Surge in syphilis cases leads some providers to ration penicillin

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When Stephen Miller left his primary care practice to work in public health two years ago, he said, he was shocked by how many syphilis cases were being treated at the clinic.

For decades, rates of sexually transmitted infections were low. But the Hamilton County Health Department in Chattanooga — a mid-sized city surrounded by national forests and located in the Appalachian foothills of Tennessee — was seeing several syphilis patients a day, Miller said. A nurse who has worked at the clinic for decades told Miller that the wave of patients was a radical departure from the norm.

What Miller observed in Chattanooga reflects a trend that is alarming for health departments across the country.

Nationwide, syphilis rates are at a 70-year high. The Centers for Disease Control and Prevention reported that Jan. 30 that 207,255 cases were reported in 2022, continuing a steep increase over five years. Between 2018 and 2022, syphilis rates will increase by nearly 80%. The epidemic of sexually transmitted infections — especially syphilis — is “out of control,” says the National Coalition of STD Directors.

The surge was even more pronounced in Tennessee, where infection rates for the first two stages of syphilis increased by 86% between 2017 and 2021.

But this difficult situation was complicated last spring by a shortage of a specific penicillin injection, a treatment for syphilis. The ongoing shortage is so acute that public health agencies have recommended that drug providers be rationed — giving priority to pregnant patients, since it is the only syphilis treatment considered safe for them. Congenital syphilis, which occurs when the mother transmits the disease to the fetus, can cause birth defects, miscarriage, and stillbirth.

Nationwide, 3,755 cases of congenital syphilis were reported to the CDC in 2022 — more than 10 times the number a decade ago, the latest data show. Of these, 231 resulted in stillbirths and 51 resulted in infant deaths. Between 2018 and 2022, the number of cases involving children has increased by 183%.

“Lack of timely testing and adequate treatment during pregnancy contributes to 88% of cases of congenital syphilis,” according to a report from the CDC released in November. “Testing and treatment gaps were present in most cases across all races, ethnicities, and US Census Bureau regions.”

Syphilis rates in Hamilton County mirrored national trends, with cases increasing among all groups, including children.

In November, the maternal and child health advocacy organization March of Dimes released its annual report on states’ health outcomes. It found that, nationwide, about 15.5% of pregnant women received care in the fifth month of pregnancy or later – or less than half of the recommended prenatal visits. In Tennessee, the rate was even worse, at 17.4%.

But Miller said even those who attend every recommended appointment can run into problems because providers are only required to test for syphilis early in pregnancy. The idea is that if you test a few weeks before birth, there is time to treat the infection.

However, that recommendation depends on whether the provider suspects that the patient has been exposed to the bacteria that causes syphilis, which may not be obvious to those in a monogamous relationship.

“What we found was, a lot of times their partner wasn’t monogamous and they were bringing that into the relationship,” Miller said.

Even if the patient initially tests negative, they may contract 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 drug called doxycycline.

Patients allergic to penicillin are often given oral antibiotics. But the World Health Organization strongly advises pregnant patients to avoid doxycycline because it can cause severe deformities of the baby’s bones and teeth.

As a result, pregnant syphilis patients are often given penicillin, even when they are allergic, using a technique called desensitization, says Houston OB-GYN Mark Tarrantine. Patients are given lower doses in a hospital setting to let their bodies get used to the drug and check for a severe reaction. A penicillin shot is a one-and-done strategy, unlike an antibiotic, which requires sticking to a two-week regimen.

“Taking a medication for a long time is hard,” Turrentine said. A single injection can provide peace of mind to patients and their physicians. “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 oral antibiotics to all nonpregnant adults with syphilis in July, said Laura Vernier, director of nursing and clinical practice.

Tarrentine said she began seeing counselors about the injectable penicillin shortage in April, at a time when the antibiotic amoxicillin had become harder to find and doctors were using penicillin as a substitute, exacerbating the potential shortage, she said.

According to the American Society of Health-System Pharmacists, the rise in syphilis has created demand for the injection that manufacturer Pfizer can’t keep up with. “There is insufficient supply to place general orders,” ASHP said in a memo.

Although penicillin has been around for a long time, it’s still difficult to manufacture because so many people are allergic, said Erin Fox, associate chief pharmacy officer at the University of Utah Health System and an associate professor at the university who studies drug shortages. .

“That means you can’t make another drug on that production line,” he said. Only large manufacturers like Pfizer have the resources to build and operate such specialized, cordoned-off facilities. “It’s not necessarily efficient — or necessarily profitable,” Fox said.

In a statement, Pfizer confirmed that amoxicillin shortages and an increase in syphilis have increased demand for injectable penicillin by nearly 70%. Representatives said the company has invested $38 million in facilities that produce this type of penicillin, hiring more workers and expanding production lines.

“This ramp up will take some time to be felt in the market, as the product cycle time is 3-6 months from when the product is manufactured to when it is available for release to customers.” The agency anticipates that the deficit will ease significantly by spring.

In the meantime, Miller said, his clinic in Chattanooga continues to be tactful. Each dose of injectable penicillin can cost hundreds of dollars. Also, it has to be kept in cold storage and it 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 reported 683 cases of syphilis statewide.

Health departments like Miller treat most syphilis patients. Many patients are referred to health departments by their providers, who work with contact tracers to identify and notify sex partners who may be infected and to test patients for other sexually transmitted infections, including HIV.

“When you diagnose in the office, think of it as seeing the tip of the iceberg,” Miller said. “You need a team of people to be able to explore and see the rest of the iceberg.”

This story is part of a partnership that includes WPLN, NPR and KFF Health News.

Kaiser Health NewsReprinted from this article khn.orgA national newsroom that produces in-depth journalism about health issues and is one of KFF’s core operating programs – the independent source for health policy research, polling and journalism.

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