1. Non-Viral STD of Major significance
Part 2
Syphilis
In part two of our discussion of non-viral std’s of major significance, we will take a brief look at syphilis. At least, prior to HIV/AIDS, syphilis was certainly historically the most famous std. however, in modern day America syphilis is of relatively small importance. In terms of the number of people who become infected and the outcomes of the disease. None the less, it still remains a target of public health efforts and is sort of a sentinel disease, that is, an indicator of sexual health and problems related to std’s.

2. Syphilis Etiology Treponema Palladium
tightly wound spirochete
actively motile
Killed by: (1) disinfecting agents (2) heat (3) soap
Does not survive in refrigerated blood past 48 hrs.
Syphilis is caused by the treponema organism, a tightly wound spirochete, or a type of bacteria. It is different than many bacteria in that it is actively motile, that is it can actively move thru interstitial spaces. However, the syphilis organism is very very fragile. It is killed by disinfecting agent, heat and soap and survives only for a short time outside the body, in refrigerated blood.

3. Syphilis Epidemiology 1943: 575,000 (very high) Humans are only host
Transmitted by mucosal contact (kissing, biting)
*late syphilis (past 4 years) rarely transmissible
*can be passed to fetus regardless of stage
Congenital, late syphilis; has declined dramatically
In U.S % with early syphilis are homosexual
Syphilis rates have declined dramatically in this country during the 1900’s, after reaching a high in 1943 or over a ½ a million new cases. Humans are the only host for the organism and it is transmitted thru close physical contact.

4. Pathogenesis of Untreated Syphilis
Primary
30% chance of contracting with contact
Incubation period days
Chancre - painless lesions (usually solitary) on genitalia; few mm. to 1-2 cm.
Subside spontaneously within 1-5 weeks
Syphilis is a very complicated disease. It is a very complex interaction between the organism and the human immune system, and therefore the outcome of infection. We will briefly look at the complicated picture of syphilis. Initial infection results in what is termed primary syphilis. It is estimated that approximately 30% of those that actually contact the organism become infected. As you can see, the incubation period is relatively long, ranging from a couple of weeks to a couple of months. The initial symptoms of primary syphilis is a lesion called a chancre (shanker), this is a painless solitary lesion usually in the genitalia, the shaft of the penis, the vulval area, but can be internal. Treated or not, the chancre typically subsides and heals spontaneously within 1 to 5 weeks, therefore the external signs of infection disappear.

5. Pathogenesis of Untreated Syphilis
Secondary
Usually develops ~ 6wks after chancre heals but may overlap
May involve many organs
Skin-macules ranging from barely visible to eruptions
Mucus membranes-raised round patches
Those people who do not get treatment then move into what is called secondary syphilis. Which usually develops 6 weeks after chancre heals but may overlap the presence of the chancre. Secondary syphilis is a disseminated infection. That is how the syphilis organism has moved through the body and can affect many organs . The outward signs of secondary syphilis are skin macules ranging from barely visible to eruptions and gray patches in the mucus membranes. There may also be fever and flu like symptoms in these infected individuals.

6. Syphilis CV damage Latent Syphilis Tertiary Syphilis
Involves long-term, untreated infection with variable effects. Recurrence of secondary symptoms may occur periodically.
Tertiary Syphilis
Symptoms appear up to 30 yrs after initial infection
CV damage
CNS damage
Over long-term, a person can lapse into latent syphilis. If left untreated latent syphilis has varying effects. In some individuals there are no long-term negative outcomes, at least none that are apparent. Other individuals suffer from recurrence of secondary symptoms, already described still other individuals develop late stage or tertiary syphilis with symptoms appearing up to 30 years after the initial infection. These symptoms range from senility brought on by CNS damage, caused by the organism; heart failure caused by the organism developing in the heart and causing damage to the heart muscle.

7. Syphilis Treatment **Penicillin- repeated screening @ 3,6 &12 mos.
1-2 wk regimen of repeated doses
Congenital Syphilis
Test performed on all pregnant initial visit
Is not transmitted until 4th month.
Symptoms similar to secondary syphilis if not fatal.
Treatment for syphilis involves penicillin, a 1 to 2 week regimen of repeated doses, and then followed with a test to make sure those have been effective. The problem with syphilis is that those individuals that syphilis is most common in, is that people with drug problems, prostitutes, the homeless, often are not very compliant with the treatment regimen. Like other std’s there is a chance of congenital syphilis. Fortunately, the organism is not transmitted until the fourth month. It is a routine gynecological practice to perform a syphilis test on an individual on initial visit when pregnancy is suspected, however,often times infected individuals do not seek medical treatment until delivery. A child infected with syphilis will not have primary syphilis because the disease is obviously in the blood stream. These individuals will have symptoms similar to secondary syphilis but also may suffer nerve damage and cardiovascular disease, and in some cases congenital syphilis can be fatal.

8. Syphilis — Reported cases by stage of infection: United States, 1941–2005
Here we see syphilis cases reported in the United States from 1941 to You can see that from the early forties to the early fifties there was a dramatic decline and then a relatively steady decline since then. There are three trends that are plotted here, those for primary and secondary syphilis, those for early latent syphilis and then the total syphilis numbers. It is important to understand that syphilis is far less common than the other std’s that we study in this unit.

9. Primary and secondary syphilis — Rates: United States, 1986–2005 and the Healthy People 2010 objective
Here we see syphilis cases as a function of rate. Again you can see these rate numbers are far less than some of the other rates we have looked at for other std’s. you can also see that there's been a significant steady decline in syphilis since the early nineties.
Note: The Healthy People 2010 objective for primary and secondary syphilis is 0.2 case per 100,000 population.

10. Primary and secondary syphilis — Rates by state: United States and outlying areas, 2005
Here we see the syphilis rates by state. Again, I want to emphasize here how relatively rare syphilis is compared to other std’s. note again, that there are regional trends associated with syphilis infections.
Note: The total rate of primary and secondary syphilis for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 3.0 per 100,000 population. The Healthy People 2010 objective is 0.2 case per 100,000 population.

11. Congenital syphilis — Rates for infants <1 year of age: United States, and the Healthy People 2010 objective
Here we see rates on the congenital syphilis. Again, we can see that in the late eighties and early nineties there was an upward trend in congenital syphilis. Since then there has been a steady decline toward the Healthy People 2010 objectives.
Note: The Healthy People 2010 objective for congenital syphilis is 1.0 case per 100,000 live births. The surveillance case definition for congenital syphilis changed in 1988.