Joel R. Greenspan

Epidemiology of Syphilis in the United States, 1941–1993

Background and Objectives: The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941–1993 in the context of some of these factors. Study Design: Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. Results: Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad‐based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. Conclusions: Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.

Deaths attributable to tubal sterilization in the United States, 1977 to 1981

In 1979, the Centers for Disease Control began surveillance of deaths attributable to tubal sterilization in order to determine why they occur and what may be done to prevent them. Since that time, 29 such deaths have been identified as occurring in the United States from 1977 through 1981. Of these 29 deaths, 11 followed complications of general anesthesia, seven were due to sepsis, four were due to hemorrhage, three were due to myocardial infarction, and four deaths were related to other causes. Some of these deaths might have been prevented by use of endotracheal intubation for general anesthesia, particularly for laparoscopic sterilization, safer use of unipolar coagulation or use of alternative techniques, careful insertion of the needle and trocar for laparoscopy, and discontinuation of oral contraceptives before sterilization. Further surveillance may help to make tubal sterilization even safer.

Screening High-Risk Adolescent Males for Chlamydia trachomatis Infection: Obtaining Urine Specimens in the Field

Background and Objectives: Reported case data suggest that few men are being tested for Chlamydia trachomatis (CT) infection (female:male reported case ratio is >5:1) partially because men seek preventive health services less frequently than women and, until recently, obtaining a CT specimen from men required a urethral swab, which has low patient acceptability. A study was conducted in San Diego, CA, to determine whether urine specimens could be obtained from high‐risk teen males in the field using a peer teen outreach approach. Goals: Identify teen males infected with CT and provide treatment and partner management services. Study Design: Prevalence survey of 261 teen males and a program cost evaluation. Results: During the 6.5‐month study period (Dec 15, 1995 to June 30, 1996) an estimated 1,860 teen males were approached and 261 submitted a urine specimen; 16 (6.1%) were positive by polymerase chain reaction. All positive males were treated with azithromycin, 1 gm, in the field, and 9 female sex partners were treated, 7 of whom were CT positive. The cost per specimen obtained and per CT infection identified was

Syphilis in San Diego County 1983–1992: Crack Cocaine, Prostitution, and the Limitations of Partner Notification

103 and

Mortality risk associated with tubal sterilization in United States hospitals

1,677, respectively. The annual cost for adding a peer teen outreach service to an existing STD program using existing staff and adding 1.2 full‐time equivalents of outreach time is approximately

The impact of laparoscopy on tubal sterilization in United States hospitals, 1970 and 1975 to 1978

25,000. Conclusion: Peer teen outreach and in‐field collection of urine specimens appear to be an acceptable alternative for screening teen males for CT and should be further evaluated in other communities.

The Association Between Oral Contraception and Hepatocellular Adenoma — A Preliminary Report

Background and Objectives Recent epidemics of syphilis have been associated with crack cocaine use and anonymous sex for drugs, suggesting a potential limitation of sex partner notification as a disease control strategy. To assess these factors in an inner city epidemic of syphilis in San Diego County, California, we performed a descriptive epidemiologic analysis. Study Design Descriptive epidemiologic data were obtained from case investigation reports of primary and secondary syphilis. Results In the middle and late phases of the epidemic (1990–1992), the incidence of syphilis in the inner city area was more than six times that in remainder of the county. Illegal drug use was reported by 30% of patients. Drug use, especially crack cocaine, was related to prostitution. The estimated total number of sex partners per patient ratio was 4.2, whereas the named sex partners per patient ratio was only 1.5. Twenty-two percent of patients did not report any named partners. Overall, only 26% of the estimated total number of sex partners received treatment. Conclusions Expanding partner notification to include more high-risk persons identified through social networks and increasing screening among high-risk populations may improve control of inner city drug/prostitution-related syphilis epidemics.

Chlamydia trachomatis infection among Hispanic women in the California-Mexico border area, 1993 : establishing screening criteria in a primary care setting

Abstract Despite the millions of women who have undergone tubal sterilization in United States hospitals, little has been published about the risk of death from these procedures. To estimate a case-fatality rate for tubal sterilization, we combined data from the Commission on Professional and Hospital Activities and the National Center for Health Statistics with a review of the clinical circumstances for each woman whose death was identified as being potentially sterilization attributable. Considering all deaths temporally associated with tubal sterilization, we estimate that the case-fatality rate is nearly 8/100,000 procedures. When only deaths determined to be attributable to the sterilization operation per se are considered, the case-fatality rate is approximately 4/100,000 procedures, making death attributable to tubal sterilization a rare event.

Demographic trends in tubal sterilization: United States 1970-1978.

During the 1970s, tubal sterilization became an important method of fertility control in the United States. Over the same period laparoscopy emerged as an important innovation, one that has been associated with both a shift from postpartum to interval sterilization and a dramatic decrease in length of hospital stay required for sterilization. The use of laparoscopy has also been associated with an increase in hospital-based outpatient sterilization, particularly in the West. The number of sterilizations performed in hospitals and the use of laparoscopy for interval sterilization in hospitals both appear to have peaked. The laparoscope is an example of a technologic advance that has reduced medical care costs.

Demographic trends of tubal sterilization in the United States 1970-75.

Women with long‐term use of oral contraception (OC) are at increased risk of developing a serious, though nonmalignant, liver tumor—hepatocellular adenoma (HCA)—according to a case‐control study conducted by the Center for Disease Control (CDC) in collaboration with the Armed Forces Institute of Pathology (AFIP). The tumor is sometimes fatal, deaths usually being due to sudden rupture and hemorrhage. This study suggests that, in addition to long‐term OC use, a womans age and the hormonal potency of the OC she uses affect her chances of developing HCA. Women 27 years old and older who have used OC with high hormonal potency for 7 or more years are at the greatest risk.