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

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Presentation on theme: "Why Is Syphilis Important? Tammy Foskey, MA Manager, STD/HIV Public Health Follow-Up Team (512) 533-3020"— Presentation transcript:

1 Why Is Syphilis Important? Tammy Foskey, MA Manager, STD/HIV Public Health Follow-Up Team tammy.foskey@dshs.state.tx.us (512) 533-3020 http://

2 Syphilis Is: A Bacterial Infection that can be chronic and systemic A Bacterial Infection that can be chronic and systemic Infectious During Specific Time Frames related to Stage Infectious During Specific Time Frames related to Stage Sexually Transmitted (oral, vaginal, anal) Sexually Transmitted (oral, vaginal, anal) Curable Curable

3 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

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5 Syphilis Syphilis is sometimes called: bad blood, bad blood, pox, or pox, or a zipper cut a zipper cut

6 Epidemiology of Syphilis In the 1940s: Syphilis was distributed widely throughout the U.S. In the 1940s: Syphilis was distributed widely throughout the U.S. 1986-90: 85% increase in the incidence of primary and secondary syphilis –Why? 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 After 1990, reported cases of syphilis decreased approximately 15% per year to an all-time low in 2000

7 Epidemiology of Syphilis (continued) Late 1990s: syphilis elimination a feasible goal Late 1990s: syphilis elimination a feasible goal Rates remain high in: 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) Recent outbreaks have been associated in men who have sex with men (MSM)

8 Syphilis – Treponema pallidum

9 Syphilis – Treponema pallidum on darkfield examination

10 How is Syphilis Transmitted? Sexual contact with infectious lesion Sexual contact with infectious lesion In utero and intrapartum In utero and intrapartum Sharing needles (extremely rare) Sharing needles (extremely rare)

11 So what Does Syphilis Look Like?

12 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

13 Common Symptoms of Syphilis Primary Stage Occurs in males and females Occurs in males and females A painless sore called a chancre develops where the spirochete entered the body 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 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 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 The person can transmit the infection very easily during this stage

14 Clinical Manifestations- Primary Syphilis Chancre 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

15 Primary syphilis-chancre

16 Primary Syphilis- chancre Source: Florida STD/HIV Prevention Training Center

17 Primary syphilis - chancre

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19 Primary syphilis – chancre of anus Primary syphilis – chancre of anus

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21 Primary syphilis - chancre

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26 Syphilis Early Latency Stage Lasts 0 - 10 weeks (average 4 weeks) Lasts 0 - 10 weeks (average 4 weeks) No symptoms are present, not infectious No symptoms are present, not infectious Happens between primary and secondary stages Happens between primary and secondary stages 2/3 of persons will have some period of latency between primary and secondary stages 2/3 of persons will have some period of latency between primary and secondary stages Blood tests are positive Blood tests are positive –VDRL or RPR –TPPA or FTA-ABS

27 Common Symptoms of Syphilis Secondary Stage May include skin rashes, fever, swollen lymph glands, headache, hair loss, and muscle ache May include skin rashes, fever, swollen lymph glands, headache, hair loss, and muscle ache The skin rash may be on the palms of hands, bottoms of the feet, or any part of the body The skin rash may be on the palms of hands, bottoms of the feet, or any part of the body The rash may last 2-6 weeks (average of 4 weeks); it will heal without treatment The rash may last 2-6 weeks (average of 4 weeks); it will heal without treatment The person may be infectious (C. Lata and/or Mucous Patches) The person may be infectious (C. Lata and/or Mucous Patches)

28 Secondary Syphilis Diagnosed by Diagnosed by –Symptoms –RPR or VDRL –FTA-ABS or TPPA –Darkfield examination (of C. lata)

29 Secondary Syphilis: Papulosquamous Body Rash Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

30 Secondary Syphilis: Generalized Body Rash Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

31 Secondary syphilis

32 Secondary Syphilis: Rash Source: Cincinnati STD/HIV Prevention Training Center

33 Secondary syphilis

34 Secondary Syphilis: Palmar Rash Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

35 Secondary Syphilis: Plantar Rash Source: Florida STD/HIV Prevention Training Center

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37 Secondary Syphilis Source: Florida STD/HIV Prevention Training Center

38 Secondary Syphilis: Condylomata Lata Source: Florida STD/HIV Prevention Training Center

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41 Secondary Syphilis: Mucous Patches

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43 Secondary syphilis: alopecia

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45 Secondary syphilis: papulo-pustular rash Secondary syphilis: papulo-pustular rash

46 Primary and Secondary Syphilis Disease Process Date of inoculation Incubation 10-90 days Avg: 21 days Primary Syphilis Lasts 1 – 5 weeks Average: 3 weeks 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

47 Neuro-Syphilis Can occur any time after initial infection 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 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: Associated with neurologic symptoms including: –Vision changes or eye pain –Hearing loss –Headaches/dizziness –Generalized weakness –Seizures –Confusion –Changes in personality or affect

48 Neurosyphilis: spirochetes in neural tissue

49 Congenital Syphilis Syphilis that is transmitted during pregnancy (or at time of delivery) Syphilis that is transmitted during pregnancy (or at time of delivery) Often the mother has received no or inadequate prenatal care Often the mother has received no or inadequate prenatal care

50 Syphilis in Pregnancy can Cause: Preterm delivery Preterm delivery Stillbirth Stillbirth Congenital infections Congenital infections Neonatal death Neonatal death

51 Kassowitz Law The longer the duration of untreated syphilis, prior to pregnancy, the less likely the fetus will be infected or stillborn.

52 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 Maternal Transmission of Syphilis

53 A routine blood test for syphilis protects the pregnant mother and her baby.

54 Texas Congenital Syphilis Cases by Year, 2000-2008

55 Texas Congenital Syphilis Cases by Year of Report and County, 2002-2008

56 Texas Congenital Syphilis Cases by Year of Report and Race, 2002-2008

57 Syphilis Treatment in Pregnancy 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 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 Treat for the appropriate stage of syphilis Treat for the appropriate stage of syphilis Some experts recommend additional Benzathine penicillin G 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis Some experts recommend additional Benzathine penicillin G 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy

58 State Statistics

59 Primary and Secondary Syphilis Cases by Year of Report - Texas, 1971-2008

60 Primary and Secondary Syphilis Cases by Year of Report - Texas, 1998-2008

61 P&S Syphilis Case Rates by Year of Report and Race/Ethnicity - Texas, 1998-2008

62 Primary and Secondary Syphilis Case Rates by Age Group - Texas, 2008

63 P&S Syphilis Case Rates by Year of Report and Sex - Texas, 1998-2007 Female Male

64 MSM P&S Syphilis by Year of Report - Texas, 2000-2008

65 HIV-Positive P&S Syphilis by Year of Report - Texas, 2000-2007

66 P&S Syphilis Cases by Surveillance Site, 2000, 2007, 2008

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68 P&S Syphilis Case Rates by County - Texas, 2008

69 2009 Year-to-Date Syphilis P&S Cases P&S Cases 20082009 # Increase % Increase TEXAS TOTAL 374401277% DALLAS52782650% TARRANT21412095% BEXAR52661427% JEFFERSON3442824% FORT BEND 4106150% Early Latent Cases TEXAS TOTAL 48069421445% DALLAS941636973% BEXAR49762755% HARRIS1431692618% JEFFERSON17321588% MONTGOMERY113121200% TRAVIS31431239%

70 National Statistics

71 Primary and secondary syphilis Rates: Total and by sex United States, 1988–2007 and the Healthy People 2010 target Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population.

72 Primary and secondary syphilis Rates by state: United States and outlying areas, 2007 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.

73 Primary and secondary syphilis Reported cases by reporting source: United States, 1984–2004 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.

74 Primary and secondary syphilis Cases by reporting source and sex: United States, 1997–2006

75 Testing and Treatment

76 Syphilis Testing Treponemal Treponemal –Darkfield –TPPA –FTA-ABS Results qualitative Results qualitative Highly specific Highly specific Once reactive, remains reactive for life Once reactive, remains reactive for life l Non-Treponemal –RPR –VDRL l Results quantitative l Highly sensitive One test alone is not sufficient for the diagnosis of syphilis except for the Darkfield!

77 RPR Card Range from 1:1 to 1:512 1:1 1:2 1:41:8 1:16 1:32 1:64 1:128 1:256 1:512

78 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)

79 Clinical and Serologic Follow-Up 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 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 four- fold decrease in titer by 6-12 months (early) or 12-24 months (late) after treatment Treatment success is determined by a four- fold 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 Lumbar puncture/CSF testing may be necessary if treatment failure is suspected

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81 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

82 So What Can You Do? Talk with all clients about the risk for STDs if they are having sex 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) Talk with clients about use of recreational drugs (meth and cocaine especially) Encourage clients to be tested for STDs regularly (every 3-6 months) 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) Develop a relationship with your local Disease Intervention Specialist (DIS) to assist you and your client with confidential notification of partner(s)

83 So What Can You Do? (contd) Ask about new partners often, so it becomes normal and comfortable for you and your clients 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 Refer to local/regional health department if new partners could be at risk for HIV and/or syphilis or other STDs

84 So What Can You Do? (contd) If you have clients that are female and are pregnant or planning to become pregnant: Be sure she is receiving regular pre-natal care Be sure she is receiving regular pre-natal care –She should be tested at her first prenatal visit –Strongly recommend re-testing during 3 rd trimester (especially in areas of the state where there are high rates of syphilis) –She will also be tested at time of delivery

85 So What Can You Do? (contd) Make referrals when appropriate to other community interventions and/or services including: 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 SISTAHealthy Relationships –Mental Health Referral –Substance Abuse Treatment

86 References www.cdc.gov/std/syphilis www.cdc.gov/std/syphilis www.cdc.gov/std/syphilis http://aids-clinical-care.jwatch.org/cgi/content/full/2003/201/1 http://aids-clinical-care.jwatch.org/cgi/content/full/2003/201/1 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 http://www.hivandhepatitis.com/recent/std/101504_b.html 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 http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 –Syphilis and HIV


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