May 2021 | Volume 70, Number 4

Contact: 971-673-1111 | [email protected] | www.healthoregon.org/cdsummary

THE DEADLY RESURGENCE OF CONGENITAL IN OREGON

ongenital syphilis (CS) is a Figure. cases and rates of early syphilis among people assigned disease that occurs when a female at birth, Oregon, 2013–2020 Cpregnant person with syphilis 20 12 passes the on to their baby 18 during pregnancy. CS can cause mis- 10 carriage, , pre-term delivery, 16 14 low birth weight, and neonatal death. 8 born with CS may experience 12 bone deformities, , hepato- 10 6 , , neurologic 8 problems, and skin . 4 6 CS cases have increased signifi- Rates Syphiis Earlly

Congenital Syphilis Syphilis CasesCongenital 4 cantly in Oregon in recent years. In 2 2013, no cases of CS were reported to 2 the Oregon Health Authority (OHA); in 0 0 contrast, in 2020, there were 19 report- 2013 2014 2015 2016 2017 2018 2019 2020 ed CS cases (Figure). In 2019, Oregon Year ranked 11th highest in the nation for Cases of congenital syphilis Rate early syphilis CS cases with a rate of 43 cases per 100,000 live births.1 CHARACTERISTICS OF PREG- Washington (7% of cases) counties. Concurrently, the rate of early NANT PEOPLE WHO DELIVERED Black/African American, American syphilis, including primary, secondary, AN WITH CS Indian/Alaska Native, Native Hawai- and early non-primary non-secondary Between 2014 and 2020, the me- ian and Pacific Islander, and Hispanic/ syphilis (formerly early latent), among dian age of the 69 pregnant people Latina/o/x pregnant people were dis- people assigned female at birth in- who delivered an infant with CS was proportionately more likely to deliver creased over 900% from less than 1 27 years with a range of 18-44 years. an infant with CS when comparing the case per 100,000 in 2013 to almost Eighty percent of cases were diag- proportion of CS cases to the propor- 10 cases per 100,000 in 2020 (Fig- nosed in just five counties including tion of pregnancies in these groups ure). Similarly, the rate of syphilis in Multnomah (36% of cases), Marion (Table 1). pregnancy increased from 18 cases (14% of cases), Jackson (13% of Forty-eight percent of pregnant per 100,000 live births in 2013 to 129 cases), Lane (9% of cases), and people who delivered an infant with CS cases per 100,000 live births in 2020. During this same period, more people Table 1. Congenital syphilis cases and live-births by race and ethnicity, Oregon, 2014–2020 assigned female at birth diagnosed CS CASES LIVE BIRTHS * 2 with early syphilis reported injection (N=69) drug use (0% in 2013 compared to 28% in 2018), more than 80% of which RACE was methamphetamine. American Indian/Alaska Native 4 (6%) 3% From 2014 through 2020, of the 248 Native Hawaiian/Pacific Islander 4 (6%) 1% pregnant Oregonians with syphilis, 69 (28%) had an infant with CS. The Black/African American 5 (7%) 3% proportion of pregnant people with Hispanic/Latino/a/x 15 (22%) 15% syphilis who delivered an infant with Asian 0 4% CS increased from 2/15 (13%) in 2014 to 19/54 (35%) in 2020. Multiracial, other race 0 5% White 40 (48%) 69% *Average percentage of live births by race and ethnicity in Oregon from 2014 through 2020 were houseless or unstably housed. Table 2. Syphilis treatment in pregnancy One-quarter had criminal justice involvement in the 12 months prior STAGE TREATMENT NOTES to or during their pregnancy. Thirty- Primary For women living with two percent had a history of injection Secondary HIV, administer at least drug use, 52% had a history of meth- Benzathine penicillin G two doses of benza- Early non-primary, non- amphetamine use, and 20% had a 2.4 million units intra- thine penicillin G 2.4 secondary history of heroin or other opiate use. muscularly (IM) x 1 million units IM and Over 90% of pregnant people who strongly consider three delivered an infant with CS reported doses only one male partner in the prior 12 Late syphilis (>1 year Benzathine penicillin G months. None were living with HIV. or unknown duration) 2.4 million units intra- Forty-five percent had a history of muscularly (IM) weekly or chlamydia and 17% x 3 were living with chronic hepatitis C. Neuro or ocular syphilis Aqueous crystalline PRENATAL CARE, SYPHILIS penicillin G 4 million STAGE, AND TREATMENT units intravenously Almost 40% of pregnant Orego- every 4 hours for 10–14 nians who delivered an infant with days CS did not receive prenatal care In the case of penicillin allergy, pregnant patients must be desensitized more than 30 days prior to delivery. prior to treatment with penicillin as this is the only recommended therapy. Nineteen percent of pregnant people who delivered an infant with CS be- ized by neonatal death for an over- nant people with syphilis likely have gan prenatal care in the first trimes- all case fatality rate of 10%. The touchpoints with other providers, ter while 30% and 12% began care median estimated gestational age systems, and services during their in the second and third trimesters, was 38 weeks with an interquartile pregnancy. Better coordination of respectively. Including those who did range (IQR) of 35 to 39 weeks and these systems has the potential to and did not receive prenatal care at a range of 22 to 41 weeks. The me- avert cases of CS. least 30 days prior to delivery, 48% dian birth weight was 2869 grams (6 Early screening of all pregnant were diagnosed with syphilis more lbs 5 oz) with an IQR of 2263 grams people for syphilis is a Grade A Unit- than 30 days prior to delivery. Among (4 lbs) to 3490 grams (7 lbs 11 oz) ed States Preventive Services Task those who had prenatal care, 64% and a range of 604 grams (1 lb 5 Force recommendation. In Oregon, were diagnosed with syphilis more oz) to 5820 grams (12 lbs 13 oz). there is room for improvement in the than 30 days prior to delivery. Twenty-seven percent of infants were screening of pregnant people for Fifty-five percent of pregnant symptomatic at birth with snuffles, syphilis. While screening at delivery people who delivered an infant with , , jaundice, hepatitis, or is common, increased screening at CS were diagnosed with late syphilis . Three-quarters first presentation to prenatal care or syphilis of unknown duration. Six received appropriate treatment with and third trimester screening may percent were diagnosed with primary either intramuscular benzathine peni- avert additional CS cases. The con- syphilis, 9% with secondary, and cillin G or intravenous aqueous crys- cerning number of seroconversions 23% with early non-primary non- talline penicillin G. and reinfections among pregnant secondary syphilis while 7% could people who delivered an infant with not be staged based on the available CONGENITAL SYPHILIS PRE- CS supports the need for early third clinical information. Sixteen percent VENTION OPPORTUNITIES trimester screening in Oregon, a of cases represented seroconver- Given the severe consequences state with high syphilis incidence and sion, meaning patients had a reactive of CS, every case is a sentinel event prevalence. In addition, the initiation syphilis screening test after a non- indicating that the healthcare system and completion of treatment can be reactive test earlier in pregnancy. is not meeting the needs of marginal- challenging. For pregnant people Twelve percent of cases experienced ized and minoritized Oregonians. We diagnosed with late syphilis or syphi- re-infection with a four-fold or greater found that almost 40% of pregnant lis of unknown duration, treatment increase in rapid plasma reagin people who delivered an infant with requires three precisely timed injec- (RPR) titer after treatment and ap- CS did not receive prenatal care. tions of Bicillin LA at seven-day inter- propriate response to initial therapy. In the context of intersecting social vals initiated at least 30 days prior to Overall, only 35% of pregnant determinants of health, including delivery. Treatment may also require people who delivered an infant with experiences of racism, houseless- coordination with additional providers CS received treatment for syphilis 30 ness, substance use, and criminal and health systems for timely initia- days or more prior to delivery. Twelve justice involvement, this finding tion and completion of this multi-dose percent received no treatment at all. suggests that safe, supportive, judg- regimen. ment-free prenatal care is not readily OUTCOMES OF INFANTS WITH accessible to all pregnant people, CONGENITAL SYPHILIS particularly those with syphilis. Preg- Five of the 69 (7%) CS cases were stillborn and 2 (3%) were character- WHAT IS OHA DOING ABOUT department to review previous 8. If you work in a correctional facility CONGENITAL SYPHILIS? RPR titers and treatment. or in community supervision and • OHA has web page for congenital • For laboratories: a pregnant person is in your custody, syphilis with helpful resources and ° If only a non-treponemal test please screen them for syphilis or guidance. (RPR) is ordered, check to see if provide access to syphilis screening • OHA is working with local public there is documentation of a previ- while they are in your custody. health authorities in counties with ous positive treponemal test. If 9. If you provide support services to the greatest burden of CS to con- none, suggest the provider order pregnant people through visiting nurs- duct case review boards to identify the syphilis screening cascade. ing programs, maternal child health opportunities for partnerships and • If only a treponemal test is ordered, programs, food and nutrition pro- systems-level change to improve care suggest the provider order the grams, school-based health centers, for pregnant people with syphilis and syphilis screening cascade. syringe service programs, homeless prevent CS. 3. Be familiar with syphilis staging and shelters, or in any other capacity, • OHA is preparing an in-depth qualita- appropriate treatment for syphilis in please provide education and coun- tive survey to learn more about the pregnancy (Table 2, page 2). A pocket seling on the importance of screening needs and perspectives of pregnant guide from the California Department for syphilis during pregnancy. people with syphilis, particularly those of Public Health is easy to follow. 10. Know that your local public health who did not receive prenatal care. Patients who are not evaluated for authority is a great resource for ques- We also hope to elucidate the other syphilis symptoms will likely need the tions about syphilis testing, staging, healthcare touchpoints that pregnant more onerous regimen of three doses and treatment. A list of local public people with syphilis have during their of Bicillin LA at weekly intervals. health authorities and their contact pregnancy. 4. Screen and treat all current partners to information can be found here. • OHA will be conducting an analysis of prevent reinfection during pregnancy. 11. Finally, share this CD Summary with Medicaid claims data to assess syphi- 5. If you are a prenatal care provider, your colleagues and community lis screening among pregnant people please screen patients for syphilis partners. insured by the Oregon Health Plan. according to OHA recommendations We hope this report provides data • OHA has an incentive program to help regardless of risk. When possible, and context to your work in caring for engage pregnant patients in care for bundle syphilis screening with other pregnant people and that you join us syphilis screening, re-screening, and prenatal care labs. in working to reverse the course of treatment. • Screen at first presentation to care. syphilis and CS in Oregon. • OHA has a Bicillin Access Program • Screen again at 28–32 weeks (early to assist clinics and providers who do third trimester) REFERENCES not routinely carry benzathine penicil- ° We recommend pairing this test- 1. Centers for Disease Control and Prevention. ing with oral glucose tolerance Sexually Transmitted Disease Surveillance lin G (Bicillin LA) to access this critical 2019. Atlanta: U.S. Department of Health medication for syphilis treatment. testing at 28 weeks. and Human Services; 2021. • OHA issued a Dear Provider Letter ° Early third trimester screening will 2. Oregon Health Authority Center for Health about syphilis in pregnancy in Novem- capture seroconversion and re- Statistics: www.oregon.gov/oha/PH/BIRTH- ber of 2018. The recommendations infection experienced by 28% of DEATHCERTIFICATES/VITALSTATISTICS/ here serve as an update to that letter. pregnant patients who delivered ANNUALREPORTS/Pages/index.aspx 3. Centers for Disease Control and Prevention. an infant with CS in 2014–2020. • The OHA STD Program is here as a Sexually Transmitted Diseases Treatment resource for you. Please call us with • Screen at delivery. Guidelines, 2015. MMWR Recomm Rep any questions, cases, or concerns at • Screen any pregnant person with a 2015;64(No. RR-3): 1–137. 971-673-0130. fetal demise after 20 weeks. 6. If you are an emergency department WE ALL PLAY A ROLE IN PRE- or urgent care provider seeing a VENTING CONGENITAL SYPHILIS pregnant person, please screen them 1. Be familiar with the two syphilis for syphilis. Screening is especially screening cascades, traditional and important if: reverse. Call your lab to find out • They have not had adequate prena- which cascade it uses and the best tal care. way to order it. • They are seeking care for symp- 2. Know these helpful tips when screen- toms, signs or a diagnosis of an ing or re-screening for syphilis STI, HIV, or hepatitis C. • For providers: • They are seeking care for sub- ° In ED, urgent care, or prena- stance use-related concerns includ- tal care settings, the syphilis ing overdose, intoxication, or an screening cascade (RPR with injury or infection related to injection reflex to titer and treponemal drug use. confirmation[traditional] or • They are experiencing houseless- treponemal test with reflex to ness. RPR and titer [reverse]) should • They are involved in the criminal be the default order. justice system. ° An RPR titer alone is only useful 7. If you are a provider of substance for monitoring infection status in use disorder treatment, please a patient with syphilis history. screen your pregnant patients for ° If a patient reports syphilis his- syphilis. tory, contact your local health PUBLIC HEALTH DIVISION

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