By Mahaa Ahmed
Mahaa Ahmed is an MSc student at the Harvard T.H. Chan School of Public Health and Research Assistant at the Maternal Health Task Force.
Beyond the devastating direct impact of SARS-CoV-2 infections, the Covid-19 pandemic has disrupted children’s education, increased gender inequality, poverty, and hunger. It has disrupted health systems and health delivery.
In the midst of the ongoing pandemic, various communities have faced threats from other infectious diseases— Bangladesh is battling dengue outbreaks while experiencing a sharp increase in Covid-19 cases, Yemen is challenged by both cholera and Covid-19 in the midst of a humanitarian crisis, and the United States is strained by Covid-19 in addition to a silent epidemic of sexually transmitted infections (STIs), which are also often referred to as sexually transmitted diseases (STDs), that has been surging in recent years. Currently, the preferred term is STIs, which was coined to distinguish between diseases caused by infections and infections themselves, which can be subclinical. The Centers for Disease Control and Prevention (CDC) primarily uses the term STDs.
The CDC recently published its 2019 National Overview on STDs, indicating that cases of chlamydia, gonorrhea, and syphilis have all reached new all-time highs. Of particular concern includes the nearly 279% increase in congenital syphilis cases from 2015. Cases are at their highest since 1995. Congenital syphilis occurs when a mother with syphilis passes on the infection to their baby. It can lead to severe health impacts, such as miscarriage, stillbirth, low birth weight, deformed bones, anemia, jaundice, blindness, and deafness. However, congenital syphilis is preventable given that syphilis is curable with antibiotics.
Amelia Hamarman is currently Assistant Manager of the New Jersey Department of Health’s (NJDOH) STD and STD-HIV Partner Services Program. In her nearly 18 years working for the NJDOH, Hamarman has advocated for increased healthcare provider education about STDs in addition to working with nearly 85 local health clinics across the state. She recently shared her insights on the recent intersection of the Covid-19 and congenital syphilis crises.
Covid-19’s Effects on STI Services
According to Hamarman, the onset of Covid-19 led to many staff being deployed to help with Covid-19 efforts. Given that many STD staff were experienced in contact tracing or partner services (as it is known in the STD world), they were called upon to train more contact tracers to establish Covid-19 surveillance. The reallocation of staff and resources has led to gaps in STI surveillance not only in NJ but also in other parts of the U.S. Although a decrease in STI cases was noted in the early quarter of the Covid-19 pandemic, cases rebounded quickly and continue to skyrocket as they have in previous years. Covid-19 led health clinics, which provide critical access to STI testing and services, to limit their hours of availability or to shutter their doors altogether. Hamarman said, “about half of our staff was deployed to help with Covid-19 [efforts].”
Congenital syphilis cases occur due to lack of prenatal care and lack of timely diagnosis and treatment of syphilis. Covid-19 has only further increased the risk of missing these opportunities to prevent congenital syphilis cases.
Combating Congenital Syphilis in the Midst of Covid-19
Congenital syphilis cases are spiraling out of control and have exceeded mother-to-child transmission of HIV during the peak of the AIDS crisis. Hamarman emphasizes that “big increases in congenital syphilis are heartbreaking and this has a lot to do with [lack of] access to care.” She said many healthcare providers have emerged from extensive medical training with little education and experience about how to meaningfully engage in conversations about sexual health with their patients. It is critical that healthcare providers remain wary of not passing moral judgement or making assumptions about their patients during these interactions.
One solution she provides is to “go to many of the major delivery hospitals across NJ to talk to obstetric and gynecology staff about how to have these conversations with patients.” During these meetings, she hones in on the fact “that we’re going to make assumptions because we are human beings, but don’t let that be your final say.” She uses herself as an example: when you see Hamarman, you’ll notice the ring on her left hand and assume that she’s married in addition to being white and middle-aged, and conclude that she is low-risk for contracting STIs. She concedes that statistically, one would not be wrong; however, it is not about statistics but rather knowing what she does on a Saturday night or a Tuesday night. If a provider never asks questions about their patients’ lives and circumstances, then they will not be able to lay the groundwork in which a patient would feel comfortable discussing with their provider.
Pregnant people with syphilis were falling through the cracks before Covid-19 even began. Congenital syphilis cases occur due to lack of prenatal care and lack of timely diagnosis and treatment of syphilis. Covid-19 has only further increased the risk of missing these opportunities to prevent congenital syphilis cases.
The call to prevent Congenital Syphilis in the Future
Hamarman puts it simply; “Let’s stop making sex such a taboo thing to talk about; let’s stop making it so hard.” Increased education of healthcare providers about counseling from a place of compassion and concern when discussing STIs with their patients as well as making it part of routine care is something she sees as crucial. Coupled with age-appropriate comprehensive universal K-12 sexual education, these approaches could eventually lead to the minimization of discomfort that arises when discussing sexual health. She is “hoping that the fire has been lit” to sustain funding for not only Covid-19 but also STIs, especially with the realization that contact tracing is a powerful tool.
A core challenge with funding includes restrictions on allocating funds to clinical services to support local STD clinics. Disease investigation services are able to find and inform partners to get tested but face challenges with limited site availability and hours.
Preventing congenital syphilis will remain a challenge in the future; however, if steps are taken towards these recommendations, then infants’ lives could be saved. The U.S. Department of Health and Human Services has launched an inaugural plan for combating STIs that provides a roadmap for various stakeholders to develop and deliver STI prevention and care programs. The plan includes an ambitious goal to reduce congenital syphilis cases by 15% over the next five years.
Other nations, such as Dominica, have successfully achieved dual elimination of mother-to-child transmission of both HIV and syphilis. Investment in robust primary prevention and treatment services for HIV/syphilis for pregnant people led to this feat and could be adoptable in the U.S. with passage of universal healthcare. News of other nations eliminating mother-to-child transmission of syphilis should serve as a testament to what can be accomplished when healthcare providers and public health researchers and practitioners work together with access to funding and political will.
Now is a critical moment to take steps to ensure that all infants born in the U.S. have opportunities to have healthy lives.