The Lancet Regional Health – Americas
Congenital syphilis (CS) is caused by vertical transmission of the bacteria Treponema pallidum from mother to baby. Globally, syphilis during pregnancy is the second major cause of stillbirth and can also result in prematurity, low birthweight, and neonatal death. Syphilis can be successfully treated with penicillin after a quick 20-min diagnostic test during prenatal visits, preventing transmission, and protecting the baby; however, if left untreated, mothers have roughly a 50% chance of infecting their babies.
Besides the devastating impacts CS has on neonates, mothers also face high mental health distress during puerperium. A study by Tavares et al done in a hotspot for CS in the northeast region of Brazil revealed that, compared with mothers of healthy neonates, mothers of neonates with CS had lower scores in all domains of quality of life (physical, psychological, social, and environmental) and higher levels of anxiety and depressive symptoms—which remain significantly higher 3 months postpartum. The study builds up evidence for a broader approach when public policies are considered to face the syphilis epidemics in the region. Although strategies are designed to eliminate syphilis and mother-to-child transmission (MTCT), adequate psychological support and counselling in the postpartum period should be considered a priority to ensure the quality of life of the mother and avoid deleterious impacts on the child's development.
The region of the Americas has the third highest rate of CS globally, with uneven distributions in different countries. Preliminary data show that 2100 babies were born with syphilis in the USA in 2020, a 12.3% increase compared with the previous year and over 200% compared with 2015. During the same period, many other countries have successfully eliminated MTCT of syphilis, including a few neighbouring countries in the Caribbean. CS is an intriguing case, where many Caribbean and Central American countries are doing far better than their richer neighbours when it comes to eliminating transmission and congenital disease. Since 2015, WHO has recognised the dual elimination of MTCT of HIV and syphilis in eight Caribbean countries and territories: Cuba (2015); Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, and St Kitts and Nevis (2017); and Domenica (2021). These successful examples have in common the implementation of coordinated, evidence-based interventions to reduce the risk of transmission and make quality antenatal care available to all, and they should be a model to follow. Although no other countries in the Americas have reached this elimination status, some have made considerable progress. In 2018, Nicaragua and Honduras increased access to prenatal care, screening, and link to treatment for positive syphilis diagnosis to 95% or more of pregnant women. WHO recommends that all pregnant women be tested for HIV, syphilis, and hepatitis B at least once during pregnancy, preferably in the first trimester. Because many people with syphilis can be asymptomatic or have minor symptoms that go unnoticed, consolidating screening as an integral part of antenatal care is a key strategy in this fight. By contrast with the remarkable advances in Central American countries, the US CDC recognised the lack of timely prenatal care and adequate treatment despite a syphilis diagnosis as the two most important prevention opportunities missed by the USA, which were reflected in the disastrous results observed in 2019–20.
To some extent, the capacity of a country to control and eliminate a preventable, easily diagnosed, and treatable disease is a reflexion of the quality of its primary care services. However, internal disparities, stigma, and other socio-determinants of health must not be overlooked. Despite being a reference for primary care access through its free unified health system (SUS), Brazil also had a 170% increase in incident syphilis cases during 2010–15, which prompted the Minister of Health to issue a “Strategic Actions Agenda for Reducing Syphilis in Brazil”, which included the pilot project “Syphilis No!”. The programme selected 100 municipalities with the highest burden of CS in 2015 to implement specific strategic actions through Research and Intervention Supporters acting closely with local health managers to expand coverage of diagnosis and timely and appropriate treatment of pregnant women and sexual partners in prenatal care, childbirth, or abortion situations. In a interrupted time series comprising periods before, during, and after interventions, Pinto et al highlighted the success of the “Syphilis No!” project, which reversed the CS trend in Brazil after 2018, while also discussing the unequal CS incidence throughout the country. The Brazilian case can be considered a model to follow; however, targeted actions rely on the availability of data and national and subnational records on syphilis and CS in the region are limited, with high rates of subnotifications. Strengthening surveillance and notification triage systems should be absolute priorities for all countries aiming for effective interventions to eliminate syphilis MTCT.
A preventable and treatable disease should be progressing towards elimination, but most countries in the Americas are far from reaching the SDG goal to reduce cases by 90% and eliminate MTCT by 2030. The roadmap to reverse this unacceptable reality and secure future generations free of diseases will require antenatal care and postpartum psychological support through an integrated health system that is universally accessible. What are we waiting for?