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Archive for July, 2014

Primary Care Corner with Geoffrey Modest MD: Delayed MMR and Seizures

16 Jul, 14 | by EBM

a study looked at 323K children in the US (from the Vaccine Safety Datalink) born between 2004 and 2008, assessing the timing of the array of first doses of childhood vaccines  and the development of seizures, with self-control — ie, noting the timing of seizure after vaccination in children who never had a prior seizure (see DOI: 10.1542/peds.2013-3429).  the seizure risk window varied a bit by different vaccines, but was 7-10 days for MMR. results:

–5667 children had seizures. of these 49.7% received the vaccines on-time in the first 2 years of life.
–in the first year of life, no diff in seizures with vaccine timing (includes DTaP, PCV, HIB, IPV, rotavirus)
–in the second year of life, the IRR (incidence rate ratio) for seizures after the first MMR given at the recommended 12-15 months was 2.65. if given between 16-23 months it was 6.53!!  in those given the combo vaccine or MMR plus varicella, the IRR at 12-15 months was 4.95, increasing to 9.80 if given between 16-23 months. these numbers were worse with longer delays (eg, if MMR given between 16-18 months, IRR was 5.09; if given between 19-21 months it was 8.75)
–although the old DTP vaccine used until the 1990s was associated with increased seizure, the subsequent DTaP vaccine is not associated with seizures

this study reinforces the importance of timely vaccine. some parents have been hesitant in this regard, anticipating an older child might tolerate the vaccine better. sometimes it is because of barriers to immunization (lack of insurance, transportation, accessible care). although this is an observational study, and it is possible that vaccine delay was related to some parental choice reflecting an increased risk of seizure, the large scope of this study makes that bias unlikely, and the more likely explanation having to do with maturity of the immune system with age and higher likelihood of febrile reaction prompting seizures.


Primary Care Corner with Geoffrey Modest MD: Gastric Cancer Screening/Prevention

15 Jul, 14 | by EBM

I have had 2 Cape Verdean patients over the past few years who have developed gastric cancer.  Several months ago I met with a Cape Verdean doctor who confirmed that gastric cancer was relatively common in Cape Verde.  Gastric cancer screening in general does not make sense in the United States given the low prevalence of gastric cancer.  However, many of our patients come from countries with much higher prevalence, prompting this review.  I am posting about this  generally because many of us see patients coming from high prevalence countries.

Most of the data is not great.  There has been mass population screening in Japan since 1983  for individuals over 40, where gastric cancer is the leading cause of cancer death.  A systematic review was done by the Japanese Health Ministry (see doi:10.1093/jjco/hyn017), which only found 10 studies directly related to screening, none of which were randomized controlled trials — only case-control or cohort studies.  They noted in Japan there has been an overall decrease of gastric cancer mortality from 1980 to 2003, from 69.9 to 34.5 per 100,000 in males, and 34.1 down to 13.2 per 100,000 in females.  In their systematic review they found that the best evidence was for barium studies (the most widely used intervention), finding a 40-60% decrease in gastric cancer mortality and a 5 year survival rate of 74-80% for those screened versus 46-56% for the non-screened group.  They found that the data were more mixed and less compelling for endoscopy screening, or blood tests for serum pepsinogen or Helicobacter pylori antibody.  A cohort study in Korea, looking retrospectively at 2485 patients with gastric adenocarcinoma, found that those screened at 4-5 year intervals had a higher risk for gastric cancer than those screened at 2-3 year intervals. Those at the highest risk, people with a family history of gastric cancer and those in their 60s, were found to have a higher stage of gastric cancer when the intervention was performed every 3 years as opposed to annually.  This all led to the recommendation for screening every 2 years by upper GI series or endoscopy for individuals over 40 years old.  Since none of these studies were RCTs, there may be significant biases (lead time bias, length bias, etc.)

There was an RCT in 2004 on H. pylori eradication as a means to prevent gastric cancer ( see JAMA 2004; 291: 187-194).  In this Chinese trial (from Fujian Province, where mortality rate from gastric cancer is 153/100K, and where they have found a 2-4 fold increase in gastric cancer in those H pylori positive) 1630 healthy carriers of H. pylori were enrolled, of whom 988 did not have any precancerous lesions on endoscopy (gastric atrophy, intestinal metaplasia, or gastric dysplasia) at study entry.  The H. pylori status was documented by the endoscopic exam.  Patients were randomly assigned H pylori therapy (a two-week course of omeprazole 20 mg, amoxicillin/clavulanate 750 mg, and metronidazole 400 mg, all twice a day) versus placebo, and followed 7.5  years.  Results:

 –76.4% of patients given triple therapy for H pylori were  successfully treated, per urea breath test.  Those who failed treatment were given quad therapy –the ultimate eradication rate was 83.7%
–Primary outcome (incidence of gastric cancer during followup): No difference, with 7 cases in the H. pylori treatment group and 11 cases in the placebo.
–Secondary outcome (incidence of gastric cancer, comparing those with or without precancerous lesions): In those without precancerous lesions none developed gastric cancer in those treated for H. pylori, 6 did the placebo group, statistically significant.  Of note, the cumulative incidence of cancer in the placebo group was increasing dramatically after about 6 years, whereas those were H. pylori negative remained without cancer (ie very impressive splaying of the curves).
–Smoking and older age were independent risk factors for the development of gastric cancer, with smoking, having a hazards, ratio of 6.2.

so, what is one to do in the United States?  At this point, given the lack of large RCTs, it seems to me to be hard to recommend an aggressive screening program with either upper GI radiography or endoscopy.  However, given the very high prevalence of H pylori infection in many of these patients (including our Cape Verdean patients), and given the known association of H. pylori infection and gastric cancer at least in some high prevalence countries, and given the RCT from Fujian Province,  I personally think that it would be appropriate to screen and treat patients for H pylori infection, using the H. pylori antibody as a reasonable marker of infection.


Primary Care Corner with Geoffrey Modest MD: WHO’s Remarkably Scary Report

11 Jul, 14 | by EBM

world health org came out with report on antimicrobial resistance (see here). remarkably scary report. their findings:

–very high levels of resistance in all WHO regions for many common bacteria. eg (with 20-50% of the 194 member states providing data):

–e coli with >50% resistance both to 3rd generation cephalosporins and to fluoroquinolones in 5/6 WHO regions
–klebsiella pneumoniae with >50% resistance to 3rd generation cephalosporins in 6/6 regions and to carbapenems in 2/6 WHO regions
–staph aureus with >50% resistance to methicillin in 5/6 regions
–strep pneumoniae with >25% resistance to penicillin in 6/6 regions
–nontyphoidal salmonella with >25% resistance to fluoroquinolones in 3/6 regions
–n gonorrhea with >25% resistance to 3rd generation cephalosporins in 3/6 regions
–there are significant gaps in information about important pathogens. surveillance not coordinated or harmonized

–multidrug resistant TB is a growing concern, and is under-reported, compromising control efforts. at this point 3.6% of new TB cases and 20.2% of previously treated have multi-drug resistance (and much higher in eastern europe and central asia)
–foci of artemisinin resistance in malaria have be found in a few countries. further spread could jeopardize important recent gains in malaria control. esp a problem in southeast asia (eg cambodia, vietnam, thailand, myanmar)
–increasing levels of HIV drug resistance has been found in patients about to start meds, with 10-17% of patients without prior treatment in europe, japan, US, australia resistant to at least one drug [this has led to recommendation a few years ago by CDC that all newly diagnosed HIV patients get a genotype, since the level of background resistance is so high]
–the data for antibacterial resistance presented above does not explain the full picture: routine surveillance in most countries is often based on patients with severe infections or when treatment has failed. community-acquired infections are underrepresented. mostly hospital data available.
–the increased resistance raises several important issues: when other drugs exist to treat these infections, they are more expensive and less available in resource-limited countries; when available, these drugs (which had been used in the past for very severe infections) are now needed much more frequently for less severe infections; some of these common infections (eg gonorrhea) are developing significant resistance to “the treatment of last resort” (3rd generation cephalosporins).

–major gaps in knowledge exist about antibiotic resistance in foodborne bacteria. need much more developed surveillance to assess levels of antibiotic resistance in bacteria carried by food-producing animals and in the food chain

–systemic candidiasis is also found to have increasing resistance to fluconazole. and even starting to show resistance to new antifungal agents (echinocandins)

general conclusion: “antimicrobial resistance (AMR) is a global health security threat that requires action across government sectors and society as a whole. surveillance that generates reliable data is the essential foundation of global strategies and public health actions to contain AMR”

other issues, as noted in NY times editorial:

–FDA has come out with very weak guidelines regarding overuse of antibiotics in agriculture and medicine: only voluntary guidelines to stop indiscriminate use of antibiotics in humans and livestock

–at this point we really need new antibiotics developed. there have been no new class of antibiotics since 1987. issue is that the $$ is in chronic meds. even over-charging for antibiotics doesn’t help much if it’s for only a 10 day course.  and, will append below a previous blog  which shows that the vast majority of R&D by big pharma is for look-alike drugs and not for important break-throughs (though their arguments supporting the huge costs of drugs hinges on the expense of R&D)

–and, i would add, the whole ecology of infectious diseases is changing with climate change: diseases that once were localized to certain areas (eg dengue and other mosquito-borne diseases) are appearing in new areas (eg, southern US). many of these are likely to spread quickly in naive population.


A previous blog post:

striking article in BMJ about the image and reality of pharmaceutical research and development (see doi: 10.1136/bmj.e4348).  the $400 billion/yr drug industry has promoted an “innovation crisis” myth that they are too strapped to do the very expensive R&D. reality is that overall there has been a constant rate of new drugs over the past 60 years. the real innovation crisis is in the fact that the percentage of new medications which really offer important therapeutic advantage is on the order of 15% (ie, vast majority of new drugs are “look-alikes”, ie yet another ACE inhibitor, statin, etc). this has not changed since i saw data in the 70s. the authors of the BMJ note “since the mid-1990s, independent reviews have also concluded that about 85-90% of all new drugs provide few or no clinical advantages for patients”. and still, of the large amount of money spent on R&D, 80% of basic research comes from public sources. they also note that the drug company claims of huge amounts spent by them on R&D are dramatically overstated (eg, 1/2 of amount stated by them comes from “estimating how much profit would have been made if the money had been invested in an index fund of pharmaceutical companies that increased in value 11%/yr, compounded over 15 yrs.”) and the down side in companies pushing for look-alike type drugs in order to extend their patents is that many of them are not as good as the original and/or less safe (eg vioxx, rosiglitazone, gatifloxacin…)


Primary Care Corner with Geoffrey Modest MD: Chronic pain, yet again

9 Jul, 14 | by EBM

in the flurry of recent articles on opioid prescribing for chronic pain, the annals of intl med came out with a systematic review and assessment of the 13 identified guidelines, evaluating them using 2 tools: AGREE II (appraisal of guidelines for research and evaluation II) and AMSTAR (a measurement tool to assess systematic reviews). for article, see doi: 10.7326/0003-4819-160-1-201401070-00732. they basically found that the only 2 guidelines which received high ratings were the Am Pain Society one (doi:10.1016/j.jpain.2008.10.008) and the Canadian National Opioid Use Guideline Group one. overall, they were quite impressed at the level of agreement in the differing guidelines. major points:

–these guideline evaluators assessed many aspects of the formulation of the guidelines, including input from providers /patients, how evidence was selected, strengths/limitations of the evidence, how recommendations formulated, external reviews prior to publication, implementation recommendations, measures to ensure editorial independence…

–a recent workers’ comp study (2012) found that 8-30% of pts with noncancer pain were on opioids, with average daily doses from 13-128 mg morphine equivalents

–nearly half of fatal overdoses were assoc with concommitant use of sedative-hypnotics, esp benzos. and esp an issue in the elderly

–leading risk factor for overdose or misuse of opioids is personal or family hx of substance abuse or psych issues

–there was general agreement that we should use extreme caution if doses greater than 90-200 mg of morphine equivalents per day. 5 guidelines published before 2012 felt that doses >200 mg morphine equiv conferred high risk, and observational studies found that the risk increased dramatically with doses over 100-200 mg.  in washington state, they began requiring workers’ comp cases get a pain management referral if pt receiving more than 120 mg/d.  no data on pain control (unfortunately) but assoc signif decrease in opioid overdoses.

–if you are considering changing opioids because you are prescribing really high dose and want to see if other opioid is more effective, you should reduce the morphine equivalent dose by 25-50% (to avoid too much opioid in what may be a more potent drug for the patient)

–be careful with methadone (long QTc, respiratory suppression due to long half-life — half-life typically 15-60 hrs, can be as high as 120 hrs) and follow more closely than other long-acting drugs (check drug-drug interactions, care with other drugs which prolong QTc).  also be careful with fentanyl patches “including limiting use to opioid-tolerant patients and being aware that unpredictable absorption can occur with fever, exercise or exposure to heat”

–important to use opioid risk assessment tools (eg appendix 4 or 5 in the am pain society paper), written treatment agreements, urine drug testing (guidelines differ a bit on frequency, but most suggest at baseline, and random thereafter, esp if risk is high).


Primary Care Corner with Geoffrey Modest MD: Chronic pain/Opioids

8 Jul, 14 | by EBM

caring for patients who have chronic pain can be one of the most challenging issues in primary care. unlike almost any other primary care issue, the use of opioids for chronic pain tends to be the most likely one to pit a provider (or staff) against the patient, the antithesis of developing a strong primary care relationship. background:

–at our health center 20+ years ago, there were at most a handful of patients on opioids for chronic non-cancer pain. currently, most of us have at least a few patients on our schedule every day coming in for opioids for noncancer pain. Similarly, all of the patients addicted to opioids in the past were using illicit drugs (basically heroin and cocaine). now, my health center experience is that pretty much all of the young opioid-addicted patients are addicted to prescribed opioids (the very typical scenario of my young suboxone — ie buprenorphine/naloxone — patients is: they were given prescription opioids for acute pain, liked the feeling, increased their consumption by buying meds on the street, became addicted, had serious problems with life (maintaining job, relationships, etc), then came for suboxone and have mostly done very well).
–a recent study suggested more than 3% of adults receive long-term opioid therapy for chronic non-cancer pain!
–One of the major reasons for this dramatic transformation was within the medical profession: The Institute of Medicine came out with clear guidelines that pain was being underassessed and undertreated, raising the request that pain assessment be a vital sign, checked at every visit.
–However, parallel with this dramatic increase of providers’ prescribing opioids, there have been dramatic increases in deaths from opioid poisoning, for example hospitalizations for opioid related overdoses doubled in the 10 year period of 1995 to 2004 in Washington state. The MMWR (see MMWR Nov 1, 2011 Vital Signs: overdose of prescription opioid pain relievers –United States 1999-2008) reported that nearly 100 people/day died of drug overdoses in the United States in 2007 (that is  >10x the death rate from asthma, at least as reported in the new york times today).  The 2007 death rate was 3 times that of 1991.  At this point the majority of overdose deaths are from prescribed opioid pain relievers.  A study in Virginia found that the majority of overdoses resulted from drug diversion to others who then OD’d.
–Another recent study (see Ann Intern Med. 2010;152:85-92) looked at the patients themselves, finding that increasing doses of prescribed opioids was associated with increasing likelihood of overdose.  This study was done at a large HMO in Seattle Washington with 10,000 people who received 3 or more opioid prescriptions within 90 days for chronic non-cancer pain between 1997 and 2005.  They found:

–opioids were mostly prescribed for musculoskeletal pains, with two thirds specifically for back or extremity pain.  Mean daily dose was 13.3 mg of morphine equivalents, with 80% of the patients using 1-20 mg per day and only 2% using 100 or more milligrams per day. (pretty low doses compared to what we typically see!)
–There were 51 opioid-related overdoses including 6 deaths
–converting the opioids to morphine equivalents using the CONSORT classification (see Clin J Pain 2008;24:521–527):
–overdose rates were somewhat higher in patients over 65 and in those with a history of depression or treatment of substance abuse
–Using the lowest group (1-20 mg per day) as a reference, those in the 20-50 mg per day had a 19% increase risk of serious overdose, the 50-100 mg per day had a 2 fold increased risk, in those greater than 100 mg per day had a 10 fold increased risk.
–similar numbers were found in a veterans study

Typically use of opioids is the last resort after the patient has failed pain management with non-opioid analgesics or anti-inflammatories, as well as other potential pain modulators (including tricyclic antidepressants; seizure meds such as gabapentin, pregabalin, or other anticonvulsants; muscle relaxants; NMDA receptor antagonist; and topical analgesics). although I suspect that we all have patients who have clearly responded to opioids clinically for non-cancer chronic pain, the actual data is not great:

–The average pain reduction through all of these modalities averages only about a 30% decrease in pain (which may well be important for the patient, but is important for us to realize and communicate to the patient that it is unlikely that they will get full resolution of their pain)

–for neuropathic pain, a 2013 Cochrane review of 31 trials (see DOI: 10.1002/14651858.CD006146.pub2) showed that: for acute pain of less than 24-hour duration (16 studies with 392 participants) — half had less pain with opioids than placebo, and more than a quarter had no difference.  6 studies with 170 participants found that the average pain score with opioids was 15/100 points less than with placebo. 14 studies with 845 participants were of intermediate duration lasting less than 12 weeks (which they comment were small studies, short duration, and potentially inadequate handling of dropouts creating bias of overestimating treatment effects) all demonstrated efficacy for neuropathic pain with at least 33% pain relief found in 57% of those on opioids versus 34% in those receiving placebo. no improvement in many aspects of emotional or physical functioning.  Common adverse effects of constipation, drowsiness, nausea, dizziness, vomiting.  They conclude that “the efficacy of opioids and chronic neuropathic pain is subject to considerable uncertainty”.

–for chronic nociceptive pain, the data are quite mixed for opioids.  Again they are a last resort for therapy.  A systematic review in the annals of internal medicine (Ann Intern Med 2007;146(2):116) of opioid treatment for chronic low back pain analyzed 4 studies comparing opioids with placebo or non-opioid controls found no difference in pain control.  5 studies directly comparing the efficacy of different opioids found a nonsignificant reduction in pain from baseline.  However, the prevalence of lifetime substance use disorders ranged from 36-56%.

–one other very unfortunate trend is that chronic pain clinics used to be multi-disciplinary, involving social workers, psychologists or psychiatrists, neurologists or other pain specialists, anesthesia.  now, these have devolved into just being anesthesiologists giving injections (at least in boston).

So, what does this mean in clinical practice when we see a patient in chronic pain who is not responding well to non-opioid therapies? My guess is that most of us see patients like this pretty often and find that often they do respond to opioids, though sometimes pretty high doses. However, the data suggest that this it is pretty uncommon in placebo-controlled trials (though were the trials constructed well?? with high enough doses of opioids??), and we know that there may be significant harms to the patient (esp if on large doses, as the studies above found) and to the community (with increasing availability of opioids on the street and associated overdoses, and we do see that in our community). Part of the answer is to follow people closely, have pain contracts/urine testing/etc, though this does tend to undercut the provider-patient relationship. What about the patient who comes into the practice on high doses of opioids? One of our residents just saw a person with trigeminal neuralgia on 60 mg of methadone and 180 mg of oxycodone a day (if you whip out your opioid conversion table, that is 450 morphine equivalents!!!). the patient states he is stable on this dose and needs to continue. His urine tox screens are appropriate. We ultimately decided to decrease his dosage in part because he may well be diverting meds (2 nieces who are reputed to be “drug addicts”) and we felt uncomfortable continuing with this high a dose for the patient’s own safety. But it’s hard to know what the right answer is…


Primary Care Corner with Geoffrey Modest MD: C. Diff

4 Jul, 14 | by EBM

there have been a couple of articles dealing with c. diff infections.

1. recent one from Mass General Hosp on use of fecal microbiota transplant (FMT) in patients with relapsing c diff infections (see DOI: 10.1093/cid/ciu135). the problem is that standard medical therapy (metronidazole or vanco) leads to recurrent c diff in 30% treated for a first episode. and, if 2 or more recurrences, there are diminishing returns: >60% have relapses. in this study, the fecal transplant was from screened, healthy volunteers, frozen and administered to 20 patients either through a nasogastric tube (10 patients) or colonoscope (10 patients). primary endpoint was resolution of diarrhea without relapse after 8 weeks. also looked at patient-reported health score. not an RCT (no placebo group). results:

–baseline: patients (average age 50) with median of 4 relapses (5 antibiotic treatment failures) –[ie, even without control group, these patients are very unlikely to respond to yet another antibiotic course]
–resolution in 14/20 (70%) patients after single FMT: 8/10 with colonoscopic transplant, 6/10 with nasogastric tube transplant.
–5 patients retreated, 4 cured: resolution increased to total of 90% after a second FMT (patients were offered retreatment by nasogastric tube or colonoscopy — all requested the NG tube)
–self-ranked health score improved significantly with treatment
–no signif adverse events

so, non-randomized study, though remarkably likely that further antibiotic therapy would be unsuccessful or to get spontaneous resolution, and had 90% cure rate, with efficacy as good with the less invasive NG tube administration technique!!!

2. an observational study of 12,026 patients at cleveland clinic between 2008-2012 who were at high risk of developing c diff — age over 55 and put on a broad-spectrum antibiotic (eg piperacillin-tazobactam, or cipro, with cipro being used 90% of the time) and a gastric acid suppressant (PPI or H2-blocker) — they compared those who happened to be on metronidazole for 1-3 days for  a non-c diff indication before being put on the broad-specturm antibiotics (n=811) vs not on metronid beforehand (n=11,215) (see logistic regression done to control for patient demographics and comorbidities. results:

–c diff developed in 11 patients on metronidazole (1.4%) vs 728 not on metronid (6.5%), finding an 80% reduction of c diff (adjusted odds ratio of 0.21). there was an incremental benefit in older patients

3. blog from 2012:

annals of internal medicine with recent meta-analysis of use of different probiotics in preventing c. diff infections (see doi: 10.7326/0003-4819-157-12-201212180-00563).

–background:  c diff infections becoming more frequent and more severe over time.  more than 300K hospitalized pts in the US are affected every year.

–presumed reason is that antibiotics (esp broad-spectrum) disturb normal GI flora. probiotics should reinoculate gut with good bugs and thereby inhibit pathogen adhesion, colonization and invasion of the mucosa

–this meta-anal looked at 20 RCTs with 3800 pts, adults and kids.

–Probiotics used in the trials included BifidobacteriumLactobacillus,Saccharomyces, and Streptococcus species.  in most studies these were given for the duration of the antibiotic regimen

–results: decreased c diff infections by 66%!!!  and, fewer adverse effects in the probiotic group vs placebo (9.3% vs 12.6%)!!

–results similar in kids and adults, and with different probiotic species (details in their Table 1)

–their conclusion:  Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in CDAD (that is, cdiff assoc diarrhea, defined as antibiotic-related diarrhea with a positive c diff test)  without an increase in clinically important adverse events


so, these 3 studies raise some issues

 –in terms of c diff treatment, esp in those with relapsing infections, the use of fecal transplants is pretty impressive in this small study.  it raises the recurrent theme (at least in my blogs…) that the microbiome of the gut is really important and disturbances, whether they be antibiotics or red meat, can lead to bad outcomes. using fecal transplants from screened healthy volunteers is one approach, and the nasogastric approach seems more tolerable. using probiotics is another approach which should be tested, esp given the study on prevention of c diff. it is inherently more appealing to me to try re-establishing a healthy microbiome than adding an antibiotic (eg, metronidazole), since the antibiotic can also lead to resistance (it is disturbing that there is increasing resistance of H Pylori to metronidazole, which seems to track with metronidazole use for non H pylori indications. a bit like HIV, in that you need more than one antibiotic to cure H pylori, and using metronidazole as a single agent for a different application (eg treating bacterial vaginosis) might lead to resistance if there is an underlying infection with H Pylori.) there is the issue that most people get probiotics in health food/vitamin stores. these are not regulated, as with FDA, so what they say on the label is not necessarily accurate.


Primary Care Corner with Geoffrey Modest MD: Opioids and Chronic Pain

3 Jul, 14 | by EBM

many of us have patients on large doses of opioids for chronic pain. there are an array of forces pushing us to decrease use of these drugs (the increase in prescription opioid drug-related deaths, the diversion of drugs leading to hospitalization and deaths of others, the increased surveillance by professional societies, insurors, etc). In the NY times there was a long story of war veterans with severe injuries who got off opioids. not much detail on their support programs, but comments that they actually felt better of the opioids. also comment that 5 years ago, 80% of injured soldiers treated at walter reed hosp in washington were put on opioids. figure now is 10%, with comment that “many patients are benefiting from the change”.  see here


Primary Care Corner with Geoffrey Modest MD: Syphilis on the Rise

1 Jul, 14 | by EBM

Data from CDC on US syphilis rates, which bottomed out in 2000 at 2.1/100K people, but in 2013 rose to 5.3/100K — as in: more than doubled!! (see here). in 2005, database included sex of sex partners, and found that in “2005-2013, primary and secondary syphilis rates increased among men of all ages and races/ethnicities cross all regions of the United States. Recent years have shown an accelerated increase in the number of cases, with the largest increases occurring among MSM.” in women rates increased during 2005-8, then decreased 2009-13 (from 0.9/100K in 2005 to 1.5/100K in 2008 then back to 0.9/100K in 2013). in the time period 2005-2013, overall annual rate almost doubled from 2.9 to 5.3 cases/100K people, with increasing male representation — up to 91.1% of all cases in 2013. rate in black men was 5.2x that of white men (27.9 vs 5.4 cases/100K) and black women had 13.3x the rate of white women (4.0 vs 0.3/100K). highest rate in the West (beating out the South for the first time in 50 years)

so, after being on the verge of syphilis elimination in 2000, there has been a dramatic rebound. of concern is the increased transmission of HIV in those with syphilis, and CDC reported rate of 50-70% HIV coinfection in MSM infected with primary or secondary syphilis. this all confirms the general sense from other data that there has been less aggressive use of barrier protection with sex, esp with MSM… and the need to use data such as above in reinforcing the importance of protection.


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