Brief Rise in Congenital Syphilis Cases Concerns State Legislators

Researchers at the Centers for Disease Control and Prevention are sounding the alarm on rising rates of syphilis, especially among pregnant women. 

Syphilis is an infectious disease normally spread through sexual contact that can lead to serious complications if left untreated. Congenital syphilis, which occurs when syphilis infection is passed from a mother to fetus during pregnancy, is especially concerning. Congenital syphilis can cause miscarriage, stillbirth or early infant death, and infected infants can experience lifelong physical and neurologic problems.  

New cases of syphilis have increased 79% since 2018 and new cases of congenital syphilis have increased 183% in that time frame according to the CDC. Notably, CDC reports congenital syphilis has increased 755% since 2012.  

Although congenital syphilis is a national concern, CDC researchers identified geographic and racial differences in the number of new cases and barriers to effective screening and treatment. Of new cases in 2018, 52.5% occurred in the South and 35.6% in the West, compared to 7.9% in the Midwest and 4.1% the Northeast. Further, 39.1% of new cases occurred among Black mothers, 31.5% occurred among Hispanic mothers, and 21.9% occurred among white mothers, with 7.6% of new cases occurring among other races/ethnicities.  

Lack of timely testing and adequate treatment during pregnancy contributed to 88% of cases of congenital syphilis according to 2022 CDC reporting. Testing and treatment gaps were present in the majority of cases across all races, ethnicities and U.S. Census Bureau regions. Nearly 9 in 10 cases of syphilis in newborns could have been prevented with adequate testing and treatment.  

While the national uptick and disparities are alarming, syphilis is preventable and easily treatable if detected early. The timely identification and treatment of syphilis in pregnant women can prevent transmission to the baby. Congenital syphilis prevention involves timely identification and treatment of pregnant women with syphilis, as well as traditional syphilis prevention strategies among women and their partners.  

The CDC recommends universal syphilis testing at the first prenatal visit—most, but not all, states have statutes or regulations to require this screening. The CDC also recommends universal screening early in the third trimester and at delivery for areas with high prevalence of syphilis. Several states have taken further measures to require syphilis screening more frequently than in the first trimester. In 2022, more than 37% of infants with congenital syphilis were born to people who had received no prenatal care, making screening outside of traditional prenatal care an important potential way to prevent congenital syphilis. Oklahoma, for example, requires health care providers attending pregnant women to follow CDC guidance on testing frequency during pregnancy. 

Texas requires syphilis testing in the first and third trimesters of pregnancy. In 2019, the state further expanded testing requirements to include syphilis testing at delivery and created the Newborn Screening Preservation Account to help cover the costs of expanded testing. The legislation also requires the Texas Department of Health and Human Services to publish a biannual report on congenital syphilis. Authors of the most recent report state that “it may take up to five years to clinically identify any true increases or decreases” in the state’s congenital syphilis cases as a result of expanded screening.  

Michigan also recently updated its screening laws, requiring third trimester testing for syphilis as well as HIV and hepatitis B. Nevada updated its syphilis screening statutes to include both the first and third trimester. Georgia requires health care providers to test all pregnant women for HIV and syphilis at the first prenatal visit, at 28 to 32 weeks' gestation, and at delivery. Oklahoma requires health care providers attending to pregnant women to follow CDC guidance on testing frequency during pregnancy.  

Improvement in syphilis screening for pregnant women can protect babies from this debilitating and sometimes deadly disease. To see your state’s current screening laws, the CDC maintains a list of state statutes related to screening during pregnancy for syphilis.  

As part of the American Rescue Plan Act, between 2021 and 2023, $200 million were allocated annually to states through the Disease Intervention Specialists Workforce Development Funding provision, administered through the CDC. The purpose of this funding was to enhance public health workforce and infrastructure to address rising rates of syphilis and other sexually transmitted infections.  

Through DISWDF, several states have recorded successes in their efforts to reduce transmission of syphilis and test and treat pregnant women. Iowa doubled its disease intervention specialist capacity and saw an 18% decline in new syphilis cases in its most populous county. Additionally, a newly created sexually transmitted infections epidemiologist position helped enhance and refine syphilis outbreak detection, especially in two counties with high Native American populations, and helped foster a partnership with the Great Plains Tribal Epidemiology Center. 

Massachusetts improved its surveillance and reporting systems and improved linkages to care, ultimately leading to faster diagnosis and treatment. Colorado increased testing of pregnant women for syphilis by 58%, crediting increased staffing. Montana used funding to increase the travel budget available to existing staff, allowing for technical assistance and training opportunities across the large and geographically diverse rural state.  

Other state policy options include:  

• Fetal Infant Morbidity and Mortality Review Boards: FIMR is a multidisciplinary, community-based, action-oriented process through which public health leaders can come to better understand fetal and infant deaths and missed opportunities for prevention. A 2017 study showed that Louisiana congenital syphilis case review boards identified specific missed opportunities, including inadequate and delayed screening and treatment and used that information to educate care providers and improve service delivery. Through statute, California requires counties that have five or more infant deaths in a single year and a higher infant death rate than the state average for two consecutive years to participate in the FIMR Process.  

• Address Substance Misuse in Pregnancy: Rates of substance use during pregnancy have increased over the last 10 years, with substance use as a patient-level barrier to syphilis screening during pregnancy. Indiana passed a law prohibiting health care professionals from sharing drug screening information of a pregnant patient with law enforcement agencies without the patient’s consent or a court order.