Division of STD Prevention Centers for Disease Control and Prevention Primary and Secondary Syphilis in the United States: Epidemiology and Emerging Issues Hillard Weinstock Division of STD Prevention Centers for Disease Control and Prevention March 11, 2008

Background Genital ulcerative infection Facilitates the transmission of HIV Syphilis and other STDs are a marker of behaviors associated with HIV transmission Untreated early syphilis during pregnancy results in infection of the fetus in >70% cases Prior to 2000, rates of primary and secondary syphilis declined for 10 years Since 2000, rates among men have increased while those among women continued to decline until 2003 In 2005, CDC began collecting information on the sex of sex partners of patients with syphilis

Primary and secondary syphilis rates in the United States, 1981–2007* Rate (per 100,000 population) *2007 data are preliminary

Primary and secondary syphilis rates By sex, United States, 1990–2007* Rate (per 100,000 men/women) * 2007data are preliminary

Primary and secondary syphilis — Age- and sex-specific rates: United States, 2006

Primary and secondary syphilis — Cases by reporting source and sex: United States, 1998–2007* *Preliminary 2007 data

Primary and secondary syphilis: Rates by race and ethnicity, 1997–2007* Rate (per 100,000 population) * 2007 data are preliminary

Primary and secondary syphilis cases: United States, 2004-2007 2007* % Change Sex Men 6,722 9,502 +41.3 Women 1,255 1,671 +33.1 Race/Ethnicity African-American 3,071 4,944 +60.9 White 2,982 3,664 +22.8 Hispanic 1,196 1,728 +44.5 Asian/PI 143 166 +16.1 American Indian/NA 73 67 -11.0 Total 7,980 11,181 +40.1 * 2007 data are preliminary

Primary and secondary syphilis — Rates by county: United States, 2006 Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population. In 2006, 2,360 (75.2%) of 3,140 counties in the U.S. reported no cases of P&S syphilis.

Primary and secondary syphilis cases, by sex, in 10 counties with largest number of cases, 2006 San Francisco Cook County, IL New York County Los Angeles Fulton County, GA San Diego Miami/Dade, FL Harris County, TX Dallas County, TX Jefferson County, AL Men Women

Primary and secondary syphilis rates by sex and race, 2004-2007* *2007 data are preliminary

Primary and secondary syphilis cases among men by region, 2004-2007* *2007 data are preliminary

Primary and secondary syphilis cases among women by region, 2004-2007* *2004 data are preliminary

Primary and secondary syphilis rate ratios between African Americans and Whites, by sex, 1996-2007* * 2007 data are preliminary

Primary and secondary syphilis by sexual orientation and race/ethnicity, 2007* Number of cases * 2007 are preliminary

Primary and secondary syphilis by sex and sexual orientation, in 23 states, 2005-2007* Number of cases * 2007 data are preliminary

Primary and secondary syphilis among MSM by race/ethnicity in 23 states, 2005-2007* Number of cases * 2007 data are preliminary

Primary and secondary syphilis among heterosexual men by race/ethnicity in 23 states, 2005-2007* Number of cases * 2007 data are preliminary

Primary and Secondary Syphilis by Stage and Sexual Orientation, 2007* Number of cases * 2007 data are preliminary

Congenital syphilis — Reported cases for infants <1 year of age and rates of primary and secondary syphilis among women, 1997–2006

Rates are greatest among African American men Summary Rates of syphilis among MSM continue to increase; MSM account for >60% of all P&S syphilis cases Rates are greatest among African American men A larger proportion of syphilis cases among MSM and women present in the secondary stage Smaller increases over past 3 years in women, especially in the South, are concerning

State and local STD programs Deborah Dowell Sharon Clanton Acknowledgements State and local STD programs Deborah Dowell Sharon Clanton Darlene Davis Rob Nelson The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the CDC/ATSDR

Primary and secondary syphilis: Male-to-female rate ratios, 1981–2007* Male:female rate ratio

Possible reasons for behavior change among MSM HIV/AIDS prevention fatigue among older gay men Few prevention efforts reaching marginalized MSM Serosorting Internet chat rooms Treatment optimism Viral load beliefs Recreational drug use (e.g., methamphetamine use)

STD surveillance “High quality national surveillance is the cornerstone of infectious disease prevention and control.” --- WHO, 2004 Information base for public health decision making and action Must respond to need for new information Must accommodate changing priorities

STD Surveillance in the U.S. Major Components Case Reporting Prevalence-monitoring Sentinel Surveillance Population-based surveys Special projects