The rise in sexually transmitted infections in the United States has taken a particularly tragic turn: More than 3,700 cases of congenital syphilis were reported in 2022, roughly 11 times the number recorded a decade ago, according to data released on Tuesday by the Centers for Disease Control and Prevention.
Syphilis during pregnancy can lead to miscarriage and stillbirth, and infants who survive may become blind or deaf, or have severe developmental delays. In 2022, the disease caused 231 stillbirths and 51 infant deaths.
Nearly 90 percent of the new cases could have been prevented with timely testing and treatment, according to the agency.
“Syphilis in babies continues to increase, and the situation is dire,” Dr. Laura Bachmann, chief medical officer at the agency’s division for prevention of sexually transmitted diseases, said in an interview. “We need to do things differently.”
“One case is an indication of a breakdown in the public health infrastructure, and now we have 3,700 cases,” she added.
The system breaks down in multiple ways. Nearly 38 percent of the 3,700 babies were born to women who received no prenatal care. Of the women who had at least one prenatal appointment, 30 percent were never tested for syphilis or were tested too late.
And among those who tested positive for syphilis, 88 percent received inadequate, undocumented or no treatment.
Public health departments used to have teams of disease-intervention specialists and nurses who made sure that pregnant women were tested and treated — even if that meant giving them shots in their homes — and traced all of their contacts, said Dr. Thomas Dobbs, dean of the University of Mississippi’s John D. Bower School of Population Health.
But those departments have been gutted over the years.
“You can’t dismantle the infrastructure of public health and not expect for bad things to happen,” Dr. Dobbs said. “I can’t believe that we’re at this state of health in a country as wealthy as we are.”
Calling the rise in congenital syphilis “a shameful crisis” accelerated by funding cutbacks and bureaucratic obstacles, the National Coalition of STD Directors on Tuesday demanded $1 billion in federal funding and a White House syphilis response coordinator to stem the tide.
Syphilis was nearly eliminated in the United States about 20 years ago, but rose by 74 percent, to 177,000 cases, between 2017 and 2021. Other S.T.I.s are also on the rise: In 2021, there were 1.6 million cases of chlamydia and more than 700,000 cases of gonorrhea.
The numbers were rising even before the pandemic, but in the past few years, a drop in routine preventive care, a shift to more telehealth appointments for prenatal care, and reduced clinic hours may have exacerbated the situation.
The reasons for the increase in congenital syphilis varied a bit by region. No testing, or testing too late, accounted for 56 percent of cases in the West, and inadequate treatment caused 55 percent of cases in the South.
In Mississippi, people may have to drive for hours to find an obstetrician, or they may not have the transportation, job or family situation to facilitate seeking health care.
“If you’re in a really poverty-endemic state like Mississippi is, where working-class folks are really just struggling to get by, everything is a barrier,” Dr. Dobbs said.
Nationwide, about one in five pregnant women who were diagnosed with syphilis did not receive any prenatal care, suggesting that they were tested in another setting, such as an emergency room, prison or needle-exchange program.
That proportion was higher in Michigan, where about a third of all S.T.I.s were diagnosed in emergency departments. “More and more people are receiving what should be routine preventive health care in emergency departments,” said Dr. Natasha Bagdasarian, the state’s chief medical executive.
Because E.R. doctors do not have longstanding relationships with the patients, “it’s easier for folks to fall through the cracks,” she said.
Syphilis was resurging primarily among men who have sex with men, but in recent years it has crept into heterosexual networks. Among women of reproductive age, syphilis diagnoses rose by 17.2 percent between 2021 and 2022, according to the new report.
But public health departments are not as well connected to heterosexual women as they are to community organizations that help gay and bisexual men with H.I.V. and S.T.I. prevention.
“There’s a lack of awareness among women of childbearing age that syphilis is still around and that it can impact them and what the consequences could look like for their unborn child,” Dr. Bagdasarian said.
Pregnant women may not have symptoms nor realize they need to be tested or treated.
The C.D.C. recommends screening for syphilis at the first prenatal visit or as soon as pregnancy is identified. For women at high risk of infection because of where they live, substance use or sexual behavior, the C.D.C. suggests screening twice more: at 28 weeks of gestation and at delivery.
Many states go further, mandating that all pregnant women be tested for the infection at all three time points. That’s in part because women who test negative early in pregnancy may acquire syphilis later on.
They may even be “at greater risk because they are no longer using protection such as condoms,” said Dr. Melanie Taylor, medical epidemiologist for the Maricopa County Department of Public Health in Arizona.
Prevention efforts must extend beyond prenatal care for pregnant women and reach their partners, as well as other heterosexual men and women, Dr. Taylor said.
Maricopa County has some of the highest congenital syphilis rates in the nation. Nearly half of the women in the county who had babies with syphilis received no prenatal care in 2022. Drug use, particularly of fentanyl and methamphetamine, and recent incarceration are big contributors, Dr. Taylor said.
The county is working with hospitals and community organizations to reach women who are using drugs, were recently incarcerated, have unstable housing or are otherwise at high risk for syphilis.
The public S.T.I. clinic, which serves up to 35,000 patients a year, charges a flat fee of $20 to test and treat patients and their partners, and waives the fee if cost is an obstacle.
Confirming a syphilis diagnosis usually takes two positive tests, but the C.D.C. is recommending that providers treat women who may not return after a single positive result.
Early cases of syphilis in a pregnant woman can be treated with a single shot of an antibiotic called benzathine penicillin G, marketed as Bicillin by Pfizer. In June, Pfizer warned the Food and Drug Administration that Bicillin was in short supply, in part because of the sharp rise in demand for syphilis treatment.
The C.D.C. has asked health care providers to prioritize Bicillin’s use for pregnant women with syphilis. The only alternative is doxycycline, which must be taken twice a day over several weeks and is not recommended for pregnant women.
The new study was conducted before the drug’s shortage, so the treatment figures for this year may be worse.
More options for treatment, particularly ones that are affordable, would ease matters, as would vaccines and better tests. “The syphilis testing technology has really not changed much in many, many, many decades,” Dr. Bachmann said.
“There’s a lot of room for work here,” she said. “It’s obvious we have a broken system.”
