The National Plan to Eliminate Syphilis from the United States - Executive Summary

Background and Rationale

As we approach the end of the 20th century, the United States is faced with a unique opportunity to eliminate syphilis within its borders. Syphilis is easy to detect and cure, given adequate access to and utilization of care. Nationally, it is at the lowest rate ever recorded and it is confined to a very limited number of geographic areas. The last epidemic peaked in 1990, with the highest syphilis rate in 40 years. By 1998, the number of cases had declined by 86 percent. Although the national syphilis rate has declined to historic lows, syphilis remains a severe public health problem in a small number of U.S. counties. In 1998, over 50% of infectious (primary and secondary or P&S) syphilis cases were reported from only 28 (<1%) counties, the majority of which are in the South. In addition, where syphilis does persist in the U.S., it disproportionately affects African Americans living in poverty. Although the Black:White ratio for reported syphilis rates has decreased by almost one-half since the early 1990s, the 1998 P&S syphilis rate for non-Hispanic Blacks was still 34 times greater than that for non-Hispanic whites.

Elimination of syphilis would have far-reaching public health implications because it would remove two devastating consequences of the disease - increased likelihood of HIV transmission and compromised ability to have healthy babies due to spontaneous abortions, stillbirths, and multi-system disorders caused by congenital syphilis acquired from mothers with syphilis. In addition, more than $996 million is spent annually as a result of syphilis. Eliminating syphilis in the United States would be a landmark achievement because it would remove these direct health burdens, and it would significantly decrease one of this Nation's most glaring racial disparities in health.

The persistence of high rates of syphilis in the United States is a sentinel event identifying communities in which there is a fundamental failure of basic public health capacity to control infectious diseases and ensure reproductive health. In these areas, syphilis elimination will be the leading edge of a broader effort to begin rebuilding this capacity. Based on the repeatedly observed seven- to ten-year syphilis cycle, there is currently a narrow window of opportunity to eliminate this disease while cases are still on the decline.

Definition and Goal

At the national level, syphilis elimination is defined as the absence of sustained transmission in the United States. At the local level, syphilis elimination is defined as the absence of transmission of new cases within the jurisdiction except within 90 days of report of an imported index case. It is anticipated that these definitions will translate to <1,000 cases (0.4/100,000 population) of primary and secondary (P&S) syphilis reported nationally each year. The national goal, therefore, is to reduce P & S syphilis cases to 1,000 or fewer and to increase the number of syphilis-free counties to 90% by 2005.

 

The Plan

While many other endemic diseases such as polio, measles, and smallpox have been eliminated through widespread use of vaccines, the strategies for syphilis elimination differ from these efforts largely because there is currently no vaccine. Past experience shows that continuing current STD prevention and control efforts, alone, will not be sufficient. New strategies are also required. Combining intensified traditional approaches with innovative approaches can generate new synergy and enhance the effectiveness of syphilis elimination efforts. Furthermore, this plan will evolve over time as new lessons are learned and applied.

Five strategies are critical for eliminating syphilis from the United States

Two strategies-strengthened community involvement and partnerships and rapid outbreak response-will be new in many parts of the U.S. The three remaining strategies-enhanced surveillance, expanded clinical and laboratory services, and enhanced health promotion-have been used for syphilis control and will be intensified and expanded for syphilis elimination. Two cross-cutting strategies are key tools for evaluating and facilitating the implementation of three additional intervention strategies.

Cross Cutting Strategies

• Enhanced surveillance -includes complete, accurate, and timely reporting of positive syphilis tests; effective, timely, and regular data analyses; development of a framework for and implementation of syphilis surveillance; and ongoing evaluation of the amount of syphilis in a community by monitoring positive syphilis tests.
  
• Strengthened community involvement and partnerships -acknowledges and responds to the effects of racism, poverty, and other relevant social issues on the persistence of syphilis in the U.S.; develops and maintains partnerships to increase the availability of and accessibility to preventive and care services; and assures that affected communities are collaborative partners in developing, delivering, and evaluating syphilis elimination interventions.

Intervention Strategies

• Rapid outbreak response -includes both the development of an outbreak response plan and establishment of area-specific criteria that determine when the outbreak response plan should be implemented.
  
• Expanded clinical and laboratory services -provides accessible and timely client-centered counseling, screening, and treatment services in sites frequented by populations at risk for syphilis; and ensures high quality syphilis preventive and care services.
  
• Enhanced health promotion -includes implementation and evaluation of appropriate and effective health promotion interventions; and timely delivery of high quality, confidential, and comprehensive client-centered partner services to patients, partners, and other identified high-risk individuals.

Geographic Focus

While national in scope, the syphilis elimination initiative focuses on areas with high syphilis morbidity and those areas with potential for syphilis re-emergence. High morbidity areas (HMAs) are defined in this plan as areas with continuing syphilis transmission, usually signaling the need to improve preventive services and to strengthen the capacity to conduct surveillance and provide access to clinical and laboratory services. HMAs must address all five of the syphilis elimination strategies. Potential re-emergence areas (PRAs) are defined in this plan as areas that currently experience little or no syphilis transmission but that are at significant risk for syphilis reintroduction because 1) they had a history of high syphilis rates in the 1990s or more recently; 2) they are a port or border jurisdiction or are located along migrant streams; 3) they are located along drug trafficking corridors; or 4) they include groups that are disproportionately affected by syphilis (e.g. drug users, people exchanging sex for money or drugs, men who have sex with men, and minority and migrant populations that are affected by racism, high rates of unemployment, poor educational opportunities, and poverty). PRAs should focus primarily on enhanced surveillance and rapid outbreak response, including the involvement of affected communities in implementing these strategies. Low morbidity areas that are not PRAs will sustain the activities of a strong STD prevention program.

Requirements for Success

This plan is intended to serve as a resource and blueprint for the many partners vital to the success of this effort. Eliminating syphilis in the U.S. requires the commitment, investment, and collaboration of opinion leaders as well as program managers at local, state, and national levels. Members and leaders of affected communities must be involved in designing and delivering syphilis services, and have the opportunity to share ownership in interventions that improve the health status of their communities.