Multistate Syphilis Outbreak Among American Indians, 2013 to 2015.

This article summarizes a multistate outbreak of heterosexual syphilis, including 134 cases of syphilis in adults and adolescents and at least 2 cases of congenital syphilis, which occurred on an American Indian reservation in the United States during 2013-2015. In addition to providing salient details about the outbreak, the article seeks to document the case-finding and treatment activities undertaken, their relative success or failure, and the lessons learned from a coordinated, multiagency response. Of 134 adult cases of syphilis, 40% were identified by enhanced, interagency contact tracing and partner services, 26% through symptomatic testing, and 16% through screening of asymptomatic individuals as the result of an electronic medical record screening prompt. A smaller proportion of cases were identified by community screening events in high-morbidity communities; high-risk venue-based screening events; other screening, including screening upon request; and prenatal screening at first trimester, third trimester, and day of delivery. Future heterosexual syphilis outbreak responders should act quickly to coordinate a package of high-yield case-finding and treatment activities-potentially including activities that seek to do the following: (1) increase prenatal screening, (2) improve community awareness and symptomatic test seeking, (3) educate providers and improve general screening for syphilis, (4) implement electronic medical record reminders for providers, (5) screen high-morbidity communities and at high-risk venues, and (6) form novel partnerships to accomplish partner services work when the context does not allow for traditional, disease intervention specialist-only partner services.

Sífilis em gestantes e sífilis congênita no Maranhão / Syphilis in pregnant women and congenital syphilis in Maranhão

Introdução: segundo estimativa da Organização Mundial da Saúde, aproximadamente 1,5 milhão de mulheres grávidas no mundo são infectadas com sífilis anualmente e metade delas terão filhos com consequências adversas. A sífilis na gestação e a sífilis congênita constituem problemas de saúde pública, tornando-se imperioso conhecer a dimensão da doença em nível local.Objetivo: descrever as características da sífilis na gestação e da sífilis congênita no Maranhão entre 2009 e 2013. Material e Métodos: estudo descritivo, retrospectivo e quantitativo, utilizando dados de domínio público e acesso irrestrito, cujo levantamento ocorreu por meio do aplicativo TABNET do Departamento de Informática do SUS, em janeiro de 2017. Resultados: no período foram confirmados 1.033 casos de sífilis em gestantes e notificados 679 casos de sífilis congênita. O município de São Luís, seguido por Imperatriz, apresentou o maior número de casos. As taxas de detecção de sífilis em gestantes e de incidência de sífilis congênita foram de 1,7 e 1,1 casos para cada 1.000 nascidos vivos, respectivamente. O maior número de casos de sífilis ocorreu em gestantes de 20 a 39 anos (69,5%), com ensino fundamental incompleto (51,1%), teste não treponêmico reativo (88,7%) e classificação da sífilis como primária (55,4%). A identificação dos casos de sífilis materna foi realizada principalmente no momento do parto (53,2%). A maioria dos casos de sífilis congênita foi na faixa etária de até 6 dias (94,3%) e teve evolução com criança viva (93,2%). Adicionalmente, a taxa de mortalidade infantil por sífilis congênita correspondeu a 2,0 óbitos por 100.000 nascidos vivos. Conclusão: a taxa de incidência da sífilis congênita permaneceu acima do desejado. A realização do teste não treponêmico encontrou-se aquém do preconizado. O diagnóstico da sífilis em gestantes foi realizado tardiamente na maioria dos casos. Houve maior ocorrência de sífilis primária, o que aumenta a possibilidade de infecção fetal.

Introduction:according to the World Health Organization estimate, roughly 1.5 million pregnant women are infected with syphilis annually and half of them will have children with adverse consequences. Gestational syphilis and congenital syphilis constitute public health problems, making it imperative to know the extent of the disease at the local level. Objective: to describe the characteristics of syphilis in pregnancy and congenital syphilis in Maranhão state between 2009 and 2013. Material andMethods: this is a descriptive, retrospective and quantitative study, using data from the public domain and unrestricted access, whose survey took place through the application TABNET, in January 2017. Results: 1,033 cases of syphilis were confirmed in pregnant women and 679 cases of congenital syphilis were notified. The city of São Luís, followed by Imperatriz, presented the highest number of cases. The rates of detection of syphilis in pregnant women and incidence of congenital syphilis were 1.7 and 1.1 cases per 1,000 live births, respectively. A greater number of syphilis cases were identified among pregnant women aged 20 to 39 years (69.5%), incomplete primary education (51.1%), reactive non-treponemic test (88.7%) and syphilis classification as primary (55.4%). The identification of cases of maternal syphilis was performed mainly at the time of delivery (53.2%). There was a greater number of cases of congenital syphilis in the age group of up to 6 days (94.3%) and most cases of syphilis congenital evolved with live child (93.2%). In addition, the infant mortality rate for congenital syphilis corresponded to 2.0 deaths per 100,000 live births. Conclusion: the incidence rate of congenital syphilis remained higher than desired. The non-treponemal test was less than recommended. The diagnosis of syphilis in pregnant women was performed late in most cases. There was a higher occurrence of primary syphilis, which increases the possibility of fetal infection.

Effectiveness of Prenatal Screening and Treatment to Prevent Congenital Syphilis, Louisiana and Florida, 2013-2014.

BACKGROUND: From 2012 to 2014, rates of congenital syphilis increased in Louisiana and Florida. We evaluated the effectiveness of early (first or second) and third trimester syphilis screening for the prevention of congenital syphilis in these high-morbidity states. METHODS: Reported syphilis cases among pregnant women in Louisiana and Florida during January 1, 2013, to December 31, 2014, were reviewed for documented screening for syphilis in the first 2 trimesters and third trimester. Pregnant women with syphilis were linked to congenital syphilis records and stratified by whether the pregnancy led to a reported congenital syphilis case. RESULTS: Seven hundred ten pregnant women with syphilis in Louisiana and Florida were linked to 155 congenital syphilis cases. Three hundred seventy (52%) pregnant women with syphilis were staged as early syphilis (n = 270) or high-titer late or unknown duration-latent syphilis (n = 100), and 109 (70% of the total) were linked to congenital syphilis cases. Screening in the first 2 trimesters identified 513 pregnant women who tested positive for syphilis, and 470 (92%) potential congenital syphilis were averted. One hundred nine pregnant women tested positive for syphilis in the third trimester, and 85 (78%) had babies without congenital syphilis. During their pregnancy, 85 (12%) women tested negative at least once, and 55 (65%) had babies with congenital syphilis. Thirty-nine women had no reported syphilis screening 30 days or longer before delivery. CONCLUSIONS: Screening for syphilis both early and in the third trimester prevented many pregnant women with syphilis from having a baby with congenital syphilis. Preventing all congenital syphilis would likely require preventing all syphilis among women.

Increase in incidence of congenital syphilis - United States, 2012-2014.

Congenital syphilis (CS) occurs when a mother infected with syphilis transmits the infection to her child during pregnancy. CS can cause severe illness, miscarriage, stillbirth, and early infant death. However, among pregnant women with syphilis who deliver after 20 weeks gestation, maternal treatment with penicillin is 98% effective at preventing CS (1). In the United States, the rate of CS decreased during 1991­2005 but increased slightly during 2005­2008 (2). To assess recent trends in CS, CDC analyzed national surveillance data reported during 2008­2014, calculated rates, and described selected characteristics of infants with CS and their mothers. The overall rate of reported CS decreased from 10.5 to 8.4 cases per 100,000 live births during 2008­2012, and then increased to 11.6 cases per 100,000 live births in 2014, the highest CS rate reported since 2001. From 2012 to 2014, reported cases and rates of CS increased across all regions of the United States. To reduce CS, the timely identification of and response to increases in syphilis among women of reproductive age and men who have sex with women are essential. All women should have access to quality prenatal care, including syphilis screening and adequate treatment, during pregnancy (3).

Congenital syphilis - United States, 2003-2008.

Untreated syphilis during pregnancy, especially early syphilis, can lead to stillbirth, neonatal death, or infant disorders such as deafness, neurologic impairment, and bone deformities. Congenital syphilis (CS) can be prevented by early detection of maternal infection and treatment at least 30 days before delivery. Changes in the population incidence of primary and secondary (P&S) syphilis among women usually are followed by similar changes in the incidence of CS. To assess recent trends in CS rates, CDC analyzed national surveillance data from the period 2003--2008. This report summarizes the results of that analysis, which indicated that, after declining for 14 years, the CS rate among infants aged <1 year increased 23%, from 8.2 cases per 100,000 live births in 2005 to 10.1 during 2008. That increase followed a 38% increase in the P&S syphilis rate among females aged >or=10 years from 2004 to 2007. During 2005-2008, CS rates increased primarily in the South (from 9.6 per 100,000 live births to 15.7) and among infants born to black mothers (from 26.6 per 100,000 live births to 34.6). Reversing the upward trend in CS rates will require collaboration among health-care providers, health departments, health insurers, policymakers, and the public to reduce syphilis among women and to increase early prenatal care access and syphilis screening during pregnancy.

Syphilis outbreak among American Indians - Arizona, 2007-2009.

On January 25, 2007, an Indian Health Service (IHS) unit notified the Arizona Department of Health Services (ADHS) of five symptomatic syphilis cases (i.e., primary or secondary syphilis) that had occurred in members of a Southwest Indian Nation during the previous 6 months. By mid-April, three more cases had been identified. On April 18, 2007, the tribe declared an outbreak of syphilis and subsequently requested public health assistance from county, state, and federal agencies. On July 10, an enhanced, coordinated multiagency response to the outbreak began, involving tribal and Pima County health departments, IHS, ADHS, and CDC. This report summarizes the enhanced outbreak response, which identified a total of 106 cases of syphilis with onset from January 2007 to June 2009, including six congenital cases (two of them stillbirths). Initial communication gaps led to delays in response to this outbreak, but communication was improved through the formation of an outbreak response group that included members from county, state, and tribal health departments and IHS. For similar outbreaks in American Indian tribes, where various public health jurisdictions exist and often have concurrent responsibilities, formation of an outbreak response group can improve control efforts.

Prenatal syphilis infection is a possible cause of preterm delivery among immigrant women from eastern Europe.

OBJECTIVE: to evaluate the prevalence of maternal syphilis at delivery and neonatal syphilis infection in an Italian urban area, in connection with the increased flow of immigration. STUDY DESIGN: A prospective surveillance study was carried out in Bologna, Italy, from November 2000 to March 2006. All pregnant women were screened for syphilis at delivery. Infants born to seropositive mothers were enrolled in a prospective follow-up. RESULTS: During the study period 19,205 women gave birth to 19,548 infants. A total of 85 women were seropositive for syphilis at delivery. The overall syphilis seroprevalence in pregnant women was 0.44%, but it was 4.3% in women from eastern Europe and 5.8% in women from Central-South America. Ten women were first found positive at delivery, as they did not receive any prenatal care. Nine of these were from eastern Europe. All their infants were asymptomatic, but six had both reactive immunoglobulin (Ig)M western blot and rapid plasma reagin tests and were considered prenatally infected. Three of six were preterm (gestational age <37 weeks). CONCLUSIONS: In Italy, congenital syphilis infection is strictly related to immigration from eastern Europe. Although it is asymptomatic, it could cause premature delivery. Therefore, it is necessary to perform serological tests during the third trimester in mothers coming from endemic areas to adequately treat syphilis in pregnancy and prevent congenital infection. If the mother's test results are not available at delivery, it is necessary to investigate the newborn, especially if it is born prematurely.

Congenital syphilis--United States, 2002.

Congenital syphilis (CS) occurs when the spirochete Treponema pallidum is transmitted from a pregnant woman with syphilis to her fetus. Untreated syphilis during pregnancy can lead to stillbirth, neonatal death, or infant disorders such as deafness, neurologic impairment, and bone deformities. This report summarizes 2002 CS surveillance data, which indicated that CS rates have decreased among all racial/ethnic minority populations and in all regions of the United States except the Northeast. To further decrease CS, collaborative efforts among health-care providers, health insurers, policymakers, and the public are needed to increase prenatal care and syphilis screening during pregnancy for women at risk for delivering infants with CS.

Congenital syphilis surveillance and newborn evaluation in a low-incidence state.

OBJECTIVES: To evaluate congenital syphilis surveillance in Minnesota, to assess the evaluation and management of newborns at risk for congenital syphilis, and to assess prenatal syphilis screening. DESIGN: Case ascertainment and medical record review. SETTING: The 7-county Minneapolis-St Paul metropolitan area. PATIENTS: Newborns at risk for congenital syphilis during a 3-year period (1992-1994). MAIN OUTCOME MEASURES: The completeness of congenital syphilis case ascertainment, maternal demographic data, maternal syphilis management, newborn evaluation for and management of congenital syphilis, and hospital syphilis screening practices at delivery. RESULTS: Eighty mother-infant pairs who were at risk for congenital syphilis were identified from 3 sources. Using the Centers for Disease Control and Prevention's congenital syphilis case definition, 36 infants (45%) were classified as probable cases, 42 (53%) were classified as noncases, and 2 (3%) were syphilitic stillbirths. Forty-seven women (59%) had syphilis serologic tests performed in the third trimester; only 37 (46%) had syphilis screening at delivery. Conditions of the mothers of 8 probable cases (22%) were diagnosed at delivery. Most probable cases (86%) were evaluated; only 56% were evaluated adequately. Twenty-five probable cases (69%) were treated. Most hospitals did not have formal policies for syphilis screening at delivery. The Minnesota Department of Health's congenital syphilis registry lacked sensitivity (39%) as a case ascertainment method. CONCLUSIONS: Clinicians should adhere to standardized protocols in the evaluation and management of at-risk newborns. Vigilant screening prenatally and at delivery and adequate follow-up are critical to reduce congenital syphilis. Improved surveillance data and resources are needed for the identification and follow-up of newborns at risk for congenital syphilis.

[Congenital syphilis as an imported disease]. / Congenitale lues als importziekte.

Two infants, a two-month-old boy and a two-month-old girl adopted from Sri Lanka, were diagnosed as having congenital syphilis and treated accordingly. The girl presented with only skin symptoms and a developing pseudoparalysis of Parrot. The boy was in quite a bad condition, having rhinitis, an oedematous appearance, skin symptoms, severe anaemia and hepatosplenomegaly. In both patients serological blood tests and cerebrospinal fluid tests for lues were positive. Both children showed osteochondritis and periostitis of the long bones on X-rays. This disease is rare in the Netherlands, but it is important to diagnose it early, because early adequate treatment may result in complete cure.

Syphilis in pregnancy: experience from a rural aboriginal community.

Syphilis in pregnancy is seldom encountered in urban Australia. This retrospective study reports on the high prevalence of syphilis and its associated complications in a group of pregnant Aboriginal women attending the Dareton Community Health Centre for antenatal care between September, 1989 and September, 1991. During this time, the centre provided antenatal care for 71 Aboriginal pregnancies and maternal syphilis was found in 20 (28%). The mean age of the women was 21.3 years (range of 14-33 years). The perinatal mortality rate was 48 per 1,000 births. All stillbirths were associated with maternal syphilis. The relative risk of stillbirth in the presence of syphilis was 4 (95% CI 2.56-6.25, p = 0.022). Prematurity was associated with maternal syphilis. The odds ratio for premature delivery was 21.5 (95% CI 2.26-2.05, p = 0.003). There was no statistical difference between the mean birth-weight and mean placental weight of term infants born to women with syphilis and women without syphilis (p = 0.35 and p = 0.31 respectively). When the placental:birth-weight ratios were considered, an apparent larger placenta was seen in association with syphilis but this was secondary to the lower birth-weights in association with prematurity. Late and poor attendance for antenatal care was a feature of all women attending this centre and not a feature associated with syphilis. The treatment and follow-up of syphilis were hindered by poor compliance.