For a seasoned professional like Stafford, the sheer numbers are startling. She’s been treating congenital syphilis with increasing frequency in recent years in a city that has the state’s highest newborn infection rates.
“People think that syphilis is gone,” said Stafford, a maternal-fetal medicine specialist and associate professor at McGovern Medical School at UTHealth Houston. “Syphilis has become an epidemic.”
Last year, syphilis cases across Texas rose by 22%, according to preliminary numbers, from 21,476 in 2020 to 25,991 in 2022, the most recent statewide data available. That’s more than double the number of cases reported in Texas five years ago.
While nearly every case is easily treatable with penicillin, untreated syphilis can be passed from an infected pregnant patient to the newborn and can result in the child’s death. Officials in Harris County, which includes Houston, announced in 2021 that syphilis-related fetal deaths increased from four in 2019 to 14 in 2020.
In 2021, Texas reported its highest-ever number of cases in newborns, at 685, according to the Texas Department of State Health Services. Then that number jumped another 39% last year to 950, preliminary state data shows.
That same year, 2,855 cases of congenital syphilis were reported in the U.S. including 220 congenital syphilis-related stillbirths and infant deaths, up from 141 in 2019.
After steadily rising for more than a dozen years, the rates have gotten so high that earlier this year, officials with the pharmaceutical giant Pfizer announced a penicillin shortage that they blamed squarely on the demand created by soaring syphilis rates in the United States.
Most of the biggest leaps in syphilis cases occurred during the pandemic because of limited access to preventive health care.
Two years after a COVID vaccine was made available and the need for social isolation has decreased, recent statistics show that the pandemic-era spike in syphilis infections may be slowing. But the number of cases remains on the upswing as infected young adults pour through the doors of doctors’ offices, hospitals and public health centers.
Officials say they are desperate to shut down the epidemic as it rages in record numbers and in nearly every county from the Gulf Coast to the Texas Panhandle.
What concerns healthcare workers the most is that the biggest jump is among adults of child-bearing age, and in newborns. Known as congenital syphilis, the disease in newborns can result in the baby's death up to 40% of the time, although the chances drop to 2% if the parent is treated at least 30 days before giving birth.
In Lubbock, where officials have seen an overall 500% increase in syphilis cases since 2019, health officials say significantly more babies have been born with the disease this year, leading to birth defects and, in some cases, deaths.
Early data shows more than 30 local cases of congenital syphilis have been reported to the Lubbock Health Department in the first half of the year, said Katherine Wells, the city’s public health director.
Last year, there were fewer than 10.
The increases have frustrated Wells, who said there was a stillbirth recently because of untreated syphilis.
“It’s really devastating,” Wells said. “She didn’t deserve to lose her baby.”
Complicating the effort to stop the spread is a national shortage of Bicillin, an injectable variety of the penicillin that is especially effective for pregnant people. Officials with the drug’s only U.S. manufacturer, Pfizer, said earlier this year that they underestimated what the demand would be and supply would be limited until next year.
Health officials in Texas have only been able to obtain 25% of their normal stockpile since April, although they are being told by Pfizer that they may be able to replenish by the end of the year, according to Douglas Loveday, a DSHS spokesperson.
DSHS is providing penicillin to local departments, which are seeing more patients referred to them by private providers who can’t get the treatment at all, Loveday said.
The agency is instructing providers to save their limited stock for pregnant patients with syphilis and use a three-week oral pill regimen to treat lower-risk patients.
With the shortage potentially lasting until next summer, Wells, Lubbock’s public health director, worries about how long her department can keep pregnant patients safe from the disease.
“Not getting these women treated and them having birth defects, that’s where my concern is from a public health standpoint,” Wells said.
An alarming increase
In Lubbock, a healthcare hub near the Texas Panhandle where rural people come from all over for screening and treatment, the syphilis infection rates have increased quickly over the years.
“We haven’t been able to get control of it,” Wells said.
The COVID-19 pandemic played a key role in the recent rise in cases.
People had reduced access to routine medical care like checkups and sexual health screenings because health care providers were inundated with coronavirus patients and people were in lockdown, said Dr. Ericka Brown, Harris County Public Health’s deputy director, who heads the health and wellness division.
A pandemic-era rise in opioid addictions, which increase STD risk, and a rise in casual sexual encounters fueled by social media — as well as the social overcorrection that likely occurred when people came out of isolation and were able to freely interact again — are also contributing factors, medical experts say.
Not unrelated is the fact that the reports of gonorrhea, which is typically screened alongside syphilis, shot up almost as much in 2020 as they had over the previous five years.
Federal health officials have also expressed concern about a downward trend in condom use by men, from 75% in 2011 to 42% in 2021, as a risk factor in skyrocketing STD rates. Syphilis is one of the sexually transmittable diseases that can be passed on in spite of condoms, particularly if the condom does not cover an infectious sore elsewhere on the body. But the risk of transmission can be reduced with regular use of them, officials say, although they call the trend just one of several contributing factors.
“There are all kinds of intersecting problems,” said Dr. Catherine Eppes, a Houston OB-GYN and a member of the Texas Medical Association’s committee on reproductive, women’s, and perinatal health.
Potentially contributing to the increase, state health officials say, is the fact that health officials have been making a better effort since 2017 to identify cases of congenital syphilis. But Eppes said a more meticulous count would not account for the significant rise in the infection rate.
“I would hope that we're more aware of how big of a problem it is and so people are screening more,” she said. “But I think, sadly, and probably more realistically, is that the increase that we saw over the last few years is just continuing. We're seeing much higher rates.”
An Old World disease
Syphilis is a bacterial infection that is passed through direct contact with an infection-related sore, usually through sexual intercourse, but can also be transmitted through sharing of needles.
The illness is not passed through casual contact with people or items, according to the Centers for Disease Control and Prevention.
Those most at risk are people who have unprotected sex with multiple partners, and those in relationships with people who have that lifestyle, according to the CDC.
But anyone who has sex is at some risk, because the infection can be present for years either with mild, vague symptoms or even more serious complications that may not point immediately to syphilis, said Stafford, the Houston OB-GYN.
The infection is known as “the great imitator” because its early symptoms of red bumps, fatigue, fever and similar signs can mirror other illnesses, from chicken pox to an allergic rash to the flu. Only 50% of people with syphilis even know they have it, Stafford said.
Half of those who test positive don’t have the classic risk factors that would have led them to do regular screenings, Stafford said — no drug use, no high-risk sexual activity. It’s most contagious in the first year or so after exposure, but syphilis can be passed along at any time while a person is infected.
Most of the new cases appear to be among men, ages 25-34, and women, ages 20-24, Brown said.
Communities of color and people earning lower incomes are disproportionately affected by the disease — more prevalence and higher death rates — because they tend to have less access to health care, Eppes said.
Left unchecked, it can lead to serious health consequences that include blindness, heart problems, organ failure, and mental illness.
Documented by historians and in literature since at least the Middle Ages, syphilis was thought to be have killed such storied figures as artists Paul Gaugin and Edouard Manet, author Oscar Wilde and Chicago gangster Al Capone before penicillin became widely available as a treatment.
The disease was nearly eliminated in the U.S., reaching an all-time low around the year 2000, after peaking in the 1950s.
Then in 2021, the U.S. recorded more cases of syphilis than it had in its history.
All hands on deck
State and local health officials are stepping up their efforts to educate doctors and the public about the prevalence of the infection, the importance of regular screening and safe sex practices, and the deadly risks of leaving syphilis untreated.
In 2022, Texas health officials produced a six-episode podcast educating public health workers and agencies that care for people of reproductive age and their babies about the screening, treatment and prevention of syphilis in newborns.
That same year, the state agency conducted syphilis training for health care workers in the Rio Grande Valley and partnered with health officials from the Denver STD Prevention and Training Center to host a webinar, as well as a congenital syphilis symposium attended by over 100 doctors, nurses and other healthcare workers from across Texas, Loveday said.
Cities have put up billboards while health departments and physician groups are hosting webinars to train doctors, and public health departments are offering free mobile screening clinics and free syphilis treatments to respond to the problem.
With the help of a $3.3 million research grant earlier this year, Stafford and a group of collaborators across the nation are working on developing a better test for syphilis diagnosis with the support of regional health departments.
She also worked with Harris Health System leadership to create an alert within the electronic health record at two major public hospitals in the area, Houston’s Ben Taub and Lyndon B. Johnson hospitals. If a syphilis screening hasn’t been done on a pregnant patient either at intake or at 28 weeks for pregnant patients, the system alerts physicians.
“It’s all hands on deck,” said Stafford, who leads a perinatal syphilis program once a week at UT Physicians in Houston.
The Lubbock Health Department has a team dedicated to tracking and treating syphilis patients. However, the federal funding for that expires next year. Wells is concerned that when it does, the disease will spread untreated throughout the community.
“We did not have enough people here on the ground to really keep STDs under control before,” Wells said.
In Harris County, officials have begun work on a robust public awareness campaign to push free testing and treatments.
“It is being well received,” Brown said. “I think the fact that people can get tested for free and get treated for free is really sparking more interest. We want to make sure that we're removing all barriers so that people can make sure that they're safe and healthy.”
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