As a physician, I have never been more concerned about rates of congenital syphilis

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In 2024, the Centers for Disease Control and Prevention reported nearly 4,000 new cases of syphilis in babies, the highest case number since the mid-1950s. Typically about 5%-10% of those reported cases are stillbirths or die soon after delivery. Many surviving babies are left with lifelong disability or developmental delay.

The increase reflects the national loss of syphilis control that began with the Great Recession and the defunding of local public health programs in 2008. As a physician and former public health official, I have never been more concerned about those rates of congenital syphilis.

Congenital syphilis is a sentinel event demonstrating failure of the local public health program.

Evaluations by the CDC have shown that most cases of congenital syphilis are due to pregnant women not being tested and, among those who test positive for syphilis, not getting treated. Some pregnant women miss out on prenatal care because of lack of insurance, poor access, fear of immigration detention, or other medical conditions like substance use or mental health problems, but even among those who receive prenatal care, only about 80% are tested.

To control congenital syphilis, the U.S. needs to treat it as a preventable outcome of missed screening, missed treatment, and missed follow-up. The playbook is well known. What’s been missing is consistent execution and capacity.

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Public health must work toward making prenatal care early, easy, and universal, with same-week prenatal care entry, walk-in and telehealth options, and evening and weekend clinics. Instead of cutting public insurance programs, Medicaid should be expanded, with presumptive eligibility in pregnancy, and have zero-cost visits, laboratory testing, and transportation. Prenatal services should be co-located where people already are, such as in Women, Infants and Children program sites, substance-use clinics, jails, reentry programs, or homeless shelters.

While nearly all states have legislated mandates for syphilis screening in pregnancy, and often up to three tests in pregnancy, public health needs to hold medical providers and health systems accountable for any lack of compliance. For those individuals and organizations not screening, public reporting of failures to test and medical-legal action could be pursued. Like other screening interventions in medical systems, reminder prompts need to be built into electronic health records systems with hard-stop order sets, monitoring dashboards, and standing nursing protocols.

Given that syphilis treatment is safe and highly effective, medical providers should follow national and expert recommendations to treat immediately upon an initial positive screening test without waiting referral or additional testing. To make immediate treatment possible, same-day injectable benzathine penicillin G has to be available in clinics and any testing location.

Easy availability of injectable penicillin may prove difficult. Injectable penicillin availability has been a problem over the past decade, with shortages, stock-outs, and recalls. Government agencies need to guarantee reliable penicillin supply and access with state and regional rotating stockpiles, rapid redistribution, and clear allocation protocols.

Who can administer injectable penicillin should be expanded to include trained nurses and pharmacists per state scope-of-practice rules. Clinics and testing sites need support with logistics and reimbursement, so they keep injectable penicillin on hand.

For longer-term impact, Congress must fund the CDC to support technical assistance to localities. Congenital syphilis prevention depends heavily on public health staff and outreach. States, counties, and cities must have an adequate number of disease intervention specialists for speedy case investigation, partner services, and linkage to care. Programs need to set and regularly report performance targets such as percent of pregnant women tested, the time from a positive test to treatment, and the percent treated adequately before delivery.

Local health care organizations and systems need to engage in real-time monitoring and accountability, with dashboards for pregnancy-associated syphilis, treatment timeliness, and missed screening. For every case, maternal-child clinical care teams should hold a “sentinel event” review (like maternal mortality reviews) to identify where the system failed and fix it.

With advances in technology, there are now three Food and Drug Administration-approved rapid point-of-care tests that are inexpensive and provide results in less than 15 minutes. Rapid point-of-care syphilis tests should be deployed in emergency departments, urgent care centers, shelters, correctional settings, and mobile clinics. Emergency departments should have “pregnancy and syphilis fast track” pathways for those not receiving prenatal care. In one study, the use of rapid syphilis testing in pregnant women in an emergency department increased screening from 2% to 56%. (Disclosure: I’ve served as a paid adviser to manufacturers of rapid syphilis tests.)

The lack of deployment of rapid point-of-care syphilis tests reflects an absence of will, leadership at multiple levels, and ongoing reimbursement challenges. Without patient advocacy and public health-minded leadership, introduction of new technology is slow and incomplete.

Syphilis soars among pregnant people

Finally, there must be more integration between maternal health and substance use treatment. In some areas, methamphetamine or opioids are major drivers of congenital syphilis. In those places, prenatal services should be paired with opioid use disorder treatment programs, harm reduction, and case management. Care should be nonjudgmental and easily accessible to keep people engaged. In some places, women who might test positive for substances are afraid to seek prenatal care out of fear of punishment. Those punitive policies need to end.

With success, a jurisdiction can show more than 95% of pregnant patients are screened early and rescreened when indicated. Clinical care outcomes can show treatment occurred within days, not weeks, after a positive test, and there is follow-up and partner treatment. There should be no cases where the mother had a positive test but was not treated adequately before delivery.

The path forward for addressing congenital syphilis is clear. It is much more difficult to generate the political will and leadership needed to bring this scourge under control. Dead babies have no voice, and the families devastated by congenital syphilis are too stigmatized to speak up. Physicians and those who care about children’s health must loudly advocate and demand attention from our public health leaders. Improvements in maternal-child health systems and public health capacity benefit everyone, save lives, and lower health care costs.

Jeffrey D. Klausner is a clinical professor of medicine at the Keck School of Medicine of the University of Southern California, a board-certified internist and infectious disease specialist, a former federal and county public health official, and longtime advocate for maternal and child health.