Resurgence of congenital syphilis signals ‘urgent need’ for testing, treatment

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Public health officials in New York are urgently promoting syphilis testing and treatment, alarmed that a preventable sexually transmitted infection once close to eradication has returned.

They are especially concerned about a resurgence of congenital syphilis, which is passed from a pregnant person to a baby. Congenital syphilis can result in miscarriage, stillbirth, prematurity and infant death, and babies born with the infection can have deformed bones, severe anemia, brain and nerve problems, and other issues.

In recent years, congenital syphilis cases have increased significantly nationwide, rising from 334 cases reported in 2012 to 3,761 in 2022, according to data from the Centers for Disease Control and Prevention. The CDC reported 231 stillbirths and 51 infant deaths in 2022.

Those outcomes are particularly distressing, experts say, because congenital syphilis is preventable and can be treated relatively easily, with a form of penicillin. But cases can emerge when pregnant people aren’t tested for syphilis at key intervals, or if they don’t have access to prenatal care.

Funding for the CDC’s prevention programs for sexually transmitted infections has been relatively flat over the past two decades, and recently, some local health departments across the country have faced steep cuts in their budgets for prevention efforts.

“We are all very concerned, as clinicians, about the increases in congenital syphilis, and syphilis in general, across the United States,” said Dr. Rodney Wright, vice chair of obstetrics at Montefiore Medical Center in the Bronx. “It’s not just a problem here in New York. It’s a problem across the entire nation.”

Congenital syphilis rates are highest in parts of the Southwest, the Midwest and the South. Native American communities have been hit particularly hard. But even in New York, which has among the lowest rates of congenital syphilis in the country, mounting cases have raised alarms.

New York is just above the national average for rates of primary and secondary syphilis — the most infectious stages of the disease — which can result in congenital cases.

Preliminary data for 2023 show about 70 congenital syphilis diagnoses in New York state, a 204% increase over the past decade, Joseph Kerwin, director of the AIDS Institute at the New York State Department of Health, said during a meeting of the New York State AIDS Advisory Council in September.

“This is the first time in this century that New York state has seen a number rise to this level,” Kerwin said of the cases.

This year, New York is on track to see at least the same number of congenital syphilis cases as last year, said Rachel Malloy, director of the Office of Sexual Health and Epidemiology at the AIDS Institute.

“Compared to the rest of the country, New York state rates are actually lower, which speaks to the magnitude of the issue, because the rates in New York state are high,” Malloy said.

Surge in Primary and Secondary Syphilis Drives Congenital Cases

When the CDC began tracking syphilis cases in the 1940s, the agency regularly recorded hundreds of thousands of total cases each year nationwide.

But by 2000, total syphilis cases had dropped to 31,618 — and just 5,979 cases of primary and secondary syphilis. That year, the rate of primary and secondary syphilis fell to its lowest point since reporting began in 1941 (2.1 cases per 100,000 people).

That data point reflected a significant achievement in the country’s fight to eliminate syphilis, which is often called “the great imitator” due to its frustratingly wide range of symptoms. At its primary stage, the infection is easy to miss, often appearing as a single, painless sore. By the secondary stage, symptoms can include a skin rash, sores, fever, muscle aches and hair loss. Left untreated, syphilis can damage the brain, heart, and other organs, and the infection can be fatal.

“We were on the verge of eliminating syphilis altogether about 20 years ago, 25 years ago,” said Preeti Pathela, executive director of the Sexually Transmitted Infections Program in the Bureau of Hepatitis, HIV, and STI at the New York City Department of Health and Mental Hygiene. “We’ve seen a rise in adult syphilis since that time.”

By 2022, the total number of syphilis cases nationwide had surged to more than 200,000. Primary and secondary syphilis cases increased to more than 59,000 (17.7 cases per 100,000 people). Over the decades, rates of primary and secondary syphilis among women have increased, a key driver of congenital cases.

In New York City, the Health Department reported a 35% increase from 2021 to 2022 in primary and secondary syphilis cases among women — primarily among Black and Latina women — but little change among men. The agency reported 19 cases of congenital syphilis across the city in 2022 — and 16 cases in just the first half of 2023, according to the agency’s preliminary data.

“It is clear that there’s been a dramatic increase here,” Pathela said.

Earlier this year, the Health Department released an advisory for health care providers warning of “alarming rates” of primary and secondary syphilis and congenital syphilis in the city, “signaling an urgent need for increased screening and appropriate treatment.”

“There has been, for a long time, a real misconception about risk, both in the community, but also among health care providers, that you don’t need to screen or test if someone doesn’t report individual risk behaviors, or sexual behaviors that might put them at risk of acquiring syphilis,” Pathela said.

For many sexually active people, living in a community with a high rate of syphilis poses a significant risk factor for acquiring the infection, she said. In 2022, the Bronx had the highest rate of primary and secondary syphilis among women ages 15 to 44 (22.5 cases per 100,000 people), followed by Brooklyn (11.4 cases per 100,000 people).

“The disproportionate burden of primary and secondary syphilis among Black and Latina and young females often reflects the impact of structural racism,” Pathela added. “That prevents many people of color from accessing care, and especially affordable care.”

Experts Urge Expanding Syphilis Testing, Treatment

The United States has reduced surges of congenital syphilis cases before — most recently in the 1990s — and experts say it can be done again.

The solution is clear, they say: closing gaps in testing and treatment. In 2022, lack of timely testing and adequate treatment contributed to almost 90% of congenital syphilis cases across the country, according to the CDC.

“The biggest part of addressing this issue is making sure people are tested and treated,” Wright, the Montefiore physician, said. “I think there may have been a bit of complacency about syphilis for a number of years.”

In New York, a new state requirement went into effect this spring which mandates a syphilis test during the third trimester of pregnancy, in addition to screening at first exam and delivery. (New York City has required third trimester syphilis testing since 2019.)

A state strategic planning group is poised to release a series of recommendations to guide New York’s efforts to reduce and eliminate congenital syphilis. And state and city officials have ramped up warnings to health providers, who may have little firsthand experience with congenital syphilis.

Over the course of his 25 year career, Wright said, congenital syphilis cases were rare — but have increased in recent years.

During the September AIDS Advisory Council meeting, he described a recent case that resulted in a neonatal death. The pregnant person, he said, had tested negative at the beginning of pregnancy but had not reached the point of third trimester testing.

The late identification of syphilis during pregnancy has been a major missed opportunity in nationwide and state prevention efforts, officials say.

Malloy, of the AIDS Institute, stressed the importance of determining the pregnancy status of any individual of reproductive capacity diagnosed with syphilis — and expanding access to prenatal care for pregnant people.

Disrupting networks of transmission is key, too. While reviewing congenital syphilis cases in the city and state, Wright noticed that in some cases, partners who were not tested or declined treatment reinfected the pregnant person.

“That drives home the point of partner notification and encouraging partner testing and treatment,” he said.

The state employs contact tracers and case investigators who follow up with people newly diagnosed with STIs and maintains a call line for providers working on congenital syphilis cases, Malloy noted.

New York City’s STI Disease Intervention Specialists work to find people who need STI treatment and help notify partners. In 2022, they conducted more than 14,000 case investigations based on positive syphilis laboratory tests. The Health Department also identified 196 cases of congenital syphilis, estimating that it averted 91% of potential cases.

“I am hopeful,” Malloy said. “We have seen syphilis and congenital syphilis go down before. I want to see it go down, and I want to see it stay down. And I do think that if we act now and act together, we will get those numbers down.”

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