Syphilis study underscores need for coverage of treatment gaps for pregnant patients

Last fall, AHCJ published a tip sheet for reporting on the syphilis crisis, including the need to highlight racial and ethnic disparities in diagnosis and treatment. Following that theme, NPR reported in March on one of the hardest hit demographic groups - Native Americans.

New Mexico, which has a substantial population of Native Americans, reported the highest rate of congenital syphilis in the U.S. Similarly, South Dakota, another state with a sizable proportion of Native Americans, topped the list for primary and secondary syphilis infections.

The previous tip sheet already provided an excellent overview of the factors contributing to the surge of syphilis cases in addition to prevention and treatment efforts. Since then, AP reported on the 9% overall rise in cases in 2022, and the CDC published a report in February describing the most current statistics available on maternal syphilis rates during pregnancy from 2016-2022.

That CDC report revealed that the rate of syphilis in mothers giving birth in the U.S. more than tripled during that five-year period, from 87.2 to 280.4 cases per 100,000 births. In line with NPR's reporting, rates rose most in American Indian and Alaska Native non-Hispanic mothers, but rates increased across all racial/ethnic demographic groups and particularly in mothers under 20 years old.

Where we are now

In April, researchers published a study in Obstetrics & Gynecology that takes a closer look at the treatment status and prenatal care among those diagnosed with syphilis during pregnancy from 2018-2021. The results drive home the importance of continued coverage on this public health crisis and on the overall need for pregnant people to receive timely prenatal care to curb congenital syphilis transmission.

Nearly one in three pregnant patients with a syphilis diagnosis received inadequate treatment or no treatment at all for their infection, and those without timely prenatal care were more than twice as likely to receive inadequate or no treatment. Those with reported substance use were twice as likely not to receive adequate treatment, and those with a history of homelessness were nearly twice as likely not to.

"These findings underscore gaps in syphilis screening and treatment for pregnant people, especially those experiencing substance use and homelessness, and the need for systems-based interventions, such as treatment outside of traditional prenatal care settings," the authors concluded.

Key takeaway: This study's conclusion holds a wealth of opportunity for reporters to discover how hospitals, Federally Qualified Health Centers (FQHCs), nonprofit groups, homeless shelters and other community resources and institutions in their area are attempting to meet this clearly unmet need among pregnant populations.

Study method

The researchers relied on data from six states reporting to the CDC's Surveillance for Emerging Threats to Pregnant People and Infants Network, or SET-NET: Arizona, Georgia, Michigan, New Jersey, New York, and Washington. (Note that these do not even include the states that top the lists for congenital and primary/secondary infections.)

Then researchers compared the demographics, clinical factors, syphilis stage and treatment status during pregnancy. The treatment status was defined as adequate or inadequate based on the CDC's Sexually Transmitted Infections Treatment Guidelines, 2021, or as untreated. The researchers also looked at whether the pregnant patient received prenatal care that was timely (at least 30 days before birth) or non-timely (less than 30 days before birth), or if they did not receive prenatal care at all.

Among the 1,476 people included in the study who had syphilis during pregnancy, just over half (58%) were adequately treated, leaving four out of 10 patients (42%) who were inadequately treated or not treated at all. A far greater proportion of the patients (82%) received timely prenatal care.

It was unsurprising that patients with non-timely prenatal care or no prenatal care were 2.5 times more likely not to receive adequate treatment or any treatment. However, nearly a third of patients (32%) who did have timely prenatal care still received inadequate treatment or no treatment for their syphilis infection. About half of that group (15%) didn't receive any treatment - despite receiving prenatal care at least a month before delivery.

The authors noted that "inadequate treatment was most frequently related to prenatal care initiation less than 30 days before pregnancy outcome," but it still leaves open questions about the other half of women who did have timely prenatal care yet weren't treated at all - a question ripe for reporting in any state given how widespread the crisis is.

Why the gap in treatment?

One possible reason for inadequate treatment, the authors speculate, could be lack of clinicians' awareness about the need for immediate treatment with benzathine penicillin G after diagnosis. It was clear from the findings, they wrote, that syphilis testing and treatment is likely already happening outside of traditional prenatal care.

"Patient counseling at the time of testing or coordination with health departments might address these issues and create opportunities to educate and plan for future benzathine penicillin G doses, if indicated," the authors wrote. They also mention the potential lack of time and administrative support clinicians have for rapidly getting results, communicating with the health department, and facilitating speedy treatment, particularly when there have been shortages of benzathine penicillin G.

Finally, the authors offer up other clinical factors that could have contributed to inadequate treatment: "syphilis testing and treatment recommendations that are difficult to interpret and implement, diagnostic algorithms including two-step testing, test turnaround time, the need for intramuscular injections, multidose regimens with defined dosing intervals for late latent or unknown syphilis, and inadequate partner treatment options."

Each of those potential factors could be something for journalists to ask about while reporting on this issue.