Thursday, November 30, 2023
| Characteristic | No. (%) | |||
|---|---|---|---|---|
| Congenital syphilis (n = 360) | Noncongenital syphilis (n = 410) | |||
| Any substance use (n = 173) |
No substance use (n = 187) |
Any substance use (n = 101) |
No substance use (n = 309) |
|
| Age, yrs, median (IQR) | 27.7 (23.4–31.9) | 26.3 (21.8–30.7) | 27.8 (23.8–31.3) | 25.3 (22.2–29.6) |
| Age group, yrs | ||||
| <25 | 55 (31.8) | 72 (38.5) | 37 (36.6) | 146 (47.2) |
| 25–29 | 59 (34.1) | 63 (33.7) | 31 (30.7) | 92 (29.8) |
| 30–34 | 37 (21.4) | 34 (18.2) | 25 (24.8) | 54 (17.5) |
| ≥35 | 21 (12.1) | 16 (8.6) | 8 (7.9) | 17 (5.5) |
| Missing/Not reported | 1 (0.6) | 2 (1.1) | 0 (—) | 0 (—) |
| Education level | ||||
| Less than high school | 51 (29.5) | 55 (29.4) | 30 (29.7) | 94 (30.4) |
| High school graduate or GED | 53 (30.6) | 50 (26.7) | 35 (34.7) | 113 (36.6) |
| Some college but no degree | 24 (13.9) | 35 (18.7) | 24 (23.8) | 59 (19.1) |
| College degree or more | 5 (2.9) | 23 (12.3) | 8 (7.9) | 22 (7.1) |
| Missing/Not reported | 40 (23.1) | 24 (12.8) | 4 (4.0) | 21 (6.8) |
| Insurance at delivery | ||||
| Public | 130 (75.1) | 91 (48.7) | 81 (80.2) | 164 (53.1) |
| Private | 12 (6.9) | 12 (6.4) | 6 (5.9) | 31 (10.0) |
| Other/None/Self-pay | 14 (8.1) | 10 (5.3) | 2 (2.0) | 12 (3.9) |
| Missing/Not reported | 17 (9.8) | 74 (39.6) | 12 (11.9) | 102 (33.0) |
| Prenatal care | ||||
| First/Second trimester | 78 (45.1) | 124 (66.3) | 79 (78.2) | 281 (90.9) |
| Third trimester | 26 (15.0) | 25 (13.4) | 13 (12.9) | 16 (5.2) |
| No care | 66 (38.2) | 35 (18.7) | 4 (4.0) | 3 (1.0) |
| Missing/Not reported | 3 (1.7) | 3 (1.6) | 5 (5.0) | 9 (2.9) |
| No. of prenatal visits, median (IQR) | 1 (0–6) | 6 (1–10) | 9 (6–11) | 10 (7–13) |
| Treatment | ||||
| Adequate§ | 26 (15.0) | 46 (24.6) | 101 (100) | 309 (100) |
| Inadequate¶ | 55 (31.8) | 62 (33.2) | NA | NA |
| Not treated during pregnancy¶ | 92 (53.2) | 79 (42.2) | NA | NA |
| History of incarceration** | ||||
| Yes | 28 (16.2) | 6 (3.2) | 11 (10.9) | 5 (1.6) |
| No | 70 (40.5) | 102 (54.5) | 63 (62.4) | 181 (58.6) |
| Missing/Not reported | 75 (43.4) | 79 (42.2) | 27 (26.7) | 123 (39.8) |
| History of homelessness** | ||||
| Yes | 46 (26.6) | 2 (1.1) | 9 (8.9) | 3 (1.0) |
| No | 70 (40.5) | 106 (56.7) | 71 (70.3) | 190 (61.5) |
| Missing/Not reported | 57 (32.9) | 79 (42.2) | 21 (20.8) | 116 (37.5) |
Table 1. Characteristics of pregnant persons with syphilis, by reported substance use* and congenital syphilis pregnancy outcome† (N = 770) — Surveillance for Emerging Threats to Pregnant People and Infants Network, Arizona and Georgia, 2018–2021
Abbreviations: CSTE = Council of State and Territorial Epidemiologists; GED = general educational development certificate; NA = not applicable.
*Any substance use includes any use of tobacco (e.g., cigars, cigarettes, smokeless tobacco, or e-cigarettes), alcohol, cannabis, illicit use of opioids (e.g., prescription opioids not taken as prescribed, fentanyl, or heroin), and other illicit, nonprescription substances (e.g., cocaine, methamphetamines, inhalants, or hallucinogens, such as LSD or PCP).
†Congenital syphilis pregnancy outcome includes pregnancy outcomes that meet the CSTE surveillance case definition for syphilitic stillborn or live-born infant with probable or confirmed congenital syphilis.
§Adequacy of treatment dependent on syphilis stage. Primary, secondary, and early latent syphilis require at least 1 dose of penicillin during pregnancy, with the dose administered ≥30 days before pregnancy outcome. Late latent, latent of unknown duration, tertiary, and other cases of syphilis require ≥3 doses of penicillin, spaced 5–9 days apart, with the first dose administered ≥30 days before delivery and the final dose administered during pregnancy.
¶Stillborn and live-born infants born to pregnant persons inadequately treated or not treated during pregnancy meet the CSTE case definition for a probable congenital syphilis pregnancy outcome.
**Within the 12 months preceding case report or positive test results or during pregnancy.
| Substance used | No. (%) | Prevalence ratio¶
(95% CI) |
|
|---|---|---|---|
| Congenital syphilis (n = 360) |
Noncongenital syphilis (n = 410) |
||
| Any substance* | 173 (48.1) | 101 (24.6) | 1.95 (1.60–2.38) |
| Tobacco | 99 (27.5) | 46 (11.2)** | 2.45 (1.78–3.37) |
| Alcohol | 29 (8.1) | 20 (4.9)** | 1.65 (0.95–2.86) |
| Cannabis | 69 (19.2) | 56 (13.7)†† | 1.40 (1.01–1.93) |
| Illicit use of opioids§§ | 75 (20.8) | 14 (3.4)** | 6.09 (3.50–10.58) |
| Illicit, nonprescription substance¶¶ | 101 (28.1) | 26 (6.4)** | 4.41 (2.94–6.63) |
Table 2. Reported substance use*,† among pregnant persons with syphilis, by congenital syphilis pregnancy outcome§ — Surveillance for Emerging Threats to Pregnant People and Infants Network, Arizona and Georgia, 2018–2021
Abbreviation: CSTE = Council of State and Territorial Epidemiologists.
*Any substance use includes any use of tobacco (e.g., cigars, cigarettes, smokeless tobacco, or e-cigarettes), alcohol, cannabis, illicit use of opioids (e.g., prescription opioids not taken as prescribed, fentanyl, or heroin), and other illicit, nonprescription substances (e.g., cocaine, methamphetamines, inhalants, or hallucinogens such as LSD or PCP).
†Numbers in categories are not mutually exclusive.
§Congenital syphilis pregnancy outcome includes pregnancy outcomes that meet CSTE surveillance case definition for syphilitic stillborn and live-born infant with probable or confirmed congenital syphilis.
¶Unadjusted.
**Denominator = 409.
††Denominator = 408.
§§Includes prescription opioids not taken as prescribed, fentanyl, and heroin.
¶¶Includes other illicit, nonprescription substances (e.g., cocaine, methamphetamines, inhalants, or hallucinogens such as LSD or PCP).
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Among pregnant persons in Arizona and Georgia, substance use prevalence was higher among those with a congenital syphilis pregnancy outcome than among those with a noncongenital syphilis outcome; the largest difference was observed in persons who used opioids illicitly or used other illicit, nonprescription substances. Consistent with previous research;[5] the prevalence of late or no prenatal care was high among persons who used any substance during pregnancy, and those who did receive care had fewer prenatal visits. Prompt diagnosis and treatment of syphilis are critical to reducing adverse syphilis-related outcomes for persons who are pregnant, congenital syphilis, and overall syphilis transmission. The need for syphilis screening and treatment should be addressed at any health care encounter during pregnancy, especially among persons who use substances, and in all health care encounters with persons of childbearing age who have a high risk for syphilitic infection.[6] Although syphilis is highly treatable with penicillin G,[5,7] one third of persons in this analysis who used any substances remained untreated.
Previous studies suggest that social determinants of health, including incarceration and homelessness, might be associated with substance use and contribute to deficiencies in care and syphilis treatment.[5,8] Although this study included small numbers and had high levels of missingness for history of incarceration and homelessness, up to one quarter of those who used substances and had a congenital syphilis pregnancy outcome had a history of incarceration or homelessness. Prioritizing persons with these lived experiences for screening and treatment of syphilis at every health care encounter is critical, and innovative strategies need to be developed to reach these populations.
The findings in this report are subject to at least five limitations. First, data collection is ongoing and is from only two states. Data from one of these states are restricted to only three counties; however, these counties represent approximately 80% of births in the state. Prevalence of substance use and other risk factors for congenital syphilis likely vary by jurisdiction, thereby limiting the generalizability of these results. Second, stigma and social desirability bias might have resulted in underreporting of substance use and contributed to the high missingness identified for history of incarceration and homelessness.[9] Further, self-reported substance use creates the potential for recall bias by congenital syphilis status if captured retrospectively (after the birth) among those with a congenital syphilis pregnancy outcome. Fourth, because treatment is highly effective, the finding of 20% of persons with adequate treatment among those with congenital syphilis outcome could be an artifact of the CSTE case definition, which includes nonspecific clinical findings for probable cases or could be related to occult or undiagnosed reinfection that could not be assessed. Finally, there is no age limit for diagnosing congenital syphilis, which might create some misclassification in these data; however, almost all congenital syphilis cases are diagnosed during the neonatal period.[10]
This report highlights the value of the SET-NET surveillance approach of linking data on pregnant persons to data on infants to understand factors related to congenital syphilis. The increasing numbers of congenital syphilis cases across the United States demand further exploration of factors that contribute to this trend and development of strategies to address missed opportunities for diagnosis and treatment before, during, and after pregnancy.[1,2] Although screening and treatment can prevent most cases of congenital syphilis, numerous barriers to implementing these prevention strategies exist, some of which might be amplified among persons who use substances. Tailored interventions need to address barriers and facilitators for accessing screening and treatment for syphilis for persons with current or previous substance use, including those with a history of incarceration and homelessness.
