P3B279: Preventing and Treating Congenital Syphilis in Rural Washington

Background: The incidence of congenital syphilis in the U.S. increased 639% between 2013 and 2021. Rural areas have been disproportionately affected. Congenital syphilis can cause serious illness, with a risk of up to 40 percent of fetal demise or death in early infancy, as well as bone anomalies, central nervous system anomalies, hearing and visual impairment, and developmental delay. Treatment for syphilis in pregnancy is highly effective and prevents congenital syphilis; early treatment of congenital syphilis prevents late manifestations. Both require timely detection and treatment and close outpatient monitoring. We describe a collaborative effort to prevent, identify, and treat congenital syphilis in response to a syphilis outbreak in an under-resourced and economically disadvantaged rural county in Central Washington, with limited laboratory resources and access to specialty care. Between 2020 and 2021, Yakima County saw a 4-fold year-over-year increase in primary and secondary syphilis cases, and in 2021, it had the highest case rate in Washington.

Methods: In November 2021, a multidisciplinary workgroup was formed to identify key drivers of congenital syphilis. A comprehensive prevention and treatment program was developed to overcome barriers, including lack of prenatal care and disjointed health care interactions, limited public health resources for ongoing monitoring, and delayed laboratory processing. Interventions included enhanced laboratory monitoring, including universal maternal testing at time of delivery and same day testing and titers, direct handoff and education to outpatient providers and public health authorities, and initiation of a simplified standardized pediatric evaluation and treatment algorithm for newborns at risk for congenital syphilis. Encounters were recorded in a weekly registry, including testing results, treatment, and follow up needs.

Results: Interventions were initiated on a rolling basis starting in April 2022. In 2022, 26 obstetric patients had positive RPR screens, and 20 newborns were evaluated for risk for congenital syphilis based on the standardized algorithm. Of those, 14 (70%) required and received treatment. During the first quarter of 2023, 5 pregnant patients had positive RPR screens, and no infants have required evaluation or treatment (Figure 1). Data collection regarding follow up for patients treated for congenital syphilis is ongoing, as exposed children require serial testing until 6 months of age; however, no child has required readmission for re-treatment.

Conclusion: Based on early results, through a collaborative approach focused on overcoming barriers to testing and treatment, we successfully identified and reduced the incidence of maternal and congenital syphilis in a rural setting and standardized treatment for affected infants. The knowledge gained from the evaluation of this program will be generalizable and could inform strategies to prevent parent-to-child transmission of syphilis as well as improve treatment for early congenital syphilis in under-resourced settings.