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Some diseases fade away. Others seem to do that, but then come roaring back. That’s what has happened with syphilis, especially congenital syphilis, a sexually transmitted infection passed from mother to child.

When I became a public health physician in 2007, congenital syphilis was something I had read about but never seen. Today, consulting on cases of it has become routine; my colleagues and I at the California Prevention Training Center received more than 100 requests for consultations about congenital syphilis in 2019 and 2020. An April 2021 report from the Centers for Disease Control and Prevention confirms this disturbing trend nationwide. In 2019, the last year with complete data, there were 1,870 cases of congenital syphilis in the U.S., a 300% increase over the past five years.

Though congenital cases are just fraction of the country’s approximately 130,000 cases of syphilis, it’s spiraling out of control, surpassing the peak of mother-to-child transmissions of HIV at the height of the AIDS crisis.

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Infants infected with HIV appear to be normal and healthy. Those born with syphilis, in contrast, can have skeletal and facial deformities, as well as deafness and blindness, and up to 40% of those with congenital syphilis are stillborn or die early. These deaths and physical problems are preventable tragedies: Testing is cheap and widely available, and treatment with antibiotics is highly effective. Every case is a sentinel event, signaling holes in the health care safety net that must be addressed with the same urgency as the perinatal HIV epidemic 30 years ago.

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Most physicians of my generation emerged from medical training unaware of syphilis. Two decades ago, this sexually transmitted infection had reached a nadir — 80% of U.S. counties reported zero cases in 1999. Capitalizing on this “narrow window of opportunity” the CDC launched an elimination campaign, the third such attempt in the agency’s history. As rates dipped lower the following year, it seemed that Y2K would usher in a syphilis-free millennium, and public health officials were poised to pop the champagne.

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But though we thought we were done with syphilis, syphilis was just getting started with us. Fueled by waning fear of HIV coupled with the rise of internet hookups, cases began to creep up in 2001.

Despite laws in most states requiring prenatal screening for syphilis and HIV with blood antibody tests, the curves of these two infections began to diverge. HIV in newborns plummeted from 1,760 cases in 1991 to 39 cases in 2018. Meanwhile, congenital syphilis cases soared, with 43 states reporting cases in 2019; Texas and California vied to be the best of the worst, accounting for half of all U.S. cases.

Pregnant people affected by syphilis and HIV reside in overlapping Venn diagrams. They tend to be people of color struggling with poverty, homelessness, substance use, or incarceration. Yet while eleventh-hour interventions such as antiretroviral therapy can prevent mother-to-child transmission of HIV, it’s not so easy to prevent transmission of syphilis, which requires one to three weekly penicillin injections delivered at least a month before delivery. Many pregnant people fall through the cracks here: One-third of congenital cases occur because the mother is not adequately treated before delivery. One in four get prenatal care only late in their pregnancies or no care at all until the onset of labor, missing the window to prevent congenital syphilis and its consequences.

Bending the curve of syphilis transmission will take a robust, coordinated prevention plan. A road map to guide this effort is the Department of Health and Human Services’ first Sexually Transmitted Infections National Strategic Plan, which went into effect in January 2021. Its five-year goals include reducing the rate of congenital syphilis by 15%, and lowering disparities among Black, Hispanic, and Native American babies, who are three to six times more likely to suffer from congenital syphilis than white infants.

More funding will be needed to get there. Until now, sexually transmitted infections like syphilis and gonorrhea have been HIV’s poor cousins: CDC funding for them has stalled out at approximately $160 million per year for nearly two decades compared to routine increases for HIV, with funding for it reaching $964 million in FY 2021.

The public health response to congenital syphilis must address lapses in maternal screening and treatment, which states are attempting through increasing the frequency of prenatal screening or deploying contact tracers to deliver penicillin to clinics so pregnant people with syphilis are given timely treatment. Clinicians also need additional anti-syphilis therapies, as the fragile supply chain for injectable penicillin makes it vulnerable to shortages.

Health departments will need to get creative in their outreach to pregnant people who don’t seek out prenatal care. In western states, where one-third of women with syphilis use methamphetamine or opioids, integrating public health efforts for sexually transmitted infection programs and substance use programs will be essential to ensure success.

The Covid-19 pandemic may inadvertently help the U.S. public health system get where it needs to go. The pandemic brought an influx of funding to health departments to modernize infrastructure and expand the contact tracing workforce. Once the end of the pandemic is in sight, it will be essential to maintain gains in staffing and pivot efforts back toward the epidemic of sexually transmitted infections and other ills that went neglected while the pandemic consumed the country’s attention.

Those of us in public health would also be wise to learn from the successes of the past. If HIV/AIDS has taught us anything, it’s that ending mother-to-child transmission of infectious diseases is achievable when health care workers and public health experts have the tools for prevention and the political will to use them. HHS must honor its commitment to the federal Sexually Transmitted Infections National Strategic Plan, fight the scourge of congenital syphilis, and provide all infants born in the U.S. the healthy starts in life they deserve.

Ina Park is a public health physician, medical director of the California Prevention Training Center at the University of California San Francisco, and author of “Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs” (Flatiron Books, 2021).

  • Syphilis rearing its ugly head – not in a third world country – but in the USA ….. And apparently this is yet another disease linked with drug use and/or rampant uncontrolled sex. Wow – what a downhill decline – for both men and women involved in the spread – not caring about bringing sick children into this world. Lots of work to be done. But the “ooh-I-might-hurt-someone’s-feelings” tip-toe-ing around “modern” naming is totally lost on me as it is very simple: only a double-X chromosome DNA imprinted Woman can bear children. The “designation at birth” and “conforming gender” hype is nauseating.

  • Australia is virtually covid-free due to quarantine and regional rapid response tactics. On one hand that creates a naive susceptible population, should an educated variant manage to sneak into this country.
    On the other, it gives us time and breathing space to work out better strategies. As was pointed out, Covid 19 only has a history 15 months. We really have a lot to learn.

  • Toujours faire un suivi correct de grossesse donc les agents de santé qui font des consultations prénatales devraient les faire comme il faut en des soins humanisés
    L’éventuel planning familial qu’il faut en discuter aussi

  • One critical prevention strategy is the early identification, treatment and comprehensive contact tracing of men with primary, secondary and early latent ( under one year in duration) syphilis who have sex with female partners. Aggressive interviewing of these infected men and immediate testing and prompt therapy (at time of first exam) of female partners can contribute to a decline in congenital syphilis. What kind of results have CA HD’s had in their interviews with men who have infectious syphilis who have sex with females?

  • Actually Steve, like your mention of the Nature article, science has finally confirmed that sexual biology is non-binary. Gender is in no way related to an individual’s sexual biology or sexual orientation. Your comment is a moot point.

    https://www.nature.com/news/sex-redefined-1.16943#/spectrum

    On a personal level, posting “this meant no offense” conveys a clear awareness and understanding that your post is in fact hurtful.

    • I wrote you a sharp reply but erased it and decided to take another tack.

      I started this with a rant about “Pregnant People” – can you explain to me who could be a “Pregnant person” besides a woman? I honestly do not understand this insistence on avoiding the term “woman”.

    • To address your points:
      1. The fact that, depending on how you define “non-binary”, between 1 in 60 and 1 in 1500 people do not have all the traits the other 59 of 60, or 1499 of 1500 people of their sex have, does not make sex non-binary. In Human reproduction, one sex gets it’s DNA into the other. The other sex takes the DNA, combines it with it’s own DNA, and gives the baby a place to grow until it can live outside. And has a way to feed the baby, who can not be immediately given solid food, after birth, through lactation.
      People who can not do either of these things, be either the donor of DNA , or the recipient, can not take part in sexual reproduction. You can not switch from one sex to another, because there is no way to get all the organs of the other sex. Perhaps that could happen some day, but it’s a science fiction dream now.
      So, sex is both binary – by obvious DESIGN – OBVIOUS – really, really, really OBVIOUS – that is why the loud denials are necessary – shouting down reality – and FIXED – you can not change sexes. It’s not possible. Since “Gender” , used in the way it is recenlty, has no meaning outside of emotional beliefs, it is completely mutable, in theory, though even there, the Nature statement it is not fixed is funny, because transgender people typically claim it IS fixed, since they say they knew they were the opposite sex from very young ages.
      As to your claim “Gender is in no way related to an individual’s sexual biology or sexual orientation” – no, even the advocates say less than 5% of people have a conflict between their sex and gender identification. So, rather than being “in no way related” there is an over 95% correlation. 95% of people feel they belong in the sex they were assigned – at CONCEPTION.
      And apparently, the great majority of male to female transsexuals want sex with men – so, sexual orientation is also connected to gender.
      And I do not think you know what a “moot point” is. Please look it up.

      As for being hurtful, I do not seek out conflict, I feel it is thrown on me by “Pregnant people” – I do not want to live in the madhouse which some political advocates seek to create. I honestly fear for the future of a child of a “pregnant person” who insists she is not a woman – if any such person even exists.

  • Please stop. Please. Or, just as a challenge to your ingenuity, try to be consistent.

    The article mentions “pregnant people”. It also uses the term “maternal” – but if there is no sex associated with being pregnant, why is the term “maternal” being used?

    When they first started with the assault on all sex-linked concepts – that is, that there are men and women and differences between them, on average – some said it would go into complete denial of biological realities, and I thought they were reactionary hysterics – but now, we have a medical publication saying “Pregnant People” as a norm. Maybe it’s a new rule that is not clear to me.

    I saw an article in Nature about some sex-linked differences in some aspect of Covid19 response – and the editors felt compelled to put out a disclaimer that sex and gender are “neither binary nor fixed” – well, you can debate, I guess, about sex chromosomes defining sex. A dishonest debate, but you could make it – but sex IS binary – the fact chromosomes do not always go where they are supposed to does not change that – and there are no pregnant males. Please stop. Please.

    PS – I do appreciate the article and mean no offense to STAT or the author.

    • Thank you, Steve. I have totally had it with all the twists of science-based DNA reality – am sick of the LGBTQ whole alphabet special stuff that all regular people are supposed to understand but truly likewise have every right to ignore. Full Stop.

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