Running Head: RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

Rising Rates of Syphilis in Hillsborough County

Danielle Finethy
University of South Florida College of Nursing

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

Rising Rates of Syphilis in Hillsborough County

A highly treatable disease that many feel is not a major threat to the health of the public is
quickly rising in numbers, syphilis. A disease that if left untreated has the potential to cause
irreversible damage to an individual infected. Syphilis has been on the rise throughout the
country and is particularly high in the southern states along with multiple other sexually
transmitted infections (Adimora, Ramirez, Schoenbach, & Cohen, 2014). Hillsborough County
has rates higher than most other counties in Florida and reasons for this are varied. One large
factor is the lack of proper education in school systems regarding sexual health and effective
methods of prevention. This paper will examine Hillsborough County as well as outline several
interventions that may aid in reducing the number of new infections reported each year.
As one of the largest counties in the state of Florida, Hillsborough has many diverse
populations as well as problems within the community as a whole. The county is located on the
West Central Coast of Florida bordered by the waters of the Gulf of Mexico, the south border is
Manatee County, Pasco County covers the north border, and the east border is large county of
Polk. There are urban and rural areas in the county, Tampa is the main urban district with many
features including a busy downtown area, historic Ybor city, and several university areas. Plant
City is on the opposite side of the spectrum with vast areas of farmland in a quiet rural setting.
Throughout the county the three largest employers are Hillsborough County School
District, the University of South Florida, and the MacDill Air Force Base, respectively
(Hillsborough County Government, 2015). These public entities are all based on improving
welfare of the community through education and safety. Major health care systems with in the
county include BayCare, Tampa General Hospital (TGH), and the Hillsborough County Health
Care Plan (HCHCP). The major hospital systems BayCare and TGH both offer comprehensive

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

health care facilities including specialized and primary care outpatient clinics. The HCHCP is
essentially an insurance plan funded by the county to provide full coverage and care for
individuals living at least 100% below the poverty level (Hillsborough County Department of
Health and Social Services, 2011).
The total population estimate in Hillsborough was 1,316,298 in July of 2014 (United
States Census Bureau, 2014). Of this population 6.4% were under the age of five, 23.2% were
under the age of 18, and 13.1% were over age 65. The racial differences show that 75.3% of
inhabitants identify as white, 17.5% as black, and 26.5% as Hispanic. Education data in the
county show that the percent of people age 25 or older who possess a high school diploma or
higher is around 87.1 and those who possess a bachelors degree or higher 29.8, both slightly
higher than the state statistics (Florida Department of Health, 2015). The median household
income is approximately $50,122 with 16.8% living below the poverty level which is almost
equal to the state percentage of 16.5 (Florida Department of Health, 2015). For persons over age
five who speak a language other than English at home the percentage is 27.2, only slightly lower
than the Florida state average of 27.8 (Florida Department of Health, 2015).
Most recent data available for specific indicators of health in Hillsborough County show
that there are several topics which are meeting or exceeding the state averages and help to
improve the overall health of the community. The percent of adults age 65 or older that have
ever received a pneumonia vaccine has been on a steady rise over the past decade and in 2013
was 68.7% compared to the state of Florida with 66.2% (Florida Department of Health, 2015).
The indicator showing the amount of adults aged 50 to 75 who received a colorectal screening
based on clinical guidelines in 2013 was 70.1% and for the state of Florida 64.7% (Florida
Department of Health, 2015). Based on this data, Hillsborough County is screening more people

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

than the state average and this is a necessary screening tool to avoid a highly preventable type of
cancer that affected approximately 35 out of every 100,000 individuals in Florida in 2012 (CDC,
2014). Access to care is always a major indicator of health for any community and Hillsborough
is exceeding that statistic compared to the state with 17.8% of adults stating that they could not
see a doctor due to cost in the past year and a state average of 20.8% (Florida Department of
Health, 2015). The HCHCP may help to improve the rate because it aims at improving access to
care for individuals residing only in Hillsborough County and offers full preventative services
and most specialty care (Hillsborough County Department of Health and Social Services, 2011).
While there are determinants of health that Hillsborough is excelling at there are certain
areas which need vast improvement. In data reported from 2012 to 2014 there was an annual
average of 1467 alcohol suspected motor vehicle crashes at a rate of 114.8 per 100,000 for
Hillsborough County as compared to the state of Florida which has a rate of 87.6 (Florida
Department of Health, 2015). This poses a major threat to the community because innocent
people may be hurt and they have no control over the precipitating events. There have been
multiple incidences in Tampa involving wrong-way drivers who have all been intoxicated and
have resulted in serious injury and death. This is a significant problem for the county and needs
to be addressed with stricter laws and regulations.
For the state of Florida the overall rate of infant death, defined as death of an infant age 0
to 364 days old, from 2012 to 2014 was 6.1 (Florida Department of Health, 2015). The rate
overall in Hillsborough County for the same time period is 7.3, and accounting for differences in
race showed that whites had a rate of 5.8 and blacks at a rate of 12.8 which is more than double
the state average (Florida Department of Health, 2015). Blacks have been disproportionately

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

higher in rates of infant deaths throughout the country and there are several reasons for this
difference including lack of access to care, deficient knowledge, and poor prenatal care.
When examining the rates of sexually transmitted disease for Hillsborough County and
the state of Florida there were extremely higher incidences in the county among all diseases
including gonorrhea, chlamydia, syphilis, and HIV. The rate of new cases of infectious syphilis
for Hillsborough County from 2012 to 2014 was 14.0 as compared to the state rate of 8.0
(Florida Department of Health, 2015). This shows that there are higher rates of risky sexual
behaviors happening throughout the county and possibly a lack of education regarding sexually
transmitted infections. This is a dangerous trend because infections that go undetected can have
serious implications on health years later if left untreated. While most frequently new infections
are occurring in men who have sex with men (MSM), females are also contracting the disease at
an increased rate and this poses risk to unborn children of women who have undetected syphilis
and can pass it to their babies causing various problems for the children affected congenitally.
The upward trend in the number of syphilis cases reported each year in Hillsborough
County will be the focus of this paper with attention to race, sex, and sexual practices. It is an
important health problem facing this county as well as the nation and is dangerous because it is
not an illness that people feel they are at risk to contract. An infection with syphilis puts the
individual at a higher risk for contracting HIV which potentiates the risk for a community who
already has a higher than average incidence of HIV infection (Patton, Su, Nelson, Weinstock,
2014). Certain demographics are more frequently infected including young adults aged 20-34
years, Black non-Hispanics, and males. Research has shown that MSM are among individuals
with the highest risk without regard to race or age.

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

The determinants of health model is a method of examining relationships that occur on an

individual or population level that affect health in either positive or negative ways. The
determinants which affect health are widespread and include personal, social, economic, and
environmental factors and fall under categories such as individual behaviors, biology and
genetics, social factors, health sciences and policymaking (Office of Disease Prevention and
Health Promotion, 2014). The topic at hand can be analyzed and examined by public health
officials to determine which areas of health may have deficits and develop a plan to make change
and improve outcomes in the health of the population or individual.
When examining the biological factors contributing to the rising rates of syphilis
infection in Hillsborough County there are two concerning trends that are shown in data
compiled from all 402 reported cases of syphilis in any stage from 2012 and those are that males
make up 75.1% of all new reported cases and non-Hispanic Blacks account for 46.8% of all new
reported cases (Florida Department of Health, 2013a). Data also shows that in 2012 there were
155 new cases of infectious primary or secondary syphilis and of these cases 32% were also
infected with HIV (Florida Department of Health, 2013b). The biological determinants of health
in Hillsborough County show that Black men are most at risk for contracting the disease.
Lifestyle and personal habits are crucial to investigate when determining reasons for a
shift in rates of sexually transmitted infections. The biological determinants of health have
shown that Black men are disproportionately affected with syphilis compared to females or other
races and it was also shown that HIV infection is closely correlated with syphilis infection as
well. The CDC started collecting an important part of data on reported cases of STDs in 2005
and that was to obtain the sex of the sex partners of individuals infected with syphilis. This has

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

helped to identify a pattern among all STD rates especially in syphilis as reported by Patton et
al., (2014),
In 2012, primary and secondary syphilis cases in the 35 reporting areas that reported the
sex of sex partners for 70% of male cases comprised 83.7% (13,113) of all nationwide
cases. In those areas, the proportion of male primary and secondary syphilis cases
attributed to MSM increased from 77.0% (6,366) in 2009 to 83.9% (8,701) in 2012..
Based on this national data it can be determined that the MSM community is the most at risk for
syphilis infection. The county has a clinic dedicated to providing testing and treatment for
STDs and it can be utilized by anyone seeking care. The fact that the health system in the
county provides confidential and cost effective care for everyone is a positive factor when
looking at what is beneficial to the current trend in syphilis cases. Having a place for people to
find out if they are infected is important for the treatment and to prevent the spread of disease,
however a more important factor is the education of individuals at risk for prevent the infection
from occurring in the first place. The Florida State Statutes 1003.42 (2)(n) and 1003.46 on
standards of education for school aged children require that abstinence from sexual activity until
marriage and the consequences of teenage pregnancy should be the standard of teaching for
health education. Schools are allowed to teach on acquired immune deficiency syndrome
(AIDS) if they choose to, as well as STDs, however within this teaching abstinence must be
encouraged as best practice and encourage children and teens that abstinence until marriage is
expected. This standard of education does not provide adequate knowledge about diseases that
are a real threat to the health of young adults.
Young adult males in Hillsborough County are at increased risk for contracting syphilis
due to inadequate knowledge of disease process and lifestyle factors contributing to the spread of

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

disease. The standards for education on the topic of sexual health are lacking the necessary
information that needs to be provided to young adults to help guide them into the transitionary
period of life where sexual activity becomes more prominent. Safe sex practices should be
encouraged and education provided on how diseases are spread and the importance of condom
use and communication with sex partners to help reduce transmission. Health professionals also
need updated education on the rise of cases so they may be better able to detect and properly
treat for syphilis, helping to reduce the number of cases that may go undetected and progress into
the latent stage. This disease is best managed through prevention of infection and preventing
reinfection in cases that have been identified through education.
The most accessible population to target with a primary level intervention is high school
students in Hillsborough County. Providing proper education on sexually transmitted disease
including HIV/AIDS and syphilis will help increase awareness of the disease and decrease
transmission. The education should include real life examples and include information relevant
to individuals of all sexual orientations and preferences including gay, bisexual, and transgender.
Including risk factors like multiple sex partners and drug and alcohol use increasing risk of
participation in risky behaviors will further increase knowledge in this at risk population. The
stakeholders will include members of the education system, parents of students, and public
health officials. The funding for educational materials and training could be obtained from
school budgets, county health departments, or state funding. There is potential for concern in
funding this initiative as it is not what is outlined in the state statute for this type of education
and may receive criticism from religious groups or conservative political groups. A community
health nurse would be to develop appropriate lessons for the intended audience, and to provide
instruction for educators on how to effectively deliver the material to students.

RISING RATES OF SYPHILIS IN HILLSBOROUGH COUNTY

Aiming to stop the rise of syphilis in Hillsborough County a secondary level prevention
strategy aimed at adults 18 years of age and older would be to include syphilis screenings at
annual preventative visits. Implementing this intervention will help screen more individuals,
diagnose and treat cases that may not be symptomatic, and give opportunity for education on the
disease and how it is spread. The stakeholders for this intervention would include community
members, health care providers, and public health entities that provide recommendations on
standard practices. Funding for this type of intervention will be provided through health
insurance for individuals receiving preventative care and from the health systems that provide
care to educate the physicians on changes to standards. A community health nurse will be able to
evaluate the effectiveness of this intervention over time by studying trends and assessing if the
screening tool is effective in finding and treating more cases.
Individuals confirmed to have active syphilis infection represent a specific population
that will benefit from tertiary level of intervention. Once an individual has been diagnosed and
treated for syphilis, providing further education is vital to prevent reinfection and prevent the
spread of disease. The stakeholders in this intervention include any individual who has
confirmed infection with syphilis, or any sexually transmitted infection, and seeks treatment
from the Hillsborough County Health Department, and also will include the health care providers
who deliver the education. Implementation of this intervention will require no further funding
since education is included treatment. The role of the community health nurse in implementing
this level of intervention will include specific education to infected individuals on the way these
infections are passed from person to person and to promote use of safe sex practices during any
and all sexual contact. Encouraging these same individuals to return for repeat testing in several

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months is also advisable to be sure that treatment has been effective and that no new infections
are present.
The rate of syphilis infection in Hillsborough County is on the rise and the population
affected most frequently is younger men in the community. The level of education received by
the time adolescents are leaving high school is less than desired when looking at sexual health
and education specifically on sexually transmitted diseases and prevention strategies. A primary
intervention aimed at changing education standards within the state of Florida will help to
provide comprehensive knowledge to young adults who are leaving high school and will enter
into a time where sexual experiences increase and other risky behaviors may also be introduced.
A policy that mandates education be provided on overall sexual health, sexually transmitted
diseases, signs and symptoms of infection, methods to prevent contraception and decrease rates
of STDs including HIV, as well as where treatment is available will benefit public health of the
community by increasing awareness and knowledge. The goal of the policy is for more adults in
the community to be properly educated on syphilis and other STDs and the desired outcome is
for less people to become infected each year. The stakeholders include students who will be
receiving the education, public officials including the board of education, and legislators who
will be responsible for changing current law. Funding may be difficult to procure due to the
controversial nature of the topic, sexual education and attempting to change laws from
abstinence only to include more realistic expectations of adolescents. The sources for funding
may be available from state education funds, or private organizations that have interest in public
health. Supporters of this proposed policy may include health care providers who are aware that
comprehensive education on sexual health is more beneficial for outcomes regarding pregnancy
and STD infection, as well as public health entities such as the CDC and state public health

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department. Potential opposing forces for the policy change may include conservative
politicians, certain religious groups, or parents of children who would receive the education.
The plan to put policy in action will include gathering supporting data from other states
that have changed their education standards from abstinence only to include all aspects of sexual
health to adolescents and present this data as support for the change. Education boards,
lobbyists, and public health officials will be among the groups contacted to start the process of
changing standards of education regarding sexual health. Presenting evidence supporting the
benefits of the policy as well as presenting current statistics on STD rates in Florida will be a
major component of the proposing the policy change. Attempting to change current education
standards will likely meet opposition at state and county levels from groups that wish to keep
abstinence only in schools. It will address the needs of a population at risk for contracting
disease simply because they have not had education on the topic and if put in action will enhance
the health and well-being of the community by reducing infection.
Changing laws on education is not an easy task and will likely take time and money to
accomplish the end result. The statistics on the rates of syphilis rising in Hillsborough County
are daunting and it is important to take steps to educate the community and instill knowledge on
how to change current trends. Implementing interventions in our community to reduce incidence
will benefit everyone as there will be less infection throughout the county. Education is the most
important tool available to improve health outcomes and it is crucial to provide information to
groups most at risk. As a nurse interested in public health and sexual health specifically, this
topic shouts as one that needs to be addressed quickly and comprehensively in the community.
Any infection that is completely preventable is one that should be well known in the community
and sadly barriers to education make that a difficult task for healthcare providers to achieve.

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References
Adimora, A. A., Ramirez, C., Schoenbach, V. J., & Cohen, M. S. (2014). Policies and politics
that promote HIV infection in the Southern United States. AIDS, 28(10), 1393-1397.
doi:10.1097/QAD.0000000000000225
CDC. (2014). Colorectal cancer rates by state. Retrieved from
http://www.cdc.gov/cancer/colorectal/statistics/state.htm
Florida Department of Health. (2013a). Age, race/ethnicity, sex report (Rep.). Retrieved from
http://www.floridahealth.gov/diseases-and-conditions/sexually-transmitted-diseases/stdstatistics/
Florida Department of Health. (2013b). Reported cases of STDs and the number of those cases
identified as co-infected with HIV [PDF]. Retrieved from
http://www.floridahealth.gov/diseases-and-conditions/sexually-transmitted-diseases/stdstatistics/
Florida Department of Health. (2015). Hillsborough County, Florida 2014 County health profile.
Retrieved from http://www.floridacharts.com/charts/CountyHealthProfile.aspx?
county=29&reportYear=2014&tn=31
Hillsborough County Department of Health and Social Services. (2011). Hillsborough
Healthcare [Brochure]. Author. Retrieved from
http://www.hillsboroughcounty.org/DocumentCenter/Home/View/622
Hillsborough County Government. (2015). Current local mitigation strategy document: Section
II profile of Hillsborough County. Retrieved from
http://www.hillsboroughcounty.org/DocumentCenter/Home/View/16554

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Office of Disease Prevention and Health Promotion. (2014). Determinants of Health. Retrieved
from https://www.healthypeople.gov/2020/about/foundation-healthmeasures/Determinants-of-Health
Patton, M. E., Su, J. R., Nelson, R., Weinstock, H. (2014). Primary and secondary syphilis
United States, 2005-2013. MMWR 63(18), 402-406. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6318a4.htm?s_cid=mm6318a4_w
United States Census Bureau. (2014). Quick facts Hillsborough County, Florida. Retrieved from
http://www.census.gov/quickfacts/table/PST045215/12057