CINCINNATI - Our series "Out from the shadows: Cincinnati's syphilis epidemic," has been honored with the "Unsung Heroes of Public Health Excellence in Media Award," by the Campaign for Public Health Foundation.
CINCINNATI -- Nearly 20 months into an all out war on the epidemic of syphilis in Hamilton County, the number of cases has taken a dip, and the public health commissioner says the aggressive campaign, with stepped-up hospital testing and a broader community outreach, has made progress against the outbreak.
“The numbers are still way too high. We should all be embarrassed by this,” said Tim Ingram. “Syphilis is 100 percent preventable and 100 percent treatable. The cost of treating it is minimal. We need to catch this before it becomes a million-dollar problem down the road. You’ve got to go after it.”
Since 2008, Hamilton County has been number one in Ohio for the number of cases and rate of syphilis. In the most recent federal ranking of counties (2011), Hamilton County ranks 15th. Since 2010, at least half of all infants born with syphilis in Ohio draw their first breaths in Hamilton County. So far this year, it’s four of eight.
“Unacceptable,” Ingram said. “We’ve had a breakdown in the system.”
A Perennial Plague
Syphilis, a centuries-old scourge of humankind, is a bacterial infection spread through sexual contact. A pregnant woman can also pass syphilis to her baby. Often, someone with syphilis isn’t aware of the infection. Untreated, syphilis is fatal, eating the nerves, brain and heart.
In 1943, a cure was discovered in penicillin. By 1999, the U.S. rate had dropped to a 70-year low. Federal health officials optimistically drafted “The National Plan to Eliminate Syphilis from the United States” inside a decade.
But in the 21st Century, syphilis re-awakened, then exploded. Cincinnati’s health department raised an alarm in 2010, putting up billboards, bus shelter banners and posters to educate the public. The numbers went higher still: In 2008, Hamilton County had 72 cases; in 2012, there were 435.
Public health authorities in Butler, Warren and Montgomery counties now worry about an Interstate 75 contagion as syphilis numbers creep up in their jurisdictions.
Pat Allingham, Hamilton County’s director of disease prevention and nursing, said theories abound about the resurgence.
“In the 1930s, 1940s and 1950s, people were tested for syphilis all the time, and then it went underground because I think a lot of physicians and clinicians just didn’t include it when testing for sexually transmitted infections,” she said. “People got complacent, and syphilis reared its ugly head back up.”
Hospitals Join Forces
In March 2012, with the trend line still climbing, the county public health commissioner declared syphilis was an epidemic in Hamilton County. Ingram also convened a summit of leaders from the area’s six major health-care systems to draw on their resources for a comprehensive plan to halt the outbreak by 2016.
- Mercy Health
- Cincinnati Children’s Hospital Medical Center
- University Hospital
- The Christ Hospital
- St. Elizabeth Healthcare.
The hospitals now test anyone who presents for any kind of care and shows symptoms of any sexually transmitted disease. Hospitals also begin treatment immediately, even before test results come back.
Then a patient will later get a knock on the door from a county disease investigator to collect sexual histories and find others who need a test. It’s a delicate task: Allingham said patients have complained about the intimate interview questions.
Initial results suggest the increased government and medical attention to syphilis is having an effect:
- Hamilton County’s 435 cases last year hit a record
- In the first six months of 2013, the county counted 172 cases.
- If that pace holds through year’s end, the county would see 344 cases.
All positive syphilis tests, whether in a hospital or a private physician’s office, are reported to county public health.
“We are going to contain this epidemic,” Ingram said. “But it’s a complex problem, and it’s going to take a lot of work.”
Taking Care Of A Social Stigma
The work takes place in ways large and small. Hamilton County has paid to print up drink coasters for bars, with a picture of a naked male mannequin and the words: “Only dummies don’t wear condoms. Take care down there.”
Next page: Affected populations, information on symptoms and treatment
Other communication tactics fall to veteran health educator Tonya Key. The county hired her last year to ramp up outreach to the community suffering the most from syphilis: African-Americans. In talking to community and religious groups, Key found a lack of knowledge that “really took me by surprise. They did not realize how syphilis was infiltrating the neighborhood and who was being affected.”
- In 2012, nearly 80 percent of the 435 cases in Hamilton County were in African-American men, mainly between ages 15 and 34. In about a third of those instances, transmission came from men having sex with men.
Now, the increase in congenital cases indicates that syphilis is breaking through in African-American women of child-bearing age who do not receive prenatal care. Women are tested for syphilis during pregnancy. In an interview, Ingram turned red in the face when he said, “We should not have one single case of congenital syphilis. Not one.”
Historically, public health officials say, churches have avoided talk about syphilis and sexually transmitted diseases. The history of syphilis also carries the weight of the notorious 40-year Tuskegee experiment, when government doctors withheld treatment from poor Alabama farmers to study how syphilis ravaged their bodies.
But in the past year, Key has met with community groups including African-American Catholic Ministries in Cincinnati about the syphilis epidemic and to push for warnings. In April, she went to Inspirational Baptist Church in Forest Park to speak to the annual Pajama Jam sleepover at the church for about 200 teenaged girls and young women.
The pastor, Bishop Dr. Victor S. Couzens, said churches resist talking about syphilis, “for the same reasons that we don’t deal with mental health issues in the African-American community as we should, or with obesity. There is a social stigma, and we have not created a safe environment for people to feel as if they can get help.”
When Key spoke at the Pajama Jam about the Hamilton County syphilis epidemic and other sexually transmitted infections, “We had a phenomenal dialogue. It gave me a lot of hope.”
“The grown-up girls, they did not want to end the session; they had lots of questions, and they were very interested,” Key said. “The 12-year-old girls were saying, ‘I have no idea what you’re talking about, but I know I don’t want anything to do with that.’ ”
About Syphilis: Symptoms, treatment
Recent DNA analysis shows that the bacteria Treponema was in the New World when Christopher Columbus arrived in 1492. His crew took the bacteria back home, where it mutated to cause a contagious infection that was sexually transmitted. Europeans accused each other of spreading it around. Italian physician and poet Girolamo Fracastoro gave the ailment its name with his 1530 poem “Syphilis sive morbus gallicus” – “Syphilis or the French Disease.”
- Primary syphilis arrives with a sore, called a chancre (SHANK-er), at the site where the bacteria infected the body, usually the penis, vagina or mouth. The sore is painless and heals by itself in three to six weeks.
- Secondary syphilis brings a rash on the palms or soles, fever, malaise, loss of appetite, muscle aches, joint paint, swollen lymph nodes, vision changes, hair loss or sores around the mouth or genitals.
- Tertiary or latent syphilis damages the heart and central nervous system, and triggers tumor growth. Death is not far behind. For centuries, the only diagnosis of syphilis was looking for symptoms, and the most common treatment was with the toxin mercury.
Infectiousness: Primary and secondary syphilis are contagious. Avoid sexual contact with a chancre or other symptoms are present. Condoms can protect against syphilis and other sexually transmitted infections.
Treatment: In 1906, a blood test was developed for syphilis. In 1943, a cure was found in penicillin. Other antibiotics are used today, including doxycycline or tetracycline. Length of treatment depends on the stage of syphilis and the patient’s overall health. Once treated, syphilis is cured in weeks, although it can last a year. Penicillin is always used against syphilis in pregnancy. Several hours after treatment, patients can experience the Jarish-Herxheimer reaction, a flu-like response as the body’s immune system combats the infection that lasts about 24 hours.
- Hamilton County’s syphilis data for the second quarter of 2013: http://www.hamiltoncountyhealth.org/files/files/Reports/Syph_Q2_2013.pdf
- City of Cincinnati Health Department fact sheet: http://www.cincinnati-oh.gov/health/personal-health/syphilis-prevention/
- Data about 2011 syphilis rates from the Centers for Disease Control and Prevention: http://www.cdc.gov/std/syphilis2011/default.htm
Look for part two of "Out from the shadows: Cincinnati's syphilis epidemic," next Thursday.