Syphilis -- United States, 1983

Although the incidence of primary and secondary syphilis in the United States steadily increased from a low of 9.4 cases per 100,000 population in 1977 to 14.6/100,000 in 1982, the reported national incidence decreased to 14.1/100,000 in 1983 (Figure 1). Reported primary and secondary syphilis cases totaled 32,698 in 1983, a 3% decrease from the 33,613 cases reported in 1982.

The changes in the number and rate of primary and secondary syphilis cases varied with sex and sexual preference. Among women, the number and rate of reported cases increased in 1983; however, among men, reported cases and the rate decreased (Table 1). Thus, the decrease in the 1983 national incidence was attributable to the decrease in the rate of reported cases occurring among men. During 1981-1983, the rate of cases per 100,000 population reported in men decreased 0.9% but increased 15% among women. The sex ratio (males:females) among primary and secondary syphilis cases increased from 1.5:1 in 1967 to 3.2:1 in 1980 but declined during 1981-1983 from 3.0:1 in 1981 to 2.6:1 in 1983.

The proportion of men with primary and secondary syphilis who named other men as sex partners increased from 23% in 1969 to 42% in 1982 but decreased to 40% in 1983. The total number of men with early infectious syphilis who named other men as sexual contacts decreased by 13% from 1982 to 1983 (Table 2).

In 1982, 24,833 early syphilis cases were reported from public clinics, compared with 8,780 cases reported from private sources. In 1983, primary and secondary syphilis cases reported from public clinics decreased to 23,949; cases reported from private sources decreased to 8,749.

Thirty-four states reported rates of primary and secondary syphilis that were lower in 1983 than in 1982. Rates varied greatly geographically from a low of 0.3/100,000 population in North Dakota to highs of 39.5/100,000 in Florida and 40.2/100,000 in Texas.

Primary and secondary syphilis rates continue to be higher in large urban areas than in less populated ones. In 1983, 63 cities with populations of 200,000 or more, comprising 26% of the U.S. population, accounted for nearly 60% of reported cases (Table 3). Cities reporting the highest rates per 100,000 population in 1983 were San Francisco, California (158.5), New Orleans, Louisiana (106.4), and Atlanta, Georgia (106.4). Cities reporting the lowest rates in 1983 were Omaha, Nebraska (0.8), Pittsburgh, Pennsylvania (1.7), and Des Moines, Iowa (1.9).

Early congenital syphilis (CS) among children under 1 year of age still contributes to neonatal morbidity. The number of cases of early CS decreased from 422 in 1971 to 104 in 1978. In 1981, reported cases increased to 160; in 1982 and 1983, 159 and 158 cases of CS were reported, respectively. Fifteen states reported no early CS in 1982 or 1983. Four states accounted for most (62%) of the cases of early CS reported in 1983: Texas (26%), Florida (15%), California (11%), and New York (9%). Though the rate of primary and secondary syphilis cases occurring among women increased 15% between 1981 and 1983, the number of cases detected through prenatal testing increased to a lesser degree. Reported by Operational Research Br, Evaluation and Statistical Svcs Br, Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The distribution of syphilis cases underwent several key changes between 1967 and 1979. The most important of these included (1) a twofold increase in the ratio of reported cases among men to reported cases among women; (2) an increase in cases among men reported by public clinics--from 32% to 56% of the total cases; and (3) an increase in the percentage of white men with early syphilis who reported at least one male sex partner from 38% in 1969 to 70% in 1979 (1). Most of these trends have continued since 1980. In addition, the percentage of total cases reported from public clinics (about 74% since 1980) and the percentage of cases among men reported from public clinics (about 55% since 1979) have been fairly constant. The ratio of cases reported among men to cases among women has declined between 1980 and 1983. The percentage of late and late latent syphilis cases reported has also declined from 59% in 1969 to 24% in 1983.

The decrease in the national incidence of reported syphilis cases may represent, in part, a response to public health recommendations to decrease risks of sexually transmitted diseases (2). With the media attention given acquired immunodeficiency syndrome (AIDS) and herpes, syphilis rates may be affected indirectly, as gonorrhea rates have been in certain localities (3,4).

The continued occurrence of a fairly constant number of cases of CS between 1981 and 1983 may reflect the increase in the incidence of early infectious syphilis among women, a lack of availability of prenatal care, or a failure of the prenatal-care system to provide timely screening, serologic testing, and prompt follow-up (5,6). Eighty percent of women with primary and secondary syphilis are in their reproductive years (15-34 years of age).

Most states require prenatal screening in the first trimester but not in the third trimester; thus, infections acquired later in pregnancy may not be detected and may cause infections in infants. States, such as Texas and Florida, where the incidence of CS is high, have established serologic screening of all cord bloods. These states have increased their chances of detecting and reporting asymptomatic cases in newborns. In states where newborns are not screened, cases of CS are not recognized until the signs become fully manifested.

Increasing the availability of prenatal care--including (1) serologic screening in the first trimester; (2) appropriate third-trimester serologic evaluation of groups at high risk (7); and (3) prompt treatment and adequate follow-up of maternal cases identified--as well as reducing the incidence of infectious syphilis among women of childbearing age may eventually prevent more cases of congenital syphilis.

References

1. Fichtner RR, Aral SO, Blount JH, Zaidi AA, Reynolds GH, Darrow WW. Syphilis in the United States: 1967-1979. Sex Transm Dis 1983;10:77-80.

2. Brown WJ, Donohue JF, Axnick NW, Blount JH, Ewen NH, Jones OG. Venereal disease casefinding and control measures in the twentieth century. In: Syphilis and other venereal diseases. Vital and Health Statistics Monographs. American Public Health Association. Cambridge: Harvard University Press 1970:36-57.

3. Judson FN. Fear of AIDS and gonorrhea rates in homosexual men. Lancet 1983;II:159-60.

4. CDC. Declining rates of rectal and pharyngeal gonorrhea among males--New York City. MMWR 1984;33:295-7.

5. Rathbun KC. Congenital syphilis. Sex Transm Dis 1983;10:93-9.

6. Mascola L, Pelosi R, Blount JH, Binkin NJ, Alexander CE, Cates W Jr. Congenital syphilis--why is it still occurring? JAMA (in press).

7. Ingall D, Musher D. Syphilis. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant. Philadelphia: WB Saunders, 1983:335-74.

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