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We agree with David Mabey and Rosanna Peeling1 that the Review by Sarah Hawkes and colleagues2 is a “timely reminder that syphilis has not disappeared, and remains a major, although entirely preventable, cause of death in newborn babies”. This reminder echoes what we wrote 10 years ago3 and highlights the absence of progress made in the intervening years. In 2007, WHO launched its global initiative to eliminate congenital syphilis. 5 years later, evidently, little has changed.

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Centers for Disease Control and Prevention, Atlanta,   makers might have chosen to give                      1   Mabey D, Peeling RW. Syphilis, still a major
GA, USA (THH); and Medical Research Council, Cape                                                                cause of infant mortality. Lancet Infect Dis
                                                       little attention to the scourge of                        2011; 11: 654–55.
Town, South Africa (RR, TM)
                                                       congenital syphilis in part because                   2   Hawkes S, Matin N, Broutet N, Low N.
1    Holtz TH, Kabera G, Mthiyane T, et al. Use of a
     WHO-recommended algorithm to reduce               of two Cochrane              systematic                   Effectiveness of interventions to improve
                                                                                                                 screening for syphilis in pregnancy: a
     mortality in seriously ill patients with HIV      reviews,4,5 which they incorrectly                        systematic review and meta-analysis.
     infection and smear-negative pulmonary
     tuberculosis in South Africa: an observational    claimed showed “no good evidence                          Lancet Infect Dis 2011; 11: 684–91.
     cohort study. Lancet Infect Dis 2011;             that the treatment of syphilis                        3   Walker DG, Walker GJ. Forgotten but not gone:
     11: 533–40.                                                                                                 the continuing scourge of congenital syphilis.
                                                       in pregnant women improved                                Lancet Infect Dis 2002; 2: 432–36.
2    WHO. Improving the diagnosis and treatment
     of smear-negative pulmonary and                   pregnancy outcome”. However, the                      4   Walker GJA. Antibiotics for syphilis diagnosed
     extrapulmonary tuberculosis among adults          systematic review,4 authored by one                       during pregnancy. Cochrane Database Syst Rev
     and adolescents: recommendations for HIV-                                                                   2001; 3: CD001143.
     prevalent and resource-constrained settings.      of us, concluded that “...there is no                 5   Blencowe H, Cousens S, Kamb M, Berman S,
     Geneva: World Health Organization; 2007.          doubt that penicillin is effective in                      Lawn JE. Lives saved tool supplement
3    Wilson D, Mbhele L, Badri M, et al. Evaluation                                                              detection and treatment of syphilis in
                                                       the treatment of syphilis in pregnancy                    pregnancy to reduce syphilis related stillbirths
     of the World Health Organization algorithm
     for the diagnosis of HIV-associated sputum        and the prevention of congenital                          and neonatal mortality. BMC Public Health
     smear-negative tuberculosis.                      syphilis”. The second review5 men-                        2011; 11 (suppl 3): S9.
     Int J Tuberc Lung Dis 2011; 15: 919–24.                                                                 6   Walker DG, Walker GJA. Prevention of
4    Schaaf HS, Nel ED, Beyers N, Gie RP, Scott F,
                                                       tioned by Mabey and Peeling1 states                       congenital syphilis—time for action.
     Donald PR. A decade of experience with            that “detection and appropriate,                          Bull World Health Organ 2004; 82: 401.
     Mycobacterium tuberculosis culture from           timely penicillin treatment is a highly               7   Walker GJA, Walker DG. Congenital syphilis:
     children: a seasonal influence on incidence of                                                               a continuing but neglected problem.
     childhood tuberculosis. Tuber Lung Dis 1996;      effective intervention to reduce                           Semin Fetal Neonatal Med 2007; 12: 198–206.
     77: 43–46.                                        adverse syphilis-related pregnancy
5    Koole O, Colebunders R. Reducing mortality        outcomes”.
     from HIV infection and tuberculosis.
     Lancet Infect Dis 2011; 11: 494–95.                  To misinterpret the findings                        We read with interest Sarah Hawkes
                                                       of systematic reviews and place                       and colleagues’ Article1 that assessed
                                                       responsibility on them for the failure                the effectiveness of interventions
                                                       to adequately control congenital                      to improve screening for syphilis in
Syphilis: still a major                                syphilis diverts attention away from                  pregnancy. The investigators highlight
                                                       organisations such as WHO, which                      several possible interventions during
cause of infant                                        should be working with governments                    pregnancy and suggest that antenatal
mortality                                              and other partners to increase                        syphilis screening could reduce the
We agree with David Mabey and                          efforts to tackle congenital syphilis.                 incidence of perinatal death and
Rosanna Peeling1 that the Review                       Unfortunately, babies in countries as                 stillbirths attributable to syphilis by
by Sarah Hawkes and colleagues2                        diverse as Australia, Belarus, China,                 50%. In addition to the interventions
is a “timely reminder that syphilis                    and Haiti continue to be born with                    during pregnancy, we would like to
has not disappeared, and remains a                     congenital syphilis. This situation                   draw attention to the importance
major, although entirely preventable,                  should be unacceptable. That                          of premarital syphilis screening for
cause of death in newborn babies”.                     antenatal screening and treatment                     prevention of adverse syphilis-related
This reminder echoes what we                           can work is well known, and yet there                 pregnancy outcomes in syphilis-
wrote 10 years ago3 and highlights                     has been limited success over the                     epidemic countries such as China.
the absence of progress made in                        past decade in controlling, let alone                   In China, premarital check-ups
the intervening years. In 2007, WHO                    eliminating, congenital syphilis. As                  that include syphilis screening were
launched its global initiative to                      we have argued previously on several                  requested by the Law Concerning the
eliminate congenital syphilis. 5 years                 occasions,3,4,6,7 the time has come to                Mother and Infant Care in 1994.2 As a
later, evidently, little has changed.                  be more ambitious, resourceful, and                   result of implementation of the Law,
  In 2002, we argued for a task-force                  innovative in preventing this tragedy.                the proportion of prospective couples
approach by international health                       Business as usual is not an option.                   receiving premarital syphilis checkups
agencies, which gives a focused but                    We declare that we have no conflicts of interest.
                                                                                                             increased steadily to a national rate
flexible commitment to dealing with                                                                           of 68% in 2002.3 However, this rate
this tragic situation, rather than one                 Damian G Walker, Godfrey J A Walker                   dropped substantially to less than
relying only on traditional antenatal                  damian.walker@gatesfoundation.org                     5% after introduction of the revised
screening and treatment.3 Mabey and                    Health Economics and Financing, Global Health, Bill   Regulations Governing Marriage
                                                       and Melinda Gates Foundation, Seattle, WA, USA
Peeling1 and Hawkes and colleagues2                    (DGW); and School of Reproductive and
                                                                                                             Registration in 2003, in which
ignored the conclusions of our 2002                    Developmental Medicine, Division of Perinatal and     compulsory premarital check-ups
Personal View. Furthermore, Mabey                      Reproductive Medicine, The University of Liverpool,   were abolished,4 partly because of
                                                       Liverpool, UK (GJAW)
and Peeling1 suggest that policy                                                                             the negative attitude toward the

www.thelancet.com/infection Vol 12 April 2012                                                                                                                                 269

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