Congenital Syphilis Cases Are on the Rise

Syphilis, among other sexually transmitted infections (STIs), is on the rise. Syphilis cases have increased by 52 percent since 2016 in the United States, according to 2020 surveillance data from the Centers for Disease Control and Prevention (CDC). Rates have climbed across genders and throughout the Midwest, Northeast and South.

The prevalence of congenital syphilis (CS), when the birthing parent passes syphilis to their baby during pregnancy, has climbed, too. In 2020, 2,148 cases were reported, a 254 percent increase over 2016, and a 15 percent increase since 2019. CS is life-threatening to infants and can result in miscarriage, preterm birth, stillbirths and death shortly after birth. The 2020 cases included 149 stillbirths and infant deaths.

"When caught early, syphilis can be curable," said Matt Higgins, spokesperson for STDcheck.com. "When left untreated, we're seeing the devastating effects it is having on babies."

CS is entirely preventable with proper testing and treatment; if unaddressed, its effects on infants can be lifelong.

What's driving this increase?

At one point in the United States, syphilis infections were nearly eradicated with absolution. But since the early 2000s, cases have resurfaced, likely from a combination of factors.

Data increasingly suggests a coalescing of two epidemics. The first is syphilis among heterosexual people and the second is drug use, specifically methamphetamines, injection drugs and heroin. Drug use more than doubled among heterosexuals with syphilis from 2013 to 2017, according to the CDC, which also reported that drug use has risen exponentially during the COVID-19 pandemic as people seek ways to cope with stress.

Lack of access to healthcare services, such as clinics that offer STI screening, likely exacerbated the increase in STI cases. People are also more likely to put off annual testing due to the COVID risk.

"Eighty-nine percent of our members reported a decrease in patient volume or a total number of clients served as a result of COVID-19," said Jennifer Mahn, M.P.A., director of clinical and sexual health at the National Coalition of STD Directors.

Although men who have sex with men are disproportionately affected by primary and secondary (P&S) syphilis, rates among women increased 24 percent from 2019 to 2020. The increase in P&S syphilis in women of reproductive age directly influences climbing rates of CS.

In 2019, the CDC's STD surveillance report indicated the most commonly missed congenital syphilis prevention opportunity was a lack of adequate maternal syphilis treatment despite confirmation of a timely diagnosis. The second-most commonly missed opportunity was a lack of timely prenatal care and subsequent lack of prompt syphilis testing.

Disproportionate access to testing and treatment

"We know that CS disproportionately impacts individuals who are excluded from formal institutions, such as the healthcare system, for a variety of reasons," Mahn said. "It is up to public health organizations and healthcare providers to meet these people where they are and work to develop inroads into providing them with trauma-informed, culturally humble healthcare and wraparound services."

STI statistics also indicate racial disparity. The CDC noted that in 2020, 32 percent of all chlamydia, gonorrhea and P&S syphilis cases were among non-Hispanic Black people. This group comprises only 12 percent of the U.S. population. The data indicated the greatest increases of P&S syphilis were among non-Hispanic American Indian/Alaska Native people.

One study published in 2021 in PLOS One collected data from 2018 to 2019 from Kerns County, California, which reported 17 percent of the state's CS cases. Researchers examined barriers to care for pregnant and postpartum people and their providers. The study revealed several structural barriers, including poverty and the inability to cover out-of-pocket costs and co-pays. The research also indicated it was difficult for many people to take time off work to attend doctor appointments. Stigma for using substances during pregnancy derailed many people from seeking care for fear of having their child taken away. Low sexual health literacy, lack of awareness of potential complications during pregnancy, citizen status and fear of deportation also presented barriers.

While persistent roadblocks deter people from seeking care, providers in the study also experienced low awareness of the guidelines for the treatment of syphilis during pregnancy set by the CDC and American College of Obstetricians and Gynecologists.

"Consequently, the prevailing narrative that we are helpless against CS because we can't force pregnant people to receive prenatal care is not supported by the data," Mahn explained. "We frequently hear from health departments that as they perform CS case investigations, they find that pregnant mothers did receive prenatal care in their third trimester, but that syphilis testing was not performed at these visits as recommended by CDC testing and treatment guidelines."

Low patient retention for people with social comorbidities, such as substance use, was also common. For patients in the study who did receive care, many were referred out of doctor's offices due to resource shortages in Bicillin, the recommended treatment for syphilis.

Treatment and prevention

"We need to have better prenatal screening for those that live in poverty-stricken areas to make sure expectant mothers are getting the healthcare they need and deserve," Higgins said.

Considering that data support the blending of two different epidemics—drug use and heterosexual syphilis—comprehensive care is crucial. Mahn said this care should include co-locating critical supportive services, harm-reduction services and drug treatment resources with STI testing, including syphilis testing, through point-of-care testing (results within about 30 minutes) at syringe service programs (SSPs).

She suggested outreach-based testing and treatment options that are non-clinic based, self-collection options, mobile van services and point-of-care testing. Nontraditional testing opportunities can extend to encampments of unhoused people, in-patient substance use disorder treatment facilities and SSPs.

Increased provider training is also a necessity.

"We need to ensure that for pregnant people, appropriate syphilis treatment is completed and that syphilis testing is done at the first prenatal visit and 28 weeks [third trimester]," Mahn continued.

When treated early, syphilis is simple to cure.

"The gold standard treatment of syphilis for pregnant mothers is injectable penicillin G benzathine, which is often available in sexual health clinics," Mahn said. "Frequently, medical providers will refer pregnant mothers with syphilis to a sexual health clinic for treatment that may require up to three injections of this medication; one injection per week for three consecutive weeks."

Preliminary 2021 data from the CDC indicates P&S syphilis cases continue to increase across genders and are up 6 percent in newborns. Cases of congenital syphilis are particularly heart-wrenching because they're entirely preventable with timely testing and treatment. Rising cases point out failing public health systems and highlight disparities in access to quality treatment across the board.