A decade ago, Alabama saw only a few annual cases of congenital syphilis. But now the cases are spiking to record levels, including 42 cases in 2022, and possibly even more in 2023. This alarming trend caused the Alabama Department of Public Health (ADPH) to issue a health alert network message to providers and the public on July 18.1
“We’ve had profound increases in congenital syphilis, beginning in 2018-2019,” says Wes Stubblefield, MD, MPH, FAAP, the district medical officer of the Northern and Northwestern Public Health Districts of ADPH. “We had the highest amount in 2022, and this year could be higher. We have seen the same increases with our syphilis non-congenital [cases], as well.”
There is no definitive answer to why overall syphilis rates are rising among the adult population. But that increase means that newborns also will be exposed.
Untreated syphilis in pregnancy can cause miscarriage, stillbirth, prematurity, low birth weight, and other health problems. When babies are born with syphilis, they may appear asymptomatic but can develop many health problems if they are not treated. These could include central nervous system abnormalities, deafness, and other diseases.1
Alabama’s increase in congenital syphilis cases indicates people were not screened adequately in pregnancy. Specifically, prenatal care providers missed opportunities to prevent cases because of delayed detection, Stubblefield explains.
Among all congenital syphilis cases reported from 2018 to 2022, there were 10 with no syphilis test recorded. The majority of the missed opportunities — 66 cases — were due to late identification.2
The ADPH has ruled out the COVID-19 pandemic as a cause of the spike in cases because data from 2006 to 2022 show congenital syphilis cases began to decline after 2011 and continued until 2016. Since 2017, there has been a steady and sharp rise in cases, according to an ADPH chart.2
One obstacle to screening is that providers sometimes do not test pregnant women for syphilis after the first trimester, Stubblefield notes.
“We don’t have a third trimester screening requirement in Alabama,” he says. “We’re trying to change the code so that [syphilis screening] is a requirement in the third trimester and at delivery, and we’re trying to get word out to all our providers — using any means we can.”
The state’s recommendations for sexually transmitted infection (STI) testing in pregnant women include:
- First/initial prenatal visit: Screen for chlamydia, gonorrhea, syphilis, hepatitis B virus, hepatitis C virus, and HIV infection. If the patient is confirmed to have HIV infection, then no HIV testing is needed throughout the pregnancy.1
- Early third trimester (between 28-32 weeks’ gestation), regardless of risk factors: Screen for syphilis and HIV.1
- Labor and delivery: Test all pregnant women at the time of labor and delivery for syphilis, HIV infection, and hepatitis B virus (HBV) (if the patient has signs and symptoms of hepatitis or has had no prior HBV testing).1
The health department has been educating providers and campaigning for public awareness about congenital syphilis for more than a year. Educational efforts include the congenital syphilis alert and outreach to medical organizations, Stubblefield says.
“We make sure prenatal care providers understand how important it is,” Stubblefield explains. “We discussed it with payers, and they all cover it. We have information for the public with printed resources, billboards, and getting the word out.”
One concern for health departments dealing with congenital syphilis spikes is there are shortages of the drug used to treat syphilis in pregnant patients.
“There’s a nationwide shortage of the only medication, a long-acting antibiotic,” Stubblefield notes.
The drug is given in an intramuscular shot to pregnant patients. Although it also can be used for other adult patients, there are alternative antibiotics, including doxycycline, that can work for them. For congenital syphilis, it is the only treatment.
“The shortage has to do with production problems,” Stubblefield adds.
The health department has encouraged all providers to consider testing patients for syphilis if their patient is diagnosed with another STI.
“We want to make sure they help people learn about sexually transmitted infections and how to talk with partners about it,” Stubblefield says. “We want the public to feel comfortable coming to our clinics and being screened for STIs if they know they were exposed or have a particular risk based on risk factors.”
Providers need to ask about patients’ risk factors for STIs routinely.
“Even in pediatrics, we try to be sensitive about it, but it’s a question that needs to be asked. That’s just part of the typical medical history,” Stubblefield explains. “Providers need to know how to approach that subject in a way that is not stigmatizing or off-putting to make sure people want to talk to them and know it’s confidential.”
REFERENCES
- Alabama Department of Public Health. Let’s Stop the Rise of Congenital Syphilis in Alabama. July 18, 2023.
- Alabama Public Health. Congenital syphilis prevention. July 24, 2023.
A decade ago, Alabama saw only a few annual cases of congenital syphilis. But now the cases are spiking to record levels, including 42 cases in 2022, and possibly even more in 2023. This alarming trend caused the Alabama Department of Public Health to issue a health alert network message to providers and the public on July 18.
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