Because congenital syphilis is readily preventable with a $10 blood test and a shot of penicillin, each case represents a failed public health system.
Congenital syphilis cases, where syphilis transfers to an unborn child during pregnancy, have risen by over 1,000 percent to 3,761 cases in 2022 from 334 in 2012. Because congenital syphilis is readily preventable with a $10 blood test and a shot of penicillin, each case represents a failed public health system.
Lower-income countries throughout the world like Cuba and Thailand have been certified as having eliminated congenital syphilis, yet rates in the United States keep increasing.
Research has shown that cases of congenital syphilis are driven by the lack of syphilis testing in pregnant women and the absence of timely treatment. Social factors suggest that pregnant women put at increased risk are women of color, poor, have a history of recent substance use or mental health issues and limited access to prenatal care. Those issues are not particularly new and have always been associated with diseases like syphilis. Yet in the past, effective public health programs supported routine testing and early treatment that resulted in the control of infection and the near absence of congenital syphilis.
Several recent system factors make the treatment of maternal syphilis, the precursor to congenital syphilis, more difficult, including an ongoing shortage of injectable penicillin. There is only one manufacturer of injectable penicillin in the U.S., Pfizer, and with a limited demand and return on investment compared to blockbuster drugs like those for weight loss or erectile dysfunction, there is little financial incentive to increase production.
There are new Food and Drug Administration-cleared rapid point-of-care diagnostic tests that could be deployed in hospitals, emergency departments and other community settings like jails or substance use treatment programs or even be included in street-based medicine and homeless outreach activities. However, the adoption of those tests has been slow due to a lack of awareness or promotion and ongoing funding constraints.
While many public health officials and doctors agree that the current situation is a crisis, federal leadership has been reluctant to consider the increase in congenital syphilis a public health emergency. Officials state that there is public health emergency "fatigue" coming on the heels of the monkeypox and COVID-19 emergencies as well as concerns about whether the 1,000 percent increase truly represents a national emergency. Many experts strongly disagree, however, and are calling for the declaration of a public health emergency now.
Section 319 of the Public Health Service Act authorizes the secretary of health to declare a public health emergency based on an emergent condition or when significant outbreaks exist. Such a declaration would allow for the immediate use of reserve funds, the acceleration of guidelines and recommendations for syphilis testing among females of reproductive age in a variety of settings, faster authorization of new tests, expanded procurement of rapid syphilis tests and potentially the use of the Defense Production Act to increase the supply of injectable penicillin. It would also create focused leadership and a monitored strategy to address the issue.
More than 10 years ago, congenital syphilis was identified as an international problem but one with little advocacy. Dead and chronically debilitated babies cannot speak up for themselves and mothers of newborns with syphilis are highly stigmatized. Stillbirths, a major outcome of maternal syphilis, are one of the most stigmatized conditions worldwide.
Society must speak up for the rights of pregnant women and the health of newborns. In 2024 we should not be facing continued increases in congenital syphilis, a scourge of prior generations.
We have the tools to prevent and control syphilis. Do we have the will? The time to declare congenital syphilis a national public health emergency is now.
Jeffrey D. Klausner, MD, MPH, is a USC professor of medicine and public health, a former Centers for Disease Control and Prevention medical officer and a former San Francisco city and county deputy health officer.
