Effective Public Health Approaches to Reducing Congenital Syphilis

Rates of congenital syphilis (CS)—when an infant contracts the disease during pregnancy or birth—are continuing to climb at an alarming rate in the United States. Although preventable, rates more than tripled between 2017 and 2021, with more than 2800 cases reported in 2021 alone. CS can cause stillbirth, infant death, or other serious and permanent complications including musculoskeletal defects (eg, impairments in the muscles, bones, and joints leading to temporary or lifelong limitations in functioning), vision and hearing problems, and developmental delays. An ASTHO technical package is a summary of a select group of related interventions that, taken together, help achieve and sustain improvements related to risk factors or health outcomes. ASTHO technical packages are based on programmatic subject matter experts' assessment of evidence-based interventions, expert recommendations, overviews of current activities, and a review of Centers for Disease Control and Prevention (CDC) and other federal funding guidance. They are not intended to be comprehensive and can be iterative. ASTHO's Congenital Syphilis Technical Package focuses on policy-level interventions that states and territories can pursue starting in pregnancy. ASTHO acknowledges other evidence-based or promising policy interventions that broadly address sexually transmitted disease (STI) prevention that are not reflected in this technical package. Furthermore, this technical package will be updated if updates to CDC's guidance on recommended syphilis screening for pregnant persons are available. Readers can stay current on these recommendations by accessing CDC Vital Signs (https://www.cdc.gov/vitalsigns/index.html).1 A summary of ASTHO's Congenital Syphilis Technical Package is outlined in the Table. TABLE - ASTHO Technical Package on Congenital Syphilis Objective Potential Indicators Mechanisms Levels of Influence Increase universal syphilis screening in pregnant persons28 Universal screening for syphilis at first prenatal visit Universal syphilis screening at 3 points of pregnancy care Review your jurisdiction's existing prenatal screening and disease reporting laws to determine if changes to the laws are required. Consult legal counsel to determine if you have direct authority to require universal syphilis screening at 3 points of pregnancy care. Determine if your jurisdiction's Medicaid program pays for syphilis screening 3× per pregnancy. If not, evaluate whether there are opportunities to change screening requirements and payment. Work with state medical licensing boards to develop provider education and awareness on universal screening. Determine feasibility of enforcement mechanisms, such as implementing fines or penalties for providers who do not screen pregnant people. Prenatal screening and disease reporting laws Legal counsel State policy makers State Medicaid partners and experts State professional licensure boards State medical and primary care associations State medical providers Optimize Medicaid eligibility, services, and alternative provider types to support pregnant people and their partners at risk for contracting syphilis5,11,28–33 Eligibility: Expanded Medicaid eligibility for family planning programs Expanded Medicaid postpartum coverage for up to 12 months Services: Comprehensive services for STI testing, treatment, and counseling Coverage of HRSN services Alternative providers: Expanded access to alternate provider types including CHWs and doulas Eligibility: Work with state Medicaid agency partners to amend state Medicaid plan through an SPA to expand Medicaid eligibility for family planning programs and expand postpartum coverage.34 Services: Work with state Medicaid agency partners to submit SPAs to ensure comprehensive coverage of STI testing, treatment, and counseling including, but not limited to, coverage of at-home testing kits. Work with state Medicaid agency partners to limit cost sharing and remove prior approval for STI testing. Work with state Medicaid agency partners to submit 1115 waiver for HRSN.35 Work with state Medicaid agency partners to inform managed care contract requirements to require Medicaid MCOs to provide HRSN.8 Providers: Work with state Medicaid agency partners to submit an SPA, 1115 waiver, or managed care requirement to authorize payment for or require use of CHWs.36 Work with state Medicaid agency partners to submit an SPA to cover doulas.12 State Medicaid agency partners and experts CMS Legal counsel State policy makers Incentivize providers to comply with universal syphilis screening requirements14,29,37–45 Quality measures: State Medicaid program uses Prenatal and Postpartum Care CMS Core Measure (NCQA, measure #1517) Incentivizes Prenatal and Postpartum Care CMS Core Measure (NCQA, measure #1517) Provider incentives: Medicaid MCOs offer provider incentives for complying with universal syphilis screening requirements Quality measures: Work with state Medicaid agency partners to implement use of Prenatal and Postpartum Care CMS Core Measure (NCQA, measure #1517). Work with state Medicaid agency partners to incentivize Prenatal and Postpartum Care CMS Core Measure (NCQA #1517). Create explicit details on the practice guidelines for STI screening during prenatal care as it relates to the NCQA prenatal care core measure. Borrow from HIV viral suppression incentive measure models to specifically target CS. Payment incentives: Work with Medicaid agency partners and MCOs to develop additional provider incentives for providers who comply with universal syphilis screening requirements. State Medicaid partners and experts CMS Private payers Establish an implementation plan for the quality strategy23 Established strategy for developing consumer education materials for individuals in Medicaid on CS risk Established strategy for providing education for Medicaid providers Consumer education: Work with state Medicaid agency partners to: a. Help facilitate Medicaid enrollment. b. Target Medicaid enrollment outreach to women in the first trimester of pregnancy. c. Ensure consumer education materials are available, clearly articulate risk, and are culturally competent. Provider education: Ensure changes to quality measure are communicated (eg, leverage Medicaid provider bulletins). Ensure changes to incentive payments are communicated and how to receive them. CMS State Medicaid partners and experts Private payers Cross-agency collaboration and governance State has cross-agency governance structure established to address CS Establish a corresponding joint Medicaid/public health quality committee related to syndemics (CS, HIV, etc) that also includes member representation is a critical action step to ensure implementation and support for the payment incentives/penalties and legislation are in place. Create a standing policy body that has a designated position for OB/GYN physician leaders to advise and engage in practice change. S/THAs could build relationships and engage with Medicaid quality committees to highlight public health data, policy, best practice, and support available to respond to the rise in cases. Private payers State Medicaid partners and experts State public health agencies State medical providers State professional licensure boards Increase access to care by removing barriers, addressing stigma, and addressing provider bias46 Increased universal syphilis screening in settings outside of prenatal care (eg, jails, safe syringe programs, emergency rooms, drug treatment programs) If applicable, removal of reporting requirements related to pregnant people who are experiencing substance use Review your jurisdiction's existing screening and disease reporting laws to determine if changes to the laws are required to promote increased syphilis screening outside of prenatal care. Review your jurisdiction's existing reporting laws to determine if removing reporting related to pregnant people who are experiencing substance use is required. Consult legal counsel to determine if you have direct authority to require it. Work with state medical licensing boards to develop education and provider awareness on stigma and provider bias. Assess and address barriers to practice to build an adequate perinatal workforce to provide women and community-centered obstetric care. Support or establish mechanisms for doula and community worker reimbursement. Enhance and expand home-visiting services to promote universal syphilis screening in pregnant persons. Ensure public health workforce receives training on structural racism and implicit bias and the role it plays in negative maternal and neonatal health outcomes. Screening and disease reporting laws Legal counsel State policymakers State Department of Corrections and local corrections and law enforcement partners Safe syringe programs Drug treatment programs Hospitals Doulas and CHWs CHW associations State home-visiting programs and federal counterparts State professional licensure boards State medical and primary care associations State medical providers Abbreviations: CHW, community health worker; CMS, Centers for Medicare & Medicaid Services; CS, congenital syphilis; HRSN, health-related social needs; MCO, managed care organization; NCQA, National Committee for Quality Assurance; OB/GYN, obstetrics and gynecology; SPA, State Plan Amendment; S/THAs, state and territorial health agencies; STI, sexually transmitted infection. Increase Universal Screenings for Pregnant Persons Testing pregnant people for syphilis at 3 points of pregnancy—first and third trimesters and at delivery—is an evidence-based approach to reduce CS. The American College of Obstetricians and Gynecologists and CDC currently recommend universal first-trimester screening and additional screening for those who are at risk or live in areas of high rates of syphilis. However, these screening recommendations rely on providers' knowledge of the epidemiology in their area and to take patient histories to accurately judge risk. In addition, jurisdictions may have other laws or recommendations that reflect variability in testing requirements. Jurisdictions can increase syphilis screening of pregnant people by modifying their laws to require screening at 3 points during pregnancy. They can do so through direct authority of state health officials, Medicaid, state medical licensing boards, and other enforcement mechanisms. How Public Health Can Leverage Medicaid to Reduce CS Rates Medicaid provides coverage for low-income adults2 nationwide and covers more than 40% of all births.3 Syphilis rates are nearly 6 times higher4 among women insured through Medicaid than among women insured through commercial insurance. Optimize Medicaid Eligibility, Services, and Providers for At-Risk Pregnant People and Their Partners States can expand eligibility for Medicaid Family Planning Programs,5 which provide family planning benefits and STI services to people who would not otherwise qualify. In most states, services are available for individuals up to 200% Federal Poverty Level (FPL). Some states (eg, Iowa6) are expanding eligibility beyond that threshold. In addition, implementing State Plan Amendments (SPAs) to expand Medicaid postpartum coverage7 can allow coverage of postpartum treatment of syphilis. States can work with Medicaid agency partners to ensure Medicaid services comprehensively cover STI testing, treatment, and counseling with minimal cost sharing. States can also submit 1115 waivers to cover unmet health-related social needs, or HRSN, services8 (eg, housing, nutrition, transportation) that exacerbate poor health outcomes and should be addressed in tandem with medical treatment. Furthermore, states can weigh in on Medicaid managed care organizations (MCOs) contract requirements (https://www.astho.org/topic/population-health-prevention/healthcare-access/medicaid/impacting-sdoh-through-managed-care-contracts) to ensure coverage of HRSN services. States can leverage alternative provider types, such as community health workers (CHWs), doulas, and perinatal case managers,9 to facilitate access to services, encourage first- and third-trimester STI screenings, and provide support services. Currently, 9 states and Washington, District of Columbia, reimburse doula services10 under Medicaid. CHWs are already providing services for people living with HIV infection11 and can perform a variety of roles, improving access to care for people with syphilis. They can help with care coordination, coaching, and providing social support and health education. State and territorial health officials (S/THAs) can work with their Medicaid agency partners to submit an SPA12 or 1115 waiver to cover CHWs, doulas, or perinatal case managers or create managed care requirements to require use of these provider types. Incentivize Providers to Comply With Universal Syphilis Screening Requirements S/THAs can work with Medicaid agency partners to adopt and incentivize the Prenatal and Postpartum Care CMS Core Measure13 (National Committee for Quality Assurance Measure #151714) as part of the state's quality strategy.15 Incentivizing the quality measure16 encourages providers to meet performance metrics through a financial incentive. Furthermore, states can update practice guidelines to encourage providers to conduct universal STI screenings during prenatal care visits, including syphilis testing in the first and third trimesters. S/THAs can work with their Medicaid agency partners and MCOs to develop additional provider incentives. For example, AmeriHealth Caritas—a Louisiana-based MCO—offers provider incentives17 for third-trimester syphilis testing. The performance is measured on the basis of the percentage of live deliveries that had at least one test for syphilis. Practices that score above the 55th percentile for third-trimester screenings are eligible for bonus payments. States can also partner with their Medicaid agency partners and incentivize consumers18 through MCOs. Several states offer incentive programs for pregnant persons who attend one or all prenatal appointments. For example, Kentucky19 offers gift cards and South Carolina20 offers items such as strollers or car seats. Establish an Implementation Plan for the Quality Strategy S/THAs can work with their Medicaid agency partners to develop consumer education materials, including information on how to enroll in Medicaid,21 covered services, provider availability, and how to reduce the risk of CS.22 Targeted enrollment outreach to pregnant persons in their first trimester is critical for early testing and treatment since being screened for syphilis is more likely23 if a person is enrolled in Medicaid earlier. S/THAs can also work with their Medicaid agency partners and MCOs to ensure Medicaid providers are aware of quality measure changes and how to leverage incentive payments by including information through communication materials including Medicaid provider bulletins and state quality strategies.24 Establish Cross-Agency Collaboration and Governance Structures A critical step in ensuring implementation of payment incentives and legislation is creating mechanisms for S/THAs and their state Medicaid agencies to better coordinate services and polices directed toward low-income individuals at risk for CS and other syndemic conditions. Strategies for cross-agency collaboration and governance could include the following: Establishing a joint Medicaid/public health quality committee related to syndemics (eg, CS and/or HIV infection). Creating a standing policy body that has a designated position for OB/GYN physician leaders to advise and engage in practice change. Building relationships and engaging with Medicaid quality committees to highlight public health data, policy, best practice, and support available to respond to the rise in cases. Remove Barriers to Care by Addressing Stigma and Provider Bias Removing barriers to screening and treatment and addressing stigma and implicit bias are critical to reducing CS rates. Structural racism and prejudice contribute to and reinforce disparities in maternal and neonatal morbidity and mortality, including rates of CS. To address stigma, policymakers must implement strategies25 that address systematic prejudice and discrimination including developing systems that have several points of entry for care, provide culturally competent training for the providers and perinatal workforce, and foster multisector referral relationships. In addition, leveraging the perinatal workforce, including doulas, can support pregnant and postpartum people in seeking and remaining in prenatal and postnatal care. Doulas act as advocates and educators26 for pregnant people and using them improves maternal and neonatal outcomes. To increase access to doulas, states should consider expanding doula coverage under Medicaid. Medicaid reimbursement of doula services—which are typically covered out-of-pocket—helps make their services available to low-income and underserved populations.27 Conclusion States and territories can address the rise in CS infections by focusing on policy-level interventions provided in ASTHO's Congenital Syphilis Technical Package. These evidence-informed practices focus primarily on pregnancy and provide recommendations for enhancing screening, optimizing Medicaid eligibility and services, establishing and implementing a quality strategy, incentivizing and educating providers, educating consumers, establishing and implementing cross-agency collaboration and governance, and increasing access to care.