By Emily Schabacker

(CN) – Twenty-five years ago, when Cynthia Morrow worked in a New York public health office, a single case of congenital syphilis, where a baby is exposed to the infection in the womb, would spark an immediate and urgent response.

“All the alarm bells went off,” said Morrow, now the director of the Roanoke Alleghany Health District in Virginia.

Today, things are different, she said. Syphilis cases are on the rise and are stretching into broader demographics. Congenital syphilis cases, though still rare, are occurring more frequently.

“This is 100% preventable,” Morrow said. “Every single congenital syphilis case is a failure of a health care delivery system and of the public health system.”

Syphilis is a sexually transmitted infection that is curable with antibiotics. If left untreated, however, it can cause serious health problems and can be passed from mother to baby during pregnancy.

The outcomes for those babies are often devastating. Many are stillborn or die shortly after birth. Others may be born with or develop health problems shortly after birth, such as deformed bones, brain and nerve problems, jaundice or organ damage, according to the Centers for Disease Control and Prevention.

Across the U.S., congenital syphilis has tripled in recent years, according to the CDC. More than 3,800 cases were reported in 2023, the highest total since 1994.

Virginia is also seeing an upward trend. In 2024, the state confirmed 35 congenital syphilis cases, representing a 66% increase from the 21 reported the year before. So far this year there have been 17 cases.

Every year since 2016 has brought at least eight more cases than the last, said Bryan Collins, assistant director of STD prevention and surveillance at the Virginia Department of Health. While case numbers remain small in certain parts of the state, including Southwest Virginia, the increase can still signal troubling gaps in care.

Early syphilis cases are also rising in Virginia. From 2018 to 2022, the number of early syphilis cases increased by 14% statewide, according to data from the Virginia Department of Health.

Syphilis is most contagious in the first year of infection. The rate of early syphilis cases gives public health officials an idea of the overall burden in the community, Collins said. He added that once a syphilis infection passes the one-year mark, it’s significantly less contagious and tracking these cases becomes less urgent. However, long-term untreated syphilis can cause severe health issues.

In Southwest Virginia, early syphilis cases increased 79% between 2021 and 2024, jumping from 110 cases to 197. So far this year, 77 cases have already been reported. 

Demographics are shifting
Historically, syphilis was most common among gay and bisexual men. That has changed over the past decade, and cases are now emerging in more women of reproductive age. The screening needed to get ahead of the spread isn’t happening, Collins said.

That’s partly because at women’s health appointments, urine tests for gonorrhea and chlamydia are most common during routine exams, but not necessarily blood draws for HIV or syphilis.

As a result, more women are developing late stage infections.

The percentage of late-stage syphilis cases — meaning the infection has been present for more than one year — involving women of childbearing age rose from 48% in 2019 to 57% in 2023, Collins said.

“The frequency with which people are being tested, that you would need in order to identify this infection early in the course of when you can intervene, is just not really happening,” Collins said.

A baby born exposed to syphilis is the result of multiple missed opportunities for care, missed screenings, delayed or absent prenatal visits and breakdowns in follow-up and treatment, Morrow said.

The CDC has recommended syphilis testing at the first prenatal appointment since the early 2000s. The American College of Obstetrics and Gynecology supports this guidance, but expanded on it in 2024. In response to the rising syphilis rates, the college now recommends that all pregnant patients be screened at every prenatal visit, regardless of their assessed risk.

That kind of care doesn’t always happen, though, Morrow said, especially in rural areas where prenatal care may be inconsistent or delayed.

“You can see where you have to have lots of holes [in the system] for a baby to be born exposed to syphilis because there have been all of those places where we should have caught it,” Morrow said.

Fewer specialists in rural, underserved areas
Jeff Crooke has driven nearly 3,500 miles for work since he started his job with the Roanoke Alleghany Health District in 2022. He treks back and forth across the four-county district, tracking down people who may have been exposed to syphilis or HIV.

Crooke is a disease intervention specialist. His goal every day is to make contact with individuals who have likely contracted an infection and gently coax them into care. Part of his work also requires him to gather the names of past and present partners in order to seek out others who might have been exposed.

When he can’t make contact by phone or by mail, he drives to their house.

“Every day that a person is not in care, we are required to make some sort of investigative effort,” Crooke said. “Some sort of effort is made every day to move that person closer to care.”

As the only specialist in the health district, he juggles 25 to 30 cases at a time. For the most part, cases are closed within 30 days, but that’s been increasingly difficult as public health agencies endure funding cuts.

Disease intervention specialists were spared during President Donald Trump’s most recent cuts to the Department of Health and Human Services. However, the Roanoke health district lost three other disease intervention specialists during the Biden administration. Other rural health districts were left without any specialists at all.

The Cumberland Plateau district, which includes Buchanan, Dickenson, Russell and Tazewell counties, has no specialists at all, according to Collins. Health departments in other areas, like Danville, Christiansburg or Wise, often step in to help.

That added burden creates delays and risks in places where patients may already face barriers like poverty, lack of transportation or substance use, Collins said.

‘The great imitator’
Syphilis is notoriously tricky to spot. Nicknamed “the great imitator,” its symptoms resemble many other illnesses. It unfolds in four stages, beginning with painless sores that can go unnoticed.

Because early-stage syphilis is most contagious, public health officials focus on identifying and treating those cases quickly. Those who remain untreated for more than a year move into late-stage syphilis, which often doesn’t present any symptoms and is harder to treat.

Untreated infections that persist for more than 10 years can lead to organ damage and damage to the brain and nervous system, according to the CDC.

In Crooke’s interviews, he’s found that there’s a great deal of misinformation about these topics. He often hears people say that they thought syphilis had been eradicated. 

“There is this complacency at work, I think. It might be appropriate to call it a lack of respect for the severity of these infections and the commonality of them,” Crooke said.

Syphilis was nearly eradicated in the 1990s due to the widespread use of penicillin. The recent resurgence is due to several new social factors that range from fallout from the COVID-19 pandemic to the opioid epidemic to the new ways people are dating, according to Collins.

Perceptions of the public health system shifted during the pandemic, with some people developing deep mistrust or hostility toward public health agencies. Increased drug use has also led more individuals to avoid any interaction with government departments. At the same time, the rise of online dating connects people with partners they might not otherwise encounter in their daily lives, expanding the pathways for disease transmission.

Overall, it’s much more difficult to contact people with suspected infections than it ever has before, Collins said.

The people who work in this field daily, though, find that stigma is one of the greatest barriers to doing their job. Crooke, who has worked in the STI field for decades, reminds people that these infections can happen to anyone.