Background: Primary and secondary syphilis infections represent recently acquired infections and are often the focus of epidemiologic reports of disease burden and trends. Latent syphilis infections may also be recently acquired, but may be classified as late latent (LL) infection when proof of acquisition in the past year cannot be documented.
Methods: Primary, secondary, early latent (EL), and LL syphilis cases reported to STD surveillance programs in New York City, Philadelphia, North Carolina, Florida, and Maricopa County, Arizona were examined in aggregate, stratified by patient sex, age group, syphilis stage, diagnosing titer (<1:4, 1:8, 1:16, 1:32, >1:64). Data were from a recent period during 2013-2015, when individual jurisdictions used consistent criteria for field investigation of reactive syphilis serologies, and syphilis case-patient interview.
Results: There were 2,201 primary (2,085 male, 116 female), 5,726 secondary (5,163 male, 563 female), 7,698 EL (6,784 male, 914 female) and 8,803 LL (6,685 male, 2,118 female) syphilis cases reported from the combined jurisdictions. The diagnostic titer was >1:64 in 49% (3,744/7,698) of EL (50% males, 38% females), and 31% (2,732/8,803) of LL cases (37% males, 14% females). Among LL cases, case-patients aged 10-19 (39%, 108/276) and 20-24 years (35%, 419/1,182) had the highest proportion titers >1:64; the proportion was higher among males (10-19: 45%, 74/165, and 20-24: 40%, 345/854) than females (10-19: 31%, 34/111, and 20-24: 23%, 74/328). Examined by jurisdiction, there was some variation in the age groups with highest proportion titers >1:64.
Conclusions: P&S represented about one third of syphilis cases and less than half infections acquired within the past year. A substantial proportion of EL and LL cases have high titers suggesting very recent acquisition, and ongoing risk for transmission, especially among males, and teens/young adults. Measures of disease burden focusing solely on P&S syphilis will grossly underestimate infectious burden.