What CDC's 2024 congenital syphilis numbers say about Black infants, and what the gap actually is

The temptation is to read this as a screening story. CDC's own race-stratified 2022 analysis says otherwise. Among non-Hispanic Black birth parents whose pregnancies produced a congenital syphilis case, the leading prevention gap was inadequate treatment after maternal diagnosis, not failure to test. Among non-Hispanic White and American Indian/Alaska Native birth parents, the leading gap was no testing or non-timely testing. Two distinct failure modes are running in parallel (McDonald et al., MMWR Vital Signs, November 17, 2023, PMID 37971936). The one that hits Black families harder is treatment completion.

Congenital syphilis is what happens when an untreated maternal Treponema pallidum infection crosses the placenta. National cases increased 755 percent during 2012 to 2021 per CDC's MMWR Vital Signs primary; the 2022 surveillance year counted 3,761 reported cases that included 231 stillbirths (6 percent) and 51 infant deaths (1 percent) per McDonald 2023 (PMID 37971936). Infants who survive can develop bone deformities, hearing loss, neurological damage, and chronic liver dysfunction. The infection is treatable in pregnancy with benzathine penicillin G, the only first-line therapy with documented fetal-protection efficacy. Doxycycline, the standard alternative for non-pregnant adults, does not adequately cross the placenta and is not used to prevent congenital transmission.

The infection is almost entirely preventable through prenatal screening and timely treatment. The US Preventive Services Task Force issued a Grade A recommendation on May 13, 2025: "The USPSTF recommends early, universal screening for syphilis infection during pregnancy; if an individual is not screened early in pregnancy, the USPSTF recommends screening at the first available opportunity" (USPSTF 2025 Recommendation). Lack of timely testing and adequate treatment during pregnancy contributed to 88 percent of 2022 congenital syphilis cases (McDonald 2023, PMID 37971936). The case counts are not driven by missing biology. They are driven by missing visits, missing tests, and missing treatment courses.

Federal screening guidance has been clear for years. CDC recommends syphilis screening at the first prenatal visit, again in the third trimester for patients at elevated risk or in high-burden areas, and at delivery. USPSTF aligned its May 2025 recommendation with universal early screening and a fallback to screening at the first available encounter if a patient enters prenatal care late.

Where screening lands in practice is a different question. Lindsey Hammerslag and colleagues at the University of Kentucky studied 2017 to 2021 Medicaid claims across Kentucky, Louisiana, and South Carolina, three Southern states carrying elevated congenital syphilis burden. Among pregnant women without recent STI diagnoses, first-trimester syphilis screening rates ranged from 62.8 percent to 85.1 percent across the three states. Black women had adjusted odds of 0.85 for first-trimester screening relative to white women in the multi-state analysis, controlling for STI history (Hammerslag et al., AJOG MFM 2023, PMID 36933802). Among high-risk deliveries, defined by prior STI or other elevated indicators, only 53.6 percent to 63.6 percent received first-trimester screening, well below the universal target.

State legislation that mandates universal screening helps narrow the gap, but slowly. Jill C. Diesel of CDC's Division of STD Prevention and Katie Macomber of the Michigan Department of Health and Human Services analyzed 211,289 Michigan Medicaid deliveries from 2017 through 2023, bracketing the state's December 2018 universal first-and-third-trimester screening mandate. Early-third-trimester screening rose from 37.1 percent to 53.7 percent post-mandate; repeat screening rose from 30.1 percent to 45.0 percent (Diesel and Macomber, Pregnancy 2025, PMID 41675262). The state moved roughly 16 percentage points in five years. Improvements were smaller in high-burden areas, which in Michigan concentrate in Detroit and Flint, both with majority-Black populations.

Here is where the Black-specific story diverges from the national headline. McDonald 2023 is the only piece of CDC primary that breaks down the prevention-gap category by maternal race and ethnicity for 2022 congenital syphilis cases. The numbers do not collapse into a single explanation.

Among non-Hispanic Black or African American birth parents whose pregnancies produced a congenital syphilis case, the leading prevention gap was inadequate treatment after maternal diagnosis: 39.2 percent of cases. Among Hispanic or Latino birth parents, the same category led at 47.4 percent. Among non-Hispanic White birth parents, the leading gap was no or non-timely testing at 40.8 percent. Among American Indian/Alaska Native birth parents, the leading gap was no or non-timely testing at 47.4 percent (McDonald 2023, PMID 37971936). The category mix is not random. Black and Hispanic families face the system after maternal diagnosis and lose the treatment course. White and AI/AN families more often never get the diagnosis in the first place.

Why treatment completion fails is structural. Maternal syphilis treatment requires benzathine penicillin G, given as one, two, or three weekly intramuscular injections depending on infection stage. The drug must be given by injection, must be in stock at the administering site, and must be received on the correct interval. If any link breaks, the treatment course is inadequate and fetal protection is compromised.

Layla Gabir and colleagues at the Maricopa County Department of Public Health surveyed 42 distinct healthcare facilities encompassing 104 outpatient obstetric-gynecologic settings in Maricopa County, Arizona, in 2021. Only 11.9 percent of the surveyed facilities, 5 of 42, had on-site benzathine penicillin G administration capacity; 71.4 percent referred patients externally for the injection (Gabir et al., Sexually Transmitted Diseases 2025, PMID 40679938). External referral means a second healthcare encounter for an injection that the patient may or may not receive, depending on whether the receiving site has BPG in stock and whether the patient can return on the correct interval. Arizona carried elevated congenital syphilis rates during the survey period.

The 2023 to 2024 benzathine penicillin G shortage hit this referral infrastructure at the worst possible moment. William Campillo Terrazas and colleagues documented the operational shortage window at a Detroit health system as May 9, 2023 through February 28, 2024 (Campillo Terrazas et al., Journal of Pharmacy Technology 2025, PMID 39545244). The Detroit cohort was 60 percent non-Hispanic Black; among the 453 patients receiving any BPG at the system during the shortage, 70 percent of doses were judicious and 30 percent were not, with streptococcal pharyngitis accounting for 128 of 135 nonjudicious uses. Among syphilis patients during the shortage, those receiving the doxycycline alternative, which is not used to prevent congenital transmission, had higher uninsured rates and outpatient treatment rates than those who received BPG. The shortage disproportionately pushed uninsured patients toward a second-line agent with different pharmacokinetic properties.

No peer-reviewed causal-attribution study currently links the 2023 to 2024 BPG shortage to a measurable number of incremental congenital syphilis cases. The peer-reviewed record places the shortage and the steepest period of case growth on the same calendar without proving direct causation. The mechanism is the structural counterfactual question worth asking of CDC, FDA, and the maternal-health research community: pushing uninsured maternal syphilis patients to a non-fetal-protecting alternative during a period of national case escalation.

One common framing forecloses on the evidence. Julie Rushmore and colleagues at CDC's Division of STD Prevention analyzed 51,209 primary and secondary syphilis cases among US women aged 15 and older from the National Notifiable Diseases Surveillance System for 2018 through 2023. Across past-year substance-use behaviors, including injection drug use, methamphetamine use, heroin use, and cocaine use, the AJPH analysis reported that "all behaviors were reported more frequently among non-Hispanic White women than non-Hispanic Black or Hispanic women" (Rushmore et al., American Journal of Public Health 2025, PMID 40934445). The Black case-count overrepresentation in congenital syphilis cannot be explained by higher substance-use prevalence in Black or Hispanic populations.

A second framing worth flagging: Jessica Frankeberger and colleagues in the Department of Pediatrics at the University of California, San Diego, studied 4,481,096 California births linked to hospital records from 2011 through 2021 and reported that 62.0 percent of California congenital syphilis cases had no maternal syphilis documentation in the linked surveillance records (Frankeberger et al., Journal of Perinatology 2026, PMID 41145729). The finding describes administrative-coding completeness in California's case-linkage system, not clinicians who missed the diagnosis at the bedside. Inside the study, Black-identified mothers with congenital syphilis-affected pregnancies were more likely to have maternal syphilis documented than the broader case population, a pattern that reflects coding under surveillance attention rather than lower clinical detection.

If you are pregnant or trying to become pregnant, the federal recommendation is for universal syphilis screening at the first prenatal visit, regardless of perceived risk. There are four specific actions that match the evidence above.

• Ask your prenatal provider, at the first visit, whether syphilis screening was ordered. The blood test is part of standard prenatal labs in most US settings; it is not an opt-in test you have to request. If your provider says screening is being reserved for higher-risk patients, the USPSTF Grade A recommendation calls for universal screening; name the recommendation by date (May 13, 2025) and ask for the test to be run.
• If you receive a positive syphilis screening result during pregnancy, ask whether your treatment course is one, two, or three benzathine penicillin G injections and at what schedule. Confirm before you leave the appointment that the medication is currently in stock at the site you are being referred to.
• If you are referred off-site for the injection, write down the verbatim address, the days and hours the injection clinic is open, and a callback number to confirm benzathine penicillin G is on hand the day you go. The treatment course only works if every injection lands on the correct interval; an out-of-stock day costs a full re-treatment cycle.
• If you are uninsured or on Medicaid and your clinician proposes doxycycline instead of benzathine penicillin G for syphilis in pregnancy, ask why. Doxycycline is not used to prevent congenital transmission. The 2023 to 2024 benzathine penicillin G shortage has resolved per peer-reviewed cohort data; supply should not be a barrier in 2026.

If you are looking for a Black clinician or a clinician who specializes in caring for Black communities for your prenatal care, the blackhealth.org provider directory lists verified providers by specialty and ZIP code.

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