Syphilis and Congenital Syphilis -- United States, 1985-1988

In 1987, 35,241 cases of primary and secondary syphilis were reported in the United States. The incidence of 14.6 cases per 100,000 persons equals that of 1982-- the highest rate since 1950. The 25% increase over the 1986 rate was the largest single-year increase since 1960. Because of this increase, the Public Health Service objective to reduce the incidence of primary and secondary syphilis to 7.0 cases/100,000 persons by 1990 (1,2) is unlikely to be achieved.

The increase in incidence was greatest for blacks and Hispanics--groups for which incidence rates were already high (Figure 1). In all racial/ethnic groups, increases were greater for females than for males. From 1986 to 1987, the rate per 100,000 persons 15-64 years of age* increased 36% for black males (106.2 to 144.9), 43% for black females (55.5 to 79.4), 7% for Hispanic males (66.0 to 70.7), and 24% for Hispanic females (17.8 to 22.0). In contrast, the rate for white males decreased from 6.4 to 5.7, while for white females, rates increased 22% (2.2 to 2.6). The decrease among white males appears to be attributable to continuing decreases in syphilis incidence among homosexual men (3).

In 1987, 57% of all reported U.S. cases were reported from Florida, California, and New York (Table 1). Six additional states and the District of Columbia had 1987 incidence rates greater than 7.0/100,000 and had increases between 1985** and 1987 (Table 1). Eleven other states had 1987 incidence rates greater than 7.0/100,000, but incidence did not increase from 1985 to 1987 (Figure 2). In Texas, rates decreased steadily from 28.4/100,000 in 1985 to 18.4/100,000 in 1987. In Nevada, Oregon, Delaware, Connecticut, and Pennsylvania, syphilis rates were below the 1990 objective of 7.0/100,000 in 1985.

The highest rates were reported in urban areas; this was especially apparent in New York and Pennsylvania. The 1987 rate per 100,000 persons was 63.5 in New York City, compared with 3.4 for the rest of New York, and 41.6 in Philadelphia, compared with 2.5 for the rest of Pennsylvania.

The national increase was first noted in the last half of 1986 (Figure 3), reflecting increases in Florida, California, and New York. The national increase peaked in the third quarter of 1987, then plateaued through the first half of 1988, again reflecting trends in Florida, California, and New York. In other areas, such as Connecticut, Tennessee, and Nevada, rates continued to increase during the first half of 1988. In Pennsylvania, where the incidence remained stable but elevated after a large increase in early 1986, the rate began to increase again in 1988.

In the second half of 1987, the rate of congenital syphilis cases increased 21% to 10.5 cases per 100,000 live births. Most cases occur in areas with high syphilis incidence among adult women; in 1987, 67% of all cases were reported from Florida, California, and New York. Reported by: Participating city and state health depts and STD control programs. Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Decreases in syphilis and gonorrhea (3-7) in homosexual men reflect changes in sexual behavior related to controlling the spread of human immunodeficiency virus (HIV) in that population. The increases in incidence of syphilis described here suggest that efforts to achieve similar behavioral changes in minority populations have not been successful (8). In addition, the evidence is strong, especially from Africa, that genital ulcer diseases like syphilis increase the efficiency of sexual transmission of HIV (9-12).

In March 1988, CDC reviewed the trends in syphilis with sexually transmitted disease experts from academic/medical institutions and state and local health departments. This group identified the following three research priorities: 1) defining the current epidemiology of syphilis, including the relationship with illegal drug use, 2) evaluating and improving the effectiveness of different intervention methods, and 3) evaluating the effect of HIV coinfection on syphilis transmission.

The following interventions were suggested as being essential if these trends of increased syphilis rates are to be reversed:

1. Reemphasize the traditional methods of syphilis control--interviews and sex partner notification.

2. Conduct screening for sexually transmitted diseases in high-risk populations.

3. Assure access to quality clinical care by removing financial barriers and other obstacles (e.g., long waiting times and lack of evening hours).

4. Enhance current surveillance systems to allow ongoing evaluation of intervention strategies and effective resource allocation.

Congenital syphilis, a preventable consequence of untreated syphilis in pregnant women, causes fetal or perinatal death in 40% of affected pregnancies (13). Because increases in congenital syphilis lag behind increases in syphilis in women by about 1 year (14), congenital syphilis can be expected to continue to increase in frequency. This may be a particular problem for urban black and Hispanic women, who have a disproportionate increase in incidence and who are less likely than white women to receive adequate prenatal care (15).

Congenital syphilis can be prevented by appropriate treatment of the mother during pregnancy (13). Syphilis screening in pregnant and childbearing-aged women is the best way to identify those who need treatment. In addition, efforts must be made to remove obstacles that prevent women from receiving early prenatal care, especially in areas with high syphilis incidence.

References

1. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980.

2. CDC. Progress toward achieving the national 1990 objectives for sexually transmitted diseases. MMWR 1987;36:173-6.

3. CDC. Continuing increase in infectious syphilis--United States. MMWR 1988;37:35-8.

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

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

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

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

8. Landrum S, Beck-Sague' C, Kraus S. Racial trends in syphilis among men with same-sex partners in Atlanta, Georgia. Am J Public Health 1988;78:66-7.

9. Plummer F, Cameron W, Simonsen N, et al. Co-factors in male-female transmission of HIV (Abstract). IV International Conference on AIDS. Book 2. Stockholm, June 12-16, 1988:200.

10. Cameron DW, D'Costa LJ, Ndinya-Achola JO, Piot P, Plummer FA. Incidence and risk factors for female to male transmission of HIV (Abstract). IV International Conference on AIDS. Book 1. Stockholm, June 12-16, 1988:275.

11. Holmberg SD, Stewart JA, Gerber AR, et al. Prior herpes simplex virus type 2 infection as a risk factor for HIV infection. JAMA 1988;259:1048-50.

12. Simonsen JN, Cameron W, Gakinya MN, et al. Human immunodeficiency virus infection among men with sexually transmitted diseases: experience from a center in Africa. N Engl J Med 1988;319:274-8.

13. CDC. Guidelines for the prevention and control of congenital syphilis. MMWR 1988;37(suppl S-1).

14. Zaidi AA, Schnell D, Reynolds GH. Time series analysis of syphilis surveillance data. Presented at CDC Symposium on Statistics in Surveillance, Atlanta, May 5, 1988.

15. Ingram DD, Makuc D, Kleinman JC. National and state trends in use of prenatal care, 1970-83. Am J Public Health 1986;76:415-23. *Ninety-nine percent of cases in 1987 occurred in persons 15-64 years old. **1985 was chosen as baseline for this comparison because, in several areas, the increases began during 1986.

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