Special Report
Antenatal Screening for Syphilis is Still Important
By Robert S. Baltimore, MD, FAAP
Congenital syphilis infection can result in stillbirth, hydrops fetalis, or prematurity. It may produce no clinical disease in the neonatal period or it may have obvious clinical manifestations, including intrauterine growth retardation, hepatosplenomegaly, lymphadenopathy, hemolytic anemia, thrombocytopenia, and bone and mucocutaneous lesions. Late manifestations of congenital syphilis that involve the central nervous system, bones and joints, teeth, eyes, and skin usually do not appear after 2 years of age. Some consequences of congenital syphilis such as interstitial keratitis and eighth nerve deafness may not become evident for many years.
Several congenital infections, including hepatitis B, HIV, and syphilis, can be detected antenatally and therapeutic intervention can markedly reduce vertical transmission. The AAP Redbook recommends universal serological testing for syphilis of pregnant women early in pregnancy and preferably again at delivery using a nontreponeal test (Venereal Disease Research Laboratory or Rapid Plasma Reagent). In areas of high prevalence and in patients considered to be at high risk, maternal testing at 28 weeks is also indicated. No newborn should be discharged from the nursery without determination of the mother’s serological status for syphilis.1 The prevalence of syphilis has decreased in many developed countries, such as the United States and United Kingdom. Many pediatricians have never seen a case of congenital syphilis. Because of this perceived rarity, cost containment considerations may lead to discussions about discontinuing routine screening of pregnant women, the way routine mandatory premarital screening for syphilis has discontinued in many states in the United States.
Hurtig and colleagues, leading a cooperative clinical group in the United Kingdom, carried out a surveillance study to determine the incidence of syphilis in pregnancy and congenital syphilis throughout the United Kingdom over a three-year period (1994-1997).2 One hundred thirty-nine pregnant women were diagnosed and treated for syphilis; 121 of these were detected through antenatal screening. Thirty-one women had early infections that are associated with a risk of vertical transmission. Nine cases of congenital infection were identified: one followed inadequate medical treatment, and the remaining eight cases had absent or delayed medical care. Because reporting was incomplete, these are minimum figures. Most of the cases of maternal syphilis occurred in metropolitan London and surroundings. Eighty percent of infected women were born outside of the United Kingdom, and 18 of 23 women with transmittable syphilis were infected abroad. Cheap and easy international travel can facilitate the movement of diseases as well as people. Syphilis is endemic in Africa and South Asia. A major epidemic is currently being experienced in Russia. Twenty-five percent of the infected women were white, 14% Asian, 31% black African, and 19% black Caribbean. Despite the prevalence of minorities and foreign-born cases, Hurtig et al argue against selective or targeted screening. Cases of maternal as well as congenital syphilis occurred in pregnancies of nonurban, white women who had been born in the United Kingdom. Further, the logistics of selective screening would include targeting minorities, which is not acceptable.
If antenatal screening for syphilis was discontinued in the United Kingdom, about $1.5 million would be saved annually because universal screening requires performing about 18,600 tests to detect one woman needing treatment and about 55,700 tests to prevent one case of congenital syphilis. However, without universal testing, at least 10 women a year with early syphilis would be missed and most of their babies would be stillborn or have congenital disease.3 Antenatal screening can also provide an early warning for local outbreaks of syphilis. Three out of 46 cases of early infectious syphilis in a recent outbreak in Bristol were identified through antenatal screening.3 These considerations were concurred with by the U.K. Public Health Laboratory Service, which recommended that universal antenatal screening for syphilis should be continued.4 These analyses and recommendations are certainly also valid in the United States. (Dr. Baltimore is Professor of Pediatrics and Epidemiology and Public Health, Yale University School of Medicine.)
References
1. AAP Committee on Infectious Diseases. 1997 Red Book. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:505-507.
2. Hurtig AK, et al. Syphilis in pregnant women and their children in the United Kingdom: Results from national clinician reporting surveys, 1994-1997. BMJ 1998;317:1617-1619.
3. Welch J. Antenatal screening for syphilis. Still important in preventing disease. BMJ 1998;317:1605-1606.
4. Report to the National Screening Committee: Antenatal screening in the UK: A systematic review and national options appraisal with recommendations. London: Public Health Laboratory Service, July 1998.
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