Test All Pregnant Women for Syphilis Early, USPSTF Says

All pregnant women should undergo early screening for syphilis, according to an updated recommendation statement from the US Preventive Services Task Force (USPSTF). This newest guidance reaffirms the statement published in 2009 and is an "A" recommendation, which means there is high certainty of a substantial net benefit.

"Syphilis is an infection that is primarily sexually transmitted. Untreated syphilis infection in pregnant women can also be transmitted to the fetus (congenital syphilis) at any time during pregnancy or at birth. Congenital syphilis is associated with stillbirth, neonatal death, and significant morbidity in infants" stress the authors, led by Susan J. Curry, PhD, from the University of Iowa, Iowa City, and colleagues.
The recommendation statement along with an evidence report were published in the September issue of JAMA, and an accompanying editorial was published online September 4 in JAMA Dermatology.

Gaps in Public Health and Clinical Practice Remain

Although women accounted for only 11% of primary and secondary syphilis cases in the United States in 2016, the incidence of primary and secondary syphilis among women doubled from 2012 to 2016.

"Not surprisingly, the incidence of congenital syphilis...closely tracks the incidence of primary and secondary syphilis among women. Indeed, cases of congenital syphilis incidence nearly doubled from 2012 (8.4 cases/100,000 live births) to 2016 (15.7 cases/100,000 live births)," says Kenneth A. Katz, MD, associate editor, JAMA Dermatology, and Department of Dermatology, Kaiser Permanente San Francisco Medical Center, California, in the editorial.
"Those rather abstract epidemiologic measures translate to very real harms. In addition to stillbirth and neonatal death, congenital syphilis is associated with acute morbidity from rash, hemorrhagic rhinitis, jaundice, lymphadenopathy, hepatosplenomegaly, skeletal abnormalities, and lasting damage from bone deformities and neurologic impairment," he stresses.
Emphasizing that this advice for screening of pregnant women for syphilis at the earliest opportunity doesn't differ from the recommendation issued in 2009, Katz says. "Clearly...gaps in public health and clinical practice remain," he notes, citing figures from a 2014 study of 458 mothers of infants with congenital syphilis which found that approximately 20% had received no prenatal care and another 10% had no available information on prenatal care.
Of those with one or more prenatal visits, 30% were inadequately treated for syphilis and 43% were not treated at all because they were not tested during pregnancy, they tested negative early in pregnancy but later developed syphilis, or they received no treatment despite testing positive.

Women who have received no prenatal care should undergo testing for syphilis when they present for delivery, the recommendations stress.

We Must Do Better

Katz also notes that the Task Force recommendation statement refers to guidelines from the Centers for Disease Control and Prevention and joint guidelines from the American Academy of Pediatrics and American College of Obstetricians and Gynecologists, which endorse repeated screening during the third trimester and at delivery for pregnant women at higher risk of syphilis, including those with a history of syphilis infection, incarceration, or drug use; those with multiple or concurrent sex partners; those who live in high-prevalence areas; and those who have a sexually transmitted infection.
He also notes that disparities in congenital syphilis exist, with a higher incidence among black, American Indian/Alaska Native, Hispanic, and Asian populations compared with white populations. Geography matters too, with higher rates in the West and South compared with the Northeast and Midwest.
Most states legally require prenatal syphilis screening, he stresses, and from a financial perspective, under the Affordable Care Act "the 'A' recommendation means that insurance companies must cover syphilis screening in pregnant women without requiring cost-sharing by patients."
"Public health authorities and physicians, including dermatologists, must do better," he urges.
Dermatologists Have An Important Role in Prevention and Control
Katz singles out dermatologists, who he says need to stay abreast of rising rates of primary and secondary syphilis among women, as well as increasing rates of congenital syphilis.
"Primary and secondary syphilis, by definition, have mucocutaneous manifestations, and mucocutaneous manifestations are common in congenital syphilis," he said.
"Dermatologists might well help diagnose and manage these patients. Keeping syphilis in mind when formulating a differential diagnosis — especially for a disease known as the 'great mimicker' — can reduce the chance of missing a diagnosis and offers an opportunity for prompt treatment that can improve outcomes, including in congenital syphilis," he explains.
As well as being aware of the USPSTF recommendations on syphilis screening in pregnant women, dermatologists should also consider nonpregnant adults and adolescents at increased risk for syphilis, he notes.
"Clinical encounters with persons who meet syphilis screening criteria but who lack signs or symptoms of syphilis should trigger recommendations and/or referrals for syphilis screening," Katz adds.
Screening for syphilis infection involves two steps. Traditionally, the first test is a "nontreponemal" antibody test — a venereal disease research laboratory (VDRL) or rapid plasma reagin (RPR) test, followed by a "treponemal" antibody detection test — a fluorescent treponemal antibody absorption or Treponema pallidum particle agglutination test — for confirmation.
Now the reverse sequence screening algorithm is also available, in which an automated treponemal antibody test such as an enzyme-linked, chemiluminescence, or multiplex flow immunoassay, is performed initially, followed by a confirmatory nontreponemal VDRL or RPR test. A second treponemal test is performed if the test results are discordant.
USPSTF members received reimbursement for travel expenses to and from USPSTF meetings and have disclosed no other relevant financial relationships. Katz has disclosed no relevant financial relationships.
JAMA. 2018;320:911-917. Recommendation Statement
JAMA. 2018;320:918-925. Evidence Report
JAMA Dermatology. Published online September 4, 2018. Editorial