- A new report found that syphilis cases are the highest they’ve been since the 1950s.
- The report reveals that cases of syphilis and congenital syphilis increased by 80% over the past five years.
- Health experts say the spike in cases shows the need for improved public outreach and education efforts.
When the Centers for Disease Control and Prevention’s (CDC) 2022 STI Surveillance Report was released recently, one statistic stood out starkly — total syphilis cases were reported at their highest since 1950.
Among the more than 2.5 million cases of syphilis, gonorrhea, and chlamydia reported nationwide, the report shows that total 2022 syphilis cases stood at 207,255, a number that includes congenital syphilis, which is passed from pregnant mothers to their babies.
Experts say these findings underscore the need for improved public health outreach and education efforts around sexually transmitted infections (STIs) and address some of the intersecting factors that exacerbate health disparities among groups that are affected the most by conditions like syphilis.
What the CDC’s report reveals about national STI numbers
These 2022 figures are the latest and most complete data for national STI numbers. The report reveals that cases of syphilis and congenital syphilis increased by 80% over the past five years, with congenital syphilis cases increasing by 937% over the past decade.
While syphilis cases have climbed, chlamydia cases stood at 1,649,716 in 2022, showing a 6.2% decrease over five years (that number stood at 1,758,668 in 2018).
Gonorrhea numbers actually “declined for the first time in at least a decade,” according to the report. Those 2022 numbers stand at 648,056 reported cases, an 8.7% decrease since 2021, which saw 710,151 reported cases.
Zeroing in further on the national syphilis epidemic, primary and secondary syphilis cases grew by 10% in 2022 and by 68% since 2018.
In the report, Laura Bachmann, MD, MPH, chief medical officer, Division of STD Prevention at the CDC, writes that the growth in these numbers in women, in turn, feeds the rise in congenital syphilis cases. They saw an increase of 31% from 2021 to 2022.
She writes that almost every state in the country reported at least one congenital syphilis case, with Texas, California, Arizona, Florida, and Louisiana collectively comprising 57% of all reported congenital syphilis cases nationwide. Bachman writes that, in 2022, these congenital syphilis infections resulted in 282 stillbirths and infant deaths.
2022 figures highlight persisting racial and ethnic disparities
Bachman writes that “Black or African American, Hispanic and Latino, and white” groups showed the highest number of syphilis cases.
When it comes to congenital syphilis specifically, in every 155 births among Native American and Alaska Native people, there was one congenital syphilis case. Additionally, Black Americans experienced 30% of congenital syphilis cases.
Men who have sex with men are disproportionately affected by STIs, and the number shows common coinfection with HIV, with 36.4% of men who have sex with men with reported primary and secondary syphilis were also diagnosed with HIV.
That being said, the 2022 report points to what it references as a “heterosexual syphilis epidemic in the United States.” The national rate of primary and secondary syphilis among women rose by 19.2%, with men who have sex with women rising at the same time.
Some of the factors contributing to the syphilis epidemic
This is just a snapshot of the wide-ranging report.
When asked to put the findings in context — exactly why are rates of STIs, like syphilis, are climbing in recent years — Bachmann told Healthline that a multitude of factors are at play here.
“The report doesn’t tell us why these STIs are increasing, but we know a wide range of factors can contribute to high levels of infections, and it’s going to take multiple solutions to turn the epidemic around,” she said.
She explained that reductions in STI screenings, treatment interventions, prevention efforts, “and partner services by health departments” have most likely contributed to national increases in STI numbers.
Additionally, she pointed to the rise in substance use nationwide, which goes hand in hand with “less safe sexual practices.”
“Syphilis and drug use are intersecting epidemics — with a substantial percentage of heterosexual syphilis transmission occurring among people who use drugs — particularly methamphetamine. We are also more than a decade into a national opioid crisis that is putting more people at risk for HIV, viral hepatitis, and STIs,” Bachmann said.
“And there continue to be social and economic conditions that make it more difficult for some groups to stay healthy. These include poverty, stigma, lack of medical insurance or a healthcare provider, unstable housing, and a higher burden of sexually transmitted infections in some communities,” Bachmann added.
Bachmann also pointed to the fact that condom use has decreased among some groups, like young Americans as well as gay and bisexual men.
“We must ensure that providers and prevention partners are equipping those no longer using condoms with the tools and information they need to protect themselves against other STIs,” she added. “And last, but not least, STIs continue to be stigmatized. This stigma can bury the truth that all people deserve quality sexual healthcare to live healthy lives. Stigma can also deter people and groups from taking action to prevent and treat STIs.”
The impact of congenital syphilis
The report shows that the application of timely testing and treatment during pregnancy could have prevented 88% of congenital syphilis cases in 2022.
Bachmann said the CDC has been “sounding the alarm about the devastating consequences of a rapidly accelerating STI epidemic for more than a decade.”
“We are calling on healthcare providers to urgently act to stop increases in congenital syphilis cases. Providers should consider starting syphilis treatment as soon as they receive the first positive test result — presumptive treatment — during pregnancy for patients who face greater obstacles to ongoing care,” she added.
She said that rapid syphilis testing and presumptive treatment could be applied in places like emergency departments, syringe service programs, in prisons, and in maternal and child health programs when a follow-up might be uncertain.
Bachmann added that in counties nationwide that have high syphilis rates, “screening should be offered to sexually active women and their partners, as well as people with other risk factors.”
There is also great opportunity for providers to collaborate with community health workers who are embedded on the ground with those most at risk. They can oftentimes help bridge some of the gaps in syphilis testing and treatment during pregnancy.
“CDC will continue to offer funding, training, guidance, and support to develop treatment guidance with the most up-to-date and effective syphilis screening and treatment options. We provide the only federal source of STD prevention funding for health departments to prevent, monitor, and rapidly detect and treat syphilis,” Bachmann said.
“We support healthcare providers through training, education, guidelines, tools, and resources, and we fund work integrating STD and substance use prevention and treatment services and maternal and child health case management services,” she added.
How to address the syphilis epidemic
In looking at the report, Kelly A. Johnson, MD, MPH, medical director for the California Prevention Training Center at UCSF, and a UCSF Infectious Diseases physician, told Healthline that social determinants of health play a major role “in vulnerability to syphilis and other STIs.”
“In California, for example, we see time and time again that lack of healthcare access, substance use, and housing instability are associated with syphilis, particularly in pregnancy. Factors such as stigma, poverty, structural racism, and discrimination are also at play, influencing the likelihood of syphilis transmission and acquisition within certain sexual networks,” Johnson explained.
She added that there are gaps in syphilis knowledge and awareness across the country that can lead to “missed opportunities” for proper screening, testing, and treatment interventions.
“Syphilis in adults and adolescents can be challenging to diagnose. This is largely because the infection is characterized by episodes or stages of active infection — during which time patients have symptoms — interspersed by periods of latent, or asymptomatic, infection. This means that patients who are completely well-appearing and report no symptoms at all can still be infected. These latent infections will not be identified unless providers know when asymptomatic screening is indicated,” Johnson said. “Even during symptomatic periods, syphilis has been called the ‘great masquerader’ for a reason. It can look like a lot of other things.”
Johnson explained that the symptoms are highly variable and “sometimes nonspecific.” This could include the presence of ulcers, sores, and rashes, to something a bit more subtle, like swollen lymph nodes, flu-like symptoms, hair loss, and neurological symptoms that can be confused for being caused by other conditions.
“Since syphilis was previously uncommon, we are now faced with a situation in which patients and providers alike may be unfamiliar with the signs and symptoms of infection, precluding diagnosis and treatment, allowing for ongoing transmission, and further compounding the problem of rising cases,” she said.
There is good news here — syphilis is easily treated, and congenital syphilis can be prevented entirely, she stressed. It goes back to raising awareness.
She also pointed to the disruptions caused by the COVID-19 pandemic. The health crisis hit public health STD control programs hard. Johnson said this meant staff, program funding, and resources were all redirected to other areas to address the pandemic.
“That said, the trends we are seeing in syphilis pre-dated COVID-19. So, while the viral pandemic did not help, I do not think it is solely to blame here,” Johnson said.
David Stein, the CEO and co-founder of at-home diagnostics and testing company Ash Wellness, told Healthline that these statistics echo what he’s been hearing from public health workers on the ground. Stein’s company offers a wide range of at-home testing, including tests for HIV and STI at large, working in partnership with some public health departments.
“It’s sad to get the confirmation of it [the rising syphilis rates], especially around congenital syphilis. If we tested more, we would catch it more, and we could treat it more and prevent it as far as passing it on to an infant,” he added.
Stein echoed Bachmann and Johnson in saying that education can play a big role.
He said that many people might not really be aware of how common and widespread these common STIs are and that they can not only be easily tested for, but treated. Stein explained that, while these infection rates climb, not enough resources and funding are making their way to accessible testing and prevention efforts.
“Public funding [for these programs] is being cut,” he said.
How to improve support for the groups and regions impacted the most
Bachmann said that “the biggest risk factor for syphilis” for many people is “where they live.”
“The reality is the rise in syphilis in the past several years means most of us live in areas that are now considered to have high rates among women of reproductive age. This means providers must seize on opportunities to address syphilis before pregnancy, by offering to screen more sexually active women and their partners on a regular basis and continuing to offer testing to people with other risk factors for syphilis,” Bachmann explained.
The disproportionate rates of syphilis in newborn babies are rooted deeply in “entrenched social factors that create greater obstacles to quality healthcare services,” she said.
This creates something of a negative domino effect. The health inequities this causes lead to higher syphilis rates in the communities and sexual networks affected the most.
Bachmann said the goal is to tailor prevention efforts “that include community-based patient navigators, case managers, and disease intervention specialists” who can directly address racial and ethnic disparities in congenital syphilis, for instance.
In speaking on the broader racial and ethnic disparities that feed into the nation’s syphilis epidemic and STI rates as a whole, Bachmann said that to see lasting progress, “we must understand the systems that create inequities and work with communities and partners to address them.”
In looking at the rising rates of syphilis among heterosexual Americans, Stein said there definitely is a blind spot in public health messaging in reaching these communities.
He said members of the LGBTQ+ community at large — particularly gay and bisexual men — have been the recipients of robust public health messaging around safe sex practices and STI awareness, all in the shadow of the HIV and AIDS crisis.
For these groups, it is relatively more common and acceptable to seek out screening, to go to clinics, and to seek out providers for sexual health information.
When it comes to the heterosexual community, he said there hasn’t been “the same understanding or appreciation of the tools we have out there.”
Stein pointed to the fact that this increase in STI rates among heterosexual people has been evidenced in other countries, but places with universal health systems, for instance, have more accessible and common testing, and they also “are a little bit ahead” of the U.S. in releasing that data, which might also make some of the figures from this report stand out so starkly.
While men who have sex with men historically have been impacted by syphilis disproportionately — they make up nearly half of the male primary and secondary syphilis cases in 2022. Johnson said it is important to emphasize that “the reality is that anyone having sex is at risk of acquiring syphilis, regardless of gender or sexual orientation.”
Other STI rates are remaining flat or declining
Outside of the rather bleak syphilis statistics, the fact that gonorrhea cases have declined for the first time in a decade, while chlamydia numbers remain level, offers some tentatively positive notes among the data, Johnson said.
“For chlamydia, we know that most cases are asymptomatic. This means that chlamydia case counts reported in surveillance data largely reflect whether people are being screened, aka, being checked for chlamydia as part of routine healthcare. We know, for example, that at the 2020 height of COVID-19, when many clinics were forced to pause preventive healthcare — including routine STI screening — there were significant decreases in reported chlamydia cases,” Johnson said.
“Now — although we are once again detecting more chlamydia cases in 2022 compared with 2020, reported chlamydia rates are still lower than they were in 2019. Unfortunately, this may reflect the fact that people are still not being screened for chlamydia at pre-pandemic levels, meaning that cases may still be occurring but going undetected and thus not reported,” Johnson said.
The gonorrhea declines might show some successful public health and clinical efforts to raise awareness to get diagnosed and tested, Johnson added.
“Still, if you zoom out, gonorrhea cases have increased by 11.1% since 2018 — and there were still around 648,000 cases in 2022 – meaning that this remains an important public health concern. I think the CDC will be looking very carefully at the 2023 data to better understand the trends we are seeing in gonorrhea,” she said.
Bachmann further contextualized those points. Since this is the first drop in reported gonorrhea cases in at least a decade, she explained that “the CDC is examining this finding closely and will be looking to final 2023 data to understand better if this signals a decline in infections and to understand better where, why, and among whom the decrease occurred with the hope we can expand on what’s working.”
STI resources currently available
For Stein, he sees at-home testing models like Ash Wellness as a positive move, but one that needs more support. He said his company’s collaboration with public health departments has revealed how effective it can be to make these types of resources available in regions hit hardest by STIs.
“I think there is an incredible opportunity that did not exist pre-COVID as far as the ability for patients to self-collect samples from home without the stigma, without the shame, without the inconvenience, without having to physically go to a lab or a health department or whatever it may be,” Stein said. “We just need more people to know about it and more of the decision-makers on the legislation level to appreciate it and put funding toward it.”
Johnson stressed that the average person should know that “STIs can happen to anyone who has sex” and that sexual healthcare should be a crucial component of one’s routine healthcare maintenance.
“While this can be difficult, the more you, your partner(s), and your healthcare providers feel comfortable discussing your sex practices and any recommended interventions, the better,” she said.
Johnson pointed to vaccines for hepatitis A, hepatitis B, HPV, mpox, and meningitis “that are indicated in certain populations to help protect against” STIs as important interventions. She also pointed to preventive tools like preexposure prophylaxis (PrEP), HIV postexposure prophylaxis for HIV prevention, and doxycycline postexposure prophylaxis (doxyPEP), for syphilis, chlamydia, and gonorrhea as effective medical tools for STI prevention.
Bachmann said it’s important to recognize that the “stigma associated with STIs buries the truth.”
“People should know, everyone deserves to live healthy lives, and they can take action to prevent and treat STIs. People can help keep themselves and their sexual partners protected from STIs by talking to their partner about STIs and considering what safe sex options are right for them, including using condoms and reducing the number of sex partners,” Bachmann added. “Getting tested for sexually transmitted infections, especially if you or your partner are pregnant or planning to get pregnant. And, ask a healthcare provider about how to prevent syphilis.”
