Editor's note: This article was updated Feb. 26 to show that 18 states, including Michigan, have screening requirements in a woman’s third trimester for all pregnancies or for those considered at high risk of infection.
Some of the communities hit hardest by the opioid epidemic and a related methamphetamine spike also are facing another health crisis: a steep rise in syphilis.
It isn’t a coincidence.
Many opioid users have started to use meth, either in combination with opioids or as a cheaper, more accessible alternative. Stimulants such as meth are even more likely than opioids to promote risky sexual behavior that increases the likelihood of contracting syphilis and other sexually transmitted diseases.
Women are increasingly susceptible as their drug use continues to rise, and more of them are passing on the disease to their infants — with deadly results.
Many addicted pregnant women forgo prenatal visits for fear of being drug tested and losing custody of their babies, doctors say. And mothers with untreated syphilis have an 80 percent chance of infecting their unborn babies, contributing to a growing crisis that many states have tried to combat in recent years.
In adults, syphilis can be cured with a course of antibiotics. But syphilis among newborns, called congenital syphilis, can cause deformities, severe anemia, an enlarged liver and spleen, jaundice or brain and nerve problems such as blindness or deafness.
Up to 40 percent of babies born to women with untreated syphilis may be stillborn or die as a newborn, according to the U.S. Centers for Disease Control and Prevention.
Sixty-four infants were stillborn in 2017; another 13 died sometime after birth. (The CDC does not have data on how long after birth the newborns died.)
Most upsetting of all, say health professionals, is that all congenital syphilis cases — and all the deaths from the disease — are preventable.
“Every case of congenital syphilis is considered a failure of the health care system,” said Taryn Couture, senior manager of policy and government relations at the National Coalition of STD Directors, “because it should be caught in the first prenatal visit that every woman has.”
The use of meth, heroin and other injection drugs among women with syphilis more than doubled between 2013 and 2017, according to a CDC report released this month. The report doesn’t include data on opioids other than heroin, but CDC spokesman Brian Katzowitz said the agency plans to add that information to future reports.
Despite the missing data, Couture said, “There’s a clear connection, as we’re seeing, between drug use, the opioid crisis and the rise of syphilis and congenital syphilis.”
Syphilis transmission is most common among men who have sex with men, and those cases accounted for most of the 30,000 syphilis infections reported in 2017.
But cases among heterosexual men more than doubled between 2013 and 2017 — a spike that signifies “heterosexual syphilis and drug use, particularly methamphetamine use, are connected and interrelated epidemics in the United States,” according to the new CDC report.
Meanwhile, more women are becoming infected: from 1,500 in 2013 to 3,722 in 2017. In many states, public health officials are witnessing the interconnected epidemics firsthand.
In Kentucky, the “main reason” for an outbreak of congenital syphilis in late 2017 was “the prevalence of opioids,” said Chang Lee, program director for the STD Prevention and Control Program at the Kentucky Department for Public Health.
Angel Stachnik, senior epidemiologist at the Southern Nevada Health District, estimated that nearly half of the congenital syphilis cases among infants in her region “involve some type of substance abuse,” meth tending to be “high-prevalence.”
Women who have received late or no prenatal care make up about a third of those who give birth to babies with congenital syphilis, according to Virginia Bowen, an epidemic intelligence service officer at the CDC.
Even women who do receive early prenatal care aren’t entirely in the clear, health professionals say, because they might miss opportunities to get treated, or to be re-screened in late pregnancy.
The CDC recommends syphilis screening at the first prenatal visit for all women, as well as early in the third trimester and at delivery for women at high risk of infection.
All but six states — Iowa, Minnesota, Mississippi, New Hampshire, North Dakota and Wisconsin — require prenatal syphilis screenings.
Most require women be tested at the first prenatal visit, though 18 states have screening requirements in a woman’s third trimester as well, either for all pregnancies or for those considered at high risk of infection.
Still, many pregnant women — particularly women of color — are slipping through the cracks. In 2017, nearly 39 percent of congenital syphilis cases, in which the race of the mother was known, were newborns with black mothers. Black mothers were more than six times more likely than white mothers to give birth to a baby with syphilis.
“A lot of the problem is non-awareness among physicians of the burden that’s in their community,” said Sandi Larson, Nevada’s state epidemiologist. “Specifically, in some of our rural communities, physicians don’t see syphilis; they don’t test for it — it’s just not on their radar.”
Women, too, don’t always know how best to protect themselves against STDs. One in three women who gave birth to a baby with syphilis in 2016 did get screened during pregnancy, but either acquired the disease after being tested or were not treated in time to prevent the infection of their newborns, according to the CDC.
Experts say states need money to raise awareness and provide treatment. Federal opioid funding, largely reserved for fighting HIV and hepatitis C, has left the fight against syphilis behind, Couture said.
Still, officials at the CDC say they’re trying to focus on low-cost efforts. In 2015, the agency’s Division of STD Prevention “started to look really closely at what causes and factors were at hand,” Bowen said, “and try to unpack what the missed opportunities are in a woman’s life that ultimately lead her to deliver a baby with congenital syphilis.”
Based on their findings, CDC researchers offered guidelines for clinicians to intervene and prevent congenital syphilis.
“But we do understand that there’s a second layer involved here, and it’s not all clinical interventions,” Bowen said. “The layers reflect how complicated these women’s lives are — it’s not just as easy as saying, ‘You just need to get to the doctor for prenatal care.’”
Between 2016 and 2017, congenital syphilis rates rose 60 percent in the South and 41 percent in the West, compared with 6 percent climbs in both the Midwest and Northeast. States reporting the highest rates of congenital syphilis in 2017 were Louisiana, Nevada, California, Texas and Florida. Across the country, cases ranged from zero in states such as Wyoming and Maine up to 281 in California.
Source: U.S. Centers for Disease Control and Prevention, "Sexually Transmitted Disease Surveillance 2017"
The CDC distributed its plans, along with $4 million for prevention efforts, to seven states — California, Florida, Georgia, Louisiana, Maryland, Ohio and Texas — as well as two cities: Chicago and Los Angeles.
“By working really closely with these nine,” Bowen said, “we think we can have a national impact.”
The states and cities receiving the money will review each 2017 congenital syphilis case to identify mistakes, such as a lack of prenatal care or a failure to screen for the disease in the third trimester.
“We want jurisdictions to get into the habit, any time they have a case of congenital syphilis, to convene their partners and to talk as a group about what the missed opportunities were, and how a case like that could be prevented in the future,” Bowen said.
In Texas, two case review boards in Houston and San Antonio have helped shed light on lesser-known issues.
For example, case reviews in the state revealed that many pregnant women with syphilis are Medicaid recipients who don’t have access to transportation. Although Medicaid transportation is available to the women, many face child care issues with other young children and Texas state law prohibits those children from using the free transportation.
As a result of those findings, two Texas state representatives, Democrat Mary González and Republican Dade Phelan, have sponsored bills that would allow women to bring their young children with them on Medicaid transportation.
“As we’ve been working on this legislation, we’ve realized just how significant the access gap to prenatal care is,” González said.
“That’s an example of how these case review boards allow us to go from the micro — of the women and the child — to the macro: finding the system-based issues that can be reformed,” said Judy Levison, an obstetrician-gynecologist and a professor at Baylor College of Medicine.
California, Florida, Texas and Nevada (which didn’t receive the CDC money) also have created social media and advertising campaigns targeted at women. And they are sending public health officials to doctors’ offices to discuss prevention and treatment.
“Physicians are usually really busy and can’t be up to par on every single recommendation that comes out of the CDC or other types of health agencies,” said Nevada’s Stachnik. “So we, as a public health department, are playing a bigger role in trying to educate our public health providers.”
Nevada public health officials also are urging agencies that provide food stamps and other public assistance to talk to young women about prenatal care and syphilis testing. The state saw 21 cases of congenital syphilis in 2017 and had the second-highest rate in the country.
Some states are turning to legislation. Michigan passed a law at the end of 2018 requiring syphilis testing during the third trimester, as did Connecticut in 2017. A similar bill was introduced last year in Ohio.
State Rep. Thomas West of Ohio, a Democrat who sponsored the bill in his state, said he plans on “moving the bill pretty aggressively.”
“I didn’t sense any opposition to the bill,” West said, “and I don’t see why anyone would actively vote against it, especially when the rates of infant mortality are this high.”