Current Trends Congenital Syphilis -- New York City, 1986-1988

From 1986 through 1988, the number of reported (1) cases of congenital syphilis (CS) in New York City (NYC) increased greater than 500%, from 57 to 357 (Figure 1). From January through June, 1989, 779 newborns with reactive serologic tests for syphilis were reported. Based on previous NYC data, an estimated 57%-68% of these infants represent true congenitally acquired infections, which projects to 888-1059 CS cases for 1989.* Because syphilis has been associated with use of crack cocaine, the NYC Department of Health conducted a case-control study to examine the relationship between maternal cocaine/crack use** and CS cases in 1988 in NYC.

Data were obtained from NYC birth certificates and an attached Confidential Medical Section containing maternal drug-use information collected routinely by a trained registrar on all mothers at delivery. Additional information on cocaine/crack use was obtained by health department personnel investigating CS reports.

Of the 357 CS cases in 1988, 302 (85%) (including three sets of twins) were matched to birth certificates; 55 (15%) could not be matched either because of discrepancies in birth date or name spelling or because they were stillborn and did not have a birth certificate. Demographic characteristics were similar for matched and unmatched infants. Controls (two for each case) were selected from birth certificate files and were matched for hospital of delivery, date of birth, and race/ethnicity. A total of 299 case-mothers and 598 control-mothers were studied; 71% were black, 22% Hispanic, 5% non-Hispanic white, and 3% of unknown or other races.

Case-mothers were similar in mean age (25 years) and Medicaid coverage to control-mothers but were less likely to be married or to have received prenatal care (Table 1). Case-mothers were significantly more likely to have used cocaine/crack during pregnancy (odds ratio (OR)=6.6); use of other drugs (but of no particular drug) was also more likely. Infants of case-mothers were more likely to be of low birth weight ( less than 2500 g) (36% of cases compared with 12% of controls; OR=4.3; 95% confidence interval (CI)=3.0-6.1) and preterm ( less than 37 weeks' gestation) (30% of cases, compared with 17% of controls; OR=2.1; 95% CI=1.5-2.9). When health department interview data about drug use (available for case-mothers only) were included in the analysis, the proportion of case-mothers who used cocaine/crack during pregnancy increased from 28% (according to birth certificate data) to 39% (117/299).

One hundred fifty-three (51%) case-mothers reported having had one or more prenatal-care visits; of these, 49 (32%) began prenatal care in the last trimester. When case-mothers were subdivided according to cocaine/crack use during pregnancy, users did not differ demographically from nonusers but were more likely to have received no prenatal care (36% vs. 24%; p less than 0.03) and less likely to have had one or more prenatal-care visits (35% vs. 62%; p less than 0.001); for 29% of users and 14% of nonusers, no data on prenatal care were available. Reported by: S Schultz, MD, Deputy Commissioner, M Zweig, MPH, T Singh, PhD, M Htoo, MD, New York City Dept of Health. Clinical Research Br, Div STD/HIV Prevention, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: In 1988, health departments reported to CDC 691 CS cases in infants less than 1 year of age--the highest number since penicillin became widely used to treat syphilis in pregnant women in the early 1950s (2). Because CS can be prevented by detection and treatment of syphilis early in pregnancy, this increase indicates gaps in syphilis control and prenatal care. Nationwide, as in NYC, the epidemiology of CS parallels trends for early syphilis in women; in addition, almost half the CS infants reported to CDC were delivered to mothers who received no prenatal care (3).

This increase in CS in NYC parallels a 240% increase in the number of reported cases of primary and secondary syphilis in women, from 541 in 1986 to 1841 in 1988. Such increases have been linked elsewhere to use of cocaine/crack (4-8). In NYC, the proportion of mothers reporting use of cocaine increased from 1 per 1000 live births in 1981 to 21 per 1000 in 1988 (9); no other drug has increased similarly in use.

The practice of trading sex with multiple partners for drugs, especially cocaine/ crack, now appears to play a major role in the transmission of syphilis (5-7). Because under these circumstances the identities of sex partners are often unknown, the traditional syphilis-control strategy of partner notification may not be effective--a failure that has been linked to CS (8). In the NYC study, cocaine/crack use was also related to lack of prenatal care. Mothers of infants with CS may not access the health-care system fully.

Primary prevention of CS will require innovative efforts to decrease syphilis incidence. Since drug users often do not use health-care services, targeted screening programs may be necessary. For example, because untreated early syphilis is present in 2% of prisoners (10), many of whom are incarcerated for drug-related offenses, screening programs could be directed at that population. Innovative screening programs are especially important for detecting and treating syphilis in males.

Prevention of CS will also require increased use of prenatal care. In all states, serologic screening for syphilis is required during pregnancy; a second screening is recommended during the third trimester for high-risk populations, and follow-up and treatment must be assured. For example, in Orange County, California, rapid syphilis screening and treatment were instituted in 1986 in prenatal-care clinics so that women could be tested and treated during the same visit; as a result, CS decreased from 12 cases in 1985 to one case each in 1987 and 1988 (11).

Screening for syphilis at delivery is also recommended by CDC for mothers who live in areas of high syphilis prevalence (12) and was recently mandated for all mothers by the State of New York. Since the consequences of nontreatment are grave and follow-up is often difficult, infants should not leave the hospital until the results of syphilis screening are known (12). Ideally, the mother's blood should be screened because use of cord blood for screening may give both false-positive and false-negative results (13).

The large increase in the number of CS cases in NYC reflects in part the use of revised, more sensitive reporting guidelines for CS. These were published in 1988, but a modified version (see box) has been approved by the Council of State and Territorial Epidemiologists and CDC. These guidelines enable reporting of CS based on information available at birth or at the initial investigation. Infants born to women with untreated or inadequately treated syphilis are now considered to have presump tive CS, regardless of symptoms or follow-up (1). Since most such infants are infected, they should be treated, even when asymptomatic (12). Despite the increased sensitivity of these guidelines, true morbidity and mortality from CS are still underestimated, largely because stillbirths are a common sequelae of untreated maternal syphilis. Although reportable under the revised guidelines, syphilis-associated stillbirths are generally unrecognized and unreported.

New York State and California are now implementing the revised reporting guidelines. In Los Angeles County, use of these guidelines has stimulated increased reporting of CS (14). Use of these guidelines should permit more accurate estimates of the number of CS cases and improve surveillance by providing comparable, representative data nationwide.

References

1. CDC. Guidelines for the prevention and control of congenital

syphilis. MMWR 1988;37 (no. S-1).

2. Venereal Disease Program, Public Health Service. VD fact sheet. Washington, DC: US Department of Health, Education, and Welfare, Public Health Service, 1954 (no. 11):16; PHS publication no. 341.

3. CDC. Congenital syphilis--United States, 1983-1985. MMWR 1986;35:625-8.

4. CDC. Syphilis and congenital syphilis--United States, 1985-1988. MMWR 1988;37:486-9.

5. CDC. Relationship of syphilis to drug use and prostitution--Connecticut and Philadelphia, Pennsylvania. MMWR 1988;37:755-8,764.

6. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution. Am J Public Health (in press). 7. Scribner R, Cohen D. The streets of Babylon: syphilis and sex for drugs in Los Angeles County (Abstract). In: Program and abstracts of the 117th annual meeting of the American Public Health Association and related organizations. Washington, DC: American Public Health Association, 1989:18.

8. Andrus JK, Fleming DW, Harger DR, et al. Partner notification and epidemic syphilis. Ann Intern Med (in press).

9. New York City Department of Health. Maternal drug abuse--New York City. City Health Information 1989;8,8:1-4. 10. Moran JS, Peterman T. Sexually transmitted diseases in prisons and jails. The Prison J (in press). 11. Lawrence AM, Morrison C. The prevention of congenital syphilis in Orange County, California (Abstract). In: Proceedings of the 1988 STD National Conference. Atlanta: US Department of Health and Human Services, Public Health Service, 1988:46. 12. CDC. 1989 Sexually transmitted diseases treatment guidelines. MMWR 1989;38(no. S-8): 9-12. 13. Larsen SA, Hunter EF, McGrew BD. Syphilis. In: Wentworth BE, Judson FN, eds. Laboratory methods for the diagnosis of sexually transmitted diseases. Washington, DC: American Public Health Association, 1984:18. 14. Cohen DA, Boyd D, Pabhudas I, Mascola L. The effects of case definition, maternal screening, and reporting criteria on rates of congenital syphilis. Am J Public Health (in press). *Numbers reported in this article differ from those in MMWR Table II because of lags in reporting.

**In this population, most cocaine was used in the form of smokable "crack"; intravenous and intranasal administration were also included. SURVEILLANCE CASE DEFINITION FOR CONGENITAL SYPHILIS

For reporting purposes, congenital syphilis includes cases of congenitally acquired syphilis in infants and children, as well as syphilitic stillbirths.A CONFIRMED CASE of congenital syphilis is an infant in whom Treponema pallidum is identified by darkfield microscopy, fluorescent antibody, or other specific stains in specimens from lesions, placenta, umbilical cord, or autopsy material.A PRESUMPTIVE CASE of congenital syphilis is either of the following:

1. Any infant whose mother had untreated or inadequately treated* syphilis at delivery, regardless of findings in the infant; OR

2. Any infant or child who has a reactive treponemal test for syphilis and any one of the following:

1. any evidence of congenital syphilis on physical examination**; or

2. any evidence of congenital syphilis on long-bone radiograph; or

3. reactive cerebrospinal fluid (CSF) VDRL***; or

4. elevated CSF cell count or protein (without other cause)***; or

5. quantitative nontreponemal serologic titers which are fourfold higher than the mother's (both drawn at birth); or

6. reactive test for FTA-ABS-19S-IgM antibody***. A SYPHILITIC STILLBIRTH is defined as a fetal death in which the mother had untreated or inadequately treated syphilis at delivery of a fetus after a 20-week gestation or of a fetus weighing greater than 500 g. *Inadequate treatment consists of any nonpenicillin therapy or penicillin given less than 30 days prior to delivery. **Signs in an infant ( less than 2 years of age) may include hepatosplenomegaly, characteristic skin rash, condyloma lata, snuffles, jaundice (syphilitic hepatitis), pseudoparalysis, or edema (nephrotic syndrome). Stigmata in an older child may include: interstitial keratitis, nerve deafness, anterior bowing of shins, frontal bossing, mulberry molars, Hutchinson's teeth, saddle nose, rhagades, or Clutton's joints. ***It may be difficult to distinguish between congenital and acquired syphilis in a seropositive child after infancy. Signs may not be obvious and stigmata may not yet have developed. Abnormal values for CSF VDRL, cell count, and protein, as well as IgM antibodies, may be found in either congenital or acquired syphilis. Findings on long-bone radiographs may help, since these would indicate congenital syphilis. The decision may ultimately be based on maternal history and clinicaljudgment; the possibility of sexual abuse also needs to be considered.

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