Syphilis in the Dakotas 1
Syphilis in the Dakotas
Jessica Scharfenberg, RN
Concordia University
MPH 510 Applied Epidemiology
Syphilis in the Dakotas 2
Syphilis is a sexually transmitted disease that is caused by the bacteria, Treponema
pallidum bacterium (CDC, 2013a; CDC, 2013b). There are three modes of transmission
associated with the disease. Transmission can occur person to person via vaginal, anal, or oral
sex when there is direct contact with a syphilis chancre (CDC, 2013a). Person to person
transmission can also occur during foreplay, without penetrative sex. Lastly, pregnant women
can transmit syphilis in-utero to their fetus (CDC, 2013a; Gill, 2014; North Dakota Department
of Health, 2014).
There are four clinical definitions of syphilis, and they are based on progressive states of
the disease. Primary syphilis occurs 10 to 90 days after infection and is categorized by one or
more chancres; firm, round, painless sores (CDC, 2013a; CDC, 2014a; CDC, 2014b; Gill, 2014).
The chancres will heal on their own within 3-6 weeks, but a person is highly infectious during
this stage. Clinical symptoms of secondary syphilis include rashes that occur as the chancres
fade, or after the chancres are gone and wart-like growths near the genitals (CDC, 2013a; CDC,
2014a; CDC, 2014b; Gill, 2014). The rashes typically present on the palms of the hands, soles of
the feet, and face. Both the rashes and wart-like growths clear on their own within 12 weeks
(CDC, 2013a; CDC, 2014a; CDC, 2014b; Gill, 2014). Those with secondary syphilis are also
highly contagious. During the latent stage of syphilis, transmission is unlikely, but those
infected may manifest neurological and cardiovascular deterioration. The last clinical definition
of syphilis is congenital syphilis, syphilis transmitted to a fetus during pregnancy. Congenital
syphilis can lead to miscarriage, premature delivery, cleft palates, bullae and vasicular patches,
and osteochondritis (CDC, 2013a; CDC, 2014a; CDC, 2014b; Gill, 2014).
Syphilis in the Dakotas 3
Syphilis chancres occur mainly on external genitals, the vagina, anus, or in the
rectum. They may also occur on the lips, hands, and in the mouth. High transmission rates can
be attributed to the fact that many people who are infected do not have symptoms; and that
chancres often go unidentified (CDC, 2014a). Due to the various staging of syphilis, the clinical
course of the disease is variable. The Center for Disease Control and Prevention, CDC, sets
forth case definitions of each stage and sub-stage to guide provider surveillance and reporting, as
syphilis is part of the National Notifiable Surveillance System (CDC, 2014a).
Stage
Primary Syphilis
Secondary Syphilis
Laboratory Criteria
T. pallidum present in clinical specimen by darkfield
microscopy
or
polymerase chain reaction
or
equivalent direct molecular methods
T. pallidum present in clinical specimen by darkfield
microscopy
or
polymerase chain reaction
or
equivalent direct molecular methods
Latent Syphilis
Early Latent
reactive nontreponemal test
and
reactive treponemal test
or
current nontreponemal test titer demonstrating fourfold
or greater increase since last nontreponemal test titer
reactive nontreponemal test
Late Latent
and
reactive treponemal test
Figure 1 describes the laboratory criteria needed for diagnosis based on three of the stages of
syphilis (CDC, 2014a).
Syphilis is a reportable infectious disease that is monitored by state health departments.
In 2012, the states of South Dakota and North Dakota began seeing an increase in syphilis cases.
Syphilis in the Dakotas 4
The number of cases has continued to rise over the past two years and there is currently an
ongoing heterosexual syphilis outbreak in North and South Dakota (Gill, 2014; North Dakota
Department of Health, 2014). Approximately 65% of all cases have been staged as either
primary or secondary syphilis during this acute outbreak. In particular, South Dakota has not
seen this many cases of syphilis in over 50 years. The acute outbreak has seen a shift in
distribution over the past two years also. In 2012, cases were mainly identified in men who had
sex with men (Gill, 2014; North Dakota Department of Health). During 2013, the shift began
towards heterosexual transmission; and currently in 2014, cases have been primarily associated
with heterosexual transmission (Gill, 2014; North Dakota Department of Health, 2014).
As of May 1, 2014 there were 46 reported cases of syphilis in South Dakota, primarily in
Native Americans associated with heterosexual transmission (Gill, 2014). One of those 46 cases
was congenital syphilis, the first case in South Dakota in decades. Due to the current situation
the Center for Disease Control and Prevention has changed pregnancy screening
recommendations in South and North Dakota; as they qualify as a high syphilis morbidity area
(Gill, 2014; North Dakota Department of Health, 2014). A three screening series is now
recommended for all pregnant women, once in the first and third trimesters and the day of
delivery. The CDC also recommends that no infant leaves the hospital without known
serological status, proven by at least one screening during pregnancy (Gill, 2014).
According to Amanda Gill, South Dakota STD program coordinator, most cases in the
2014 year have been found within a specific geographical location along the northern border of
South Dakota, and adjacent areas of North Dakota (Gill, 2014). Standing Rock Reservation in
Corson County South Dakota and Sioux County North Dakota has been 2014’s main infection
area, accounting for 39 of South Dakota’s 46 cases as of May 1, 2014 (Gill.2014). She also
Syphilis in the Dakotas 5
states that there has been a shift within races, originally a predominantly white infection, has
shifted to Native Americans within the reservation (Gill, 2014). Gill says this shift is also being
seen in North Dakota.
Preliminary numbers from North Dakota in 2013 identify 13 cases of primary, secondary,
or early latent syphilis; and an additional 13 cases of latent syphilis (North Dakota Department of
Health, 2014). 38% of the early syphilis cases reported in 2013 were located in Sioux County,
North Dakota with 42% being American Indian, 35% white, and the remaining 19% African
American. 18 of the cases were identified in males and 8 were female cases (North Dakota
Department of Health, 2014). Unlike the 75% of national cases that occur in men who have sex
with men, a majority of North Dakota’s cases were reported in heterosexual individuals (North
Dakota Department of Health, 2014). Only 7 of the 26 cases in 2013 were identified in
homosexual males. Both North Dakota and South Dakota are urging treatment before lab
confirmation of syphilis to help contain the outbreak. They are also requesting that reports of
suspected syphilis be reported to local health departments before lab confirmation.
Syphilis in the Dakotas 6
North Dakota Reported Syphilis Cases
by Year
Number of Cases
12
10
10
8
6
4
4
3
4
2
2
0
2009
2010
2011
2012
2013
Year
Figure 2 depicts the change in reported cases of syphilis in North Dakota from 2009 to 2013
(Denver Prevention Training Center, South Dakota Department of Health, & North Dakota
Department of Health, 2014).
South Dakota Reported Syphilis Cases
by Year
Number of Cases
60
49
50
40
30
21
20
10
2
4
2009
2010
0
0
2011
2012
2013
Year
Figure 3 depicts the change in reported cases of syphilis in South Dakota from 2009 to 2013
(Denver Prevention and Training Center et al., 2014).
Syphilis in the Dakotas 7
Number of Cases
2012 South Dakota Syphilis Cases by
Age
14
12
10
8
6
4
2
0
13
8
0
0
0
<1 year 1-4 years 5-14 years
0
15-24
years
0
25-39
years
40-64
years
65+ years
Age
Figure 4 depicts the age of groups of those with syphilis in South Dakota in 2012 (Denver
Prevention and Training Center et al., 2014).
2013 South Dakota Syphilis Cases by
Age
Number of Cases
25
21
20
15
15
12
10
5
0
0
1
0
0
<1 year 1-4 years 5-14 years
15-24
years
25-39
years
40-64
years
65+ years
Age
Figure 5 depicts the age groups of those with syphilis in South Dakota in 2013 (Denver
Prevention and Training Center et al., 2014).
Syphilis in the Dakotas 8
2013 North Dakota Syphilis Cases by
Age
Number of Cases
5
4
4
4
3
2
2
1
0
0
0
0
0
<1 year
1-4 years 5-14 years
15-24
years
25-39
years
40-64
years
65+ years
Age
Figure 6 depicts the age groups of those with syphilis in North Dakota in 2013 (Denver
Prevention and Training Center et al., 2014).
2012 South Dakota Syphilis Cases by
Orientation
15
16
Number of Cases
14
12
10
8
6
4
4
2
2
0
HRH
MSM
Orientation
Refused
MSM-Men who have sex with men HRH-Hish risk heterosexual
Figure 7 depicts sexual orientation of those with syphilis in South Dakota in 2012 (Denver
Prevention and Training Center et al., 2014).
Syphilis in the Dakotas 9
2012 South Dakota Syphilis Cases by
Race
Number of Cases
20
18
15
10
5
3
0
White
Other
Race
Figure 8 depicts those with syphilis in South Dakota in 2012 based on race (Denver
Prevention and Training Center et al., 2014).
2012 South Dakota Syphilis Cases by
Sex
25
Number of Cases
20
20
15
10
5
1
0
Female
Male
Sex
Figure 9 depicts syphilis cases in South Dakota in 2012 based on sex (Denver Prevention and
Training Center et al., 2014).
Syphilis in the Dakotas 10
2013 South Dakota Syphilis Cases by
Orientation
35
Number of Cases
30
29
25
19
20
15
10
5
1
0
HRH
HRH-High risk heterosexual
MSM
Orientation
Refused
MSM-Men who have sex with men
Figure 10 depicts the shift in sexual orientation for those in South Dakota infected with syphilis
in 2013 (Denver Prevention and Training Center et al., 2014).
2013 South Dakota Syphilis Cases by
Race
30
Number of Cases
25
25
20
20
15
10
4
5
0
White
Native American
Race
Other
Figure 11 depicts the shift in race for those infected with syphilis in South Dakota in 2013
(Denver Prevention and Training Center et al., 2014).
Syphilis in the Dakotas 11
2013 South Dakota Syphilis Cases by
Sex
33
35
Number of Cases
30
25
20
15
15
10
5
0
Female
Male
Sex
Figure 12 depicts the shift in sex of those in South Dakota infected with syphilis (Denver
Prevention and Training Center et al., 2014).
Discussion
Numerous shifts have been seen with this epidemic including age, sex, orientation, and
race. An endemic case number between one and five has been expected while looking at
historical trends (Gill, 2014; North Dakota Department of Health, 2014). Concern has risen, as
the outbreak is localized within an impoverished area with limited access to care.
If syphilis is caught early enough it can be cured with antibiotic treatment (CDC 2013a;
CDC, 2013b). There are numerous barriers though, with catching it early. Contacting and
treating partners is the largest of barriers. Oftentimes physicians rely on the identified carrier to
notify their sex partners, in which they do not do so; or only notify select partners (CDC,
2014a). Delays in reporting cases to the local health department also impede on the timeliness of
investigations (CDC, 2014a). Lastly, a majority of those who contract syphilis practice sexual
promiscuity with multiple, anonymous partners who are unidentifiable (CDC, 2014a).
Syphilis in the Dakotas 12
Lack of health equity is contributing to the current syphilis distribution in North and
South Dakota. Health equity is the equal chance for everyone to be healthy regardless of race,
ethnicity, income, gender, religion, sexual identity, and disability (CDC, 2014c). Research
alludes to higher STD rates, including syphilis, is minority groups such as Native Americans
(CDC, 2014c). Native Americans on reservations in the Dakotas often face poverty,
unemployment, and low education levels leading to lower sexual health levels.
According to the CDC, those who cannot afford basic needs also have trouble accessing
quality sexual health services (CDC, 2014c). Minority groups also tend to distrust health care
systems due to discrimination, leading to less preventative visits. Lastly, those who are sexually
active in communities with high STD rates are at greater odds of selecting an infected partner
(CDC, 2014c). All of these theories contribute to the hypothesis of why the Standing Rock
Native American Reservation is in the midst of a syphilis outbreak.
Further research is needed and is currently being performed to develop better syphilis
diagnostic and treatment techniques. Priority is being put towards developing a urine or saliva
test, instead of blood only testing (NIAID, 2010). As a field epidemiologist, this would be
beneficial as gathering blood samples can be tedious and difficult while in the field. Researchers
are also focusing on syphilis vaccine development (NIAID, 2010).
Although some of the prevention research sounds promising; current priority needs to be
shifted to the syphilis outbreak in the Dakotas. Social factors, such as quality health care access
and poverty need to be addressed in order to gain control of the outbreak. Theories have been
developed as to how syphilis is spreading through the Dakotas, but gaps is research still exist as
to why the shifts in age, race, sex, and orientation are occurring. Once the gaps have been filled,
control is imminent.
Syphilis in the Dakotas 13
References
Center for Disease Control and Prevention. [CDC]. (2013a). Syphilis: Physician's pocket
guide. Department of Health and Human Services.
Center for Disease Control and Prevention. [CDC]. (2013b, May 22). Syphilis facts &
brochures. Retrieved from http://www.cdc.gov/std/syphilis/facts-brochures.htm
Center for Disease Control and Prevention. [CDC]. (2014a). Primary and secondary syphilis
— United States, 2005–2013. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6318a4.htm?s_cid=mm6318a4_w
Center for Disease Control and Prevention. [CDC]. (2014b, January 1). NNDSS condition
case definition: Syphilis. Retrieved from
http://wwwn.cdc.gov/NNDSS/script/casedef.aspx?CondYrID=941&DatePub=1/1/2014
Center for Disease Control and Prevention. [CDC]. (2014c, March 10). STD health equity.
Retrieved from http://www.cdc.gov/std/health-disparities/default.htm
Denver Prevention Training Center, South Dakota Department of Health, & North Dakota
Department of Health (2014). Syphilis in the Dakotas: A two part webinar series.
Gill, A. (2014). May 2014 syphilis provider memo. South Dakota Department of Health.
National Institute of Allergy and Infectious Disease. [NIAID]. (2010, December 10). Syphilis
research. Retrieved from
http://www.niaid.nih.gov/topics/syphilis/research/Pages/research.aspx
North Dakota Department of Health (2014). Guidance for providers on syphilis diagnosis
and treatment. Retrieved from North Dakota Department of Health-Health Alert
Netweork website: http://www.ndhan.gov/data/health/HAN%202014-0214_Syphilis.pdf
Syphilis in the Dakotas 14