Combatting the rise in congenital syphilis: How service providers can support prevention, testing and treatment

In recent years there has been a staggering rise in the number of cases of syphilis in women* of reproductive age in Canada. This has led to an increase in the number of cases of congenital syphilis (babies being born with syphilis). Congenital syphilis disproportionately affects the infants of Indigenous women and women who use drugs because these groups experience systematic discrimination leading to barriers to accessing prenatal and overall healthcare. Service providers have an important role to play in addressing syphilis and helping to connect women, including pregnant women, to appropriate care, including prevention, testing and treatment services.

*In this article, we have used the term “women” to describe cisgender women, as this is the term used in epidemiological reports. We acknowledge the diversity of people who may become pregnant, which includes trans people.

Maternal and congenital syphilis

Syphilis is a bacterial infection that is transmitted through vaginal, anal and oral sex.¹ It is also less commonly passed through sharing equipment used for injecting drugs,^2–4 through deep kissing^5,6 and through sharing sex toys.⁷ Syphilis can be passed from a pregnant woman to her infant during pregnancy or childbirth or through breastfeeding.⁸

Some people with syphilis do not experience any symptoms, and others experience symptoms ranging from mild to severe.¹ Syphilis is usually treated and cured with a single injection of penicillin. In adults, syphilis does not generally cause serious health problems if it is detected and treated early. Being cured of syphilis does not prevent a person from getting it again. There is no vaccine to prevent syphilis.

Maternal syphilis is syphilis in a person who is pregnant. Maternal syphilis can lead to miscarriage, stillbirth, preterm birth or congenital syphilis.

Congenital syphilis is syphilis transmitted to a baby during pregnancy or delivery. Babies born with syphilis may be asymptomatic or may have severe manifestations of the infection, such as hepatosplenomegaly, anemia or a desquamating rash. If the infant does not have symptoms and is left untreated, they can go on to develop developmental abnormalities, including facial, dental or skeletal malformations, neurological issues and problems with vision or hearing.^8,9

The likelihood of a baby being born with syphilis depends on the following factors:

• The woman’s syphilis stage during pregnancy: The chance of syphilis being passed to a baby is related to the stage of maternal syphilis. Syphilis is most likely to pass if the woman is in the primary or secondary stage of infection when she becomes pregnant or if she gets syphilis while pregnant.¹⁰
• How far along the pregnancy is (gestational age) at the time of treatment: Nearly all transmissions to babies are prevented if the mother receives treatment during the first 28 weeks of pregnancy.^11,12The chance of passing syphilis to a baby increases with increasing gestational age.⁸ This means that the risk becomes higher if treatment is received later in pregnancy or if the person is not treated at all.^8,12

Trends in the rates of congenital syphilis in Canada

In recent years, there has been a dramatic rise in the number of cases of congenital syphilis, coinciding with a dramatic increase in the rate of syphilis cases in women of reproductive age (i.e., 15 to 39 years old).^13,14 The number of confirmed cases of congenital syphilis increased 1,271% from 2017 to 2021 while the rate of syphilis diagnoses among women of reproductive age increased 768% over the same time period.

*This does not include presumed cases that were not confirmed with a blood test. The actual number is probably higher.

While cases of congenital syphilis have occurred across Canada, the Prairie provinces have been disproportionately affected.¹⁵ In 2020, 86% of confirmed congenital syphilis cases in Canada were in Alberta, Saskatchewan or Manitoba.¹⁵ These provinces also had the highest proportion of syphilis cases among women of reproductive age.¹⁵

National surveillance data do not provide comprehensive information about the characteristics of women who give birth to babies with congenital syphilis, but studies done in Alberta^3,16,17 and Manitoba¹⁸ provide some insight. Most cases of congenital syphilis occur when a woman receives no prenatal care or inadequate care (e.g., where a woman accesses care but does not receive syphilis testing and treatment), and among women who acquire syphilis or become reinfected later in their pregnancy.^16–18 Congenital syphilis has disproportionately affected the infants of women who use drugs^3,16–18 and Indigenous women.^3,16,17 This may be because women who use drugs and Indigenous women are known to face systemic barriers to healthcare access because of racism and discrimination they experience in the healthcare system.

Preventing congenital syphilis

Addressing syphilis among women and men of reproductive age will have the downstream effect of helping to prevent congenital syphilis. Using condoms during anal and vaginal sex and using condoms or dental dams for oral sex helps to prevent syphilis.¹ However, condoms do not completely eliminate the risk, as syphilis can pass through skin-to-skin contact if the person with syphilis has a sore. Using new equipment each time a person injects drugs will prevent syphilis from passing. Anyone who may be at risk of syphilis through sex or injection drug use should be tested for syphilis regularly and treated if necessary. Getting treatment for syphilis is important for a person’s health and prevents syphilis from passing to others, including to their baby if the person is pregnant.

To detect and treat syphilis as early as possible in pregnancy and to detect syphilis infections that occur during pregnancy, Canadian guidelines¹ recommend screening all pregnant women in their first trimester or at their first prenatal visit. For women at ongoing risk for syphilis and those who live in areas where there is a syphilis outbreak among heterosexual people, Canadian guidelines recommend screening again at 28–32 weeks’ gestation and once more at the time of delivery. The guidelines also recommend that more frequent screening (e.g., monthly) be considered for individuals at high ongoing risk. Some provinces and territories have put out their own guidelines or directives for more frequent universal testing, in response to outbreaks.^19–24                                

Barriers to prenatal care for women who use drugs and Indigenous women

Addressing barriers to receiving adequate prenatal care is crucial for diagnosing and treating cases of maternal syphilis and preventing congenital syphilis. It is especially important to address barriers to care among women who use drugs and Indigenous women, as they may face substantial barriers to accessing prenatal care.

Pregnant women who use drugs often describe interactions with healthcare providers during pregnancy and the postpartum period as adversarial or judgmental, rather than supportive.²⁵ Anti-Indigenous racism creates barriers for Indigenous women to access healthcare generally and perinatal care specifically.²⁶ This includes institutional racism as well as racism and discrimination that Indigenous people face from individual healthcare providers.

Fear of child apprehension can be a major barrier to accessing care for women who use drugs^27,28 and Indigenous women.²⁶ Some women who use drugs may avoid prenatal care altogether for fear that their child(ren) will be apprehended because of their substance use.²⁷ There is a long history of the Canadian government removing Indigenous children from their families, starting with Indian residential schools and continuing with the apprehension of thousands of Indigenous children by child-welfare agencies in the 1960s to 1980s, known as the Sixties Scoop. Indigenous children continue to be grossly overrepresented in the foster care system.²⁹ Indigenous women who are experiencing any factors that might put them at risk for child removal (such as lack of secure housing, poverty or drug use) may avoid interacting with the healthcare system to avoid being reported to child and family services.

How service providers can help to prevent congenital syphilis

Addressing high rates of syphilis among women and men

Service providers should work to address syphilis among all women and men of reproductive age, which will help to prevent congenital syphilis:

• Provide education about syphilis, including how it is transmitted, the increasing risk of syphilis, how it can be prevented, and syphilis testing and treatment. Promote the message that syphilis is easily treated if it is diagnosed early.
• Support access to syphilis prevention, testing and treatment. This includes direct support, such as providing condoms, dental dams and injection drug use equipment, and information about where people can receive testing and treatment. It can also include offering services or providing referrals to services that address broader issues that impact a person’s health, such as support with housing and food security, substance use services or mental health services.

Addressing maternal syphilis and reducing barriers to prenatal care

Service providers can play an important role in providing education and support around syphilis prevention, testing and treatment among pregnant women and in addressing barriers to prenatal care that may exist in the community:

• Recognize that pregnant women who use drugs have a right to access the full spectrum of drug treatment and harm reduction services. Many pregnant women are highly motivated to stop using drugs or reduce their use before becoming a parent.^28,30 They may require assistance to access non-judgmental substance use treatment from providers who are comfortable working with pregnant women. Those who continue to use drugs need access to harm reduction, including drug use equipment, programs such as supervised consumption services and safer supply programs in regions where they are available.²⁷ It is crucial that anyone providing services to pregnant women who use drugs is supportive and respectful of their clients, to help them remain engaged in care.^27,31
• Work to ensure that pregnant people who use drugs have access to a range of services that they may need to improve their health and well-being. Some services that may be useful include child and family services, housing, drug treatment and harm reduction programs, primary and perinatal healthcare and culturally appropriate programs for Indigenous women.^31,32 Programs that provide wholistic care to address multiple needs of pregnant women who use drugs have been shown to increase engagement in care.³¹ These programs are established in many cities in Canada.³² In regions where they are not available, service providers can work to improve access to the services needed in the community.
• Consider ways to support Indigenous women to become engaged in prenatal care. This may include traditional Indigenous midwifery, involvement of community Elders and other cultural birth practices.^32–34 Non-Indigenous healthcare providers can also be given training to build their cultural competency and challenge anti-Indigenous racism.²⁶
• Work to form positive relationships with local child-welfare service representatives, to support pregnant women who may be at risk of child apprehension. If the discussion with a child and family service worker begins before the baby is born, a plan can be made and often the baby can remain with the mother.^27,31,32
• Encourage women who are pregnant or planning to become pregnant to get tested for syphilis and treated if necessary. Educate women about the need for retesting during pregnancy if they are at ongoing risk for syphilis.
• Provide education and support to pregnant women who are at ongoing risk for syphilis. This can include providing condoms and drug use equipment, as well as other supports such as harm reduction programs and referrals to drug treatment programs (if wanted).

Related resources

Syphilis: What you need to know – brochure

Syphilis – fact sheet

A resurgence of syphilis in Canada: Who is being affected most and what interventions are needed? 

Parenting, substance use and the child welfare system: Sharing lived experiences and providing support – CATIE blog

Views from the front lines: Congenital syphilis

National, provincial and territorial guidelines and directives for syphilis testing in pregnancy

Canadian Guidelines on Sexually Transmitted Infections: Syphilis – Public Health Agency of Canada

New Recommendations for Syphilis Screening in Pregnancy – Perinatal Services BC

Alberta Prenatal Screening Guidelines for Select Communicable Diseases – Alberta Health Services

Sexually Transmitted Infection Screening – Saskatchewan Health Authority

Memo: Syphilis Infection in Pregnancy and Congenital Syphilis in Manitoba – Manitoba Health, Seniors and Active Living

Syphilis Serology – Newfoundland and Labrador Public Health Laboratory

New Brunswick Clinician’s Guide to Syphilis Diagnosis and Treatment 2013 – Government of New Brunswick

NWT Clinical Practice Information Notice – Government of Northwest Territories

Nunavut Communicable Disease and Surveillance Manual – Government of Nunavut

References

1. Public Health Agency of Canada. Canadian guidelines on sexually transmitted Infections: syphilis. Ottawa (ON): Public Health Agency of Canada. Available from: https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis.html
2. Loza O, Patterson TL, Rusch M et al. Drug-related behaviors independently associated with syphilis infection among female sex workers in two Mexico-U.S. border cities. Addiction. 2010 Aug;105(8):1448-56.
3. Raval M, Gratrix J, Plitt S et al. Retrospective cohort study examining the correlates of reported lifetime stimulant use in persons diagnosed with infectious syphilis in Alberta, Canada, 2018 to 2019. Sexually Transmitted Diseases. 2022 Aug 24;49(8):551-9.
4. Plotzker RE, Burghardt NO, Murphy RD et al. Congenital syphilis prevention in the context of methamphetamine use and homelessness. American Journal on Addictions. 2022 May;31(3):210-8.
5. Yu X, Zheng H. Syphilitic chancre of the lips transmitted by kissing: a case report and review of the literature. Medicine. 2016 Apr;95(14):e3303.
6. Liu XK, Wang ZS, Li J. Kissing chancre of primary syphilis. IDCases. 2017;7:38-9.
7. Champenois K, Cousien A, Ndiaye B et al. Risk factors for syphilis infection in men who have sex with men: results of a case–control study in Lille, France. Sexually Transmitted Infections. 2013 Mar 1;89(2):128-32.
8. National Collaborating Centre for Infectious Diseases. 2022. Congenital syphilis disease brief. Winnipeg (MB); National Collaborating Centre for Infectious Diseases. Available from: https://nccid.ca/debrief/congenital-syphilis/
9. David M, Hcini N, Mandelbrot L et al. Fetal and neonatal abnormalities due to congenital syphilis: a literature review. Prenatal Diagnosis. 2022 May;42(5):643-55.
10. Cooper JM, Sánchez PJ. Congenital syphilis. Seminars in Perinatology. 2018 Apr;42(3):176-84.
11. Fiumara NJ. Syphilis in newborn children. Clinical Obstetrics and Gynecology. 1975 Mar 1;18(1):183-9.
12. Plotzker RE, Murphy RD, Stoltey JE. Congenital syphilis prevention: strategies, evidence, and future directions. Sexually transmitted Diseases. 2018 Sep 1;45(9S):S29-37.
13. Public Health Agency of Canada. Syphilis in Canada: technical report on epidemiological trends, determinants and Interventions. Ottawa (ON): Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada; 2020. Available from: https://www.canada.ca/en/services/health/publications/diseases-conditions/syphilis-epidemiological-report.html
14. Public Health Agency of Canada. Infectious syphilis and congenital syphilis in Canada [infographic]. Ottawa (ON): Public Health Agency of Canada; 2021. Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2022-48/issue-11-12-november-december-2022/infectious-congenital-syphilis-canada-2021.html
15. Aho J, Lybeck C, Tetteh A et al. Syphilis resurgence in Canada: rising syphilis rates in Canada, 2011–2020. Canada Communicable Disease Report. 2022 Feb 2;48(23):52-60.
16. Round JM, Plitt SS, Eisenbeis L et al. Examination of care milestones for preventing congenital syphilis transmission among syphilis-infected pregnant women in Alberta, Canada: 2017–2019. Sexually Transmitted Diseases. 2022 Jul 1;49(7):477-83.
17. Gratrix J, Karwacki J, Eagle L et al. Outcomes of infectious syphilis in pregnant patients and maternal factors associated with congenital syphilis diagnosis, Alberta, 2017-2020. Canada Communicable Disease Report. 2022 Feb 24;48(2-3):61-7.
18. Benoit P, Tennenhouse L, Lapple A et al. Syphilis resurgence in Canada: congenital syphilis re-emergence in Winnipeg, Manitoba. Canada Communicable Disease Report. 2022 Feb 2;48(2-3):89-94.
19. Perinatal Services BC. New recommendations for syphilis screening in pregnancy. Vancouver (BC): Perinatal Services BC; 2019. Available from: http://www.perinatalservicesbc.ca/about/news-stories/stories/new-recommendations-for-syphilis-screening
20. Alberta Health Services. Alberta prenatal screening guidelines for select communicable diseases. Edmonton (AB): Alberta Health Services; 2018. Available from: https://open.alberta.ca/dataset/0ac7acb6-dc90-4133-8f63-5946d4bbf4d1/resource/782751ed-17b9-4116-9aa4-227e55ec0299/download/alberta-prenatal-screening-guidelines-2018-10.pdf
21. Saskatchewan Health Authority. Sexually transmitted infection screening. Saskatoon (SK): Saskatchewan Health Authority; 2022. Available from: https://www.saskhealthauthority.ca/your-health/conditions-diseases-services/healthline-online/ug2222#
22. Manitoba Health. Memo: Syphilis infection in pregnancy and congenital syphilis in Manitoba. Winnipeg (MB): Manitoba Health; 2020. Available from: https://www.gov.mb.ca/health/publichealth/cdc/docs/hcp/2020/072120.pdf
23. Government of the Northwest Territories. NWT clinical practice information notice. Yellowknife (NT): Government of the Northwest Territories; 2022. Available from: https://www.hss.gov.nt.ca/professionals/sites/professionals/files/resources/cpi-176-revised-enhanced-congenital-syphilis-screening-treatment-reporting.pdf
24. Government of Nunavut. Nunavut communicable disease and surveillance manual. Iqaluit (NU): Government of Nunavut; 2020. Available from: https://www.gov.nu.ca/sites/default/files/nu_communicable_diseases_manual_-_complete_2020oct16.pdf
25. Renbarger KM, Shieh C, Moorman M et al. Health care encounters of pregnant and postpartum women with substance use disorders. Western Journal of Nursing Research. 2020 Aug;42(8):612-28.
26. Native Women’s Association of Canada. Misconduct, missing, and murdered: the experiences of anti-Indigenous racism in reproductive healthcare among Indigenous women, girls, two-spirit, transgender, and gender-diverse people, and the MMIWG2S+ genocide. Gatineau (QC): Native Women’s Association of Canada; 2022. Available from: https://nwac.ca/assets-knowledge-centre/9-Dec-Racism-in-Healthcare.pdf
27. National Safer Supply Community of Practice. Harm reduction, safer supply & experiences of pre- and peri-natal care. Available from: https://www.nss-aps.ca/fr/node/2683
28. Hubberstey C, Rutman D, Schmidt RA et al. Multi-service programs for pregnant and parenting women with substance use concerns: women’s perspectives on why they seek help and their significant changes. International Journal of Environmental Research and Public Health. 2019 Sep;16(18):3299.
29. Truth and Reconciliation Commission of Canada. Honouring the truth, reconciling for the future: Summary of the final report of the Truth and Reconciliation Commission of Canada. Truth and Reconciliation Commission of Canada; 2015.
30. Tsuda‐McCaie F, Kotera Y. A qualitative meta‐synthesis of pregnant women's experiences of accessing and receiving treatment for opioid use disorder. Drug and Alcohol Review. 2022 May;41(4):851-62.
31. Hubberstey C, Rutman D, Van Bibber M et al. Wraparound programs for pregnant and parenting women with substance use concerns in Canada: Partnerships are essential. Health & Social Care in the Community. 2022 Sep;30(5):e2264-76.
32. Rutman, D., Hubberstey, C., Van Bibber M et al. Co-Creating Evidence Evaluation report: Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk. 2021.  
33. Healthcare Excellence Canada. Safe and respectful First Nations, Inuits and Métis maternal and newborn care webinar. Sept. 17, 2021. Available from: https://www.youtube.com/watch?v=e2ayVX_9Jsk
34. Provincial Perinatal Substance Use Project. Elders visioning perinatal substance use toolkit. Vancouver (BC): BC Women’s Hospital and Health Centre; 2021. Available from: http://www.bcwomens.ca/Professional-Resources-site/Documents/Perinatal%20Substance%20Use/PHSA_Elder_Visioning_PSU_toolkit_FINAL%2022Nov2021.pdf

About the author(s)

Mallory Harrigan is CATIE's knowledge specialist, HIV testing. She has a master’s degree in community psychology from Wilfrid Laurier University.