Health Advisory: Congenital Syphilis Increasing in New York State
From: New York State Department of Health, AIDS Institute, Office of Sexual Health and Epidemiology
Date: June 2, 2021
(NYS) OUTSIDE OF NEW YORK CITY (NYC) [1]
Congenital syphilis diagnoses have been increasing since 2016: Between 2015 – 2017 there were 14 congenital syphilis diagnoses versus 31 congenital syphilis diagnoses in the 2018 – 2020 period.
- Congenital syphilis increases have accompanied sustained annual early syphilis increases in both males and females (sex assigned at birth).
- Pregnant persons with reported syphilis increased by 51% from 35 in 2016 to 53 in 2020.
- Preliminary data suggest this concerning trend will continue, with five congenital syphilis diagnoses reported in the first four months of 2021.
- 48% (n=10) of congenital syphilis diagnoses from 2019-2020 occurred among infants of persons who likely acquired syphilis during pregnancy2; 24% (n=5) acquired syphilis late in pregnancy.
- To prevent congenital syphilis, screening of pregnant persons throughout pregnancy is recommended with third trimester screening highly recommended for all pregnant persons.
Background
From the historical low of 35 diagnoses in 2000, early syphilis (which includes primary, secondary, and early non-primary and non-secondary) diagnoses have steadily increased; between 2010 (n=271) and 2019 (n=1,582), reported diagnoses increased by 483%.
Mirroring national[2] and regional[3] trends and increases, most of the early syphilis diagnoses are among males (26.2 per 100,000 population in 2019) compared to females (4.3 per 100,000 population in 2019). However, the rate of increase among females has exceeded that among males, and reports of drug-risk related behaviors among females diagnosed with syphilis have been observed.[4]
While the statewide early syphilis and congenital syphilis increases have been noteworthy, counties listed below (in descending order of total congenital syphilis diagnoses from 2018-2021) have shown increases in both diagnoses of early syphilis and congenital syphilis.
|
County name |
Early syphilis diagnoses (males and females) |
Congenital syphilis diagnoses¥ |
|||||||
|
2018 |
2019 |
2020* |
Total |
2018 |
2019 |
2020* |
2021* |
Total |
|
|
Erie |
91 |
109 |
112 |
312 |
– |
1 |
1 |
2 |
4 |
|
Orange |
64 |
105 |
96 |
265 |
– |
1 |
3 |
– |
4 |
|
Suffolk |
151 |
166 |
167 |
484 |
2 |
1 |
1 |
– |
4 |
|
Albany |
55 |
98 |
74 |
227 |
1 |
2 |
– |
– |
3 |
|
Monroe |
195 |
287 |
265 |
747 |
– |
1 |
1 |
1 |
3 |
|
Schenectady |
34 |
40 |
24 |
98 |
1 |
1 |
– |
1 |
3 |
|
Westchester |
130 |
140 |
165 |
435 |
2 |
– |
1 |
– |
3 |
|
Oneida |
16 |
18 |
12 |
46 |
– |
– |
2 |
– |
2 |
|
All other counties outside of NYC** |
496 |
619 |
524 |
1,639 |
3 |
3 |
3 |
1 |
10 |
|
Total |
1,232 |
1,582 |
1,439 |
4,253 |
9 |
10 |
12 |
5 |
36 |
*2020 and 2021 surveillance data are considered preliminary and are subject to change.
** Other counties with congenital syphilis births include Broome, Clinton, Cortland, Dutchess, Greene, Herkimer, Nassau, Otsego, Ulster, and Wayne.
¥ Includes both live-births and still births
What Health Care Providers Can Do to Support Sexual Health and Prevent Congenital Syphilis and Syphilis
- Please note, where facility-based services and in-person patient-clinician contact is limited during COVID-19, providers should follow the CDC guidance on therapeutic options for symptomatic patients and their partners when in-person clinical evaluation is not feasible. Visit https://www.cdc.gov/std/dstdp/DCL–STDTreatment–COVID19–04062020.pdf?deliveryName=USCDCNPIN_252–DM25769 for more information.
- Guidance and resources on preventing COVID-19 while maintaining sexual health care: https://www.health.ny.gov/diseases/aids/general/prep/docs/dear_colleagu e_12–pdf
Screening
- New York State Public Health Law mandates syphilis screening of pregnant persons at the time pregnancy is first identified and again upon delivery.[5]
- Third trimester screening/testing for syphilisat 28 weeks of pregnancy for all pregnant persons, or as soon thereafter as reasonably possible but no later than at 32 weeks of pregnancy, is highly recommended to avert congenital syphilis.
This is already a requirement in New York City per Section 11.33 of the New York City Health Code.[6]
- Providers are encouraged to pair third trimester syphilis screening with the strongly recommended third trimester HIV screening.
- Make sexual health discussions a routine part of every prenatal visit, regardless of the outcome of the first syphilis test. Screen for syphilis and other sexually transmitted infections (STIs) as warranted (changes in sex partners or behaviors, STI status of sex partners, etc.).
- Providers are encouraged to link partners of pregnant persons to HIV, syphilis, and other STI testing.
- Determine the pregnancy status of all persons of reproductive age diagnosed with syphilis.
- When requesting lab tests/screening for syphilis, please indicate in the requisition form that the person is pregnant. This will help public health programs and ensure partner services are made available to persons with syphilis diagnosis.
- Consider screening for syphilis in patients who present with symptoms of unknown origin such as unexplained rashes, sores, or lesions.
Diagnosis and Treatment
- To diagnose syphilis, laboratory testing must include both treponemal and nontreponemal tests. Unless specified by the provider, the sequence of these tests (i.e. treponemal or non-treponemal test first) differs across laboratories and results must be carefully interpreted to distinguish current syphilis infection from previous infection. It is important that providers understand their syphilis screening algorithm. See the Centers for Disease Control and Prevention’s (CDC) 2015 STD Treatment Guidelines for more information: https://www.cdc.gov/std/tg2015/syphilis–htm
- In cases where the laboratory evidence of syphilis is inconclusive or ambiguous, pregnant persons should be presumed infected (with or without symptoms) unless syphilis can be ruled out through evidence of treatment and patterns in follow-up antibody titers documented in the medical record.
- Providers are encouraged to work with the local health department to consult the syphilis registry, and to help inform syphilis diagnosis and treatment decisions.
- Treat all females with confirmed or suspected syphilis of any stage, or syphilis exposure, according to current CDC guidelines. The only recommended treatment option for pregnant persons remains Penicillin G benzathine (BicillinLA). Pregnant persons who report a penicillin allergy can be considered for further allergy testing to assess risks for IgE allergic reactions and should, as needed, be desensitized and treated with penicillin. See the CDC’s 2015 STD Treatment Guidelines for more information: https://www.cdc.gov/std/tg2015/syphilis–htm
- Treatment for congenital syphilis in infants is determined based on maternal history of syphilis infection and treatment, and current laboratory and physical examination results. Consult the CDC 2015 Sexually Transmitted Diseases Treatment Guidelines for Congenital Syphilis: https://www.cdc.gov/std/tg2015/congenital.htm
- All infants diagnosed with congenital syphilis should be physically and serologically monitored closely in the months following birth.
- Per NYS DOH Communicable Disease reporting requirements, immediately report new positive prenatal or delivery syphilis tests to the local health department by phone, followed by submission of the confidential case report form (DOH-389). The state or local health department can assist in following-up with patients and their partners to ensure access to care. Information is available at: https://www.health.ny.gov/forms/doh–pdf and https://www.health.ny.gov/forms/instructions/doh–389_instructions.pdf
Additional Actions
- Conduct a complete sexual health history, risk, and drug use assessment for every Ask about specific behaviors, such as the number of partners, type of sex (i.e., vaginal, anal, oral), sex of partners, drugs used, and route of drug ingestion, to help guide laboratory testing. Visit www.ncshguide.org/providers or GOALS Framework for Sexual History taking in Primary Care – https://www.hivguidelines.org/prep–for–prevention/for–care–providers/#tab_3 for guidance and additional resources.
- Facilitate partner management by:
- Offering and providing Expedited Partner Therapy (EPT) for gonorrhea, chlamydia and/or trichomoniasis, where indicated, and
- Encouraging patients to refer their sex or needle sharing partners to medical care for STI screening and treatment including HIV testing, and
- Contacting your local partner services.
- Offer and perform HIV testing for every patient age 13 years and older.
- Offer HIV Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP).
- Collaborate with State and County public health personnel on partner notification efforts.
- Refer consenting patients to community-based organizations (CBOs) for support services, as needed.
- Report all suspected and confirmed STI cases promptly to your local county health department. Information is available at health.ny.gov/forms/doh389.pdf and www.health.ny.gov/forms/instructions/doh–389_instructions.pdf.
- Ensure your employees and colleagues have access to current information and tools to promote health equity. Please see https://www.cdc.gov/std/healthdisparities/default.htm for more information.
What Community Based Organizations and Supportive Service Providers Can Do to Help Prevent STIs
- Assess risk: conduct a comprehensive behavioral sexual risk assessment for program participants/clients. Ask about specific behaviors, such as the number of partners, type of sex (i.e. vaginal, anal, oral), sex of partners, drugs used, and route of drug ingestion to help guide testing efforts.
- Implement targeted client recruitment: prioritize agency services to identify persons who do not access health care services or who may not otherwise have access to HIV and STI testing in clinical settings as they may benefit most from HIV and STI testing services in nonclinical settings.
- Offer syphilis, HIV, and other STI testing to females of childbearing age: Family Planning providers should screen for STIs as needed, regardless of pregnancy intention.
- Support females of childbearing age in their family planning efforts, including assessing pregnancy intention, contraceptive needs, linkage to pregnancy testing, adherence to pre- and postnatal care visit schedule, medication adherence, and psychosocial supports.
- Provide harm reduction services: facilitate access to clean syringes and essential support services for people who use drugs.
- Engage in condom promotion, education, and distribution: make condoms available at no cost and in ways that reduce embarrassment or discomfort. Information about the New York State Condom Program is available at https://www.health.ny.gov/diseases/aids/consumers/condoms/nyscondom.htm
- Conduct HIV/STI testing activities with people under 18: People under 18 can consent to STI testing, treatment, and prevention regardless of their insurance status. Partner services and other supportive services are encouraged to support minors to navigate healthcare systems. For more information please see: https://www.health.ny.gov/diseases/communicable/std/docs/faq_billing_consent. pdf and https://www.health.ny.gov/diseases/communicable/std/docs/letter_minor_consent.pdf
- Offer navigation services: assist persons living with HIV, or persons who are HIV negative and at risk, to obtain timely, essential, and appropriate medical, prevention, and support services (including linkage to HIV biomedical interventions such as Pre Exposure Prophylaxis and Post Exposure Prophylaxis PrEP/PEP) to optimize health and prevent HIV/STI/HCV transmission and acquisition.
- Work with existing coordinating and community planning bodies: these may include the NYS Ending the Epidemic regional steering committees, the NYS HIV Advisory Body, and NY Links, to plan, promote, and conduct community education events/activities, foster dialogue, and share resources.
- Provide effective behavioral interventions: implement prevention activities that are culturally relevant, linguistically appropriate, and have been shown to be successful by program evaluation or research.
Resources
Congenital Syphilis overview (courtesy of the Clinical Education Initiative): https://ceitraining.org/courses/course_detail.cfm?mediaID=415#.YKQWtahudaR
Signs and symptoms of syphilis: https://www.cdc.gov/std/training/clinicalslides/
Free and confidential HIV and STI testing is available at local health department STD clinics. For clinic locations and hours, please visit:
https://providerdirectory.aidsinstituteny.org/
Clinical Education Initiative Sexual Health Center of Excellence:
866-637-2342 to access expert medical consultation on diagnosis, treatment and management of STD infections. Training calendar and archived webinars are available at www.ceitraining.org
NYSDOH Office of Sexual Health and Epidemiology at 518-474-3598 or stdc@health.ny.gov for information and assistance with STI reporting
Local Health Department and NYSDOH Regional Contacts for Partner Services: https://www.health.ny.gov/diseases/aids/providers/regulations/partner_services/contacts .htm
National STD Curriculum: CDC-supported web-based training for clinicians. https://www.std.uw.edu/
HIV Pre-Exposure Prophylaxis (PrEP) and Non-Occupational Post-Exposure Prophylaxis (PEP): www.health.ny.gov/diseases/aids/general/prep
[1] Congenital syphilis diagnoses in New York City have remained elevated since 2018, at which time an advisory was issued: https://www1.nyc.gov/assets/doh/downloads/pdf/han/alert/2019/congenital–syphilis–cases–in–nyc.pdf 2 Calculation based on persons who initially screened negative for syphilis earlier in their pregnancy.
[2] https://www.cdc.gov/std/statistics/2019/default.htm
[3] Connecticut released a congenital syphilis health advisory on May 10, 2021, please contact stdc@health.ny.gov for a copy of the advisory.
[4] https://pubmed.ncbi.nlm.nih.gov/33967232/
[5] NYS Public Health Law, Article 23 Section §2308; New York Code of Rules and Regulations, Title 10, §69-2.2
[6] https://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi–congenital–syphilis.pdf
