TALKING POINTS - CONGENITAL SYPHILIS MEDIA TELEBRIEFING

JUDY WASSERHEIT, M.D., M.P.H.
DIRECTOR, DIVISION OF STD PREVENTION

Good morning, and thank you for joining us today . . .

• I am Judy Wasserheit, Director of the CDC's STD Prevention Program.
  
• Also, with me today is George Counts, Director of CDC's syphilis elimination activities.

We are pleased to share with you today the results of a new CDC study demonstrating a remarkable drop in rates of syphilis among infants. These data are extremely encouraging, particularly coming just three years after the launch of CDC's national Syphilis Elimination initiative.

By now, you should have all received a press release and a copy of the MMWR report on congenital syphilis. If you have not, or if you have any questions after this call, please call our media office at 404-639-8895.

Now to set the stage a bit-

• First, I will provide an overview of syphilis in the United States today, and briefly discuss CDC's National Syphilis Elimination Plan, which first began in 1998
  
• Dr. Counts will then discuss today's MMWR report on syphilis rates among infants. I will then open the floor for any questions you might have.

Syphilis Overview

The last U.S. syphilis epidemic peaked in 1990, with the highest syphilis rates in 40 years. Although infections have subsided since then to the lowest level since reporting began, history shows that syphilis rates tend to run in seven to 10 year cycles. Unless we take action to eliminate it now, we could once again experience a rise in syphilis rates.

Thankfully, we have the tools and resources at hand to effectively eliminate syphilis in the United States. Syphilis is easily diagnosed and cured, given adequate access to and utilization of care. The challenge is to ensure that all Americans are able to benefit from syphilis treatment.

Today, syphilis disproportionately affects African Americans living in poverty, primarily in the South and in selected urban areas. For these communities, the consequences of syphilis are severe: increased likelihood of HIV transmission and compromises to infant health, resulting from the transmission of syphilis from mother to child. Eliminating syphilis in the United States would be a landmark achievement. It would significantly improve the well being of women and infants, decrease one of the most glaring racial disparities in health and reduce HIV transmission in the United States.

Let me take a moment to define what we mean when we talk about syphilis elimination:

• Syphilis elimination is the absence of sustained transmission in the United States. This means that, while there may be occasional outbreaks, these outbreaks can be quickly identified and contained, eliminating the risk of a new epidemic.
  
• Our national goal, therefore, is to reduce infectious syphilis cases to 1,000 or fewer annually, and to increase the number of syphilis-free counties to at least 90% by 2005. The data that Dr. Counts will discuss today represent an important step toward our national goal of syphilis elimination.

Three years ago, in 1998, CDC initiated a national effort to eliminate syphilis in the United States. The fact that we had the lowest syphilis rates in U.S. history and the geographic concentration of disease provided an opportunity to build on current STD prevention and control efforts to combine intensified traditional approaches with innovative new ones. Five strategies are critical to this effort:

• Foremost among these is strengthened community involvement and partnership. Because syphilis is highly localized, CDC is working closely with community partners and state and local governments to strengthen programs in hardest-hit communities.
  
• CDC is also working with the appropriate authorities at local and state levels to develop rapid response plans in the event of a syphilis outbreak.
  
• Through our expanded partnerships, CDC is helping communities at greatest risk improve access to timely clinical and laboratory services, including counseling, screening and treatment.
  
• CDC is working with our partners to implement effective health information campaigns, so that high-risk individuals are aware of the risk and know how to reduce it.
  
• Finally, our capacity to track or monitor syphilis has also been significantly stepped up. Today's study is a result of this effort.

This comprehensive approach, instituted just three years ago, has begun to produce real progress toward our national goal of syphilis elimination and to have a profound impact on improving infant health. I'll now turn the call over to Dr. George Counts, who will present our new data showing a significant reduction in syphilis among infants.

GEORGE COUNTS, MD
DIRECTOR OF CDC'S SYPHILIS ELIMINATION ACTIVITIES

Thank you, Judy. Syphilis among infants, known as congenital syphilis, is acquired when an infected pregnant woman transmits the infection to her fetus. Left untreated, up to 40% of congenital infections will result in infant death. Infected children who are not treated may suffer neurological impairment, seizures, deafness, or bone deformities.

Thankfully, if syphilis is detected in pregnant women, it can be treated with a single-dose of penicillin, an inexpensive, widely available antibiotic that is effective and safe for both mother and child.

Congenital syphilis data are reported to CDC from all 50 states and the District of Columbia. To evaluate progress in eliminating syphilis in the United States, CDC compared reported rates in 2000 with rates in 1997, the year before CDC syphilis elimination efforts began.

In 2000, 529 congenital syphilis cases were reported to CDC, representing approximately 13 of every 100,000 live births. Overall, congenital syphilis rates dropped 51% since 1997.

Cases in 2000 appeared in 155 counties, which represent only 5% of all counties in the United States. A regional breakdown of congenital syphilis shows that rates were highest in the South, with congenital syphilis occurring in approximately 19 of every 100,000 live births. Rates in other regions were significantly lower.

As in past years, minorities had the highest rates of congenital syphilis in 2000. African Americans had the highest rate-49.3 per 100,000 births-followed by Hispanics/Latinos at 22.6. The rate for whites was lowest, at 1.5.

Despite these continuing racial disparities, almost all racial groups experienced a significant drop in congenital syphilis rates. Rates declined 59.7% for African Americans and 58.3% for whites. Hispanics/Latinos experienced a smaller, but still significant decrease of 32.5%. The only racial group to experience a slight rise was American Indians/Alaska Natives, up by only one case.

When tracking congenital syphilis, it's also important to examine the rates of syphilis among women. Rates of congenital syphilis closely follow trends in infectious syphilis in women of reproductive age, as infants become infected from their mothers during pregnancy or delivery. In 2000, 2,219 infectious syphilis cases among women of childbearing age - age 15 to 44 years - were reported to CDC, a 38% drop from 3,590 cases in 1997, the year before the syphilis elimination campaign was begun.

A significant portion of the overall decline in syphilis among infants and women may be attributed to syphilis elimination programs initiated in recent years by CDC in collaboration with state and local partners. Many of these efforts have been targeted to the racial and ethnic minority communities that continue to report the highest rates of congenital syphilis, the majority of which are located in the South.

Despite these positive steps, many challenges remain. Racial and ethnic minorities continue to be disproportionately affected by congenital syphilis, as evidenced by the 33-to-1 ratio of African American to white cases. The high rates continue to be concentrated in the Southern states and a few northern and western urban areas. In some populations segments within these areas, limited access to comprehensive prenatal care - often as a result of poverty -may be a persistent barrier to the prevention of congenital syphilis.

Other challenges include the growing number of uninsured women, the limited expansion of prenatal care provided by Medicaid managed care and Child Health Insurance Programs, and the decreased funding of publicly funded clinics, emergency departments, and other safety net providers that serve poor, uninsured, racial and ethnic minority women and adolescents.

In order to effectively treat infected pregnant women, healthcare providers must regularly screen pregnant women. In a 1998 national survey, only 85% of obstetricians and gynecologists reported routinely screening their pregnant clients for syphilis.

Currently, CDC recommends that health care providers test all women for syphilis during the early stages of pregnancy. In areas where syphilis prevalence is high and for pregnant women at high risk for syphilis infection, CDC also recommends providers test their patients early during pregnancy and twice in the third trimester, including once at delivery. Because stillborn delivery can be due to syphilis, all women who deliver a stillborn infant after 20 weeks of gestation should also be tested for syphilis and treated if infected.

Syphilis screening should also be offered in emergency departments, jails, prisons and other settings that provide episodic care to pregnant women at high risk for syphilis.

In conclusion, let me make one point absolutely clear: elimination of congenital syphilis is a feasible goal because of the limited number of cases and its highly concentrated geographic distribution. The cornerstone of congenital syphilis prevention is early detection of maternal syphilis and treatment with safe and effective antibiotics. These simple actions could contribute to the complete elimination of syphilis among infants, and significantly improve infant health in the United States. If we fail to take advantage of this historic opportunity, the health of our families and our communities will continue to suffer.

JUDY WASSERHEIT, M.D., M.P.H.

Concluding Remarks

Thank you George.

This study demonstrates that, through effective planning and coordination among national, state and local entities, both public and private, we have made remarkable strides in just a few short years.

Cutting rates of congenital syphilis in half in just three years is a tremendous success not simply because of the hundreds of babies who will enter the world healthy, but also because syphilis elimination activities appear to be improving prenatal care in many of our poorest, most vulnerable communities.

Through syphilis elimination activities, we can not only save lives, but at the same time, save more than one billion dollars annually in direct and indirect health care costs associated with syphilis and its complications. Clearly, this goal must remain a public health priority.

Now we would be glad to take any questions.