April 15, 2022
For a decade, the number of babies born with syphilis in the U.S. has surged, undeterred. Data released Tuesday by the Centers for Disease Control and Prevention shows just how dire the outbreak has become.
In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.
About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness and organ damage.
For public health officials, the situation is all the more heartbreaking, considering that congenital syphilis rates reached near-historic modern lows from 2000 to 2012 amid ambitious prevention and education efforts. By 2020, following a sharp erosion in funding and attention, the nationwide case rate was more than seven times that of 2012.
"The really depressing thing about it is we had this thing virtually eradicated back in the year 2000," said William Andrews, a public information officer for Oklahoma's sexual health and harm reduction service. "Now it's back with a vengeance. We are really trying to get the message out that sexual health is health. It's nothing to be ashamed of."
Even as caseloads soar, the CDC budget for sexually transmitted disease prevention — the primary funding source for most public health departments — has been largely stagnant for two decades, its purchasing power dragged even lower by inflation.
Tuesday's CDC report on STD trends provides official data on congenital syphilis cases for 2020, as well as preliminary case counts for 2021 that are expected to increase. CDC data shows that congenital syphilis rates in 2020 continued to climb in already overwhelmed states like Texas, California and Nevada and that the disease is now present in almost every state in the nation. All but three states — Maine, New Hampshire and Vermont — reported congenital syphilis cases in 2020.
From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.
Preventing congenital syphilis — the term used when syphilis is transferred to a fetus in utero — is from a medical standpoint exceedingly simple: If a pregnant woman is diagnosed at least a month before giving birth, just a few shots of penicillin have a near-perfect cure rate for mother and baby. But funding cuts and competing priorities in the nation's fragmented public health care system have vastly narrowed access to such services.
The reasons pregnant people with syphilis go undiagnosed or untreated vary geographically, according to data collected by states and analyzed by the CDC.
In Western states, the largest share of cases involve women who have received little to no prenatal care and aren't tested for syphilis until they give birth. Many have substance use disorders, primarily related to methamphetamines. "They've felt a lot of judgment and stigma by the medical community," said Dr. Stephanie Pierce, a maternal fetal medicine specialist at the University of Oklahoma who runs a clinic for women with high-risk pregnancies.
In Southern states, a CDC study of 2018 data found that the largest share of congenital syphilis cases were among women who had been tested and diagnosed but hadn't received treatment. That year, among Black moms who gave birth to a baby with syphilis, 37% had not been treated adequately even though they'd received a timely diagnosis. Among white moms, that number was 24%. Long-standing racism in medical care, poverty, transportation issues, poorly funded public health departments and crowded clinics whose employees are too overworked to follow up with patients all contribute to the problem, according to infectious disease experts.
Doctors are also noticing a growing number of women who are treated for syphilis but reinfected during pregnancy. Amid rising cases and stagnant resources, some states have focused disease investigations on pregnant women of childbearing age; they can no longer prioritize treating sexual partners who are also infected.
Dr. Eric McGrath, a pediatric infectious disease specialist at Wayne State University School of Medicine in Detroit, said that he'd seen several newborns in recent years whose mothers had been treated for syphilis but then were re-exposed during pregnancy by partners who hadn't been treated.
Treating a newborn baby for syphilis isn't trivial. Penicillin carries little risk, but delivering it to a baby often involves a lumbar puncture and other painful procedures. And treatment typically means keeping the baby in the hospital for 10 days, interrupting an important time for family bonding.
McGrath has seen a couple of babies in his career who weren't diagnosed or treated at birth and later came to him with full-blown syphilis complications, including full-body rashes and inflamed livers. It was an awful experience he doesn't want to repeat. The preferred course, he said, is to spare the baby the ordeal and treat parents early in the pregnancy.
But in some places, providers aren't routinely testing for syphilis. Although most states mandate testing at some point during pregnancy, as of last year just 14 required it for everyone in the third trimester. The CDC recommends third-trimester testing in areas with high rates of syphilis, a growing share of the U.S.
After Arizona declared a statewide outbreak in 2018, state health officials wanted to know whether widespread testing in the third trimester could have prevented infections. Looking at 18 months of data, analysts found that nearly three-quarters of the more than 200 pregnant women diagnosed with syphilis in 2017 and the first half of 2018 got treatment. That left 57 babies born with syphilis, nine of whom died. The analysts estimated that a third of the infections could have been prevented with testing in the third trimester.
Based on the numbers they saw in those 18 months, officials estimated that screening all women on Medicaid in the third trimester would cost the state $113,300 annually, and that treating all cases of syphilis that screening would catch could be done for just $113. Factoring in the hospitalization costs for infected infants, the officials concluded the additional testing would save the state money.
And yet prevention money has been hard to come by. Taking inflation into account, CDC prevention funding for STDs has fallen 41% since 2003, according to an analysis by the National Coalition of STD Directors. That's even as cases have risen, leaving public health departments saddled with more work and far less money.
Janine Waters, STD program manager for the state of New Mexico, has watched the unraveling. When Waters started her career more than 20 years ago, she and her colleagues followed up on every case of chlamydia, gonorrhea and syphilis reported, not only making sure that people got treatment but also getting in touch with their sexual partners, with the aim of stopping the spread of infection. In a 2019 interview with KHN, she said her team was struggling to keep up with syphilis alone, even as they registered with dread congenital syphilis cases surging in neighboring Texas and Arizona.
By 2020, New Mexico had the highest rate of congenital syphilis in the country.
The COVID-19 pandemic drained the remaining resources. Half of health departments across the country discontinued STD fieldwork altogether, diverting their resources to COVID. In California, which for years has struggled with high rates of congenital syphilis, three-quarters of local health departments dispatched more than half of their STD staffers to work on COVID.
As the pandemic ebbs — at least in the short term — many public health departments are turning their attention back to syphilis and other diseases. And they are doing it with reinforcements. Although the Biden administration's proposed STD prevention budget for 2023 remains flat, the American Rescue Plan Act included $200 million to help health departments boost contact tracing and surveillance for COVID and other infectious diseases. Many departments are funneling that money toward STDs.
The money is an infusion that state health officials say will make a difference. But when taking inflation into account, it essentially brings STD prevention funding back to what it was in 2003, said Stephanie Arnold Pang of the National Coalition of STD Directors. And the American Rescue Plan money doesn't cover some aspects of STD prevention, including clinical services.
The coalition wants to revive dedicated STD clinics, where people can drop in for testing and treatment at little to no cost. Advocates say that would fill a void that has plagued treatment efforts since public clinics closed en masse in the wake of the 2008 recession.
Texas, battling its own pervasive outbreak, will use its share of American Rescue Plan money to fill 94 new positions focused on various aspects of STD prevention. Those hires will bolster a range of measures the state put in place before the pandemic, including an updated data system to track infections, review boards in major cities that examine what went wrong for every case of congenital syphilis, and a requirement that providers test for syphilis during the third trimester of pregnancy. The suite of interventions seems to be working, but it could be a while before cases go down, said Amy Carter, the state's congenital syphilis coordinator.
"The growth didn't happen overnight," Carter said. "So our prevention efforts aren't going to have a direct impact overnight either."