From the Johns Hopkins Bayview Medical Center, Baltimore, Maryland
Correspondence: Jonathan M. Zenilman, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224. E-mail: firstname.lastname@example.org.
Received for publication January 28, 2008, and accepted February 4, 2008.
Congenital syphilis is completely preventable and has been targeted for elimination by the WHO.1 Current guidelines recommend routine serologic screening of pregnant women during the first prenatal visit and repeat testing in women at higher risk during the last trimester.2 Incident cases are universally recognized as a sentinel public health event, and the most consistent risk is lack of adequate prenatal care. Because of the effectiveness of screening and maternal treatment CS occurs in infants born to mothers who are at the fringes of society, either because of drug abuse, extreme poverty, or lack of access to health care.
Since end of World War II, the epidemiologic curve of syphilis has consistently reflected emerging social trends. Since the crack cocaine-fueled epidemic of the early 1990s, the dramatically reduced syphilis incidence in heterosexuals, especially minority women, has been a signature public health achievement. These decreases were accompanied by similar drops of congenital infection.
During the past decade, 2 new disturbing syphilis trends have emerged. The increased incidence of disease in men who have sex with men, coupled with high rates of HIV coinfection, has been well documented.3 Nationally, CDC estimated that in 2003, 62% of all cases occurred in MSM. However, simmering below the surface has been the increase in heterosexual Hispanic cases, especially in undocumented immigrants. Immigration is rapidly emerging as a key risk factor for heterosexual syphilis. Paz-Bailey et al.4 recently described a large syphilis outbreak in immigrant Hispanic men in Alabama, which was associated with crack cocaine and prostitution. Similar patterns have been observed in Europe, including a recently described outbreak of congenital syphilis where the migration source countries are in Eastern Europe.5
Taylor et al.6 described the epidemiology of syphilis in Maricopa County, AZ, which encompasses the Phoenix metropolitan area—one of the fastest growing urban centers in the United States. In 2000–2005, 41% of syphilis reports in the county were in heterosexual women—more than twice the national ratio. Nearly half were in Hispanics, and an astounding 19% of women were pregnant at time of diagnosis. During the study period, an alarming 131 congenital syphilis cases were diagnosed, including 23 stillbirths. The root-cause analysis documented that 44% of the mothers were noncitizens, and that there were multiple problems in accessing prenatal care, including no prenatal care, delayed prenatal care, poor follow-up for prenatal serological testing, and reduced serological testing rates in the last trimester. Health access issues due to financial and legal barriers far outpaced cases associated with drug use and commercial sex work. The authors propose that this problem will worsen with the requirement implemented in 2006 that patients present proof of citizenship that will be required to access health care.
Creating obstacles to prenatal care has been long recognized by the perinatal community as incredibly short sighted, and major advances were made in provision of prenatal and infant care, even for the uninsured, during the past 3 decades. Independent of the humanitarian impact, for syphilis and other STDs, cost-effectiveness data for prevention are particularly strong. Chesson et al.7 has estimated that between 1990 and 2003, the reduced incidence of syphilis and gonorrhea, independent of the impact on HIV incidence, saved more than $1 billion, of which 14% of savings were due to reduced congenital syphilis alone. Similarly, in a previous analysis, which modeled the 1990 heterosexual epidemic, de Lissovoy et al.8 estimated the cost of a hospital stay for CS treatment for uncomplicated disease as $3062 (using 1990 dollars); cases of symptomatic and complicated disease are exponentially higher. These estimates, extrapolated to 2008, would be at least 3 to 4 times higher.
Immigration has emerged as a hot-button issue in the current political climate, with accompanying rhetoric and occasional demagoguery proposing to restrict services being provided to some of our society’s most vulnerable individuals. Implementing barriers to preventive and prenatal care may be politically attractive, but will have real potential for severe and costly impact. Taylor et al. demonstrated the impact on congenital syphilis, a completely preventable disease, which is affecting newborn United States citizens and costing us all.
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2. Centers for Disease Control, Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1–94.
3. Heffelfinger JD, Swint EB, Berman SM, et al. Trends in primary and secondary syphilis among men who have sex with men in the United States. Am J Public Health 2007; 97:1076–1083.
4. Paz-Bailey G, Teran S, Levine W, et al. Syphilis outbreak among Hispanic immigrants in Decatur, Alabama: Association with commercial sex. Sex Transm Dis 2004; 31:20–25.
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7. Chesson HW, Gift TL, Pulver AL. The economic value of reductions in gonorrhea and syphilis incidence in the United States, 1990–2003. Prev Med 2006; 43:411–415.
8. de Lissovoy G, Zenilman J, Nelson KE, et al. The cost of a preventable disease: Estimated U.S. national medical expenditures for congenital syphilis, 1990. Public Health Rep 1995; 110:403–409.