By Rebecca Bowers

EXECUTIVE SUMMARY

Cases of congenital syphilis have more than doubled since 2013, according to the Centers for Disease Control and Prevention. All pregnant women should visit a healthcare provider as soon as possible to be tested for syphilis, but one test may not be enough to catch all cases.

  • The number of reported congenital syphilis cases rose from 362 in 2013 to 918 in 2017, representing the highest number of cases recorded in 20 years. A total of 37 states reported cases, with most cases concentrated in western and southern states.
  • Women who have a high risk for syphilis or who live in areas with a high prevalence of the infection should be tested at the first prenatal visit, and again early in the third trimester, and at delivery.

The number of cases of congenital syphilis has more than doubled since 2013, according to the Centers for Disease Control and Prevention (CDC). All pregnant women should visit a healthcare provider as soon as possible during each pregnancy to be tested for syphilis, according to recommendations.1

The stakes are high. When syphilis infection goes untreated during pregnancy, it directly affects the risk for adverse outcomes in pregnancy. Authors of a 2013 systematic review found that during pregnancy, untreated syphilis infection in mothers was associated with the following absolute differences compared to mothers without the infection: 21% for stillbirth or fetal loss, 9% for neonatal death, and 5% for a premature or low birth weight baby.2 When infants are born with congenital syphilis, they often don’t have symptoms at birth. However, some babies may develop signs of the infection, such as rash, hemorrhagic rhinitis, lymphadenopathy, hepatosplenomegaly, and skeletal abnormalities, within the first several weeks of life.3 Further symptoms include anemia, meningitis, and neurologic impairment, such as blindness or deafness.

“When passed to a baby, syphilis can result in miscarriage, newborn death, and severe lifelong physical and mental health problems,” notes Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “No parent should have to bear the death of a child when it would have been prevented with a simple test and safe treatment.”

The number of reported congenital syphilis cases rose from 362 in 2013 to 918 in 2017, representing the highest number of cases recorded in 20 years, according to the CDC. A total of 37 states reported cases, with most cases concentrated in western and southern states. The increase in congenital syphilis mirrors similar upturns in syphilis among reproductive-age women and is moving ahead of national increases in all sexually transmitted diseases (STDs).1

Test All Pregnant Women

The CDC now recommends that all pregnant women undergo syphilis testing the first time they see a healthcare provider about their pregnancy. However, one test may not be enough for many women, the agency advises. Women who are at high risk for the infection or who live in areas of high prevalence of the infection should undergo testing at the first prenatal visit, then again early in the third trimester, and also at delivery. If women are sexually active, they can reduce their risk of acquiring syphilis infection by being in a long-term, mutually monogamous relationship with a partner who has undergone syphilis testing and by using condoms consistently and correctly at every act of intercourse.4

Joint guidance from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists also endorses repeat screening for syphilis. These organizations recommend that women who are at high risk receive repeat screening for the infection early in the third trimester of pregnancy (at about 28 weeks of gestation) and then again at delivery.5

To protect every baby, clinicians must start the process by protecting every mother, says Gail Bolan, MD, director of the CDC’s Division of STD Prevention.

“Early testing and prompt treatment to cure any infections are critical first steps, but too many women are falling through the cracks of the system,” said Bolan in a press statement. “If we’re going to reverse the resurgence of congenital syphilis, that has to change.”

Check your area for syphilis rates, and consider advocating for policy changes to support additional screening beyond the CDC recommendations. Although most states have laws that require syphilis screening during the first trimester of pregnancy, several states also have added third trimester screening. For example, Louisiana, Georgia, and Texas recently added third trimester syphilis screening to state laws.6

The CDC is working to support states with a high burden of disease to improve local systems for prevention and enhance identification and treatment of pregnant women with syphilis. It also is examining factors that are contributing to the resurgence of congenital syphilis to improve prevention programs. By partnering with community organizations such as March of Dimes, the agency hopes to increase awareness among pregnant women about the risk factors of congenital syphilis.

The CDC also is funding a pilot project in nine hard-hit areas to address congenital syphilis infection further. These areas include California (excluding Los Angeles and San Francisco), Chicago, Florida, Georgia, Los Angeles, Louisiana, Maryland (including Baltimore), Ohio, and Texas.

Task Force Backs Early Screening

The U.S. Preventive Services Task Force recently published a final recommendation statement on screening for syphilis infection in pregnant women.7 In its review of available evidence, the task force examined whether screening helps prevent infection in babies.8 Based on its review, the advisory group now recommends that all pregnant women receive early screening for syphilis infection.

“Screening for and treatment of syphilis in pregnant women is extremely effective in preventing the infection from being passed to the baby,” says task force member Melissa Simon, MD, MPH, George H. Gardner professor of clinical gynecology, the vice chair of clinical research in the Department of Obstetrics and Gynecology, and professor of preventive medicine and medical social sciences at Northwestern University Feinberg School of Medicine. “Treatment is most effective when it is done early, so we strongly recommend that all women be screened as early in their pregnancy as possible.”

Treponema pallidum bacteria cause syphilis infections. The current syphilis screening tests identify the infection by detecting the antibodies to it. Traditional screening for infection has called for an initial “nontreponemal” antibody test, such as a Venereal Disease Research Laboratory test or rapid plasma reagin test, then followed with a confirmatory “treponemal” test to detect antibodies, such as a fluorescent treponemal antibody absorption or T. pallidum particle agglutination test. Because of the complexity of nontreponemal tests, a reverse sequence screening algorithm is used. This process involves use of a treponemal test, such as an enzyme-linked, chemiluminescence, or multiplex flow immunoassay, and then a nontreponemal test. A second treponemal test is performed if the reverse sequence algorithm test results are discordant.7

Since 2015, the CDC has recommended use of parenteral Benzathine penicillin G to treat pregnant women with syphilis infection.4 Treatment is most effective when started early in pregnancy.

“An infected mother can pass syphilis to her baby at any time during the pregnancy, causing serious health problems for the baby, including death,” says task force member Chien-Wen Tseng, MD, MPH, MSEE, Hawaii Medical Service Association endowed chair in health services and quality research, a professor, and the associate director of research in the Department of Family Medicine and Community Health at the University of Hawaii John A. Burns School of Medicine. “Since the early stages of syphilis may have no symptoms, it is important for all pregnant women to be screened to protect their health and the health of their babies.”

REFERENCES

  1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Atlanta: U.S. Department of Health and Human Services; 2018.
  2. Gomez GB, Kamb ML, Newman LM, et al. Untreated maternal syphilis and adverse outcomes of pregnancy: A systematic review and meta-analysis. Bull World Health Organ 2013;91:217-226.
  3. Kingston M, French P, Higgins S, et al; Members of the Syphilis Guidelines Revision Group 2015. UK national guidelines on the management of syphilis 2015. Int J STD AIDS 2016;27:421-446.
  4. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
  5. American Academy of Pediatrics; American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; 2017.
  6. Allen ML, Smith W. Congenital syphilis on the rise. April 22, 2016. National Coalition of STD Directors. Available at: https://bit.ly/2yEVpuj. Accessed Oct. 18, 2018.
  7. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for syphilis infection in pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. JAMA 2018;320:911-917.
  8. Lin JS, Eder ML, Bean SI. Screening for syphilis infection in pregnant women: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018;320:918-925.