Alabama Department of Public Health. Sexually Transmitted Diseases

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1 Alabama Department of Public Health Sexually Transmitted Diseases Annual Report 29

2 August 16, 21 Dear Alabama Stakeholder: The Division of Sexually Transmitted Disease Prevention and Control of the Alabama Department of Public Health (ADPH) is pleased to provide the 29 Alabama Sexually Transmitted Disease Annual Report. The report highlights the impact of sexually transmitted diseases among the residents of Alabama. The information in the narrative, graphs, and tables herein highlights the increasing numbers of STDs affecting our state. All 29 data are from the ADPH Division of STD Prevention and Control STD surveillance system as of June 6, 21. STDs can cause significant health problems among those who become infected. For instance, untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease (PID). Other young women may suffer ectopic pregnancies and chronic pelvic pain. STDs can also lead to infertility. Young people and racial/ethnic minorities bear a disproportionate burden of STDs in Alabama. The ADPH Division of Sexually Transmitted Disease Prevention and Control is working to address these health disparities by collaborating with local/county health departments, community based organizations, the Centers for Disease Control and Prevention, and Alabama medical providers to promote STD prevention and intervention statewide. Through this report, we hope to disseminate useful and pertinent data to the public and community leaders in Alabama. It is our belief that this information can promote dialogue about disease prevention, promote medical treatment and services, and improve the sexual health of all Alabamians. Please do not hesitate to contact us with further questions regarding STD education, prevention, and screening opportunities. Sincerely, Anthony Merriweather, M.S.P.H. Director, Division of STD Prevention and Control Alabama Department of Public Health 1

3 Table of Figures and Tables Figure and Table Number and Title Page Figure 1: Chlamydia Cases, Alabama Figure 2: Chlamydia Cases by Race/Ethnicity, Alabama Figure 3: Chlamydia Cases by Race/Ethnicity, and Gender, Alabama Figure 4: Chlamydia Cases by Gender, Alabama Figure 5: Chlamydia Cases by Age Group, Alabama Figure 6: Chlamydia Case Rate per 1, by Age Group, Alabama Figure 7: Chlamydia Cases by County, Alabama 29 7 Figure 8: Chlamydia Case Rate per 1, by County, Alabama Figure 9: Gonorrhea Cases by, Alabama Figure 1: Gonorrhea Cases by Race/Ethnicity, Alabama Figure 11: Gonorrhea Cases by Race/Ethnicity and Gender, Alabama Figure 12: Gonorrhea Cases by Gender, Alabama Figure 13: Gonorrhea Cases by Age Group, Alabama Figure 14: Gonorrhea Case Rate per 1, by Age Group, Alabama Figure 15: Gonorrhea Cases by County, Alabama Figure 16: Gonorrhea Case Rate per 1, by County, Alabama Figure 17: P&S Syphilis Cases, Alabama Figure 18: P&S Cases by Race/Ethnicity, Alabama Figure 19: P&S Syphilis Cases by Race/Ethnicity and Gender, Alabama Figure 2: P&S Syphilis Cases by Gender, Alabama Table 1: P&S Syphilis Risk Factors Among Males, Alabama Table 2: P&S Syphilis Risk Factors Among Females, Alabama Figure 21: P&S Syphilis Cases by County, Alabama Figure 22: P&S Syphilis Case Rate per 1, by County, Alabama Figure 23: EL Syphilis Cases, Alabama Figure 24: EL Cases by Race/Ethnicity, Alabama Figure 25: EL Syphilis Cases by Gender, Alabama Figure 26: EL Syphilis Cases by Race/Ethnicity and Gender, Alabama Table 3: EL Syphilis Risk Factors Among Males, Alabama Table 4: EL Syphilis Risk Factors Among Females, Alabama Figure 27: EL Syphilis Cases by County, Alabama Figure 28: EL Syphilis Case Rate per 1, by County, Alabama Figure 29: Congenital Syphilis Cases, Alabama

4 The purpose of the Division of Sexually Transmitted Disease Control and Prevention of the Alabama Department of Public Health (ADPH) is to develop, implement, and evaluate a comprehensive sexually transmitted disease (STD) surveillance program in order to 1) reduce the number of Alabama residents with an STD; 2) reduce the impact STDs has on Alabama s population and the health care system; 3) determine the burden of disease in Alabama and identify at-risk populations; 4) conduct effective and efficient case management to ensure patients reported with an STD are treated according to the treatment guidelines established by CDC; 5) conduct partner services including risk-reduction counseling; 6) prevent STD-related infertility; 7) reduce the syphilis rates in high morbidity areas; 8) provide HIV partner notification; and 9) link HIV patients to healthcare and social services. In addition, the program conducts enhanced case finding activities through community outreach and STD screenings to reduce the transmission and complications of STDs. By collaborating with other governmental and non-governmental agencies including public and private laboratories, the Division of Sexually Transmitted Disease Control and Prevention promotes increased efficiency and flexibility in providing comprehensive services and prevention messages for populations at risk for multiple health problems. Chlamydia In 29, a total of 25,91 Alabama residents were reported with chlamydia (Figure 1). This represents a 94.1% (12,554) increase compared with the number of cases reported in 24. The increase in the number of chlamydia cases detected from 24 to 27 is a direct result in the utilization of a more sensitive chlamydia/gonorrhea testing kit. This has facilitated better diagnosis of chlamydia as well as early treatment of the disease which in turn reduces disease severity. Since 27 the number of chlamydia cases has plateaued to an average of 25, cases per year. In 29, the national case rate for chlamydia was per 1,. Alabama s 29 case rate for chlamydia was per 1,. This ranks Alabama s morbidity as sixth highest in the nation. Figure 1. Chlamydia Cases, Alabama Rate per 1, Chlamydia Cases Case Rate 3

5 From 2-29, the reported number of chlamydia cases was highest in Blacks (Figure 2). The number of chlamydia cases among Blacks has increased by 66.8% (5,526) since 24. In 29, Blacks comprised nearly 27% of Alabama s population. Yet they comprised 53.3% (13,81/25,91) of the cases reported in 29. Blacks (1,122.2 per 1,) had the highest reported case rate followed by Hispanics (119.6 per 1,), and Whites (96.8 per 1,). Figure 2. Chlamydia Cases by Race/Ethnicity, Alabama Black Latino White Among all race/ethnic and gender, Black females have consistently accounted for the majority of chlamydia cases (Figure 3). Although the number of Black females diagnosed with chlamydia declined by 7.4% (791) from 28 to 29, they represented 38.% (9,848/25,91) of the reported chlamydia cases followed by 15.3% Black males (3,952/25,91), 9.4% White females (2,426/25,91), and 2.8% White males (729/25,91). The number of cases reported among Black males, White females, and Hispanic males has been relatively stable for the past three years. 12 Figure 3. Chlamydia Cases by Race/Ethnicity and Gender, Alabama Black Female White Female Latino Female Black Male White Male Latino Male 4

6 Since the Centers for Disease Control and Prevention emphasized the importance of screening females for chlamydia via the Infertility Prevention Project (IPP), it is not surprising that the majority of Alabama chlamydia cases have been reported among females (Figure 4). In 29, females represented 74.9% (19,397/25,91) of the chlamydia cases reported in Alabama. Furthermore, the number of females and males reported with chlamydia has increased by 3.7% and 8.3%, respectively, from 28 to 29. Figure 4. Chlamydia Cases by Gender, Alabama Female Male In 29, the number of chlamydia cases reported among persons age has been identical to those persons age 2-24 (Figure 5). This trend also reflects CDC emphasis on screening persons age Moreover, persons age represented the third largest age group for chlamydia infections in Alabama. Persons age and accounted for 74.8% (19,375/25,91) of the chlamydia cases reported in 29. Furthermore, Black females comprised 39.6% (7,673/19,375) of the cases reported among these age groups Figure 5. Chlamydia Cases by Age Group, Alabama Age 1-14 Age Age 2-24 Age Age 3-34 Age

7 In 29, among people 15-19, the chlamydia case rate was 2,922.4 per 1, population and 3,71.4 per 1, population for people People age had the third highest rate of infection at 1,144.3 per 1, population. A breakdown of 29 chlamydia case rates is presented in Figure 6. Figure 6. Chlamydia Case Rate per 1, Population by Age Group, Alabama 29 Age Groups < Alabama Rates per 1, Population In 29 the number of chlamydia cases was highest in Jefferson (5,31), Mobile (3,469), Montgomery (2,164), Madison (1,572), and Tuscaloosa (1,324) counties (Figure 7). Of the cases reported from these areas nearly 63.3% (8,762/13,839) were reported among Blacks. Almost 2.5% (5,31/25,91) of the chlamydia cases reported in 29 were residents of Jefferson County. 6

8 Figure 7. Chlamydia Cases by County, Alabama 29 Although Dallas County reported the sixth highest number of chlamydia cases in 29, they had the highest rate of chlamydia infection (1,521./1,) in Alabama (Figure 8). The rates of chlamydia infection among the urban areas of Jefferson County (85.2/1,), Mobile County (853.8 per 1,), and Montgomery County (962.6/1,) were also among the highest in Alabama. These counties contain a significant burden of Alabama s chlamydia cases. 7

9 Figure 8. Chlamydia Case Rate per 1, by County, Alabama 29 Gonorrhea The number of gonorrhea cases reported in Alabama decreased by 31.2% (3,393) from 27 to 29. In 29, a total of 7,484 Alabama residents were reported with gonorrhea resulting in a case rate of 16.5/1, (Figure 9). Alabama s gonorrhea case rate is the lowest it has been in the past ten years. Yet it still remains above the national rate of 95.4 per 1,. Alabama s morbidity is the fifth highest in the nation. Figure 9. Gonorrhea Cases, Alabama Rate per 1, Gonorrhea Cases Case Rate 8

10 The number of Blacks reported with gonorrhea has dramatically decreased in the past three years. In 29, a total of 4,652 cases were diagnosed among Alabama s Black population (Figure 1). The number of cases reported among Blacks and Whites has declined by 29.% and 47.3%, respectively, from 26 to 29. Among Alabama s Latino population, the number of gonorrhea cases has remained relatively stable. Blacks also had the highest rate of gonorrhea infection (378.3/1,) compared with any other racial/ethnic group Figure 1. Gonorrhea Cases by Race/Ethnicity, Alabama Black Latino White The number of gonorrhea cases reported among males was similar to the number of cases reported among females from 2 to 23. However, over the past four years not only has the number of cases among females and males declined by 28.4% and 29.%, respectively, the ratio of male-to-female cases has narrowed (Figure 11). Figure 11. Gonorrhea Cases by Gender, Alabama Female Male The number of cases diagnosed among Black females, Black males, White females, and White males has declined by 29.9%, 28.%, 48.6%, 43.4% respectively, from 26 to 29 (Figure 12). 9

11 Figure 12. Gonorrhea Cases by Race/Ethnicity and Gender, Alabama Black Female White Female Black Male White Male Although the number of gonorrhea cases among all age groups has declined in the past 3 years, persons age and 2-24 continue to comprise the majority of the gonorrhea cases in Alabama (Figure 13). Of the 2,323 cases reported in 29 among people age and 2,726 cases reported among people age 2-24, Blacks represented nearly 55.7% (1,293/2,323) and 66.% (1,8/2,726), respectively, of the cases. Figure 13. Gonorrhea Cases by Age and Group, Alabama Age 1-14 Age Age 2-24 Age Age 3-34 Age In 29, among people 15-19, the gonorrhea case rate was 77.8 per 1, population and per 1, population for people People age had the third highest rate of infection at per 1, population. A breakdown of 29 gonorrhea case rates is presented in Figure 14. 1

12 Figure 14. Gonorrhea Case Rate per 1, Population by Age Group, Alabama 29 Age Groups < Alabama Rates per 1, Population Over 6.9% (4,558/7,484) of the gonorrhea cases reported in 29 occurred in Alabama s urban and military areas (Jefferson, Madison, Mobile, Montgomery, and Tuscaloosa counties) (Figure 15). Of the 4,558 gonorrhea cases reported in these counties in 29, 66.9% (3,48/4,558) were among Blacks and 35.% (1,596/4,558) were among Black females. 11

13 Figure 15. Gonorrhea Cases by County, Alabama 29 Hale, Lowndes, Montgomery, and Sumter counties had the highest rate of gonorrhea infection 29 (Figure 16). However, Hale, Lowndes, and Sumter counties reported small case numbers. As a result of high gonorrhea morbidity, the counties with the highest rate of gonorrhea infection in 29 were Montgomery (422.1/1,), Jefferson (273.2/1,), and Mobile (231.8//1,). 12

14 Figure 16. Gonorrhea Case Rate per 1, by County, Alabama 29 Primary and Secondary Syphilis From 23 to 29, Alabama s primary and secondary (P&S) syphilis cases increased by 271.8% (299 cases). A total of 49 Alabama residents were diagnosed with P&S in 29 (Figure 17). This reflects a 9.3% decline compared with the number of cases diagnosed in 28 (451 cases). The 29 national case rate for P&S was 4.6 per 1,. That same year, Alabama s case rate ranked fourth in the nation at 8.8 per 1,. 13

15 Figure 17. P&S Syphilis Cases, Alabama Rate per 1, P&S Cases Case Rate Blacks continue to represent the majority of P&S cases diagnosed among Alabama residents (Figure 18). Between 23-29, the number of P&S cases among Blacks and Whites increased by 269.% (226 cases) and 234.8% (53 cases), respectively. Although the number of P&S cases is small among Alabama s Latino population, the number of cases increased from 1 case in 23 to 14 cases in 29. The number of cases reported in 29 represents the second highest number of P&S cases diagnosed among the Alabama s Latino population in the past 1 years. Figure 18. P&S Cases by Race/Ethnicity, Alabama Black Latino White Among all racial/ethnic groups, Black males represented 52.6% (215/49) of the cases diagnosed in 29 followed by 23.2% among Black females (95/49) (Figure 19). However, the number of cases diagnosed among Black females decreased by 28.% in 29 from the previous year. 14

16 Figure 19. P&S Syphilis Cases by Race/Ethnicity and Gender, Alabama Black Female White Female Black Male White Male Over 46.2% (189/49) of the P&S cases reported 29 were Black residents of Jefferson (97), Montgomery (39), Madison (29), and Tuscaloosa (24) counties. The number of P&S cases has been consistently higher among males compared to females. In 29, a total of 277 males were diagnosed with P&S compared to 132 females (Figure 2). The male-to-female ratio increased from 1.6 in 28 to 2.1 in Figure 2. P&S Syphilis Cases by Gender, Alabama Female Male Disease Intervention Specialists (DIS) interviewed 94.9% (388/49) of the P&S cases reported in 29. An equal number of the males interviewed reported homosexual (128) and heterosexual (129) activity as their risk factor (Table 1). In 28, 63.3% (169/267) of the males interviewed reported heterosexual activity as their primary risk factor for contracting P&S. This reflects a major shift from the risk factors reported in 29. The vast majority of males who identified themselves as non-injection drug users selected crack cocaine as their drug of choice. A large number of males and females who identified heterosexual activity as the primary risk factor also 15

17 identified a crack cocaine association, either sex with a crack cocaine user or the use of crack cocaine, as a contributing factor. Table 2 reflects the heterosexual activity for females reported with P&S syphilis in 29. Over the past ten years no significant trends exist when P&S syphilis is analyzed by age group. Table 1. P&S Syphilis Risk Factors Among Males, Alabama 29 No. % MSM Related MSM 55 MSM, Non-IDU 47 Bisexual Only 9 Bisexual, Non-IDU 7 MSM, Sex w/hiv+ 5 Bisexual, Sex w/hiv+ 1 Bisexual, Sex for Drugs/Money, Non-IDU 1 MSM, Sex w/idu 1 MSM, Sex for Drugs/Money 1 MSM, Sex for Drugs/Money, Non-IDU 1 Heterosexual Related Activities Heterosexual, Non-IDU 51 Heterosexual Only 38 Heterosexual, Sex w/crack User, 16 Non-IDU Heterosexual, Sex w/crack User 8 Heterosexual, Sex for Drugs/Money 6 Heterosexual, Sex w/crack User, 4 Sex for Drugs/Money, Non-IDU Heterosexual, Sex for Drugs/Money, 2 Non-IDU Heterosexual, Sex w/idu, 1 Non-IDU Heterosexual, Sex w/crack User, 1 Sex for Drugs/Money Heterosexual, IDU 1 Heterosexual, Sex w/hiv+, Sex w/idu, 1 Sex w/crack User, Sex for Dugs/Money, Non-IDU Unknown 2.8 TOTAL

18 Table 2. P&S Syphilis Risk Factors Among Females, Alabama 29 No. % Sexual Related Activities Heterosexual Only 56 Heterosexual, Non-IDU 39 Heterosexual, Sex for Drugs/Money 9 Non-IDU Bisexual, Non-IDU 3 Heterosexual, Sex w/crack User, 3 Sex for Drugs/Money, Non-IDU Bisexual, Sex for Drugs/Money, 3 Non-IDU Heterosexual, Sex w/hiv+ 2 Heterosexual, Sex w/bisexual Male, 2 Sex for Dugs/Money, Non-IDU Heterosexual, Sex w/crack User, 2 Non-IDU Heterosexual, Sex w/bisexual Male, 1 Sex w/idu, Sex for Drugs/Money, Sex w/crack User Heterosexual, Sex w/crack User 1 Heterosexual, IDU, Sex for Drugs/Money, 1 Sex w/ Crack User, Non-IDU Heterosexual, Sex w/bisexual Male, 1 Non-IDU Sex w/female, Non-IDU 1 Heterosexual, Sex w/idu, 1 Non-IDU Heterosexual, Sex for Drugs/Money 1 Bisexual, Sex w/idu, Non-IDU 1 Heterosexual, Sex w/bisexual Male, 1 Sex w/hiv+, Non-IDU Bisexual 1 Total The number of P&S cases declined in Dallas (59.3%), Madison (54.7%), Morgan (4.9%), and Jefferson (37.8%) counties. However, Jefferson (112), Madison (43), Montgomery (42), Houston (26), Mobile (25), and Tuscaloosa (24) counties represented 66.5% (272/49) of the reported cases in 29 (Figure 21). 17

19 Figure 21. P&S Syphilis Cases by County, Alabama 29 Marengo and Lowndes counties had the highest case rates per 1, at 31.6 and 28.5, respectively. These rates are a direct reflection of the counties small population size (Figure 22). Based on the number of P&S cases reported by county, Houston (26.4), Dallas (25.7), St Clair (18.8), and Montgomery (18.7) counties rates of infection were the highest among Alabama counties in

20 Figure 22. P&S Syphilis Case Rate per 1, by County, Alabama 29 Early Latent Syphilis The number of Early Latent Syphilis (EL) has increased by 125.5% from 25 to 29. In 29, a total of 415 EL cases were reported to ADPH Division of STD Prevention and Control (Figure 23). This reflects a rate of infection of 8.9 per 1, which is similar to that reported for P&S cases during the same reporting period. 19

21 Figure 23. EL Syphilis Cases by, Alabama Rate 1, EL Cases Case Rate Over the past ten years the number of cases was the highest among Blacks. From 23 to 29, the number of cases diagnosed among Blacks and Whites increased by 171.1% (195) and 328.6% (69), respectively (Figure 24). In 29, Blacks accounted for 75.6% (39/49) of the reported cases compared to 22.% Whites (9/49) and 3.4% Hispanics (14/49). However, the number of cases reported among Blacks and Whites declined by 1.9% and 14.3%, respectively, from 28 and 29. As stated earlier, the number of cases reported among Alabama s Latino population is small, the number of cases reported (14) in 29 was the second highest number of cases among Alabama s Latino population in the past 1 years. Figure 24. EL Cases by Race/Ethnicity, Alabama Black Latino White Over the past ten years the number of EL cases for males has mirrored the number of cases reported for females. However, the ratio of male-to-female cases has widened. In 29 the ratio was 1.4:1 compared to 1.1:1 in 28. In 29, males represented nearly 59.4% (243/49) of the reported cases compared to 41.8% females (171/49) (Figure 25). 2

22 Figure 25. EL Syphilis Cases by Gender, Alabama Female Male The number of cases has consistently been highest in Black males and females followed by White females and White males (Figure 26). In 29, a total of 23 EL cases among Black males were reported to Division of STD Prevention and Control. This reflects an increase of 7.4% from the number of cases reported in 28. Figure 26. EL Syphilis Cases by Race/Ethnicity and Gender,Alabama Black Female White Female Black Male White Male DIS interviewed 95.2% (395/415) of the EL syphilis cases reported in 29. Nearly 65.9% of the males and 98.2% females interviewed reported heterosexual activity as their primary risk factor. (Tables 3 and 4). A high number of the males and females who identified heterosexual activity as their primary risk factor also identified a crack cocaine association, either sex with a crack cocaine user or the use of crack cocaine, as a contributing factor. 21

23 Table 3. Early Late Syphilis Risk Factors Among Males, Alabama 29 No. % MSM Related MSM Only 35 MSM, Non-IDU 23 Bisexual, Non-IDU 6 Bisexual Only 4 MSM, Sex for Drugs/Money, Non-IDU 4 MSM, Non-IDU, Sex w/hiv+ 2 Bisexual, Sex for Drugs/Money, Non-IDU 2 MSM, Sex w/hiv+ 2 Heterosexual Related Activities Heterosexual, Non-IDU 51 Heterosexual Only 45 Sex w/crack User 12 Sex for Drugs/Money, Non-IDU 12 Sex w/crack User, Non-IDU 11 Sex w/crack User, Sex for Drugs/Money, 7 Non-IDU Sex for Drugs/Money 4 Sex w/crack User, Sex w/idu, 2 Sex for Drugs/Money, Non-IDU Sex w/crack User, Sex w/hiv+, Non-IDU 1 Sex w/crack User, Sex for Drugs/Money 1 IDU, Non-IDU 1 Unknown 4 TOTAL

24 Table 4. Early Latent Syphilis Risk Factors Among Females, Alabama 29 No. % Sexual Related Activities Heterosexual Only 86 Heterosexual, Non-IDU 36 Heterosexual, Sex for Drugs/Money, 11 Non-IDU Heterosexual w/crack User, Non-IDU 6 Bisexual, Non-IDU 5 Heterosexual, Sex w/crack User, 4 Sex for Drugs/Money Heterosexual, Sex for Drugs/Money 1 Sex w/female Only 3 Bisexual, Sex for Drugs/Money, 3 Non-IDU Bisexual Only 2 Heterosexual w/bisexual Male 2 Heterosexual, IDU 1 Bisexual, Sex for Drugs/Money, 1 Heterosexual w/hiv+, Sex w/crack User, Non-IDU Heterosexual, Sex w/crack User 1 Heterosexual, Sex w/bisexual Male 1 Non-IDU Bisexual, IDU, Non-IDU 1 Heterosexual, Sex for Drugs/Money, IDU 1 Sex w/crack User, Non-IDU Bisexual, Sex for Drugs/Money, 1 Sex w/crack User, Non-IDU Total Jefferson County reported the largest number of cases (121) reported in 29 followed by Madison (55), Montgomery (36), Houston (26), and Tuscaloosa (26) counties (Figure 27). These counties accounted for nearly 63.6% (264/415) of the EL cases reported in 29 and 76.9% (23/264) of the cases reported were among Blacks. Furthermore, Jefferson and Madison counties have consistently reported the highest number of EL cases over the past ten years. 23

25 Figure 27. EL Syphilis Cases by County, Alabama 29 Based on the number of EL cases reported by county, Dallas (44.3), Houston (26.4), Jefferson (18.3), St Clair (17.5, Madison (17.2), Montgomery (16.), and Tuscaloosa (14.5) counties rates of infection were the highest among Alabama counties in 29 (Figure 28). 24

26 Figure 28. EL Syphilis Cases Rate per 1, County, Alabama 29 Congenital Syphilis In 29, Alabama continued to face the challenge of high congenital syphilis cases and case rates (Figure 28). Alabama continues to have one of the highest congenital syphilis rates in the United States. In 29, Alabama s congenital syphilis rate was 18.6 per 1, live births compared to the national rate of 8.3 per 1, live births. 25

27 Figure 29. Congenital Syphilis Cases, Alabama Rate per 1, Year of Birth Stillbirths Live Births Rate In 29, eleven presumptive cases and 1 syphilitic Stillbirth were reported from 8 counties (Jefferson County 4 cases, Madison County 2, Montgomery County 1, Etowah County 1, St Clair County 1, Geneva County 1, Dale County 1, and Dallas County 1) in Alabama. Of the 12 reported cases, 75% (9/12) were black and 25% (3/12) were white. More males (9) than females (3) were reported with congenital syphilis in the state. Of the 12 cases reported congenital syphilis cases reported, 1 mothers received prenatal care between 1 to 17 times before delivery and 2 mothers received no prenatal care. Of the 1 mothers that received prenatal care, all were initially tested for syphilis between 2 to 8 months prior to delivery. The initial syphilis test for 8 mothers was non-reactive. The remaining two were reactive. Two mothers whose initial tests were reactive were in their third trimester of pregnancy. Among the 8 mothers whose initial tests result were non-reactive, 1 was reactive 38 days before delivery but treatment was started less than 3 days before delivery, two had reactive test results 5 and 8 days, respectively, before delivery and 5 had reactive test results on the day of delivery. All 11 exposed babies were adequately treated to prevent complications. As of June 21, 7 presumptive cases of congenital syphilis have been reported. Five mothers of the 7 cases reported received prenatal care between 2 to 14 times before delivery and 2 received no prenatal care. Of the 5 mothers that received prenatal care were initially tested for syphilis between 2 to 6 months prior to delivery. The initial tests for 3 mothers were nonreactive and two were reactive. However, 2 mothers were not treated adequately before delivery. 26

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