Delayed testing, limited access to care, and lack of sexual health literacy contribute to rise in syphilis cases in newborns
More North Carolina babies are being born with syphilis, and state health officials are urging women to get tested before they give birth to help catch the sexually transmitted illness early.
In December, North Carolina Department of Health and Human Services issued a public health alert on the rise of syphilis in women and children.
Reported cases among women rose 538% between 2012 and 2021, DHHS said in that alert. During that same time period, there was an associated 4,100% increase in babies born with congenital syphilis.
Health officials say a rise in riskier sexual behaviors, especially among younger adults, coupled with a drop in overall concern or awareness about sexually transmitted infections, has led to increases in STIs such as syphilis. Syphilis is a bacterial infection transmitted by sexual contact.
They also stress that syphilis is treatable. The earlier the infection is addressed, the better — especially for babies.
“Congenital syphilis can have long-lasting effects on a child's health and development,” said Matt Jenkins, HIV/STD director for Mecklenburg County Public Health.
Newborns at risk
Sexually transmitted infections had all been rising for several years, even before the COVID-19 pandemic led people to delay or skip testing and treatment, according to the Centers for Disease Control and Prevention.
Easily transmittable, syphilis presents initially as sores in the genital area and later as a rough, red rash, according to the CDC. Later stages can have no symptoms, but left untreated, syphilis can cause damage to the brain, heart and other organs.
A newborn may not show any signs of infection but can develop serious problems within a few weeks — or even years — if not treated. Likely health issues include developmental delays, hearing loss, vision problems, bone abnormalities and neurological issues, among others.
In pregnant people, syphilis can lead to premature birth, low birth weight, stillbirth or a newborn’s death shortly after birth.
Mecklenburg County accounted for 12 of the state’s 55 cases of congenital syphilis last year, Jenkins said. Through June this year, seven cases have been reported in the county, he said.
Kimberly Newton, a family medicine doctor and OB-GYN with Cone Health who also serves as medical director for Alamance County, didn’t have exact numbers for Alamance or Guilford counties, where she works.
She did say she has seen more cases in recent years.
CDC statistics show that men account for most syphilis cases, with the majority of those cases among gay men, bisexual men and other men who have sex with men.
However, the number of cases in women and newborns has been rising in recent years — a worrying trend, health officials say.
"The good news is that sexually transmitted infections are preventable," said Evelyn Foust, chief of NCDHHS Division of Public Health’s Communicable Disease Branch, in a statement in April during STI Awareness Month. "We need to empower ourselves to learn about them, how to talk about them, when to test for them and where to go for care and treatment.”
Barriers to care
A variety of factors put pregnant people at risk of contracting syphilis, according to the CDC. They include having sex for compensation, with multiple partners or while using drugs; getting late or no prenatal care; using methamphetamine or heroin; being incarcerated (or having an incarcerated partner); and having unstable housing or being homeless.
Kimberly Newton is a family medicine doctor and OB-GYN with Cone Health who also serves as medical director in Alamance County.
Lack of knowledge about STIs may also be playing a role, Newton said. She said generations of people have now had only abstinence-only or non-comprehensive sex ed classes in the state’s public schools, so they may not have complete information about how these infections get passed around and how to protect themselves.
Multiple screenings are important if there is a chance a mother may have contracted syphilis during the pregnancy. One of the hardest conversations is having to tell someone who previously tested negative that they are now positive during their pregnancy, Newton said.
“The most common question is, ‘Is my baby going to be OK?’ with any prenatal diagnosis,” she said. “With congenital syphilis, it’s really hard to know until your baby is born. And that is really hard (to share) as a practitioner and really hard to hear as a family.”
There are several reasons women may be delaying a syphilis test while pregnant, Jenkins said.
It could be lack of knowledge about the importance of early prenatal care, limited access to health care services, financial constraints, fear, stigma associated with seeking care, or even logistical challenges in scheduling appointments, he said in an email to NC Health News.
Newton added that even in areas where there are plenty of providers, access may still be limited if they are not accepting new patients. And she agreed that financial constraints often delay care.
“The economic reality of all of our patients is when you have your prenatal visit, you basically have to take a half day off work,” she said. “And for an hourly worker, that is huge.”
Historically marginalized communities may be more hesitant to get care because of bad experiences with health care among members of their communities, Newton said.
“If you are a transgender man walking into an OB-GYN office, it might not feel the most welcoming,” she said.
Language can be another barrier, Newton said.
“How do you explain how bacteria work when people have never even heard the word in their language?” she asked.
Newton said people may want to just blame the patient for not getting care earlier, but there are usually barriers keeping them away.
“There is no patient that I have ever met that is positive for syphilis that was volitionally trying not to get care,” she said.
Jenkins said addressing the many barriers and promoting early and consistent prenatal care is “crucial in preventing congenital syphilis.”
With the General Assembly approving Medicaid expansion, more people will be covered for routine testing and treatment, including STIs, once the policy goes into effect.
In 2021, 43 percent of congenital syphilis mothers in North Carolina had little or no prenatal care before delivery, DHHS reported.
Earlier care would have allowed for earlier detection and treatment for both mother and baby.
However, a national study released that same year showed that some newborns are going home without being diagnosed with syphilis, despite testing protocols.
The overall number of congenital syphilis cases in the country increased from 462 to 1,306 between 2014 and 2018, according to the study published in Pediatrics, the journal of the American Academy of Pediatrics.
The authors found reports of 67 children with symptoms of congenital syphilis a month after their birth during that four-year span.
As the number of congenital syphilis cases in the country is higher than it has been in more than 20 years, “many pediatric providers may be evaluating and treating infants with [congenital syphilis] for the first time in their careers and should be prepared to do so,” the authors wrote.
Among their recommendations, the authors said pediatric providers should review maternal records and confirm maternal syphilis status, advocate for maternal testing at delivery, and consider a congenital syphilis diagnosis regardless of maternal history.
While cases of STIs rise across the country, funding to stem that growth is decreasing. During the pandemic, Congress funneled more than $1 billion into strengthening the public health workforce over a five-year period. In June, as part of a debt limit deal to avoid defaulting on U.S. obligations, lawmakers clawed back $400 million of that health funding, even as the Biden administration had recently issued a multi-agency plan to combat rising STI rates.
The money had been used to hire 3,000 disease intervention specialists — public health workers who do contact tracing, investigate disease outbreaks and connect people to testing and treatment services.
Newton didn’t have an exact number on the local impact of those cuts. But she said a systematic defunding of public health over the past three decades has trickled down to local health departments, which are indirectly funded by these federal programs.
Yet, as public health departments, they’re mandated to provide the care, even when they do not have the staffing or other resources, she said.
David C. Harvey, executive director of the National Coalition of STD Directors, called the funding cut a “devastating blow to the fight against rising STI rates” and pledged to fight to get the funding back.
“This will be an uphill battle,” he said in a statement, “but it's a battle the nation needs us to fight.”