A Devastating Surge in Congenital Syphilis: How Can We Stop It?

Hi. I'm Dr Laura Bachmann, chief medical officer for the Division of Sexually Transmitted Disease Prevention at the Centers for Disease Control and Prevention (CDC). I'm reaching out to healthcare providers with this critical news: Congenital syphilis cases have more than doubled in 4 years, reaching a 20-year high. CDC's latest annual report, Sexually Transmitted Diseases Surveillance 2017, reveals that there were 918 cases in 2017 alone^[1]—a rise that parallels similar increases in primary and secondary syphilis among women of reproductive age. The report also shows sustained increases across the nation for all reportable sexually transmitted diseases (STDs).^[1]

With congenital syphilis, we face an issue that needs both national and local action. Thirty-seven states reported at least one case in 2017, and some parts of the country—primarily Western and Southern states—remain disproportionately burdened.^[1] Even one case is too many with effective screening and treatment options available.

Syphilis during pregnancy can lead to significant health outcomes for an infant. Historical data indicate that up to 40% of pregnancies with untreated syphilis will result in miscarriage, stillbirth, or early infant death. Untreated infants who live may develop severe morbidity, such as skeletal abnormalities; hepatosplenomegaly; interstitial keratitis; sensorineural deafness; or meningitis, which can cause developmental delays and seizures.

We can avoid these devastating health outcomes with timely detection and treatment; however, we know we are missing opportunities to prevent congenital syphilis. For example, we know that too many pregnant women receive late or no prenatal care. Two other common missed opportunities relate to treatment and rescreening. Since long-acting benzathine penicillin G is not generally available in prenatal care settings, many women with positive screening tests are referred to a healthcare setting where the drug is available but are then lost in the private or public healthcare systems and never treated. And some women may test negative in the first trimester but acquire syphilis later in pregnancy.^[2]

The good news? There are five specific actions you can take to help protect your pregnant patients and their babies:

• Test pregnant women for syphilis per CDC guidelines as reaffirmed by the US Preventive Services Task Force (USPSTF). Test all pregnant women at their first prenatal visit; this is required by law in 42 states and Washington, DC.^[3] But remember: One test isn't enough for every pregnancy. Test pregnant patients at the beginning of the third trimester—approximately 28 weeks' gestation—if they live in high-prevalence areas, if they are at high risk for syphilis, or if required by state law; 17 states currently require third-trimester screening.^[3] Known risk factors for syphilis among women include multiple sex partners; substance use disorders; poverty; exchanging sex for drugs, money, or housing; and a history of incarceration. Some women may present with no risk factors of their own but are at risk because of partners with these risk factors.

• Treat women with diagnosed or suspected syphilis immediately . Test and treat her sex partner as well to avoid reinfection. Use penicillin, the only CDC-recommended course of treatment for pregnant women. Contact your state or local health department if you have challenges obtaining it, or if you refer a patient to another clinic for treatment and you can't verify that she was seen and treated.

• Confirm syphilis testing at delivery. Before discharging the mother or infant from the hospital, make sure the mother has been tested for syphilis at least once during pregnancy or at delivery. If she tests positive, manage the newborn per CDC guidelines for congenital syphilis. All women who deliver a stillborn infant should be tested for syphilis.

• Know whether syphilis is prevalent in your community. To learn more about syphilis burden in your community, refer to the 2017 CDC STD Surveillance Report or contact your local health department. If you have any doubts about your patient's risk or if your community prevalence is high, consider a third-trimester screening test.

• Finally, report all cases of syphilis by stage and congenital syphilis to the local or state health department right away. Congenital syphilis cases should be reported within 24 hours.

Thank you for your attention and for your help protecting mothers and their children from this preventable infection.

Web Resources

• A Guide to Taking a Sexual History. Covers five key areas to openly discuss with patients, including sample dialogue.

• Sexual Health and Your Patient: A Provider's Guide. A guide to better integrate sexual health conversations and related preventive sexual health services into routine adolescent and adult visits.

• CDC's STD Treatment Guidelines. Comprehensive, evidence-based diagnostic and treatment information for specific STDs; printable wall charts and pocket guides, as well as a downloadable mobile app, are also available from this page.

• USPSTF Final Recommendation Statement: Syphilis Infection in Pregnant Women: Screening . A review of the evidence on screening for syphilis infection in pregnant women and clinical considerations.

• STD Clinical Consultation Network. The National Network of STD Clinical Prevention Training Centers provides healthcare professionals and STD program staff with online clinical consultation for STD treatment and care.

• National STD Curriculum. A modular learning experience that helps users learn how to manage STDs. It is continuously updated and integrates CDC's most recent STD Treatment Guidelines. Free CME/CNE available.

• Syphilis: A Provider's Guide to Treatment and Prevention. This pocket guide is a complement to CDC's STD Treatment Guidelines and includes images of typical and atypical symptoms, as well as information to help address syphilis diagnostic challenges.

• Reducing Syphilis Rates: A Healthcare Provider's Role. This video provides an overview of three key actions providers can take to reduce the rise in syphilis.

• Let's Work Together to Stem the Tide of Rising Syphilis in the United States. CDC's call to action includes specific steps providers can take to reduce syphilis among gay and bisexual men and pregnant women.

Public Information from the CDC and Medscape

Cite this: A Devastating Surge in Congenital Syphilis: How Can We Stop It? - Medscape - Jan 14, 2019.