April is Sexually Transmitted Disease Awareness Month. This is particularly important to note for the people of Niagara County because the increased occurrence of sexually transmitted diseases, especially Syphilis, indicates that we have to do better with education and prevention among our citizens.
Recent trends over the past few years point to a rise in Syphilis especially among the gay population, but heterosexuals are also affected. Syphilis was once thought to have been eradicated, but according to Leung-Chen (2008), there has been a resurgence in recent years, for reasons that are not yet well understood. According to Reinberg, The Centers for Disease Control and Prevention data show that in 1999, 79% of the 3,115 counties in the United States reported no cases per 100,000 people, the lowest since 1941, when reporting began. Primary and secondary Syphilis have been on the rise for seven consecutive years, from 2001 (three cases per 100,000 people) to 2006 (5.7 cases per 100,000), and to 6.4 cases per 100.000 in 2007. Transmission among men who have sex with men (MSM) may be largely responsible for these increases, although it was only in 2005 that the Centers for Disease Control began to request that case reports include the sex of patients’ sexual partners (Leung-Chen, 2008). In 2006, MSM accounted for 64% of primary and secondary syphilis cases (Leung-Chen, 2008).
In 2004 the Niagara County Department of Health STD Clinic reported no cases of syphilis, in 2005 there was one case, in 2006 four cases, in 2007 no cases, and in 2008 it jumped back up to four cases. In the first two months of 2009 alone, four cases in Niagara County have already been reported. It is interesting to note here that our neighboring Erie County, according the CDC reported thirteen cases in 2004, nine cases in 2005, and twenty-eight cases in 2006. (Bureau of STD Control Data, 2004-2008).While these numbers might at first appear low, it is essential to note that they in fact reflect a marked increase. Sexual behavior patterns of some who are infected make it likely that their sexual partners will become infected, and that in turn the sexual partners of their partners will also become infected, with ever-increasing spread. Also, these numbers represent only those cases known to the local department of health. Education, case-finding, and treatment are essential to stop the spread.
According to Kevin Fenton, MD, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, “STD’s remain a major threat to the health of gay and bisexual men, in part because having an STD other than HIV can increase the risk of transmitting or acquiring HIV”. Further, “The resurgence of syphilis among MSM represents a formidable challenge to our STD prevention efforts, but one that is surmountable.
The solution comes down to making STD screening and treatment a central part of medical care for gay and bisexual men, while finding innovative ways to help MSM avoid STD infections – including HIV – in the first place” (Chicago Tribune, 2008, March 12). Since 2002, CDC has recommended that sexually active MSM be tested at least annually for syphilis, chlamydia, and gonorrhea – at all anatomic sites of reported STD exposure. However, several other recent studies presented at the 2008 National STD Prevention Conference in Chicago found that the rates of STD screening among gay and bisexual men remain high. CDC also recommends at least annual STD testing for all individuals with HIV infection.
How would a person know or suspect that he/she has contracted Syphilis? The signs and symptoms of Syphilis occur in four stages: primary, secondary, latent, and final or tertiary stage. There is an incubation period of 9 days to three months following contracting syphilis before an individual shows the first signs and symptoms of the disease.
The primary stage often begins with a sore, called a chancre, on the part that has been in contact with the infection, the genitals, rectum or mouth. The chancre feels like a button, firm, oval and round. Swelling of the glands in the groin may occur but is not usually sore or tender. One does not usually feel ill in the primary stage and the chancre heals after a few weeks without treatment. This is a problem because the syphilis is not gone. It continues to spread throughout the body.
The secondary stage can often occur after a gap of several weeks when the bacteria have spread through the body. At this stage one may begin to experience headaches, general aches and pains, sickness, loss of appetite and fever. Breaks in the skin occur and sometimes a dark red rash that can last for a few weeks or months. The rash appears on the backs of the legs, front of the arms, back, face, hands and feet. It does not itch and may be either raised or flat in appearance. Other symptoms in the secondary stage may also include sores in the mouth, nose, throat, genitals, or in the folds of the skin. Hair can fall out in patches. These signs and symptoms will disappear without treatment in 3 weeks to nine months, but the bacteria are still present in the body and the person still has syphilis.
The Latent Stage can last from a few months up to 50 years! There are no symptoms and after about two years the one infected ceases to be infectious.
About 30% of those who are not treated for their Syphilis will exhibit the final, or Tertiary Stage of disease. Common symptoms are painful, permanent ulcers on the skin, lesions on ligaments, joints and bones. Internal organs including the brain, nerves, eyes, heart, blood vessels, and liver may be damaged. As a result, infected persons might experience difficulty coordinating muscle movements, paralysis, blindness, numbness, dementia, insanity, and death (Mosby, 2008). Information such as this can be easily accessed by the public at sites such as About.com/Men’s Health or WebMd. However, while public sites such as these can be quite informative, individuals should not use them as their sole source of health information, and should seek professional advice and treatment through their primary medical provider or clinic at the first sign of symptoms.
Syphilis is far from a new disease. According to Leung-Chen (2008), Syphilis takes its name from a poem, Syphilis Sive Morbus Gallicus (translated as “Syphilis, or the French Disease”), by Girolamo Fracastoro, 1478-1553. In Fracastoro’s poem, a shepherd named Syphilis is stricken with a mysterious malady as divine punishment for insulting Apollo. Fracastoro also was first to propose a germ theory for the disease. The first well-documented outbreak of syphilis in Europe was in 1495, among soldiers fighting in the Italian War of 1494-1498. First to fall ill were Spanish troops sent to aid the kingdom of Naples against a multi national army of mercenaries fighting for the French. When the French army occupied Naples, the contagion quickly spread among them. Within two years, syphilis was rampant throughout Western Europe. By 1498, when it broke out in India, perhaps having been carried there by the explorer Vasco da Gama and his crewmen, it was pandemic. In 1505 it reached Canton, China. The origin of the disease was a matter of sharp debate, even as the pandemic spread. One mid-20th century writer, Charles-Edward Amory Winslow, put it this way: “As is usual in pandemics, each nation cast the blame on the preceding victim. To the Turks syphilis was the disease of the Christians, to the English it was the French Pox, to the French the Neopolitan disease, to the Italians the Spanish disease. Still, it wasn’t until 1905 that it’s causative organism, the spirochete bacterium Treponemapallidum, was first described by Fritz Schaudinn and Erich Hoffman in 1905. In 1913, Hideyo Noguchi proved that it causes the disease.
There is a significant history of the study of syphilis in the United States, perhaps most notably the infamous Tuskegee experiment that began in 1932(CDC, 2009).The U.S. Public Health Service conducted this 40-year study of 600 poor black sharecroppers living in Macon County, Alabama, 399 of whom had late-stage syphilis; 201 were uninfected control subjects. These men, their spouses, and their children were not told what disease they had, nor were they treated. Instead, from 1932 until the story had leaked to the Associated Press in 1972, researchers gathered data on the progression of their illness through clinical examination, spinal tap, blood testing, and autopsy; no formal protocol had ever been devised. When penicillin became available in the 1940’s, the test subjects were deliberately denied it. By the time the study was stopped, syphilis had killed 28 of the men directly and 100 through complications. Forty wives had been infected and 19 children had been born with syphilis. After the Tuskegee experiment came to light, The National Research Act was signed into law, requiring the establishment of institutional review boards to oversee all biomedical and behavioral research involving human subjects.
How can we reduce the rise of syphilis in the gay population? MSM need to be educated about the dangers of Syphilis, and screened, tested and treated. But what if they don’t come into the clinic? One innovative way to reach MSM is outlined in an article in the Journal of the American Sexually Transmitted Disease Association. According to Blank, et al (2005), this method, the Hot Shot! Healthy Men’s Night Out Program, was a New York City based program designed with a field-based holistic approach to MSM health and wellness. The medical experimenters, with the help of their internal and community partners developed a modest package of “transportable” interventions specific to the morbidity and mortality documented in the neighborhoods most affected by syphilis. These interventions included general screening services (hypertension, diabetes, drug abuse, depression), diagnostic services (HIV, syphilis, gonorrhea, and chlamydia testing), and referral services (tobacco cessation, crystal methamphetamine counseling).They offered their package of services in nontraditional venues such as bars and clubs, specifically those identified through their syphilis case interviews. When possible, they integrated these services with scheduled social events at the venues. The idea was to bring essential health care services into a nonmedical social setting in order to attract MSM who might not otherwise have sought out such services.
Niagara County offers a range of services for prevention and treatment of Syphilis and other sexually transmitted diseases. The Niagara County Department of Health holds STD clinics every Monday and Wednesday (except on national holidays) from 10:00 A.M. to 3:30 P.M. The clinic is located on the first floor of Trott Access Center, 1001 – 11th Street, Niagara Falls, NY. Specialized staff provides counseling, education and testing for STD’s and HIV. Services are confidential and free of charge. To learn more about STD’s, including HIV, visit www.nyhealth.gov. For more information about STD testing, contact the Niagara County Department of Health at (716) 278-1900 or visit www.niagaracounty.com/health/Nu_transmitted.asp. To find other testing sites in your area, visit www.hivtest.org. Additional information and activities for the 2009 STD Awareness Month can be found online at www.cdcnpin.org/stdawareness.
Khalifah Glover, RN is a practicing nurse and student at the State University of New York at Buffalo in the RN to BS program. This article was written while on clinical assignment at the Niagara County Department of Health.