Selective Screening to Augment Syphilis Case-Finding -- Dallas, 1991

Increased use of crack cocaine and the exchange of sex for drugs have been major contributors to the increased occurrence of syphilis in U.S. urban, minority populations (1-3). Because many persons who use drugs do not voluntarily seek health care (1,4), and because their sex partners are often difficult to locate (5), a substantial number of persons may have undiagnosed syphilis infections, thereby contributing to continuing transmission. Because of the continuing increase in the number of persons in Dallas County (1990 population: 1.8 million), Texas, in whom early syphilis * had been diagnosed, and who had reported having had sex partners at crack motels and crack houses (i.e., places where crack cocaine was sold), in February 1991, the Dallas Countywide Health Department (DCHD) developed a sexually transmitted disease (STD) screening program aimed specifically at those sites. This report describes Dallas County's selective screening program and summarizes results of the program from March 1 through December 31, 1991. Program Development

The Dallas County STD Program (DCSTDP) modified a previously used approach (1) to address needs specific to the target population in Dallas and to augment other STD intervention methods employed by the DCHD. To reach the high-risk population, the DCSTDP identified 21 sites for STD screening -- predominantly crack motels and crack houses named by persons with early syphilis during interviews with disease intervention specialists. Information sought during interviews included not only the identity of sex partners of syphilis patients but locations where syphilis may have been acquired.

A team consisting of a supervisor and two disease intervention specialists familiar with the community visited the sites and was responsible for 1) obtaining specimens on-site for serologic testing for syphilis and human immunodeficiency virus (HIV); 2) ensuring treatment of all persons determined to have been infected with or exposed to an STD; and 3) collecting and maintaining data for case-finding and follow-up, including names and aliases of identified syphilis patients and their sex partners and sites where high-risk sexual contact or illicit drug use were known to occur (e.g., lists of crack motels or crack houses).

Two physicians in private practice in the affected communities assisted in the screening program. These physicians examined patients, obtained serologic tests for syphilis and HIV, and treated patients referred by the health department for syphilis; the STD program provided medication and a monetary stipend to the physicians. The DCHD also developed cooperative agreements with social service and community-based organizations** to provide comprehensive care for persons using crack cocaine. Care included, for example, HIV pretest counseling at the time of syphilis screening and drug rehabilitation referrals. Selective Screening Activities

All persons tested for syphilis also received HIV pretest counseling; patients were offered a choice of either confidential or anonymous voluntary testing ***. To decrease the number of persons lost to follow-up, the team emphasized establishing rapport between public health workers and persons at each site. The team also distributed condoms and business cards and conducted demonstrations for individuals and groups on the correct use of condoms.

From March 1 through December 31, 1991, 250 persons were serologically tested by rapid plasma reagin tests at the 21 sites. Persons were identified for testing if they either had sexual contact with a person who had early syphilis or had been identified during a cluster interview **** (6) as having other risk factors for syphilis. Of the 250 persons, 78 (31%) tested positive and were treated for early syphilis (six with primary syphilis; 29, secondary syphilis; and 43, early latent syphilis), 42 (17%) were preventively treated, 15 (6%) were determined to have been treated previously, and 112 (45%) were uninfected; three (1%) persons were lost to follow-up.

Of the 250, 126 chose to receive an HIV-antibody test. Of those, six (5%) tested positive. Four of the six reported injecting-drug use, and all six reported high-risk sexual exposure.

Of the 78 persons identified with untreated syphilis, 61 (78%) received clinical examination and treatment at the DCHD clinic; of these, 38 (62%) also had other STDs: 13 had gonorrhea; 12, pelvic inflammatory disease; seven, nongonococcal urethritis; two, herpes; two, chancroid; one, human papillomavirus infection; and one, lymphogranuloma venereum.

Reported by: D Hutcheson, T Tucker, J Mayfield, C Parker, A Gonzales, P Yacovone, R Stinson, L Mims, G Stokes, M Davis, STD Program; JR Farris, MD, Dallas Countywide Health Department, Dallas. Clinical Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The Dallas project successfully employed nontraditional outreach methods to facilitate identification and serologic testing of persons at high risk for syphilis and HIV infection because of behaviors associated with their crack cocaine use. For example, because sex-partner notification is difficult among this population, community-based efforts focused on the identification of specific sex-for-drugs locations rather than named sex partners of persons with early syphilis. Because most crack-related activities occur within well-defined areas (7), the recognition of these locations facilitated identification, testing, and appropriate follow-up of sex partners and other persons at high risk for syphilis. In addition, the team approach and the involvement of private-sector physicians established in the community and of community-based organizations appeared to contribute to the high follow-up rate for persons who were tested. During a similar outreach effort in Philadelphia (1), 33% of seroreactive persons could not be located, compared with the 1% who were lost to follow-up in the Dallas project.

The approach of the Dallas project combined innovative methods, traditional partner notification, and cluster investigation methods. Measures to improve relations between the DCSTDP and the target community also may have contributed to the success of the project. Efforts to identify and treat infected persons in Dallas were considered effective when compared with methods employed in other locations (1,6,8 ). In addition, this approach permitted DCSTDP to identify and work effectively with a previously inaccessible high-risk population.

The findings in this report underscore the potential effectiveness of a team approach in disease-control strategies and the role for community coalitions in the identification, treatment, and follow-up of persons belonging to disenfranchised groups (9). The Dallas project may serve as a model for other health departments and communities with high rates of syphilis and other STDs, although future projects should consider including data and design elements necessary to fully evaluate efficacy and cost-effectiveness.

References

1. CDC. Alternative case-finding methods in a crack-related syphilis epidemic -- Philadelphia. MMWR 1991;40:77-80.

2. Aral SO, Holmes KK. Sexually transmitted diseases in the AIDS era. Sci Am 1991;264:62-9.

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

4. Marx R, Aral SO, Rolfs RT, Sterk CE, Kahn JG. Crack, sex, and STD. Sex Transm Dis 1991;18:92-101.

5. Greenberg J, Schnell D, Conlon R. Behavior of crack cocaine users and their impact on early syphilis intervention. Sex Transm Dis 1992;19:346-50.

6. CDC. Epidemic early syphilis -- Montgomery County, Alabama, 1990- 1991. MMWR 1992; 42:790-4.

7. Bowser BP. Crack and AIDS: an ethnographic impression. J Natl Med Assoc 1989;81:538-40.

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

9. CDC. Gang-related outbreak of penicillinase-producing Neisseria gonorrhoeae and other sexually transmitted diseases -- Colorado Springs, Colorado, 1989-1991. MMWR 1993;42:25-8.

• Syphilis with a duration of less than 1 year. ** These included the Behavior Modification Research Project of the HIV Census Tract, Project Impact and the Parent Mentor Project of the Texas Department of Human Services, the Minority HIV Prevention Project of the Dallas Urban League, and the Dallas Council on Alcohol and Drug Abuse. *** State law requires that every patient be offered the choice of either anonymous or confidential HIV-antibody testing. **** Cluster investigation methods and the cluster interview are methods to identify persons at high risk for syphilis other than those who were sex partners of the person being interviewed.

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