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The US is enduring a sharp spike in cases of babies born with syphilis, an illness that not only threatens infants’ health, but also shows that the system providing healthcare for pregnant women is fracturing.
Congenital syphilis has risen to its highest rate in 30 years, according to a recent report by the US Centers for Disease Control and Prevention, reaching 3,761 cases in 2022. That might sound like a minuscule portion of US births, which exceed 3.6 million per year. But because the illness is so serious in newborns, health authorities are ringing the alarm. Those cases included 231 lost pregnancies and 51 infant deaths. Surviving babies are at risk of blindness, deafness, and developmental delays.
Pinpointing the immediate cause of the illness is not complicated: Pregnant women with syphilis did not receive the single shot of penicillin that would have cured their own infections and kept them from passing it on to their children. But the reasons why that intervention didn’t take place varied: Some women were never tested, some didn’t receive the appropriate treatment, and some weren’t treated at all. Two out of five women whose children were born with syphilis last year never received any prenatal care.
The single biggest risk for having a child with syphilis, according to the report, was simply living in a county where syphilis rates are high—and that covers 38 percent of them in the US, and 72 percent of the national population. “I think that many jurisdictions are aware of their problems with increases in syphilis and congenital syphilis,” says Robert McDonald, a physician and medical officer in the CDC’s Division of STD Prevention, and the report’s lead author. “But I am not sure that providers and the public at large fully understand how much of a problem syphilis has become.”
To understand the striking rise in congenital infections—by tenfold between 2012 and 2022, and a third just between 2021 and 2022—it helps to recognize several trends. The first is that the epidemiology of the disease has been changing. What had been mostly an infection of men who have sex with men has been crossing into heterosexual men as well, and from them into women. Because the sore that indicates infection may be less noticeable in women, they may not know they are infected—a problem, because untreated syphilis can lead to grave health problems even outside of pregnancy.
The second trend is the dismantling of the national infrastructure that once worked to control sexually transmitted infections. As the National Academies of Sciences, Engineering, and Medicine documented in 2021, the CDC’s budget for STD control—much of which is sent to states—has been cut 40 percent since 2003. And the third is the patchwork nature of American healthcare, in which many people don’t have a single medical professional overseeing all their needs. Women who rely on publicly-funded medicine have even less continuity.
Those trends have combined to affect “women from vulnerable communities … usually women who are Black or brown, with lower financial means, lack of access to transportation, [and] inability to take time off work,” says Natasha Bagdasarian, a physician and the chief medical executive for the state of Michigan, which had 38 congenital cases of the disease in 2022. “What we're seeing when we review cases of congenital syphilis are individuals who, rather than have a single healthcare provider through their pregnancy, have gone to urgent cares or ERs, or gone to one physician and then switched to another because of life circumstances.”
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A study presented on Sunday, November 12, at the American Public Health Association’s annual meeting in Atlanta demonstrated who the most vulnerable women are, using one state’s hospital discharge data, which contains diagnosis codes for insurance billing. In Mississippi, 367 infants were born with congenital syphilis between 2016 and 2022, according to Manuela Staneva, an epidemiologist with the Mississippi State Department of Health; there were 10 cases in 2016 and 110 in 2022, a 1,000 percent increase. Among the mothers, 93 percent were on Medicaid, indicating they were poor; 58 percent lived in rural areas; and 71 percent were Black—a signal of the unequal influence of race on health, because the state population is only about 38 percent African American. (This data was also published recently in Emerging Infectious Diseases.)
“This is the price paid by babies,” Staneva said in her presentation. “It’s pretty disturbing.”
At this point, most states require women who make it to doctors’ offices during their pregnancies to be tested for syphilis at least once. Some jurisdictions, including New York, require a third-trimester test in addition to a first-trimester one. Mississippi instituted first and third trimester screening last March, just a few months after its health department, including Staneva, began investigating congenital syphilis there. Still, a handful of states have no such laws.
Yet mandating testing hasn’t solved the nationwide problem because the process of syphilis testing doesn’t match the reality of the lives of marginalized women. The gold standard for detection is to perform a blood test, send it off to a lab, receive the results several days later, and then bring the woman back to her healthcare provider for the shot. That is more follow-up than some women can navigate. “There are times when we test somebody and it can take more than a week for the results to come back,” says McDonald, who sees patients in Atlanta. “It's really hard to track people down again: They've forgotten about their concerns, other things have come up in their lives, sometimes their phones get disconnected.”
Aside from condoms, there are few effective options for protecting women; the “morning after pill” that is now recommended for men who have sex with men has not worked well in cisgender women. The best solution, so far, is to make tests—including fast but less-precise rapid tests—a routine procedure at any point where a pregnant woman might be medically checked: not just ERs and urgent care centers, but syringe exchange programs and jails. That’s not easy, Bagdasarian points out: “Emergency department physicians are used to taking care of the issue that is brought to them, and this would be very outside routine care.”
To solve that mismatch, her department is negotiating an arrangement in which ERs in Michigan would offer syphilis tests and the health department would pick up from there, making sure that the test result is logged, and that the woman is notified and gets transportation to wherever she can receive the shot. In New York City, which had 24 cases of congenital syphilis in 2021 compared with 17 two years earlier, the Department of Hospitals and Mental Health assigns social workers to any pregnant woman diagnosed with syphilis to ensure she gets followup, and links her to public and private maternal health programs as well.
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Some state efforts have demonstrated that it is possible to make a difference in congenital syphilis. Louisiana, which five years ago had one of the highest rates in the US, instituted a suite of programs, including conducting a medical review of every case and notifying healthcare providers when some other entity had diagnosed a case they’d missed. But its health department also created simple innovations that nevertheless required regulatory changes and extra staff time. They began shipping the single-shot penicillin regimen to community health centers, and created teams of nurses and infectious disease investigators who visit women’s homes to administer it.
In 2022, 115 babies with congenital syphilis were born in Louisiana—but the state health department estimates that it prevented 209 cases, the number of pregnant women diagnosed with syphilis whom it was able to reach and treat in time.
“Everyone's goal is to make treatment available and have it happen as quickly as possible,” says Samuel Burgess, director of the state’s STD/HIV/Hepatitis program. “The less amount of hours and effort that we have to spend—trying to follow up with people, seeing if they made it to the doctor, following up with doctors’ offices to see if they got treatment documented—the better.”
