Congenital Syphilis: Case Increases Raise Index of Suspicion among MSAW Patients

While congenital syphilis is completely preventable, cases in the United States have risen 740.3% over 10 years -- from 462 cases in 2014 to 3,882 cases in 2023. Congenital syphilis case increases were particularly notable among women (636.4%), and men who have sex with women (410.5%)¹ during the same period. While the population most affected by syphilis remains men who have sex with men (MSM), these poorly understood changes among heterosexuals warrant additional attention and effort to prevent congenital syphilis and related infant deaths, stillbirths, and debilitating health outcomes that can affect infants that survive over the course of their life.

Of particular interest to Migrant Clinicians Network is the increased risk these recent epidemiologic changes may mean for migratory and seasonal agricultural workers (MSAWs). While current data on MSAWs and sexually transmitted infections are sparse, we know that many do not have easy access to health care or transportation, may lack insurance, may have language and financial barriers, and may move frequently, making it hard to start or stay in prenatal care.² Additionally, regular relocation may influence people to seek new partners in their new locations. An increase in the number of partners brings increased risk for the individual, and potentially for a long-term partner to whom they may return later.^3,4

Furthermore, the National Agricultural Worker Survey: 2021-2022 reports that 75% of agricultural workers identify as Hispanic/Latino and 9% as Indigenous based on primary language reported.⁵ Cases of congenital syphilis were highest among Hispanic/Latina birth parents, followed closely by Black/African American parents. Both populations, along with the American Indian/Alaska Native and Native Hawaiian/Pacific Islanders, are significantly and disproportionately affected,¹ indicating the importance of a concentrated effort to serve these communities in syphilis detection and prevention.  
 

Hutchinson teeth in children is caused by exposure to syphilis while in utero or during birth.

Community health centers (CHCs), in partnership with health departments, can increase opportunities for testing, appropriate syphilis staging, completion of treatment, and partner services. CHCs are often the most convenient place for MSAWs to seek health care, whether at a physical clinic, on a mobile unit, or during other types of outreach. Awareness of the current increase in syphilis in women and babies should drive staff to initiate conversations and services for reproductive health, plans to become pregnant, partners or changes in partners, and prenatal care if already pregnant, then initiating testing as appropriate. 

Providers should have a testing algorithm in place. The traditional algorithm starts with a non-treponemal (RPR) and follows reactives with a treponemal (EIA) to confirm. The reverse algorithm starts with a treponemal (EIA) and confirms with a non-treponemal (RPR). In the reverse algorithm, a non-reactive RPR is followed with a second treponemal (TPPA) to confirm a truly negative result. Staging is the next critical step to determine appropriate treatment. Use the Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines to ensure correct dosing by syphilis stage. (See Resources at the end of this article.) Contact your local or state health department (HD) for additional support or questions about staging or dosing.

Clinicians who have not worked with local or state HDs may not be aware of other services that are available and that could facilitate treatment initiation, completion of treatment, and follow-up with partners. For example, HDs may be able to share the specific penicillin that is necessary to adequately treat syphilis, and which many providers do not always have in stock. As mentioned, HDs can help with staging a syphilis diagnosis to ensure appropriate levels of treatment and help find a patient if they are not responding to requests for follow-up. 

Health departments also have Disease Investigation Specialists (DIS) that may be able to meet the patient at a place convenient for them to receive treatment. They often offer confidential partner services for people who are not comfortable letting a partner know that they were diagnosed with syphilis. HDs will not only attempt to call cases and their partners, but they may also go to their home or other places to find them to ensure they are aware of their potential exposure, and offer testing and treatment at a convenient time and place. 

Even when a clinic may not need those supports from a health department, it will be helpful for clinicians to let patients diagnosed with syphilis know that a DIS will reach out to them, that the DIS are not concerned with immigration status, and that conversations are confidential. They will ask about partners to ensure that any partners are tested and treated to prevent further spread of syphilis and prevent re-infection of the patient. While this may feel uncomfortable for some patients, syphilis is a required reportable condition; if the clinician does not report, the laboratory will, and HDs are required by law to follow-up on all syphilis cases. It is all about prevention and decreasing the spread of disease. 

Finally, Migrant Clinicians Network can assist patients diagnosed with syphilis and/or in prenatal care if the patient is moving. Health Network, our continuity of care program, can help find care at the patient’s new location, transfer medical records, and support follow-up care through the process. Sign up here to enroll a patient: https://www.migrantclinician.org/our-work/health-network.html

Learn more about syphilis prevention, testing, staging, treatment, and taking a sexual history: 

• https://www.cdc.gov/std/treatment-guidelines/pocket-guide.pdf 
• https://www.cdc.gov/std/treatment-guidelines/wall-chart.pdf 
• https://www.cdc.gov/syphilis/media/pdfs/2024/07/Prenatal-Syphilis-Screening-Laws-Web-Document-25-July-2024-final.pdf 
• https://www.std.uw.edu/page/clinical-guides/guides#doxy-pep 
• https://www.cdc.gov/sti/hcp/clinical-guidance/taking-a-sexual-history.html

References

1. 2024. CDC/NCHHSTP. Sexually Transmitted Infections, 2023. 2023-STI-Surveillance-Syphilis.pptx, accessed: December 2024.

2. 2024. Farmworker Justice. Issue Brief: Farmworkers and HIV. 

3. Wilson Chialepeh N, Sathiyasusuman A. 2015. Associated Risk Factors of STIs and Multiple Sexual Relationships among Youths in Malawi. PLOS ONE 10(8): e0134286 

4. Mercer CH, Jones KG, Geary RS, et al. 2018. Association of Timing of Sexual Partnerships and Perceptions of Partners' Concurrency with Reporting of Sexually Transmitted Infection Diagnosis. JAMA Netw Open;1(8):e185957

5. 2023. JBS International/US DOL. Findings from the National Agricultural Workers Survey (NAWS) 2021–2022: A Demographic and Employment Profile of United States Crop Workers. Findings from the National Agricultural Workers Survey (NAWS) 2021–2022: A Demographic and Employment Profile of United States Crop Workers. Accessed: December 2024.