support
Programme supervision 400 000 400 000 400 000 400 000 1 600 000
Advocacy and policy development 150 000 150 000 150 000 150 000 600 000
Evidence-based guideline develop- 300 000 300 000 300 000 300 000 1 200 000
ment, training and dissemination
Evaluation of indicators and impact 200 000 200 000 200 000 200 000 800 000
Strengthening of laboratory quality 300 000 300 000 300 000 300 000 1 200 000
assurance and test procurement
Policy, implementation barriers and 200 000 200 000 200 000 600 000
operational research
Research on social sciences or part- 150 000 150 000 300 000
ner management
Subtotal country support 1 550 000 1 700 000 1 700 000 1 350 000 6 300 000
Subtotal 15 400 000
Administrative support (13%) 2 002 000
Grand total 3 825 000 3 975 000 3 975 000 3 625 000 17 402 000
28
Appendix 3: list of tools available for country-level

activities
Advocacy and programme tools Nine steps for developing a scaling-up
strategy
The global elimination of congenital syphilis: • Description: a guide for programme managers
rationale and strategy for action and technical support agencies to facilitate
• Description: document outlining strategies for systematic planning for scaling up
elimination that can be used for advocacy and
• Available at: http://www.expandnet.net/
implementation
PDFs/ExpandNet-WHO%20Nine%20Step%20
• Available at: http://www.who.int/ Guide%20published.pdf
reproductivehealth/publications/
rtis/9789241595858/en/index.html
Clinical guidelines
A strategic approach to strengthening control Sexually transmitted and other reproductive
of reproductive tract and sexually transmitted tract infections: a guide to essential practice
infections • Description: a reference manual developed for
• Description: programme manager tool based health-care workers and programme managers
on stepwise and comprehensive approach to on STI/reproductive tract infection (RTI) control
integrate interventions in existing programmes and management in reproductive health settings
or to strengthen health programmes (family planning and maternal and child health
• Available at: http://www.who.int/ clinics as well as primary health care)
reproductivehealth/publications/ • Available at: http://www.who.int/
rtis/9789241598569/en/index.html reproductivehealth/publications/
Methods for surveillance and monitoring
of congenital syphilis elimination within Standards for maternal and neonatal care:
existing systems prevention of mother-to-child transmission of
• Description: tool for regional and national syphilis
programme managers on the core indicators • Description: World Health Organization (WHO)
for elimination of congenital syphilis (MTCT of recommendations on essential care for women
syphilis) efforts that are harmonized with and and their babies
integrated into existing data-collection systems
• Available at: http://www.who.int/
• Available at: http://www.who.int/ reproductivehealth/publications/maternal_
reproductivehealth/publications/ perinatal_health/prevention_mtct_syphilis.pdf
Regional and national treatment/
Global strategy for the prevention and control management guidelines
of STIs: 2006–2015. Breaking the chain of • Description: Expert recommendations on clinical
transmission management of syphilis and MTCT of syphilis
• Description: a technical and advocacy document that is locally relevant. Most nations have this
intended to offer guidance on how to improve information in national treatment guidelines
sexually transmitted infection (STI) control
programmes
The use of rapid syphilis tests
• Available at: http://www.who.int/ • Description: information for health-care workers
reproductivehealth/publications/ and laboratory technicians on the use and
rtis/9789241563475/en/ interpretation of rapid plasma reagin (RPR) and
point-of-care rapid treponemal syphilis tests
• Available at: http://www.who.int/
reproductivehealth/publications/rtis/TDR_
SDI_06_1/en/index.html
29
Appendix 4: Battling Syphilis – a Team Approach (BASTA)

participant affiliations
Alberta Health Services of Canada National Center for STD Control, China
Amsterdam institute for Global Health and National Coalition of STD, United States (NCSD)
Development (AIGHD)
Norwegian Agency for Development Cooperation
Brazil Ministry of Health (Norad)
CDC Foundation PATH
Centers for Disease Control and Prevention, United The Population Council
States (CDC)
Public Health Agency of Canada
Centro Internacional de Entrenamiento e
United Nations Population Fund (UNFPA)
Investigaciones Médicas (CIDEIM)
United Nations Children’s Fund (UNICEF)
Centro Latinoamericano de Perinatologia (CLAP)
United States Office of the US Global AIDS
Children’s Investment Fund Foundation (CIFF)
Coordinator (OGAC)
Cornell University
United States Agency for International Development
Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) (USAID)
Engenderhealth Universidad Peruana Cayetano Heredia
FHI360 University of Alabama Birmingham
The Global Fund University of Antwerp
Harvard University University of Barcelona
Health Alliance International University of California Los Angeles
Imperial College London University of California San Francisco
Institute of Development Studies University College London
Jhpiego University of Gent
Johns Hopkins University University of North Carolina
Joint United Nations Programme on HIV/AIDS University of Victoria
(UNAIDS)
University of Washington
London School of Hygiene and Tropical Medicine
Washington University in St Louis
(LSHTM)
30
For more information, please contact:
ISBN 978 92 4 150434 8
Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Fax: +41 22 791 4171
E-mail: [email protected]
www.who.int/reproductivehealth

Prolaps Uteri

Uploaded by

Copyright:

Available Formats

Prolaps Uteri

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Prolaps Uteri

Uploaded by

Copyright:

Available Formats

Investment case for

initiative for the global elimination of congenital syphilis

ISBN 978 92 4 150434 8 (NLM classification: WC 161)

© World Health Organization 2012

Printed by the WHO Document Production Services, Geneva, Switzerland

Abbreviations and acronyms vi

1. The case for investment 2

2. Details of the initiative: objectives, activities and stakeholders 10

3. The strength of this initiative 19

Appendix 1: economic analysis and disability-adjusted life years calculations 26

Appendix 3: list of tools available for country-level activities 29

Appendix 4: Battling Syphilis – a Team Approach (BASTA) participant affiliations 30

Abbreviations and acronyms

Moreover, a number of factors make this the ideal

1. The case for investment

1.1 Mother-to-child transmission of

An HIV-positive mother in Haiti successfully completes therapy for prevention of mother-to-child-

MTCT of syphilis, tetanus, malaria,

2. Details of the initiative: objectives, activities and

2.1 Choosing 12 intensified support

What is the impact of syphilis in pregnancy? Multicountry studies, possibly linking

Monitoring and evaluation issues Studies at country, regional and global

Countries are encouraged to identify opportunities

Core process indicators – routine

Additional indicators – as able

2.3 Key initiative partners Staff of the Department of HIV/AIDS collaborate

WHO programme director

Intensified support Intensified support

• an advocacy, communication and fundraising • review narrative and financial reports;

3. The strength of this initiative

3.1 Leveraging existing investments in • health-system initiatives to promote integrated

providers at the lowest level of health care. However,

These are just a few examples of the efforts and

38. Pregnancy, childbirth, postpartum, and newborn

Appendix 1: economic analysis and disability-adjusted life

Our key cost assumption concerned the cost of

Appendix 2: proposed budget for the initiative for the global

Appendix 3: list of tools available for country-level

Appendix 4: Battling Syphilis – a Team Approach (BASTA)

You might also like