STD Quarterly: Syphilis elimination program pays off: Lower congenital syphilis rates

Efforts must continue to reach elimination goals

Vigilance in detecting and treating primary and secondary syphilis in the United States is reaping rewards: The syphilis rate among infants in 2000 declined by 51% since 1997, the year before the Atlanta-based Centers for Disease Control and Prevention (CDC) launched its national syphilis elimination campaign.1

Cases of congenital syphilis (CS) in 2000 appeared in 155 counties, which represent only 5% of all counties in the United States.1 A regional breakdown of CS indicates 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.1

Congenital syphilis is acquired when an infected pregnant woman transmits the infection to her fetus. Rates of congenital syphilis closely follow trends in primary and secondary syphilis in women, as infants become infected from their mothers during pregnancy or delivery. In 2000, 2,219 infectious syphilis cases among women of childbearing age (ages 15-44) were reported to the CDC, a 38% drop from 3,590 cases in 1997.2

Left untreated, up to 40% of congenital infections will result in infant death, says George Counts, MD, director of CDC’s syphilis elimination activities. Infected children who are not treated may suffer neurological impairment, seizures, deafness, or bone deformities. If syphilis is detected in pregnant women, however, it can be treated with a single dose of penicillin, an inexpensive, widely available antibiotic that is effective and safe for mother and child, he notes.

While news of the reduction in CS rates has been hailed as an important milestone, there still is work to do to reach the national goals of reducing infectious syphilis cases to 1,000 or fewer annually and increasing the number of syphilis-free counties to at least 90% by 2005, say CDC officials.

Racial disparities eyed

The new CDC data indicate that despite signs of decline overall, minority groups, especially African-Americans, continue to be disproportionately affected by syphilis.2

In 2000, the congenital syphilis rates were 49.3 cases per 100,000 live births for African-Americans, 22.6 cases per 100,000 live births for Hispanics, 13.2 cases per 100,000 live births for American Indians/ Alaska Natives, 5.9 cases per 100,000 live births for Asian/Pacific Islanders, and 1.5 cases per 100,000 live births for whites.1

Progress is being made in impacting CS rates, according to CDC information. From 1997 to 2000, CS rates declined 59.7% for African-Americans, 58.3% for whites, 32.5% for Hispanics, and 29.8% for Asian/Pacific Islanders.1 American Indians/ Alaska Natives experienced a slight increase.1

In a 1998 national survey, only 85% of OB/GYNs reported routinely screening pregnant women for syphilis.3 To combat congenital syphilis, the CDC recommends that health care providers test all women for syphilis during the early stages of pregnancy.2 In areas where syphilis prevalence is high and for pregnant women at high risk, CDC recommends that 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 infection, all women who deliver a stillborn infant after 20 weeks of gestation also should be tested for syphilis and treated if infected, according to the CDC.2 Syphilis screening also should be offered in emergency departments, jails, prisons, and other settings that provide episodic care to pregnant women at high risk for syphilis.1

Focus on pilot programs

Syphilis elimination is defined as the absence of sustained transmission. When elimination goals are achieved, the occasional outbreaks can be identified quickly and contained, thus eliminating the risk of a new epidemic, explain CDC officials.

With syphilis rates at their lowest levels in U.S. history, the CDC moved forward in 1998 with its syphilis elimination program. (See Contraceptive Technology Update’s September 1997 issue of STD Quarterly, "Syphilis hits 40-year low: Is elimination within reach?" p. 111, and p. 113, "What can turn the tide?") The geographic concentration of disease provided public health officials an opportunity to build on current STD prevention and control efforts to combine intensified traditional approaches with innovative new ones, say CDC officials.

When the syphilis elimination plan was launched in 1998, the CDC targeted 31 sites with the highest levels of syphilis morbidity and awarded funding to establish local syphilis elimination plans, says Counts.

In addition to targeting those sites, the CDC designated three U.S. counties with high levels of syphilis as demonstration sites, Counts explains. The three sites — Marion County in Indiana, Wake County in North Carolina, and Davidson County in Tennessee — received additional funds to field-test the CDC’s national plan, says Counts.

The demonstration sites focus on strengthening community involvement and partnership. The CDC is working closely with community partners and state and local governments to fortify programs in hardest-hit communities.

The partnerships are paying off, according to Counts. While the national primary and secondary syphilis rates fell by about 10% from 1999 to 2000, the rates among the three demonstration sites fell two to three times faster, he says.

"What that tells us is that if you aggressively focus additional resources to a community, those that have strong community partnerships, you can make a bigger impact on decreasing the syphilis rate," he notes.

For example, Davidson County has made great strides in attacking its syphilis rates through its jail-screening program. During a 14-month period, one-third of all new syphilis cases in the county were detected by screening metro jail inmates.4

According to Chris Freeman, program director for the STD/HIV program at the Metro Davidson County Health Department in Nashville, the county is using its "STD-Free" program to address not only syphilis, but other sexually transmitted diseases (STDs) as well.

A community coalition approach, "STD-Free" brings together community members and health department personnel who subsequently are divided into five sections: education, which includes local schools; private providers and hospitals; community services, which includes social services and other allied personnel; religious- and faith-based; and correctional, which includes local law enforcement personnel. These groups meet on a regular basis to identify and address STD concerns.

"I think it has given the community some ownership of the problem, more so than just a health department problem," says Freeman. "Because of that, I think there’s been more of a community awareness, a lot more community education, not necessarily by the health department staff, but by other members of the community that keep those issues out on everybody’s radar screen."

Outreach screenings and educational sessions are used in the "STD-Free" approach, says Freeman.

"Any opportunity — health fairs, college meetings, or any type of gathering — is a great opportunity for us to set up a table or display so we can talk about STDs in Davidson County," notes Freeman.

Time for action is now

According to the CDC, the last U.S. syphilis epidemic peaked in 1990, with the highest syphilis rates in 40 years. Although infections have subsided to the lowest level since reporting began, syphilis rates tend to run in seven- to 10-year cycles, note CDC officials. Unless continued action is taken to eliminate the disease, the United States once again could experience a rise in syphilis rates.

The syphilis elimination activities and interventions now in place are assisting in reducing the prevalence of syphilis among women of reproductive age and, in turn, eliminating congenital syphilis. With early detection of maternal syphilis and treatment with safe, effective antibiotics, syphilis among infants can be eliminated, says the CDC.1

"If we fail to take advantage of this historic opportunity, the health of our families and our communities will continue to suffer," says Counts.

References

  1. Centers for Disease Control and Prevention. Congenital syphilis — United States, 2000. MMWR 2001; 50:573-577.
  2. Centers for Disease Control and Prevention. Syphilis among infants down more than half in three years. Press release. Atlanta; July 12, 2001.
  3. St. Lawrence J, Montano DE, Kasprzyk D, et al. National survey of US physicians’ STD screening, testing, case reporting, clinical and partner notification practices. Presented at the 2000 National STD Prevention Conference. Milwaukee; Dec. 4-7, 2000.
  4. Snyder B. Screening metro inmates helps cut syphilis rate for first time since 1994. Nashville Tennessean, Aug. 20, 2001: accessed at www.aegis.com/news/ads/2001/ AD011619.html