Important note: Information in this article was accurate in December 1988. The state of the art may have changed since the publication date.Morbidity and Mortality Weekly Report - December 16, 1988 / 37(49);755-758,764
Centers for Disease Control and Prevention
Since 1984, in many areas of the United States, reported rates of syphilis have greatly increased (1). Between 1984 and 1987, annual rates of syphilis (primary and secondary) increased 70% in the state of Connecticut and 74% in the city of Philadelphia (Figure 1). These trends have continued in 1988; in the first quarter of this year, annualized rates increased by 70% in Connecticut and by 25% in Philadelphia compared with 1987 annual rates. Investigations were conducted at these two sites to identify factors associated with this increase.
In Philadelphia and Connecticut, over 80% of all newly diagnosed patients with early syphilis are interviewed and counseled. Cases are detected through reporting by public clinics and private health-care providers and through laboratory screening. During the interviews, information is collected about patients' lifestyles to help locate sexual contacts. In Philadelphia and Connecticut, records from these interviews were abstracted and analyzed for the years 1985-1987. In Connecticut, all interviews of persons with primary and secondary syphilis were abstracted; in Philadelphia, a sample of interviews* was chosen that involved persons with primary, secondary, and latent syphilis present less than 1 year.
At both sites during the 3-year period, the proportion of men with syphilis who reported sexual contact with men decreased substantially. In Connecticut, the proportion of men with syphilis who reported being homosexual or bisexual decreased from 38% (48/126) in 1985 to 11% (21/197) in 1987; in Philadelphia, the percentage declined from 53% (49/93) to 18% (25/137) during this 3-year period.
In contrast, recorded use of illicit drugs and reported prostitution or contact with a prostitute among heterosexual syphilis patients increased greatly during this period. Among females at both study sites, the proportion reporting to be prostitutes increased more than threefold and the proportion reporting use of drugs increased more than sixfold (Figure 2). Heterosexual male syphilis patients showed similar but smaller increases in recorded drug use. Prostitute contact by this group occurred more frequently in Connecticut than in Philadelphia but increased at both sites. Reported by: G Joachim, JL Hadler, MD, State Epidemiologist, Connecticut Dept of Health Svcs. M Goldberg, RG Sharrar, MD, Philadelphia Dept of Public Health; R David, MD, State Epidemiologist, Pennsylvania State Dept of Health. Div of Sexually Transmitted Diseases, Center for Prevention Svcs; Div of Field Svcs, Epidemiology Program Office, CDC.
Editorial Note: Although prostitution has long been associated with syphilis (and other sexually transmitted diseases) (2), it appears to have been relatively unimportant in the overall epidemiology of syphilis in the United States during the last 2 decades (3,4). Drug use has only recently been associated with the spread of syphilis (1). Since drug use and prostitute contact were not recorded systematically on case interview forms, the true frequency of these behaviors among syphilis patients is probably underestimated. This underreporting of these behaviors, if combined with changing interviewers' perceptions, could bias the findings in Connecticut and Philadelphia. However, the consistency between the two sites and the magnitude of the increase in reporting of prostitution and drug use suggest that the trends observed in Connecticut and Philadelphia reflect real changes in the epidemiology of syphilis.
The decrease in the proportion of male syphilis patients who are homosexual/ bisexual has been noted in California and New York City (5), in outbreaks in Manitoba (6) and Florida (7), and in a sample of states with recent increases in syphilis (8). In the Florida outbreak, prostitutes were also found to be an important risk group. The results of the studies in Connecticut and Philadelphia support these other findings and suggest that the emergence of syphilis among prostitutes, drug users, and their sexual contacts may be a widespread national phenomenon.
The possibility of an increase in syphilis among persons in these risk groups has important implications for the control of syphilis and other sexually transmitted diseases, including human immunodeficiency virus (HIV) infections. Prostitutes tend to have large numbers of anonymous sexual partners who are difficult to locate by traditional methods of partner notification. Prostitutes who also frequently use intravenous (IV) drugs and, in some parts of the country, those with a history of IV-drug use have high rates of infection with HIV (9). Recent studies have suggested that sexually transmitted diseases that cause genital ulcers, such as syphilis, greatly increase the likelihood that HIV infection, when present, will be transmitted (10-12). To limit the spread of syphilis, which may also help limit the spead of HIV, public health officials may need to modify current control methods to better identify and treat syphilis-infected prostitutes, drug users, and their sexual contacts (1).
CDC. Syphilis and congenital syphilis--United States, 1985-1988. MMWR 1988;37:486-9.
Brandt AM. The syphilis epidemic and its relation to AIDS. Science 1988;239:375-80.
Willcox RR. Prostitution and venereal disease. Br J Vener Dis 1962;38:37-42.
Perine PL, Handsfield HH, Holmes KK, Blount JH. Epidemiology of the sexually transmitted diseases. Ann Rev Public Health 1985;6:85-106.
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