The United States Preventive Services Task Force (USPSTF) has issued an updated draft recommendation urging early syphilis screening for all pregnant individuals, regardless of symptoms or risk factors. The recommendation emphasizes that those with positive screening results should receive timely, evidence-based care to prevent syphilis-related complications.
This new draft reaffirms the USPSTF’s 2018 stance, which concluded that the benefits of early syphilis screening far outweigh any potential risks. While the current update is based on the same evidence as previous recommendations, it is open for public comment until December 23.
A Growing Concern
Dr. Carlos R. Jaén, a USPSTF panel member and family medicine expert at The University of Texas Health Science Center at San Antonio, stressed that congenital syphilis remains a significant health issue. “The number of cases has increased dramatically, with rates 10 times higher than a decade ago. This is despite the fact that syphilis is a preventable condition that can be easily treated,” he said.
Untreated syphilis during pregnancy can result in severe health outcomes, including miscarriage, premature birth, stillbirth, and neonatal death. For infants, syphilis can cause deformities, anemia, liver and spleen enlargement, jaundice, meningitis, and lasting brain or nerve damage, leading to permanent vision or hearing loss.
Alignment with Other Healthcare Organizations
The USPSTF’s updated recommendation aligns with guidance from other medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG). In April 2024, ACOG released an advisory recommending universal syphilis screening for all pregnant individuals. This includes initial testing during the first prenatal visit, with rescreening during the third trimester and at birth, rather than relying on risk-based testing.
ACOG’s advisory also highlighted that 40% of infants born with congenital syphilis were born to individuals who had no prenatal care. The group calls for using any healthcare visit during pregnancy—such as those in emergency departments or maternal health clinics—as an opportunity for syphilis screening.
Barriers to Access and Late Testing
While syphilis screening during pregnancy is recommended, there is currently no official guidance on preconception screening for individuals planning a pregnancy. However, experts suggest that syphilis testing could be incorporated into general health checkups for those preparing for pregnancy, along with other tests for sexually transmitted infections (STIs) and blood pressure.
Dr. Lynn M. Yee, a maternal-fetal medicine expert at Northwestern University, pointed out that differential access to healthcare is a key challenge. “Some patients may not have access to early care or may present too late for effective treatment,” she said. Stigma and bias among healthcare providers can also contribute to missed screenings, particularly if clinicians do not believe their patients are at risk.
The Numbers Behind the Surge
In 2022, the U.S. saw 3,761 cases of congenital syphilis, the highest number in over 30 years. This includes 231 stillbirths and 51 infant deaths. The number of cases has more than tripled since 2012, with significant increases linked to factors such as socioeconomic status, access to care, and immigration challenges.
Although syphilis primarily affects men, the incidence rate among women has risen sharply, with rates from 2017 to 2021 showing a two- to fourfold increase in women compared to men.
Challenges in Prevention
Despite the availability of simple, cost-effective tests and the availability of penicillin treatment, congenital syphilis remains a persistent problem. Dr. Bryant, a maternal-fetal medicine specialist, noted that many women are still presenting late in pregnancy for testing. “Delayed access to care is one of the main reasons for these rising numbers,” she explained.
Reinfection can also be a concern, particularly if a patient continues to engage with a partner who refuses treatment, according to Dr. Yee. She also noted that syphilis testing is not a one-time event but requires a two-step process, and misinterpretation of serology results can complicate diagnosis and treatment.
Signs of Hope
On a positive note, the Centers for Disease Control and Prevention (CDC) reports that the rate of increase in congenital syphilis cases may be slowing. In 2022, the number of newborn syphilis cases rose by 3%, a significant drop from the 30% or more increase seen in previous years. For example, between 2020 and 2021, cases surged by 32%, leading to 220 stillbirths and infant deaths.
Looking Ahead
The USPSTF has identified several gaps in knowledge, particularly regarding the benefits and harms of repeat syphilis screenings during pregnancy and the use of rapid point-of-care tests. There is also a need for research on the disparities in syphilis incidence and screening rates, with a particular focus on vulnerable populations.
The CDC has noted that infants born to Black, Hispanic, or Native American mothers are up to eight times more likely to be affected by congenital syphilis than those born to White mothers.
Conclusion
As the fight against congenital syphilis continues, experts emphasize the importance of early detection and timely treatment. Addressing barriers to care and increasing access to screening can significantly reduce the number of cases and improve outcomes for both mothers and babies.
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