The U.S. Preventive Services Task Force has reaffirmed its A recommendation for universal screening for syphilis infection in all pregnant individuals, according to a newly published statement.

The USPSTF recommends early, universal screening for syphilis infection during pregnancy and, if an individual is not screened early, screening at the first available opportunity. This reaffirmation maintains the Task Force’s 2018 recommendation, supported by their conclusion that screening for syphilis infection in pregnancy has a substantial net benefit with high certainty.

Congenital Syphilis Rates Reach 30-Year High

In 2023, there were 3,882 cases of congenital syphilis in the United States, including 279 stillbirths and neonatal or infant deaths related to congenital syphilis—the highest number reported in more than 30 years.

Incidence has increased, with cases rising more than 10-fold over the past decade, from 334 cases in 2012 to 3,882 cases in 2023. The Centers for Disease Control and Prevention (CDC) estimates that almost 90% of new congenital syphilis cases could have been prevented with timely testing and treatment.

Significant Racial and Ethnic Disparities

The USPSTF statement highlights substantial disparities in congenital syphilis rates across racial and ethnic groups. Based on 2023 CDC surveillance data, congenital syphilis rates per 100,000 live births were:

• 9.3 cases in Asian women

• 222 cases in Black women

• 125 cases in Hispanic or Latina women

• 680.8 cases in Native American/Alaska Native women

• 295.6 cases in Native Hawaiian/Pacific Islander women

• 82.2 cases in multiracial women

• 57.3 cases in White women.

A 2022 analysis noted that among congenital syphilis cases diagnosed in late pregnancy after an earlier negative screening, 40.6% occurred in Black women, 28.4% in Hispanic or Latina women, and 19.8% in White women.

Social factors such as poverty, neighborhood conditions, incarceration rates, segregation, and the ratio of men to women may influence sexual behavior and sexual networks, contributing to the observed racial disparities in sexually transmitted infection rates.

Screening Recommendations and Testing Methods

Screening should occur as early in pregnancy as possible. If early testing is not performed, testing should occur at the first available opportunity, including at admission for delivery.

Screening involves a blood test that detects antibodies reflecting infection with Treponema pallidum, the causative organism of syphilis. Testing typically follows a two-step algorithm: a nontreponemal test (eg, Venereal Disease Research Laboratory or rapid plasma reagin test) followed by a confirmatory treponemal test (eg, T pallidum particle agglutination test) to improve diagnostic accuracy.

Point-of-care tests using finger stick blood samples are available but require confirmatory testing, as their role in guiding treatment decisions is not fully established.

Treatment Protocols and Prevention Potential

The CDC recommends parenteral penicillin G as the only treatment for syphilis with documented efficacy during pregnancy. Treatment protocols vary depending on the stage of syphilis infection, with later-stage infections requiring longer treatment durations. For pregnant women with a reported penicillin allergy, desensitization followed by penicillin treatment is recommended. Approximately 10% of patients report a penicillin allergy, although the true prevalence of allergy may be lower.

Retrospective studies estimate that 25% to 50% of congenital syphilis cases could be prevented by repeat screening in the third trimester.

Although the USPSTF does not specifically recommend repeat screening, organizations such as the CDC, Women’s Preventive Services Initiative, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists recommend rescreening at approximately 28 weeks of gestation and again at delivery for individuals at high risk.

While harms from screening and treatment are possible, they are small. Potential harms include false-positive or discordant test results requiring additional evaluation, patient anxiety, and rare adverse reactions to antibiotic treatment, such as the Jarisch-Herxheimer reaction or hypersensitivity reactions to penicillin.

Source: JAMA