“A lot of those conversations will include: ‘This is a monogamous patient that I don’t think is likely to have syphilis; aren’t these most likely false positive results?’” Dr. Eppes recalled. “Because testing is complicated, and usually two- or three-tiered, a lot of people tend to look at a patient and then make some assumptions about whether or not it’s a false positive.”
Those assumptions stem from a longstanding and unhelpful phenomenon.
“The stigma of sexually transmitted infections envelops syphilis treatment and interpretation and creates some myths that we at this point just need to completely dispel and test everybody, treat everybody, to reduce the rising rates,” said Dr. Eppes, a Houston maternal-fetal medicine physician.
Texas’ rates of syphilis – a curable sexually transmitted infection (STI) that can cause serious health problems if left untreated – and congenital syphilis, which is passed to a fetus during pregnancy or to a newborn during delivery, are sky high. The terms epidemic and outbreak both apply, according to Jennifer Shuford, MD, commissioner of the Texas Department of State Health Services (DSHS).
At fourth highest in the country, Texas’ congenital syphilis rate eclipses the national trend. In 2016, the Texas and national statistics roughly converged. Whereas those numbers had increased by between three- and fourfold nationally in 2020, Texas saw closer to a ninefold increase in the number of babies born with congenital syphilis in that same time span. (See “Epidemic Proportion,” page 33.)
With the long latency and ambiguous presentation of syphilis making it notoriously tricky to pin down, physician education – irrespective of specialty – has a role in helping to demystify the state’s epidemic by bringing it to light, enabling more pregnant patients and their partners to receive timely treatment. Leveraging first-hand experience and the proficiency afforded by a longer tenure of practice could also support this outcome.
Conversely, training targeted to younger doctors, who might operate under the misconception that the disease is obsolete, represents another opportunity to bulwark against the stealth pathogen.
“Physicians early in their career [who completed their training when the state’s syphilis numbers were much lower] may not recognize syphilis and may not be very familiar with interpreting diagnostic algorithms,” said Emily Adhikari, MD, who notes that an infection is often asymptomatic.
The chair of TMA’s Committee on Infectious Diseases emphasizes the importance of physicians maintaining clear and effective channels of communication with public health authorities. Keeping those pathways open means not having to relearn them when a public health crisis such as a congenital syphilis outbreak emerges, potentially saving valuable chunks of epidemiologic time.
The disparity in the state’s congenital syphilis statistics versus the national numbers result from a mix of several factors, according to DSHS.
“We’ve worked hard to find congenital syphilis cases using different methods, so that increases the case count,” Dr. Shuford said. “However, we also know that Texas has more than its share of STIs, at least partly because of the challenges around having the resources to test and treat STIs across such a large and diverse geographical area.”
The stark picture of Texas’ syphilis statistics came into full view in 2023.
“The number of syphilis cases in women in 2023 was five times higher than it was a decade before,” Dr. Shuford said. “When we look at congenital syphilis in 2023, our case counts were 12 times higher than they were a decade before. Those are the increases that we’re seeing, and that’s what’s worrisome.”
That year, Texas saw 930 cases of congenital syphilis across 114 counties. (See “Congenital Syphilis in Texas,” page 35.) In response, DSHS is ramping up educational efforts and pressing state legislature for increased funds to combat the infection and its cascade of devastating effects including perinatal death, stillbirth, preterm delivery, and developmental delays for the two to three affected infants born each day in Texas.
DSHS wants to invest in education for physicians and other health care practitioners, and additionally, develop a statewide hotline as a resource for physicians to consult for help in making or staging a diagnosis and in determining how best to treat a newborn with congenital syphilis, Dr. Shuford says.
TMA testified in support of a legislative budget exceptional item in the fall seeking additional resources to fund those priorities, with an overarching goal of empowering DSHS to improve timely diagnosis and treatment of mothers and infants, bolster investment in health care infrastructure, and expand access to care in all areas of Texas to curb the syphilis epidemic. Congenital syphilis prevention also figures into TMA’s legislative priority to support women’s health. (See “Improve Women’s Health and Clarify Life-of-the-Mother Exceptions,” page 22.)
In September, DSHS hosted a Congenital Syphilis Summit in Houston for maternal and pediatric health care professionals, public health experts, and community health workers.
At the summit, Dr. Eppes presented new American College of Obstetricians and Gynecologists guidance for testing for syphilis in pregnancy that aligns with the state’s thrice-mandated screenings: at the first prenatal visit, during the third trimester, and at birth. The presentation included flowcharts for parsing complex screening algorithms and treatment protocols. It also included tools to assist physicians in recognizing, diagnosing, and treating patients with syphilis.
Educating Texas Physicians
Along with facilitating communication between institutions and community health partners, shedding stigma and enhancing awareness is key. The myth that which patients are at risk for sexually transmitted infections will be obvious to physicians crumbles under the weight of the state’s syphilis statistics, Dr. Eppes says.
“It needs to be standardized testing and treatment for everyone,” she said.
Dr. Adhikari, a maternal-fetal medicine physician and medical director of perinatal infectious diseases for Parkland Hospital System in Dallas, points to guidance issued by the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force, which base their recommendations on a patient’s age, sexual activity, history of sexually transmitted infections, and drug use. Departing from that short list of factors doesn’t align with science, she says.
“If we start to implement judgment calls [about who is or isn’t at risk] based on, for example, race or ethnicity, we do that not in a framework of what is evidence-based guidance,” she said. “That represents a missed opportunity and perhaps bias on the part of a clinician.”
The complexities of some co-occurring conditions, for example substance use disorder, highlight the usefulness of universal screening for sexually active patients.
“We can’t elicit all of the nuanced information to determine risk behavior sometimes, so we just need to understand that if a person is having sex, that person is eligible for screening,” Dr. Adhikari said.
A syndemic approach, which Dr. Adhikari advocates for, works as a sort of clinical Venn diagram through which to view a given patient’s constellation of conditions that may overlap and interact in ways that affect their disease burden.
CDC’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention notes that syndemics are compounded by intersecting disparities that drive poor health outcomes, including disparities that occur based on gender, race, ethnicity, education, income, disability, geographic location, and sexual orientation, and are directly related to nonmedical drivers of health, including poverty, unequal access to health care, stigma, and racism.
Something as basic as transportation can derail syphilis treatment completion, particularly in rural areas, where a local health department might lack partner treatment services.
“That means that the patient, in order to get [his or her] partner treated, [has] to go to the regional health department, which may be an hour or two drive,” Dr. Adhikari said. “If a patient and partner don’t have a car, that’s not going to happen, so then they’re just going to reinfect each other. If you don’t provide public health services near the patient’s location, then you’re not going to solve the problem.”
While the legislature deliberates the fate of the exceptional item that could finance novel solutions to a decade-long problem, DSHS offers a slew of data-driven tools to serve and educate physicians – syphilis and congenital syphilis dashboards that break down the numbers by county and a congenital syphilis webpage that links to dozens of resources, including information about free, 24/7 telehealth support for physicians who treat neonatal congenital syphilis among them.
Dr. Adhikari, who was interviewed on DSHS’ six-episode podcast, “Exploring an Epidemic: Congenital Syphilis in Texas,” leads a TMA work group on syphilis and congenital syphilis. The group is developing a quick-reference CME document that delves into various case presentations, which includes a poster-like diagram that walks through the screening algorithm, expected to be available in February in the TMA Education Center.
She names streamlined referrals, outreach and education, and collaboration between clinicians and public health entities as key tools in the arsenal to combat syphilis in Texas.
“I think there is hope. It just takes a lot of time, and it’s being built. But I think it’s working. It just feels like we’re still climbing the mountain,” she said.