OMS eliminación de la transmisión madre-hijo de sífilis 2012
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  • 1. Investment case for eliminating mother-to-child transmission of syphilis Promoting better maternal and child health and stronger health systemsinitiative for the global elimination of congenital syphilis
  • 2. Investment case for eliminatingmother-to-child transmission of syphilisPromoting better maternal and child health and stronger health systems
  • 3. WHO Library Cataloguing-in-Publication DataInvestment case for eliminating mother-to-child transmission of syphilis: promoting better maternal andchild health and stronger health systems.1.Syphilis – transmission. 2.Syphilis – prevention and control. 3.Syphilis, Congenital. 4.Infectious DiseaseTransmission, Vertical. 5.Infant, Newborn, Diseases. I.World Health Organization.ISBN 978 92 4 150434 8 (NLM classification: WC 161)© World Health Organization 2012All 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: bookorders@who.int).Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercialdistribution – 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 statusof any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries. Dotted lines on maps represent approximate border lines for which there may not yet be fullagreement.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 arenot mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initialcapital 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 thereader. In no event shall the World Health Organization be liable for damages arising from its use.Printed by the WHO Document Production Services, Geneva, Switzerlandii
  • 4. ContentsAbbreviations and acronyms ivExecutive summary 11. The case for investment 21.1 Mother-to-child transmission of syphilis: a continuing public health burden 21.2 Addressing syphilis in pregnant women: a feasible solution 31.3 Why now is the time to invest in elimination of mother-to-child transmission of syphilis 31.4 Why the problem persists 51.5 The strong economic case for syphilis elimination 61.6 Who should invest in the elimination of mother-to-child transmission of syphilis? 81.7 How much and what sort of investment is needed? 92. Details of the initiative: objectives, activities and stakeholders 102.1 Choosing 10 intensified support countries 102.2 Activities 112.3 Key initiative partners 152.4 Management structure 163. The strength of this initiative 193.1 Leveraging existing investments in maternal and child health 193.2 Supporting country-level impact through global coordination 193.3 Investing in surveillance, monitoring and evaluation 203.4 Implementing knowledge and best practices 21References 23Appendix 1: economic analysis and disability-adjusted life years calculations 26Appendix 2: proposed budget for the initiative for the global elimination ofmother-to-child transmission of syphilis 28Appendix 3: list of tools available for country-level activities 29Advocacy and programme tools 29Clinical guidelines 29Appendix 4: Battling Syphilis – a Team Approach (BASTA) participant affiliations 30 iii
  • 5. Investment case for eliminating mother-to-child transmission of syphilisAbbreviations and acronymsANC antenatal careBASTA Battling Against Syphilis – a Team ApproachCDC Centers for Disease Control and Prevention (USA)DALY disability-adjusted life yearDSTDP Division of STD PreventionMCA WHO Department of Maternal, Child and Adolescent HealthMCH maternal and child healthMDG millennium development goalMTCT mother-to-child transmission (of syphilis and/or HIV)NGO nongovernmental organizationPAHO Pan American Health OrganizationPGT programme guidance toolPMTCT prevention of mother-to-child transmission (of HIV)RHR WHO Department of Reproductive Health and ResearchRPR rapid plasma reaginRTI reproductive tract infectionSTI sexually transmitted infectionUN United NationsUNAIDS Joint United Nations Programme on HIV/AIDSUNFPA United Nations Population FundUNICEF United Nations Children’s FundUSA United States of AmericaVDRL venereal disease research laboratoryWHO World Health Organizationiv
  • 6. Investment case for eliminating mother-to-child transmission of syphilisExecutive summaryNearly 1.5 million pregnant women are infected This investment case outlines why and how anwith probable active syphilis each year, and investment of US$17 million over 4 years can:approximately half of infected pregnant women whoare untreated, will experience adverse outcomes • reduce adverse outcomes of syphilis indue to syphilis, such as early fetal loss and stillbirth, pregnancy by 2015 through intensified support to 12 high-burden countries, and develop aneonatal death, low-birth-weight infants, and infants stronger global network to eliminate MTCT ofwith 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 healthstillbirths and fetal and neonatal deaths, and an services, as well as maternal and child healthadditional 215 000 infants at increased risk of dying services, to ensure dual elimination of MTCT offrom 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 atMother-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 andrelatively simple to eliminate and it is inexpensive international consultations, it is clear that a numberto 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, preventionInvesting in screening and treatment for syphilis of MTCT of HIV, and other programmes, which arein pregnant women ranks as one of the most funded through various sources. Countries havecost-effective antenatal interventions. Screening asked for technical support to prioritize and scaleall pregnant women, using simple and low-cost up interventions for MTCT of syphilis in a waytechnologies, is feasible, even in low-resource that builds upon existing investments in maternalsettings. Syphilis is easily cured with penicillin, and and child health services. The investment caseMTCT of syphilis is easily prevented when pregnant is not intended to provide resources for routinemothers with syphilis infection are identified programme management and operations at theearly and treated promptly. Penicillin is off patent, country level, but rather to assist countries inwidely 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 healthinexpensive. plans and expenditure for ANC.Moreover, a number of factors make this the ideal Despite its devastating impact, MTCT of syphilistime to invest, specifically: the strong political is preventable and curable. And now – more thanwill on the part of many governments in high- ever before – is the right time to address it with aburden countries to support the Global strategy coordinated, strategic global initiative. Investmentfor women’s and children’s health; the resources in the elimination of MTCT of syphilis will contributeand attention being devoted to achieving the significantly to improved maternal and child healthMillennium Development Goals (MDGs), particularly around the world, including achievement of MDGsHIV, reproductive, maternal, newborn and child 4, 5 and 6, while also strengthening underlyinghealth objectives (MDGs 4, 5 and 6); the push for health systems.dual elimination of MTCT of HIV and syphilis; theincreased availability and use of antenatal care (ANC)in many countries; and technological advances inscreening for syphilis in low-resource settings. 1
  • 7. Investment case for eliminating mother-to-child transmission of syphilis1. The case for investment1.1 Mother-to-child transmission of This document uses the term mother-to-childsyphilis: a continuing public health transmission (MTCT) of syphilis throughout,burden but it should be noted that most of the relatedAn estimated 11 million people acquire new syphilis literature to date uses the term congenitalinfections annually (1). This is despite the fact that a syphilis. The term MTCT is preferred, as itsuccessful test for syphilis has been available since better reflects the range of adverse outcomesthe early 1900s and effective treatment (penicillin) that occur when syphilis is transmitted fromhas been widely available since the 1940s. mother to child. MTCT of syphilis is any adverse outcome in a fetus or neonate associatedIn 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, lowWorld Health Organization (WHO) global burden of birth weight and clinical evidence of syphilis indisease estimate of deaths due to syphilis among a neonate.children aged 0–4 years was approximately 64 000deaths, or 0.6% of all deaths in children aged under5 years (4). However, it is widely felt that syphilis Untreated maternal syphilis results in MTCT ofis underdiagnosed as a cause of death in death syphilis (see text box) in over half of affectedregistries and verbal autopsies, and estimates in pregnancies (see Table 1.1). A recent meta-analysissome developing countries have suggested that of syphilis-associated pregnancy outcomes found amother-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
  • 8. Investment case for eliminating mother-to-child transmission of syphilisto 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 theseinfants with clinical evidence of syphilis (16%) – two diagnostic options, programmes can achievewho are then at higher risk of ill health. Estimates universal access to syphilis screening in pregnantfor 2008 suggest that globally there are nearly women. If syphilis is diagnosed early and treated1.5 million pregnant women infected with probable promptly, penicillin is highly effective in treatingactive syphilis each year (8). Although there is wide maternal infection and preventing MTCT of syphilisvariation in antenatal care (ANC) practices globally, (11). Penicillin is off patent, widely available, on thethe vast majority of pregnant women with syphilis WHO list of essential medicines (12) and, aboveare 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 developedThus, assuming that 30–70% (depending on region) resistance to penicillin.of all pregnant women with syphilis were testedand treated early enough to avert an adverse 1.3 Why now is the time to investoutcome, in 2008 there were an estimated 520 000 in elimination of mother-to-childpregnancies and neonates adversely affected by transmission of syphilissyphilis, including 215 000 early fetal losses and More than ever before, elimination of MTCT ofstillbirths and 90 000 neonatal deaths. syphilis as a public health problem is feasible, achievable and affordable.1.2 Addressing syphilis in pregnantwomen: a feasible solution The Millennium Development GoalAdverse pregnancy outcomes caused by untreated “window of opportunity”maternal syphilis are preventable and curable, and As we near the 2015 deadline for achievinginterventions to improve screening and treatment the Millennium Development Goals (MDGs),for syphilis in pregnancy can substantially reduce there is increased global commitment andthe current global burden of preventable perinatal attention to improving child and maternal healthmortality and morbidity (9) Detection and treatment (MDGs 4 and 5). This paves the way for tacklingof syphilis has been identified as being one of the MTCT of syphilis as an important contributor tomost effective and cost-effective interventions maternal and infant morbidity and mortality.to prevent stillbirths and neonatal deaths (10).Screening all pregnant women, using simple andlow-cost technologies, is feasible, even in low- Elimination of MTCT of syphilis will contributeresource 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 toNew point-of-care tests, which can use whole-blood reductions in other preventable infections affectingsamples from a finger prick, provide results and pregnancy, including perinatal malaria, maternalallow for treatment at a single visit. They can be and neonatal tetanus, and HIV transmission toused in all health-care settings, even in the face of neonates, and can improve maternal health. Thislimited electricity, refrigeration or skilled laboratory will bolster efforts to achieve MDGs 4, 5 and 6staff. Existing tests (rapid plasma reagin (RPR) (combat HIV/AIDS, malaria and other diseases), asor venereal disease research laboratory (VDRL)) highlighted in the 2009 United Nations (UN) MDGcan also be used successfully in settings with report (13). 3
  • 9. Investment case for eliminating mother-to-child transmission of syphilisMDG 4: reduce child mortality conditions during pregnancy. Through the initiativeInfant and child mortality have declined globally, outlined in this document, maternal health willbut the pace of progress is uneven. In 2010, an be improved as a result of earlier ANC and fewerestimated 8 million children died before their spontaneous abortions and stillbirths. In addition,fifth birthday – mainly from preventable causes. the simultaneous implementation of interventionsMTCT of syphilis is a preventable cause of low birth to eliminate MTCT of syphilis, and efforts to controlweight, neonatal death, stillbirth and congenital sexually transmitted infections (STIs) in the generalinfection (3). The UN MDG report states that “many adult population, will also reduce the incidence andcountries, 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 otheron strengthening health systems to provide ANC, diseaseswhich includes screening for MTCT of syphilis, will It is estimated that women account for about halfhelp to address this public health tragedy. of all people living with HIV infection, and that the vast majority of HIV-infected women live inMDG 5: improve maternal health developing countries. Given the common mode ofANC is a core component of comprehensive sexual transmission, coinfection of HIV and syphilismaternal health care. The UN MDG report is not uncommon. Syphilis infection is a recognizedemphasizes that “many health problems among cofactor for increased risk of HIV transmission andpregnant women are preventable, detectable acquisition, and maternal syphilis infection has evenor treatable through visits with trained health been associated with increased risk of MTCT of HIVworkers before birth” (13). In all regions, progress (15, 16).has been made on ensuring that more womenreach and receive at least one ANC visit in their WHO recognizes that HIV services should bepregnancy – thus providing more opportunities integrated within a package of core interventions forfor 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
  • 10. Investment case for eliminating mother-to-child transmission of syphilissyphilis screening and care (17). Systematic screening More availability and utilization of antenatalof women for syphilis in programmes for PMTCT of care than ever beforeHIV will allow mothers and infants to be tested and, The relatively high utilization of ANC by pregnantwhere necessary, treated for both HIV infection and women in many countries makes this servicesyphilis, thereby reducing fetal and infant deaths. an ideal venue to implement population-basedTreating maternal syphilis infections also improves interventions. Although women often delay seekingmaternal and neonatal health. Moreover, the Joint care until later in pregnancy, an estimated 82% ofUnited Nations Programme on HIV/AIDS (UNAIDS) pregnant women have at least one ANC visit (24).recognizes testing and treatment of syphilis inpregnant women as an indicator of quality ANC An important component of the initiative proposedservices 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 universallyGlobal momentum to eliminate new HIV provided to women at low or no cost, as part ofinfections among children an integrated service package of proven-effectiveThe global call to eliminate new HIV infections antenatal interventions. Early ANC also improvesamong 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 toimproved health outcomes (17, 19). Three WHO Important technological advancesregions (Region of the Americas, South-East Asia Existing screening for syphilis (i.e. RPR testing) isRegion, and Western Pacific Region) have launched simple and cheap, but requires a basic laboratoryelimination of MTCT of HIV as a dual elimination capacity and quality control that may not beinitiative with MTCT of syphilis, and the African available at many antenatal facilities, particularly inRegion includes elimination of MTCT of syphilis remote settings or in resource-poor settings withwithin 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-sitepromote synergies for overall strengthening of the diagnosis of syphilis and prompt treatment ofperinatal 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 transmissionof syphilis supports the global strategy for infected women to be diagnosed and treated in awomen’s and children’s health single antenatal visit. Extensive research has helpedWith just a short amount of time left to achieve greatly in our understanding of more effectivethe MDGs, the UN Secretary-General launched the diagnostic tools, algorithms and approaches inGlobal 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 pricesservice delivery of proven interventions. As a (i.e. at less than US$1 per test).result, many countries have committed to improvecoordination around maternal and neonatal 1.4 Why the problem persistshealth issues and create platforms for integration. In theory, it is easy and cheap to prevent andBringing ministries of health and partners together treat MTCT of syphilis. In practice, however, thereto 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 awarenesswomen with syphilis, is a specific example of an of the true impact of MTCT of syphilis and theactivity called for within the global strategy. extent of the problem. Without diagnostic testing, 5
  • 11. Investment case for eliminating mother-to-child transmission of syphilissyphilis-associated fetal loss and stillbirth, neonatal 1.5 The strong economic case fordeaths and premature births are not recognized as syphilis eliminationbeing caused by syphilis or as being preventable.Lack of awareness about the true toll of maternal Economic costs of mother-to-childsyphilis is a significant barrier at all levels – in transmission of syphilis The direct medical costs of MTCT of syphiliscommunities, among service providers and are substantial, because of the infection’s highprogramme 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 directaccountability for measures to control MTCT of medical costs. It involves indirect costs, such as lostsyphilis is a problem, since efforts involve both STI productivity, and other non-medical costs, such asand maternal and child health (MCH) programmes. special educational needs and the emotional impactIn addition, many existing ANC programmes do not of having a disabled child, which are extremelyhave the information, training and technology they difficult to quantify.need to incorporate maternal syphilis screening andtreatment into their health-care systems. Although the full economic cost of MTCT of syphilis has not been definitively determined, availableOther 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 action6
  • 12. Investment case for eliminating mother-to-child transmission of syphilishealth systems. For example, in the United States be prevented or treated through improving currentof America (USA), the hospital cost per newborn ANC programmes. For each ill-health outcome, theinfant with congenital syphilis (MTCT of syphilis) economic cost and the health burden (in actualwas 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 ofhospital-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 causeof addressing the adverse outcomes associated with different types of outcomes, and estimates are notsyphilis in pregnant women are calculated to be available for all potential outcomes (e.g. stillbirthUS$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 ANCAlthough the direct medical costs of MTCT of screening programmes in eight different countrysyphilis are estimated to be lower than those of case scenarios, which vary in terms of syphilissome other perinatal infections, such as vertically testing and treatment coverage (high (70%) or lowtransmitted HIV (estimated to be US$3520 million), (20%)), syphilis ANC prevalence (high (3%) or lowthe current global burden of disease attributable to (0.5%)), and country cost of health services (highMTCT of syphilis as measured in disability-adjusted or low). For each of the eight different countryyears (DALYs) is enormous, at approximately scenarios, the cost analysis assesses the cost of3.6 million. A DALY is a time-based measure of the the intervention (i.e. implementing testing andburden of disease that combines years of life lost treatment of syphilis in pregnancy), while thedue to premature mortality with the time lived in health-impact analysis estimates the health benefitsa state of less than full health. Table 1.3 outlines of the intervention in terms of DALYs averted.several conditions affecting pregnancy that could Table 1.3 Disease burden in pregnant women, associated perinatal deaths, DALYs and direct medical costs for syphilis, tetanus, malaria, hypertension and HIV Clinical cases Deaths DALYs Direct medical costs (US$) 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
  • 13. Investment case for eliminating mother-to-child transmission of syphilisTable 1.4Estimated net cost (in US$) over 4 years, number of DALYs averted over 4 years and cost per DALYaverted for eight country scenarios varying by burden of disease, syphilis testing and treatmentcoverage, and health-care costsaCountry Prevalence Proportion of Health- Net cost (savings) of Number Cost perscenario of syphilis all pregnant care cost intervention (4 years) of DALYs DALY in pregnant women structure (cost of intervention averted averted, women tested and minus disease costs (4 years) US$ treated averted), US$A High Low Low (1 943 017) 106 042 Cost savingbB High Low High (12 261 250) 106 042 Cost savingC High High Low (765 563) 39 155 Cost savingD High High High (4 587 778) 39 155 Cost savingE Low Low Low 1 736 807 17 678 98.25F Low Low High 543 472 17 678 30.74G Low High Low 593 188 6527 90.88H Low High High 140 282 6527 21.49a Classifications used for this exercise are: prevalence of syphilis = high (3%) or low (0.5%), proportion of all pregnant womentested and treated = high (70%) or low (20%), health-care cost structure = high (1) or low (0.25), based on WHO CHOICE (CHoosingInterventions 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 costssaved by the intervention. An intervention is said to 1.6 Who should invest in thebe “cost-saving” if it pays for itself in terms of offset elimination of mother-to-childmedical 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, andpresented in Table 1.4 for each of the eight different specifically to eliminate MTCT of syphilis, can becountry 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, programmesare calculated as a ratio per 1 million pregnancies, and initiatives having a positive impact on healththe results should scale (i.e. the costs and the health that extends beyond the borders of any specificoutcomes would change similarly for smaller or country (33). However, even with widespreadlarger populations), thus leaving the cost per DALY consensus around the financial and social benefitsunchanged 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 – anWe found that controlling MTCT of syphilis would especially high proportion of all stillbirths inbe a “cost-saving” intervention in four of the eight developing countries. In addition, in 2008, MTCTcountry scenarios examined – i.e. the intervention of syphilis contributed to approximately 90 000will “pay for itself” in offset medical costs. In the neonatal deaths, 65 000 low-birth-weight orother four scenarios, the cost per DALY averted is premature babies and 150 000 babies born withbetween US$20 and US$100, far below the annual syphilis infection – almost all preventable.8
  • 14. Investment case for eliminating mother-to-child transmission of syphilis• 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. 1.1Reported syphilis prevalence for 2010 (2009 for Indonesia) in intensified support countries for theinvestment 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, HIVand 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
  • 15. Investment case for eliminating mother-to-child transmission of syphilis2. Details of the initiative: objectives, activities and stakeholdersThe overall goal of the initiative is global elimination • reduce adverse outcomes of pregnancy due toof MTCT of syphilis as a public health problem (34). MTCT of syphilis through intensified supportThe specific goals of this elimination effort are to in 12 focus countries by 2015: achieved by scaling up early maternal syphilis screeningprevent transmission of syphilis from mother to for all pregnant women and ensuring promptchild 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 existingGiven the difficulties in diagnosing and reporting health systems, commodities distribution and monitoring and evaluation systems;MTCT of syphilis consistently throughout theworld, a specific global target for a case rate • promote collaboration among differentfor MTCT of syphilis has not been set. However, stakeholders working to reduce the overall the burden of syphilis: this will include buildingcountries and regions are encouraged to identify on synergies and forging partnerships amongcountry- or region-specific goals and targets different groups and agencies that address adultto measure the impact of elimination efforts. syphilis.The Region of the Americas, South-East Asia To realize these objectives, specific activities will beRegion, and Western Pacific Region have defined carried out in 12 intensified support countries and atelimination of congenital syphilis (MTCT of syphilis) regional and global levels. In addition, the supportas corresponding to an incidence of 0.5 cases or network created by the investment case will providefewer per 1000 births (including stillbirths) (21, 22). general support to other high-burden countriesHowever, this specific threshold was established for requesting technical assistance to eliminate MTCT ofthese regions and may not be appropriate for the syphilis.rest of the world. 2.1 Choosing 12 intensified supportElimination can be achieved by strengthening countriesreproductive and sexual health programmes toensure: 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 ANCinvestment case: services;10
  • 16. Investment case for eliminating mother-to-child transmission of syphilis• 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 regionalAll of the countries selected for intensified support levels.have made significant investments in establishingeffective ANC programmes, and their participation Activity stream 1: gathering evidence to guidein the initiative should strengthen these investments best practiceover 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 – isthe highest burden of disease may not have data needed to strengthen the implementation andavailable and that data on burden of disease effectiveness of country plans for eliminatingchange over time. However, other countries will the condition. Proposed research areas are notreceive general support through the network stand-alone activities, but exist to strengthen theestablished 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 eliminateaddition, once activities in the 12 intensified support MTCT of syphilis.countries are under way, a phased approach tosupporting other high-burden countries in future Table 2.1 outlines some of the areas of researchphases of the investment case will be discussed and necessary to support the implementation anddeveloped. 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 evidenceWhile the initiative is designed to bring about a gaps; therefore, research priorities will be set locallymajor reduction in cases of MTCT of syphilis in 12 – and may be drawn from this indicative list, orintensified support countries, investment case funds from elsewhere. It is expected that countries willare not primarily intended for routine programme also leverage additional funds to support evidenceexpenses. Instead, investment case funds are sought gathering locally.to provide assistance with integrating syphilisinterventions into existing programmes, and Activity stream 2: building capacity for theensuring and sustaining the effectiveness of these development and implementation of nationalinterventions. To this end, funding for the initiative planswill be devoted to three activity streams: While each country has its own unique issues regarding elimination of MTCT of syphilis, this1. 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
  • 17. Investment case for eliminating mother-to-child transmission of syphilis 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
  • 18. Investment case for eliminating mother-to-child transmission of syphilisIntensified support countries will receive technical to support implementation of the country planssupport to develop their own national plans (see Appendix 3). The tools and technical supportthrough 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 opportunitiesto develop integrated plans or plans that take Activity stream 3: monitoring and evaluationother programmes into account, such as the dual Monitoring and evaluation are critical componentsinitiatives 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 willOnce plans have been developed, each country be used to ensure that programmes have sufficientwill be encouraged and supported to follow a coverage and quality to meet the initiative’sstep-by-step approach to implementation, such as goal, and that key subpopulations are targetedthat based on WHO’s programme guidance tool for appropriately. It will also serve as vital evidence forreproductive 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 ensurenumber 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
  • 19. Investment case for eliminating mother-to-child transmission of syphilisAt 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 monitoringservices coverage; surveillance and data systems; reports at all levels, with prompt feedback tomaternal, newborn and child health programme programmes;integration) to learn from each other. • development of sustainable mechanisms for providing ongoing support for in-countryAt the global level, impact indicators will be used to monitoring and evaluation of the adversemonitor global programme impact, while the tools outcomes of pregnancy that result from syphilis infection.developed and lessons learnt through this initiativewill contribute to scale-up in other countries in the Indicators and targets for the elimination offuture. mother-to-child transmission of syphilis Extensive consultations with a wide range ofA broad range of activities are planned to monitor stakeholders have identified a limited number ofand 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
  • 20. Investment case for eliminating mother-to-child transmission of syphilis2.3 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-servicesIn-country activities for intensified support providers, health-care institutions, people living withcountries will be led by a programme coordinator HIV and other partners. The aim is to strengthenworking with a country team, made up of key all aspects of the health sector, in order to deliverstakeholders such as representatives from involved much-needed HIV services. WHO provides technicalhealth programmes (maternal and child health, support and develops evidence-based norms andSTI/HIV etc.), WHO country offices, representatives standards to help transform the goal of universalof civil society, representatives of primary access to HIV care into a reality. An importantstakeholder groups, donors, multilaterals, bilaterals, aspect of universal access to HIV is to strengthennongovernmental organizations (NGOs), research and expand health systems, including those forinvestigators and communications specialists. prevention and treatment of MTCT of syphilis.The World Health Organization WHO will manage the technical, programmatic andThe WHO Department of Reproductive Health resource-building functions of the initiative. It willand Research (RHR), with the assistance of the also appoint seven full-time staff at the global andDepartments of Maternal, Child and Adolescent regional level: a programme director, a laboratoryHealth (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 beIn addition, WHO regional advisers covering one or used at the global, regional and country levels tomore of the areas of STI, HIV, reproductive health promote advocacy, strengthen policy, developand MCH will provide similar functions at the guidelines, scale up programmes, and supportregional level. essential research to support elimination of MTCT of syphilis. Funds channelled through WHO are notThe mission of RHR is to help people to lead intended for routine programme costs.healthy sexual and reproductive lives. In pursuitof this mission, the department endeavours to United Nations agency partnersstrengthen the capacity of countries to enable The United Nations Population Fund (UNFPA) is anpeople to promote and protect their own sexual and international development agency that promotesreproductive health and that of their partners, and the right of every woman, man and child to enjoyto have access to, and receive, high-quality sexual a life of health and equal opportunity. UNFPAand reproductive health services when needed. supports countries in using population data for policies and programmes to reduce poverty and toMCA works to strengthen WHO capacity to support ensure that every pregnancy is wanted, every birthcountries’ efforts to improve maternal, newborn is safe, every young person is free of HIV/AIDS, andand child health and reduce maternal, perinatal every girl and woman is treated with dignity andand child mortality. The department aims to respect. For the initiative for the elimination of MTCTreinforce advocacy, technical support, monitoring of syphilis, UNFPA plans to support introductoryand evaluation, and partnerships in countries, to activities, implementation and upscaling, as wellensure that WHO can provide the most up-to-date as capacity building and logistics management. Ininformation and guidance on maternal, newborn addition, UNFPA can facilitate pooled procurementand child health, including issues related to MTCT of and support countries to integrate adequatesyphilis. programmes in their national budget. 15
  • 21. Investment case for eliminating mother-to-child transmission of syphilisThe 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 globalThe heart of UNICEF’s work is in the field. Each initiative, as well as quality assurance of laboratorycountry office carries out UNICEF’s mission through and health services.a unique programme of cooperation developedwith the host government. Regional offices guide Battling Against Syphilis – a Team Approachthis work and provide technical assistance to (BASTA)country offices as needed. For the initiative for the An informal collaboration of key partners interestedelimination of MTCT of syphilis, UNICEF plans to in eliminating MTCT of syphilis was created by WHOsupport 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 ideasThe 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 worldfamily, bringing together the efforts and resources in bilaterals, NGOs, academic centres, professionalof 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 offor people living with HIV, and mitigate the impact the investment case and research agenda outlinedof the epidemic. The UNAIDS Secretariat works on in this document, and has promoted and supportedthe ground in more than 80 countries worldwide. collaborative efforts, including disseminationCoherent 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, andinitiative for the elimination of MTCT of syphilis, integration of elimination of MTCT of syphilis intoUNAIDS plans to support advocacy on HIV-infected their respective work agendas.women, and linkages between HIV programmes, STIcontrol programmes and sexual and reproductive In March 2012, several BASTA collaborators createdhealth programmes. the Global Congenital Syphilis Partnership, hosted in the London School of Hygiene and TropicalUnited States of America Centers for Disease Medicine. WHO looks forward to collaborating withControl 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, andand 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 ofcollaborating to create the expertise, information • mobilize global commitment and action to scale up knowledge transfer and capacity building toand tools that people and communities need to accelerate the elimination of MTCT of syphilis;protect their health, CDC works with global partnerson specific global goals, including public health • optimize the use of available tools in the fight against MTCT of syphilis, and enhance deliveryprogrammes aimed at reducing infant mortality. of syphilis diagnosis and treatment, especially inThe Division of STD [Sexually Transmitted Disease] pregnant women.Prevention (DSTDP) in the National Center forHIV, Viral Hepatitis, STD and TB Prevention isCDC’s component agency supporting the global 2.4 Management structureelimination of MTCT of syphilis. In the initiative WHO will coordinate the activities of each of thefor the elimination of MTCT of syphilis, DSTDP will main partners involved in the initiative, as well16
  • 22. Investment case for eliminating mother-to-child transmission of syphilisas donor inputs and reporting requirements, and The core team will be composed of the WHOa global fundraising and advocacy campaign. programme director, the regional programmeInitiative partners will also be responsible officers (who will represent the intensified supportfor disseminating outputs (e.g. at national country teams), the advocacy/communication/and international meetings), updating and fundraising officer, the laboratory quality assurancereviewing existing guidelines, and disseminating and procurement officer, and the financialrecommendations to both intensified and general management/administrative officer. The core teamsupport countries. will report to the steering committee. The steering committee will be composed of the core team, asThese activities will be undertaken through a close well as representatives of key UN partner agenciescollaboration between staff at global and regional and other partners. The core team and the steeringlevels who are dedicated to work on this elimination committee will need to be financially and logisticallyinitiative, as well as staff working for allied supported to achieve their mandates.programmes that are fundamental to the successof the initiative (e.g. staff working on maternal child The role of the core team is to ensure coordinationhealth, and those working on STI control and HIV at all levels, in both intensified and general supportprogrammes). countries:Fig. 2.1 is a graphical representation of the overall • the programme director, based at WHOmanagement structure for implementing the headquarters, will act on behalf of the steering committee to oversee the core team. This personinitiative. The roles and responsibilities of the major will have primary responsibility for programmeplayers are described next. implementation, coordination of the programme and with partners, and achievement ofFig. 2.1Management structure of the initiative for the global elimination of mother-to-child transmission ofsyphilis 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
  • 23. Investment case for eliminating mother-to-child transmission of syphilis 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
  • 24. Investment case for eliminating mother-to-child transmission of syphilis3. The strength of this initiative3.1 Leveraging existing investments in • health-system initiatives to promote integratedmaternal and child health comprehensive sexual and reproductive health care.This initiative will build on investments in maternaland child health services that have already been In addition, it is recognized that the elimination ofmade by governments and donors in developing MTCT of syphilis is likely to be more achievable ifcountries. It works through, and therefore inevitably syphilis screening and treatment activities are alsostrengthens, national health systems, particularly included in the existing health initiatives (such asantenatal and other reproductive and sexual health- elimination of MTCT of HIV). Therefore, combiningcare programmes. syphilis interventions with basic ANC programmes as well as prevention of MTCT programmes makesToday, over three quarters of all pregnant women medical, economic and political sense (37).receive at least one ANC visit (24). This is anindication that programmes and infrastructure exist Recent efforts by WHO have simplified ANC andin many countries, and that there is widespread provided norms to encourage health-care workersawareness and acceptance of ANC by pregnant to emphasize a few essential components of carewomen. (38, 39). This initiative will build on these norms and provide support for health-services evaluation thatThis initiative will help to maximize the ability of can jump-start feasible and efficient managementthese 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 allpregnant women and ensure that they receive 3.2 Supporting country-level impacttesting (and, where indicated) treatment for syphilis through global coordinationat their first antenatal clinic visit. We support a The initiative outlined in this investment case doessimple, integrated and effective ANC approach that seek a limited amount of funding for country-can provide sustainable services within the broad level programme implementation. Countriescontext of strengthening primary health care, while identified for intensified support – which all haveconcentrating on this prevalent, high-burden and a high burden of MTCT of syphilis – will already beneglected disease. committed to syphilis elimination and have ANC programmes in place, backed by other sourcesThe focus on early access to services and the quality of funding. They also may already be receivingof comprehensive ANC will strengthen synergistic substantial financial support for HIV, tuberculosisefforts to reduce the burdens of HIV, malaria, and malaria prevention (e.g. The Global Fund totetanus, parasites and accompanying anaemia, as Fight AIDS, Tuberculosis and Malaria). It is hopedwell as MTCT of syphilis. As such, it will promote that the funding for country-level programmesynergies 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
  • 25. Investment case for eliminating mother-to-child transmission of syphilisThrough a series of global, regional and national Adverse pregnancy outcomes are the criticalconsultations, countries have indicated that they public health problem associated with maternalneed technical assistance to learn how to integrate syphilis infection. The congenital syphilis caseand scale up syphilis screening and treatment rate is the most widely recognized measure of theinto existing programmes and to monitor these impact of elimination efforts. Unfortunately, globalinterventions. Countries have also indicated a need surveillance of MTCT of syphilis is challenging, sinceto bring more attention to the burden of MTCT of there is no single test or combination of laboratorysyphilis at all levels, which will help to prioritize the tests to definitively diagnose an infected infant. As aissue on national and international health agendas. result, a case definition for congenital syphilis must rely on clinical history and examination. Thus, caseTo this end, the initiative will mobilize regional and definitions vary widely by country, and a globallyglobal stakeholders into a network that can deliver accepted surveillance case definition is still underrapid, targeted technical assistance to intensified development.support countries to work alongside nationalcounterparts to fully and effectively integrate Maternal syphilis infection also contributessyphilis interventions into existing ANC and PMTCT substantially to rates of stillbirth, though thisof 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 universalglobal levels, to work with national colleagues measuring of stillbirth rates, we are proposing thisto monitor the scale-up of country-level syphilis- as a potentially sensitive and specific measure of theelimination 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 ofcountries, it is anticipated that the network created stillbirth rates will not only allow us to assess theby the investment case will also be able to provide impact of this initiative, it will also help supportgeneral 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 globalPrevious WHO/CDC technical consultations have level are under way to identify criteria and processesrecommended the development of a monitoring for validation of elimination. Given that there aresystem based upon already-established national several countries that may actually have eliminatedsystems for ANC. Such an approach supports MTCT of syphilis already, establishment of such aoverall 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 howservices. Through these consultations, a list of the to maintain elimination. In addition, validation maycritical benchmarks was proposed for appropriate be an important motivator to engage countrieslocal programmes within each country, with in elimination, and encourage countries to goannual measurement recommended. Some have the last distance to provide services for even thealready been tried out in local settings; others need most difficult-to-reach populations. The validationfurther evaluation for feasibility. Investment in process is being undertaken jointly with the globalthis initiative will support local and national-level programme to eliminate MTCT of HIV, given theresearch needed to solidify the critical programme commonalities of the initiatives and programmebenchmarks that will be adopted globally. platforms.20
  • 26. Investment case for eliminating mother-to-child transmission of syphilis3.4 Implementing knowledge and best costing, too, for example (42). The next step forpractices the South-East Asia and Western Pacific Regions, however, is to identify resources to work withThis investment case represents a new direction for countries to establish integrated policies and ensureWHO and its partners in their goal of eliminating clinical guidelines and monitoring systems supportMTCT of syphilis, but it also builds upon many years these policies. The African Region is currentlyof experience and evidence gathering. In recent developing a regional framework for eliminationyears, several state-of-the-art reviews on maternal of MTCT of HIV, which includes the strengtheningand congenital syphilis (MTCT of syphilis) have been of related MCH services such as the elimination ofpublished to highlight the problem and advocate MTCT of syphilis (22).action for its elimination (40). These reviews provideempirical 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 criticalprogrammes attempting to intervene and address for expanding testing to pregnant women seenthis burden. in peripheral health settings. All regions have also expressed the need to establish criteria andAt regional level, some longstanding efforts a process for validation of elimination that isto eliminate MTCT of syphilis have made great integrated with that for MTCT of HIV. Thus, it isprogress, but still need assistance to reach the last crucial that WHO works closely with the regions todistance. For example, the Pan American Health facilitate interregional collaboration and establishOrganization (PAHO) has developed several tools to credible, sustainable processes for validation ofassist 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 ofsupport to provide technical assistance to countries improving best practices for syphilis testing. WHOand strengthen monitoring and evaluation systems. and other partners also support the elimination ofIn the WHO South-East Asia and Western Pacific MTCT of syphilis through work on improved rapidRegions, 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 rapidmade great strides in outlining a strategy for dual point-of-care tests that use whole blood (e.g. fingerelimination of MTCT of HIV and syphilis, including prick) samples that can be used by health-careindicators 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
  • 27. Investment case for eliminating mother-to-child transmission of syphilisproviders at the lowest level of health care. However,the syphilis point-of-care tests currently availablecommercially are treponemal, meaning that theycan only measure a lifetime history of syphilisexposure. Thus, additional support is needed forWHO to encourage development and field testingof nontreponemal tests to measure current syphilisinfection, as well as bundled diagnostics that allowconcomitant testing for syphilis, HIV, hepatitis B,etc. The development of such tests is critical forminimizing the burden of primary care healthworkers to provide quality, integrated care.These are just a few examples of the efforts andadvances that this initiative will build upon andhelp to advance. Now – more than ever before – isthe right time to address MTCT of syphilis witha large-scale, global initiative. Investment todaywill contribute significantly to maternal and childhealth improvements around the world, includingachievement of the MDGs.22
  • 28. Investment case for eliminating mother-to-child transmission of syphilisReferences1. 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 policy4. 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 is5. 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. The impact of syphilis on adverse index.html, accessed 20 August 2012). pregnancy outcomes: a systematic literature 18. Joint action for results: UNAIDS outcome review and meta-analysis. Submitted for framework, 2009–2011. Geneva, UNAIDS, publication. 2009 (http://data.unaids.org/pub/8. 2008 global estimates of syphilis in pregnancy BaseDocument/2010/jc1713_joint_action_ and associated adverse outcomes. Geneva, World en.pdf, accessed 20 August 2012). Health Organization. Submitted for publication. 19. Countdown to zero: global plan for the elimination9. Hawkes S et al. Effectiveness of interventions to of new HIV infections among children by 2015 improve screening for syphilis in pregnancy: a and keeping their mothers alive. Geneva, systematic review and meta-analysis. The Lancet UNAIDS, 2011 (http://www.unaids.org/en/ Infectious Diseases, 2011, 11:684–691. media/unaids/contentassets/documents/ unaidspublication/2011/20110609_JC2137_10. Bhutta Z et al. Stillbirths: what difference can Global-Plan-Elimination-HIV-Children_en.pdf, we make and at what cost? The Lancet, 2011, accessed 20 August 2012). 377:1523–1538. 23
  • 29. Investment case for eliminating mother-to-child transmission of syphilis20. 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. CHOosing22. 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. accessed 29 August 2012). In press. 33. Global public goods for health - the report23. 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_ accessed 20 August 2012). 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. Geneva, World Health Organization, 200926. 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 2928. 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
  • 30. Investment case for eliminating mother-to-child transmission of syphilis38. 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, accessed 20 August 2012).39. Standards for maternal and neonatal care. Geneva, World Health Organization, 2007 (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, accessed 29 August 2012).42. Elimination of parent-to-child transmission. Cost analysis of elimination (http://www. eptctasiapacific.org/funding-resource-needs, accessed 29 August 2012).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
  • 31. Investment case for eliminating mother-to-child transmission of syphilisAppendix 1: economic analysis and disability-adjusted lifeyears calculationsMethods We assumed, based on published evidence, that treatment was 90% effective, that coverageWe conducted an illustrative analysis of the 4-year depends on the current proportion tested andcost, health impact, and cost-effectiveness of treated: 70–95% of women are in antenatal caresyphilis 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 adverseterms 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 fromlow, based on WHO CHOICE (Choosing Interventions a systematic search and abstraction of studies ofthat are Cost Effective) unit cost data). untreated syphilis.The cost analysis assessed the cost of the We also assumed that treating syphilis reducedintervention – implementing expanded testing the horizontal spread of syphilis and had a modestand treatment of syphilis in pregnancy. The health- (20%) effect in reducing the effect of syphilisimpact analysis translated increased testing and as a cofactor for transmission of HIV. The DALYstreatment into adverse outcomes averted, and the averted per adverse event averted were derivedassociated 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, butoffsetting savings due to averted adverse outcomes, the analysis did not discount over the 4 years ofand if there was still a net cost, that cost was divided initiative implementation. Further details (includingby the DALYs averted. The key inputs, assumptions sensitivity analyses) are available in a technicaland 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 Resultsimplementing testing and treatment. This was We found that controlling mother-to-childderived 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 countrydoses) were determined from the World Health scenarios we examined. The initiative was costOrganization (WHO) bulk procurement system, with saving in these four countries, even when excludingallowances for delivery costs. The costs of labour the benefits of reducing the horizontal spread ofand 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 andof treatment with three doses of penicillin wasUS$3.72–3.79.26
  • 32. Investment case for eliminating mother-to-child transmission of syphilisTable A.1Inputs and assumptions for illustrative analysis of the 4-year cost, health impact, and cost-effectivenessof syphilis programmes in 8 hypothetical country case scenariosParameter Value or rangea Source/notesAdverse event rateStillbirth/early fetal loss 0.209 Synthesis of research findings (Table 1.1)Early neonatal death 0.093 Synthesis of research findings (Table 1.1)Infected infant 0.155 Synthesis of research findings (Table 1.1)Prematurity or low birth weight 0.058 Synthesis of research findings (Table 1.1)Costs, US$Stillbirth / spontaneous abortion (0)–(1) Per Rydzak and Goldie 2008 (43), delivery of healthy infant = US$58Perinatal death 893–3571 Per Rydzak and Goldie, 2008 (43), adjust- ed per WHO CHOICE inpatient unit costsInfected infant 182–243 Per Blandford et al, 2007 (27), and Rydzak and Goldie, 2008 (43), includes adjust- ment for 30% discovery rate, adjusted per WHO CHOICE outpatient unit costsPrematurity or low birth weight 366–1464 Per Rydzak and Goldie, 2008 (43), adjust- ed per WHO CHOICE inpatient unit costsPrimary syphilis 15 Estimate based on single visit, test, peni- cillinSecondary and early latent syphilis 15 Same as primaryLate latent and tertiary syphilis 500–2000 Based on Chesson et al, 2004 (45) esti- mates for USA,, adjusted for lower price and lower incidental treatment in devel- oping countries and WHO CHOICE inpa- tient unit costsHIV infection 6500 (28)Syphilis test, test + labour/supplies 1.83–2.30 Based on WHO Bulk Procurement esti- mates (WHO, unpublished data, 2012)Course of benzathine benzylpenicillin (3 3.72–3.79 Based on WHO Bulk Procurement esti-doses) mates (WHO, unpublished data, 2012)a Values in parentheses indicate negative values. 27
  • 33. Investment case for eliminating mother-to-child transmission of syphilisAppendix 2: proposed budget for the initiative for the globalelimination of mother-to-child transmission of syphilis 5-year budget summary in US$ 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 1 P3, regional officer 230 000 230 000 230 000 230 000 920 000 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 00028
  • 34. Investment case for eliminating mother-to-child transmission of syphilisAppendix 3: list of tools available for country-levelactivitiesAdvocacy and programme tools Nine steps for developing a scaling-up strategyThe global elimination of congenital syphilis: • Description: a guide for programme managersrationale 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 guidelinesA strategic approach to strengthening control Sexually transmitted and other reproductiveof reproductive tract and sexually transmitted tract infections: a guide to essential practiceinfections • 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/ rtis/9241592656/en/index.htmlMethods for surveillance and monitoringof 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 rtis/9789241503020/en/index.html Regional and national treatment/Global strategy for the prevention and control management guidelinesof STIs: 2006–2015. Breaking the chain of • Description: Expert recommendations on clinicaltransmission 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
  • 35. Investment case for eliminating mother-to-child transmission of syphilisAppendix 4: Battling Syphilis – a Team Approach (BASTA)participant affiliationsAlberta Health Services of Canada National Center for STD Control, ChinaAmsterdam institute for Global Health and National Coalition of STD, United States (NCSD)Development (AIGHD) Norwegian Agency for Development CooperationBrazil Ministry of Health (Norad)CDC Foundation PATHCenters for Disease Control and Prevention, United The Population CouncilStates (CDC) Public Health Agency of CanadaCentro 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 AIDSChildren’s Investment Fund Foundation (CIFF) Coordinator (OGAC)Cornell University United States Agency for International DevelopmentElizabeth Glaser Pediatric AIDS Foundation (EGPAF) (USAID)Engenderhealth Universidad Peruana Cayetano HerediaFHI360 University of Alabama BirminghamThe Global Fund University of AntwerpHarvard University University of BarcelonaHealth Alliance International University of California Los AngelesImperial College London University of California San FranciscoInstitute of Development Studies University College LondonJhpiego University of GentJohns Hopkins University University of North CarolinaJoint United Nations Programme on HIV/AIDS University of Victoria(UNAIDS) University of WashingtonLondon School of Hygiene and Tropical Medicine Washington University in St Louis(LSHTM)30
  • 36. For more information, please contact: ISBN 978 92 4 150434 8Department of Reproductive Health and ResearchWorld Health OrganizationAvenue Appia 20, CH-1211 Geneva 27, SwitzerlandFax: +41 22 791 4171E-mail: reproductivehealth@who.intwww.who.int/reproductivehealth