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Current Trends Increases in Primary and Secondary Syphilis - - United States

After a 5-year trend of decreasing incidence of primary and secondary syphilis in the United States, 8,274 cases were reported during the first 3 months of 1987. This is an increase of 1,549 cases (23%) over the 6,725 cases reported during the first 3 months of 1986. The estimated annual rate per 100,000 population rose from 10.9 cases to 13.3 cases (Figure 1). An increase of this magnitude has not been observed in over 10 years.

Increases of 20 or more cases over the number reported during the first 3 months of 1986 were observed in eight states, four major metropolitan areas, and the Commonwealth of Puerto Rico (Table 1). The three areas reporting the largest numerical increases were California, Florida, and New York City. In California, increases of 10 or more cases occurred in Los Angeles, Long Beach, and seven smaller counties*. Ten counties in Florida experienced increases, the largest being in Dade, Orange, and Palm Beach counties. In New York City, all boroughs except Richmond experienced substantial increases.

All three areas with the largest increases had collected demographic data and information on the sexual preferences of patients with cases reported during the periods January-March 1986 and January-March 1987 (Table 2). In California and New York City, increases in primary and secondary syphilis occurred exclusively among heterosexuals. In addition, blacks experienced greater increases than whites in these two areas. In Florida, the increase occurred in each demographic group and in each group with similar sexual preferences. The ratio of cases among males to cases among females in the three areas fell from 2.6:1 to 2.1:1. For several other areas experiencing increases in total cases, the incidence declined for white men citing at least one male sexual partner. Reported by: MH Wilder, MD, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. S Schultz, MD, New York City Health Dept. S Fannin, MD, County of Los Angeles Dept of Health Svcs; K Acree, MDCM, MPH, JD, Acting State Epidemiologist, California Dept of Health Svcs. Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although primary and secondary syphilis had been declining since 1982 (1), they now appear to be on the upsurge in some areas. While 70% of cases among males occurred among homosexual and bisexual men during the 1970s (2), cases among these groups now appear to be on the decline in some areas (Table 2). As with two smaller outbreaks in the 1980s (3,4), the current increases appear to be largely among heterosexuals.

The increases in primary and secondary syphilis have prompted two major concerns. First, this trend is likely to have a severe adverse effect on efforts to control congenital syphilis. While sexually acquired syphilis that is diagnosed in its early stages can be effectively treated with long-acting penicillin preparations, congenitally acquired syphilis is responsible for high rates of infant morbidity and mortality (5). After an 8-year decline, the incidence of congenital syphilis among infants began rising in 1983 (6). The areas with the largest increases in primary and secondary syphilis already have some of the highest rates of congenital syphilis in the nation (6). Any increases in acquired syphilis among heterosexual adults in these areas are certain to be followed by further increases in congenital syphilis.

Second, a history of sexually transmitted disease is associated with increased risk for human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) among both homosexuals (7,8) and heterosexuals (9). New York City and Florida have increased incidences of syphilis as well as high rates of AIDS among heterosexuals, particularly among those who abuse intravenous drugs (10). Because genital ulceration is associated with higher rates of HIV infection (11,12), the increases in primary and secondary syphilis in these areas may be the forerunner of future increases in HIV-related morbidity and mortality. Moreover, on the basis of case reports of treatment failures (13) and an atypical course in one patient (14), concerns have been raised about the effects of HIV-infection on the natural history and response to treatment of syphilis. These reports suggest the potential for problems in the management of patients with both infections.


  1. CDC. Annual summary 1984. MMWR 1986;33(54):57-9.

  2. Fichtner RR, Aral SO, Blount JH, Zaidi AA, Reynolds GH, Darrow WW. Syphilis in the United States: 1968-1979. Sex Transm Dis 1983;10:77-80.

  3. CDC. Early syphilis--Broward County, Florida. MMWR 1987;36:221-4.

  4. Lee CB, Brunham RC, Sherman E, Harding GKM. Epidemiology of an outbreak of infectious syphilis in Manitoba. Am J Epidemiol 1987;125:277-83.

  5. Murphy K, Patamasucon P. Congenital syphilis. In: Holmes KK, Mardh PA, Sparling PF, Weisner PJ, eds. Sexually transmitted diseases. New York: McGraw Hill Co, 1984:352.

  6. CDC. Congenital syphilis--United States, 1983-1985. MMWR 1986;35:625-9.

  7. Jaffe HW, Choi K, Thomas PA, et al. National case-control study of Kaposi's sarcoma and Pneumocystis carinii pneumonia in homosexual men: part 1, epidemiologic results. Ann Intern Med 1983;99:145-51.

  8. Moss AR, Osmond D, Bacchetti P, Chermann J, Barre-Sinoussi F, Carlson J. Risk factors for AIDS and HIV seropositivity in homosexual men. Am J Epidemiol 1987;125:1035-47.

  9. Castro KG, Fischl MA, Landesman SH, et al. Risk factors for AIDS among Haitians in the United States. Atlanta, Georgia: International Conference on AIDS, April 14-17, 1985: 45.

  10. CDC. Update: acquired immunodeficiency syndrome--United States. MMWR 1986;35:757- 60, 765-6.

  11. Cameron DW, Plummer FA, Simonsen JN, et al. Female to male heterosexual transmission of HIV infection in Nairobi. Washington, DC: III International Conference on AIDS, June 1-5, 1987. Abstract MP91:25.

  12. Greenblatt RM, Lukehart SL, Plummer FA, et al. Genital ulceration as a risk factor for human immunodeficiency virus infection in Kenya. Washington, DC: III International Conference on AIDS, June 1-5, 1987. Abstract ThP68:174.

  13. Berry CD, Hooten TM, Collier AC, Lukehart SA. Neurologic relapse after benzathine penicillin therapy for secondary syphilis in a patient with HIV infection. N Engl J Med 1987;316:1587-9.

  14. Johns DR, Tierney M, Selsenstein D. Alteration in the natural history of neurosyphilis by concurrent infection with the human immunodeficiency virus. N Engl J Med 1987;316: 1569-72.

*San Francisco continued a 5-year trend of decreasing incidence.

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