With Texas leading the nation in the number of congenital syphilis cases, a Texas Medical Association collaboration on new resources aims to help all physicians understand the growing public health threat and tackle it head on through improved diagnosis and treatment of the disease.
All clinicians in all specialties should be on the lookout for syphilis because the problem affects patients of all backgrounds, says Jennifer Shuford, MD, Texas’ chief epidemiologist at the Department of State Health Services (DSHS).
“We are seeing syphilis in women of reproductive age all across our state,” she said. “It’s not something that can just be identified by obstetricians. It can also be identified in emergency room visits and by primary care physicians. There are lots of opportunities for physicians … to help us decrease congenital syphilis in Texas.”
To that end, TMA’s Committee on Infectious Diseases and Committee on Reproductive, Women’s, and Perinatal Health; the Texas Collaborative for Healthy Mothers and Babies; and DSHS worked together to produce a fact sheet and CME designed to debunk persistent myths and improve physician education about the disease.
Part of the problem is that many people – including physicians – discount the threat syphilis poses to pregnant women, Dr. Shuford says.
“A lot people think that syphilis may have been eradicated and that we don’t have congenital syphilis anymore, and, unfortunately, that is not true,” she said. “In recent years, we’ve seen increases in both adults and babies.”
Texas’ high case count is coupled with its having the nation’s third-highest rate of congenital syphilis per 100,000 live births, behind New Mexico and Arizona, according to 2020 data from the Centers for Disease Control and Prevention.
“The reason this is important for physicians is that we know from our case investigations that some of these pregnant women were actually in prenatal care in time to get diagnosed and treated for syphilis, but they just weren’t treated in time to prevent a case of congenital syphilis,” Dr. Shuford said. “So, there are some missed opportunities for treatment of these women among physicians.”
Syphilis can be misdiagnosed easily because the testing for it is confusing, says Houston obstetrician-gynecologist Catherine Eppes, MD, former member of TMA’s Committee on Infectious Diseases who now serves on the Committee on Reproductive, Women’s, and Perinatal Health.
“If you have a positive test, there’s a whole wide range of things it might be, including previously treated syphilis,” she said. “You have to combine the test results with clinical exam findings and historical treatments.”
Also, some physicians don’t realize Texas law recently changed and now requires pregnant women to be tested for syphilis at three points – at their first prenatal visit, in their third trimester, and at delivery, Dr. Shuford says.
Syphilis can be treated easily with one to three doses of penicillin or related antibiotics, although the number of doses differs depending on the stage of the disease being addressed, Dr. Eppes says. Some physicians do not prescribe enough penicillin, allowing the disease to progress.
Treating pregnant women also is more complicated because it requires injectable penicillin, Dr. Shuford says.
“Benzathine penicillin G given intramuscularly can treat both the mom and the baby – it gets into the fetal compartment,” she said. “That is the only treatment we know of that can adequately treat the mom and baby during pregnancy.”
Dr. Eppes says the use of penicillin raises more obstacles for treatment because some patients are allergic to it. In those cases, the patients should go through treatments for desensitization to penicillin so they can take the medication.
She adds that the resurgence in congenital syphilis can be traced back to several causes, including lack of adequate prenatal care for low-income mothers, increased opioid use, and nonmedical factors that also drive patients’ health – such lack of transportation to and from physician appointments.