Community approach gets a grip on syphilis
Cases of primary and secondary syphilis are at their lowest levels in the United States since reporting began in 1941.1 If that statistic leaves you complacent, then take a tip from public health officials in Guilford County, NC: Never lose your vigilance, because the outbreak in an outlying area may be at your doorstep the next day.
Syphilis is manifested increasingly as an epidemic rather than an endemic disease in the United States; focal outbreaks are still occurring. That message was driven home to workers at the Greensboro-based health department when an increase in syphilis cases from neighboring Forsyth County soon manifested as a sharp uptick in cases in Guilford County.
In 1996 and 1997, 153 cases of primary and secondary syphilis were reported each year in Guilford County, representing a 147% increase from the 62 cases reported in 1994.2 A concerted effort among Guilford County health officials and community resources took a fast-track, broad-based approach to tackling the problem.
Along with help from the North Carolina Division of Epidemiology in Raleigh and the Centers for Disease Control and Prevention (CDC) in Atlanta, the group effort appears to have paid off. Based on reported cases of primary and secondary syphilis in Guilford County through August 1998, cases are expected to decrease 38% in 1998 from 1997.
"We have projected that there will be a sig nificant decrease for the end of 1998," reports Madeline Sutton, MD, MPH, a CDC epidemic intelligence service officer. "After instituting some of the interventions that came out of their community outreach effort and CDC’s part of the investigation and later initiatives that followed, it looks like they [Guilford County] were able to have an impact."
Increase in cases not surprising
Use of crack cocaine and exchange of sex for drugs are fuel for a syphilis outbreak.3 Because Guilford County is intersected by two major highways, it is not surprising that syphilis should flare up, explains Harold Gabel, MD, MPH, director of the county health department. When the increase was identified, local officials swiftly moved into place. Calling in state and national health resources, the county pulled representatives from a broad cross-section of community groups into what was dubbed the "War Room."
"We began to sit down and figure out how to get on top of this thing," reports Gabel. "It was a fairly intense process with a table with about 20 people sitting around it from all different places: CDC assignees, state people, community-based organization people, our own staff, health educators, and STD investigators."
Participants fanned out across the county to spread the news about the plan to combat syphilis. Gabel went to county OB/GYNS to ask that women be tested at delivery in addition to the first and third trimesters. He also let local internists know that if they suspect syphilis in a patient, they should call the health department for immediate testing. Judges were asked to be particularly vigilant with people arrested for prostitution or drugs in terms of urging them to get tested for syphilis.
Officials formed Rapid Intervention Outreach Teams to educate the community about syphilis, notes Sutton. Members spent two or three days doing active research, such as drawing blood, to detect more cases. Public health officials worked closely with law enforcement to offer earlier testing within the correctional facilities. While full testing was being performed some 10 to 14 days after incarceration, many inmates were moving out before testing was provided.
"We now have people going into the jails at least twice a week for education and testing," Gabel says. "We all have constraints in terms of money, space, and time, and jails aren’t med ical units, but they have really tried hard to make the testing as available as possible and to set space aside and to do it as frequently as possible."
Guilford health officials participated in a recent regional sheriffs’ conference to update law enforcement officers from the 11 surrounding counties on syphilis, he says. Jails and hospital emergency departments have been identified as sites of high syphilis prevalence during epidemics, since many arrested persons lack medical insurance or used emergency department services at their last medical visit.4 By targeting these areas, public health officials can make an impact on syphilis in areas with endemic or epidemic syphilis.
Public perceptions of local health departments are not always good ones, notes Gabel. Guilford public officials were concerned at first that many citizens would not want to come to the health department for screening. Thanks to the efforts of the local organizations who participated in the syphilis outreach program, the department now has increased acceptance in the community.
"The community organizations which went out into neighborhoods had credibility because they were either associated with the communities or had entrees," he says. "By doing street outreach, they not only got into these neighborhoods, but they built up our credibility."
References
1. Primary and secondary syphilis — United States, 1997. MMWR 1998; 47:493-497.
2. Outbreak of primary and secondary syphilis — Guilford County, North Carolina, 1996-1997. MMWR 1998; 47:1,070-1,073.
3. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine and prostitution. Am J Public Health 1990; 80:853-57.
4. Beltrami JF, Cohen DA, Hamrick JT, et al. Rapid screening and treatment for sexually transmitted diseases in arrestees: a feasible control measure. Am J Public Health 1997; 87:1,423-1,426.
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