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Media Release 28 November 2001 

Media Briefing Transcript: CDC's Report on the National Syphilis Elimination Effort

Syphilis Elimination - History in the Making

SPEAKERS:

Ronald O. Valdiserri, M.D., M.P.H.
Deputy Director, CDC's National Center for HIV, STD, and TB Prevention

George Counts, M.D.
Director of CDC 's syphilis elimination activities

AT&T Moderator As a reminder, today's conference is being recorded and available for replay. Replay information will be given at the conclusion of today's conference call.

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

Dr. Valdiserri Good morning, everyone. This is Ron Valdiserri. I'm the Deputy Director of the National Center for HIV, STD and TB prevention at the Centers for Disease Control and Prevention in Atlanta, Georgia. We're delighted that all of you have joined us today. With me today is Dr. George Counts, who is the Director of CDC's Syphilis Elimination activities.

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.

  
Dr. Counts Thank you, Ron. The overall number of cases of syphilis in the United States reached an all time low in the year 2000. Only 5,979 cases of primary and secondary syphilis were reported, a decline of 9.6% since 1999. This represents a 30% drop since 1997, the year before CDC initiated its Syphilis Elimination plan, and an 89.2% drop since the epidemic last peaked in 1990.

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.

  
Dr. Valdiserri Thank you, George. Through effective planning and coordination among national, state, and local organizations, both public and private, we have seen remarkable reductions in syphilis rates over just a few years. Special syphilis elimination programs supported through CDC and other federal partners are doing a tremendous job in helping the United States reduce its syphilis rates. These programs also demonstrate the power of public/private partnerships to improve health. Syphilis rates have dropped dramatically in the past decade. We have a historic opportunity to continue this progress and eliminate syphilis in the United Sates.

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?

  
R. Milford Yes. Rob Milford from CBS News. In light of the public's awareness of anthrax, smallpox, and everything else, this may get overlooked in the journals and in the public. It really is a big deal, isn't it? We're really conquering yet another disease?
  
Dr. Valdiserri It's absolutely a big deal. We, as Dr. Counts pointed out, have made tremendous progress towards syphilis elimination. I think it's important to point out that since the beginning of our efforts we've tried to inform the public that syphilis outbreaks are really a barometer of community health. Anything that can be done to strengthen our capacity to detect and intervene early in terms of syphilis elimination is also going to help strengthen the overall public health infrastructure. So we see these efforts as being helpful broadly to the field of public health.

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.

  
Moderator First question in queue is from Bob Roar from Bay Area Reporter. Please go ahead.
  
B. Roar I actually had a couple of interrelated questions about the syphilis outbreak and men having sex with men. Do you have any total numbers on those? Are there any changes in demographics that you see from the other patterns?
  
Dr. Valdiserri Let me say that we could provide numbers from the individual outbreaks that have taken place in several communities across the United States. There does tend to be variation in terms of the demographics in terms of race ethnicity. George, I don't know if you want to comment more generally on that?
  
Dr. Counts Just some general comments. As you are aware, CDC has been investigating outbreaks of syphilis reported among men who have sex with men for about the past couple of years, and they are occurring in the cities that you mentioned plus some others.

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.

  
Dr. Valdiserri Thank you. Next question.
  
Moderator The next question is form Charles Ornstein from Los Angeles Times. Please go ahead.
  
C. Ornstein Hi. I just wanted to follow-up on that question dealing with men who have sex with men. Can you address a little bit, Dr. Valdiserri, the next round of demonstration projects that you may put in place to deal with the men who have sex with men issue or guidances from your office, and whether or not they're going to target this issue as the next focus?
  
Dr. Valdiserri I would be glad to provide some information on that and then ask George to add to that. Let me be clear that we at CDC for the past 24 months have been very concerned about this issue and have undertaken a number of activities to begin to try to address it. In fact, there was a large regional meeting that took place in Los Angeles on Monday and Tuesday of this week that brought together health department, and community-based providers, and folks from the academic community to talk about ways and share experiences with improving HIV and STD prevention services for men who have sex with men. That meeting wasn't focused exclusively on syphilis, but syphilis and other STD's was certainly a major component. That was the third of four regional meetings that have taken place since September of this year.

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?

  
Dr. Counts Yes. The comment included a question about demonstration projects. The initial demonstration sites were funded for a specific purpose. That is to look at the national plan and demonstrate service, kind of field and laboratories as it were, to focus on the national plan itself, so we won't be setting up demonstration sites to address new target communities. What we are doing however is that with the additional funding, which is the supplemental funding that goes out each year to specific communities, we are allowing additional funding so that they could take portions of their funding to address specific new needs in their community. Among these new needs could be focusing more on men who have sex with men.
  
Dr. Valdiserri One other point I'd like to make is, actually two points before we move onto the next question, that we are aware of the fact that many of our grantees, many of the organizations receiving resources from CDC, are putting specific resources into intensifying syphilis elimination efforts among MSN communities.

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.

  
Moderator The next question is from Erin McClain from Associated Press. Please go ahead.
  
E. McClam Hi, doctors. Thanks for having this telebriefing. You mentioned syphilis has a sort of a barometer of public health, and I was wondering if you could sort of expand on that. How much overlap is there, for example, in your HIV prevention efforts and your syphilis prevention efforts? What other diseases can we sort of attack by taking on syphilis this way?
  
Dr. Valdiserri I would be glad to make a comment on that, and I know George would want to as well. You'll remember, and you'll see in the press materials that you received, when we talked about the five elements that are integral to syphilis elimination. If you look at these five elements and compare them to what public health experts talk about as the essential public health functions, regardless of the illness or disease or condition that we're dealing with, you'll see great consistency. For instance, the capacity to detect outbreaks early on. It expands across all public health, not just infectious disease, but other conditions as well. The ability to form strong partnerships with communities, so that health departments are working closely with communicates and effected communities, is something that is absolutely essential in all dimensions of public health. I want to underscore that some of the specific steps that we have taken in terms of our syphilis elimination activities are really part and parcel of a sound public health system.

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.

  
Dr. Counts Just to add one particular point to that, in addition to the steps necessary to prevent and control syphilis leading to improved measures for other diseases, as Dr. Valdiserri just said, in addition, the key point we feel is this, because of the contribution of syphilis to HIV, we feel that an effort, which can eliminate syphilis will have a tremendous impact on HIV prevention and control. That's a very important measure.
  
Dr. Valdiserri Next question, please.
  
Moderator The next question is from Steven Smith from Miami Herald. Please go ahead.
  
S. Smith Hi. Good afternoon. I was wondering, and this is teasing off what Dr. Counts was just mentioning, the degree to which your sanguine assessment regarding syphilis is circumscribed by some of the pretty potent reports we're seeing in communities such as South Florida, San Francisco, and New York, of rebounding HIV rates? When you look at some of the landmark work done by Bill Darrow of FIU, formally of PVC, that show infection rates among young gay men in South Beach, for instance, being as high as perhaps one in five, it would seem that maybe this sanguine assessment about syphilis is not entirely warranted. So I'm wondering how you sort of square what seem to be two counter trends?
  
Dr. Valdiserri This is Dr. Valdiserri. First of all, let me say that I don't think that we're sanguine about syphilis elimination. We certainly wanted to share with the media and public health community in the U.S. that we're making progress, but both George and I, at various points in our presentation, pointed out that it's possible for that progress to reverse unless we sustain it. So we're clearly aware of the fact that syphilis elimination is not a given without ongoing sustained efforts.

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.

  
Dr. Counts Just as a follow-up to that point, among the outbreaks of cases of syphilis among MSM, one of the most troubling and distressing aspects, of course, is the co-infection of HIV seen in the cases of syphilis among men who mainly have sex with men. The percentages might range from 20% to 70% of these men are co-infected with HIV. Obviously that's a very troubling element, and heightens our activities focusing on these groups.
  
Moderator The next question is from Gina Barton from Indianapolis Star. Please go ahead.
  
G. Barton You highlighted Marion County as one of the places that had good success with decreasing rates, but yet we're still number two, with more than 300 cases. What more should places like Indianapolis with very high rates be doing to make sure they continue to decrease in the future?
  
Dr. Counts I think that the efforts taken in Marion County reflected an aggressive program on the part of the city, the county, the state of Indiana, as well as help from the Center for Disease Control. The health officials at Marion County have mounted an aggressive campaign, and they are making excellent progress, although you're right. There still are 300 cases of syphilis in Marion County. I think the rates are going in the right direction, and early evidence from the year 2000 indicate that the progression in Marion County will continue, and we're very pleased with the results in Indianapolis.
  
Dr. Valdiserri Just to underscore the issue of sustaining, this is an important theme across public health. It's important when we have trends headed in the right direction that we sustain these efforts and not back away from our efforts.
  
Moderator The next question is from Rich Bareaney from San Antonio Express. Please go ahead.
  
R. Bareaney Thank you. Other than the reasons that you touched on this morning, is there any other explanation for the 12.5% increase in syphilis rates among Hispanics? Is it simply men having sex with men and lack of access to medical care?
  
Dr. Counts I believe that while there can be many reasons, including some of the ones that you mentioned, and at this time we can't really tease out all the factors. What we can say are the things that you mentioned for sure. Some of the cases and the outbreaks, a substantial proportion of cases and the outbreaks that we have seen involving men who have sex with men have involved Hispanics. If you look at the male to female rate among the various racial groups, as we mentioned, they are increasing since 1994. They are increasing most notably among Hispanics and Latinos, suggesting that the cases among overall Hispanics are due to MSM, but we don't have all the answers for that.
  
Moderator The next question is from Sanjay Bhatt from Palm Beach Post. Please go ahead.
  
S. Bhatt Thank you. Is there routine syphilis screening going on in county jails across the country? If not, how representative is the reported rate of syphilis nationwide?
  
Dr. Counts Reported rates nationwide reflect many conglomerate factors coming together. In terms of screening in jails, communities around the country who have a large morbidity of syphilis evaluate in their community where the case is coming from. In some communities clearly it effects populations, which interact with the correctional system. In those communities there is jail screening. In those communities, in many of them, they have been very productive in terms of identifying cases. In other communities the issues of jail screening might not be so cogent. The ultimate answer is to evaluate each community on a local level, determine whether or not jail screening would be productive for that community, and jail screening is being done in the ones in which it suggested it would be of value.
  
Dr. Valdiserri George, just to follow-up on the journalist's question, I think it's probably fair to say that we do need to do more in those correctional settings. We don't want to imply that everywhere that routine screening is taking place. I think what George was trying to point out, again, getting back to basic good practices in public health. The programs need to be driven by an assessment of needs and need to be driven by what the epidemiology tells us. That's, I think, what he was underscoring, but we would add that we have a lot more to do in terms of syphilis services and HIV prevention services in correctional settings.
  
Moderator The next question is from Eric Erickson from Southern Voice. Please go ahead.
  
E. Erickson My question regards to significant risk for MSMs again, and how does it specifically compare with the rates for other STD's among MSMs, especially since the list can affect ones ability to transmit HIV?
  
Dr. Valdiserri Let me begin by saying that we're focusing on syphilis, so we've talked about a variety of syphilis outbreaks among various MSM populations across the United States. We have also, in the past few years, seen outbreaks of other sexually transmissible diseases, including gonorrhea, and chlamydia, and I think most recently you may be aware of the fact that CDC reported on an outbreak of shigella that was sexually transmitted among MSM. That was on the West Coast. All of these outbreaks and sexually transmissible diseases, along with reports of increases in unsafe behaviors, these reports tend to come from various studies across the U.S., again suggest that we're in a situation where at least for some populations of men who have sex with men that we might be poised for a resurgence of HIV.

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.

  
Dr. Counts Right, which you would expect because they're all transmitted diseases and would be transmitted by the same risky behavior.
  
Dr. Valdiserri I think the other point perhaps you were asking is that syphilis is not the only sexually transmissible disease that can increase the risk of transmitting or acquiring HIV. Also the non-ulcerative STDs have been associated with an increased risk of acquiring or transmitting HIV. That's why in the United States and in other parts of the world, strengthened STD prevention and control programs are considered to be an essential element to control the spread of HIV.
  
Moderator The next question is from Diane Sugg from Baltimore Sun. Please go ahead.
  
D. Sugg Thank you. I'm wondering what the plans are for continuing the financial support that you're giving places like Baltimore? One of the problems we had here with our outbreaks was that there were federal cutbacks that led to a lower number of workers at our STD clinics. Now that we've got money from you guys we're doing a lot better, but five years from now or three years from now if the money gets cut off I'm wondering if we'll be right back where we started?
  
Dr. Valdiserri Let me make a general comment on resources and then turn it to George. I think all of you are aware of the fact that our resources at CDC come to us from the United States Congress, so we always try to do the best job with the resources that we have in hand. I guess I'm trying to say we're not the only element in the equation of resource allocation. George, you might want to speak more specifically to the Baltimore question.
  
Dr. Counts When the syphilis elimination effort was made and the funds were awarded to various local communities to help with their syphilis elimination activities, as you have been made aware, many of these communities have been very successful so far in controlling their syphilis. But now it would not make sense after they have been successful to remove the funding which supported their efforts in being successful in the first place. So our plans are of course to continue support for those communities, even where they have been successful, but obviously this is all affected by the amount of funding that the federal government and we have.
  
Dr. Valdiserri One last comment on that. You heard both of us, George and I both, talk about the importance of public and private partnerships. I think it's always important to understand that public resources are not the only resources available to address syphilis and other sexually transmissible diseases. That's why it's also very important to have strong relationships with the private sector, to try to broaden that resource base. The bottom line is we always try to make the best resource allocation decisions given the resources that are available to us.
  
Moderator Next question from Duncan Osborne from LGNY. Please go ahead.
  
D. Osborne Doctors, looking at these 21 counties and the city of Baltimore, can you further define the extent to which these cases result from sex between men who have sex with men and heterosexuals? My sense is that most of these result from MSM activity. Am I right about that or am I wrong?
  
Dr. Counts I think you are wrong about that, because if you look at those counties, which have the largest amount of primary and secondary syphilis in the year 2000, many of these are large urban areas from Cook County, Indianapolis, and Detroit. Those do not reflect, primarily, men who have sex with men. Those reflect heterosexual syphilis. I think that although we are seeing gradual increases in syphilis occurring in men who have sex with men around the country, the total number of such cases is relatively small compared to the total number of syphilis cases occurring each year, so although the numbers are relatively small, we are obviously very concerned about it. But the total number of cases that you see in any given year are heavily driven by syphilis occurring among heterosexuals.
  
Dr. Valdiserri Just one last point, Duncan. As you're likely aware, this is part of the complexity of communicating this message that overall rates are decreasing. As George mentioned, overall, most of the cases of primary and secondary syphilis are heterosexually transmitted, but there are also important local outbreaks.

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.

  
Dr. Counts Right. Your point is very well taken, that part of the difficulty is that we don't have complete and accurate data from across the country in terms of behavioral risk factors. That limits our ability to try to generalize in terms of how much syphilis occurring among MSM is occurring. To address that, we are increasing the surveillance with specific CDC funded project, looking at certain sentinel cities around the United States, which will include behavioral risk factors. Also, we are developing a uniform interview document that will be used in the future, which will be standardized across the country in all areas for syphilis surveillance. That will be a big help to us.
  
Dr. Valdiserri Thank you. Next question, please.
  
Moderator The next question is from Nancy McVicar from Sun Sentinel Florida. Please go ahead.
  
N. McVicar Thanks for having this briefing. I just wanted to ask you if you are seeing a lot of young people being infected with syphilis. Also, something about the transmission rate in infants, is that something that we should be concerned about right now?
  
Dr. Counts Let me take the infant question first. Cases of congenital syphilis continue to occur, but we are pleased that we have gone from approximately 1,000 cases of syphilis occurring among infants in 1997, to 500 or so cases occurred in the year 2000. We have cut the cases of congenital syphilis almost in half, and that's due to more aggressive screening and testing of pregnant women.

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.

  
Moderator The next question is from Wendy Wendland from Detroit Free Press. Please go ahead.
  
W. Wendland Hi. Thank you, doctors. I had a question. In Detroit the numbers have actually gone up over the last couple of years. I wondered if there are other cities or other communities in this list of 22 that have also seen their numbers go up, and if they're may be an expansion of your pilot projects in those communities?
  
Dr. Counts If you look across the country at the 31 or so communities, which received syphilis elimination funding, approximately 12, I believe, over the past year have had some increase. But if you look at the total number of cases nationwide, as you said, we are seeing cases overall going down very nicely. So what we have is communities which we're not having much syphilis back three or four years ago, it is now beginning to appear, other communities which had a lot of syphilis two or three years ago, and they have had substantial reduction.

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.

  
Moderator The next question is from Victoria Eliot from American Medical News. Please go ahead.
  
V. Eliot Hi. I was wondering since so many public health resources are concentrated on the anthrax scare, if that was affecting efforts to eliminate syphilis at all?
  
Dr. Valdiserri Let me take that question first. At the Center for Disease Control and Prevention, the answer to that would be no. We are still committed to syphilis elimination. As I mentioned earlier, we think that it's possible. We know that it's been achieved in other industrialized nations in the world. I think there is a broader question that really goes beyond CDC to the American public, and that is what decisions the American public might make about how scarce public health resources are invested in the years to come. I want to just remind everyone that syphilis has not gone away because of anthrax, nor has tuberculosis, nor have HIV or any of the other sexually transmissible diseases that we deal with.
  
Dr. Counts The only thing that I would add to that would be that at the local and state level, where public health officials, STD health workers, and others, if they were to be devoted to focus more on bio-terrorism issues, it could have an impact on STD control efforts. But as of right now, we're not seeing an impact yet.

  

Moderator The next question is from Brian Betchel from Infectious Disease News. Please go ahead.
  
B. Betchel Thank you. Dr. Counts, I noticed in the press kit that there's been almost a 90% drop in syphilis cases between 1990 and 2000, and that seems, of course, dramatic. But I'm wondering what factors led to this or if there is something particular to syphilis that led to such a dramatic production?
  
Dr. Counts As Dr. Valdiserri mentioned, over the past 40 years we have seen cases in rates of syphilis go up and down in seven to ten-year cycles. What made 1990 different from previous peaks was the fact that it was so high, so that since 1990, as you said, rates have fallen dramatically. They have fallen dramatically in previous peaks, but they have fallen dramatically since then.

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.

  
Moderator The next question is from Mary Powers from the Commercial Appeal. Please go ahead.
  
M. Powers Thank you for taking the time to answer these questions. Unlike Detroit, Memphis has seen its rate come down and the number of case come down, but very, very modestly. Is there anything communities can look at to just assess how good a job is being done locally with this additional federal funding?
  
Dr. Counts One of the things that we are doing for each community, which receives syphilis elimination funding, is to have a program assessment. By that we mean a team of officials from the CDC, with help from the local communities, will perform a complete evaluation of the local syphilis elimination efforts in those individual communities. Following that program assessment, needs are identified. These needs could be personnel, technical assistance, resource needs, whatever. I know that this has been done in Memphis, so that Shelby County, Memphis, and the CDC, and our partnerships are working in that effort. The numbers have fallen, as you say. They've gone from 258 in 1999 down to 246 in the year 2000. I believe that we will see in the year 2001 that the numbers will continue to fall.
  
Moderator The next question is from Randy Dotinga from Health Scott News Service. Please go ahead.
  
R. Dotinga Hi. I'm trying to pin down some numbers on the MSM. How many cases are we aware of of MSM from 2000, and if you had to guess, how many more do we not have specifically categorized in that category?
  
Dr. Valdiserri I think, as was mentioned earlier, part of the difficulty we face is that nationally we don't have information on sexual practices that would enable us nationally to say with certainty how many cases of primary and secondary syphilis in 2000 are the result of male to male sexual contact. That is clearly a problem. It's clearly a deficit. That's why we've instituted these special surveillance studies in 11 cities that will enable us to have this specific information. We really can't guess at it at this point in time.

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?

  
Dr. Counts No. That's fine.
  
Moderator A follow-up question from Bob Roar from Bay Area Reporter. Please go ahead.
  
B. Roar Hi. When we talk about HIV and syphilis and other STDs, there's sort of a chicken and egg scenario here of trying to figure out which comes first or which impacts the other. Have you collected any data in terms of how many of these folks are also HIV infected? I'm thinking particularly of some of the work out of Seattle, I guess, with MSMs. A very high percentage of those people were already HIV infected, and knew their status, and sort of gets to the bare-backing issue.
  
Dr. Valdiserri As Dr. Counts mentioned earlier, in the majority of the MSM syphilis outbreaks that have been studied over the past two years, a significant proportion of those men are infected with HIV. It ranges from anywhere from 20% to 70%, depending upon the outbreak and locality, but as a recurrent theme, many of those men are co-infected with HIV. Hence the concern on the HIV side of the equation that some of these, I don't want to generalize, it's very important to be careful not to generalize, but that some of these men and some of these populations may no longer be adhering, say, to sexual practices. Again, this is due to a number of factors, misperceptions about some folks think that if they're under treatment with highly active anti-retroviral therapy and their viral load is down, they think that they're not able to translate HIV. There certainly have been alterations in the perception of risk related to HIV as a result of improvements in treatment, issues of prevention, burnout, etc. It's multifaceted. It's complicated. But to answer your question, in all of these outbreaks a substantial number of these men are co-infected with HIV.
  
Moderator We have a follow-up question from Steven Smith from Miami Herald. Please go ahead.
  
S. Smith I was wondering if you could discuss the reliability of these data a little bit? I guess by that I mean that if we look at the rate figures, just statistically the rate figures demonstrate some grossly significant variations, almost to the point of calling into question statistical reliability. You add in to the fact that among those top ten are two of the communities whose prevention programs you specifically cited, Marion County and Davidson County. So I'm wondering if it's reasonable to suggest that say in those communities, because there have been these significant prevention efforts, concomitantly there has been a better assessment of the actual infection rate.
  
Dr. Counts That's a very good question, and it highlights the two ways that you must look at STD data from any community. With our syphilis elimination effort we have a goal to reduce the number of cases occurring in the United States to a certain level, so we focus on the number of cases. We have concentrated on those cities and those counties, which have the greatest number of cases. But when it comes to a discussion of rates, obviously the rate is influenced by the population density. For example, you could have Los Angeles, which might have a substantial number of cases of syphilis, but the rates would be very low because of the large population. So we look at them both, and we are focusing primarily on the cases when we talk about improvement and successes. But you're right about you need to look at both, but they tell you different things.
  
Dr. Valdiserri Just a more general comment on evaluation of efforts, because I think this does come back to how do we know what we're doing is having an impact. Clearly these are not controlled clinical trials. It wouldn't be ethical to do a controlled clinical trial in this group, but we do look at other indicators. We don't just look at the rates. We look at a variety of other programmatic indicators, a variety of other rates of other sexually transmissible diseases and HIV. So I think you're question is a fair one. How do we know that what we are doing is having an impact? I can answer that generally by saying that we do have other evaluation criteria, and we could put you in touch with folks who could talk about that in more detail. If you're interested, I would call the number that I sited earlier.
  
Moderator The next question is a follow-up from Sanjay Bhatt from Palm Beach Post. Please go ahead.
  
S. Bhatt Palm Beach County has asked for CDC funding to resume routine screening of people brought to its jail, which raises the question, was there a falloff in federal funding available for screening in the jails since 1990? Could that be a factor in the decline in reported rates of syphilis infection?
  
Dr. Counts I know that the cases in Palm Beach County have gone from 37 to 90-some, so that they have increased, but your question about the provision of additional jail screening funds specific to Palm Beach County, there has been an assessment performed in Miami Dade County. Out of that assessment was a combination of efforts by the state of Florida and by the Miami Dade County focusing on what were needed in Miami Dade County. Now there hasn't been a specific assessment done in Palm Beach County, but if additional needs were identified, specifically to set up a jail program, the Center would address those needs and respond appropriately, but I can't tell you anything specific about Palm Beach County. I appreciate that it's...from Miami.
  
Dr. Valdiserri Just as a general comment, we don't have, in terms of the syphilis elimination, a separate funding stream for screening correctional settings. I mentioned this earlier, part of what we're dealing with here is trying to give communities the appropriate surveillance information and the appropriate tools they need to make the best informed decisions about where resources should be deployed. I think it's fair to say that there's never enough resource to meet every need.

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?

  
Moderator You have a final follow-up from Eric Erickson from Southern Voice. Please go ahead.
  
E. Erickson Do we know how many of these cases, because sometimes people don't use all their medications and they may not treat it correctly after they see the physician, how many are recurring and how many are new?
  
Dr. Counts No, I can't specifically tell you how many newly diagnosed cases are recurrences, because if a person has had syphilis and the disease has been treated, that person is not susceptible for a certain period of time to be re-infected. However, the immunity wanes very quickly so that a person who has been infected at one time maybe several months or years later be re-infected and would be counted appropriately as a new case of syphilis.
  
Dr. Valdiserri If there are no final questions, on behalf of George, myself, and our CDC colleagues in the room here, we want to thank all of you for your time and interest in syphilis elimination. As I mentioned earlier, if there's a need for follow-up information, please feel free to visit our Web site or to call our press office. Thank you very much for your time and interest. That concludes our press briefing.
  
Moderator Ladies and gentlemen, this conference is available for replay, beginning today at 2:30 p.m. Central Time, through Monday December 3rd at midnight. To access the Executive Playback Service, dial 1-800-475-6701. Enter the access code 612072.

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.

 
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