PUEBLO — Two days each week, a tiny room inside the Pueblo county jail transforms into a health clinic to screen, test and educate women of reproductive age for syphilis, with the hope that if and when they become pregnant, their baby is safe.
Many women seated inside that room have never heard of the sexually transmitted disease — one that is preventable and easily treated with penicillin, but continues to rise among Colorado newborns after being passed on by their mothers.
In Pueblo County, where 45% of the state’s congenital syphilis cases were recorded last year, public health officials are tackling the issue inside the jail through a federally funded pilot program, reaching women who might not have regular access to health care and some who might not visit a doctor a single time throughout their pregnancy.
More than a quarter of the 440 screenings performed inside the jail during the first year of the program, launched last February, came back positive for syphilis. Six pregnant women were treated through the program, according to the county’s health department
The bacterial infection, which is passed from mother to baby through the placenta, is not the only sexually transmitted disease on the rise in Colorado, but it’s the most dangerous to newborn babies. It can cause stillbirth, skeletal deformities, developmental delays and vision and hearing problems.
The Colorado Department of Public Health and Environment is still finalizing its count, but so far has recorded 32 babies born with syphilis last year, compared with 31 in 2021 and 22 in 2020.
At least one of those babies died from congenital syphilis in 2022 and in 2021, there were four stillbirths and two fetal deaths, CDPHE said. The first congenital syphilis death in Colorado was reported in 2020.
Most jails don’t offer routine STI testing for incarcerated people, unless requested, but the program in Pueblo offers a unique approach to address the increasing cases of the disease, that usually poses no risk to the baby if detected and treated at least 30 days before delivery.
With a quick finger prick, a nurse tests women for syphilis and HIV and in 10 minutes, she delivers the results. She collects urine to test for chlamydia and gonorrhea. If positive for syphilis, she starts the treatment immediately with a shot of penicillin.
Providing health care to a fluctuating population
On a Wednesday morning, Pueblo County health department nurse Connie Marie (a pseudonym she uses inside the jail for safety) checked the jail roster, looking for women between the ages of 18 and 45 who recently booked into jail. Any incarcerated pregnant woman goes to the top of her list.
With the escort of a jail deputy, Marie pulled a duffel bag full of testing equipment and a blue cooler filled with penicillin and set up shop in a cramped room on the third floor. Orders from jail deputies echoed off the concrete walls and across the hall, about a dozen women, dressed in gray sweatshirts and brown pants, left their cells to eat lunch.
“It’s curable and treatable. We’re doing this for females so they don’t pass it on to their babies,” Marie said to a woman in her mid-20s who sat in a green plastic chair waiting for her results. If caught early, syphilis can be treated with a single dose of penicillin, while later stages require three doses, each a week apart.
Marie gave the woman a pamphlet, showing her where she can access family planning and birth control at the community health center once she’s released. After 10 minutes, Marie told her she was negative and the woman went back to her cell.
Another woman who agreed to be tested spewed random phone numbers and rattled off stories about her family as Marie listened and waited for a brief pause to tell her about the risks of syphilis. In the past year, the woman has been tested four times as she cycles in and out of jail.
Two women on another floor got their second dose of penicillin after testing positive last week. If they aren’t released from jail by next week, Marie will give them their third and final dose.
Pueblo’s program is also the first in the state to offer field-delivery therapy, or treating patients right where they are. During screenings inside the jail, Marie records the women’s contact information and tells them how to stay safe from STIs and how important it is to finish treatment if they are released.
Marie and a disease intervention specialist with the state health department will meet women at their house or a friend’s, a community health center, or a halfway house until treatment is finished and offer to treat their partners, too. After each completed dose outside the jail, the health department gives women a $25 Walmart gift card.
Providing health care to a population that is constantly fluctuating, with people rotating in and out of jail every day, makes Marie’s job tricky. After providing the first dose, she isn’t sure she will see them again.
On Wednesday, a woman said she doesn’t have a phone number and couldn’t provide any contact information for a friend or family member.
“Most of the time we’re not notified when the individual is released and so we spend a lot of time trying to track them down,” Alicia Solis, a program manager with the county’s health department said. “Unfortunately, we don’t get many calling us back to complete (treatment). So we do spend a lot of time trying to find the individual trying to convince them to come in.”
Often, they have to restart the treatment as the window to receive the next dose has passed.
And there are setbacks. One pregnant woman who was treated for syphilis ended up getting it again right before she delivered, passing it on to her baby, Marie said.
“You can treat it and cure it but you could always get it again. That educational piece is really big for us because we let them know that this can happen again,” she said.
What might be the hardest part in driving down the county’s syphilis rates is encouraging anyone who is sexually active to get tested, Solis said. Even if you test positive and get treated and your partner isn’t treated, you can get it again.
“I know it’s taboo for a lot of people to talk about their sexual history, but in order for us to reduce these rates in our county, we have to get rid of that stigma and we have to start talking about it and get getting individuals screened and tested and treated in order for them to be able to have a healthy sexual life,” Solis said.
‘It’s a historic disease, but it’s still here’
Colorado has seen a significant increase in cases of syphilis among women of reproductive age over the past several years, sounding the alarm for public officials worried about babies becoming infected.
From 2017 to 2021, the number of reproductive-age women diagnosed with syphilis increased by over 502% and the number of congenital syphilis cases increased by 540% in that same time, according to data from CDPHE.
In 2022, Pueblo County’s syphilis infection rate was 2.32 cases per 1,000 people — more than four times the country’s infection rate in 2021.
The county’s rise in cases was startling and a “wake-up call” to health care leaders, Justin Gage, program manager at the Pueblo Department of Public Health and Environment, said last year.
The cases caught the attention of the Centers for Disease Control and Prevention — which reached out to the state to help develop the pilot program inside the jail.
The increase in syphilis cases shows the importance of public health, said Dr. Daniel Pastula, an associate professor of neurology, infectious disease and epidemiology at the University of Colorado School of Medicine and Colorado School of Public Health.
“It’s completely preventable and it’s completely treatable if you catch it early on,” Pastula said, urging people to learn about sexually transmitted infections and how to get tested. “It’s a historic disease, but it’s still here.”
People who have more than one sexual partner should be regularly screened for STIs, he said. Although wearing condoms significantly reduces the risk of transferring syphilis, they do not eliminate it.
Symptoms of syphilis can include sores and rashes, but for some, symptoms may not appear at all and the bacteria can linger inside the body for years. In rare cases, it can spread to the brain and nervous system. Pregnant women, especially, should understand the risk of syphilis and test for it early in their pregnancy, according to the CDC. (Colorado law requires pregnant women to be tested for syphilis).
Nationwide, congenital syphilis cases have more than tripled in recent years, with more than 2,000 cases reported in 2020, according to the CDC. Colorado remains below the national rate for primary, secondary and congenital syphilis.
A request to expand the program to El Paso, Jefferson county jails
Evidence shows that screening in jails and prisons yields high positivity rates for STIs and HIV, but almost no county jails have the resources to offer regular screening for inmates due to budget cuts and financial restrictions.
Last fall, the state health department requested nearly $2.5 million to fund Pueblo’s program through 2025 and expand it to El Paso and Jefferson county jails, which also have some of the highest rates of syphilis in the state.
Funding for one year was approved by the Joint Budget Committee, but is waiting for legislative approval, CDPHE spokeswoman Gabi Johnston said.
“Failure to fund this project beyond FY 2022-23 could result in a continued increase in the incidence of syphilis and congenital syphilis in Colorado,” CDPHE wrote in its funding request.
Of the 818 diagnoses of syphilis among women of reproductive age in 2022, 26.4% of the cases were in Denver, followed by Pueblo County with 25.8%, then Adams (9.3%), El Paso (8.9%) and Jeffferson (7.8%), state data show.
Several barriers, like homelessness, financial restraints and social stigmas, prevent women involved in the criminal justice system from accessing health care, the state wrote. While in jail, they often don’t have adequate services for STI prevention and aren’t connected with the services after they are released.
A recent grant from the CDC will allow testing to continue inside the Pueblo County jail through 2024. If additional funding is approved by the state, Pueblo County plans to hire another nurse and possibly start testing men at the jail, as well.
Solis, who said the county is still in the “learning process,” encourages health officials from other counties to reach out with questions.
“I would encourage them that even if it seems like it’s a huge wall to climb, that they start step-by-step to get over that wall because it’s going to be very beneficial for the community to maintain a healthy population.”