Health Advisory: Continued increase in syphilis cases including congenital syphilis cases; routine testing of sexually active women recommended

April 11, 2023

Action Requested 

• Be aware of a continued increase in primary and secondary syphilis cases as well as congenital syphilis cases. 
  • The case rate for primary and secondary syphilis in Snohomish County has doubled since 2019. In 2022, 94 cases were reported (11.1 cases per 100,000), compared to 46 (5.6 cases per 100,000) in 2019. 
  • From 2015 to 2020, no cases of congenital syphilis were reported. In 2021 and 2022, multiple cases have been reported each year, representing a large relative increase in incidence of this potentially devastating and preventable disease
  • Local public health and the Washington State Department of Health have asked clinicians to assist in preventing spread of syphilis, particularly congenital syphilis.
• Follow recommendations (see page 3 of this advisory) from local public health and the Washington State Department of Health for routine screening for some cisgender (meaning gender identity corresponds to sex assigned at birth) women and men who have sex with women.
• Treat all patients with signs or symptoms consistent with primary or secondary syphilis when they present for care. 
• Perform serological tests on patients with signs or symptoms of syphilis. Do not wait for the test results to provide treatment, particularly among pregnant women, individuals who are living homeless, and others for whom medical follow-up is difficult to ensure.
• All pregnant women should be tested for syphilis at the first pre-natal visit and some women should be tested more than once during pregnancy.
  • Ask about pregnancy status of patients who are pregnancy capable and offer screening in non-OB/GYN settings in the absence of identified prenatal care.
  • Congenital syphilis (CS) occurs when babies are born to women with untreated syphilis. CS can cause miscarriage, still birth, pre-maturity, low birth weight or death shortly after birth. CS can also cause deformed bones, severe anemia, hepato-splenomegaly, jaundice, neurologic complications including blindness and deafness, meningitis, and skin rashes. CS is preventable with appropriate testing and treatment.
• Treat any patient who reports sexual exposure to someone with syphilis, even in the absence of signs or symptoms of infection or a positive test result. Serological testing can be falsely negative early in infection (i.e., “incubating syphilis”). 
• Know the symptoms of primary and secondary syphilis
  • Primary: A syphilitic chancre is usually a firm ulcer at the site of inoculation; it is usually painless and may be associated with localized lymphadenopathy.
  • Secondary: Rash is the most common symptom and may present as a generalized maculopapular rash on the torso with or without palmar and plantar lesions, though the rash may also be pustular; other presentations of rash include condyloma lata, mucous patches, alopecia. Other symptoms include generalized malaise, lymphadenopathy, sore throat and arthralgias.
• Know the treatment of early syphilis (primary, secondary, and early latent): benzathine penicillin (bicillin) 2.4 million units intramuscularly once. Patients with late latent syphilis or syphilis of unknown duration require three injections spaced one week apart.
• Report all cases of syphilis in Snohomish County patients to the Snohomish County Health Department. 
  • Please complete the STD Reporting Form and fax to the Snohomish County Health Department at 425-339-8707. If you have questions about reporting an STD to the Snohomish County Health Department, please call 425-339-5261. 

Resources

• Sexually Transmitted Diseases | Snohomish County Health Department, WA (snohd.org)
• Sexually Transmitted Disease (STD) | Washington State Department of Health
• STI Treatment Guidelines (cdc.gov)