In April 1995, a public sexually transmitted disease (STD) clinic in the northwest (NW) ward of the District of Columbia closed, leaving one public STD clinic in the southeast (SE) ward to provide public STD services for the entire city. This report summarizes an investigation by CDC following a request from the District of Columbia Department of Health's STD program to evaluate the impact of the NW STD clinic closure on STD case reports. The findings of this investigation indicate that the clinic closure resulted in a marked decrease in reported syphilis in the NW ward, and suggest that NW ward residents with syphilis and their partners may not have received proper diagnostic testing, therapy, and counseling.

To determine the number and characteristics of patients seen at the STD clinics, the health department's STD clinic reports from May 1, 1994, to April 30, 1996 (the 12 months before and the 12 months after the clinic closed) were reviewed. To assess ward- and clinic-specific trends in case reporting, syphilis and gonorrhea case reports in the health department's STD surveillance database were analyzed. For this analysis, data for the year before and the year after the clinic closed were available for primary and secondary (P&S) syphilis cases, and data for 4 months before and 4 months after the clinic closed were available for gonorrhea cases.

Compared with the 12-month period before the NW STD clinic closed, during the 12-month period after the clinic closed the overall number of patient visits at the health department's STD clinics decreased 37%, from 20,155 to 12,759. The reported cases of P&S syphilis decreased 23%, from 143 cases before the clinic closure to 110 cases after the closure. Among those residing in the NW ward, the number of reported cases of P&S syphilis decreased 57%, from 44 cases to 19 cases. However, reported cases among persons residing in the SE ward increased 10% during the same period, from 52 cases to 57 cases. The number of reported cases among women residing in the NW ward did not change, whereas reported cases among women residing in the SE ward increased by 41%, from 22 to 31 (Figure_1). However, among men residing in the NW ward, the number of reported cases decreased 78% (from 32 to seven), and reported cases from men residing in the SE ward decreased 13% (from 30 to 26).

Cases of reported gonorrhea in the District of Columbia decreased 26%, from 6935 cases before the clinic closure to 5166 cases after the closure. The decline in reported gonorrhea cases was seen in all wards.

The numbers of P&S syphilis cases reported for NW residents at the SE STD clinic did not change substantially following the NW STD clinic closure. However, the number of gonorrhea cases reported among NW residents increased at the SE STD clinic from 22 cases to 153 cases.

Reported by: M Levy, MD, J Heath, District of Columbia Dept of Health. Epidemiology and Surveillance Br, Div of Sexually Transmitted Disease Prevention, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: Although in the United States syphilis has declined to historically low levels (1), it remains a problem in the District of Columbia. In 1996, the city's syphilis rate was 13th highest for U.S. cities of greater than 200,000 population (2). Data from this investigation suggest that closing the NW STD clinic resulted in unreported syphilis cases. Reporting of syphilis cases is essential if health departments are to ensure that patients and their sex partners are treated and counseled properly, that trends in disease are monitored effectively, and that outbreaks are identified and addressed promptly.

The substantial increase in syphilis among women residing in the SE ward following the clinic closure suggests that a simultaneous increase in the NW ward might not have been detected. Cases in the NW ward may have been missed because of limited access to STD care after the NW STD clinic closure. The number of cases reported among women residing in the NW ward did not decrease as it did for men, possibly because a higher proportion of women than men are tested for syphilis in health-care settings other than STD clinics (e.g., family planning and antenatal care).

The elimination of STD care can result in substantial decreases in STD clinic visits, laboratory testing, and chlamydia and gonorrhea case reports (3). In the District of Columbia, gonorrhea case reports declined, but decreases in all wards were similar. Differences between the specific behaviors of syphilis patients and gonorrhea patients may help to explain the differential impact on reporting. Syphilis patients are more likely than gonorrhea patients to have a greater number of unnamed sex partners and to engage in illicit-drug use and exchange of sex for drugs or money (4). Syphilis patients and their partners may have particular difficulty accessing the health-care system. The signs and symptoms of early syphilis in men often are transient and painless compared with the often persistent urethral discharge and dysuria of gonorrhea; thus, persons with syphilis may not seek health care as readily as persons with gonorrhea. The loss of a public STD clinic may have had a greater impact on the likelihood of identifying, locating, and treating syphilis patients than gonorrhea patients.

The findings in this report are subject to at least two limitations. First, patients who would have been served by the NW STD clinic may have sought STD services from other health-care facilities; however, if such cases were not reported to the health department their sex partners probably did not receive adequate follow-up. Second, although the clinic closure appears to be the most likely explanation for the sharp decline in reporting of syphilis cases among NW residents, other unmeasured factors might have affected the syphilis and gonorrhea rates in the NW ward and elsewhere in the city.

When considering closing any public facility providing health-care services, health departments should evaluate the potential impact on populations with high rates of disease. Specifically, they should assess the extent to which these patients can access the remaining health-care facilities and the capacity of these facilities to handle an increase in patient volume. In settings such as the District of Columbia, measures to increase syphilis case finding should be implemented by expanding routine syphilis serologic screening, strengthening partner notification activities, and improving patient education.

References

1. CDC. Primary and secondary syphilis -- United States, 1997. MMWR 1998;47:493-7.

2. Division of STD Prevention. Sexually transmitted disease surveillance, 1996. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1997.

3. Kimball AM, Lafferty WE, Kassler WJ, Hundt A, MacCornack R, Bolan G. The impact of health care market changes on local decision making and STD care: experience in three counties. Am J Prev Med 1997;13(suppl 6):75-84.

4. Andrus JK, Fleming DW, Harger DR, et al. Partner notification: can it control epidemic syphilis? Ann Intern Med 1990;112:539-43.

   
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