The world is sitting at a cusp: How best to respond to the rising number of cases of the human version of the monkeypox virus. The current international outbreak (B1) has already spread to more than 58 countries with more than 6,000 cases — with ongoing monitoring of thousands more people with close contact. Monkeypox has been a heightened concern in several countries worldwide, especially Britain, Germany, Spain, and Portugal. So far, this is the largest international outbreak the world has seen.
The U.S. must immediately scale up the volume of and access to testing, not only for monkeypox but also for syphilis. For both diseases, we need to act quickly to ensure appropriate access to testing while also deploying pharmaceutical interventions. This multifaceted approach will help guarantee adequate surveillance and vaccination for people at high-risk before symptom onset.
What Does Syphilis Have to Do With It?
Syphilis is a known sexually transmitted infection (STI) that can manifest in lesions in the groin area and can transmit through bodily fluid. The genital sores associated with syphilis can make it easier to transmit other diseases such as HIV — and especially pressing at the current moment, genital sores or lesions are also common transmission pathways for the current B1 monkeypox outbreak. While monkeypox has not technically been categorized as an STI, there have been reports of some monkeypox patients also having STIs.
By scaling up testing and treatment for syphilis, we can better identify people who may be more likely to get and transmit monkeypox. Additionally, because the lesions in the genital region can be difficult to distinguish from those associated with syphilis, testing for both conditions is important.
The incidence of syphilis has been increasing in the U.S. In 2020 alone, there were more than 130,000 new cases of syphilis. While 43% of the new infections occur in men who have sex with men, cases have also been rising in heterosexual men and women, and over 50% of the new infections were in people ages 15 to 24. Congenital cases (passed during pregnancy from mom to baby) have also risen, and the rates are much higher for births to women who are American Indian/Alaskan Natives, Black/African American, Hispanic, or Native Hawaiian/Pacific Islander compared to those who are white or Asian. The CDC notes that the disparities in reported STIs are likely due to the higher prevalence in a community and reduced access to quality healthcare. The increase in syphilis may even be under-reported, as many people may have missed or had fewer screenings during the last 2 years.
Despite this surge, syphilis is quite easy to treat: it only requires a single shot of penicillin. As such, increasing testing can make a big difference in slowing the spread of syphilis, and potentially monkeypox as well.
A Three-Pronged Approach to Scaling Up Testing
Testing for monkeypox typically begins with a swab of a lesion or rash. This is done by a healthcare provider, who currently must get permission for the test from public health officials before sending it to a laboratory. A positive test for an orthopoxvirus receives follow-up testing at the CDC to verify if it is monkeypox. In contrast, testing for syphilis currently requires a blood sample to be sent to a laboratory, and prior approval is not needed. It is possible to deploy testing in communities, with broader access than just in physician practices.
A three-pronged testing strategy for the monkeypox virus and syphilis is necessary to slow the spread of both conditions. Recently, the CDC has been shipping tests for monkeypox to several large laboratories, which is an important first step. A second aspect is that the federal government should partner with manufacturers of tests and test components to ensure a sufficient supply of tests to deploy in communities. Finally, there must be a focus on the “last-mile” problem associated with testing: distribution and administration at the end of a system tends to be the most challenging part of any health or supply chain system.
There are recent reports that testing has been difficult to access. This needs to be addressed immediately, not only with the necessary supplies, but also with streamlined backend processes that make it easier for providers to ensure a test will be financially covered and a laboratory is available to process the test. This may also become easier as more companies roll out testing as new tests are developed and approved, but that process will likely take time. If we could test for syphilis or monkeypox as easily as for COVID-19 then it would be more difficult for these STIs to spread undetected.
It’s also crucial how we deploy these tests — not only in health clinics and providers’ offices, but also in pharmacies and with mobile outreach. This should be a collaborative effort, not one that falls only on the shoulders of federal government, state, and local agencies. It should include partnerships with insurance companies, employers, churches, pharmacies, and other businesses that have a direct touchpoint with the public.
We should also consider targeting broader testing for syphilis and monkeypox to populations that may be especially vulnerable: communities with higher prevalence, pregnant women, men who have sex with men, and anyone with a positive diagnosis for another STI. For recently-detected syphilis cases, a test for monkeypox should also be considered (and vice versa) since the diseases have some common transmission pathways.
We have a chance to stop monkeypox from becoming widespread in the U.S. through scaled testing for monkeypox and syphilis. Testing for syphilis can also help identify cases of monkeypox, especially in populations that may be at higher risk of monkeypox. It’s possible we may even find that rising rates of syphilis were associated with the current monkeypox outbreak. We also have a chance to reduce the damage from undiagnosed syphilis cases, which may continue for years after an infection, and to reduce disparities in health outcomes for monkeypox and other STIs. Learning valuable lessons from the early days of COVID-19, policymakers must invest immediately to promote wide-scale access for testing.
Julie Swann, PhD, is a professor of industrial engineering in the Fitts School of Industrial and Systems Engineering at North Carolina State University. Swann applies systems engineering and analytics tools to pandemic modeling and interventions for the system. She was a senior science advisor at the CDC during the H1N1 pandemic and recently advocated for increased surveillance testing on campus. Swann is a prominent member of INFORMS.
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