The Re-emergence of Syphilis

1. The Re-emergence of Syphilis George Washington University School of Public Health and Health Services Department of Epidemiology and Biostatistics October 12, 2007

2. Outline Syphilis Elimination Four stages of syphilis Diagnosis Treatment Follow-up United States data Washington, DC data Congenital Syphilis

3. Objectives Discuss the National Plan to Eliminate Syphilis List the four stages of syphilis and define infectious syphilis Recall at least one recommended syphilis treatment Describe the trends and demographics of infectious syphilis is the United States Describe the trends and demographics of infectious syphilis in Washington, DC At the conclusion of this 50 minute review of syphilis and it�s reemergence, the participant should be able to:At the conclusion of this 50 minute review of syphilis and it�s reemergence, the participant should be able to:

4. Who am I? Bruce W. Furness, MD, MPH Received my MD degree from Georgetown University in 1994 � Washington, DC Completed 4 years of Internal Medicine/Pediatric residency training at UCLA / Cedars-Sinai Medical Center � Los Angeles, CA Recruited into CDC�s 2-year Epidemic Intelligence Service (EIS) Fellowship - Division of Parasitic Diseases � Atlanta, GA

5. Received my MPH degree from Johns Hopkins University in 2001 � Baltimore, MD Employed by The Centers for Disease Control and Prevention (CDC), National Center for HIV, STD, and TB Prevention (NCHSTP), Division of STD Prevention (DSTDP), Epidemiology and Surveillance Branch (ESB), Field Epidemiology Unit (FEU) Assigned to both the Washington, DC STD Control Program and the National Syphilis Elimination Rapid Response Team (RRT) Who am I? (cont�d)

6. A multi-disciplinary, mobile, field-based unit Created in 2001 by CDC�s Division of STD Prevention Part of the National Plan to Eliminate Syphilis from the United States Charged with helping state and local health departments rapidly detect, assess, and respond to syphilis outbreaks The National Syphilis Elimination Rapid Response Team (RRT)

7. National Plan to Eliminate Syphilis Launched in 1999 by the CDC Purpose = to end sustained transmission of syphilis in the United States Why? Low rate of infectious syphilis Concentration of the majority of cases in a small number of geographic areas How? Focused efforts on the populations most affected by syphilis Heterosexual minority populations, particularly African Americans The low rate of infectious syphilis and the concentration of the majority of syphilis cases in a small number of geographic areas in the United States led to the development of the CDC�s National Plan to Eliminate Syphilis, announced by Surgeon General David Satcher in 1999The low rate of infectious syphilis and the concentration of the majority of syphilis cases in a small number of geographic areas in the United States led to the development of the CDC�s National Plan to Eliminate Syphilis, announced by Surgeon General David Satcher in 1999

8. Revised Target Elimination of syphilis from the United States Interim elimination targets (by 2010) Reduce rates of infectious syphilis in the U.S. to less than 2.2 per 100,000 population Reduce congenital syphilis to fewer than 3.9 per 100,000 live births Reduce Black to White health disparities to a ratio of less than 3:1 The original ambitious plan called for reducing infectious syphilis cases to 1,000 or fewer (<0.4 / 100,000 population) and to increase the number of syphilis-free counties to 90% by 2005 The original ambitious plan called for reducing infectious syphilis cases to 1,000 or fewer (<0.4 / 100,000 population) and to increase the number of syphilis-free counties to 90% by 2005

9. Strategic Goals #1 - invest in and enhance public health services and interventions Improve surveillance and outbreak response Improve diagnosis, treatment, and prevention services Improve testing and laboratory services The plan is guided by three goals, each of which includes concrete activities for CDC, state and local health departments, community organizations, and private healthcare providers� Collect info on the gender of sexual partners Increasing the proportion of pregnant women screened during prenatal care visits Rapid syphilis testThe plan is guided by three goals, each of which includes concrete activities for CDC, state and local health departments, community organizations, and private healthcare providers� Collect info on the gender of sexual partners Increasing the proportion of pregnant women screened during prenatal care visits Rapid syphilis test

10. #2 - prioritize and target interventions to populations at greatest risk Target interventions for groups most at risk Mobilize and support private healthcare providers #3 - improve accountability of prevention efforts Improve training and staff development Use data-driven planning and evaluation Carry out new research and development activities Strategic Goals (cont�d) Developing internet-based interventions for MSM Provide training, policy guidance, and up-to-date syphilis information to private providers Complements the healthcare provider training � websites, patient appropriate lingo, etc. Evidence-based planning and evaluation of programs help ensure the best use of limited program resources Research the cost-effectiveness of new syphilis prevention interventions � does IPN work, are syphilis awareness campaigns useful?Developing internet-based interventions for MSM Provide training, policy guidance, and up-to-date syphilis information to private providers Complements the healthcare provider training � websites, patient appropriate lingo, etc. Evidence-based planning and evaluation of programs help ensure the best use of limited program resources Research the cost-effectiveness of new syphilis prevention interventions � does IPN work, are syphilis awareness campaigns useful?

11. What Do These Men Have in Common? Charles VIII The King of France from 1483 - 1498 Ivan the Terrible The first ruler of Russia to assume the title of tsar Friedrich Nietzsche The highly significant German philosopher Al Capone The infamous American gangster known as �scarface� Paul Gauguin The French post-impressionist painter Adolf Hitler The German Chancellor and leader of the Nazi party

12. Syphilis A complex sexually transmitted disease (STD) caused by the spirochete bacterium Treponema pallidum Has a highly variable clinical course Often called �the great imitator� because so many of the signs and symptoms are indistinguishable from those of many other diseases Passed from person to person through direct contact with a syphilis sore or rash

13. Treponema pallidum This is an electron micrograph of the spirochete T. pallidum. Spirochetes are a phylum of distinctive bacteria, which have long, helically coiled cells. This is an electron micrograph of the spirochete T. pallidum. Spirochetes are a phylum of distinctive bacteria, which have long, helically coiled cells.

14. Syphilis & HIV The clinical manifestations, serologic responses, efficacy of treatment, and occurrence of complications of syphilis have always been complex HIV coinfection adds to the confusion Because syphilis is a disease with a broad range of manifestations and variable course, assessing reports of unusual clinical or laboratory findings in HIV-coinfected patients is difficult �If you know syphilis, you know medicine��If you know syphilis, you know medicine�

15. Public Health Importance Untreated syphilis damages internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints This damage may be serious enough to cause death Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection There is an estimated 2- to 5-fold increased risk of acquiring HIV infection when syphilis is present The syphilis bacterium can infect the baby of a woman during her pregnancy

16. Infectious Syphilis There are 4 stages of syphilis: Primary Secondary Latent Tertiary Primary and secondary syphilis are the most infectious stages And are therefore used as a measure of disease incidence

17. Primary Syphilis First stage of T. pallidum infection Characterized by lesions (chancres) occurring at the site of entry (either through mucous membranes or epithelial tears) Lesions appear 10 � 90 days after infection (average = 21 days) Lesions are painless and self limited and usually last 3-6 weeks without treatment

18. Primary Syphilis The sore of primary syphilis is usually single, firm, round, small, and painless.The sore of primary syphilis is usually single, firm, round, small, and painless.

19. Primary Syphilis This is the typical sore of primary syphilis. It is usually firm, small, round, and painless.This is the typical sore of primary syphilis. It is usually firm, small, round, and painless.

20. Secondary Syphilis The second stage of T. pallidum infection Characterized by a rash that may include the palms of the hands and the soles of the feet (palmar / plantar rashes) and/or mucous membrane lesions (condyloma lata) The rash may appear before the primary lesion has healed or several weeks afterward The rash is also painless and self limited, and although can last for a year, usually resolves within a few weeks without treatment

21. Secondary Syphilis This the typical rash of secondary syphilis - rough, red, or reddish-brown spots that usually affect the palms of the hands and the soles of the feet, but can appear anywhere on the body.This the typical rash of secondary syphilis - rough, red, or reddish-brown spots that usually affect the palms of the hands and the soles of the feet, but can appear anywhere on the body.

22. Secondary Syphilis The rash of secondary syphilis usually consists of rough, red or reddish brown spots, that do not itch The rash of secondary syphilis usually consists of rough, red or reddish brown spots, that do not itch

23. Latent Syphilis The third (hidden) stage of T. pallidum infection Characterized by no distinguishable signs or symptoms Begins when the secondary symptoms disappear and persists for years or decades Detected by serologic testing

24. Tertiary Syphilis The fourth stage of T. pallidum infection Manifestations occur much later in life and cause significant morbidity Gummatous syphilis Cardiovascular syphilis Neurosyphilis Twenty percent of untreated patients die of the disease

25. Gummatous Syphilis Gummatous syphilis presents as destructive lesions of the skin and bonesGummatous syphilis presents as destructive lesions of the skin and bones

26. Prevention The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact Or, to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected Latex male condoms, when used consistently and correctly, can reduce the risk of syphilis only when the infected areas are covered or protected by the condom

27. Diagnosis Definitive Darkfield examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis Presumptive A presumptive diagnosis is possible with the use of two types of serologic tests for syphilis Nontreponemal tests Treponemal tests Darkfield Microscopy - the microscopic examination of chancre fluid using dark ground illumination � is the most specific technique for diagnosing syphilis when an active chancre is present Darkfield Microscopy - the microscopic examination of chancre fluid using dark ground illumination � is the most specific technique for diagnosing syphilis when an active chancre is present

28. Nontreponemal Tests Include: Rapid Plasma Reagin (RPR) assay Venereal Disease Research Laboratory (VDRL) assay Measures nonspecific antibodies False-positive reactions can occur Used for screening After adequate treatment, usually become non-reactive

29. Nontreponemal Tests (cont�d) Nontreponemal test antibody titers usually correlate with disease activity Results should be reported quantitatively The use of only one type of serologic test is insufficient for diagnosis because false-positive nontreponemal test results may occur secondary to various medical conditions

30. Treponemal Tests Include: T. pallidum hemagglutination assay (TPHA) Fluorescent treponemal antibody absorbtion assay (FTA-ABS) Enzyme-linked immunosorbent assay (EIA) for anti-treponemal IgG T. pallidum particle agglutination (TP-PA) Measures more specific antibodies

31. Treponemal Tests (cont�d) Usually used for confirmation Correlate poorly with disease activity Most patients who have reactive treponemal tests will have reactive tests for the remainder of their lives, regardless of treatment or disease activity

32. Sensitivity & Specificity of Tests for Syphilis

33. Diagnosis of Neurosyphilis No test can be used alone to diagnose neurosyphilis The VDRL-CSF (a VDRL assay on cerebral spinal fluid) is highly specific, but it is insensitive When reactive in the absence of substantial contamination of cerebral spinal fluid (CSF) with blood, it is considered diagnostic of neurosyphilis The CSF FTA-ABS is less specific (i.e., yields more false-positive results), but the test is highly sensitive A negative CSF FTA-ABS test can be used to exclude neurosyphilis

34. Neurosyphilis and HIV Centers for Disease Control and Prevention. Symptomatic Early Neurosyphilis Among HIV-Positive Men Who Have Sex with Men � Four Cities, United States, January 2002�June 2004. MMWR 2007;56:625-628. The estimated risk for having symptomatic early neurosyphilis in this population with early syphilis was 1.7% (40 of 2,380), and the risk for having neurosyphilis with persistent symptoms 6 months after treatment was 0.5% (12 [30% of 40] of 2,380). Health-care providers should be alert to signs and symptoms of neurosyphilis among MSM and should counsel MSM about the various symptoms of neurosyphilis and the risk for illness and permanent disabilityHealth-care providers should be alert to signs and symptoms of neurosyphilis among MSM and should counsel MSM about the various symptoms of neurosyphilis and the risk for illness and permanent disability

35. Treatment Mercury �A night in the arms of Venus leads to a lifetime of Mercury� Salvarsan & Neoalvarsan Arsenic-containing drugs Malaria Some who developed high fevers could be cured of syphilis Penicillin Discovered during and widespread after World War II

36. Treatment (cont�d) Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of syphilis The preparations used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage, clinical manifestations of the disease, and co-morbidities Neither combinations of benzathine penicillin and procaine penicillin nor oral penicillin preparations are considered appropriate for the treatment of syphilis

37. Treatment of Early Syphilis Includes primary, secondary, and early latent syphilis (<1 year) Benzathine penicillin G 2.4 million units IM in a single dose Alternatives: Doxycycline 100mg po BID x 14 days Tetracycline 500mg po QID x 14 days Pediatric dose = 50,000 units/kg IM in a single dose (maximum = 2.4 million units)

38. Treatment of Late Syphilis Includes late latent (>1 year), late latent of unknown duration, and tertiary syphilis (excluding neurosyphilis) Benzathine penicillin G 2.4 million units IM q week x 3 (7.2 million units total) Alternatives: Doxycycline 100mg po BID x 28 days Tetracycline 500 mg po QID x 28 days Pediatric dose = 50,000 units/kg IM q week x 3 (maximum total = 7.2 million units)

39. Treatment of Neurosyphilis Aqueous crystalline penicillin G 3 to 4 million units IV q 4 hours for 10-14 days (18-24 million units/day) Alternative = 2.4 million units of procaine penicillin G IM q day plus probenecid 500mg po QID both for 10-14 days

40. Follow-Up Treatment failure can occur with any regimen However, assessing response to treatment frequently is difficult and definitive criteria for cure or failure have not been established Nontreponemal test titers might decline more slowly for persons who previously had syphilis

41. Follow-Up (cont�d) Patients should be reexamined clinically and serologically 6 months and 12 months after treatment More frequent evaluation might be prudent if follow-up is uncertain HIV-infected patients should be evaluated more frequently At 3-month intervals instead of 6-month intervals

42. Treatment Failure Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer probably failed treatment or were reinfected These patients should be retreated and reevaluated for HIV infection 15% of patients with early syphilis treated with the recommended therapy will not achieve a two dilution decline in nontreponemal titer used to define response at 1 year after treatment

43. Infectious Syphilis, United States, 1970 - 2004 The rate of primary and secondary syphilis � the most infectious stages of the disease � declined 90% from 1990 to 2000. In 2000, the rate was the lowest since reporting began in 1941.The rate of primary and secondary syphilis � the most infectious stages of the disease � declined 90% from 1990 to 2000. In 2000, the rate was the lowest since reporting began in 1941.

44. Infectious Syphilis, United States, 2000�2005 However, over the past six years the syphilis rate in the United States has been increasing.However, over the past six years the syphilis rate in the United States has been increasing.

45. Infectious Syphilis by Sex, United States, 2000-2005 Overall, increases in primary and secondary syphilis rates between 2000 and 2006 were observed only among men. Notably, in 2004, for the first time in over 10 years, the rate among females did not decrease.Overall, increases in primary and secondary syphilis rates between 2000 and 2006 were observed only among men. Notably, in 2004, for the first time in over 10 years, the rate among females did not decrease.

46. Male : Female Ratio of Infectious Syphilis Cases, United States, 2000�2005 The male-to-female ratio for primary and secondary syphilis has risen steadily between 2000 and 2004 (from 1.4 to 5.4), suggesting increased syphilis transmission among MSM. This increase occurred among all racial and ethnic groups.The male-to-female ratio for primary and secondary syphilis has risen steadily between 2000 and 2004 (from 1.4 to 5.4), suggesting increased syphilis transmission among MSM. This increase occurred among all racial and ethnic groups.

47. Estimated Infectious Syphilis Cases by Transmission Category, United States, 2004 Peterman TA, Furness BW. The resurgence of syphilis among men who have sex with men. Current Opinion Infect Dis 2007;20:54-59. Increasing cases of primary and secondary syphilis among MSM are believed to be largely responsible for the overall increases in the national syphilis rate observed since 2000. CDC estimates that MSM compromised 64% of the primary and secondary cases in 2004, up from 5% in 1999.Increasing cases of primary and secondary syphilis among MSM are believed to be largely responsible for the overall increases in the national syphilis rate observed since 2000. CDC estimates that MSM compromised 64% of the primary and secondary cases in 2004, up from 5% in 1999.

48. Infectious Syphilis by Race, United States, 2000-2005 Racial gaps in syphilis numbers have narrowed. This has been due to both declining disease rates among African Americans and the significant increases among white men in recent years. In 2004, the syphilis rates among blacks increased for the first time in more than a decade, with the most significant increases among black men.Racial gaps in syphilis numbers have narrowed. This has been due to both declining disease rates among African Americans and the significant increases among white men in recent years. In 2004, the syphilis rates among blacks increased for the first time in more than a decade, with the most significant increases among black men.

49. Infectious Syphilis by Ethnicity, United States, 2000-2005 Similar to White non-Hispanics, the number of primary and secondary syphilis cases reported among Hispanics has also steadily increased from 2000 to 2006.Similar to White non-Hispanics, the number of primary and secondary syphilis cases reported among Hispanics has also steadily increased from 2000 to 2006.

50. Infectious Syphilis by Age Category, United States, 2000-2005 For each year from 2000 to 2006 the most number of infectious syphilis cases have been reported among those 30-39 years of age (red), followed by those 20-29 years of age (green).For each year from 2000 to 2006 the most number of infectious syphilis cases have been reported among those 30-39 years of age (red), followed by those 20-29 years of age (green).

51. Infectious Syphilis by Provider Type, United States, 1984-2004

52. Infectious Syphilis Rates by State, 2004 Rate = cases per 100,000 populationRate = cases per 100,000 population

53. Infectious Syphilis Rates by State, 2005

54. Infectious Syphilis, Washington, DC, 2000-2006 Although the number of infectious syphilis cases reported in the District of Columbia decreased 79% from 1994 to 2000 (from 178 to 38, respectively), from 2000 to 2005, the number of infectious syphilis cases reported increased 200% (from 38 to 114, respectively).Although the number of infectious syphilis cases reported in the District of Columbia decreased 79% from 1994 to 2000 (from 178 to 38, respectively), from 2000 to 2005, the number of infectious syphilis cases reported increased 200% (from 38 to 114, respectively).

55. Infectious Syphilis, Washington, DC, 2000-2005 This table compares infectious syphilis case numbers and rates in Washington, DC to other major metropolitan areas of the United States with >200,000 population, as reported by the Centers for Disease Control & Prevention. As a reminder, I want to emphasize that the National Syphilis Elimination Goal for 2005 was < 0.4 cases per 100,000 population.This table compares infectious syphilis case numbers and rates in Washington, DC to other major metropolitan areas of the United States with >200,000 population, as reported by the Centers for Disease Control & Prevention. As a reminder, I want to emphasize that the National Syphilis Elimination Goal for 2005 was < 0.4 cases per 100,000 population.

56. Infectious Syphilis by Sex, Washington, DC, 2000-2006 Most of the infectious syphilis cases reported in Washington, DC from 2000 to 2005 were among men. The number of cases reported among women decreased from 2000 to 2003 (from 10 to 3, respectively), but then increased from 2003 to 2005 (from 3 to 11, respectively).Most of the infectious syphilis cases reported in Washington, DC from 2000 to 2005 were among men. The number of cases reported among women decreased from 2000 to 2003 (from 10 to 3, respectively), but then increased from 2003 to 2005 (from 3 to 11, respectively).

57. Infectious Syphilis by Race, Washington, DC, 2000-2006 Most of the infectious syphilis cases reported in Washington, DC from 2000 to 2005 were among Blacks. Of note, there were 3 cases reported among Asian / Pacific Islanders in 2001 and 2005. Most of the infectious syphilis cases reported in Washington, DC from 2000 to 2005 were among Blacks. Of note, there were 3 cases reported among Asian / Pacific Islanders in 2001 and 2005.

58. Percent of Infectious Syphilis Cases Reported, by Race, Washington, DC, 2000-2006 The percentage of infectious syphilis cases reported among Blacks, though, has been gradually decreasing over time, while the percentage of infectious syphilis cases reported among Whites has been gradually increasing.The percentage of infectious syphilis cases reported among Blacks, though, has been gradually decreasing over time, while the percentage of infectious syphilis cases reported among Whites has been gradually increasing.

59. Infectious Syphilis by Ethnicity, Washington, DC, 2000-2006 Both the number of infectious syphilis cases reported and the percent of total infectious syphilis cases reported among Hispanics increased from 2001 to 2004, but then decreased in 2005.Both the number of infectious syphilis cases reported and the percent of total infectious syphilis cases reported among Hispanics increased from 2001 to 2004, but then decreased in 2005.

60. Infectious Syphilis by Age Category, Washington, DC, 2000-2006 In each year, the greatest number of cases were reported among persons aged 30-39 years (represented by the lime green bar). In each year, most cases were reported among 20-49 year olds (represented by the yellow, lime green, and orange bars). Congenital syphilis cases (< 10 y. o.) (represented by the red bar), decreased from 2000 to 2005. Of note, there were no congenital syphilis cases reported in Washington, DC in 2005. In each year, the greatest number of cases were reported among persons aged 30-39 years (represented by the lime green bar). In each year, most cases were reported among 20-49 year olds (represented by the yellow, lime green, and orange bars). Congenital syphilis cases (< 10 y. o.) (represented by the red bar), decreased from 2000 to 2005. Of note, there were no congenital syphilis cases reported in Washington, DC in 2005.

61. Infectious Syphilis by Ward, Washington, DC, 2000-2006 In 2000, the greatest number of cases were reported in Ward 8 (represented by the dark green bar). In 2001 and 2005, the greatest number of cases were reported in Ward 2 (represented by the dark blue bar). In 2002, the greatest number of cases were reported in Ward 1 (represented by the red bar). In 2004, the greatest number of cases were reported equally in Wards 1 and 2.In 2000, the greatest number of cases were reported in Ward 8 (represented by the dark green bar). In 2001 and 2005, the greatest number of cases were reported in Ward 2 (represented by the dark blue bar). In 2002, the greatest number of cases were reported in Ward 1 (represented by the red bar). In 2004, the greatest number of cases were reported equally in Wards 1 and 2.

62. Infectious Syphilis by Provider Type, Washington, DC, 2000-2006

63. Infectious Syphilis by Selected Providers, Washington, DC, 2000-2006 This bar graph represents the infectious syphilis cases from the three providers reporting the greatest number of cases in Washington, DC.This bar graph represents the infectious syphilis cases from the three providers reporting the greatest number of cases in Washington, DC.

64. Infectious Syphilis Among MSM, Washington, DC, 2000-2006 Although the number of infectious syphilis cases reported among MSM has steadily increased over the last 6 years (from 16 to 69, respectively), the percentage of infectious syphilis cases reported decreased over the last 3 years (from 76% to 61% respectively).Although the number of infectious syphilis cases reported among MSM has steadily increased over the last 6 years (from 16 to 69, respectively), the percentage of infectious syphilis cases reported decreased over the last 3 years (from 76% to 61% respectively).

65. Congenital Syphilis A wide spectrum of severity exists, and only severe cases are clinically apparent at birth Infant or child < 2 years of age Hepatosplenomegaly, rash, condyloma lata, snuffles, jaundice, pseudoparalysis, anemia or edema Older children Stigmata: interstitial keratitis, nerve deafness, anterior bowing of shins, frontal bossing, mulberry molars, Hutchinson teeth, saddle nose, rhagades, or Clutton joints A condition caused by infection in utero with Treponema plallidumA condition caused by infection in utero with Treponema plallidum

66. Probable Congenital Syphilis A condition affecting an infant whose mother had untreated or inadequately treated syphilis at delivery, regardless of signs in the infant, or an infant or child who has a reactive treponemal test for syphilis and any one of the following: Any evidence on physical examination Any evidence on radiographs of long bones A reactive CSF VDRL An elevated CSF cell count or protein (without other cause) A reactive fluorescent treponemal antibody absorbtion assay (FTA-ABS) or enzyme-linked immunosorbent assay (EIA) for anti-treponemal IgM Inadequate treatment consists of any non-penicillin therapy or penicillin given less than 30 days before deliveryInadequate treatment consists of any non-penicillin therapy or penicillin given less than 30 days before delivery

67. Confirmed Congenital Syphilis A case that is laboratory confirmed Demonstration of T. pallidum in specimens from lesions, placenta, umbilical cord, or autopsy material: Darkfield microscopy Fluorescent antibody Other specific stains in specimens

68. Congenital Syphilis, United States, 2001�2005

69. References Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006;55(RR-11):1-94. Centers for Disease Control and Prevention. Report of the Syphilis Elimination Consultation, 1-2 August 2005. Atlanta. October 2005. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2005. Atlanta, GA: U.S. Department of Health and Human Services, November 2006.

70. Reportable STDs For questions, comments, or concerns about reporting syphilis and/or other STDs, please contact the Washington, DC STD Control Program Special Project Coordinator: (202) 442-4760 or Paulette.Jackson@dc.gov