Babies have it tough enough these days, what with having to compete with TikTok and Instagram for attention from their caregivers and the near certainty of catastrophic global chaos in their lifetimes resulting from climate change, H5N1 bird flu, or artificial intelligence gone rogue. The last thing that they need is syphilis. But here we are…again.
In October of 2021, I wrote about how cases of syphilis had been steadily increasing since a nadir in 2000 and a significant shift in the affected populations:
Cases of syphilis crept up slightly in 2001 and a trend of steady yearly increases in new infections has continued ever since. In 2019, the most recent year with complete and official data, almost 39,000 cases of primary and secondary syphilis were reported to the CDC. Since case counts began to increase in 2001, the majority of cases have been diagnosed in men, in particular men who have sex with men. Over the past few years, however, cases in men who have sex with men have leveled off at around 55-60% of total male cases, and significant increases are occurring in heterosexual men and women. Rates of syphilis have also increased across the United States and are no longer relegated to the South and a few large cities in other regions.
Not surprisingly, as cases of syphilis have increased in women there has been an increase in the incidence of babies infected during pregnancy. After a few years of stability, 2013 saw an increase in congenital syphilis with 9.2 cases for every 100,000 live births. Every year since 2012 has been worse than the year before. In 2019, there were 1,870 cases reported or 48.5 per 100,000 live births, which was about 40% more than in 2018, and an increase of about 400% from 2012. Not only are cases increasing in number, but they are more distributed across the country, with 43 states and the District of Columbia reporting at least once case of congenital syphilis in 2019.
https://sciencebasedmedicine.org/cases-of-newborn-syphilis-are-increasing-at-an-alarming-rate/
This trend continued the following year, which I wrote about in April of 2022:
Primary and secondary syphilis, which are the stages when the infection is easily spread from person to person through intimate contact, increased by about 7% in 2020 with 41,655 reported cases. Congenital syphilis, which puts children at risk for debilitating sequelae and even death, increased by 15% with 2,148 cases and 149 deaths, continuing the alarming trend I discussed in that October post.
https://sciencebasedmedicine.org/new-cdc-data-confirms-continued-rise-in-sexually-transmitted-diseases/
Cases of syphilis, in adults and newborns, have continued to increase. In 2021, the number of primary and secondary cases reported to the CDC increased by 30% to 53,767. Rates were higher in all age groups, in both men and women, and in all regions of the United States. Syphilis in all women increased by 55% (200% since 2017), and 52% when focusing on women between the ages of 15 and 44 years. To make this concerning trend even more clear, the number of states reporting more than 100 cases of syphilis in women of reproductive age increased from 3 in 2012 to 29 in 2021.
More younger women with syphilis, and continued disparities in healthcare access, unsurprisingly continued to result in more cases of congenital infection. There were 2,855 cases reported in 2021, an increase of 30% compared to the previous year, and 219% compared to 2017. 220 of these cases resulted in either stillbirth or infant death. 46 states as well as the District of Columbia reported at least one case of congenital syphilis.
But wait, there’s more.
In 2022, reported cases of primary and secondary syphilis increased another 9% to 59,016. Rates in women of reproductive age increased in 35 states and 17% overall. Syphilis diagnosed in newborns increased 30%, with 3,755 cases reported to the CDC, which was the most since 1991, and which included 282 stillbirths and infant deaths.
We are still months away from the publication of 2023 syphilis data, but it is hard to imagine that it will be good or even improved. In November, when 2022 data was being finalized, the CDC and the American Academy of Pediatrics appropriately raised the alarm and began calling for action, both pointing out that the vast majority of cases of congenital syphilis were preventable:
https://www.cdc.gov/media/releases/2023/s1107-newborn-syphilis.html
- Almost 9 in 10 cases of newborn syphilis in 2022 might have been prevented with timely testing and treatment during pregnancy.
- More than half were among people who tested positive for syphilis during pregnancy but did not receive adequate or timely treatment.
- Nearly 40 percent were among mothers who were not in prenatal care.
One way to address the rising rates of syphilis in pregnant women and the increased risk of congenital syphilis would be to reverse centuries of systemic racism and to do away with all disparities in healthcare experienced by women across all racial, ethic, and socioeconomic groups. Universal healthcare and better prevention and treatment of substance use disorder would also be nice. While we are coming together as a country to begin working on that, another approach would be to increase testing.
For decades, screening of pregnant women for syphilis has been a standard part of the first prenatal visit. Repeat testing later in pregnancy, typically at around the 28th week of gestation and again at the time of delivery, has been recommended for patients at increased risk of exposure to syphilis. Though it has depended on the state, as laws vary, and the particular provider, many women have been tested at 28 weeks regardless of risk factors. The screening test at the time of delivery, except for those high risk patients, is not generally a common practice.
In response to the rising rates of syphilis in younger women who are not always checking those historical high risk boxes, the American College of Obstetrics and Gynecology issued new recommendations last month:
According to the new ACOG Practice Advisory, obstetrician–gynecologists and other obstetric care professionals should screen all pregnant individuals serologically for syphilis at the first prenatal care visit, followed by universal rescreening during the third trimester and again at birth. This is a change from previous guidance, which recommended risk-based testing in the third trimester only for individuals living in communities with high rates of syphilis and for those who have been at risk of syphilis acquisition during pregnancy.
https://www.acog.org/news/news-releases/2024/04/acog-recommends-obstetrician-gynecologists-increase-syphilis-screening-for-pregnant-individuals
40% of congenital syphilis cases are diagnosed in infants born to mothers who, for a variety of reasons, did not receive prenatal care. So the above recommendation is not going to prevent all cases since in requires early and consistent visits to an obstetrician, family doctor, or certified midwife. The CDC is calling for syphilis screening and treatment during pregnancy whenever the opportunity arises for women who have not yet, and may not ever, establish prenatal care. This includes settings such as emergency departments, jail intake, syringe service programs, and mother and child health programs.
More screening is clearly necessary to help reduce the disease burden in women who may become or who already are pregnant. But just as important is treatment and further testing once syphilis is diagnosed. Immediate treatment at the time of diagnosis, usually with an intramuscular dose of penicillin, is key. Unfortunately, there have been significant issues with shortages of this medication that are expected to continue for months. Oh yeah, we should fix that too.