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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. - PowerPoint PPT Presentation
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Syphilis Surveillance:What are we looking at?
Tom Peterman Richard KahnCarol Ciesielski Elizabeth Ortiz-RiosBruce Furness Susan BlankJulie Schillinger Bob GunnMelanie Taylor
Field Epidemiology Unit ESB, DSTDP, CDC
Syphilis stage definitions confusing, especially latent syphilis.
Some: Don’t understand definition. Don’t like the definition. Stage at the time DIS sees case.
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
Syphilis of Unknown Duration
? probable early infections that did not meet the definition for Early Latent.
Rate of primary and secondary, early latent, late latent, and unknown duration syphilis,
New York City, 1992-2002
0
10
20
30
40
50
60
70
80
92 93 94 95 96 97 98 99 0 1 2
Year
Rat
e (p
er 1
00,0
00)
Late Latent
Early latent
Primary & Secondary
Unknown Duration
Rate of primary and secondary, early latent, late latent, and unknown duration syphilis,
Chicago, 1992-2002
0
10
20
30
40
50
60
70
80
90
92 93 94 95 96 97 98 99 0 1 2
Year
Rat
e (p
er 1
00,0
00)
Late Latent
Early latent
Primary & Secondary Unknown Duration
Chicago
0
10
20
30
40
50
60
70
80
90
92 93 94 95 96 97 98 99 0 1 2
Year
Rat
e (p
er 1
00,0
00)
Los Angeles
0
5
10
15
20
25
30
35
40
Year
Rat
e (p
er 1
00,0
00)
San Diego
0
2
4
6
8
10
12
14
Year
Rat
e (p
er 1
00,0
00)
0
10
20
30
40
50
60
70
80
Year
Rat
e (p
er 1
00,0
00)
New York City
San Juan
0
10
20
30
40
50
60
70
92 93 94 95 96 97 98 99 0 1 2
Year
Rat
e (p
er 1
00,0
00)
Washington D.C.
0
20
40
60
80
100
120
140
160
180
Year
Rat
e (p
er 1
00,0
00)
Early latent
Late Latent
Primary & Secondary
Late Latent
Late LatentEarly latent
Early latent
Discuss syphilis classification, Reactor grid.Review syphilis records starting in 2002, + 30 cases each of primary, secondary, early latent, unknown duration, late latent.
Methods
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.
Sites’ Stage (n) CDC Stage Not Primary Secondary Early L Unk Late SyphilisPrimary 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
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.
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.
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.
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.
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 stageMost had neg RPR or previoustreatment without titer rise.
Unknown Duration:
“Unknown” is often confused with “not known”. Median age for primary and secondary syphilis is 35.
Recommendation: Drop it.
Discussion
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.
Early LatentConsider 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
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.
