Congenital Syphilis: 88% of 2022 U.S. Cases Were Missed Chances to Prevent It

Summary

Congenital syphilis — syphilis passed from a pregnant person to the baby — can cause stillbirth, miscarriage and infant death, and surviving infants who aren't adequately treated may develop blindness, deafness, developmental delay or bone problems. It is preventable with timely testing and treatment during pregnancy. Yet while other infections passed at birth, such as HIV and hepatitis B, are falling, congenital syphilis is surging.

Key numbers (CDC Vital Signs, 2023)

• 3,761 cases reported in 2022, including 231 stillbirths (6%) and 51 infant deaths (1%).
• Up 31.7% from 2021, and more than 10 times the 334 cases of 2012.
• Cases rose 755% from 2012 to 2021, alongside a 676% rise in primary and secondary syphilis among women 15–44 (from 2.1 to 16.3 per 100,000), which reached 19.1 in 2022.
• 88% of 2022 cases involved missing or late testing or inadequate treatment during pregnancy.

Congenital syphilis cases among infants (bars) and primary and secondary syphilis rates among women 15–44 (line), 2012–2022. CDC.

Where prevention failed

CDC sorted every 2022 case into one of six categories, in order:

Adequate treatment means a penicillin-based regimen, correctly dosed and spaced for the stage of infection, begun at least 30 days before delivery. Of the 2,179 people tested in time without late infection, more than two-thirds were inadequately treated and nearly 20% had no documented treatment; only 262 were adequately treated.

Missed opportunities to prevent congenital syphilis, 2022. Shaded boxes are missed opportunities. CDC.

Who and where

• No or late testing was the biggest gap in the West (56.2%), Northeast (50.0%) and Midwest (40.4%); inadequate treatment dominated the South (54.5%).
• No or late testing led among American Indian or Alaska Native (47.4%), Native Hawaiian or Pacific Islander (61.0%) and White (40.8%) birth parents; inadequate treatment among Black (39.2%) and Hispanic (47.4%) birth parents.
• No prenatal care was documented in 37.9% of cases — 70% of those with no or late testing, and 20.4% of those tested in time (so some testing happened outside prenatal care).

What can help

• Treat faster: rapid point-of-care syphilis tests (recommended by the World Health Organization where delays lose patients), field-delivered treatment and disease intervention specialists who link people to care.
• Use the right drug: benzathine penicillin G is the only recommended treatment in pregnancy — an injection given once, or three times 7–9 days apart, depending on stage — and prevents up to 98% of congenital syphilis. Amid a shortage, CDC has asked that it be prioritized for pregnant patients.
• Screen more widely: CDC recommends testing at the first prenatal visit (or as soon as pregnancy is known), and again at 28 weeks and at delivery for those in high-syphilis communities, at high risk, or not tested earlier. In 2021, 38% of U.S. counties, home to 72% of the population, were above the Healthy People 2030 target of 4.6 cases per 100,000 women 15–44 — where offering tests to sexually active women and their partners could help. Racial disparities reflect access to care, sexual networks and systemic racism, not behavior; geographic screening can reduce stigma.
• Test wherever people are: emergency departments, jail intake, syringe services programs and maternal and child health programs — and treat any syphilis found in pregnancy as a priority for rapid follow-up, with someone clearly responsible for treatment.

Limitations: case reports carry little on social determinants of health; reporting varies by jurisdiction; and testing or treatment that happened but wasn't documented can't be counted.

Congenital syphilis is at its highest level in at least 30 years. Barriers range from substance use and insurance to structural inequities, limited access and drug shortages.

Sources

Based on Robert McDonald et al., "Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; published by CDC. The report gives the 2012 count as 335 in one place and 334 in another.