Syphilis Elimination Effort (SEE)

I'll turn the conference call over to Dr. Ron Valdiserri at the CDC. Please go ahead, sir.

We are pleased to share with you today new data, which shows substantial progress towards our national goal of syphilis elimination. The overall syphilis rate has declined to an all time low just three years after the launch of CDC's National Syphilis Elimination Plan. Based largely on the success of state and local public health programs and innovative community partnerships, this dramatic reduction suggests a unique opportunity to eliminate syphilis in this country.

By now we hope that all of you have received the press release and a fact sheet on CDC's community partnership activities to eliminate syphilis. If you have not, or if you have any questions after this call, please feel free to contact our media office, and I'm going to give you their telephone number. It is 404-639-8895. You can also visit our Web site, which is www.cdc.gov/std.

Now to set the stage a bit for our teleconference this morning, first I'm going to provide an overview of syphilis in the United States, where we are today, and briefly discuss CDC's National Syphilis Elimination Plan, which first began in 1998. Then I'm going to turn the presentation over to Dr. Counts, who will discuss record declines in national syphilis rates, as well as several innovative CDC sponsored community programs that are contributing to these declines. We will then open the floor for any questions you might have.

The overall syphilis rate in the United States fell to an all time low in 2000, representing a significant decline from the year before. This continues a steady decline in rates since the U.S. syphilis epidemic last peaked in 1990. History shows us that syphilis rates tend to run in seven to ten-year cycles, and the continuing decline in national rates suggests that we may have altered that trend. However, unless we sustain action to eliminate syphilis, we could once again experience a rise in syphilis rates.

The good news is that we have the tools and the resources at hand to effectively eliminate syphilis in the United States. Syphilis is easily diagnosed and cured, given adequate access to and utilization of care. The challenge we face is to ensure that all people in the United States have access to syphilis diagnosis and treatment.

In the United States syphilis cases remain centered in a small number of counties. Although all racial and ethnic groups are effected by this disease, the communities most affected tend to be made up of African Americans living in resourced poor communities, precisely those areas that very often lack access to adequate healthcare.

Before we move on, let me make sure that everyone understands what syphilis is and what its consequences are. As you know, syphilis is a sexually transmitted disease. Left untreated, it can leave to cardiovascular and neurologic diseases. Its presence also increases HIV transmission two to fivefold. Untreated syphilis during pregnancy can result in infant death in up to 40% of cases. As such, eliminating syphilis in the United States would be a landmark achievement. It would greatly improve the wellbeing of people in resourced poor communities, and it could reduce HIV transmission rates in this country.

Eliminating syphilis, which is 21 times more common in African Americans and three times more common in Latinos than white Americans, would also decreases one of the most glaring racial disparities in healthcare today.

So what exactly do we mean by syphilis elimination? Syphilis elimination is defined as the absence of sustained transmission in the U.S. This means that while there may be occasional outbreaks, these outbreaks would be quickly identified and contained, eliminating the risk of a new epidemic. That's what we're aiming for. It is important to note that syphilis has been eliminated in other industrialized nations, including Canada and England, so we're definitely talking about something that is possible and readily achievable.

In the United States our national goal is to reduce infectious syphilis cases to 1,000 or fewer each year, and to increase the number of syphilis-free counties to at least 90% by 2005. In the year 2000, more than 80% of all of the U.S. counties, and there are 3,139 counties in the United States, so more than 80% of all of those counties reported no cases of primary or secondary syphilis. Half of all primary and secondary cases of syphilis in the U.S. in the year 2000 were concentrated in only 21 counties and one city. This concentration of syphilis in a small number of communities represents both an opportunity and a challenge.

There years ago, in 1998, CDC and its partners initiated a national effort to eliminate syphilis in the United States. The lowest syphilis rates in U.S. history and a concentration of disease in a few geographic areas provided us an opportunity to build on current STD prevention and control efforts by combining intensified traditional approaches with innovative new approaches. There are five strategies that are critical to our syphilis elimination efforts. Let me take a few moments to briefly describe them.

Foremost among these strategies is the strengthening of community involvement and partnership. Because syphilis is highly localized, CDC is working closely with community partners, and state and local governments to strengthen programs in the hardest hit communities. Many programs are receiving supplemental funding to support community outreach activities, utilizing public and private partnerships. In Tennessee, Indiana, and North Carolina, CDC has funded syphilis elimination demonstration projects in three counties. Dr. Counts will share with you the progress made in each of these areas.

Through these expanded partnerships with nonprofit and community organizations, and federal, state, and local government public health agencies, communities at greatest risk are gaining access to timely clinical and laboratory services, including counseling, screening, and treatment. These communities are being aware of the risk of syphilis and how to reduce it through effective health information campaigns sponsored by local governments, partners, and public health departments. CDC is also working to form multi-disciplinary rapid response teams that can work closely with local and state health officials in the event of a syphilis outbreak.

Finally, our capacity to track and monitor syphilis has also been significantly increased since we increased our support to syphilis case management and surveillance programs. Today's new data are a result of those increased efforts.

This comprehensive approach instituted just three years ago has begun to payoff in terms of real progress towards our national goal of syphilis elimination, and these efforts will have a profound impact on improving health in affected communities.

I would now like to turn over the call to Dr. George Counts, who will present our new data showing continuing reductions in overall syphilis rates. George.

A substantial portion of the overall decline in syphilis can be attributed to syphilis elimination activities. Many of these efforts have been targeted to communities that continue to report the highest number of cases and rates of primary, secondary syphilis, and congenital syphilis, but challenges remain.

As in past years, minorities and men continue to be disproportionately impacted by syphilis. The overall rates for primary and secondary syphilis among African Americans declined by an impressive 40% from 1997 to 2000, but remained much higher than for whites. Among Hispanics and Latinos, rates actually increased by 12.5% in the same period.

In 2000, the reported rate of syphilis among men was 1.5 times greater than the reported rate among women. The male to female ratio has risen steadily since 1994 when it was one to one, reflecting an equal number of cases among men and women.

Since 1999, primary and secondary syphilis outbreaks have occurred among men who have sex with men in several U.S. cities, including Los Angeles, Seattle, New York, Chicago, Miami Beach, and others. These outbreaks coincide with other evidence of increases in sexual risk behavior among some populations of men who have sex with men.

I would now like to briefly share with you three examples of innovative community outreach programs that are meeting these challenges in affected communities. CDC has funded syphilis elimination demonstration sites in three communities. In addition to syphilis elimination funding provided to all communities with high syphilis morbidity, these programs receive supplemental federal funding to support public/private partnerships to fight syphilis, and are helping CDC evaluate and refine the national strategies for syphilis elimination. Most importantly, these programs have led to dramatic decreases in the syphilis rates in their communities.

In Nashville, Tennessee, which is located in Davidson County, public health officials have partnered with STG3, a dynamic community coalition, including members of faith communities, schools and colleges, community groups, and healthcare agencies, to eliminate syphilis from their communities. The health department also has developed innovative syphilis programs, including a screening program at the county jail that provides 24 hour a day testing and treatment. As a result of these efforts, syphilis cases in Davidson County have dropped from 250 in 1999 to 200 cases in the year 2000.

In Marion County, Indiana, including Indianapolis, reported cases of syphilis have decreased from 407 in 1999 to 301 cases in 2000. Much of the progress has been made with the help of the Stamp Out Syphilis Coalition. Comprised of grassroots communities and faith-based organizations, city officials, state legislators, and concerned citizens, the coalition supports educational and outreach programs in neighborhoods, clubs, barber, and beauty shops, and laundromats. Public health outreach workers also provide community-based testing for syphilis and HIV, while key hospitals provide enhanced STD prevention services. This project also has initiated a syphilis prevention campaign through billboards, bus ads, and radio spots.

In the third community, with the help of the Knockout Syphilis Community Task Force, reported cases of syphilis have declined 27% from 1999 to 2000 in Wake County, North Carolina, which includes Raleigh. Knockout Syphilis brings together retired school officials, representatives from sororities, substance abuse programs, faith-based and youth organizations to raise community awareness around syphilis elimination. Syphilis screening has not only been implemented in the county jail, but in home and on the street outreach and testing are available in the communities hardest hit by the syphilis epidemic.

These innovative programs have greatly enhanced the impact of CDC's syphilis elimination efforts. Moreover, they demonstrate that elimination of syphilis is a feasible goal when public agencies partner with affected communities. By meeting this goal we can greatly improve the health of these communities, reduce racial health disparities, and slow the spread of HIV.

I'll now turn it back to Dr. Valdiserri for our few final comments.

At this point in time, we're going to open up our presentation for questions. I'm going to begin by seeing if there are any questions here in the room, and then we'll go to the telephone. So let me ask, are there any questions in the room?

Are there any other questions from the floor? All right. What we're going to do then is take questions from our colleagues who have joined us by telephone. We're glad to have many of you on the line today. I would like to give all of you an opportunity to ask at least one question, so I'm going to ask callers to limit to a single question. If we have time after we've given everyone a chance to ask a single question, we'll come back, and if someone has additional questions we'll be glad to take those up.

I also want to point out that if we do end up running out of time I would ask folks who feel like they need additional information or might like to schedule individual interviews to contact the CDC press office. I gave you that number at the beginning of the process. I'll just repeat it one more time here, 404-639-8895.

Let's go ahead and take the first question. Please identify yourself and your publication.

In terms of demographics, although the syphilis cases that we reported nationally have been predominantly among African Americans and we talked about the health disparity, among the outbreaks of syphilis among MSM there are slightly different demographic features, in that more cases are occurring among whites and Latinos than among African Americans.

Although we don't have a copy that's yet ready for public distribution, I also wish to share with you that we have been working with our federal advisory committee and other outside experts to expand or to add an expanded portion to our Syphilis Elimination plan that deals specifically with MSM populations and outlines some specific steps that can be taken to address this issue. We expect to have that document ready for public distribution likely early in 2002. George, I don't know if you want to add to that?

The last point I'd like to make is that CDC over the past several months has been doing outreach to the gay media to try to work with them to continue to get the message out about the importance of early diagnosis and treatment of syphilis.

I'd like to take the next question.

As I mentioned, since the beginning of the launch in 1998, we have tried to describe syphilis elimination in the context of overall community health. We feel since we're dealing with the disease that is easily diagnosed and easily treated, when we have situations like with syphilis in the U.S. that show profound disparities across racial and ethnic groups, we see that this really points out a breakdown in public health. The steps that we take to eliminate syphilis are really steps that are going to strengthen the public health infrastructure.

We also, I think, always face a communication dilemma when we talk about the national picture versus what's happening in communities. This is particularly relevant for syphilis outbreaks among MSM. It is true that nationally we are seeing declines in syphilis that are associated with our ongoing syphilis elimination efforts. But we also understand that in communities like Miami, like Los Angeles, like Chicago, where there have been outbreaks of syphilis among MSM, that we really have to intensify our efforts.

Now, specifically on the issue of HIV and syphilis, you're absolutely right. We are very concerned about what's happening in MSM communities. We're concerned about the intersection of syphilis and HIV transmission. As you likely know, it's a very complicated issue. There are many factors that contribute to it. CDC has been, again, for about the past 18 months or so, trying to raise awareness about the possibility of a resurgence in HIV among MSM across the United States. We've taken a number of steps to try to heighten the awareness of that. We've sent out alerts to community partners, to state and local health departments. We've published articles in our weekly report, Morbidity and Mortality Weekly Report. We're holding these regional meetings, as I pointed out. So you're absolutely right. We have to stay vigilant, we have to continue to focus on evolving trends, and we have to be very aware of the intersection between HIV and syphilis epidemics in the U.S., particularly as it relates to MSM.

Let me also just pause for an editorial moment in case, I think maybe most of you are aware of this, but to let those of you who may not be aware of it know that the reason CDC uses the expression men who have sex with men is that we want to encompass both gay identified and non-gay identified men who are engaging in these activities. So to answer your question, we are seeing outbreaks of STDs in other MSM populations.

I think the other thing that we need to mention, this is an element of the expansion of the elimination plan that I referred to, is that we do need to do a better job of collecting information about sexual practices in terms of the transmission of syphilis. For many of our STDs this is not routinely done, and it can be difficult to tell whether a case is, unless anatomically you get a clue, heterosexual or homosexual in origin. George you might want to just comment on that, because I think it's an important point. We have started some expanded surveillance activities to try to get more detailed information about sexual practices and transmission.

Your question about the ages, syphilis continues to occur primarily among women in their 20s and primarily among men in their 30s. While we certainly have specific instances of younger men and younger women developing syphilis, and those concern us, we continue to see the disease focus primarily on the second and third decade.

We are aware, of course, that cases in Detroit or Wayne County are increasing, and the state of Michigan, and the city of Detroit, and the country of Wayne, are already taking aggressive measures. They are trying to get control of that, along with help from CDC.

Among the factors that you could imagine which might have been playing a role, were an increased focus of local and state health officials on STD control programs, especially syphilis. There could have been some waning of the crack epidemic in this country, which fueled some of the rise in primary and secondary syphilis in the late '80s, the effects of safe sex messages into the '90s, and perhaps some unknown factor about the organism that causes infectious diseases to cycle. There could have been many factors. The thing of note about it is not only has it come down dramatically, but since 1998, since we started the syphilis elimination effort, they have continued to fall rather than going back up as they might have if we had not been focusing our efforts on syphilis elimination.

We do have some indications. For instance, Dr. Counts mentioned earlier, when he was talking about the 12.5% increase in Hispanic and Latino populations, that there is a suspicion there that some of the increases being driven by MSM activity because of the increased ratio of male to female cases. We're very cautious to say that we don't have that exact information. We also want to add that we consider that to be a deficit and that's why we've instituted these studies, so that we can get a better handle nationally on what's happening.

George, do you want to add anything?

I think the way I would generally answer your question is that we want to make sure that we have the kind of surveillance information that is needed, and again, that community groups have access to that information, understand that information, and can work with health departments to make decisions about where resources are best deployed to eliminate syphilis.

Do we have any other questions?

That does conclude your conference for today. Thank you for your participation and thank you for using AT&T Executive Teleconference. You may now disconnect.