SYPHILLIS (SCREENING) IN PREGNANCY
Evidence Statement
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Updated 10/3/11
Evidence StatementClinical Preventive Service RecommendationsU.S. Preventive Services Task Force RecommendationThe U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all pregnant women for syphilis infection.1For the USPSTF recommendation on syphilis in the general population, see Syphilis (Screening) Evidence Rating: A (Strongly Recommended/Good Evidence) The USPSTF found convincing observational evidence that the universal screening of pregnant women decreases the proportion of infants with clinical manifestations of syphilis infection. The USPSTF concludes that the benefits of screening all pregnant women for syphilis infection substantially outweigh potential harms.1 CDC RecommendationThe Centers for Disease Control and Prevention (CDC) recommends a serologic test for syphilis for all pregnant women at the first prenatal visit. Women who are at high risk for syphilis morbidity, are previously untested, or have a positive serology in the first trimester should be screened again early in the third trimester (28 weeks gestation) and at delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery.2Evidence Rating: Not Specified Condition / Disease Specific InformationEpidemiology of Condition/DiseaseSyphilis is a serious sexually transmitted infection (STI) that, if left untreated during pregnancy, is associated with stillbirth, neonatal death, bone deformities, and neurologic impairment.1In addition to sexual transmission, syphilis can be passed from an infected mother to her infant during pregnancy and delivery. Infection of the fetus can occur not only if maternal syphilis is detected during pregnancy, but if the mother had syphilis up to four years preceding the pregnancy.3 Congenital syphilis is particularly severe and results in fetal or infant death in 40% of cases.1 Between 2006 and 2007, the rate of congenital syphilis increased 16%.4 A large majority of congenital syphilis cases occur because the mother lacks documented treatment or receives inadequate treatment of syphilis before or during pregnancy.5 Infected infants who survive may suffer serious central nervous system abnormalities, deafness, bone and joint deformities, skin abnormalities, blood disorders, and other problems.5 Condition/Disease Risk FactorsThe prevalence of syphilis infection varies widely among communities and patient populations.1 Some populations have a particularly high risk of infection, specifically African-Americans and people living in the Southeastern United States.6The Value of PreventionEconomic Burden of Condition/DiseaseCongenital syphilis is a costly disease to treat at approximately $6,738 per case (direct medical costs only).7Workplace Burden of Condition/DiseaseThe health, disability, and life insurance costs of syphilis-infected employees impose a significant economic burden on employers. In addition to the first-year direct medical costs for an infant born with congenital syphilis of $6,738, affected women may also lose work time in order to seek treatment for themselves or for their infants. The indirect costs associated with congenital syphilis are estimated at $3,369 in the first year and $60,421 lifetime (all figures in 2006 dollars).7Economic Benefit of Preventive InterventionScreening and early detection are key to averting costs associated with disease progression, long-term complications, and neonatal transmission. For example, treatment for early stage syphilis ($41.26) is much less expensive than treatment for later stage disease ($2,062) (both figures in year 2001 dollars).8 Furthermore, treatment of P&S syphilis in women can avert the $6,738 (in year 2006 dollars) associated with the first-year direct medical costs of an infant with congenital syphilis.7Estimated Cost of Preventive InterventionIn 2007, the median private-sector cost of screening for syphilis was $5.9 Approximately 95% of all paid claims fell within the range of $2 to $25.9For 2009, the Centers for Medicare & Medicaid Services (CMS) allowable fees for the tests shown above ranged from $6.23-$119.34 (2008 dollars).10 The cost per case of syphilis treated and cost per case of congenital syphilis prevented through screening will depend on population prevalence and other factors. Estimated Cost of TreatmentThe cost of treating syphilis will vary depending on the medication used and other factors. The public sector cost of standard IM benzathine penicillin therapy ranged from $18.64 to $22.22 (in year 2001 dollars).8 The cost of treatment of infants perinatally exposed to syphilis without physical signs of congenital syphilis range from $370 to $2,700 (in year 2000 dollars), depending on the treatment regimen used.11Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive InterventionSerological screening of pregnant women can be cost-effective even when there is a very low prevalence of maternal infection because screening is inexpensive but treating congenital syphilis is costly.12Preventive Intervention InformationPreventive Intervention: Purpose of ScreeningScreening for syphilis allows clinicians to identify affected patients and begin treatment early in the course of disease. Early intervention improves outcomes and avoids the health and economic consequences of latent disease in the mother and the occurrence of congenital syphilis.2 Treatment also reduces the risk of transmission between the affected woman and her sexual partner(s).Benefits and Risks of InterventionNo studies have documented harms associated with screening for syphilis. Theoretical harms include partner discord, stigma, unnecessary anxiety, treatment in the case of a false-positive result, and opportunity costs (in terms of time and resources) to both the clinician and patient. Harms of treatment include allergic reactions to penicillin and other side effects of treatment medications such as the Jarisch-Herxheimer reaction (fever, headache, and pain that occurs during the 24 hours after initiating antibiotic treatment for syphilis and is caused by the release of fragments of the dead, infective microorganism into the bloodstream).1The benefits associated with screening are substantial. Screening allows for early detection and treatment, prevention of complications that may occur in later stages of the disease, and prevention of neonatal transmission. Antibiotic treatment for syphilis is effective and inexpensive. Therefore, the USPSTF concluded that the benefits of screening pregnant women for syphilis infection substantially outweigh the potential harms.1 Initiation, Cessation, and Interval of ScreeningAll pregnant women should be screened for syphilis at their first prenatal care visit. For women in high-risk groups, repeat serologic testing may be necessary in the third trimester (28 weeks) and again at delivery.1,2 Follow-up serologic tests should be obtained to document successful treatment.1Intervention ProcessA variety of syphilis tests are available and in development. Screening for syphilis typically involves the use of 2 different tests, a nontreponemal test and a treponemal-specific test, for screening and confirmation. For example, a nontreponemal blood test such as the venereal disease research laboratory (VDRL) or the rapid plasma reagin (RPR) may be performed. A second, different kind of test, such as the fluorescent treponemal antibody absorbed (FTA-ABS) or the T. pallidum particle agglutination (TP-PA) may then be used to confirm the results of the nontreponemal test.16 Syphilis screening tests that are approved by the Food and Drug Administration (FDA) or are pending FDA approval include16:
Treatment InformationSyphilis should be treated with an antibiotic regimen appropriate for the woman's stage of disease. Some experts recommend additional therapy (e.g., a second dose of benzathine penicillin 2.4 million units IM) one week after the initial dose, particularly for those women in the third trimester of pregnancy and for women who have secondary syphilis during pregnancy.13 Women who are allergic to penicillin should undergo drug desensitization prior to treatment, as doxycycline is contraindicated during pregnancy.14Infants should be treated for presumed congenital syphilis if they were born to mothers who, at delivery:
Health benefits should include provisions for treatment services. Strength of EvidenceThe level of evidence supporting the recommendations contained in this section is described below.Evidence-Based Research: Summary Plan DescriptionCovered Screening
Initiation, Cessation, and IntervalSyphilis screening is a covered benefit for all pregnant women at their first prenatal care visit. Women with a positive screen are eligible for a confirmatory test. Women who are at high risk for syphilis, are previously untested, or have a positive serology in the first trimester are eligible for re-screening and confirmatory testing during the third trimester and at delivery, or as medically indicated.CPT Codes
Other Information and ResourcesBusiness Group Resource(s)CDC ResourceAuthor(s)Choucair J, Lentine D, Campbell KP, Chattopadhyay S. Syphilis evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006. Updated 2011.AcknowledgmentsThe National Business Group on Health would like to thank the Centers for Disease Control and Prevention's Division of Sexually Transmitted Disease Prevention for their review and update of this statement in December 2009.References
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