In 2002, the overall rate of syphilis infection in the United States increased by for the first time since 1990. Since the disease had been widely thought to be on a permanent decline--with possible near-elimination (as defined by the CDC) this year--the health community responded quickly to the increase. The centuries-old sexually transmitted infection (STI) has received significantly more scrutiny than it has in the last decade. In addition, prevention advocates have begun re-introducing syphilis into public education programs that had previously passed over the disease.

Background

Though its origins are hotly debated, Treponema pallidum, a bacterium that causes syphilis, has been a part of human history for hundreds of years, appearing in an epidemic outbreak in the 1600's. Prior to the discovery of the antibacterial properties of penicillin in 1929, early treatments for the disease included the highly toxic application of mercury to late-stage sores, as well as a variety of arsenic compounds, the most successful of which called Salvarson.

Like many STIs, syphilis has been highly stigmatized throughout history (a trend that continues in some segments of society today). In the darker corners of syphilis' history, leper colonies were established for victims, and advances in treatment were met with resistance by those who felt the disease marked its victims as morally inferior.

In response to the only other outbreak of epidemic proportions following WWII, widespread treatment and an educational campaign significantly contained rates of infection throughout the last 50 years, despite some increases in both the 1960's and 1970's. In the 1980's close monitoring indicated a higher incidence of infection in urban areas, a trend which continues today. Nearly all of the reported increases in infection over the last five years have been in urban areas.

The recent increases--though far from epidemic proportions, and even possibly the result of an observed trend of the disease to increase and decrease in seven-to-ten year cycles--cannot be considered without examining how the portrait of the disease is changing.

Introduction and Transmission

Syphilis is a curable, bacterial infection that, once inside the body, enters the blood stream and attaches to cells. If left untreated, syphilis can cause blindness, insanity, paralysis and can afflict bones and internal organs.

It is transmitted through direct contact with a syphilis sore, which can occur through sexual or nonsexual contact on external genitals, vagina, anus, in the rectum, in the mouth and on lips. According to a 2002 report released by the Chicago Department of Public Health (CDPH) oral sex seems to be growing as a method of transmission (especially among gay and bisexual male populations). Oral sex was responsible for approximately 15 percent of all reported cases in the study from 1998- 2002.

Syphilis can also be transmitted from a pregnant mother to her fetus.

Because the bacteria that causes syphilis is fragile outside the body, the infection cannot be spread through contact with items such as toilet seats, doorknobs, eating utensils, or shared clothing, or through hot tubs, baths or swimming pools.

Symptoms

Syphilis occurs in four distinct stages if left untreated: Primary, Secondary, Latent Stage and Late Stage (also known as Tertiary).

• Primary Syphilis: Can occur 10- 90 days after infection. Usually, in this stage, a single painless sore appears on or outside the genitals (penis, scrotum, vagina), inside the vagina or rectum, at or around the anus, or on the mouth, lips or at the back of the throat (less common). The sore will go away without treatment, but the infected person can still transmit the infection to others.
• Secondary Syphilis: 17 days to 6 1/2; months after infection. In this stage, symptoms, which can last up to 6 weeks, may include a rough, reddish-brown non-itching rash that appears on the palms of hands and/or soles of feet. Rashes may occur on other parts of the body. Grayish-white sores may appear on the mouth, throat or cervix. Raised skin lesions or "warts" may appear in the anus or genital area. Other symptoms may include headaches, patchy hair loss, sore throat and swollen lymph glands. Again, symptoms will go away without treatment, but the infection will still be present if untreated.
• Latent Stage: 2- 30 years after infection. There are no symptoms or signs of the disease during the latent stage. Syphilis can be detected during this time through a blood test.
• Late Stage (Tertiary): 2- 30 years after infection. Symptoms can include problems with heart and blood vessels, chronic nervous disorders such as blindness, insanity and paralysis, as well as small bumps or tumors that can develop on the skin, bones, liver or other organs.

Detection and Treatments

Syphilis can be tested for in the Primary and Secondary stages by your health provider testing fluid taken from a sore, lesion or wart (known as the Darkfield Exam). Syphilis can be also detected through a blood test or by testing spinal fluid. Though less likely to cause damage if treated early, syphilis can be treated and generally cured at any stage, through use of penicillin or another antibiotic. Consult a physician before treating, especially if you have HIV or are pregnant.

Risk of Transmission and Methods of Prevention

In 2002, the CDC reported a 12.4 percent increase in reported infections of primary and secondary syphilis nationwide. Currently, populations experiencing the highest growing risk for infection are gay and bisexual men in urban areas. In 2002, the 63 largest cities accounted for 62.7 percent of syphilis cases, compared with 57.8 percent in 2001. And while the number of cases reported in 2002 by the CDC indicated continued decline among women and African-Americans, syphilis continues to disproportionately affect African-Americans, with reported rates at 16 times higher for African-Americans than for white Americans.

Health officials who have monitored syphilis infection rates have observed that the risk behaviors for syphilis mirror those of HIV. In addition, syphis lesions increase risk of HIV transmission between 2 and 5 times, indicating that a rise in syphilis infections could predict a similar increase in HIV transmission.

Furthermore, because the risk of HIV transmission through oral sex is somewhat lower than other (vaginal, anal) forms of sex, people who consider unprotected oral sex to be a lower-risk sexual practice may be at greater risk for contracting syphilis through oral sex.

Other than through abstinence or mutual monogamy, to reduce risk of transmission, use Latex condoms for vaginal and anal sex. Use barrier methods during oral sex. A non-lubricated condom can be used for mouth-to-penis contact. Plastic wrap, a dental dam, or a latex condom cut-up and opened flat can reduce the risk of transmission during mouth-to-vulva/vagina or oral-anal (rimming) contact.

For vaginal, anal, and oral sex, condoms may help protect covered areas from infection, but do not protect other exposed areas (such as the scrotum or anal area).

Conclusion

Syphilis is not a dead disease. As with any other STI, prevention is the best way to reduce risk and engage in safer, healthier sex. Although syphilis is curable, early detection through regular exams and honest communication with sexual partners who may be infected remains just as important to your sexual health.

Resources

CDC National Prevention Information Network (NPIN)

American Social Health Association (ASHA)