Background:
Community syphilis persistence may be maintained by small groups of high-risk persons within a larger group of low-risk persons.

Objective:
To determine which control strategies identified high-risk early syphilis cases of high prevention value

Method:
In two cities with recent heterosexual outbreaks data were abstracted for ‘early' syphilis cases from 1997 - 2002. Stage and number of sex partners were used to estimate the relative likelihood and magnitude of future transmission, had the case not been treated. We estimated the relative transmission potential for each stage of syphilis (primary = 4.3, secondary = 2.5 and early-latent = 1.0) and multiplied by the number of partners to determine a prevention value score. Cases scoring > 10 were considered high-risk. Cases were stratified by the method used to detect the case.

Result:
Of 1700 female early syphilis cases, 174 (10%) were high-value. Female cases were identified by private physicians (28% of all cases and 16% of high-value cases), jails (19% of all, 40% of high-value), partner notification (16% of all, 10% of high-value), STD clinic (9% of all, 13% of high-value) and the emergency room (8% of all, 4% of high-value).
Of 1851 male cases, 228 (12%) were high-value. Male cases were identified by jails (27% of all cases and 14% of high-value cases), STD clinic (21% of all, 47% of high-value), private physicians (17% of all, 17% of high-value), partner notification (14% of all, 11% of high-value), and the emergency room (6% of all, 14% of high-value).


Conclusion:
Private physicians identified the largest number of female cases and jail screening identified the most high-value cases. The jail identified the largest number of male cases and the STD clinic identified the most high-value cases.

Implications:
Health officials should evaluate and prioritize strategies that identify high prevention value cases before promoting those that are directed at low-risk individuals.