Syphilis on the rise again in Sonoma County after taking dip during pandemic

After modest declines during the pandemic, cases of syphilis, a dangerous sexually transmitted infection, are creeping upward in Sonoma County.

There have been 144 cases of early-stage syphilis detected this year, compared with 116 cases in 2021 — a 24% increase, county health officials said. In 2020, there were 120 cases.

The increase has local health officials and medical professionals concerned about further spread, particularly among expecting mothers who are at risk of infecting babies at birth.

Gabriel Kaplan, director of the Sonoma County Public Health Division, said the reasons for the spike are unclear, adding that syphilis “waxes and wanes” periodically.

“Now, that may have been because people weren't getting tested (during the pandemic) and that's why the numbers were low,” he said. “It may have been that people were avoiding the doctor. It may have been people weren't seeing other people during the pandemic and so the numbers were low. But we do see a number that is resurgent in this county relative to the last two years.”

Kaplan and other local health officials said the local increase mirrors similar increases in the state and across the country.

Of particular concern for health care professionals are cases of congenital syphilis, in which a mother passes the infection on to her baby during pregnancy. Between 2017 and 2021, there were seven probable cases of congenital syphilis.

Across the country, during that same four-year period, the number of syphilis cases increased 68% to 171,074 cases in 2021. Meanwhile, congenital syphilis increased 115% to 2,021 cases last year, according to data from the federal Centers for Disease Control and Prevention.

Syphilis is a sexually transmitted disease that if left untreated can cause serious health problems. It is usually contracted through direct skin-to-skin contact with a syphilis sore during vaginal, anal or oral sex. You can’t get it through casual contact with objects like toilet seats, doorknobs, hot tubs or by sharing clothing or eating utensils.

In the United States, most cases of syphilis are among gay, bisexual and other men who have sex with men, according to the CDC. Syphilis rates among men who have sex with men have increased nearly every year for about 20 years, the agency said.

But anyone can contract syphilis, said Dr. Erin Lund, a family medicine and obstetrics provider at Santa Rosa Community Health and founder of the its New Beginnings Program for high-risk pregnant patients and their babies.

Lund said that like other sexually transmitted diseases, rates of syphilis rise and fall in waves. Lund said many cases are being detected among people experiencing homelessness and those with substance use disorders, but not exclusively.

“We're seeing it in a whole host of patients, regardless of those risk factors, just because the rates are now increased in our community,” she said. “So anybody who's having intercourse is potentially at risk, depending on how many partners they've had and who those partners may have been with.”

Lund said increases in syphilis rates raise concerns about possible increases in HIV infections, as syphilis is a marker for higher-risk sexual practices. What’s more, she said an active sexually transmitted infection such as syphilis makes one more vulnerable to HIV; such an infection can “affect how easy it is for HIV to penetrate and get into the body,” she said.

Lund said 15 years ago syphilis cases were primarily found in men who have sex with men, but it has since increasingly spread among the heterosexual population.

“And so our rates we're seeing in female patients has gone up dramatically,” she said, stressing the importance of getting screened regularly for those who are sexually active.

“It should become sort of part of routine, STI screening,” she said. “And until you know your partner’s status, you should use condoms. We know condoms … are very effective at preventing infection.”

Symptoms include a painless ulcer or chancre in the genitals, usually soon after infection. But Lund said there is usually no pain and symptoms can often go unnoticed, making it difficult to determine when the person was infected.

When detected early, treatment consists of a single shot of penicillin. Later stages of infection require three shots a week apart. Regular testing or screening can mean the difference between one or three painful shots.

“People who aren't getting tested regularly, we don't know how often they might have had it,” she said. “So, then we do we treat them with three shots of penicillin a week apart to be safe.”

Dr. Sundari Mase, the county’s health officer, said syphilis can be best treated through early detection, and anyone who is at risk of infection should be screened and tested. In the case of women who are pregnant, it’s especially important to establish strong prenatal care and to do all the screen tests that are required.

“The people who are falling through the cracks are those who don’t have prenatal care,” Mase said. “That’s who we need to be reaching out to.”

Current screening requirements for pregnant women call for syphilis testing during the first trimester, again during the third trimester and also during delivery. The battery of tests throughout the pregnancy ensures that a syphilis infection is not missed.

“If it’s a high-risk OB setting, we definitely want people to be tested three times because they can be sexually active up until the day they deliver,” said Alan Powell, a public health investigator with the county Department of Health Services.

Powell, who is among the county’s staff that does outreach to those at high risk of contracting syphilis, said that throughout the state congenital syphilis has primarily seen among those who use methamphetamine, but also fentanyl and heroin. They’re often homeless or lack prenatal care, he said.

“We have those same risk factors here in Sonoma County, so our goal is to do outreach and education in that population,” he said.

Powell said county health services staff link up with local health care providers like Providence and Santa Rosa Community Health to “wrap our arms” around anyone at high risk of contracting syphilis and may not follow through with their prenatal care schedule.

“Often it's not just getting somebody diagnosed, but also helping them stay motivated to continue with their prenatal appointments all the way to the very end,” Powell said.

People who are homeless often find it difficult to go to the a clinic or doctor’s office, he said. “We, in essence, bring the clinic to the street … by going into the homeless camps and doing rapid syphilis test, rapid HIV tests.”

The California Department of Public Health has in recent years called on local public health agencies to ramp up testing of both HIV and syphilis among high-risk groups to address alarming increases in both congenital syphilis and perinatal HIV.

Last November, the state public health agency issued screening and testing guidance that recommended opt-out HIV and syphilis testing for all pregnant patients receiving services at emergency departments; urgent care clinics; jails; mental health, drug treatment, and syringe services programs; and street medicine or homeless outreach programs.

The guidance also called for screening pregnant patients for HIV at least once and for syphilis three times during pregnancy. The state pointed out that significant racial disparities have been observed, with rates of congenital syphilis among black and Native American infants significantly higher than that of the state overall.

Lund stressed the importance of early diagnosis during pregnancy.

“What’s essential is having people get into prenatal care as early as possible and getting those labs done as early as possible, so that we can identify early and treat early and the bacteria doesn't have a chance to cross the placenta and affect the baby,” she said.

Lund said the number of syphilis cases among pregnant patients has steadily grown in recent years.

In 2019, 446 cases of congenital syphilis were reported in the state, the highest number of cases since 1993. The following year, there were six perinatal HIV transmissions in California, compared with four the previous year and three in 2018.

“We have encountered five to 10 pregnant patients a year in our practice at Santa Rosa Community Health as opposed to none in my practice 15 years ago,” Lund said. “Of those prenatal cases, most of them get treated early enough that we prevent transmission to the baby.”

But she said every year, her practice sees patients get diagnosed late in their pregnancy, which requires the baby to be treated with antibiotics for 10 days in the neonatal intensive care unit for presumed congenital syphilis.

“As far as I’m aware none of these babies have had physical effects of these infections but it is a concerning trend,” she said.

In contrast, at Kaiser Permanente Santa Rosa Medical Center, a fully integrated health care system with a smaller share of the county’s indigent patients, has not seen significant increases in the number of cases of prenatal syphilis.

Dr. Kristin Steuerle, a pediatric hospitalist at Kaiser Santa Rosa and chief of the inpatient pediatrics department, said Kaiser also has robust testing and screening requirement.

“We've been very fortunate, mostly because people do have good prenatal care, and come to their appointments … because of that we actually are not seeing an increase in cases within our system and not really a significant increase during the pregnancy,” said Steuerle, who is also medical director of Kaiser’s regional newborn program.

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @pressreno.