The COVID-19 pandemic highlights the critical importance of a robust and prepared public health infrastructure that can support people with limited income and resources — a grim reality for an increasing number of Americans given the mass shutdown of the U.S. economy.
Unfortunately, a decades-long divestment from public health has come home to roost: Alongside the inadequate response of our health system to the COVID-19 pandemic, we face a national five-year surge of sexually transmitted infections (STIs), including congenital syphilis, reaching an all-time high. A well-funded Medicaid program is now more critical than ever.
Earlier this year, the Trump administration announced a new plan to cut Medicaid funding through the creation of a block grant program, which critics say creates barriers to health care for low-income people, especially for the millions of low-income adults without children who gained coverage under the ACA’s Medicaid expansion. This program would serve as an alternative for the currently 14 states that have not adopted Medicaid expansion for low-income adults under the 2010 Affordable Care Act (ACA).
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The timing of the proposal remains unclear, but the decision not to opt for Medicaid expansion for low-income adults a decade ago may be coming back to haunt the states that refused to sign on to the Affordable Care Act. One of the repercussions is the national resurgence of STIs, including congenital syphilis, where Texas, a non-expansion state, leads the nation, according to the Centers for Disease Control (CDC) 2018 Sexually Transmitted Disease Surveillance released last October.
Nationwide, the syphilis rate increased 34 percent in 2018 compared with 2016, with 4,416 cases among women giving birth in 2018, according to recent CDC data. Although syphilis is the least commonly reported STI, cases of congenital syphilis have nearly tripled in the past four years.
Congenital syphilis is a preventable condition that experts say is due to an inadequate health care safety net, with few provisions to help pregnant people overcome barriers to health care.
Irene Stafford, professor at the University of Texas Health Science Center Division of Maternal-Fetal Medicine in Houston, works with cases of congenital syphilis. Stafford says potential cuts to Medicaid would not help in the current fight to control congenital syphilis in Texas. From a provider perspective, Stafford says that syphilis is “a hard disease to manage” that requires consistent and diligent follow-up and adherence to guidelines.
“We need as much support from the government and from Medicaid as possible to help at least support the congenital syphilis follow-up,” Stafford told Truthout.
She says that provider follow-up is crucial in the fight against syphilis, and provider availability to follow-up with syphilis patients relies on resources and funding. And now, with hospitals expected to be at over-capacity dealing with severe coronavirus cases, many providers would not have the capacity or availability to address these concerns.
For now, the general recommendation for physicians has been to continue prenatal visits, said Judy Levison, obstetrician-gynecologist at Baylor College of Medicine, in an email correspondence, but to “space [appointments for prenatal visits] further apart than the usual” and consolidate blood tests and vaccinations when possible, in accordance with recommendations made by the American College of Obstetricians and Gynecologists.
Stafford also says that while pregnant people and children in Texas are likely to be covered by Medicaid in the case of potential cuts, funding cuts could impact at-risk populations not covered by Medicaid, such as low-income men of color. Pregnant people may still interact with such groups and still increase the possibility of acquiring an infection.
Low-income women of all races, as well as Black and Latina women, are disproportionately affected by congenital syphilis, and have had chronic lack of access to health care, according to Martha Rac, a maternal medicine physician and professor at Baylor College of Medicine in Houston.
“Any sort of cut to Medicaid or cap to Medicaid redistribution of funds — however that’s going to be defined — is going to disproportionately affect those women that need it the most,” Rac told Truthout.
Congenital syphilis can result in severe health complications for infants, including death, but is preventable when detected. Passed from the pregnant person to the newborn infant, congenital syphilis can cause miscarriage, low birth weight, preterm birth and even death — up to 40 percent of infants born to those with untreated syphilis are stillborn or die from the infection as a newborn. Effective prevention and control of syphilis depend on vigilant screening, and for pregnant people, screenings during prenatal care visits.
The CDC recommends all pregnant people get tested for syphilis during their first trimester, with additional testing for those considered at increased risk of acquiring the infection and those who live in communities with an increased prevalence of syphilis. At the time this was written, the CDC did not offer advice for how these guidelines would be impacted by the pandemic, according to Levison.
People who test positive should seek treatment in the form of antibiotics immediately and continue to get routine screening, while pregnant people should be screened during the first prenatal visit. Screening for syphilis is especially important because symptoms can be mild, similar to those of other health conditions, or even nonexistent, so testing is the only way to know for sure.
New CDC data show that in 2018, the national rate of congenital syphilis was 33 cases per 100,000 live births. Texas ranked first among states with a rate of 92.2 cases per 100,000 live births, accounting for 28 percent of the 1,306 reported congenital syphilis cases in the U.S., with 367 cases. According to 2018 STD Surveillance data from the Texas Department of Health and Human Services, syphilis rates among women of child-bearing age (15 to 44 years old) has increased from 1,537 in 2015 to 2,401 in 2018. The increase in congenital syphilis is a direct function of the general increase in STIs in the nation, including those among people of child-bearing age. These data show Black and Latina women account for nine out of ten congenital syphilis cases — 45 percent and 44 percent of congenital syphilis cases in 2018, respectively.
The same data show, surprisingly, 76 percent of Texas women who delivered an infant with congenital syphilis in 2018 reported receiving prenatal care, with 60 percent of those women initiating prenatal care in the first trimester. Although Texas is a non-expansion state, pregnant women who meet certain income requirements can still receive Medicaid benefits, including prenatal care.
“These women are getting in care at some point, so there’s a breakdown somewhere in the system, whether it’s provider familiarity, whether it’s follow-up care, whether it’s … adherence to the appropriate CDC recommendations,” said Rac.
So why are Texas infants experiencing such high congenital syphilis rates?
Getting pregnant people screened for syphilis — and STIs more generally — is critical in the fight against congenital syphilis, Texas physicians say.
Levison of Baylor College of Medicine provides care for women living with HIV and is a co-lead of the Fetal and Infant Morbidity Review of Syphilis and HIV (FIMRSH) for Houston. FIMRSH meets quarterly to review cases of infants born with syphilis or HIV to examine common themes in barriers to care and inform lawmakers and other institutions to change policies to reduce these barriers.
With the encouragement of the CDC, Levison’s team developed the first Review for Houston in 2015, made up of physicians, nurses and social workers, as well as epidemiologists and community health workers. It also included those who work in the mental health and carceral systems, said Levison, given that a substantial proportion of cases involve mental health and substance use disorders.
Every quarter, they review cases of perinatal HIV and syphilis, which can include interviews with women with reported perinatal HIV and syphilis.
Levison says the point of the FIMRSH is to examine what factors led to cases of perinatal HIV and syphilis and determine where intervention is needed in order to increase access to screening and treatment. She says that Texas health care is “such a fragmented system” that many “don’t know where to turn.” Barriers to screening, treatment and follow-up are related to poverty, lack of transportation, incarceration, substance abuse and mental health issues.
Emily Adhikari, professor at the University of Texas Southwestern in Dallas, and medical director of the Perinatal Infectious Disease department at Parkland Health and Hospital System, agrees that the factors that lead to congenital syphilis rates in Texas are multifaceted. Adhikari oversees and directs the obstetric infectious disease clinic for Parkland Hospital, which is the referral clinic for all of the prenatal systems for Dallas County, and says early diagnosis is key to treating congenital syphilis.
“[F]rom a maternal perspective … awareness of the need for early prenatal care is critical,” she said, which includes the ability to simply call to make an appointment, get the appointment and get to the appointment. She cites patient, provider and systems-level factors that prevent pregnant people from getting the necessary care to prevent and treat syphilis. These include poverty, the ability to get an appointment and transportation, as well as public health awareness about syphilis, which she says may be tied to decreased federal funding in STI prevention.
Junda Woo is the medical director for the City of San Antonio Metropolitan Health District and says the congenital syphilis rates in Texas are not the least bit surprising.
“We never expanded Medicaid. We have a frayed safety net…. Once [people] are pregnant, they don’t know where to get to access care, they don’t know they’re eligible to access care, and they don’t know it’s important to get care,” she told Truthout.
Woo says that many women may be afraid or unable to seek care assistance even if they are in need of care.
“There are a lot of women who simply do not access prenatal care — at least half of the [Fetal and Infant Morbidity Review] cases. Sometimes it’s the lack of information; sometimes, on top of that, there’s domestic violence, substance use — all the things that compound people’s difficulty in getting care. People might be afraid to access care because they’re not citizens,” said Woo.
Interviewed experts constantly cited transportation as a major barrier for low-income people who do not have access to a car in the sprawling, car-dependent Texas landscape.
“Transportation has come up a lot,” said Amanda Evans, a pediatric infectious disease physician and professor at the University of Texas Southwestern Medical Center in Dallas. Evans is also the medical director of the center’s pediatric infectious disease clinic and finds that congenital patients are her number one no-show for follow-ups. She says her clinic works with transportation services and cab companies to get mothers to the clinic so they can get their infants screened and tested.
Typically, Medicare and Medicaid cover emergency ambulance transportation. But federal regulations allow for Medicaid recipients to get nonemergency medical transportation, or rides to and from medical providers, if they met requirements and rules set forth by their state. Texas Medical Transportation program provides rides to doctor’s and dentist’s office, pharmacist, or any place that provides health care services for Medicaid enrollees.
Information from the Houston FIMRSH board contributed to the passage of new legislation to address the transportation barrier to care and treatment, like HB 25. Introduced by Rep. Mary Gonzalez (D-El Paso), the law resulted in a pilot project for Medicaid transportation that would ease the burden of accessing transportation for pregnant people, including the incorporation of ride-share services and allowing pregnant people to bring their dependent children on Medicaid medical transportation. Previously, pregnant people could not bring small children to prenatal visits when using Medicaid’s medical transportation service.
Lack of awareness among providers and the public about syphilis contribute to inadequate screening for patients. In response to the growing syphilis problem in Texas, providers are now mandated to test pregnant people three times during the course of the pregnancy. But Levison says that many providers may not think their patients are in need of screening for syphilis.
“We have encountered clinicians who didn’t know they were supposed to [screen]. And we’ve encountered a clinician who knew about the law but felt that this didn’t exist in ‘our backyard’…. My response is that you don’t know until you look,” Levison said.
Woo has also encountered doctors who missed opportunities to test for syphilis in their pregnant patients because they think syphilis is not a problem in their patient population. However, with a surge in attention to the syphilis problem and the importance of screening, she thinks “people have gotten the message.”
Levison says the many in the public may assume they are being screened for STIs like syphilis and HIV during a normal check-up with a doctor when they are not. “If anything, the public these days assume they are being tested when they may or may not be.”
Adhikari says this may be due to the decreases in federal funding for STI prevention and treatment, which has resulted in the public not thinking STI prevention is a critical public health issue.
Indeed, public health experts and advocates suggest the record-high rates result from the failure of federal funding to keep up. According to CDC representative Jacqueline Petty, while CDC funding has been stable, “the purchasing power of that funding declined 35 percent from 2003-2018,” resulting in more than half of local STD programs experiencing budget cuts — leading to clinic closures, reduced screening and staff loss nationwide. Fewer services and resources geared toward STI prevention means more opportunities for missed infections that go untreated, and more transmission into communities.
“I think … public health awareness is an important issue too,” Adhikari said. “If people don’t think about syphilis as important, they think it’s gone. They think … it’s not important anymore.”
At least $70 million is needed to accelerate the public health response to rising STDs and related challenges, according to the National Coalition of STD Directors. Funding cuts from the Great Recession undid years of STI prevention and treatment efforts that brought syphilis rates to record lows in 2000 and 2001 — a feat that suggested the possibility of eradicating the disease at the time.
At this moment medical providers are contending with difficult clinical scenarios of rationing care to alleviate resources shortages. What is not known is the potential impact of this unpreparedness on the surge of congenital syphilis cases. But providers already anticipate not being able to treat other illnesses and issues due to shortages caused by the COVID-19 outbreak.