Acquired syphilis

After declining every year during 1990-2000, the rate of primary and secondary (P&S) syphilis in the United States increased in 2001. To characterize the epidemiology of syphilis in the United States, CDC analyzed national surveillance data for 2002 *. This report summarizes the results of that analysis, which indicate that the number of reported cases of P&S syphilis increased 12.4% in 2002. As in 2001, this increase occurred only among men, suggesting that this increase occurred particularly among men who have sex with men (MSM). For the 12th consecutive year, the number of P&S syphilis cases declined among women (Figure) and non-Hispanic blacks. These data suggest that although efforts to reduce syphilis among these populations have been effective, additional intervention strategies are needed to prevent syphilis among MSM.

CDC analyzed surveillance data for syphilis cases reported weekly to health departments nationwide in 2002. Data included each patient's county of residence, sex, stage of disease, race/ethnicity, and age. Data on reported cases of P&S syphilis were analyzed because these cases represented incidence (i.e., newly acquired infections within the study period) better than cases of latent infection, which were acquired months or years before diagnosis. P&S syphilis rates were calculated by using population denominators from the U.S. Bureau of the Census (1).

During 2001-2002, the rate of P&S syphilis increased 9.1% (from 2.2 cases per 100,000 population in 2001 to 2.4 cases in 2002). In 2002, a total of 6,862 cases of P&S syphilis were reported, an increase of 12.4% over the 6,103 cases reported in 2001, and the rate of P&S syphilis was 3.5 times higher among men than among women (3.8 versus 1.1 cases per 100,000 population) (Table 1). During 2001-2002, the overall male-to-female P&S syphilis rate ratio increased 66.7% (from 2.1 to 3.5) (Figure); the male-to-female rate ratio increased among non-Hispanic whites (from 6.0 to 11.0), non-Hispanic blacks (from 1.6 to 2.1), and Hispanics (from 3.7 to 5.0); the rate ratio declined slightly among Asians/Pacific Islanders (from 10.0 to 8.0) and remained unchanged among American Indians/Alaska Natives (AI/ANs) (1.2). The male-to-female rate ratio increased in 27 states and the District of Columbia.

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During 2001-2002, the rate of P&S syphilis decreased 10.9% among non-Hispanic blacks (2.2% among men and 22.6% among women) and 42.9% among AI/ANs (44.7% among men and 42.l% among women) (Table 1). Rates increased 71.4% among non-Hispanic white men (83.3%) and 28.6% among Hispanic men (36.4%); rates were unchanged among women of both populations. The rate increased 80.0% among Asians/Pacific Islanders (60.0% among men and 100% among women). In 2002, the rate of P&S syphilis among non-Hispanic blacks was 8.2 times higher than among non-Hispanic whites, compared with 15.7 times higher in 2001.

By region ([dagger]), the South had the highest rate of P&S syphilis (3.1 cases per 100,000 population) in 2002. However, the rate of P&S syphilis in the South declined 8.8% during 2001-2002 (Table 1). The P&S syphilis rate increased 64.3% in the West, 54.5% in the Northeast, and 16.7% in the Midwest. In 2002, P&S syphilis cases from the South accounted for less than half (45.8%) of total syphilis cases, compared with 56.2% in 2001. During 2001-2002, male-to-female rate ratios increased in all regions; the rate ratio increased 56.0% in the Northeast (from 5.0 to 7.8), 40.0% in the West (from 6.0 to 8.4), 35.3% in the South (from 1.7 to 2.3), and 33.3% in the Midwest (from 2.1 to 2.8).

During 2001-2002, the overall rate of P&S syphilis for 63 selected U.S. cities with population of >200,000 increased 20.8% (from 4.8 to 5.8 cases per 100,000 population); the overall male-to-female P&S syphilis rate ratio in these cities increased 57.7% (from 2.6 to 4.1). In 2002, several large cities had high male-to-female rate ratios; among the 19 cities reporting >50 P&S syphilis cases, the median rate ratio was 4.4 (range: 0.8-78.8) (Table 2).

In 2002, among 3,139 counties in the United States, 2,534 (80.7%) reported no cases of P&S syphilis; approximately half of the reported cases occurred in 16 counties and one city, compared with 20 counties and one city in 200l. In 2002, the 63 large cities accounted for 62.7% of P&S syphilis cases, compared with 57.8% in 2001.

Editorial Note: Although efforts to reduce syphilis among women and non-Hispanic blacks have been effective, the rate of P&S syphilis among men continued to increase in 2002. Increases among men occurred in all regions of the United States and among all racial/ethnic populations except non-Hispanic blacks and AI/ANs. On the basis of male-to-female rate ratios and locally collected risk data, much of the increase in syphilis among men can be attributed to cases occurring among MSM. Increased risk-taking in this population has been documented (2,3), and syphilis outbreaks among MSM in large cities have been reported (4-7). A high rate of human immunodeficiency virus (HIV) co-infection has been reported among MSM involved in these outbreaks (4,5,7), raising concern about HIV transmission. Although the sex of infected persons' sex partners is recorded by certain local health departments, these data are not reported nationally. If the entire increase in the male-to-female rate ratio since 2000 (Figure) is attributed to an increase in cases among MSM, >40% of P&S cases reported in 2002 occurred among MSM.

The declining rate of P&S syphilis among non-Hispanic blacks and the increasing rate of infection among non-Hispanic whites has decreased the disparity in rates of infection between the two populations. The decline among non-Hispanic blacks has occurred predominantly among women; the increase among non-Hispanic whites has occurred exclusively among men.

Although the South continues to have the highest rate of P&S syphilis, the rate of disease has declined in this region every year since 1990; in 2002, for the first time since 1984, this region accounted for <50% of reported cases. However, P&S syphilis rates have increased in the West, Northeast, and Midwest. In 2002, the increased rate of P&S syphilis in large cities reflected an urban concentration of disease.

Efforts are under way to address the increasing rate of P&S syphilis among MSM. To improve national surveillance, CDC is conducting a pilot program to evaluate the national collection of information on behaviors and risk factors for persons infected with syphilis. In 2002, in collaboration with local health departments, CDC conducted an assessment of sex behaviors and sexually transmitted disease occurrence in eight U.S. cities that have reported increases in syphilis cases among MSM. CDC has provided additional funding to support interventions in these cities. In addition, because a substantial number of MSM with syphilis report meeting anonymous partners in venues such as bathhouses and Internet chat rooms (4,5,7), CDC is developing and evaluating new strategies for locating and treating sex partners (e.g., using e-mail addresses of contacts) to ensure that they receive adequate treatment.

The findings in this report are subject to at least three limitations. First, the quality of surveillance data varies at local and state levels. Second, national syphilis reporting is incomplete. For example, case finding for syphilis depends on persons having known sex partners and being willing to identify their partners to health department personnel; in the current epidemic, the anonymity of sex partners might have decreased the number of cases detected by contact tracing (8). Finally, rates of disease among Asians/Pacific Islanders and AI/ANs should be interpreted with caution because of the limited number of cases of P&S syphilis reported among these populations.

In 1999, CDC launched the National Syphilis Elimination Plan (9). Initial efforts focused on syphilis in the South and among minority populations and contributed to the decrease in syphilis in the South and among non-Hispanic blacks and women. To eliminate syphilis, prevention efforts must be continued among these populations and modified and expanded to prevent and control syphilis in other populations. The increase in syphilis among MSM raises challenges for the control and eventual elimination of syphilis. CDC is working with state and local public health organizations to develop and evaluate effective intervention strategies directed toward MSM, including education, risk reduction, appropriate screening and treatment, and community mobilization.

* Data for 2002 are summarized for the reporting year December 30, 2001-December 28, 2002.

([dagger]) Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

References

(1.) CDC. Sexually Transmitted Disease Surveillance, 2002. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC (in press).

(2.) Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health 2002;92:388-94.

(3.) Rietmeijer CA, Patnaik JL, Judson FN, Douglas JM. Increases in gonorrhea and sexual risk behaviors among men who have sex with men: A 12-year trend analysis at the Denver Metro Health Clinic. Sex Transm Dis 2003;30:562-7.

(4.) CDC. Resurgent bacterial sexually transmitted disease among men who have sex with men--King County, Washington, 1997-1999. MMWR 1999;48:773-7.

(5.) CDC. Outbreak of syphilis among men who have sex with men--Southern California, 2000. MMWR 2001;50:117-20.

(6.) Bronzan R, Echavarria L, Hermida J, Trepka M, Burns T, Fox K. Syphilis among men who have sex with men (MSM) in Miami-Dade County, Florida [Abstract]. In: Program and Abstracts of the 2002 National STD Prevention Conference, San Diego, California, March 4-7, 2002.

(7.) CDC. Primary and secondary syphilis among men who have sex with men--New York City, 2001. MMWR 2002;51:853-6.

(8.) Gorbach PM, Aral SO, Celum C, et al. To notify or not to notify: STD patients' perspectives of partner notification in Seattle. Sex Transm Dis 2000;27:193-200.

(9.) CDC. The National Plan to Eliminate Syphilis from the United States. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention, 1999. Available at http://wwww.cdc.gov/stopsyphilis/plan.pdf.

Reported by: State and local health depts. JD Heffelfinger, MD, HS Weinstock, MD, SM Berman, MD, EB Swint, MS, Div of Sexually Transmitted Disease Prevention, National Center for HIV, STD, and TB Prevention; E Samoff, PhD, EIS Officer, CDC.

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