The rate of congenital syphilis (CS) in the United States reached a low of 8.4 cases per 100,000 live births in 2012 after four years of steady decline. However, between 2012 and 2014, the national CS rate spiked 38 percent overall. This increase reflected a 22 percent hike in the combined rate of primary and secondary syphilis among women during the same period.
This information was released in the Nov. 13 issue(www.cdc.gov) of the CDC's Morbidity and Mortality Weekly Report (MMWR), in which the agency suggested that each case of CS results from missed opportunities for prevention in the health care system and the public health sector.
Two major opportunities to prevent CS, according to the CDC, are primary prevention of syphilis among women of reproductive age and men who have sex with women, as well as prevention of mother-to-infant transmission among infected pregnant women.
Accordingly, the agency recommends that all pregnant women be screened for syphilis at their first prenatal visit. Women at increased risk for syphilis and women who live in geographic areas with high morbidity levels should also be screened at the beginning of their third trimester and again at delivery.
For its part, the U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all pregnant women(www.uspreventiveservicestaskforce.org) for syphilis infection, as well as people at increased risk(www.uspreventiveservicestaskforce.org) for infection. The AAFP's recommendations on syphilis screening mirror those of the USPSTF.
- The Nov. 13 Morbidity and Mortality Weekly Report highlighted a 38 percent increase in congenital syphilis (CS) in the United States from 2012-2014.
- All racial and ethnic groups experienced increases in both case counts and rates of CS from 2012 to 2014, with rates among whites, Hispanics and blacks increasing 61 percent, 39 percent and 19 percent, respectively.
- The CDC explained that two opportunities to prevent CS are primary prevention of syphilis among women of reproductive age and men who have sex with women, as well as prevention of mother-to-infant transmission among infected pregnant women.
The MMWR report said a substantial percentage of CS cases can be attributed to a lack of prenatal care, but even among those receiving some prenatal care, the detection and treatment of maternal syphilis often occurs too late to prevent CS.
The CDC said health professionals who provide prenatal care should partner with health departments and other local organizations to remove barriers for vulnerable pregnant women to receive early and adequate prenatal care. Women who are uninsured or underinsured or who have substance use issues are at greatest risk to receive inadequate or no prenatal care and are at greater risk for CS.
Benzathine penicillin G is the only known effective treatment for preventing CS, and maternal treatment is considered inadequate if initiated too late (less than 30 days before delivery), if a nonpenicillin therapy is administered or if the dose of penicillin administered is inadequate for the mother's stage of syphilis.
Between 2012 and 2014, the overall number of reported CS cases in the United States rose from 334 to 458 -- that is, from 8.4 cases per 100,000 live births to 11.6 cases per 100,000 live births.
Increases in CS rates occurred in all regions but were greatest in the West, where the rate more than doubled (from 5.5 to 12.8 cases per 100,000 live births). In total, 19 states reported increases in both number of CS cases and rates of CS from 2012 to 2014.
It's worth noting that all racial and ethnic groups experienced increases in case counts and rates of CS between 2012 and 2014, with rates among whites, Hispanics and blacks increasing 61 percent, 39 percent and 19 percent, respectively. In 2014, the CS rate among blacks remained about 10 times the rate seen among whites and three times the rate seen among Hispanics.
Family Physician's Take
Margaux Lazarin, D.O., M.P.H., practices at the Urban Horizons Family Health Center in the Bronx, N.Y., where, she told AAFP News, "We have seen an increase in rates of sexually transmitted infections (STIs), including secondary syphilis, at our clinic and in the community."
According to Lazarin, the health center's staff members follow the USPSTF/AAFP guidelines to screen all pregnant women for syphilis. "We also screen for hepatitis B, HIV, gonorrhea and chlamydia at their initial prenatal visit, and then we offer STI screening again in the third trimester," she said.
Lazarin said prevention of CS is key and takes a group effort. "On a communitywide level, there needs to be education about syphilis (and STI) prevention, as well as access to condoms, screening and testing," she said. "For individual patients, the recommendations are to screen all 'at-risk' individuals, such as patients who exchange sex for money and/or have multiple partners."
Also, preconception counseling offers an excellent opportunity to discuss the important topics a patient should be considering before getting pregnant, she said. "But unfortunately, half of pregnancies in this country are unplanned, and low-income patients are disproportionately burdened by decreased access to care, which often delays treatment," Lazarin added.
For these low-income and under- or uninsured patients, she said, clinics like hers -- federally qualified health centers that see all patients regardless of their ability to pay -- as well as public hospital systems and groups such as Planned Parenthood may offer the best opportunities to receive care.
A final note: Lazarin said it's important to get a good sexual history on prenatal patients with syphilis because their partners will also need to be treated presumptively. "Depending on the duration of the symptoms/the specific diagnosis (e.g., primary, secondary or early latent), partners as far back as a year may need treatment," she said.
Related AAFP News Coverage
Group Visits: A Patient-Centered Approach to Improving Pregnancy Outcomes
More From AAFP
Family Doctor.org: Syphilis(familydoctor.org)
Clinical Recommendations: Maternity Care