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  • STD Control Branch

    Update on Syphilis in Women and Congenital Syphilis for Pediatric Providers

    Julie Stoltey, MD MPH Public Health Medical Officer

    California Department of Public Health

    STD Control Branch

    Bay Area Infectious Disease Conference January 24, 2018 for Prenatal & Pediatric Providers

  • STD Control Branch

    Overview

    • Summarize epidemiologic trends in syphilis in women and congenital syphilis in California

    • Review recommended treatment for syphilis in pregnancy

    • Describe characteristics of congenital syphilis cases in California and appropriate evaluation and management

  • STD Control Branch

    0

    100

    200

    300

    400

    500

    1990 1995 2000 2005 2010 2016

    R at

    e p

    e r

    1 0

    0 ,0

    0 0

    p o

    p u

    la ti

    o n

    Year

    Chlamydia

    Gonorrhea

    Early Syphilis 28.5 (N=11,222)

    164.3 (N=64,677)

    504.4 (N=198,503)

    Chlamydia, Gonorrhea, and Early Syphilis California Incidence Rates, 1990–2016

    Rev. 6/2017

  • STD Control Branch

    0

    2,500

    5,000

    7,500

    10,000

    1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

    N u

    m b

    e r

    o f

    C as

    e s

    Year

    0

    50

    100

    150

    1940 1950 1960 1970 1980 1990 2000 2010

    R at

    e p

    er 1

    0 0

    ,0 0

    0

    Year

    Early Latent Syphilis Incidence Rates California, 1940-2016

    Early Syphilis*, Number of Cases by Gender & Gender of Sex Partners, California, 1996–2016

    ALL MALE

    FEMALE

    MSM + MSM&W

    * Includes primary, secondary, and early latent syphilis. Rev. 6/2017

  • STD Control Branch

    Female Early Syphilis

    0

    300

    600

    900

    1,200

    1,500

    2009 2010 2011 2012 2013 2014 2015 2016

    N u

    m b

    e r

    o f

    C as

    e s

    Year

    Female Early Syphilis* Cases California, 2009–2016

    * Includes primary, secondary, and early latent syphilis.

    Rev. 6/2017

    2012-2016 Cases ↑ 450%

  • STD Control Branch

    050100150 0 50 100 150

    10-14

    15-19

    20-24

    25-29

    30-34

    35-44

    45+

    Total

    Early Syphilis* Incidence Rates by Gender and Age Group (in years)

    California, 2016

    Male Rate per 100,000 Female

    * Includes primary, secondary, and early latent syphilis. Rev. 6/2017

  • STD Control Branch

    Early Syphilis*, Incidence Rates by County and Gender California, 2016

    * Includes primary, secondary, and early latent syphilis.

    FEMALES MALES

    Rev. 6/2017

  • STD Control Branch

    0

    5

    10

    15

    20

    25

    2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

    R at

    e p

    e r

    1 0

    0 ,0

    0 0

    p o

    p u

    la ti

    o n

    Year

    NA/AN A/PI Black Latina White

    Note: NA/AN = Native American/Alaskan Native, A/PI = Asian/Pacific Islander.

    Race/ethnicity “Not Specified” ranged from 0% to 6.7% of cases for females in any given year.

    Early Syphilis* Incidence Rates for Females by Race/Ethnicity

    California, 2007–2016

    * Includes primary, secondary, and early latent syphilis. Rev. 6/2017

  • STD Control Branch

    0

    10

    20

    30

    2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

    P e

    rc e

    n t

    o f

    In te

    rv ie

    w e

    d C

    as e

    s

    Year

    Percent of Interviewed Early Syphilis* Cases who Reported Methamphetamine Use, by Sexual Orientation,

    California, 2007–2016

    MSM only

    MSW/MSM&W

    Female

    * Includes primary, secondary, and early latent syphilis. Rev. 6/2017

    MSM=Men who have sex w/men, MSW=Men who have sex w/women, MSM&W=Men who have sex with men & women

  • STD Control Branch

    0

    25

    50

    75

    100

    125

    1990 1995 2000 2010 2016

    R at

    e p

    e r

    1 0

    0 ,0

    0 0

    l iv

    e b

    ir th

    s

    Year

    California

    CA=42.4

    Congenital Syphilis, California versus United States Incidence Rates, 1990–2016

    2020 Objective (9.6)

    Note: The Modified Kaufman Criteria were used through 1989. The CDC Case Definition (MMWR 1989; 48: 828) was used effective January 1, 1990. California data prior to 1985 include all cases of congenital syphilis, regardless of age.

    United States

    US=15.7

    Rev. 6/2017

    California congenital syphilis cases represented 33% of all CS cases in the U.S. in 2016.

  • STD Control Branch

    Congenital Syphilis — States With Highest Number of Cases and Highest Rates per 100,000 Live Births, 2016

    States with Highest Number of Cases:

    Rank State 2016 Cases

    1 California 206

    2 Texas 71

    3 Florida 59

    4 Louisiana 48

    5 Georgia 21

    6 Illinois 18

    7 North Carolina 16

    8 Maryland 16

    9 Arizona 15

    10 10

    New York Michigan

    13 13

    States with Highest Rates:

    Rank State 2016 Rate

    1 Louisiana 74.4

    2 California 41.0

    3 Nevada 33.5

    4 Florida 26.8

    5 Maryland 21.6

    6 Texas 17.8

    7 Arizona 17.3

    8 South Dakota 16.3

    9 Georgia 16.0

    10 10

    Arkansas South Carolina

    15.6 15.6

  • STD Control Branch

    0

    50

    100

    150

    200

    250

    0

    4

    8

    12

    16

    20

    2010 2011 2012 2013 2014 2015 2016

    Number of Congenital Cases

    Early Syphilis Rate

    Early Syphilis Rate per 100,000 Females Number of Congenital of Childbearing Age (15-44 years) Syphilis Cases

    Congenital Syphilis Cases versus Female Early Syphilis* Incidence Rates, California, 2010–2016

    * Includes primary, secondary, and early latent syphilis.

    2012-2016 Congenital Syphilis

    Cases ↑ >500%

  • STD Control Branch

    Congenital Syphilis Number of Cases by County, California, 2016

    Rev. 6/2017

  • STD Control Branch

    Syphilis Overview

    • Causative organism: Treponema pallidum, a spirochete bacterium

    • Transmission: – Sexual (intimate skin-to-skin contact)

    – Vertical

    – Blood

    • Causes systemic infection

    • Characterized by episodes of active disease during which patients have signs/symptoms of infection, interrupted by periods of latent infection – Lab testing is required to diagnose patients

    • Incubation period: 10-90 days

    Image courtesy: Gregory Melcher, UC Davis Susan Philip, SF DPH & UCSF

  • STD Control Branch

    Prevention of congenital syphilis requires prevention/treatment of

    maternal syphilis

  • STD Control Branch

    Syphilis Natural History

    30-50%Exposure Primary 30% TertiaryLatentSecondary

    25%

    Neurosyphilis can occur at any stage

    Incubation Period

    3-4 weeks

    2-6 weeks

    After 3-8 weeks lesions disappear

    spontaneously

    2-20 years Possible relapse

  • STD Control Branch

    Syphilis Staging Flowchart

    YES

    Chancre Rash, etc.

    NO

    PRIMARY SECONDARY

    LATENT

    ANY IN PAST YEAR? • Negative syphilis serology • Known contact to an early case • Good history of typical signs/symptoms • 4-fold increase in titer • Only possible exposure was this year

    NOYES

    EARLY LATENT (< 1 year)

    LATE LATENT or UNKNOWN DURATION

    SIGNS OR SYMPTOMS?

  • STD Control Branch

    Treatment is Based on Duration of Infection

    PRIMARY, SECONDARY, and EARLY LATENT (< 1 year)

    LATE LATENT or UNKNOWN DURATION

    Benzathine penicillin

    G 2.4 million units IM

    in a single dose

    Benzathine Penicillin

    G 2.4 million units

    once per week for 3

    weeks**

    CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

    **In pregnancy, should adhere to 7 days between doses Bicillin L-A is the trade name. DO NOT USE Bicillin C-R!

    In pregnancy, benzathine penicillin is the only recommended therapy. No alternatives.

    http://www.cdc.gov/std/treatment

  • STD Control Branch

    Diagnosing Syphilis

    • Syphilis is diagnosed by:

    – Reviewing patient history

    – Assessing sexual risk

    – Conducting a physical exam

    – Interpreting serologic test results

  • STD Control Branch

    Syphilis Screening Paradigm

    Non-treponemal

    tests (e.g., RPR, VDRL)

    • NON-SPECIFIC

    ANTIBODIES TO

    LIPOIDAL ANTIGENS

    • QUANTITATIVE

    • REACTIVITY DECLINES

    WITH TIME

    TRADITIONAL

    Treponemal tests (e.g., TPPA, FTA-Abs)

    •TP-SPECIFIC ANTIBODIES

    • QUALITATIVE

    • USUALLY DETECTABL

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