Running head: PRIMARY AND SECONDARY SYPHILIS 1

Primary and Secondary Syphilis: On the Rise in Orange County, California

Taylor Brashears

University of South Florida

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Primary and Secondary Syphilis: On the Rise in Orange County, California

The number of new primary and secondary cases reported is abounding in Orange

County, California. From 2010 to 2015, the prevalence tripled (Centers for Disease Control and

Prevention, 2015). For a county that prides itself for its state of health, this is an alarming fact.

Although the rate of primary and secondary syphilis has been increasing for multiple years, with

proper plans and precautions implemented, it is possible to reverse the trend and return the

county to its prior state of health.

Overview of Orange County

Located in southern California, Orange County is geographically small, but does not lack

in its population size. The county has a total land area of 790 square miles (United States Census

Bureau, 2016b), making it the smallest county in the region. Los Angeles County, San Diego

County, San Bernardino County, and Riverside County surround Orange County. To the west,

Orange County has 42 miles of coastline along the Pacific Ocean (Orange County Healthier

Together, 2017). These numerous public, private, and state beaches attract millions of visitors

every year, and attract a multitude of residents.

Although modest in geographical size, this term is not used to define Orange Countys

population size. With an estimated population of 3,175,532 (United States Census Bureau,

2016b), it is one of the most densely populated counties in the United States (United States

Census Bureau, 2010a). Due to this, it is classified as an urban area (United States Census

Bureau, 2010b). Over 60% of the population is between the ages of 18 and 64, with a nearly

even divide between males and females (United States Census Bureau, 2016b). Those who are

white alone (not Hispanic or Latino) make up 41.4% of the population and those who are

Hispanic or Latino make up 34.4%. Asians make up another 20%, and the remaining 4.2%
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consists of African Americans and those who identify as other (United States Census Bureau,

2016b). Since the county is so densely populated there are a multitude of different employers

throughout. The largest employer of the county is Walt Disney Co. due to theme park

Disneyland. The next largest employer is the University of California in Irvine, the only

University of California in Orange County. The Boeing Company, an aerospace business, also

employs are large amount of people within the county (Location OC, 2015). Orange County

boasts a numerous amount of major healthcare systems, including St. Josephs Health, Kaiser

Permanente, Memorial Health Care Systems, United Healthcare Group, and Tenet Healthcare

Corp (Location OC, 2015). Even though Orange County may be small, it is one of Californias

most successful counties in regards to socioeconomic status.

Comparison of Local vs. State Populations

Most of Orange Countys socioeconomic status indicators surpass the averages in

California. In Orange County, only 12.3% of families lived below the poverty line, compared to

Californias average of 16.1% (Centers for Disease Control and Prevention, 2015). Orange

County boasts a population with 84.3% of residents aged 25 of older having a high school

diploma, compared to Californias average of 81.8% (United States Census Bureau, 2016b).

45.7% of the population in California speaks a language other than English at home. Of those

among that group, 20.4% speak English less than very well (United States Census Bureau,

2016a). In California, the average percentage of people who do not speak English at home is

43.9%, and among those people, an average of 18.8% of people do not speak English very well

(United States Census Bureau, 2016a). In Orange County, only 9% of the population does not

have health insurance, whereas an average of 9.5% of the population in California does not have
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health insurance (Orange Countys Healthier Together, 2017). These statistics show that Orange

County prioritizes the health, well-being, and integration of its residents, a strength of the county.

Analysis and Interpretation of Data

Multiple factors determine the overall health of a community. The population of Orange

County has multiple strengths that demonstrate health is a priority of the citizens, including those

who create laws and policies. Although Orange County has multiple strengths, it also has areas

in which improvements are necessary. By recognizing these weaknesses, lawmakers and

policymakers are able to work to improve these areas that need attention.

Identified Strengths

One of the strengths of the population in Orange County is that 89.6% of women initiated

prenatal care within the first trimester of pregnancy compared to the United States average of

73.1% of women (Orange Countys Healthier Together, 2013), which is essential for detecting

and treating fetal and maternal medical problems. This statistic proves that some form of

healthcare is accessible to a majority of its female residents and demonstrates the populations

concern for fetal and maternal health. Another strength of the county is that its infant mortality

rate (number of deaths of infants under one year of age) in Orange County is at 3.8 per 1,000

births whereas the national average is 6.5 per 1,000 births ((Orange Countys Healthier Together,

2013). A low infant mortality rate indicates that healthcare is continuing to be provided after

birth and that resources are available to aide in keeping a baby healthy. In Orange County, only

an average of 5.4% of students who began high school dropped out before graduating, compared

to Californias average drop out rate of 9.8% (Orange Countys Healthier Together, 2017). This

demonstrates that kids are not only attending school, but are disciplined, participating in class,

completing assignments, and learning the required material. It also shows the efforts and ability
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of school faculty and administration to enforce rules and policies upon its students. Although

Orange County has multiple strengths, it also has its weaknesses.

Identified Weaknesses

An indication that Orange County has areas to improve on is the fact that 9.7% of

households live in crowded living conditions compared to the national average of 3.3% (Orange

Countys Healthier Together, 2013). This may be due to the extremely high cost of living.

According to the county, resident needs to be earning at least $28 per hour, if working 40 hours

per week, to be able to afford a single room apartment (Orange Countys Healthier Together,

2017). This forces community members to share apartments and houses, diminishing a sense of

independence. Another weakness of Orange County is the rate at which partner abuse occurs. A

study reports 4.9% of adults report intimate partner abuse within the last 12 months compared to

the national average of 3.5% (Orange Countys Healthier Together, 2017). This is concerning

due to the fact it demonstrates a lack of a healthy way to express anger and frustration, a lack of

respect, and promotes further violent activity in the family. Another concerning statistic is the

increase in the rate of new cases of primary and secondary syphilis in the county. In the last five

years, rates have increased over 300% from 77 news cases to 355 new cases annually (Centers

for Disease Control and Prevention, 2015). This indicates that the population is not properly

educated on the prevention, treatment, and severity of sexually transmitted infections.

Identification of a Priority Health Issue

There are multiple health issues that can be improved upon, but the most important issue

that needs to be addressed is the rising rate of primary and secondary syphilis throughout Orange

County. In 2010, primary and secondary syphilis was diagnosed at a rate of 2.6 new cases per

100,000 people, amounting to a total of 77 new cases (United States Census Bureau). In 2015,
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the rates increased an astounding amount to 8.1 new cases per 100,000 people, amounting to a

total of 255 new cases (United States Census Bureau, 2016a). This rate represents a 311%

increase in only five years. This sexually transmitted disease has received national recognition,

as evidenced by Healthy People including reducing its rates by 10% from the baseline in 2008 in

Healthy People 2020. Not only is the American society failing to decrease the incidence rate of

this possible life-threatening infection, it is failing miserably.

Primary and secondary syphilis pose more of a threat than simply sores and rashes on the

body. It has the ability to cause damage internally to the brain and the heart (Southern Nevada

Health District, 2017), increases the chances of becoming infected with HIV (Centers for

Disease Control and Prevention, 2014a), and can be transferred from mother to baby during

pregnancy (Gomez et al., 2013). According to studies, the development of neurosyphilis can

occur at any time during the infection and can mimic many other neurological disorders, making

it difficult to diagnose. Due to this, treatment is often not immediate, which leads to further

progression of the symptoms (Yao et al., 2017). According to the CDC, the HIV coninfection

rate is as high as 50-70% (Centers for Disease Control and Prevention, 2014a) among specific

populations with primary and secondary syphilis. This is concerning data due to the possible

consequences of HIV, including AIDS and death. When a pregnant mother with syphilis remains

untreated, lasting effects can occur to the baby, including fetal loss, stillbirth, and prematurity

(Gomez et al., 2013). The issue of primary and secondary syphilis must be addressed to prevent

further spread of this distressing infection.

Discussion and Application of Community Health Models

Health models greatly impact the health of a community, especially the Determinants-of-

Health model. This model defines factors that have the ability to affect the health status of an
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individual, community, or region. These factors may be categorized as biological, individual

behavior, social environment, physical environment, or health services (Centers for Disease

Control and Prevention, 2017a). Multiple determinants of health affect the incidence rate of

primary and secondary syphilis in Orange County. A biological factor that affects the rate of

incidence is race and ethnicity. According to Harling and colleagues, racial and ethnic minorities

are at a higher risk for sexually transmitted infections (Harling, Subramanian, Barnighausen, &

Kawachi, 2013). The same study also concluded that socioeconomic status, a social

environmental factor, affects rates as well. Those with a lower socioeconomic status and lower

income experienced higher rates of syphilis (Harling, Subramanian, Barnighausen, & Kawachi,

2013). Another social environmental factor that impacts a community is the availability of

diagnostic tools and treatment options. Individual behavior, including lifestyle choices, plays a

significant role in the transmission and contraction of syphilis. Behaviors such as unprotected

sex, multiple sexual partners, men having sex with other men, low self esteem, and lack of

knowledge (Santelli, Lowry, Brener, & Robin, 2000; Centers for Disease Control and

Prevention, 2017b). A health service that positively impacts the spread of syphilis is California

Health and Safety Code Section 120290. This is a policy that states it is illegal for any person

with a communicable disease to willingly spread it to another individual and such an action is

punishable by law (California Legislative Information, 2016). This model allows for a better

understanding of syphilis and ways to prevent the spread of it.

Population Diagnosis

Intermediate school and high school students in Orange County are at a high risk for

spreading primary and secondary syphilis due to insufficient teaching of the signs and symptoms

of the infection and where to seek further information if one thinks he or she may have a sexually
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transmitted infection, as evidenced by the fact that every year nearly three million teenagers

report getting a new sexually transmitted disease (University of California, San Francisco, 2017).

Community/Population-based Interventions

Interventions to decrease the rates of primary and secondary syphilis among middle and

high school age children are necessary. The alarming increase of rates over the past five years

has demonstrated that rates will not decrease without appropriate action. By using community

health models such as the Determinants-of-Health model, primary, secondary, and tertiary

interventions can be developed and implemented to reduce these rates.

Primary Level of Prevention

Primary prevention interventions are precautions taken and implemented policies to

protect community members at risk for a certain disease or harm (Savage, Kub, & Groves,

2016). To prevent middle school and high school aged children from becoming infected with

primary and secondary syphilis, education is key (Gani, Raza Chowdhury, & Nystrom, 2014).

The amount of formal sex education teenagers are receiving is declining (Guttmacher Institute,

2016), resulting in many kids not being educated on life threatening diseases. To reverse this

trend and prevent an increase in rates of new syphilis cases, actions must be taken. In order to

target all middle school and high school age children, a health promoting, system-wide education

plan must be implemented. Public health nurses will be assigned to multiple middle schools and

high schools, both private and public, and will provide a three-hour education seminar on

sexually transmitted infections, including syphilis. This three-hour seminar will be spread out

over a period of three days to adapt to the students attention span and will include topics the

United Nations deems important for education, such as how to avoid getting STIs, how to

practice safe sex, and how to determine ones risk for receiving an STI (Joint United Nations
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Program on HIV/ AIDS, n.d.) Although the intervention is geared towards students, many more

parties than just the students are involved. Others involved include: teachers at the schools, as

children will be taken away from their classrooms for a total of three hours, parents of the school

age children since they have a say in whether or not they want their children receiving this

information, tax payers that fund public education who may or may not want to pay for this

information to be taught, healthcare agencies and providers who want to promote the health and

well-being of their communities, and government officials and legislators who decide where

money for public education and public health nurses is allocated. The funding of this three-hour

seminar will be provided from the public education fund of the state of California, as this

teaching is necessary in promoting the health and safety of school age children and the

generations to come. By providing education, the incidence of new rates of syphilis is extremely

likely to decrease (Joint United Nations Program on HIV/ AIDS, n.d.).

Secondary Level of Prevention

Secondary prevention interventions are those that detect presence of disease early on to

prevent further progression and complications of it. Secondary prevention interventions are a

necessity for detecting and treating primary and secondary syphilis since many in the population

do not even know they are infected (Centers for Disease Control and Prevention, 2013). To

ensure these school age children are knowledgeable about their sexual health status, a plan must

be implemented at a system-wide level. On a specified day, multiple public health nurses will

visit a middle school or high school and set up screening booths, in which children will enter and

have the opportunity to be screened for primary and secondary syphilis. Every student present at

school aged twelve or older will be required to enter the booth for a minimum of five minutes,

whether or not the student chooses to have the screening done. This will allow students who do
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want to be screened to not feel ashamed or embarrassed and will allow students who do not wish

to be screen the authority to exercise that right. Stakeholders in this prevention plan include:

parents who may or may not want their child getting screen, health care providers who will be

educating children about their sexual health status and preventing the further spread of syphilis,

screening companies who will provide the screening equipment, and government officials and

legislatures, who work to eliminate the problem of sexually transmitted disease. The allotted

money for pubic health by the Affordable Care Act will fund this intervention (U.S. Department

of Health and Human Services, 2016). By providing screening opportunities, school age children

will become aware of any sexually transmitted infections they my have and can seek treatment of

those diseases.

Tertiary Level of Prevention

Tertiary prevention interventions occur once a person already has a disease or

complication. Rather than prevention of this disease of complication, tertiary prevention focuses

on preventing progression or complications it (Savage, Kub, & Groves, 2016). This may include

progression and complications for the individual or may include progression to the rest of the

community. To prevent primary and secondary syphilis from spreading throughout a community,

those affected with it must be educated on the possible modes of transmission and when

transmission is possible. A public health nurse will be assigned to middle schools and high

schools throughout the county and will teach an hour-long seminar on these topics. All students

of the school must attend, regardless of their sexual health status. This will ensure that all of the

students receive formal education on preventing the spread, which can applied for current or

future use. Stakeholders of this intervention include: community members who do not want

primary and secondary syphilis spreading throughout the community, health care providers who
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will be educating the adolescents, parents who do not want their sexually active child receiving a

primary or secondary syphilis, and state officials and legislatures who work to decline the rate of

newly reported syphilis cases. The public health nurses will the funded through the states

education fund, since this is another form of education for its students. By educated those

affected with syphilis, transmission will decrease and will therefore decrease the rate of new

syphilis cases.

Development of Health Policy

Healthy policies specific to public health are established to reach certain goals regarding

the health of the community (World Health Organization, 2017). A thorough, well-planned

health policy has the potential to transform society and impact the health of millions of people.

According to the Centers for Disease Control (CDC), the difficulty to access testing for sexually

transmitted disease is a factor increasing the risk of an STD (Centers for Disease Control and

Prevention, 2016). To effective reduce the rate of new cases of primary and secondary syphilis in

middle school and high school age children a health policy must be developed. The goal of this

health policy must be to educate adolescents on their sexual health status to prevent spreading of

the disease. Screening for the infection, a secondary level of prevention, must be easily

accessible to this population. The CDC also states only 13% of students in high school have been

screen for a sexually transmitted disease (Centers for Disease Control and Prevention, 2014b)

even though roughly 50% of the new cases of sexually transmitted infections are in young adults

aged 15-24 (Centers for Disease Control and Prevention, 2016). To increase the rate of students

that are getting screened and becoming informed about their sexual health, public health nurses

will conduct screenings at middle schools and high schools. Although some may pose the

question of legality, California has a state law allowing those twelve and older to screen for
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sexually transmitted diseases without parental consent (Guttmacher Institute, 2017). Each middle

school and high school will be assigned two days, one during the first half of the school year and

the other during the second half, in which nurses will be sent out and set up a mobile screening

site. There will be multiple screening stations, all enclosed inside of a black curtain, allowing for

privacy. On the schools assigned day, all students over the age of twelve will enter a testing

station. If a student wishes to be tested, he or she will be screened, and if the student does not

want to be tested, he or she will remain in the enclosed curtain for a minimum amount of time.

This will allow for the students choice to be confidential, unless he or she wishes to tell. When

the results return, the nurses will return to the school, set up the curtains again, and students will

enter again. Those who took the tests will be given the results, and those who did not will remain

in the enclosed area for a minimum amount of time. The students who tested positive for syphilis

will be provided information with where they may seek treatment and how to prevent spreading

it. Stakeholders in this prevention plan include: parents who may or may not want their child

getting screen, health care providers who will be screening educating children about their sexual

health status and preventing the further spread of syphilis, screening companies who will provide

the screening equipment, and government officials and legislatures, who work to eliminate the

problem of sexually transmitted disease. The Affordable Care Act allotted funds to be used for

public health (U.S. Department of Health and Human Services, 2016), which would be the

primary funding source for this policy. Supporters of this policy would be students, parents,

health care providers, and government officials and legislatures, and members of society who

wish to eradicate the spread of sexually transmitted diseases. These supporters will educate

others and allow them to see the importance of knowing ones sexual health status. Opposing

forces of this health policy would include those who pay taxes who do not realize the importance
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of testing, teachers, whose students will be out of the classroom during hours in which they are

able to teach, and those who insist that only abstinence is the answer to this worldwide problem.

To implement this plan, gaining the funding to implement the policy is of utmost importance.

Once the funding is received, public health nurses will go to the schools and inform school

administrators of the newly implemented policy. They will then schedule the days on which the

screenings and feedback will occur. This health policy will result in adolescents receiving

information and education on their sexual health status. Since this population accounts for such

a large proportion of new STDs this policy will decrease the transmission rate of syphilis,

therefore, creating a healthier population.

Conclusion

Primary and secondary syphilis has recently become a large problem in Orange County,

California. This poses a serious threat to the health of the population. By implementing a policy

that allows middle school and high school students to be confidentially screened for syphilis free

of charge, this high-risk population will become educated on their sexual health status and will

learn how to stop the spread of syphilis. This will improve the health of this specific population

and the generations to come afterwards.

By writing this paper, I have learned that public health is an important aspect of every

persons life. Nurses have an opportunity to impact thousands of lives, since everyone, in every

community, is affected in one way or another by public health policies. I have also learned more

information on sexually transmitted diseases, especially syphilis, which I may now use to teach

and educate people wherever I end up practicing. I believe writing this paper has allowed me to

realize the potential I have to affect the lives of others in more ways than I previously knew to be

possible.
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