Transcript Why Is Syphilis Important? Tammy Foskey, MA Manager, STD/HIV Public Health Follow-Up Team [email protected] (512) 533-3020

Why Is Syphilis Important?
Tammy Foskey, MA
Manager, STD/HIV Public Health Follow-Up Team
[email protected]
(512) 533-3020
Syphilis Is:
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A Bacterial Infection that can be
chronic and systemic
Infectious During Specific Time
Frames related to Stage
Sexually Transmitted (oral, vaginal,
anal)
Curable
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Many persons (including physicians) are
unaware that we are currently seeing an
increase in the number of syphilis infections
Syphilis can increase the risk for
transmission of HIV (if co-infected) by 3-5x
Having HIV can make someone more
susceptible to an infection with syphilis, if
exposed
Syphilis increases HIV viral load and
decreases CD4 cell counts in HIV-infected
persons with new syphilis infections
Syphilis
Syphilis is sometimes called:
 “bad blood”,
 pox, or
 a “zipper cut”
Epidemiology of Syphilis
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In the 1940s: Syphilis was distributed widely
throughout the U.S.
1986-90: 85% increase in the incidence of
primary and secondary syphilis –Why?
After 1990, reported cases of syphilis
decreased approximately 15% per year to
an all-time low in 2000
Epidemiology of Syphilis
(continued)
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Late 1990s: syphilis elimination a feasible
goal
Rates remain high in:
– Some urban areas throughout the U.S.;
– Rural areas in the South;
– Some minority populations who suffer
from poverty, lack of access to health
care, and breakdown of stable
community and personal relationships.
Recent outbreaks have been associated in
men who have sex with men (MSM)
Syphilis –
Treponema pallidum
Syphilis –
Treponema pallidum
on darkfield examination
How is Syphilis Transmitted?
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Sexual contact with infectious lesion
In utero and intrapartum
Sharing needles (extremely rare)
So what Does Syphilis
Look Like?
Syphilis has Several Stages
with different signs/symptoms
Incubation Stage
10 - 90 Days
Average 21 Days
Not infectious to others during this stage
No signs/symptoms are present
Blood tests are negative
Common Symptoms of Syphilis
Primary Stage
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Occurs in males and females
A painless sore called a chancre develops
where the spirochete entered the body
The sore may be located on the genitals, lips,
anus, or other area of direct contact
The chancre will last 1-5 weeks (on average 3
weeks) and heal without treatment
The person can transmit the infection very
easily during this stage
Clinical ManifestationsPrimary Syphilis
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Chancre
– Clean based, painless, indurated ulcer with
smooth firm borders
– Unnoticed in 15-30% of patients often
because of the location and because it is
painless
– Resolves in 1-5 weeks
– HIGHLY INFECTIOUS
Blood tests may not show infection for up to
7 days after the chancre develops
Primary syphilis-chancre
Primary Syphilis- chancre
Source: Florida STD/HIV Prevention Training Center
Primary syphilis - chancre
Primary syphilis - chancre
Primary syphilis –
chancre of anus
Primary syphilis - chancre
Syphilis
Early Latency Stage
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Lasts 0 - 10 weeks (average 4 weeks)
No symptoms are present, not infectious
Happens between primary and secondary
stages
2/3 of persons will have some period of
latency between primary and secondary
stages
Blood tests are positive
– VDRL or RPR
– TPPA or FTA-ABS
Common Symptoms of Syphilis
Secondary Stage
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May include skin rashes, fever, swollen lymph
glands, headache, hair loss, and muscle ache
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The skin rash may be on the palms of hands,
bottoms of the feet, or any part of the body
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The rash may last 2-6 weeks (average of 4
weeks); it will heal without treatment
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The person may be infectious (C. Lata and/or
Mucous Patches)
Secondary Syphilis
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Diagnosed by
– Symptoms
– RPR or VDRL
– FTA-ABS or TPPA
– Darkfield examination (of C. lata)
Secondary Syphilis:
Papulosquamous Body Rash
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
Secondary Syphilis:
Generalized Body Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Secondary syphilis
Secondary Syphilis: Rash
Source: Cincinnati STD/HIV Prevention Training Center
Secondary syphilis
Secondary Syphilis:
Palmar Rash
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
Secondary Syphilis:
Plantar Rash
Source: Florida STD/HIV Prevention Training Center
Secondary Syphilis
Source: Florida STD/HIV Prevention Training Center
Secondary Syphilis:
Condylomata Lata
Source: Florida STD/HIV Prevention Training Center
Secondary Syphilis:
Mucous Patches
Secondary syphilis:
alopecia
Secondary syphilis:
papulo-pustular rash
Primary and Secondary Syphilis
Disease Process
Incubation
10-90 days
Avg: 21 days
Primary Syphilis
Lasts 1 – 5 weeks
Average: 3 weeks
Date of inoculation
Early Latency
0 – 10 weeks
Avg: 4 weeks
Secondary Syphilis:
Lasts 2-6 weeks
Average: 4 weeks
Most will have a period of latency
between primary and secondary.
If not, overlap could be 2-3 days
Neuro-Syphilis
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Can occur any time after initial infection
May occur more commonly early in the course of
infection (secondary or latent) when someone is
co-infected with HIV
Associated with neurologic symptoms including:
– Vision changes or eye pain
– Hearing loss
– Headaches/dizziness
– Generalized weakness
– Seizures
– Confusion
– Changes in personality or affect
Neurosyphilis:
spirochetes in neural tissue
Congenital Syphilis
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Syphilis that is transmitted during
pregnancy (or at time of delivery)
Often the mother has received no or
inadequate prenatal care
Syphilis in Pregnancy
can Cause:
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Preterm delivery
Stillbirth
Congenital infections
Neonatal death
Kassowitz Law
The longer the duration of untreated
syphilis, prior to pregnancy,
the less likely the fetus will be infected
or stillborn.
Maternal Transmission
of Syphilis
Infants
born to
untreated
syphilis
mothers
26% remain free of disease
or revert to sero-negative
25% remain sero-positive
but not clinically affected
49% display
symptoms of
syphilis
40% risk
for infant
death
A routine blood test for
syphilis protects the
pregnant mother and
her baby.
Texas Congenital Syphilis Cases by Year,
2000-2008
Congenital Cases
Congenital Cases
Female P&S Rate
120
3.5
100
3
2.5
80
2
60
1.5
40
1
20
0.5
0
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
Female P&S Rates
4
140
Texas Congenital Syphilis Cases by Year of
Report and County, 2002-2008
140
Harris
Dallas
Other Counties
120
Cases
100
80
60
40
20
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
Texas Congenital Syphilis Cases by Year of
Report and Race, 2002-2008
140
120
Hispanic
African American
White
Oth/Unk
Cases
100
80
60
40
20
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
Syphilis
Treatment in Pregnancy
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Screen for syphilis at first prenatal visit; repeat RPR
at 28 and 32 weeks’ gestation and at time of delivery
for those at high risk or high prevalence areas
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Treat for the appropriate stage of syphilis
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Some experts recommend additional Benzathine
penicillin G 2.4 mu IM after the initial dose for
primary, secondary, or early latent syphilis
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Management and counseling may be facilitated by
sonographic fetal evaluation for congenital syphilis
in the second half of pregnancy
State Statistics
Primary and Secondary Syphilis Cases by
Year of Report - Texas, 1971-2008
7,000
6,000
Cases
5,000
4,000
3,000
2,000
1,000
0
71
73
75
77
79
81
83
85
87
89
91
Year
93
95
97
99
01
03
05
07
Primary and Secondary Syphilis Cases by Year of
Report - Texas, 1998-2008
1,600
1,400
1,200
Cases
1,000
800
600
400
200
0
1998
1999
2000
2001
2002
2003
Year
2004
2005
2006
2007
2008
P&S Syphilis Case Rates by Year of Report and
Race/Ethnicity - Texas, 1998-2008
35
Cases per 100,000
30
White
Af. American
Hispanic
25
20
15
10
5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Primary and Secondary Syphilis Case Rates by
Age Group - Texas, 2008
18
Cases per 100,000
16
14
12
10
8
6
4
2
0
10-14
15-19
20-24
25-29
30-34
Age Group
35-39
40-44
45+
P&S Syphilis Case Rates by Year of Report and Sex Texas, 1998-2007
9
Cases per 100,000
8
Male
7
6
5
4
3
Female
2
1
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
MSM P&S Syphilis by Year of Report - Texas,
2000-2008
1,600
1,400
MSM P&S
Male P&S
Female P&S
1,200
Cases
1,000
800
600
400
200
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
HIV-Positive P&S Syphilis by Year of Report Texas, 2000-2007
450
HIV-Positive P&S Cases
400
350
300
250
200
150
100
50
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
P&S Syphilis Cases by Surveillance Site,
2000, 2007, 2008
500
2000
2007
2008
450
400
Cases
350
300
250
200
150
100
50
0
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STD Program
P&S Syphilis Cases by Surveillance Site,
2000, 2007, 2008
60
2000
2007
2008
50
Cases
40
30
20
10
0
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11
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7
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10
P&S Syphilis Case Rates by County Texas, 2008
Rates
0.0 Cases/100,000
0.1 to 3.9 Cases/100,000
4.0 to 9.9 Cases/100,000
10 or More Cases/100,000
2009 Year-to-Date Syphilis
P&S Cases
TEXAS TOTAL
2008
2009
# Increase
% Increase
374
401
27
7%
DALLAS
52
78
26
50%
TARRANT
21
41
20
95%
BEXAR
52
66
14
27%
JEFFERSON
34
42
8
24%
FORT BEND
4
10
6
150%
480
694
214
45%
DALLAS
94
163
69
73%
BEXAR
49
76
27
55%
HARRIS
143
169
26
18%
17
32
15
88%
1
13
12
1200%
31
43
12
39%
Early Latent Cases
TEXAS TOTAL
JEFFERSON
MONTGOMERY
TRAVIS
National Statistics
Primary and secondary syphilis —
Rates: Total and by sex
United States, 1988–2007 and
the Healthy People 2010 target
Rate (per 100,000 population)
25
Male
Female
Total
2010 Target
20
15
10
5
0
1988
90
92
94
96
98
2000
02
04
Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000
population.
06
Primary and secondary syphilis —
Rates by state:
United States and outlying areas, 2007
2 .4
0 .8
0 .7
0 .2
0 .5
1 .1
0 .1
1 .2
0 .9
0 .8
0 .2
4 .4
0 .7
0 .8
5 .6
1 .2
5 .5
1 .2
2 .1
3 .6
1 .0
1 .7
0 .9
0 .3 3 .0
4 .1
2 .4
1 .8
3 .6
6 .1
4 .3
2 .1
4 .6
8 .3
R ate per 100,000
population
7 .3
4 .9
1 2 .4
1 .0
0 .7
1.6
2.3
2.4
3.4
1.1
2.6
2.1
6.1
30.6
1 .3
Gu a m 4 .7
4 .8
VT
NH
MA
RI
CT
NJ
DE
MD
DC
5 .0
<=0.2
(n= 4)
0.21-2.2
(n= 24)
>2.2
(n= 26)
Pu e rto Ri c o 4 .3
Vi rg i n Is . 0 .0
Note: The total rate of P&S syphilis for the United States and outlying areas
(Guam, Puerto Rico and Virgin Islands) was 3.8 per 100,000 population. The
Healthy People 2010 target is 0.2 case per 100,000 population.
Primary and secondary syphilis —
Reported cases by reporting source:
United States, 1984–2004
Cases (in thousands)
50
non-STD Clinic
STD Clinic
40
30
20
10
0
1984
86
88
90
92
94
96
98
2001
02
Note: Prior to 1996, the STD clinic source of report corresponded to public (clinic)
source of report, and the non-STD clinic category corresponded to private source
of report. After 1996, as states began reporting morbidity data electronically, the
specific source of report (i.e., STD clinic) began to be reported from an increasing
number of states.
04
Primary and secondary syphilis —
Cases by reporting source and sex:
United States, 1997–2006
Cases (in thousands)
8.0
non-STD Clinic Male
non-STD Clinic Female
STD Clinic Male
STD Clinic Female
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1997
98
99
2000
01
02
03
04
05
06
Testing and Treatment
Syphilis Testing
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Non-Treponemal
– RPR
– VDRL
Results quantitative
Highly sensitive
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Treponemal
– Darkfield
– TPPA
– FTA-ABS
Results qualitative
Highly specific
Once reactive, remains
reactive for life
One test alone is not sufficient for the diagnosis
of syphilis except for the Darkfield!
RPR Card
Range from 1:1 to 1:512
1:1
1:2
1:4
1:8
1:16
1:32
1:64
1:128
1:256
1:512
Penicillin
The drug of choice since 1943
Benzathine Penicillin G-LA
2.4mu given as 1.2mu/dose intramuscularly
Infection with syphilis under 1 year, 1x
Infection with syphilis (unknown duration or longer
than 1 year), 3x (1x/week for three weeks)
Clinical and Serologic
Follow-Up
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All HIV-infected patients treated for syphilis
should be evaluated clinically and
serologically at 3, 6, 9, 12, and 24 months to
rule out treatment failure
Treatment success is determined by a fourfold decrease in titer by 6-12 months (early)
or 12-24 months (late) after treatment
Lumbar puncture/CSF testing may be
necessary if treatment failure is suspected
Syphilis
Management of Sex Partners
All sex partners should be treated. For identification of
at-risk partners, the time periods are:
3 months plus duration of symptoms –primary
6 months plus duration of symptoms –secondary
1 year for early latent syphilis
Treat if testing is unavailable
So What Can You Do?
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Talk with all clients about the risk for STDs if
they are having sex
Talk with clients about use of recreational
drugs (meth and cocaine especially)
Encourage clients to be tested for STDs
regularly (every 3-6 months)
Develop a relationship with your local
Disease Intervention Specialist (DIS) to
assist you and your client with confidential
notification of partner(s)
So What Can You Do?
(cont’d)
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Ask about new partners often, so it
becomes “normal” and comfortable for
you and your clients
Refer to local/regional health
department if new partners could be at
risk for HIV and/or syphilis or other
STDs
So What Can You Do?
(cont’d)
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If you have clients that are female and are
pregnant or planning to become pregnant:
Be sure she is receiving regular pre-natal
care
– She should be tested at her first prenatal
visit
– Strongly recommend re-testing during 3rd
trimester (especially in areas of the state
where there are high rates of syphilis)
– She will also be tested at time of delivery
So What Can You Do?
(cont’d)

Make referrals when appropriate to other
community interventions and/or services
including:
– Comprehensive Risk Counseling Services
(CRCS)
– Group and Community Level Interventions,
i.e.
WiLLOW
Mpowerment
SISTA
Healthy Relationships
– Mental Health Referral
– Substance Abuse Treatment
References
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www.cdc.gov/std/syphilis
http://aids-clinical-care.jwatch.org/cgi/content/full/2003/201/1
– HIV and Syphilis Co-infection: Trends and Interactions
http://www.hivandhepatitis.com/recent/std/101504_b.html
– Syphilis Increases HIV Viral Load and Decreases CD4
Cell Counts
http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04
– Syphilis and HIV