The Congenital Syphilis Crisis
At the turn of the century, the United States was nearing elimination of syphilis. However, in the 23 years since then, congenital syphilis has alarmingly resurfaced, revealing significant vulnerabilities in our healthcare system. Highlighted by a newly released Centers for Disease Control and Prevention (CDC) report, syphilis’ resurgence is a critical public health concern demanding immediate and comprehensive action.
The Escalating Crisis
Since 2017, recent CDC data indicates a dramatic 75% increase in syphilis cases in the United States, with congenital syphilis cases tripling in the same timeframe. In 2020, 2,148 newborns were affected, a jump from 1,870 in 2019. This worrying trend extends globally, as a Lancet study corroborates, and the World Health Organization (WHO) estimates nearly 1 million annual congenital syphilis cases worldwide. These cases often result in severe outcomes, including stillbirths, neonatal deaths, and lifelong health complications.
The surge in congenital syphilis necessitates a critical examination of its root causes, including inadequate prenatal care, healthcare access barriers, and insufficient sexual education.
Integrated Response to Syphilis Resurgence
The re-emergence of syphilis is deeply rooted in social and healthcare dynamics and exacerbated by the COVID-19 pandemic. This situation calls for an integrated response from the medical community and society as a whole, addressing both the underlying factors and the immediate challenges.
The CDC has identified significant disparities in syphilis rates among Native American, Native Hawaiian, Pacific Islander, and Black populations. These disparities are linked to broader social determinants of health, which have been further strained by the COVID-19 pandemic, as noted by the American Journal of Public Health. The pandemic's impact on healthcare services has led to increased sexually transmitted infection (STI) rates, including syphilis, due to reduced healthcare access.
Challenges and Care in Syphilis Prevention and Treatment
The medical community, including the Health Resources and Services Administration (HRSA) and dermatologists as discussed in JAMA Dermatology, plays a crucial role in addressing the syphilis epidemic. Their efforts are key to bridging healthcare access gaps and tackling systemic challenges. However, these initiatives are hindered by significant hurdles, such as medical resource shortages, emphasizing the need for a sustained, integrated approach to this public health crisis.
A major challenge is the shortage of Bicillin L-A, the primary treatment antibiotic, as highlighted by The New York Times. This shortage, caused by increased demand and manufacturing constraints, poses a significant risk, especially for pregnant women and birthing persons, and necessitates alternative strategies and early intervention to prevent mother-to-child transmission.
Coordinated Multi-sector Response
Recognizing these challenges, the medical community, led by organizations like the National Association of County and City Health Officials (NACCHO), is advocating for a coordinated response. This approach involves:
Rapid Testing and Treatment: Prioritizing rapid syphilis testing for pregnant women and birthing persons, especially in underserved areas, to prevent congenital syphilis.
Educational Campaigns: Launching culturally sensitive educational campaigns about prenatal care and regular syphilis testing during pregnancy.
Enhanced Prenatal Care Access: Expanding access to quality prenatal care, integrating routine syphilis testing into prenatal check-ups, and ensuring affordable treatment options.
Policy and Funding Support: Advocating for increased funding and policy support to enhance resources for syphilis testing, treatment, and prenatal care services.
Community Engagement and Education
To effectively combat the resurgence of syphilis, a multifaceted community engagement and education strategy is essential. This approach should encompass:
Integrated Awareness Initiatives: Implement targeted campaigns across diverse platforms to educate on syphilis risks, prevention, and treatment. These should be inclusive, culturally sensitive, and utilize local media, social platforms, and community events for maximum reach and impact.
Collaborative Community Leadership and Healthcare Partnerships: Engage community leaders, influencers, and healthcare providers in a collaborative effort. This includes disseminating information, advocating for prevention and treatment, and organizing educational workshops and seminars. These partnerships are vital for credibility and creating effective referral systems for medical consultation or treatment.
Enhanced Comprehensive Sex Education: Strengthen sex education programs in schools and community centers, covering all aspects of sexual health. This should include STI prevention, contraception, and healthy relationships, tailored to be culturally sensitive and inclusive.
Active Community Involvement and Feedback: Encourage community feedback and involvement in the planning and implementation of syphilis education and prevention programs. This ensures the initiatives are relevant, effective, and address specific community needs.
The Role of Sex Education in Preventing Congenital Syphilis
Comprehensive sex education is a pivotal element in combating congenital syphilis. This education equips people with essential knowledge and tools for informed decisions about sexual health, playing a critical role in STI prevention, including syphilis.
Key Insights and Evidence:
Gap in Education and Its Consequences: Reports from sources like NPR and the Texas Tribune highlight the link between the rise in congenital syphilis and inadequate sex education. This gap, which is especially pronounced in resource-limited areas, leaves many, particularly adolescents and young adults, vulnerable due to a lack of essential sexual health knowledge.
Societal and Cultural Barriers: Cultural stigmas and taboos, as discussed in BBC Future, often impede the implementation of comprehensive sex education, leading to misinformation and increased STI risks.
Supporting Data for Comprehensive Education:
◦ The American College of Obstetricians and Gynecologists (ACOG) and studies in the Journal of Adolescent Health underscore the effectiveness of comprehensive sex education in reducing risky behaviors and STI rates.
◦ Research from PubMed Central and the Guttmacher Institute links inadequate sex education to higher STI and unintended pregnancy rates, advocating for inclusive and comprehensive programs.
Importance of Cultural Sensitivity: Studies emphasize the need for culturally sensitive and inclusive sex education, which has been shown to positively impact sexual behavior and contraception use among adolescents.
Policy, Public Health, and Community Approach to Syphilis
The fight against the syphilis epidemic necessitates a unified approach, combining policy initiatives, public health strategies, and community involvement. Central to this effort is the Pasteur Act, reintroduced in Congress to foster antibiotic research and development, a critical step in combating drug-resistant pathogens and diseases like syphilis. This act also highlights the need for equitable access to treatments, particularly for marginalized communities disproportionately affected by congenital syphilis.
Focused Policy and Public Health Efforts:
Support for the Pasteur Act: Advocacy for this act is crucial to stimulate antibiotic innovation and ensure the availability of new treatments for those in need, particularly in underprivileged communities.
Increased Funding for Public Health Campaigns: Investing more in public health campaigns is essential to educate high-risk communities about syphilis prevention and treatment.
Strengthening Healthcare Systems: There's a pressing need to enhance healthcare infrastructure, especially in areas lacking adequate medical resources, to manage the rising cases of congenital syphilis.
Ensuring Equitable Healthcare Access: Policies should aim to provide universal access to quality healthcare, including STI testing and treatment, with a focus on reaching marginalized groups.
Community and Healthcare Provider Engagement:
Healthcare Providers' Role: Emphasizing prenatal care and routine syphilis testing for pregnant women and birthing persons during every patient encounter is critical to prevent the transmission of syphilis to newborns.
Community Involvement: Supporting comprehensive sex education and advocating for the destigmatization of sexual health are essential. Communities and individuals should be encouraged to practice regular testing and safe sex.
This collective effort, integrating medical, educational, and policy measures, is vital to significantly reduce the incidence of congenital syphilis. By working together, we can protect future generations and address the broader aspects of this public health challenge.
For more information, the CDC's congenital syphilis fact sheet provides detailed insights into prevention strategies and the impact of the disease.
New STI Surveillance Report – It’s Not Good
In late 2021, ProPublica profiled the efforts of a local public health worker, Mai Yang, Mai Yang, as she sought to track down a pregnant client recently screened for syphilis Yang was urgent in the need to find this client and get her curative treatment, three uncomfortable injections of penicillin, completed at least 30 days before giving birth. Congenital syphilis is a killer with a near 40% chance of a newborn dying or being stillborn. Beyond death, congenital syphilis risks a range of difficulties, from disabling deformities to cognitive dysfunction. COVID-19 impacts were readily felt throughout the story as Yang’s client, Angelica, struggled with housing, a language barrier required an interpreter, and, eventually, the clinic Yang sought to link Angelica to was not able to accommodate a walk-in appointment, despite Yang having gotten assurances they could.
Last week, the Centers for Disease Control and Prevention (CDC) released its annual sexually transmitted infection (STI) surveillance report for the year 2021, and the news, while not surprising in retrospect, is not good. Both syphilis and congenital syphilis cases rose about 32%, compared to 2020. 2020, on its own saw a moderate rise in both syphilis and congenital syphilis. However, the CDC notes 2020 as the most affected year in STI surveillance with a marked decreases in screening activities in much of 2020 and higher than previous baseline diagnoses throughout much 2021 (mostly around the 150% level but a massive spike well above 200% around November 2021 – or about the time of ProPublica’s report being published).
Gonorrhea and chlamydia cases rose, though not as dramatically. Herpes, despite being a prevalent STI, is not a reportable illness and thus not tracked in the annual report.
This marks the eight consecutive year of increasing STI diagnosis, as noted by the National Coalition of STD Directors and Association of State and Territorial Health Officials. The situation is dire, going forward. Public health offices across the country are expecting to see an exodus of staff in the next 5 years. Between low pay and poor benefits relative to the private sector and displeasure with supervisors (which may be attributed to a lack of flexibility befitting the modern world or political pressures exerted at the appointment level), young and even well-established professionals are planning on leaving this space. And none of that necessarily reflects struggles with private partners or contracted clinics, which are equally struggling with securing funding and meeting ever increasing demands to do more with less.
In the ProPublica article, former CDC Director Dr. Tom Frieden reflected on how the United States has a terrible tendency to go through “a deadly cycle of panic and neglect”. And the same might be considered here. When President Biden announced in May of 2021 that his administration would be working to secure funding for “tens of thousands” of jobs to respond to COVID-19 and support local public health officials, there was an implication those dollars (secured in the American rescue Plan) would also fund positions that had been left to atrophy or were usurped by COVID-19 activities – most notably, disease intervention specialists. But COVID-19 is winding down, in so far as the Biden Administration seems prepared to invest much in the way of workforce dollars, and that promise made in 2021, was supposed to extend through 2026. If comments from federal legislators last year were any indication, there’s not much hope yet in this Congress choosing to ensure funding is secured to help these programs meet their goals.
In a recent interview, U.S Food and Drug Administration (FDA) Commissioner Dr. Robert Califf said “misinformation” was a leading cause of a decline United States life expectancy. And while that may one element of the issue, an abject failure to appropriately fund, stay competitive with the private market, and retain the talent needed to execute public health programs is core and central to this issue. The latest STI surveillance report shows us this plainly. Technology can only do so much in terms of outreach and extending capacity – in order to meet the demands of public health, the human element must be sufficiently supported.
Advocates would do well to take the long-view of their work. It is critically necessary to support existing public health programming and to address disparities being laid bare by annual surveillance data in order to reach an equitable health dynamic in this country – health justice. We cannot get there without supporting public health entities, shielding them from the politicalization of their mission work, and ensuring they’re appropriately appreciated for the life-saving work they do. We cannot represent patients when we don’t know who they are. We must participate with our partners in elevating the STI crisis for what it is – a public health emergency.