Lack of testing, inadequate treatment led to continued spike in congenital syphilis in 2022

Congenital syphilis has several consequences during pregnancy including miscarriage, stillbirth, infant death, and maternal and infant morbidity. Since 2012, there have been substantial increases in congenital syphilis cases in the United States, increasing by 755% from 2012 to 2021, according to a new Morbidity and Mortality Weekly Report (MMWR) from the Centers for Disease Control and Prevention (CDC).

In this timeframe, reported cases increased from 335 in 2012 to 2865 in 2021. The disease that results from perinatal transmission of syphilis is preventable through means of timely testing and appropriate treatment during pregnancy.

The CDC recommends syphilis screening during pregnancy at the first prenatal care visit. If access to prenatal care is not optimal, screening should take place as soon as the pregnancy is identified. Screenings are recommended at 28 weeks’ gestation and at delivery for those living in areas with high syphilis rates, are at high risk for syphilis acquisition during pregnancy, or those who were not previously tested during pregnancy.

To identify missed prevention opportunities, investigators of the study published in MMWR developed a mutually exclusive 6-part cascading framework of risk factors. It includes:

• No documented testing or nontimely testing
• Late identification of seroconversion during pregnancy
• No treatment or nondocumented treatment
• Inadequate treatment
• Evidence of congenital syphilis despite adequate maternal treatment documentation
• Insufficient data to recognize a missed prevention opportunity

The study used congenital syphilis cases reported to the CDC’s National Notifiable Diseases Surveillance System (NNDSS) in 2022. Upon examination, cases were assigned to 1 of the 6 framework categories, first determining if timely testing took place amid pregnancy (testing completed ≥30 days before delivery). Cases met the 2018 Council of State and Territorial Epidemiologists congenital syphilis case definition.

There was a total of 3761 congenital syphilis cases reported to NNDSS in 2022. Of these, 6% (231) were stillbirths and 84% (3530) were liveborn infants. There were 51 infant deaths (1%). Compared to 2021, the 3761 cases in 2022 represented a 31.7% increase.

A concurrent 17.2% increase in rates of primary and secondary cases among females aged 15 to 44 years was observed. Compared to 2012, more than 10 times as many congenital syphilis cases were reported in 2022.

In all cases reported in 2022, 87.8% of birth parents (3302) received no or nontimely testing (1385), or no or nondocumented testing (423). Inadequate treatment during pregnancy was reported in 39.7% of birth parents (1494). In 5.2% of cases (197), syphilis was diagnosed late in pregnancy, following an earlier nonreactive test.

Results demonstrated that 57.9% of cases (2179) had timely testing and no late identification of syphilis. Of these, nearly 40% (1494) had documentation of inadequate treatment, nearly 20% (423) received no treatment or had nondocumented treatment. The remaining 12% (262) received adequate treatment.

Geographically in the United States, no testing or nontimely testing made up approximately half of cases in the West (56.2%) and Northeast (50.0%) Census Bureau regions. In the Midwest no testing and nontimely testing made up the largest percentage of cases in the Midwest region (40.4%).

The same category resulted in the highest percentage of missed care opportunities for prevention for non-Hispanic American Indian or Alaska Native (47.4%), non-Hispanic Black or African American (39.2%), and Hispanic or Latino (47.4%) birth parents.

No prenatal care was documented in 1426 (37.9%) of pregnancies resulting in a congenital syphilis outcome. In 2022, a lack of timely testing and adequate treatment amid pregnancy contributed to 88% of congenital syphilis cases in 2022.

The rapidly increasing rates of congenital syphilis in the United States are the highest in 30 years, according to the CDC. Multifactorial barriers for prevention have been observed, including at the patient level. These include substance use and insurance status.

System level barriers also exist, such as limited access to health care, medication shortages, and structural inequities. Improvements in timely testing and appropriate treatment, along with addressing the barriers associated with the increase in cases at local and national levels “will help control the congenital syphilis epidemic in the United States,” the report concluded.

Reference:

Vital signs: Missed opportunities for preventing congenital syphilis – United States, 2022. Morbidity and Mortality Weekly Report. November 7, 2023. Accessed November 9, 2023. https://www.cdc.gov/mmwr/volumes/72/wr/mm7246e1.htm?s_cid=mm7246e1_w