Combatting the Resurgence of Syphilis
By Carol A. Kemper, MD, FACP
Source: Rubin R. Syphilis has surged for reasons that go beyond the pathogen that causes it. JAMA 2024;332:92-95.
Syphilis has continued its upward trend, reaching the highest number of cases in the United States in 2023 since the 1950s. There was a brief dip in cases during the first few months of social isolation with COVID, but, overall, cases have doubled since 2015. It is obvious the current approach of testing those who present with symptoms or other sexually transmitted infections (STIs) is not sufficient.
In August 2023, the U.S. Department of Health and Human Services created a National Syphilis and Congenital Syphilis Syndemic (NSCSS) Federal Task Force to investigate and combat the factors contributing to the syphilis epidemic. The use of the word syndemic was telling, indicating the federal government acknowledges the importance of such social factors as sexual behavior and public health coupled with drug use and mental health, and homelessness. This article explores the problems contributing to the rise in syphilis cases:
- A main factor underlying this explosion in syphilis cases is the gradual reduction in public health dollars, both on the federal level as well as the state level, which has strained and even resulted in the elimination of many public health and mental health programs. This reduction in public health funding began with the recession in 2008 and continued through the Obama and Trump administrations — right up to the COVID pandemic. At present, there are only 300 public health laboratories in the United States. This infrastructure is not just critical to providing STI surveillance and treatment, but it provides treatment for tuberculosis and human immunodeficiency virus (HIV), environmental and water testing, wastewater testing for pathogens, and monitoring for foodborne illnesses. I live in California, one of the wealthiest states in the United States, and only 29 of the 61 health jurisdictions in California have a public health laboratory. I remember a time in the 1990-2000s when our county had 30 public health nurses who provided outreach for tuberculosis (TB), HIV, and STI contact tracing and treatment. The last I heard, there were nine public health nurses — for a county that is 90 miles long with nearly 2 million people.
- The COVID pandemic shocked this already strained system, resulting in a diversion of limited resources away from STI treatment and mental health. Many STI clinics were simply closed during COVID. To date, public health in many areas has not recovered, and many seasoned public health workers have quit or retired from extreme burnout. While COVID may have put a dent in people’s sex lives for a few months in early 2020, evidence suggests that sexual activity rebounded by June to July 2020. This three-month hiatus in sexual activity resulted in a transient dip in STI cases, which then was offset by the lack of access to STI clinics. Jenness et al calculated that if social (sexual) distancing lasted only three months and the diminished access to public health services lasted 18 months, an estimated excess 57,500 STI and 870 additional HIV cases would occur in the United States over the next five years.1
- The rise in drug use, especially methamphetamines and fentanyl, has been associated with an increase in STIs and syphilis.
- The lack of availability of benzyl penicillin G (BPG), coupled with the recent shortage in BPG, makes access to effective treatment more difficult. In January 2024, the U.S. Food and Drug Administration allowed benzathine benzylpenicillin to be imported from Italy. Just this week, we attempted to locate treatment for a patient — her primary care physician had already informed her they did not have BPG. We contacted a local urgent care in her area, which said they do not give BPG injections. She is going to have to drive more than two hours every week for three weeks for treatment at our facility.
- Targeted testing for syphilis obviously is failing. Similar to screening for latent TB, the provider’s perception of risk is key. However, studies suggest that even when an electronic record flags a chart for STI screening based on simple criteria (high-risk sexual behavior, a history of STI, and pregnancy), only a minority are screened.
- There is a lack of access to primary care, in part because of insurance issues but also because of a burgeoning shortage of primary care physicians. Many individuals receive their only care through local emergency rooms. Capturing this population when they present for care is critical. In 2019, the University of Chicago began a pilot program to provide universal syphilis screening for all emergency room visits.
- Syphilis surveillance during pregnancy is imperfect. Forty-five states require prenatal screening, but the time testing is required differs between states: 84% require first-trimester screening; 17% require third-trimester screening; a few require first-trimester screening along with late-trimester screening for those at risk; and a few require testing at the time of delivery. But prenatal care is haphazard in this country, especially for women with mental health issues or substance use, and screening is not always done. And there are no penalties for failure to screen. There was an opportunity to screen the woman with syphilis described earlier when she was pregnant 12 years ago (in California), but none was performed.
- Ironically, modern technology has made contact tracing harder. Apps for sexual hook-ups make anonymous sex easier, which makes contact tracing impossible. Outbreaks of syphilis often can be traced to large sex parties, where partner identification may not be possible. The increase in homelessness renders contact tracing difficult. People may not have a fixed address or a publicly available phone number.
- And finally, syphilis serologies can be confusing. There is just too much ambiguity in syphilis serologies: which test is falsely positive, which is falsely negative. I often hear primary care physicians say they no longer feel “comfortable” making a diagnosis or offering treatment for syphilis.
What can be done:
- Expand public health dollars, infrastructure, and laboratory support, with integrated modern computer systems and electronic medical records, and beef up the public health workforce.
- Expand availability of STI treatment centers.
- Increase the feet-on-the-ground outreach for healthcare among the homeless.
- Have universal screening for syphilis, similar to HIV, especially when individuals are in contact with emergency rooms, urgent care, and primary care.
- Provide improved prenatal care and universal screening for pregnant women at least once during every pregnancy; consider repeat testing in the third trimester or at the time of delivery.
- Improve access and availability of BPG.
- Expand use of doxycycline for post-exposure prophylaxis, which reduces the risk of syphilis and other STIs; one expert referred to it as the “morning-after pill for STI.”
- Improve education of our primary care clinicians for interpretation of syphilis serologies, coupled with clearer guidance on treatment. Keep it simple.
- And the big-ticket item: Expand treatment for mental health and substance use disorder.
Carol A. Kemper, MD, FACP, is Medical Director, Infection Prevention, El Camino Hospital, Palo Alto Medical Foundation.
Reference
- Jenness SM, Le Guillou A, Chandra C, et al. Projected HIV and bacterial sexually transmitted infection incidence following COVID-19-related sexual distancing and clinical service interruption. J Infect Dis 2021;223:1019-1028.
Syphilis has continued its upward trend, reaching the highest number of cases in the United States in 2023 since the 1950s. There was a brief dip in cases during the first few months of social isolation with COVID, but, overall, cases have doubled since 2015. It is obvious the current approach of testing those who present with symptoms or other sexually transmitted infections is not sufficient.
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