BQ Journal Vol 54 - Q1 2024 - 44

Morbidity and Mortality Weekly Report
inappropriate selection of an antimicrobial agent, dosing, or
spacing of doses, as well as an insufficient interval between
initiation of treatment and delivery; ongoing analyses aim to
describe specific sources of inadequate treatment to better guide
public health action. Strategies that reduce loss to follow-up
and decrease the time between testing and treatment could
increase the likelihood of adequate treatment. This outcome
has been achieved at some medical facilities and health organizations
through implementation of rapid syphilis pointof-care
testing (10), which the World Health Organization
recommends during pregnancy in settings where a delay in
diagnosis can lead to loss to follow-up (11). Innovations in
treatment and close follow-up (e.g., field-delivered treatment
and disease intervention specialists trained to prevent and
control infectious diseases providing linkage to care) can help
facilitate adequate treatment (12-14).
Recommended Treatment for Prevention of Congenital Syphilis
Benzathine penicillin G is the only recommended treatment
for syphilis during pregnancy; this drug must be administered
as an injection by a trained professional as either a single dose
or as 3 doses spaced 7-9 days apart, depending on the stage of
infection (6). The success rate of this treatment in preventing
congenital syphilis has been reported to be as high as 98% (15).
Although this analysis includes cases with clinical evidence of
congenital syphilis despite adequate treatment, some of these
cases might be explained by undetected reinfection late in pregnancy.
Because the United States is currently facing a shortage
of benzathine penicillin G, CDC has encouraged providers
and health departments to prioritize benzathine penicillin G
for the treatment of syphilis in pregnancy.¶
Individual Screening Based on Risk Factors and Community
Syphilis Rates
Historically, syphilis screening and interventions have
targeted individual risk factors, but for many sexually active
persons, their most significant risk factor is living in a
community with high rates of syphilis (4,6). CDC guidelines
recommend syphilis screening for sexually active persons in
communities with high rates of syphilis (6); however, the
threshold for a high rate is not defined. Currently, the Healthy
People 2030 goal is to reduce the rate of primary and secondary
syphilis cases among females aged 15-44 years to 4.6 per
100,000 population.** In counties with a rate that exceeds this
goal, offering syphilis testing to sexually active females aged
15-44 years and their sex partners might help identify syphilis
cases and prevent spread, support progress toward meeting the
¶ www.cdc.gov/std/dstdp/dcl/2023-july-20-Mena-BicillinLA.htm
** https://health.gov/healthypeople/objectives-and-data/browse-objectives/
sexually-transmitted-infections/reduce-syphilis-rate-females-sti-03
1273
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
†† https://www.cdc.gov/nchhstp/atlas/syphilis/index.html
§§ https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm
Healthy People 2030 goals, and reduce congenital syphilis. In
2021, 38% of U.S. counties, accounting for 72% of the U.S.
population, had syphilis rates above the goal level†† . Disparities
in syphilis rates by race and ethnicity are not explained by
differences in sexual behaviors, but rather reflect access to sexual
health care, differences in sexual networks, and persistent and
systemic racism in medical care (6,16). Screening based on
geographic risk can decrease stigma and biases associated with
screening based on individual risk factors. In counties already at
or below the Healthy People 2030 goal level, clinicians should
continue to assess individual risk factors (e.g., diagnosis of
other sexually transmitted infections, a new partner, history
of incarceration, transactional sex work, or being a male aged
<29 years) to determine screening needs.§§
More than 37% of infants with congenital syphilis were born
to persons who had received no prenatal care. Among congenital
syphilis cases, no or nontimely testing during pregnancy
was the most frequently missed opportunity identified among
birth parents without documented prenatal care. Among those
with a timely test obtained during pregnancy, 20.4% had no
prenatal care documented, suggesting that testing occurred outside
prenatal care. In addition to improving access to prenatal
care, approaches to providing care outside of clinical settings
(e.g., use of rapid tests, field-delivered treatment, active case
follow-up, and linkage to care by disease intervention specialists)
are needed to ensure appropriate and timely screening
and treatment. Any encounter with medical or public health
professionals during pregnancy is an opportunity to identify
and treat syphilis, thereby preventing congenital syphilis as
well as maternal morbidity. Screening for syphilis at encounters
outside traditional prenatal care (e.g., emergency department,
jail intake, syringe services program, and maternal and child
health programs) might help identify and treat persons with
syphilis who might not otherwise receive adequate prenatal
care (13,14,17-19). In addition, the identification of syphilis
during pregnancy should be seen as a high priority for rapid
follow-up, with a systematic approach to defining who will be
responsible for ensuring timely treatment.
Limitations
The findings in this report are subject to at least three limitations.
First, national congenital syphilis case data contain
limited information about social determinants of health. The
underlying individual and structural barriers (e.g., systemic
inequities and limited health care access) leading to the missed
opportunities described in this report are beyond the scope of
this analysis. Second, jurisdictional differences in reporting
completeness and accuracy for congenital syphilis cases likely
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http://www.cdc.gov/std/dstdp/dcl/2023-july-20-Mena-BicillinLA.htm https://www.health.gov/healthypeople/objectives-and-data/browse-objectives/sexually-transmitted-infections/reduce-syphilis-rate-females-sti-03 https://www.cdc.gov/nchhstp/atlas/syphilis/index.html https://www.health.gov/healthypeople/objectives-and-data/browse-objectives/sexually-transmitted-infections/reduce-syphilis-rate-females-sti-03 https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm
BQ Journal Vol 54 - Q1 2024

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