Current Trends Increases in Primary and Secondary Syphilis -
- United States
After a 5-year trend of decreasing incidence of primary and
secondary syphilis in the United States, 8,274 cases were reported
during the first 3 months of 1987. This is an increase of 1,549
cases
(23%) over the 6,725 cases reported during the first 3 months of
1986.
The estimated annual rate per 100,000 population rose from 10.9
cases
to 13.3 cases (Figure 1). An increase of this magnitude has not
been
observed in over 10 years.
Increases of 20 or more cases over the number reported during
the
first 3 months of 1986 were observed in eight states, four major
metropolitan areas, and the Commonwealth of Puerto Rico (Table 1).
The
three areas reporting the largest numerical increases were
California,
Florida, and New York City. In California, increases of 10 or more
cases occurred in Los Angeles, Long Beach, and seven smaller
counties*. Ten counties in Florida experienced increases, the
largest
being in Dade, Orange, and Palm Beach counties. In New York City,
all
boroughs except Richmond experienced substantial increases.
All three areas with the largest increases had collected
demographic data and information on the sexual preferences of
patients
with cases reported during the periods January-March 1986 and
January-March 1987 (Table 2). In California and New York City,
increases in primary and secondary syphilis occurred exclusively
among
heterosexuals. In addition, blacks experienced greater increases
than
whites in these two areas. In Florida, the increase occurred in
each
demographic group and in each group with similar sexual
preferences.
The ratio of cases among males to cases among females in the three
areas fell from 2.6:1 to 2.1:1. For several other areas
experiencing
increases in total cases, the incidence declined for white men
citing
at least one male sexual partner.
Reported by: MH Wilder, MD, Acting State Epidemiologist, Florida
Dept
of Health and Rehabilitative Svcs. S Schultz, MD, New York City
Health
Dept. S Fannin, MD, County of Los Angeles Dept of Health Svcs; K
Acree, MDCM, MPH, JD, Acting State Epidemiologist, California Dept
of
Health Svcs. Div of Sexually Transmitted Diseases, Center for
Prevention Svcs, CDC.
Editorial Note
Editorial Note: Although primary and secondary syphilis had been
declining since 1982 (1), they now appear to be on the upsurge in
some
areas. While 70% of cases among males occurred among homosexual and
bisexual men during the 1970s (2), cases among these groups now
appear
to be on the decline in some areas (Table 2). As with two smaller
outbreaks in the 1980s (3,4), the current increases appear to be
largely among heterosexuals.
The increases in primary and secondary syphilis have prompted
two
major concerns. First, this trend is likely to have a severe
adverse
effect on efforts to control congenital syphilis. While sexually
acquired syphilis that is diagnosed in its early stages can be
effectively treated with long-acting penicillin preparations,
congenitally acquired syphilis is responsible for high rates of
infant
morbidity and mortality (5). After an 8-year decline, the incidence
of
congenital syphilis among infants began rising in 1983 (6). The
areas
with the largest increases in primary and secondary syphilis
already
have some of the highest rates of congenital syphilis in the nation
(6). Any increases in acquired syphilis among heterosexual adults
in
these areas are certain to be followed by further increases in
congenital syphilis.
Second, a history of sexually transmitted disease is associated
with increased risk for human immunodeficiency virus (HIV)
infection
and acquired immunodeficiency syndrome (AIDS) among both
homosexuals
(7,8) and heterosexuals (9). New York City and Florida have
increased
incidences of syphilis as well as high rates of AIDS among
heterosexuals, particularly among those who abuse intravenous drugs
(10). Because genital ulceration is associated with higher rates of
HIV infection (11,12), the increases in primary and secondary
syphilis
in these areas may be the forerunner of future increases in
HIV-related morbidity and mortality. Moreover, on the basis of case
reports of treatment failures (13) and an atypical course in one
patient (14), concerns have been raised about the effects of
HIV-infection on the natural history and response to treatment of
syphilis. These reports suggest the potential for problems in the
management of patients with both infections.
References
CDC. Annual summary 1984. MMWR 1986;33(54):57-9.
Fichtner RR, Aral SO, Blount JH, Zaidi AA, Reynolds GH, Darrow
WW.
Syphilis in the United States: 1968-1979. Sex Transm Dis
1983;10:77-80.
CDC. Early syphilis--Broward County, Florida. MMWR
1987;36:221-4.
Lee CB, Brunham RC, Sherman E, Harding GKM. Epidemiology of an
outbreak of infectious syphilis in Manitoba. Am J Epidemiol
1987;125:277-83.
Murphy K, Patamasucon P. Congenital syphilis. In: Holmes KK,
Mardh
PA, Sparling PF, Weisner PJ, eds. Sexually transmitted
diseases.
New York: McGraw Hill Co, 1984:352.
Jaffe HW, Choi K, Thomas PA, et al. National case-control study
of
Kaposi's sarcoma and Pneumocystis carinii pneumonia in
homosexual
men: part 1, epidemiologic results. Ann Intern Med
1983;99:145-51.
Moss AR, Osmond D, Bacchetti P, Chermann J, Barre-Sinoussi F,
Carlson J. Risk factors for AIDS and HIV seropositivity in
homosexual men. Am J Epidemiol 1987;125:1035-47.
Castro KG, Fischl MA, Landesman SH, et al. Risk factors for
AIDS
among Haitians in the United States. Atlanta, Georgia:
International Conference on AIDS, April 14-17, 1985: 45.
CDC. Update: acquired immunodeficiency syndrome--United States.
MMWR 1986;35:757- 60, 765-6.
Cameron DW, Plummer FA, Simonsen JN, et al. Female to male
heterosexual transmission of HIV infection in Nairobi.
Washington,
DC: III International Conference on AIDS, June 1-5, 1987.
Abstract
MP91:25.
Greenblatt RM, Lukehart SL, Plummer FA, et al. Genital
ulceration
as a risk factor for human immunodeficiency virus infection in
Kenya. Washington, DC: III International Conference on AIDS,
June
1-5, 1987. Abstract ThP68:174.
Berry CD, Hooten TM, Collier AC, Lukehart SA. Neurologic
relapse
after benzathine penicillin therapy for secondary syphilis in a
patient with HIV infection. N Engl J Med 1987;316:1587-9.
Johns DR, Tierney M, Selsenstein D. Alteration in the natural
history of neurosyphilis by concurrent infection with the human
immunodeficiency virus. N Engl J Med 1987;316: 1569-72.
*San Francisco continued a 5-year trend of decreasing incidence.
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