The National Plan 

United States 

to 

Department of Health and Human Services 

Centers for Disease Control and Prevention 

Prepared by: 

Division of STD Prevention 

National Center for HIV, STD and TB prevention 

Centers for Disease Control and Prevention 

Department of Health and Human Services 

MAY 2006 

Eliminate Syphilis from the 
The National Plan 

United States 

to 

Department of Health and Human Services 

Centers for Disease Control and Prevention 

Prepared by: 

Division of STD Prevention 

National Center for HIV, STD and TB prevention 

Centers for Disease Control and Prevention 

Department of Health and Human Services 

MAY 2006 

Eliminate Syphilis from the 
Copyright information 

All material contained in this report is produced in support of the CDC Syphilis Elimination Eff ort 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. 

Obtaining copies 

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

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

Georgia 30333. 

CDC Creative Services 104467 
Centers for Disease Control and 

Prevention . . . . . . . . . . . . . . . . . . . . . . Julie Louise Gerberding, M.D., M.P.H. 

Director 

Coordinating Center for 

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . .Mitchell L. Cohen, M.D.

Director 

National Center for 

HIV, STD and TB Prevention . . . . . . . . . . . . . . Kevin A. Fenton, M.D., Ph.D.

Director 

Division of STD Prevention . . . . . . . . . . . . . . John M. Douglas, Jr., M.D. 

Director 

The National Plan to Eliminate Syphilis from the United States iii 

CONTENTS 

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Definitions and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

PA R T A Introduction to the U.S. Syphilis Elimination Eff ort 

CHAPTER 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

How to use this document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

CHAPTER 2 The Syphilis Elimination Effort — progress to date . . . . . . . . . . . . . . . . . .4

The National Plan to Eliminate Syphilis from the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Achievements to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Lessons learned from the fi rst five years of implementation of the SEE . . . . . . . . . . . . . . . . . . . . . . . . 6

CHAPTER 3 Syphilis Elimination—challenges and opportunities . . . . . . . . . . . . . . . . .7

Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Public health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Implications for reframing future efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PA R T B Mission, Goals and Strategies 

CHAPTER 4 Mission, goals and strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Core Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

The 3-By-3 approach to Syphilis Elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Implementing the 3-By-3 approach to Syphilis Elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

CHAPTER 5 Syphilis Elimination Goal I: Investment in, and enhancement of, 

public health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Improve and enhance syphilis surveillance and outbreak response . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Improve and assure the quality of clinical and partner services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Improve and assure the quality of laboratory services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

The National Plan to Eliminate Syphilis from the United States v 
CONTENTS 

CHAPTER 6 Syphilis Elimination Goal II: Prioritization of culturally 

competent interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Mobilization of affected communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Tailoring intervention strategies for affected populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Mobilizing health care providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Mobilization and creation of alliances with organizational partners . . . . . . . . . . . . . . . . . . . . . . . . . . 26

CHAPTER 7 Syphilis Elimination Goal III: Accountable services and interventions . . .29

Training and staff development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Evidence-based action planning, monitoring, and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Research and development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

PA R T C Implementing the 3-By-3 Approach to Syphilis Elimination 

CHAPTER 8 Roles and responsibilities for Syphilis Elimination and next steps . . . . . .34

Roles and responsibilities for Syphilis Elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

CHAPTER 9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Appendices 

APPENDIX 1 SEE Global Logic Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

APPENDIX 2 Required and recommended Syphilis Elimination activities . . . . . . . . . .40

APPENDIX 3 SEE activities by required and recommended categories . . . . . . . . . . . . .49

APPENDIX 4 CDC GPRA goals for Syphilis Elimination . . . . . . . . . . . . . . . . . . . . . .52

APPENDIX 5 2004 P&S syphilis rates and threshold SEE targets for 

U.S. project areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

vi The National Plan to Eliminate Syphilis from the United States 
EXECUTIVE SUMMARY 

Executive Summary 

I n 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 fi ght 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, evidencebased 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). 

The National Plan to Eliminate Syphilis from the United States vii 
DEFINITIONS AND ABBREVIATIONS 

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 immunodefi ciency 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 Eff ort 

SETA Syphilis Elimination Technical Appendix 

STD Sexually Transmitted Disease 

Unsafe Sexual Activity Sexual activities which are likely to transmit HIV or other STD’s. Th ese activities 

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

unprotected anal, oral, or vaginal intercourse 

VCT Voluntary counseling and testing 

viii The National Plan to Eliminate Syphilis from the United States 
PART A Introduction to the U.S. 

Syphilis Elimination Effort 

PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

CHAPTER 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 

Eff ort (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)1 

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. 

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 Eff ort 

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 eff ectiveness 

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 eff orts. 

The National Plan to Eliminate Syphilis from the United States 3 
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

CHAPTER 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 Plan2 defi ned 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. Th is 

goal was recently refined as part of the goals developed 

for CDC’s Government Performance Review Act 

(GPRA) of 19933 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 (defi ned 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 defi ned 

geographic area as a result of deliberate eff orts”)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.2

 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 intensifi ed. 

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 $107 Million 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 

20015

 presenting challenges and new opportunities 

for reframing our eff orts. 

4 The National Plan to Eliminate Syphilis from the United States 
The National Plan to Eliminate Syphilis from the United States 5

PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT

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. Th e 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. Th e 2001 

Syphilis Elimination Health Communication Plan6

provided guidance on building momentum for the 

1999 SEE Plan at the national, state, and local levels. 

It identifi ed the need for SEE support from three key 

target audiences: policymakers, health care providers 

and associations, and community representatives 

from aff ected 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.

Figure 1. Reductions in reported cases of primary and secondary syphilis, United States, 1999 and 2004.
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

Expanded access to STD treatment and care 

services 

Since 1999, the additional investment in syphilis 

elimination has resulted in additional benefi ts 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 fi rst fi ve 

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).8

 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 coordination have 

been essential to achieving success.8 

• 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 fl exible 

enough to meet the new challenges. Th is 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;8 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 eff ort at 

state and local levels. 

6 The National Plan to Eliminate Syphilis from the United States 
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

CHAPTER 3 Syphilis Elimination—challenges 

and opportunities 

The epidemiology of syphilis represents a dynamic of the SEE, it is important that due consideration be 

interaction between behavior, biology, and the given to identifying, understanding and tackling these 

effectiveness of public health interventions.11,12 In challenges while concomitantly seeking opportunities 

this section, we highlight some of the key challenges for enhancing the capacity of STD programs to 

facing the successful implementation of the SEE at respond eff ectively. 

national, state and local levels. In reframing the future 

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

The National Plan to Eliminate Syphilis from the United States 7 
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

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 HIVpositive MSM bearing a disproportionate burden of 

disease.5

 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 optimism13 

combined with expansions in venues and networks 

that facilitate risky behaviors, have been identifi ed 

among the major driving factors.13 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 reversing5

, 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 methamphetamine may 

be contributing to rises in disease incidence in 

heterosexuals8

, 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. 

Drug addiction and usage 

Recreational drug use and abuse fuel high-risk sexual 

behaviors act as co-factors 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 1990s16, 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 insuffi cient drug 

treatment services, especially in rural areas, where 

most social services are under-funded and 

under-staff ed. 

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 

8 The National Plan to Eliminate Syphilis from the United States 
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

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

United States 1997–2004. 

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 benefi t 

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. 

Public health services 

Clinical services. Improving access to high quality 

syphilis diagnostic and treatment services has 

always been a core strategy for syphilis elimination.2 

However, in many parts of the country, providing 

quality clinical services to populations at risk is 

becoming increasingly diffi cult. Disinvestment in 

local STD programs, loss of experienced program 

staff, or deployment of clinic staff to support nonSTD 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 signifi cant 

barrier to accessing health care. 

The National Plan to Eliminate Syphilis from the United States 9 
PART A INTRODUCTION TO THE U.S. SYPHILIS ELIMINATION EFFORT 

Private sector burden of disease 

As syphilis is now increasingly diagnosed in the 

private sector4

, 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.8

 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.8

 Consideration should also be given to 

re-evaluating 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 benefi ts 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 eff orts 

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.12 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 

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 eff ective 

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. 

• Supporting professional development and 

training in methods for enhancing local syphilis 

elimination eff orts. 

10 The National Plan to Eliminate Syphilis from the United States 
Mission, Goals and 

Strategies 

PART B 

PART B MISSION, GOALS AND STRATEGIES 

CHAPTER 4 Mission, goals and strategies

Mission 

The mission of the Syphilis Elimination Eff ort (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 eff ective 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 SEErelated 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. Th e SEE 

will prize scientific integrity and professional 

excellence. 

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 

The National Plan to Eliminate Syphilis from the United States 13 
PART B MISSION, GOALS AND STRATEGIES 

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 defi ned specific health impact goals to 

prioritize and focus its work and investments and to 

measure progress. The Syphilis Elimination Eff ort is 

particularly relevant to achieving CDC Goals related 

to Healthy People in Every Stage of Life, and Healthy 

People in Healthy Places*

, 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,2

 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 defi ned 

(see Appendix 4), and provide a framework for our 

national targets. Th ey 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. 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. Th ese 

strategies are interrelated (e.g., enhancing SEE 

interventions will require evaluation). 

The 3-By-3 approach differs from, but is 

complementary to, the 1999 plan2 by streamlining the 

elimination goals and expanding the SEE strategies 

to include provider mobilization, training, research, 

monitoring, and evaluation. Eff ective outbreak 

response, a key strategy in the 1999 plan2

, will form 

part of the recommended activities for investment in 

public health services. 

* 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. Th is includes 

Healthy Communities and Health Care Settings. 

14 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

Syphilis Elimination Goal 

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. 

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. 

3. Accountable services and interventions. Public 

health services will improve the eff ectiveness of 

their interventions by improving accountability 

for their planning, implementation, and 

evaluation. 

Syphilis Elimination Strategies 

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 

1. Mobilization of aff ected communities 

2. Tailoring intervention strategies for 

aff ected populations 

3. Mobilization of, and creating alliances with 

health care providers 

1. Training and staff development 

2. Evidence-based action planning, monitoring, 

and evaluation 

3. Research and development 

Table 1. The 3-By-3 approach to Syphilis Elimination in the United States. 

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 identifi es 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 eff ective 

or promising interventions from which their local 

syphilis elimination responses may be drawn. 

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. 

The National Plan to Eliminate Syphilis from the United States 15 
PART B MISSION, GOALS AND STRATEGIES 

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. Th ese 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 identifi ed 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. 

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

16 The National Plan to Eliminate Syphilis from the United States 
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. Th e 

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 

evidence-based 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. 

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 SEEspecific targeted funds. As one of the lessons learned 

from previous syphilis elimination efforts is to avoid 

PART B MISSION, GOALS AND STRATEGIES 

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 evidencebased 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. 

The National Plan to Eliminate Syphilis from the United States 17 
PART B MISSION, GOALS AND STRATEGIES 

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

18 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

CHAPTER 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 Eff ort 

(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. 

Th e 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. Th ese are: 

1. Improve and enhance syphilis surveillance and 

outbreak response; 

2. Improve and assure quality of clinical and 

partner services; and 

3. 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 eff ects. 

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 specifi c 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 . 

The National Plan to Eliminate Syphilis from the United States 19 
PART B MISSION, GOALS AND STRATEGIES 

SEE Activity 5. State and local health 

departments should adopt CDC/ Council of 

State and Territorial Epidemiologists syphilis 

surveillance case defi nitions. 

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 subgroups, 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. Th e 

response to a 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.2 

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 identifi cation 

and response plans be in place to eff ectively identify, 

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-specifi c 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 ineffi cient 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: 

diagnose, manage, and report rapid increases in syphilis. 

In this regard, syphilis preparedness and outbreak SEE Activity 11. State and local health 

response forms part of an essential component of departments should document the number of 

preventing and controlling syphilis. 

20 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

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. 

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 notifi ed 

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 effi cient 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 studies1

 on the effectiveness of partner 

notifi cation confi rm 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 

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). 

The National Plan to Eliminate Syphilis from the United States 21 
PART B MISSION, GOALS AND STRATEGIES 

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 non-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 effi cacy 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 specifi c, 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-ofcare 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. 

22 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

CHAPTER 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 

aff ected communities. 

In prioritizing culturally competent interventions, the 

SEE promotes three key strategies for implementation 

of key activities. Th ese are: 

1. Mobilization of aff ected communities; 

2. Tailoring intervention strategies for aff ected 

populations; and 

3. Mobilization of and creating alliances with 

organizational partners. 

Mobilization of aff ected 

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.28 In the 1999 National Plan to 

Eliminate Syphilis from the United States, eff ective 

community participation was discussed as an essential 

feature of the cross-cutting strategy, Community 

Involvement and Organizational Partnerships.29 It was 

described as a means of: 

1. Facilitating communication between aff ected 

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.30 

Community mobilization is an essential component 

of community and public health programs.31 

However, it is also a concept that has been defi ned 

The National Plan to Eliminate Syphilis from the United States 23 
PART B MISSION, GOALS AND STRATEGIES 

in a variety of ways; reflecting varying degrees of 

community or client power in relationship to external 

institutions.32 Moreover, the definition of community 

varies and is not always bound by geography, but 

often entails cultural identity and experiences33 (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. 

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-specifi c 

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 eff orts. 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 

eff orts. 

Tailoring intervention strategies 

for aff ected 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 misclassifi ed 

syphilis morbidity (e.g., Asian-Pacific Islanders and 

Native Americans).35 

Tailored interventions attempt to facilitate riskreductive 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 aff ected by 

syphilis to inform the development or tailoring of 

culturally appropriate interventions. 

SEE Activity 34. State and local health 

departments and CBOs should incorporate 

assessment data into tailored intervention 

24 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

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 multifaceted: 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 eff ective 

public and private health service responses for an 

eff ective 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 Internetbased interventions in order to increase partner 

notifi cation 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 eff ectiveness 

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 

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% 

The National Plan to Eliminate Syphilis from the United States 25 
PART B MISSION, GOALS AND STRATEGIES 

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 specifi ed above, 

practicing in public and private settings is critical for 

the success of the Syphilis Elimination Eff ort. 

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 costeffective, 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 eff orts. 

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 specifi c 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., webbased 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 

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. Th is 

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. 

26 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

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 fi ve 

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 fi nancial 

operations. 

Starting in 2002, a fi ve-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 lock-up facility.44 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 

eff ective.45,46 The Institute of Medicine report, “Th e 

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 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 communitybased setting for case-fi nding, 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. 

The National Plan to Eliminate Syphilis from the United States 27 
PART B MISSION, GOALS AND STRATEGIES 

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 birthweight 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 eff ective 

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. Th e 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. Th e 

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-tochild 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. 

28 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

CHAPTER 7 Syphilis Elimination Goal III: 

Accountable services 

and interventions 

The creation of a dynamic, evidence-based, and 

culturally competent prevention and control 

plan for syphilis requires attention to eff ective 

implementation, monitoring, and evaluation. Th is 

should be seen as part of a systematic approach 

to ensure that appropriate and eff ective 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. Th ese are: 

1. Training and staff development; 

2. Evidence-based program planning, monitoring, 

and evaluation; and 

3. 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 identifi ed 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 Th e 

1999 plan also identifi ed 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. 

SEE Activity 60. CDC and state and local 

health departments will work together to 

identify nationally and locally available training 

opportunities and resources. 

The National Plan to Eliminate Syphilis from the United States 29 
PART B MISSION, GOALS AND STRATEGIES 

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 signifi cant 

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 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 evidencebased action plans by December 2008. 

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. 

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 quantifi able 

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 specifi ed outcomes, 

they facilitate the comparison of programmatic 

30 The National Plan to Eliminate Syphilis from the United States 
PART B MISSION, GOALS AND STRATEGIES 

efforts over time, and they encourage project areas 

to implement and document “best practices”. Th e 

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. Th ey 

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 scientifi c 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. 

Th e SEE research strategy focuses on four key 

activities: 

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-eff ectiveness 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. 

The National Plan to Eliminate Syphilis from the United States 31 

Implementing the 

Syphilis Elimination 

PART C 

3-By-3 Approach to 
PART C IMPLEMENTING THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION 

CHAPTER 8 Roles and responsibilities for 

Syphilis Elimination and 

next steps

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 Eff ort, 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 Eff ort. 

• 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. 

• 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 Eff orts 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 Eff ort 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 eff ort. 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. 

34 The National Plan to Eliminate Syphilis from the United States 
PART C IMPLEMENTING THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION 

• Support community action to improve health, 

including liaison with community and privates 

sector partners. 

• Provide equitable access to health care. 

• Act as an advocate for health gain through the 

Syphilis Elimination eff ort. 

• 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. 

• Promote local collaboration and joint planning 

between STD and HIV agencies and providers. 

Organizational partners 

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 aff ecting 

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. 

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 Eff ort 

Technical Appendix will be published by CDC by 

June 2006. 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. 

The National Plan to Eliminate Syphilis from the United States 35 
PART C IMPLEMENTING THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION 

CHAPTER 9 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.2

 Today, 

changes in sexual behavior, driven by a number of 

social and economic factors, may be infl uencing 

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 eff orts. 

36 The National Plan to Eliminate Syphilis from the United States 
The National Plan to Eliminate Syphilis from the United States 37

PART C IMPLEMENTING THE 3-BY-3 APPROACH TO SYPHILIS ELIMINATION

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.2

 Today, 

changes in sexual behavior, driven by a number of 

social and economic factors, may be infl uencing 

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 eff orts.

CHAPTER 10 Conclusion Appendices 

� 

APPENDICES 

APPENDIX 1

SEE Global Logic Model Mission: To promote health and quality of life by preventing, controlling, and eliminating endogenous transmission of syphilis from the United States. INPUTS ACTIVITIES OUTPUTS OUTCOMES • Funding Invest in Public Health Services • Data collected on cases and sex partners Short Intermediate Long o CDC Surveillance • Timely submission of reports o Other federal • Epidemic • Improved • Reduced P&S • Collect, report, analyze, and use • Prevalence monitored characterized information syphilis incidence sources syphilis data for action • Surveillance systems evaluated management in men and women o State sources • Assess quality/completeness of data

�• Disease burden, populations & trends 

�• Improved response system and data of existing • Reduced incidence o Private sources • Monitor reports from labs and private identifi ed health services to sharing capabilities of congenital • State, local, and providers • Reporting requirements enforced outbreaks or rising • Increased adherence syphilis federal legislation • Build epidemiology capacity • Syphilis outbreak response plan incidence of clinical staff to • Reduced black to and administrative 

policy Clinical and Laboratory Services developed • Increased early clinical guidelines while ratio for P&S access to and • Greater patient syphilis 

o Federal agencies patients

• Partnerships • Test, diagnose, treat, interview, counsel eff ective clinical adherence to • Reduced high 

o State agencies • Assess effi ciency of clinics (e.g., number • Infected patients identifi ed, treated, 

o Local agencies of turnaways, wait times) and counseled

 o CBOs • Screen in jails, especially females • Populations disproportionately aff ected 

care treatment regimens morbidity areas 

• Increased use of • Decreased sexual 

clinical services risk behaviors (e.g.,

• Training in • Screen, diagnose and treat aff ected � screened, diagnosed, treated, and 

�• Increased awareness use of recreational 

areas such as in community drugs, inconsistent populations (e.g., pregnant women, counseled 

interviewing, newborns, MSM, inmates) • Clinics run at optimal effi ciency • Increased use of condoms,

surveillance, • Outreach screening in diverse • Quality of services monitored partnerships multiple sex 

epidemiology, etc. venues (e.g., drug treatment centers, between STD partners) 

• Technical bathhouses, jails) • Patients counseled programs, • Reduced 

Assistance � • Disseminate the use and interpretation 

�• Partners identifi ed, tested, & treated 

� community 

� transmission 

� of laboratory tests organizations, and • Increased local 

private providers health promotion Partner services • Community participation integrated in • Increased screening, capacity • Interview patients and partners using setting goals, planning/implementing • Reduction of optimal interviewing techniques interventions, and evaluating outcomes treatment, and prevalence of • Contact cases and partners to assess • Outreach conducted among health care counseling by 

risk, counsel, and treat providers private providers syphilis in pregnant 

• Alliances established with community • Increased screening women Deliver evidence-based and 

� organizations, private and public health 

� of pregnant • Increased syphilis culturally competent interventions care providers, and law enforcement women, MSM and elimination 

• Mobilize aff ected communities and • High-risk populations screened (e.g., inmates according programs that are eff ective in organizations/health care providers/ jail inmates, MSM, pregnant women) to standards 

political entities that serve them • Tailored and cultural competent • Increased partners achieving goals 

• Fund community organizations interventions developed for those elicited and cases initiated • Tailor interventions for those aff ected disproportionately aff ected • Develop internet interventions • Program • Provide partners with up-to-date • Trained staff (i.e., behavioral improvements 

information interventions, data management/ made as indicated 

• Train providers on cultural competence analysis, clinical/laboratory by evaluation methods, community involvement results 

Increase accountability of services techniques, cultural competence, • Institutionalized 

� and interventions health communication, and program evidence-based evaluation) and accountability • Training and staff development • Action plans developed and culture • Evaluate activities routinely disseminated

• Conduct research • Programs monitored and evaluated 

• Biomedical and behavioral applied 

research agenda built

• Performance measures adopted and 

monitored 

The National Plan to Eliminate Syphilis from the United States 39
APPENDICES 

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 

eff orts. 

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, benefi ts 

outweigh harms. 

C. Insuffi cient 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. 

Rating 

A 

• 

guidance 

B 

of their epidemiologic data on syphilis. 

• 

• A 

epidemiology training and capacity building to STD 

• 

training 

B 

• 

B 

• 

needed, basis 

A 

Surveillance Standard 

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 

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 

SEE Activity 3. CDC, state, and local health departments 

will promote routine and regular (at least quarterly) analysis 

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 

SEE Activity 4. State health departments should provide 

program staff . 

Each HMA should ensure that syphilis surveillance staff 

has epidemiologic training and opportunities to improve 

SEE Activity 5. State and local health departments 

should adopt CDC/ Council of State and Territorial 

Epidemiologists syphilis surveillance case defi nitions. 

CDC in partnership with stakeholders to review and 

produce updated guidelines on syphilis case defi nitions 

by end 2007 

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 

40 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

• B 

C 

Rating 

2006 A 

• 

B 

Rating 

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 

B 

• 

B 

• 

syphilis 

• >90% of STD clinic attenders diagnosed with an STD C 

• 

• 55,56,20 

B 

• 

• B 

statutes. 

• 

57 

• All HMAs should collect data monthly 

• 

A 

is primarily in MSM populations, state and local health 

• 20 

• All HMAs should collect data monthly 

• 

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 

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 

Outbreak response Standard 

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 

• CDC to produce a Syphilis Outbreak Plan template for 

use by state and local health departments by end 2007 

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 

Clinical services Standard 

SEE Activity 11. State and local health departments should 

surveillance of access to care measures. Data should be 

reported in the annual (project period) grant progress 

report 

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. 

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 

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 

(other than syphilis) should be screened for syphilis 

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 reports 

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 

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 

Syphilis screening in pregnancy should be done at fi rst 

prenatal visit. Where indicated, additional screening may 

be done early in the third trimester and at delivery

These data should be reported in project period (annual) 

progress reports 

SEE Activity 17. In geographic locations where transmission 

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 risk

These data should be reported in project period (annual) 

progress reports 

The National Plan to Eliminate Syphilis from the United States 41
APPENDICES 

women. 

• 58 

A 

Rating 

• 

P&S syphilis on an annual basis A 

use the geographic and socio-demographic concentration of 

syphilis to inform the best locations for DIS for immediate 

• 

P&S syphilis on an annual basis B 

• 

P&S syphilis on an annual basis B 

Rating 

• 

• A 

• 

A 

laboratories to facilitate PCR testing for syphilis. 

• 

2007 B 

to examine the utility and acceptability of typing and subtyping methods for T pallidum

• 

B 

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 

National guidelines recommend screening arrestees for 

syphilis within 14 days of incarceration

Partner services Standard 

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 

SEE Activity 20. State and local health departments should 

case-interviewing and partner follow up. 

State and local health departments in HMAs should 

audit the outcomes of partner notification activities for 

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 

Laboratory services Standard 

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 

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 

SEE Activity 24. CDC will establish a network of regional CDC to establish regional laboratory network by end 

SEE Activity 25. CDC should fund demonstration projects 

 in outbreak situations. 

CDC to work with program consultants to identify 

suitable areas with syphilis outbreaks to participate in 

this program by end 2007 

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 • All project areas should implement the new syphilis 

ensure ongoing monitoring of surveillance data in order to surveillance data collection instrument by end of 2007 

track evolution in local epidemics and inform appropriate 

community partnerships. • HMAs should produce an annual report containing an 

analysis of syphilis surveillance data and summarizing 

A 

local syphilis elimination interventions for stakeholders 

42 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

• 

that include members of the affected communities to 

health and non-health agencies, and institutions 

plan 

• 

and institutional context of its persistence and designing 

B 

• 

annually 

A 

• 

• A 

• 

analysis of behaviorally high incidence persons to B 

Ethnic minorities Rating 

• 

• 

syphilis elimination and ethnic minorities should be 

• 

centers/index.html 

A 

(e.g., annually). 

• 

least bi-annually 

A 

• 

updated as needed 

B 

planning. 

of the target population(s) on an annual basis 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: 

All HMAs describe community participation activities 

determine the non-governmental, community-based, 

involved in the development of the syphilis elimination 

Describe how community coalitions, advisory groups, 

or taskforces and other partners are involved in 

reviewing the epidemiology of syphilis and the social 

and implementing locally relevant, syphilis prevention 

interventions and control services 

SEE Activity 28. In designated high morbidity areas 

(HMAs), state and local health departments will establish 

meaningful community participation in local SEE eff orts. 

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 

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 aff ected populations 

All HMAs must report on activities of these funded 

organizations in future project period (annual) progress 

reports 

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 

eff orts. 

All HMAs should maintain sentinel surveillance and 

ensure appropriate community representation in the 

participatory syphilis elimination eff orts 

Standard 

SEE Activity 31. CDC, state, and local health departments 

should enhance national, state, and local prevention eff orts, 

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 

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) 

www.eff ectiveinterventions.org 

• Training for DEBI can be provided by the National 

Network of STD/HIV Prevention Training Centers 

(PTCs) http://depts.washington.edu/nnptc/regional_ 

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 

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 

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 aff ected 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 

SEE Activity 34. State and local health departments and 

CBOs should incorporate assessment data into tailored 

intervention development and prevention intervention 

• Tailored local syphilis prevention interventions for 

ethnic minorities should be reviewed for appropriateness 

The National Plan to Eliminate Syphilis from the United States 43
APPENDICES 

identify key local stakeholders to establish inter-agency 

• 

annually 

A 

Men who have sex with men Rating 

of their epidemiologic data on syphilis. 

• 

• 

• 

A 

• 

annually 

• 

syphilis/ sexual health issues 

A 

• 

• 

• 

A 

• 

session annually on cultural/gender/sexuality sensitivity 

• Each STD clinic should nominate 1 DIS to lead on 

ISP 

A 

• 

A 

• 

A 

MSM clinical sessions etc.). 

• 

A 

SEE Activity 35. State and local health departments should 

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 

Standard 

SEE Activity 3. CDC, state, and local health departments 

will promote routine and regular (at least quarterly) analysis 

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 

SEE Activity 28. In designated high morbidity areas 

(HMAs), state and local health departments will establish 

meaningful community participation in local SEE eff orts. 

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 

All HMAs with MSM epidemics should have a multidisciplinary, multi-partner workgroup on MSM and 

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 

SEE Activity 37. State and local health departments should 

develop and use Internet-based interventions in order to 

increase partner notifi cation efficacy, MSM engagement, and 

participation in SEE activities. 

All STD clinic staff to participate in at least 1 training 

training and MSM health. This should include sexuality, 

sexual behaviors, drug use, and other health and 

psychosocial issues faced by MSM 

MSM health issues. He/she should act as a liaison for 

local MSM providers and facilitate collaborations with 

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. Th ey 

should be responsible for coordinating a working group 

on internet activities and developing annual plan of 

activities/ interventions with internet 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. 

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 

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, 

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 

44 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

• Local sites should plan at least 1 major MSM targeted 

A 

• 

C 

• Local sites should clarify and document pathways for 

B 

Rating 

• 

local SEE, impact of syphilis, signs and symptoms, 

• 

• 

B 

• 

• 

• 

A 

• 

• 

B 

• 

A 

• 

• A 

Rating 

SEE Activity 41. State and local health departments should 

enhance syphilis education and sexual health promotion 

with MSM within STD clinics and the community. 

health promotion and education intervention per 

annum during rapid increase and hyperendemic 

epidemic phases. These may be new or adapted health 

promotion interventions 

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). 

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 

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. 

referral to drug treatment programs for MSM grappling 

with crystal methamphetamine use and addiction 

Provider mobilization Standard 

SEE Activity 44. State and local health departments should 

designate a health department liaison for provider outreach 

for ongoing SEE eff orts. 

State and local health department should ensure that 

local health care providers (HCPs) a) are aware of the 

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 

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 

SEE Activity 46. State and local health departments should 

develop Memoranda of Understanding (MOA) with specifi c 

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 

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 

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 

Jail-based screening Standard 

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 A sector partners to identify needs, set priorities and 

facilitate communications 

The National Plan to Eliminate Syphilis from the United States 45 
APPENDICES 

• 

B 

collect jail-based syphilis morbidity and behavioral data. • 

• 

• 

B 

sharing capabilities. 

• 

• C 

C 

• 

• 

B 

Congenital syphilis Rating 

• 

annually 

A 

• 

A 

detection of syphilis. 

• 

A 

• 

• B 

SEE Activity 49. State and local health departments 

should establish or maintain effective partnerships with 

jails as a community-based setting for case-fi nding, disease 

surveillance, treatment, and research.. 

State and local health departments should develop 

formal MOU/MOA to formalize partnerships 

SEE Activity 50. State and local health departments will 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 eff ort 

Distribute annual reports to all relevant project area 

providers (private and public) 

SEE Activity 51. State and local health departments will 

work to improve information management systems and data 

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 jailbased screening and intervention data 

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 

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 

Standard 

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 

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 

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 

State and local health departments should utilize POG 

guidelines, syphilis surveillance guidelines, and CDC 

STD Treatment Guidelines to develop local policies and 

protocols 

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 

46 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

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. 

Rating 

• 

B 

• 

A 

• 

A 

activities. 

• 

B 

C 

Evidence-based action planning Rating 

syphilis elimination evidence-based action plans. 

• 

A 

• Annual updates of local SEE evidence-based action plans A 

• 

limited) 

• Each action step or change to be sought should include 

o What actions or changes will occur 

o Who

o 

o 

out these changes 

o Communication

A 

• 

draft of the SEE plan for submission to CDC A 

stakeholders. 

All HMAs should consider dissemination of their local 

• 

• 

• 

disseminated to local staff 

• 

• 

B 

Training and staff development Standard 

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 

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 

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 

SEE Activity 61. State and local health departments will 

ensure adequate training of supervisors to support local SEE 

CDC to identify and disseminate training opportunities 

to SEE coordinators, and project areas 

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 

Standard 

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 

All HMAs to develop local SEE evidence-based action 

plans by FY 2008 

SEE Activity 64. CDC will request complete evidence-based 

action plans from all HMAs from FY 2008 onwards. to be submitted to CDC by 1 October of each year 

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, timethe following information: 

 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 

 (who should know what?) 

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 2008. 

Local SEE coordinators, in partnership with appropriate 

senior STD program managers should prepare the fi rst 

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 

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 

Parts of plan published in local PHD correspondence 

STD program staff trained on parts of the plan 

The National Plan to Eliminate Syphilis from the United States 47 
APPENDICES 

Rating 

• 

A 

• 

A 

• 

A 

determinants and consequences of syphilis epidemics and 

• 

A 

Monitoring and evaluation Rating 

elimination. 

• 

2008 

A 

plan.. 

• 

A 

• 

action plans 

• 

funding 

A 

and make explicit, mechanisms to facilitate sharing of this 

information. 

• 

should be disseminated widely 

B 

Research and development Standard 

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 fi led 

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 fi led 

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 fi led 

SEE Activity 75. CDC and its SEE partners will conduct 

research to address economic, social, and behavioral 

prevention. 

CDC with its partners to develop a syphilis elimination 

research plan by end 2006 to inform research and 

development activities in this fi led 

Standard 

SEE Activity 68. CDC, state and local health departments 

will prioritize risk groups and interventions for syphilis 

Prioritized, evidence-based interventions to be provided 

by all HMAs using the action planning template by FY 

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 

Activities and recommended standards to be provided 

with the launch of the 2006 SEE Plan by end 2006 

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 

CDC to undertake summative evaluation of SEE 

support to project area during the penultimate year of 

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 

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. Th ese fi ndings 

48 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

APPENDIX 3 

SEE activities by required and 

recommended categories 

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 eff orts. 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 eff orts 

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. 

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. 

The National Plan to Eliminate Syphilis from the United States 49 
APPENDICES 

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 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 2008. 

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. 

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 defi nitions. 

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. 

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. 

50 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

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 inter-agency 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 

notifi cation 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 

eff orts. 

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 notifi cation, 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. 

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. 

The National Plan to Eliminate Syphilis from the United States 51 
APPENDICES 

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. Th e 

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 eff ectiveness 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 effi ciency 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 Long-term goal 

2002 2005 2006 2007 2008 2009 2010 

population 2.4 2.5 2.5 2.4 2.3 2.2 

3.8 4.5 4.5 4.4 4.3 4.2 

1.1 0.58 0.53 0.47 0.43 0.38 

10.2 6.0 5.4 4.8 4.4 3.9 (62%) 

8.1 3.6:1 3.5:1 3.1:1 2.9:1 3:1 (63%) 

Annual targets 

Incidence of P&S Syphilis/100,000 

Incidence of P&S Syphilis/100,000 

population (Men) 

Incidence of P&S Syphilis/100,000 

population (Women) 

Incidence of Congenital Syphilis/100,000 

live births 

Black: white ratio of P&S syphilis 

52 The National Plan to Eliminate Syphilis from the United States 
APPENDICES 

APPENDIX 5 

2004 P&S syphilis rates and threshold 

SEE targets for U.S. 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.

2004 P&S 

cases 

2004 rates 

per 100,000 

population 

Upper HMA 

2.0 per 

100,000 pop. 

Lower HMA 

1.0 per 

100,000 pop. 

SEE Elimination 

goal of 0.4 per 

100,000 pop. 

192 2.4 160 80 32 

130 2.3 113 57 23 

852 4.1 416 208 83 

211 33.6 13 6 3 

550 6.7 164 82 33 

59 2.1 56 28 11 

Louisiana 331 7.4 89 45 18 

Alabama 167 3.8 88 44 18 

115 2.9 79 40 16 

Chicago 306 10 61 31 12 

200 5.3 75 38 15 

237 2.1 226 113 45 

739 4.6 321 161 64 

116 1.6 73 29 

California 599 2.5 479 240 96 

159 3.4 94 47 19 

40 1.5 27 11 

60 1 ( 24 

94 1.7 55 22 

157 3.1 101 51 20 

47 1.2 39 16 

25 0.7 14 

71 4.8 30 15 6 

29 0.5 23 

80 0.82 39 

192 1.9 202 101 40 

150 1.8 167 83 33 

91 15.9 11 6 2 

150 2.5 120 60 24 

50 0.49 41 

29 0.8 15 

25 0.5 20 

Colorado 55 1.3 42 17 

Los Angeles 401 4.3 187 93 37 

108 1.02 212 106 42 

607 7.5 162 81 32 

Connecticut 45 1.3 69 35 14 

115 1.8 128 64 26 

335 44.6 15 8 3 

81 4.5 18 18 7

Alaska 8 1.3 6 2 

9 1.1 8 3 

9 0.7 13 5 

24 1.9 13 5 

5 0.2 

Kansas 24 0.9 11 

2 0.2 

3 0.3 

7 0.4 

39 2 ( 20 8 

5 0.4 

0 0 

26 2.5 21 10 5 

0 0 

13 0.6 9 

1 0.2 

3 0.2 

3 0.6 2 

 Currently funded 

project areas reported 

threshold target of threshold target of 

North Carolina 

Tennessee 

Texas 

Baltimore 

Georgia 

Mississippi 

South Carolina 

Puerto Rico 

Ohio 

Florida 

Virginia (Achieved) 

Maryland excl Baltimore 

Arkansas (Achieved) 

Indiana Achieved) (Achieved) 

Missouri (Achieved) 

Arizona 

Kentucky (Achieved) 

Oklahoma (Achieved) (Achieved) 

Philadelphia 

Wisconsin (Achieved) (Achieved) 

Illinois ex Chicago (Achieved) (Achieved) 

Michigan 

New Jersey 

Washington, D.C. 

Washington 

Pennsylvania (excl Phil.) (Achieved) (Achieved) 

Oregon (Achieved) (Achieved) 

Minnesota (Achieved) (Achieved) 

(Achieved) 

New York State ex NYC 

New York City 

Massachusetts 

San Francisco 

New Mexico 

 Project areas not receiving Syphilis Elimination Funding (2005) 

(Achieved) 

Delaware (Achieved) 

Hawaii (Achieved) 

Idaho (Achieved) 

Iowa (Achieved) (Achieved) (Achieved) 

(Achieved) (Achieved) 

Maine (Achieved) (Achieved) (Achieved) 

Montana (Achieved) (Achieved) (Achieved) 

Nebraska (Achieved) (Achieved) (Achieved) 

Nevada Achieved) 

New Hampshire (Achieved) (Achieved) (Achieved) 

North Dakota (Achieved) (Achieved) (Achieved) 

Rhode Island 

South Dakota (Achieved) (Achieved) (Achieved) 

Utah (Achieved) (Achieved) 

Vermont (Achieved) (Achieved) (Achieved) 

West Virginia (Achieved) (Achieved) (Achieved) 

Wyoming (Achieved) (Achieved) 

The National Plan to Eliminate Syphilis from the United States 53 
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