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July 18, 2008

Syphilis is back

City officials worry about a rise in the once almost-eradicated STD

Cleveland--Syphilis infections are on the rise, hitting gay and bisexual men especially hard, and the Cleveland Department of Public Health is trying to turn the tide before it reaches epidemic levels.

Health officials noticed an increase at the end of last year, but the scope of the rise only became clear months later: a three-fold jump in syphilis cases in Cuyahoga County.

From June 2006 to June 2007, Cuyahoga County saw only 26 cases of the sexually-transmitted infection, or 1.8 cases per 100,000. However, in the nine months following that, twice as many cases were reported to health workers--52 cases, or 5.1 per 100,000.

Men who have sex with men, some of whom identified as bisexual, comprised 60 percent of the cases. Of the cases spread through heterosexual contact, 90 percent were found in African Americans.

Nearly three-fifths of those reported cases were in Cleveland itself, the rest in the suburbs.

The levels are reminiscent of what was seen in the mid 1990s, when syphilis cases were declining from their highs in the 1980s.

“What we’re seeing now mirrors what we saw in 1997,” said biostatistician David Bruckman during a July 8 press conference.

Other city officials noted that during the 1980s, when syphilis infections were at epidemic levels, they were seeing as many as 150 cases per 100,000 residents. Those numbers were cut to 6 per 100,000 by the end of the 1990s and 1.8 a year ago. Now they’re back over 5.

According to the officials, who also included HIV/AIDS project coordinator David Merriman, disease intervention specialist Bruce Hagins, Health Commissioner Karen K. Butler and Cuyahoga County Health Commissioner Terry Allan, syphilis had almost been eradicated in Ohio before the turn of the millennium, but shifts in funding turned resources away from putting the final nail in the disease’s coffin.

Columbus infection rate is higher

While there was uniform concern over the increases in Cleveland, there was also a unanimous expression of relief that the situation in northeast Ohio was not as bad as central Ohio, where Columbus is apparently hit even harder.

In 2006, Columbus had 214 cases of syphilis, or 19.5 out of 100,000, and last year that dipped down to 194, or 17.7 out of 100,000.

Columbus, however, is primarily seeing increases in syphilis among gay and bisexual men, while the divergent populations in Cleveland offer even more cause for concern.

The syphilis outbreak is of major concern for some other reasons as well. Congenital syphilis, that is, passed from mother to unborn child, can cause severe birth defects. While that is not a primary issue among gay men, bisexual men and men who have sex with men but do not identify as gay may infect their female partners.

Syphilis is also one of the most easily transmitted STDs. That, combined with the difficulty in accurately diagnosing the illness, can lead to progression without treatment.

In its first active stage, which starts around 10 days, there is a lesion at the infection site. Lesions can be mistaken for cold sores or herpes, but they also might not be visible externally, which can be the case with transmission through vaginal or anal sex. The lesion lasts three to four weeks and then disappears.

Syphilis then goes into its first latency stage, which can last up to a month. Secondary syphilis symptoms then appear, which is a body rash that can resemble chicken pox but does not itch. The rash will also go away over time, but syphilis stays in the bloodstream and can damage other organs.

The disease is at its most infectious during the two years following transmission, and can be passed to a sexual partner even during a latency period.

For health officials, the most frustrating part of the rise in syphilis infections is the ease with which it can be treated. Within the first year, a megadose of penicillin or similar antibiotics will wipe the disease out, and since the drugs are almost invariably given in injection form, syphilis has developed no drug resistance.

Health care workers have always preferred the injections, since giving a course of antibiotic pills leaves open the possibility of patients not taking the full treatment. It is that lack of compliance that leads to drug-resistant ailments.

One of the factors that lead to this increase in infections is the same harm reduction strategy that was used to supplement the fight against HIV. Many people focused more on oral sex, since the chance of HIV transmission through blow jobs is much lower than through vaginal or anal sex. Youth also are less likely to identify oral sex as “real” sex.

Unfortunately, unlike HIV, syphilis is easily transmissible through oral sex, so medical professions recommend using condoms for it, too.

The officials also recommended having full STD screenings when getting an HIV test, which is recommended every six months to a year for sexually active adults. While blood work can be done in 24 hours if the doctor puts a rush order on it, syphilis, at least when it is not in a latency period, can often be diagnosed visually.

Cleveland and Cuyahoga County officials also pointed to the rise of internet “hook-ups” as a factor in the increase, especially among gay and bisexual men. Without much effort, a single individual can have multiple partners in a short length of time, which can also make it difficult to notify sexual liaisons of the need to get tested if one is diagnosed with syphilis.

Hagins said that the health department is trying to increase its outreach to websites to warn users of the risks and pass along prevention and treatment information.

Other steps being taken to combat the outbreak include routine syphilis testing coupled with the confidential HIV testing at Cleveland’s J. Glen Smith and Thomas McCafferty Health Centers, a redeployment of disease intervention specialists to focus on finding undiagnosed cases and a public awareness campaign targeting bars, clubs, community centers and other places where people meet, as well as outreach to medical professionals so they can increase their diligence in spotting the disease.




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