October 25, 2017
Dear Colleague:
There are many issues demanding your time and attention, however I am writing today concerning a specific sexually transmitted infection (STI), syphilis. I also wanted to be sure that you were aware of a general increase in STI in many parts of Virginia. This correspondence is provided to make you aware of significant increases in reported congenital syphilis cases and syphilis cases among women in Virginia. This correspondence includes information and reminders regarding the following topics:
Key Observations
- Syphilis diagnoses among women have been increasing in Virginia, as have diagnoses of congenital syphilis.
- Most congenital syphilis cases diagnosed in Virginia in 2016 occurred due to either a lack of prenatal care or the mother’s seroconversion after a negative syphilis test at the first prenatal visit.
Syphilis Morbidity Increases
- Virginia’s 2016 rate of total early syphilis (TES) diagnoses (primary, secondary and early latent syphilis) increased by 13.2% from 2015, following a 57.1% increase from 2014-2015.
- While the majority of Virginia’s TES cases continue to occur among men, TES diagnoses among women increased 51.1% from 2015; diagnoses among men increased 8.4%.
- Eight congenital syphilis cases were diagnosed in 2016, and eight so far in 2017. This is a significant increase from an average of one to three congenital syphilis cases diagnosed per year over the last decade.
- Virginia’s trends are consistent with national trends, according to the newly released 2016 STD Surveillance Report. In addition, in April 2017, the Centers for Disease Control and Prevention (CDC) released a nationwide “Call to Action: Let’s Work Together to Stem the Tide of Rising Syphilis in the United States.”
Screening Recommendations
- Complete a sexual history for your patients to assess individual risk and counseling needs.
- CDC recommends that health care providers screen all pregnant women for syphilis at the first prenatal visit. For women at high risk for syphilis, CDC also recommends repeat testing at the beginning of the third trimester (28-32 weeks), and again at delivery. High risk women include (but may not be limited to) those women with a history of sexually transmitted infection (STI), incarceration, drug use, or multiple or concurrent partners, and those who live in areas with high prevalence. Women who were previously untested should also be screened early in the third trimester and at delivery.
- Placental inflammation from congenital infection might increase the risk for perinatal transmission of HIV. CDC recommends that health care providers screen all pregnant women for HIV at the first prenatal visit. For women at high risk, it is also recommended that providers retest in the third trimester. Women with no prenatal care should be tested for HIV at the time of delivery.
- Many STDs can impact the health of a pregnant woman and her baby. Please familiarize yourself with the CDC 2015 Sexually Transmitted Diseases (STD) Treatment Guidelines for more information on screening, testing, and treatment for HIV and other STDs in different populations, including pregnant women.
Treatment and Other Actions
- Per the CDC 2015 STD Treatment Guidelines, health care providers should treat pregnant women with syphilis with intramuscular benzathine penicillin G (Bicillin L-A) or, if diagnosed with neurosyphilis, intravenous aqueous crystalline penicillin G or intramuscular procaine penicillin G. Doxycycline, tetracycline, or other alternative treatments for syphilis are not acceptable treatment options during pregnancy. Pregnant women who report a penicillin allergy must be desensitized. Questions about clinical management can be directed to the National Network of STD Clinical Prevention Training Centers (NNPTC) STD Clinical Consultation Network.
- Ensure all patients diagnosed with syphilis understand the importance of notifying their partners about the need to get tested. Physicians can contact their local health department for assistance with partner services, including partner notification and follow up.
Thank you for your efforts to ensure identification and reporting of syphilis cases. Please report syphilis to your local health department according to the Board of Health Regulations for Disease Reporting and Control. For more information, contact Ashley Carter or 804-864-8042, or visit the VDH-STD program or CDC-Division of STD Prevention websites.
And let me also thank you for your continued efforts to improve and maintain the health of all people in Virginia.
Sincerely,
Marissa J. Levine, MD, MPH, FAAFP
State Health Commissioner