Baltimore health officials are working to contain a syphilis outbreak -- linked to increased crack cocaine use -- that they fear could foreshadow a future rise in AIDS cases.
Warnings are being sent to local physicians and health care providers, cautioning them to be on the alert for symptoms of the contagious disease, such as painless genital sores or rashes on the hands and face.
The latest figures show that the number of city cases has soared by 83 percent in one year, from 192 cases in 1994 to 351 cases in 1995, putting Baltimore's rate among the highest of large U.S. cities last year.
The outbreak follows a score of others across the country, from California to the rural South, most linked to surges in crack cocaine use.
The disease is transmitted through sexual contact. If caught early, syphilis can be easily treated with penicillin shots and cured, but people can catch it again and again. If left untreated, it can eventually damage vital organs such as the heart and brain.
Although syphilis has rarely progressed that far recently, the disease has widespread public health consequences. Anyone who has syphilitic lesions is much more likely to get HIV or infect their sex partners with the virus that causes AIDS.
Public health experts are beginning to see the syphilis outbreaks as an early warning system for future increases in AIDS cases.
Syphilis also can be passed from pregnant women to their offspring, who suffer complications including birth defects, blindness and even stillbirths.
City health workers have tracked the outbreak to three Baltimore communities, particularly to neighborhoods where the sex-for-crack trade leads some drug users to have hundreds of partners a year.
"We believe it is the heavy drug areas that are mainly affected," said Dr. Peter Beilenson, Baltimore City health commissioner.
"This is just another reason that we need to focus on drug treatment and prevention, because so many of the ills affecting Baltimore and other areas are related to drug use."
The crack cocaine epidemic hit Baltimore later than other cities, partly because local drug users preferred heroin and have been less transient.
Nationwide, crack use -- and the syphilis linked to it -- were prevalent as far back as 1990. That year, the U.S. incidence of syphilis reached 20.3 cases per 100,000 people, the highest rate since 1949, according to the U.S. Centers for Disease Control and Prevention.
Since then, many cities have seen their rates of syphilis drop because of treatment, notification of partners of those infected, and less crack cocaine use.
By 1994, the last year for which figures are available, the national incidence fell to 8.1 per 100,000 people.
In Baltimore, though, the incidence of syphilis in 1994 was 26 per 100,000, more than three times the national average. Statistics also show that crack use in the city was increasing.
The federal system that tracks cocaine abuse in Baltimore through emergency rooms and other sources showed use of crack -- as opposed to the powder form -- rose from 10 percent in 1989 to 50 percent in 1994.
The syphilis increase has apparently been limited to parts of Baltimore, because no surrounding counties have shown a similar pattern, said Dr. Ebenezer Israel, director of the epidemiology and disease control program at the state Department of Health and Mental Hygiene.
Investigators from the U.S. Centers for Disease Control who recently examined the situation in Baltimore said they tried to determine if cutbacks in the city Health Department's staff led to the outbreak, or hampered its containment. Dr. Peter Kilmarx, in the CDC's Epidemic Intelligence Service, said they weren't able to prove that.
"Our conclusion is the main factor has been the crack epidemic," said Dr. Kilmarx, adding that lack of access to medical care, or not recognizing that medical care is needed, may also be involved.
But he noted that treating those who are infected and tracking down their sex partners is essential to contain the disease. The Baltimore City Health Department has successfully used that tactic to reduce the spread of tuberculosis.
For that disease, workers actually go to the houses of those with TB and watch them take the medicine.
The intervention unit that does this outreach work for sexually-transmitted diseases lost several staff members in the last several years, Dr. Beilenson said.
But since syphilis -- and HIV -- are considered priorities, he said the unit hasn't scaled back its work.
Dr. Beilenson acknowledged the department has had to reduce its work with other sexually-transmitted diseases, but he expects to improve that once the unit adds seven people this month, bringing its staff to a total of 17.