Comeback of syphilis

Sacramento Bee - Nov. 27, 2001
http://www.sacbee.com/content/news/story/1233283p-1301723c.html
Comeback of syphilis stuns officials
The outbreak is linked to high-risk sexual behavior of gay and bisexual men.
By Aurelio Rojas

Last of three parts.

LOS ANGELES - Syphilis rates were at historic lows, and Los Angeles County was ahead of the federal government target for eliminating the ancient sexual scourge. The disease had nearly disappeared in the county's gay population early last year when doctors at an AIDS Healthcare Foundation clinic began diagnosing the first of two dozen cases involving gay or bisexual men.

Health officials were alarmed - syphilis is often a precursor of a jump in other sexually transmitted diseases, including AIDS. In response, they launched a $560,000 safe-sex media campaign and four months later declared the outbreak under control.

This summer, as a 37-year-old floral designer named Todd was trying to make sense of a rash spreading over his body, health officials made a startling about-face. They admitted syphilis was now endemic among men who have sex with men, meaning it would be around for the foreseeable future.

"Everyone I know knows I'm HIV positive, but only my therapist and best friend know I have syphilis," said Todd, who agreed to be interviewed on the condition his last name not be used. "It's not something anyone wants to admit."

Bucking a nationwide decline, syphilis rates are rising in parts of California, including Sacramento County. The latest surge has been mostly confined to men who have sex with men, but syphilis has historically been a heterosexual disease, and health officials fear bisexual men may be infecting their female partners.

A Centers for Disease Control and Prevention (CDC) official blames the outbreak in Los Angeles on a "combination of denial and incompetence." Investigators discovered most men who contracted the disease shrugged off the lessons of the AIDS epidemic and had unprotected sex, often with multiple partners they did not know and met in public places or through the Internet.

As the problem developed, the same county-based public health system responsible for sounding an alarm in the event of a bioterrorism attack failed to detect the outbreak. Such an attack would probably surface as do most infectious diseases - first identified by local doctors or by the local health department. But until the AIDS Healthcare Foundation reported the first syphilis cases, doctors were failing to diagnose the disease or were ignoring a state law that requires them to report any cases of 85 communicable diseases to the county.

The law is rarely enforced, and fewer than a handful of doctors have been cited or fined under a 4-year-old state law that was supposed to crack down on violators. Dr. Jonathan Fielding, the county's health officer, said some syphilis cases were reported six months late because doctors were too busy or thought someone in their office would do the paperwork. "It would have been much better earlier because we would have had more time to stop the transmission," Fielding said.

The outbreak is a setback for the national syphilis elimination project, launched two years ago by the Centers for Disease Control. Defeating syphilis would mean eliminating a communicable disease without a vaccine for the first time in U.S. history.

Michael Weinstein, president of the AIDS Healthcare Foundation, said the county erred by prematurely declaring victory over the outbreak and failing to sustain its prevention campaign in the bars and bath houses where syphilis was making its resurgence. "The public health people are so few in numbers, they're always running from fire to fire," Weinstein said. "There's never enough resources because (sexually transmitted diseases) make most politicians uneasy. We live in a hedonistic society with moralistic attitudes."

Ailments transmitted through sex make up more than 75% of infectious diseases reported in California. Teenagers account for about a quarter of the estimated 1.2 million new sexually transmitted disease cases reported each year.

New strains are identified each decade, and one relative newcomer, chlamydia, is the leading cause of preventable infertility in women. Indeed, women bear the disproportionate burden of such STD-related complications as inflammatory disease and cancer of the reproductive tract.

Health officials say stagnating budgets for public health, the closure of dedicated STD clinics and the growth of managed care organizations have reduced screening and other prevention services as well as rapid case detection and treatment. Not only is syphilis on the rise in California, but after a three-decade decline, so is gonorrhea.

Public health officials say funding levels have not allowed them to keep pace with infectious diseases they encounter on a day-to-day basis. Amid new fears that a disease such as smallpox could be weaponized by terrorists, they say they cannot guarantee such an attack would be detected quickly. "It depends on the condition and the agent and all those things," said Dr. James Haughton, Los Angeles County's medical director of public health. During last year's Democratic National Convention, Haughton said, the county had a "very aggressive" surveillance system designed to detect any bioterrorism attack. "Together (with the CDC) we staffed people around the clock and had computer-based programing and all of that," he said. "We need those tools every day."

Intervention - the hallmark of effective communicable disease strategy - requires ample staff to follow up on cases. But when it comes to sexually transmitted diseases, fewer than 100 county employees in California are assigned full-time to prevention programs, according to the California Conference of Local Health Officers. "Many counties ask the state for assistance in carrying out their activities because they don't have the resources at the local level," said Dr. Gail Bolan, chief of the STD Control Branch of the state Department of Health Services, which has about 50 investigators. "When you have over 95,000 cases of chlamydia like we did last year, there's no way we have enough staff to follow up on those cases."

There was a time when Los Angeles County aggressively investigated STD cases by locating the partners of patients and treating them, if necessary, Fielding said. He said it now has too many cases to do that effectively.

To illustrate how disease surveillance and containment should work, Fielding cited a strategy that has nearly eradicated measles since an outbreak in 1991-92 cost the state $31 million. "The reason we do a good job with measles is that every time we get a case, it's a big deal," he said. The strategy involves building a fire wall around victims, as well as testing and treating people who have been in close contact.

Until recently, that approach had been working with syphilis - a disease that can be easily treated with penicillin. Left unchecked, it can spread with great efficiency, and the sores the disease causes can make it easier for AIDS to spread. Syphilis can also lead to dementia, paralysis, blindness and death.

Lee Klosinski, director of education for AIDS Project Los Angeles, said doctors who did not report the initial cases in Los Angeles "may have thought they were doing their patients a favor."

"They didn't want to subject them to embarrassing follow-up interviews and questions about their partners," Klosinski said. But Bolan said the syphilis bacterium often hides in a body. Some doctors may have failed to detect it or perhaps mistook it for herpes. Indeed, syphilis has been called the "great imitator" because many of its symptoms are indistinguishable from those of other diseases.

In Los Angeles this year, the number of syphilis cases involving men who had sex with men rose 39% through October compared with the same 10-month period last year. Cases have almost doubled in San Francisco, while Sacramento County - which reported only one case last year - has already recorded 10 cases this year, six involving men who had sex with men.

"Our tools to control syphilis are being challenged by this epidemic because many cases involve anonymous sex - making it difficult to track down the partners," Bolan said. Studies show that both HIV-negative and HIV-positive people, encouraged by powerfully effective drug cocktails and longer life-spans for AIDS patients, have reverted to riskier sexual behavior. Todd acknowledges he had anonymous sex with men he met in clubs or picked up on the street - a practice he has since curtailed. "I wasn't thinking I'd get syphilis," he said. "But when you manage to survive with HIV, you start thinking like that."

This summer, as a chicken-pox-like rash was spreading over his body, a county health department investigator left a note on his door asking him to telephone. "When I called the health department, a woman told me she thought I had syphilis because a man I'd been with had become infected," Todd recalled.

He doesn't know anyone else who admits to having it, and neither does Klosinski. "The (disease surveillance) system probably works better in communities where this has not been an issue," Klosinski said. "But I don't think the public health people were ready for this in this community. Just like they weren't ready for HIV."

A 1998 survey by the California Conference of Local Health Officers estimated it would take a $22 million infusion from the state to shore up local disease surveillance statewide - a proposal that has not generated much support in Sacramento.

Among the most pressing needs cited by health departments were strengthening general communicable disease surveillance, sexually transmitted disease programs and public health laboratories.

Some states, for example, have developed a central computer system for timely reporting of sexually transmitted diseases. But in California, "five cases could be happening at the same time in five counties and we wouldn't know about it until we got the reports," Bolan said.

Like syphilis, smallpox and anthrax can be difficult to diagnose. Indeed, the family of a postal worker who died last month after inhaling anthrax has sued his health maintenance organization for misdiagnosing his symptoms as a cold. Wonders Cesar Portillo, an AIDS Healthcare Foundation outreach worker: "How are we ever going to stop anthrax or smallpox when we couldn't stop syphilis?" It may be, however, that the anthrax attacks that hit the East Coast this fall will do for the public health system what years of lobbying at the state and local level could not. Sens. Edward Kennedy, D-Mass., and Bill Frist, R-Tenn., have introduced a bill that would provide $3.2 billion to fund an array of public health defense programs. Advocates say even if the nation never experiences a large-scale bioterrorism attack, the money would benefit other disease surveillance. "There is no local solution to this problem," Haughton said. "The fact is, all the things that we're doing, trying to keep this thing afloat - we're really nibbling around the margins."

The Bee's Aurelio Rojas can be reached at (916) 326-5539 or arojas@sacbee.com