Epidemiologic Notes and Reports Early Syphilis -- Broward County, Florida

During the 1980s, the number of early syphilis (primary, secondary, and early latent) cases in Broward County, Florida, has increased--from 328 in 1980 to over 1,150 in 1986 (Figure 2), with a peak in the last half of 1985. From 1984 to 1985, primary and secondary (P&S) syphilis accounted for most of the increase in Broward County.

This upward trend in P&S syphilis in Broward County contrasts with the general downward trend observed from 1982 to 1985 in both Florida and the rest of the United States (Figure 3). However, Florida, with 37.6 cases per 100,000 population in 1986, still has the highest rate of P&S syphilis in the country.

In 1985, rates of early syphilis in Broward County were highest in the 20- to 24-year-old age group and were 446/100,000 for men and 290/100,000 for women in this group. Rates of early syphilis adjusted for race were 730/100,000 for blacks, 21/100,000 for whites, and 50/100,000 for Hispanics. Ninety-six percent of cases among women occurred among those of childbearing age (15-44 years of age). As a result, the number of cases of congenital syphilis increased to 25 in 1986; 10 had been reported in 1985, and six, in 1984.

Two studies were performed to identify characteristics of patients reported during the months of greatest increase. First, surveillance data routinely gathered on all patients with early syphilis from 1980 through 1985 were reviewed. Second, detailed clinical and behavioral data were collected from interview records of a systematic 25% sample of patients diagnosed with syphilis in 1985. These data included reason for seeking medical attention, address of residence, sexual preference for males, and history of prostitution for females. These two data sets were compared with surveillance data from previous years.

In 1985, early syphilis cases occurred primarily among heterosexual blacks in Broward County. Eighty percent (836) of reported cases occurred among blacks; 18% (187), among whites; and 2% (20), among Hispanics. In contrast, the percentage of syphilis cases among blacks had ranged from 48% to 64% during the 4 previous years. Heterosexual males, who represented 39% of reported male patients in 1982, constituted 80% of male patients by 1985. Over 70% of early syphilis patients reported in 1985 lived in 11 census tracts that together contained less than 15% of the 1,162,031 residents of Broward County. The median income in these census tracts is $15,000 per year. The concentration of cases clustered in these census tracts was greater in the latter part of 1985 than in the earlier part of that year.

These results prompted further investigation. The systematic 25% sample collected for 1985 was extended to include a similar sample of cases reported in the last 6 months of 1984 and the first 3 months of 1986. The sample was then divided into two periods: July 1, 1984, through June 30, 1985, the interval immediately preceding the rapid increase in reporting of cases (endemic cases), and July 1, 1985, through March 31, 1986, the interval of greatest increase (epidemic cases). Female patients diagnosed during the epidemic months were significantly more likely to be prostitutes than those reported during the prior 12 months (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.1-6.1). Male patients were significantly more likely to be exclusively heterosexual than those reported in prior months (OR = 2.07, 95% CI = 1.1-3.9). During the 9 epidemic months as compared with the previous endemic months, more patients were examined for lesions and symptoms, and fewer patients were identified either during screening or as sexual partners of infected persons (OR = 1.87, 95% CI = 1.2-2.8). Thus, the ratio of symptomatic (P&S) to asymptomatic (early latent) patients increased from 0.9 : 1 in the endemic period to 1.3 : 1 in the epidemic period.

The Broward County Department of Health responded to these increases in early syphilis by intensifying surveillance efforts, including active surveillance of laboratories that perform serologic tests for syphilis. Moreover, serologic screening was increased in the high-prevalence census tracts and in high-risk populations, including jail inmates of both sexes. County facilities providing prenatal care intensified their rescreening program for asymptomatic women during the third trimester. The ratio of symptomatic to asymptomatic patients decreased, from 1.9 : 1 in the first quarter to 1.4 : 1 in the second quarter of 1986. In the last quarter of 1986, a decrease in early syphilis was observed. Reported by: C Konigsberg, MD, Broward County Dept of Public Health; JJ Witte, MD, M Wilder, MD, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. Epidemiology Research Br, Program Svcs Br, Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The increase in early syphilis in Broward County, as in another outbreak in the 1980s (1), was largely due to heterosexual transmission. In addition, female prostitution, which has contributed to syphilis transmission in other outbreaks (1,2), appears to have played an increasing role in early syphilis occurring in Broward County. Moreover, early syphilis cases are concentrated largely in low-income areas of the county.

Along with national trends (3), early syphilis cases among male homosexuals in Broward County are decreasing both in absolute numbers and in the percentage of total cases. This may be partially explained by changes in lifestyle among male homosexuals in response to the threat of acquired immunodeficiency syndrome. Such changes may reduce their acquisition of syphilis, as it may have reduced their rate of infection with other sexually transmitted pathogens (4,5).

The high rate of early syphilis in women of childbearing age has contributed to increases in cases of congenital syphilis. Prenatal serologic testing for syphilis at the initial visit and in the third trimester (6) has been widely implemented and should increase the identification of asymptomatic infected women and prevent congenital syphilis infections. High priority is being given to identifying and treating sexual partners of heterosexual male patients to interrupt transmission to women within the community and to detect infections in women before they become pregnant.

The syphilis problem in Florida is not restricted to Broward County. However, serologic screening of sexually active residents of high-incidence areas and in high-risk populations is increasing the number of diagnoses of asymptomatic cases in Broward County. Throughout Florida, contact tracing (7) and serologic screening (8) of populations at risk are being used to identify asymptomatic infected persons and thereby to control the spread of syphilis.

References

1. Lee CB, Brunham RC, Sherman E, Harding GKM. Epidemiology of an outbreak of infectious syphilis in Manitoba. Am J Epidemiol 1987;125:277-83.

2. Kinsie PM. Impact of prostitution on syphilis control. In: Proceedings of the world forum on syphilis and other treponematosis. Atlanta, Georgia: US Department of Health, Education, and Welfare, Public Health Service, CDC, 1962:149-52.

3. CDC. Syphilis--United States, 1983. MMWR 1984;33:433-6,441.

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

5. Judson FN. Fear of AIDS and gonorrhoea rates in homosexual men (Letter). Lancet 1983;2:159-60.

6. Mascola L, Pelosi R, Blount JH, Binkin NJ, Alexander CE, Cates W Jr. Congenital syphilis: why is it still occurring? JAMA 1984;252:1719-22.

7. Brown WJ, Donohue JF, Axnick NW, et al. Syphilis and other venereal diseases. In: Vital and Health Statistics Monographs. Cambridge, Massachusetts: Harvard University Press, 1970.

8. Hart G. Syphilis tests in diagnostic and therapeutic decision making. Ann Intern Med 1986;104:368-76.

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