Skip Navigation LinksCDPH-Updates-Syphilis-Screening-Recommendations California Department of Public Health (CDPH) Updates Syphilis Screening Recommendations

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GAVIN NEWSOM
Governor

State of Californiaā€”Health and Human Services Agency
California Department of Public Health


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TO: Healthcare Providers
California Department of Public Health (CDPH) Updates Syphilis Screening Recommendations
10/14/2024



ā€‹Key Messā€‹ages  

  • California is issuing updated syphilis serologic screening recommendations in response to rising syphilis and congenital syphilis (CS) rates in the state. These recommendations are applicable statewide, regardless of local case rates. 
  • All sexually active persons 15-44 years old, regardless of gender identity or sexual orientation, should now be screened for syphilis at least once in their lifetime. Following the initial screen, CDPH recommends that syphilis screening be offered annually.  

  • Syphilis testing should be included whenever a person of any age is tested for HIV or other sexually transmitted infections, including mpox.  

  • All pregnant persons should now be screened for syphilis three times: (1) at confirmation of pregnancy or first prenatal encounter, (2) early in the third trimester (at approximately 28 weeks gestation or as soon as possible thereafter), and (3) at delivery.  

  • All persons 15-44 years old who enter a correctional facility should ideally be screened for syphilis ā€‹ā€‹ā€‹at intake.   

  • Emergency departments and hospital-affiliated urgent care clinics should screen all pregnant persons for syphilis prior to discharge if syphilis test results are not available for the current pregnancy.  

  • CDPH encourages health care providers to empirically treat for syphilis while awaiting confirmatory testing, if clinically indicated, among persons who have preliminary positive treponemal or non-treponemal test results -- particularly if the likelihood of successful patient follow-up is uncertain. 


ā€‹Table 1: Crosswalk comparing prior and updated CDPH syphilis screā€‹ening recommendations 

Population or Setting 

Former CDPH Recommendations  

Updated CDPH Recommendations (2024)  

Seā€‹xually active people  

All sexually active people who could ā€‹become pregnant should receive at least one lifetime screen for syphilis, with additional screening for those at increased risk.   

 

 

 

 

INCLUSIVE OF ALL GENDERS AND SEXUAL Oā€‹RIENTATIONS: 

All sexually active persons 15-44 years old should be screened for syphilis at least once in their lifetime and be offered screening annually thereafter. More frequent screening should be considered for sexually active adults and adolescents of any age at increased risk of syphilis infection. 

During other STI screeniā€‹ng 


All sexually active people who could become pregnant should be screened for syphilis at the time of each HIV test. 

Syphilis testing should be included whenever a person of any age is tested for HIV or other sexually transmitted infections, including mpox.   

Pregnaā€‹nt persons  


All pregnant persons should be screened for syphilis at least twice during pregnancy: once at either confirmation of pregnancy or at the first prenatal encounter (ideally during the first trimester) ā€“ and again during the third trimester (ideally between 28-32 weeks gestation), regardless of whether such testing was performed or offered during the first two trimesters.  

Patients should be screened for syphilis at delivery except those at low risk who have a documented negative screen in the third trimester.

All pregnant persons, regardless of risk behaviors, should be screened for syphilis three times:  ā€‹

  1. Once at confirmation of pregnancy or at the firsā€‹t prenatal encounter (ideally in the first trimester), 

  1. Early in the third trimester (at approximately 28 weeks gestation or as soon as possible thereafter), and 

  1. Again at deliveā€‹ry. 


Correctional facilities


All peā€‹ople who are or could become pregnant entering an adult correctional facility located in aā€Ælocal health jurisdiction with high-CS morbidity should be screened for syphilis at intake, or asā€Æclose to intake as feasible.ā€Æ 

All persons 15-44 year old who enter a correctional facility should ideally be screened for syphilis at intake.ā€ÆIf not completed at intake, syphilis testing should be done as close to intake as possible or included as part of the initial medical examination/health appraisal. 

Emergency departments & hospital-affiliaā€‹ted urgent care clinics  


Emergency department (ED) providers in local health jurisdictions with high-CS morbidity should consider confirming the syphilis status of all pregnant patients prior to discharge, eiā€‹ther via documented test results in pregnancy, or a syphilis test in the ED if documentation is unavailable. 

REGARDLESS ā€‹OF LOCAL CS RATES: 

Emergency departments and hospital-affiliated urgent care clinics should screen all pregnant persons for syphilis prior to discharge if syphilis test results are not available for the current pregnancy.  

ā€‹Backgrā€‹ound  

In 2020, the California Department of Public Health (CDPH) Sexually Transmitted Diseases (STD) Control Branch released Expanded Syphilis Screening Recommendations for the Prevention of Congenital Syphilis (CS) (PDF)[1ā€‹ā€‹ā€‹ā€‹]ā€‹ā€‹ā€‹ā€‹ to enable more timely identification of new syphilis infections in people who are or could become pregnant. Despite these efforts, syphilis rates in adultsā€‹ā€‹/adolescents and CS rose by 131 and 125 percent, respectively, from 2020 through 2022. CDPH Sā€‹TD Control Branch is thus releasing updated serologic screening guidelines to mitigate the ongoing syphilis and CS epidemics.  

The purpose of this letter is to inform clinicians in California of updated syphilis serologic screening recommendations for pregnant and non-pregnant persons. Recommendations now apply statewide, regardless of local syphilis ā€‹or CS case rates, and include people of all genders and sexual orientations.

Recomā€‹mendations  

  1. All sexually active persons 15-44 years old, regardless of gender identity or sexual orientation, should now be screened for syphilis at least once in their lifetime. Following the initial screen, CDPH recommends that syphilis screening be offered annually to all sexually active people 15-44 years old. Moreā€‹ frequent screening should be considered for sexually ā€‹active adults and adolescents of any age at increased risk[iā€‹ā€‹] of syphilis infection.  

  2. Syphilis testing should be included whenever a person of any age is tested for HIV or other sexually transmitted infections, including mpox.

  3. All pregnant persons, regardless of risk behaviors, should be screā€‹ened for syphilis three times:  ā€‹

    1. Once at confirmation of pregnancy or at the first prenatal encounter (ideally in the first trimester), 

    2. Early in the third trimester (at approximately 28 weeks gestation or as soon as possible thereafter), and 

    3. Again at delivery[iiā€‹ā€‹ā€‹ā€‹ā€‹]. 

  4. ā€‹All persons 15-44 years old who enter a correctional facility should ideally be screened for syphilisā€‹ at intake. If not completed at intake, syphilis screening should be done as close to intake as possible or included as part of the initial medical examination/health appraisal. 

  5. Emergencā€‹y departments and hospital-affiliated urgent care clinics should screen all pregnant persons for syphilis prior to discharge if syphilis test results are not available for the current pregnancy.   ā€‹

Rationale

Recommendations #1 and #2: CDPH first recommends all sexually active persons 15-44 years old ā€“ regardless of sex listed at birth, gender identity, or sexual orientation ā€“ receive at least one lifetime screen for syphilis and be offered screening annually thereafter. This change aligns with a recent U.S. Centers for Disease Control and Prevention (CDC) recommendation to offer syphilis screening to all sexually active persons aged 15-44 years old in counties with a primary and secondary syphilis rate among women 15-44 years old that is greater than 4.6/100,000 population (CDC ā€‹MMWR[2ā€‹ā€‹ā€‹ā€‹][3ā€‹ā€‹ā€‹ā€‹ā€‹]) ā€“ a threshold derived from Healthy People 20ā€‹30 (HP 2030) objectives[4ā€‹ā€‹ā€‹ā€‹ā€‹ā€‹]. Although CDC does not delineate a screening frequency, given Californiaā€™s high rates of syphilis and the fact that most individuals remain sexually active throughout their lifetime, CDPH believes offering annual screening will identify syphilis infections and control the epidemic.  

In California, the cumulative incidence of primary and secondary syphilis among women 15-44 years old (at 20.7/100,000 in 2022) far exceeds the HP 2030 threshold.  This HP 2030 threshold is also exceeded in 48 of the stateā€™s 61 local health jurisdictions (with these 48 jurisdictions collectively encompassing 97.7% of Californiaā€™s male and female populations 15-44 years old in 2022), further supporting statewide implementation of at least one-time syphilis screening among all sexually active people 15-44 years old.  

The expansion of syphilis screening to a minimum of one lifetime screen for sexually active people will also remove any requirement for patients to disclose or for clinicians to assess potentially stigmatizing sexual health risk factors and behaviors to determine eligibility for initial syphilis screening. Syphilis testing should also be included whenever a person of any age is tested for HIV or any other sexually transmitted infection (including mpox), given overlapping risk factors for these infections.  

Of note, the recommendation for a minimum of one lifetime screening for syphilis is inclusive of males aged 15-44, regardless of the genders of their sex partners. Current CDC guidelines recommend screening asymptomatic men who have sex with women (MSW) for syphilis only if certain risk factors are present, including age less than 29 years old. However, in California from 2021-2023 the incidence of total syphilis among MSW was higher among men 30-34 and 35-39 years old (99.6 and 90.4/100,000 respectively) than it was among people younger than 29 years old (25ā€“29-year-olds: 83.2/100,000; 20ā€“24-year-olds: 45.5/100,000; 15-19 year olds: 12.2/100,000). During this same time, MSW 25-39 years old also had an incidence of syphilis that surpassed the cumulative incidence among the total population of men who have sex with men of any age (MSM) (73.8/100,000) ā€“ a population that, regardless of age, is currently recommended to receive more frequent screening (at least annually) per current California and CDC screening guidelines. In 2022, the rate of total syphilis among women 15-44 years old was 110.6/100,000 people, higher than the rates of total syphilis among MSW or MSM. Hence, performing at least one lifetime syphilis screening for MSW 15-44 years old, and offering annual screening thereafter, are data-driven approaches to the prevention and control of syphilis. CDPH also anticipates that screening MSW for syphilis has the potential to reduce syphilis transmission to people who are or could become pregnant. 

This guidance regarding at least one lifetime syphilis screening for people aged 15-44 years old extends to non-binary populations, transgender women (TGW), transgender men (TGM), and other gender identities. While estimates of the rate of syphilis in these populations are difficult to determine because of limited population estimates, in 2022,  the most recent year for which data were available, the rates of total early syphilis in transgender men and women were 29.2 and 423.2 cases per 100,000 people, with the rate of total early syphilis among TGW being 5.26 times the rate of cisgender men and the rate in TGM 1.5 times that of cisgender women. CDC recommends for trans/gender diverse individuals to consider screening at least annually based on reported sexual behaviors and exposure.  

Following the initial screen, CDPH recommends that syphilis screening be offered annually to all sexually active people 15-44 years old. Offering annual screening is not a requireā€‹ment to test but allows for a recurring discussion around syphilis screening between health care providers and patients, thereby facilitating access to screening when desired. Patients who are at lower risk of syphilis exposures may be more likely to opt out of annual screening, thereby increasing the positive predictive value of the screening tests when performed. This approach is likely to: (1) diagnose syphilis infections that would not have otherwise been identified, and (2) allow providers to identify syphilis more effectively when 15ā€“44-year-olds present for care, since people in this age range are less likely to access care than their older counterparts. 

Recommendation #3: For all pregnant persons, regardless of risk behaviors, CDPH now recommends screening for syphilis three times ā€“ once at confirmation of pregnancy or at the first prenatal encounter (ideally during the 1st trimester), early in the third trimester (at approximately 28 weeks gestation or as soon as possible thereafter), and again at delivery. This change to universal three-time screening in pregnancy is consistent with new recommendations recently put forth in April 2024 by the Americaā€‹ā€‹n College of Obstetricians and Gynecologists (ACOG)[5ā€‹ā€‹] and is a practice already implemented in multiple other states (including but not limited to Alabama, Arizona, Georgia, New Jersey, North Carolina, and Texas), some of which had lower rates of CS in 2022 than California.   

In 2022, over 98% of pregnancies in California were in local health jurisdictions that would have been screened for syphilis at delivery based on the previous 2020 syphilis screening guidelines. The purpose of changing to universal at-delivery screening is to simplify implementation since providers may not always know the syphilis rates in the counties where their patients (or their partners) live, thus making testing routine rather than risk-based. The goals of these updated pregnancy screening include: (1) detecting CS cases that may otherwise be missed, (2) providing prompt treatment, and (3) averting potential CS sequelae. Similar to CDC recoā€‹ā€‹mmendations[6ā€‹ā€‹ā€‹ā€‹], CDPH continues to recommend that third trimester syphilis screening be done early in the third trimester ā€“ at approximately 28 weeks gestation or as soon as possible thereafter. Since syphilis treatment among pregnant persons must begin at least 30 days prior to delivery to prevent CS, screening as early as possible in the third trimester increases the likelihood of timely diagnosis and treatment to effectively prevent CS.

Recommendations #4 and #5: Finally, CDPH recommends dedicated syphilis screening in correctional facilities, emergency departments, and hospital-affiliated urgent care clinics ā€“ regardless of local CS rates ā€“ because these facilities serve as vital touchpoints for patients who may not otherwise have regular access to healthcare.   

In correctional settings, CDPH now recommends that all persons 15-44 years old should ideally be screened for syphilis at intake. If not completed at intake, syphilis screening should be done as close to intake as possible or included as part of the initial medical examination/health appraisal. This builds on the previous CDPH screening recommendation (which focused on incarcerated persons who are or may become pregnant) and reflects the new recommendation to offer annual screening for all sexually active persons 15-44 years old. This new recommendation also prioritizes screening in a population that can experience barriers to routine preventive care.   ā€‹

In emergency departments and hospital-affiliated urgent care clinics, CDPH now recommends screening all pregnant persons for syphilis prior to discharge if syphilis test results are not available for the current pregnancy. Inadequate screening is the most frequently identified missed opportunity for CS prevention in pregnant persons (CDC MMWR[2ā€‹ā€‹]); emergency departments and urgent care clinics may be the only place where pregnant persons with otherwise limited healthcare access encounter the medical system. From 2020 to 2023, 288 (24 percent) of 1204 interviewed pregnant people with syphilis in California reported accessing healthcare in emergency departments during their pregnancy, underscoring the fact that emergency departments and hospital-affiliated urgent care clinics can be a crucial safety net for equitable syphilis diagnosis, treatment, and linkage to care.   

Additional notes on syphilis screening: Opt-out testing and use of rapid tests (PDF) ā€‹[7ā€‹ā€‹ā€‹ā€‹ā€‹] may increase screening uptake, and either the traditional or reverse sequence screening algorithm (PDF) [8ā€‹] can be used. Both algorithms have upsides and downsides: the traditional algorithm may be less sensitive in detecting early or late latent syphilis, while the reverse sequence algorithm may have more false positives in populations with lower prevalence of syphilis [9ā€‹ā€‹ā€‹ā€‹ā€‹].  Regardless of screening algorithm selected, CDPH encourages health care providers to empirically treat for syphilis while awaiting confirmatory testing, if clinically indicated, among persons with preliminary positive treponemal or non-treponemal test results -- particularly if the likelihood of successful patient follow-up is uncertain.  

Conclusion: CDPH appreciates your attention to these further expanded California syphilis screening recommendations as health care providers and public health practitioners work together to stem the syphilis and CS epidemics in our state. Clinicians should otherwise continue to adhere to all CDPH sexually transmitted infection (STI), human immunodeficiency virus (HIV), and hepatitis C virus screeningā€‹ guidelines[10ā€‹ā€‹ā€‹ā€‹].   ā€‹

References  

[1ā€‹]ā€‹ CDPH STD Control Branch. Expanded Syphilis Screening Recommendations for the Prevention of Congenital Syphilis (PDF). Accessed May 10th 2024.  

[2ā€‹ā€‹] McDonald et al. Vital Signs: Missed Opportunities for Prevention Congenital Syphilis ā€“ United States, 2022. MMWR November 17, 2023 / 72(46);1269ā€“1274. Accessed May 10, 2024.  

[3ā€‹ā€‹] CDC County Level Syphilis Rates to Direct Screening Efforts. Accessed June 17, 2024 

[4ā€‹ā€‹] US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030: Reduce the Syphilis Rate in Females ā€“ STI-03. Accessed May 10, 2024.  

[5ā€‹ā€‹] American College of Obstetricians and Gynecologists. Practice Advisory: Screening for Syphilis in Pregnancy. April 2024. Accessed May 10, 2024.  

[6ā€‹ā€‹] CDC. Screening Recommendations and Considerations Referenced in the Treatment Guidelines and Original Sources. Accessed May 20, 2024.  

[7ā€‹ā€‹] National Syphilis and Congenital Syphilis Federal Task Force. Considerations for Implementation of Point of Care (POC) Tests for Syphilis (PDF). Accessed June 14, 2024. 

[8ā€‹ā€‹] California Prevention Training Center at the University of California San Francisco. Clinical Interpretation of Syphilis Screening Algorithms (PDF). Accessed June 6, 2024. 

[9ā€‹ā€‹] Papp et al. CDC Laboratory Recommendations for Syphilis Testing, United States, 2024. MMWR Recomm Rep. 2024 Feb 8;73(1):1-32. Accessed July 11, 2024.  

[10ā€‹ā€‹] CDPH STD Control Branch. California STI Screening Recommendations. Accessed May 10, 2024.  


[iā€‹]Individuals at increased risk for syphilis include men who have sex with men, persons with HIV or on HIV pre-exposure prophylaxis, pregnant people with late or limited prenatal care, and people experiencing homelessness or unstable housing, methamphetamine use, incarceration (within past year), or with a new/recent STI diagnosis. 

[iiā€‹ā€‹] California Health and Safety Code 120685(a) requires ā€œevery licensed health care professional engaged in providing prenatal care or attending a birthing patient at the time of deliveryā€ to provide syphilis screening as outlined in the most recent CDPH guidelines.ā€‹ā€‹