FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION Bureau of the Census.2 The 1999 rates reported in whites (0.5); the 1999 rate Primary and and numbers of cases were compared for blacks declined 10% compared with with data for 19983 and 1997.4 1998. The rate for Hispanics in- Secondary Syphilis— In 1999, 6657 cases of P&S syphilis creased 20% (from 1.5 in 1998 to 1.8 United States, 1999 were reported in the United States (2.5 in 1999). The increase in rate for His- per 100,000 population), a 5.4% de- panics was attributed to an increased MMWR. 2001;50:113-117 crease from the 7035 cases (rate: 2.6) number of cases in men; the number reported in 1998 and a 22% decrease of cases in women remained stable. 1 table, 1 figure omitted from the 8556 cases (rate: 3.2) re- Rates for American Indians/Alaska Na- IN OCTOBER 1999, CDC, IN COLLABO- ported in 1997. The South continues to tives and for Asians/Pacific Islanders ration with other federal partners, have the highest rate in the country were unchanged from 1998 (2.7 and launched the National Plan to Elimi- (4.5).* From 1998 to 1999, rates de- 0.4, respectively). nate Syphilis in the United States. In clined 10% in the South (from 5.0 to Rates for P&S syphilis in 1999 were 1998, Congress initiated funding for the 4.5) and 12.5% in the Northeast (0.8 45% higher for men (2.9) than for syphilis elimination effort. Syphilis elimi- to 0.7). The rate for the West re- women (2.0). The male-to-female rate nation is defined as the absence of sus- mained unchanged (1.0), and the rate ratio in 1999 was 1.5:1, and has been tained transmission (i.e., no transmis- for the Midwest increased from 1.9 in increasing since 1994, when it was 1:1. sion after 90 days of the report of an 1998 to 2.2 in 1999. P&S syphilis rates The increase occurred in all racial/ imported index case). The national goal have declined in 28 states since 1998, ethnic groups except Asians/Pacific Is- for syphilis elimination is to reduce pri- and 39 states have rates below the na- landers and American Indians/Alaska mary and secondary (P&S) syphilis to tional health objective for 2000 of 4.0. Natives. The greatest increase oc- ,1000 cases (rate: 0.4 per 100,000 Nine of the 11 states that have rates curred among Hispanics, from 2.3:1 in population) and to increase the num- above the 2000 objective are in the 1998 to 2.9:1 in 1999. An increase in ber of syphilis-free counties to 90% by South. The rates for 1999 increased in the male-to-female rate ratio occurred 2005.1 To describe the epidemiology of 14 states; increases were largest in In- in 16 (62%) of the 26 states that re- syphilis in the United States, CDC ana- diana (from 3.6 to 7.6), Oklahoma (2.9 ported $25 cases in 1999. The male- lyzed notifiable disease surveillance data to 5.6), and Washington (0.8 to1.4). to-female rate ratio was remarkably high for 1999. This report summarizes the re- In 1999, of 3115 U.S. counties, 2473 in some cities, such as Seattle (38:1) and sults of that analysis, which indicate that, (79.4%) reported no cases of P&S syphi- San Francisco (25:1). in 1999, P&S syphilis declined to a rate lis, compared with 2430 (78.0%) coun- Reported by: State and local health depts. Epidemi- of 2.5 cases per 100,000 population, the ties reporting no cases in 1998 and 2324 ology and Surveillance Br, Statistics and Data Man- lowest rate ever reported, and that syphi- (74.6%) in 1997. In 1999, 2850 (91.5%) agement Br, Div of Sexually Transmitted Disease Pre- vention, National Center for HIV, STD, and TB lis transmission increasingly is concen- counties reported rates below the 2000 Prevention, CDC. trated in a few geographic areas. objective. Of the 265 counties (8.5% of Summary data for syphilis cases re- all counties) with P&S syphilis rates CDC Editorial Note: The number and ported to state health departments and above the 2000 objective, 243 were in rate of P&S syphilis cases reported in the District of Columbia for 1999 were the South. In 1999, 22 counties and Bal- 1999 were the lowest ever reported in sent quarterly and annually to CDC. timore, Maryland; Danville, Virginia; and the United States1 with a 22% decline in These data included the number of St. Louis, Missouri, accounted for 50% both cases and rates since 1997, reflect- syphilis cases by patients’ county of resi- of all reported P&S syphilis cases in the ing the substantial progress that has been dence, sex, stage of disease, racial/ United States. The overall rate for 63 of made since efforts to eliminate syphilis ethnic group, and age group. Data on the largest cities in the United States began. The disease has become increas- reported P&S syphilis were analyzed for (population .200,000) was 5.1 cases ingly concentrated in a few geographic this report because these cases better per 100,000 persons; 24 large cities had areas; in 1999, 50% of P&S syphilis represented incidence (i.e., newly ac- rates higher than the 2000 objective. Cit- cases occurred in ,1% of counties; quired infections within the evaluated ies with the highest rates of P&S syphi- approximately 80% of counties reported time) than reported cases of latent in- lis were Indianapolis, Indiana (50.0); no cases of syphilis. Although syphilis fection, which are usually acquired Nashville, Tennessee (46.8); and Balti- rates remain higher in the South than months or years before diagnosis. P&S more, Maryland (38.1). in other regions, the South had a 32% syphilis rates were calculated by using The 1999 reported rate of P&S syphi- decline in the P&S syphilis rate from population denominators from the U.S. lis in blacks (15.2) was 30 times the rate 1997 to 1999, illustrating that the 1284 JAMA, March 14, 2001—Vol 285, No. 10 (Reprinted) ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION greatest improvements in disease con- however, the increases also may be at- trol have taken place where syphilis inci- tributed to increases in populations that Outbreak of Syphilis dence has been greatest. Eliminating have been difficult to reach for pur- syphilis would reduce the likelihood of poses of syphilis prevention and con- Among Men Who human immunodeficiency virus (HIV) trol, such as MSM, who previously have Have Sex With transmission and improve reproduc- not been a focus of the national syphi- tive health by preventing spontaneous lis elimination effort. Men—Southern abortions, stillbirths, and developmen- The findings in this report are sub- California, 2000 tal disabilities caused by congenital ject to at least three limitations. First, the syphilis. In addition, syphilis elimina- quality of surveillance activities and data MMWR. 2001;50:117-120 tion would help to rebuild the capacity vary at local and state levels. Second, of communities to control infectious dis- sexually transmitted disease reporting is 1 figure omitted eases and reduce racial disparities.1 incomplete. Finally, cases among pa- SYPHILIS IS A SEXUALLY TRANSMITTED DIS- Syphilis continues to disproportion- tients attending public sector clinics may ease (STD) caused by infection with the ately affect minority populations de- be more likely to be reported than cases spirochete Treponema pallidum, and like spite progress in reducing this racial dis- diagnosed in the private sector, which other genital ulcer diseases, syphilis en- parity. P&S syphilis rates for blacks have could magnify the racial/ethnic differ- hances the transmission of human im- remained substantially higher than those ences in reported rates; persons of mi- munodeficiency virus (HIV).1 During for whites. However, the magnitude of nority race/ethnicity may be more likely the 1990s, syphilis occurred predomi- this difference has decreased 30% since to attend public clinics. nantly among heterosexual blacks in the 1997. The persistence of racial dispari- The variation in the demographic South and in large cities. However, re- ties in syphilis incidence is, in part, at- characteristics of syphilis patients over cent outbreaks of syphilis have oc- tributable to differences between blacks time and among regions highlights the curred among men who have sex with and whites regarding poverty and in ac- need to recognize and respond to the men (MSM).2,3 A large syphilis out- cess to and use of health-care services, changing epidemiology of this disease. break occurred among MSM during especially in the rural South.5,6 In addi- Because increases in syphilis may emerge January-July 2000 in southern Califor- tion, rates increased 20% among His- in areas or subpopulations that are not nia. During the outbreak period, the panics, due to an increase among males. specifically targeted by ongoing elimi- proportion of primary and secondary Historically, rates of syphilis have nation efforts, it is necessary to continu- (P&S) syphilis cases among MSM in- been higher for men than women. The ally reassess and refine surveillance, pre- creased to 51% from 26% for the same male-to-female rate ratio peaked at 3.5:1 vention, and control strategies. period in 1999. This report summa- in 1980 during the height of syphilis To sustain progress toward syphilis rizes the findings of an investigation of transmission among men who have sex elimination, communities must under- this syphilis outbreak, which indicate with men (MSM) and decreased to 1:1 stand local patterns of syphilis transmis- a substantial increase in the number of in 1994; since then, it has increased sion and develop intervention strate- syphilis cases among MSM, many of gradually.