Syphilis, a genital ulcerative disease, facilitates the transmission of HIV
and may be important in contributing to HIV transmission in those parts of
the country where rates of both infections are high. Untreated early syphilis
in pregnant women results in perinatal death in up to 40% of cases and, if
acquired during the four years preceding pregnancy, may lead to infection of
the fetus in over 70% of cases.1
The rate of primary and secondary (P&S) syphilis reported in the United
States decreased during the 1990s; in 2000, the rate was the lowest since reporting
began in 1941 (Figure 24). The low rate of infectious syphilis and the concentration
of the majority of syphilis cases in a small number of geographic areas in
the United States led to the development of the CDC's National Plan to Eliminate
Syphilis, which was announced by Surgeon General David Satcher in October 1999.2Collaboration
with diverse organizations, public health professionals, the private medical
community, and other partners working in the fields of STD and HIV is essential
for the successful elimination of syphilis in the United States.3
Although the rate of P&S syphilis in the United States declined by 90%
during 1990-2000, the rate of P&S syphilis increased from 2000 to 2004.
Overall increases in rates during 2000-2004 were observed only among men. In
2004, for the first time in over ten years, the rate of primary and secondary
syphilis among women did not decrease; it remained the same between 2003 and
2004 at 0.8 cases per 100,000 population.
Despite national progress toward syphilis elimination syphilis remains an
important problem in the South and in urban areas in other regions of the country.
Increases among men who have sex with men have occurred at least since 2000
and continue through 2004. These men have been characterized by high rates
of HIV co-infection and high-risk sexual behavior.4-11
In 2004, P&S syphilis cases reported to CDC increased to 7,980 from
7,177 in 2003, an increase of 11.2%. The rate of P&S syphilis in the
United States in 2004 (2.7 cases per 100,000 population) was 8% higher than
the rate in 2003 (2.5 cases per 100,000 population), and it is greater than
the Healthy People 2010 (HP2010) target of 0.2 case per 100,000 population
(Figure 26, Table
1).12
During 2003-2004, the number of cases of early latent syphilis reported
to CDC decreased 7.1% (from 8,361 to 7,768) while the number of cases of
late and late latent syphilis decreased 5.6% (from 18,319 to 17,300) (Table
1). The total number of cases of syphilis (all stages: P&S, early latent,
late latent, and congenital syphilis) reported to CDC decreased 2.6% (from
34,289 to 33,401) during 2003-2004 (Table 1).
The rate of P&S syphilis increased 11.9% among men (from 4.2 cases
to 4.7 cases per 100,000 men) between 2003 and 2004 (Figure
30, Table 28).
During this time, the rate remained unchanged among women (0.8 cases per
100,000 women) (Figure 30, Table
27).
The male-to-female rate ratio for P&S syphilis has risen steadily since
1996 when it was 1.2 (Figure 32), suggesting an increase in syphilis among
MSM during this time. The male-to-female rate ratio in 2002 was 3.4; in 2003
it was 5.2, and in 2004 it was 5.9.
Between 2003 and 2004, the male-to-female rate ratio for P&S syphilis
decreased among whites (from 14 to 10), among Asian/Pacific Islanders (from
19 to 11) and among American Indians/Alaska Natives (from 2.8 to 1.2). The
male-to-female rate ratio increased among African-Americans (from 2.7 to
3.3) and among Hispanics (from 6.1 to 7.9). (Table
34B).
An increase in the male-to-female rate ratio for P&S syphilis occurred
in the District of Columbia, Puerto Rico and in 23 (68%) of 34 states that
reported at least 25 cases in 2004.
In 2004, syphilis rates increased for men and women in almost all racial
and ethnic groups. African-Americans accounted for 41% of cases of P&S
syphilis in 2004 and 39.2% in 2003. During 2003-2004, the rate of P&S
syphilis increased 16.9% among African-Americans, reflecting a 22.2% increase
in the number of cases among men (from 2,005 to 2,450) and a 1% increase
among women (from 805 to 813). The rate among non-Hispanic whites increased
6.7%; cases among men increased 5.9% (from 2,783 to 2,947) and cases among
women increased 12.8% (from 227 to 256). The rate among Hispanics increased
10.3%; cases among men increased 13.9% (from 1,001 to 1,140), and cases among
women decreased 13.2% (from 159 to 138). The rate among Asian/Pacific Islanders
increased 20%; cases among men increased (from 119 to 142) and increased
among women (from 8 to 11). The rate among American Indian/Alaska Natives
increased 14.3%; cases among men decreased (from 50 to 42), but increased
among women (from 19 to 35). (Figure 31, Tables
34A and 34B).
In 2004, the rate of P&S syphilis reported among African-Americans
(9.0 cases per 100,000 population) was 6 times greater than the rate among
non-Hispanic whites (1.6 cases per 100,000 population). This differential
was more than that in 2003, when the rate of P&S syphilis among African-Americans
was 5 times greater than the rate among non-Hispanic whites (Table
34B) and
reflects an increase in syphilis among African-Americans for the first time
in over a decade.
The incidence of P&S syphilis was highest among women aged 20-24 years
(3.0 cases per 100,000 population) and among men aged 35-39 (12.4 cases per
100,000 population) in 2004 (Figure 33, Table
33).
The South accounted for 48% of P&S syphilis in 2004 and 45% in 2003.
During 2003-2004, rates increased in all U.S. regions except the Midwest;
rates increased 16.1% in the South (from 3.1 to 3.6 cases per 100,000 population),
4.8% in the Northeast (from 2.1 to 2.2), and 7.4% in the West (from 2.7 to
2.9); the rate remained the same in the Midwest at 1.6. The 2004 rates in
all regions were greater than the HP2010 target of 0.2 case per 100,000 population
(Figure 29, Table
26).
In 2004, P&S syphilis rates in 6 states and one outlying area were
less than or equal to the HP2010 national target of 0.2 case per 100,000
population (Figure 27, Table
24). Nine states and two outlying areas reported
five or fewer cases of P&S syphilis in 2004 (Tables
24 and 26).
In 2004, 2,488 (79.3%) of 3,139 counties in the United States reported
no cases of P&S syphilis compared with 2,530 (80.6%) counties reporting
no cases in 2003. Of 651 counties reporting at least one case of P&S
syphilis in 2004, 5 (0.8%) had rates at or below the HP2010 target of 0.2
case per 100,000 population. Rates of P&S syphilis were above the HP2010
target for 646 counties in 2004 (Figure 28). These 646 counties (20.6% of
the total number of counties in the United States) accounted for 99.2% of
the total P&S syphilis cases reported in 2004.
In 2004, half of the total number of P&S syphilis cases were reported
from 19 counties and 1 city (Table 25).
The overall rate of P&S syphilis in 2004 for 63 selected large U.S.
cities (6.7 cases per 100,000 population) increased 9.8% from the rate in
2003 (Table 30). Rates exceeded the HP2010 target of 0.2 case per 100,000
population in all but 1 of the 63 cities in 2004 (Table
29).
During 1990-2004, the proportion of P&S syphilis cases reported from
sources other than STD clinics increased from 25.6% to 64.4% (Figure
25).
During 2000-2004, the number of cases reported from non-STD clinic sources
increased each year and the number of cases reported from STD clinics decreased
each year.
Congenital Syphilis
Between 2003 and 2004, the overall rate of congenital syphilis decreased
17.8% in the United States, from 10.7 to 8.8 cases per 100,000 live births
(Figure 37, Table
39). The continuing decline in the rate of congenital syphilis
(Figure 37) likely reflects the substantial reduction in the rate of P&S
syphilis among women that has occurred during the last decade (Figure
36).13,14
During 1991-2004, the average yearly percentage decrease in the congenital
syphilis rate was 17.2% (Table 39). The average yearly percentage decrease
in the rate of P&S syphilis among women during 1991-2004 was 21.4%. Overall,
there has been a 92% decrease in cases of congenital syphilis since 1991.
In 2004, 31 states and one outlying area had rates of congenital syphilis
that exceeded the HP2010 target of 1.0 case per 100,000 live births (Tables
40-41).
Thirty-two (51%) of 63 selected cities in the United States had congenital
syphilis rates greater than the HP2010 target of 1.0 case per 100,000 live
births in 2004 (Table 42). All of these cities had rates that were more than
eight times the HP2010 target.
Additional information about syphilis and congenital syphilis in racial
and ethnic minority populations, adolescents, men who have sex with men,
and other at risk populations can be found in the Special
Focus Profiles.
1 Ingraham NR. The value of penicillin alone in the prevention
and treatment of congenital syphilis. Acta Derm Venereol 31 (suppl 24):60,1951.
2 Division of STD Prevention. The National
Plan to Eliminate Syphilis from the United States. National Center for HIV, STD, and TB Prevention,
Centers for Disease Control and Prevention, 1999.
3 Centers for Disease Control and Prevention. Primary and
secondary syphilis - United States, 1999. MMWR 2000;50:113-117.
4 Centers for Disease Control and Prevention. Resurgent bacterial
sexually transmitted disease among men who have sex with men - King County,
Washington, 1997-1999. MMWR 1999;48:773-777.
5 Centers for Disease Control and Prevention. Outbreak of
syphilis among men who have sex with men -Southern California, 2000. MMWR 2001;50(7):117-20.
6 Bronzan R, Echavarria L, Hermida J, Trepka M, Burns T, Fox,
K. Syphilis among men who have sex with men (MSM) in Miami - Dade County, Florida
[Abstract no. P135]. In: Program and abstracts of the 2002 National STD Prevention
Conference, San Diego, California, March 4-7, 2002.
7 Centers for Disease Control and Prevention. Primary and
secondary syphilis among men who have sex with men - New York City, 2001. MMWR 2002;51:853-6.
8 Chen SY, Gibson S, Katz MH, Klausner JD, Dilley JW, Schwarcz
SK, Kellogg TA, McFarland W. Continuing increases in sexual risk behavior and
sexually transmitted diseases among men who have sex with men: San Francisco,
California, 1999-2001 [Letter]. Am J Public Health 2002;92:1387-8.
9 Ciesielski CA, Boghani S. HIV infection among men with infectious
syphilis in Chicago, 1998-2000 [Abstract no. 12]. In: Program and abstracts
of the 9th Conference on Retroviruses and Opportunistic Infections, Seattle,
Washington, February 24-28, 2002.
10 D'Souza G, Lee JH, Paffel JM. Outbreak of syphilis among
men who have sex with men in Houston, Texas. Sexually Transmitted Diseases 2003;30:872-3.
11 Robinson BC, Chiliade PA, Lee C, Bautista J, Saenz G. Redirecting
elimination efforts in response to the changing epidemiology of syphilis [Abstract
167]. In: Program and abstracts of the 2004 National STD Prevention Conference,
Philadelphia, Pennsylvania, March 8-11, 2004.
12 U.S. Department of Health and Human Services. Healthy
People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving
Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.
13 Centers for Disease Control and Prevention. Congenital
syphilis - United States, 2002. MMWR 2004;53:716-9.
14 Centers for Disease Control and Prevention. Primary and
secondary syphilis - United States, 2002. MMWR 2003;52(46):1117-20.
Syphilis 1 
