Congenital Syphilis Health Advisory - 10/03/19

HEALTH ADVISORY:
Congenital Syphilis
October 3, 2019

Summary

Reported syphilis cases are increasing nationally and in Texas.

• Reported congenital syphilis (CS) cases are also increasing.
• In Texas, 367 cases of CS were reported in 2018, which includes confirmed and probable (suspected) cases, as well as syphilitic stillbirths.

New state legislation was enacted on September 1, 2019 to increase syphilis testing in pregnant women. Testing is now mandated:

• At first prenatal care examination
• During third trimester (no earlier than 28 weeks gestation)
• At delivery

Texas healthcare providers are urged to:

• Screen all pregnant women for syphilis according to new testing requirements.
• Look for clinical signs/symptoms of syphilis in all patients.
• Treat patients with evidence of syphilis or recent exposure to syphilis on-site when possible. Document stage of syphilis and treatment administered.
• Report syphilis cases to your local or regional health department at the time of diagnosis. Include pregnancy status and treatment in the report.
• Test and evaluate newborns potentially exposed to syphilis in utero.
• Update electronic health record/electronic medical record systems to reflect new testing requirements.

Background

Syphilis cases have been increasing in men and women nationally, including women of childbearing age. Untreated syphilis during pregnancy can result in devastating health outcomes for the baby, including stillbirth or perinatal death, but congenital syphilis can be prevented by timely treatment of maternal syphilis.

In 2018, Texas saw increased cases of syphilis in women of childbearing age and of CS. In Texas, the number of CS cases increased 124% between 2017 (164 cases) and 2018 (367 cases). This is largest number of CS cases reported annually in Texas in more than 20 years and includes 352 probable cases, 2 confirmed cases, and 13 cases of syphilitic stillbirth.

New Legislation

As of September 1, 2019 Texas Health and Safety Code §81.090 mandates syphilis screening:

• At first prenatal care examination
• During third trimester (no earlier than 28 weeks gestation)
• At delivery

This represents a change from previous testing requirements, which mandated syphilis testing two times during pregnancy: at the first prenatal care examination and again during the third trimester.

Recommendations for Healthcare Providers

Screen all pregnant women for syphilis at the first prenatal encounter, during the third trimester (no earlier than 28 weeks gestation), and at delivery.

Evaluate for clinical signs/symptoms and laboratory evidence of syphilis. (Signs/symptoms of syphilis are summarized in table 1 below.)

• Look for clinical manifestations of early syphilis, which include:
  • Chancre, which typically presents as a painless ulcer with raised margin and non-purulent base, often near the anus, genitalia, or mouth
  • Bilateral rash on palms/soles
  • Generalized body rash of any type, often on the trunk
  • Condyloma lata, presenting as large, raised, gray or white lesions on moist, warm areas of the body
• Order serologic tests for syphilis.
• Review syphilis test results in the context of the patient’s prior syphilis testing and treatment. If documentation of prior treatment is not available, contact your local or regional health department for additional syphilis testing and treatment history.
• Consider consulting an infectious disease specialist for assistance interpreting results and determining appropriate treatment, if needed.
• Thoroughly evaluate all newborns potentially exposed to syphilis in utero.

Treat promptly pregnant women who are diagnosed with syphilis or exposed to syphilis over the last 90 days. (Recommended treatment is summarized in table 2 below.)

• Parenteral penicillin G is the only acceptable syphilis treatment for pregnant women. Intramuscular benzathine penicillin G is the recommended treatment for pregnant women with syphilis who do not have neurologic involvement.
  • Pregnant women with syphilis who report a penicillin allergy must be desensitized and then treated with parenteral penicillin G.
• The treatment regimen must be appropriate for stage of infection, as detailed in the Centers for Disease Control and Prevention 2015 Sexually Transmitted Disease (STD) Treatment Guidelines ( www.cdc.gov/std/tg2015/default.htm).
  • For patients with late latent syphilis, administer the three doses of benzathine penicillin G at one-week intervals. Pregnant women who miss any dose by greater than 14 days must repeat the full course.
  • Repeat syphilis titers monthly to document adequacy of response to treatment. Because many patients will deliver before their serologic response to treatment can be adequately assessed, post-partum follow-up of both mother and newborn are critical.
  • Screen for HIV in accordance with Texas Health and Safety Code §81.090.
    • Syphilis treatment recommendations are the same regardless of HIV status.
  • Consider referral of patients to the local health department STD clinic for assistance with syphilis treatment.

Report promptly.

• Promptly notify your local or regional health department of syphilis (any stage) at the time of diagnosis. Include pregnancy status in the report.
  • All primary and secondary syphilis cases are required to be reported within 24-hours by telephone for public health follow-up.
  • All other syphilis cases and syphilis test results are required to be reported within seven days (within three days for laboratories).
  • To facilitate timely and adequate treatment for pregnant women, DSHS recommends reporting these syphilis diagnoses within 24 hours by telephone. For more information regarding reporting, please visit /hivstd/healthcare/reporting.shtm
• People known (or suspected) to be pregnant are given highest priority. Local or regional health departments will contact providers to gather clinical, testing, treatment, risk, and partner information.

Update your electronic health record (EHR)/electronic medical record (EMR).

• Review current EHR/EMR systems to ensure that automated laboratory test algorithms, as well as other prompts or flags, are updated to incorporate current testing requirements.

See Table 1. Summary of Signs and Symptoms of Syphilis by Stage of Infection and Table 2. Summary of Recommended Treatment Regimens for Syphilis Cases Without Neurologic Involvement, per CDC Guidelines for more information.