CountyBackground:
In 2018 Yakima County saw 48 cases of syphilis, a 30% increase from the previous year and above our annualaverage of 38 cases per year over the past 5 years.  Approximately half of these cases were among the MSM population but there was a significant increase in cases amongheterosexual individualsand particularly amongwomen.

There has been an increased incidence of congenital syphilis across the state as well, with potential complications including fetal loss (incidence of up to 40%) and congenital birth defects.
Syphilis is a notifiable condition in Washington State. These notificationsallowlocal public health departments to identify and treatcasecontacts. This is especially important as transmission ratesof the disease areatapproximately 30%during the early stages of contracting illness.
Primary syphilis is characterized by a painless, firm ulcer at the site of inoculation with or without local lymphadenopathy.
Secondary syphilis often presents with a generalized maculopapular rash on the trunk with or without palmar and plantar lesions. Rarely this rash can be pustular or involve wart-like lesions, mucous patches, alopecia or non-dermatologic symptoms such as malaise, fatigue, arthralgias, sore throat or lymphadenopathy.
Neurosyphilis is an uncommon but important potential complication of syphilis infection, occurring at any stage of infection and potentially leading to hearing loss, blindness, gait disturbance, paralysis, or stroke.
Syphilis can be easily treated when detected through appropriate screening.

Actions requested
:
1)Optimize syphilis surveillance in pregnancy to reduce the risk of congenital syphilis.
a.Test all women in the first trimester or at presentation to care if presenting after the first trimester
b.Test all high-risk women again in the third trimesterANDat the time of delivery. The following risks constitute “high risk”: homelessness; methamphetamine, cocaine, opioid use; exchanging sex for money, drugs, or other commodities; having a sex partner who is a man who has sex with other men.
c.Consider repeating syphilis testing in the third trimester ORat the time of delivery for all pregnant womenuntil syphilis rates in the community have decline
d.Screening for all individuals should be with RPR or EIA but any positives must be confirmed with a titer. See CDC STD treatment guidelinesor consult with a Yakima Health District Communicable Disease team member.
2)Treat anyone with symptoms of primary or secondary syphilis and anyone reporting sexual exposure to a person with confirmed syphilis. Serology is required to track treatment success but do not await results to initiate treatment. Primary syphilis, secondary syphilis and early latent syphilis are all treated with2.4million unitsbenzathine penicillin G IM once. Late latent syphilis requires three injections spaced at weekly intervals. Contact YHD or reference the CDC STD treatment guidelines below for treatment options for PCN-allergic patients.
3)Counsel all sexually active individuals about risk factors, signs and symptoms for syphilis as well as about syphilis prevention.
4)Screen all individuals at risk for syphilis or with suspected syphilis infection for neurosyphilisthrough questions about recent changes in hearing or vision. If neurosyphilis symptoms are present the individual will need more extensive testing-please consult the CDC STD treatment guidelines below, the YHD, or an Infectious Disease physician.
5)Test all sexually active men who have sex with men (MSM) at least annually, and those who have HIV or use methamphetamine every 3 months. Patients who are not sexually active or who are in mutually monogamous long-term relationships do not require screening.
6)Test heterosexuals who pay for/ receive money or drugs for sex (or who have anonymous partners)for syphilis at least annually.
7)Report all syphilis cases to the Yakima health District here within 1 working day

If you have any questions regarding lab interpretation, staging, treatment, access to medication or other aspects of syphilis diagnosis, treatment and management please contact David Miller, BSN, RN at 509-249-6532.

If your organization would benefit from further information about syphilis or a formal presentation please contact Melissa Sixberry, Director of Disease Control at 509-249-6509.

Thank you for your partnership,
Teresa Everson, MD, MPHHealth Officer, Yakima Health District

Resources
CDC 2015 STD Treatment Guidelines
Notifiable Conditions List