BQ Journal Vol 54 - Q1 2024 - 41

Morbidity and Mortality Weekly Report
Methods
Study Population
Cases of congenital syphilis that meet the 2018 Council
of State and Territorial Epidemiologists congenital syphilis
case definition* are reported to CDC's National Notifiable
Diseases Surveillance System (NNDSS). Data are from all
50 states, the District of Columbia, and U.S. territories and
freely associated states.
Classification of Missed Opportunities
To identify potential missed prevention opportunities among
congenital syphilis-associated pregnancies, a mutually exclusive
six-part cascading framework of risk factors was developed that
includes 1) no documented testing or nontimely testing, 2) late
identification of seroconversion during pregnancy, 3) no treatment
or nondocumented treatment, 4) inadequate treatment,
5) clinical evidence of congenital syphilis despite documentation
of adequate maternal treatment, and 6) insufficient data
to identify a missed prevention opportunity for the case. Using
a stepwise approach, cases of congenital syphilis reported via
NNDSS in 2022 were examined and assigned to one of the six
framework categories, starting with determining whether timely
testing occurred during pregnancy, defined as testing completed
≥30 days before delivery (9). Cases for which documentation
of timely testing was absent were categorized as " nontimely or
no documented testing. " Cases for which the syphilis diagnosis
was received late in pregnancy (<30 days before delivery), after
earlier nonreactive testing (i.e., testing without evidence of
syphilis), were categorized as late identification of seroconversion.
Congenital syphilis cases for which timely testing led to
a syphilis diagnosis during pregnancy were assessed based on
whether treatment adequate to prevent congenital syphilis,
defined as a penicillin-based regimen initiated ≥30 days before
delivery, with dosing and spacing appropriate for the stage of
syphilis (5,6), was documented. Cases without adequate documentation
of treatment were categorized as either 1) inadequate
treatment or 2) no or nondocumented treatment. Finally, those
congenital syphilis cases that occurred despite documentation
of timely testing and adequate treatment were categorized as
either 1) clinical evidence of congenital syphilis despite adequate
treatment during pregnancy or 2) insufficient data to identify
the missed opportunity despite careful review.
Data Analysis
Numbers of congenital syphilis cases and rates of primary
and secondary syphilis among females aged 15-44 years in
* https://ndc.services.cdc.gov/case-definitions/syphilis-2018/
2022 were compared with annual data from 2012 through
2021. Missed opportunities for prevention were stratified by
U.S. Census Bureau region and by race and ethnicity of the
birth parent. Prenatal testing and treatment status were stratified
according to whether at least one prenatal care visit had
occurred during the pregnancy. Analyses were completed using
Stata statistical software (version 15.1; StataCorp). This activity
was reviewed by CDC, deemed not research, and was conducted
consistent with applicable federal law and CDC policy.†
Results
Congenital Syphilis Cases and Outcomes
In 2022, a total of 3,761 congenital syphilis cases were
reported via NNDSS, including 231 (6%) stillbirths and 3,530
(84%) liveborn infants (with 51 [1%] infant deaths). This
represents a 31.7% increase in congenital syphilis cases from
those reported during 2021, concurrent with a 17.2% increase
in rates of primary and secondary syphilis cases among females
aged 15-44 years (from 16.3 to 19.1 per 100,000 population)
(Figure 1). More than 10 times as many congenital syphilis
cases were reported in 2022 (3,761) than in 2012 (334).
Missed Opportunities for Prevention of Congenital Syphilis
Among all (3,761) congenital syphilis cases reported in 2022,
the birth parent of most patients (3,302; 87.8%) received
either no or nontimely testing (1,385; 36.8%), or no or
nondocumented (423; 11.2%) or inadequate (1,494; 39.7%)
treatment during pregnancy. Among 197 (5.2%) congenital
syphilis cases, syphilis was diagnosed late in pregnancy, after
earlier nonreactive testing (Figure 2). Among 2,179 (57.9%)
cases for which timely testing and no late identification of
syphilis had occurred, more than two thirds (1,494; 39.7%
of all congenital syphilis cases) had documentation of inadequate
treatment during pregnancy, nearly 20% (423; 19.4%
[11.2% of all cases]) received no treatment or nondocumented
treatment, and the remaining 262 (12.0% [7.0% of all cases])
received adequate treatment. Among these 262 cases, clinical
evidence of congenital syphilis (e.g., on the basis of physical
exam, radiographic findings, or laboratory findings) was noted
in the newborn despite documentation of adequate treatment
in one half (130; 3.5% of all cases), and insufficient data were
available to identify missed opportunities to prevent congenital
syphilis in the remaining patients (132; 3.5% of all cases).
† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
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US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
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https://ndc.services.cdc.gov/case-definitions/syphilis-2018/
BQ Journal Vol 54 - Q1 2024

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