Vials of penicillin for injection are kept refrigerated at the Metro Public Health Department in Nashville, Tennessee. Penicillin injections are the go-to treatment for syphilis and are the only treatment considered safe for pregnant people with the disease.
Katherine Sweeney/WPLN
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Katherine Sweeney/WPLN
Vials of penicillin for injection are kept refrigerated at the Metro Public Health Department in Nashville, Tennessee. Penicillin injections are the go-to treatment for syphilis and are the only treatment considered safe for pregnant people with the disease.
Katherine Sweeney/WPLN
When Stephen Miller left primary care to work in public health a little less than two years ago, he said he was shocked by the number of syphilis cases the clinic was treating.
For decades, rates of sexually transmitted diseases were low. But the Hamilton County Health Department in Chattanooga, a medium-sized city surrounded by national forests and located in Tennessee's Appalachian foothills, was seeing several syphilis patients a day, Miller said. Nurses who have worked in clinics for decades told Miller that the wave of patients is a radical change from normal.
What Miller observed in Chattanooga reflects a trend that is alarming health departments across the country.
Nationwide, syphilis rates are at their highest in 70 years. The Centers for Disease Control and Prevention announced on January 30 that 207,255 cases will be reported in 2022, continuing a five-year surge. From 2018 to 2022, the incidence of syphilis increased by approximately 80%. The National Association of Sexually Transmitted Disease Officers said the epidemic of sexually transmitted diseases, particularly syphilis, is “out of control.”
This surge was even more pronounced in Tennessee, where the first two stages of syphilis infection rates increased by 86% between 2017 and 2021.
But this already difficult situation was further complicated last spring by a shortage of a certain penicillin injection, the go-to treatment for syphilis. The ongoing shortage is so severe that public health authorities are urging health care workers to prioritize pregnant patients by giving them the drug because it is the only syphilis treatment considered safe for pregnant women. It is recommended that they be distributed. Congenital syphilis occurs when a mother spreads the disease to her fetus and can cause birth defects, miscarriage, and stillbirth.
According to recent data, 3,755 cases of congenital syphilis were reported to the CDC nationwide in 2022, 10 times more than a decade ago. Of these cases, 231 resulted in stillbirth and 51 resulted in infant death. The number of infant infections increased by 183% between 2018 and 2022.
A report released by the CDC in November stated that “lack of timely testing and appropriate treatment during pregnancy contributed to 88% of congenital syphilis cases.” “Testing and treatment gaps existed for the majority of cases across all races, ethnicities, and U.S. Census Bureau regions.”
Syphilis rates in Hamilton County mirror national trends, with increasing numbers of cases among all groups, including infants.
March of Dimes, a maternal and child health advocacy group, released its annual report on health outcomes in each state in November. It found that about 15.5% of pregnant women nationwide either started receiving care after the fifth month of pregnancy or attended less than half of the recommended prenatal visits. Tennessee's rate was even worse, at 17.4%.
But Miller said health care providers are only required to test for syphilis early in pregnancy, so problems can occur even in people who attend all recommended visits. The idea is that if the test is done a few weeks before birth, there will be time to treat the infection.
But that recommendation depends on whether the health care provider suspects the patient has been exposed to the bacteria that causes syphilis, which is clear to those who claim their relationship is monogamous. Maybe not.
“What we found is that often their partners weren't as monogamous and they brought that into the relationship,” Miller said.
Even if the patient initially tested negative, he said, the patient could have contracted syphilis later in pregnancy, when testing for the disease is not routine.
Two antibiotics are used to treat syphilis: injectable penicillin and an oral drug called doxycycline.
Oral antibiotics are often prescribed for patients who are allergic to penicillin. However, the World Health Organization strongly recommends that pregnant patients avoid doxycycline.
As a result, pregnant women with syphilis are often given penicillin, even if they have an allergy, using a technique called desensitization, said Houston obstetrician-gynecologist Mark Turrentine. Patients are given low doses of drugs in the hospital to help their bodies get used to the drugs and to check for serious reactions. Penicillin injections are a one-time technique, unlike antibiotics, which require continuous administration for two weeks.
“It's difficult to take medication for a long period of time,” Turrentine said. A single injection provides peace of mind for patients and clinicians. “If for some reason they don't come back, there's no need to worry,” he said.
Metro Public Health in Nashville, Tenn., began giving oral antibiotics to all non-pregnant adults infected with syphilis in July, said Laura Barnier, nursing and clinical director.
Turrentine said he started seeing advisories about injectable penicillin shortages in April, around the time that the antibiotic amoxicillin became difficult to obtain and doctors were using penicillin as a substitute, potentially intensifying the shortage. He said there is.
According to the American Society of Health-System Pharmacists, the rise in syphilis cases is creating demand for injectables that manufacturer Pfizer cannot meet. “Supply is insufficient for regular orders,” ASHP said in a memo.
Penicillin has been around for a long time, but it's difficult to manufacture, mainly because so many people are allergic to it, said Dr. Roberts, deputy chief pharmacy officer at the University of Utah Health System. said Erin Fox, an adjunct professor at the university who studies drug shortages. .
“That means you can't make other drugs on that line,” she says. Only major manufacturers like Pfizer have the resources to build and operate such dedicated, isolated facilities. “It's not necessarily efficient and it's not necessarily profitable,” Fox said.
Pfizer acknowledged in a statement that demand for injectable penicillin has increased by about 70% due to amoxicillin shortages and a spike in syphilis cases. According to a representative, the company has invested $38 million in a facility to produce this form of penicillin, hired more staff and expanded its production line.
“This increase will take some time to be felt in the market, as product cycle times from the time a product is manufactured to the time it is released to a customer are three to six months,” the statement said. It's dark. The company expects the shortage to ease significantly by spring.
In the meantime, Miller said his clinic in Chattanooga continues to develop strategies. His single cost of penicillin injections can cost several hundred dollars. Additionally, it must be kept refrigerated and has a shelf life of 48 months.
Although the number of cases has increased dramatically, syphilis remains relatively rare. More than 7 million people live in Tennessee, and in 2019, health care providers across the state reported 683 cases of syphilis.
Health departments such as Miller's treat the majority of syphilis patients. Many cases are referred to health departments by health care providers, who work with contact tracers to identify and notify potentially infected sexual partners and to treat other sexually transmitted infections, including HIV. We are testing patients for.
“When you diagnose in the office, think of yourself as only seeing the tip of the iceberg,” Miller says. “We need a team of individuals to explore and examine the rest of the iceberg.”
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