Syphilis Cases in Infants May Be Under-Reported

The number of babies born with syphilis in Los Angeles County may be four to five times greater than public statistics suggest, according to health officials who are considering whether to broaden the criteria for reporting cases of congenital syphilis.

A preliminary examination suggests that there may have been as many as 200 cases in 1987, rather than the 39 officially reported. Through October, 1988, there have been 59 cases officially recorded--a 100% increase over the same period last year--and the official figure is expected to reach 70 or 80 by year’s end. Under the broader criteria, however, the numbers could approach 400 in 1988, officials said.

Serious Outbreak

Either way, the number of children reported born with syphilis in the county this year illustrates an especially tragic dimension to what officials say is the worst syphilis outbreak here in 40 years.

The question of how many babies are counted is a matter of degree. Because congenital syphilis is hard to diagnose, physicians may be uncertain. Los Angeles County counts only cases that are almost 100% sure, leaving out those with a greater margin of doubt.

Broadening the criteria would not affect treatment, since babies merely suspected of infection are currently treated, county officials insist. But it could influence the public perception of the severity of the county’s continuing syphilis epidemic.

Meanwhile, more than six months after the Board of Supervisors voted unanimously to spend nearly $3 million to bolster efforts to fight the epidemic, half the positions created by the new funding remain unfilled and disease rates are still among the highest in the country.

In the Central Jail--believed to offer a rare opportunity to screen and treat people at high risk of carrying and spreading the infection--a planned pilot program of intensive screening that had been scheduled to start this week has been postponed until 1989.

And while county health officials say they are encouraged by indications that that the rise in syphilis rates is slowing and may even be leveling off, the number of new cases of penicillin-resistant gonorrhea has suddenly jumped dramatically.

“It took us a year and a half to get where we were,” Dr. Shirley Fannin, the official in charge of communicable disease control, said this week of the syphilis outbreak. “I would think it would take a year and a half to get out.”

The rate of infectious syphilis in Los Angeles County has risen since 1985 from 24.3 to 55.6 per 100,000 population--nearly four times the national level. Officials have said the rise in some areas is the worst they have seen since the introduction of penicillin in the 1940s.

County and federal health officials trace the increase here and elsewhere to several factors, including reductions in public funding and shifts of resources to fight AIDS. They also blame rising use of crack cocaine and the practice of exchanging sex for drugs.

The rise in cases of congenital syphilis has been among the most dramatic--from five in 1984 to 39 last year. Health officials fear that the reported cases may top 70 this year. Many of those children will be severely disabled and some may die.

Congenital syphilis can lead to anemia, jaundice and painful inflammation of bones and cartilage. In advanced stages, it has been linked to neurological problems and damage to hearing and vision. Some fetuses infected in the womb are born dead.

Hidden Cases Possible

But because of the difficulty of diagnosing infection in a newborn, the publicly released figures may not be telling the entire story. County officials say they report only those cases that are “99% sure” and not so-called “possible” cases.

The confusion arises from the fact that a newborn may carry antibodies to the bacterium that causes syphilis but not be infected. For example, the mother’s antibodies may be in the child’s blood without the child being infected.

Without overt signs of congenital syphilis, such as abnormalities of bones and spinal fluid, it is difficult to determine that a baby is infected. It is sometimes necessary to follow the child for months, which is often impossible in a poor or transient population.

Cities and counties vary widely in their reporting practices: Some report only definite and so-called probable cases, others include so-called possible cases. Officials at the federal Centers for Disease Control say federal guidelines on reporting are in flux.

“There are many (cases) where you can be maybe 80% or 50% sure,” Dr. Deborah Cohen of the Department of Health Services’ sexually-transmitted disease control program said Wednesday. Those cases have not be added to the reported statistics, she said.

Cohen and others say physicians have not ignored those suspected cases: They treat those babies for syphilis anyway, as a precaution. Nevertheless, the numbers reported publicly may be misrepresenting the extent of the epidemic and its effect on children, some believe.

“I thought that it is not the best picture of the problem and it doesn’t permit for adequate resource planning,” Cohen said. A more inclusive system of reporting might be more likely to inspire public concern and encourage prevention, testing and treatment.

(The county currently recommends that all women receiving pregnancy tests also be tested for syphilis. Other groups recommended for regular screening include women of childbearing age, people with two or more sexual partners, drug users and clients of prostitutes.)

Screening Postponed

Meanwhile, a plan to try intensive screening at the Central Jail was postponed this week.

Dr. John Clark, the jail’s chief physician, said the plan to screen 10,000 inmates over 15 days in order to determine whether routine screening might be cost-effective had been scheduled to go into effect last Monday but was postponed, probably until early 1989.

The project was postponed in part because of a county memorandum of understanding that would bar overtime pay for certain employees who would implement the program, one health official said. However, he said the county expects to find another method of payment.

Routine syphilis screening in the jail was abandoned in 1986 after Clark found it was absorbing 60% of the personnel’s time in the jail’s medical laboratory. The jail currently screens only inmates determined in interviews as likely to be infected.