1. Syphilis Surveillance: What are we looking at? Tom Peterman Richard Kahn Carol Ciesielski Elizabeth Ortiz-Rios Bruce Furness Susan Blank Julie Schillinger Bob Gunn Melanie Taylor Field Epidemiology Unit ESB, DSTDP, CDC

2. Syphilis stage definitions confusing, especially latent syphilis. Some: Don’t understand definition. Don’t like the definition. Stage at the time DIS sees case.

3. Priorities differ when the stage is not known: Clinician: Treatment BPGx1 (if <1 year) BPGx3 (if Late latent) DIS: Partner notification interviews: Primary 3 months+/- Secondary 6 months +/- Early latent 1 year Late latent none. Surveillance Trends: Primary and Secondary (most important) Early latent (less important) Late latent (not too important) Consistent

4. Syphilis of Unknown Duration ? probable early infections that did not meet the definition for Early Latent.

5. Rate of primary and secondary, early latent, late latent, and unknown duration syphilis, New York City, 1992-2002 Late Latent Early latent Primary & Secondary Unknown Duration

6. Rate of primary and secondary, early latent, late latent, and unknown duration syphilis, Chicago, 1992-2002 Late Latent Early latent Primary & SecondaryUnknown Duration

7. Chicago Los Angeles San Diego New York City San Juan Washington D.C. Early latent Late Latent Primary & Secondary Late Latent Early latent

8. Discuss syphilis classification, Reactor grid. Review syphilis records starting in 2002, + 30 cases each of primary, secondary, early latent, unknown duration, late latent. Methods

9. CDC Definitions: Primary: Ulcer and positive test. Secondary: mucocutaneous lesions and RPR>4. Early Latent: In the past 12 months: Seroconversion; Sx of P&S; or Exposure to early syphilis. Unknown duration: Not early latent syphilis, and patient age 13-35, and nontreponemal titer >32. Late latent: None of the above, and not previously diagnosed, and + treponemal and nontreponemal tests.

10. Sites’ Stage (n) CDC Stage Not Primary Secondary Early L Unk Late Syphilis Primary 94 3 3 (150) Secondary 96 3 1 1 (218) Early L 3 2 53 13 28 1 (250) Unknown 5 50 41 5 (143) Late L 2 4 2 79 13 (212) Comparison of Sites’ and CDC Stage (%) Results

11. Agreement with CDC definition, by site (%) Chi PR DC NY SD LA Primary 100 71 100 97 88 100 Secondary 100 89 91 100 100 100 Early L 59 68 26 24 86 69 Unknown 13 na 23 17 86 91 Late L 80 83 67 66 85 91 Some notes inconsistent Ulcer but lab tests negative.

12. Agreement with CDC definition, by site (%) Chi PR DC NY SD LA Primary 100 71 100 97 88 100 Secondary 100 89 91 100 100 100 Early L 59 68 26 24 86 69 Unknown 13 na 23 17 86 91 Late L 80 83 67 66 85 91 SD and LA used form for recording stage and rationale. LA intentionally changed Early Latent defn to include patients with >4-fold titer decrease in year after treatment.

13. Agreement with CDC definition, by site (%) Chi PR DC NY SD LA Primary 100 71 100 97 88 100 Secondary 100 89 91 100 100 100 Early L 59 68 26 24 86 69 Unknown 13 na 23 17 86 91 Late L 80 83 67 66 85 91 Some called Early L if they seemed to be recently infected— high titer, young age, many partners.

14. Agreement with CDC definition, by site (%) Chi PR DC NY SD LA Primary 100 71 100 97 88 100 Secondary 100 89 91 100 100 100 Early L 59 68 26 24 86 69 Unknown 13 na 23 17 86 91 Late L 80 83 67 66 85 91 PR wasn’t using, NY began using mid-way (defn age <45) Others apparently thought “unknown” meant “not known”. QA can improve, all thought this stage should be dropped.

15. Agreement with CDC definition, by site (%) Chi PR DC NY SD LA Primary 100 71 100 97 88 100 Secondary 100 89 91 100 100 100 Early L 59 68 26 24 86 69 Unknown 13 na 23 17 86 91 Late L 80 83 67 66 85 91 Some in every stage Most had neg RPR or previous treatment without titer rise.

16. Unknown Duration: “Unknown” is often confused with “not known”. Median age for primary and secondary syphilis is 35. Recommendation: Drop it. Discussion

17. Early Latent: Only 53% met definition (range 24-85%) Big problem--Early Latent is important: Measures incidence. Using primary syphilis to measure incidence is biased. (women and MSM less likely to have Primary) Early Latent identifies persons missed at Primary and Secondary stages. Current definition highly influenced by: Disease investigation activity Knowledge of partners Serology testing and records availability.

18. Early Latent Consider including anyone with titer >32 Most would be early cases. Less influenced by availability of partner information. Easier to relate to. However, titers vary by test, may be influenced by HIV

19. Summary: Latent syphilis surveillance is a mess! Recognize different perspectives: Clinical, Partner investigation, Surveillance. Change surveillance definitions: Drop Unknown Duration. ? Expand Early latent to include titers > 32.