Disease Prevention

Fight Continues Against Syphilis Comeback

Direct Relief identifies hardest-hit U.S. communities are in Southeast, New York City and San Francisco.

Rates of primary and scondary syphilis, as shown in the map above, are on the rise in the United States, Darker areas show counties with higher case numbers. (Direct Relief map)
Rates of primary and scondary syphilis, as shown in the map above, are on the rise in the United States, Darker areas show counties with higher case numbers. (Direct Relief map)

In the 1990s, syphilis in the United States seemed to be going the way of the floppy disk.

But unlike the obsolete technology, the bacterial infection has made a roaring comeback in recent years, along with chlamydia and gonorrhea, reaching a record in 2017 with more than 2 million new cases, according to the U.S. Centers for Disease Control and Prevention. Syphilis accounts for 30,644 of those cases, up 76% in 2017 compared to 2013.

This staggering rise comes after a period of historic lows. In 1998, syphilis cases decreased by 86% from 1990 and were at World War II levels, according to a 2017 Lancet-published paper authored by Dr. Edward W. Hook III, professor of medicine, epidemiology and microbiology at University of Alabama at Birmingham.

The spike since 2013 has frustrated health care providers and public health officials, since syphilis is relatively easy to diagnose and cure.

“We should’ve had success in eliminating it years and years ago,” said Hook.

And the stakes are high, based on the latest guidance from the CDC, which outlines the potential outcomes of untreated syphilis.

“There are more serious consequences than previously thought: ocular symptoms, neurological symptoms, auditory symptoms, said Kyle Bernstein, PhD, CDC Division of STD branch chief for epidemiology and statistics.

A person exposed to HIV also has a higher risk of contracting the virus if they suffer from syphilis, according to the CDC.

The bacterial infection can become a congenital disease, and potentially life-threatening to the infant. Instances of congenital syphilis have more than doubled from 2013-2017 and there is an 80% chance of a mother passing syphilis to her baby if it’s left untreated. New cases in women surged 21% from 2016-2017.

“There is not one magic factor causing all this,” said Bernstein, but both he and Hook noted the erosion of public health funding across the U.S. as one contributing issue, which has made it more difficult for people with less means to access even basic healthcare.

In 2017, $750 million was cut from the CDC’s budget to fund the U.S. public health system via the Prevention and Public Health Fund, with $1.35 billion to be cut from that program over the next 10 years.

“Persons in lower socioeconomic situations have less access to healthcare, less access to culturally competent healthcare, and are not accessing screening services as much as folks who have higher socioeconomic status,” said Bernstein, who added, along with Hook, that another at-risk population is men who have sex with men.

A Battle on Two Fronts

Hook referenced the stigmas which surround sexually transmitted diseases as a reason for why people are reluctant to be tested, especially if it’s less readily accessible to them.

“Nobody wants to think they have an STI (sexually transmitted infection which can precede a sexually transmitted disease), so they don’t necessarily seek care for those problems, and the lack of access makes it harder to get care,” he said.

“Since the very beginning of the 20th century, there have been organized public health efforts to control STIs, which by and large have not succeeded very well, and I think stigma is a large part of that,” he said.

These factors have contributed to a situation where the chances of an American contracting syphilis are below 1%. But for individuals who have contracted syphilis, the risk of contracting it again jumps to approximately 25%, according to figures cited by Dr. Hook

The challenges presented are particularly acute at health centers and free clinics, which primarily serve low-income and uninsured patients. Many clinics have seen their budgets cut, which has hampered their ability to treat STDs, as do the pervasive daily challenges facing many of their patients.

Manhattan-based Ryan Health has avoided financial struggles thanks to being a Federally Qualified Health Center and receiving grants to combat STD’s.

“With the help of these financial resources, we are able to respond to the STD epidemic,” said Dr. Jeanne Carey, Medical Director of Ryan Health’s East Village, Manhattan location.

She also noted the barriers that impair access treatment.

“Patients who are not documented or who lack health insurance may be reluctant to seek medical care; they may not realize that there are federally qualified health centers and city department of health clinics where they can access confidential STD counseling, testing and treatment for very low or no cost,” she said.

Dr. Jeanne Carey, Medical Director of Ryan Health’s East Village, Manhattan location (Photo courtesy of Ryan Health)

Because of the difficulties in consistent treatment, Bicillin is the preferred treatment option, since it only requires a single dose and eliminates the need for repeat visits. It is also the only treatment available for pregnant women.

“It is slowly released from the muscle which leads to prolonged drug levels in the body. This is a big advantage for patients who have medication adherence barriers, since the other treatment protocols require multiple doses for multiple days and may not be as effective,” explained Direct Relief Pharmacist Alycia Clark.

Smarter Ways to Attack an Old Disease

Direct Relief has provided Pfizer-donated Bicillin throughout the United States after undertaking an initiative to better understand where syphilis rates were spiking by analyzing and mapping new cases relative to population sizes.

“With the syphilis infection rates climbing in the United States it was important that the donation of Bicillin was distributed effectively and used to help communities hardest hit,” said Rose Levy, a U.S. Program Manager at Direct Relief.

In the per capita report, counties with big cities — New York City and San Francisco — appeared alongside sparsely-populated rural counties, such as Cook County, Georgia, and Tunica, Mississippi.

The map, created using Esri ArcGIS software, displays CDC data of primary and secondary rates of syphilis by U.S. county.

Bernstein suggested several ways to help alleviate the transmission of syphilis from a public health standpoint.

“There are a number of things important to advancing the field, including better diagnostics done at point of care, rapid care, more alternative treatments,” he said.

For pregnant women, he recommended testing at the first prenatal visit, at 28 weeks, and at delivery.

“Through increased screening, we are diagnosing and treating STDs in a lot of people who had no symptoms and did not consider themselves to be at risk,” said Carey, about all populations.

With syphilis, screening is important because the symptoms in the primary (usually painless sores) and secondary (rashes and legions) stages will typically resolve on their own, even though the bacteria stays present and can cause more complications such as tertiary stage syphilis, neurosyphilis, or ocular syphilis, which attack the organs, brain and nervous system, or eyes, respectively.

Bernstein warned that the current situation is a “sentinel event, like a canary in the coal mine,” referring to larger systemic issues within the healthcare system that have allowed for syphilis cases to increase.

“We don’t want to accept this increase as the new normal,” Bernstein said.

While the broader political and societal issues may take some time to address, Bernstein pointed out a fundamental reason to remain optimistic about beating back the disease.

“[Syphilis] remains pretty simple to detect and treat,” he said.

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