Notice to Readers: Recommendation Regarding Screening of Refugee Children for Treponemal Infection

In October 2004, CDC's Divisions of Sexually Transmitted Disease Prevention and Global Migration and Quarantine received reports of positive syphilis tests for refugee children who arrived in the United States from Liberia and Somalia. Infection with Treponema pallidum subsp. pallidum, T. pallidum subsp. pertenue, T. pallidum subsp. endemicum, and Treponema carateum cause syphilis, yaws, bejel/endemic syphilis, and pinta, respectively. This group of infections causes various disfiguring skin lesions and rashes; long-term infection can result in deformations of bone and nasopharyngeal tissue, aortitis, and other destructive lesions (1). Serologic tests cannot differentiate between infections caused by these treponemes; infection with any of them will cause positive results using both treponemal and nontreponemal tests routinely used for diagnosis of syphilis.

T. pallidum subsp. pallidum is the only T. pallidum subspecies present in the United States. This bacterium causes syphilis and is the only sexually acquired treponemal infection. The endemic subspecies (i.e., T. pallidum subsp. pertenue, T. pallidum subsp. endemicum, and T. carateum) are transmitted by contact with infected skin and usually are diseases of childhood (2). Countries in which T. pallidum subsp. pertenue, T. pallidum subsp. endemicum, and T. carateum are endemic include Liberia and Somalia (3). Refugees and immigrants who originate from these countries can be at risk for these infections.

CDC recommends that all children from areas where treponemes are known to be endemic be considered for screening by Rapid Plasma Reagin or Venereal Disease Research Laboratory tests at the initial health screening. If the screening test is positive (irrespective of titer), a treponemal confirmatory test (e.g., the fluorescent treponemal antibody absorbed test [FTA-ABS] or the T. pallidum particle agglutination assay [TP-PA]) should be performed. In children, treponemal infection as indicated by positive screening and confirmatory tests might be caused by 1) nonsexual exposure to a person infected with non-venereal T. pallidum subspecies, 2) congenital transmission from an infected mother (occurs only with syphilis), or 3) consensual or nonconsensual sexual exposure (occurs only with syphilis). An algorithm has been developed to assist in assessment of children from areas with endemic treponematoses with positive screening and treponemal serologic tests.* If the mother's treponemal test is negative, and she reports no history of syphilis, congenital syphilis can be excluded; therefore, testing the mother might be valuable, even if current syphilis infection is not suspected.

To assist in evaluation of refugee and immigrant children, a list of countries in which endemic treponemal infection has been reported is provided. Surveillance for treponemal infections is not performed uniformly in all countries; in areas disrupted by war or civil disturbance, surveillance might not be possible. Therefore, the list of countries where treponemes are endemic is based on data that are not recent and are inconsistently collected (3). Countries where disease caused by endemic T. pallidum subspecies has been reported include the following: Africa: Angola, Benin, Botswana, Burkina Faso, Cameroon, Central African Republic, Chad, Republic of the Congo, Cote d'Ivoire, Democratic Republic of the Congo, Ethiopia, Gabon, Ghana, Guinea, Liberia, Mali, Mauritania, Niger, Rwanda, Senegal, Somalia, South Africa, Sudan, and Togo. Middle East: Saudi Arabia. Asia: Cambodia, India, Indonesia, Pakistan, and Sri Lanka. Western Pacific: Papua New Guinea, Solomon Islands, and Vanuatu. Americas (4): Colombia, Ecuador, Haiti, Guyana, Martinique, Mexico, Surinam, and Venezuela. Europe: none.

In the United States, syphilis is a notifiable disease and should be reported to local and state health departments when diagnosed. Suspected cases of yaws or other non-venereal treponemal infections can be reported to CDC at telephone 404-639-8368.

References

1. Antal GM, Lukehart SA, Meheus AZ. The endemic treponematoses. Microbes Infect 2002;4:83--94.
2. Parish JL. Treponemal infections in the pediatric population. Clin Dermatol 2001;18:687--700.
3. Meheus A, Antal GM. The endemic treponematoses: not yet eradicated. World Health Stat Q 1992;45:228--37.
4. Hopkins DR. Yaws in the Americas, 1950--1975. J Infect Dis 1977;136:548--54.

* Available at http://www.cdc.gov/std/syphilis/treponemalalgorithm.pdf.

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Date last reviewed: 9/22/2005