The Spike in Syphilis Infections

Syphilis is an ancient disease. There is evidence of the disease as early as the late 1400s. By the 1530s, it was known as “the great pox” due to the associated rash and was embarrassing enough that no country wanted to take credit for it. “Germans and English called it ‘the French pox;’ Russians, ‘the Polish sickness;’ Poles, ‘the German sickness;’ French, ‘the Neapolitan sickness;’ Flemish, Dutch, Portuguese, and North Africans, ‘the Spanish sickness’ or ‘the Castillian sickness;’ and the Japanese, ‘the Canton rash’ or the ‘Chinese ulcer.’”¹ Once the 1700s rolled around, physicians were beginning to study syphilis and conduct experiments. Treatments, such as eating or inhaling mercury², were often painful and accompanied by adverse reactions until the discovery of penicillin in 1928. By 1943, penicillin was the main treatment for syphilis and still is today.³

The Great Pretender

Because syphilis rates had been reasonably low for decades, many physicians practicing today have little experience diagnosing “the great pretender,” so-called because syphilis can “cause a head-scratching constellation of symptoms”⁴ or patients can be altogether asymptomatic. Once a patient is infected, it usually takes 18-21 days for a painless ulceration—or chancre—to appear, usually on the genitals. It’s easy to miss the chancre in women because of its location in the vagina or on the cervix. A chancre will usually last 3-6 weeks and then heal spontaneously. This is primary syphilis. Patients move into the secondary syphilis phase about 3-10 weeks after the chancre heals. Patients present with a rash that includes palms and soles and there may sometimes be mucosal lesions as well. Other symptoms might include “malaise, appetite loss, fever, headache, stiff neck, myalgias, lacrimation, photophobia, red and painful eyes, back pain, arthralgias, pharyngitis, flu-like symptoms, pruritus (more common in immunocompromised patients), lymphadenopathy, splenomegaly, bursitis, and tenosynovitis”⁵ making it hard to distinguish from a variety of other diagnoses. If left untreated, tertiary syphilis can develop months or years after the initial infection. Tertiary syphilis can affect the central nervous system, heart, bones, and skin. In infants, congenital syphilis contracted from the mother’s bloodstream can result in “hepatomegaly, splenomegaly, lymphadenopathy, mucous patches, hemolytic anemia, thrombocytopenia, periostitis, and intrauterine growth retardation.”⁶

Back with a Vengeance

In the early 1940s, the rate of syphilis infection was quite high, but as treatment became available and awareness increased, the rate of new infections dropped significantly. By 2000, the national rate of primary and secondary syphilis was the lowest since recording began in 1941, with just 2.1 cases per 100,000 population.⁷ “There was great hope for syphilis elimination in the United States,” said Gail Bolan, director of the Centers for Disease Control and Prevention’s (CDC) division of sexually transmitted disease prevention. “Unfortunately, our national data now show that syphilis is thriving.”⁸ In 2016, the number of syphilis cases rose to 8.7 cases per 100,000 population—quadruple the number from 2000. In some hard-hit counties, like Los Angeles County in California, the rate of infection in men went from 12.4 per 100,000 in 2011 to 22.8 per 100,000 just four years later. During the same period women increased from 0.5 to 2.4 cases per 100,000.⁹

Who is Most Affected?

The primary impact of the rise in syphilis has been on men who have sex with men (MSM) and disproportionately affects men of African American and Hispanic descent. In 2015, MSM accounted for 14,229 out of 23,873 (59.6%) cases of primary and secondary syphilis.⁴ Several factors may be at the root of the problem. As the AIDS crisis of the 1980s fades into history, fears of contracting HIV have decreased (especially thanks to pre-exposure prophylaxis, or PrEP) and MSM are not as diligent about using condoms as they once were. Dating apps like Grindr and Manhunt have come under fire as they provide greater opportunities for anonymous sexual encounters. Although dating apps are adding more tools for users to disclose sexual and health histories, fact sheets, and resources for treatment, they can make tracking down past partners more difficult for public health workers.⁴ As more women contract syphilis, the rate of congenital syphilis has risen significantly. From 2014 to 2015, primary and secondary syphilis infections increased 27%⁸, with another increase of 35.7%⁷ the following year. “It’s been an absolute explosion,” said neonatologist Gurvir Khurana of the congenital syphilis rate in Kern County, California. “It’s just spreading very, very quickly.”⁸ Having no prenatal care—or even late or limited prenatal care—has been associated with the rise in congenital syphilis in infants. Until recently, congenital syphilis wasn’t a significant concern for many pregnant women as they were not aware of the danger. After hearing an explanation of how syphilis can affect babies, 18-year-old Serenity Thomason, who was 6-months pregnant said, “That’s scary. I never heard about syphilis.”⁸ Up to 40% of babies who contract syphilis in utero are stillborn or die from infection in infancy.¹⁰

High-Risk Behavior and Syphilis

“Drugs like meth really ramp up someone’s sexual appetite, and so they tend to have a lot of partners,” says Portia King, a long-time Oklahoma state health investigator.¹¹ Syphilis has been associated with the rise of methamphetamine use and the opioid epidemic. As drug users share needles, exchange sex for drugs, and engage in drug-fueled sexual encounters, they put themselves at high risk for contracting syphilis, along with other sexually transmitted diseases (STDs). “You’re just busy thinking about drugs,” said Renee Nichols, 22, who is a recovering meth addict. “You’re not thinking about if I have sex with this person that I might get a disease.”⁸ Public health officials around the country are discovering that gang membership is also a contributing factor in contracting syphilis. Oklahoma City investigators were puzzled when a boy and two girls in juvenile detention tested positive for syphilis. Then, a few months later, a prison inmate tested positive and gave investigators a list of 24 sex partners which included “so-called pass-around girls for gangs,” whose sexual favors are traded for heroin or meth. Investigators soon declared an outbreak as they followed the spread of the disease.¹²

What Can Health Care Professionals Do?

The CDC and other health organizations have made suggestions about how to raise awareness of syphilis and prevent its spread:

• Have an open and honest dialogue with patients about their sexual history and practices.
• Test pregnant women at their first prenatal visit and treat, if necessary. Test again at delivery. If a woman is determined to be at risk, one or more additional tests can be completed throughout the pregnancy.
• Educate patients about syphilis, its symptoms, how it’s spread, and possible health effects in the short- and long-term.
• Encourage safe sex using condoms, especially for MSM.
• Recommend frequent testing, as often as every three months, for those at risk for syphilis and other STDs.
• Work to increase funding for prevention, testing, and treatment, especially for local health departments and clinics that provide STD testing to at-risk communities.
• Create new and better tests to detect the active infection.
• Report new cases and track down partners that may also be infected so they can be treated.¹⁶

Public health officials continue to research and test new ways of stopping the spread of syphilis. These include targeting specific neighborhoods with high incidence and patients who already have HIV, as more than half of new cases are in HIV-infected patients. “There’s more room to better understand what we could do to decrease the spread of syphilis,” said Dr. Sonali Kulkarni, medical director for Los Angeles County’s division of HIV and STD programs.⁹

References

1. Rothschild BM. History of syphilis. Clinical Infectious Diseases. 2005;40(10) https://academic.oup.com/cid/article/40/10/1454/308400. Published May 15, 2005. Accessed December 5, 2017.

2. Inglis-Arkell E. The things people did to fight syphilis were utterly horrifying. Gizmodo. https://io9.gizmodo.com/the-things-people-did-to-fight-syphilis-were-utterly-ho-1691855614. Published March 17, 2015. Accessed December 5, 2017.

3. Tampa M, Sarbu I, Matei C, Benea V, Georgescu S. Brief history of syphilis. Journal of Medicine and Life. 2014;7(1):4-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956094/. Published March 25, 2014. Accessed December 5, 2017.

4. Toy S. Syphilis rates are on the rise, and dating apps may be playing a role, experts say. USA TODAY. July 11, 2017. https://www.usatoday.com/story/news/2017/07/11/syphilis-rates-rising-dating-apps/455104001/. Accessed December 5, 2017.

5. Burgin S, Tan B, Goldsmith LA. Secondary syphilis. VisualDx. https://www.visualdx.com/visualdx/diagnosis/secondary%20syphilis?diagnosisId=52368&moduleId=101. Updated July 7, 2016. Accessed December 5, 2017.

6. Burkhart CN, Morrell D, Goldsmith LA, Esterly N. Early congenital syphilis. VisualDx. https://www.visualdx.com/visualdx/diagnosis/early%20congenital%20syphilis?moduleId=23&diagnosisId=52366. Updated October 16, 2015. Accessed December 5, 2017.

7. Centers for Disease Control and Prevention. Syphilis. 2016 Sexually Transmitted Disease Surveillance.  Updated September 26, 2017. Accessed December 5, 2017.

8. Gorman A. Record STD rates drive syphilis in newborns. CNN. http://www.cnn.com/2017/03/01/health/syphilis-newborns-partner/index.html. Updated March 1, 2017. Accessed December 5, 2017.

9. Karlamangla S. Knocking on doors, climbing through fences: How LA county’s health investigators are out trying to stop syphilis. Los Angeles Times. https://www.latimes.com/local/la-me-ln-syphilis-investigator-20170830-htmlstory.html. Published August 30, 2017. Accessed December 5, 2017.

10. Centers for Disease Control and Prevention. CDC call to action: Let’s work together to stem the tide of rising syphilis in the United States. https://www.cdc.gov/std/syphilis/SyphilisCalltoActionApril2017.pdf. Published April 2017. Accessed December 5, 2017.

11. May C. Meth addiction and sex trafficking are fueling Oklahoma’s growing syphilis outbreak. Salon. https://www.salon.com/2017/09/02/meth-addiction-and-sex-trafficking-are-fueling-oklahomas-growing-syphilis-outbreak/. Published September 2, 2017. Accessed December 5, 2017.

12. Hoffman J. Hunting a killer: Sex, drugs, and the return of syphilis. New York Times. August 24, 2017. https://www.nytimes.com/2017/08/24/health/syphilis-std-united-states.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront. Accessed December 5, 2017.