The National Plan to Eliminate Syphilis 

from the United States 

Prepared by the Division of STD Prevention 

National Centers for HIV, STD and TB Prevention 

Centers for Disease Control and Prevention 

Atlanta, Georgia 30333 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

May 2006 
 

 

 

 

The National Plan to Eliminate Syphilis from 

 the United States 

 

 

 

 

Prepared by: 

Division of STD Prevention 

National Center for HIV, STD and TB Prevention 

Centers for Disease Control and Prevention (CDC) 

Atlanta, Georgia 30333 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

May 2006 
Copyright Information 

All material contained in this report is produced in support of the CDC Syphilis Elimination Effort activities 

and is in the public domain. It may be cited and used without special permission; however citation of the 

source is appreciated. 

Suggested Citation

Centers for Disease Control and Prevention. Together we can. The National Plan to Eliminate Syphilis 

from the United States. Atlanta, GA: US Department of Health and Human Services, May 2006. 

Copies can be obtained from the Division of STD Prevention, National Center of HIV, STD, and TB 

Prevention, Centers for Disease Control and Prevention. 1600 Clifton Road, Mail-Stop E-02, Atlanta 

Georgia 30333 
Table of Contents 

Table of Contents 

DEFINITIONS AND ABBREVIATIONS........................................................................................................5

EXECUTIVE SUMMARY ..............................................................................................................................6

PART A: INTRODUCTION TO THE US SYPHILIS ELIMINATION EFFORT.............................................7

1. INTRODUCTION.......................................................................................................................................8

PURPOSE ....................................................................................................................................................8

HOW TO USE THIS DOCUMENT.......................................................................................................................8

2. THE SYPHILIS ELIMINATION EFFORT –PROGRESS TO DATE .........................................................9

THE NATIONAL PLAN TO ELIMINATE SYPHILIS FROM THE UNITED STATES .......................................................9

ACHIEVEMENTS TO DATE ..............................................................................................................................9

LESSONS LEARNED FROM THE FIRST FIVE YEARS OF IMPLEMENTATION OF THE SEE ......................................10

3. SYPHILIS ELIMINATION:......................................................................................................................12

CHALLENGES AND OPPORTUNITIES....................................................................................................12

BEHAVIOR .................................................................................................................................................12

BIOLOGY ...................................................................................................................................................13

PUBLIC HEALTH SERVICES ..........................................................................................................................14

IMPLICATIONS FOR REFRAMING FUTURE EFFORTS ........................................................................................14

PART B: MISSION, GOALS AND STRATEGIES ...................................................................................16

4. MISSION, GOALS, AND STRATEGIES ................................................................................................17

MISSION ....................................................................................................................................................17

VISION ......................................................................................................................................................17

CORE VALUES ...........................................................................................................................................17

GOALS ......................................................................................................................................................18

TARGETS...................................................................................................................................................18

THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION........................................................................................19

IMPLEMENTING THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION .................................................................20

5. SYPHILIS ELIMINATION GOAL I: INVESTMENT IN, AND ENHANCEMENT OF, PUBLIC HEALTH 

SERVICES..................................................................................................................................................22

IMPROVE AND ENHANCE SYPHILIS SURVEILLANCE AND OUTBREAK RESPONSE ................................................23

IMPROVE AND ASSURE THE QUALITY OF CLINICAL AND PARTNER SERVICES ....................................................24

IMPROVE AND ASSURE THE QUALITY OF LABORATORY SERVICES...................................................................25

6. SYPHILIS ELIMINATION GOAL II: PRIORITIZATION OF CULTURALLY COMPETENT 

INTERVENTIONS.......................................................................................................................................27

MOBILIZATION OF AFFECTED COMMUNITIES .................................................................................................27

TAILORING INTERVENTION STRATEGIES FOR AFFECTED POPULATIONS...........................................................28

MOBILIZING HEALTH CARE PROVIDERS ........................................................................................................30

MOBILIZATION AND CREATION OF ALLIANCES WITH ORGANIZATIONAL PARTNERS ............................................30

7. SYPHILIS ELIMINATION GOAL III: ACCOUNTABLE SERVICES & INTERVENTIONS ....................33

TRAINING AND STAFF DEVELOPMENT...........................................................................................................33

EVIDENCE-BASED ACTION PLANNING, MONITORING, AND EVALUATION ...........................................................34

RESEARCH AND DEVELOPMENT...................................................................................................................35

PART C: IMPLEMENTING THE 3-BY-3 APPROACH TO .......................................................................37

3
Table of Contents 

4

SYPHILIS ELIMINATION ...........................................................................................................................37

8. ROLES AND RESPONSIBILITIES FOR SYPHILIS ELIMINATION......................................................38

9. NEXT STEPS..........................................................................................................................................39

THE SEE COORDINATION TEAM ..................................................................................................................39

WITHIN ONE YEAR ......................................................................................................................................39

WITHIN TWO YEARS....................................................................................................................................39

10. CONCLUSION......................................................................................................................................40

REFERENCES............................................................................................................................................59

List of Appendices 

APPENDIX 1 SEE Global Logic Model.......................................................................................................41

APPENDIX 2 Required and recommended syphilis elimination activities ..................................................42

APPENDIX 3 List of SEE by Required & Recommended Categories Only................................................52

APPENDIX 4 CDC GPRA Goals for Syphilis Elimination...........................................................................56

APPENDIX 5 2004 P&S syphilis rates and threshold SEE targets for US project areas ...........................57

List of Figures 

Figure 1. Reductions in reported cases of primary and secondary syphilis, U.S. 1999 & 2004.................10

Figure 2. Recent trends in the epidemiology of primary and secondary syphilis in the United States.......12

Figure 3. Trends in primary and secondary syphilis among non-Hispanic Blacks and Whites by 

geographic region and gender, United States 1997-2004 ..................................................................13

Figure 4. Implementing the 3x3 approach to Syphilis Elimination in the United States .............................21

Figure 5. Prioritizing SEE interventions based on epidemic phase, an example. ......................................22
Definitions and Abbreviations 

ANC Antenatal care clinic 

CBO Community-based organization 

CLIA Clinical Laboratory Improvement Amendments which approves a laboratory to 

accept and test human specimens. 

CSTE Council of State and Territorial Epidemiologists 

DIS Disease Intervention Specialist 

Elimination Controlling the manifestations of a disease so that it is no longer considered a 

public health problem. The absence of sustained transmission of primary and 

secondary syphilis in the United States. Operationally defined at the national 

level as fewer than 1000 cases (0.4 per 100,000 population) of reported primary 

and secondary syphilis cases each year. 

Epi-AID CDC-sponsored onsite epidemiologic investigation which allows CDC to 

respond rapidly to public health problems in need of urgent attention, thereby 

providing an important service to state and other public health agencies; and to 

provide supervised training opportunities for EIS officers (and, sometimes, other 

CDC trainees) to actively participate in epidemiologic investigations 

GPRA Government Performance Review Act 

Health Professional Registered nurse, physicians’ assistant, or physician. 

HIV Human immunodeficiency virus. 

HMA High syphilis morbidity area 

Law Applicable local, state, and federal statutes, regulations, and ordinances. 

MTCT Mother-to-child transmission 

MSM Men who have sex with men. 

P&S syphilis Primary and secondary syphilis 

NCSD The National Coalition of STD Directors 

PTC Prevention Training Center 

RRT The Rapid Response Team, CDC-sponsored onsite syphilis elimination 

technical support 

SEE Syphilis Elimination Effort 

SETA Syphilis Elimination Technical Appendix 

STD Sexually Transmitted Disease 

Unsafe Sexual 

Activity 

Sexual activities which are likely to transmit HIV or other STD’s. These activities 

include but are not limited to the exchange of infected bodily fluids through 

unprotected anal, oral, or vaginal intercourse 

VCT Voluntary counseling and testing 

 
Introduction 

6

Executive Summary 

In October 1999, the Centers for Disease Control and Prevention (CDC), in collaboration with 

federal, state, local, and non-governmental partners, launched the National Plan to Eliminate 

Syphilis. In the plan, CDC identified key strategies needed for successful elimination of syphilis 

from the United States: expanded surveillance and outbreak response activities, rapid screening 

and treatment in and out of medical settings, expanded laboratory services, strengthened 

community involvement and agency partnerships, and enhanced health promotion. 

In the six years since its establishment, numerous gains have been made in reducing disease 

incidence in key groups, raising professional and public awareness of syphilis, increasing financial 

investment into public Sexually Transmitted Disease (STD) clinic services, and building local public 

health and community capacity to fight this devastating disease. However, new challenges have 

emerged. After reaching a nadir in 2001, diagnoses of primary and secondary syphilis are again on 

the increase. Today, more than 60% of new infections are diagnosed in men who have sex with 

men (MSM). 

The evolving epidemiology, changing risk groups, and social environments present challenges for 

elimination and STD program activities. Syphilis is now increasingly diagnosed in the private sector, 

raising concerns about the effectiveness of the identification and management in this setting. Public 

health services face increasing pressures from rising demand and decreasing financial resources. 

The social contexts of poverty, racism, homophobia, and socio-economic discrimination continue to 

drive the concentration of the disease in those with high-risk sexual behaviors, poor access to care, 

or both. 

In reframing the future of the Syphilis Elimination Effort, CDC’s vision is to create a dynamic, 

evidence-based and culturally competent prevention and control action plan for the elimination of 

syphilis from the United States. By 2010, interim elimination targets will be to reduce rates of 

primary and secondary syphilis in the United States to less than 2.2 per 100,000 population; 

congenital syphilis to fewer than 3.9 per 100,000 live births; and Black: White racial disparities to a 

ratio of less than 3:1. In order to achieve this, CDC will focus syphilis elimination activities in 

achieving three strategic goals: Investment in and enhancement of public health services; 

prioritization of evidence-based, culturally competent interventions; and creating 

accountable services and interventions. 

For each of the three goals, CDC recommends that syphilis elimination activities be delivered in 

three strategic areas of focus (The 3-By-3 approach to syphilis elimination). This results in nine 

strategies: Surveillance, Clinical and Laboratory Services, Community Mobilization, Health care 

Provider Mobilization; Tailoring of Interventions; Evidence-based Action Planning, Monitoring and 

Evaluation; Training and Staff Development; and Research. 

This plan provides a framework for continuing to deliver interventions aimed at eliminating syphilis 

as a public health problem in the United States. It should not be seen as a rigid blueprint for 

eliminating syphilis instantly. Rather, the plan provides guidance that helps local, state, and national 

partners to effectively focus on the problem in order to get the most important things done in the 

most cost-effective, ethical, and acceptable ways possible. 

Further details on the strategies and recommended activities are contained in an accompanying 

Syphilis Elimination Technical Appendix (SETA). 
Introduction 

7

Part A:

Introduction to the US Syphilis Elimination Effort
Introduction 

1. Introduction 

Purpose 

This document sets out the strategic framework and action plans to continue progress towards eliminating 

syphilis from the United States. The strategies and recommended activities have been developed based 

on available evidence, expert opinion, and lessons learned from colleagues involved in the local, state, 

and national implementation of the Syphilis Elimination Effort (SEE). 

This plan also sets out the core values underpinning the SEE. It is intended to provide a framework within 

which CDC, states, and local health departments, community and relevant organizational partners will 

develop and deliver syphilis elimination activities that are best suited to the evolving epidemiology and to 

public health infrastructures. 

A Syphilis Elimination Technical Appendix (SETA) accompanies this plan and provides further detail on 

the recommended strategies, standards, and methods of evaluation. We strongly advise readers to use 

this companion document in preparing their annual action plans, developing local research agendas, or 

evaluating interventions. 

1

How to use this document 

This 2006 Syphilis Elimination Effort (SEE) Plan is divided into four sections. 

■ Part A (Chapters 1-3) provides an introduction to the United States Syphilis Elimination Effort 

and outlines accomplishments and challenges to date. 

■ Part B (Chapters 4 – 7) outlines the framework and rationale for the reframing of the SEE 

National Plan, with the discussion of the vision, mission statement, strategic approach, and 

guidelines for implementing the 3-By-3 approach. A detailed consideration of the SEE 

recommended strategies is contained here. 

■ Part C (Chapters 8-10) describes the roles and responsibilities at local, state, and national 

levels, a timetable for implementation, and conclusions. 

■ The Appendices contain relevant materials for assisting public health departments in 

developing, implementing, and evaluating their syphilis elimination action plans. 

While providing a structure for conceptualizing the strategic response to syphilis elimination, the SEE 

Plan is not intended to be prescriptive. On the contrary, this document places a value on identifying and 

delivering local syphilis elimination activities that are flexible, adaptable, and responsive to changes in the 

environment, organism, and population-wide sexual behavior. A prioritization process, based on an 

activity’s feasibility, cost, and evidence of effectiveness was used to determine which activities are 

required and which are recommended. Required activities are to be given the highest priority for 

implementation; however, it is important to note that Recommended activities are also crucial for 

enhancing syphilis prevention and control efforts. 
SEE Progress to date 

2. The Syphilis Elimination Effort –Progress to date 

The National Plan to Eliminate Syphilis from the United 

States 

The Syphilis Elimination Effort (SEE) is a collaborative effort between the Centers for Disease Control and 

Prevention (CDC) and a wide range of partners working in the public and private sectors at national, state, 

and local levels. The National Plan to Eliminate Syphilis2

 from the United States, on which the SEE is based, 

was launched in October 1999. 

The 1999 National Plan defined syphilis elimination at the national level as the absence of sustained 

transmission of syphilis in the United States, with an operational goal of < 1000 cases of primary and 

secondary (P&S) syphilis reported per year. This goal was recently refined as part of the goals developed for 

CDC’s Government Performance Review Act (GPRA) of 1993

2 

3

 Goals (see APPENDIX 4), which set an 

interim target of 2.2 reported cases of P&S syphilis per 100,000 population by 2010. 

In 1999, disease elimination (defined as “controlling the manifestations of a disease so that it is no longer 

considered a public health problem” or as “reduction to zero of a specified disease in a defined geographic 

area as a result of deliberate efforts”)4

 was considered plausible for the United States because of historically 

low rates of infection, geographically limited disease incidence, and the availability of inexpensive and 

effective diagnostic tests and therapy. 

The SEE was based upon the understanding that eliminating syphilis would require combining intensified 

traditional approaches to STD control with innovative approaches to generate new synergy and to enhance 

the effectiveness of syphilis elimination activities. Five strategies were recommended for eliminating syphilis 

from the United States. Two strategies – strengthened community involvement and partnerships, and rapid 

outbreak response – were new to syphilis control in many parts of the United States, and three strategies – 

enhanced surveillance, expanded clinical and laboratory services, and enhanced health promotion – had 

been used for syphilis control previously and were intensified. 

While national in scope, the SEE focused on areas with high syphilis morbidity and those areas with potential 

for syphilis re-emergence. Today, CDC disburses SEE funds directly to High Morbidity Areas (HMAs) – 

defined as areas with sustained syphilis transmission, usually signaling the need to improve preventive 

services and strengthen capacity. 

Between 1999 and 2004, CDC invested in excess of $107million to HMAs to support infrastructure, 

interventions, evaluation, research, community outreach, and clinical and laboratory services. Additional 

investment from CDC has also been provided in the form of technical assistance, Rapid Response Team 

deployments, Program Assessments, Epi-AID deployments, and research and evaluation support. 

Achievements to date 

Reductions in disease incidence in key groups. Since 1999, there have been marked changes in the 

epidemiology of infectious syphilis in the U.S (Figure 1 and Figure 2). There have been substantial reductions 

in diagnosed disease in women and newborn infants (congenital syphilis). Between 1991 and 2004 congenital 

cases declined by 92% (107.3 cases per 100,000 live births to 8.8 cases per 100,000 live births). Rates of 

P&S syphilis among women fell from 2.0 to 0.8 per 100,000 population.5

 Rates in African Americans fell from 

14.3 to 8.9 per 100,000 population. The Black: White racial disparity, a major focus of syphilis elimination, has 

also markedly reduced, falling from 28.6:1 in 1999 to 5.6:1 in 2004. Despite these gains, however, overall 

rates of primary and secondary syphilis have been on the rise since 2001 presenting challenges and new 

opportunities for reframing our efforts. 
SEE Progress to date 

10

Figure 1. Reductions in reported cases of primary and secondary syphilis, U.S. 1999 & 2004 

 

Primary and secondary syphilis —

Rates by state and territory: United

States, 2004

Rate per 100,000

population

Guam 0.0 

Puerto Rico 4.7 

Virgin Is. 4.6 

<=0.2.0

0.21-4.00

>4.00

3.7

1.2

2.8 1.7

3.8 1.4

4.3

6.3

0.6

1.8

3.1 1.0

0.2

0.9 1.1

7.4

0.2

1.9

0.5

2.0

1.6

0.4

0.4 1.8

4.4

3.8

2.3

0.0

2.1

0.7

0.8

1.0

2.8

0.0

2.2

3.7

0.6

1.6

2.4

0.2

0.5

0.6

VT 0.2 NH 0.4 MA 1.8 RI 2.4 CT 1.3 NJ 1.7 DE 1.1 MD 6.9 DC 12.2

(N= 7)

(N= 39)

(N= 8)

Rate per 100,000 population

Guam 1.5 

Puerto Rico 18.0

Virgin Is. 11.3

<=0.2.0

0.21-4.00

>4.00

22.9

1.1

8.8 16.2

19.6 1.6

56.1

60.0

1.0

0.2

8.5 1.4

1.3

3.2 1.5

29.0

37.7

1.1

7.6

1.4

28.0

3.2

0.3

1.9 18.6

2.1

29.9

21.7

18.0

25.5

9.7

0.5

1.8

4.2

8.7

0.1

25.4

0.9

9.7

1.1

3.4

0.7

VT 0.2 NH 1.9 MA 8.4 RI 3.1 CT 34.7 NJ 19.7 DE 35.5 MD 17.0 DC 145.8

(N= 2)

(N= 23)

(N= 29)

Primary and secondary syphilis 

Rates by state and territory, 

United States 

Improved partnerships with communities. To date, more than 170 community-based organizations 

(CBOs), agencies, and institutions have been funded to conduct local syphilis elimination activities. The CBOs 

represent diverse constituencies, including private health care providers, social service providers, civic 

organizations and community coalitions, HIV prevention and care organizations, faith-based organizations, 

and substance abuse treatment and prevention organizations. Community partners have provided a range of 

services including outreach screening and STD health education in high-risk venues, individual and group 

risk-reduction counseling, patient and client advocacy, and program planning. 

Increased awareness about and knowledge of syphilis. National, state, and local public heath and social 

marketing campaigns on syphilis have increased professional and public awareness of syphilis, its 

complications, and prevention strategies. The 2001 Syphilis Elimination Health Communication Plan6

provided guidance on building momentum for the 1999 SEE Plan at the national, state, and local levels. It 

identified the need for SEE support from three key target audiences: policymakers, health care providers and 

associations, and community representatives from affected communities. In 2004, the CDC’s SEE community

mobilization toolkit7

 provided further guidance on social marketing of the SEE, as well as resources on 

syphilis, including radio spots, posters, advertising campaigns. 

Expanded access to STD treatment and care services. Since 1999, the additional investment in syphilis 

elimination has resulted in additional benefits for STD prevention and care. Syphilis elimination investment

has contributed to increasing local STD prevention capacity through expansions in STD clinic staff cadre, 

developing the infrastructure of STD clinics, increasing the number of STD clinical sessions, and establishing

outreach clinical services.8

 This increased capacity within the public health sector has helped local sites to 

enhance their prevention and control of syphilis and other STDs and has facilitated more robust local 

responses to threats such as syphilis outbreaks. 

Lessons learned from the first five years of 

implementation of the SEE 

Although no overall evaluation of the 1999 National Plan has been undertaken, key lessons relevant to 

programmatic implementation and strategic planning have been obtained from local SEE-funded project 

areas during the Syphilis Elimination Program Assessments (2003)9

 and Syphilis Elimination Listening Tour

(2005). Some of the key lessons include: 

■ Wherever possible, integrate syphilis elimination with other STD and HIV prevention and 

control programs. In many areas where gains have been made in reducing levels of endemic

syphilis, the adoption of multi-disciplinary, multi-level syphilis elimination interventions and 
SEE Progress to date 

11

coordination have been essential to achieving success. 

■ Apply locally available surveillance and research data to develop evidence-based 

strategies. Good surveillance is the cornerstone of disease elimination. It is essential that all 

locally available data, Disease Intervention Specialists (DIS) case analysis, social network 

analysis, surveillance, and epidemiologic research be used and applied to developing locally 

appropriate, acceptable, and accountable syphilis prevention interventions. 

■ Local syphilis elimination activities should be flexible enough to respond to rapidly 

evolving epidemics. Syphilis epidemics have changed and will evolve, affecting new groups 

and communities. It is vitally important that local elimination activities track and pre-empt the 

disease spread, and be flexible enough to meet the new challenges. This may require creating 

new community partnerships, reprioritizing interventions, and re-aligning available funds for 

areas or populations in greatest need. 

■ Adopt a holistic approach to eliminating syphilis which takes into consideration the 

social determinants of disease transmission. The populations affected by syphilis are 

ethnically, socially and culturally diverse, necessitating tailored and targeted interventions. 

Social contexts such as unemployment, discrimination, and substance abuse will often need to 

be tackled alongside the provision of high quality clinical services. Successful elimination will 

therefore require STD programs to create alliances with traditional and non-traditional partners 

within and outside of the public health sector. 

■ Provide high quality STD services. High quality STD services and good surveillance are key to 

syphilis elimination. Improving internal communications between DIS staff and clinical staff (in 

the public and private sector) was identified as an important lesson learned; so too was the need 

to ensure adequate STD program staff training and development, and valuing, developing, and 

utilizing the general knowledge and skills of the STD program staff. 

■ Engage and collaborate with communities and local private providers. Collaborative 

partnerships in syphilis elimination, across a variety of agencies, institutions, and communities, 

are vital. This is especially relevant as syphilis is increasingly diagnosed outside of the public 

health sector. Collaborations and outreach activities can provide substantial benefit, including 

the building of rapport; developing strategic alliances with diverse groups; and mobilizing 

disenfranchised groups. 

■ Understand and develop strategies for the Internet. The Internet is a rapidly growing venue 

for the acquisition of sex partners.10 There is a need to learn from, and adapt, best practices in 

the field with regards to engaging clients and service providers; providing skills and training to 

DIS and STD program staff on Internet-based syphilis prevention interventions; standardizing 

approaches to Internet Service Providers (ISP) and webmasters and users; and examining ways 

to avoid duplication of effort at state and local levels. 
Current Challenges and Opportunites 

3. Syphilis Elimination: 

 Challenges and opportunities 

The epidemiology of syphilis represents a dynamic interaction between behavior, biology, and the 

effectiveness of public health interventions.11 12 In this section, we highlight some of the key challenges 

facing the successful implementation of the SEE at national, state and local levels. In reframing the future 

of the SEE, it is important that due consideration be given to identifying, understanding and tackling these 

challenges while concomitantly seeking opportunities for enhancing the capacity of STD programs to 

respond effectively. 

Figure 2. Recent trends in the epidemiology of primary and secondary syphilis in the United 

States. 

Primary and secondary syphilis:

Male-to-female rate ratios, 1981–2004

0

5

10

15

20

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Year

P & S rates per 100,000 pop.

0

2

4

6

8

10

Male: Female rate ratio

Primary and secondary syphilis. M:F 

rate ratio in selected cities, 1999-2004

1

10

100

1000

1999 2000 2001 2002 2003 2004

Year of report

M:F ratio

New York

San Franciso

Los Angeles

Atlanta

Houston

Miami

Behavior 

Men who have sex with men. The recent resurgence of syphilis and other STDs in men who have sex 

with men (MSM) (see Figure 2) presents new challenges to syphilis elimination.13 By 2004, more than 

60% of new diagnoses of P&S syphilis were estimated to occur in MSM, with HIV-positive MSM bearing a 

disproportionate burden of disease. Disease rates are now highest in MSM aged 35-39 years, and while 

the majority of diagnoses of disease are in White non-Hispanic men, recent increases have been marked

in African American men. A recent study found that approximately 20% of P&S syphilis infections in MSM 

are believed to have been acquired through unprotected oro-genital intercourse.14 

The rising incidence of syphilis in MSM is in part attributable to recent increases in high-risk sexual 

behavior. High rates of new sex partner acquisition and partner change rates with rises in unprotected 

penetrative sex have been documented across the United States. The reasons for the increases are 

complex, however HIV sero-sorting, safer sex fatigue, recreational drug use (especially crystal 

methamphetamine), and HIV treatment optimism combined with expansions in venues and networks that 

facilitate risky behaviors, have been identified among the major driving factors. All this has occurred 

within the context of homophobia and discrimination being experienced by many MSM. Successful 

syphilis elimination will require an acknowledgement of the multi-faceted risk factors and will ensure that 

prevention interventions are holistic and are occurring on many fronts. 

Heterosexuals. Although the incidence of syphilis in heterosexual women and men has been declining in 

recent years (Figure 3), there are early signs that this trend may be reversing, and increased vigilance will 

be needed to avoid a resurgence of disease. The risk factors for disease transmission between

heterosexuals in the past– drug use (crack cocaine), prostitution, socio-economic deprivation, and poor 

access to curative services15 remain relevant today. Anecdotal reports suggest that crystal 
Current Challenges and Opportunities 

13

methamphetamine may be contributing to rises in disease incidence in heterosexuals, however, further 

work will be required to confirm and quantify its contribution. Although a potential threat, evidence 

regarding bridging between MSM and heterosexual populations is scant. Similarly, the Internet has not 

yet been implicated as a major determinant of syphilis transmission in heterosexuals; and vigilance will be 

required on this issue. 

Figure 3. Trends in primary and secondary syphilis among non-Hispanic Blacks and Whites by

geographic region and gender, United States 1997-2004

Primary and secondary syphilis:

Rates for black non Hispanics, by gender and

region, 1997–2004

0

4

8

12

16

20

24

28

32

36

1997

19981999

2000

2001

2002

2003

2004

Northeast

Midwest

South

West

Rate (per 100,000 population)

0

4

8

12

16

20

24

28

19971998

1999

200020012002

20032004

Men Women

Drug addiction and usage. Recreational drug use and abuse fuel high-risk sexual behaviors act as cofactors for disease transmission16 17 and, where lifestyles have become disrupted, require access to 

appropriate rehabilitation and drug treatment services. Crack cocaine use was a cofactor for syphilis 

transmission in the early 1990s, and remain factors for disease spread among poor urban heterosexuals. 

Today, crystal methamphetamine use is an established cofactor for syphilis acquisition in MSM.

18 In many 

states, there are insufficient drug treatment services, especially in rural areas, where most social services

are under-funded and under-staffed. 

Biology 

Azithromycin resistance. Although Treponema pallidum remains fully susceptible to penicillin, recent 

studies have demonstrated and confirmed a point mutation within the 23S ribosomal RNA (rRNA) gene, 

at a ribosomal site targeted by macrolides. For example, among syphilis lesions being tested for this point 

mutation, the positivity was between 22 and 56 percent from San Francisco, 11 percent in Baltimore, 13 

percent from Seattle, and 88 percent from Dublin, Ireland. No prospective study of humans treated for 

early syphilis with azithromycin has yet examined the influence of the 23S rRNA mutation in T. pallidum

on treatment outcomes. It remains unclear whether T. pallidum containing this mutation represents a 

single clone spread extensively within sexual networks in North America and Ireland or multiple strains 

that emerged independently. It is also unclear whether selective pressure from macrolide use for syphilis 

or other conditions may have contributed to the emergence of macrolide- resistant T. pallidum. 

Syphilis and HIV interaction. HIV/AIDS is a major public health concern and more than a million people 

are estimated to be living with HIV infection in the United States, approximately 25% of whom remain 

undiagnosed.19 Syphilis enhances HIV transmission and acquisition, and HIV infection influences the 

natural history and clinical progression of syphilis.20 Among MSM, a substantial proportion of men with 

incident syphilis infection are also HIV positive, reflecting both high risk sexual behaviors within this 

group, as well as participation in sexual networks which facilitate disease transmission. Within many local 

health departments, the separation of STD and HIV programs limits routine integration of prevention 

interventions. For example, interventions to expand HIV testing uptake in order to reduce undiagnosed 

prevalent HIV infections do not always permit opportunities for concomitant syphilis testing. Efforts to 

prevent syphilis benefit HIV prevention efforts. Opportunities to combine syphilis testing with HIV testing 

should be sought and encouraged, especially for population sub-groups at risk for both infections. 

0

2

4

6

1997 1998 1999 2000 2001 2002 2003 2004

Northeast

Midwest

South

West

Rate (per 100,000 population)

Men Women

0

1

2

1997 1998 1999 2000 2001 2002 2003 2004

Men 

Primary and secondary syphilis 

Rates for Whites, by gender and region, 

1997-2004 

Women 
Current Challenges and Opportunities 

14

Public health services 

Clinical services. Improving access to high quality syphilis diagnostic and treatment services has always 

been a core strategy for syphilis elimination. However, in many parts of the country, providing quality 

clinical services to populations at risk is becoming increasingly difficult. Disinvestment in local STD 

programs, loss of experienced program staff, or deployment of clinic staff to support non-STD activities all 

have a negative impact on local capacity to treat infected individuals or to contact and notify exposed sex 

partners. In many rural areas, with large geographical distances, transportation for economically 

disadvantaged persons is a significant barrier to accessing health care. 

Private sector burden of disease. As syphilis is now increasingly diagnosed in the private sector, 

effective public-private partnerships with jointly agreed clinical management protocols will be required. 

Private practitioners in high incidence areas need to be aware of their public health roles and 

responsibilities in STD control (e.g., accurate disease staging, appropriate therapy, disease reporting, and 

patient participation in partner services), and may require proactive training and support to ensure that 

high quality services and practices are maintained. 

Partner services. Effective partner services, in public and private sector settings, are essential for good 

disease control. However, in many areas, Disease Intervention Specialists (DIS) staff members have not 

been able to keep abreast of the rapidly changing social contexts for syphilis transmission or the 

demands of dealing with different patient groups and their expectations. For example, DIS staff members 

in some STD programs lack access to computers, any standardized guidance on Internet interventions, or 

the skills to intervene effectively with MSM populations. Consideration should also be given to reevaluating partner notification (PN) methods for syphilis to determine the relative effectiveness of PN 

strategies and to ensure that enhanced methods are implemented. 

Laboratory services: The inability to cultivate Treponema pallidum on artificial media, problems related 

to the microscopic diagnosis of the disease and long periods of unapparent infection have resulted in 

serologic tests remaining the most frequent means of establishing a diagnosis of syphilis.21 In addition, 

these tests are the only means whereby responses to therapy can be monitored. There is an urgent need 

to modernize syphilis diagnostic techniques with the development of both rapid treponemal and nontreponemal (point-of-care) tests. New opportunities for combining syphilis testing in traditional as well as 

non-traditional sites would be facilitated, as well as testing for syphilis alongside HIV. Studies in Europe 

have highlighted the potential benefits of utilizing oral fluid assays as an adjunct to outreach screening22; 

however, further research is needed to validate the performance of these new tools. Partnerships 

between CDC, the Food and Drug Administration (FDA), and National Institutes of Health (NIH) are 

required to determine the most appropriate course of action to facilitate licensing of such tests in the 

United States. 

Implications for reframing future efforts 

Poverty and lack of education provide ample opportunity for the reseeding and resurgence of syphilis in 

the poor, especially historically underserved minority and migrant communities. High quality health 

services, while crucial, are only one of the determinants of health, and most health gain will come from 

going upstream to focus on those factors such as employment, housing and quality of living 

environments, social relationships, and education that are the main determinants of health in populations. 

In reframing the future directions of the syphilis elimination effort, we must continue to acknowledge that 

reducing syphilis, and creating healthy societies and individuals largely results from actions outside the 

public health sector. Nevertheless, the public health sector has a key role to play in creating alliances with 

a wide range of stakeholders and in developing, implementing and evaluating disease control 

interventions in a variety of settings. 

Over the next decade, clear opportunities for improving the implementation of syphilis elimination 
Current Challenges and Opportunities 

15

activities exist and include: 

■ Reframing the SEE to meet the challenge of newly emergent populations at risk, especially 

men who have sex with men; 

■ Improving the performance of existing effective interventions through the development of 

appropriate measures, collaboration between stakeholders and focusing on early diagnosis 

and treatment. 

■ Improving program planning and accountability so that scarce funds are directed to support 

interventions based on evidence, and ensuring that these efforts are monitored and 

evaluated to ensure optimum implementation; 

■ Disseminating research, surveillance data, and other evidence to support decision-making; 

■ Improving relationships with state, local and national multi-professional groups; and 

■ Supporting professional development and training in methods for enhancing local syphilis 

elimination efforts. 
Missions, goals and strategies 

Part B:

 Mission, Goals and Strategies 
Investment in public health services 

4. Mission, goals, and strategies 

Mission 

The mission of the Syphilis Elimination Effort (SEE) is to promote health and quality of life by preventing, 

controlling, and eliminating endemic transmission of syphilis from the United States. 

In collaboration with partners within and outside CDC, the SEE provides national leadership for syphilis 

prevention, research and surveillance, and the development and testing of effective biomedical and 

behavioral interventions to reduce syphilis transmission in the United States. In so doing, the SEE plan 

guides the development, implementation, and evaluation of evidence-based prevention programs serving 

persons affected by, or at risk for, syphilis infection.

Vision

The vision of the Syphilis Elimination Effort is to create and implement a dynamic, evidence-based, 

culturally competent prevention and control strategy for syphilis in the United States.

■ Dynamic - Recent trends in syphilis in the United States reflect the dynamic interplay between

biological features of the organism, high-risk sexual behaviors between individuals, and the 

effectiveness of our prevention programs. It is essential that the SEE maintains the ability to 

rapidly respond to the evolving epidemiology.

■ Evidence-based - Evidence-based public health interventions demand that programs and 

policies be developed, implemented, and evaluated through application of principles of 

scientific reasoning, including systematic uses of data and information systems and 

appropriate use of behavioral science theory and program planning models. 

■ Culturally competent - Cultural competence is the integration and transformation of 

knowledge about individuals and groups of people into specific standards, policies, practices,

and attitudes used in appropriate cultural settings to increase the quality of services; thereby 

producing better outcomes.23 24

Core Values 

The Syphilis Elimination Effort is built upon CDC’s core values of accountability, respect, and integrity. 

■ Accountability - As stewards of public trust and public funds, the SEE is a decisive and 

compassionate intervention in service to the people’s health. CDC will ensure that SEE-related 

research and services are based on sound science and meet real public needs to achieve our

public health goals. 

■ Respect – The SEE respects and understands our interdependence with all people throughout 

the United States, treating them and their contributions with dignity and valuing individual and

cultural diversity. 

■ Integrity – The SEE and its partners will be honest and ethical in all that they do. The SEE will 

prize scientific integrity and professional excellence. 

17
Investment in public health services 

Goals 

To provide a clear sense of direction, CDC recommends three key goals for eliminating syphilis from the 

United States: 

■ Investment in, and enhancement of, public health services and interventions - Public

health services will achieve excellence in the diagnosis and management of syphilis, partner 

services, and reporting of syphilis and its adverse outcomes, especially for those at greatest 

risk of health disparities. 

■ Prioritization of evidence-based, culturally competent interventions – Public health 

services will improve the acceptability and appropriateness of their response to syphilis 

epidemics and enhance their advocacy base through the creation of productive and proactive 

partnerships with external stakeholders.

■ Accountable services and interventions - Public health services will improve the 

effectiveness of their interventions by improving accountability for their planning, 

implementation, and evaluation. 

CDC is committed to achieving true improvements in people’s health. To do this, the agency has defined 

specific health impact goals to prioritize and focus its work and investments and to measure progress. The 

Syphilis Elimination Effort is particularly relevant to achieving CDC Goals related to Healthy People in Every 

Stage of Life, and Healthy People in Healthy Places1

, as well as to the overarching Healthy People 2010 

goal of eliminating health disparities. 

Targets 

Disease elimination involves controlling the manifestations of a disease so that it is no longer considered a 

public health problem. In the 1999 plan, syphilis elimination at the national level was operationally defined 

as fewer than 1000 cases of primary and secondary syphilis cases per annum occurring in the mainland 

United States. Although the definition of syphilis elimination remains the same, interim targets for syphilis 

elimination for 2010 have been identified in the 2006 plan and provide a pathway for continued progress 

toward elimination. CDC’s Government Performance Review Act (GPRA) goals for syphilis elimination have 

been defined (see APPENDIX 4), and provide a framework for our national targets. They are: 

■ To reduce primary and secondary syphilis cases to a rate of 2.2 per 100,000 population with a 

rate of 4.2 per 100,000 among men and 0.38 per 100,000 among women by 2010 

■ To reduce the incidence of congenital syphilis to 3.9 per 100,000 live births by 2010 

■ To reduce the black: white ratio of primary and secondary syphilis to 3:1 by 2010. 

The 1999 Syphilis Elimination National Plan defined elimination at the local level as the absence of 

transmission of new cases within the jurisdiction, except within 90 days of report of an imported index case.

 

1 Healthy People in Every Stage of Life—All people, and especially those at greater risk of health disparities, will achieve their 

optimal lifespan with the best possible quality of health in every stage of life. Healthy People in Healthy Places—The places where 

people live, work, learn, and play will protect and promote their health and safety, especially those at greater risk of health

disparities. This includes Healthy Communities and Health care settings.

18
Investment in public health services 

However, local elimination targets were not set for specific jurisdictions. In reframing the future of the 

syphilis elimination effort, CDC will encourage local target setting to be undertaken as part of the 

development of local evidence-based action plans. 

The 3-By-3 approach to syphilis elimination 

The Syphilis Elimination Effort (SEE) Plan will focus on a shared vision, goals, and core strategies in order 

to provide a coherent and consistent framework for coordinating activities. In this regard, the SEE Plan calls 

for implementing evidence-based and culturally competent activities. Each of the three syphilis elimination 

goals: Investment in public health services; delivering prioritized, culturally competent interventions; and 

increasing accountability of services and interventions has three recommended strategic areas of focus 

(see Table 1). This is the 3-By-3 approach to syphilis elimination. These strategies are interrelated 

(e.g., enhancing SEE interventions will require evaluation). 

The 3-By-3 approach differs from, but is complementary to, the 1999 plan by streamlining the elimination 

goals and expanding the SEE strategies to include provider mobilization, training, research, monitoring, and 

evaluation. Effective outbreak response, a key strategy in the 1999 plan, will form part of the recommended 

activities for investment in public health services. 

Table 1. The 3-By-3 approach to syphilis elimination in the United States 

SYPHILIS ELIMINATION GOAL SYPHILIS ELIMINATION STRATEGIES 

1. Investment in, and enhancement of, public

health services and interventions - Public 

health services will achieve excellence in the 

diagnosis, management and reporting of 

syphilis and its adverse outcomes, especially

those at greatest risk of health disparities.

1. Improve and enhance syphilis surveillance and outbreak response

2. Improve and quality assure clinical and partner services

3. Improve and quality assure laboratory services 

2. Prioritization of evidence-based, culturally

competent interventions – Public health 

services will improve the advocacy,

acceptability and appropriateness of their 

response to syphilis epidemics through the 

creation of productive and proactive

partnerships with external stakeholders. 

1. Mobilization of affected communities 

2. Tailoring intervention strategies for affected populations. 

3. Mobilization of, and creating alliances with health care providers 

3. Accountable services and interventions - 

Public health services will improve the

effectiveness of their interventions by

improving accountability for their planning, 

implementation, and evaluation. 

1. Training and staff development 

2. Evidence-based action planning, monitoring, and evaluation 

3. Research and development 

The SEE Logic model. A global logic model for the 2006 Syphilis Elimination Effort (illustrating the 3-By-3

approach) is contained in Appendix 1. A logic model is a picture of how a program works. It identifies 

program components and shows how they relate to each other. Logic models can benefit program planning 

by: 1) building understanding of and clarity about a program for stakeholders; 2) identifying resources 

needed for a program; 3) identifying the sequence of activities that should be implemented and how the 

program will attain the expected results; 4) identifying where the barriers to the implementation and 

achieving of the expected outcomes might be; and 5) serving as a basis for monitoring and evaluation. 

Chapters 5-7 in this document provide additional details on the three main Syphilis Elimination goals, 

strategic areas of focus, and recommended activities at local, state, and national levels. Appendix 2 

provides further information on the standards for the recommended activities; the level of evidence to 

support them; and an indication of how they may be prioritized at the local level. In addition, the SEE 

Technical Appendix offers extensive detail on all of the required and recommended strategies and activities. 

It is not intended that state and local health departments will implement all of the recommended 

activities. Rather, sites should see these activities as a compendium of effective or promising interventions

from which their local syphilis elimination responses may be drawn.

19
Investment in public health services 

Implementing the 3-By-3 approach to syphilis 

elimination 

The 3-By-3 approach to syphilis elimination outlines the goals, strategies, and activities recommended for 

effective prevention and control of syphilis in the United States (see Figure 4). However, a step-wise 

implementation of the approach is recommended in which 1) available local epidemiologic and surveillance 

data are combined with, 2) self-assessment and collaborative partnering with stakeholders to produce, and 

3) an evidence-based action plan which can be prospectively monitored and evaluated for progress. 

Guiding principles: A number of key principles will be used by the CDC to inform the implementation of 

the 3-by-3 approach to syphilis elimination. These include: 

■ All project areas (even those with low incidence) will have some role to play in syphilis 

elimination. 

■ The unit of monitoring and implementation of the SEE is the project area. 

■ The SEE thresholds will be set at the project area level, which are predominantly states. 

However, the threshold for project areas which are cities (e.g., Los Angeles, Chicago) will be

different from thresholds for states. 

■ Project areas in need of intensive syphilis elimination support will be able to develop an 

evidence-based action plan using recommended strategies and activities outlined in this 

report. 

Baseline. Syphilis Preparedness. As most counties will have little or no syphilis, it is imperative that CDC, 

state and local partners remain vigilant and maintain a high index of monitoring and surveillance to ensure

that disease incidence remains low and that new infections be readily identified and treated. Effective 

syphilis preparedness suggests that local jurisdictions have appropriate outbreak plans in place to deal 

with unexpected increases in disease incidence above baseline levels. 

Step 1. HMA designation. There will be clear guidelines for identifying project areas in need of federal 

investment and support for syphilis elimination. A standard definition of a High Morbidity Areas (HMAs) 

threshold [2.0 per 100,000 population], based on a specific disease rate, will be used. 

Step 2. Evidence-based action planning. Once the HMA threshold is crossed, project areas will become 

eligible for a syphilis elimination assessment to determine what financial or human resource investment (for

example Epi-AID or RRT) would be most useful. The assessment should determine the nature of the 

epidemic and the distribution and quality of existing public health infrastructures. The assessment should 

result in the development of a mutually agreed upon evidence-based action plan for reducing syphilis 

rates to below 1.0 per 100,000 within a 3-5 year period. 

Step 3. Implementation and monitoring. Once CDC and the project area have agreed on the evidencebased action plan, appropriate resources (financial or human, or both) will be disbursed or deployed. CDC 

will provide assistance to local sites in the prioritization, implementation, and tailoring of their interventions.

This will be in addition to local investment in syphilis elimination activities (e.g., realignment of resources 

and staff). Proactive monitoring and evaluation support will be given to HMAs to ensure that their goals and 

set objectives are being met and that the evidence-based activities are being delivered as promised. 

20
Investment in public health services 

Figure 4. Implementing the 3x3 approach to Syphilis Elimination in the United States 

YES

Baseline 

Syphilis 

Preparedness 

Step 1 

High Morbidity

Area 

Step 2 

Evidencebased action

Step 3 

Implementation

and monitoring 

Step 4 

Summative

evaluation 

Maintenance 

phase 

of SEE support 

Re-prioritize

and retarget

interventions

NO

HMA Threshold 

[2.0 per 100,000 pop] 

Targeted financial and 

technical support 

Phased 

Reallocation of 

SEE support 

NO

YES 

Rates 

remain 

below HMA 

Elimination 

Targets met? 

Step 4. Summative evaluation. Finally, a summative evaluation of the local SEE program, using 

standardized criteria and assessment tools, will be undertaken in the final year of funding. This will 

determine whether investments should continue or may be reduced or withdrawn. In an era of limited funds, 

it is unlikely that project areas will be able to hold onto funds indefinitely, as resources may need to be 

shifted to areas with greater burdens of disease. 

Phased reallocation of resources: When the elimination objectives are met, then the project area will 

begin discussions with CDC about the manner and timing for the reallocation of SEE-specific targeted 

funds. As one of the lessons learned from previous syphilis elimination efforts is to avoid sudden withdrawal 

of investment, this phase will most likely involve a 2-year maintenance period with level funding, followed by

phased reductions in funding to within 30% of initial investment. 

Re-prioritization and retargeting of interventions: Existing project areas that receive Syphilis Elimination 

funding and fail to meet their elimination targets will be required to identify the most important weakness in 

their programs and submit evidence-based action plans towards addressing these within a given time 

period. They will then continue with steps 3 and 4. 

It is not the intention that all activities are relevant or appropriate for all types of syphilis epidemics and it is 

vitally important that local sites are able to use their surveillance data to refine the application of the syphilis 

elimination activities. One suggestion for prioritizing interventions is by understanding the epidemic phase, 

and applying appropriate intervention strategies dependent upon the epidemic phase.25 Figure 5 illustrates 

a potential method for prioritizing interventions based upon the epidemic phase.

21
Investment in public health services 

Figure 5. Prioritizing SEE interventions based on epidemic phase, an example. 

SEE STRATEGIES Low Endemic Outbreak Hyperendemic Decline 

Surveillance & outbreak 

response 

++ +++ +++ ++ 

Clinical and PN services + +++ +++ ++ 

Laboratory services + +++ +++ ++ 

Mobilization of affected 

communities - +++ +++ ++ 

Tailoring intervention 

strategies - ++ ++ + 

Mobilization of 

organizational partners - +++ +++ + 

Training and staff 

development 

+ +++ ++ + 

Evidence based action 

planning, monitoring and 

evaluation 

+ +++ +++ ++ 

Research and 

development - ++ ++ - 

0

5

10

15

20

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1

Year/ Months

P

& S rates per 100,000 

pop.

Key

- Optional 

+ Recommended

++ Highly recommended 

+++ Essential 

5. Syphilis Elimination Goal I: Investment in, and 

enhancement of, public health services 

Syphilis prevention and control activities predominantly take place within the context of health services

including STD, Infectious Disease, Public Health Community, HIV, Outreach or other services. The success 

of the Syphilis Elimination Effort (SEE) will therefore reflect the levels of investment and support provided to 

these structures and the professionals that work within them. From this point, effective partnerships with 

other agencies and communities can be developed. Investment in and enhancement of public health 

services will also require that due attention be paid to proper action planning, monitoring and evaluation, 

and an ongoing program of research and development. 

The first goal of the United States Syphilis Elimination Effort is that public health services will 

achieve excellence in the diagnosis and management of syphilis, partner services, and reporting of 

syphilis and its adverse outcomes, especially for those at greatest risk of health disparities.

In order to achieve this goal, the SEE will recommend activities in three key strategic areas for intervention. 

These are: 

I. Improve and enhance syphilis surveillance and outbreak response

22
Investment in public health services 

II. Improve and assure quality of clinical and partner services

III. Improve and assure quality of laboratory services

Improve and enhance syphilis surveillance and 

outbreak response 

Surveillance. Surveillance is defined as the systematic and ongoing collection, analysis, interpretation and 

dissemination of data to inform public health action. Surveillance is the foundation for preventing and 

controlling all communicable diseases and this holds true for syphilis.26 Strong surveillance capacity must 

be in place in order to characterize the epidemic, direct or inform programmatic efforts, inform research, 

tailor interventions to the populations at risk, and monitor and evaluate their effects. 

The primary surveillance approach for syphilis is through nationally notifiable disease reporting of incident

cases. Syphilis monitoring at local, state, and national levels can be used to determine disease burden and 

trends, and identify populations with high rates of infection. Additionally, syphilis data should be used to 

assess the yield of specific screening activities by identifying new cases detected in relation to the number 

of screening tests performed. 

Key recommended surveillance activities for elimination of syphilis include: 

SEE ACTIVITY 1. State and local health departments will collect and report gender of sex partners/ 

sexuality data to CDC by end-2006. 

SEE ACTIVITY 2. State and local health departments should quarterly assess case report data for 

duplications, errors, and omissions and annually assess for accuracy, completeness and 

sensitivity, promptness, validity and quality. 

SEE ACTIVITY 3. CDC, state, and local health departments will promote routine and regular (at least 

quarterly) analysis of their epidemiologic data on syphilis. 

SEE ACTIVITY 4. State health departments should provide epidemiology training and capacity building

to STD program staff. 

SEE ACTIVITY 5. State and local health departments should adopt CDC/ Council of State and Territorial 

Epidemiologists syphilis surveillance case definitions.

SEE ACTIVITY 6. CDC, state and local health departments will encourage and monitor (quarterly basis) 

syphilis reporting from public and private providers. 

SEE ACTIVITY 7. State and local health departments will use reactor grids to prioritize follow up of 

syphilis cases. These should be evaluated annually or more frequently if the local 

epidemiology changes. 

SEE ACTIVITY 8. CDC, state and local health departments should use syphilis prevalence monitoring 

to determine changes over time and assess impact of prevention interventions. 

Syphilis outbreak response. In 2005, over 75% of counties in the United States reported no syphilis, and 

the majority of others had comparatively low incidence rates in comparison to other STDs and infectious

diseases. Nevertheless, all jurisdictions have a role to play in ensuring that disease rates be monitored and 

that all efforts be made to reduce them over time. This is the basic function of a disease control program. 

In low or zero incidence areas or population sub-groups, the reemergence of syphilis may be heralded by 

rapid growth in disease incidence, partially driven by exposure of a population to a new pathogen, but also 

due to the lag between disease introduction and clinical recognition and response. It is crucial that these 

sites rapidly detect every case of syphilis and notify the jurisdiction or county of origin. The response to a 

23
Investment in public health services 

case in these settings should be similar in speed and intensity to a case of bacterial meningitis, botulism, or

other communicable disease for which an immediate response is mandatory.

The 1999 Plan recommended that all areas of the country develop an outbreak response plan and establish 

area-specific criteria that determine when the outbreak response plan is to be implemented. State and local

health departments should ensure that outbreak identification and response plans be in place to effectively 

identify, diagnose, manage, and report rapid increases in syphilis. In this regard, syphilis preparedness and

outbreak response forms part of an essential component of preventing and controlling syphilis. 

Key recommended syphilis outbreak response activities for elimination of syphilis include: 

SEE ACTIVITY 9. All state and local health departments will develop a Syphilis Outbreak Response 

Plan. This should be reviewed and updated if necessary, on an annual basis. 

SEE ACTIVITY 10. All state and local health departments should develop area-specific criteria that 

determine when the outbreak response plan is to be implemented. This should be reviewed 

and updated if necessary, on an annual basis. 

Improve and assure the quality of clinical and partner 

services 

Clinical services. Although a substantial proportion of STD clinical services in the United States are being

performed by private providers, dedicated public STD clinics continue to play an important role in providing 

low or no cost clinical care for individuals who cannot afford private health care or who prefer to access a 

specialty clinic for confidential services. However, public dedicated STD clinics face many challenges in 

providing easily accessible and high-quality care due to inefficient patient flow, inadequate staffing, and 

other operational factors. Increasingly, private providers provide more of the STD services in the United 

States, although the screening, treatment, and patient follow up according to recommended standards are 

less than optimal.

Clinical services for syphilis include early access to care, accurate diagnosis and staging, appropriate 

treatment, patient counseling, partner management, and follow-up. Prompt quality clinical management of 

individuals diagnosed with or exposed to infectious syphilis is a fundamental component for the prevention

and control of syphilis and is a joint responsibility between health departments and providers. Because 

syphilis is an easily treatable bacterial infection, effective clinical care is an important factor in interrupting 

transmission. 

Key recommended clinical activities for the elimination of syphilis include: 

SEE ACTIVITY 11. State and local health departments should document the number of clients turned 

away and the length of wait times (for an appointment or to be seen once in the clinic) at 

public STD clinics. 

SEE ACTIVITY 12. State and local health departments should assess and increase the proportion of 

local health departments that have relationships with non-traditional health care providers 

(e.g., community centers, outreach clinics etc.) where at-risk populations seek services. 

SEE ACTIVITY 13. State and local health departments should monitor and work towards increasing the 

proportion of STD clinic attenders, and those found to have an STD, who receive a screening 

test for syphilis according to recognized standards.

SEE ACTIVITY 14. CDC, in partnership with the National Coalition of STD Directors (NCSD) and state 

and local health departments, should develop and implement a quality assurance tool for 

clinic use to ensure that key activities are implemented according to recognized standards. 

24
Investment in public health services 

SEE ACTIVITY 15. State and local health departments should document the number of syphilis tests 

performed annually in sentinel public and private laboratories and measure the time for 

reporting results to providers and health departments.

SEE ACTIVITY 16. State and local health departments should monitor and work towards increasing the 

proportion of pregnant females screened for syphilis during prenatal health care visits, 

according to recognized standards and state statutes. 

SEE ACTIVITY 17. In geographic locations where transmission is primarily in MSM populations, state 

and local health departments should monitor and work towards increasing the proportion of 

clients screened routinely for syphilis by HIV care providers. 

SEE ACTIVITY 18. In geographic locations where transmission is primarily in heterosexual 

populations, state and local health departments should monitor and work towards increasing 

the proportion of arrestees/inmates screened and treated for syphilis in local jails, with an

emphasis on women. 

Partner services. Partner notification (PN) for syphilis is the process by which sex partners of an individual 

diagnosed with early syphilis are identified, contacted, and notified of their exposure, and offered 

appropriate clinical services to reduce their risk of infection or onward transmission of the disease; and to 

identify unnamed partners or persons with symptoms of syphilis. PN is therefore a key strategy to control 

syphilis through reducing the proportion of infected persons in the population. PN provides a more efficient

syphilis prevention strategy, compared to screening and treating the entire population, as it focuses upon 

persons more likely than others to be infected with syphilis. 

Published studies on the effectiveness of partner notification confirm that: 1) provider referral is more 

effective than patient referral; 2) social network approaches can enhance the effectiveness of PN activities; 

3) community involvement in partner notification, e.g., DIS trained interviewers or placing DIS in community 

settings can enhance PN outcomes; and 4) newer techniques (e.g., enhanced interviewing, peer-driven 

cluster referral and Internet PN) provide additional strategies for enhancing PN responses, although the 

data are still to be thoroughly evaluated. 

Key recommended partner services activities for elimination of syphilis include: 

SEE ACTIVITY 19. State and local health departments should apply optimum interviewing techniques 

(see the Syphilis Elimination Technical Appendix) to maximize the number of partners elicited 

and partners initiated. 

SEE ACTIVITY 20. State and local health departments should use the geographic and sociodemographic concentration of syphilis to inform the best locations for DIS for immediate 

case-interviewing and partner follow up.

SEE ACTIVITY 21. State and local health departments should communicate and collaborate with other 

parties interested in partner notification for the elimination of syphilis (for example CBOs, 

private providers, jails). 

Improve and assure the quality of laboratory services 

High quality laboratory services are essential for an enhanced response for syphilis elimination. While 

recently developed molecular diagnostic tests have frequently replaced darkfield microscopy to detect T 

pallidum in suspected primary and secondary syphilis lesions; and molecular typing techniques have 

provided a better understanding of the epidemiology of the disease, serologic testing remains the most 

frequent method for diagnosis of the disease. Currently available serologic tests for syphilis are either non25
Investment in public health services 

treponemal/ reagin-based tests (e.g., the RPR and VDRL tests) or treponemal tests (e.g., the FTA-ABS, 

TPPA, and ELISA tests). Traditionally, the relatively inexpensive non-treponemal tests have been used as 

initial screening tests. Quantitatively, these tests are also used to assess the efficacy of therapy. Thus, after 

successful treatment of early syphilis, the titer of positive non-treponemal tests should fall and eventually 

become negative. However, successful treatment of later stages of the disease may result in persistence of 

positive antibody titers. Unfortunately, non-treponemal tests lack specificity, and therefore traditionally, sera 

that have proved reactive by these screening tests have been confirmed to be truly positive by re-testing

with a more specific, but relatively expensive treponemal test. 

In low prevalence settings, such as in the United States, an alternative testing strategy has been proposed

whereby a treponemal test is used for initial screening and the non-treponemal test is used as the 

‘confirmatory’ test that also provides a better indicator of activity of disease. This approach is particularly 

attractive in two situations. Firstly, in laboratories with a very high throughput of specimens and where 

automation would favor an ELISA-based screening platform, and secondly, in resource-poor settings where

a point-of-care (rapid) test would facilitate provision of treatment at the initial clinic visit.27 It should be noted 

that, for surveillance purposes, the use of treponemal antibody tests alone should be discouraged, since a 

significant decrease in the prevalence of treponemal antibodies in the population will take several decades, 

even following successful disease interventions. 

Key recommended laboratory services activities for elimination of syphilis include: 

SEE ACTIVITY 22. CDC and its partners will update the Manual of Tests for Syphilis by the end of 2006. 

In addition, CDC will produce and disseminate widely, policy guidance on the use and

interpretation of results of treponemal tests when used as screening tests.

SEE ACTIVITY 23. CDC and its partners will undertake research and evaluation of point-of-care tests 

for implementation in the United States within the next 5 years. 

SEE ACTIVITY 24. CDC will establish a network of regional laboratories to facilitate PCR testing for 

syphilis. 

SEE ACTIVITY 25. CDC should fund demonstration projects to examine the utility and acceptability of 

typing and sub-typing methods for T pallidum in outbreak situations. 

26
Prioritize interventions 

6. Syphilis Elimination Goal II: Prioritization of 

culturally competent interventions 

In an era of competing pressures on public health resources, the implementation of syphilis elimination 

activities should be prioritized, taking into consideration all available local, regional, and national data on 

syphilis epidemics to identify which interventions are the most effective; where they should be targeted; 

and how they can provide the greatest public health gain. Prioritization can make resources go further. 

However, it will require active, systematic, and expert reviews of surveillance and research data by those 

involved in syphilis prevention and control at local and national levels. 

Prioritization of our effort and interventions will also require that we appropriately tailor and target our 

interventions. The history of syphilis in the United States dictates that the syphilis elimination efforts must 

acknowledge and be responsive to the legacies of distrust (e.g., Tuskegee Study), racism, 

marginalization of certain populations, and poverty in communities in which syphilis persists. More 

recently, the increasing disease incidence in men who have sex with men has required the establishment 

of new partnerships with communities and groups. In looking to the future, it is essential that the Syphilis 

Elimination Effort includes mechanisms by which strategic partnerships with affected communities can be 

readily established and developed as the epidemic evolves. 

The second goal of the Syphilis Elimination Effort is to improve public health services through 

advocacy, acceptability, and appropriateness of the public health response to syphilis epidemics 

by prioritizing and delivering evidence-based and culturally competent interventions in 

partnership with external stakeholders and affected communities. 

In prioritizing culturally competent interventions, the SEE promotes three key strategies for 

implementation of key activities. These are: 

I. Mobilization of affected communities 

II. Tailoring intervention strategies for affected populations

III. Mobilization of and creating alliances with organizational partners 

Mobilization of affected communities 

Community mobilization. The current U.S. epidemic of infectious syphilis disproportionately affects 

disadvantaged ethnic minority communities and men who have sex with men. The persons most at risk 

for infectious syphilis are often also socially marginalized and frequently distrusting of government 

authorities such as health departments. In the 1999 National Plan to Eliminate Syphilis from the United 

States, effective community participation was discussed as an essential feature of the cross-cutting 

strategy, Community Involvement and Organizational Partnerships. It was described as a means of: 1) 

facilitating communication between affected communities and STD programs, 2) restoring, building, and 

maintaining trust, 3) improving access to and use of STD services, 4) improving the cultural competence 

of interventions, and 5) mobilizing community-based efforts to sustain syphilis elimination activities over 

time.

28

29

30

Community mobilization is an essential component of community and public health programs. 

However, it is also a concept that has been defined in a variety of ways; reflecting varying degrees of 

community or client power in relationship to external institutions. Moreover, the definition of community 

varies and is not always bound by geography, but often entails cultural identity and experiences (e.g., 

Gay men, Hip-Hop youth). Successful community participation in public health efforts is best achieved 

when affected community members collaborate in equal partnership with health professionals to 

determine health goals, implement interventions, and evaluate outcomes. 

31

32 

33

27
Prioritize interventions 

In 2005, CDC launched a Syphilis Elimination Effort (SEE) Community Mobilization Toolkit34 to give state 

and local health departments the tools to reach out and build coalitions and alliances needed to mobilize 

specific target audiences. Target-specific materials in the kit provide resources to increase local 

awareness, visibility, and salience of the syphilis elimination program. The kit provides guidance and the 

necessary tools for involving, mobilizing, and sustaining community efforts not only for syphilis, but for a 

variety of public health issues. 

Key recommended community mobilization activities for elimination of syphilis include: 

SEE ACTIVITY 26. State and local health departments will ensure ongoing monitoring of surveillance 

data in order to track evolution in local epidemics and inform appropriate community

partnerships. 

SEE ACTIVITY 27. CDC, state and local health departments should distribute and adapt 

recommendations contained in the CDC SEE Community Mobilization tool-kit. 

SEE ACTIVITY 28. In designated high morbidity areas (HMAs), state and local health departments 

will establish meaningful community participation in local SEE efforts. This should be 

evaluated on a regular basis.

SEE ACTIVITY 29. HMAs receiving CDC SEE funding will disburse between 15% to 30% of SEEdedicated funds to support relevant CBO-led activities. The funding level will be determined 

by epidemic phase and existing CBO infrastructure and capacity. 

SEE ACTIVITY 30. State and local health departments will ensure that local data are reviewed

regularly with community partners, and used to inform community-driven prevention efforts.

Tailoring intervention strategies for affected 

populations 

Black and ethnic minorities: Tailored interventions for ethnic minorities are needed in the 2006 Syphilis 

Elimination Plan to address the needs of specific ethnic minorities who are currently disproportionately 

affected by syphilis (i.e., African Americans and Latinos), as well as to address possible morbidity in 

ethnic minorities that have low or potentially under-documented and/or misclassified syphilis morbidity 

(e.g., Asian-Pacific Islanders and Native Americans).35 

Tailored interventions attempt to facilitate risk-reductive change by identifying and utilizing the 

characteristics that are distinct to the targeted topic, context, or population as part of the intervention 

strategies. Interventions can be tailored to address a specific issue, such as tailoring the Popular Opinion 

Leader (POL) model for HIV prevention to address syphilis prevention by creating syphilis prevention 

messages. Interventions can also be tailored to address a specific population. Using the POL example 

again, the model was originally tested with Gay men, but it can be and has been tailored for women. 

Recommended activities for tailoring syphilis elimination interventions include: 

SEE ACTIVITY 31. CDC, state, and local health departments should enhance national, state, and 

local prevention efforts, by tailoring interventions for ethnic minorities that are 

disproportionately affected by syphilis. 

SEE ACTIVITY 32. State and local health departments should provide cultural sensitivity training for 

publicly funded SE staff and other interested service providers on a regular basis (e.g., 

annually). 

SEE ACTIVITY 33. CDC will work in partnership with state and local health departments to undertake 

assessments of health-care seeking; health care access; partner services; and screening for 

ethnic minority populations affected by syphilis to inform the development or tailoring of

28
Prioritize interventions 

culturally appropriate interventions. 

SEE ACTIVITY 34. State and local health departments and CBOs should incorporate assessment 

data into tailored intervention development and prevention intervention planning. 

SEE ACTIVITY 35. State and local health departments should identify key local stakeholders to 

establish inter-agency alliances, collaborations, and partnerships to enhance syphilis 

elimination interventions. 

Men who have sex with men (MSM): Men who have sex with men are at increased risk for acquiring 

STDs, and bear a disproportionate burden of STD in the population.

36 37 The reasons are multi-faceted: 

some MSM report higher numbers of lifetime sex partners; higher rates of partner change and partner

acquisition rates than heterosexuals; and STD prevalence in MSM population exceeds that of the general 

population.38 39 In addition, recent concerns have been expressed about the increases in sexual risk 

behaviors of MSM being driven by recreational drug use and abuse, poor mental health, discrimination, 

and quantitative and qualitative changes in the sexual market place (venues facilitating sex partner

acquisition, including the Internet).38 40 41

With an excess of 60% of P&S syphilis diagnoses currently occurring among MSM, it is essential that the 

SEE be made relevant, appropriate, and acceptable to this population. This is especially important as 

many MSM may also be HIV-positive or dealing with a range of adverse health and social issues. One 

strategy for framing the message is promoting syphilis prevention as part of an overall sexual health 

strategy for MSM. This approach may be facilitated by combining HIV, syphilis and hepatitis B 

interventions for MSM in public, private, and outreach provider services, particularly in HIV health care 

settings. An alternative approach is to consider the elimination of syphilis as an issue of “health rights” for 

MSM. Whatever the approach, it is important that community mobilization occur alongside effective public

and private health service responses for an effective approach. 

Key recommended activities for controlling syphilis in MSM include: 

SEE ACTIVITY 36. CDC, state, and local health departments will collect and report data on gender of 

sexual partners/ sexual preference of syphilis index patients. 

SEE ACTIVITY 37. State and local health departments should develop and use Internet-based 

interventions in order to increase partner notification efficacy, MSM engagement, and 

participation in SEE activities. 

SEE ACTIVITY 38. State and local health departments will employ provider outreach, education and 

mobilization to raise awareness, encourage reporting, and improve effectiveness and 

quality of clinical management; including establishing systems to promptly respond to

clinical and prevention questions from providers. 

SEE ACTIVITY 39. In designated high morbidity areas (HMAs), state and local health departments 

should facilitate concomitant annual syphilis testing for sexually active HIV positive MSM. 

SEE ACTIVITY 40. State and local health departments should enhance access to syphilis screening 

through improving access to STD care facilities (e.g., extended operating times, MSM 

clinical sessions etc.). 

SEE ACTIVITY 41. State and local health departments should enhance syphilis education and sexual 

health promotion with MSM within STD clinics and the community. 

SEE ACTIVITY 42. State and local health departments should undertake outreach syphilis screening 

for MSM in bathhouses, bookstores, when there are demonstrated links to ongoing disease 

transmission or where the intervention is combined with other health interventions (e.g., 

hepatitis B vaccination, HIV testing). 

SEE ACTIVITY 43. State and local health departments will create partnerships with local drug 

treatment centers and programs and will clarify pathways for treatment and rehabilitation 

29
Prioritize interventions 

for recreational drug use.

Mobilizing health care providers 

The provision of STD care and prevention services has historically resided at publicly funded STD clinics. 

However, a significant shift toward private practice began taking place in the 1990s, necessitating links 

between public health clinics and the physicians in community-based practices. According to the 1992 

National Health and Social Life Survey, almost half of the respondents who had ever had an STD sought 

care in a private practice setting.42 About 24% received STD care in a community health center clinic, 

emergency room, family planning clinic or other health care facility. Therefore, involvement of all of the 

health care providers (HCPs) as specified above, practicing in public and private settings is critical for the 

success of the Syphilis Elimination Effort. 

Historically, the term “health care provider” has referred exclusively to the physician as provider. 

However, the number of mid-level clinicians (nurses, nurse practitioners and physician assistants) who 

provide health care in various health care settings has been rising steadily. Their growing role in the 

management of patients has been shown to be cost-effective, providing greater efficiency in the delivery 

of care. This will likely yield benefits in terms of patient education and support, as well as greater patient 

adherence to treatment regimens.43 

Mobilization of health care providers will therefore be a key responsibility of state and local health 

departments in their response to syphilis epidemics. Such mobilization will require the building of 

relationships and alliances with key stakeholders in the community and supporting innovative practices 

which result in identification or improved management of syphilis. Examples of mobilization include: 

sharing epidemiologic data; hosting joint or open educational events regarding recognition, diagnosis, and 

management of syphilis; provider visitations by DIS; providing an accountable system to promptly 

respond to clinical and prevention provider questions; developing cooperative agreements to facilitate 

patient access, referral or partner notification; and including practitioners in social marketing interventions.

Recommended activities for eliminating syphilis through provider mobilization include: 

SEE ACTIVITY 44. State and local health departments should designate a health department liaison 

for provider outreach for ongoing SEE efforts. 

SEE ACTIVITY 45. CDC, state and local health departments should provide in-service training and 

technical assistance to private health care providers (including physicians, practice nurses 

etc.) 

SEE ACTIVITY 46. State and local health departments should develop Memoranda of Understanding 

(MOA) with specific providers or CBOs (seeing a high number of syphilis cases) in order to 

clarify procedures for diagnosis, partner notification, and reporting. 

SEE ACTIVITY 47. State and local health departments should develop and widely disseminate 

policies and protocols for syphilis diagnosis and care in hospitals, emergency rooms, 

corrections facilities and other settings (e.g., web-based health alerts or newsletters). 

SEE ACTIVITY 48. CDC, state and local health departments should provide easy access to reliable 

and up to date syphilis data for their respective SEE stakeholders. 

Mobilization and creation of alliances with 

organizational partners 

Alliances between different organizational partners are a key method for enhancing public health 

services. Potential partners include jails, community organizations, policymakers, other social service 

30
Prioritize interventions 

agencies, and institutions that serve persons at risk for syphilis. In principle, alliances to enhance syphilis 

elimination should broadly engage local partners to: gain a wider understanding of how health

improvement can be achieved; ensure better coordination between local health and environment 

services; increase local capacity and abilities in public health skills; develop local health promotion 

capacity in conjunction with local health promotion specialists; facilitate a network for sharing health and 

environment information; and support communities in action to improve health, living conditions, and life 

chances.

Local areas should urgently consider the case for establishing organizational partnerships (e.g., 

partnerships with community health centers or AIDS Service Organizations) for syphilis elimination. This 

would contribute a public health dimension to the statutory and other responsibilities which local health 

departments already carry for community planning and for delivering a wide range of health services to 

the public. Local health departments should convene partnerships of local interests, drawn from various 

local stakeholders, including voluntary and private sectors, and local businesses and employers. 

Community health centers. Partnerships should also be considered with community health centers, 

which include all the diverse public and non-profit organizations and programs that receive federal 

funding under section 330 of the Public Health Service (PHS) Act, as amended by the Health Centers 

Consolidated Act of 1996 (P.L. 104-299) and the Safety Net Amendments of 2002. Health centers are 

characterized by five essential elements: 1) they are located in or serve a high need community; 2) they 

provide comprehensive primary care services as well as supportive services; 3) their services are 

available to all residents of their service areas, with fees adjusted upon patients’ ability to pay; 4) they are 

governed by a community board with a majority of members being health center patients; and, 5) they 

meet a range of performance and accountability requirements regarding their administrative, clinical, and 

financial operations. Starting in 2002, a five-year, $780 million Initiative for Health Centers was launched

aimed at creating new or expanded access points and enabling the Health Center Programs to reach an 

additional 6.1 million patients by the end of Fiscal Year 2006. The goal is to strengthen the health care 

safety net for those most in need, many of whom may be at risk for syphilis. For further information about 

these centers, local programs should visit http://bphc.hrsa.gov/chc/ .

Screening and treatment in jails: The term ‘corrections’ is usually used to describe a confinement 

facility administered by a federal, state, county, or city law enforcement agency. Jails are intended for 

persons that have been detained pending adjudication, or persons committed after adjudication, usually 

those committed for sentences of a year or less. 44 STD prevalence is estimated to be higher in persons in 

jail facilities than in the general population. Arrestees are at high risk for STD infection because of: 

substance abuse, high-risk sexual behaviors, multiple sex partners, including commercial sex work, and 

limited access to health care. 

Untreated syphilis often moves from the community, through correction settings, and back to the 

community. Jails generally have a very rapid turnover of detainees; the average stay may be as short as

48 hours. It is estimated that between 25% and 50% of all detainees spend less than 24 hours in a lockup facility. As a general rule, jails serve as temporary holding facilities that release individuals back into 

the community, often without any concerted effort to detect asymptomatic infected persons or provide 

treatment. Therefore, to reach the highest number of these high risk persons, establishing rapid screening 

and treatment programs in the intake/booking areas of jails is an important SEE strategy. Such programs

are feasible and effective.45 46 The Institute of Medicine report, “The Hidden Epidemic,” recommended 

providing STD services in prisons, jails, and juvenile facilities as part of a comprehensive STD prevention 

program. Rapid STD testing and treatment in jails is especially important for STD control in the 

community, especially in the context of predominantly heterosexual transmission, and may be critical for 

the success of syphilis elimination. 47

The strategy for controlling of syphilis in jail populations in the United States prioritizes the following 

activities: 

SEE ACTIVITY 18. In geographic locations where transmission is primarily in heterosexual 

populations, state and local health departments should monitor and work towards

increasing the proportion of arrestees/inmates screened and treated for syphilis in local 

31
Prioritize interventions 

jails, with an emphasis on women. Periodic point prevalence surveillance in areas with

predominantly MSM epidemics may also be warranted. 

SEE ACTIVITY 49. State and local health departments should establish or maintain effective 

partnerships with jails as a community-based setting for case-finding, disease surveillance, 

treatment, and research.

SEE ACTIVITY 50. State and local health departments will collect jail-based syphilis morbidity and 

behavioral data. 

SEE ACTIVITY 51. State and local health departments will work to improve information management 

systems and data sharing capabilities. 

SEE ACTIVITY 52. CDC, state and local health departments should provide cross-training 

experiences for public health and detention staff. 

SEE ACTIVITY 53. State and local health departments should assign STD program staff to jails to

complement and support screening and treatment activity where indicated.

Screening in antenatal clinics: Pregnant women who are infected with syphilis can transmit the 

infection to the fetus, causing congenital syphilis (CS) with serious adverse outcomes of the pregnancy in 

at least 50% of the cases. Elimination of congenital syphilis would contribute importantly to reduction of 

lost pregnancies, preterm/low birth-weight infants, and prenatal death. Although numbers and rates of CS 

have been declining in the United States, there remains a danger of a resurgence should syphilis recur 

among heterosexual populations. Yet, unlike many neonatal infections, this is a preventable disease 

which could be eliminated through effective antenatal screening and treatment of infected pregnant 

women. 

A further reduction in CS is feasible with a relatively simple set of existing interventions focusing on the 

care of mothers and newborns. The building blocks for CS prevention in the United States are already in 

place: policy guidelines for universal antenatal syphilis screening; levels of antenatal attendance are high; 

screening tests are low-cost; and treatment with penicillin is inexpensive. The overarching goal should 

therefore be the elimination of CS as a public health problem in the United States, with the specific goal of

prevention of mother-to-child transmission of syphilis through reduction of prevalence of syphilis in 

pregnant women. In addition, local jurisdictions should undertake regular audits to identify missed 

opportunities for diagnosing congenital syphilis as part of their quality improvement activities.

The strategy for elimination of congenital syphilis from the United States prioritizes four activities: 

SEE ACTIVITY 54. CDC, state and local health departments should maintain activities to ensure 

sustained political commitment and advocacy for congenital syphilis elimination (e.g., 

mobilizing organizational partners). 

SEE ACTIVITY 55. CDC, state and local health departments will work to increase access to, and 

quality of mother and child health services, ensuring that all pregnant women are 

adequately screened and treated, and decreasing the frequency of missed opportunities for 

screening women outside mother and child care. 

SEE ACTIVITY 56. State and local health departments will ensure screening and treatment of all 

pregnant women for syphilis, using recommended diagnostic algorithms for the detection of 

syphilis. 

SEE ACTIVITY 57. CDC, state and local health departments will undertake congenital syphilis 

relevant surveillance, monitoring and evaluation activities, including improving surveillance 

systems, developing performance measures, and strengthening monitoring and evaluation 

systems. 

32
Accountable services and interventions 

7. Syphilis Elimination Goal III: Accountable services 

& interventions 

The creation of a dynamic, evidence-based, and culturally competent prevention and control plan for 

syphilis requires attention to effective implementation, monitoring, and evaluation. This should be seen

as part of a systematic approach to ensure that appropriate and effective methods and ethical standards 

are adhered to for all syphilis elimination activities. Colleagues involved in syphilis elimination at local, 

state and national levels should have the training and re-training to develop or improve their relevant 

skills.

The third goal of the Syphilis Elimination Effort is to improve the public health services’ response 

to syphilis epidemics by improving the effectiveness of interventions through enhanced 

accountability in the planning, implementation, and evaluation of interventions. 

To improve the implementation of the syphilis elimination effort, three main strategies will be required. 

These are: 

I. Training and staff development 

II. Evidence-based program planning, monitoring, and evaluation 

III. Research and development 

Training and staff development 

Training is defined in the Program Operations Guidelines for STD Prevention (POG)48 as a set of 

activities designed to develop specific skill levels of workers who are required to perform various public 

health activities. Training is not only necessary for establishing skills; it is an ongoing process necessary 

for the maintenance and enhancement of skills. The Institute of Medicine’s Future of Public Heath49 cites 

the continuing evolution of public health as justification for the constant need to update and enhance the 

knowledge and skills of those involved in public health. 

The 1999 National Plan to Eliminate Syphilis specifically addressed training, and identified a number of 

persons involved in syphilis elimination activities who may have need for training, including health 

department personnel, private providers, laboratorians, and community representatives.50 The 1999 plan

also identified specific topics for training, including clinical and laboratory methods, behavioral 

intervention approaches, data management and analysis, community involvement techniques, social and 

behavioral assessment, health communication, and evaluation. 

Training is needed today to improve syphilis elimination efforts for professionals working in both the public

and private sectors. In this regard, the STD/HIV Prevention Training Centers (PTCs) are likely play a 

substantial role in ensuring that opportunities are available for public and private practitioners to avail 

themselves of high quality training opportunities. 

The plan for elimination of syphilis in the United States prioritizes the following training and staff 

development activities: 

SEE ACTIVITY 58. CDC and state and local health departments should undertake routine and regular 

assessment of program staff training needs. 

SEE ACTIVITY 59. CDC, in partnership with NCSD and PTCs should identify training opportunities

for private practitioners relevant to syphilis elimination.

33
Accountable services and interventions 

SEE ACTIVITY 60. CDC and state and local health departments will work together to identify

nationally and locally available training opportunities and resources. 

SEE ACTIVITY 61. State and local health departments will ensure adequate training of supervisors to 

support local SEE activities. 

SEE ACTIVITY 62. State and local health departments should assign one or more management staff 

to be accountable for training and staff development for syphilis elimination activities.

SEE ACTIVITY 63. CDC in partnership with NCSD, state and local health departments will provide 

technical assistance for the development, use, and monitoring and evaluation of syphilis 

elimination evidence-based action plans.

Evidence-based action planning, monitoring, and 

evaluation 

Evidence-based program planning. An action plan states specifically what steps or tasks will be 

accomplished to achieve defined set objectives. It includes a schedule with deadlines for significant 

actions, resources necessary to achieve the objective, and methods to measure the objectives.51 52 53 

Evidence-based action planning is essential for changing those practices which may limit the success of 

local syphilis elimination activities. 

Evidence-based action planning is key to lending credibility to an organization; ensuring attention to 

details in the planning process; understanding what is and isn't possible for the organization to do; and 

enhancing efficiency. Evidence-based action planning also saves time, energy, and resources in the long 

run, and increases the chances that people will do what needs to be done. The better local syphilis 

elimination interventions are planned, managed, and monitored the more successful they are likely to be. 

With respect to evidence-based action planning, the plan for elimination of syphilis from the United States 

will prioritize the following activities for evidence-based action planning: 

SEE ACTIVITY 63. CDC in partnership with NCSD, state and local health departments will provide 

technical assistance for the development, use, and monitoring and evaluation of syphilis 

elimination evidence-based action plans. 

SEE ACTIVITY 64. CDC will request complete evidence-based action plans from all new HMAs from 

FY 2007 onwards, and for all existing HMAs from FY 2008 onwards. 

SEE ACTIVITY 65. State and local health departments will develop syphilis elimination action plans 

that are supported by surveillance or research evidence, and integrated into the

performance of SE coordinators and local action teams.

SEE ACTIVITY 66. CDC, in partnership with state and local health departments, will use a standard 

format for local syphilis elimination evidence-based action plans by December 2007. 

SEE ACTIVITY 67. State and local health departments should ensure that their local syphilis 

elimination action plans are shared locally and are widely available for review by

stakeholders. 

Monitoring and evaluation. Monitoring involves assessing and documenting program procedures to 

assure that activities have been performed appropriately and are contributing to the success of the 

program. Monitoring is often focused on developing information systems to provide data on processes 

and outcomes. 

34
Accountable services and interventions 

Program evaluation is essential to monitor and improve planning and management.54 Program evaluation 

is a systematic way to improve and account for actions. It answers the questions, “why?” or “why not?” It 

relies on a collaborative process to identify priorities and commit to addressing shortcomings. Evaluation 

is only worthwhile if results are used to improve program outcomes. There are two types of evaluation. 

Outcome evaluation determines whether the activities result in changes in the target population (e.g., 

increased knowledge, decreased disease). Process evaluation determines whether activities are 

implemented as intended. 

CDC Performance Measures: Performance measures (or indicators) are quantifiable information that 

provides insight into the yield or effect of a particular element of an STD prevention program. 

Performance measures can be important tools for program management. They allow programs to 

monitor progress toward specified outcomes, they facilitate the comparison of programmatic efforts over 

time, and they encourage project areas to implement and document “best practices”. The current 

performance measures encourage programs to focus on those activities over which they may exert 

influence (e.g., chlamydia screening at juvenile detention facilities), in contrast to those they can directly 

control (e.g., partner services in publicly funded sites). These measures are heavily focused on syphilis 

activities, with two linked to surveillance, four to partner services, and three to screening. They should 

play an important role in monitoring program performance for syphilis elimination. Over time, the 

systematic evaluation of performance measures will allow for refinement and the establishment of new 

measures to meet national, state, and local prevention program needs and will facilitate program 

improvement. For further information on the current CDC Division of STD Prevention Performance 

measures, please see www.cdc.gov/std/. 

With respect to program monitoring and evaluation, the plan for elimination of syphilis from the United 

States prioritizes the following activities: 

SEE ACTIVITY 68. CDC, state and local health departments will prioritize risk groups and 

interventions for syphilis elimination. 

SEE ACTIVITY 69. CDC, in partnership with its stakeholders, will provide explicit requirements, 

recommendations and standards for syphilis elimination activities at all levels in the plan. 

SEE ACTIVITY 70. CDC, in partnership with state and local health departments, will routinely monitor 

syphilis elimination activities to ensure that standards are met and that priorities are being 

addressed. 

SEE ACTIVITY 71. CDC, state and local health departments will share findings of evaluation activities 

at all levels. CDC, through the Syphilis Elimination coordination, will identify and make 

explicit, mechanisms to facilitate sharing of this information. 

Research and development 

Research strategies frame the scientific questions associated with important health and epidemiologic 

issues and delineate the research needs and relative priorities required to address those questions. SEE 

relevant research should focus on developing indicators and studies that allow an improved 

understanding of the social, behavioral, economic, biomedical, and cultural determinants of syphilis 

epidemics and prevention interventions. 

The SEE Research Strategy should highlight significant information gaps in each of the above areas, 

prioritize the research needs, and propose advisory guidelines indicating how available resources can be 

used to advance scientific knowledge and influence social and environmental factors that contribute to 

syphilis prevalence and severity. 

The SEE research strategy focuses on four key activities: 

SEE ACTIVITY 72. CDC working in partnership with SEE partners will deliver broadly applicable tools 

35
Accountable services and interventions 

and methods for syphilis diagnosis, prevention, and control. 

SEE ACTIVITY 73. CDC and its SEE partners will develop and share syphilis prevention and 

diagnostic technologies and approaches.

SEE ACTIVITY 74. CDC and its SEE partners will evaluate the effectiveness and cost-effectiveness of 

selected syphilis prevention interventions. 

SEE ACTIVITY 75. CDC and its SEE partners will conduct research to address economic, social, and 

behavioral determinants and consequences of syphilis epidemics and prevention. 

36
Implementing the 3-by-3 approach 

Part C: Implementing the 3-by-3 approach to 

Syphilis Elimination

37
Next steps 

8. Roles and Responsibilities for Syphilis Elimination 

This section describes the range of possible national, state, and local partners in the Syphilis Elimination 

Effort and their potential contribution to improving health and reducing the incidence of syphilis in the 

United States. Although the SEE is not likely to enlist a large group of partners at the outset, best practice 

suggests that it is better to start with a core group and build alliances over time. The core partners are 

likely to include state and local health departments, representatives from the public and private sectors, 

private health care providers, and other relevant organizations (e.g., local corrections, community health 

centers). 

Centers for Disease Control. The CDC has a vital role in implementing high quality response to the 

syphilis elimination effort, in addition to its prime responsibility for protecting the public’s health. CDC will: 

■ Act as an agent for health gain through the syphilis elimination effort; 

■ Provide advice on the design and implementation of syphilis prevention, screening and 

treatment programs; 

■ Provide financial and human resources to support and enhance state and local responses to 

eliminating syphilis within their jurisdictions when indicated; 

■ Analyze and report on the epidemiology of syphilis and its adverse outcomes; 

■ Establish national research priorities for syphilis prevention and control; 

■ Support staff training and development; 

■ Promote collaboration between STD and HIV agencies and providers; and

■ Monitor SEE action plans and progress reports from HMAs. 

State and local health departments. State and local public health departments, often in collaboration 

with institutional and community partners, provide comprehensive community services which protect 

health and prevent disease and in many respects will form the center for coordination and implementation 

of syphilis elimination efforts within states and counties. It is reasonable for local syphilis elimination 

efforts to be led by health departments, as these agencies are generally responsible for providing 

cohesive public health services including the provision of high quality STD services, partner services, 

treatment for STDs, jail screening and treatment, secondary prevention counseling services, and liaison 

with private and voluntary sector agencies. 

To assist in this leadership function we recommend that all health departments identify a syphilis 

elimination effort coordinator to help coordinate and manage the range of local syphilis prevention and 

control activities and to be seen as a natural point of focus for the effort. Specifically however, state and 

local health departments will: 

■ Develop annual action plans incorporating the 3-by-3 approach to syphilis elimination and 

the recommended strategies and activities; 

■ Identify funds to support local syphilis elimination activities, commensurate to disease 

epidemiology and local prioritization of resources; 

■ Create local organizational partnerships for syphilis elimination; 

■ Support community action to improve health, including liaison with community and privates

sector partners; 

38
Next steps 

■ Provide equitable access to health care;

■ Act as an advocate for health gain through the syphilis elimination effort; 

■ Provide advice on the design and implementation of syphilis prevention, screening and 

treatment programs; 

■ Analyze and report on the local epidemiology of syphilis and its adverse outcomes; 

■ Support local staff training and development; and 

■ Promote local collaboration and joint planning between STD and HIV agencies and 

providers. 

Organizational partners have a vital role in eliminating syphilis through social and economic

development and through the provision of health and community care services. Faith-based and other 

community groups are often well placed to understand the contexts and circumstances affecting local 

people for improved services and the barriers to change. Community groups should therefore be 

considered as core partners for syphilis elimination. The local syphilis elimination effort should involve 

such groups on local interventions and seek their view when developing annual action plans.

9. Next steps 

The SEE coordination team 

The Syphilis Elimination Effort coordinating team at the Centers for Disease Control and Prevention was 

established in 2005. A cross-Divisional work group with representation from each of the Division of STD 

Prevention branches meets on a weekly basis to review progress in the SEE and to guide strategic 

planning and implementation. A national network of Syphilis Elimination Coordinators will be established 

with an initial focus on streamlining staff training and development to enhance SEE implementation. 

Within one year 

Standardized templates for preparing evidence-based action plans and undertaking interim monitoring 

and summative evaluations will be produced by CDC by December 2006. The Syphilis Elimination Effort 

Technical Appendix will be published by CDC by June 2006. A Syphilis Elimination Effort Action Plan will 

be published by CDC by June 2006 which will outline a timetable for action for the next five years. Also a 

Syphilis Elimination Research and Development Strategy for the United States will be prepared by CDC 

by December 2006. 

Within two years 

CDC will develop and disseminate to state and local health departments a template outbreak response 

plan by June 2007. All SEE funded High Morbidity Areas will be asked to submit annual evidence-based 

action plans for their syphilis elimination activities. 

39
Conclusion 

40

10. Conclusion 

This plan provides a framework for continuing to deliver interventions aimed at eliminating syphilis as a 

public health problem in the United States. It should not be seen as a rigid blueprint for eliminating 

syphilis overnight. Rather, in thinking about the future of the Syphilis Elimination Effort, the plan provides 

a path that helps us to effectively focus on the problem in order to get the most important things done in 

the most cost effective, ethical, and acceptable way possible. 

As we enter the 21st century, the United States has made great strides in reducing the incidence of 

syphilis within its borders. Yet, syphilis remains a formidable foe. Nevertheless, it remains relatively easy 

to detect and cure given adequate access to, and utilization of, care. It remains at substantially lower 

rates compared to other STDs, and its localization within certain population sub-groups should make it 

more amenable for targeting and elimination. As the syphilis epidemic continues to evolve, we can be 

certain that, as we move towards our goal, syphilis may move to new communities or to return to those 

previously affected. Vigilance is required. 

In 1999, the persistence of syphilis was said to reflect a failure in our public health capacity. Today, 

changes in sexual behavior, driven by a number of social and economic factors, may be influencing which 

geographic locations, and which population sub-groups are affected by this disease. However, the 

benefits of elimination - improvements in health, reductions in health care costs, development of public 

health capacity, and reductions in racial disparities-- remain the same. It is the potential of reaping these 

benefits that should continue to inspire our efforts. 
 Short In

41

APPENDIX 1 SEE Global Logic Model Mission: To promote health and quality of life by preventing, controlling, and eli

minating endogenous transmission of syphilis from 

• I

mac

• I

cg

• G

ar

• D

bricp

• R• I

p

• R

pp

• I

eta

 INPUTS 

A

CTIVITIES OUTPUTS OUTCOM

• Epidemic characterized • Improved response of 

existing health services to outbreaks or risingincidence 

• Increased early access to 

and effective clinical care 

• Increased use of clinical

services 

• Increased awareness in

community

• Increased partnerships 

between STD programs, community organizations, and private providers 

• Increased screening, 

treatment, and counselingby private providers 

• Increased screening of 

pregnant women, MSM and inmates according to standards

• Increased partners elicited 

and cases initiated

• Program improvements 

made as indicated byevaluation results 

• Institutionalized evidencebased and accountability

culture 

• Trained staff (i.e., behavioral interventions, data

management/analysis, clinical/laboratorymethods, community involvement techniques, cultural competence, health communication, and program evaluation)

• Action plans developed and disseminated • Programs monitored and evaluated • Biomedical and behavioral applied research

agenda built 

• Performance measures adopted and monitored• Data collected on cases and sex partners • Timely submission of reports • Prevalence monitored • Surveillance syste

ms evaluated 

• Disease burden, populations & trends identified • Reporting requirements enforced • Syphilis outbreak response plan developed • Infected patients identified, treated, and 

counseled 

• Populations disproportionately affected screened, 

diagnosed, treated, and counseled 

• Clinics run at optimal efficiency• Quality of services monitored • Patients counseled• Partners identified, tested, & treated • Community participation integrated in setting

goals, planning/implementing interventions, andevaluating outcomes

• Outreach conducted among health care providers • Alliances established with community

organizations, private and public health care providers, and law enforcement

• High-risk populations screened (e.g., jail inmates, 

MSM, pregnant women) 

• Tailored and cultural competent interventions

developed for those disproportionately affected

Invest in Public Health Services

Surveillance 

Collect, report, analyze, and use syphilis data

for action 

Assess quality/completeness of data Monitor reports fro

m labs and private 

providers 

Build epidemiology capacity

Clinical and Laboratory Services

• Test, diagnose, treat, interview, counsel 

patients 

• Assess efficiency of clinics (e.g., number of

turnaways, wait times) 

• Screen in jails, especially females • Screen, diagnose and treat affected 

populations (e.g., pregnant women, ne

wborns, 

MSM, inmates)

• Outreach screening in diverse venues (e.g., 

drug treatment centers, bathhouses, jails) 

• Disseminate the use and interpretation of 

laboratory tests 

Partner services

• Intervie

w patients and partners using optimal 

interviewing techniques 

• Contact cases and partners to assess risk, 

counsel, and treat 

Deliver evidence-based and culturally competent 

interventions

• Mobilize affected communities and

organizations/health care providers/ political entities that serve them 

• Fund community organizations • Tailor interventions for those affected• Develop internet interventions • Provide partners with up-to-date information.• Train providers on cultural competence 

Increase accountability of services and

interventions

• Training and staff development • Evaluate activities routinely• Conduct research

• Funding 

o CDC o Other federal

sources 

o State sources o Private 

sources 

● State, local, and

federal legislationand administrative policy

• Partnerships 

o Federal 

agencies 

o State agencies o Local agencieso CBOs

• Training in areas 

such asinterviewing, surveillance,epidemiology, etc. 

• Technical 

Assistance 
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

APPENDIX 2 Required and recommended syphilis elimination 

activities 

Note: 

1. For the purposes of this document, “will” denotes required activities and “should” denotes recommended activities. 

2. Required activities are to be given the highest priority for implementation; however Recommended activities are also

crucial for enhancing syphilis prevention and control efforts. 

3. Activity numbers are reference numbers and will not necessarily appear in numeric sequence. 

4. Grades of Activity: A- Strongly recommended: Good evidence, benefits substantially outweigh harms, should be 

prioritized. B – Recommend: At least fair evidence, benefits outweigh harms. C – Insufficient evidence. Uncertain 

balance of benefits and harms – lack of evidence on clinical outcomes, poor quality of existing studies, or conflicting

results – may make recommendations based on other grounds. 

5. Further details on the rationale and evidence for the recommended activities are contained in the Syphilis Elimination 

Technical Appendix. 

GOAL I: Investment in public health services 

Public health services will achieve excellence in the diagnosis, management and reporting of syphilis and its adverse 

outcomes, especially those at greatest risk of health disparities.

Surveillance Standard Rating

SEE ACTIVITY 1. State and local health departments 

will collect and report gender of sex partners/ sexuality

data to CDC by end-2006. 

● All project areas to routinely collect and report information 

on syphilis in MSM by end 2006 

A 

SEE ACTIVITY 2. State and local health departments 

should quarterly assess case report data for 

duplications, errors, and omissions and annually

assess for accuracy, completeness and sensitivity, 

promptness, validity and quality.

● An assessment of the accuracy, completeness, 

sensitivity, promptness, validity, and quality of syphilis 

surveillance should be undertaken in accordance with 

Comprehensive STD Prevention Systems (CSPS) grant 

guidance 

B 

SEE ACTIVITY 3. CDC, state, and local health 

departments will promote routine and regular (at least 

quarterly) analysis of their epidemiologic data on 

syphilis. 

● All project areas should implement the new syphilis

surveillance data collection instrument by end of 2007 

● HMAs should produce an annual report containing an 

analysis of syphilis surveillance data and summarizing 

local syphilis elimination interventions for stakeholders 

A 

SEE ACTIVITY 4. State health departments should

provide epidemiology training and capacity building to 

STD program staff. 

● Each HMA should ensure that syphilis surveillance staff 

has epidemiologic training and opportunities to improve 

training 

B 

SEE ACTIVITY 5. State and local health departments 

should adopt CDC/ Council of State and Territorial 

Epidemiologists syphilis surveillance case definitions. 

● CDC in partnership with stakeholders to review and 

produce updated guidelines on syphilis case definitions 

by end 2007 

B 

SEE ACTIVITY 6. CDC, state and local health 

departments will encourage and monitor (quarterly

basis) syphilis reporting from public and private 

providers 

● All high morbidity areas (HMAs) should distribute syphilis 

case definitions and reporting requirements to local 

physicians and stakeholders on a regular, and as needed, 

basis 

A 

SEE ACTIVITY 7. State and local health departments 

will use reactor grids to prioritize follow up of syphilis

cases

● State and local health departments should document the 

use of reactor-grid evaluations appropriately 

B 

SEE ACTIVITY 8. CDC, state and local health 

departments should use syphilis prevalence 

monitoring to determine changes over time and 

assess impact of prevention interventions. 

● Where available, syphilis prevalence monitoring results 

should be reviewed on an annual basis 

C 

42
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Outbreak response Standard Rating

SEE ACTIVITY 9. All state and local health 

departments will develop a Syphilis Outbreak 

Response Plan. This should be reviewed and updated 

if necessary, on an annual basis 

● All state and local health departments in HMAs should 

review and update their syphilis outbreak plans by end 

2006 

● CDC to produce a Syphilis Outbreak Plan template for 

use by state and local health departments by end 2007 

A 

SEE ACTIVITY 10. All state and local health 

departments should develop area-specific criteria that 

determine when the outbreak response plan is to be 

implemented. This should be reviewed and updated if 

necessary, on an annual basis 

● All state and local health departments in non-HMAs

should review and update their syphilis outbreak plans 

(including area-specific thresholds) by end 2006 

B 

Clinical services Standard Rating

SEE ACTIVITY 11. State and local health departments 

should document the number of clients turned away

and the length of wait times (for an appointment or to 

be seen once in the clinic) at public STD clinics. 

● All HMAs should maintain monthly sentinel surveillance of 

access to care measures. Data should be reported in the 

annual (project period) grant progress report 

B 

SEE ACTIVITY 12. State and local health departments 

should assess and increase the proportion of local 

health departments that have relationships with nontraditional health care 

● All HMAs should describe current agreements between 

local health departments and non-traditional health care 

facilities biannually. Increase the proportion of local 

health with contracts yearly. Report status in future

project period (annual) progress reports 

B 

SEE ACTIVITY 13. State and local health departments 

should monitor and work towards increasing the 

proportion of STD clinic attenders, and those found to 

have an STD, who receive a screening test for syphilis 

according to recognized standards. 

● 90% of all STD clinic attenders should be screened for 

syphilis 

● >90% of STD clinic attenders diagnosed with an STD 

(other than syphilis) should be screened for syphilis 

C 

SEE ACTIVITY 14. CDC, in partnership with the 

National Coalition of STD Directors (NCSD) and state 

and local health departments, should develop and

implement a quality assurance tool for clinic use to 

ensure that key activities are implemented according to 

recognized standards. 

● CDC in collaboration with all HMAs to develop a clinical 

quality assurance tool by end 2007 

● All HMAs should report status in implementing the tool in 

future project period (annual) progress reports55,56,20

B 

SEE ACTIVITY 15. State and local health departments 

should document the number of syphilis tests 

performed annually in sentinel public and private 

laboratories and measure the time for reporting results 

to providers and health departments.

● All HMAs should collect and review monthly syphilis 

testing data on a quarterly basis 

● These data should be reported in project period (annual) 

progress reports

B 

SEE ACTIVITY 16. State and local health departments 

should monitor and work towards increasing the 

proportion of pregnant females screened for syphilis 

during prenatal health care visits, according to 

recognized standards and state statutes.

● Syphilis screening in pregnancy should be done at first 

prenatal visit. Where indicated, additional screening may

be done early in the third trimester and at delivery

57

● All HMAs should collect data monthly

● These data should be reported in project period (annual) 

progress reports

A 

SEE ACTIVITY 17. In geographic locations where 

transmission is primarily in MSM populations, state and 

local health departments should monitor and work 

towards increasing the proportion of clients screened 

routinely for syphilis by HIV care providers. 

● Screening in MSM - at least annually in sexually active 

MSM or every 3-6 months in MSM at high risk20

● All HMAs should collect data monthly

● These data should be reported in project period (annual) 

progress reports

A 

SEE ACTIVITY 18. In geographic locations where 

transmission is primarily in heterosexual populations, 

state and local health departments should monitor and 

work towards increasing the proportion of 

arrestees/inmates screened and treated for syphilis in 

local jails, with an emphasis on women.

● National guidelines recommend screening arrestees for 

syphilis within 14 days of incarceration58

A 

43
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Partner services Standard Rating

SEE ACTIVITY 19. State and local health departments 

should apply optimum interviewing techniques (see the 

Syphilis Elimination Technical Appendix) to maximize 

the number of partners elicited and partners initiated. 

● State and local health departments in HMAs should audit 

the outcomes of partner notification activities for P&S 

syphilis on an annual basis 

A 

SEE ACTIVITY 20. State and local health departments 

should use the geographic and socio-demographic 

concentration of syphilis to inform the best locations for

DIS for immediate case-interviewing and partner follow

up 

● State and local health departments in HMAs should audit 

the outcomes of partner notification activities for P&S 

syphilis on an annual basis 

B 

SEE ACTIVITY 21. State and local health departments 

should communicate and collaborate with other parties 

interested in partner notification for the elimination of 

syphilis (for example CBOs, private providers, jails).

● State and local health departments in HMAs should audit 

the outcomes of partner notification activities for P&S 

syphilis on an annual basis 

B 

Laboratory services Standard Rating

SEE ACTIVITY 22. CDC and its partners will update 

the Manual of Tests for Syphilis by the end of 2006. In 

addition, CDC will produce and disseminate widely, 

policy guidance on the use and interpretation of results 

of treponemal tests when used as screening tests. 

● Manual of tests update to be completed by end 2006 

● CDC to produce policy guidance on use of treponemal 

tests as screening tests to be produced by end-2006 

A 

SEE ACTIVITY 23. CDC and its partners will undertake 

research and evaluation of point-of-care tests for 

implementation in the United States within the next 5 

years. 

● Strategic plan for evaluation and licensing of syphilis point 

of care tests to be produced by CDC by end 2006

A 

SEE ACTIVITY 24. CDC will establish a network of 

regional laboratories to facilitate PCR testing for 

syphilis. 

● CDC to establish regional laboratory network by end 2007 B 

SEE ACTIVITY 25. CDC should fund demonstration 

projects to examine the utility and acceptability of 

typing and sub-typing methods for T pallidum in 

outbreak situations. 

● CDC to work with program consultants to identify suitable 

areas with syphilis outbreaks to participate in this 

program by end 2007 

B 

GOAL 2: Prioritization of evidence-based, culturally competent interventions 

Public health services will improve their advocacy, acceptability, and appropriateness of their response to syphilis 

epidemics through the creation of productive and proactive partnerships with external stakeholders. 

Community mobilization Standard Rating

SEE ACTIVITY 26. State and local health 

departments will ensure ongoing monitoring of 

surveillance data in order to track evolution in local 

epidemics and inform appropriate community

partnerships. 

● All project areas should implement the new syphilis

surveillance data collection instrument by end of 2007 

● HMAs should produce an annual report containing an 

analysis of syphilis surveillance data and summarizing 

local syphilis elimination interventions for stakeholders 

A 

SEE ACTIVITY 27. CDC, state and local health 

departments should distribute and adapt 

recommendations contained in the CDC SEE 

Community Mobilization tool-kit 

In the annual (project period) grant progress report: 

o All HMAs describe community participation 

activities that include members of the affected 

communities to determine the non-governmental, 

community-based, health and non-health agencies, 

and institutions involved in the development of the 

syphilis elimination plan; 

o Describe how community coalitions, advisory

groups, or taskforces and other partners are 

involved in reviewing the epidemiology of syphilis 

and the social and institutional context of its 

persistence and designing and implementing locally 

relevant, syphilis prevention interventions and 

control services 

B 

SEE ACTIVITY 28. In designated high morbidity areas 

(HMAs), state and local health departments will 

establish meaningful community participation in local 

● Locally appropriate mechanisms for ensuring community

participation (e.g., working groups, community forums 

etc.) should be identified by each HMA. This should be 

A 

44
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

SEE efforts. This should be evaluated on a regular 

basis. 

documented and reviewed annually 

SEE ACTIVITY 29. HMAs receiving CDC SEE funding 

will disburse between 15% to 30% of SEE- dedicated 

funds to support relevant CBO-led activities. 

As required by the CSPS grant award: 

● All HMAs must award 15%-30% of SE funds to 

community organizations that serve affected populations 

● All HMAs must report on activities of these funded

organizations in future project period (annual) progress 

reports 

A 

SEE ACTIVITY 30. State and local health 

departments will ensure that local data are reviewed

regularly with community partners, and used to inform 

community-driven prevention efforts 

● All HMAs should maintain sentinel surveillance and 

analysis of behaviorally high incidence persons to ensure 

appropriate community representation in the participatory

syphilis elimination efforts 

B 

Ethnic minorities Standard Rating

SEE ACTIVITY 31. CDC, state, and local health 

departments should enhance national, state, and local 

prevention efforts, by tailoring interventions for ethnic 

minorities that are disproportionately affected by

syphilis. 

● The CDC Program Assessments Monograph should be 

reviewed by each HMA to determine how SEE-related 

prevention activities can be enhanced by end 2006

● Local intervention efforts, successes and challenges in 

syphilis elimination and ethnic minorities should be 

reviewed and documented by HMAs annually

● Areas should review and consider for implementation one 

of the tailored interventions available through the 

Diffusion of Effective Behavioral Interventions (DEBI) 

http://www.effectiveinterventions.org/ 

● Training for DEBI can be provided by the National 

Network of STD/HIV Prevention Training Centers (PTCs) 

http://depts.washington.edu/nnptc/regional_centers/index.

html

A 

SEE ACTIVITY 32. State and local health 

departments should provide cultural sensitivity training 

for publicly funded SE staff and other interested 

service providers on a regular basis (e.g., annually).

● All syphilis elimination coordinators should participate in 

cultural sensitivity training in order to serve as a resource 

for their project area. This should be updated at least biannually

A 

SEE ACTIVITY 33. CDC will work in partnership with

state and local health departments to undertake 

assessments of health-care seeking; health care 

access; partner services; and screening for ethnic 

minority populations affected by syphilis to inform the 

development or tailoring of culturally appropriate 

interventions. 

● Current sources of research and assessment data should 

be reviewed and new data collected to develop a 

representative perspective of the target communities 

These data should be reviewed at least annually and 

updated as needed 

B 

SEE ACTIVITY 34. State and local health 

departments and CBOs should incorporate 

assessment data into tailored intervention 

development and prevention intervention planning. 

● Tailored local syphilis prevention interventions for ethnic 

minorities should be reviewed for appropriateness of the 

target population(s) on an annual basis 

A 

SEE ACTIVITY 35. State and local health 

departments should identify key local stakeholders to 

establish inter-agency alliances, collaborations, and 

partnerships to enhance syphilis elimination 

interventions. 

● Locally appropriate mechanisms for ensuring community

participation (e.g., working groups, community forums 

etc.) should be identified by each HMA. This should be 

documented and reviewed annually 

A 

45
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Men who have sex with men Standard Rating

SEE ACTIVITY 3. CDC, state, and local health 

departments will promote routine and regular (at least 

quarterly) analysis of their epidemiologic data on 

syphilis. 

● All local providers should receive notification of the 

emergence of syphilis outbreaks among MSM 

● Annual reports on syphilis in MSM in locality to be

produced and distributed to all providers (private and 

public) in locality at least once annually. In areas with 

rapidly progressing epidemics a more frequent 

correspondence should be considered 

● All HMAs to identify and create partnerships with health 

care providers reporting substantial numbers of syphilis 

and HIV in MSM clients. This should be reviewed on 

annual basis 

A 

SEE ACTIVITY 28. In designated high morbidity areas 

(HMAs), state and local health departments will 

establish meaningful community participation in local 

SEE efforts. This should be evaluated on a regular 

basis. 

● Locally appropriate mechanisms for ensuring community

participation (e.g., working groups, community forums 

etc.) should be identified by each HMA. This should be 

documented and reviewed annually

● All HMAs with MSM epidemics should have a multidisciplinary, multi-partner workgroup on MSM and 

syphilis/ sexual health issues 

A 

SEE ACTIVITY 36. CDC, state, and local health 

departments will collect and report data on gender of 

sexual partners/ sexual preference of syphilis index

patients. 

● All HMAs to routinely collect information on syphilis in 

MSM by end 2006 

● Data on MSM syphilis epidemiology and local risk factors 

should be reviewed on quarterly basis by the local 

syphilis elimination coordinator and working group 

(including community partners) 

● Annual reports on syphilis among MSM in locality to be 

produced and distributed to all providers (private and 

public) in locality at least once annually. In areas with 

rapidly progressing epidemics a more frequent 

correspondence should be considered 

A 

SEE ACTIVITY 37. State and local health 

departments should develop and use Internet-based 

interventions in order to increase partner notification 

efficacy, MSM engagement, and participation in SEE 

activities. 

● All STD clinic staff to participate in at least 1 training 

session annually on cultural/gender/sexuality sensitivity

training and MSM health. This should include sexuality,

sexual behaviors, drug use, and other health and 

psychosocial issues faced by MSM 

● Each STD clinic should nominate 1 DIS to lead on MSM 

health issues. He/she should act as a liaison for local 

MSM providers and facilitate collaborations with ISP 

A 

SEE ACTIVITY 38. State and local health 

departments will employ provider outreach, education 

and mobilization to raise awareness, encourage 

reporting, and improve effectiveness and quality of

clinical management;

● Each HMA should have at least one DIS specializing in 

the internet partner notification and MSM. They should be 

responsible for coordinating a working group on internet 

activities and developing annual plan of activities/ 

interventions with internet providers 

A 

SEE ACTIVITY 39. In designated high morbidity areas 

(HMAs), state and local health departments should

facilitate concomitant annual syphilis testing for 

sexually active HIV positive MSM.

● All sexually active HIV+ MSM attending public treatment 

centers should be screened every 6 months for syphilis 

as part of their routine HIV care investigations. In 

outbreak sites this may be increased to quarterly

A 

SEE ACTIVITY 40. State and local health 

departments should enhance access to syphilis 

screening through improving access to STD care 

facilities (e.g., extended operating times, MSM clinical 

sessions etc.).

● All HMAs may consider extending STD clinic services to 

non-traditional hours (evening and weekends) specifically

targeting MSM clientele for syphilis testing. This may be 

combined with other sexual health interventions 

A 

SEE ACTIVITY 41. State and local health 

departments should enhance syphilis education and 

sexual health promotion with MSM within STD clinics 

and the community. 

● Local sites should plan at least 1 major MSM targeted 

health promotion and education intervention per annum 

during rapid increase and hyperendemic epidemic 

phases. These may be new or adapted health promotion 

interventions 

A 

SEE ACTIVITY 42. State and local health 

departments should undertake outreach syphilis 

screening for MSM in bathhouses, bookstores, when

there are demonstrated links to ongoing disease 

● This intervention may be useful in the acute phase of an 

outbreak where cluster investigations may yield high 

number of cases. It may also be recommended as part of 

a community wide awareness raising and screening 

C 

46
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Men who have sex with men Standard Rating

transmission or where the intervention is combined

with other health interventions (e.g., hepatitis B 

vaccination, HIV testing) 

program 

SEE ACTIVITY 43. State and local health 

departments will create partnerships with local drug

treatment centers and programs and will clarify

pathways for treatment and rehabilitation for 

recreational drug use.

● Local sites should clarify and document pathways for 

referral to drug treatment programs for MSM grappling 

with crystal methamphetamine use and addiction 

B 

Provider mobilization Standard Rating

SEE ACTIVITY 44. State and local health 

departments should designate a health department

liaison for provider outreach for ongoing SEE efforts 

● State and local health department should ensure that 

local health care providers (HCPs) 

a) are aware of the local SEE, impact of syphilis, signs 

and symptoms, diagnosis, treatment, and reporting 

guidelines, 

b) take sexual history from patients, 

c) refer patients to the HD for partner notification 

● SEE Toolkit materials developed for HCPs should be 

disseminated by state and local health departments

● Mechanisms to facilitate good communication and 

collaborations between HCPs and the Health Department 

should be identified, implemented, and reviewed annually

B 

SEE ACTIVITY 45. CDC, state and local health 

departments should provide in-service training and 

technical assistance to private health care providers 

● Utilize NNPTCs 

● Explore the possibility of collaborations with local 

universities for grand rounds, seminars, and other training 

opportunities 

● Work closely with local medical associations 

● Familiarize relevant HD staff and HCPs with the 

guidelines set forth in POG 

A 

SEE ACTIVITY 46. State and local health 

departments should develop Memoranda of 

Understanding (MOA) with specific providers or CBOs 

(seeing a high number of syphilis cases) in order to 

clarify procedures for diagnosis, partner notification, 

and reporting. 

● All HMAs to identify and create partnerships with health 

care providers reporting substantial numbers of syphilis 

and HIV in MSM clients. This should be reviewed on 

annual basis 

● The MOA should clearly define roles, responsibilities and 

should assign clear tasks to each party involved 

B 

SEE ACTIVITY 47. State and local health 

departments should develop and widely disseminate 

policies and protocols for syphilis diagnosis and care 

in hospitals, emergency rooms, corrections facilities

and other settings 

● State and local health departments should utilize POG 

guidelines and CDC STD Treatment Guidelines to

develop local policies and protocols 

A 

SEE ACTIVITY 48. CDC, state and local health 

departments should provide easy access to reliable 

and up to date syphilis data for their respective SEE 

stakeholders. 

● All project areas should implement the new syphilis

surveillance data collection instrument by end of 2007 

● HMAs should produce an annual report containing an 

analysis of syphilis surveillance data and summarizing 

local syphilis elimination interventions for stakeholders 

A 

47
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Jail-based screening Standard Rating

SEE ACTIVITY 18. In geographic locations where 

transmission is primarily in heterosexual populations, 

state and local health departments should monitor and 

work towards increasing the proportion of 

arrestees/inmates screened and treated for syphilis in 

local jails, with an emphasis on women. 

● State and local health departments should establish a 

community/corrections leadership group that includes 

cross-section of jail, health, and community, private 

sector partners to identify needs, set priorities and 

facilitate communications 

A 

SEE ACTIVITY 49. State and local health departments 

should establish or maintain effective partnerships with 

jails as a community-based setting for case-finding, 

disease surveillance, treatment, and research. 

● State and local health departments should develop formal 

MOU/MOA to formalize partnerships 

B 

SEE ACTIVITY 50. State and local health departments 

will collect jail-based syphilis morbidity and behavioral 

data 

Where indicated, HMAs should: 

● Collect venue-based syphilis case data by race, sex, age, 

arrest codes, and risk-factors (i.e., sexual orientation) 

● Review data from jail-based syphilis morbidity and 

arrestee risk factors reviewed on quarterly basis by 

project area syphilis coalition for trends and when 

indicated redirection of programmatic effort 

● Distribute annual reports to all relevant project area

providers (private and public) 

B 

SEE ACTIVITY 51. State and local health departments 

will work to improve information management systems 

and data sharing capabilities 

● Support the use of electronic medical record systems 

that, while not violating a patient’s privacy, enhances 

disease reporting and follow up 

● Ensure that the data system is maintained and upgraded 

routinely to ensure the efficient management of jail-based 

screening and intervention data 

C 

SEE ACTIVITY 52. CDC, state and local health 

departments should provide cross-training experiences 

for public health and detention staff 

● This should be done in collaboration with the CDC, the 

Prevention Training Centers and include the American 

Jail Association, the National Commission on 

Correctional Heath Care and the DSTD Prevention 

Training Centers as subject matter experts and advocacy

partners 

C 

SEE ACTIVITY 53. State and local health departments 

should assign STD program staff to jails to complement 

and support screening and treatment activity

● Establish and maintain collaborative data collection and 

reporting relationships 

● Support and monitor the use of CDC STD treatment 

guidelines, NCCHC clinical guidelines and performance 

standards 

● Establish joint public health/corrections group to address 

operational research, demonstration and program 

evaluation needs 

B 

48
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Congenital syphilis Standard Rating

SEE ACTIVITY 54. CDC, state and local health 

departments should maintain activities to ensure 

sustained political commitment and advocacy for 

congenital syphilis elimination (e.g., mobilizing 

organizational partners). 

● Locally appropriate mechanisms for ensuring community

participation (e.g., working groups, community forums 

etc.) should be identified by each HMA. This should be 

documented and reviewed annually 

A 

SEE ACTIVITY 55. CDC, state and local health 

departments will work to increase access to, and 

quality of mother and child health services, ensuring 

that all pregnant women are adequately screened and 

treated, and decreasing the frequency of missed 

opportunities for screening women outside mother and 

child care. 

● State and local health departments should utilize POG 

guidelines; syphilis surveillance guidelines and CDC STD 

Treatment Guidelines to develop local policies and 

protocols 

A 

SEE ACTIVITY 56. State and local health departments 

will ensure screening and treatment of all pregnant

women for syphilis, using recommended diagnostic 

algorithms for the detection of syphilis. 

● State and local health departments should utilize POG 

guidelines, syphilis surveillance guidelines, and CDC STD 

Treatment Guidelines to develop local policies and 

protocols 

A 

SEE ACTIVITY 57. CDC, state and local health 

departments will undertake congenital syphilis relevant 

surveillance, monitoring and evaluation activities, 

including improving surveillance systems, developing 

performance measures, and strengthening monitoring 

and evaluation systems. 

● All project areas should implement the new syphilis

surveillance data collection instrument by end of 2007 

● HMAs should produce an annual report containing an 

analysis of syphilis surveillance data and summarizing 

local syphilis elimination interventions for stakeholders 

B 

GOAL 3: Accountable services and interventions 

Public health services will improve the effectiveness of their interventions by improving accountability for their planning, 

implementation and evaluation. 

Training and staff development Standard Rating

SEE ACTIVITY 58. CDC and state and local health 

departments should undertake routine and regular

assessment of program staff training needs 

● CDC and project areas to use existing performance 

review mechanisms to identify training needs of staff 

related to syphilis elimination on an annual basis 

B 

SEE ACTIVITY 59. CDC, in partnership with NCSD 

and PTCs should identify training opportunities for 

private practitioners relevant to syphilis elimination

● CDC to identify and disseminate training opportunities for 

SEE coordinators 

A 

SEE ACTIVITY 60. CDC and state and local health 

departments will work together to identify nationally

and locally available training opportunities and 

resources 

● CDC to identify and disseminate training opportunities for 

SEE coordinators 

A 

SEE ACTIVITY 61. State and local health departments 

will ensure adequate training of supervisors to support 

local SEE activities. 

● CDC to identify and disseminate training opportunities to 

SEE coordinators, and project areas 

B 

SEE ACTIVITY 62. State and local health departments 

should assign one or more management staff to be

accountable for training and staff development 

● To be agreed upon C 

SEE ACTIVITY 63. CDC in partnership with NCSD,

state and local health departments will provide 

technical assistance for the development, use, and 

monitoring and evaluation of syphilis elimination 

evidence-based action plans. 

● All HMAs to develop local SEE evidence-based action 

plans by FY 2007

A 

49
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Evidence-based action planning Standard Priority

SEE ACTIVITY 64. CDC will request complete 

evidence-based action plans from all new HMAs from 

FY 2007 onwards, and for all existing HMAs from FY

2008 onwards. 

● Annual updates of local SEE evidence-based action plans 

to be submitted to CDC by 1 October of each year

A 

SEE ACTIVITY 65. State and local health departments 

will develop syphilis elimination action plans that are 

supported by surveillance or research evidence, and 

integrated into the performance of SE coordinators and 

local action teams. 

● All SEE action plan objectives should be SMART 

(specific, measurable, achievable, reproducible, timelimited)

● Each action step or change to be sought should include 

the following information: 

● What actions or changes will occur; 

● Who will carry out these changes; 

● By when they will take place, and for how long; 

● What resources (i.e., money, staff) are needed to 

carry out these changes; 

● Communication (who should know what?) 

A 

SEE ACTIVITY 66. CDC, in partnership with state and 

local health departments, will use a standard format for 

local syphilis elimination evidence-based action plans 

by December 2007. 

● Local SEE coordinators, in partnership with appropriate 

senior STD program managers should prepare the first 

draft of the SEE plan for submission to CDC 

A 

SEE ACTIVITY 67. State and local health departments 

should ensure that their local syphilis elimination action 

plans are shared locally and are widely available for 

review by stakeholders. 

All HMAs should consider dissemination of their local SEE plans by

at minimum 3 of the following strategies: 

● Copy of plan sent to PHD Board 

● All members of PHD receive copy of plan 

● Local SEE mission, vision, and value statements to be 

disseminated to local staff 

● Parts of plan published in local PHD correspondence 

● STD program staff trained on parts of the plan 

A 

Monitoring and evaluation Standard Priority

SEE ACTIVITY 68. CDC, state and local health 

departments will prioritize risk groups and interventions 

for syphilis elimination. 

● Prioritized, evidence-based interventions to be provided 

by all HMAs using the action planning template by FY

2007 

A 

SEE ACTIVITY 69. CDC, in partnership with its 

stakeholders, will provide explicit requirements, 

recommendations and standards for syphilis 

elimination activities at all levels in the plan. 

● Activities and recommended standards to be provided 

with the launch of the 2006 SEE Plan by end 2006 

A 

SEE ACTIVITY 70. CDC, in partnership with state and 

local health departments, will routinely monitor syphilis 

elimination activities to ensure that standards are met 

and that priorities are being addressed. 

● SEE funded project areas to submit 6-monthly progress 

reports on SEE activities to CDC based upon their action 

plans 

● CDC to undertake summative evaluation of SEE support 

to project area during the penultimate year of funding 

A 

SEE ACTIVITY 71. CDC, state and local health 

departments will share findings of evaluation activities 

at all levels. CDC, through the Syphilis Elimination 

coordination, will identify and make explicit, 

mechanisms to facilitate sharing of this information. 

● All SEE funded areas and the CDC will work together to 

identify key opportunities for sharing findings of SEE 

evaluation activities on a regular basis. These findings 

should be disseminated widely

B 

50
APPENDIX 2. REQUIRED and RECOMMENDED STRATEGIES AND ACTIVITIES 

Research and development Standard Priority

SEE ACTIVITY 72. CDC working in partnership with 

SEE partners will deliver broadly applicable tools and 

methods for syphilis diagnosis, prevention, and control 

● CDC with its partners to develop a syphilis elimination 

research plan by end 2006 to inform research and 

development activities in this filed 

A 

SEE ACTIVITY 73. CDC and its SEE partners will 

develop and share syphilis prevention and diagnostic 

technologies and approaches 

● CDC with its partners to develop a syphilis elimination 

research plan by end 2006 to inform research and 

development activities in this filed. 

A 

SEE ACTIVITY 74. CDC and its SEE partners will 

evaluate the effectiveness and cost-effectiveness of 

selected syphilis prevention interventions 

● CDC with its partners to develop a syphilis elimination 

research plan by end 2006 to inform research and 

development activities in this filed 

A 

SEE ACTIVITY 75. CDC and its SEE partners will 

conduct research to address economic, social, and 

behavioral determinants and consequences of syphilis 

epidemics and prevention. 

● CDC with its partners to develop a syphilis elimination 

research plan by end 2006 to inform research and 

development activities in this filed 

A 

51
APPENDIX 3. PRIORITY SEE INTERVENTIONS 

APPENDIX 3 List of SEE by Required & Recommended 

Categories Only

List of SEE required activities 

● SEE ACTIVITY 1. State and local health departments will collect and report gender of sex partners/ sexuality

data to CDC by end-2006. 

● SEE ACTIVITY 3. CDC, state, and local health departments will promote routine and regular (at least quarterly)

analysis of their epidemiologic data on syphilis. 

● SEE ACTIVITY 6. CDC, state and local health departments will encourage and monitor (quarterly basis) syphilis 

reporting from public and private providers. 

● SEE ACTIVITY 7. State and local health departments will use reactor grids to prioritize follow up of syphilis 

cases. These should be evaluated annually or more frequently if the local epidemiology changes. 

● SEE ACTIVITY 9. All state and local health departments will develop a Syphilis Outbreak Response Plan. This 

should be reviewed and updated if necessary, on an annual basis. 

● SEE ACTIVITY 22. CDC and its partners will update the Manual of Tests for Syphilis by the end of 2006. In 

addition, CDC will produce and disseminate widely, policy guidance on the use and interpretation of results of 

treponemal tests when used as screening tests. 

● SEE ACTIVITY 23. CDC and its partners will undertake research and evaluation of point-of-care tests for 

implementation in the United States within the next 5 years. 

● SEE ACTIVITY 24. CDC will establish a network of regional laboratories to facilitate PCR testing for syphilis. 

● SEE ACTIVITY 26. State and local health departments will ensure ongoing monitoring of surveillance data in 

order to track evolution in local epidemics and inform appropriate community partnerships. 

● SEE ACTIVITY 28. In designated high morbidity areas (HMAs), state and local health departments will establish 

meaningful community participation in local SEE efforts. This should be evaluated on a regular basis. 

● SEE ACTIVITY 29. HMAs receiving CDC SEE funding will disburse between 15% to 30% of SEE- dedicated 

funds to support relevant CBO-led activities. The funding level will be determined by epidemic phase and 

existing CBO infrastructure and capacity.

● SEE ACTIVITY 30. State and local health departments will ensure that local data are reviewed regularly with 

community partners, and used to inform community-driven prevention efforts 

● SEE ACTIVITY 33. CDC will work in partnership with state and local health departments to undertake 

assessments of health-care seeking; health care access; partner services; and screening for ethnic minority

populations affected by syphilis to inform the development or tailoring of culturally appropriate interventions. 

● SEE ACTIVITY 36. CDC, state, and local health departments will collect and report data on gender of sexual 

partners/ sexual preference of syphilis index patients. 

● SEE ACTIVITY 38. State and local health departments will employ provider outreach, education and 

mobilization to raise awareness, encourage reporting, and improve effectiveness and quality of clinical 

management;

● SEE ACTIVITY 43. State and local health departments will create partnerships with local drug treatment centers 

and programs and will clarify pathways for treatment and rehabilitation for recreational drug use.

● SEE ACTIVITY 50. State and local health departments will collect jail-based syphilis morbidity and behavioral 

data. 

● SEE ACTIVITY 51. State and local health departments will work to improve information management systems 

and data sharing capabilities. 

● SEE ACTIVITY 55. CDC, state and local health departments will work to increase access to, and quality of 

mother and child health services, ensuring that all pregnant women are adequately screened and treated, and 

decreasing the frequency of missed opportunities for screening women outside mother and child care. 

● SEE ACTIVITY 56. State and local health departments will ensure screening and treatment of all pregnant 

women for syphilis, using recommended diagnostic algorithms for the detection of syphilis. 

● SEE ACTIVITY 57. CDC, state and local health departments will undertake congenital syphilis relevant 

surveillance, monitoring and evaluation activities, including improving surveillance systems, developing 

performance measures, and strengthening monitoring and evaluation systems. 

52
APPENDIX 3. PRIORITY SEE INTERVENTIONS 

● SEE ACTIVITY 60. CDC and state and local health departments will work together to identify nationally and 

locally available training opportunities and resources. 

● SEE ACTIVITY 61. State and local health departments will ensure adequate training of supervisors to support 

local SEE activities. 

● SEE ACTIVITY 63. CDC in partnership with NCSD, state and local health departments will provide technical 

assistance for the development, use, and monitoring and evaluation of syphilis elimination evidence-based 

action plans. 

● SEE ACTIVITY 64. CDC will request complete evidence-based action plans from all new HMAs from FY 2007 

onwards, and for all existing HMAs from FY 2008 onwards. 

● SEE ACTIVITY 65. State and local health departments will develop syphilis elimination action plans that are 

supported by surveillance or research evidence, and integrated into the performance of SE coordinators and 

local action teams. 

● SEE ACTIVITY 66. CDC, in partnership with state and local health departments, will use a standard format for 

local syphilis elimination evidence-based action plans by December 2007. 

● SEE ACTIVITY 68. CDC, state and local health departments will prioritize risk groups and interventions for 

syphilis elimination. 

● SEE ACTIVITY 69. CDC, in partnership with its stakeholders, will provide explicit requirements, 

recommendations and standards for syphilis elimination activities at all levels in the plan. 

● SEE ACTIVITY 70. CDC, in partnership with state and local health departments, will routinely monitor syphilis 

elimination activities to ensure that standards are met and that priorities are being addressed. 

● SEE ACTIVITY 71. CDC, state and local health departments will share findings of evaluation activities at all 

levels. CDC, through the Syphilis Elimination coordination, will identify and make explicit, mechanisms to 

facilitate sharing of this information. 

● SEE ACTIVITY 72. CDC working in partnership with SEE partners will deliver broadly applicable tools and 

methods for syphilis diagnosis, prevention, and control. 

● SEE ACTIVITY 73. CDC and its SEE partners will develop and share syphilis prevention and diagnostic 

technologies and approaches. 

● SEE ACTIVITY 74. CDC and its SEE partners will evaluate the effectiveness and cost-effectiveness of selected 

syphilis prevention interventions. 

● SEE ACTIVITY 75. CDC and its SEE partners will conduct research to address economic, social, and 

behavioral determinants and consequences of syphilis epidemics and prevention. 

List of SEE recommended activities 

● SEE ACTIVITY 2. State and local health departments should quarterly assess case report data for duplications, 

errors, and omissions and annually assess for accuracy, completeness and sensitivity, promptness, validity and 

quality.

● SEE ACTIVITY 4. State health departments should provide epidemiology training and capacity building to STD 

program staff. 

● SEE ACTIVITY 5. State and local health departments should adopt CDC/ Council of State and Territorial 

Epidemiologists syphilis surveillance case definitions. 

● SEE ACTIVITY 8. CDC, state and local health departments should use syphilis prevalence monitoring to

determine changes over time and assess impact of prevention interventions. 

● SEE ACTIVITY 10. All state and local health departments should develop area-specific criteria that determine 

when the outbreak response plan is to be implemented. This should be reviewed and updated if necessary, on 

an annual basis. 

● SEE ACTIVITY 11. State and local health departments should document the number of clients turned away and 

the length of wait times (for an appointment or to be seen once in the clinic) at public STD clinics. 

● SEE ACTIVITY 12. State and local health departments should assess and increase the proportion of local 

health departments that have relationships with non-traditional health care providers (e.g., community centers, 

outreach clinics etc.) where at-risk populations seek services. 

● SEE ACTIVITY 13. State and local health departments should monitor and work towards increasing the 

proportion of STD clinic attenders, and those found to have an STD, who receive a screening test for syphilis 

according to recognized standards. 

53
APPENDIX 3. PRIORITY SEE INTERVENTIONS 

● SEE ACTIVITY 14. CDC, in partnership with the National Coalition of STD Directors (NCSD) and state and local 

health departments, should develop and implement a quality assurance tool for clinic use to ensure that key

activities are implemented according to recognized standards. 

● SEE ACTIVITY 15. State and local health departments should document the number of syphilis tests performed 

annually in sentinel public and private laboratories and measure the time for reporting results to providers and 

health departments. 

● SEE ACTIVITY 16. State and local health departments should monitor and work towards increasing the 

proportion of pregnant females screened for syphilis during prenatal health care visits, according to recognized 

standards and state statutes. 

● SEE ACTIVITY 17. In geographic locations where transmission is primarily in MSM populations, state and local 

health departments should monitor and work towards increasing the proportion of clients screened routinely for 

syphilis by HIV care providers. 

● SEE ACTIVITY 18. In geographic locations where transmission is primarily in heterosexual populations, state 

and local health departments should monitor and work towards increasing the proportion of arrestees/inmates 

screened and treated for syphilis in local jails, with an emphasis on women. 

● SEE ACTIVITY 19. State and local health departments should apply optimum interviewing techniques (see the 

Syphilis Elimination Technical Appendix) to maximize the number of partners elicited and partners initiated. 

● SEE ACTIVITY 20. State and local health departments should use the geographic and socio-demographic 

concentration of syphilis to inform the best locations for DIS for immediate case-interviewing and partner follow

up. 

● SEE ACTIVITY 21. State and local health departments should communicate and collaborate with other parties 

interested in partner notification for the elimination of syphilis (for example CBOs, private providers, jails).

● SEE ACTIVITY 25. CDC should fund demonstration projects to examine the utility and acceptability of typing 

and sub-typing methods for T pallidum in outbreak situations. 

● SEE ACTIVITY 27. CDC, state and local health departments should distribute and adapt recommendations 

contained in the CDC SEE Community Mobilization tool-kit. 

● SEE ACTIVITY 31. CDC, state, and local health departments should enhance national, state, and local 

prevention efforts, by tailoring interventions for ethnic minorities that are disproportionately affected by syphilis. 

● SEE ACTIVITY 32. State and local health departments should provide cultural sensitivity training for publicly

funded SE staff and other interested service providers on a regular basis (e.g., annually). 

● SEE ACTIVITY 34. State and local health departments and CBOs should incorporate assessment data into 

tailored intervention development and prevention intervention planning. 

● SEE ACTIVITY 35. State and local health departments should identify key local stakeholders to establish interagency alliances, collaborations, and partnerships to enhance syphilis elimination interventions. 

● SEE ACTIVITY 37. State and local health departments should develop and use Internet-based interventions in 

order to increase partner notification efficacy, MSM engagement, and participation in SEE activities. 

● SEE ACTIVITY 39. In designated high morbidity areas (HMAs), state and local health departments should 

facilitate concomitant annual syphilis testing for sexually active HIV positive MSM. 

● SEE ACTIVITY 40. State and local health departments should enhance access to syphilis screening through 

improving access to STD care facilities (e.g., extended operating times, MSM clinical sessions etc.). 

● SEE ACTIVITY 41. State and local health departments should enhance syphilis education and sexual health 

promotion with MSM within STD clinics and the community. 

● SEE ACTIVITY 42. State and local health departments should undertake outreach syphilis screening for MSM 

in bathhouses, bookstores, when there are demonstrated links to ongoing disease transmission or where the 

intervention is combined with other health interventions (e.g., hepatitis B vaccination, HIV testing). 

● SEE ACTIVITY 44. State and local health departments should designate a health department liaison for 

provider outreach for ongoing SEE efforts. 

● SEE ACTIVITY 45. CDC, state and local health departments should provide in-service training and technical 

assistance to private health care providers (including physicians, practice nurses etc.) 

● SEE ACTIVITY 46. State and local health departments should develop Memoranda of Understanding (MOA) 

with specific providers or CBOs (seeing a high number of syphilis cases) in order to clarify procedures for 

diagnosis, partner notification, and reporting. 

● SEE ACTIVITY 47. State and local health departments should develop and widely disseminate policies and 

protocols for syphilis diagnosis and care in hospitals, emergency rooms, corrections facilities and other settings 

(e.g., web-based health alerts or newsletters). 

54
APPENDIX 3. PRIORITY SEE INTERVENTIONS 

● SEE ACTIVITY 48. CDC, state and local health departments should provide easy access to reliable and up to 

date syphilis data for their respective SEE stakeholders. 

● SEE ACTIVITY 49. State and local health departments should establish or maintain effective partnerships with 

jails as a community-based setting for case-finding, disease surveillance, treatment, and research. 

● SEE ACTIVITY 52. CDC, state and local health departments should provide cross-training experiences for 

public health and detention staff. 

● SEE ACTIVITY 53. State and local health departments should assign STD program staff to jails to complement 

and support screening and treatment activity where indicated. 

● SEE ACTIVITY 54. CDC, state and local health departments should maintain activities to ensure sustained 

political commitment and advocacy for congenital syphilis elimination (e.g., mobilizing organizational partners). 

● SEE ACTIVITY 58. CDC and state and local health departments should undertake routine and regular 

assessment of program staff training needs. 

● SEE ACTIVITY 59. CDC, in partnership with NCSD and PTCs should identify training opportunities for private 

practitioners relevant to syphilis elimination. 

● SEE ACTIVITY 62. State and local health departments should assign one or more management staff to be 

accountable for training and staff development for syphilis elimination activities. 

● SEE ACTIVITY 67. State and local health departments should ensure that their local syphilis elimination action 

plans are shared locally and are widely available for review by stakeholders. 

55
APPENDIX 4. GPRA GOALS 

APPENDIX 4 CDC GPRA Goals for Syphilis Elimination 

The Government Performance Reporting Act (GPRA) of 1993 provides for the establishment of

strategic planning and performance measurement in the Federal Government, and for other 

purposes. The purposes of this Act are to: 

(1) improve the confidence of the American people in the capability of the Federal 

Government, by systematically holding Federal agencies accountable for achieving 

program results; 

(2) initiate program performance reform with a series of pilot projects in setting program 

goals, measuring program performance against those goals, and reporting publicly on 

their progress; 

(3) improve Federal program effectiveness and public accountability by promoting a new 

focus on results, service quality, and customer satisfaction; 

(4) help Federal managers improve service delivery, by requiring that they plan for meeting 

program objectives and by providing them with information about program results and 

service quality; 

(5) improve congressional decision-making by providing more objective information on 

achieving statutory objectives, and on the relative effectiveness and efficiency of Federal 

programs and spending; and 

(6) improve internal management of the Federal Government. 

CDC identified key goals for the elimination of syphilis from the United States: investment in, and 

enhancement of, public health services and interventions, prioritization of evidence-based, 

culturally competent interventions, and ensuring accountable services and interventions. In the 

table below we illustrate the overall GRPA targets and interim annual measures for the period 

2006-2010. 

CDC GPRA Goals for the elimination of syphilis in the United States 

Baseline Annual Targets Long-Term Goal

2002 2005 2006 2007 2008 2009 2010 

Incidence of P&S Syphilis/100,000 population 

 

2.4 2.5 2.5 2.4 2.3 2.2 

Incidence of P&S Syphilis/100,000 pop. (Men) 

Incidence of P&S Syphilis/100,000 pop. 

(Women) 

3.8 

1.1 

4.5 

0.58 

4.5 

0.53 

4.4 

0.47 

4.3 

0.43 

4.2 

0.38 

Incidence of Congenital Syphilis/100,000 live 

births 

10.2 6.0 5.4 4.8 4.4 3.9 (62%) 

Black: white ratio of P&S syphilis 

8.1 3.6:1 3.5:1 3.1:1 2.9:1 3:1 (63%) 

56
APPENDIX 5. 2004 P&S SYPHILIS RATES AND SEE TARGETS 

APPENDIX 5 2004 P&S syphilis rates and threshold SEE 

targets for US project areas 

This table provides estimates of syphilis incidence (rates per 100,000 population) using the High Morbidity Area (HMA) 

thresholds outlined in this document. The upper HMA threshold denotes the point at which SEE funds will be disbursed to 

project areas. The lower HMA threshold denotes levels at which phased reductions in SEE funding should be considered. 

The rate of 0.4 per 100,000 equals to the SEE goal of <1000 cases of P&S syphilis per annum. “Achieved” in this table 

denotes areas which have met the syphilis elimination goal. 

 Currently funded Project 

areas 

2004 

P&S 

cases 

reported 

2004 rates 

per 

100,000 

population 

UPPER HMA

threshold target

of 2.0 per 100,000 

pop. 

LOWER HMA

threshold target of 

1.0 per 100,000 pop. 

SEE Elimination 

goal of 0.4 per 

100,000 pop. 

North Carolina 192 2.4 160 80 32

Tennessee 130 2.3 113 57 23

Texas 852 4.1 416 208 83

Baltimore 211 33.6 13 6 3

Georgia 550 6.7 164 82 33

Mississippi 59 2.1 56 28 11

Louisiana 331 7.4 89 45 18

Alabama 167 3.8 88 44 18

South Carolina 115 2.9 79 40 16

Chicago 306 10 61 31 12

Puerto Rico 200 5.3 75 38 15

Ohio 237 2.1 226 113 45

Florida 739 4.6 321 161 64

Virginia 116 1.6 (ACHIEVED) 73 29

California 599 2.5 479 240 96

Maryland excl Baltimore 159 3.4 94 47 19

Arkansas 40 1.5 (ACHIEVED) 27 11

Indiana 60 1 (ACHIEVED) (ACHIEVED) 24

Missouri 94 1.7 (ACHIEVED) 55 22

Arizona 157 3.1 101 51 20

Kentucky 47 1.2 (ACHIEVED) 39 16

Oklahoma 25 0.7 (ACHIEVED) (ACHIEVED) 14

Philadelphia 71 4.8 30 15 6

Wisconsin 29 0.5 (ACHIEVED) (ACHIEVED) 23

Illinois ex Chicago 80 0.82 (ACHIEVED) (ACHIEVED) 39

Michigan 192 1.9 202 101 40

New Jersey 150 1.8 167 83 33

Washington, D.C. 91 15.9 11 6 2

Washington 150 2.5 120 60 24

Pennsylvania (excl Phil.) 50 0.49 (ACHIEVED) (ACHIEVED) 41

Oregon 29 0.8 (ACHIEVED) (ACHIEVED) 15

Minnesota 25 0.5 (ACHIEVED) (ACHIEVED) 20

Colorado 55 1.3 (ACHIEVED) 42 17

Los Angeles 401 4.3 187 93 37

New York State ex NYC 108 1.02 212 106 42

New York City 607 7.5 162 81 32

Connecticut 45 1.3 69 35 14

Massachusetts 115 1.8 128 64 26

San Francisco 335 44.6 15 8 3

New Mexico 81 4.5 18 18 7

 Project areas not receiving Syphilis Elimination Funding (2005) 

Alaska 8 1.3 (ACHIEVED) 6 2

Delaware 9 1.1 (ACHIEVED) 8 3

Hawaii 9 0.7 (ACHIEVED) 13 5

Idaho 24 1.9 (ACHIEVED) 13 5

Iowa 5 0.2 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Kansas 24 0.9 (ACHIEVED) (ACHIEVED) 11

Maine 2 0.2 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Montana 3 0.3 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Nebraska 7 0.4 (ACHIEVED) (ACHIEVED) (ACHIEVED)

57
APPENDIX 5. 2004 P&S SYPHILIS RATES AND SEE TARGETS 

 Currently funded Project 

areas 

2004 

P&S 

cases 

reported 

2004 rates 

per 

100,000 

population 

UPPER HMA

threshold target

of 2.0 per 100,000 

pop. 

LOWER HMA

threshold target of 

1.0 per 100,000 pop. 

SEE Elimination 

goal of 0.4 per 

100,000 pop. 

Nevada 39 2 (ACHIEVED) 20 8

New Hampshire 5 0.4 (ACHIEVED) (ACHIEVED) (ACHIEVED)

North Dakota 0 0 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Rhode Island 26 2.5 21 10 5

South Dakota 0 0 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Utah 13 0.6 (ACHIEVED) (ACHIEVED) 9

Vermont 1 0.2 (ACHIEVED) (ACHIEVED) (ACHIEVED)

West Virginia 3 0.2 (ACHIEVED) (ACHIEVED) (ACHIEVED)

Wyoming 3 0.6 (ACHIEVED) (ACHIEVED) 2

58
References 

References

 

1 Centers for Disease Control and Prevention. Syphilis Elimination Effort. Technical Appendix. Atlanta. 

2005. 

2 Centers for Disease Control and Prevention. The national plan to eliminate syphilis from the United 

States. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for HIV, 

STD, and TB Prevention, 1999: 1-84. 

3 Further information available from the Office of Management and Budget. Executive Office of the 

President website at http://www.whitehouse.gov/omb/mgmt-gpra/gplaw2m.html. Last accessed on 

October 2005. 

4 Douglas JM Jr, Peterman TA, Fenton KA. Syphilis among men who have sex with men: challenges to 

syphilis elimination in the United States. Sex Transm Dis. 2005 Oct;32(10 Suppl):S80-3. 

5 Centers for Disease Control and Prevention. STD Annual Report for 2004. 

6 Centers for Disease Control and Prevention. Syphilis Elimination Communication Plan. Available at 

http://www.cdc.gov/stopsyphilis/CommPlan.htm. Last accessed September 1, 2005. 

7 Centers for Disease Control and Prevention. Syphilis Elimination Effort Community Mobilization Tool-kit. 

Available at http://www.cdc.gov/std/see/ . Last accessed September 1, 2005. 

8 Valentine J and Fenton KA. The Syphilis Elimination Listening Tour Report. Atlanta. August 2005 

9 Centers for Disease Control and Prevention. Syphilis Elimination Program Assessment Report. 2003. 

10 McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually 

transmitted diseases. JAMA. 2000 Jul 26;284(4):443-6. 

11 Aral SO, Padian NS, Holmes KK. Advances in multilevel approaches to understanding the 

epidemiology and prevention of sexually transmitted infections and HIV: an overview. J Infect Dis. 2005 

Feb 1;191 Suppl 1:S1-6. 

12 Wasserheit JN. Syphilis: a barometer of community health. Sex Transm Dis. 2000 Jul;27(6):311-2. 

13 Fenton KA, Imrie J. Increasing rates of sexually transmitted diseases in homosexual men in Western 

Europe and the United States: why? Infect Dis Clin North Am. 2005 Jun;19(2):311-31. 

14 Centers for Disease Control and Prevention (CDC). Transmission of primary and secondary syphilis by 

oral sex--Chicago, Illinois, 1998-2002. MMWR Morb Mortal Wkly Rep. 2004 Oct 22;53(41):966-8. 

15 Golden MR, Marra CM, Holmes KK. Update on syphilis: resurgence of an old problem.JAMA. 2003 

Sep 17;290(11):1510-4. 

16 Marx R, Aral SO, Rolfs RT, Sterk CE, Kahn JG. Crack, sex, and STD. Sex Transm Dis. 1991 AprJun;18(2):92-101. 

59
References 

 

17 Aral SO. Sexually transmitted diseases: magnitude, determinants and consequences. Int J STD 

AIDS. 2001 Apr;12(4):211-5. 

18 Hirshfield S, Remien RH, Humberstone M, Walavalkar I, Chiasson MA. Substance use and high-risk 

sex among men who have sex with men: a national online study in the USA.AIDS Care. 2004 

Nov;16(8):1036-47. 

19 Centers for Disease Control and Prevention (CDC). Trends in HIV/AIDS diagnoses--33 states, 2001-

2004. MMWR Morb Mortal Wkly Rep. 2005 Nov 18;54(45):1149-53. 

20 Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus 

infection and other sexually transmitted diseases. Sex Transm Dis. 1992 Mar-Apr;19(2):61-77. 

21 A manual of tests for syphilis. Larsen SA, Pope V, Johnson RE & Kennedy EJ. Eds. 9th Ed. 1998. 

American Public Health Association. Washington, DC. 

22 Lambert NL, Fisher M, Imrie J, Watson R, Mercer CH, Parry JV, Phillips A, Iversen A, Perry N, Dean 

GL. Community based syphilis screening: feasibility, acceptability, and effectiveness in case finding. Sex 

Transm Infect. 2005 Jun;81(3):213-216. 

23 Cross T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, 

volume I. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical 

Assistance Center; Isaacs, M. and Benjamin, M. (1991). Towards a culturally competent system of care, 

volume II, programs which utilize culturally competent principles. Washington, D.C.: Georgetown 

University Child Development Center, CASSP Technical Assistance Center. 

24 Davis, K. (1997). Exploring the intersection between cultural competency and managed behavioral 

health care policy: Implications for state and county mental health agencies. Alexandria, VA: National 

Technical Assistance Center for State Mental Health Planning. 

25 Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications 

for prevention strategies. J Infect Dis. 1996 Oct;174 Suppl 2:S201-13. 

26 Centers for Disease Control and Prevention. Recommendations for Public Health Surveilance of 

Syphilis in the United States. 2003. Atlanta, GA, U.S. Department of Health and Human Services. 

27 The Sexually Transmitted Diseases Diagnostics Initiative. Diagnostics Evaluation Series No.1. 

2003.World Health Organization. Geneva. 

28 Thomas JC, Eng E, Earp JA, & Ellis H. Trust and collaboration in the prevention of sexually 

transmitted diseases. Public Health Reports, 2001: 116(6): 540-7. 

29 CDC. The national plan to eliminate syphilis from the United States. Atlanta, Georgia: U.S. 

Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention, 

1999: 1-84. 

30 CDC. The community mobilization guide: Together We Can SEE. Atlanta, Georgia: U.S. Department 

of Health and Human Services, CDC, National Coordinating Center for Infectious Diseases, National 

Center for HIV, STD, TB Prevention, 2005: 1-56. 

31 Morgan, LM. Community participation in health: perpetual allure, persistent challenge. Health Policy 

and Planning, 2001: 16(3): 221-230. 

60
References 

 

32 Robertson, A & Minkler, M. New health promotion movement: a critical examination. Health Education 

Quarterly, 1994: 21(3): 295-312. 

33 Israel, BA, Checkoway, B, Schulz, A, & Zimmerman, M. Health education and community 

empowerment: conceptualizing and measuring perceptions of individual, organizational, and community 

control. Health Education Quarterly, 1994: 21(3): 149170. 

34 Centers for Disease Control and Prevention (CDC). Syphilis Elimination Toolkit webpage. URL: 

http://www.cdc.gov/std/SEE/description.htm

35 National Commission on AIDS. The challenge of HIV/AIDS in communities of color. Washington, DC: 

National Commission on AIDS, 1992:57-61. 

36 Fenton KA. A multilevel approach to understanding the resurgence and evolution of infectious syphilis 

in Western Europe. Euro Surveill. 2004 Dec 1;9(12):3-4. 

37 Ciesielski CA. Sexually Transmitted Diseases in Men Who Have Sex with Men: An Epidemiologic 

Review. Curr Infect Dis Rep. 2003 Apr;5(2):145-152. 

38 Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed for a resurgence of the HIV 

epidemic among men who have sex with men? Am J Public Health. 2001 Jun;91(6):883-8. 

39 Fenton KA, Imrie J. Increasing sexually transmitted diseases among men who have sex with men in 

Western Europe and the United States: Why? In press. Current Opinion in Infectious Dis. 2005

40 Taylor M, Aynalem G, Smith L, Bemis C, Kenney K, Kerndt P. Correlates of Internet use to meet sex 

partners among men who have sex with men diagnosed with early syphilis in Los Angeles County. Sex 

Transm Dis. 2004 Sep;31(9):552-6. 

41 Centers for Disease Control and Prevention (CDC). Internet use and early syphilis infection among 

men who have sex with men—San Francisco, California, 1999-2003. MMWR Morb Mortal Wkly Rep. 

2003 Dec 19;52(50):1229-32. 

42 Brackbill RM, Strenberg MR, Fishbein M. Where do people go for treatment of sexually transmitted 

diseases? Fam Plann Perspect 1999;31(1):10-15. 

43 Chamberlain JM, Klig J. Extending the physician’s reach: physician assistants, nurse practitioners, and 

trauma technologists. Clin Pediat Em Med 2001;2(4):239-246. 

44 U.S.DHHS, PHS, CDC, NCHSTP, OHD, Surgeon General's Call to Action on Corrections and

Community Health - First Draft 7/2004; 7/1/04 

45 Beltrami JF, Cohen DA, Hamrick JT, Farley TA. Rapid screening and treatment for sexually 

transmitted diseases upon arrest: a feasible STD control measure. Am J of Public Health 1997;87:1423-

1426. 

46 Silberstein GS, Coles FB, Greenberg A, Singer L, Voigt R. Effectiveness and cost-benefit of 

enhancements to a syphilis screening and treatment program at a county jail. Sexually Transmitted 

Diseases 2000; 27(9) 508-517. 

47 Institute of Medicine ,“The Hidden Epidemic”: Confronting Sexually Transmitted Diseases; Establishing 

an Effective National System to Prevent STDs; pages 271-274;1997 

61
References 

 

48 Centers for Disease Control and Prevention (CDC). Program Operations Guidelines for STD 

Prevention – Training and Professional Development. [online] Available from URL: 

http://www.cdc.gov/std/program/ 

49 Institute of Medicine (US). Future of Public Health. Washington, DC: National Academy Press; 1997. 

50 Centers for Disease Control and Prevention, Division of STD Prevention. The National Plan to 

Eliminate Syphilis from the United States. Atlanta, GA:1999: 21 

51 Barry, B.W. (1984). Strategic planning workbook for nonprofit organizations. St. Paul: MN: Amherst H. 

Wilder Foundation.

52 Berkowitz, W.R. (1982). Community impact: creating grassroots change in hard times. Cambridge, 

MA: Schenkman Publishing. 

53 Bryson, J. M. (1988). Strategic planning for public and nonprofit organizations: A guide to 

strengthening and sustaining organizational achievement. San Francisco: Jossey-Bass Publishers. 

54 Centers for Disease Control and Prevention (CDC). Framework for Program Evaluation in Public Health 

[online] 1999. [cited 2005 May 26] Available from URL: 

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4811a1.htm

55 Centers for Disease Control and Prevention. Program Operations Guidelines for STD Prevention, 

Medical and Laboratory Services. 

56 National Network of STD/HIV Prevention Training Centers. The Clinical Approach to the STD Patient. 

June 2004. 

57 Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. 

MMWR 2002;51(No. RR-6). 

58 National Commission on Correctional Health Care. Standards for Health Services in Jails, Chicago, IL: 

National Commission on Correctional Health Care; 1996. 

62