Orange County Health Care Agency

Infectious Syphilis Cases More than Quadruple in OC in Last 5 years; other STDs increase as well

Increases in STDs have been reported in California as well as across the US. Orange County has experienced significant increases in syphilis, gonorrhea and chlamydia from 2011-2015, and the trend continued in 2016 (year-end data not final yet), with case numbers at the end of November being equal to or higher than cases for all of 2015. The increases in Orange County by disease for 2011-2015 are as follows:

• Syphilis: 330% increase in cases of primary, secondary and early latent syphilis, which are the “early”,
  or contagious forms of syphilis (from 108 cases in 2011 to 464 cases in 2015)
• Chlamydia: 46% increase (from 7924 cases in 2011 to 11,561 cases in 2015)
• Gonorrhea: 138% increase (from 976 cases in 2011 to 2317 cases in 2015)

In order to address this increase in STDS, it is important for clinicians to recognize the risk for STDs in
patients, perform the appropriate diagnostic tests, give appropriate treatment and report STDs in a timely fashion.

Persons living with HIV and men who have sex with men (MSM) are populations which are
disproportionately affected by syphilis, although in Orange County, increases have also been seen in
women and men who have sex with women (MSW). Some important points in regards to screening
and treatment of syphilis are:

• Screen HIV+ individuals and MSMs at least annually, and more often (every 3-6 months) if at increased risk (multiple partners, anonymous partners, etc.)
• Screen women and men who have multiple partners
• Screen all pregnant women at first prenatal visit, and repeat at 36 weeks if at increased risk
•  Confirm positive nontreponemal tests (RPR or VDRL) with a treponemal test (FTA-ABS, TP-PA or EIA)
• Repeat RPR/VDRL on day of treatment; use this result as a baseline to follow response
• Benzathine penicillin (Bicillin L-A®) is the optimal therapy for syphilis; use according to CDC guidelines (http://www.cdc.gov/std/treatment/default.htm)
• When evaluating people who have been exposed to an early case of syphilis (primary, secondary or
  early latent), if the exposure has taken place within the last 90 days, all serologic tests may be
  negative; therefore, in addition to testing, empiric treatment with a single dose of Bicillin L-A®2.4 million units IM is indicated.
• If your office does not have access to Bicillin L-A® you can send your syphilis patients to the County STD clinic in Santa Ana for the required injections. Please call Diana Cuevas (714) 834-8007 to arrange the referral

To learn more about management and staging of syphilis, please view this brief video.

In Orange County, young women (aged 15-24 years old) have the highest rate of CT infection, and the CDC recommends routine annual screening for CT in sexually active women under age of 25. Men aged 20-34 have the highest rates of GC infection, but the CDC does not recommend routine screening for GC in men. MSMs are a risk group for both infections, and routine annual screening for GC and CT in all exposed sites is recommended, with more frequent screening based on risk. It is important to note that GC and CT may infect extragenital sites (oropharynx and rectum) as a result of oral or anal sex, and many of these extragenital infections are completely asymptomatic. Studies have shown that in MSM, if urine screening is the only test done, 75% of CT and more than 90% of GC infections will be missed. To learn more about extragenital testing for GC and CT, please view this brief video. For anybody diagnosed with GC or CT infection, repeat screening is recommended three months after treatment because of the risk for reinfection.

Perform a sexual history on patients to determine risk; a good approach is to follow the “5 P’s”: ask about
partners (male, female or both), practices (sites of exposure), protection (use of condoms for each area
exposed), past history of STDs and pregnancy plans/prevention. To view a short video on taking a sexual
history, click here.

All cases of syphilis, GC and CT are reportable using the Confidential Morbidity report (CMR), which can be found here. GC and CT cases are reportable within 7 calendar days, but syphilis cases must be reported within one working day.

Additional videos on STD management can be seen here.

To learn more about STD Screening recs, see the summary here.

For questions regarding the management of STDs, please contact Dr. Christopher Ried, OC Health
Care Agency’s Medical Director of STD/HIV, at 714-834-8598.