Although syphilis mostly afflicts gay and bisexual men who are African American or Hispanic, nationwide rates are rising among white women and their infants. Nearly five times as many babies across the country are born with syphilis as with HIV.
OKLAHOMA CITY — Syphilis, the deadly sexually transmitted infection that can lead to blindness, paralysis and dementia, is roaring back around the country, another consequence of the heroin and methamphetamine epidemics, as users trade sex for drugs.
For months, health officials in socially conservative Oklahoma City have been staggered by a fast-spreading outbreak of a disease that, for nearly two decades, was considered all but extinguished.
To locate possible patients and draw their blood for testing, Oklahoma’s syphilis detectives have been knocking on doors in dilapidated apartment complexes and dingy motels, driving down lonely rural roads and interviewing prison inmates. Syphilis has led them to members of 17 gangs; to drug dealers; to prostitutes, pimps and johns; and to their spouses and lovers, all caught in the disease’s undertow.
“Syphilis doesn’t sleep for anyone,” said Portia King, a veteran Oklahoma state health investigator. “We have 200 open cases of sex partners we’re looking for. And the spread is migrating out of the city.”
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Although syphilis still mostly afflicts gay and bisexual men who are African American or Hispanic, nationwide rates are rising among white women and their infants. Nearly five times as many babies across the country are born with syphilis as with HIV.
There were 214 reported cases of syphilis in King County in the first quarter of 2017, compared with 159 in the same time period in 2016, according to Public Health — Seattle and King County.
The health department said in October 2016 that there had been an “alarming increase” in syphilis in King County. Clinicians diagnosed 444 cases of early syphilis in 2015, which was a 51 percent increase from the year before. More than 90 percent of syphilis cases are diagnosed in men who have sex with men, but the health department said it was seeing more cases in heterosexuals, including pregnant women.
Syphilis is devilishly difficult to contain, but may be even more so now. Because most doctors haven’t seen a case since the late 1990s, they often misdiagnose it. The cumbersome two-step lab test is antiquated. Although syphilis can be cured with an injection, there has been a shortage of the antibiotic, made only by Pfizer, for over a year.
And funding for clinics dedicated to preventing sexually transmitted diseases is down. In 2012, half of state programs that address sexually transmitted infections experienced reductions; funding has largely stayed flat since then. The Trump administration has proposed a 17 percent cut to the federal prevention budget.
Nearly 24,000 cases of early-stage syphilis, when the disease is most contagious, were reported in the United States in 2015, the most recent data. That was a 19 percent rise over the previous year. The total for 2015, including those with later-stage disease, was nearly 75,000, according to the Centers for Disease Control and Prevention.
The way to shut down an outbreak is to locate all the sex partners of people who are infected and persuade them to get tested, treated and disclose other partners. That task has fallen on a handful of the health department’s disease-intervention specialists.
This most recent wave of infections, spread through gang networks and prostitution rings, has made their jobs not only difficult but also dangerous.
Syphilis, caused by bacteria, has been well known for centuries, chronicled as a scourge since at least the 1400s.
In 1932, the U.S. government began the ignominious “Tuskegee Study of Untreated Syphilis in the Negro Male” to observe the progress of the disease in black Alabama sharecroppers. Although penicillin had become accepted as the cure by 1945, Tuskegee researchers left the men untreated until 1972, when the study was shut down.
By then, largely because of treatment and public education, syphilis was disappearing. A generation of physicians rarely learned to recognize it firsthand.
But with the AIDS epidemic, syphilis surged, peaking around 1990. It was most common — and still is — among men who had sex with men, often those whose HIV status made them vulnerable to other sexually transmitted infections.
Once again, public-health campaigns sent syphilis into retreat. By 2000, only 5,970 cases were reported in the United States, the lowest since 1941, when reporting became mandatory.
But in the last few years, it has crept back.
Here in Oklahoma City, 199 cases have been connected so far this year. More than half the patients are white and female. The youngest girl is 14; the oldest man, 61. Three stillbirths have been attributed to syphilis and 13 of the infected were pregnant women.
Rare permutations are now more common. Ocular syphilis, which can strike at any stage of infection, often appears as blurred vision and reddened eyes. Congenital syphilis can cause deformed bones in newborns.
Many people never suspect they have the disease. Early symptoms, including genital lesions and, later, rashes on palms and soles, have led patients and health-care providers to mistake it for herpes or allergic reactions. The disease can lie dormant for decades and then affect the liver, joints, blood vessels.
Once people are treated, though cured, they will almost always test positive. It is difficult to know whether a positive result indicates a new infection. After transmission, the bacteria may take three months to register. Those who test negative may have the disease.
This spring the Centers for Disease Control called for educating doctors and nurses about symptoms, testing pregnant women considered at risk and developing a better diagnostic test.
The cure for syphilis — usually two injections of Bicillin L-A, a type of penicillin — is relatively simple. But supplies have dwindled. Recently in Oklahoma, there were only seven doses statewide. Pfizer announced that stockpiles would be replenished by the end of 2017.
After several months, dispirited Oklahoma investigators acknowledged that old-school tactics for locating contacts, like knocking on doors and cold-calling, were not very effective. Many people they sought are transient and use disposable phones.
“But they want to stay connected to their friends and their drugs,” said King, a supervising investigator. “So they’re all on Facebook. That’s where we’re finding them.”
Through Facebook, investigators memorize faces and gang tattoos, and follow the flare-ups and flameouts of relationships. As gang members and dealers post partying plans, the sleuths determine where to point their investigation. They send potential patients messages through Facebook.
Erinn Williams is the lead field investigator for the Oklahoma City outbreak. Her team realized they were tracking a spread that reached back to last summer, involved members and associates of 17 gangs, and had infected young people from stable backgrounds who had used prescription opioids, then heroin. Patients often had symptoms that were a signature of this outbreak: weeping genital warts, called condylomata lata; patchy hair loss; and mucosal oozes inside the mouth.
The office has come to understand why more than half of this outbreak’s victims are women: “The men give up the women’s names,” King said. “But the women are too loyal or afraid to give up the men. “
But recently investigators persuaded a gang leader to text members, ordering them to contact Williams.
Every day, the team checks arrest reports for people they are seeking. Chloe Hickman interviews inmates.
“Most of them don’t know what syphilis is. When I say it’s curable, they relax. And they’ll give me names.”
Usually such efforts lead to sagas of unrelenting grimness: mothers who prostitute daughters, and men who forcibly inject runaways with drugs to hook them, a practice known as guerrilla pimping.