by Catherine Colquitt, MD
Texas is making headlines, and not in a good way.
Our state has the highest rate of syphilis cases in the nation, and five of our metropolitan areas are in the top tier in the nation in reporting of syphilis cases. This dubious distinction comes with increasing congenital syphilis (CS) incidence, too. In 2018 (2019 data are still being compiled) Texas reported 367 cases of congenital syphilis (a 64.57 percent increase in CS compared with published 2017 state data), with 21 of them coming from Tarrant County.
For reference, in 1998, syphilis rates in the US dropped to historic lows and the CDC and other partners wrote of eradicating syphilis in the U.S., but by 2012, syphilis rates had begun to climb rapidly and are soaring today. In 2017, the CDC issued a call to action entitled “Let’s Work Together to Stem the Tide of Rising Syphilis in the United States.” This 12-page document suggested roles for patients, clinicians, public health entities, state health departments, community leaders, biomedical science, universities, and industry partners, among others, in curbing the incidence of syphilis.
However, syphilis rates continue to climb, and Texas is reporting marked year-on-year increases in CS as well. In 2015, the Texas Legislature amended Texas Health and Safety Code, Section 81.090, which mandates syphilis testing of all pregnant women at their first prenatal visit and in the third trimester (2015 CDC Sexually Transmitted Disease Guidelines recommend that the third trimester syphilis screening occur between 28 and 32 weeks of pregnancy). This requires the Texas Department of State Health Services (TxDSHS) to present a biennial CS report to the legislature by January 1 of odd-numbered years for its review and consideration.
The current TxDSHS Congenital Syphilis Report (January 2019) states that “in 2017 nationally, Texas ranked fourth (case rate). There were 166 cases of congenital syphilis reported to DSHS. The rate was 41.7 cases per 100,000 births. Texas accounted for 18.1 percent or nearly one-fifth of the total congenital syphilis cases reported in the United States.”
The CDC estimates that 40 percent of infants born to women with untreated syphilis are stillborn or die as newborns. Usually syphilis is transmitted to the fetus when the mother has primary or secondary syphilis while pregnant, but women with untreated or inadequately treated syphilis, early latent or late latent syphilis, still have a 23 percent chance of an adverse syphilis-related pregnancy outcome. In order to prevent CS, maternal treatment must occur at least 30 days before delivery of the infant (if the mother is treated more than one month prior to delivery, her treatment will address the infection in both mother and fetus).
CS is classified based on the timing of symptoms and signs in the affected child. Early CS presents with vision or hearing impairment, runny nose (“snuffles”), anemia, hepatitis, splenomegaly, long bone abnormalities, developmental delay, and rash manifest before the child’s second birthday. Late CS (from second birthday onward) signs and symptoms include dental and bony abnormalities (remember Hutchinson’s incisors and saber shins?), hearing and vision deficits, and central nervous system manifestations such as gummas and encephalitis, and (rarely) cardiovascular pathologic effects.
TxDSHS has piloted adding CS to regional Fetal Infant Morbidity Reviews in two areas hardest hit by the recent and ongoing rise in CS cases, Harris and Bexar Counties, and is developing an enhanced surveillance system to ensure more complete reporting. The agency is also facilitating improved pregnancy assessments of women with or exposed to syphilis, working to expedite prenatal care referrals for syphilis infected pregnant women, and is partnering with hospitals to provide assessment and management of syphilis in antepartum, intrapartum, and postpartum settings.
Even in the late 1990s and early 2000s with U.S. syphilis rates at historic lows, wide racial and socioeconomic disparities in syphilis rates were observed. Women at highest risk for syphilis during pregnancy include those without insurance (and therefore with late or no access to prenatal care), in poverty, involved in sex work, using illegal drugs, infected with another STD, and in communities with high syphilis rates.
We are still using the same medication to treat syphilis that were transformative in the 1930s and 1940s, and we still rely on syphilis diagnosis and response to treatment which measure antibody titers, having no gold standard for directly establishing active infection (except dark field exam of clinical specimen, rarely done these days).
We need a vaccine against syphilis and new medications to treat it, especially in penicillin-allergic pregnant women with an absolute contraindication to desensitization (such as Stevens-Johnson syndrome). In the meantime, we can use the tools we have to better serve our patients and prevent tragic vertical transmission of an infection we once thought was on its way out.