Babies lose their lives to syphilis. She's trying to stop it

A public health investigator listens to a woman on a street corner on L.A.'s Skid Row.

Nov. 16, 2023 3 AM PT

Under the afternoon sun, Maggie Tran stopped one person after another on a hectic stretch of Skid Row, asking if they knew a particular woman.

No one seemed to recognize the name she repeated at tent after tent as she made her way along the block. “She could have a whole different name out here,” one person replied. “Do you have a picture?”

Tran shook her head before heading back to her SUV, disappointed but undeterred. It’s rare for Tran to find the people she’s looking for right away.

As a public health investigator, she searches for clues: An emergency contact number listed by a patient during a clinic visit. An old address saved in a database. The location of a homeless encampment where outreach workers found a particular person in the past.

Then she heads to the streets. Her job at the Los Angeles County Department of Public Health is to track down a crucial set of patients who slipped away from the health system: women of childbearing age who have tested positive for syphilis, a sexually transmitted disease that can cost newborns their lives.

Cases of syphilis have skyrocketed in L.A. County and across the country, with devastating results. Left untreated in adults, it can damage organs and infiltrate the brain, possibly leading to dementia and blindness. Men have suffered at higher rates than women, but a rise in cases among women has spurred particular alarm because newborns infected in utero can be stillborn or suffer enduring medical issues.

The disease can be stopped with antibiotics if detected and treated in time. Yet last year, L.A. County reported 136 cases of infected newborns — up from just four a decade earlier — including 13 that resulted in stillbirth.

The number of cases of congenital syphilis rose from 335 to 3761 between 2012 and 2022.

Across the U.S., the number of such congenital syphilis cases reported annually among newborns ballooned from 335 in 2012 to 3,761 in 2022. The syphilis surge resulted in 231 stillbirths and 51 infant deaths last year in what one official called “an unacceptable American crisis.”

Tran is part of an L.A. County effort to turn those numbers around. Whenever someone tests positive for syphilis, the results must be reported to the county. Some patients are easily reached, but others cannot be found by public health nurses.

Those are the women whom Tran and her colleagues on the syphilis special investigation team are seeking. Finding them is crucial: Last year, 88% of congenital syphilis cases across the U.S. might have been averted with timely testing and adequate treatment, researchers at the Centers for Disease Control and Prevention concluded.

When other efforts to reach such patients have fallen short, “our program is almost like a program of last resort,” said Magdalena Esquivel, chief of direct community services at the L.A. County Department of Public Health’s Division of HIV and STD Programs.

“Many of these clients have a history of trauma, mental health conditions, substance use, developmental disabilities — multiple reasons for fear and stigma around healthcare,” Esquivel said. “They may be doing transactional sex work” or have immigration concerns, and “some may fear losing kids.”

In a Westlake office building last month, Tran sat in her cubicle and scoured a host of government, healthcare and public records databases for any useful details. She recounted how one case had played out: Tran had combed through physician notes and found the phone number for the mother of a would-be patient, who told Tran it had been months since she had heard from her daughter.

The mother said the woman had been staying at a shelter when she last heard from her, but she didn’t know exactly where. Tran kept digging and turned up a possible address for the woman, but it led to an apartment complex that was locked. She wedged a letter in the door.

Maggie Tran searches databases on her computer.

Even if the trail seems to have run cold, she keeps checking the databases for anything new. “There might be hope that if she tested again, maybe she had an address this time, or a phone number,” she said. “Or maybe she’s still at the hospital.”

Tran ferreted out a Social Security number for the patient from a confidential report about her test result, then plugged that into the databases. That turned up another test the woman had taken as an unidentified “Jane Doe,” shedding more light on the progress of her infection.

After roughly a week of sleuthing, she found the woman in another database: Jail bookings. Public health staff would go find the patient at the jail and offer her treatment. Because of the “Jane Doe” test results, they could assure her she would need only one shot.

“I’ll take this as a big win,” Tran said. “It’s rare to be able to find a patient this fast.”

Tran and her colleagues also help people get to the treatment they need. Behind the wheel of her white SUV, she hunted for a parking spot in an industrial stretch of the San Gabriel Valley, where she met a woman and her partner who live near railroad tracks. The couple piled into the back seat.

The woman, who asked not to be identified, said she had no idea she had syphilis before the public health team showed up to follow up on her test result. A message had been relayed to her earlier, but the county official did not say why they were calling.

When working the phones or hitting the streets, Tran does not explain why she is searching for someone, in order to avoid revealing sensitive information about their medical care.

“I can’t share,” she told one person at a downtown encampment, identifying herself only as being with the county. “We’re just looking for them.”

Maggie Tran speaks with a woman on Skid Row.

Holding back on details protects the privacy of the women Tran is seeking, but it can also be unnerving for people who fear they may somehow be in trouble.

The woman Tran picked up for an appointment said the efforts to reach her had initially felt “scary.” Whatever the county was trying to reach her about felt like “just adding one more thing to this life of mine,” she said as Tran drove them to a nearby clinic. But now “at least I’m fixing it.”

Syphilis can sometimes be treated with one shot of antibiotics, but if the disease is more advanced it can take three shots given roughly a week apart. Tran cautioned the couple that depending on test results, they might have to come back the following week.

“I’ll be keeping in touch with you guys,” she told them.

Missing the second or third shot means starting the series over, so public health officials have to keep tabs on hard-to-reach patients. And if clinics are short on bicillin — a key treatment that has been in limited supply this fall — some patients may need an alternative regimen that requires weeks of pills. That can be a challenge for patients who live in unstable conditions or have mental health problems, county officials said.

Public health researchers have bemoaned the soaring numbers of babies infected with syphilis as evidence of missed opportunities to serve vulnerable women, including those who are unhoused or grappling with drug addiction.

“The STD crisis has been worsening for more than a decade,” said Mario Pérez, director of the Division of HIV and STD Programs at the L.A. County Department of Public Health. Report after report shows that “we’re losing some control. The congenital syphilis crisis epitomizes that.”

The surging numbers are especially galling in a country that appeared within reach of wiping out syphilis around the turn of the millennium. Since then, tumbling rates of condom use, increased use of methamphetamine that loosens sexual inhibitions, underfunding of STD prevention and other factors have combined to reverse that progress, experts said.

The pandemic exacerbated the crisis, as day-to-day testing and treatment services were interrupted and public health teams were pulled onto COVID-19 duties. In L.A. County, for instance, routine syphilis screening for women at a county jail was suspended for roughly two years, and up to 75% of county STD prevention staff were reassigned at points in the pandemic, according to county reports.

“There are consequences when investments in public health are inadequate,” said David C. Harvey, executive director of the National Coalition of STD Directors. Right now, that consequence is “the death of infants.”

In California, pregnant patients are legally required to be screened for syphilis at their first prenatal visit, but some never get prenatal care at all. Others have no regular phone number or address that clinicians can use to follow up with their test results and ensure they get treated. Another challenge is that the syphilis spike has been tangled with drug addiction, and many people who use drugs are hesitant to seek medical care.

Pregnant people may be “scared of going to the doctor if they use drugs or are unstably housed” because they fear those things could affect their parental rights, said Dr. Rosalyn Plotzker, a preventive medicine specialist at UC San Francisco.

Jolene Yoneoka speaks during a meeting at an L.A. County office.

Plotzker and other researchers found that California babies born with syphilis were more likely to have parents who were homeless or who used methamphetamine. But if parents who were unhoused or using meth got prenatal care, the rate of syphilis prevention was much closer to that of parents without those challenges. The findings underscore that access to care is critical, Plotzker said.

Los Angeles County launched its syphilis specialized investigation team a little over a year ago, starting with two part-time investigators. It has since expanded to five investigators with the help of a nearly $4-million annual state grant for syphilis prevention, as well as other funds. Tran said the added staffing had eased her caseload, which now stands around 10 cases at a time.

Between September 2022 and October 2023, the syphilis team was asked to find 119 people who could not be tracked down by other programs and ultimately got 26 of them treated. The remaining patients could not be located, refused treatment, or were directed to other units or agencies.

The team also seeks out partners of the women they are assigned to find, aiming to get them treated as well.

To encourage patients to take the time to get treated, the investigators offer incentives such as gift cards to grocery stores and fast-food restaurants. If people need to take weeks of pills, the county can arrange for temporary housing in Skid Row to help ensure they finish the treatment.

As Tran drove the couple back from the San Gabriel Valley clinic, the woman said she was glad she had started treatment. She had learned about neurosyphilis, which can afflict the brain after an infection, and wondered if it was tied to a psychiatric episode that she suffered in the past.

Even if syphilis had not affected her at all, “I don’t want to be infected or infect other people,” she said. “I want to do the right thing.”