Why syphilis cases are surging in US, Michigan after nearly being eradicated


Detroit — Back from the brink of eradication, syphilis is spiking in Michigan, prompting alarm within the medical community.

Mirroring national patterns, the number of syphilis cases doubled in Michigan between 2017 and 2022, according to the Michigan Department of Health and Human Services. In Detroit alone, which has the highest number of cases in the state, cases nearly tripled during the same period.

Experts pointed to a number of factors for the increase, especially in babies being born with syphilis infections: insufficient prenatal health care, lack of testing and education, public health dollars shifted away from sexually transmitted infections testing to COVID-19 during the pandemic, and a shortage of a type of antibiotic that treats syphilis. The epidemiology of infections also has changed, they say.

“It really looked like for a while that we had beaten syphilis, and syphilis was no longer an issue,” said Natasha Bagdasarian, Michigan’s chief medical executive. “And then we started to see this resurgence you can see just in the last few years.”

State and local health officials are working to boost testing, raise awareness and reduce the stigma associated with seeking treatment. In Detroit, the city’s health department is trying to step up awareness and testing for syphilis, not just among residents but health care providers who might not be testing for it.

The Detroit department received a grant from the National Association of County and City Health Officials to combat rising syphilis rates, said Claudia Weaver Richardson, an obstetrician and medical director of the department. It plans to continue efforts to educate providers and start a listening campaign. Richardson said they want to do more to boost awareness, even among health care providers.

“We want to hear (from) women in high-risk groups about their lives and about risk, barriers and opportunities for syphilis testing in their communities,” Richardson said. “We also want to survey our providers as well, and with that, we want to understand, are they testing for syphilis? And if they’re not, what are their reasons for not testing for syphilis?”

While the disease once mostly affected men with male sexual partners, experts said that’s changing. The proportion of primary and secondary cases in Michigan residents who report only heterosexual sex has more than doubled since 2013, increasing from 19% to 48% in 2022, according to the health department.

And as more women become infected, congenital syphilis cases or those transmitted from mother to infant, are also on the rise. Michigan experienced 37 cases of this in 2022 and 42 in 2021, and the numbers have been trending up since 2009 when there were four reported cases.

“It is happening in our backyards,” Bagdasarian said. “And each case of congenital syphilis is a failure.”

By the numbers

In 2022, 207,255 cases of syphilis were reported nationwide, the greatest number since 1950, according to the Centers for Disease Control and Prevention. This is an explosion of cases compared with 2000, when 5,979 cases of primary and secondary syphilis were reported in the U.S., 288 of which were in Wayne County, according to the CDC.

The number of syphilis cases in the U.S. had reached a low point by the late 1990s and early 2000s, said Nicholas Yared, an infectious disease physician with Henry Ford Health.

As is the case with other sexually transmitted infections, or STIs, syphilis still disproportionately affects men with male sexual partners and both men and women of color, said Shira Heisler, medical director of the Detroit Public Health STD Clinic, where anybody can receive testing for syphilis, HIV, chlamydia, gonorrhea and Hepatitis C, regardless of health insurance status.

Syphilis is a highly contagious sexually transmitted disease that is spread through unprotected sex. Its symptoms mimic those of other diseases, leading to its nickname as the “great imitator.” Without treatment, it can linger in an individual’s system for years and, in rare instances, can damage organs or lead to death.

In 2022, there were 972 diagnoses of primary and secondary syphilis in Michigan, 313 of which were in Detroit, according to the state health department. Five years prior, in 2017, there were 480 cases in Michigan and 108 in Detroit alone, the health department reported. In 2012, there were 295 new cases statewide, 123 of which were in Detroit proper.

In Michigan, men make up a majority of all syphilis cases at 79%, but Black men have a 10.2 times higher rate of diagnosis than White men, according to the state health department. Gay and bisexual men also still make up the largest percentage of all primary and secondary syphilis cases in Michigan at 39%, despite being roughly 6% of the general population, according to the health department.

“This is a really big indicator that we are doing something wrong, this is not a biological or physiological thing,” Heisler said.

She blamed a stigma and other factors such as public policy as contributing to this situation.

Lack of prenatal care is a common barrier to syphilis treatment, and 69% of the 37 cases of congenital syphilis in 2022 reported either no or inadequate access to prenatal care, according to the state health department.

Pregnant people with untreated syphilis are at risk for stillbirths or having their children die shortly after childbirth, according to the CDC. Live babies born with syphilis who don’t receive treatment immediately may have developmental delays, seizures or die. But treatment with penicillin can prevent congenital syphilis 98% of the time, according to the CDC.

“We can treat it, and we can prevent the transmission to the baby,” Heisler said, adding that it’s “the one thing that’s hopeful in the syphilis epidemic.”

Treatment options

For patients infected with syphilis, the bacterial infection is treatable and curable without permanent damage if caught in time. Penicillin, which was first invented in 1928, is the silver bullet for treating syphilis. Doxycycline, first produced in the 1960s, can also work in earlier cases.

One new drug, Doxy-PEP, has also demonstrated substantial benefits in reducing not just syphilis infections but chlamydia and gonorrhea when taken after someone has been exposed, according to the CDC. The drug is most effective in men and transgender women who have sex with men, said Heisler with the Detroit Public Health STD Clinic, which was the first in Michigan to offer Doxy-PEP.

“We now have a preventative intervention to curb syphilis in the group it’s predominately affecting,” Heisler said.

Stages of infection

Syphilis infection has three main stages. The primary stage is characterized by sores at the location where syphilis enters the body, according to the CDC. They typically heal within three to six weeks, regardless of receiving treatment.

“The first stage, usually in the majority of people, they’ll get actually a painless lesion that will develop typically in the genital region or along the mouth, and that occurs within a couple of weeks after exposure,” Henry Ford Health’s Yared said.

If a person does not receive treatment, the infection progresses to the secondary stage, when skin rashes and mucous membrane lesions emerge, according to the CDC. People may also experience fevers, swollen lymph nodes, a sore throat, patchy hair loss, headaches, weight loss, muscle aches and fatigue.

“In the secondary stage, the symptoms vary, but the most classic ones include people developing a rash,” Yared said.

The latent stage is when a person shows no physical signs or symptoms of syphilis but can still transmit it. This stage can last for years, according to the CDC.

At any infection stage, syphilis can affect the nervous system, visual system and auditory system. Symptoms include changes in mental status, blindness and hearing loss, which can be permanent.

“I think what’s challenging is there’s sort of this myriad symptoms, there’s these different stages,” Yared said. “It can be hard to diagnose if you’re not thinking about it.”

Epidemiologic change

The CDC credited several strategies during the 1990s with lowering rates of syphilis, including better community awareness, expanded surveillance, faster screening in and out of medical settings, and expanded laboratory services.

As it became a less common condition, people became less and less aware of what to look out for in themselves and sexual partners, Yared added.

Cases started to increase significantly in 2017 and 2018 because there was a change in the epidemiology of the infection, Michigan’s chief medical executive Bagdasarian said. While syphilis used to predominantly circulate in communities of gay and bisexual men, cases in heterosexual men followed by heterosexual women started to rise around this time, she said.

“The way that public health has been underfunded and sort of under-resourced for many, many decades — it really meant that public health (officials) could only put their attention on the most critical issues,” Bagdasarian said. “For decades, there was a lot of outreach and a lot of resources going into the MSM (men who have sex with men) community because we had to sort of prioritize.”

As cases rose in heterosexual communities, it became harder for public health officials to engage with new populations who may not have known they were at risk, Bagdasarian said. Then COVID-19 hit, which drew already limited public health resources away from testing for sexually transmitted infections.

“That took a lot of our resources away,” Bagdasarian said.

Increasing education

While most syphilis cases are relatively simple to treat, not all affected communities have access to health care, particularly prenatal care, Michigan’s chief medical executive said.

“There is a huge racial and ethnic disparity, and when we look at who’s being impacted by syphilis, we’re seeing that this is predominantly happening in African American communities,” Bagdasarian said. “We’re doing a lot of outreach and education to health care providers about the importance of syphilis testing and treatment.”

The state health department now is working with emergency departments to see how to increase testing for syphilis, she said. If pregnant mothers don’t have regular prenatal care, they might go to an emergency department for other reasons, she said.

“If you treat a pregnant woman with penicillin, which is our oldest antibiotic and one of our cheapest antibiotics, you can prevent congenital syphilis,” Bagdasarian said.

“The vast majority of OB/GYNs, they know that they should be testing for syphilis, and they know how to treat for syphilis,” she added.

But the 37 Michigan cases of congenital syphilis in 2022 reflect mothers who didn’t have sufficient prenatal care and “slipped through the cracks,” Bagdasarian said.

In Detroit, the city’s health department’s HIV/STI Prevention Division is doing a lot of community education and outreach events surrounding multiple STIs, not just syphilis, and distributing condoms in high-risk populations, Richardson said.

The city has also started a physician detailing program. Health department education professionals are sent directly to providers’ offices to offer education on syphilis testing and referrals, urging them to do testing.

“We’re getting to areas such as urgent care centers where many people just go when they have a problem,” Richardson said, adding that providers often may not consider testing for syphilis when case numbers aren’t high.

The Detroit STD Clinic’s Heisler said she lectures primary care providers and urgent care centers about symptoms to watch for and the need for testing and treatment.

“So much of STDs are diagnosed outside of an STD clinic, and so that’s kind of where the issue is coming (from),” Heisler said.

Removing stigma

Removing the stigma associated with STIs and increasing education, especially in populations now more affected by syphilis, also is crucial, experts agreed. Henry Ford Health’s Yared suggested putting more resources into syphilis prevention messaging and starting educational efforts earlier for high school and college-age students.

Increasing testing, particularly point-of-care testing that is done at the same time and place as patient care, is also key so fewer patients are lost to follow-up, Bagdasarian said.

“I say if anybody’s having sex, please order routine STI testing even if they’re monogamous. You have no idea what their partner’s doing,” Heisler agreed. “This is a way to stay healthy. … Just get routine testing, which includes HIV and syphilis.”

To that end, the Detroit Health Department offers syphilis testing at its I Decide Reproductive Health Care clinic and has partnered with local pharmacies, Richardson said. When a test comes back positive, patients can be referred to a medical provider for follow-up services, she said.

Even after an infection is identified, medical experts sometimes face challenges. Due to high demand, the Food and Drug Administration in April reported a shortage in bicillin, also known as penicillin G, the antibiotic most commonly used to treat syphilis.

“We have been working really closely with federal partners to make sure we have enough bicillin to make sure we have it at enough locations around the state so that anyone who needs it can access it,” Bagdasarian said.

Last month the FDA approved the temporary importation of Extencilline, a bicillin equivalent distributed in other countries, to help dampen the shortage.

“When those sorts of barriers come up or challenges (bicillin shortage), we hope that our physician detailing health educators can support them in connecting them to resources to help manage those barriers,” Richardson said.



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