Addressing the Rise of Syphilis in the U.S.

Buddy Creech: [00:00:12] Hi everyone, this is Buddy Creech and welcome to Let's Talk ID. Our guest today is Dr. Laura Bachmann, who has more than 20 years of experience in STI and HIV care in both the academic and public health settings. Since 2018, she has served as Chief Medical Officer in the Division of STD prevention at the Centers for Disease Control and Prevention. She and her team led the development of CDC's 2020 recommendations for providing quality STD clinical services and the 2021 CDC STI treatment guidelines. Dr. Bachmann received her medical degree at UNC Chapel Hill and her MPH at the University of Alabama in Birmingham. After completing an internal medicine residency and ID fellowship at UAB, she joined the faculty there. In 2008, she moved to North Carolina and prior to joining the CDC was professor of medicine at Wake Forest and director of the Guilford County Department of Health. Doctor Brightman, thanks for joining us today.

Laura Bachmann: [00:01:07] Thank you for inviting me. It's good to be here.

Buddy Creech: [00:01:10] Of course, you know, we're going to talk about the exciting topic of syphilis. This probably goes into the maybe the top four reasons why I didn't go into adult infectious diseases. Because syphilis seems to look like every other disease. Or at least it it can. And it's such, for me at least, it's such an intimidating disease process. It's a weird organism that causes weird symptoms sometimes. And yet there's also that classic presentation that we study from the very first days of medical school. So can you just kind of give us, for the purpose of just level setting, where are we with syphilis in the US right now? What are the big-ticket items right now that we just all need to be aware of?

Laura Bachmann: [00:01:53] Sure, thank you. And as you point out, I mean, syphilis has been with us for forever, but it is very complicated. And it still is a challenge with diagnosis and management, even for master clinicians. But you know where we are with syphilis right now. Syphilis has continued to increase in our 2022 data. That's the last published surveillance data. We're seeing the highest number since the 1950s. And that's more than 200,000 cases of syphilis. You know, we know that untreated syphilis has a lot of complications, potentially, whether it be neurologic, whether it be, you know, congenital syphilis, miscarriage, stillbirth. Et cetera. So it's really not good news. Associated with these increases, we're seeing increases in congenital syphilis. And we had over 3700 cases in 2022. Over 250 deaths were attributable to congenital syphilis. And you know, we know that the majority of these cases are totally preventable. Nine out of ten of the cases that we saw nationally would have been prevented with timely testing and treatment. So very worrisome trends that we're seeing right now.

Buddy Creech: [00:02:57] When you mentioned that, you know, one of the things that I think gets drilled into us as pediatricians is this notion of, you know, there are a few things that we're not going to miss before a baby leaves the nursery. And of course, these are for hospital births, but we're not going to miss hepatitis B because we know we have a window of intervention there if we can. And we're not going to discharge a baby until we know syphilis status on the mom. But it sounds like maybe that's not common practice everywhere. Or if it is, something is still leading us to fall through the cracks there, either in interpretation or actual testing. And is it clear which one of that is is more common? Is it an issue of understanding what the RPR or what the testing means, or is it an issue of some folks just aren't even being tested?

Laura Bachmann: [00:03:47] Well, I think it really is a combination. And when we look at our data for missed opportunities, we can see, for instance, 40% of the people who were pregnant and who delivered a child with congenital syphilis never even graced the door of the prenatal clinic.

Buddy Creech: [00:04:06] Sure.

Laura Bachmann: [00:04:06] When that happens, you know, as providers, we're limited in terms of what we can do in terms of diagnosis and treating if we never see the patient. But we did also see that a significant proportion of people who did make it into clinic and were tested were not treated in a timely manner. That points more to things that as providers, we have more direct control over. And then of course, there are syphilis cases that are acquired during pregnancy. And if the third trimester or the 28-week testing is not performed, then those cases can be missed. And as you point out, it really is important that no baby leave the hospital before that status on mom is known.

Buddy Creech: [00:04:49] And that I have to admit, this is one of the places as the PIDS ID consultant, at least in our hospital, where I feel so terrible because you've got this healthy looking baby, you've got a mom who may be ready to leave the hospital, and we're the ones holding it up because we're either waiting on a lab to come back, or we're trying to figure out how to coordinate testing for the mom, who is now discharged from the hospital. But the baby is still there because of us, and it just becomes it's as much of a medical challenge as it is an operational and sometimes social challenge. So can you talk a little bit about why we see such an increase? I mean, I get it, if we're not testing appropriately, if we're not treating appropriately, then obviously there's going to be a bigger burden of disease. But I'm really curious. I mean, what are those key drivers that are fueling this epidemic of syphilis in the US?

Laura Bachmann: [00:05:41] So for syphilis in particular, we're seeing impacts from decreases in STI services at the local and the state level. This has been going on for quite a few years now due to lack of resources. And of course, Covid took, you know, hit the health departments pretty hard as well in terms of diverting resources requiring, you know, leading to closures of clinics, etc. So reductions in STI services, we are seeing increases in substance use in some populations. And we know that that impacts decisions around sexual behaviors. There's social and economic conditions that are contributing. And that is in general, you know, that that's not even really just about syphilis. That's we see this throughout healthcare where some people, it just makes it harder for people to stay healthy when they don't have resources, they don't have access to care. Lack of insurance. We're seeing decreases in condom use in some groups. You know, there's maternal deserts, care deserts in several places in the country. And overarching all of this is stigma. Stigma that we've had. It feels like I guess it has been forever around sex, around STIs, that affect a patient's willingness to seek care and to talk to a provider about what's really going on with them. But also it does impact the providers willingness to ask questions and have that conversation as well.

Buddy Creech: [00:07:04] Well, and I wonder I mean, it's probably no surprise that many of the areas that are experiencing the largest jumps in the number of syphilis cases are often places where either that public health infrastructure is increasingly lean, where those services aren't being as provided either because of funding or because of just choices being made by state or local legislatures about what to do. But I guess also this issue of stigma is really interesting is this idea of there are things that folks are willing to talk to their providers about, and there are things that are simply more embarrassing or more private. And that's a real challenge. I don't even know how to begin to unpack that one, especially given some of the differences between urban and rural, different states, different areas, different religious or philosophical backgrounds of the patient or the provider. That gets really complicated really fast.

Laura Bachmann: [00:08:03] It does. It does. And it's something it's an area that in medical school training is not really emphasized. And we've been very disease focused in our training, approaching it as a sexual health issue, broadening it, making it routinizing these questions so that people don't feel singled out. You know, those are some steps. But as you mentioned, there's a lot to get into with that one topic. And we do have resources as well on our website at CDC to help providers navigate some of those questions. But yeah, it is an important piece. Providers are getting more comfortable with the conversation.

Buddy Creech: [00:08:41] Well, for everyone who's listening, who is in medical school leadership or curriculum design, let this be a call for an even greater emphasis on communication skills, how to address uncomfortable topics in a way that's winsome and that can address the elephant in the room without making that elephant seem bigger. Right. I mean, this would be a skill that I think all of us would benefit from even being better at. Even those of us who might feel like we have a little bit of skill in that. My goodness, we need to be even better to that point. Is there any movement towards, it'd be complicated for syphilis, my goodness, but is there any movement towards home or remote testing or testing that takes the sort of the provider out of it just to try to okay, we've got a stigma. No matter what we do, people may be challenged by that. Is there a way like we've done with Covid, like we might do with other infections, that we would test more privately and then give people a mechanism to seek care if they have a positive result. I mean, is that even on the radar?

Laura Bachmann: [00:09:50] Well, in the you're pointing to an important area and it's an important solution. But I don't think we have the absolute solution here. But it's the need for innovation and the way to do things differently, and to have options for patients to seek care and receive care in ways that they're comfortable with. There have been some movements around home testing for gonorrhea and chlamydia. There's been the first FDA approved test, but for syphilis, as you know, it's complicated. We're still working with the same technology for the most part, that we've had since Wasserman developed that first test. And it's complicated even for infectious disease providers interpreting titers, etc. So, there is a movement, a lot of thought going into that right now, but we definitely need more innovation around that topic.

Buddy Creech: [00:10:39] Well, that would get exciting. And you're right. This is I mean, it's complicated for trained ID providers to deal with this. I can't even imagine what that looks like for a patient to receive a printout or a screen and their patient portal that gives them a result. They're not going to have any idea what to do with that. I mean, you mentioned congenital syphilis a few minutes ago, and I decided not to follow you there because every pediatrician listening right now has palpitations thinking about table three point whatever in the red book, because it's not necessarily complicated, but my goodness, it feels complicated. And I think every PIDS ID specialist, except those who are just fully committed to syphilis care and research, we have to look at that thing every single time. So I'm wondering if there are some pearls around the congenital syphilis part that we should talk about. I mean, we've talked about it a little bit. I was just in London and it was awesome. They every time on the on the tube there was if you see something then say something and we'll get it sorted. And so then the tagline was see it, say it, sorted. And I'm like, okay, that's pretty cool. I don't know what that is for syphilis other than test for it, treat for it if you know it's there, and quite frankly, there are ways to treat for it, even if it's maybe not there, but at least the likelihood is reasonable that it's there. So do you want to kind of demystify that congenital syphilis workup and treatment plan without getting too much into the weeds?

Laura Bachmann: [00:12:12] Well, I don't know that I could justify those tables because I agree there's a lot of things to consider. We've talked about talking to people about risks and all that, but I want to make the point that an individual's risk for syphilis is a lot of times driven primarily by where they live. Geographic location has a huge impact. Prevalence of syphilis in the local areas has a huge impact on an individual's risk, so they may not have individual level risk as we define it, but they may be in a network that has higher syphilis rates. And we put out a Vital Signs report in November of 2023 around this. If we look at the Healthy People 2030 goal, 70% of the population is living in a county where that goal has been already there way above that goal. So, you know, screening in reproductive age women and their partners is a really important piece and related to your congenital syphilis question. Also, just having that awareness as well as what the prevalence is in the community since, again, it may not come down and particularly difficult for women to, you know, sometimes pinpoint individual risk factors that would make you more likely to test. So being more routinized and thinking about it from a geographic perspective as well is really important.

Buddy Creech: [00:13:36] That's really helpful. You know, it's interesting we continue to add to the arsenal of tools that our maternal health providers have for preventive care during pregnancy. We have more vaccines available than we've ever had that prevent some of the worst diseases, both in pregnancy and in the newborn. And I wonder sometimes if that sometimes lulls us into a forgetfulness about these oldies, but goodies like syphilis, or like GC and chlamydia, where, you're right, where if we don't have an individual risk factor, we might sleep on it a little bit and not think it's critical. And yet there are many places. Southeast is one of those where we are here in Nashville and Memphis and Birmingham and New Orleans, where there's just such a sheer volume of disease that maybe we can trust that an individual has low risk factors individually for syphilis. But then we trust but verify and we make sure for the sake of the child. And maybe that's part of the conversation is we want to we want to make sure that we do everything we can to keep this baby healthy. Just a thought occurred to me. I mean, this isn't I would imagine the syphilis epidemic is not unique to the US. Obviously, we're talking about that today, and that's where your focus has been. But is this a worldwide phenomenon right now too? And are there similar drivers elsewhere contributing to this epidemic?

Laura Bachmann: [00:14:57] Several countries now are seeing increases. But then there are countries who are making progress in the elimination of congenital syphilis. So I think again that like these social determinants, these underlying systemic factors. I mean, we haven't talked a lot about disparities, but maybe this would be the place to do that. I mean, every community is affected in some way by the syphilis epidemic, but we also know that certain groups are disproportionately affected. And some of that is from health inequities over time that have led to health disparities. For instance, we know in the Native American population right now, 1 in 155 births in 2022 had was a congenital syphilis case. Now, if you think about that number, I mean, that is insanely high and points to other challenges, systemic issues that the population has been faced with over time that have led to some of these increases. It's important that we realize that, yes, everyone can be affected, but some are more so than others.

Buddy Creech: [00:16:03] Well, what an unfortunate storm to have come together where those that are at most risk for syphilis may also be those that are at the highest risk for suboptimal access to care. Like that's like the worst combination ever because we're already blocked from having an effective strategy because those we need to reach the most are at highest risk for health care disparities as well.

Laura Bachmann: [00:16:33] Right, and you know what that points to is the need for innovation around health care delivery. I mean we focused on, this is complicated and ID physicians struggle with it, but also it's important to notice that most syphilis is diagnosed outside of a sexual health clinic setting and that providers, all sorts of providers, primary care providers, emergency department providers, providers working in correctional facilities all have a role to play here because you're interfacing with people who are at risk for having syphilis. And so making sure that those providers also understand the guidelines and the need to test and feel comfortable with that, but also the need for us to figure out innovative ways to get populations who aren't coming, walking into the doors of our clinic. And, you know, that gets into testing in the field, treating in the field, some of these interventions that are being looked at now, but we need to go further in terms of better diagnostic tests, better options for treatment besides a parenteral drug.

Buddy Creech: [00:17:38] Well, exactly. And I want to think about that. And in the meantime, while those innovations are developed and then implemented and deployed, I mean, we've got to destigmatize it. And I think about some of I mean, we could have a whole other bit on the HPV vaccine rollout and how in so many communities there was such antagonism because it was viewed as a sex vaccine, and I think we started to make more inroads when we said, can we not talk about that? Can we just call this a cancer vaccine, which is what it is? And people are like, oh, I'll get a cancer vaccine. That sounds great. It's sometimes the words matter, right? The words matter. Rather than making this be a, it is a sexually transmitted infection, I understand that, but it's also a child health issue. And while it's not merely a child health issue, that's certainly one angle that we can use in some individuals to say what we're most what we care most about is child health. And how you got this is is sometimes irrelevant. We just got to deal with it. And then those who are particularly trained in sexual health can begin to to really help think about individual level risk factors and unpacking all of that. But at some level, we've just got to have a conversation about we're trying to keep kids and people healthy.

Buddy Creech: [00:18:56] So let's talk about the shortages of or the challenges around treatment and even the shortages around penicillin. It seems like that has let up recently, but we always hold our breath when we get an email from our pharmacist saying we have eight vials of benzathine, penicillin, or whatever it might be. So can you talk a little bit about where we are there and where you hope some innovation around treatment will follow?

Laura Bachmann: [00:19:20] First, you know, the recommended treatment for syphilis is penicillin, penicillin and penicillin. That has been the case. We've not had innovation around that either over decades, since a little bit more than a year ago now, we've had a Bicillin L-A® shortage. One producer in the United States of Bicillin L-A®. Thankfully, through a lot of effort, that shortage has not been officially released, but great progress is being made. But it points again to the need for alternatives. And we do have a drug, doxycycline, that can be used as an alternative. It really is one of these that we have a lot of experience with it, but it has to be taken orally and for longer periods of time, which makes people worry about adherence issues. So I think it's important that we understand more about doxycycline adherence and how that interplay in effectiveness compared to penicillin, so that we have that option. But also like new drugs, it's really important that we get have access to new drugs. Pregnant people don't have the doxycycline option. And if there is a severe penicillin allergy that's really a problem to manage, you know, with desensitization and that sort of thing. So really important that we that we have some innovation and development of some new drugs for syphilis.

Buddy Creech: [00:20:39] That's such a, I mean, it's a complicated organism. It's complicated testing. It's really simple treatment, but not a lot of ability to flex in and out of that depending on hypersensitivity, availability, presence of pregnancy or not. So this is one of those classic examples of something that's so simple and yet so complicated simultaneously. Well, I want to end by just asking you, where do you hope we go in the next 3 to 5 years? I mean, we've got this clarion call that we've got to do something. If we don't do something, we're going to continue to have issues. So where do you hope we go in the next 3 to 5?

Laura Bachmann: [00:21:19] One of the very important things for us to keep in mind is that we're all going to have to work on this together. There is a tendency to look to CDC to control the STI epidemic, and obviously that is not working. It's very complicated. There's not enough resources, even if it was possible for CDC alone to do this. We've got to have people like you, like other colleagues in IDSA, our other colleagues in other specialties of medicine, but also people in industry and people, you know, the community is really going to take a village to have more of a comprehensive approach to deal with this. If we're going to deal with it, especially long term, and prevent that. So I'm hoping for that, that we're going to work better and more effectively together. And of course, I'm hoping that, you know, we will continue to see innovation around diagnosing treatment, prevention, those sorts of things as well.

Buddy Creech: [00:22:13] I mean that's yeah, that's the clarion call. The call has been sounded and now it's up to us to respond. So, Dr. Bachmann, thank you for sharing your time with us today. This is remarkably helpful. For more information, certainly we can go to the CDC website. We can go to the IDSA and PIDs website. This is a complicated disease that we want to get right. So thank you for sharing your expertise with us today.

Laura Bachmann: [00:22:33] Thank you for inviting me.

Buddy Creech: [00:22:35] As always, you can find more information about this topic and others on the IDSA and PIDs websites, as well as at cdc.gov. We look forward to you joining us next time on Let's Talk ID. Let's Talk ID is produced by the Infectious Diseases Society of America, and it's edited and mixed by Bentley Brown.