Examining associations in congenital syphilis infection and socioeconomic factors between California's small-to-medium and large metro counties

Multilevel Drivers of Congenital Syphilis, Oregon, 2013 to 2021

BACKGROUND

Despite the availability of curative penicillin treatment for syphilis during pregnancy, congenital syphilis (CS) cases have surged in the United States, including in Oregon.

METHODS

We conducted a retrospective analysis of individual- and county-level predictors of CS among pregnant people with syphilis in Oregon from 2013 to 2021. Data were collated from surveillance reports, County Health Rankings, and other sources with upstream county-level data. We used multilevel Poisson regression models to assess associations between CS and individual- and county-level factors.

RESULTS

Among 343 people with syphilis during pregnancy, 95 (27.6%) were associated with a case of CS. At the individual level, a history of injection drug use and a history of corrections involvement were associated with an increased risk of CS, whereas a recent gonorrhea diagnosis was associated with a decreased risk of CS. County-level violent crime rate, unemployment, income inequality, and adverse childhood experiences increased the risk of CS. Higher county-level socioenvironmental challenges exacerbated CS risk, particularly among people with corrections involvement.

CONCLUSIONS

Injection drug use, corrections involvement, and county-level socioenvironmental challenges increased CS risk among pregnant people with syphilis in Oregon. Urgent interventions are needed, including innovative care models, policy reforms targeting systemic issues, and enhanced collaboration with community services to address the escalating CS crisis.

Disparities in Syphilis Trends and the Impact of the COVID-19 Pandemic: A Joinpoint Analysis of Florida Surveillance Data (2013-2022)

INTRODUCTION

Syphilis, a sexually transmitted infection caused by the bacterium ​​​​​​Treponema pallidum, has reemerged at an increasing rate globally in recent years, posing a significant public health concern. Visualizing and analyzing time series trends of syphilis across various demographics and geographic regions, and how syphilis trends varied during the pandemic coronavirus disease 2019 (COVID-19), would help public health policymakers develop targeted strategies and interventions to effectively address the rising rates of syphilis, ultimately improving overall public health outcomes.

METHODS

 A retrospective study was conducted using surveillance data on infectious syphilis cases reported to the Florida Department of Health, between 2013 and 2022. Age-standardized syphilis rates (ASSRs) per 100,000 persons were calculated using the 2000 U.S. standard population data. The average annual percentage change (AAPC) in the ASSRs was analyzed according to age, gender, race, geographic locations, and the COVID-19 pandemic period to quantify the epidemiological syphilis trends using joinpoint regression models.

RESULTS

 In Florida, the ASSR significantly increased from 8.65/100,000 in 2013 to 23.08/100,000 in 2022 across different demographic groups, with an overall AAPC of 11.47 (95% confidence interval (CI): 9.85-13.43). This increase in the AAPC was more pronounced in females (AAPC = 20.97; 95% CI, 18.61-24.49) than in males (AAPC = 10.34; 95% CI, 8.19-12.98). The increasing trends of infectious syphilis were observed across all age groups, with greater increases among those aged 25-49 years (AAPC = 12.32; 95% CI, 10.09-15.18), aged 50-69 years (AAPC = 13.42; 95% CI, 9.41-18.89), and aged over 70 years (AAPC = 13.63; 95% CI, 9.23-21.95), compared to those aged less than 24 years (AAPC = 7.86; 95% CI, 7.06-8.81). The increasing trends were comparable across racial groups, with an AAPC of 8.08 (95% CI, 5.47-11.15) for Hispanics, 11.84 (95% CI, 10.02-14.09) for non-Hispanic Whites, 10.49 (95% CI, 8.75-12.66) for non-Hispanic Blacks, and 11.29 (95% CI, 5.28-19.57) for non-Hispanic individuals of other races, respectively. The AAPC for the COVID-19 pandemic period was 12.99 (95% CI, 8.48-16.21), which was comparable to the pre-pandemic period (AAPC = 11.58; 95% CI, 10.17-12.76), indicating that this upward trend in infectious syphilis persisted throughout the COVID-19 pandemic. At the county level, over the 10-year period, the average ASSRs ranged from 0.89/100,000 in 2013 to 25.41/100,000 in 2022, with the estimated AAPCs varied from 2.47 (95% CI, -1.89 to 6.92) in Monroe County to 50.01 (95% CI, 37.71-62.27) in Okaloosa County.

CONCLUSIONS

 The trend of infectious syphilis increases substantially from 2013 to 2022, with notable differences observed among age, gender, and geographic regions in Florida. Females experienced a greater rise in infectious syphilis cases compared to males. This upward trend in infectious syphilis persisted throughout the COVID-19 pandemic. Efforts are needed to implement strategies to address the rising syphilis rates within high-incidence groups and communities across the state.

Congenital Syphilis: A Re-Emerging but Preventable Infection

Congenital syphilis presents a significant global burden, contributing to fetal loss, stillbirth, neonatal mortality, and congenital infection. Despite the target established in 2007 by the World Health Organization (WHO) of fewer than 50 cases per 100,000 live births, the global incidence is on the rise, particularly in low- and middle-income regions. Recent data indicate a rate of 473 cases per 100,000 live births, resulting in 661,000 total cases of congenital syphilis, including 355,000 adverse birth outcomes such as early fetal deaths, stillbirths, neonatal deaths, preterm or low-birth-weight births, and infants with clinical congenital syphilis. Alarmingly, only 6% of these adverse outcomes occurred in mothers who were enrolled, screened, and treated. Unlike many neonatal infections, congenital syphilis is preventable through effective antenatal screening and treatment of infected pregnant women. However, despite available screening tools, affordable treatment options, and the integration of prevention programs into antenatal care in various countries, congenital syphilis remains a pressing public health concern worldwide. This review aims to summarize the current epidemiology, transmission, and treatment of syphilis in pregnancy, as well as to explore global efforts to reduce vertical transmission and address the reasons for falling short of the WHO elimination target.

Sexually Transmitted Infections in the Emergency Department

As the United States faces a worsening epidemic of sexually transmitted infections (STIs), emergency departments (EDs) play a critical role in identifying and treating these infections. The growing health inequities in the distribution and disproportionate impact of STIs add to the urgency of providing high-quality sexual health care through the ED. Changes in population health are reflected in the new Centers for Disease Control recommendations on screening, diagnostic testing, and treatment of STIs. This review covers common, as well as and less common or emerging STIs, and discusses the state-of-the-art guidance on testing paradigms, extragenital sampling, and antimicrobial treatment and prevention of STIs.

Resurgence of congenital syphilis: new strategies against an old foe

Congenital syphilis is a major global cause of fetal loss, stillbirth, neonatal death, and congenital infection. In 2020, the global rate of congenital syphilis was 425 cases per 100 000 livebirths-substantially higher than WHO's elimination target of 50 cases per 100 000 livebirths. Case rates are rising in many high-income countries, but remain low compared with those in low-income and middle-income settings. This Review aims to summarise the current epidemiology and knowledge on transmission and treatment of syphilis in pregnancy, and proposes measures to reduce the rising incidence seen worldwide. We also describe emerging diagnostic and treatment tools to prevent vertical transmission and improve management of congenital syphilis. Finally, we outline a programme of public health priorities, which include research, clinical, and preventive strategies.

Maternal and congenital syphilis attributable to ethnoracial inequalities: a national record-linkage longitudinal study of 15 million births in Brazil

BACKGROUND

This study estimated ethnoracial inequalities in maternal and congenital syphilis in Brazil, understanding race as a relational category product of a sociopolitical construct that functions as an essential tool of racism and its manifestations.

METHODS

We linked routinely collected data from Jan 1, 2012 to Dec 31, 2017 to conduct a population-based study in Brazil. We estimated the attributable fraction of race (skin colour) for the entire population and specific subgroups compared with White women using adjusted logistic regression. We also obtained the attributable fraction of the intersection between two social markers (race and education) and compared it with White women with more than 12 years of education as the baseline.

FINDINGS

Of 15 810 488 birth records, 144 564 women had maternal syphilis and 79 580 had congenital syphilis. If all women had the same baseline risk as White women, 35% (95% CI 34·89-36·10) of all maternal syphilis and 41% (40·49-42·09) of all congenital syphilis would have been prevented. Compared with other ethnoracial categories, these percentages were higher among Parda/Brown women (46% [45·74-47·20] of maternal syphilis and 52% [51·09-52·93] of congenital syphilis would have been prevented) and Black women (61% [60·25-61·75] of maternal syphilis and 67% [65·87-67·60] of congenital syphilis would have been prevented). If all ethnoracial groups had the same risk as White women with more than 12 years of education, 87% of all maternal syphilis and 89% of all congenital syphilis would have been prevented.

INTERPRETATION

Only through effective control of maternal syphilis among populations at higher risk (eg, Black and Parda/Brown women with lower educational levels) can WHO's global health initiative to eliminate mother-to-child transmission of syphilis be made feasible. Recognising that racism and other intersecting forms of oppression affect the lives of minoritised groups and advocating for actions through the lens of intersectionality is imperative for attaining and guaranteeing health equity. Achieving health equality needs to be addressed to achieve syphilis control. Given the scale and complexity of the problem (which is unlikely to be unique to Brazil), structural issues and social markers of oppression, such as race and education, must be considered to prevent maternal and congenital syphilis and improve maternal and child outcomes globally.

FUNDING

Wellcome Trust, CNPq-Brazil.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

Spike in Congenital Syphilis, Mississippi, USA, 2016-2022

In Mississippi, USA, infant hospitalization with congenital syphilis (CS) spiked by 1,000%, from 10 in 2016 to 110 in 2022. To determine the causes of this alarming development, we analyzed Mississippi hospital discharge data to evaluate trends, demographics, outcomes, and risk factors for infants diagnosed with CS hospitalized during 2016–2022. Of the 367 infants hospitalized with a CS diagnosis, 97.6% were newborn, 92.6% were covered by Medicaid, 71.1% were African American, and 58.0% were nonurban residents. Newborns with CS had higher odds of being affected by maternal illicit drug use, being born prematurely (<37 weeks), and having very low birthweight (<1,500 g) than those without CS. Mean length of hospital stay (14.5 days vs. 3.8 days) and mean charges ($56,802 vs. $13,945) were also higher for infants with CS than for those without. To address escalation of CS, Mississippi should invest in comprehensive prenatal care and early treatment of vulnerable populations.

Congenital Syphilis-An Illustrative Review

Congenital syphilis is caused by the spirochete, Treponema pallidum, which can be transmitted from an infected mother to her fetus during pregnancy or by contact with a maternal lesion at the time of delivery. The incidence of congenital syphilis is rapidly increasing all over world with 700,000 to 1.5 million cases reported annually between 2016 and 2023. Despite the widespread availability of Penicillin, 2677 cases were reported in 2021 in the US. Clinical manifestations at birth can vary widely ranging from asymptomatic infection to stillbirth or neonatal death. Low birth weight, rash, hepatosplenomegaly, osteolytic bone lesions, pseudoparalysis, central nervous system infection, and long-term disabilities have been reported in newborns with congenital syphilis. Prevention of congenital syphilis is multifaceted and involves routine antenatal screening, timely treatment of perinatal syphilis with penicillin, partner tracing and treatment, and health education programs emphasizing safe sex practices and strategies to curb illicit drug use. Neonatal management includes risk stratification based on maternal syphilis history, evaluation (nontreponemal testing, complete blood counts, cerebrospinal fluid, and long-bone analysis), treatment with penicillin, and followup treponemal testing. Public health measures that enhance early detection during pregnancy and treatment with penicillin, especially in high-risk mothers, are urgently needed to prevent future cases of congenital syphilis.

Congenital Syphilis Epidemiology, Prevention, and Management in the United States: A 2022 Update

Congenital syphilis (CS) has dramatically increased in the United States (US) in the past decade despite the widespread availability of penicillin. Once considered an infection on the verge of elimination, CS has re-emerged as a familiar neonatal pathogen in US hospitals. This rise in cases has prompted the evaluation of potential causes and updates in prevention and management guidelines. Following a structured narrative approach, we reviewed CS data reports, peer-reviewed research articles, and updated management guidelines from state health departments over the past two decades. Our main search criteria centered on the treatment and prevention of CS, with a focus on prenatal health disparities. We identified geographical regions reporting disproportionate rates of CS, examined state laws regarding maternal syphilis testing, and evaluated potential reasons for the recent rise in cases. This article examines the current epidemiology, screening, and management recommendations for perinatal and CS in the US. It also reviews pathogenesis and clinical features in perinatal and pediatric populations. Finally, it highlights the likely contributing factors to increased CS rates and identifies areas for future research. Dramatically rising CS cases in certain regions and racial groups reflect gaps in the prevention, timely diagnosis, treatment, and management of perinatal syphilis and CS. Healthcare providers attending to mothers and children should recognize the re-emergence of this pathogen and be familiar with new screening and management guidelines. Increased federal funding for targeted interventions and research that address vulnerable populations is critical to curbing the re-emergence of this infection.