How worried are you about syphilis? In the summer of Monkeypox coverage, syphilis can sound quaintly yesteryear, bringing to mind alleged famous sufferers like Nietzsche, Napoleon, and Tolstoy. It’s not exactly top of mind in the sexual health media; most recent sexually transmitted infection (STI) campaigns have focused on the Human Papillomavirus (HPV) vaccine or pre-exposure prophylaxis (PrEP) for HIV prevention. Chlamydia trachomatis also gets a fair amount of coverage as the most common STI bacterial pathogen in the world. But syphilis? Mainstream culture just doesn’t spend a lot of ink or airtime on it.
Yet syphilis is very much a 2022 epidemic reaching alarming proportions – especially in South Dakota Tribal communities.
Our Chief Nursing Officer Whittney LaCroix, who regularly treats syphilis patients, provided an inside look at the problem. “While our Native communities were combating the COVID-19 pandemic, another challenge loomed in its shadow,” she said. “The incidence of syphilis infections has greatly impacted Indian Country – and now it’s the new public health issue wreaking havoc on our people.”
Whittney explained that South Dakota has seen a 1200% increase in infections over a 5-year period – with three out of four of those infections among Native Americans. “This sharp rise has also resulted in the fetal and infant deaths,” she said. “Working with local leaders and community members to bring awareness is key.”
Syphilis 101: The Potential Damage of Dormant Infections
Syphilis spreads through by direct contact with a syphilis sore during vaginal, anal, or oral sex. It can also be spread from a mother to fetus. There are four stages to infection: primary, secondary, latent, and tertiary. The early symptoms – such as a faint rash or painless sore – can be easy to miss.
Once an infection moves into the latent stage, syphilis can remain in a patient’s body for years without symptoms. But 10 or 20 years down the road, the patient could experience damage to the brain, eyes, heart, nerves, bones, and liver, including blindness and dementia.
The good news is that syphilis is curable with antibiotics. But diagnosis has to precede treatment – and because many patients don’t know they’re infected, opt-out testing is critical.
“A Silent Epidemic Creeping Across the Country”
Medical Director Dr. Thomas Barrows shared an experience from early in his career that has stayed with him to this day.
“When I was a resident, I treated a 68-year-old woman with dementia who was in a nursing home. She’d been a resident there since she was 58,” he said. “It’s unusual to have advanced dementia at that age so I tested her – and it turned out she had long-term syphilis.”
Today he calls syphilis “a silent epidemic creeping across the country” – both because of the alarming climb in cases and the potential for long-term repercussions. He points out that syphilis is not just a problem in Indian Country, but is climbing across the United States and in Europe as well. An estimated six to seven million people around the globe are infected with the syphilis microbe every year. From 2016 to 2020, congenital syphilis cases increased 254%.
But Indian Country suffers from a lack of resources and local public health experts, which may be one reason why 75% of South Dakota spread is in Tribal communities. Native American men have 2.1 times the rate of syphilis as white men; Native women have 5.4 times the rate as white women.
Because testing is so vital, Dr. Barrows is exploring ways to expand automated testing capabilities in his facilities, such as standing orders and expedited partner testing. Currently he collaborates with a public health official from Indian Health Service (IHS) who recently examined two years of syphilis tests; the official found a 15% positivity rate. By improving syphilis documentation and testing, they hope to identify cases sooner, connect more patients to treatment, and better contain infection.
Testing Guidelines and Barriers
As part of their syphilis guidelines, the CDC US Preventive Services Task Force recommends opt-out testing. Instead of waiting for patients to request a test, healthcare systems notify patients they will be screened unless they decline. The task force recommends syphilis screenings for all adolescents and adults at increased risk in the U.S. Pregnant women should be tested in their first trimester, third trimester, and at delivery, as well as women who’ve had a miscarriage.
“But how do you test everyone?” asked Dr. Barrows. “There are eleven thousand people in Rosebud. We need to do what we did with COVID – billboards, health fairs, drive-through testing.”
Another barrier: what happens after a test. “We’re losing people to follow-up,” Dr. Barrows said. He explained that while Rapid Plasma Reagin (RPR) testing can be performed as a point-of-care rapid diagnostic test, at present, his IHS facility lacks this capability. The RPR test is a send-out, and it can take up to a week to obtain a result. A positive RPR test is usually then reflexed to a confirmatory and more specific test to identify antibodies to T. pallidum, the bacterium that causes syphilis.
“Patients are often lost to follow up during such testing delays,” he said. “Skipping directly to the T. pallidum test – an alternate testing strategy endorsed by the CDC – or providing in-house laboratory support for rapid diagnostics are strategies we are presently reviewing.”
In the other direction, some patients with syphilis are identified and treated on the spot by public health nurses – but Indian Health Service won’t always know about it and so it’s not documented in the patients’ records.
Spreading Syphilis Awareness
There is no vaccine for syphilis. Prevention, education, testing, and treatment are the best weapons at our disposal. As with any effort to control infectious disease, collaboration is key. “Addressing syphilis has to be a multidisciplinary effort,” said Dr. Barrows.
Whittney LaCroix provided a plan that mirrors many pandemic tactics, including:
- Education: Get the message out on the disease and how it spreads, she advised. Educate the public with flyers, posters, town forums, and radio and TV spots. Also effective: Q&A sessions with local leaders and healthcare professionals.
- Prevention: Provide everyone with the means necessary to stop infection. “Giving individuals the knowledge and tools they need to prevent the disease will keep others safe and reduce the spread,” said Whittney.
- Testing: Hospitals and communities need to work together to identify the right time to test and what populations to target. Two effective strategies: holding (and publicizing) testing events and implementing testing protocols for clinics and hospitals.
- Treatment: Evidenced-based protocols can help ensure that each patient has access to treatment in a timely and effective manner.
Dr. Barrows pointed out that the right infrastructure is an important component of effective treatment and testing. “This is partly a technology-based solution,” he said. “ER doctors are busy. They need a technology solution they don’t have.”
From Contagion to Collaboration
Syphilis may sound like a disease from our history books, but its modern rise has troubling implications for Indigenous health. There’s no time to waste. Now is the right moment for healthcare facilities across Tribal nations to implement new testing and treatment protocols. “Better testing is critical,” said Dr. Barrows. “From adolescents to adults, we’ll fail them in this healthcare matter if we don’t act.”
