When Stephen Miller left primary care practice to work in public health a little less than two years ago, he said, he was shocked by how many syphilis cases the clinic was seeing.
For decades, rates of sexually transmitted infections have been low. But the Hamilton County Health Department in Chattanooga — a mid-sized city surrounded by national forests and located in the gentle Tennessee foothills — was seeing several syphilis patients a day, Miller said. A nurse who has worked at the clinic for decades told Miller that the surge of patients was a radical change from the norm.
What Miller observed in Chattanooga reflects a trend that is raising alarm bells for health departments across the country.
Nationally, syphilis rates are at a 70-year high. The Centers for Disease Control and Prevention said on Jan. 30 that 207,255 cases were reported in 2022, continuing a sharp increase over five years. Between 2018 and 2022, syphilis rates increased by about 80%. The epidemic of sexually transmitted infections — especially syphilis — is “out of control,” the National Coalition of STD Directors said.
The increase was even sharper in Tennessee, where infection rates for the first two stages of syphilis rose 86 percent between 2017 and 2021.
But this already difficult situation was complicated last spring by the lack of a specific penicillin injection that is the best treatment for syphilis. The ongoing shortage is so severe that public health agencies have advised providers to ration the drug – giving priority to pregnant patients, as it is the only syphilis treatment considered safe for them. Congenital syphilis, which occurs when the mother passes the disease to the fetus, can cause birth defects, miscarriages, and stillbirth.
Nationwide, 3,755 cases of congenital syphilis were reported to the CDC in 2022 — 10 times higher than the number a decade ago, the latest data show. Of these cases, 231 resulted in stillbirth and 51 resulted in infant death. The number of cases in babies increased by 183% between 2018 and 2022.
“Lack of timely testing and appropriate treatment during pregnancy contributed to 88% of cases of congenital syphilis,” said a report from the CDC published in November. “Testing and treatment gaps were present in the majority of cases across all races, ethnicities, and US Census Bureau regions.”
Hamilton County’s syphilis rates mirror the national trend, with cases increasing for all groups, including infants.
In November, the maternal and infant health advocacy organization March of Dimes released its annual state health outcomes report. It found that, nationally, about 15.5% of pregnant women received care from the fifth month of pregnancy or later – or attended less than half of the recommended antenatal visits. In Tennessee, the rate was even worse, at 17.4 percent.
But Miller said even those who attend every recommended appointment can run into problems because providers are required to test for syphilis only early in pregnancy. The idea is that if you test a few weeks before birth, there is time to treat the infection.
However, this recommendation depends on whether the provider suspects the patient has been exposed to the bacteria that causes syphilis, which may not be obvious for people who say their relationships are monogamous.
“What we found is that a lot of times their partner wasn’t that monogamous and they brought that into the relationship,” Miller said.
Even if the patient tested negative initially, she may have contracted syphilis later in pregnancy, when testing for the disease is not routine, he said.
Two antibiotics are used to treat syphilis, injectable penicillin and an oral medication called doxycycline.
Patients who are allergic to penicillin are often prescribed the oral antibiotic. But the World Health Organization strongly advises pregnant patients to avoid doxycycline because it can cause severe bone and tooth deformities in the baby.
As a result, pregnant syphilis patients often receive penicillin, even when they are allergic, using a technique called desensitization, said Mark Turrentine, a Houston OB-GYN. Patients are given low doses in a hospital setting to help their bodies get used to the drug and to check for a severe reaction. The penicillin shot is a stand-alone technique, unlike an antibiotic, which requires a two-week regimen.
“It’s hard to take a drug for a long time,” Turrentine said. The single injection can give patients and their clinicians peace of mind. “If they don’t come back for whatever reason, you don’t worry about it,” he said.
The Metro Public Health Department in Nashville, Tennessee, began giving all non-pregnant adults with syphilis the oral antibiotic in July, said Laura Varnier, nursing and clinical director.
Turrentine said he started seeing tips about a shortage of injectable penicillin in April, around the time the antibiotic amoxicillin became hard to find and doctors were using penicillin as a substitute, possibly accelerating the shortage, he said.
The rise in syphilis has created a demand for the injection that maker Pfizer can’t keep up with, according to the American Society of Health-System Pharmacists. “There is insufficient supply for routine orders,” ASHP said in a note.
Although penicillin has been around for a long time, making it is difficult, mainly because so many people are allergic, said Erin Fox, associate director of pharmacy for the University of Utah Health System and an assistant professor at the university who studies the drug shortages. .
“That means you can’t make any more drugs on that production line,” he said. Only large manufacturers like Pfizer have the resources to build and operate such a specialized, confined facility. “It’s not necessarily efficient — or necessarily profitable,” Fox said.
In a statement, Pfizer confirmed that the shortage of amoxicillin and the rise of syphilis increased the demand for injectable penicillin by about 70%. Representatives said the company invested $38 million in the facility that makes this form of penicillin, hiring more staff and expanding the production line.
“This increase will take some time to be felt in the market as the product cycle is 3-6 months from the time the product is manufactured to the time it is available for release to customers,” the statement said. The company estimated that the shortage would ease significantly by spring.
Meanwhile, Miller said, his Chattanooga clinic continues to strategize. Each dose of injectable penicillin can cost hundreds of dollars. Additionally, it must be placed in cold storage and expires after 48 months.
Even with the dramatic increase in cases, syphilis is still relatively rare. More than 7 million people live in Tennessee, and in 2019, providers statewide reported 683 cases of syphilis.
Health departments like Miller’s treat the majority of syphilis patients. Many patients are referred by their provider to the health department, which works with contact tracers to identify and notify sex partners who may be affected and screens patients for other sexually transmitted infections, including HIV.
“When you make the diagnosis in the office, think of it as seeing the tip of the iceberg,” Miller said. “You need a group of people to be able to explore and look at the rest of the iceberg.”
This story is part of a partnership involving WPLN, NPR and KFF Health News.
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