In the debut episode, podcast host and DSHS program consultant Larry Prescott speaks with guests Dr. Virginia Bowen of the U.S. Centers for Disease Control and Prevention and Jessica Del Toro, DSHS Congenital Syphilis Epidemiologist. These experts review congenital syphilis data and trends at the state and national levels and discuss Texas’ enhanced surveillance activities. They also examine the factors contributing to Texas ranking first in the United States in reported congenital syphilis cases.

Larry Prescott: 0:00

Welcome to Exploring and Epidemic: Congenital Syphilis in Texas. I'm your host, Larry Prescott.

In this podcast series, we'll be exploring what's happening with syphilis and congenital syphilis in Texas through interviews with national and local experts. We’ll talk about babies being diagnosed with congenital syphilis in Texas. And we’ll also discuss how we, as a care community, can address the rising rates of congenital syphilis in Texas. After all, this is a 100% preventable disease with tests and treatment at our disposal if we all do our part.

I'd like to begin our first episode of this series by taking an in-depth look at how syphilis and congenital syphilis is impacting our country and the state of Texas.

I have with me today two experts who are going to help us understand current trends in the United States and how Texas has been affected.

Dr. Ginny Bowen: 0:49

My name is Dr. Virginia Bowen, and I am an epidemiologist in the CDC division of STD prevention. My main job is to help monitor trends nationally, but also to work with state and local health departments, to make sure that they are able to keep tabs on their own rise and fall in cases and work with them on prevention and surveillance.

Jessica Del Toro: 1:08

My name is Jessica Del Toro. I am the congenital syphilis epidemiologist for the Texas Department of State Health Services. I conduct analysis on the data associated with congenital syphilis to include screenings, surveillance efforts, epidemiological trends, and public health followup.

Larry Prescott: 1:30

Before I begin today, I’d like to begin with Dr. Bowen. Dr. Bowen, thank you for being here with us today, and please tell us about the current trends of congenital syphilis.

Dr. Ginny Bowen: 1:38

Thanks for having me, Larry. I appreciate it. Folks that don't know the history here in the U.S. probably are not aware that we almost reached a place where we could say that congenital syphilis was eliminated in the United States 20 years ago. We were so close. We had about 300, 350 cases of congenital syphilis reported in one year. And everybody said, this is it. We can

do it. We can make this final push and we can get to whatever that magic number is. And the truth is that was 20 years ago and it didn't really happen.

The grow kind of happened slowly and it started on the west coast. They saw the first signs of this increase, and then it kind of slowly trickled across the United States and everybody else began to see the same increases as well. So here we are now and for the past eight years, I would say, we have seen increases in congenital syphilis in all regions of the United States. All racial and ethnic groups of women are delivering babies with congenital syphilis. Almost every state in the United States is now reporting at least one case of congenital syphilis. It's a different place than we were at 20 years ago. And it's an unfortunate place for us to be. But the fact that we've reached very, very low levels before, gives me hope that we can do it again.

Larry Prescott: 3:18

You know, I'm reminded of something. A few years back the Centers for Disease Control put out a project called Syphilis Elimination. And during that time I was working with that project, we brought the information out about syphilis elimination it was the same point. We thought we could eliminate syphilis from the United States as well.

But I found that doing work with that project, that the more information that we put out about signs and symptoms, people became more aware of it and our rates went up higher. We found more cases. Is that the same with congenital syphilis?

Dr. Ginny Bowen: 3:45

It's a good question, Larry. I mean, I think a lot of times when we draw attention to an issue and we really do ramp up our efforts to diagnose more syphilis. We should really expect that our case counts, our numbers, are going to go up. And that seems like the logical thing that you would want to see happen first when you're doing a good job at unearthing a disease that can sometimes be asymptomatic. I mean, we have women walking around right now in the United States of America who have no idea that they have syphilis and it's just due to the natural history of the disease.

You know, they may have had a chancre, and it may have gone unnoticed because it was painless and then it resolved on its own. And then they may have had a very mild rash and they might have written it off and said, this is my laundry detergent. And then that goes away on its own. And here we are. And we're in a place now where she or he is walking around with no signs and symptoms of disease, may still be infectious to others, certainly might still be infectious to a fetus if they were carrying an infant. We want to diagnose all of that asymptomatic or what we call latent disease. And that would be the first step if we do our jobs well, and we really do implement new expanded screening opportunities to men and women we're going to see our case counts go up before we see them go down.

I'm not a hundred percent sure that the increases we're seeing right now are just due to fantastic screening. I think we still have a long ways to go on that front.

Larry Prescott: 5:09

Can you tell us why you think the rates are going up? And, if I can put a follow-up question to that, why syphilis and why now?

Dr. Ginny Bowen: 5:15

I think what we're seeing right now is actually a resurgence of heterosexual syphilis. We have seen slow and steady increases in syphilis among men who have sex with men, what we sometimes call MSM. For the past 20 years, those rates have gone up, up, up. And we really only saw a leveling off of syphilis among men who have sex with men for the first time last year we were able to say, “wow, this looks like we may have turned a corner on MSM syphilis.” We're certainly seeing a slowing and maybe a leveling off, but at the exact same time that we're seeing this among men who have sex with men, we're seeing big increases in syphilis among women and men who have sex with women.

So, why now? We really believe that at one point in time we had a super-strong network of specialty STD clinics that cared for patients with these concerns, that might've been otherwise stigmatizing. Things that you didn't want to talk to your primary care doctor about.

We have seen a bit of a fracturing of our specialty STD clinics in the United States as more and more folks tend to turn to a medical home, like a primary care physician, for this type of care. In general, in the United States, we've seen a lot of disruptions in health care over the past decade, and it's hard to put a finger on whether that is a problem. We also have seen some trends in other social and behavioral things in the United States. We have seen increases in drug use in the United States in the past decade. So there's no denying that there may be a piece at play there as well.

Larry Prescott: 6:48

So we see there’s a number of variables involved, it could be contributing to the increase in these rates and everything affecting us right now.

Dr. Ginny Bowen: 6:54

Yeah, absolutely. A lot of things involved all at one time, hard to tease apart who’s a greater contributor.

Larry Prescott: 7:00

In regards to congenital syphilis then, how do you think Texas compares with the rest of the nation?

Dr. Ginny Bowen: 7:05

You know, a few thoughts about Texas.

That tripling in a two-year period is incredibly fast and high. I know you are a very large state in Texas, so it makes sense from a case count perspective that you would have a lot of cases, but you also have one of the highest rates in the

nation, which means on a per capita basis, syphilis among women and congenital syphilis are both quite high in Texas right now.

And I think that might be due to the fact that the state has made some really great strides in the past five years in expanding screening for syphilis, among pregnant women. So I think it could be hinting at what we talked about earlier, Larry, which is that as you look for more syphilis, you're probably going to find more syphilis.

So I do think that this is not all a bad thing, but it is something that we're watching and keeping an eye on. And we want to make sure that we've really expanded that screening to a place where everyone's infection can be found, especially during pregnancy.

Larry Prescott: 8:23

Yeah. I'm in total agreement with the expanded testing. Like I said, the more you look the more you'll find. Which is always a good thing for us. And along that note, I'd like to switch gears right now.

Jessica, I know you have your fingers on the pulse of what's happening with congenital syphilis in Texas. So why don't you tell us about your job and what you know about the impact of congenital syphilis in Texas?

Jessica Del Toro: 8:41

I currently serve as a core team member on our fetal infant morbidity review boards here in Texas in the San Antonio, Houston and Dallas-Fort Worth areas.

And that is just one in every 750 born here in Texas. You know, it really shows the issue that we're dealing with here in Texas and the need for continued conversation, education and activities, surrounding congenital syphilis, and syphilis among people of childbearing capacity.

Larry Prescott: 9:33

Wonderful. Wonderful. Yeah, well what have you seen to be the biggest missed opportunities that we've experienced here in Texas?

Jessica Del Toro: 9:39

So what we've seen is that 72% of women delivering infants with congenital syphilis had either inadequate syphilis treatment or no treatment at all, and we would really like to see that adequate treatment increase among all people being diagnosed with syphilis. Another thing that we saw was that 25% of people who were engaging in prenatal care did not enter prenatal care until the second trimester and 17% had no prenatal care at all.

When individuals do not access prenatal care early, during their pregnancy, it ultimately results in late syphilis diagnoses. And it does leave little room for early syphilis diagnoses as well as early treatment adequacy prior to delivery.

So when it comes to inadequate treatment, I know, as a former DIS and person that's dealt with syphilis in, I'll say non-pregnant populations, sometimes we encounter patients who don't want to come back for the series of shots. Some patients need three shots. They'll take the first one and then we lose them in the system. But then there has been some issues where providers have not wanted to do the full-scale range of treatment also. Do you think we need more provider education?

Absolutely. Provider education is one of the efforts that Texas is taking to address maternal syphilis and congenital syphilis in Texas. Back in 2020, we held a congenital syphilis provider symposium where we learned about syphilis, congenital syphilis, what's going on in Texas. We highlighted our high morbidity areas to include the Fetal Infant Morbidity Review Boards, and it allowed providers the opportunity to learn more about the clinical aspects of syphilis and what type of impact maternal syphilis can have on a fetus.

You know, there are also some bigger systems-level issues that really are not at the individual provider level. You might have individual clinicians that are doing a phenomenal job, but really the system makes it hard for people to do the right thing sometimes. There are private OB/GYN offices that might diagnose a woman with syphilis, and it's really hard to get her back in for treatment in an expedient way.

It might be that treatment isn't available in that particular clinic because they don't see enough syphilis to justify keeping that expensive medication on the shelf, in this case, you know, in a refrigerator. But it might also be that the scheduling system and the schedulers at the front desk need to be aware that this is a really high priority issue, and that you can't just ask the woman to show up at her next prenatal visit in four weeks. Many of these women deliver premature infants, and so preparing and acknowledging the fact that you might be lucky to make it to 36 weeks, which makes this an even more urgent issue. So there are really a lot of systems issues at play that all have to be worked on at the same time that you're also working at the individual provider level to make sure everyone really knows how to treat syphilis.

Yeah, I understand, because, again, I'll say as a former DIS, pregnant females have always been the number one priority. We try to get those people back to the clinics and back to the clinicians as soon as possible. So they are a number one priority, and I can see how that relates to us right now.

And Jessica, I’ll just follow up with anything else that you want to add about the efforts that we are conducting here in Texas to address the increase in maternal syphilis and congenital syphilis.

I would like to refer back to what Dr. Bowen was mentioning about having Bicillin syphilis treatment on hand in provider clinics. That is one of the efforts that our local and regional programs are trying to make headway in, whether that be delivering Bicillin directly to providers’ offices, or even offering at-home treatments. That is a large effort that our local and regional health departments are trying to make.

Yeah, I liked the sound of that in-home treatment portion, because there's something we always wish the DIS could do, you know, we’re going out there to talk to people, boy, if we could talk to them and treat them at the same time, that would really be something great, but I know that requires some specifications to be able to treat people in the field as well. Thank you so much, Jessica.

I’d like to bring it right now back to Dr. Bowen to take our last question for the day.

Well, Larry, this is a rapidly changing landscape when it comes to prenatal testing requirements. I mean, goodness, of all 50 states in the United States of America I think 44 out of the 50 have some type of regulation or law on the books that requires syphilis testing during pregnancy; at least once. And then if you take it even further, I would say the majority of those also require at least a second test somewhere during pregnancy. You guys are now in this very elite category, that requires three tests during pregnancy, and you're certainly not alone.

I mean, there are many other states, high morbidity states, like you, that require three tests during pregnancy now. The first two tests that you offer during someone's pregnancy, those are the tests that are designed to prevent congenital syphilis, right.

Because if I find it early enough and I treat this pregnant person, at least 30 days before delivery, I've got a 98% chance of preventing that infant from being a case. I think that this is the path forward. Again treatment is highly efficacious, and those first two screens are where the money's at.

The third screen is really important because we do see, in high morbidity areas like Texas, reinfection is a real concern. There was a high morbidity state in the south. They put out a paper recently that showed 7% of all pregnant women with syphilis, who were eligible or qualified to get a re-infection, got a re-infection during pregnancy.

So 7%, that's pretty high, which means that even if you do those first two screens really well, there is still a lot of syphilis in the community. And we're naive if we think that pregnant women are not out there having sex. And so there's a chance that in the last trimester, someone could still bump into syphilis.

And that is just reality. So that third screen, even though it may not be fantastic for preventing congenital syphilis, it's super important for making sure that we catch that syphilis on the day the baby is born. We get mom treated so that she is healthy, right. She's still a very important part of this equation. And we make sure that that baby does not go on to develop some really tragic outcomes.

We've seen prolific case reports in the past few years in major medical journals about babies who returned to the emergency department four months after birth, six months after birth with injuries that look like child abuse. I mean bones that are so brittle and broken that they’re worked up as child abuse. And if only a day of delivery test had taken place, you know, we might've caught that infant before they were discharged from the hospital and they could have gotten some fantastic treatment. Three tests are super important. I'm really proud of Texas for taking that step. And I think it's going to reap great rewards for the babies in Texas.

We certainly hope so. We certainly hope so. We certainly hope so.

Well, I want to thank our guests, Dr. Virginia Bowen and Jessica Del Toro, once again for joining us. And I hope that you'll join us next week as we discuss social determinants of health that are impacting congenital syphilis in Texas.

Exploring an Epidemic: Congenital Syphilis in Texas was developed by the Texas Department of State Health Services in collaboration with the Denver Prevention Training Center.