Date of Award

Spring 2026

Language

English

Embargo Period

3-13-2026

Document Type

Dissertation

Degree Name

Doctor of Public Health (DrPH)

College/School/Department

College of Integrated Health Sciences

Program

Public Health

First Advisor

Tomoko Udo

Committee Members

Tomoko Udo, James Tesoriero, Thomas O'Grady, Stephen Weinberg

Keywords

New York State, Syphilis, Congenital Syphilis

Subject Categories

Congenital, Hereditary, and Neonatal Diseases and Abnormalities | Epidemiology | Maternal and Child Health

Abstract

Syphilis is caused by Treponema pallidum and transmitted through direct contact with infected mucosal lesions and via vertical transmission during pregnancy (i.e., congenital). Transmission of syphilis to an infant during pregnancy (i.e., congenital syphilis [CS]) can lead to early fetal death, stillbirth, neonatal death, preterm birth, low birthweight, and congenital infection in infants. The United States (U.S.) is experiencing epidemic increases in both females of reproductive age with syphilis and infants with CS. In New York State (NYS), these trends have also occurred, especially after COVID-19 emergence, and increases in reported cases and incidence rates are comparable to national statistics. Given the recent resurgence of syphilis among females of childbearing age, research into the recent changes in trends and the intersectionality with social determinants of health (SDOH) and risk of syphilis infection is needed.

This study had three specific aims: 1. To describe the recent epidemiology and temporal trends of syphilis among females of childbearing age in the non-New York City parts of NYS (Rest of State, or ROS) by using NYS disease surveillance, U.S. Census Bureau, and USDA data, from 2013 to 2022; 2. To identify the factors associated with an increased risk of birthing an infant with CS by comparing the characteristics of pregnant females who delivered an infant with CS and pregnant females who did not deliver an infant with CS; 3. To describe the characteristics of pregnant females and infants born with CS, identify significant changes among pregnant females who delivered an infant with CS, and identify CS prevention opportunities.

Study aim #1, several notable results were observed. There has been an increasing number of syphilis diagnoses among females, most notably during the height of the COVID-19 pandemic. The largest proportion of syphilis occurred among persons of non-Hispanic Black race and ethnicity, of which nearly one-third had a previously diagnosed STI, among persons residing in areas with a lower median income and higher food stamp/SNAP usage, and among Medicaid recipients (comprising 6 in 10 diagnoses). After COVID-19 emerged, there was a greater proportion of syphilis diagnoses occurring in females residing in Western NY who were aged 20-29 years, non-Hispanic Black race and ethnicity, were diagnosed with early syphilis, had an STI history, and were insured through Medicaid. Third, incidence rates of both early and late syphilis were highest among females of non-Hispanic Black race and ethnicity and all persons aged 20-34 years. Lastly, after COVID-19 emerged, there were initially several months of decline in expected cases of syphilis, followed by sustained monthly counts exceeding expected values.

In study aim #2, only the stage of syphilis infection during pregnancy was identified to be a statistically significant predictor of CS. Females who were diagnosed with early syphilis during pregnancy (including at delivery) were three times more likely to deliver an infant with CS. Most pregnant females diagnosed with syphilis, both delivering infants with CS and not, resided in economically disadvantaged areas and experienced income inequality as evidenced by the higher proportion of CS among persons who were Medicaid insured.

In study aim #3, among pregnant females who delivered infants with CS, approximately one-third were pre-term (< 37 weeks of gestation), of those receiving prenatal care, approximately four in ten were not screened for syphilis at the first prenatal care visit, over half had an STI history, and four in ten reported using substances during pregnancy. Following the emergence of COVID-19, there was nearly a fourfold increase in CS births in Western NY. Other shifts that occurred post-COVID-19 emergence were increased proportions of CS among females with the following characteristics: older ages (30-49 years), Hispanic and non-Hispanic Black race/ethnicity, diagnosed late syphilis, untimely or no prenatal care, not screened at first prenatal care visit, and having a previous STI. Overall, nearly two-thirds of all infants born with CS occurred in females who either had untimely or no prenatal care or individuals who seroconverted during pregnancy (i.e., late identification of seroconversion).

Disparities were identified by key demographics and socioeconomic indicators, highlighting priority populations for focused prevention. Given the recent spike in syphilis incidence and considering the underdiagnosis stemming from issues accessing preventive healthcare during the height of the COVID-19 pandemic, the underdiagnosis of syphilis in the population is concerning. Among pregnant females, CS prevention remains a top priority. It is crucial to maintain and strengthen preventive health services, especially by routinely conducting syphilis screenings. Based on this study, there are several public health recommendations, including improving provider risk assessments, facilitating syphilis screening, patient-centered care models for improved engagement, adherence to NYS syphilis screening laws and federal treatment guidelines, broader health education geared toward the public and health care providers, and improvement of surveillance and data systems.

License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.

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