Current Trends Primary and Secondary Syphilis --- United States, 1981 - 1990

Since 1985, the number of primary and secondary (P&S) syphilis cases reported in the United States has been increasing. In 1990, 50,223 cases were reported, a 9% increase from 1989. The incidence of 20 cases per 100,000 persons, a 75% increase from 1985, is the highest since 1949. This report summarizes the incidence of P&S syphilis during 1990 and provides comparison data from 1981--1990.

From 1985 through 1990, P&S syphilis rates for black men increased from 69 to 156 per 100,000 (126%), and for black women, from 35 to 116 per 100,000 (231%) (Figure 1). For non-Hispanic white men, the rate declined from 6 to 3 per 100,000. Rates for American Indian/Alaskan Native men were higher than rates for white men, peaking at 21 per 100,000 in 1983 and decreasing to 9 per 100,000 in 1990. Although rates for American Indian/Alaskan Native women decreased, they were based on fewer than 100 cases per year.

In 1990, P&S syphilis rates were greater than 7 per 100,000 persons in 26 states (Figure 2, page 321). From 1985 through 1990, rates increased in 25 of these 26 states; since 1989, rates have increased more than 40% in seven southern states: Alabama (55%), Arkansas (65%), Louisiana (67%), Mississippi (59%), North Carolina (45%), Tennessee (46%), and Virginia (47%) (Figure 3, page 321).

For most of the United States, the highest rates of P&S syphilis occurred in urban areas. In 1990, large cities with rates greater than 100 per 100,000 persons were Atlanta (222 cases per 100,000 persons), Washington, D.C. (183), New Orleans (174), Newark (160), Memphis (158), Philadelphia (147), and Charlotte, North Carolina (102) (Table 1, page 322). Although rates continued to increase in several cities involved early (before 1988) in the epidemic, the largest increases from 1989 to 1990 occurred in areas not previously affected, including several cities in the midwest---Cincinnati (107%), Cleveland (235%), Columbus (293%), and Toledo (278%), Ohio; Milwaukee (153%), Wisconsin; and St. Louis (172%), Missouri.

In some cities where the incidence increased early in the epidemic, rates have begun to decline. For example, in New York City the rate in 1990 declined 15% after a peak of 68 per 100,000 in 1988. Similar declines occurred in Portland (65%), Miami (51%), and San Diego (10%) following peak rates in 1988. From 1987 through 1990, P&S syphilis rates in Los Angeles decreased 56%, from 52 to 23 per 100,000.

Through 1988, the epidemic affected population centers primarily on the east, west, and gulf coasts. From 1989 to 1990, rates declined in several of these areas, while in the midwest and south-central region rates increased (Figure 3). Reported by: Participating city and state health depts and STD control programs. Surveillance and Information Systems Br, Clinical Research Br, Div of STD/HIV Prevention, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note:Since the current P&S syphilis epidemic began in 1986, the most notable trends have been 1) the substantial increase in cases involving black heterosexuals, 2) changes in geographic distribution, and 3) the association of the epidemic with crack cocaine use.

For non-Hispanic white men, the decline in incidence has been attributed to decreased transmission among homosexual men (1). In contrast, for blacks, the epidemic has been sustained through heterosexual transmission (2). Differences in risk for syphilis between racial/ethnic groups and regions may be attributed in part to private/public access to care, reporting practices, and/or case ascertainment. For example, blacks may be more likely to obtain care from publicly funded sexually transmitted disease (STD) clinics, where reporting is often more complete than reporting from other sources; however, such differences in reporting are unlikely to fully account for the large increase among blacks.

Three factors have contributed to the increase in the current syphilis epidemic. First, syphilis transmission has increased among medically hard-to-reach groups, such as crack cocaine users and other drug users. Cocaine use and the environment in which cocaine is used and exchanged appear to promote high-risk sexual behaviors, such as sex with multiple anonymous partners in exchange for drugs (3,4). In these settings, sex partners are difficult to locate for diagnosis and treatment by STD-control programs (5). Second, persons in groups at increased risk for syphilis may not have access to health care, know when or how to seek appropriate health care, or consider health care a high priority. Third, declines in socioeconomic and education levels in certain populations (e.g., persons of lower income levels who live in an inner-city environment) have been associated with increased unemployment, drug use, prostitution, and family disruption---conditions conducive to the spread of syphilis (6).

Surveillance and epidemiologic data can assist STD-control programs in their syphilis-control efforts. For example, data collected from patient interviews conducted at jails and detention centers or sites frequented by syphilis patients can be used to identify persons at increased risk for syphilis (7). However, the cost and effectiveness of these strategies in reducing the incidence and prevalence of syphilis must be rigorously evaluated.

Control measures may be more effective when they are supported by the affected communities and complemented by accessible clinical care. In addition, strengthened local, state, and national surveillance systems are essential to improved understanding of the current syphilis epidemic and for evaluation of intervention strategies.

References

1. Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981--89. JAMA 1990;264:1432--7.

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

3. CDC. Relationship of syphilis to drug use and prostitution---Connecticut and Philadelphia, Pennsylvania. MMWR 1988;37:755--8,764.

4. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution. Am J Public Health 1990;80:853--7.

5. Andrus JK, Fleming DW, Harger DR, et al. Partner notification: can it control epidemic syphilis? Ann Intern Med 1990;112:539--43.

6. Fullilove MT, Fullilove RE. Intersecting epidemics: black teen crack use and sexually transmitted disease. J Am Med Wom Assoc 1989;44:146--53.

7. CDC. Epidemic early syphilis---Escambia County, Florida, 1987 and July 1989--June 1990. MMWR 1991;40:323--5.

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