Public health intervention in a cocaine-related syphilis outbreak

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

Infection Risk in Sexual Contacts of Syphilis: A Systematic Review and Meta-analysis

OBJECTIVES

Current guidelines recommend offering epidemiological treatment to asymptomatic contacts of early syphilis. This is on the expectation that up to 60% of sexual contacts of patients with syphilis will be infected. However, the evidence for this figure is sparse. We performed a systematic review and meta-analysis, to estimate the proportion of sexual contacts of syphilis that are infected with syphilis.

METHODS

Two electronic databases (Medline and Embase) were reviewed in March 2021, to identify studies that reported rates of infection in sexual contacts of syphilis.

RESULTS

Of 3,051 Embase and 1,828 Medline articles identified, 32 were included in the meta-analysis. In total 36,397 contacts were tested. The proportion of contacts infected varied across the studies, ranging from 10.7% to 97.5%, resulting in considerable heterogeneity (I²=98.5%). Pooling the studies gave an estimated proportion of infected contacts of 32.6% (95% confidence interval: 26.2% - 39.7%).

CONCLUSIONS

The risk of infection in sexual contacts of syphilis reported in the literature is highly variable, with a pooled estimate of 32.6%. This will help guide decisions regarding epidemiological treatment of sexual contacts of patients with syphilis. These decisions are increasingly important in this era of antibiotic resistance, with increasing emphasis being placed on antimicrobial stewardship.

Context-Appropriate Interventions to Prevent Syphilis: A Narrative Review

BACKGROUND

The success of an intervention to prevent syphilis will depend on the context and the goal of the intervention. To help programs choose interventions, we reviewed major changes in context and types of interventions that may be effective.

METHODS

We reviewed the literature on the changing context of syphilis in the United States and interventions to prevent syphilis, focusing on articles that included evidence of effectiveness.

RESULTS

Populations acquiring syphilis are constantly changing. Currently, incidence is very high among men who have sex with men (MSM). Among adults, late disease caused by syphilis has become rare. Congenital syphilis incidence has been low but is increasing, and morbidity and mortality remain high when babies are infected. Congenital syphilis now causes more deaths than syphilis among adults.Routine screening of MSM can identify and treat infections before they progress to disease (secondary prevention). Screening rates are highest when done as part of routine standing orders. Partner notification effectiveness has decreased, partly because many partners are anonymous. Most congenital syphilis can be prevented by screening pregnant women; it has been eliminated in areas where intense primary prevention efforts eliminated syphilis among women.

CONCLUSIONS

So far, no program has stopped the increasing rates of infection among MSM, but secondary prevention efforts have prevented most disability. Congenital syphilis is increasing, and can be decreased by screening pregnant women and stopped by intensive efforts to prevent infection among women.

Public health interventions to control syphilis

Syphilis control strategies are old, but interventions have changed and there is now a more scientific approach to evidence of effectiveness. We searched PubMed using 'syphilis control' to identify papers that measured the effectiveness of interventions. We also included novel approaches and comprehensive responses to outbreaks. Few papers used high-quality research methodology and fewer evaluated impact on prevalence or incidence; most assessed intermediate outcomes. Syphilis can often be controlled by a combination of case finding, treatment and education. However, outbreaks are unique and ongoing evaluation is needed to see if interventions are producing intended intermediate outcomes at reasonable costs.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007

BACKGROUND

Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens.

METHODS

Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated.

RESULTS

Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from $144 to $3454. Data quality from other venues varied greatly between sites and was often poor.

CONCLUSIONS

Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

The intersection between HIV and syphilis in men who have sex with men: some fresh perspectives

Syphilis is increasing in men who have sex with men and disproportionately affects HIV-infected men. Here we review the epidemiology, diagnostic techniques, treatment guidelines, follow-up procedures and control of syphilis. The difference in these factors in HIV-infected men and uninfected men and evidence for this is reviewed. We explain that HIV-infected men are at higher risk of syphilis acquisition as a result of different behavioral factors. Thus, some control strategies may be different for HIV-infected men owing to these factors and also because HIV-infected men are more closely linked with medical care. There is no strong evidence to suggest there should be any differences in diagnostic techniques, treatment guidelines or follow-up procedures between HIV-infected and uninfected men.

Misclassification of the stages of syphilis: implications for surveillance

SHORT SUMMARY

Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested.

BACKGROUND

Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions.

OBJECTIVE

Assess validity of reported syphilis stages.

METHODS

Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions.

RESULTS

Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age < or =35 and nontreponemal test titer > or =32) was often misinterpreted to mean "not known." Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers.

CONCLUSIONS

The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

Congenital Syphilis Resurgent

Syphilis is resurgent in many parts of the world. Even in those countries where rates have fallen focal outbreaks still occur. Congenital syphilis is an inevitable consequence of undetected and untreated syphilis in a pregnant woman. Universal screening in pregnancy, even if the positive yield from the test is low, remains the keystone to congenital syphilis prevention. Programmatic attention to testing, treating, education, and contact tracing in pregnancy and subsequent late trimester retesting of high-risk women will lower congenital infection rates. Any slip in this meticulous process inevitably leads to resurgence of congenital syphilis.

Targeted mass treatment for syphilis with oral azithromycin

From mid 1997 to end of 1999, there was a sexually-transmitted infectious syphilis outbreak mainly in heterosexual people in British Columbia, Canada, that was concentrated in Vancouver. The rate across the province increased from less than 0.5 to 3.4 per 100000, and the rate in Vancouver reached 12.9 per 100000. We aimed to eliminate the syphillis outbreak by treating people at risk of infection. In 2000, a targeted mass treatment programme provided azithromycin (1.8 g orally) to 4384 at-risk residents in this city. After the programme, syphilis frequency fell significantly for 6 months (p=0.016), but rose again in 2001. Results from curve fitting analyses showed that the number of cases in 2001 (177) was higher than expected (0.0001<p<0.0044). This rate rebound and the absence of a sustained effect suggest that targeted mass treatment for syphilis, even though feasible, should not be done routinely.

Elimination and reintroduction of primary and secondary syphilis

OBJECTIVES

This study was conducted to define factors associated with the epidemic spread, elimination, and reintroduction of primary and secondary syphilis in King County, Washington, from 1987 through 1998.

METHODS

Reports of primary and secondary syphilis in King County from 1987 through 1998 were reviewed retrospectively.

RESULTS

During the epidemic spread of syphilis, only 15.8% of cases were imported. A total of 24.0% of patients reported cocaine use, and 18.3% of female patients reported having commercial sex. During the elimination of syphilis, significantly higher percentages of cases were imported and lower percentages of patients reported cocaine use or female commercial sex. During the reintroduction of syphilis in 1997-1998, 68% of patients were men who reported sex with men; of this 68%, 66% were sero-positive for HIV. Most men reporting sex with men were 30 years or older and recruited many anonymous partners.

CONCLUSIONS

As syphilis wanes, local control must focus on outbreaks following its reintroduction. Resurgence of syphilis among men reporting sex with men recapitulates the epidemiology of syphilis before the historical advent of AIDS, warranting immediate attention to this problem.

Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features

Syphilis is a chronic disease with a waxing and waning course, the manifestations of which have been described for centuries. It occurs worldwide, and the incidence varies significantly with geographic location. Transmission is mainly by sexual contact. The causative organism, Treponema pallidum, was first described in 1905, but because of the inability to culture the organism and the limitations of direct microscopy, serologic testing is the mainstay of laboratory diagnosis. The disease has been arbitrarily divided into several stages. The primary stage is defined by a chancre at the site of inoculation. The secondary stage is characterized by a polymorphic rash, lymphadenopathy, and other systemic manifestations. A variable asymptomatic latent period follows, which for epidemiologic purposes is divided into early (<1 year) and late (>1 year) stages. The early stages (primary, secondary, and early latent) are potentially infectious. The tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system. Congenital infection may result in protean early or late manifestations. Unlike many other bacteria causing infectious diseases, the organism remains sensitive to penicillin, and this remains the mainstay of therapy.

Screening and empiric treatment for syphilis in an inner-city emergency department

OBJECTIVE

To examine targeted screening and empiric treatment for syphilis in an urban ED.

METHODS

Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university-affiliated, inner-city ED. Emergency patients who perceived that they had high-risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high-risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR-positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination-Treponema pallidum (MHA-TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum.

RESULTS

Of 806 patients presenting to the ED, 276 (34%) admitted to high-risk behavior. Of 373 patients tested by RPR in the ED (216 high-risk and 157 control patients), no significant difference was found between the high-risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA-TP [47 (22%) vs 25 (16%)]. In the high-risk group, the women were more likely than the men to be MHA-TP-positive (OR = 2.58, 95% CI 1.12-7.98, p = 0.04). Among the women, the MHA-TP was more often positive for the high-risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12-4.67, p = 0.023). For the high-risk group, seven (3%) new cases of syphilis were managed empirically, vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high-risk patients and five of 155 (3%) control subjects (p = 0.13).

CONCLUSION

This inner-city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow-up.

Emergency department-based surveillance for syphilis during an outbreak in Philadelphia

STUDY OBJECTIVE

To identify missed opportunities for syphilis treatment during an outbreak.

DESIGN

Prospective prevalence survey.

SETTING

Urban hospital emergency department.

PARTICIPANTS

Nine hundred sixty-one persons aged 15 to 44 years seeking medical attention in the ED who were not suspected of having any sexually transmitted disease (STD) at the time of their visit.

INTERVENTION

Serologic testing for syphilis and public health follow-up as needed.

MEASUREMENTS AND MAIN RESULTS

Twenty-one non-STD patients (2%) had untreated early syphilis, and 22 (2%) had positive serology but were lost to follow-up. Among 271 STD patients seen in the ED during the same period, 15 cases (6%) were detected. We estimate that 80 or more additional untreated early syphilis cases would have been identified had all 15- to 44-year-old patients entering the ED been tested. The cost of screening was $251 per case detected.

CONCLUSION

Patients not suspected of having any STD account for most early syphilis cases among all ED patients. Screening and on-site treatment for syphilis should be offered to all young adults seeking medical attention in the ED during syphilis outbreaks.

The phenomenon of abusable psychotropic use among North American youth

Abusable psychotropic use can, and does, affect all North American youth, either directly or indirectly, regardless of age, gender, culture, ethnic background, education, race, or socioeconomic status. Over the last decade, the morbidity and mortality associated with abusable psychotropic use among youth have become staggering. A current overview of the phenomenon of abusable psychotropic use among youth in North America, including the use of alcohol, cannabis, cocaine, LSD, nicotine, and polyabusable psychotropic use, is presented with attention to the expanding role of clinical pharmacologists in relation to both prevention and treatment. The Mega Interactive Model of Abusable Psychotropic Use Among Youth is presented as a heuristic device to assist clinical pharmacologists, and other health care providers, in addressing the multifactorial interactive aspects of this complex phenomenon as observed in the pediatric age group. In this regard, attention is given to the interaction of the Abusable Psychotropic Dimension, including the Abusable Psychotropic Variables (e.g., pharmacokinetics, abuse potential) and Pattern of Use Variables (e.g., social use, abuse, compulsive use), with the Young Person, Societal, and Time Dimensions.

Entangled epidemics: cocaine use and HIV disease

Over the past decade, two epidemics have had a severe impact on public health in this country. These health problems involve cocaine abuse and AIDS (or HIV disease). The processes of these two conditions are clearly not independent of each other and may be quite complex. Understanding of this relationship has been hampered by a myriad of social, biological and behavioral variables that are entangled with the basic cocaine-HIV association. This article presents a paradigm for discussion of the interaction between cocaine exposure and HIV disease based on three mechanisms: the relationship between cocaine exposure and increased opportunity for HIV exposure, the direct role that cocaine plays in altering susceptibility to HIV infection, and the influence that cocaine use has on the progression of HIV disease. The goal of this structured approach is to enhance conceptual understanding of the cocaine-HIV relationship while recognizing the complexity of the issue and the limitations of current research efforts. This model will serve as a framework for the discussion of implications for future research, clinical practice, and public policy.

Three models to promote syphilis screening and treatment in a high risk population

Three syphilis control models targeted at a high incidence area were implemented and evaluated over a 31-month period. These models consisted of (1) street-based outreach and referral to community health clinics for free sexually transmitted disease screening and treatment, (2) off-site syphilis screening at high risk locations and referral for free treatment, and (3) off-site syphilis screening and referral at high risk locations with monetary incentives offered for obtaining test results and seeking treatment if required. Off-site screening--conducted at homeless shelters, soup kitchens, drug treatment centers, and community fairs--was found to be significantly more effective in promoting syphilis screening than outreach and referral to community health centers. For the off-site screening models, monetary incentives were related to an increase in the proportion of individuals at homeless shelters and soup kitchens who agreed to be tested, and to an increase in the proportion of people at homeless shelters, soup kitchens and drug treatment centers who sought their test results and obtained treatment, if required.