The Resurgence of Syphilis

Objectives

• Describe the pathophysiology, stages, and incidence of syphilis
• Define treatment interventions applicable to EMS providers
• Present a case for precautions and screening procedures for disease prevention

Syphilis case numbers have been increasing in the United States for several years. In 2017 there were more than 27,000 cases reported, an all-time high. Now stronger action is being undertaken to address this issue. 

The CDC’s Division of Sexually Transmitted Disease (STD) Prevention first published a national plan to eliminate syphilis in the United States in October 1999. The plan’s goal was to increase the number of syphilis-free American counties to 90% by 2005. This goal was not met, and cases have continued to increase since. For example, during 2015–2016, the national syphilis rate increased by 17.6% to its highest reported rate since 1993. This prompts questions about what was in the original plan and why it failed. 

The plan published in 1999 stated that for it to be successful, there needed to be a commitment and investment on the part of program managers at the local, state, and national levels. Many states responded by developing written plans to eliminate syphilis cases. However, it does not appear these plans were put into action. Testing was limited to hepatitis B, hepatitis C, and HIV as part of routine postexposure guidelines from CDC and OSHA bloodborne pathogens regulations. States published plans but never disseminated any notification to medical practitioners. 

Budget cuts to programs have also been a factor. One report from North Carolina noted, “In 2003, at the highest point of federal funding support, Forsyth County reported 1 case of syphilis. Numbers remained low in Forsyth County over the following several years but, after the money all but dried up, came roaring back in 2009 with 195 cases and a case rate of 34.3 per 100,000. These numbers are even higher than at the start of the syphilis elimination effort.”

An important fact to remember: Syphilis is a disease that is preventable and easy to cure with penicillin. Additionally, it is a disease of the underserved and disadvantaged in the United States, with rates among African-Americans, Latinos, and native Hawaiians/Pacific Islanders all more than double those of white Americans.  

The CDC issued a new call to action in April 2017 that called for increased surveillance, data collection, and community involvement. This plan came about following a noted increase of cases since 2000. Rates of syphilis have been increasing in men, women, and once again in newborns (congenital syphilis). Rates increased by 19% in 2014 and 2015, with a similar increase noted in just the first six months of 2016. During 2012–2016, the syphilis rate increased among all race/ethnicity groups. Pregnant women and men who have sex with men (MSM) have been identified as two of the highest-risk populations that should be targeted for screening. 

The Disease: A Review

Syphilis is caused by the bacterium Treponema pallidum. This is a sexually transmitted disease that can present in four stages if not treated. Transmission is by direct contact with a syphilitic sore on the skin (chancre) or in the mucous membranes. Syphilis is most likely transmitted during oral, anal, and vaginal sexual activity. It can also be passed from mother to fetus during pregnancy or to an infant during delivery. Transmission from mother to child in utero can result in fetal demise.

This disease has four stages: primary, secondary, latent, and tertiary. 

During the primary stage there will be one or several painless, firm, round sores termed chancres. These appear about three weeks after exposure. Chancres disappear within 3–6 weeks, but without treatment the disease may progress to the secondary phase. Syphilis can appear to be very similar to HIV infection. Also, it occurs far more frequently in HIV-infected individuals. 

In the secondary stage the following may occur: a non-itchy rash that is rough, red or reddish-brown in color, that starts on the trunk and spreads to the entire body, including the palms of the hands and soles of the feet; oral, anal, and genital wartlike sores; muscle aches; fever; sore throat; swollen lymph nodes; patchy hair loss; fatigue; weight loss; and headaches. If this is not recognized or treated, there may be progression to latent or tertiary stages.

The third or latent stage presents with no outward symptoms and can last for years before progressing to the tertiary stage. During this stage, which can occur 10–30 years after onset of the infection (normally after a period of latency), there are no symptoms. The CDC says treatment should be offered even without symptoms. 

During the tertiary stage the disease presents with damage to the heart, blood vessels, liver, bones, and joints, soft tissue swellings that can occur anywhere on the body, and organ damage. 

Another stage that may occur is neurosyphilis, a condition in which the bacteria spreads to the nervous system. A rare form of neurosyphilis, tabes dorsalis, presents with dementia or altered mental status, an abnormal gait, numbness in the extremities, headache or seizures, and vision problems or loss. The incidence of tabes dorsalis is rising, in part due to coinfection with HIV. This disease can be fatal in some untreated individuals; the treatment is IV penicillin.

Congenital Syphilis

Cases of congenital syphilis are also increasing. In 2016 there were a total of 628 reported cases, including 41 syphilitic stillbirths. This number represents a 27.6% increase in one year. Infected mothers transfer syphilis to their fetuses. All pregnant women are tested for syphilis as part of standard prenatal care; however, access to complete prenatal care can be a challenge for some. 

Symptoms that may suggest congenital syphilis are divided into early signs (first two years of life) and late signs (onset after the second year of life). About two-thirds of infants with congenital syphilis are asymptomatic at birth. Patient assessment should include asking whether the patient has been receiving prenatal care and whether there has ever been a history of STD. Symptoms, if present, may include rash, jaundice, and hepatosplenomegaly.

Currently there is no test available to screen babies at birth. A baby who is suspect for congenital syphilis will require hospital admission and treatment with IV penicillin G.

Treatment

With early diagnosis, syphilis is an easily treatable disease. Treatment involves a single intramuscular injection of long-acting benzathine penicillin. The dose is 2.4 million units. Treatment results in a cure for this disease for persons in the primary, secondary, and early latent stages.

For persons with latent syphilis, three injections are administered at weekly intervals. Persons with penicillin allergy may receive doxycycline or tetracycline, and infants and children who have a history of penicillin allergy should be desensitized to allow for treatment with penicillin. 

Implications for Providers

It is important for prehospital providers to be aware of the signs and symptoms of syphilis. It is also beneficial to be aware of the case rate in your area and state. Identification in the field as part of physical assessment will assist in bringing attention to this disease and encourage testing.

Education and training on syphilis is a training requirement in the OSHA bloodborne pathogens standard, 29 CFR 1910.1030, and its companion document, Compliance Directive CPL 02-02.069. OSHA recognizes syphilis as a possible occupational health risk.

Ask pregnant women whether they’ve had prenatal care, whether it was complete, and whether any abnormal test results were found.

Risk for occupational exposure to syphilis would be related primarily to injury with a contaminated needle. It has long been recommended by the CDC that persons who test positive for HIV be tested for syphilis, as there is often coinfection. Thus, testing for syphilis should be a part of postexposure testing in cases where the source is positive for HIV infection. 

A call for routine universal testing for syphilis was published in the CDC STD guidelines updated in the fall of 2015. The guidelines include the following: 1) universal screening and evaluation of serologic and behavioral data from high-risk populations; 2) annual testing for hepatitis C in persons with HIV infection; 3) correctional facilities staying apprised of syphilis prevalence as it changes over time; and 4) routine testing for pregnant women.

In addition, the U.S. Preventive Services Task Force states that all nonpregnant adults and adolescents at increased risk for contracting syphilis should be routinely screened for infection. High-risk population groups include men who have sex with men, sex workers, HIV-positive persons, inmates, persons who inject drugs, the economically disadvantaged, and senior community members. 

It is clear that a disease such as syphilis cannot be eliminated without screening, testing, treatment, and follow-up with the sexual partners of persons found to be infected. This will take an effort on the part of all healthcare workers. Perhaps this begins with bringing about awareness of this disease and the case numbers in this country. EMS personnel can assist and raise awareness of this critical issue. 

Resources

Avert. Syphilis Symptoms & Treatment, https://www.avert.org/sex-stis/sexually-transmitted-infections/syphilis. 

Bowen V, Su J, Torrone E, Kidd S, Weinstock H. Increase in Incidence of Congenital Syphilis—United States, 2012–2014. MMWR, 2015 Nov 13; 64(44): 1,241–5. 

Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines, https://www.cdc.gov/std/tg2015/default.htm. 

Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Congenital Syphilis, https://www.cdc.gov/std/tg2015/congenital.htm. 

Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Management of Persons Who Have a History of Penicillin Allergy, https://www.cdc.gov/std/tg2015/pen-allergy.htm. 

Centers for Disease Control and Prevention. 2016 Sexually Transmitted Diseases Surveillance, https://www.cdc.gov/std/stats16/default.htm. 

Centers for Disease Control and Prevention. CDC Call to Action: Let’s Work Together to Stem the Tide of Rising Syphilis in the United States, https://www.cdc.gov/std/syphilis/syphiliscalltoactionapril2017.pdf. 

Centers for Disease Control and Prevention. National Plan to Eliminate Syphilis From the United States, https://www.cdc.gov/stopsyphilis/plan.htm. 

Hess KL, Fisher DG, Reynolds GL. Sensitivity and specificity of point-of-care rapid combination syphilis-HIV-HCV tests. PLoS One, 2014 Nov 6; 9(11): e112190. 

Lab Tests Online/AACC. Rapid Screening Test for Syphilis Gets Waiver for Wider Use, https://labtestsonline.org/news/150130syphilis. 

MedlinePlus. Congenital syphilis, https://medlineplus.gov/ency/article/001344.htm. 

National Institute of Neurological Disorders and Stroke. Tabes Dorsalis Information Page, https://www.ninds.nih.gov/Disorders/All-Disorders/Tabes-Dorsalis-Information-Page. 

Peterman TA, Fakile YF. What is the use of rapid syphilis tests in the United States? Sex Transm Dis, 2016 Mar; 43(3): 201–3. 

Tinajeros F, Grossman D, Richmond K, et al. Diagnostic accuracy of a point-of-care syphilis test when used among pregnant women in Bolivia. Sex Transm Infect, 2006 Dec; 82 Suppl 5: v17–21. 

Zetola NM, Klausner JD. Syphilis and HIV infection: An update. Clin Infect Dis, 2007 May 1; 44(9): 1,222–8. 

Sidebar: Syphilis Testing

There are now two rapid tests for syphilis that take 10–15 minutes and can performed by finger-stick. One test is Syphilis Health Check (from Trinity Biocheck); the other is Determine (from Alere). Both tests are CLIA (Clinical Laboratory Improvement Amendments)-waivered, which means they can be performed in diverse healthcare settings. However, these tests would generally not be performed in the emergent setting when an exposure might have occurred. They screen for an antibody, and if positive, confirmatory testing is performed. Additional tests are under development that will combine HIV, HCV, and syphilis testing in one rapid test that could be point-of-care, allowing for increased screening and diagnosis, treatment initiation, and timely referrals to improve outcomes.

This CE activity is approved by EMS World, an organization accredited by the Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE), for 0.5 CEU upon successful completion of the post-test available at EMSWorldCE.com. Test costs $6.95. Questions? E-mail editor@EMSWorld.com.

Katherine West, RN, BSN, MSEd, is an infection-control consultant with Infection Control/Emerging Concepts in Clearwater, Fla., and a member of the EMS World editorial advisory board.