Going, going, . . . but not gone: Can we eliminate syphilis transmission within the U.S.?

The Centers for Disease Control and Prevention (CDC) has launched a campaign to eliminate syphilis transmission within the United States. Syphilis is an especially destructive sexually transmitted disease (STD) caused by a spirochete bacterium, Treponema pallidum. The sequelae of untreated syphilis may include irreversible neurologic damage, blindness, destruction of skin and bones, damage to the heart and blood vessels, and premature death. The genital sores associated with syphilis make it easier to both acquire and transmit the human immunodeficiency virus (HIV) through sexual contact. Pregnant women who become infected with syphilis may have spontaneous abortions or stillbirths or give birth to infants with congenital syphilis. Infants with congenital syphilis are likely to have permanent damage to one or more of their body systems.

Syphilis elimination would have many positive public health implications. The devastating consequences of untreated syphilis and congenital syphilis could be avoided and HIV transmission might be reduced. Elimination is theoretically possible because syphilis is easy to detect and cure. A single dose of penicillin is an effective treatment against primary or secondary syphilis, and syphilis bacteria are not known to have developed antibiotic resistance. It is now an excellent time to start an elimination campaign because the rates in the U.S. are currently the lowest ever recorded. There are areas within the U.S., however, where syphilis remains a serious problem. In 1998, 6,993 cases of primary and secondary syphilis were reported in the U.S., and more than 50% of these cases were reported from 28 U.S. counties (<1% of all U.S. counties), the majority of which are in the South.

Five strategies have been proposed by the CDC for syphilis elimination. These include enhancing surveillance for syphilis; strengthening community involvement and partnerships, particularly in communities with high syphilis rates; developing a rapid outbreak response plan to combat syphilis; expanding clinical and laboratory services, particularly in areas with populations at high risk for syphilis; and, enhancing health promotion interventions, including confidential partner notification services. The primary focus of the syphilis elimination campaign will be on areas that either have high rates of syphilis morbidity (high morbidity areas) or have the potential for syphilis re-emergence (potential re-emergence areas). High morbidity areas are defined as areas with ongoing syphilis transmission at high rates (e.g., the 28 U.S. counties with >50% of the primary and secondary cases). Potential re-emergence areas are defined as areas that currently experience little or no syphilis transmission but are at significant risk for syphilis reintroduction because: 1) they have a history of high syphilis rates at some time in the 1990s; 2) they are a port city or border area, or are located on routes that are routinely traveled by migrant workers; 3) they are located along known drug trafficking corridors; or, 4) they include large populations of people known historically to have been disproportionately affected by syphilis. Areas that are not high morbidity areas or potential re-emergence areas are termed ‘low morbidity areas’. Low morbidity areas are not being targeted specifically in the elimination campaign, but are being encouraged to maintain strong prevention programs for all STDs, including syphilis.

Utah is considered to be a low morbidity area for syphilis. Since 1990, an average of eight cases of primary or secondary syphilis have been reported in Utah each year. Nearly all of the cases reported since 1990 have been found, upon investigation, to have had sexual contact with a person or persons who live or travel outside of Utah. While there are not many cases of syphilis diagnosed in Utah, health care providers should still consider syphilis as a potential diagnosis in patients who are at risk of contracting STDs. Syphilis should definitely be considered if the patient has had sexual contact with persons who live or travel outside of Utah. Also, because untreated syphilis in a pregnant woman can infect and even kill her developing baby, it is very important that all pregnant women have a blood test for syphilis.

People who test positive for syphilis or are diagnosed with other sexually transmitted diseases (i.e., chlamydia, gonorrhea, or pelvic inflammatory disease) should be reported to the Utah Department of Health or to their local health department as soon as possible. Trained disease investigation specialists will then conduct confidential case investigations to identify the sexual contacts of these people and refer them for medical care. These investigations are absolutely confidential and the identity of the infected person, even if that person is a minor, will not be revealed to anyone besides those individuals conducting the case investigation. Investigations are crucial to the success of any STD prevention and control program, because identifying (and referring for medical care) the sexual contacts of an infected person is vital in stopping disease transmission.

1. Anti-HAV positive (+), anti-HAV IgM negative (-), HBsAg (+), anti-HBs (-), anti-HBc IgM (+), anti-HBc (+), HbeAg (+), anti-HCV (+).

2. Anti-HAV (+), anti-HBc (+) and anti-HCV (+) with supplemental RIBA (+).

3. HBsAg (+), anti-HBs (-), anti-HBc IgM (-), anti-HBc IgG (+), HBeAg (+), anti-Hbe (-), anti-HAV (+).

4. HBsAg (-), anti-HBs (+), anti-HBc IgM (-), anti-HBc IgG (+), HBeAg (-), anti-Hbe (+), anti-HAV (+), anti-HAV IgM (-), anti-HCV (-).

Hepatitis B & C Reporting Issues

Acute hepatitis B

“Acute hepatitis B” should be reported any time the anti-HBc IgM is positive. “Acute hepatitis B” should also be reported when the HBsAg is positive, the anti-HBc IgM has not been performed, and the patient has classic symptoms of acute viral hepatitis. Please include onset date, symptoms, and all available hepatitis panel and serum aminotransferase levels.

“Chronic hepatitis B” should be reported when the HBsAg is positive, anti-HBc is positive, and anti-HBc IgM is negative. Please include all available hepatitis panel results and serum aminotransferase levels. Such cases need not be reported if the case has previously been reported.

“Acute HCV” should be reported when the patient has 1) classic symptoms of acute viral hepatitis 2) a negative anti-HAV IgM, negative anti-HBc IgM (if done) or negative HBsAg, and a positive anti-HCV, verified by a reactive supplemental test such as a Recombinant Immunoblot Assay (RIBA) or PCR amplification and 3) serum aminotransferase levels >2.5 times the upper limit of normal.

“Chronic HCV” or HCV, Status Unknown” should be reported when an asymptomatic patient has 1) a positive anti-HCV with a positive supplemental HCV test (e.g., RIBA or HCV RNA), and 2) a negative anti-HAV IgM, a negative HBsAg and a negative anti-HBcIgM (if done). Liver function tests may be within normal range or elevated. Please include hepatitis C virus genotyping and serotyping when available.

Hepatitis unspecified

“Hepatitis Unspecified” should be reported when 1) the patient has classic symptoms of acute viral hepatitis 2) the anti-HAV, anti-HBcIgM (if done) or HBsAg, and the anti-HCV (if done) are all negative, and 3) the serum aminotransferase levels are >2.5 times the upper limit of normal. Be aware that patients infected with HCV may test negative on first test but the HCV antibody is present, in almost all patients by four weeks after onset of acute illness.

Who should report?

Laboratories should report all positive anti-HAV IgM, HBsAg, anti-HBc IgM, and HCV RIBA test results. Physicians should report diagnosed cases of acute and chronic hepatitis B and C with supportive clinical and laboratory data.

Answers:

1. (d) This set of lab results indicates an acute case of hepatitis B. A positive HBsAg shows the client to be contagious; the positive anti-HBc IgM designates acute infection as opposed to chronic; the positive HBeAg indicates active viral replication, thus the patient is highly contagious. Liver function tests (LFT), ALT and AST are generally normal in the early acute state of HBV infection and become elevated as the infection progresses. Anti-HCV can be considered a screening test for hepatitis C. In this case, additional testing (RIBA, HCV RNA [by PCR]) is required to confirm a diagnosis of hepatitis C, either acute or chronic. A positive anti-HAV with a negative anti-HAV IgM would indicate a past infection with hepatitis A and the patient is immune.

2. (b) The hepatitis C test results indicate this patient has or has had hepatitis C. Additional testing is required to determine disease status. If the patient is chronically infected, increases in the serum aminotransferases (ALT and AST) can range from 0 to 20 times (usually less than five times) the upper limit of normal. Testing for HCV RNA is helpful in determining chronic infection in patients with normal ALT levels. The hepatitis A (anti-HAV+) and hepatitis B (anti-HBc+) test results do not differentiate between acute and chronic infection. Additional testing (anti-HAV IgM and anti-HBc IgM) is required to determine hepatitis A and hepatitis B status.

3. (c) The anti-HBc IgM negative test with a positive HBsAg indicates chronic hepatitis B infection. The HBeAg may or may not be positive during chronic infection and the ALT and AST may or may not be elevated. A positive anti-HAV does not differentiate between acute or past infection of hepatitis A. An anti-HAV IgM is required to assess acute infection.

Send comments to:  The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104, or call (801) 538-6191

Approval 8000008:  Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Gerrie Dowdle, MSPH, Managing Editor
Connie Dean, Production Assistant