Center for Disease Control and Prevention data published earlier this year shows that Oregon has some of the highest rates of syphilis infections, landing ninth out of all states. At the same time, more than 3,700 babies were born with congenital syphilis in the U.S. last year — the highest count in more than 30 years. Tim Menza is the medical director of the HIV/STD/TB section of Oregon Health Authority. They join us to share more on what the current trends are in the state and what’s being done to address them.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. We turn now to syphilis. The Center for Disease Control and Prevention announced earlier this month that more than 3,700 babies were born with congenital syphilis in the US last year; it was a 32% increase from the year before, and 10 times higher than just a decade ago. Recent CDC data has also shown that Oregon has the ninth highest syphilis rate in the country. Tim Menza is an infectious disease doctor at OHSU who focuses on sexually transmitted diseases for the Oregon Health Authority. He joins us now. Welcome to the show.
Tim Menza: Hey, thanks, Dave.
Miller: I want to start with the basics here. What is syphilis?
Menza: Syphilis is a condition that affects multiple body systems. It’s caused by a bacteria called Treponema pallidum. It’s in fact an infection that’s been around for centuries, if not millennia. It spreads through vaginal, oral, or anal sex, and syphilis, as you’d mentioned, can also spread from a pregnant person with syphilis to a fetus during pregnancy.
It’s not spread by casual contact, and syphilis, like other sexually transmitted infections, is really a part of being a sexually active person. It’s diagnosed by a sexual history, a clinical examination in combination with a blood test, and the blood test has generally two steps: a screening test and a confirmatory test. Syphilis is treated with penicillin or another antibiotic called doxycycline.
Miller: I’ve read that this has been called a silent invasion. What does that mean?
Menza: What we’ve been noticing in terms of the increase in syphilis is that back in the late 1990′s and early 2000′s, the rates of syphilis were so low that researchers really thought that syphilis might be eradicated from the United States. Year over year, it has been slowly increasing, little by little. It’s been accelerating, though, in more recent past, such that in 2022 the rate of syphilis in Oregon is the highest it’s been in recent history with almost 2,500 cases. For comparison, in 2013 there were fewer than 600 cases. More recently, we’ve really seen the steep increase in the rate of syphilis between 2020 and 2021, during the COVID pandemic, and with continuing increases into 2022.
As you mentioned, in 2021 Oregon ranked ninth in the nation for specifically primary and secondary syphilis, which are the first two symptomatic stages of syphilis, and in fact eighth in the nation for primary and secondary syphilis among people assigned female at birth, which is a change from what we were noticing with that slow incremental increase, where most of the infections were among men. We really started to see an acceleration in the rates of primary and secondary syphilis among people assigned female at birth now.
Miller: Those are questions of demographics and gender. What about geography? Are there patterns that stand out to you?
Menza: One of the things that we do notice is that the west coast in particular is quite affected, Oregon and California. As we move through the southwest and southern United States, in Oregon specifically, what we see is largely along the I-5 Corridor, but we do see increasing rates of syphilis in more rural and frontier areas as well.
Miller: How likely is it that somebody would have syphilis, but either not even know it, either have mild symptoms or symptoms that they don’t pay attention to, as opposed to having a sense that something is wrong, but for any number of reasons not seeking treatment?
Menza: Well, both things are true. I think I might add a third: that if they do seek treatment, perhaps their healthcare provider, given those really low rates of syphilis in the late 90′s and early 2000′s, if folks were training during that time, they just don’t necessarily recognize the presentation of syphilis. I will say also that Sir William Osler said “To know syphilis is to know medicine,” right? Because syphilis presents in a wide variety of ways. It’s also been called The Great Imitator in that it presents in a wide variety of ways that could be mistaken for other things. Going back to the piece of ‘might someone not notice symptoms?’ Yeah, that’s often the case.
Syphilis has four stages. The first stage is called primary syphilis, and it occurs about 10 to 90 days after infection. It’s characterized by a painless break in the skin, an ulcer, the technical name is a shanker, and it usually occurs at the site where the bacteria enters the skin. This could be the mouth, the lips, the tongue, the vulva, the vagina, the penis, and/or the anus or rectum. Oftentimes, people may not notice it because it’s actually inside, and it goes away after a few weeks without treatment. Folks might notice it, but then it disappears, and might say, ok, well, that’s gone. Similarly, if they’re presenting to a health care provider, they might not do an exam that looks for specific things or recognize the symptoms to then go ahead and treat.
The complicating thing is then secondary syphilis occurs potentially after an asymptomatic phase. Primary syphilis resolves and then secondary syphilis occurs, and that is characterized by a rash, usually on the palms and soles, but it cost could also be on the trunk, the chest, the abdomen, back, arms and legs, and oftentimes it’s mistaken for other things because it looks so non-specific. Again, the other thing is it also goes away without treatment, so the same things apply for primary syphilis as they do for secondary syphilis in that there’s something that looks like it could be other things, and then it just resolves. It doesn’t mean the infection has gone away, it’s just gone what we call latent, or becomes an asymptomatic persistent infection.
Miller: I want to turn it back to something you mentioned twice now: that doctors maybe who got their training, say, in the late 90′s or early 2000′s, that they may not have encountered this. Is medical training changing now to stay current with the population’s needs?
Menza: I think so. That’s a big question. I think in terms of syphilis, I do think we’re reintroducing it. Definitely in my work at OHSU, in my work with provider organizations, we’re doing a lot of training on syphilis these days, a lot of training on STIs in general, just because we’ve seen increases over time in all STIs, including gonorrhea and chlamydia, including syphilis. There is an effort to bring this back to the fore, and make sure that people recognize how to clinically diagnose, how to test for, and how to treat syphilis, in addition to gonorrhea, chlamydia, and other sexually transmitted infections like HIV as well.
Miller: I want to turn specifically to questions about congenital syphilis, which a lot of people may have seen some articles about recently because that was the focus of some recent CDC data. How common is this in Oregon right now? Meaning, babies being born with syphilis.
Menza: Let me just start by saying that not even one congenital syphilis case should happen in a modern health care system. What we’ve been seeing in Oregon is in 2013, there were no cases of congenital syphilis. In 2014, there were two, and in 2022 there were 37. This year there are 27 cases as of November 8th, 2023.
Miller: What are the potential repercussions of congenital syphilis?
Menza: Congenital syphilis can affect how the baby grows, how soon a baby is born, and its weight at delivery. It can also affect the skin, the blood cells, the liver and spleen, the nervous system, the bones, and other body systems. It’s prevented by screening three times during pregnancy, and treating the pregnant person with syphilis with penicillin delivered by a trained professional, with a single dose or three weekly doses depending on the stage. The treatment is 98% effective in preventing congenital syphilis.
Babies born with syphilis can also be treated with penicillin. That said, there are missed opportunities for the prevention of congenital syphilis in Oregon, falling broadly into two categories. One is no access or very late access to prenatal care, and if someone is diagnosed, then inadequate treatment of the pregnant person. In those cases where we don’t see treatment during pregnancy, we’ll see that 10% of babies with syphilis die. The majority are stillborn and a smaller proportion die within the first year of life.
By preventing congenital syphilis, we’re preventing, of course, the short and long term health consequences of syphilis and babies. We’re keeping babies alive and we’re ensuring that pregnant people and their families don’t have to experience the trauma and sorrow of losing an infant.
Miller: What do you see as the systemic reasons why somebody who, say, even tests positive during pregnancy for syphilis, wouldn’t get adequate treatment for themselves and for their baby?
Menza: This is a complicated problem. Let me just contextualize things a little bit; we’ve definitely seen that social and economic factors intersect with the spread of syphilis, including lots and lots of topics you’ve talked about on your show: systemic racism, poverty, housing instability, substance use, mental health, mass incarceration. Congenital syphilis, and syphilis in general, is really a symptom of the social and economic crises at play in Oregon in the United States, and all policies, health policy addressing these crises will impact syphilis. Then how does this impact whether someone might access prenatal care or persistent prenatal care in order to be screened and treated for syphilis?
There’s a legacy here in the United States, a legacy of curtailing reproductive autonomy through the medical system, particularly for pregnant people who are Black, Indigenous, Latina, Pacific Islander, folks who use substances are experiencing poverty, have mental health challenges or other disabilities, and who might be involved in the criminal justice system. Many pregnant people have faced or may face punitive consequences should they seek healthcare while pregnant. Those consequences could range from poor care to mistreatment, to being reported to law enforcement and or the Department of Human Services, to having their children taken from them, to outright incarceration. The risk for some pregnant people of accessing prenatal care or persisting in prenatal care just may be too high. And while there are some great programs that exist that support pregnant people’s engagement in care, especially those affected by these social and economic barriers, there are just not enough resources to provide that low barrier, culturally tailored trauma informed care services for pregnant people who need extra support.
Miller: The huge increase in congenital cases of syphilis that the CDC reported, that was from last year, from 2022, but according to the associated press, there’s been a newer nationwide problem this year: supply shortages that have made it increasingly difficult for doctors to get benzathine penicillin injections, which I’ve read is the main treatment for congenital syphilis. Is that shortage affecting Oregon as well?
Menza: It is affecting Oregon in that we are monitoring the situation quite closely. Thus far, we’ve been able to treat all the pregnant people who’ve needed benzathine penicillin with benzathine penicillin. But it is a source of stress, I think, for a lot of providers, and for me and the folks I work with, my colleagues and all the local public health agencies who are seeing pregnant people with syphilis. This is one piece of this larger piece, of there’s just not enough resources and funding for the public health infrastructure and workforce for sexually transmitted infection prevention.
In addition to this Bicillin shortage, which has happened before and we worry will happen again, we’ve also seen this contraction in public health services for sexual health over the last five years that really accelerated during COVID-19. As rates of STIs have continued to rise, funding from the federal level to the state level to the local level really has remained flat or has decreased. In fact, there was a recent rescission of federal funds for an STD workforce development grant, a casualty of the debt ceiling negotiations that affected all states including Oregon, which lost millions of dollars.
Miller: This was, as you said, part of the debt ceiling negotiations, so in order for us to not default on the money that we have already spent, money that among other things was going to go towards preventing sexually transmitted diseases, it was cut nationwide. What exactly is not happening in Oregon that would have been happening if it weren’t for that cut?
Menza: It’s largely the expansion of the STD workforce. What we mean by that is we, the state, would receive that money and then we would push that money out to local public health agencies to then hire staff to do interviews and provide partner services to people diagnosed with sexually transmitted infections, and also to do testing events, provide testing in the community, potentially link up to community based organizations to provide both awareness and education, but also provide sexual health services.
Miller: Studies have found that PrEP, the medicine intended solely to prevent people from contracting HIV, that it can lead to less condom use. Is there a connection between PrEP and the increase in other sexually transmitted diseases like syphilis?
Menza: I think that there’s some conflicting evidence here. And I don’t know if that’s the whole story. Of course, when you take HIV out of the equation with PrEP, pre-exposure prophylaxis, which is 99% effective against acquisition of HIV, and you also introduce U=U - which is ‘undetectable equals untransmittable’ where people living with HIV on effective treatment who have undetectable viral loads cannot transmit HIV sexually - yeah, you take HIV out of the equation and of course, there’s going to result in a change of behaviors because HIV is not necessarily the impetus for using condoms at this point.
But [for] HIV, that knowledge [of] PrEP and U=U and education has really been focused on gay, bisexual, and other men who have sex with men. So maybe it explains part of the increase of syphilis there, but when we think about the changes in demographics around syphilis now, where there are more heterosexually active people and more people who use drugs who are acquiring syphilis, it doesn’t necessarily translate to those populations. Because while those folks are eligible for PrEP, really, the advertisements and the push for PrEP uptake really wasn’t focused among women specifically, among people who inject drugs specifically. I think that’s changing, so yes, but it’s probably not the whole story.
Miller: Before I say goodbye, just a sort of a big picture question here. The COVID-19 pandemic highlighted the importance of public health agencies, but also it eventually led, I think, in our very polarized country, to a significant percentage of the public, especially more conservative people, coming to mistrust the government’s health care pronouncements. Obviously, that had to do with things like vaccine recommendations. Do you think that that mistrust has affected other public health efforts like yours?
Menza: I think it’s part of it. I do see that. We definitely feel this when we interview folks newly diagnosed with sexually transmitted infections; oftentimes we will offer assistance in notifying partners, and folks aren’t really willing to share. I understand that. I think we have to do public health a little bit differently. I do think that trust is a big thing, community engagement is a big thing, and I think that’s where we really need to focus our efforts moving forward in creating a public health system that’s community engaged, community informed, and ultimately a trusted resource.
Miller: Tim Menza, thanks very much.
Menza: Thank you.
Miller: Tim Menza is an infectious disease doctor at OHSU and the medical director of the HIV/STD/TB section of the Oregon Health Authority.
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