BPHC Bulletin: Joint HRSA-CDC Letter on Congenital Syphilis

April 3, 2024

Dear Colleague:

This letter is to share information from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) to address the increases in congenital syphilis cases nationwide and how we can work together to continue to address this concerning trend. The U.S. Department of Health and Human Services has established the National Syphilis and Congenital Syphilis Syndemic Federal Task Force to leverage federal resources to reduce rates, address disparities, and share resources with impacted communities.¹ As part of that collaboration, we are writing this letter to share CDC’s latest national data on congenital syphilis, reflecting tremendous increases in recent years, and to offer suggestions for how to work together to address this concerning trend.

Building on a decade of increases, reported congenital syphilis cases increased 31% in just 1 year, from 2021-2022. Congenital syphilis occurs when pregnant people with syphilis pass the infection to their fetus or infant. This disease can result in miscarriage, stillbirths, infant deaths, and lifelong medical issues. In 2022, there were a total of 3,755 cases of congenital syphilis reported for a rate of 102.5 per 100,000 live births. Tragically, these infections resulted in 282 stillbirths and infant deaths in 2022. The burden of syphilis and congenital syphilis is not equally distributed. States in the south and southwest report much higher rates than other parts of the country. Racial and ethnic minorities continue to be disproportionately affected. The highest number of cases occurred among those who are Black or African American, Hispanic and Latino, and White. American Indian or Alaska Native people experienced the highest rate of congenital syphilis — for every 155 births in 2022, there was one congenital syphilis case. Black or African American people experienced about 30% of congenital syphilis cases in 2022. The increase in congenital syphilis follows a steady growth in primary and secondary syphilis — the most infectious stages of the disease — among women of reproductive age combined with social and economic factors that create barriers to high-quality prenatal care, threatening the health of babies.²

Untreated, congenital syphilis can have lifelong consequences, but it is preventable with timely testing and treatment. A recent report analyzed missed opportunities for preventing congenital syphilis and offered strategies that could encourage timely syphilis testing and treatment during pregnancy and found that barriers to prevention included medical insurance status and access to healthcare that limited access to testing and treatment.³ All healthcare providers, including community health centers, have a critical role in reversing this alarming trend and protecting the health of our nation’s patients, including the youngest patients. One of the most effective ways to prevent congenital syphilis is timely syphilis screening and treatment during pregnancy in accordance with CDC treatment guidelines.⁴ Timely syphilis testing and treatment during pregnancy might have prevented almost 9 in 10 (or 88%) congenital syphilis cases in 2022. For people who are pregnant and not in prenatal care, any healthcare encounter during pregnancy is an opportunity to screen for and treat syphilis. Additionally, providers should follow CDC’s syphilis screening guidelines for sexually active patients,⁴ and consider using county-level syphilis rates to direct screening efforts.⁵ Taking a comprehensive sexual history from patients helps identify their unique risk factors and supports appropriate counseling and education, testing, and treatment as needed.⁶

It is important to note that syphilis is curable with antibiotics, but early diagnosis and treatment are essential to preventing complications and transmission. According to the CDC,⁷ if syphilis is detected in a pregnant person, they should be treated immediately with benzathine penicillin G, the only recommended therapy for syphilis in pregnancy. Currently, the Food and Drug Administration lists Penicillin G benzathine injectable suspension products (Bicillin L-A®) on their drug shortage webpage, noting limited supply due to increased demand. To mitigate the effects of this drug shortage, the Food and Drug Administration has worked with Laboratoires Delbert on the temporary importation and use of Extencilline (benzathine benzylpenicillin injection, powder, for suspension).⁸ Those encountering challenges securing Bicillin L-A® to treat pregnant patients with syphilis can contact stdshortages@cdc.gov.⁹

All cases of syphilis and congenital syphilis should also be reported to local or state health departments, which play a critical role in partner notification and follow-up services. For Indian Health Service facilities, guidance on reporting can be found in Part 3, Chapter 33 of the Indian Health Manual.¹⁰ We encourage you to review the CDC¹¹ website for additional resources and tools for more information on the screening, diagnosis, treatment, and management of these infections. As a reminder, HRSA-supported health centers¹² provide high-quality, affordable, and accessible primary care. Health centers may use Health Center Program funding to cover the cost of syphilis testing.

Thank you for your collaboration in this work to address the rise in syphilis and congenital syphilis in our communities and improve the health outcomes of our patients and their babies. A list of resources has been added to this letter.

Sincerely,

/s/ Jonathan Mermin                                              /s/ James Macrae

Jonathan Mermin, MD, MPH (RADM, USPHS)            James Macrae
Director, National Center for HIV, Viral Hepatitis,      Associate Administrator
STD and TB Prevention, CDC                                   Bureau of Primary Health Care, HRSA

Endnotes

¹ https://www.hhs.gov/about/news/2023/11/15/readout-adm-rachel-levines-visit-georgia-learn-impacts-congenital-syphilis-syphilis.html

² Figures (cdc.gov)

³ Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022 | MMWR (cdc.gov)

⁴ Sexually Transmitted Infections (STI) Screening Recommendations (cdc.gov)

⁵ County-level Syphilis Rates | AtlasPlus | NCHHSTP | CDC

⁶ A Guide to Taking a Sexual History (cdc.gov)

⁷ Syphilis During Pregnancy – STI Treatment Guidelines (cdc.gov)

⁸ FDA Drug Shortages and Information about Extencilline

⁹ Clinical Reminders during Bicillin L-A® Shortage (cdc.gov)

¹⁰ Part 3 Chapter 33 – Infection Control and Prevention (ihs.gov)

¹¹ Sexually Transmitted Diseases - Information from CDC

¹² Home | Bureau of Primary Health Care (hrsa.gov)

Resources

1. Recording Available: Congenital Syphilis – Care Models, Treatment. No Time to Lues: A Call to Arms Amidst a Congenital Syphilis Epidemic - Zoom (zoomgov.com)
2. CDC STI Treatment Guidelines provides syphilis screening and treatment recommendations
3. CDC Syphilis Treatment and Care webpage provides current data and treatment recommendations for primary, secondary, tertiary, congenital, ocular, neurosyphilis, and perinatal syphilis infections.
4. Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022 | MMWR (cdc.gov) Overview of the missed prevention opportunities during pregnancy strategies that support timely syphilis testing and treatment.
5. CDC call to action (2017): https://www.cdc.gov/std/syphilis/syphiliscalltoactionapril2017.pdf (PDF)
6. Healthy People 2030 Sexually Transmitted Infections Objectives
7. STI National Strategic Plan (STI Plan) 2021-2025
8. U.S. Preventive Services Task Force STI Screening Recommendations
9. Uniform Data System data
10. Bicillin Shortage CDC response and treatment guidelines
11. Indian Country Extension for Community Healthcare Outcomes (ECHO) models: https://www.indiancountryecho.org/?s=syphilis 
12. HRSA Dear Colleague Letter: Syphilis and congenital syphilis in Indian Country https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/syphilis-congenital-syphilis-indian-country.pdf (PDF)
13. Testing guidelines ACOG: Adhikari, E. H. (2020). Syphilis in Pregnancy.  Obstetrics & Gynecology, 135(5), 1121–1135. Screening early in pregnancy, repeat screening in the third trimester and at delivery among women at high risk, adherence to recommended treatment regimens, and prompt reporting of newly diagnosed syphilis cases to local public health authorities are strategies that obstetrician-gynecologists can employ to fight the current epidemic. In this report, clinical manifestations, and management of syphilis in pregnancy are reviewed, and both traditional and reverse sequence screening algorithms are reviewed in detail in the context of clinical obstetrics.
14. National Network of Sexually Transmitted Disease Clinical Prevention Training Centers: https://nnptc.org/
15. HRSA-funded State Offices of Rural Health collaborate with public and private organizations across the state to improve access to health care services. Activities include information and data dissemination, program design and rural workforce recruitment and retention.
16. Evidence-Based Toolkits for Rural Community Health: https://www.ruralhealthinfo.org/toolkits
17. https://www.poctrn.org/itap-diagnostic-mpox-lesion-panel
18. https://www.nibib.nih.gov/covid-19/radx-tech-program/ITAP
19. Find a Health Center (hrsa.gov)