Syphilis cases have nearly tripled in Buncombe County since 2015

Most adults have at least a passing understanding of the dangers of common modern sexually transmitted diseases (STDs), such as AIDS, human papillomavirus and herpes. But for many, syphilis has never been on the radar.

A sexually spread bacterial infection notoriously suffered by famous people from the past — Ivan the Terrible, Oscar Wilde, Al Capone and Christopher Columbus were all known or presumed to have been afflicted — the disease has not vanished during modern times. In fact, a 2024 report from the national Centers for Disease Control and Prevention says the number of new syphilis cases in the U.S. rose nearly 80% between 2018 and 2022.

And Western North Carolina has not escaped the escalation. According to Dr. Jennifer Mullendore, medical director for Buncombe County Department of Health & Human Services, the rate of new cases in Buncombe County has nearly tripled since 2015.

Mullendore, who oversees all county clinical programs, including its sexually transmitted infection clinic on Coxe Avenue, recently sat down with Xpress to shed some light on what syphilis is, how to prevent and treat it, and why its prevalence is increasing in WNC.

This interview has been edited for brevity and clarity.

Xpress: Since many folks may not be familiar with syphilis, can you explain what it is?

Mullendore: Syphilis is a treatable and curable infection caused by a type of bacteria. It is transmitted mainly through direct contact with a sore, typically during vaginal, anal or oral sex. It can also be spread during pregnancy from a pregnant person to their fetus. It’s a pretty complex infection and very ancient.

It has four different stages that it can progress through, and each of those has different signs and symptoms. Some of the stages have different recommended treatments, so the earlier it’s detected and treated, the better. The first stage, primary syphilis, typically shows up as one or more sores at the site where the syphilis bacteria entered the body. If you’re having vaginal penile sex, then it’s going to probably be on the vagina or the penis. Those sores don’t usually show up until two to six weeks after the infection.

Are the sores painful?

This is the tricky part — typically, they’re painless. So if you have a lesion in your vagina or your anus, and it doesn’t cause pain, how do you know it’s there? Some can be painful, but if you don’t notice it, you don’t get it checked. They can last for three to six weeks and are typically firm and round. They’ll go away on their own because the body’s immune system is able to easily get rid of them. But you’re still infected.

What are the next stages?

The second stage is called secondary syphilis. At that point, the bacteria has moved beyond the site of initial infection, and it’s replicating quickly and infecting many parts of the body. We often see a pretty nonspecific skin rash that is typically darker, like red or reddish brown, and slightly raised. It can be on the torso, and we can see it on the palms of the hands and soles of the feet. During that stage, people can also have lesions on their mucous membranes, in their mouth or again in their vagina or in their anus. They can have nonspecific symptoms like fever and swollen lymph nodes and can get patchy hair loss. And again, those symptoms will go away, even without treatment, but you’re still infected.

The big thing is that during the primary and secondary stages is really when syphilis can be spread sexually. After that, we move into what’s called latent syphilis — latent meaning it’s dormant: The infection is in you, but you don’t actually have any visible signs or symptoms.

Then there is a tertiary stage of syphilis that, thankfully in this day and age, is not that common. It definitely was more common before we had treatment options. This one is very serious. This is where you can get significant damage to things like the heart and the brain. This occurs 10-30 years after infection. And it can be fatal, because of the damage it’s doing to your heart and your blood vessels and things. I read a stat that 10% of people with syphilis who are not treated are going to die from it.

Something that we have been seeing more in the past several years is that at any of those stages of syphilis, if it’s untreated, it can spread to the brain, to other parts of the nervous system, to the eyes and the ears. So people get symptoms like severe headaches, confusion, redness of the eyes, tinnitus or ringing in the ears or dizziness. If somebody has those symptoms and we suspect or know they have syphilis, that’s an emergency situation, because you can permanently lose your eyesight or hearing.

The other thing is that at any stage, it can be spread to the fetus and cause congenital syphilis, which is a big issue that has been in the news recently across the country.

What individuals or groups are most at risk for contracting syphilis or experiencing severe symptoms?

The most severe outcomes are seen in the babies of pregnant people who have syphilis. Congenital syphilis can lead to miscarriage, stillbirth, premature birth, low birth weight and death of the baby shortly after it’s born. Up to 40% of babies born to people with untreated syphilis die from the infection. And those babies who do survive can still have significant health problems. They can have issues like brittle or deformed bones; their livers and spleens can be enlarged; they can have severe anemia, developmental delays, issues with blindness, deafness and seizures. It’s entirely preventable, yet it’s on the rise in North Carolina and across the U.S.

As for who’s most at risk, anyone who’s having sex is potentially at risk. It can be any age, sexual orientation, gender identity, race or ethnicity, income level — it doesn’t matter. Just like with other sexually transmitted infections, if you have multiple sex partners, you’re at higher risk. With dating apps and online [dating], a lot of people now don’t know the name of the person or the people they’ve had sex with, so that makes it hard for us to do contact tracing, informing and getting the partners treated.

Can you talk about the syphilis situation in Buncombe County?

Newly diagnosed early syphilis infections — meaning primary, secondary and what’s called early latent syphilis, when people can still spread it through sexual contact — have been increasing over the last decade in Buncombe County. In 2015, we had 25 early syphilis infections reported. And by 2022, it was all the way up to 74. … In 2023, it was fairly stable at 71. So, still significant numbers. When I do the math, that’s a 184% increase in newly diagnosed early syphilis infections from 2015 to 2023.

Why does it seem to be suddenly reemerging as a health issue?

The increase is definitely more dramatic recently, but it actually started in the early 2000s. In the 1990s, the U.S. had the lowest documented rates of syphilis, coming out of the time when we didn’t have effective treatments for HIV. So there was a lot of money being poured into sexual health, and sexual behaviors were different because people were scared about HIV. Then in the early 2000s, we got down to the lowest documented rates of syphilis, and syphilis prevention was no longer prioritized. The funding dried up, as it is apt to do in public health when we fix a problem or get it under control.

In the 2000s, the initial increase was mainly in men who have sex with men. And that has to do with them having closer, smaller social networks. More recently, the increase has been seen in the heterosexual population, and substance use has been associated with driving some of that. So now we have this larger population at risk, so we’re going to see more cases.

The increase in women being infected has been pretty dramatic across the U.S., and that’s led to a dramatic increase in congenital syphilis — that’s the case in North Carolina and across the country. Thankfully, though we’ve had some concerning situations, we’re not seeing that significant impact in Buncombe County for congenital syphilis.

In North Carolina, it’s the law that health care providers who take care of pregnant people do three syphilis tests throughout pregnancy, with the goal of detecting it early and getting treatment for defects in the fetus. If people aren’t accessing prenatal care, they’re not getting tested and not getting diagnosed and treated.

What treatments are available for syphilis?

If a nonpregnant person is diagnosed with primary or secondary syphilis, it’s just one shot, and then they’re good. If you’re pregnant, it’s one shot a week for three weeks, and if you miss a week, we’ve got to start over. So the goal is to get that treatment done at least 30 days before delivery to increase your chance of the baby not being affected. But if you’re not showing up for your visits, if you have transportation issues, it’s a huge thing. And that’s what’s making congenital syphilis increase. … There’s also a pill, doxycycline, that’s an option for some people, but it can’t be used in pregnancy.

Other than abstinence, what are the best ways of protecting yourself against syphilis?

Limiting the number of sexual partners you have, knowing their history, knowing their names, and getting regular testing. The recommendation is that people who have multiple sex partners or change their sex partners get tested every three months for sexually transmitted infections. Then also making sure that if you’ve tested positive for something, you get treated, making sure your partners or former partners get treated, and then completing the treatment. And then condoms. If there’s a lesion on something that’s covered by a condom, that will be successful at preventing infection.

Can folks get syphilis testing and treatment through Buncombe County Health & Human Services?

We have a sexually transmitted infection clinic, and our services are confidential and free. We do robust testing for syphilis, HIV, gonorrhea, chlamydia and other infections, and we offer the treatments for free.

We also have a mobile team that has been a great benefit when we have individuals in the community who can’t come in for care. Our mobile team takes treatment out to the individuals at their homes and ensures that they complete their treatment.

They’re also getting ready, hopefully, in a month or so, to roll out rapid syphilis testing out in the community, so people will know within 20 minutes if they have syphilis. They’ll have a calendar online at avl.mx/e0h.

I really want people to know that we have these free and confidential services, and I think we do a great job of educating people and providing the care they need in a respectful and compassionate way.

Buncombe County’s free STI Testing and Treatment Clinic is at 40 Coxe Ave. Hours are 8 a.m.-5 p.m., Monday-Friday. To make an appointment, call 828-250-5109. For details on Buncombe County’s Public Health Mobile Team services, visit avl.mx/e0h.