Updated Syphilis Guidelines

Updated Syphilis Guidelines

November 28, 2023

Dear Colleague,

Given the rise in syphilis and congenital syphilis cases, the Centers for Disease Control and Prevention (CDC) has strengthened its recommendations for screening and treating pregnant and reproductive-age patients. Virginia’s recommendations are based on the most recent complete year of data, which is 2022. The CDC is expected to update their recommendations based on 2022 data in January 2024.

In addition, the Virginia Department of Health has launched a new syphilis website with important information about syphilis infections and resources for both the public and healthcare providers.  The webpage includes a data dashboard with up-to-date information on annual and monthly syphilis case counts in Virginia, including current year data.

The Virginia Department of Health requests your support in addressing the rapidly rising syphilis and congenital syphilis cases.  In Virginia, syphilis rates have risen by 120% in the last decade (2013 to 2022), and rates of congenital syphilis have increased by 541%.  Nationally, there was a ten-fold increase in congenital syphilis cases between 2012 and 2022. The CDC’s recent analysis shows that nearly nine in ten cases of congenital syphilis in 2022 might have been prevented with timely testing and treatment during pregnancy.  More than half of the cases were among women who tested positive for syphilis during pregnancy and did not receive adequate or timely treatment.  Nearly 40% of cases were among women who were not receiving prenatal care.

The burden of congenital syphilis is not distributed equally across the population.  Racial and ethnic minorities are more likely to have babies born infected with syphilis than white women.  Healthcare workers should attempt to remove as many barriers to care as possible to ensure that health access is equitable for all. While prenatal care settings have traditionally been a common setting for diagnosing and treating syphilis among pregnant women, all healthcare providers play a critical role in screening reproductive age individuals.   

CDC currently recommends the following: 

  • Address syphilis before pregnancy: Offer syphilis screening to all sexually active people ages 15-44 living in counties with high syphilis rates.  For many people, the most significant risk factor for syphilis is living in a community with high rates of syphilis. Virginia has 38 localities (counties or cities) with elevated rates of primary & secondary syphilis among reproductive aged women (greater than 4.6 per 100,000) based on 2022 data.
  • Continue to screen all pregnant women for syphilis during the first trimester, preferably at their first prenatal visit. Rescreen early in the third trimester (28-32 weeks), and again at delivery if living in a county with high syphilis rates or otherwise at higher risk. Screen women at delivery if they delivered a stillborn infant (after 20 weeks), did not receive prenatal care, or were not screened previously during pregnancy.
  • Ensure all people get the treatment they need. Consider starting syphilis treatment immediately following a positive rapid (point-of-care) syphilis test during pregnancy if the patient faces obstacles to ongoing care (and still perform full confirmatory syphilis testing).  Bicillin is the only recommended treatment for syphilis during pregnancy.  Due to the ongoing bicillin shortage, prioritize bicillin for pregnant women.  If you have a pregnant patient and bicillin is not available, please refer your patient to your local health department.
  • Make any healthcare encounter during pregnancy an opportunity to treat and prevent congenital syphilis. Meet people where they are with syphilis testing and treatment, including outside of usual prenatal care settings. Emergency departments, syringe service programs, prisons/jails, and maternal and child health programs can be important venues for identifying and treating syphilis.
  • Work with local community health workers (including disease intervention specialists), who can help to overcome additional barriers to syphilis testing and treatment during pregnancy.

Thank you for your partnership in this important work. For questions about these screening and treatment recommendations, please contact your local health department or hiv-stdhotline@vdh.virginia.gov.


Karen Shelton, MD

State Health Commissioner