January 2014

Recent Changes to Gonorrhea and Syphilis Case Definitions: Program Impact

The Council of State and Territorial Epidemiologists (CSTE) approved new position statements

for gonorrhea (ID-13-03) and syphilis (ID-13-04) during the summer of 2013. These position 

statements include revisions to the surveillance case definitions for gonorrhea and syphilis. The 

old case definitions are available on CDC’s STD Surveillance Case Definitions page. These 

changes are now effective, as of January 1, 2014. Listed below are the major changes these 

revisions introduce, along with potential programmatic implications for surveillance.

By ensuring that reported cases of gonorrhea and syphilis meet these revised surveillance case 

definitions, we can obtain the most accurate surveillance for these diseases and better address 

them. 

Changes for gonorrhea

• Physician diagnosis no longer establishes a case of gonorrhea — cases must have laboratory 

evidence of gonococcal infection, as defined by the surveillance case definitions. This change 

is not anticipated to have any impact upon program activity.

Changes for syphilis

• Physician diagnosis no longer establishes a case of syphilis — cases must meet the 

surveillance case definitions. This change should simplify case reporting.

• Laboratory methods have been updated (e.g., unavailable tests like DFA and MHA-TP have 

been omitted, and newer tests like PCR and treponemal EIA, CIA, and TP-PA are 

mentioned). No impact upon program activity is anticipated.

• "Secondary syphilis" now requires BOTH a reactive treponemal test AND a nontreponemal 

titer ≥4. Because common practice is to obtain both treponemal and nontreponemal serologic 

tests, this change is not anticipated to affect program activity.

• "Syphilis, latency of unknown duration" has been omitted. These cases should now be 

reported as “late latent syphilis”, resulting in a corresponding increase in case counts of late 

latent syphilis. That said, programs can still prioritize cases based upon age, titer, etc.

• Latent syphilis (early or late) still requires both reactive treponemal AND nontreponemal 

tests. This reminder is not anticipated to have any impact upon program activity.

• A case of latent syphilis with any of the following criteria within the past 12 months is 

considered “syphilis, early latent”. These additional criteria might allow more cases to be 

classified as early latent syphilis.

o Documented seroconversion or fourfold or greater increase in titer of a 

nontreponemal test 

o Documented seroconversion on a treponemal test 

o A history of symptoms consistent with a diagnosis of primary or secondary syphilis
o Sexual exposure to a person with primary, secondary, or early latent syphilis 

o Only sexual contact was within the last 12 months (sexual debut)

• “Syphilis, late, with clinical manifestations” can include neurosyphilis. The previous case 

definition of late syphilis specifically excluded neurosyphilis. Very small increases in case 

counts of late syphilis might be anticipated. (As a reminder: neurosyphilis can occur at any

stage of infection and should not be reported as its own stage, but should be reported by stage 

of infection “with neurologic manifestations”.)

• For neurosyphilis, quantitative cutoffs are provided for "elevated" cerebrospinal fluid (CSF) 

white blood cell count and protein concentration. These quantitative measures should provide 

an objective measure of what is and is not “elevated”, and simplify characterization of 

neurologic manifestations of syphilis.

No changes were introduced for congenital syphilis or syphilitic stillbirth.