Lena Rosengren-Hovee, MD, MPH, MHS; Becky White, MD, MPH; and Joe Tucker, MD, PhD
Chapel Hill, NC— A newly published case study in the Journal of Correctional Health Care urges immediate action to strengthen syphilis screening protocols for pregnant individuals in U.S. jails and prisons. Researchers at the Institute for Global Health and Infectious Diseases recently published “Syphilis Screening Among Pregnant Individuals in Carceral Settings: Near Misses and a Call to Action” describing how a single third‑trimester syphilis test likely prevented congenital syphilis in an incarcerated pregnant patient—underscoring a widespread and unaddressed gap in national screening guidelines. The authors include Lina Rosengren-Hovee, MD, MPH; Andrea K. Knittel, MD, PhD; Becky L. White, MD, MPH; and Joseph D. Tucker, MD, PhD.
“We are seeing preventable cases of congenital syphilis slip through the cracks simply because repeat screening isn’t happening,” said Dr. Rosengren, associate professor of medicine. “A single third‑trimester test—especially in carceral settings—can make the difference between a healthy newborn and a life‑threatening infection. Universal screening is not just good medicine; it’s an ethical imperative.”
The Rise of Congenital Syphilis Rates
The U.S. has seen congenital syphilis cases climb from 12.4 per 100,000 live births in 2015 to 109.6 in 2024, marking the 12th consecutive year of increase, according to CDC surveillance data. In North Carolina, congenital syphilis cases were up 36% in 2022. Pregnant individuals with histories of incarceration face significantly higher syphilis rates, making early and repeat screening a critical public health priority.
Third‑Trimester Test
The study centers on a 35‑year‑old incarcerated pregnant patient who twice tested negative for syphilis early in pregnancy using routine nontreponemal tests. Only in the third trimester—when she presented with a palmar rash—did repeat screening reveal a new reactive infection requiring immediate treatment. Thanks to timely third‑trimester testing and treatment, the patient’s infant avoided congenital syphilis, receiving preventive evaluation and care.
The authors describe multiple similar cases in the statewide prison prenatal system in which third‑trimester screening could have prevented congenital syphilis but went undetected due to a lack of standardized repeat testing. No surveillance system currently documents these near‑misses, leaving the scope of the problem unknown.
Guideline Gaps
Despite clear evidence that early serologic tests can miss recent infections or reinfections, there is no national consensus requiring universal third‑trimester screening:
The American College of Obstetricians and Gynecologists (2024) recently adopted universal third‑trimester screening.
The US Preventive Services Task Force (2025) reaffirmed early screening only, citing insufficient evidence for universal repeat testing.
Centers for Disease Control and Prevention (2021) recommends third‑trimester testing only for those deemed at elevated risk—a category that explicitly includes incarcerated individuals.
This patchwork of recommendations means that many carceral systems lack policies requiring routine third‑trimester syphilis tests, despite the population’s elevated risk and limited access to consistent prenatal care.
Call for Action
With evidence that 88% of congenital syphilis cases in 2022 were preventable, with timely testing and treatment, the authors argue that universal third‑trimester syphilis screening should be implemented across all U.S. jails and prisons
This case is a warning we can’t afford to ignore,” said Dr. Rosengren. “We are calling for universal third‑trimester syphilis screening in all carceral settings because too many mothers and infants are slipping through gaps in the system. The evidence is clear and the time to act is now.”
About the Institute for Global Health and Infectious Diseases
Established in 2007, the UNC Institute for Global Health & Infectious Diseases at the University of North Carolina at Chapel Hill started over 30 years ago with infectious disease physician researchers at the UNC School of Medicine, studying HIV in China and Malawi. Through the years, our work has expanded to include emerging pathogens, cancer, women’s health and vector-borne disease like malaria–shaping policy through evidence-based research around the world. At UNC-Chapel Hill, the Institute facilitates research excellence while nurturing emerging scientists to advance patient care and practice, addressing the most important global health issues of our time–through research, training and service.
