Erica Hensley
Skyrocketing rates of syphilis — a disease that once seemed to be on the wane — is imperiling the lives of thousands of newborns as mothers who have gone untreated pass the sexually transmitted ailment on to their babies, data from the U.S. Centers for Disease Control shows. If it isn’t diagnosed and treated promptly, syphilis can cause seizures, heart failure and permanent organ damage in children and adults.
The statistics are harrowing: By the end of 2022, syphilis hit a 72-year high, with 205,000 total cases. More than 3,500 of those were in babies — up from just 300 a decade prior, according to CDC statistics. Of those cases nearly 10% resulted in stillbirth or infant death.
Indeed, not since 1950 have more pregnant women and babies been sick with syphilis — a perfect storm of slashed public health funding and the spread of so-called maternity-care deserts, defined as counties lacking maternity-care hospitals or obstetric providers. By one estimate, some 6.9 million U.S. women live in places with no or low access to maternity care.
The tragedy of this is that syphilis, when caught early, is curable with modern-day forms of penicillin — although long-undiagnosed and asymptomatic cases can pose a more complicated treatment regimen. “There really should never be a baby born with congenital syphilis. It’s so treatable,” says Dr. Kimberly Stanford, an emergency medicine specialist whose University of Chicago Medicine screening program diagnoses at least two dozen syphilis patients in her ER every month. Almost half of the patients screened are women of reproductive age — about 1,000 of whom were pregnant last year.
From Stanford’s perspective, lack of access to prenatal care is clearly a main driver of the increase in syphilis cases. “In a society like ours, all pregnant women should have access to that care,” she says. “A preventable condition like this that causes such severe consequences in infants, I think it really gets people’s attention, as it should.”
The surge is wreaking havoc across the country. Houston declared it an official outbreak last July, unlocking funds to support a city-wide response.
Since 2020, California health officials have sent increasingly urgent demands for local providers to screen, based on state law.
In 2022, syphilis in Mississippi babies jumped 1,000% from 2016, prompting state officials to mandate universal screening for pregnant people — one of the last states to do so.
But so far, these interventions haven’t curbed the spread and federal agencies have been slow to react. CDC cuts have knee-capped state contact tracing programs that were just starting to get their arms around local transmission patterns.
Nine out of ten cases of congenital syphilis, passed to babies through the womb, are preventable with adequate prenatal treatment, according to the most recent CDC data. Almost all map out multiple missed opportunities where providers could have intervened.
More than a third of the parents of babies born with syphilis weren’t tested themselves.
Of those that were, more than half never received treatment. Black and Hispanic women were least likely to receive treatment, according to the same report, creating a disproportionate syphilis burden on parents and babies of color.
Stanford understands the value of screening. As an ER physician and infectious disease researcher, she was one of the first in the country to launch a universal opt-out syphilis testing program in the University of Chicago Medical Center’s emergency department.
Many of Stanford’s pregnant patients live in under-resourced communities and don’t have regular access to care, she says, echoing national trends of declining primary care. And those are the same communities where syphilis is most predominant. “They’re coming to the ER for their care. It is absolutely the best opportunity to reach them for syphilis screening early in pregnancy,” she says. “We can and should try to fix all of the reasons why they’re here, but in the meantime, we need to understand that this is what people are doing and meet them where they are.”
MAKING A BAD PROBLEM WORSE
A long-brewing shortage of bicillin, the gold-standard penicillin shot to treat syphilis — and the only approved treatment for pregnant patients — has made treating the sometimes tricky infection even more difficult, says Dr. Irene Stafford, OBGYN at Houston’s University of Texas hospital who specializes in perinatal infectious diseases.
At least once a week, Stafford struggles to get enough penicillin for her patients. “The bicillin shortage has been a tremendous problem,” she says — causing a time-consuming dance between hospital and private pharmacies, and calling in favors from the Houston Health Department. “It’s just penicillin. But if they’re not making it at the rate that you’re consuming it, then that’s a problem.”
Pfizer, the sole manufacturer of bicillin, blames the shortage on sudden spikes in demand over the last few years. The pharmaceutical company says they’ve invested millions to ramp up production and alleviate the shortage by spring.
As early as 2017, CDC noted global shortages of bicillin. It has long-been listed as an essential medicine by the World Health Organization. The first similar list in the U.S. also listed it in 2020. The Biden administration in 2021 cited low reimbursement rates and cheap Chinese production costs as straining the bicillin supply chain .
Providers say they were caught off guard with sudden demand too, and by the time syphilis showed up in babies, it was too late.
Since 2023, regulators have urged providers to ration bicillin for pregnant patients with syphilis, and use a 14-day regimen of doxycycline — an antibiotic with antiviral properties — for everyone else. But like many drugs, doxycycline’s safety and efficacy as a bicillin substitute for pregnant women is problematic because it hasn’t been studied in pregnant patients.
“We haven’t done anybody any favors by excluding pregnant women from these trials,” Stafford says. “There are very few studies looking at alternatives.”
Taken together, the shortage has been in the making for years, yet regulators have been slow to react. It wasn’t until January that the FDA secured an alternative from France that’s currently being imported.
On a call with federal health officials, “I was begging — we’re waving our white flag here. We’re SOS,” Stafford says. “How can we say we care about equity and minority populations that are underserved? How do we say that was a straight face?”
But it’s not just the shortage — syphilis, in certain stages, can be a hard infection to diagnose and treat. More than half of Stafford’s patients are asymptomatic.
“You just kind of slowly brew a syphilis infection,” she says. “If you do have a lesion, you may think you’ve cut yourself. I’ve heard flea bites, eczema — you name it. Because it doesn’t hurt or burn, you don’t feel that bad.” And all the while, it’s transmissible.
Nationally, Stafford’s patients mirror the national demographics. Like Stanford’s Chicago patients, most are uninsured or on Medicaid, and lack regular access to care and transportation. To avoid risk of losing track of them, she needs the drug on-hand to start treatment right away.
Amid federal cuts to its state Sexually Transmitted Infections (STI) programs, much of CDC’s recent syphilis work has focused on galvanizing widespread testing among providers. But despite the recent spikes in pregnant patients and babies, the agency hasn’t updated its syphilis screening guidelines, which call for all pregnant women to be screened at their “first prenatal visit.” Adding confusion for providers, each state has different screening guidelines — calling for testing during the first trimester, all three, birth, or none at all.
But meanwhile, CDC reports reiterate that more than a third of syphilis cases among babies had parents who didn’t have access to prenatal care.
“What we need is already in the screening recommendations. CDC cannot do this alone.” says Dr. Robert McDonald, medical officer in CDC’s Division of STD Prevention. “Equitably stopping the syphilis epidemic and addressing the nation’s broader STI challenges requires a coordinated and sustained effort shared by federal leadership, state and local health departments, healthcare systems, providers, and private industry.”
HOW WE GOT HERE
Syphilis was nearing eradication in the U.S. by the end of the 1990s. Aggressive STI prevention campaigns — driven by the HIV/AIDS epidemic — coupled with federal and state funds devoted to testing and treatment tapered much of the spread.
By 2000, there were just 6,000 new cases per year, and almost no congenital syphilis.
But by 2012, syphilis started to spike again — mostly in men. Due to the successful public health campaigns the decades prior, much STI-specific funding to local health departments, especially for staffing, had waned.
“Public health systems have been neglected. The increase in STIs track with the deterioration of our infrastructure,” says Dr. Laurie Bachmann, CDC’s STI prevention branch director.
Compounded by COVID lockdowns and slashed reproductive health funding, 2020 was a tipping point for new STI infections, according to CDC.
Still, syphilis was mainly spreading among men. But federal screening and treatment guidelines never updated accordingly — instead, only recommending it for “high risk” and pregnant patients.
Providers say this outdated advice can give a false sense of reassurance to some. “If you’re having sex you’re at risk, period,” Stafford says.
When more and more cases were finally getting downstream to women, most on-hand penicillin treatments were already snapped up. By the time the FDA issued a shortage warning last June, it was too late for the more than half of providers that don’t have systematic policies for tracking shortages.
“Now that syphilis has become more common, I think it has opened people’s eyes,” says Stanford in Chicago. “We’re seeing people getting really, really sick in a way that a lot of us hadn’t ever seen because it had largely disappeared.”
Stafford agrees and says congenital syphilis is a canary in the coal mine of U.S. healthcare failures.
“Looking at this baby who is profoundly sick and seizing in the NICU, all I can think is how did we even get here? It’s a failure of our public health care system to take care of pregnant women,” she says.
That’s why both physicians are pushing ahead with universal opt-out programs — where most patients are offered testing right on the spot, but can decline — instead of waiting for impending federal guidelines. But across the country UT Houston and University of Chicago are unique — most hospitals aren’t on board, despite having similar CDC-recommended programs for HIV.
University of Chicago Medical Center ER has tested nearly 90,000 patients for syphilis since 2019. UT Houston also launched a universal opt-out rapid testing program for all patients in their prenatal clinics, coupled with on-site treatment for anybody who’s positive. As the biggest city in a state with one of the highest transmission rates, it’s the only option to stem further spread, says Stafford.
“Syphilis diagnosis is incredibly timely because if you don’t get on top of it you’re going to end up unfortunately with a sick baby,” Stafford says. “And sometimes, before they even get to the third trimester, a dead baby.”
