During our recent visits to a series of health facilities to discuss the alarming rise in sexually transmitted infection (STI) rates, clinicians expressed relief at finally discussing something other than COVID-19. While the trajectory of the pandemic remains uncertain, there is no shortage of other health topics that need urgent attention.
Arguably, one of the next public health emergencies will be responding to the increase in STIs. Even before the COVID-19 pandemic, STI rates were . As health systems return to pre-pandemic delivery of services, the ongoing of STIs is coming into focus.
Most alarming is the resurgence of syphilis, known as the "Great Imitator" for the challenges it presents to clinical diagnosis. The latest rates suggest that far from the plans to eliminate syphilis in the and the , the disease has once again emerged as a public health threat. According to recently released , cases of syphilis from 2016 to 2020, and congenital syphilis cases are up by 235%. Preliminary show yet another increase of congenital syphilis, considered a sentinel event in the healthcare system.
This growing infectious disease threat deserves urgent attention. Untreated syphilis has severe long-term health consequences and . Congenital syphilis leads to greater rates of . Infants who survive can have lifelong disabilities from the infection.
To counteract this trend, we can apply lessons from the COVID-19 pandemic response and previous syphilis outbreaks. Resources, outreach, and innovation can greatly extend the reach and impact of biomedical interventions.
In a rural syphilis outbreak in 2017, a majority of diagnoses came not from primary care screening, but rather partner services outreach. Partner services that provide contact tracing and clinical follow up via disease intervention specialists (DIS), public health nurses, and community health workers are essential to address the nationwide surge in syphilis.
We saw a similar model as part of the COVID-19 response, when Congressional funding was used to scale up a large cadre of DIS to investigate cases, notify contacts, and link people to testing and treatment services. These trained DIS can now be pulled into other critical case investigation for communicable diseases like syphilis.
In addition to partner services, facility-based policy and practice can be the foundation of an effective response to syphilis. Our clinical colleagues had multiple examples of how they have expanded syphilis testing and improved access to care locally. Some hospitals have instituted an annual STI screening reminder into their electronic health record. Others have bundled pregnancy tests into STI test panels for females as a bulwark against congenital syphilis. Other interventions include standing protocols, presumptive treatment, and rapid testing. Standing protocols let other members of the medical team order STI panels when indicated, which reduces the burden on the provider and increases the likelihood of screening regardless of where the patient accesses the health system. Presumptive treatment of syphilis, including field-based treatment, reaches patients who may be unable to easily access care. Point of care rapid syphilis tests can ensure treatment in contexts where an immediate diagnosis is critical.
One concern is that some facilities that are not eligible for public health pricing have reported stockouts of benzathine penicillin G -- the only recommended treatment for syphilis. This single source medication inexplicably costs several hundred dollars for the series of three injections, compared to less than a dollar for 340(b) pricing. The cost has driven hospital-based pharmacies to be conservative in the quantities they keep in stock, leading to supply ruptures when the facility experiences a surge in diagnoses. Public health leadership and the manufacturer must ensure that syphilis treatment is available and affordable.
Syphilis must be viewed as a public health emergency. As with COVID-19, policymakers can make a difference by removing administrative and resource barriers that can impede the response to syphilis. Federal partners must explore new avenues to fund the fight against this surge of syphilis. As with COVID-19, strong and supportive messaging from community and medical leaders will be needed. We have tried and true tools to address this public health crisis. It is imperative to invest in these tools, prioritizing them for highest risk communities.
Jessica Leston, MPH, is the Clinical Programs Manager at the Northwest Portland Area Indian Health Board. Brigg Reilley, MPH, is the HIV/HCV Program Manager at the Northwest Portland Area Indian Health Board. These programs receive funding from the Health and Human Services Minority HIV/AIDS Fund and the Indian Health Service.