The Milwaukee Journal Sentinel reported last week that a cluster of 125 people in Milwaukee had been diagnosed with HIV, syphilis or both, including a dozen or so high school students. Additionally, three infants were born last year with congenital syphilis, a condition where the infected mother passes the bacteria that causes the disease to her newborn.
Health advocates in Milwaukee, including Melissa Ugland, a public health consultant, have called the situation an epidemic requiring immediate attention. The AIDS Resource Center of Wisconsin has confirmed the report and believes the numbers identified will rise when attention is directed to a more rigorous investigation of the situation.
The Milwaukee Health Department had been publicly silent on the issue until the Journal Sentinel broke the news of the discovery of the cluster of infected people.
The only action from the Health Department before news of the outbreak had been a general statement regarding the rising rate of Sexually Transmitted Diseases (STD) in the city. Their efforts to date had been to join with the Milwaukee County Transit System to launch an ad campaign promoting awareness about STDs and where people can go to get free testing.
The Journal Sentinel also noted that Milwaukee Mayor Tom Barrett was briefed on the epidemic of HIV and syphilis by his former health commissioner Bevan Baker in December and then again in January but made no public pronouncements or warnings about the public health crisis.
Syphilis is a sexually transmitted infection caused by the bacteria Treponema pallidum. The disease begins as a painless chancre sore that will heal in 3 to 6 weeks. If left untreated, the disease manifests as a diffuse rash frequently involving the palms and soles. These are accompanied by flu-like symptoms that include fever, swollen lymph nodes, and sore throat. There is usually a latent phase that can last for years where there are few symptoms. The last phase of the disease can lead to soft noncancerous growths as well as neurological or cardiac symptoms.
Congenital syphilis may lead to congenital disabilities, miscarriages or premature births, stillbirths or death in the newborn. Additionally, newborns with congenital syphilis can have developmental delays, seizure disorders as well as organ dysfunction with their liver and spleen.
Given the rarity of syphilis infection, this cluster of infected people is a serious public health development that will require the immediate mobilization of health professionals to contain. The disease is, however, very readily treatable with antibiotics. The discovery of penicillin and its effectiveness to treat syphilis has been essential in nearly eradicating the disease in the US.
Milwaukee Public Schools spokesperson Andy Nelson released a statement in the wake of the revelations noting that the school is now working in general to educate students about staying healthy: “Because schools have a significant number of students in the 15-18 age group, we are working with the Milwaukee Health Department, in a collaborative and preventive effort, to share information with young people in middle schools and high schools to keep them healthy and to protect their health.”
Nelson added that the Health Department had informed the district that the entire city is experiencing an increase in sexually transmitted diseases, especially among younger people. Beyond such cursory disclosures, the implication of this development and why it is happening, a plan of action and details on how to contain this epidemic have not been forthcoming from the city.
A cluster is defined as an unusually high incidence of a particular disease that occurs in close geographic and temporal proximity. Most of those in this affected outbreak are men, 45 percent of whom are also infected with HIV. It should not come as a surprise that students from high schools have been identified among this cohort. The Milwaukee Health Department has noted that people between the ages of 15 to 24 make up 37.4 percent of HIV cases while those 20 to 29 make up 57.1 percent of syphilis cases.
A number of statistics reveal that limited funding for public health initiatives, including immunizations and health screenings, had primed the city for an STD outbreak. The recent city budget allocated on $13.5 million and 252 full-time employees to the health department down from $13.7 million and 337 employees a decade before. Approximately 7000 people were seen in the city’s STD clinics in 2006 but this declined to fewer than 6000 by 2017.
Other disconcerting statistics include a decline in annual childhood immunizations in the city from a peak of 30,000 in 2000 to only 8,000 in 2017. In 2007 Milwaukee had an immunization rate of only 40 percent even though the US Department of Health and Human Services had set a goal of 90 percent. The infant mortality rate continues to remain high in Milwaukee at 9.4 per 1000, almost twice the national average, which sits at 5.82. For African Americans, there has been little improvement in infant mortality for more than two decades with a current rate of 15 per 1000, a figure that is 3.2 times higher than for whites and Hispanics.
In 1941, syphilis infection was at the rate of nearly 400 per 100,000 but by 2000, the national rate had declined to just 2.1 cases per 100,000. Since 2000 syphilis infections have been on the rise, mostly attributed to men who have sex with men. However, in 2013 the rate increased for men and women and by 2016, a total of 27,814 cases of primary and secondary syphilis were reported in the United States, yielding a rate of 8.7 cases per 100,000. There were 628 cases of congenital syphilis, an increase of 27.6 percent that led to the death of more than 40 newborns.
The CDC put out a press release in September 2017 warning that STDs are at a record high and urgent attention is needed to prevent these infections. More than two million cases of chlamydia, gonorrhea, and syphilis were reported in the United States in 2016, the highest number ever, according to their annual Sexually Transmitted Disease Surveillance Report. The CDC highlighted the acceleration of the epidemic among multiple vulnerable populations such as men who have sex with men, women and newborns.
“The resurgence of syphilis, and particularly congenital syphilis, is not an arbitrary event, but rather a symptom of deteriorating public health infrastructure and lack of access to health care,” Dr. Gail Bolan of the CDC noted at the time of the report. “It is exposing hidden, fragile populations in need that are not getting the health care and preventive services they deserve.”
Over the last decades, thirty-one states have made cuts to their public health budgets while federal funding has remained flat. The implementation of Medicaid work requirements are expeccted to exacerbate matters even further.
A 2017 study published in the medical journal Sexually Transmitted Diseases examined US public STD clinical services and found that 61.5 percent of local health departments reported recent budget cuts. This resulted in fewer clinic hours, reduced screening and reduced partner services. About 25 percent had to increase their fees or copays. In 2012, 52 percent of state and local STD programs experienced budget cuts. Since 2008, local health departments have lost 55,590 staff from layoffs or attrition.