Syphilis rates in Alaska have risen annually since 2018; a similar trend is being seen nationally. In Alaska, most cases have occurred in people who self-identify as heterosexual and are living in urban environments (29% of whom were experiencing homelessness or unstably housed in 2021). About half of the 2021 cases were in women, and nearly 90% of them were of reproductive age. This has resulted in a concomitant rise in congenital syphilis cases in Alaska. Racial/ethnic disparities also persist. Coinfection with other STIs (sexually-transmitted infections) and heroin/methamphetamine use are commonly identified co-factors.
Alaska statute 18.15.150 maintains that patients must be serologically tested for syphilis during their first prenatal care (PNC) visit unless they refuse testing. Due to the rapidly rising syphilis rate in Alaska women of reproductive age, we are recommending increased perinatal testing that is consistent with steps that other states have already taken to avert congenital syphilis cases (see below).
The purpose of this is to provide updated guidance and resources regarding the prevention and diagnosis of congenital syphilis during the current epidemic, which constitutes a change in guidance to that which was published in a recent Epidemiology Bulletin on congenital syphilis (CS). An update to the recent CS Bulletin will be released to reflect this updated guidance: https://epi.alaska.gov/bulletins/docs/b2023_09.pdf.
Alaska Division of Public Health Updated Congenital Syphilis Screening Guidance
• Screen all pregnant people (regardless of risk factors) during their first prenatal visit, during their third trimester of pregnancy, and at the time of delivery.
• Screen pregnant people seen for medical services unrelated to their pregnancy (e.g., during an outpatient clinic, urgent care, or emergency department visit) if they have not already had prenatal care with appropriate syphilis screening or if they are at increased risk for syphilis acquisition (e.g., sex with multiple partners, sex in conjunction with drug use or transactional sex, late entry to prenatal care or no prenatal care, methamphetamine or heroin use, incarceration of the pregnant person or their partner, and unstable housing or homelessness).
• Diagnostic considerations for pregnant people are available on CDC’s Syphilis During Pregnancy website.
• Screen for other sexually transmitted infections in anyone who is at increased risk for syphilis or who tests positive for syphilis, including HIV and extragenital testing.
• All neonates born to people who have a) reactive nontreponemal or treponemal test results, or b) a history of syphilis in pregnancy with non-reactive RPR results at delivery should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL) performed on the neonate’s serum as soon as possible after delivery. Umbilical cord blood testing can be unreliable and is not recommended. The nontreponemal test performed on the neonate should be the same type of nontreponemal test performed on the pregnant person, utilizing the same laboratory.
Treatment / Penicillin G Benzathine (Bicillin L-A®) Availability
• The FDA listed a shortage of penicillin G benzathine injectable suspension products (Bicillin L-A®) on April 26, 2023. Pfizer provided an availability update on June 12, 2023, with an expected recovery in the second quarter of 2024. There are no emergency stockpiles of this medication, and product is being allocated with limited inventory released, resulting in the supply not meeting demand.
• Bicillin L-A® is the only CDC-recommended treatment for some patients, including pregnant people infected with or exposed to syphilis, and babies with congenital syphilis. Although Bicillin L-A® remains the treatment of choice for patients with syphilis, CDC has recommended that healthcare providers prioritize the use of Bicillin L-A® to treat pregnant people and babies with congenital syphilis.
• Consider prioritizing unstably housed/homeless persons for Bicillin L-A® treatment after pregnant people infected with or exposed to syphilis and babies with congenital syphilis.
• Doxycycline is an alternative therapy for non-pregnant patients diagnosed with or exposed to syphilis; however, doxycycline is an FDA Pregnancy Category D medication, and is not recommended as an alternative treatment for pregnant individuals.
Point of Care Testing
• Syphilis rapid tests can be applied at point of care (POC) to detect antibodies to Treponema pallidum antigen or anticardiolipin antibodies.
• The advantages of rapid POC tests include quick turnaround time, the ability to provide treatment immediately, and that minimal technical training is necessary in non‐laboratory settings.
• Syphilis rapid POC tests should ideally be administered with a blood draw for RPR testing.
• Syphilis rapid POC tests are most suitable for patients who are at high risk for being lost to follow-up, for those giving birth with no serology on file and the laboratory turnaround time is long, and in persons who have not had a previous documented syphilis infection.
Syphilis among American Indian/Alaska Native Communities
• On July 6, 2023, the US Department of Health & Human Services (DHHS) circulated a letter to inform recipients of the rise in syphilis cases among American Indian/Alaska Native (AI/AN) communities.
• The DHHS letter has many recommendations and follows three-point syphilis testing for all pregnant people.