States Amending Policies to Slow Congenital Syphilis Increases

April 11, 2025 | Amelia Poulin

Syphilis among newborns, or congenital syphilis, is preventable. Yet the latest CDC data show that congenital syphilis cases have more than doubled (106%) from 2019-2023. In 2023 alone, there were nearly 4,000 cases of congenital syphilis resulting in 279 stillbirths and infant deaths. Timely testing and adequate treatment during pregnancy might have prevented up to 80% of these cases. Increases in congenital syphilis often mirror increases in syphilis among reproductive-aged women. From 2022 to 2023, the rate of syphilis (all stages) increased 6.8% among women aged 15–44 years; rates also increased in 39 states and Washington, D.C.

CDC recommends testing pregnant women for syphilis at the first prenatal visit, as well as at 28 weeks gestation and delivery if they are at increased risk of infection. Syphilis testing recommendations extend to asymptomatic women who are at increased risk for infection as they may face additional barriers to health care. ASTHO’s policy-level interventions for states and territories suggest universal syphilis testing for pregnant women. Additionally, states have been taking action to increase access to syphilis testing for people, including those who are pregnant.

The Syndemic Perspective

A history of incarceration, sex work, drug use, and geography can all significantly increase risk for sexually transmitted infections (STIs), HIV, tuberculosis (TB), and more. Structural barriers, including housing instability, economic insecurity, stigma, and restricted health care access, create conditions that heighten vulnerability to multiple infections. These conditions do not occur in isolation but rather as part of a syndemic, where overlapping epidemics interact with and exacerbate one another.

Health agencies may be positioned to address upstream and root cause issues recognizing and addressing the intersections of these disease areas and related structural and social issues (e.g., drug use and poverty). Health agencies carry a wealth of interdisciplinary expertise, with staff leading efforts around data collection and surveillance, policy, community mitigation, and more, all of which support capacity to identify root causes and design an evidence-based, multifaceted response.

Policies that prioritize housing stability, harm reduction services, and access to comprehensive health care, including STI screening, can help mitigate these risks and improve health outcomes.

Geography can also increase the chances of syphilis transmission. Some regions with limited health care infrastructure, provider shortages, and limited STI prevention program funding and capacity may have higher rates of infection. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Social and economic differences across different geographic locations contribute to varying levels of disease burden.

By adopting a syndemic framework, states can move beyond disease-specific interventions and implement comprehensive strategies that address upstream factors contributing to disease transmission.

State Actions

Several states have introduced or passed legislation to expand syphilis testing access, with a focus on increasing screening opportunities, mandating insurance coverage, and ensuring appropriate prenatal testing protocols.

Syphilis Testing

In 2024, Colorado enacted HB 24-1456, which gave the state’s Board of Health rulemaking authority over syphilis testing. This flexibility allows the state to adapt its public health response based on emerging epidemiological trends as new data on syphilis transmission and congenital infections become available.

The 2025 legislative sessions have highlighted additional approaches to expanding access to syphilis testing. The New York legislature introduced S 2704, which would require health insurance coverage for certain approved STI home test kits. This policy would provide individuals who face barriers to in-person care a convenient and private way to get tested and stay healthy. Oregon is also addressing testing accessibility through HB 2943, which would require hospitals to test people for HIV and syphilis when they have blood tests done in the emergency department (ED). Since EDs often serve populations who do not routinely access preventive health care (e.g., people experiencing homelessness or struggling with substance use disorders), this legislation would strengthen the role of emergency settings in STI prevention and intervention.

Perinatal Syphilis Testing

Recognizing the importance of perinatal screening, several states have introduced legislation to add requirements for syphilis testing at key points in pregnancy. Tennessee recently enacted SB 1283, which requires that health care providers take a blood sample to screen for syphilis, hepatitis B, and hepatitis C at the first prenatal examination, ten days after the examination, and at delivery. This approach aligns with CDC recommendations and ensures infections are identified and treated in time to prevent congenital transmission. Similarly, Nebraska LB 41 would require testing for syphilis at the first examination, in the third trimester, and at birth (with the mother’s consent), reinforcing a multi-point screening strategy to detect and treat infections that may develop later in pregnancy.

Missouri’s SB 178 would take a comprehensive approach to syphilis prevention during pregnancy by requiring an additional test at 28 weeks, a critical point for intervention. The legislation would also require treatment for mothers who test positive for an STI, reducing the risk of congenital infections. Additionally, it would expand Expedited Partner Therapy by allowing any health care professional authorized to prescribe medications to administer Expedited Partner Therapy as well as include other STIs in the treatment, enabling faster treatment for sexual partners who might otherwise go untreated and continue the cycle of transmission.

Policy Considerations

Expanding both syphilis and perinatal syphilis testing policies demonstrate a growing recognition of the need for proactive, evidence-based strategies to address the increasing rates of syphilis and congenital syphilis. However, the ability of policies to affect public health outcomes may depend on continued resource allocation, workforce training, and public awareness campaigns. State and territorial health agencies can consider additional measures, such as integrating syphilis screening into routine primary care visits and providing funding for community-based outreach.

Conclusion

These legislative actions represent various approaches states are taking to addressing syphilis. Implementing screening protocols aligned with current evidence may contribute to efforts to address syphilis and congenital syphilis. By leveraging legislative action and evidence-based interventions, states can improve health outcomes and reduce disparities in syphilis and other STIs. A comprehensive approach that includes additional testing, expanded health care access, and targeted interventions for populations at higher risk for infection or severe disease may ensure better health outcomes for parents and infants alike. ASTHO will continue to monitor and report on this important public health issue.