Commentary

Abstract

[Ann Emerg Med. 2010;56:297.]Congenital syphilis results from transplacental migration of Treponema pallidum and can occur during any maternal stage of infection and at any gestational age, although most infection is believed to occur after about 4 months of gestation.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google Scholar Syphilis has a high rate of maternal-fetal transmission and is believed to affect 80% of children born to infected women.2Centers for Disease Control and PreventionSexually Transmitted Disease Surveillance, 2008. US Dept of Health and Human Services, Atlanta, GA2009http://www.cdc.gov/std/stats08/surv2008-Complete.pdfGoogle Scholar Perinatal death results in about 40% of cases. Although about half of surviving neonates with congenital syphilis are asymptomatic, effects may be severe and include deafness, bony abnormalities, and variable degrees of cognitive and developmental abnormalities. The cost of caring for a child born with congenital syphilis can be staggering. A widely cited estimate from the 1990s placed the medical costs associated with congenital syphilis in the United States at more than $18 million annually, not including the indirect costs of special education and economic losses.3Workowski K.A. Berman S.M. Sexually transmitted diseases treatment guidelines, 2006.MMWR Recomm Rep. 2006; 55: 1-94PubMed Google ScholarCongenital syphilis is largely preventable. Adequate treatment of the mother at any time in pregnancy usually prevents infection of the fetus.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google Scholar The CDC recommends that all women be tested for syphilis on their first prenatal visit. Testing is recommended again in the third trimester and at delivery for women who had a positive test result at their first visit, who are at high risk, or who are in areas with a high incidence of syphilis.3Workowski K.A. Berman S.M. Sexually transmitted diseases treatment guidelines, 2006.MMWR Recomm Rep. 2006; 55: 1-94PubMed Google Scholar The availability of reliable screening tests, the efficacy of treatment, and the high cost of untreated disease render effective maternal syphilis screening programs extremely cost-effective.4Schmid G. Economic and programmatic aspects of congenital syphilis prevention.Bull World Health Organ. 2004; 82: 402-409PubMed Google ScholarPrevious outbreaks of syphilis in the United States have been attributed to behaviors in specific subpopulations: the “sexual revolution” of the 1960s, in conjunction with the epidemic of HIV in men who have sex with men in the 1980s, and concentrated in heterosexual African-American southern populations in the early 1990s.5Breban R. Supervie V. Okano J.T. et al.Is there any evidence that syphilis epidemics cycle?.Lancet Infect Dis. 2008; 8: 577-581Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This last resurgence was met with a vigorous CDC effort to eradicate the disease, and by 2004 the incidence of syphilis was at an all-time low. However, syphilis rates are again on the increase, primarily in the southern United States. Following this trend, rates of congenital syphilis increased nationwide between 2005 and 2008.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google ScholarThe current resurgence of syphilis in the United States has been primarily observed in minority populations, those with low socioeconomic status, and with poor access to health care.2Centers for Disease Control and PreventionSexually Transmitted Disease Surveillance, 2008. US Dept of Health and Human Services, Atlanta, GA2009http://www.cdc.gov/std/stats08/surv2008-Complete.pdfGoogle Scholar These are often individuals who rely disproportionately on the emergency department (ED) for primary medical care. Emergency physicians are therefore in an excellent position to identify previously unrecognized cases of syphilis in pregnant women and help to reverse the increase in congenital syphilis. The current study demonstrated that one third of mothers of infants with congenital syphilis received no prenatal care. In Philadelphia, there were 9 cases of congenital syphilis in 2007. Seven of these infants were delivered at our hospital, and 4 of those 7 mothers had visited our ED during their pregnancy (personal communication, Felicia M.T. Lewis, CDC/Philadelphia Department of Public Health, May 2010). In theory, an effective syphilis screening program based in our ED could have prevented most cases of congenital syphilis in infants delivered in Philadelphia that year.The CDC and many emergency physicians advocate ED-based HIV screening in high-risk populations.6Branson B.M. Handsfield H.H. Lampe M.A. et al.Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.MMWR Morb Mortal Wkly Rep. 2006; 55: 1-17PubMed Google Scholar, 7Borg K. To test or not to test? HIV, emergency department and the new Centers for Disease Control prevention guidelines.Ann Emerg Med. 2007; 49: 573-574Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Although syphilis has not traditionally been considered a disease meriting an ED-focused public health initiative,8Irvin C.B. Wyer P.C. Gerson L.W. et al.Preventive care in the emergency department, part II: clinical preventive services—an emergency medicine evidence-based review.Acad Emerg Med. 2000; 7: 1042-1054Crossref PubMed Scopus (156) Google Scholar a similar approach could be used for ED-based syphilis screening programs. At least 1 major urban health department mandates syphilis testing for all pregnant women during an ED encounter if they have not already been screened.9Philadelphia Department of Public HealthHealth alert: new syphilis screening recommendations, February 24, 2010.https://hip.phila.gov/xv/Portals/0/HIP/Health_Alerts/2010/PDPH-HAN_Alert_1_SyphilisScreeningRecs_02242010.pdfGoogle Scholar However, to our knowledge there are no recent studies of the utility or feasibility of ED-based syphilis screening programs. Numerous practical considerations need to be addressed before routine ED screening can be recommended. These concerns include acting on test results obtained after ED discharge, arranging primary care or return ED visits for treatment, creating linkages to public health departments, partner testing, compensation for test costs, and legal concerns.Reversing the current trend in increasing congenital syphilis rates will require the combined effort of public education, enhanced provider awareness, increased access to testing, and facilitation of treatment and follow-up. Whether syphilis screening is conducted in the ED or explicit instructions for follow-up testing are provided to pregnant women, emergency physicians who treat pregnant women without prenatal care should increase their vigilance for the disease and be open to the possibility of performing screening syphilis testing in pregnant women who seek care in the ED for any reason. [Ann Emerg Med. 2010;56:297.] Congenital syphilis results from transplacental migration of Treponema pallidum and can occur during any maternal stage of infection and at any gestational age, although most infection is believed to occur after about 4 months of gestation.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google Scholar Syphilis has a high rate of maternal-fetal transmission and is believed to affect 80% of children born to infected women.2Centers for Disease Control and PreventionSexually Transmitted Disease Surveillance, 2008. US Dept of Health and Human Services, Atlanta, GA2009http://www.cdc.gov/std/stats08/surv2008-Complete.pdfGoogle Scholar Perinatal death results in about 40% of cases. Although about half of surviving neonates with congenital syphilis are asymptomatic, effects may be severe and include deafness, bony abnormalities, and variable degrees of cognitive and developmental abnormalities. The cost of caring for a child born with congenital syphilis can be staggering. A widely cited estimate from the 1990s placed the medical costs associated with congenital syphilis in the United States at more than $18 million annually, not including the indirect costs of special education and economic losses.3Workowski K.A. Berman S.M. Sexually transmitted diseases treatment guidelines, 2006.MMWR Recomm Rep. 2006; 55: 1-94PubMed Google Scholar Congenital syphilis is largely preventable. Adequate treatment of the mother at any time in pregnancy usually prevents infection of the fetus.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google Scholar The CDC recommends that all women be tested for syphilis on their first prenatal visit. Testing is recommended again in the third trimester and at delivery for women who had a positive test result at their first visit, who are at high risk, or who are in areas with a high incidence of syphilis.3Workowski K.A. Berman S.M. Sexually transmitted diseases treatment guidelines, 2006.MMWR Recomm Rep. 2006; 55: 1-94PubMed Google Scholar The availability of reliable screening tests, the efficacy of treatment, and the high cost of untreated disease render effective maternal syphilis screening programs extremely cost-effective.4Schmid G. Economic and programmatic aspects of congenital syphilis prevention.Bull World Health Organ. 2004; 82: 402-409PubMed Google Scholar Previous outbreaks of syphilis in the United States have been attributed to behaviors in specific subpopulations: the “sexual revolution” of the 1960s, in conjunction with the epidemic of HIV in men who have sex with men in the 1980s, and concentrated in heterosexual African-American southern populations in the early 1990s.5Breban R. Supervie V. Okano J.T. et al.Is there any evidence that syphilis epidemics cycle?.Lancet Infect Dis. 2008; 8: 577-581Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This last resurgence was met with a vigorous CDC effort to eradicate the disease, and by 2004 the incidence of syphilis was at an all-time low. However, syphilis rates are again on the increase, primarily in the southern United States. Following this trend, rates of congenital syphilis increased nationwide between 2005 and 2008.1Tramont E.D. Treponema pallidum (syphilis).in: Mandell G.L. Bennett J. Dolin R. Principles and Practice of Infectious Diseases. 7th ed. Churchill-Livingstone, New York, NY2009: 3043-3044Google Scholar The current resurgence of syphilis in the United States has been primarily observed in minority populations, those with low socioeconomic status, and with poor access to health care.2Centers for Disease Control and PreventionSexually Transmitted Disease Surveillance, 2008. US Dept of Health and Human Services, Atlanta, GA2009http://www.cdc.gov/std/stats08/surv2008-Complete.pdfGoogle Scholar These are often individuals who rely disproportionately on the emergency department (ED) for primary medical care. Emergency physicians are therefore in an excellent position to identify previously unrecognized cases of syphilis in pregnant women and help to reverse the increase in congenital syphilis. The current study demonstrated that one third of mothers of infants with congenital syphilis received no prenatal care. In Philadelphia, there were 9 cases of congenital syphilis in 2007. Seven of these infants were delivered at our hospital, and 4 of those 7 mothers had visited our ED during their pregnancy (personal communication, Felicia M.T. Lewis, CDC/Philadelphia Department of Public Health, May 2010). In theory, an effective syphilis screening program based in our ED could have prevented most cases of congenital syphilis in infants delivered in Philadelphia that year. The CDC and many emergency physicians advocate ED-based HIV screening in high-risk populations.6Branson B.M. Handsfield H.H. Lampe M.A. et al.Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.MMWR Morb Mortal Wkly Rep. 2006; 55: 1-17PubMed Google Scholar, 7Borg K. To test or not to test? HIV, emergency department and the new Centers for Disease Control prevention guidelines.Ann Emerg Med. 2007; 49: 573-574Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Although syphilis has not traditionally been considered a disease meriting an ED-focused public health initiative,8Irvin C.B. Wyer P.C. Gerson L.W. et al.Preventive care in the emergency department, part II: clinical preventive services—an emergency medicine evidence-based review.Acad Emerg Med. 2000; 7: 1042-1054Crossref PubMed Scopus (156) Google Scholar a similar approach could be used for ED-based syphilis screening programs. At least 1 major urban health department mandates syphilis testing for all pregnant women during an ED encounter if they have not already been screened.9Philadelphia Department of Public HealthHealth alert: new syphilis screening recommendations, February 24, 2010.https://hip.phila.gov/xv/Portals/0/HIP/Health_Alerts/2010/PDPH-HAN_Alert_1_SyphilisScreeningRecs_02242010.pdfGoogle Scholar However, to our knowledge there are no recent studies of the utility or feasibility of ED-based syphilis screening programs. Numerous practical considerations need to be addressed before routine ED screening can be recommended. These concerns include acting on test results obtained after ED discharge, arranging primary care or return ED visits for treatment, creating linkages to public health departments, partner testing, compensation for test costs, and legal concerns. Reversing the current trend in increasing congenital syphilis rates will require the combined effort of public education, enhanced provider awareness, increased access to testing, and facilitation of treatment and follow-up. Whether syphilis screening is conducted in the ED or explicit instructions for follow-up testing are provided to pregnant women, emergency physicians who treat pregnant women without prenatal care should increase their vigilance for the disease and be open to the possibility of performing screening syphilis testing in pregnant women who seek care in the ED for any reason. Congenital Syphilis—United States 2003-2008Annals of Emergency MedicineVol. 56Issue 3Preview[Centers for Disease Control and Prevention. Congenital syphilis—United States 2003-2008. MMWR Morb Mortal Wkly Rep. 2010;59:413-417.] Full-Text PDF