The increase in sexually transmitted infections in the United States has generated a particularly tragic situation: in 2022, there were more than 3,700 cases of congenital syphilis, approximately eleven times more than a decade ago, according to data published on November 7 by the Centers for Disease Control and Prevention (CDC).
Syphilis during pregnancy can cause miscarriages and stillbirths, and surviving babies may suffer from blindness, deafness, or severe developmental delays. In 2022, the disease caused 231 stillbirths and 51 infant deaths.
According to the agency, almost 90 percent of new cases could have been prevented with timely testing and treatment. “Syphilis in babies continues to increase and the situation is serious,” said Laura Bachmann, medical director of the agency’s sexually transmitted disease prevention division, in an interview. “We have to do things differently.” “A single case is indicative of a failure in the public health infrastructure, and now we have 3,700 cases,” she added.
The system fails in multiple ways. The mothers of nearly 38 percent of the 3,700 babies did not receive prenatal care. Of the women who attended at least one prenatal appointment, 30 percent never underwent syphilis testing or did so too late. And among those who tested positive for syphilis, 88 percent received inadequate, undocumented, or no treatment.
Public health departments used to have teams of disease intervention specialists and nurses who ensured that pregnant women were tested and treated—even if that meant going to their homes to administer injections—and tracked all their contacts, said Thomas Dobbs, dean of the John D. Bower School of Population Health at the University of Mississippi.
But those departments have been dismantled over the years. “You can’t dismantle the public health infrastructure and expect negative things not to happen,” Dobbs said. “I can’t believe we’re in this state of health in such a rich country as ours.”
On November 7, the National Coalition of STD Directors called the increase in congenital syphilis a “shameful crisis,” accelerated by funding cuts and bureaucratic obstacles, and demanded $1 billion in federal funding and a syphilis response coordinator at the White House to curb the surge.
In the United States, syphilis was nearly eliminated about twenty years ago, but it increased by 74 percent, to 177,000 cases, between 2017 and 2021. Other STDs are also on the rise: in 2021, there were 1.6 million cases of chlamydia and over 700,000 cases of gonorrhea.
The numbers were increasing even before the pandemic, but in recent years, a decline in routine preventive care, a shift to more telehealth appointments for prenatal care, and reduced clinic hours may have worsened the situation.
The reasons for the increase in congenital syphilis varied slightly by region. Lack of testing or testing too late accounted for 56 percent of cases in the western region, and inadequate treatment accounted for 55 percent of cases in the southern region.
In Mississippi, people sometimes have to drive several hours to find an obstetrician or lack transportation, work, or family situations that facilitate seeking healthcare. “If you’re in a state where poverty is endemic, like Mississippi, where the working class struggles to get by, everything becomes an obstacle,” Dobbs explained.
Throughout the country, approximately one in five pregnant women diagnosed with syphilis did not receive prenatal care, suggesting that they were tested in another setting, such as an emergency room, prison, or needle exchange program.
This proportion was higher in Michigan, where about one-third of all STDs were diagnosed in emergency departments. “More and more people are receiving what should be routine preventive healthcare in emergency departments,” said Natasha Bagdasarian, the state’s medical director.
Since emergency room doctors do not have a long-term relationship with patients, “it’s easier for people to go unnoticed,” she noted.
Syphilis was mainly resurging among men who have sex with men, but in recent years it has also increased in heterosexual circles. Among women of reproductive age, syphilis diagnoses increased by 17.2 percent between 2021 and 2022, according to the new report.
But public health departments are not as well connected with heterosexual women as they are with community organizations that help gay and bisexual men with HIV and STD prevention.
“There is a lack of awareness among women of childbearing age that syphilis still exists and can affect them and what the consequences might be for the child they are carrying,” Bagdasarian said.
Pregnant women may not have symptoms or realize that they need to be tested or treated.
The CDC recommends requesting a syphilis test at the first prenatal visit or as soon as pregnancy is confirmed. For women at high risk of infection due to their place of residence, substance use, or sexual behavior, the CDC recommends two additional tests: at 28 weeks of gestation and at the time of delivery.
Many states go further and require all pregnant women to undergo screening tests for infection at all three time points. This is partly because women who test negative early in pregnancy may contract syphilis later on.
They may even be “at higher risk because they no longer use protection like condoms,” said Melanie Taylor, a medical epidemiologist at the Maricopa County Department of Public Health in Arizona.
Prevention efforts need to go beyond prenatal care for pregnant women and reach their partners, as well as other heterosexual men and women, Taylor said.
Maricopa County has some of the highest rates of congenital syphilis in the country. Almost half of the county’s women who had babies with syphilis did not receive prenatal care in 2022. Drug use, particularly fentanyl and methamphetamine, as well as recent periods of incarceration, are major contributors, Taylor explained.
The county works with hospitals and community organizations to reach out to women who use drugs, who have recently been incarcerated, who have unstable housing situations, or who are otherwise at high risk of contracting syphilis.
The public STD clinic, which serves up to 35,000 people per year, charges a flat fee of $20 to evaluate and treat patients and their partners and waives the fee if cost is a barrier.
Confirming a syphilis diagnosis usually requires two positive tests, but the CDC recommends that healthcare providers treat women who may not return after receiving a positive result.
Early cases of syphilis in a pregnant woman can be treated with a single injection of an antibiotic called benzathine penicillin G, marketed as Bicillin by Pfizer. In June, Pfizer warned the Food and Drug Administration that Bicillin was in short supply, in part due to the sharp increase in demand for syphilis treatments.
The CDC has urged healthcare professionals to prioritize the use of Bicillin in cases of pregnant women with syphilis. The only alternative is doxycycline, which must be taken twice daily for several weeks and is not recommended for pregnant women.
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