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1. A Road Map for the Global Elimination of Congenital Syphilis

Author

Mary L. Kamb, Lori M. Newman, Patricia L. Riley, Jennifer Mark, Sarah J. Hawkes, Tasneem Malik, and Nathalie Broutet

Subjects
Gynecology and obstetrics, RG1-991
Abstract

Congenital syphilis is the oldest recognized congenital infection, and continues to account for extensive global perinatal morbidity and mortality today. Serious adverse pregnancy outcomes caused by maternal syphilis infection are prevented with screening early in pregnancy and prompt treatment of women testing positive. Intramuscular penicillin, an inexpensive antibiotic on the essential medicine list of nations all over the world, effectively cures infection and prevents congenital syphilis. In fact, at a cost of $11–15 per disability adjusted life year (DALY) averted, maternal syphilis screening and treatment is among the most cost-effective public health interventions in existence. Yet implementation of this basic public health intervention is sporadic in countries with highest congenital syphilis burden. We discuss the global burden of this devastating disease, current progress and ongoing challenges for its elimination in countries with highest prevalence, and next steps in ensuring a world free of preventable perinatal deaths caused by syphilis.

Published
2010
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4. The cost and cost-effectiveness of scaling up screening and treatment of syphilis in pregnancy: a model.

Author

James G Kahn, Aliya Jiwani, Gabriela B Gomez, Sarah J Hawkes, Harrell W Chesson, Nathalie Broutet, Mary L Kamb, and Lori M Newman

Subjects
Medicine, Science
Abstract

BackgroundSyphilis in pregnancy imposes a significant global health and economic burden. More than half of cases result in serious adverse events, including infant mortality and infection. The annual global burden from mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million disability-adjusted life years (DALYs) and $309 million in medical costs. Syphilis screening and treatment is simple, effective, and affordable, yet, worldwide, most pregnant women do not receive these services. We assessed cost-effectiveness of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in various programmatic, epidemiologic, and economic contexts.Methods and findingsWe modeled the cost, health impact, and cost-effectiveness of expanded syphilis screening and treatment in ANC, compared to current services, for 1,000,000 pregnancies per year over four years. We defined eight generic country scenarios by systematically varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. We calculated program and net costs, DALYs averted, and net costs per DALY averted over four years in each scenario. Program costs are estimated at $4,142,287 - $8,235,796 per million pregnant women (2010 USD). Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program averts an estimated 5,754 - 93,484 DALYs, yielding net savings in four scenarios, and a cost per DALY averted of $24 - $111 in the four scenarios with net costs. Results were robust in sensitivity analyses.ConclusionsEliminating MTCT of syphilis through expanded screening and treatment in ANC is likely to be highly cost-effective by WHO-defined thresholds in a wide range of settings. Countries with high prevalence, low current service coverage, and high healthcare cost would benefit most. Future analyses can be tailored to countries using local epidemiologic and programmatic data.

Published
2014
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5. Early antenatal care: does it make a difference to outcomes of pregnancy associated with syphilis? A systematic review and meta-analysis.

Author

Sarah J Hawkes, Gabriela B Gomez, and Nathalie Broutet

Subjects
Medicine, Science
Abstract

Despite an increase in the proportion of women who access antenatal care, mother-to-child transmission of syphilis continues to be a consequence of undiagnosed, untreated, or inadequately treated maternal syphilis. We reviewed evidence on the optimal timing of antenatal interventions to prevent mother-to-child transmission of syphilis and its associated adverse outcomes.Systematic review and meta-analysis of published literature. English-language articles were included if they (1) reported the gestational age at which the mother was screened or tested for syphilis; (2) reported on pregnancy outcome. No publication date limits were set.We identified a total of 1,199 publications, of which 84 were selected for further review and five were included. All showed a lower prevalence of any adverse outcome among women who received an intervention (to include screening and treatment) in the first and second trimesters of pregnancy compared to the third trimester. The overall odds ratio for any adverse outcome was 2.24 (95% CI 1.28, 3.93). All sub-analyses by type of outcome presented important heterogeneity between studies, except for those studies reporting an infected infant (odds ratio 2.92, 95% CI 0.66, 12.87; I(2) = 48.2%, p = 0.165).Our review has shown that the timing of antenatal care interventions makes a significant difference in the risk of having an adverse outcome due to syphilis. Women who sought care in the first two trimesters of their pregnancy, and received the appropriate intervention, were more likely to have a healthy infant, compared to women screened and treated in the third trimester. Encouraging ALL pregnant women to seek care in the first two trimesters of their pregnancy should be a priority for health programmes. For interventions to be effective within these health programmes, health systems and community engagement programmes need to be strengthened to enable pregnant women to seek antenatal care early.

Published
2013
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6. Contributors

Author

Mark J. Abzug, Elisabeth E. Adderson, Allison L. Agwu, Kevin Alby, Grace M. Aldrovandi, Upton D. Allen, Gerardo Alvarez-Hernández, Krow Ampofo, Evan J. Anderson, Margot Anderson, Stella Antonara, Monica I. Ardura, Paul M. Arguin, John C. Arnold, Naomi E. Aronson, Ann M. Arvin, Shai Ashkenazi, Edwin J. Asturias, Vahe Badalyan, Carol J. Baker, Karthik Balakrishnan, Brittany S. Barros, William J. Barson, Daniel G. Bausch, Kirsten Bechtel, Daniel K. Benjamin, David M. Berman, David A. Blanco, Karen C. Bloch, Margaret J. Blythe, Joseph A. Bocchini, Anna Bowen, William R. Bowie, Thomas G. Boyce, John S. Bradley, Michael T. Brady, Denise F. Bratcher, Paula K. Braverman, Joseph Bresee, Itzhak Brook, Kevin E. Brown, Kristina Bryant, E. Stephen Buescher, Jane L. Burns, Carrie L. Byington, Andres F. Camacho-Gonzalez, Paul Cantey, Bryan D. Carter, Mary T. Caserta, Luis A. Castagnini, Chiara Cerini, Ellen Gould Chadwick, Silvia S. Chiang, John C. Christenson, Susan E. Coffin, Melissa G. Collier, Jennifer P. Collins, Laurie S. Conklin, Beverly L. Connelly, Despina Contopoulos-Ioannidis, James H. Conway, Margaret M. Cortese, Elaine G. Cox, C. Buddy Creech, Jonathan D. Crews, Dennis J. Cunningham, Nigel Curtis, Natalie J.M. Dailey, Lara A. Danziger-Isakov, Toni Darville, Gregory A. Dasch, Irini Daskalaki, Robert S. Daum, Michael Davenport, H. Dele Davies, Fatimah S. Dawood, J. Christopher Day, Maite de la Morena, Gail J. Demmler-Harrison, Gregory P. DeMuri, Dickson D. Despommier, Karen A. Diefenbach, Kathryn M. Edwards, Morven S. Edwards, Lawrence F. Eichenfield, Dirk M. Elston, Beth Emerson, Moshe Ephros, Guliz Erdem, Marina E. Eremeeva, Jessica E. Ericson, Douglas H. Esposito, Monica M. Farley, Anat R. Feingold, Kristina N. Feja, Adam Finn, Marc Fischer, Patricia M. Flynn, LeAnne M. Fox, Michael M. Frank, Douglas R. Fredrick, Robert W. Frenck, Sheila Fallon Friedlander, Hayley A. Gans, Gregory M. Gauthier, Jeffrey S. Gerber, Francis Gigliotti, Mark A. Gilger, Carol A. Glaser, Amanda F. Goddard, Benjamin D. Gold, Jane M. Gould, Michael Green, David Greenberg, Tanya Greywal, Daniel Griffin, Patricia M. Griffin, Alexei A. Grom, Kathleen Gutierrez, Julie Gutman, Judith A. Guzman-Cottrill, Aron J. Hall, Jin-Young Han, Marvin B. Harper, Julie R. Harris, Christopher J. Harrison, David B. Haslam, Sarah J. Hawkes, J. Owen Hendley, Marion C.W. Henry, Joseph A. Hilinski, Susan L. Hills, Scott D. Holmberg, Deborah Holtzman, David K. Hong, Peter J. Hotez, Katherine K. Hsu, David A. Hunstad, Loris Y. Hwang, Mary Anne Jackson, Richard F. Jacobs, Ravi Jhaveri, Kateřina Jirků-Pomajbíková, Jeffrey L. Jones, Mahima Karki, M. Gary Karlowicz, Ben Z. Katz, Ishminder Kaur, Gilbert J. Kersh, Jay S. Keystone, Muhammad Ali Khan, David W. Kimberlin, Martin B. Kleiman, Bruce S. Klein, Karl Klontz, Barbara Knust, Andrew Y. Koh, E. Kent Korgenski, Paul Krogstad, Preeta Krishnan Kutty, Christine T. Lauren, Hillary S. Lawrence, Amy Leber, Grace M. Lee, Eugene Leibovitz, Eyal Leshem, Stéphanie Levasseur, David B. Lewis, Robyn A. Livingston, Eloisa Llata, Sarah S. Long, Ben A. Lopman, Yalda C. Lucero, Jorge Luján-Zilbermann, Katherine Luzuriaga, Noni E. MacDonald, Yvonne A. Maldonado, John Manaloor, Chitra S. Mani, Kalpana Manthiram, Gary S. Marshall, Stacey W. Martin, Almea Matanock, Catalina Matiz, Alison C. Mawle, Tony Mazzulli, Kathleen A. McGann, Kenneth McIntosh, Lucy A. McNamara, Michal Meir, Debrah Meislich, H. Cody Meissner, Elissa Meites, Asunción Mejías, Jussi Mertsola, Kevin Messacar, Mohammed Nael Mhaissen, Marian G. Michaels, Melissa B. Miller, Eric D. Mintz, John F. Modlin, Parvathi Mohan, Susan P. Montgomery, José G. Montoya, Pedro L. Moro, Anna-Barbara Moscicki, R. Lawrence Moss, Angela L. Myers, Simon Nadel, Michael N. Neely, Karen P. Neil, Joanna Nelson, Noele P. Nelson, William L. Nicholson, Victor Nizet, Amy Jo Nopper, Theresa J. Ochoa, Walter A. Orenstein, Miguel O'Ryan, Christopher D. Paddock, Harpreet Pall, Suresh Kumar Panuganti, Diane E. Pappas, Robert F. Pass, Thomas F. Patterson, Monica E. Patton, Stephen I. Pelton, Brett W. Petersen, Larry K. Pickering, Swetha Pinninti, Paul J. Planet, Andrew J. Pollard, Klara M. Posfay-Barbe, Casper S. Poulsen, Susan M. Poutanen, Ann M. Powers, Charles G. Prober, Octavio Ramilo, Shawn J. Rangel, Suchitra Rao, Sarah A. Rawstron, Jennifer S. Read, Michael D. Reed, Ryan F. Relich, Megan E. Reller, Neil Rellosa, Katherine A. Rempe, Melissa A. Reyes, Samuel E. Rice-Townsend, Frank O. Richards, José R. Romero, David A. Rosen, Christina A. Rostad, G. Ingrid J.G. Rours, Janell A. Routh, Anne H. Rowley, Lorry G. Rubin, Edward T. Ryan, Lisa Saiman, Julia S. Sammons, Laura Sass, Jason B. Sauberan, Sarah Schillie, Grant S. Schulert, Jennifer E. Schuster, Kevin L. Schwartz, Bethany K. Sederdahl, Jose A. Serpa, Kara N. Shah, Samir S. Shah, Andi L. Shane, Eugene D. Shapiro, Jana Shaw, Avinash K. Shetty, Linda M. Dairiki, George Kelly Siberry, Jane D. Siegel, Robert David Siegel, Kari A. Simonsen, Nalini Singh, Upinder Singh, P. Brian Smith, John D. Snyder, Eunkyung Song, Jennifer L. Sorrell, Emily Souder, Joseph W. St. Geme, Mary Allen Staat, J. Erin Staples, Jeffrey R. Starke, William J. Steinbach, Christen R. Stensvold, Bradley P. Stoner, Raymond A. Strikas, Jonathan B. Strober, Paul K. Sue, Deanna A. Sutton, Douglas Swanson, Jacqueline E. Tate, Marc Tebruegge, Eyasu H. Teshale, Amelia B. Thompson, George R. Thompson, Robert Thompson-Stone, Richard B. Thomson, Emily A. Thorell, Nicole H. Tobin, Philip Toltzis, James Treat, Stephanie B. Troy, Russell B. Van, Louise Elaine Vaz, Jennifer Vodzak, Ellen R. Wald, Rebecca Wallihan, Zoon Wangu, Matthew Washam, Joshua R. Watson, Rachel L. Wattier, Geoffrey A. Weinberg, A. Clinton White, Harold C. Wiesenfeld, John V. Williams, Rodney E. Willoughby, Sarah L. Wingerter, Robert R. Wittler, Karen K. Wong, Kimberly A. Workowski, Terry W. Wright, Pablo Yagupsky, Catherine Yen, Jumi Yi, Jonathan S. Yoder, Edward J. Young, Andrea L. Zaenglein, and Kanecia Zimmerman

Published
2018
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7. Contributors

Author

Elisabeth E. Adderson, Aarti Agarwal, Grace M. Aldrovandi, Upton D. Allen, Manuel R. Amieva, Krow Ampofo, Alicia D. Anderson, Margot Anderson, Paul M. Arguin, John C. Arnold, Ann M. Arvin, Shai Ashkenazi, Carol J. Baker, William J. Barson, Daniel G. Bausch, Kirsten Bechtel, Daniel K. Benjamin, Frank E. Berkowitz, Margaret J. Blythe, Joseph A. Bocchini, Michael Boeckh, Anna Bowen, William R. Bowie, Thomas G. Boyce, John S. Bradley, Michael T. Brady, Denise F. Bratcher, Paula K. Braverman, Caroline Breese Hall, Joseph S. Bresee, Itzhak Brook, Kristina Bryant, E. Stephen Buescher, Jane L. Burns, Gale R. Burstein, Carrie L. Byington, Kathy K. Byrd, Michael Cappello, Bryan D. Carter, Emily J. Cartwright, Mary T. Caserta, Chiara Cerini, Ellen Gould Chadwick, Beth Cheesebrough, P. Joan Chesney, John C. Christenson, Thomas G. Cleary, Susan E. Coffin, Laura M. Conklin, Laurie S. Conklin, Beverly L. Connelly, Despina Contopoulos-Ioannidis, James H. Conway, Margaret M. Cortese, C. Michael Cotten, Elaine Cox, Maryanne E. Crockett, James E. Crowe, Nigel Curtis, Dennis J. Cunningham, Linda Marie Dairiki Shortliffe, Toni Darville, Gregory A. Dasch, Irini Daskalaki, Robert S. Daum, Fatimah S. Dawood, Gail J. Demmler, Dickson D. Despommier, Karen A. Diefenbach, Christopher C. Dvorak, Kathryn M. Edwards, Morven S. Edwards, Lawrence F. Eichenfield, Dirk M. Elston, Janet A. Englund, Veronique Erard, Marina E. Eremeeva, Anat R. Feingold, Adam Finn, Anthony E. Fiore, Marc Fischer, Sarah J. Fitch, Patricia M. Flynn, LeAnne M. Fox, Michael M. Frank, Douglas R. Fredrick, Sheila Fallon Friedlander, Hayley A. Gans, Carla G. Garcia, Maria C. Garzon, Jeffrey S. Gerber, Michael D. Geschwind, Laura B. Gieraltowski, Francis Gigliotti, Peter H. Gilligan, Carol Glaser, Benjamin D. Gold, Brahm Goldstein, Jane M. Gould, Michael Green, David Greenberg, Patricia M. Griffin, Alexei A. Grom, Kathleen Gutierrez, Judith A. Guzman-Cottrill, Aron J. Hall, Marvin B. Harper, Christopher J. Harrison, David B. Haslam, Sarah J. Hawkes, Edward B. Hayes, Rohan Hazra, Sara Jane Heilig, J. Owen Hendley, Marion C.W. Henry, Joseph A. Hilinski, Scott D. Holmberg, Deborah Holtzman, Peter J. Hotez, Katherine K. Hsu, Dale J. Hu, Loris Y. Hwang, David Y. Hyun, Mary Anne Jackson, Richard F. Jacobs, Jeffrey L. Jones, Saleem Kamili, M. Gary Karlowicz, Ben Z. Katz, Gilbert J. Kersh, Laura M. Kester, Jay S. Keystone, David W. Kimberlin, Martin B. Kleiman, Mark W. Kline, Andrew Y. Koh, Andreas Konstantopoulos, Katalin I. Koranyi, E. Kent Korgenski, Andrew T. Kroger, Paul Krogstad, Christine T. Lauren, Hillary S. Lawrence, Eugene Leibovitz, Stéphanie Levasseur, David B. Lewis, Jay M. Lieberman, Jen-Jane Liu, Robyn A. Livingston, Eloisa Llata, Anagha R. Loharikar, Sarah S. Long, Ben A. Lopman, Bennett Lorber, Donald E. Low, Yalda C. Lucero, Jorge Luján-Zilbermann, Katherine Luzuriaga, Noni E. MacDonald, Adam MacNeil, Yvonne A. Maldonado, Chitra S. Mani, Mario J. Marcon, Gary S. Marshall, Stacey W. Martin, Catalina Matiz, Alison C. Mawle, Tony Mazzulli, George H. McCracken, Matthew B. McDonald, Robert S. McGregor, Kenneth McIntosh, Meredith McMorrow, Candice McNeil, Jennifer H. McQuiston, Debrah Meislich, H. Cody Meissner, Asunción Mejías, Manoj P. Menon, Jussi Mertsola, Marian G. Michaels, Melissa B. Miller, Eric D. Mintz, John F. Modlin, Parvathi Mohan, Susan P. Montgomery, Jose G. Montoya, Zack S. Moore, Maite de la Morena, Pedro L. Moro, Anna-Barbara Moscicki, R. Lawrence Moss, Trudy V. Murphy, Dennis L. Murray, Angela L. Myers, Simon Nadel, James P. Nataro, Michael N. Neely, William L. Nicholson, Victor Nizet, Amy Jo Nopper, Anna Norrby-Teglund, Theresa J. Ochoa, Miguel O’Ryan, Walter A. Orenstein, Christopher D. Paddock, Diane E. Pappas, Robert F. Pass, Thomas F. Patterson, Stephen I. Pelton, Larry K. Pickering, Caroline Diane Sarah Piggott, Philip A. Pizzo, Andrew J. Pollard, Klara M. Posfay-Barbe, Susan M. Poutanen, Dwight A. Powell, Alice S. Prince, Charles G. Prober, Octavio Ramilo, Shawn J. Rangel, Sarah A. Rawstron, Jennifer S. Read, Michael D. Reed, Joanna J. Regan, Megan E. Reller, Melissa A. Reyes, Peter A. Rice, Samuel E. Rice-Townsend, Frank O. Richards, Gail L. Rodgers, Pierre E. Rollin, José R. Romero, G. Ingrid J.G. Rours, Anne H. Rowley, Sharon L. Roy, Lorry G. Rubin, Guillermo M. Ruiz-Palacios, Lisa Saiman, Laura Sass, Jason B. Sauberan, Peter M. Schantz, Eileen Schneider, Gordon E. Schutze, Benjamin Schwartz, Heidi Schwarzwald, Kara N. Shah, Samir S. Shah, Andi L. Shane, Craig A. Shapiro, Eugene D. Shapiro, Umid M. Sharapov, Jana Shaw, George Kelly Siberry, Jane D. Siegel, Robert David Siegel, Nalini Singh, Upinder Singh, P. Brian Smith, John D. Snyder, David E. Soper, Mary Allen Staat, J. Erin Staples, Jeffrey R. Starke, William J. Steinbach, Ina Stephens, Joseph W. St. Geme, Bradley P. Stoner, Jonathan B. Strober, Kanta Subbarao, Deanna A. Sutton, Douglas Swanson, Leonel T. Takada, Jacqueline E. Tate, Robert V. Tauxe, Marc Tebruegge, Eyasu H. Teshale, George R. Thompson, Herbert A. Thompson, Richard B. Thomson, Emily A. Thorell, Rania A. Tohme, Robert W. Tolan, Philip Toltzis, James Treat, Stephanie B. Troy, Russell B. Van Dyke, Jorge J. Velarde, Jennifer Vodzak, Ellen R. Wald, Geoffrey A. Weinberg, A. Clinton White, Marc-Alain Widdowson, Harold C. Wiesenfeld, John V. Williams, Roxanne E. Williams, Rodney E. Willoughby, Craig M. Wilson, Sarah L. Wingerter, Jerry A. Winkelstein, Kimberly A. Workowski, Terry W. Wright, Pablo Yagupsky, Nada Yazigi, Catherine Yen, Edward J. Young, Andrea L. Zaenglein, and Theoklis E. Zaoutis

Published
2012
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8. Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis

Author

Nicola Low, Sarah J Hawkes, and Dadong Wu

Subjects
Medicine (General), R5-920, Infectious and parasitic diseases, RC109-216
Abstract

Introduction Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation.Methods Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts.Results A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control.Conclusion Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts’ views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.

Published
2024
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9. Scaling up syphilis testing in China: implementation beyond the clinic

Author

Joseph D Tucker, Sarah J Hawkes, Yue-Pin Yin, Rosanna W Peeling, Myron S Cohen, and Xiang-Sheng Chen

Subjects
Public aspects of medicine, RA1-1270
Abstract

China is experiencing a syphilis epidemic of enormous proportions. The regions most heavily affected by syphilis correspond to regions where sexually transmitted HIV infection is also a major public health threat. Many high-risk patients in China fail to receive routine syphilis screening. This missed public health opportunity stems from both a failure of many high-risk individuals to seek clinical care and a disconnect between policy and practice. New point-of-care syphilis testing enables screening in non-traditional settings such as community organizations or sex venues. This paper describes the current Chinese syphilis policies, suggests a spatiotemporal framework (based on targeting high-risk times and places) to improve screening and care practices, and emphasizes a syphilis control policy extending beyond the clinical setting.

Published
2010

10. Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis

Author

Gabriela B Gomez, Mary L Kamb, Lori M Newman, Jennifer Mark, Nathalie Broutet, and Sarah J Hawkes

Subjects
Public aspects of medicine, RA1-1270
Abstract

OBJECTIVE: To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis. METHODS: PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for Treponema pallidum infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses. FINDINGS: Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0-74.1]; I²=91.8%; P

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