Alarming rise in newborns with syphilis sign of gaps in access to care, doctors say
For much of his medical career, Dr. Ari Bitnun rarely had to consider the symptoms that indicated a baby was sick with syphilis.
Rashes, often on the palms and soles of the feet. Poor weight gain and growth. Persistent nasal discharge, sometimes bloody. Swollen liver and spleen.
He made sure the medical students he taught had a clear understanding of the infection and the importance of prenatal screening to catch asymptomatic cases, as well as the dangers that syphilis posed when passed from mothers to babies during pregnancy.
But for decades, he and other doctors in Canada didn’t often see realworld cases of babies with syphilis. It seemed to be a disease of the past, reduced to a rarity by advances in medicine and prenatal care.
“You never saw congenital syphilis,” said Bitnun, an infectious disease physician at the Hospital for Sick Children. “It was something you learned about but didn’t see.”
Now, he says, that’s changed.
Cases of congenital syphilis in Ontario have recently spiked to numbers not seen in decades, setting off alarm bells for experts who say the rapid increase signals a dangerous gap in public health.
In 2022, the last year for which figures are available, there were 27 cases of early congenital syphilis in the province — up from five in 2020, according to data from Public Health Ontario. Between 2014 and 2019 there were only one or two cases each year, and 2013 saw no recorded case.
‘‘ All of a sudden, it was all over the place.
DR. ARI BITNUN ON THE RISE IN CONGENITAL SYPHILIS CASES
“All of a sudden, it was all over the place,” said Bitnun, director of the Congenital & Perinatal Infection Clinic at SickKids. “We’re getting calls all the time from pediatricians about a baby born to a mom who didn’t get treated properly.”
Once in decline, cases of syphilis are soaring in Ontario, mirroring trends seen elsewhere in Canada and around the world.
The sexually transmitted infection (STI), caused by the bacterium Treponema pallidum, is preventable and easily cured with antibiotics. Left untreated, the disease can cause blindness and paralysis, along with other dire consequences, including memory problems and organ damage. Its resurgence has health experts calling for greater public health efforts, especially for the most vulnerable.
In the U.S., figures released last month by the Centers for Disease Control and Prevention show there were 207,000 diagnosed syphilis cases in 2022 — the highest number on record since the 1950s.
In 2022, there were 13,953 cases of infectious syphilis in Canada; the rate of 36.1 cases per 100,000 population represents an 11 per cent increase over 2021.
A January report from Public Health Ontario shows the incidence of infectious syphilis in this province has steadily increased for much of the last decade and in 2022 reached its highest level — 23.6 cases per 100,000 — since 2013. In some regions of the province, including in Thunder Bay and the Kingston area, the incidence rates increased between 2020 and 2022 by more than 250 per cent.
And though figures are not yet available for 2023, infectious disease experts say the alarming trend appears to be getting worse.
“Clinically, I feel like I saw even more syphilis last year than in 2022,” said Dr. Malika Sharma, staff physician at St. Michael’s Hospital, a part of Unity Health Toronto.
“It’s showing us that people are having difficulty accessing care — prevention, counselling, testing, treatment, all the things that we know help bring STI rates down.”
Dr. Austin Zygmunt, a public health physician with the communicable disease team at Public Health Ontario, said 2022 figures show the highest incidence rate for syphilis continues to be among people ages 25 to 39 and that the infection predominantly still affects men.
However, he said, the proportion of cases among women has been steadily increasing.
Among women of child-bearing age, which includes those ages 15 to 44, data shows those living in areas with the most socio-economic marginalization, a measure closely tied to poverty and the ability to access housing and other basic materials, have the highest rates of infectious syphilis, Zygmunt said.
He said an upcoming Public Health Ontario report looks more closely at what’s driving rates of congenital syphilis in the province.
“We found those who really struggle from a socio-economic perspective were the individuals who had infectious syphilis during their pregnancy and transmitted it to their fetus or their baby,” Zygmunt said. “(The finding) supports this common principle in public health that providing essential supports, and supporting those with low socio-economic status, can help improve health outcomes.”
Dr. Vanessa Allen, a medical microbiologist and infectious diseases physician at Sinai Health and the University Health Network, found the 2022 spike in cases of congenital syphilis “shocking.”
“Twenty-seven congenital cases is something that I have not seen in my lifetime,” she said. “We were always taught that (that kind of spike) means there’s something considerably problematic in the delivery of a public health system overall.
“It means some people aren’t getting screened early on.”
In Canada, pregnant people undergo routine screening for syphilis and other infectious diseases, including HIV, in the first trimester.
Many people with syphilis experience symptoms, such as swollen glands, fever, and the appearance of round and painless ulcers, rashes and wartlike sores, in the early stages of the infection. Untreated latent syphilis may appear years after the initial infection and can affect the brain, heart and nervous system.
But the infection can also be asymptomatic or its symptoms so mild that individuals are not aware they have syphilis. The infection can still be transmitted in the absence of symptoms.
Pregnant people are screened for syphilis to help catch cases, especially those with unclear or hidden symptoms, because the infection is dangerous to the fetus and newborns. Untreated syphilis during pregnancy can lead to a miscarriage, stillbirth or infant death, and babies born with the infection who aren’t swiftly treated can have serious health problems.
“What I was taught as an infectious disease trainee is that we should not see congenital syphilis cases because we are screening,” said Allen. Pregnant people with syphilis are treated with antibiotics, and their babies receive follow-up care after birth.
“We have a very large program which involves screening all pregnant women for syphilis so that it can be detected earlier. It is so important to prevent a very serious infection.”
Allen says the spike in congenital syphilis reveals that too many women in Ontario don’t have access to good prenatal care.
“It suggests there are health-care access issues and for some groups those gaps are much wider.”
Bitnun pointed to Manitoba, which has recently changed its syphilis screening strategy following a surge in congenital cases. Pregnant people are now screened twice for the infection, once in the first trimester and again later in pregnancy, he said.
“They decided, regardless of risk factors, that syphilis is so prevalent they’re going to test all women in the third trimester,” Bitnun said, adding he’s not sure Ontario yet needs to implement such a strategy. “But obviously that (strategy) only works if women are able to access care.”
Experts say that reducing syphilis rates — and other STIs — across all groups will require breaking down barriers and finding new ways to reach individuals to help them easily access testing and treatment. One example is GetaKit run by the University of Ottawa, which mails individuals requisitions and swabs for STIs that can be taken to community labs across the province.
But experts also stress that further bolstering public health surveillance and expanding system outreach measures is critical, alongside strengthening primary care and access to prenatal care. Currently, some 2.3 million Ontarians do not have access to a primary care doctor, according to the Ontario Medical Association.
Sharma says it’s critically important when thinking of public health solutions to focus on the upstream factors that affect health outcomes, such as a lack of safe housing, food and financial insecurity and other factors including LGBTQ discrimination.
“People don’t just end up on the margins; someone, whether it’s individuals, institutions or societies, usually all of those things together are pushing people to the margins,” she says. “STI rates, like so many other communicable and non communicable illnesses, reflect whether we are creating a livable society.”
Sharma says her recent clinical experience mirrors the Public Health Ontario findings. In the past year, she’s seen an increase in pregnant people with syphilis, including those who test positive later in pregnancy. She says this reflects a health system failing to meet these patients’ needs.
She worries about the people that she and other health professionals never see.
“When we’re seeing such high rates in pregnancy, and rising rates of congenital syphilis, it tells us there’s likely others we are missing.”
‘‘ It’s showing us that people are having difficulty accessing care — prevention, counselling, testing, treatment, all the things that we know help bring STI rates down.
DR. MALIKA SHARMA STAFF PHYSICIAN AT ST. MICHAEL’S HOSPITAL