The Syphilis Epidemic Among Heterosexuals Is Accelerating: Evidence From King County, Washington

BACKGROUND: We characterized the rapid increase in syphilis among cisgender women in King County, Washington, and compared it with trends among cisgender men who have sex with men. METHOD: We used surveillance data from King County, 2007 to 2022, to describe incidence trends stratified by syphilis stage, gender, and gender of sex partners; trends in pregnant cases and congenital syphilis; and trends in rapid plasma reagin titer at diagnosis among late/unknown duration cases. We used joinpoint regression to analyze trends. RESULTS: Among cisgender women, all-stage syphilis incidence remained stable from 2007 to 2010 but then increased by 16.3% per year (95% CI, 12.0%–20.7%) from 2010 to 2020 and 90.1% per year (95% CI, 26.4%–185.9%) from 2020 to 2022. Early syphilis rates rose gradually from 2007 to 2017 (18% per year; 95% CI, 7.4%–29.6%) and then rapidly from 2017 to 2022 (62.5% per year; 95% CI, 24.1%–112.9%). In contrast, the increase in late/unknown duration syphilis incidence was delayed. Among cisgender men who have sex with women, all-stage syphilis remained stable from 2007 to 2014 and increased 25.0% per year (95% CI, 14.0%–37.0%) from 2014 to 2022. Syphilis incidence increased steadily among men who have sex with men, with all-stage incidence increasing 7.0% per year (95% CI, 4.8%–9.2%) from 2007 to 2022. Median rapid plasma reagin titer among late/unknown duration cases increased significantly over the analysis period. CONCLUSIONS: An explosive epidemic of syphilis is ongoing in King County. The delayed increase in asymptomatic late/unknown duration cases relative to early symptomatic cases suggests that there is a large and growing reservoir of recently acquired undiagnosed syphilis in women. New clinical and public health activities are urgently needed to control the growing epidemic.