Health Advisory: Treatment and Expanded Universal Screening for Syphilis Recommended for all Pregnant People

10/30/2024

Action Requested 

• Help in preventing congenital syphilis in our communities by screening all pregnant people for syphilis at their first prenatal visit, in the early third trimester, and at delivery. Every contact with a pregnant person is an opportunity to screen for syphilis, when indicated.
• Conduct universal syphilis screening at least 3 time points in pregnancy following the April 2024 guidance from the American College of Obstetricians and Gynecologists.
  1. At first prenatal care visit
  2. At 24-28 weeks (early third trimester)
     • This can be done at the same time as the oral glucose tolerance test.
     • It allows enough time to complete treatment before delivery.
     • It helps detect new infections or reinfections during pregnancy.
  3. At delivery
• Screen pregnant individuals with limited, no, or unknown prenatal care for syphilis whenever they seek medical care, including in emergency departments, urgent care, drug treatment programs, syringe service programs, and in correctional facilities. If they screen positive for syphilis or have symptoms of primary or secondary syphilis, treat them without delay.
• Screen all pregnant individuals for HIV, hepatitis B, and hepatitis C infections that can occur with syphilis to prevent perinatal transmission.

For syphilis treatment and follow-up: 

• Check the pregnancy status of any individual with syphilis who is capable of becoming pregnant and start treatment immediately. 
• Follow the recommendations in the 2021 CDC STI Treatment Guidelines for evaluation and treatment of syphilis among adults, infants, and children.
• Notify the local health jurisdiction where the individual lives within 3 days of diagnosis. Let the patient know that a health department employee will be reaching out to them about this diagnosis. Prompt reporting supports rapid public health intervention to prevent further spread of disease. For Snohomish providers, the STI team can be reached at 425-339-5261. Case Reports | Washington State Department of Health; Syphilis Reporting Guidelines (wa.gov)
• Work with your Local Health Jurisdiction (LHJ) or State Field Services team to find pregnant individuals with syphilis who may have missed follow-up care. Help them navigate any barriers to successful treatment, preventing congenital syphilis.
• Contact your local health jurisdiction or reach out to Pfizer directly for assistance if you experience a Bicillin L-A (penicillin G benzathine) supply issue.  

Background

In 2020, Washington reported 10 cases of congenital syphilis and 70 cases of syphilis in pregnant individuals. In 2021, the number of reported congenital syphilis cases increased to 53 with 116 reported cases of syphilis in pregnant individuals. In 2022, there were 52 reported congenital syphilis cases and 152 reported cases of syphilis in pregnant individuals. Unfortunately, these numbers have remained high, with 57 congenital syphilis cases reported in 2023 among 169 reported cases of syphilis in pregnant individuals. The early numbers for 2024 continue to be alarming.

In Snohomish County since 2020, there have been 160 cases of syphilis in pregnancy-capable individuals resulting in 10 cases of congenital syphilis. There were no congenital syphilis cases in Snohomish County from 2014-2020.

 The American College of Obstetricians and Gynecologists now recommends universal screening at 3 points in time during the gestational period rather than risk-based screening. Universal screening at 3 points in time is cost-effective. 

 Washington Apple Health covers the costs of all syphilis testing during pregnancy. Prenatal screening should also include testing for HIV, hepatitis B, and hepatitis C.

 Traditionally, the algorithm for syphilis serologic screening starts with a nontreponemal test like an RPR. Any reactive or positive specimens are tested for confirmation by treponemal antibody testing. The reverse sequence algorithm starts with a treponemal test, which is less likely to be falsely positive and may detect very early and very late syphilis. However, the testing approach used should be based on available resources, test volumes, and patient populations served. CDC Laboratory Recommendations for Syphilis Testing, United States, 2024 | MMWR

Screen all pregnant people with no, limited, or unknown prenatal care any time they visit the emergency department, a substance use disorder treatment program, or a correctional facility. For many pregnant individuals with syphilis, these settings may be their only touchpoint with the health care system before delivery. If a patient comes in for prenatal screening, make sure you also screen them for syphilis during the same visit. 

 Benzathine penicillin G is 98% effective in preventing congenital syphilis. Treat pregnant individuals with primary, secondary, or early non-primary non-secondary syphilis with one dose of 2.4 million units of benzathine penicillin G. Treat pregnant individuals with late or unknown duration syphilis with three doses of 2.4 million units of benzathine penicillin G spaced 6-9 days apart. Doses spaced >9 days need re-treatment. If you need assistance with staging a patient's syphilis, you can reach out to your local health department. For Snohomish providers, the STI team can be reached at 425-339-5261. 

 Start treatment as soon as possible and no later than 14 days after diagnosis. By notifying your local health department of the diagnosis, they can help ensure timely treatment. Treat pregnant people with symptoms of primary or secondary syphilis at the time of evaluation without waiting for serologic testing to return. For pregnant people who have a reactive screening test like a point-of-care rapid test or other rapid screening modality, start treatment while awaiting confirmatory results. Remember to take a careful allergy history if a penicillin allergy is reported; many penicillin allergies are not true allergies or have waned with time.

 Partner treatment is critical to avoid reinfection. Treat anyone who may have been exposed to syphilis at the time of testing. Strongly encourage pregnant individuals with syphilis to inform partners of their syphilis diagnosis and urge partners to get tested and treated. Consider testing and treating your pregnant patient’s partner in your practice. Let your patients know that Washington State Disease Intervention Specialists (DIS) will reach out to them to help with any barriers to treatment and follow-up, such as transportation, and may offer incentives for them and their partners such as free testing for other STIs and treatment. 

We encourage medical providers to work closely with DIS. DIS can help locate patients lost to follow-up and do field visits for testing and treatment. 

Because an RPR may fluctuate after treatment, we recommend repeating an RPR no sooner than 8 weeks after treatment. For patients treated before 24 weeks estimated gestational age (EGA), recheck an RPR at 24-28 weeks EGA and at delivery. For patients treated after 24 weeks EGA, recheck an RPR at delivery. Only 38% of treated pregnant individuals with syphilis experience a four-fold decrease in RPR titer before delivery, as there isn’t enough time to observe this decline in titer. However, treated pregnant individuals without a four-fold decline in RPR titer were not more likely to deliver an infant with congenital syphilis. 

 Rescreen any time there is concern about re-exposure, reinfection, or symptoms of primary or secondary syphilis. Re-treatment is appropriate if the RPR titer increases four-fold e.g., from 1:4 to 1:16 or after re-exposure to a sexual partner with syphilis, regardless of the RPR titer.

Resources

• Washington State Local Health Jurisdictions: Find contacts for your local health jurisdiction.
• Washington Department of Health Syphilis: Information on syphilis from WA DOH.
• Public Health—Seattle & King County Syphilis: Information on syphilis from Public Health—Seattle & King County. 
• CDC 2021 STI Treatment Guidelines: Current evidence-based prevention, diagnostic, and treatment recommendations for clinical guidance. Health care providers should always assess patients based on their clinical circumstances and local context.
• Managing Persons Who Have a History of Penicillin Allergy
• STD Clinical Consultation Network: A free clinical consultation service provided by expert faculty at regional STD Prevention Training Centers, as part of the National Network of STD Clinical Prevention Training Centers. The STD clinical consultation service is only available to licensed healthcare professionals and STD program staff.
• Screening for Syphilis in Pregnancy | ACOG: The most recent ACOG guidelines recommend universal syphilis screening at three time points in pregnancy.