In a recent study published in the journal Dr Morbidity and Mortality Weekly Report, The researchers analyzed data from the United States (US) Centers for Disease Control and Prevention’s (CDC) National Notifiable Disease Surveillance System (NNDSS) on congenital syphilis cases across the country. Their findings showed that lack of testing and appropriate treatment was responsible for nearly 90% of congenital syphilis in 2022, resulting in 231 stillbirths and 51 infant deaths. A comparison with the 2021 report shows a 31.7% increase in the number of patients in just one year. Improved prenatal care, timely diagnosis, and effective clinical intervention can help prevent disease and reverse this alarming trend.
Study: Vital signs: missed opportunities to prevent congenital syphilis — United States, 2022. Image credit: Peddalanka Ramesh Babu/Shutterstock
Congenital syphilis and its associated risks
Syphilis is a sexually transmitted disease (STD) caused by the syphilis bacteria. Treponema pallidum. It is usually painless, with symptoms including genital, rectal, and oral sores. Based on the progression of the disease, syphilis infection is classified into four main stages – primary, secondary, latent and tertiary. With adequate medication, usually antibiotics, syphilis is a curable condition, although damage can cause permanent scarring as the disease progresses.
Congenital syphilis involves the transmission of syphilis from an infected mother to her child during pregnancy or delivery. Given the underdeveloped immune system of fetuses and newborns, the effects of syphilis are significantly more severe than in adults, often resulting in stillbirth, abortion, or infant mortality in the first few days of life. Even for children who survive infection, the risk of lifelong blindness, hearing loss, developmental delays, and skeletal abnormalities is high.
Alarmingly, while other STDs, including human immunodeficiency virus (HIV) and hepatitis B, are declining in the United States (US), there is a 755% increase in reported congenital syphilis from 2012 to 2021. This trend illustrates a strong correlation with syphilis infections among women, which increased by 676% over the same period. Observational reports suggest a geographic and racial disparity in syphilis prevalence, which may explain the increase in congenital syphilis despite CDC recommendations for syphilis screening at the first prenatal care visit.
“CDC recommends screening at 28 weeks’ gestation and delivery for women who 1) live in communities with high rates of syphilis, 2) are at high risk for acquiring syphilis during pregnancy (eg, substance use or a new sexual partner), or 3) tested earlier in pregnancy. Not done.”
To reduce mortality and morbidity from these incurable conditions, it is essential to verify and recognize disease prevalence disparities and to take measures to prevent lost opportunities (under- or delayed diagnosis and treatment).
About the study
Data for this study were obtained from CDC’s National Notifiable Diseases Surveillance System (NNDSS) and congenital syphilis records from all 50 US states, territories, and the District of Columbia. Cases of congenital syphilis were classified into one of six categories based on the potential for missed prevention opportunities. These include: 1. No documented testing/untimely testing, 2. No treatment or undocumented treatment, 3. Late detection, 4. Inadequate treatment, 5. Congenital syphilis despite adequate testing and treatment, and 6. Lack of data.
Timely testing was defined as testing more than 30 days before delivery. The study cohort included all women aged 15 to 44 years, and demographic and geographic data were obtained from the US Population Bureau.
Study results
CDC NNDSS data revealed a total of 3,761 cases of congenital syphilis in 2022. Of these, 231 (6%) were stillbirths and 51 (1%) were neonatal deaths. These findings equate to a 31.7% increase in congenital syphilis cases compared to 2021. This corresponds to a 17.2% increase in syphilis cases among women aged 15 to 44 and a 10-fold increase over the previous 10 years.
Statistical analysis showed that lack or untimely testing accounted for 36.8% of all congenital syphilis cases (N = 1,385), unconfirmed or no treatment in 11.2% (N = 423), and inadequate treatment in 39.7% (N = 1,494). One hundred nine-seven (5.2%) cases were diagnosed within 30 days of delivery. Surprisingly, despite clinically documented adequate treatment, 130 newborns were reported to have syphilis (3.5%).
Analyzes of variance revealed that the West, Northeast, and Midwest regions showed the highest concentrations of non- or untimed tests (56.2%, 50.0%, and 40.4%). Alarmingly, the region has the highest concentration of female syphilis cases for 2022 in the Midwest. White Americans (40.8%) depicted a much lower prevalence of congenital syphilis than non-Hispanic American Indians or Alaska Natives (47.4%) and Pacific Islanders. Inadequate treatment despite accurate and timely diagnosis was most prevalent among Blacks (39.2%) and Latinos (47.4%).
Conclusion
The current study investigates the factors responsible for the rising rate of congenital syphilis in America. Their findings suggest that the increasing number of syphilis cases among American women aged 15 to 44, combined with a lack of timely testing and/or adequate treatment, is the underlying factor behind these observations.
“The rate of congenital syphilis is increasing rapidly in the United States and is at its highest level in at least 30 years. Barriers to preventing congenital syphilis are multifaceted, at the patient level, such as substance use and insurance status, and at the system level, including structural disparities, limited access to health care, and drug shortages. Addressing patient- and system-level barriers to testing, treatment, and access to care can help prevent congenital syphilis. Improvements in timely testing and appropriate treatment of syphilis through appropriate local and national strategies will help control the congenital syphilis epidemic in the United States.”