DHS Health Alert #31: Adult and Congenital Syphilis Cases Are Spiking in Milwaukee: Providers Should Prioritize Syphilis Testing in All Medical Settings

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DHS Health Alert Network

Wisconsin DHS Health Alert #31:

Adult and Congenital Syphilis Cases Are Spiking in Milwaukee: Providers Should Prioritize Syphilis Testing in All Medical Settings

Bureau of Communicable Diseases
Bureau of Community Health Promotion

June 14, 2021

Main Points

  • The incidence of syphilis in the City of Milwaukee has risen significantly during the COVID-19 pandemic. The number of primary and secondary cases of syphilis increased nearly 300% in 2020 compared to pre-pandemic levels, with a disproportionate increase among women. In 2020, the City of Milwaukee also had 7 cases of congenital syphilis, higher than any year in recent decades.
  • All pregnant people should undergo routine serologic screening for syphilis when pregnancy is first diagnosed. Screening should be repeated at 28 weeks gestation for pregnant patients living in counties with elevated rates of primary and secondary syphilis, which currently include Brown, Dane, Milwaukee, Racine, Waukesha, and Winnebago.
  • In all areas of Wisconsin, no patient giving birth and no newborn infant should leave the hospital without maternal serologic status having been documented at least once during pregnancy, and again at delivery if risk factors are present.
  • Pregnant people who have not been receiving routine prenatal care should be tested for syphilis during any health care encounter (e.g. emergency departments or urgent care visits), so as to not miss any opportunities to diagnose and treat syphilis.
  • All cases of syphilis should be reported within 72 hours to your local health officer.  

Dear Colleagues,

A recent analysis of disease surveillance data by the City of Milwaukee Health Department has detected a substantial increase in cases of syphilis, co-incident with the COVID-19 pandemic. The incidence of primary and secondary syphilis has increased by nearly 300% over pre-pandemic levels. Compared to syphilis surveillance data from prior years, data from the current outbreak shows a significant increase in the proportion of cases who are female. Syphilis cases in men increased from 75 baseline cases to 188 recent cases, a 251% increase, while cases in women increased from 8 to 41, a 413% increase. A significant number of people interviewed because of a new syphilis infection during 2019 and 2020 reported risky behaviors including injection drug use or the exchange of sex for money or drugs.

Most alarming in the setting of the surge in syphilis cases among people of reproductive age has been a spike in congenital syphilis. In 2020, the City of Milwaukee had 7 cases of congenital syphilis, higher than any year in recent decades.

Congenital syphilis occurs when the spirochete Treponema pallidum is transmitted transplacentally from an infected pregnant person to the fetus. Up to ~40% of babies acquiring syphilis prenatally may be born stillborn or die from the infection in the newborn period. Congenital syphilis may additionally cause miscarriage, prematurity, or low birth weight. Clinical manifestations include enlarged liver or spleen, rash, jaundice, severe anemia, deformed bones, blindness, deafness, and meningitis. Congenital syphilis can have devastating consequences but is completely preventable with early detection and treatment.

According to the CDC 2015 Sexually Transmitted Diseases Treatment Guidelines, serologic testing is recommended for all pregnant people at the first prenatal visit. In communities with higher prevalence of syphilis, the CDC recommends repeat syphilis testing at 28 weeks, and preferably again at delivery if at risk. While there is no universally accepted definition of high syphilis prevalence, some jurisdictions have adopted a level of 2 cases of primary and secondary syphilis per 100,000 residents as the benchmark for recommending more frequent syphilis testing during pregnancy. Using this criterion, DHS now recommends third trimester syphilis testing for all pregnant patients in 6 Wisconsin counties that exceeded this level in 2020 and had 5 or more total cases. These include Brown County, Dane County, Milwaukee County, Racine County, Waukesha County, and Winnebago County.

It is also important to note that the epidemiology of syphilis in Wisconsin reflects the longstanding racial inequities observed across a wide range of health conditions. For example, 65.9% of syphilis cases in the city of Milwaukee diagnosed from 2018-2020 were among Black residents. Continued efforts to address upstream and root causes of these inequities remain important. Additional modifiable risk factors that remain important to address as we work to decrease the spike in syphilis cases developing nationwide and in Milwaukee include combatting poverty, increasing access and utilization of prenatal care services, enhancing trust between patients and healthcare providers, improving access to mental health services, and assuring equitable housing and living conditions for all people in Wisconsin.

In summary, DHS now requests that Wisconsin providers take action to respond to the growing burden of syphilis, with a goal of eliminating congenital syphilis in Wisconsin:

  • All pregnant patients should be screened for syphilis. Providers should consider syphilis testing at the time of diagnosis of pregnancy, especially if patients are uninsured or have other barriers to health care. All patients should have syphilis testing performed at or before the first prenatal care visit.
  • In 6 counties with a high burden of syphilis, repeat syphilis testing should be done at 28 weeks gestation, because of increased syphilis prevalence.
  • In all Wisconsin jurisdictions, repeat syphilis testing should be done at 28 weeks and at the time of delivery if maternal risk factors are present, including exposure to any sexually transmitted disease, exchanging sex for money or drugs, or injection drug use.
  • Neonates born to patients whose syphilis status is unknown at the time of delivery can be tested for syphilis with RPR on a cord blood sample.
  • All patients diagnosed with syphilis should be tested for HIV.

For questions about syphilis reporting and surveillance in Wisconsin visit the DHS STI Program website at https://www.dhs.wisconsin.gov/std/health-pros.htm or contact Brandon Kufalk, STI Program Unit Supervisor for DHS at 608-867-4539 or Brandon.Kufalk@dhs.wisconsin.gov.

Thank you for your collaboration on this important public health issue.


Ryan Westergaard, MD, PhD, MPH
Chief Medical Officer and State Epidemiologist for Communicable Diseases Wisconsin Department of Health Services

Jasmine Zapata, MD, MPH
Chief Medical Officer and State Epidemiologist for Community Health Wisconsin Department of Health Services

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