In the first half of 2019, there were two cases of congenital syphilis diagnosed in British Columbia; the first cases since 2013. In the context of 919 cases of infectious syphilis reported in BC in 2018—representing the highest number of cases in 30 years—and other concerning epidemiologic trends (for example, increased cases in females of childbearing age), BC’s provincial health officer declared a syphilis outbreak in July 2019. Following consultation between members of the BCCDC, Perinatal Services BC, and reproductive and pediatric infectious diseases experts from BC Women’s Hospital and Health Centre, the decision was made to institute interim provincial guidelines for enhanced syphilis screening in pregnancy. These took effect in September 2019.

The existing standard recommendations for syphilis screening in pregnancy remain the same: for testing to be done in the first trimester or at the first prenatal visit; additional screening done only in cases where there is clinical suspicion for ongoing risk during pregnancy. Additionally, a pregnancy test is recommended for any individual diagnosed with syphilis who is able to become pregnant. The revised guidelines recommend the addition of a syphilis screening test at delivery (or any time after week 35 for those planning home births). The overarching goal of these interim guidelines is to maximize detection and prevention of maternal and congenital syphilis while maintaining a responsible approach to screening. More specifically, the objectives of the guidelines are the following:

1. To determine the epidemiology of maternal and congenital syphilis in BC. Ultimately, the goal is to determine how many cases of maternal and/or congenital syphilis are being missed with BC’s current screening approach. Given the high rates of syphilis-associated spontaneous abortion,[1] the elevated transplacental transmission rate, particularly in early syphilis,[2,3] and the long window period,[4] it is plausible that cases are, in fact, being missed in BC. The addition of screening at delivery over a time-limited period will provide valuable information and ensure a comprehensive picture of syphilis epidemiology in BC is obtained.   
2. To ensure timely identification and treatment of maternal and congenital syphilis. Syphilis in pregnancy is associated with adverse health outcomes that can significantly impact the health of both mother and fetus.[5] As a majority of infants born with congenital syphilis are asymptomatic at birth,[4] most of those untreated will develop symptoms within months.[6] In the vast majority of cases, maternal treatment is curative for fetal infection, and early treatment of the newborn will prevent most symptoms,[7,8] making early detection a priority.

Implementing these revised, interim syphilis screening guidelines in pregnancy are one part of a larger effort led by the BCCDC and its partners in addressing the syphilis outbreak. Near-future efforts will focus on revising BCCDC’s Syphilis Action Plan,[9] and emphasis will be placed on addressing the outbreak in gay, bisexual, and other men who have sex with men, who remain the population most impacted by syphilis.
—Troy Grennan, MD
BC Centre for Disease Control (BCCDC), University of British Columbia (UBC)
—Ellen Giesbrecht, MD
UBC, Perinatal Services BC, BC Women’s Hospital and Health Centre
—Gina Ogilvie, MD
BCCDC, UBC, BC Women’s Hospital and Health Centre
—Ann Pederson, PhD
UBC, Perinatal Services BC, BC Women’s Hospital and Health Centre
—Julie van Schalkwyk, MD
UBC, BC Women’s Hospital and Health Centre
—Mark Gilbert, MD
BCCDC, UBC
—Jason Wong, MD
BCCDC, UBC

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Centers for Disease Control and Prevention. Congenital syphilis–United States, 1998. MMWR Morb Mort Wkly Rep 1999;48:757.

2.    Fiumara NJ, Fleming WL, Downing JG, Good FL. The incidence of prenatal syphilis at the Boston City Hospital. N Engl J Med 1952;247:48.

3.    Ingraham NR. The value of penicillin alone in the prevention and treatment of congenital syphilis. Acta Derm Venereol Suppl 1959;31(Suppl 24):60.

4.    Herremans T, Kortbeek L, Nottermans DW. A review of diagnostic tests for congenital syphilis in newborns. Eur J Clin Microbiol Infect Dis 2010;29:495.

5.    Ray JG. Lues-lues: Maternal and fetal considerations of syphilis. Obstet Gynecol Surv 1995;50:845.

6.    Dobson SR, Sanchez PJ. Syphilis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. 8th ed. Cherry JD, Harrison GJ, Kaplan SL, et al., editors. Philadelphia, PA: Elsevier Saunders; 2019. p. 1268.

7.    Blencowe H, Cousens S, Kamb M, et al. Lives Saved Tool supplement detection and treatment of syphilis in pregnancy to reduce syphilis related stillbirths and neonatal mortality. BMC Public Health 2011;11(Suppl 3):S9.

8.    Stamos JK, Rowley AH. Timely diagnosis of congenital infections. Pediatr Clin North Am 1994;41:1017.

9.    BC Centre for Disease Control. Accessed 22 July 2019. www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/STI/Syphilis%20Action%20Plan.pdf [16].