430
Articles
Controlling a Syphilis Epidemic DEBORAH A. COHEN, MD, MPH, New Orleans, Louisiana; and RICHARD SCRIBNER, MD, MPH, and DAVID CORY, Los Angeles, California
In 1986 the rate of infectious syphilis (primary and secondary) in Los Angeles County began to rise from previously stable levels of about 23.5 per 100,000 to peak at 55.6 per 100,000 in 1987. The incidence of congenital syphilis increased from 205 cases in 1987 to 575 cases in 1989. The county's Sexually Transmitted Disease Program instituted a disease-specific plan to address the epidemic. Factors considered in designing the program included the high morbidity and mortality associated with congenital infection, the existence of latent infection, self-limiting symptoms, and the availability of an inexpensive screening test and curative treatment. Policy changes implemented comprised expanded screening, expanded surveillance, increased contact tracing, and the initiation of condom promotion programs. To evaluate the relative effectiveness of Los Angeles County's syphilis control efforts, the epidemic curve for infectious syphilis was compared with trends in other urban areas. Although the rate of infectious syphilis climbed a year earlier in Los Angeles than in other cities, it returned to baseline levels when other cities' rates remained at epidemic levels. (Cohen DA, Scribner R, Cory D: Controlling a syphilis epidemic. West J Med 1992 Oct; 157:430-432) In the shadow of the acquired immunodeficiency
syndrome epidemic, the rate of primary and secondary syphilis in Los Angeles more than doubled from 23.5 per 100,000 in 1985 to 55.6 per 100,000 in 1987.1 An intensive program to limit the incidence of syphilis and congenital syphilis was planned and implemented throughout Los Angeles County. The program addressed the following unique characteristics of syphilis: its self-limiting, painless symptoms and latent stages, so that those infected may not know and have little motivation to seek treatment; the accessibility of an inexpensive screening test; the high morbidity and mortality associated with congenital infection; and the availability of inexpensive, curative treatment.
Background In 1987 there were about 11,000 cases of syphilis reported in Los Angeles County. Nearly 80% of the 7,144 cases of infectious and early latent syphilis were reported from seven health districts centered around South Central Los Angeles.2 The rates of infectious syphilis were highest among 25- to 29-year-olds (144.1 per 100,000) and among African Americans (300.6 per 100,000) and Hispanics (42.5 per 100,000). Rates among whites and Asians were 10.3 per 100,000 and 3.1 per 100,000, respectively.' The rate of congenital syphilis was 137 per 100,000 births, with African Americans having the highest rate (519 per 100,000) followed by Hispanics (74 per 100,000).3
Possible Causes of the Syphilis Epidemic Several factors may have contributed to the increase in the incidence of infectious and congenital syphilis: * Countywide screening for syphilis decreased; in the 1980s a serologic test for syphilis was eliminated as a routine screening test and was recommended only when patients admitted to high-risk behaviors. * A $25 sexually transmitted disease (STD) clinic fee was initiated in 1986, and clinic attendance decreased. * Staffing of field investigators for the follow-up of syphilis cases decreased.
* "Crack" cocaine appeared, and its use was associated with the "sex for drugs" phenomenon.5 Interventions to address three of the four hypothesized contributing factors were developed and implemented. The Los Angeles County Board of Supervisors earmarked an additional $2.7 million for syphilis control and suspended the $25 STD clinic fee.
Interventions
Screening Activities The STD Programn recommended that syphilis screening be performed throughout the county for the following people: Increase
All women of childbearing age, with pregnant women being screened three times-first and third trimesters and at delivery. All sexually active teens. *
*
All persons with two or more sex partners in six months. * All persons who use illicit drugs such as cocaine, marijuana, or heroin. * All persons who have had sex with prostitutes. * All persons with any other STD or who are positive for the human immunodeficiency virus. In public health clinics, all new family planning patients and those returning for annual checkups were screened for syphilis. To make an early diagnosis and treat infected women who might not enroll for prenatal care or who might have to wait as long as eight weeks for their first prenatal appointment, it was recommended that all who came in for a pregnancy test also be tested for syphilis. This strategy had been effective in adjacent Orange County in preventing congenital syphilis.6 In several STD clinics syphilis screening was made available to patients who did not want to wait for an appointment. The capability of clinics to perform immediate rapid plasma reagin tests was assessed and improved. The prevalence of syphilis was also studied among detain*
From the Departments of Family Medicine (Dr Cohen) and Preventive Medicine (Dr University of Southern California School of Medicine, Los Angeles. Dr Cohen currently with the Department of Medicine, Section of HIV, Louisiana State University Scribner), Medical Center, New Orleans. Mr Cory is an independent consultant in public health. is Reprint requests to Deborah A. Cohen, MD, MPH, Dept of Medicine, Section of HIV, Louisiana State University Medical Center, 1542 Tulane Ave, New LA
Orleans,
701 12.
THE WESTERN JOURNAL OF MEDICINE II IL. TV L.-J, IL.1411
-. -
*
OCTOBER 1992 *
157
*
ees at Men's Central Jail in Los Angeles. This was done to determine whether routine or selective screening and empiric treatment should be implemented.
Improve Access to Clinic Services All of the STD clinics with the highest morbidity were provided with additional staff. This was done to increase the number of patients who could be seen in any given clinic session and to keep the clinic open one evening a week. Increase Field Follow-up and Improve Surveillance Additional investigative staff were hired. The Centers for Disease Control also designated Los Angeles County as a training center for public health representatives who do partner notification. Educational programs were developed for nursing staff to improve follow-up skills of postpartum women and infected infants discharged before treatment and evaluation. Nurses had an opportunity to review cases in which there had been a substantial delay in field follow-up, -60
t20 10 _ 1985
,
1986
1988
1987
1989
431
4
1990
Year
Figure 1.-The graph shows the syphilis rates for Los Angeles County, 1985 to 1990. -=early latent, - =-primary and secondary,--*-- =congenital (cases/10,000 live births)
resulting in infants with congenital syphilis becoming symptomatic. Through role playing, nurses learned how to handle investigations of possible cases of congenital syphilis in the future. Improved referral and follow-up of infants with congenital syphilis were arranged before hospital discharge, to ensure that the infants would receive a full course of therapy at a local district health center. Promote Condom Use in Clinics and Increase Health Education Efforts Before the epidemic, condoms were available in STD clinics but were dispensed at the discretion of an STD clinician. A county policy was developed in which all STD patients were offered ten free condoms at every visit. In addition, the nonlubricated condoms were replaced with condoms lubricated with nonoxynol 9. A health education program in the STD clinic waiting areas encouraged patients to adopt safer sexual practices. Full-time health educators were assigned to five ofthe clinics with the highest morbidity rates and part-time educators to four other STD clinics. The health educators ensured that the patients would be provided with free condoms, demonstrated how to use a condom, and led discussions about negotiating condom use with sex partners. Continuing medical education lectures on the epidemiology of syphilis in Los Angeles and on the management of syphilis and congenital syphilis were scheduled at all highincidence hospitals. Communitywide outreach included lectures at local schools, providing condoms for distribution at local businesses in areas with high morbidity, providing education and condoms to persons enrolled at drug rehabilitation
centers, and doing syphilis screening in housing projects and parks in areas with high morbidity.
Methods To evaluate the effectiveness of the Los Angeles program, secular trends of rates of syphilis in Los Angeles County were examined and compared with rates of infectious syphilis in other urban areas with similar high-risk populations. All comparative data were obtained from the Centers for Disease Control.7 In addition, several of the interventions were individually evaluated. Results Figure 1 shows the rate of cases of infectious, early latent, and congenital syphilis from 1985 through 1990.2 Initially the rate of infectious syphilis went down while that of early latent syphilis rose. The number of cases of congenital syphilis also rose substantially. In 1990 the rates of both infectious syphilis and early latent syphilis decreased, while that of congenital syphilis remained high. As shown in Figure 2, in contrast to Washington, DC, New York, and other cities in the United States, the Los Angeles epidemic of infectious syphilis began a year earlier but returned to pre-epidemic levels by 1990. The comparison cities had persistently high rates of syphilis.
Syphilis Screening Between 1987 and 1989, the number of serologic tests for syphilis performed by the Los Angeles County Public Health Laboratory increased by 45.6%, from 107,458 to 156,505 (R. Barnes, PhD, Director, Public Health Laboratory, oral communication, March 1991). Of the 6,428 women who had pregnancy tests at public health family planning clinics between January and August 1989, 60 had serologic tests reactive for syphilis. Of these, 43 (72%) were diagnosed as new cases of syphilis and, at the time of our review, 33 of the women had been treated for syphilis, potentially preventing
8Cn
C.,
cL)
1982
1983
1984
1985
1986
1987
Year
Figure 2.-The graph shows cases of primary and secondary syphilis in selected cities, 1982 to 1990 (from the Centers for Disease Control'). - = Los Angeles; * = New York City; a = Washington, DC; - - a- - = US cities
33 cases of congenital syphilis. A conservative estimate of the rate of syphilis (all stages) among women seeking pregnancy tests at public health family planning clinics is 669 per 100,000 (43 per 6,428). The screening project at Men's Central Jail documented a 2% rate of untreated syphilis among the 6,217 men tested and booked between 6 PM and 6 AM during the weeks of March and April 1989. The rate of infectious syphilis (primary and secondary) among African Americans was 984 per 100,000 and among Hispanics, 418 per 100,000.8
Clinical Services An intensive evaluation of clinical services was undertaken and audits were done of the following procedures:
432
A SYPHILIS EPIDEMIC~~~~~~~ EPIDEMIC
432
syphilis screening guidelines, routine questioning of pregroutine questioning of STD patients if they had pregnant partners, availability of immediate syphilis testing, offering ten free condoms to all patients, simplified registration procedures with waiting time reduced to a maximum of an hour, priority given to patients referred as contacts of syphilis patients, elimination of informally established clinician:patient ratios, educational efforts in waiting areas, and evening clinic hours. Clinics were audited four times over the year to see what percentage of the items were implemented by six clinics with high morbidity rates. Each of the clinics improved its compliance with the recommendations, but none were able to adopt all of the recommendations. Decreasing waiting time was the item most frequently failed. Health educators in each of five districts reached more than 20,000 patients with sexually transmitted diseases. Three methods to promote condom use were compared. One method taught basic condom skills. A second method concentrated on how to convince sex partners to use a condom and eroticized condom use. The third method provided free condoms that were made available to patients at local businesses. Only the first two methods appeared effective with male patients in reducing the rates of STD reinfections, with decreases of as much as 50% compared with controls. None of the interventions were effective with female patients.9 Several articles about the syphilis epidemic were published in the local medical society journal.'0-12 There was some short-lived publicity in local newspapers. Also, grand rounds sessions on the epidemic and the management, treatment, and prevention of syphilis and congenital syphilis for physicians were offered at all hospitals, particularly those that had a high incidence of congenital syphilis. About 25 nant women about enrollment in prenatal care,
sessions were conducted and were well received. Discussion Although the epidemic curve of the syphilis incidence in Los Angeles County is consistent with the establishment of an effective control program, it is impossible to know whether the incidence of infectious syphilis (primary and secondary) decreased as a result of the interventions or if the decrease represented the natural course of the epidemic.13 During an epidemic, it is impossible to know whether rates will continue to climb, and so action must be taken. Infectious syphilis rates have risen in many US urban areas through 1990 (see Figure 2). Although they began to decline in 1991,14 the persistence of high rates in cities like Washington, DC, and New York lends support to the relative effectiveness of the control program in Los Angeles. In contrast to the Los Angeles County Department of Health Services, few other local health departments have been able to provide services for STD treatment gratis or to mount substantial prevention and control measures. Other unique local factors in Los Angeles, such as lower population density, the lack of good public transport, lower rates of HIV infection, and different patterns of illicit drug use, may have offered additional protection against continued syphilis transmission. Further evaluation of the effectiveness of syphilis control efforts is warranted. Partner notification activities (contact tracing) were the most difficult to assess because they are not uniformly reported by all staff members. Because no summary is kept of the diagnoses of patients visiting STD clinics, it was also not possible to assess to what extent improved access to clinical services contributed to controlling infectious syphilis. The increased countywide screening efforts likely played
A
SYPHILIS
an important role in the dramatic increase in the rates of early latent syphilis and congenital syphilis. Several promising screening recommendations targeting high-risk populations, however, were not put into effect. For example, no resources were allocated to continue a screening and treatment program in custody facilities. In 1989 it was calculated that on a daily basis at least eight inmates infected with syphilis at the time of incarceration were released into the community untreated. Since then, it is likely that several thousand men and women have missed the opportunity for diagnosis and treatment. Another study of the incidence of syphilis among this population is crucial to determine whether clinic- and community-based efforts were able to reach this population. Despite the continued high rates ofcongenital syphilis, no efforts were made to impose mandatory screening at birth by modifying state law. Specimens of cord bloods should be screened at the time of delivery so that patients with asymptomatic congenital syphilis can be treated and the true epidemic of congenital syphilis can be monitored. Without early treatment, a variety of symptoms, from "snuffles" (bloody nasal discharge) to neurosyphilis, may develop in infants with congenital syphilis and result in mental deficiencies."5 In summary, a contemporary syphilis control program should be disease-specific and target high-risk populations. The most intensive screening with rapid treatment of cases should be done among pregnant women, newborns, and women of childbearing age, for whom the consequences of disease are most severe. Other high-risk groups should be targeted: those with few resources and diminished access to health care'6 and those charged with criminal offenses. Screening must be consistent and continue for a period of time beyond the point when the epidemic is contained and rates revert to baseline levels. If screening efforts are reduced too quickly, it is impossible to know whether the subsequent rates of early syphilis are artifactual or reflect an actual decreased incidence of disease. REFERENCES 1. Communicable Disease Morbidity Report. Los Angeles, Calif, County Dept of Health Services, 1985 and 1987 2. Venereal Disease Record System, S-10, Sexually Transmitted Disease Program, Public Health Programs and Services. Los Angeles, Calif, County Dept of Health Services, 1988 3. Cohen DA, Boyd D, Prabhudas I, Mascola L: The effects of case definition in maternal screening and reporting criteria on rates of congenital syphilis. Am J Public Health 1990; 80:316-317 4. Fisher M (Ed): Guide to Clinical Preventive Services, Report of the US Preventive Services Task Force. Baltimore, Md, Williams & Wilkins, 1989, pp 331-339 5. Sheriffs Annual Fiscal Summary, July 1989-June 1990. Los Angeles, Calif, County Sheriffs Dept, 1990 6. Lawrence AM, Morrison C: The prevention of congenital syphilis in Orange County, Calif (abstr), In Proceedings of the 1988 STD National Conference, Atlanta, Ga, US Dept of Health and Human Services, 1988, Abstract 46 7. Centers for Disease Control (CDC): Sexually Transmitted Diseases Surveillance Report 1990, Surveillance and Information Branch. Atlanta, Ga, CDC, 1991 8. Cohen DA, Scribner R, Clark J, Cory D: The potential role of custody facilities in controlling STDs. Am J Public Health 1992; 82:552-556 9. Cohen DA, Dent C, MacKinnon D, Hahn G: Condoms for men, not women: Results of brief promotion programs. Sex Transm Dis 1992, in press 10. Cohen DA, Pogostin C, Marty M, Chavers C, Coombs J: Reporting sexually transmitted diseases: A physician's legal-and moral-obligation. LACMA Physician 1988 Mar; 118:27-31 11. Cohen DA: Shadow across Los Angeles: The county's syphilis epidemic. LACMA Physician 1988 Jun; 118:28-34 12. Cohen DA, Scribner R, Bartholomew R: Babies with syphilis: A preventable tragedy. LACMA Physician 1989 Apr; 119:29-31 13. Bregman DJ, Langmuir AD: Farr's law applied to AIDS projections. JAMA 1990; 263:1522-1525 14. CDC: Cases of selected notifiable disease-May 31, 1991. MMWR 1991; 40:349 15. Schulz KF, Murphy FK, Patamasucon P, Meheus AZ: Congenital syphilis, In Holmes KK, Mardh PA, Sparling PF, et al (Eds): Sexually Transmitted Diseases. New York, NY, McGraw-Hill, 1990, pp 821-842 16. Hahn RA, Magder LS, Aral SO, Johnson RE, Larsen SA: Race and the prevalence of syphilis seroreactivity in the United States population: A national sero-epidemiologic study. Am J Public Health 1989; 79:467-470
Articles
Controlling a Syphilis Epidemic DEBORAH A. COHEN, MD, MPH, New Orleans, Louisiana; and RICHARD SCRIBNER, MD, MPH, and DAVID CORY, Los Angeles, California
In 1986 the rate of infectious syphilis (primary and secondary) in Los Angeles County began to rise from previously stable levels of about 23.5 per 100,000 to peak at 55.6 per 100,000 in 1987. The incidence of congenital syphilis increased from 205 cases in 1987 to 575 cases in 1989. The county's Sexually Transmitted Disease Program instituted a disease-specific plan to address the epidemic. Factors considered in designing the program included the high morbidity and mortality associated with congenital infection, the existence of latent infection, self-limiting symptoms, and the availability of an inexpensive screening test and curative treatment. Policy changes implemented comprised expanded screening, expanded surveillance, increased contact tracing, and the initiation of condom promotion programs. To evaluate the relative effectiveness of Los Angeles County's syphilis control efforts, the epidemic curve for infectious syphilis was compared with trends in other urban areas. Although the rate of infectious syphilis climbed a year earlier in Los Angeles than in other cities, it returned to baseline levels when other cities' rates remained at epidemic levels. (Cohen DA, Scribner R, Cory D: Controlling a syphilis epidemic. West J Med 1992 Oct; 157:430-432) In the shadow of the acquired immunodeficiency
syndrome epidemic, the rate of primary and secondary syphilis in Los Angeles more than doubled from 23.5 per 100,000 in 1985 to 55.6 per 100,000 in 1987.1 An intensive program to limit the incidence of syphilis and congenital syphilis was planned and implemented throughout Los Angeles County. The program addressed the following unique characteristics of syphilis: its self-limiting, painless symptoms and latent stages, so that those infected may not know and have little motivation to seek treatment; the accessibility of an inexpensive screening test; the high morbidity and mortality associated with congenital infection; and the availability of inexpensive, curative treatment.
Background In 1987 there were about 11,000 cases of syphilis reported in Los Angeles County. Nearly 80% of the 7,144 cases of infectious and early latent syphilis were reported from seven health districts centered around South Central Los Angeles.2 The rates of infectious syphilis were highest among 25- to 29-year-olds (144.1 per 100,000) and among African Americans (300.6 per 100,000) and Hispanics (42.5 per 100,000). Rates among whites and Asians were 10.3 per 100,000 and 3.1 per 100,000, respectively.' The rate of congenital syphilis was 137 per 100,000 births, with African Americans having the highest rate (519 per 100,000) followed by Hispanics (74 per 100,000).3
Possible Causes of the Syphilis Epidemic Several factors may have contributed to the increase in the incidence of infectious and congenital syphilis: * Countywide screening for syphilis decreased; in the 1980s a serologic test for syphilis was eliminated as a routine screening test and was recommended only when patients admitted to high-risk behaviors. * A $25 sexually transmitted disease (STD) clinic fee was initiated in 1986, and clinic attendance decreased. * Staffing of field investigators for the follow-up of syphilis cases decreased.
* "Crack" cocaine appeared, and its use was associated with the "sex for drugs" phenomenon.5 Interventions to address three of the four hypothesized contributing factors were developed and implemented. The Los Angeles County Board of Supervisors earmarked an additional $2.7 million for syphilis control and suspended the $25 STD clinic fee.
Interventions
Screening Activities The STD Programn recommended that syphilis screening be performed throughout the county for the following people: Increase
All women of childbearing age, with pregnant women being screened three times-first and third trimesters and at delivery. All sexually active teens. *
*
All persons with two or more sex partners in six months. * All persons who use illicit drugs such as cocaine, marijuana, or heroin. * All persons who have had sex with prostitutes. * All persons with any other STD or who are positive for the human immunodeficiency virus. In public health clinics, all new family planning patients and those returning for annual checkups were screened for syphilis. To make an early diagnosis and treat infected women who might not enroll for prenatal care or who might have to wait as long as eight weeks for their first prenatal appointment, it was recommended that all who came in for a pregnancy test also be tested for syphilis. This strategy had been effective in adjacent Orange County in preventing congenital syphilis.6 In several STD clinics syphilis screening was made available to patients who did not want to wait for an appointment. The capability of clinics to perform immediate rapid plasma reagin tests was assessed and improved. The prevalence of syphilis was also studied among detain*
From the Departments of Family Medicine (Dr Cohen) and Preventive Medicine (Dr University of Southern California School of Medicine, Los Angeles. Dr Cohen currently with the Department of Medicine, Section of HIV, Louisiana State University Scribner), Medical Center, New Orleans. Mr Cory is an independent consultant in public health. is Reprint requests to Deborah A. Cohen, MD, MPH, Dept of Medicine, Section of HIV, Louisiana State University Medical Center, 1542 Tulane Ave, New LA
Orleans,
701 12.
THE WESTERN JOURNAL OF MEDICINE II IL. TV L.-J, IL.1411
-. -
*
OCTOBER 1992 *
157
*
ees at Men's Central Jail in Los Angeles. This was done to determine whether routine or selective screening and empiric treatment should be implemented.
Improve Access to Clinic Services All of the STD clinics with the highest morbidity were provided with additional staff. This was done to increase the number of patients who could be seen in any given clinic session and to keep the clinic open one evening a week. Increase Field Follow-up and Improve Surveillance Additional investigative staff were hired. The Centers for Disease Control also designated Los Angeles County as a training center for public health representatives who do partner notification. Educational programs were developed for nursing staff to improve follow-up skills of postpartum women and infected infants discharged before treatment and evaluation. Nurses had an opportunity to review cases in which there had been a substantial delay in field follow-up, -60
t20 10 _ 1985
,
1986
1988
1987
1989
431
4
1990
Year
Figure 1.-The graph shows the syphilis rates for Los Angeles County, 1985 to 1990. -=early latent, - =-primary and secondary,--*-- =congenital (cases/10,000 live births)
resulting in infants with congenital syphilis becoming symptomatic. Through role playing, nurses learned how to handle investigations of possible cases of congenital syphilis in the future. Improved referral and follow-up of infants with congenital syphilis were arranged before hospital discharge, to ensure that the infants would receive a full course of therapy at a local district health center. Promote Condom Use in Clinics and Increase Health Education Efforts Before the epidemic, condoms were available in STD clinics but were dispensed at the discretion of an STD clinician. A county policy was developed in which all STD patients were offered ten free condoms at every visit. In addition, the nonlubricated condoms were replaced with condoms lubricated with nonoxynol 9. A health education program in the STD clinic waiting areas encouraged patients to adopt safer sexual practices. Full-time health educators were assigned to five ofthe clinics with the highest morbidity rates and part-time educators to four other STD clinics. The health educators ensured that the patients would be provided with free condoms, demonstrated how to use a condom, and led discussions about negotiating condom use with sex partners. Continuing medical education lectures on the epidemiology of syphilis in Los Angeles and on the management of syphilis and congenital syphilis were scheduled at all highincidence hospitals. Communitywide outreach included lectures at local schools, providing condoms for distribution at local businesses in areas with high morbidity, providing education and condoms to persons enrolled at drug rehabilitation
centers, and doing syphilis screening in housing projects and parks in areas with high morbidity.
Methods To evaluate the effectiveness of the Los Angeles program, secular trends of rates of syphilis in Los Angeles County were examined and compared with rates of infectious syphilis in other urban areas with similar high-risk populations. All comparative data were obtained from the Centers for Disease Control.7 In addition, several of the interventions were individually evaluated. Results Figure 1 shows the rate of cases of infectious, early latent, and congenital syphilis from 1985 through 1990.2 Initially the rate of infectious syphilis went down while that of early latent syphilis rose. The number of cases of congenital syphilis also rose substantially. In 1990 the rates of both infectious syphilis and early latent syphilis decreased, while that of congenital syphilis remained high. As shown in Figure 2, in contrast to Washington, DC, New York, and other cities in the United States, the Los Angeles epidemic of infectious syphilis began a year earlier but returned to pre-epidemic levels by 1990. The comparison cities had persistently high rates of syphilis.
Syphilis Screening Between 1987 and 1989, the number of serologic tests for syphilis performed by the Los Angeles County Public Health Laboratory increased by 45.6%, from 107,458 to 156,505 (R. Barnes, PhD, Director, Public Health Laboratory, oral communication, March 1991). Of the 6,428 women who had pregnancy tests at public health family planning clinics between January and August 1989, 60 had serologic tests reactive for syphilis. Of these, 43 (72%) were diagnosed as new cases of syphilis and, at the time of our review, 33 of the women had been treated for syphilis, potentially preventing
8Cn
C.,
cL)
1982
1983
1984
1985
1986
1987
Year
Figure 2.-The graph shows cases of primary and secondary syphilis in selected cities, 1982 to 1990 (from the Centers for Disease Control'). - = Los Angeles; * = New York City; a = Washington, DC; - - a- - = US cities
33 cases of congenital syphilis. A conservative estimate of the rate of syphilis (all stages) among women seeking pregnancy tests at public health family planning clinics is 669 per 100,000 (43 per 6,428). The screening project at Men's Central Jail documented a 2% rate of untreated syphilis among the 6,217 men tested and booked between 6 PM and 6 AM during the weeks of March and April 1989. The rate of infectious syphilis (primary and secondary) among African Americans was 984 per 100,000 and among Hispanics, 418 per 100,000.8
Clinical Services An intensive evaluation of clinical services was undertaken and audits were done of the following procedures:
432
A SYPHILIS EPIDEMIC~~~~~~~ EPIDEMIC
432
syphilis screening guidelines, routine questioning of pregroutine questioning of STD patients if they had pregnant partners, availability of immediate syphilis testing, offering ten free condoms to all patients, simplified registration procedures with waiting time reduced to a maximum of an hour, priority given to patients referred as contacts of syphilis patients, elimination of informally established clinician:patient ratios, educational efforts in waiting areas, and evening clinic hours. Clinics were audited four times over the year to see what percentage of the items were implemented by six clinics with high morbidity rates. Each of the clinics improved its compliance with the recommendations, but none were able to adopt all of the recommendations. Decreasing waiting time was the item most frequently failed. Health educators in each of five districts reached more than 20,000 patients with sexually transmitted diseases. Three methods to promote condom use were compared. One method taught basic condom skills. A second method concentrated on how to convince sex partners to use a condom and eroticized condom use. The third method provided free condoms that were made available to patients at local businesses. Only the first two methods appeared effective with male patients in reducing the rates of STD reinfections, with decreases of as much as 50% compared with controls. None of the interventions were effective with female patients.9 Several articles about the syphilis epidemic were published in the local medical society journal.'0-12 There was some short-lived publicity in local newspapers. Also, grand rounds sessions on the epidemic and the management, treatment, and prevention of syphilis and congenital syphilis for physicians were offered at all hospitals, particularly those that had a high incidence of congenital syphilis. About 25 nant women about enrollment in prenatal care,
sessions were conducted and were well received. Discussion Although the epidemic curve of the syphilis incidence in Los Angeles County is consistent with the establishment of an effective control program, it is impossible to know whether the incidence of infectious syphilis (primary and secondary) decreased as a result of the interventions or if the decrease represented the natural course of the epidemic.13 During an epidemic, it is impossible to know whether rates will continue to climb, and so action must be taken. Infectious syphilis rates have risen in many US urban areas through 1990 (see Figure 2). Although they began to decline in 1991,14 the persistence of high rates in cities like Washington, DC, and New York lends support to the relative effectiveness of the control program in Los Angeles. In contrast to the Los Angeles County Department of Health Services, few other local health departments have been able to provide services for STD treatment gratis or to mount substantial prevention and control measures. Other unique local factors in Los Angeles, such as lower population density, the lack of good public transport, lower rates of HIV infection, and different patterns of illicit drug use, may have offered additional protection against continued syphilis transmission. Further evaluation of the effectiveness of syphilis control efforts is warranted. Partner notification activities (contact tracing) were the most difficult to assess because they are not uniformly reported by all staff members. Because no summary is kept of the diagnoses of patients visiting STD clinics, it was also not possible to assess to what extent improved access to clinical services contributed to controlling infectious syphilis. The increased countywide screening efforts likely played
A
SYPHILIS
an important role in the dramatic increase in the rates of early latent syphilis and congenital syphilis. Several promising screening recommendations targeting high-risk populations, however, were not put into effect. For example, no resources were allocated to continue a screening and treatment program in custody facilities. In 1989 it was calculated that on a daily basis at least eight inmates infected with syphilis at the time of incarceration were released into the community untreated. Since then, it is likely that several thousand men and women have missed the opportunity for diagnosis and treatment. Another study of the incidence of syphilis among this population is crucial to determine whether clinic- and community-based efforts were able to reach this population. Despite the continued high rates ofcongenital syphilis, no efforts were made to impose mandatory screening at birth by modifying state law. Specimens of cord bloods should be screened at the time of delivery so that patients with asymptomatic congenital syphilis can be treated and the true epidemic of congenital syphilis can be monitored. Without early treatment, a variety of symptoms, from "snuffles" (bloody nasal discharge) to neurosyphilis, may develop in infants with congenital syphilis and result in mental deficiencies."5 In summary, a contemporary syphilis control program should be disease-specific and target high-risk populations. The most intensive screening with rapid treatment of cases should be done among pregnant women, newborns, and women of childbearing age, for whom the consequences of disease are most severe. Other high-risk groups should be targeted: those with few resources and diminished access to health care'6 and those charged with criminal offenses. Screening must be consistent and continue for a period of time beyond the point when the epidemic is contained and rates revert to baseline levels. If screening efforts are reduced too quickly, it is impossible to know whether the subsequent rates of early syphilis are artifactual or reflect an actual decreased incidence of disease. REFERENCES 1. Communicable Disease Morbidity Report. Los Angeles, Calif, County Dept of Health Services, 1985 and 1987 2. Venereal Disease Record System, S-10, Sexually Transmitted Disease Program, Public Health Programs and Services. Los Angeles, Calif, County Dept of Health Services, 1988 3. Cohen DA, Boyd D, Prabhudas I, Mascola L: The effects of case definition in maternal screening and reporting criteria on rates of congenital syphilis. Am J Public Health 1990; 80:316-317 4. Fisher M (Ed): Guide to Clinical Preventive Services, Report of the US Preventive Services Task Force. Baltimore, Md, Williams & Wilkins, 1989, pp 331-339 5. Sheriffs Annual Fiscal Summary, July 1989-June 1990. Los Angeles, Calif, County Sheriffs Dept, 1990 6. Lawrence AM, Morrison C: The prevention of congenital syphilis in Orange County, Calif (abstr), In Proceedings of the 1988 STD National Conference, Atlanta, Ga, US Dept of Health and Human Services, 1988, Abstract 46 7. Centers for Disease Control (CDC): Sexually Transmitted Diseases Surveillance Report 1990, Surveillance and Information Branch. Atlanta, Ga, CDC, 1991 8. Cohen DA, Scribner R, Clark J, Cory D: The potential role of custody facilities in controlling STDs. Am J Public Health 1992; 82:552-556 9. Cohen DA, Dent C, MacKinnon D, Hahn G: Condoms for men, not women: Results of brief promotion programs. Sex Transm Dis 1992, in press 10. Cohen DA, Pogostin C, Marty M, Chavers C, Coombs J: Reporting sexually transmitted diseases: A physician's legal-and moral-obligation. LACMA Physician 1988 Mar; 118:27-31 11. Cohen DA: Shadow across Los Angeles: The county's syphilis epidemic. LACMA Physician 1988 Jun; 118:28-34 12. Cohen DA, Scribner R, Bartholomew R: Babies with syphilis: A preventable tragedy. LACMA Physician 1989 Apr; 119:29-31 13. Bregman DJ, Langmuir AD: Farr's law applied to AIDS projections. JAMA 1990; 263:1522-1525 14. CDC: Cases of selected notifiable disease-May 31, 1991. MMWR 1991; 40:349 15. Schulz KF, Murphy FK, Patamasucon P, Meheus AZ: Congenital syphilis, In Holmes KK, Mardh PA, Sparling PF, et al (Eds): Sexually Transmitted Diseases. New York, NY, McGraw-Hill, 1990, pp 821-842 16. Hahn RA, Magder LS, Aral SO, Johnson RE, Larsen SA: Race and the prevalence of syphilis seroreactivity in the United States population: A national sero-epidemiologic study. Am J Public Health 1989; 79:467-470
