July 23, 2024
Dear Colleague:
I am writing to share an update on the national shortage of Penicillin G benzathine (Bicillin L-A®), as well as updates on syphilis trends and clinical manifestations in Virginia.
The Centers for Disease Control and Prevention shared an update from Pfizer on June 10, 2024, noting that the manufacturer has available supply of 2.4 million Units/4 milliliter Bicillin L-A®. In light of this update, please treat all patients with Bicillin L-A,® in keeping with CDC guidance. If you are still unable to access Bicillin L-A, from your wholesaler or the manufacturer, please refer patients to their local health department for treatment. Alternative treatment options are also described in my letter from June 2023.
Data from 2023 reflect that syphilis continues to present a growing concern in Virginia. Compared to 2022, cases of early syphilis increased 16%, and there was a 30% increase in syphilis cases of late or unknown duration. These data, preliminary data from 2024, and healthcare provider resources are all available on our syphilis webpage. As syphilis cases have increased, the number of cases with ocular, otic and/or neurological manifestations have also increased. In 2023 in Virginia there were 65 syphilis cases with ocular, 15 with otic and 66 with neurological clinical manifestations. These counts likely reflect underreporting of these manifestations.
Virginia’s congenital syphilis cases also continued to increase in 2023, with a total of 21 cases diagnosed. In 2022, 20 cases were diagnosed. To date in 2024, 12 cases have been diagnosed putting Virginia on pace to again exceed the previous year’s total.
About 11% of all patients diagnosed with early syphilis self-reported use of opioids, methamphetamine, or cocaine. About half of patients (48%) who gave birth to an infant with congenital syphilis reported using one of these substances.
Clinicians and allied health professionals represent our first line of defense in detecting syphilis. Please help us identify and reduce the spread of syphilis in Virginia.
- Conduct a full sexual health history for all patients.
- Screen for syphilis in all patients aged 15-44 years who are sexually active and living in a county with high incidence of syphilis, in keeping with CDC recommendations to prevent cases of congenital syphilis. For all other counties, continue to assess risk factors to recommend testing. Test all symptomatic patients for syphilis, regardless of their risk factors or where they live.
- In keeping with updated recommendations from the American College of Obstetricians and Gynecologists (ACOG), serologically screen all pregnant persons at their first prenatal care visit, followed by universal rescreening early in the third trimester (28-32 weeks) and again at delivery, regardless of risk.
- Order both treponemal and nontreponemal serologic tests to detect active syphilis infection (ex: reflex RPR and TPPA, or EIA reflex to RPR reflex to TPPA). The results of these tests can be used in combination with signs and symptoms in the last 12 months to differentiate between early or late syphilis infection. Ordering only one of these tests may delay identification and treatment of an active infection.
- Stage cases of syphilis and consider syphilis for your differential diagnosis, as it can mimic many other conditions. Syphilis has four stages: primary, secondary, latent, and tertiary. Each stage has different signs and symptoms. The earlier stages are considered the most infectious. Ocular, otic and neurological manifestations of syphilis can occur at any stage.
- Everyone who tests positive for syphilis should also receive an HIV test unless their HIV positive status is already documented. All syphilis patients who are HIV negative should be offered Pre-Exposure Prophylaxis for HIV (PrEP).
- Consider prescribing Doxycycline as post-exposure prophylaxis (DoxyPEP) for syphilis for patients who are clinically indicated.
Thank you for your continued partnership in sexually transmitted infection prevention.
Sincerely,
Karen Shelton, MD
State Health Commissioner