National Clinical Training Center for Family Planning



Podcast TranscriptTitle: The Current State of Syphilis in the U.S.Speaker: Dr. Ina ParkDuration: 00:18:21NCTCFP (00:04):Hello, and welcome to The Family Planning Files, a podcast from the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning is one of the training centers funded through the Office of Population Affairs to provide programming to enhance the knowledge of family planning staff. I'm your host, Katherine Atcheson.NCTCFP (00:23):In today's episode, the first of our three episode series on syphilis, we'll be discussing the epidemiology of syphilis in the United States. We will also be touching on neurosyphilis, ocular syphilis and congenital syphilis, which were previously rare conditions that are now becoming more common. For today's podcast, we're joined by Dr. Ina Park. Dr. Park is an associate professor of family and community medicine at the University of California San Francisco School of Medicine, is medical director of the California Prevention Training Center and is a medical consultant with the Centers for Disease Control and Prevention, where she was one of the coauthors of the forthcoming 2020 CDC STD Treatment Guidelines. Welcome to the podcast, Dr. Park.Dr. Ina Park (01:04):Oh, thanks for having me. I'm really looking forward to talking to your listeners today.NCTCFP (01:08):So we'll just start with the latest statistics on syphilis from the CDC in order to give our listeners sort of a lay of the land. What can you tell us about them?Dr. Ina Park (01:16):Unfortunately, the most recent data we have are actually for 2018 because the 2019 data will be out probably in September or October. But for 2018 that year, there were over 115,000 cases of syphilis reported to the CDC, and so that was the highest number recorded since 1991. So a third of these, so that would be about 35,000, were primary and secondary syphilis cases. And so that was a 71% increase. A third of these, about 35,000 cases, were primary and secondary syphilis cases, and that reflects a 71% increase over the past five years.Dr. Ina Park (01:48):So just as a reminder to your listeners, primary and secondary syphilis are the most infectious stages, and we're going to discuss that more in the next episode of this podcast.NCTCFP (01:55):Well, that sounds like a lot of syphilis. How long have these high rates been happening?Dr. Ina Park (02:00):Well, just to give your listeners some perspective, in 2000 and 2001, we basically almost eliminated syphilis in the U.S. if you can believe that. And the rate of primary and secondary syphilis cases at that time was just over two cases per a hundred thousand people in the population. So that was the lowest rate ever reported since we started actually recording syphilis in 1941. So since then the rate has increased almost every year since 2001. So we thought it was gone, but it's clearly not. It's definitely back.NCTCFP (02:29):With all the new cases we're seeing, is there also some data about which populations are most affected by these increases in syphilis cases?Dr. Ina Park (02:37):For sure. This rise in syphilis is mostly attributable to increased cases among men, and so specifically among gay, bisexual and other men who have sex with men. And we refer to that more broadly as MSM or men who have sex with men, and they are really accounting for the majority of primary and secondary syphilis cases in the U.S. and there's an intersection there with HIV as well. So about 40% of the syphilis cases among men who have sex with men are also living with HIV. So in the past few years, there's also not only increases among MSM, but now there's increases in syphilis among men who are having sex with women and women as well, regardless of the gender of their sex partners. So the increase in women is particularly concerning because as you can imagine, it's associated with a striking increase as well in congenital syphilis.Dr. Ina Park (03:23):So in 2018, for example, there were over 1,300 cases of congenital syphilis. And so it's even more dramatic than what I talked about before. This is actually 185% increase over the past five years, and that included almost a hundred stillbirths and neonatal deaths. And so just to give you some perspective in the year that we had 1,300 cases of congenital syphilis, we had only 66 cases of perinatal HIV transmission. So as you can see, Katherine, we've had really great success in preventing mother to child transmission of HIV, but we have a long way to go when it comes to congenital syphilis.NCTCFP (03:55):Well, since most of our listeners are associated with the Title X program and serve mostly women, can you tell us a little bit more about women with syphilis in pregnancy? What sort of factors can contribute to a case of congenital syphilis?Dr. Ina Park (04:08):In about a third of the cases for women who are having a baby who's born with congenital syphilis, about a third of those did not receive any prenatal care and a little less than one third of women are actually tested and did get prenatal care, but they just didn't get treated in time to prevent their case of congenital syphilis. And we're going to talk more about the specifics of what kind of treatment is needed in the next podcast, but just as a preview, listeners should know that a patient actually has to initiate treatment at least 30 days prior to delivery to confidently avoid a case of genital syphilis.Dr. Ina Park (04:38):So then there was about 14% of women who actually were negative at the first prenatal visit, but then they got infected later in the pregnancy, and then they didn't know though until it was sort of too late and then a much smaller percentage of women who actually got prenatal care and went to multiple prenatal visits and for some reason, the testing just fell through the cracks.NCTCFP (04:55):So for the women who are either not receiving prenatal care or are late in getting prenatal care, what do we know about those women and why it happens to them in particular?Dr. Ina Park (05:06):So we know substance use is certainly an issue, but there's a lot of regional variation with this, and you and I have talked about this before that the intersection of syphilis and substance use for some reason is really prominent in the Western States. And you know, where I live out in California, especially, a third of women with primary and secondary syphilis have reported using crystal meth, but in the South by comparison, it's like less than 8%. And in the Northeast, you know, in new England, it's actually less than 1%. So the issue is we know that there's use involved, but what were the other risk factors that might've led to the congenital syphilis and the syphilis in pregnancy in this case, like, was the woman engaged in transactional sex? Were her partners possibly engaged in drug use, but they themselves weren't? And these are factors that CDC, unfortunately, we don't actually collect those data. And so I don't know why the South and the Northeast, what were the risk factors that led to congenital syphilis in those circumstances. We just know that they weren't necessarily associated with substance use, like they are in the West.NCTCFP (06:04):Once a fetus or baby's affected, how do congenital syphilis infections behave differently than syphilis infections in adults?Dr. Ina Park (06:11):Well, there's two big differences, Katherine. Like for adults, as you can imagine, the point of entry for syphilis is through the skin, right? From genital to genital contact or oral genital contact. And it causes a local reaction, right? So you get an ulcer or a chancre at the site where the syphilis enters, and then the infection, the bacteria, actually then disseminates more widely through the body.Dr. Ina Park (06:32):But if you think about the fetus, the infection is passing directly from the mother into the bloodstream via the placenta. So once the fetus contracts syphilis, it disseminates pretty much immediately. And so listeners need to remember that the fetal immune system is not really developed in the first trimester. So the fetus really has little or no defenses if they get infected during that time. An infection in the first trimester, if goes unchecked, it can lead to severe organ damage, of course stillbirth, fetal death.Dr. Ina Park (06:58):And so on the other hand, you can also get infected later in gestation and a baby might appear completely normal at birth yet still have congenital syphilis. So the treatment protocols for infants are dependent of course, on both the results of the infant and the mother's tests. And they're going to be found in the CDC STD Treatment Guidelines. They can be there now in the 2015, and then they'll also be repeated in the 2020 guidelines.NCTCFP (07:20):Given that Title X clinicians who make up the majority of our audience don't deliver prenatal care in their practice or other care for pregnant patients, but do provide preconception and inter conception care, what are some of your recommendations for family planning providers in the Title X program to combat syphilis in women of childbearing potential?Dr. Ina Park (07:42):So right now different states have different recommendations about whether to screen all patients with childbearing potential for syphilis. So it's really important to check with your clinical protocols around this because each state is actually able to make its own sort of laws and regulations around this. All women need to be tested for syphilis at some point in pregnancy and at the first prenatal visit. Some states are actually adding like third trimester screening as well as delivery screening. Title X providers do a lot of pregnancy testing, so even if they don't do prenatal care, they're certainly doing that.Dr. Ina Park (08:11):And so one thing is that if you have a patient who has a positive pregnancy test, you can order syphilis testing as well. That would be great information to know. The earlier you get the infection, you know, the better it is for both mom and baby. Regardless of whether or not the patient is going to continue the pregnancy or not, diagnosing syphilis early is a good idea.NCTCFP (08:29):Well, we've talked quite a bit about syphilis among women and infants, so let's switch gears a little bit and talk about syphilis among MSM. You mentioned earlier in the podcast as that population being particularly affected by syphilis. What are the issues driving the epidemic in this population?Dr. Ina Park (08:46):Well, one thing we talked about was syphilis and its relationship to HIV. And so, you know, one of the things that happened was that folks with HIV, who, as I told you do have a substantial role in the burden of syphilis as well in the United States are living longer when the combination antiretroviral therapy came out in 1996. And they have longer healthier lives. People that are resuming normal sexual activity, and remember about 40% of the primary and secondary syphilis cases in MSM are among people who are living with HIV.Dr. Ina Park (09:15):So then in 2001, the birth of sort of internet dating sites for MSM also began to take off. And then the smartphone based hookup apps came around in 2009. So these innovations made it easier for people to meet partners, often more quickly with greater frequency in larger numbers than in previous generations. So I think likely a combination of these factors influenced the increases in syphilis among MSM that we're seeing today.NCTCFP (09:40):I also hear people talking about HIV preexposure prophylaxis, or PrEP, as another reason why syphilis is increasing among MSM. What do you think?Dr. Ina Park (09:50):Just as an aside for your listeners who might not be as familiar with HIV PrEP, it's use of combination antiretroviral therapy. It's two actual drugs in one pill taken daily, which is effective at preventing HIV. And then very recently as well, there's going to be an injection coming out. And so there's going to be more ways to take PrEP, but it's sometimes, you know, even referred to by some folks as a birth control pill for HIV. And so one issue with PrEP is that some people who use PrEP decide they don't want to use condoms anymore. And so the question I think that you're asking is whether or not the introduction of PrEP is really driving the increase in syphilis.Dr. Ina Park (10:22):One thing I wanted to point out is that PrEP was FDA approved in 2012, but syphilis was already on its way up starting in 2001. I think it could be accelerating the pace of the increase, but that had started way before PrEP was actually even introduced. And so avoiding syphilis is not a reason to also avoid PrEP. I think if you're a good candidate for PrEP, you know, go ahead and take it. And if folks are trying to avoid syphilis, then you know, adding condoms on would be a way to potentially avoid syphilis in this situation.NCTCFP (10:51):What about substance use in this population? Earlier in the podcast, we talked about increasing rates of crystal methamphetamine use in women being tied to syphilis in some regions, but is the same true for MSM?Dr. Ina Park (11:03):You know, not really. The trends that we see in women are not really actually reflected in this population. So of course there's substance use in all swaths of the population, but according to the CDC, rates of drug use, so that includes in this case meth, heroin and cocaine, have actually been pretty stable among MSM over time, and the proportion of syphilis cases who report substance use is actually much lower in this population than among women in the West, for example. So we know that substance use can absolutely be involved in higher risk sexual activity, but in this case, it's not really seeming like intersecting epidemics at this point.NCTCFP (11:40):So while there are syphilis epidemics among both women with male partners and MSM or men with male partners, what I'm hearing is that the characteristics of these epidemics are really quite different.Dr. Ina Park (11:51):Yeah, there's unique factors sort of driving the increases in each population. And you know, just as a reminder to everyone, we are certainly seeing increases in women, but MSM still make up the majority of syphilis cases in the U.S.NCTCFP (12:03):Now that there are so many more cases of syphilis around, are we also seeing more or more severe cases of complications such as neurosyphilis or ocular syphilis?Dr. Ina Park (12:14):So that's a great question, Katherine, and it's not totally clear. The thing about neurosyphilis is that it isn't really a separate stage of syphilis by itself. It’s, I want you to think about it more like a complication of syphilis, that it can occur at any stage of disease. So someone could come in with an ulcer or a rash, and that person would normally be characterized as having primary or secondary syphilis. They can actually have neurosyphilis at the same time.Dr. Ina Park (12:38):You can have no physical findings and also have neurosyphilis at the same time and that'd be your only symptom. And just to remind folks, the symptoms of neurosyphilis would be something like problems with your cranial nerves, auditory or visual changes, loss of sense of vibration, and it can actually in severe cases cause meningitis, stroke. It can alter your mental status. And so the issue is, is that we're seeing so much more syphilis in general, that we are going to expect to see more neurosyphilis.Dr. Ina Park (13:05):And so it's hard to say whether or not neurosyphilis alone is just going up or it's just reflecting the fact that we're seeing more disease in general. And this issue actually came up specifically because there were several cities like Seattle, San Francisco, Los Angeles actually started reporting a specific kind of neurosyphilis called ocular syphilis. So it's syphilis affecting, you know, any part of the eye and from the conjunctiva all the way down to the optic nerve, and these clusters of ocular syphilis were mostly among MSM. And it wasn't clear whether this was just some particular strain of syphilis causing these clusters, or if they were just occurring because there's just more syphilis around in general. And ocular syphilis you know, is a really serious complication of syphilis that can cause uveitis, optic neuritis, and you can come with any sort of constellation of symptoms like red eye, floaters in your visual field, or visual changes or blindness or vision loss. So it's pretty serious, and it's something that we're certainly seeing more of.NCTCFP (14:02):That sounds like it would be very challenging to diagnose. When a patient comes into a clinic reporting headaches or red eyes, changes in their vision, syphilis probably isn't the first thing on a clinician's mind, especially if they're not in the practice of seeing lots of STIs or in a sexual health clinical setting, right?Dr. Ina Park (14:24):Exactly. And I've heard so many reports of patients being bounced around from the clinic to the emergency department to various specialists with long delays before finally getting diagnosed because people aren't necessarily thinking of syphilis. And unfortunately I've heard of multiple cases of people with permanent vision loss related to a delay in diagnosis of syphilis. And so it's just not on people's minds. So that's part of the reason why you and I are talking today. It's just getting it on people's radar and key for clinicians to realize that if you see someone who has sex with new visual changes, it's important to get testing for syphilis. It's cheap, you know, it's quick. It's important to do and you can literally save someone's vision this way.NCTCFP (15:02):What about otologic syphilis, or syphilis that affects the hearing? Is that also increasing?Dr. Ina Park (15:08):So there haven't been the same reports that I talked about earlier about clusters or outbreaks of otosyphilis or otologic syphilis, but just so your clinicians are aware, syphilis can certainly affect the auditory system. And so for you guys listening out there, if you have a sexually active patient who has new onset hearing loss or tinnitus, ringing in the ears, it's a really good idea to just get a syphilis test to cover your bases.NCTCFP (15:31):For suspected neurosyphilis or ocular syphilis, should family planning, clinicians refer out for a CSF examination?Dr. Ina Park (15:39):Certainly. I think probably most family planning clinicians aren't going to have that capacity in their clinical settings. So, and then just to remind everybody that remember neurosyphilis can happen coincident with any stage of syphilis. So if a patient has a very characteristic rash of secondary syphilis, but also has new neurologic symptoms, then it'd be a great idea to refer them out for a CSF exam or consult with an ID specialist. And since most family planning providers aren't going to be doing this in their setting.NCTCFP (16:06):Sadly our time is about up today. But before you go, Dr. Park, can you tell our listeners where they can find more information about current syphilis trends and complications like neuro and ocular syphilis?Dr. Ina Park (16:18):Yes. The CDC will be posting updates about syphilis trends and new clusters or outbreaks about for ocular otologic or neurosyphilis on their website. So that's STD. And so any breaking news on new clusters also will be published in the CDC's morbidity and mortality weekly report. Right now, most of that report is actually related to COVID, but certainly if we identify a cluster of any of these complications then it will probably appear there.NCTCFP (16:45):Well, thank you so much for joining us today, Dr. Park, and for sharing your time and expertise. We look forward to having you on again for our next episode in our syphilis podcast series where we'll discuss signs, symptoms and staging of syphilis. For more content, including our other syphilis podcasts, search for The Family Planning Files podcast, or subscribe to our show on iTunes, Google Play, Spotify, Stitcher or wherever you listen to podcasts. For a transcript of this podcast, as well as other online learning activities and continuing education opportunities, please visit our website at .NCTCFP (17:22):This podcast is supported by award number 5FPTPA006029-02-00 from the U.S. Department of Health and Human Services, or HHS, Office of the Assistant Secretary of Health, or OASH, Office of Population Affairs, or OPA. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of HHS, OASH or OPA. Theme music written by Dan Jones and performed by Dan Jones and the Squids. Other production support provided by the Collaboration to Advance Health Services at the University of Missouri Kansas City School of Nursing and Health Studies.NCTCFP (18:05):And thank you to our listeners for tuning in today. We hope that you'll join us next time for another episode of The Family Planning Files. ................
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