Sat in today on communicable disease workshops happening at the Friday Center
One of the sessions was about the state’s current syphilis outbreak by the always entertaining Peter Leone .
And, yes, you’re not misreading that: NC currently has an outbreak of syphilis (PDF). In 2008, there were 509 cases. That number jumped to 937 in 2009, nearly double. Leone says without prompt intervention, those numbers will go even higher. They’re trending that way for 2010.
Syphilis rates for select counties
Leone talks about the numbers of cases increasing in Mecklenburg, Forsyth, Wake and Wayne . Other counties have cases, but the epidemic is concentrated in those counties. Leone who reminds us that ‘people don’t stay at home to have sex’ and that’s why the outbreak has been ongoing for a couple of years now, with nodes in places that tend to be located on interstate highways. Following that logic, Leone says Guilford County should have more cases than it does. Numbers there have been remarkably low, with little variation in cases, but he notes that’s starting to change.
Mecklenburg has been climbing steadily, more than 174 cases in 2009 (up from 91 cases in 2008). And as Leone has said, “as Mecklenburg goes, so goes the state.”
What’s really sad is that in Forsyth, numbers had dropped to one case of primary syphilis (the infectious stage of the disease) in 2003. Only ONE case. But in the typical fashion, when public health professionals are successful, no disease happens, so the problem is over, right?
Nonetheless, numbers drop, presto, blammo, funding gets cut. It’s the way of the world in public health – Forsyth’s syphilis prevention funding was cut in 2006.
Predictably, three years after the funds went away, cases had climbed to 46 in Forsyth, giving the county the highest rate in the state.
So, the big question is why. Leone warns against making simple inferences from the numbers and coming up with simple solutions. He says the increase of syphilis is a multifactorial issue, tied in with race, poverty, sexuality and education.
The short answer is that numbers are climbing most in the black MSM community (men who have sex with men). There are now different ways for people to connect, and they’re doing just that.
“Folks can’t get STD online, but they can find one another and hook up that way,” says Leone.
And hook up, they do. And they hook up with friends, and friends of friends. Leone says providers need to question folks about more than just whether or not they’re engaging in risky behavior, but to ask about their partners and friends, too. Just take a look at this diagram from a disease investigation. All those circles represent folks who came up with syphilis. Investigators asked about direct sexual contacts, but not friends, etc. So, it looks as if some of those cases are pretty random…
Tracing sexual contacts in a syphilis outbreak
But, it’s not terribly surprising that people who have syphilis might end up knowing other people who might end up having syphilis. They engage in similar activities, perhaps have sex with one another… and when you start asking about social contacts, friends, etc, this is what you get.
Start asking about who knows who and this is what you get.
And it’s not just a problem for ‘them,’ i.e. those men who are having sex with men. To illustrate, he told a story about a woman who was in a ‘monogamous’ relationship for 14 years. Well… at least she thought the relationship was monogamous, until she was diagnosed with HIV.
Leone urges routine HIV AND syphilis screening for anyone who comes into STD clinics across the state. They travel together.
And he says syphilis harbinger of more HIV cases out there that aren’t being caught, syphilis has a short transmission time, so people who come up with it are often an indicator of where HIV will end up moving.
Can we stop talking about Tuskegee yet?
Leone says he’s not seen as many co-infected cases of syphilis and HIV in black MSM, ever.
“Syphilis is an old disease, the reason we see it is because of societal issues, not behavior alone,” he says. Leone notes some of the people coming up with the disease are teens.
“Is there something particular about a 15 year old MSM that he’s having lots of sex?” Leone asks. He says the reasons behind the behavior are wrapped up in lots of societal issues. For one thing there’s still a lot of distrust in the African American community of public health folks. Talk about syphilis – um, remember. Tuskegee was ALL about syphilis. So it’s a sensitive topic.
“It’s about how we treat MSM, how we treat minorities, how we treat kids,” Leone says. “If you’re a 15 year old who’s just figured out you’re gay, and you’re out of school for the summer and there’s no adult supervision, no recreational activities. PLUS if you’re ostracized from your church… and community… and school because you’re gay, you relate by getting together with other kids like you. You’re gonna have sex.”
Leone says we’ve spent years looking for a vaccine, a clean, silver bullet, but one hasn’t emerged. What we haven’t done as a society is the same kind of work around homophobia, poverty, racism, etc.
So, for example, Leone says public health leaders should be talking about 100% graduation from high school as being effective for STD control. And that’s not just about getting comprehensive sex ed or not. Leone notes knowledge doesn’t result in behavior change often. So, while those young MSM who are engaging in risky behavior ARE the generation who didn’t have comprehensive sex ed, that’s not the only factor behind the risky behavior.
Even when we have done comprehensive sex ed, Leone says we’ve done sex ed the same way we’ve approached smoking – tell ’em to just stop having sex.
“But you’re not going to stop people from having sex. You’re just not,” Leone says.
Leone was followed by Connie Jones and Holly Watkins to talk about how state health officials are working with counties in a syphilis epidemic response team. One small part of their effort is a series of public service announcements being aired on local channels. Take a look:
They’re also heading out to clubs to do on site testing.
Keep your ears open. I’m going to do a story on this!!