Colorado sounds alarm over spike in syphilis among mothers, babies: 'One case is one case too many'

Eight times as many babies were born with syphilis in Colorado in 2022 as in 2017, and while the numbers are still small, the public health community is racing to get the disease under control.

Untreated syphilis during pregnancy can cause miscarriages, stillbirth or infant death; premature birth; low birthweight; and disabilities, including deafness or blindness. Some babies appear healthy at birth, but get sick from congenital syphilis in the following weeks.

Colorado's five-year increase, from four cases in 2017 to a preliminary count of 34 in 2022, is part of a nationwide trend—one that's almost entirely preventable. State law requires that everyone get tested for syphilis, a sexually transmitted infection, during their first prenatal visit, and prompt antibiotic treatment can prevent complications.

"One case is one case too many," said Lacy Mulleavey, prevention and field services program manager for the Colorado Department of Public Health and Environment. "We need to act quickly on this."

The health department reported a preliminary count of 3,056 syphilis cases of all types in Colorado last year, which was about a 33% increase compared to the previous year.

Nationwide data for 2022 isn't available yet, but cases rose 32% from 2020 to 2021, reaching more than 176,000. Congenital syphilis affected more than 2,800 babies in 2021—an increase of almost one-third, and the highest rate since 1993. About 220 of those babies were stillborn or died in infancy.

From 2011 to 2015, rates of syphilis among women between 15 and 44 were relatively stable nationwide, but they began rising sharply in the second half of the decade. Some epidemiologists think the rise in infections among women reflects increases in injection drug use, as well as related factors that raise risk, like homelessness, HIV infection and trading sex for drugs or money.

While the majority of syphilis cases still affect men—particularly those who report they had male sexual partners—cases in women of reproductive age rose about twice as fast as overall cases, Mulleavey said. Some of the increase is due to a greater emphasis on testing, she said, because, until recent years, women generally weren't screened for syphilis in the way they were for chlamydia and gonorrhea.

There's a special emphasis on preventing and treating syphilis in women of reproductive age because of the potential harm to infants, but it's also a serious threat to men, Mulleavey said.

Most people don't develop serious complications until they've been infected for decades, but the bacteria can invade the nervous system at any point, particularly if a person has a compromised immune system, she said. Neurosyphilis can cause strokes and loss of hearing or vision.

"We have put in a ton of effort to increase provider awareness and community awareness that syphilis is still around," she said.

More screening urged in pregnancy

On April 10, Colorado's health department issued an advisory to providers reminding them that congenital syphilis is still a threat, and encouraging them to screen all pregnant patients in the third trimester, as well as the first.

While third-trimester screening isn't required under state law, it represents another opportunity to find women who were infected or reinfected after their first screening, or who didn't receive early prenatal care, Mulleavey said. About one-quarter of women whose babies had congenital syphilis in 2022 were infected during their pregnancies.

The department also urged emergency rooms and urgent care centers to screen for syphilis if a patient has relevant symptoms, or reports risk factors for sexually transmitted infections, Mulleavey said. Fewer people have been seeking testing and treatment at designated sexual health clinics, and many of them are ending up in emergency rooms or urgent care instead, she said.

Syphilis is transmitted via contact with a sore known as a chancre, which can be small or in a location that's not easily visible. Condoms reduce the risk, but don't prevent all transmission.

At some point after the chancre heals, people typically have a rash, possibly with flu-like symptoms. The infection can then go silent for years. If left untreated, the bacteria can eventually invade the brain, heart and other organs.

Insurance plans cover screening for sexually transmitted infections, and people without insurance can get testing and treatment at a state-fund sexual health clinic or from some community groups that receive grants, Mulleavey said. People who want a more private experience can order an at-home test kit, she said.

The state budget for the upcoming year also includes additional funding to expand a pilot program in the Pueblo County jail. The program offers women of reproductive age a blood test for syphilis and treatment if it comes back positive.

In the state budget for the coming year, the program would receive about $1.2 million in new state funding, which is partially offset by the loss of $365,000 from the federal government. A narrative accompanying the state budget said that will allow it to expand into El Paso and Jefferson counties, though representatives for Jefferson County Public Health declined to discuss the program until the funding is finalized.

As of 2020, El Paso and Jefferson counties had total syphilis rates below the state average. The department was looking specifically at rates of syphilis among reproductive-age women, however, as well as which health departments had the capacity to take on a new initiative, Mulleavey said.

"Ideally, we would love to be able to continue to expand it," she said.

El Paso County Public Health released a statement saying it was "particularly concerned" by the more than 500% countwide increase in syphilis infections among women of reproductive age from 2018, when 12 tested positive, to 2022, when 73 did. Overall cases in El Paso County rose 176%, from 92 in 2018 to 254 in 2022. In that time, the county ranged between zero and four babies with congenital syphilis each year.

With the grant, it would be possible for the El Paso County department to test and treat pregnant women for syphilis, on top of continuing to offer education to health care providers and working with partners on outreach, the statement said.

"With this most recent funding, EPCPH looks forward to the opportunity to partner with state and local partners to continue targeted efforts to mitigate the impacts of syphilis in El Paso County," it said.

Need for a 'united front'

Pueblo County had the highest rate of syphilis cases among women of reproductive age in Colorado, with roughly four times the cases compared to its population as in Denver, as of 2020.

Alicia Solis, program manager at the Pueblo Department of Public Health and Environment, thinks the high rates reflect both improving detection and an increase in infections. Rates of HIV, chlamydia and gonorrhea also have risen, and people who haven't received education about sexual health don't know the symptoms of sexually transmitted infections or the importance of getting treatment, she said.

About 27% of the women tested in the Pueblo County Detention Center had syphilis, usually in a later stage when it isn't causing symptoms, Solis said. At that point, a patient needs three shots of penicillin, each given a week apart.

The county's public health nurse working in the jail and a disease intervention specialist from the state health department try to follow up with everyone who leaves the jail before completing treatment, but that can be a challenge, since some people don't give their real contact information, she said.

If they do find a patient, however, they can bring the shot to her and any sexual partners she identifies wherever they're most comfortable, including at home, Solis said.

"If they choose to meet at Loaf 'N Jug, we can do that," she said.

Medical officials at the Pueblo County jail said about 69% of women who test positive there ultimately complete their treatment. Staff in the jail try to educate patients about the long-term risks to their health and to any future children they might have, but treating a disease that isn't causing any symptoms at the moment often isn't someone's highest priority after leaving jail, officials said.

There are some signs that the program is helping, because Pueblo County had fewer congenital syphilis cases in the first quarter of 2023 than it did at the same time in the previous two years, Solis said. (The data hasn't been released yet.)

Still, it's going to take more than one initiative to bring rates down, Solis said, ideally, every young person would receive education about sexually transmitted infections, every doctor would test their sexually active patients and there would be more resources for those who don't have a regular place to seek care. The Pueblo health department offers sexual health lessons in some schools and partners with community organizations, but it's not the "united front" that's needed, she said.

"I'm hoping that if we're working on all these ends, we can reduce the rates," she said. "It's going to be a team effort."

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