Opinion: As a physician, I have never been more concerned about rates of congenital syphilis

In 2024, the Centers for Disease Control and Prevention reported nearly 4,000 new cases of syphilis in babies, the highest case number since the mid-1950s. Typically about 5%-10% of those reported cases are stillbirths or die soon after delivery. Many surviving babies are left with lifelong disability or developmental delay.

The increase reflects the national loss of syphilis control that began with the Great Recession and the defunding of local public health programs in 2008. As a physician and former public health official, I have never been more concerned about those rates of congenital syphilis.

Congenital syphilis is a sentinel event demonstrating failure of the local public health program.

Evaluations by the CDC have shown that most cases of congenital syphilis are due to pregnant women not being tested and, among those who test positive for syphilis, not getting treated. Some pregnant women miss out on prenatal care because of lack of insurance, poor access, fear of immigration detention, or other medical conditions like substance use or mental health problems, but even among those who receive prenatal care, only about 80% are tested .

To control congenital syphilis , the U.S. needs to treat it as a preventable outcome of missed screening, missed treatment, and missed follow-up. The playbook is well known. What’s been missing is consistent execution and capacity.

Public health must work toward making prenatal care early, easy, and universal, with same-week prenatal care entry, walk-in and telehealth options, and evening and weekend clinics. Instead of cutting public insurance programs, Medicaid should be expanded, with presumptive eligibility in pregnancy, and have zero-cost visits, laboratory testing, and transportation. Prenatal services should be co-located where people already are, such as in Women, Infants and Children program sites, substance-use clinics, jails, reentry programs, or homeless shelters.

While nearly all states have legislated mandates for syphilis screening in pregnancy, and often up to three tests in pregnancy, public health needs to hold medical providers and health systems accountable for any lack of compliance. For those individuals and organizations not screening, public reporting of failures to test and medical-legal action could be pursued. Like other screening interventions in medical systems, reminder prompts need to be built into electronic health records systems with hard-stop order sets, monitoring dashboards, and standing nursing protocols.

Given that syphilis treatment is safe and highly effective, medical providers should follow national and expert recommendations to treat immediately upon an initial positive screening test without waiting referral or additional testing. To make immediate treatment possible, same-day injectable benzathine penicillin G has to be available in clinics and any testing location.

Easy availability of injectable penicillin may prove difficult. Injectable penicillin availability has been a problem over the past decade, with shortages , stock-outs, and recalls . Government agencies need to guarantee reliable penicillin supply and access with state and regional rotating stockpiles, rapid redistribution, and clear allocation protocols.

Who can administer injectable penicillin should be expanded to include trained nurses and pharmacists per state scope-of-practice rules. Clinics and testing sites need support with logistics and reimbursement, so they keep injectable penicillin on hand.

For longer-term impact, Congress must fund the CDC to support technical assistance to localities. Congenital syphilis prevention depends heavily on public health staff and outreach. States, counties, and cities must have an adequate number of disease intervention specialists for speedy case investigation, partner services, and linkage to care. Programs need to set and regularly report performance targets such as percent of pregnant women tested, the time from a positive test to treatment , and the percent treated adequately before delivery.

Local health care organizations and systems need to engage in real-time monitoring and accountability, with dashboards for pregnancy-associated syphilis, treatment timeliness, and missed screening. For every case, maternal-child clinical care teams should hold a “sentinel event” review (like maternal mortality reviews) to identify where the system failed and fix it.

With advances in technology, there are now three Food and Drug Administration-approved rapid point-of-care tests that are inexpensive and provide results in less than 15 minutes. Rapid point-of-care syphilis tests should be deployed in emergency departments, urgent care centers, shelters, correctional settings, and mobile clinics. Emergency departments should have “pregnancy and syphilis fast track” pathways for those not receiving prenatal care. In one study , the use of rapid syphilis testing in pregnant women in an emergency department increased…