Congenital Syphilis Still Diagnosed Beyond Neonatal Period in US

(Reuters Health) – The annual number of congenital syphilis cases reported to the U.S. Centers for Disease Control and Prevention (CDC) surged 183% from 462 cases in 2014 to 1,306 cases in 2018, and too many of these cases are being missed at or before birth, researchers say.

During the entire study period, a total of 3,834 infants were delivered with congenital syphilis, the study team reports in Pediatrics. Of these deliveries, 55.5% were liveborn and asymptomatic when syphilis was diagnosed, while 38.1% were liveborn and symptomatic, and 6.4% were stillborn.

Over the study period, the proportion of infants diagnosed with congenital syphilis beyond the neonatal period declined from 5.9% to 2.9%. However, there were 67 cases of symptomatic infants diagnosed beyond the neonatal period.

“This finding was concerning as infants who are diagnosed and treated later in life may develop long-term problems from congenital syphilis, which include intellectual disabilities, physical deformities, and deafness,” said lead study author Dr. Anne Kimball of the Division of Sexually Transmitted Diseases Prevention at the CDC in Atlanta, Georgia.

“Congenital syphilis can be prevented by diagnosing and adequately treating maternal infection during pregnancy or prior to pregnancy,” Dr. Kimball said by email.

For this reason, the CDC recommends universal screening for syphilis early in pregnancy, with repeat screening at 28 weeks’ gestation and at delivery for pregnant people at increased risk for syphilis acquisition on the basis of individual risk factors or high community prevalence, Dr. Kimball said.

Maternal serological status should also be confirmed before mothers and infants are discharged from the hospital after labor and delivery, including confirmation that the mother received at least one syphilis test during pregnancy and again at delivery for mothers at increased risk, Dr. Kimball said.

Among the cases of congenital syphilis found after the neonatal period, the majority had physical examination findings (67%) or abnormal long-bone radiographs (69%) indicating congenital syphilis.

Many of these infants (36%) also had reactive syphilis testing in the cerebrospinal fluid; cases had a median serum nontreponemal titer of 1:256.

Cases diagnosed after the neonatal stage had a median age of 67 days, although the ages ranged from 29 to 249 days.

The majority of the 66 mothers with infants diagnosed after the neonatal stage had received prenatal care (83%). However, just 26% of these women received a diagnosis during pregnancy or at delivery, and 42% didn’t receive a syphilis test until after delivery.

Almost one in four of these women (24%) had an initial negative test result and seroconverted during pregnancy.

One limitation of the study is the potential for variation in provider documentation and health department collection of congenital syphilis data to influence the outcomes, the authors note.

Even so, the results underscore the importance of screening and prevention efforts during routine prenatal care, said Emily Harville, an associate professor of epidemiology at Tulane School of Public Health and Tropical Medicine in New Orleans, who wasn’t involved in the study. Many barriers can make this difficult to achieve, particularly for some vulnerable and high-risk populations, Harville said.

“Maternal syphilis often goes along with other issues like homelessness, partner violence, or substance use, and that can make accessing care and consistent follow-up – which is necessary for treatment of syphilis – difficult,” Harville said by email.

When women do get referred for tests, labs may be in a different location than doctors, and patients may need to return for treatment because rapid tests aren’t available, Harville said. Some doctors don’t start the right type of antibiotic. In other instances, doctors may treat women but not follow up with their partners, leaving the potential for reinfection.

Prenatal charts documenting syphilis diagnosis or treatment may also not be available at delivery to ensure that protocols are followed, Harville said.

“All of these point to improving continuity of care and limiting the chance that people will fall between the cracks,” Harville said.

SOURCE: Pediatrics, online August 31, 2021.

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