Epi news

Winter 2009
EPI NEWS VOL. 7 NO.1
A Publication of the Genesee County Health Department
Syphilis at a Glance
yphilis is a curable genital ulcerative disease caused primarily among heterosexuals (1:1 male to female ratio) by the bacterium Treponema pallidum. It is a highly and individuals with high risk behaviors. These behaviors S infectious organism that is primarily spread though include substance use, having multiple partners, and sexual contact with a 60% transmission probability. trading sex for drugs or money. The median age among the Infection with syphilis bacteria causes a systemic disease cases in the outbreak is 29 years. The majority of cases live that manifests in stages if left untreated. The disease in the city of Flint and a large racial disparity is seen increases the risk of transmitting and acquiring HIV among the cases, with over 85% of cases among African (human immunodeficiency virus) by 3- to 5-fold and may Americans. As a result of the high rate of infection in be important in contributing to HIV transmission in those females, 7 cases of congenital syphilis were reported in parts of the country where rates of both infections are high. T. pallidum can also be transferred across the placenta with yphilis has often been called “the great imitator” infection of the fetus of a pregnant woman in 80% of cases. because many of the signs and symptoms are Perinatal death can result in up to 40% of cases or the baby Sindistinguishable from those of other diseases. The can be born with serious mental and physical problems. primary stage of syphilis manifests 10 to 90 days after he rate of syphilis infection dramatically decreased infection and is marked by the appearance of a single in the 1950s due to the discovery of penicillin, painless chancre at the sight of inoculation, but there may T which is still the drug of choice, as a successful be multiple sores. The chancre lasts 3 to 6 weeks and will treatment for the disease. In the year 2000, the rate of heal without treatment. Two to 12 weeks after initial primary and secondary (P&S) syphilis in the United States infection secondary stage symptoms appear and are (US) was the lowest ever recorded. Between 2006 and characterized by a generalized skin rash and mucous 2007, syphilis cases increased 15.2%, indicating the 7th membrane lesions. The rash of secondary syphilis appears consecutive yearly increase in syphilis in the US. Increases as rough, red, or reddish brown spots often involving the in P&S syphilis cases have been in part due to outbreaks palms of the hands and soles of the feet. The degree of among high risk behavior groups including illicit drug severity of the rash varies and it may be subtle and mimic users and men who have sex with men leading to an other dermatologic diseases. Systemic symptoms of increase in the male to female ratio of P&S syphilis cases, secondary syphilis that can commonly occur during this but 2007 marked the 3rd consecutive increase in cases stage include lymphadenopathy, fever, alopecia, among women. Even more alarming is the increase in the headaches, weight loss, malaise, and fatigue. Other rate of congenital syphilis after a 14 year decline. Among symptoms may include mucus lesions, condylomata lata, adults, most P&S syphilis in 2007 cases occurred in and meningitis. The signs and symptoms of secondary persons 25 to 29 years of age. Recent increases in the P&S syphilis will resolve with or without treatment, but the syphilis rate have been documented among all race groups. infection will progress to the latent stages of disease during Although the disparity in rates between Whites and African which no symptoms are present for a long period of time. Americans had declined over time, African Americans People who are not treated will eventually develop have had a larger burden of syphilis with a 6-fold higher complications of tertiary syphilis in which the bacteria rate in 2007. Michigan is considered a low morbidity state damage the heart, eyes, brain, nervous system, bones, for syphilis. In 2007, 123 cases of P&S syphilis were joints, or almost any other part of the body. This stage can reported in Michigan representing a rate of 1.2 cases per last for years, or even for decades. Tertiary syphilis can 100,000. Of those, 69 (50.4%) were reported from the city result in mental illness, blindness, other neurologic of Detroit which has historically had the highest rates of problems, heart disease, and death. Co-infection with HIV increases the risk of neurological involvement and greatly yphilis morbidity in Michigan has recently changed. accelerates the progression to neurosyphilis.
The purpose of this newsletter is to inform the community and health care Department (GCHD) annouced that Flint and providers in Genesee County about disease trends in the county. We Genesee County were experiencing a significant outbreak welcome any comments or questions. Contact Fatema Mamou, MPH, of infectious syphilis. In 2008, 131 cases of infectious Epidemiologist, at (810) 768-7971 or email syphilis were reported in Genesee County, representing a 600% increase compared to 2007. The outbreak is nitial screening for syphilis is performed with one of n important treatment consideration in preventing the nontreponemal antibody tests, the Venereal the transmission of disease is identifying sexual Disease Research Laboratory (VDRL) test, or the partners of infected patients. The sexual Rapid Plasma Reagin (RPR) test. These tests are very transmission of T. pallidum occurs when mucocutaneous sensitive, but not necessarily specific for syphilis. The syphilitic lesions are present, usually within the first year specific treponemal tests include the Fluorescent of infection. However, sexual partners of a patient with any Treponemal Antibody Absorbed (FTA-ABS) and T. stage of syphilis should be evaluated. Partners exposed pallidum particle agglutination (TP-PA). Compared with within 90 days of the diagnosis of primary, secondary or nontreponemal tests, treponemal tests may be positive early latent syphilis may be infected even if they are earlier in the course of infection. Nontreponemal test seronegative, so presumptive treatment is recommended. antibody titers should be reported quantitatively and Partners exposed after the 90 days following diagnosis typically become non-reactive with time after treatment. In should be treated presumptively if serologic test results are most cases treponemal tests remain active regardless of not immediately available and the opportunity for follow- treatment or disease activity. The definitive method to up is uncertain. Long-term sexual partners of patients with detect T. pallidum is direct visualization of the organism latent syphilis should be evaluated clinically and by darkfield examinations or direct fluorescent antibody serologically for syphilis, and treated accordingly. s a result of the ongoing syphilis outbreak in Flint uring the primary, secondary, and early latent and Genesee County the GCHD has asked health phases of syphilis, a single dose of penicillin care providers to increase screening for syphilis D administered parenternally will cure the disease. among their patients. In this period of high morbidity, People who are allergic to penicillin (and not pregnant) testing for syphilis should be performed if one or more of may be given oral antibiotics (doxycycline or tetracycline) the following criteria is met: 1) Patients with signs or for 2 weeks. People who are diagnosed to be in the late symptoms indicative of syphilis (these patients should be latent stage of syphilis and those with tertiary syphilis will presumptively treated if it is believed that the patient is require 3 doses of penicillin, at 1 week intervals. For those infectious or may be difficult to follow-up), 2) Patients allergic to penicillin, oral antibiotics (doxycycline or with a history of signs or symptoms of syphilis, 3) Patients tetracycline) are given and patients must be closely admitting to sexual contact with someone who had monitored with serologic and clinical follow-up. If syphilis symptoms indicative of syphilis, 4) Patients exhibiting high has advanced to neurosyphilis, treatment with IV penicillin risk lifestyle behaviors such as substance abuse, every 4 hours for 10-14 days may be required. A pregnant unprotected sex, or multiple partners, and 5) Patients who woman with syphilis must be treated with penicillin. If she test positive or present with signs or symptoms of another is allergic to it she must allow for desensitization sexually transmitted disease. In addition, expanded procedures. A Herxheimer reaction may occur in patients screening of pregnant women should be performed. All 2-12 hours after treatment begins as a result of the dying pregnant women in Genesee County should be tested for bacteria within the body which can lead to constitutional syphilis during her third trimester visit and at delivery symptoms and exacerbation of previous symptoms. This regardless of previous test results. Health care providers must report all cases of syphilis to the health department. Selected Reportable Communicable Diseases in Genesee County
Reported cases in
Reported cases in
Reported cases
Reported cases
Total reported
the week ending
previous week,
to date this FY*
to date last FY
cases last FY
1/10/2009
ending 1/3/2009
2008-2009
2007- 2008
2007-2008
Chickenpox
Pertussis
Flu-like illness
Chlamydia
Gonorrhea
HIV, Adult
Infectious Syphilis, Adult
Hepatitis B, Acute
Hepatitis C, Chronic
Campylobacter
Hepatitis A
Salmonellosis
Meningitis-Viral
Meningococcal Disease
Y – Fiscal Year, October 1-September 30 Genesee County Health Department
John D. McKellar, MPA, Acting Health Officer • Gary K. Johnson, MD, MPH, Medical Director
630 S. Saginaw Street, Flint, MI 48502

Source: http://t.gchd.us/Newsletters/Epidemiology/EPI-Winter2009.pdf