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SPEAKER 1: Welcome to Public Health On Call,

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a podcast from the Johns Hopkins Bloomberg School

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of Public Health, where we bring evidence, experience,

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and perspective to make sense of today's leading health

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challenges. [RHYTHMIC MUSIC]

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If you have questions or ideas for us,

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please send an email to [email protected].

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That's [email protected]

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for future podcast episodes.

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LINDSAY SMITH ROGERS: This is Lindsay Smith Rogers.

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Today, a health crisis among residents

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of reservations in the Great Plains region of the US.

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Dr. Meghan Curry O'Connell, Chief Public Health Officer

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at the Great Plains Tribal Leaders Health

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Board and a member of the Cherokee Nation,

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talks with me about the alarming rise of syphilis cases

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that have far outpaced even national numbers

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and why she and other public health officials

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are struggling to respond.

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Let's listen.

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Dr. Meghan Curry O'Connell, thank you so much for being on Public Health On Call.

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Would you start off by telling us a little bit about your role and your work?

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MEGHAN CURRY O'CONNELL: Sure. Well, thank you so much for having me.

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I am currently the Chief Public Health

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Officer for the Great Plains Tribal Leaders Health Board.

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We serve the tribal communities in North Dakota, South Dakota,

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Nebraska and Iowa. And in my role, I support of all of our public health activities

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that may be going on in the area, including things

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like public health services that we may provide,

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to helping provide trainings and capacity-building

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for the tribal communities that, essentially, are our bosses.

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I work for all of them to help support their health

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and public health activities. LINDSAY SMITH ROGERS: And today we're

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going to talk specifically about syphilis. We know that nationwide, there has

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been quite a spike in syphilis, but this is really, really

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evident among the people that you work with. Could you talk a little bit about that?

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MEGHAN CURRY O'CONNELL: Yes. Nationally, we've seen an increase

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in syphilis among all Americans, especially since 2020.

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And the data is a little bit older, so the latest national data we have

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is from 2022 that's been released so far.

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And it-- nationally, the increase has been about 150%.

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So that's very high, but among American Indians in our area,

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it's nearly 2,000%.

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So it's far outpaced what we've seen nationally

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among all Americans. And nationally among American Indians,

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the rates have been very high.

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But among those that we serve in the Great Plains,

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the increase has been even sharper.

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LINDSAY SMITH ROGERS: Are there specific groups within this population that are being more impacted than others?

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MEGHAN CURRY O'CONNELL: It's kind of younger adults, first of all.

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So sometimes I think we think STIs are always in children--

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or, you know, older children, teenagers.

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That's not necessarily the case. Kind of that 25 to 35-year-old age group has had more cases

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than others. And then, what's a little bit unusual in the cases

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among American Indians is the impact on women.

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So historically, in the recent history,

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syphilis is often thought of something that primarily occurs among men who have sex with men.

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And you see this in the national data. Even in the last couple of years,

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there's many more men diagnosed with syphilis than women,

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except among American Indians.

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So what we're seeing is a ratio of 1 male

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to 1 female that's diagnosed with syphilis

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among American Indians. And so a lot of the cases are hetero-ly-- transmitted

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through heterosexual sex.

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And we have many more women that are impacted.

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And the reason that's important to point out

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is there's clearly something different going on

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in this outbreak than is happening

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in other parts of the country and in other racial and ethnic

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groups. But also, it impacts the rates of congenital syphilis.

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So congenital syphilis is, of course,

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syphilis that the fetus or infant gets from the mother

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during pregnancy. And American Indians also have the highest rates

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of congenital syphilis of any racial or ethnic group.

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And part of what's driving that is because there's so many women of childbearing age

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who are infected with syphilis.

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LINDSAY SMITH ROGERS: So you have a 2,000% increase,

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and then you're seeing some unusual transmission patterns.

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What do we know about why this is happening?

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MEGHAN CURRY O'CONNELL: I don't think we know nearly enough, unfortunately.

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We know some things from data that has been released from state public health agencies

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or from the federal government-- like I mentioned,

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that it's disproportionately impacting Native women

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in particular and Native people, that much of the transmission

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is through heterosexual sex, and there are some other trends--

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for example, that a fair number, but by no means all people,

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have a history of substance use at some point.

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And so there are some hints. But why this is occurring in this particular way

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among this population, I don't think we know all of the answers to that yet, unfortunately.

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LINDSAY SMITH ROGERS: And so your job as the Chief Public

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Health Officer, you know, you see something like this,

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and you might start to think about a response.

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What would an ideal public health response look like.

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In this case? MEGHAN CURRY O'CONNELL: An ideal public health response

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is not sexy. [LAUGHS] It's not fancy.

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It's very old-school. There's nothing, I think, new or inventive

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that I have to bring to that.

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But we know that it works, and we

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know that it's the only thing that works to address these infectious disease outbreaks,

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whether it's syphilis, or COVID, or tuberculosis, or anything

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else. So what does that look like?

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It looks like a lot of people who are trained to find cases--

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people who have tested positive for syphilis in this case--

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and to go out and talk to them and ask

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them lots of questions about their life

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and their sexual partners and to educate them about syphilis.

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So that's the first component that's really important.

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You need to find the people who have tested positive,

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elicit their contacts so that you can go talk to those people,

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too, and start to spread out to people who

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haven't been tested yet, but who likely or possibly could

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have syphilis. And we've been doing that in public health for a long time.

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And so that's really important. And then the other piece of that is making sure people

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are treated. So when you're doing that, you want

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to make sure you're treating people, either

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by bringing someone who can treat with you--

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giving them penicillin in the field, for example, in the case of syphilis,

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driving them back to the clinic to get treated,

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and then, when you go talk to their partners,

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doing the same thing. So the more people you can talk to, identify,

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who have syphilis or are at high risk for syphilis

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and get them treated, that's how we start to stop the spread.

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And it's not simply enough to rely

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on each individual coming in and getting tested

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and them getting treated. You have to do both.

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LINDSAY SMITH ROGERS: But that's not happening here.

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Can you tell us why? MEGHAN CURRY O'CONNELL: It's not happening, unfortunately.

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I think part of it is because this type of work

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is very labor-intensive.

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It's not cheap. There's not a lot of ways to leverage or utilize technology

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to make it go better.

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Especially in the areas we're talking about,

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cell service isn't even a guarantee.

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So even if you were to call people, or text them, or use

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an app, they might not be able to access it on their phone

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where they're at. And additionally, in the areas we're talking about,

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they're very rural. So that adds a lot of expense and time to these efforts

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because you can't just walk around the block and be within,

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you know, a couple hundred feet of dozens

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of syphilis cases or something. People are spread out over very long distances.

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And so that makes it harder. But also, as we mentioned before,

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there's been this huge increase-- you know, nearly 2,000% in our area--

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of cases, but there hasn't been that same increase

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in funding or public health workers

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to keep up with the demand.

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Public health departments just don't

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have the resources to respond to something like that--

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frankly, similar to what was seen in COVID, right?

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There was this new disease that needed all these interventions,

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and there just wasn't enough of everything to go around.

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And unfortunately, we came off of that

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and went right into a syphilis outbreak that needs

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the same type of attention. LINDSAY SMITH ROGERS: There was a request for an emergency

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declaration that was filed. Can you talk us through that?

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MEGHAN CURRY O'CONNELL: Sure. In February, the Great Plains Tribal Leaders Health Board--

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which is, again, all of the tribes in the Great Plains area

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of North Dakota, South Dakota, Nebraska, and Iowa have come together and worked together since

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the '80s in this Health Board--

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they passed a resolution regarding

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the syphilis emergency.

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And then we asked-- we, as part of that request, we made a formal request

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to HHS Secretary Becerra to declare a Public Health

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Emergency. So that declaration has to come from the federal government.

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It can come from him specifically. I believe the President can also do it in order to release some

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of these resources that are needed to address this nearly

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2,000% increase in cases, because it hadn't been done yet.

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So we've talked some about needing more resources

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in terms of people, money to hire people.

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We haven't talked about some of the other challenges that

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have been involved in this-- for example,

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like needing penicillin to treat people.

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There's been a shortage in America for not quite,

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but about a year. That's the best treatment for syphilis.

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It can be hard to get.

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It's improving, but that's impacted the response.

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It's very expensive. And so all of these different pieces

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that are needed, asking the Secretary to declare

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an emergency so that some of those resources

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could be released in this emergency setting.

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LINDSAY SMITH ROGERS: And what do you expect to see happening next?

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MEGHAN CURRY O'CONNELL: So we have not yet received a response

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from HHS or Secretary Becerra.

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It's been almost two months since we made the request.

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And, of course, in that time, people continue to get infected.

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Unfortunately, infants continue to get infected and die.

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You know, syphilis, you can have--

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in a lot of cases, you can have syphilis for a long time,

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and you'll be OK.

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Eventually, if you get screened and treated appropriately,

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nothing will happen. There are some cases, though, that

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can be very serious right away.

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And, obviously, we don't want people to be sick regardless.

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But in the case of congenital syphilis,

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it's very, very time-sensitive and very, very serious.

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Babies that are infected with congenital syphilis

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can die, up to 40% of them.

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It's kind of a big range, but a huge percentage of them

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can die shortly after birth or can be born deceased--

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so a stillbirth. Or they can have serious health issues

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and, even if they aren't born with any symptoms,

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will need to be treated often for a couple of weeks' stay

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in the ICU with antibiotics.

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And it's completely preventable if we catch those moms

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and get them treated. But there is this very urgent, time-sensitive issue

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around congenital syphilis because we can only get them,

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we can only prevent it while the mom is still pregnant.

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Part of this urgency, too, also has to do with those babies.

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You know, every moment in a pregnancy that we're not

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able to find the mom or, for whatever reason,

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she's unable to be tested or treated,

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you know, it's a very high risk for that infant.

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And so with the Emergency, trying to act on that by

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not only protecting the moms, but everybody around.

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And again, if we remember from COVID, it's not enough to focus on that most vulnerable person,

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the baby. You have to treat everybody around them so they don't

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get sick in the first place. It's super important and very concerning that infants--

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and particularly Native infants-- are continuing to get infected and therefore

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die and have some other serious medical outcomes as well.

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I'm not sure why not. I think there are-- it depends on who

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and which group we're talking about.

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Again, the data is collected in a variety of different ways

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at a variety of different sources. So there's the clinical collection by a doctor.

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They do your syphilis test, for example. And then, there's the public health collection

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at the next level, which is often at the state, which gets that from the clinical facilities.

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And then, there's also the federal level. So it's kind of complicated.

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I think one of the big challenges

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that tribes and tribal epidemiology centers--

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or TECs, which we have one in the Great Plains--

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run into, is this whole system was

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created without any consideration for their need

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or use of the data. So a lot of this information flows all the time.

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It's totally legal. Tribes and TECs were often included,

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at least on the federal side, in the laws

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that allow the data to be shared-- so HIPAA as an example.

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But the systems that were set up to share the data

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did not include tribes or TECs. And that system has been there forever.

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You know, I've done it as a physician. You fill out the form, and you send it to a state lab.

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And everybody just kind of does that. And then, you know, the tribes or TECs come along and say, hey,

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we'd like that, too. And everybody goes, what?

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You know, like, that's-- no, I don't think we can share with you.

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It's kind of a weird request. We've never done that before.

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And so it's not something that historically has been taken

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into consideration on that boots-on-the-ground level,

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that there's this clear data stream. And so I think a lot of the challenges around data access

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have to do with that issue.

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LINDSAY SMITH ROGERS: So you have a pretty major problem

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with syphilis going on. You've asked for an emergency declaration to help free up some

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resources for you to do the traditional "unsexy,"

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as you called it, public health work to actually, you know,

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turn this around. But a huge part of this is that you're

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just not getting even the basic data

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to understand what's happening. So even without an emergency declaration,

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you can't do your job. So what is the next step here?

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MEGHAN CURRY O'CONNELL: We are making headway,

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and we continue to work on all of these issues.

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We do currently, actually, right now have a CDC deployment

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to the area to help find cases, and work on that issue,

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and do some training with staff so that they can continue

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to do that in the future. This was able to happen because we are--

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we have begun to receive some information

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from the State of South Dakota around these cases,

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and hopefully, we'll be able to continue that in the future.

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But you're right, without it, we're

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very limited in what we can be able to do.

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So for the previous two years, when that information

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was not available at all, we've done kind of everything we can.

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But in my role, it feels more reactive than proactive, right?

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So we try to test as many people as we can

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and connect them to care, or we do education events.

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We have PSAs and that kind of thing

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running all over on all the different platforms

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and trying to get the word out.

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We've educated providers. We're doing these coordination events.

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We also had the CDC out in the summer to do an epi where they help us understand what's going on

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to see what else we can do. But to really kind of get ahead of it,

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you do need that data to be proactive.

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And again, we have some, but we don't have all that we need.

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We don't have it in the whole area, for example.

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And it's very difficult to do without that information.

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I mean, it's, frankly, impossible

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to do without that information. It's essential to epidemiology and public health

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that you know who's sick, right? And if we don't know who's sick, you

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can't do those interventions.

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LINDSAY SMITH ROGERS: Well. Dr. Meghan Curry O'Connell, thank you

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for taking time out of what I know is a very busy time to come and talk to us about this situation.

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And we'll certainly continue to follow along.

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MEGHAN CURRY O'CONNELL: Thank you so much for having me.

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I really appreciate the opportunity to talk about what we're doing here.

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Thank you. [RHYTHMIC MUSIC]

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SPEAKER 1: Public Health On Call is a podcast from the Johns

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Hopkins Bloomberg School of Public Health,

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Produced by Joshua Sharfstein, Lindsay Smith Rogers, Stephanie

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Desmon, and Grace Cecere.

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Audio production by JB Arbogast, Holly Cardinale, Spencer Greer,

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Matthew Martin, and Philip Porter,

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with support from Chip Hickey. Distribution by Nick Moran.

17:22

Production support from Katherine Ricardo.

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Social media run by Grace Cecere and Aliza Rosen.

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If you have questions or ideas for us,

17:32

please send an email to [email protected]

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that's [email protected]

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for future podcast episodes.

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Thank you for listening.