New syphilis cases in Los Angeles County rose sharply in 2005 after leveling off in the previous two years, according to a report released last week.
The tally of 1,217 cases was an increase of more than 40% from the 2004 total of 865 and nearly three times the number reported in 2001.
Two-thirds of the new cases were among gay and bisexual men, but women saw a 56% increase over the previous year, according to the report by the county's Department of Health Services.
Cases among women rose from 89 in 2004 to 139 last year, constituting 11% of new syphilis reports. The vast majority of those infections occurred among African Americans and Latinas.
"We were hoping there would be a leveling in light of the earlier two-year trend" and eventually a decline, said Dr. Peter Kerndt, director of the health department's sexually transmitted disease program. "So the fact that it's continued to rise, that's of concern."
The trend follows a three-year, $1-million syphilis awareness campaign by the health department.
Kerndt said the rise in syphilis cases was particularly troubling because rates of gonorrhea and chlamydia also have been rising, although not as much.
Although increased screening may partially explain the jump, Kerndt said the upswing also suggests an increase in unsafe sex, drug use and sex with strangers met through the Internet.
Syphilis is easily treated with antibiotics if caught early but is potentially disabling or fatal if left untreated.
It is most commonly marked by sores on the genitals and is spread through direct contact with a sore through vaginal, anal or oral sex.
Health officials are concerned because syphilis sores can facilitate the spread of HIV. Some experts believe an increase in the number of syphilis cases could presage a rise in HIV infections, though others argue that many gay and bisexual men who become infected with syphilis already are HIV positive.
New research suggests syphilis is also associated with a more rapid progression of HIV, said Dr. Jeffrey Klausner, San Francisco's director of sexually transmitted disease control.
Northern California generally saw decreases or a leveling of cases in 2005 while Southern California saw a jump, said Michael Samuel, the state health department's chief of STD surveillance and epidemiology.
New syphilis cases in San Francisco, for example, fell 22%, from 550 in 2004 to 427 last year.
The reasons for the geographic variations were unclear, Samuel said.
Klausner said, however, that dealing with Los Angeles County's syphilis epidemic was more problematic than San Francisco's, where syphilis is almost entirely confined to gay and bisexual males.
"You have much greater geographic diversity, racial and ethnic diversity, socioeconomic diversity, and that makes it much more challenging to control," he said.
Cases among gay and bisexual men continued to be concentrated in Hollywood and West Hollywood, with most cases among women reported in South Los Angeles -- an area Kerndt said the syphilis awareness campaign had not targeted because previous reports did not show syphilis to be emerging there.
Most newly infected women were of child-bearing age. That concerns health officials because babies infected with syphilis through their mothers may be stillborn, malformed or developmentally delayed.
Overall, African Americans experienced a 49% increase in new cases; Latinos, 42%; and whites, 29%.
Kerndt said the increase of syphilis in women suggested that bisexual men were infecting their female partners. He said the disease's spread to minority populations suggested growing sexual activity between white men who are gay or bisexual and minority partners.
Some local healthcare advocates blamed the county health department for the jump, saying its anti-syphilis campaign was inadequate.
Launched in 2002 and continuing sporadically through 2005, Los Angeles' $1-million "Stop the Sores" campaign focused on raising awareness about syphilis and increasing testing for it.
The campaign was built around a character called "Phil," a bumpy red sore who sported silver shoes and an earring. About 40,000 squeezable versions of the character were handed out, and it was featured in ads in gay publications.
San Francisco during the same time had a $650,000 "Healthy Penis" campaign that Los Angeles health officials had rejected as too racy and potentially offensive. Both campaigns followed earlier syphilis outbreaks.
"From the very beginning we said advertising is all well and good, but you need more screening and more treatment," said Michael Weinstein, president of the AIDS Healthcare Foundation, which worked with the L.A. County health department on the campaign. "From Day One this has never been implemented the way we felt it should be."
Weinstein said the department should have been more aggressive in reaching out to affected communities, sending safer-sex messages in Internet chat rooms, for example, and coordinating with local healthcare groups to offer testing in mobile units
"All those cute little plastic Phils ... ended up on everyone's desk," said Craig Thompson, executive director of AIDS Project Los Angeles. "I'm not sure that they impacted the life of any sexually active gay man."
Kerndt said evaluations showed individuals exposed to the campaign were more likely to get tested and that the campaign had increased the frequency with which HIV care providers tested for syphilis.
He said the county health department is considering another public health campaign specifically targeting Hollywood, West Hollywood and South Los Angeles.