Syphilis Is Rising—And May Not Be Recognized
Several states across the US are reporting sharp increases in syphilis rates and in other sexually transmitted diseases.Duluth saw an increase in HIV as well as syphilis, homelessness and drug dependency.
With syphilis, men who have sex with men (MSM) and those with HIV have had the largest increase in cases.
People of color are disproportionately affected. Khalid Bo-Subait, MN STD surveillance coordinator, said, "Disparities and rates of STDs are not explained by differences in sexual behavior, but are due to differences in health insurance coverage, employment status and access to health care with preventative, screening and treatment services." The CDC echoes that, adding “and differences in sexual network characteristics.”
The effect of the Covid epidemic on STDs is not entirely clear. The CDC reports that at the end of 2020, cases of gonorrhea and primary & secondary (P&S) syphilis were up 10% and 7%, respectively, compared to 2019. Congenital syphilis cases are up nearly 15% from 2019 and 235% from 2016. But chlamydia, usually the leader in STDs, declined by 13% from 2019. The decline is thought to be due to decreased physician services and testing availability. During the height of Covid, public health services were decimated, with every spare person shifted to working on Covid.
Add that most of the early STD infections are asymptomatic. This increases the likelihood that there will be further spread between sex partners or that the infection will be at a later, more difficult to treat stage. With syphilis, in particular, while the early stages are asymptomatic, later infections can affect the nervous system, heart, brain, eyes, and more. It’s been called “The Great Imitator” and can mimic many other diseases.
While low in absolute numbers, perhaps the most concerning increases have been in cases of congenital syphilis—where a baby acquires the infection from the mother during pregnancy. The CDC says syphilis among newborns (i.e., congenital syphilis) has increased, with cases up nearly 15% from 2019 and 235% from 2016.
Lima, Ohio, has recently seen such an increase in congenital syphilis. So has St. Louis, with the highest number of congenital syphilis cases seen since 1994.
Congenital syphilis is 100% preventable if the mother is treated during pregnancy. If not, the baby may die in the womb or be born with severe neurologic problems.
This is why some states have mandated that pregnant women be tested when they first present for prenatal care and during the third trimester. Unfortunately, many women are not tested. In Indiana, 19% of women were not tested for syphilis at any time during pregnancy. Only 27% of high-risk women were tested at delivery. Even worse, 9% were tested only at delivery. Why are basic standards in prenatal care not being followed?
Caroline Chen has written the best article on syphilis. In it, she quotes Dr. Tom Frieden as our going through “‘a deadly cycle of panic and neglect’ in which emergencies propel officials to scramble and throw money at a problem — whether that's Ebola, Zika or COVID-19. Then, as fear ebbs, so does the attention and motivation to finish the task.”
Most recently, there was Covid. Now public health officers will need to focus on the monkeypox outbreak, which is rapidly growing, given our delayed response.
This nightmare scenario is growing for several reasons. One is that people who have gotten monkeypox—mostly MSM—may also have become infected with gonorrhea, syphilis, or Herpes, and the rashes of the latter two can look similar to monkeypox. It’s essential that patients be tested for all STDs.
David C. Harvey, the executive director of the National Coalition of STD Directors, notes that lack of accessible testing, stigma and fragmented funding are major factors in the rising STD rates. Lack of point of care diagnostic testing and education about symptoms among the public and physicians will further fuel both monkeypox and similar STDs.
Public health has been disparaged and underfunded for years. Attacks from antivaxxers have fueled the exodus of experienced public health workers.
With the current political climate and move towards “Don’t say gay,” abstinence only, and limited sex education in many states, one might well expect further increases in STDs and difficulty controlling any new infectious disease
