Surge in syphilis cases leads some providers to ration penicillin

Surge in syphilis cases leads some providers to ration penicillin

Stephen Miller said that when he left a primary care clinic less than two years ago to work in public health, he was shocked by the number of syphilis cases the clinic was treating.

STI rates have been low for decades. But the Hamilton County Health Department in Chattanooga, a mid-sized city in Tennessee’s Appalachian foothills surrounded by national forests, sees several syphilis patients every day, Miller said. A nurse who has worked at the clinic for decades told Miller that the influx of patients represents a radical change from the norm.

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

Nationwide, syphilis rates are at a 70-year high. The U.S. Centers for Disease Control and Prevention said on January 30 that 207,255 cases were reported in 2022, continuing a sharp increase in five years. Between 2018 and 2022, the incidence of syphilis increased by approximately 80%. The National Alliance of STD Directors says the epidemic of sexually transmitted infections – particularly syphilis – is “out of control”.

The surge is even more pronounced in Tennessee, where syphilis infection rates increased by 86% between 2017 and 2021.

But last spring, an already difficult situation was complicated by a shortage of penicillin injections, the preferred treatment for syphilis. The ongoing shortage is so severe that public health agencies are recommending that providers ration the drug — prioritizing pregnant patients because it is the only syphilis treatment considered safe for them. Congenital syphilis occurs when a mother transmits the disease to her fetus and can cause birth defects, miscarriage, and stillbirth.

The latest data shows that 3,755 cases of congenital syphilis were reported to the CDC nationwide in 2022, a number that is 10 times higher than a decade ago. Of these, 231 resulted in stillbirth and 51 resulted in infant death. Between 2018 and 2022, the number of infant cases increased by 183%.

A November report from the U.S. Centers for Disease Control and Prevention (CDC) states that “88 percent of congenital syphilis cases are due to a lack of timely testing and adequate treatment during pregnancy.” “Among all races, ethnicities, and U.S. Census Gaps in testing and treatment exist among most cases in the region.”

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

In November, the March of Dimes, a maternal and infant health advocacy group, released its annual report on state health. The study found that nationwide, about 15.5% of pregnant women started receiving care in their fifth month of pregnancy or later, or attended fewer than half the recommended prenatal visits. In Tennessee, the rate is even worse, at 17.4%.

But Miller said even those who attend every recommended appointment may run into problems because providers are only required to test for syphilis early in pregnancy. The idea is that if you get tested a few weeks before birth, you’ll have 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 to someone who identifies as monogamous.

“What we find is that a lot of times their partners are not that monogamous, but they bring that into the relationship,” Miller said.

Even if patients initially test negative, they could contract syphilis later in pregnancy, when testing for the disease is not routine, he said.

There are two antibiotics used to treat syphilis: injectable penicillin and the oral drug doxycycline.

People who are allergic to penicillin are usually given oral antibiotics. But the World Health Organization strongly recommends that pregnant patients avoid doxycycline because it can cause severe bone and dental deformities in babies.

Therefore, pregnant syphilis patients are often given penicillin even if they are allergic, using a technique called desensitization, says Mark Turrentine, a Houston ob-gyn. Patients receive low-dose treatment in the hospital to help their bodies adjust to the drug and to check for serious reactions. Penicillin injections are a one-time technique, unlike antibiotics, which require a two-week course.

“It’s difficult to take medication long-term,” Trentin said. A single injection provides peace of mind to patients and their clinicians. “If they don’t come back for some reason, you don’t have to worry,” he said.

Laura Varnier, director of nursing and clinical affairs at Nashville, Tenn., public health, said the department began offering oral antibiotics in July to all non-pregnant adults with syphilis.

Turrentine said he began seeing inquiries about shortages of injectable penicillin in April, when the antibiotic amoxicillin became harder to find and doctors were using penicillin as an alternative, potentially exacerbating the shortage.

According to the American Society of Health-System Pharmacists, the rise in syphilis has created a demand for the injection that manufacturer Pfizer has been unable to meet. “Normally ordered supplies are insufficient,” ASHP said in a memo.

Erin Fox, associate chief pharmacy officer at the University of Utah Health System and an adjunct professor at the university who studies drug shortages, said that although penicillin has been around for a long time, producing it has been difficult, largely because so many people are allergic. .

“That means you can’t make other drugs on this line,” she said. Only a major manufacturer like Pfizer would have the resources to build and operate such a dedicated, enclosed facility. “It’s not necessarily efficient, it’s not necessarily profitable,” Fox said.

Pfizer confirmed in a statement that amoxicillin shortages and a surge in syphilis have increased demand for the injectable penicillin by about 70%. The company invested $38 million in the plant that makes the penicillin, hiring more workers and expanding production lines, representatives said.

“It will take some time for the market to feel this increase, as the product cycle from product manufacturing to release to customers is 3-6 months,” the statement read. The company expects shortages to ease significantly by spring .

In the meantime, Miller said his Chattanooga-based clinic is continuing to strategize. Injectable penicillin can cost hundreds of dollars per dose. Plus, it must be refrigerated and expires after 48 months.

Even with the dramatic increase in cases, syphilis remains relatively rare. More than 7 million people live in Tennessee, and in 2019, 683 cases of syphilis were reported to health care facilities across the state.

Health departments like Miller’s treated most of the syphilis patients. Many patients are referred to health departments by their providers, who work with contact tracers to identify and notify potentially affected sexual partners and test patients for other sexually transmitted infections, including HIV.

“When you diagnose in the office, you only see the tip of the iceberg,” Miller said. “You need a team of individuals to explore and observe the rest of the iceberg.”

This story is part of a partnership that includes Wireless PLN, NPRand KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF’s core operating programs – an independent source of health policy research, polling and news. Learn more about KFF.

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