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Update on Syphilis for Women’s Health Nurses
IN PRACTICE women's health
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Update on Syphilis for Women’s Health Nurses
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Alison O. Marshall ABSTRACT: After declining for many years, rates of syphilis in the United States are increasing. In this article, I explore possible reasons why women, and specifically pregnant women, are not getting tested properly. Lack of prenatal care, poor access to prenatal care, and improper prenatal care all have contributed to cases of congenital syphilis. Clinicians working in women’s health care can address this issue by taking accurate sexual histories, remaining open to sexual fluidity among their patients, being knowledgeable about the appropriate guidelines for testing for syphilis, and routinely offering screening to any woman at risk. Syphilis is a treatable and preventable sexually transmitted infection, and nurses, advanced practice nurses, and midwives can significantly contribute to reversing the current trend. doi: 10.1016/j.nwh.2020.01.009
Accepted January 2020
KEYWORDS: congenital syphilis, evidence-based practice, screening, sexually transmitted infection, STI, syphilis
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fter reaching record low numbers in 2000 and 2001, the United States has seen a sharp increase in the rates of all forms of syphilis, including congenital syphilis (Bowen, Su, Torrone, Kidd, & Weinstock, 2015). Nationally, congenital syphilis rates increased 72.7% from 2012 to 2014 (Bowen et al., 2015). Women infected with syphilis during pregnancy have increased risks of miscarriage, stillbirth, and permanent fetal abnormalities (Bowen et al., 2015). This is especially troubling because syphilis and
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congenital syphilis are both completely preventable. Why now? Why are rates of syphilis rising among all groups of women but more in the U.S. West and South and among women of color? What is happening that is causing women to proceed through the entirety of a pregnancy without this infection being discovered? Herein, I explore some of the potential reasons for the syphilis surge and what nurses, advanced practice nurses, and midwives can do to improve health outcomes for women and newborns. ª 2020 AWHONN; doi: 10.1016/j.nwh.2020.01.009
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CLINICAL IMPLICATIONS n Rates of syphilis are increasing across the country, including
rates of congenital syphilis. Untreated syphilis has major health implications. n Women’s health providers, including nurses, must take accurate
and thorough sexual histories, at least once a year in nonpregnant patients and at the first prenatal visit for pregnant patients. A brief review of a woman’s sexual health thereafter in pregnancy can help providers identify changing sexual patterns. n Clinicians should refrain from making assumptions regarding
women’s sexual practices and preferences, and they should understand that more women are foregoing classic binary categorization of sexual preference. n Women’s health providers should familiarize themselves with the
syphilis testing options in their practices. n All pregnant women should have at least one syphilis screening
and should be screened more than once if sexual risk exists.
History of Testing for Syphilis Serologic testing for syphilis began in 1906, after August Paul van Wasserman and Albert Neisser determined that the blood or cerebrospinal fluid in persons infected with syphilis would react to cardiolipin extracted from bovines. This became known as the Wasserman test (Harris, Rosenberg, & Riedel, 1946). However, this test did not isolate syphilis antibodies themselves and would also react in other conditions, such as systemic lupus erythematosus (Harris et al., 1946). The Venereal Disease Research Laboratory (VDRL) refined this technology, thereby developing the first widely used screening tool for syphilis (Harris et al., 1946). Similar technology was used to develop the rapid plasma reagin (RPR). These two tests each have their own advantages: the RPR does not require use of a microscope to interpret the test result, whereas the VDRL tool does, and the VDRL has lower rates of false negative results when testing cerebrospinal fluid than the RPR (Larsen, Steiner, & Rudolph, 1995). For screening purposes, the RPR is more widely used; the result is delivered as a ratio, which can be serially tracked to show effective treatment of the disease (Morshed & Singh, 2015). Together, these two tests were the mainstay of syphilis diagnostics until the early 2000s. At that time, new tests were developed that accurately detected the presence of treponemal proteins in the blood, which are specific only to syphilis (Sena, White, & Sparling, 2010). The most commonly used treponemal tests are the Treponema pallidum particle agglutination test and the fluorescent treponemal antibody absorbed test (Henao-Martínez & Johnson, 2014). Compared with
Alison O. Marshall, MSN, RN, FNP-C, is a clinical instructor at the William F. Connell School of Nursing at Boston College in Chestnut Hill, MA, and faculty at the Sylvie Ratelle STD/HIV Prevention Center of New England in Jamaica Plain, MA. ORCID: 0000-0001-8474-1751. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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After reaching record low numbers in 2000 and 2001, the United States has seen a sharp increase in the rates of all forms of syphilis, including congenital syphilis nontreponemal tests, treponemal tests are better at identifying early cases of primary syphilis (Ratnam, 2005). However, these tests were more expensive than the VDRL and RPR, which cost between $0.18 and $0.44, whereas the fluorescent treponemal antibody absorbed test and T. pallidum particle agglutination test cost $2.13 and $2.14, respectively (Pope, 2004). Given the increased sensitivity of the treponemal tests, they were used reflexively to confirm a positive nontreponemal test result (Binnicker, Jespersen, & Rollins, 2011). Many health care practices across the country continue to use this two-step model. In 2009, a group of laboratory experts convened to review the syphilis testing algorithm. They determined that the order of syphilis testing should be reversed in some cases (Association of Public Health Laboratories, 2009). For example, in areas where syphilis rates are high and in populations with high risk for sexually transmitted infection (STI), the use of treponemal tests before nontreponemal tests improves clinical detection rates, particularly in early infection (Henao-Martínez & Johnson, 2014). Providers using this method order the treponemal test first, and if it returns a positive result, they then order the nontreponemal test, typically the RPR, to confirm infection and to track the ratio to confirm treatment success. The different tests are summarized in Table 1.
Guidelines and Legislation for Testing Although many considerations must be taken when determining which test to order first, algorithms exist to help clinicians in their clinical decision making, particularly in the case of
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TABLE 1 SYPHILIS TESTING Test Name
Type of Test
Venereal Disease Research Laboratory (VDRL)
Nontreponemal
Rapid plasma reagin (RPR)
Nontreponemal
Advantages and Disadvantages
Duration of Positive Result
Returns to negative Advantages: eventually after treatment Less expensive than treponemal tests for most individuals Validated Disadvantages: Microscope required for interpretation False negatives possible, particularly in early infection Returns to negative Advantages: eventually after treatment Less expensive than treponemal tests for most individuals Validated Reported as a ratio, which allows clinicians to confirm the effectiveness of treatment Disadvantages: False negatives possible, particularly in early infection
Treponema Treponemal pallidum particle agglutination (TP-PA)
Once positive, remains positive for an individual’s lifetime
Advantages Better early infection detection rates than nontreponemal tests Validated Disadvantages: More expensive than nontreponemal tests Cannot be used to confirm effective treatment
Fluorescent treponemal antibody absorbed (FTAABS)
Treponemal
Once positive, remains positive for an individual’s lifetime
Advantages: Better early infection detection rates than nontreponemal tests Validated Disadvantages: More expensive than nontreponemal tests Cannot be used to confirm effective treatment
Note. Sources: Centers for Disease Control and Prevention (2015a); Henao-Martínez and Johnson (2014).
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pregnant women (New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections & New York City STD Prevention Training Center, 2019). Multiple national and international guidelines advise screening women for syphilis at least once during pregnancy and repetitively if there is risk of acquisition during pregnancy (American College of Obstetricians and Gynecologists, 2017; Centers for Disease Control and Prevention [CDC], 2015b; World Health Organization, 2017). Furthermore, these guidelines have clear and specific sections that outline which factors constitute risk for multiple populations (American College of Obstetricians and Gynecologists, 2017; CDC, 2015b; World Health Organization, 2017). The CDC also provides a summary of state-specific legislation regarding syphilis screening in pregnancy for easy clinical reference (CDC, 2018a). In some cases, omitting syphilis testing for specific patient populations is illegal; however, eight states have no screening requirements at all (CDC,
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2018a). Using these clinical tools along with knowing the disease risk in a community and when during a woman’s pregnancy to test enables nurses and other clinicians to choose the most appropriate testing sequence.
More than half of all individuals diagnosed with STIs in the United States annually are younger than age 25 years
Congenital Syphilis Research has been conducted specifically regarding the increase in rates of congenital syphilis. Slutsker, Hennessy,
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and Schillinger (2018) studied cases of mother–infant dyads in which the fetus developed congenital syphilis in New York state between 2010 and 2016. A total of 578 women tested positive for syphilis while pregnant, of whom 68 progressed untreated until the time of birth, resulting in infected neonates. Of these 68 women, 50% were younger than 30 years, 78% were women of color, and 55% were born outside of the United States (Slutsker et al., 2018). Twenty-two infected women (32% of 68) had negative screening test results in the first trimester and later contracted syphilis during pregnancy (Slutsker et al., 2018). Fifteen of these 22 women were not tested again during pregnancy, even though 12 of them had significant risk factors for acquiring syphilis (Slutsker et al., 2018). Another major issue for almost 30% of the 68 women was absent or late entry into prenatal care. Social determinants of health, such as substance misuse disorder, lack of health insurance, mental health disorders, and recent arrival into the country, were identified in 70% of these cases as reasons why women did not seek out or obtain prenatal care (Slutsker et al., 2018). Perhaps more concerning, four of the women received timely prenatal care but were never screened for syphilis (Slutsker et al., 2018). It is unclear why these women were not screened. One possibility to consider, however, was the insurance status of these women. Although the study did not examine this specifically, it should be considered that some of the women were uninsured. Similarly, women who are underinsured may have some coverage for prenatal care, but their plans may not offer full coverage for all prenatal tests. In the long term, the costs associated with progressive syphilis are much greater than the cost of the screening test, yet, in the short term, avoiding screening may have been the only viable choice. One woman, who went to the emergency department with symptoms of syphilis in her third trimester, was not tested and subsequently went on to have a stillbirth (Slutsker et al., 2018).
Implications for Nursing Practice What can women’s health nurses, advanced practice nurses, midwives, and other clinicians glean from this small study? The time used to screen women is indeed time well spent. Herein, I provide recommendations for steps clinicians can take in their provision of health care to women at risk for syphilis.
Engage With the Woman A thorough sexual history (see Box 1) should be taken at the first prenatal visit, and sexual health should be briefly discussed at subsequent prenatal visits to assess for changing sexual patterns and changes in risk.
Know the Community Know the clinical population in your area. Do you work in an area with high rates of syphilis? Be aware of the common risk factors. By paying special attention to the epidemiology of this
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BOX 1 CONSIDERATIONS FOR TAKING A THOROUGH SEXUAL HISTORY Do not assume that a woman is monogamous during her pregnancy. Do not assume that the biological father of the fetus is her current partner. Do not assume strict heterosexuality simply because she is pregnant. Always ask about her ability to make her own sexual decisions, and screen for intimate partner violence/ coercion. Know the signs of sex trafficking and screen women appropriately during prenatal care. current spread, we can accurately target areas where infection rates are high and ensure that providers are practicing the most current and guideline-driven health care.
Look for Risk Factors The results of the study by Slutsker et al. (2018) showed several risk factors, including social determinants of health. However, other factors exist that increase the risk of STIs in women. Women who engage in risky sexual behaviors before they are pregnant are more likely to continue to engage in these behaviors while pregnant (CDC, 2015b, 2018b). It is ideal that women avoid the acquisition of STIs during their pregnancy, but, as clinicians, we know that this is not always possible. Talk to women nonjudgmentally and find out what life is like for them outside of the health care facility. If there is risk, these women will need more frequent STI testing throughout their pregnancies. Also, it is worth taking time to provide health education during these visits on steps women can take to protect themselves and when to seek care should concerns arise. Another group of women who likely need education about syphilis are those younger than 25 years, regardless of sexual identity. Young people continue to make up a disproportionate number of persons contracting STIs. More than half of all individuals diagnosed with STIs in the United States annually are younger than 25 years (CDC, 2015b). Adolescents experience many firsts during their adolescent years, including first sexual experiences and first time negotiating decisions regarding alcohol consumption. Sexual decision making that comes after the consumption of alcohol has been shown to lower condom use rates during intercourse, even if, when sober, women note that condom use is important to provide protection against STIs (Davis et al., 2014). A large metaanalysis from 2015 showed that young women who drink alcohol are more likely to experience depression, anxiety, and other psychological disorders than men (de Haan, Egberts, & Heerdink, 2015). Depression is directly related to lower condom use in both sexes, but more so in women (Islam & Laugen, 2015).
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barriers to engaging in the safest sex. This could be another reason why rates of syphilis are increasing. As providers, we need to increase the odds that transmission does not occur. Takeaway points are summarized in Box 2.
Gender and Sexual Expression
Nurses and other clinicians can provide optimal care by ensuring that an accurate and detailed sexual history is taken at least once for nonpregnant women and at prenatal visits based on risk for those who are pregnant As many clinicians are aware, body image pressure to look a specific way exists across many cultures, not only in the United States. A large, longitudinal study done in Australia noted that girls as young as 14 years expressed feelings of body dissatisfaction and that these views persisted over time (Craike et al., 2016). Women who are dissatisfied with their bodies or body image are also less likely to ask their partners to wear condoms during sex (Blashill & Safren, 2015). Women are also less likely to require condom use if they do not hold the sexual power in a relationship. Researchers examined both same-sex and different-sex couples and found that women were less likely to hold the sexual power in different-sex couples (Tschann, Adler, Millstein, Gurvey, & Ellen, 2002). Thus, if a woman is in the less powerful position, she has less ability to negotiate condom use. Taken together, these results indicate that young women who are experimenting with alcohol and sex and have concerns about their body image and sense of self may have
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One final factor to consider regarding syphilis in your clinical practice is the moving and changing landscape of gender and sexual expression. Since 2000, there has been a significant body of work examining the concept of sexual fluidity, much of which built on the work of L. M. Diamond in Utah. Being sexually interested in men and women is becoming more common, as is declining to define one’s own sexuality in a binary manner of heterosexual or homosexual (Diamond, 2016). Of sexually fluid respondents in a study conducted by Katz-Wise and Hyde (2015), sexually fluid female respondents were more likely to report positive feelings regarding having sex with partners of both sexes and believing that sexual desires could change over time. For younger female patients, this idea may be more ingrained and accepted than for members of previous generations. The need for a gender-nonspecific sexual history becomes very important in these instances. We know that clients, as humans, want to tell health care providers what they think we want to hear. Using biased language that assumes that a client has partners only of the opposite sex or that the gender of a client’s current partner is the same as that of all of her previous partners results in missed opportunities to identify a woman’s STI risk. Every client deserves a lifelong sexual history conversation, at least once, to establish patterns over time. For example, screening for syphilis is not as important for women who are exclusively with women as it is for those who are engaging in penile/vaginal intercourse, yet every person deserves good education about how STIs are transmitted and acquired, as well as what factors make transmission/acquisition more likely. Boxing individuals into a sexual category and never allowing for change from this category places clinicians and their clients in a place where opportunities to uncover STIs are missed.
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BOX 2 CONSIDERATIONS FOR ADDRESSING RISK FACTORS FOR STI INFECTION If you provide health care to young women, it is imperative to ask them about their sense of self. Do they like the way they look? Are they confident making decisions about what happens to their body? Is the opinion or viewpoint of a partner more important than what she thinks herself? Ask about alcohol, drugs, and sex. Are they interested in experimenting with anything in these three categories? Have they already? What do they know about alcohol use? Are they aware that they may think and act differently when under the influence of drugs and alcohol? Are they aware that the same holds true for their partners? Ask very specifically if a woman believes she can ask her partner(s) to use condoms. Assess for barriers to condom use during this conversation, understanding that, for adolescents, barriers may need only to be perceived, not actualized, to influence behavior. It is also a good idea to have condoms to give away in a discreet fashion. At my clinic in South Boston, we place 10 condoms in a brown paper bag and wrap it so it is a small, flat package without markings. It is similarly sized to a smartphone, and a woman can put one or two packages in her bag or pocket as she leaves without calling attention to the package contents. Other clinics I’ve visited leave an open jar or basket of condoms in every exam room. This allows the patient to privately take some while waiting for the provider to enter the room. Finally, regardless of their ability to adopt condom use immediately, educate clients about sexually transmitted infections, not forgetting to mention syphilis. Because numbers were historically low in the early 2000s, many individuals may not realize that they are at risk for this particular infection. Unlike viral STIs, syphilis in all stages and during pregnancy can be cured with a common antibiotic and will not recur unless re-exposure occurs (CDC, 2015b). Women should seek care often if concerned about exposure to STIs. Many public and private insurance plans cover the cost of STI testing if needed, even multiple times a year, based on risk.
Conclusion Rates of syphilis are increasing across the country. Although it is an infection that we can easily test for and treat if discovered, left undiscovered, it can contribute to the morbidity and mortality of women and carry lifelong health implications for a newborn. Nurses and other clinicians can provide optimal care by ensuring that an accurate and detailed sexual history is taken at least once for nonpregnant women and at prenatal visits based on risk for those who are pregnant, especially if their social situation is not stable. Clinicians should also know their laboratory protocol—is the RPR or VDRL still considered the first-line test, or has the shift to the treponemal tests been made? What tests are covered by the public insurance options in your community? How about the private insurance plans? As mentioned earlier, many insurance options will cover a syphilis screening up to once a year in those without risk and multiple times a year for those with risk. If you have taken a good history that outlines a patient’s risk for acquiring an STI, there should be no problem getting the tests covered. If for any reason the test is not covered, find out how much a woman could pay out of pocket for the test or if there are any programs in your community that could help defray the cost of testing. Most important, partner with women to keep them safe and well. As nurses, advanced practice nurses, and midwives, we have the education and training to approach each client as a whole person. Doing so for sexual health allows us to create alliances with our clients that they may not have in any other relationship. Keeping women engaged with us is the key to long-term advances in their health and wellness. Even if you don’t always know what to do, ensuring that you are their ally
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will promote better health outcomes. Ask often, test when needed, and educate always. Let’s make these syphilis rates return to where they should be—zero! NWH
References American College of Obstetricians and Gynecologists. (2017). Clinical practice: Syphilis resurgence reminds us of the importance of STD screening and treatment during prenatal care. Retrieved from https:// www.acog.org/About-ACOG/ACOG-Departments/ACOG-Rounds/ May-2017/Syphilis-Resurgence?IsMobileSet¼false Association of Public Health Laboratories. (2009). Laboratory diagnostic testing for Treponema pallidum—Expert consultation meeting summary report, January 13-15, 2009. Silver Spring, MD: Association of Public Health Laboratories. Retrieved from https://www.aphl.org/ programs/infectious_disease/std/Documents/ID_2009Jan_ Laboratory-Guidelines-Treponema-pallidum-Meeting-Report.pdf Binnicker, M. J., Jespersen, D. J., & Rollins, L. O. (2011). Treponemaspecific tests for serodiagnosis of syphilis: Comparative evaluation of seven assays. Journal of Clinical Microbiology, 49(4), 1313–1317. https://doi.org/10.1128/JCM.02555-10 Blashill, A. J., & Safren, S. A. (2015). Body dissatisfaction and condom use self-efficacy: A metaanalysis. Body Image, 12, 73–77. https:// doi.org/10.1016/j.bodyim.2014.10.002 Bowen, V., Su, J., Torrone, E., Kidd, S., & Weinstock, H. (2015). Increase in incidence of congenital syphilis—United States, 2012–2014. Morbidity and Mortality Weekly Report, 64(44), 1241–1245. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a3. htm Centers for Disease Control and Prevention. (2015a). Syphilis. Retrieved from https://www.cdc.gov/std/tg2015/syphilis.htm Centers for Disease Control and Prevention. (2015b). Sexually transmitted diseases treatment guidelines. Morbidity and Mortality Weekly Report. 64(RR3), 1–137. Retrieved from https://www.cdc. gov/mmwr/preview/mmwrhtml/rr6403a1.htm
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Centers for Disease Control and Prevention. (2018a). State statutory and regulatory language regarding prenatal syphilis screenings in the United States, 2018. Retrieved from https://www.cdc.gov/std/ treatment/syphilis-screenings-2018.htm
Katz-Wise, S. L., & Hyde, J. S. (2015). Sexual fluidity and related attitudes and beliefs among young adults with a same-gender orientation. Archives of Sexual Behavior, 44(5), 1459–1470. https://doi.org/ 10.1007/s10508-014-0420-1
Centers for Disease Control and Prevention. (2018b). Youth risk behavior surveillance—United States, 2017. Morbidity and Mortality Weekly Report. 67(8), 1–114. Retrieved from https://www.cdc.gov/mmwr/ volumes/67/ss/ss6708a1.htm
Larsen, S. A., Steiner, B. M., & Rudolph, A. H. (1995). Laboratory diagnosis and interpretation of tests for syphilis. Clinical Microbiology Reviews, 8(1), 1–21. https://doi.org/10.1128/CMR.8.1.1
Craike, M., Young, J. A., Symons, C. M., Pain, M. D., Harvey, J. T., Eime, R. M., & Payne, W. R. (2016). Trends in body image of adolescent females in metropolitan and non-metropolitan regions: A longitudinal study. BMC Public Health, 16(1), 1–9. https://doi.org/10.1186/ s12889-016-3815-1 Davis, K. C., Masters, N. T., Eakins, D., Danube, C. L., George, W. H., Norris, J., & Heiman, J. R. (2014). Alcohol intoxication and condom use self-efficacy effects on women’s condom use intentions. Addictive Behaviors, 39(1), 153–158. https://doi.org/10.1016/ j.addbeh.2013.09.019 de Haan, L., Egberts, A. C. G., & Heerdink, E. R. (2015). The relation between risk-taking behavior and alcohol use in young adults is different for men and women. Drug and Alcohol Dependence, 155, 222–227. https://doi.org/10.1016/j.drugalcdep.2015.07.013 Diamond, L. M. (2016). Sexual fluidity in males and females. Current Sexual Health Reports, 8, 249–256. https://doi.org/10.1007/ s11930-016-0092-z
Morshed, M. G., & Singh, A. E. (2015). Recent trends in the serologic diagnosis of syphilis. Clinical and Vaccine Immunology, 22(2), 137– 147. https://doi.org/10.1128/CV1.00681-14 New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections & New York City STD Prevention Training Center. (2019). The diagnosis, management and prevention of syphilis: An update and review. Retrieved from https://www.nycptc. org/x/Syphilis_Monograph_2019_NYC_PTC_NYC_DOHMH.pdf Pope, V. (2004). Use of treponemal tests to screen for syphilis. Retrieved Q6 from https://www.medscape.com/viewarticle/489478_2 Ratnam, S. (2005). The laboratory diagnosis of syphilis. Canadian Journal of Infectious Disease, 16(1), 45–51. https://doi.org/10.1155/2005/ 597580 Sena, A. C., White, B. L., & Sparling, P. F. (2010). Novel Treponema pallidum serologic tests: A paradigm shift in syphilis screening for the 21st century. Clinical Infectious Diseases, 51(6), 700–708. https:// doi.org/10.1086/655832
Harris, A., Rosenberg, A. A., & Riedel, L. M. (1946). A microflocculation test for syphilis using cardiolipin antigen: Preliminary report. Journal of Venereal Disease Information, 27, 159–172.
Slutsker, J. S., Hennessy, R. R., & Schillinger, J. A. (2018). Factors contributing to congenital syphilis cases—New York City, 2010–2016. Morbidity and Mortality Weekly Report, 67(39), 1088–1093. https:// doi.org/10.15585/mmsr.mm6739a3
Henao-Martínez, A. F., & Johnson, S. C. (2014). Diagnostic tests for syphilis: New tests and new algorithms. Neurology Clinical Practice, 4(2), 114–122. https://doi.org/10.1212/ 01.CPJ.0000435752.17621.48
Tschann, J. M., Adler, N. E., Millstein, S. G., Gurvey, J. E., & Ellen, J. M. (2002). Relative power between sexual partners and condom use among adolescents. Journal of Adolescent Health, 31(1), 17–25. https://doi.org/10.1016/S1054-139X(01)00418-9
Islam, N., & Laugen, C. (2015). Gender differences in depression and condom use among sexually active Canadians. Journal of Affective Disorders, 174, 511–515. https://doi.org/10.1016/ j.jad.2014.12.013
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Update on Syphilis for Women’s Health Nurses
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Alison O. Marshall ABSTRACT: After declining for many years, rates of syphilis in the United States are increasing. In this article, I explore possible reasons why women, and specifically pregnant women, are not getting tested properly. Lack of prenatal care, poor access to prenatal care, and improper prenatal care all have contributed to cases of congenital syphilis. Clinicians working in women’s health care can address this issue by taking accurate sexual histories, remaining open to sexual fluidity among their patients, being knowledgeable about the appropriate guidelines for testing for syphilis, and routinely offering screening to any woman at risk. Syphilis is a treatable and preventable sexually transmitted infection, and nurses, advanced practice nurses, and midwives can significantly contribute to reversing the current trend. doi: 10.1016/j.nwh.2020.01.009
Accepted January 2020
KEYWORDS: congenital syphilis, evidence-based practice, screening, sexually transmitted infection, STI, syphilis
Photo ª Christoph Burgstedt / iStockphoto.com
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fter reaching record low numbers in 2000 and 2001, the United States has seen a sharp increase in the rates of all forms of syphilis, including congenital syphilis (Bowen, Su, Torrone, Kidd, & Weinstock, 2015). Nationally, congenital syphilis rates increased 72.7% from 2012 to 2014 (Bowen et al., 2015). Women infected with syphilis during pregnancy have increased risks of miscarriage, stillbirth, and permanent fetal abnormalities (Bowen et al., 2015). This is especially troubling because syphilis and
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congenital syphilis are both completely preventable. Why now? Why are rates of syphilis rising among all groups of women but more in the U.S. West and South and among women of color? What is happening that is causing women to proceed through the entirety of a pregnancy without this infection being discovered? Herein, I explore some of the potential reasons for the syphilis surge and what nurses, advanced practice nurses, and midwives can do to improve health outcomes for women and newborns. ª 2020 AWHONN; doi: 10.1016/j.nwh.2020.01.009
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CLINICAL IMPLICATIONS n Rates of syphilis are increasing across the country, including
rates of congenital syphilis. Untreated syphilis has major health implications. n Women’s health providers, including nurses, must take accurate
and thorough sexual histories, at least once a year in nonpregnant patients and at the first prenatal visit for pregnant patients. A brief review of a woman’s sexual health thereafter in pregnancy can help providers identify changing sexual patterns. n Clinicians should refrain from making assumptions regarding
women’s sexual practices and preferences, and they should understand that more women are foregoing classic binary categorization of sexual preference. n Women’s health providers should familiarize themselves with the
syphilis testing options in their practices. n All pregnant women should have at least one syphilis screening
and should be screened more than once if sexual risk exists.
History of Testing for Syphilis Serologic testing for syphilis began in 1906, after August Paul van Wasserman and Albert Neisser determined that the blood or cerebrospinal fluid in persons infected with syphilis would react to cardiolipin extracted from bovines. This became known as the Wasserman test (Harris, Rosenberg, & Riedel, 1946). However, this test did not isolate syphilis antibodies themselves and would also react in other conditions, such as systemic lupus erythematosus (Harris et al., 1946). The Venereal Disease Research Laboratory (VDRL) refined this technology, thereby developing the first widely used screening tool for syphilis (Harris et al., 1946). Similar technology was used to develop the rapid plasma reagin (RPR). These two tests each have their own advantages: the RPR does not require use of a microscope to interpret the test result, whereas the VDRL tool does, and the VDRL has lower rates of false negative results when testing cerebrospinal fluid than the RPR (Larsen, Steiner, & Rudolph, 1995). For screening purposes, the RPR is more widely used; the result is delivered as a ratio, which can be serially tracked to show effective treatment of the disease (Morshed & Singh, 2015). Together, these two tests were the mainstay of syphilis diagnostics until the early 2000s. At that time, new tests were developed that accurately detected the presence of treponemal proteins in the blood, which are specific only to syphilis (Sena, White, & Sparling, 2010). The most commonly used treponemal tests are the Treponema pallidum particle agglutination test and the fluorescent treponemal antibody absorbed test (Henao-Martínez & Johnson, 2014). Compared with
Alison O. Marshall, MSN, RN, FNP-C, is a clinical instructor at the William F. Connell School of Nursing at Boston College in Chestnut Hill, MA, and faculty at the Sylvie Ratelle STD/HIV Prevention Center of New England in Jamaica Plain, MA. ORCID: 0000-0001-8474-1751. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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After reaching record low numbers in 2000 and 2001, the United States has seen a sharp increase in the rates of all forms of syphilis, including congenital syphilis nontreponemal tests, treponemal tests are better at identifying early cases of primary syphilis (Ratnam, 2005). However, these tests were more expensive than the VDRL and RPR, which cost between $0.18 and $0.44, whereas the fluorescent treponemal antibody absorbed test and T. pallidum particle agglutination test cost $2.13 and $2.14, respectively (Pope, 2004). Given the increased sensitivity of the treponemal tests, they were used reflexively to confirm a positive nontreponemal test result (Binnicker, Jespersen, & Rollins, 2011). Many health care practices across the country continue to use this two-step model. In 2009, a group of laboratory experts convened to review the syphilis testing algorithm. They determined that the order of syphilis testing should be reversed in some cases (Association of Public Health Laboratories, 2009). For example, in areas where syphilis rates are high and in populations with high risk for sexually transmitted infection (STI), the use of treponemal tests before nontreponemal tests improves clinical detection rates, particularly in early infection (Henao-Martínez & Johnson, 2014). Providers using this method order the treponemal test first, and if it returns a positive result, they then order the nontreponemal test, typically the RPR, to confirm infection and to track the ratio to confirm treatment success. The different tests are summarized in Table 1.
Guidelines and Legislation for Testing Although many considerations must be taken when determining which test to order first, algorithms exist to help clinicians in their clinical decision making, particularly in the case of
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TABLE 1 SYPHILIS TESTING Test Name
Type of Test
Venereal Disease Research Laboratory (VDRL)
Nontreponemal
Rapid plasma reagin (RPR)
Nontreponemal
Advantages and Disadvantages
Duration of Positive Result
Returns to negative Advantages: eventually after treatment Less expensive than treponemal tests for most individuals Validated Disadvantages: Microscope required for interpretation False negatives possible, particularly in early infection Returns to negative Advantages: eventually after treatment Less expensive than treponemal tests for most individuals Validated Reported as a ratio, which allows clinicians to confirm the effectiveness of treatment Disadvantages: False negatives possible, particularly in early infection
Treponema Treponemal pallidum particle agglutination (TP-PA)
Once positive, remains positive for an individual’s lifetime
Advantages Better early infection detection rates than nontreponemal tests Validated Disadvantages: More expensive than nontreponemal tests Cannot be used to confirm effective treatment
Fluorescent treponemal antibody absorbed (FTAABS)
Treponemal
Once positive, remains positive for an individual’s lifetime
Advantages: Better early infection detection rates than nontreponemal tests Validated Disadvantages: More expensive than nontreponemal tests Cannot be used to confirm effective treatment
Note. Sources: Centers for Disease Control and Prevention (2015a); Henao-Martínez and Johnson (2014).
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pregnant women (New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections & New York City STD Prevention Training Center, 2019). Multiple national and international guidelines advise screening women for syphilis at least once during pregnancy and repetitively if there is risk of acquisition during pregnancy (American College of Obstetricians and Gynecologists, 2017; Centers for Disease Control and Prevention [CDC], 2015b; World Health Organization, 2017). Furthermore, these guidelines have clear and specific sections that outline which factors constitute risk for multiple populations (American College of Obstetricians and Gynecologists, 2017; CDC, 2015b; World Health Organization, 2017). The CDC also provides a summary of state-specific legislation regarding syphilis screening in pregnancy for easy clinical reference (CDC, 2018a). In some cases, omitting syphilis testing for specific patient populations is illegal; however, eight states have no screening requirements at all (CDC,
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2018a). Using these clinical tools along with knowing the disease risk in a community and when during a woman’s pregnancy to test enables nurses and other clinicians to choose the most appropriate testing sequence.
More than half of all individuals diagnosed with STIs in the United States annually are younger than age 25 years
Congenital Syphilis Research has been conducted specifically regarding the increase in rates of congenital syphilis. Slutsker, Hennessy,
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and Schillinger (2018) studied cases of mother–infant dyads in which the fetus developed congenital syphilis in New York state between 2010 and 2016. A total of 578 women tested positive for syphilis while pregnant, of whom 68 progressed untreated until the time of birth, resulting in infected neonates. Of these 68 women, 50% were younger than 30 years, 78% were women of color, and 55% were born outside of the United States (Slutsker et al., 2018). Twenty-two infected women (32% of 68) had negative screening test results in the first trimester and later contracted syphilis during pregnancy (Slutsker et al., 2018). Fifteen of these 22 women were not tested again during pregnancy, even though 12 of them had significant risk factors for acquiring syphilis (Slutsker et al., 2018). Another major issue for almost 30% of the 68 women was absent or late entry into prenatal care. Social determinants of health, such as substance misuse disorder, lack of health insurance, mental health disorders, and recent arrival into the country, were identified in 70% of these cases as reasons why women did not seek out or obtain prenatal care (Slutsker et al., 2018). Perhaps more concerning, four of the women received timely prenatal care but were never screened for syphilis (Slutsker et al., 2018). It is unclear why these women were not screened. One possibility to consider, however, was the insurance status of these women. Although the study did not examine this specifically, it should be considered that some of the women were uninsured. Similarly, women who are underinsured may have some coverage for prenatal care, but their plans may not offer full coverage for all prenatal tests. In the long term, the costs associated with progressive syphilis are much greater than the cost of the screening test, yet, in the short term, avoiding screening may have been the only viable choice. One woman, who went to the emergency department with symptoms of syphilis in her third trimester, was not tested and subsequently went on to have a stillbirth (Slutsker et al., 2018).
Implications for Nursing Practice What can women’s health nurses, advanced practice nurses, midwives, and other clinicians glean from this small study? The time used to screen women is indeed time well spent. Herein, I provide recommendations for steps clinicians can take in their provision of health care to women at risk for syphilis.
Engage With the Woman A thorough sexual history (see Box 1) should be taken at the first prenatal visit, and sexual health should be briefly discussed at subsequent prenatal visits to assess for changing sexual patterns and changes in risk.
Know the Community Know the clinical population in your area. Do you work in an area with high rates of syphilis? Be aware of the common risk factors. By paying special attention to the epidemiology of this
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BOX 1 CONSIDERATIONS FOR TAKING A THOROUGH SEXUAL HISTORY Do not assume that a woman is monogamous during her pregnancy. Do not assume that the biological father of the fetus is her current partner. Do not assume strict heterosexuality simply because she is pregnant. Always ask about her ability to make her own sexual decisions, and screen for intimate partner violence/ coercion. Know the signs of sex trafficking and screen women appropriately during prenatal care. current spread, we can accurately target areas where infection rates are high and ensure that providers are practicing the most current and guideline-driven health care.
Look for Risk Factors The results of the study by Slutsker et al. (2018) showed several risk factors, including social determinants of health. However, other factors exist that increase the risk of STIs in women. Women who engage in risky sexual behaviors before they are pregnant are more likely to continue to engage in these behaviors while pregnant (CDC, 2015b, 2018b). It is ideal that women avoid the acquisition of STIs during their pregnancy, but, as clinicians, we know that this is not always possible. Talk to women nonjudgmentally and find out what life is like for them outside of the health care facility. If there is risk, these women will need more frequent STI testing throughout their pregnancies. Also, it is worth taking time to provide health education during these visits on steps women can take to protect themselves and when to seek care should concerns arise. Another group of women who likely need education about syphilis are those younger than 25 years, regardless of sexual identity. Young people continue to make up a disproportionate number of persons contracting STIs. More than half of all individuals diagnosed with STIs in the United States annually are younger than 25 years (CDC, 2015b). Adolescents experience many firsts during their adolescent years, including first sexual experiences and first time negotiating decisions regarding alcohol consumption. Sexual decision making that comes after the consumption of alcohol has been shown to lower condom use rates during intercourse, even if, when sober, women note that condom use is important to provide protection against STIs (Davis et al., 2014). A large metaanalysis from 2015 showed that young women who drink alcohol are more likely to experience depression, anxiety, and other psychological disorders than men (de Haan, Egberts, & Heerdink, 2015). Depression is directly related to lower condom use in both sexes, but more so in women (Islam & Laugen, 2015).
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barriers to engaging in the safest sex. This could be another reason why rates of syphilis are increasing. As providers, we need to increase the odds that transmission does not occur. Takeaway points are summarized in Box 2.
Gender and Sexual Expression
Nurses and other clinicians can provide optimal care by ensuring that an accurate and detailed sexual history is taken at least once for nonpregnant women and at prenatal visits based on risk for those who are pregnant As many clinicians are aware, body image pressure to look a specific way exists across many cultures, not only in the United States. A large, longitudinal study done in Australia noted that girls as young as 14 years expressed feelings of body dissatisfaction and that these views persisted over time (Craike et al., 2016). Women who are dissatisfied with their bodies or body image are also less likely to ask their partners to wear condoms during sex (Blashill & Safren, 2015). Women are also less likely to require condom use if they do not hold the sexual power in a relationship. Researchers examined both same-sex and different-sex couples and found that women were less likely to hold the sexual power in different-sex couples (Tschann, Adler, Millstein, Gurvey, & Ellen, 2002). Thus, if a woman is in the less powerful position, she has less ability to negotiate condom use. Taken together, these results indicate that young women who are experimenting with alcohol and sex and have concerns about their body image and sense of self may have
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One final factor to consider regarding syphilis in your clinical practice is the moving and changing landscape of gender and sexual expression. Since 2000, there has been a significant body of work examining the concept of sexual fluidity, much of which built on the work of L. M. Diamond in Utah. Being sexually interested in men and women is becoming more common, as is declining to define one’s own sexuality in a binary manner of heterosexual or homosexual (Diamond, 2016). Of sexually fluid respondents in a study conducted by Katz-Wise and Hyde (2015), sexually fluid female respondents were more likely to report positive feelings regarding having sex with partners of both sexes and believing that sexual desires could change over time. For younger female patients, this idea may be more ingrained and accepted than for members of previous generations. The need for a gender-nonspecific sexual history becomes very important in these instances. We know that clients, as humans, want to tell health care providers what they think we want to hear. Using biased language that assumes that a client has partners only of the opposite sex or that the gender of a client’s current partner is the same as that of all of her previous partners results in missed opportunities to identify a woman’s STI risk. Every client deserves a lifelong sexual history conversation, at least once, to establish patterns over time. For example, screening for syphilis is not as important for women who are exclusively with women as it is for those who are engaging in penile/vaginal intercourse, yet every person deserves good education about how STIs are transmitted and acquired, as well as what factors make transmission/acquisition more likely. Boxing individuals into a sexual category and never allowing for change from this category places clinicians and their clients in a place where opportunities to uncover STIs are missed.
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BOX 2 CONSIDERATIONS FOR ADDRESSING RISK FACTORS FOR STI INFECTION If you provide health care to young women, it is imperative to ask them about their sense of self. Do they like the way they look? Are they confident making decisions about what happens to their body? Is the opinion or viewpoint of a partner more important than what she thinks herself? Ask about alcohol, drugs, and sex. Are they interested in experimenting with anything in these three categories? Have they already? What do they know about alcohol use? Are they aware that they may think and act differently when under the influence of drugs and alcohol? Are they aware that the same holds true for their partners? Ask very specifically if a woman believes she can ask her partner(s) to use condoms. Assess for barriers to condom use during this conversation, understanding that, for adolescents, barriers may need only to be perceived, not actualized, to influence behavior. It is also a good idea to have condoms to give away in a discreet fashion. At my clinic in South Boston, we place 10 condoms in a brown paper bag and wrap it so it is a small, flat package without markings. It is similarly sized to a smartphone, and a woman can put one or two packages in her bag or pocket as she leaves without calling attention to the package contents. Other clinics I’ve visited leave an open jar or basket of condoms in every exam room. This allows the patient to privately take some while waiting for the provider to enter the room. Finally, regardless of their ability to adopt condom use immediately, educate clients about sexually transmitted infections, not forgetting to mention syphilis. Because numbers were historically low in the early 2000s, many individuals may not realize that they are at risk for this particular infection. Unlike viral STIs, syphilis in all stages and during pregnancy can be cured with a common antibiotic and will not recur unless re-exposure occurs (CDC, 2015b). Women should seek care often if concerned about exposure to STIs. Many public and private insurance plans cover the cost of STI testing if needed, even multiple times a year, based on risk.
Conclusion Rates of syphilis are increasing across the country. Although it is an infection that we can easily test for and treat if discovered, left undiscovered, it can contribute to the morbidity and mortality of women and carry lifelong health implications for a newborn. Nurses and other clinicians can provide optimal care by ensuring that an accurate and detailed sexual history is taken at least once for nonpregnant women and at prenatal visits based on risk for those who are pregnant, especially if their social situation is not stable. Clinicians should also know their laboratory protocol—is the RPR or VDRL still considered the first-line test, or has the shift to the treponemal tests been made? What tests are covered by the public insurance options in your community? How about the private insurance plans? As mentioned earlier, many insurance options will cover a syphilis screening up to once a year in those without risk and multiple times a year for those with risk. If you have taken a good history that outlines a patient’s risk for acquiring an STI, there should be no problem getting the tests covered. If for any reason the test is not covered, find out how much a woman could pay out of pocket for the test or if there are any programs in your community that could help defray the cost of testing. Most important, partner with women to keep them safe and well. As nurses, advanced practice nurses, and midwives, we have the education and training to approach each client as a whole person. Doing so for sexual health allows us to create alliances with our clients that they may not have in any other relationship. Keeping women engaged with us is the key to long-term advances in their health and wellness. Even if you don’t always know what to do, ensuring that you are their ally
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will promote better health outcomes. Ask often, test when needed, and educate always. Let’s make these syphilis rates return to where they should be—zero! NWH
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