- Email: [email protected]
Congenital syphilis: Old disease New resurgence
Congenital Syphilis: Old Disease, n New Resurgence n Patricia
Hryzak
Lind,
MS, RNC
The resurgence of syphilis has a detrimental effect on the health of communities and populations. As this epidemic continues, pediatric nurse practitioners may care for children with congenital syphilis. Children with congenital syphilis are at increased risk for physical abnormalities and developmental delays. Frequent physical and developmental assessments with goal-oriented plans will assist the child and family to achieve their maximum potential. Pediatric nurse practitioners who are knowledgeable about congenital syphilis, its manifestations, and associated nursing care needs will serve as case managers for children and their families with this diagnosis. J PEDIATR HEALTH CARE.
(1992).
6, 12-17.
I he recent resurgence of syphilis within ulations and geographic areas influences
various popthe pediatric nurse practitioner’s provision of primary care. Primary and secondary syphilis cases are at the highest rate since 1950 (CDC, 1988a). In 1986 alone, there was a 25% increase in the number of syphilis cases reported over the previous year. Because of this dramatic increase, it is unlikely that the Public Health Service will achieve its objective of reducing the incidence of primary and secondary syphilis to 7 cases per 100,000 persons by 1990 (CDC, 1988b).
I
n 1986 alone, there was a 25% increase in the number of syphilis cases reported over the previous year.
It is postulated that the increase in syphilis cases is the result of a change in the epidemiology of syphilis. Although the number of reported cases of syphilis in the homosexual and bisexual communities has decreased, an increase in the number of cases of syphilis among heterosexuals has been reported. This may be the result of changes in sexual practice and the increased use of condoms by homosexuals. Another factor cited in case reports and client interviews is the exchange of drugs for sex within the heterosexual community and
Patricia Hryzak Lind, MS, RNC, is the Director of Nursing and Resource Development and assistant professor of Clinical Strong Memorial Hospital, the University of Rochester, Rochester, Prior to this position, she was a pediatric at an urban health center in Rochester,
nurse practitioner New York.
Education Nursing at New York.
and nurse manager
Reprint requests: Patricia Hryrak Lind, MS, RNC, Director of Nursing cation/Resource Development, University of Rochester, 601 Elmwood nue, Rochester, NY 14692. 25/l/27651
12
EduAve-
the possible correlation of this behavior with the increase in the incidence of syphilis and other sexually transmitted diseases (CDC, 1988b). The rising incidence of syphilis among the heterosexual community is related to an occurrence of infected women and their infants. The Center for Disease Control (CDC) reports that increases in congenital syphilis lag behind increases in syphilis in women by about one year (Zaidi, Schnell, & Reynolds, 1988). Recent CDC statistics note a disproportionate increase in cases of syphilis among urban black and Hispanic women of childbearing age. Concurrently, studies suggest that the presence of genital ulcer disease (syphilis, chancroid, etc.) increases the risk of becoming infected with the Human Immunodeficiency Virus (HIV) (Cameron, D’Costa, Ndinya-Achola, Piot, & Plumner, 1988). Family planning clinics in New York state report that Hispanic men and women had the highest HIV infection rate (0.81%), followed by blacks (0.70%), others (0.43%), and whites (0.15%) (New York State Health Department, 1989a). The same publication reports that the newborn HIV seroprevalence rate for Hispanics is 1.34% and for blacks is 1.82Oh, compared with the rate for white newborns of 0.13%. Therefore, concurrent syphilis and HIV infection will affect more women and their subsequent children. It is important for the nurse practitioner to have knowledge of the cause and transmission of syphilis. Syphilis is a systemic, communicable infection caused by Treponema pallidurn, a long, slender, tightly coiled, motile, spirochete that survives poorly outside the body (Speck & Toltzis, 1987). Congenital syphilis develops if the mother contracts syphilis before or during the pregnancy; the infection is passed through the placenta to the infant. The risk of transplacental transmission varies with the stage of maternal illness. Thus, untreated JOURNAL
OF
PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Congenital
pregnant women with primary and secondary syphilis are more likely to transmit infection to their unborn infants than women with latent infection (Speck & Toltzis, 1987). However, it is possible for a woman with a history of syphilis or who has a developing infection to deliver an infected infant even if previous infants were uninfected. Congenital syphilis causes fetal or perinatal death in 40% of affected pregnancies (CDC, 1988b). In the United States, syphilis rarely causes spontaneous abortion? but stillbirths remain a major complication of the disease. In Africa, autopsies of stillborn infants revealed extensive hepatic, splenic, and pancreatic fibrosis; bone and bone marrow changes; increased hematopoiesis; and placental enlargement suggestive of intrauterine hypoxia (Judge, Tafari, Naeye, & Marboe, 1986).
T
he risk of transplacental with the stage of maternal
transmission illness.
varies
n ASSESSING THE INFANT AT RISK FOR SYPHILIS
Knowledge of the risk factors related to syphilis is essential information for the pediatric nurse practitioner. A high degree of suspicion must be maintained when assessing infants at risk. for congenital syphilis. Risk factors for infants include those born to mothers with (a) documented syphilitic infections before or during a pregnancy, (b) treatment for syphilis in advanced stages of pregnancy, and (c) concurrent infection with the HIV virus. Syphilis that has been inadequately treated or a pregnant woman whose immune system is impaired increases the risk to the infant. Having adequate knowledge about the biological mother is important. Syphilis seroprevalence rates for adoptees remains low, but should be considered (Lange & Warnock-E&hart, 1987). To fully evaluate the mother’s health status, the prenatal and postpamlm records, and laboratory tests with results and treatment should be made available to the pediatric practitioner at the time of delivery. n
STAGES OF CONGENITAL
SYPHILIS
There are two stages of congenital syphilis: early and late. Early manifestations of syphilis appear during the first two years of life as a result of active infection, whereas late manifestations of syphilis appear years after birth and result from hypersensitivity phenomena and/or residual scarring (Speck & Toltzis, 1987). Early congenital syphilis ha5svariable clinical manifestations and is similar to the secondary stage of acquired syphilis. As the infant grows and develops, close observation and assessments will alert the nurse practitioner to the presence of congenital syphilis. The prodrome of con-
Syphilis
13
genital syphilis may not be linked to the classic skin lesions seen in adults. The infant may be febrile, restless, anemic, and fail to gain weight. Mucosal or skin lesions may erupt at any time and may be considered analogous to the secondary stage of acquired syphilis. Syphilitic symptoms may involve many organ systems at once or may occur singularly. n
SKIN MANIFESTATIONS
The infant may develop a reddish maculopapular rash involving the soles and/or palms. The rash may be transient, reoccurring weeks to months after its initial eruption. The rash may be bullous, and scarring does not occur. Wart-like moist lesions at the mucocutaneous junction of the mouth, anus, and external genitalia (analogous to the condylomata lata of acquired syphilis) may also be present. These cutaneous lesions are highly infectious, often recur over a period of weeks or months, and eventually disappear (Speck & Toltzis, 1987). These lesions may heal with permanent scars termed “rhagades,” especially around the corners of the mouth and on the chin. The presence of an excoriated upper lip and ulcerated nasal mucosa may be caused by “snuffles,” the profuse, purulent, blood-tinged nasal discharge of syphilitic rhinitis. n
SKELETAL MANIFESTATIONS
Radiologic changes in the skeleton are often diagnostic in early congenital syphilis. Osteochondritis at multiple sites, periostitis, and widened and serrated epiphyseal lines may be evident (Speck & Toltzis, 1987). These tindings may contribute to pseudoparalysis of one or more limbs. Long-term effects may include anterior curving of the tibia (saber shin), swollen joints, and destruction of the nasal bridge or joints. n CENTRAL NERVOUS SYSTEM MANIFESTATIONS
Central nervous system involvement is related to the presence of infection in the cerebrospinal fluid. Inadequate treatment may lead to acute meningovascular syphilis and subsequent hydrocephalus, retardation, and seizures. Eighth nerve deafness may be unilateral or bilateral and may appear at any age. Patients have vertigo and high tone hearing loss, which progresses to permanent deafness (Speck & Toltzis, 1987). n
SYPHILITIC STIGMATA
Infants with early congenital syphilis may exhibit the rhagade scarring of mucosal ulcerations. They may also have a prominent square forehead (cranial bossing) or a flat nasal bridge (saddle nose) caused by nasal mucosa ulceration from syphilitic rhinitis. Further changes may be identified as the child develops. A syphilitic infection during the first weeks of intrauterine life may have an
14
n
Volume 6, Number 1 lanuary-February 1992
Lind
TABLE
Treatment
guidelines
DRUG
Recommended Alternative Prophylactic
Treatment
Treatment Treatment
Treatment for Syphilis of > 1 Year Duration
Aqueous Penicillin G Procaine Penicillin Benzathine Penicillin G Benzathine Penicillin G
DOSAGE klnitslkg)
50,000-150,000
METHOD OF ADMiNISTRATION
LENGTH OF ADMlNtSTRATlON
Intravenous
Every 8-12 hours
lo-14
50,000
Intramuscular
Every day
1O-1 4 days*
50,000
Intramuscular
One timet
50,000
tntramuscular
Once a week for 3 doses
*If more than 1 day of therapy is missed, the entire course should be restarted. tFor infants who require evaluation but do not meet treatment guidelines, and adequate follow-up Adapted from Ingall, Dobson, and Musher (1990) and New York State Health Department (1989c).
impact on permanent teeth, in the form of notched or Hutchinson incisors. Nails may also be ridged and have syphilitic paronychia from finger sucking. n
DOSAGE 1NTERVAL
OTHER MANIFESTATIONS
Changes may occur after infancy that affect other body systems and represent a delayed hypersensitivity phenomenon. Unilateral or bilateral interstitial keratitis may appear at any age. Intense photophobia and lacrimation occur, followed within weeks or months by corneal opacification and complete blindness (Speck & Toltzis, 1987). Termed Hutchinson’s triad, interstitial keratitis is seen in conjunction with eighth cranial nerve deafness and notched permanent incisors. DIAGNOSTIC EVALUATION AND PHARMACOLOGIC TREATMENT
n
The evaluation of infants at risk for congenital syphilis is dependent on the seropositive state of the mother. Diagnostic testing is necessary for infants born of women with syphilis who were (a) treated less than 1 month before delivery, (b) treated with a nonpenicillin regimen, (c) without the expected decrease in nontreponemal antibody titers following penicillin therapy, (d) without a well documented history of complete treatment, or (e) with insufficient follow-up titers during pregnancy to assessdisease activity (New York State Health Department, 1989~). Infants of women with untreated syphilis require a complete serologic evaluation. Hematologic investigation, quantitative measurement of immunoglobins in cord blood, skeletal radiographs, and a lumbar puncture are indicated for infants with a suspicious quantitative Venereal Disease Research Laboratory test (VDRL) (Ingall, Dobson, & Musher, 1990). Serologic diagnosis must take into account the presence of maternal antibodies. Maternal VDRL levels and fluorescent treponemal antibodies (FTA-ABS) are pas-
cannot
days
be assured.
sively transferred to the infant through the placenta. These levels should progressively decline as time passes and should disappear by 3 to 4 months of age (Ingall et al., 1990). Therefore, serologic evaluations of the infant are made over time and in consultation with a pediatric infectious disease specialist. Treatment is based on classification of confirmed or compatible cases. A definite diagnosis of syphilis is made if T. pallidurn is found by darkfield microscopy evaluation. Other parameters for definitive diagnosis are any of the following: (a) a fourfold or greater increase in serologic test for syphilis [STS] (VDRL or rapid plasma reagin [RPR]) values and a positive treponemal test, (b) a reactive STS (VDRL or treponemal hemagglutination [TPHA]) with concurrent snuffles, condylomata lata or osseous lesions or (c) a reactive STS (VDRL or RPR) within the cerebral spinal fluid (Ingall et al., 1990). The probable diagnosis of syphilis is made if the infant has a reactive STS (VDRL or TPHA) with other suspicious clinical manifestations. Syphilis is also suspected if the infant’s STS remains reactive after 4 months of age or if there is a reactive treponemal antibody test after 9 to 12 months of age. Because of the potential for neurosyphilis, treatment is indicated for infants with abnormal cerebrospinal fluid findings. Despite negative cerebrospinal fluid serology, treatment is indicated for infants with 5 or more white blood cells per millimeter or 50 milligrams of protein per deciliter of cerebrospinal fluid (Table). Following treatment, infants need continued evaluation by physical assessments and serologic evaluation. Follow-up can be incorporated into routine well child care visits unless abnormal findings are noted (see Box). Infants with diagnosed neurosyphilis must be followed with periodic serologic testing and repeat cerebrospinal fluid examinations at 6-month intervals for 3 years (Committee on Infectious Disease, 1988).
Journal of Pediatric Health Care
Congenital
Syphilis
15
BOX Schedule of Fobw-Up After Treatment or prophylaxis for Congenital Syphilis For Patients Diagnosed as Having Congenital Syphilis:
n
1. Reagin testing every 3 months for the first 15 months, then every 6 months until negative or stable at low titer. 2. Treponemal antibody test after 15 months of age. 3. Repeat evaluation of cerebral spinal fluid 2 years after treatment if the patient was treated for or showed any signs of central nervous system disease. 4. Careful developmental evaluation, vision testing, and hearing testing before 3 years of age or at the time of diagnosis.
For Patient Treated in Utero or at Birth Because of Maternal Syphilis:* 1. Reagin testing at birth and then every 3 months until at least 6 months of age and test is negative. 2. Treponemal antibody test after 15 months of age.
For Women Treated for Syphilis Dusing Pregnancy: 1. Reagin testing monthly until delivery, then every 3 months until negative. 2. Retreatment anytime there is a fourfold rise in reagin titer. *Any time the patient meets the criteria for the diagnosis of congenital syphilis, followup should be that indicated for a diagnosed case. From
“Syphilis” by C. Wilfert and L. Gutman, 1987, Textbook of pediatric infectious disease, (pp. 619) by R. D. Feigen and J. D. Cherry (Eds.), Philadelphia: W. B. Saunders Co. Copyright 1987 by W. B. Saunders Co. Reprinted by permission.
Recommendations for seropositive untreated infants include quantitative STS and treponemal tests at 1, 2, 3, and 6 months of age. As a result of maternal antibodies, nontreponemal antibody titers (RPR, VDRL) should decrease by 3 months of age and should be absent at 6 months of age (New York State Health Department, 1989~). Treponemal antibodies may be present for up to one year and should be evaluated after age 15 months (Ingall et al., 1990). Further evaluation and treatment are based on abnormal findings. Retreatment of the infant is indicated if (a) the clinical signs or symptoms of syphilis persist or recur, (b) there is a fourfold increase in the titer of a nontreponemal test, or (c) with an initially higher titer, nontreponemal tests fail to decrease fourfold in one year (Committee on Infectious Disease, 1988). Pharmacologic treatment should follow the guidelines for patients who have syphilis for one year or more duration (Box).
F
ollowing treatment, infants need continued evaluation by physical assessments and serologic evaluation. OBJECTIVES AND COALS OF THE NURSE PRACTITIONER’S CARE Overview n
Pediatric nurse practitioners have many opportunities to assist parents and their children who have been ex-
posed to syphilis. The roles and involvement of the nurse practitioner will vary according to the needs of the patient population. The nurse practitioner may provide education and preventive care, diagnose and treat patients with acute or congenital syphilis, or act as a case manager for children with congenital syphilis. As a direct provider of care, the nurse practitioner must have current knowledge of the signs, symptoms, and treaUnent of syphilis for the pediatric population. Knowledge of the physical manifestations of acute and congenital syphilis, coupled with a knowledge of the patient’s history and risk factors, will assist the practitioner in diagnosis of the disease process. Recognition of the dermatologic manifestations of syphilis also is essential information. Because the diagnosis and correct treatment of syphilis is an important individual and public health concern, consultation with another health care provider who is skilled at making this diagnosis may be necessary. Local and state health departments are resources that can provide the nurse practitioner with current treatment guidelines, trends in syphilis for a specific geographic area, and can assist in case finding and treatment of individuals exposed to the patient. Pregnant women, exposed infants and children, adolescents, and families have different health care and educational requirements. An assessment of the family’s strengths and areas of need will aid the practitioner in formulating a plan of care. Initial and ongoing devel-
16
Volume 6, Number 1 January-February 1992
Lind
opmental and family assessments provide baseline and historic information about a child’s and family’s progress. At-risk children may reside in potentially compromised family situations and need continuous multisystern interventions to promote their optimal health. Care for Exposed Infants and Children Information concerning the family and parenting practices serves as part of the infant’s data base. Data about the mother’s pregnancy will provide information about her physical condition and about psychosocial concerns such as planning of the pregnancy, familial support, and parenting beliefs. The presence of congenital syphilis must alert the nurse practitioner to potential maternal behaviors that continue to pose a risk to the infant. Continued substance use, prostitution, and/or presence or potential for maternal HIV infection impact on the mother’s parenting abilities and the infant’s safety and well being.
T
he presence of congenital syphilis must alert the nurse practitioner to potential maternal behaviors that continue to pose a risk to the infant. Parents with these high risk behaviors may not be cognizant of the importance of frequent health care visits or may not be attentive to the preventive care and health teaching. Infant stimulation to enhance a compromised child’s development or to encourage a normal child in a less than optimal social situation may not be valued or provided by the family. The nurse practitioner may involve family supports, parenting organizations, or social services to enhance parental resources. Home observations and parental teaching by a community health nurse also will augment the practitioner’s data base and teaching. The involvement of child protective services also should be considered if parents fail to provide for the infant’s health, safety, and optimal development. Parental knowledge about the importance, timing, and implications of developmental and physical assessments is essential. The pediatric nurse practitioner’s identification of risk factors such as central nervous system involvement with potential hydrocephalus, neurological deficits, and seizures are indications for referrals for a thorough neurological assessment and for parental education on pertinent and reportable observations. Physical and developmental areas of concern include the possibility or progressive hearing loss resulting from eighth cranial nerve damage from syphilis and/or the use of antibiotics. Parents and care providers should be alerted if the infant shows little or no interest in sounds, does not blink at a loud noise, does not attend
to mother’s voice or musical toys by age 3 months, does not coo or gurgle, has decreased vocalization after 6 or 8 months of age, or shows increased gesturing or hyperactivity (Klijanowicz & Lavole, 1986). Because hearing loss may become more progressive, clinical manifestations will change as the child grows and develops. Otolaryngolic examinations and referrals for complete audiologic examination are indicated based on the infant’s history and behavior.
P
arental knowledge about the importance, timing, and implications of developmental and physical assessments is essential. Skeletal involvement may manifest itself as pseudoparalysis of one or more limbs. Therefore, close observations of the infant’s symmetrical extremity development, tone, strength, and range of motion should be included at each visit. Other body systems may be affected after infancy and may also affect the child’s development. Eye infections with increased lacrimation and photophobia may indicate interstitial keratitis and warrant immediate referral to an ophthalmologist. Without prompt and adequate treatment, permanent loss of vision may result. Regular developmental assessments based on risk factors and observable behaviors will assist the nurse practitioner in determining the need for evaluation and additional referrals. The severity of the syphilitic disease and the environmental or societal causes of delayed growth or development will impact the timing and frequency of well child and referral appointments. Care for Pregnant Women A pediatric nurse practitioner may provide direct care to the pregnant adolescent. The issue of syphilis may also be of concern to pregnant women whose children are cared for by the nurse practitioner. In either case, if the woman is at risk for syphilis, she should be evaluated as soon as possible. Sexually active adolescents should be evaluated for syphilis and pregnancy based on history, risk factors, and symptoms. In the event of pregnancy, a pediatric or family nurse practitioner may be the initial health care provider to inform the adolescent. This may be an emotionally difficult visit for the adolescent. However, the health of the adolescent and the fetus also must be evaluated. Based on the history, chief complaint, and physical examination, screening and treatment for syphilis may be necessary at the initial visit. Education regarding the prevention of subsequent sexually transmitted diseases and the need for early and regular prenatal care will enhance the health status of the mother and her infant.
lournal of Pediatric Health
Congenital
Care
Based on the pediatric nurse practitioners’ scope of practice, direct care may be provided to the pregnant adolescent or she may be referred to an obstetric care provider. If the patient is at risk for syphilis, assistance with appointment scheduling and education regarding the importance of compliance is essential. Educational Aspects Educating patients and families about sexually transmitted diseases, including syphilis, is an essential aspect of the nurse practitioner’s care. Prevention of syphilis and other diseases is an important community health issue that impacts on all members of society. Emphasizing education and disease prevention with sexually active adolescents will enhance the health of the teenager and will contribute to the well being of future generations. Educational opportunities for adolescents and parents exist at health care visits, prenatal classes and planned educational seminars. Because of epidemiologic and societal trends, educational content about syphilis should include information on prevention, detection, use of health care and community resources, and the increasing association between sexually transmitted disease and HIV infection. The practitioner also can provide education in the prevention of adolescent pregnancy. Parental education regarding syphilis is geared to the acute or chronic care phase of their infant’s illness. During the acute care phase, the nurse practitioner provides information about the disease process, treatment options, and immediate explanations of the health care needs of the infant. Developmental observations, infant stimulation, signs and symptoms of syphilitic sequelae, and parental reporting of untoward findings are explained because these are appropriate to the infant’s long-term care needs.
W
hen acting as a case manager, the practitioner integrates education, direct care, and advocacy.
When acting as a case manager, the practitioner integrates education, direct care, and advocacy. Using the assessment data and current knowledge, the nurse case manager’s role extends to the family and to the community. Parental empowerment through knowledge of syphilis, community resources, and the health care system will encourage parents to seek optimal resources for their child. Educating parents on the special needs of the child and teaching them to be advocates on their child’s behalf are life-long skills. Parents may be highly motivated to act as advocates after they have resolved their feelings of grief and guilt.
Syphilis
17
Professional and peer support through a linkage with another affected family may be helpful. Resolution of these feelings combined with the knowledge and power to encourage their child’s optimal development may be a mutual goal of the practitioner and family. The care of a family whose infant has contracted syphilis is complex and challenging. The skilled nurse practitioner can provide the necessary support, education, and coordination of services to promote optimal health for the child, family, and the public health of the community. Through education, the nurse practitioner provides preventive services to patients and their families. By remaining clinically current in one’s knowledge of syphilis, accurate diagnosis and treatment may arrest the spread of this disease and abate the ramifications of its sequelae. n
REFERENCES Cameron, D. W., D’Costa, L. J., Ndinya-Achola, J. O., Piot, P., & Phunner, F. A. (1988, June). Incia!znce and risk factors for fern& to mde transmtision of HIV. Paper presented at the Fourth International Conference on AIDS, Stockholm, Sweden. Centers for Disease Control (CDC). (1988a). Continuing increase in infectious syphilis. Morbidity and Mortality Weekly Report, 37, (3), 35-39. Centers for Disease Control (CDC). (1988b). Syphilis and congenital syphilis. Morbidity and Mortaliq Weekly Report, 37, (32), l-4. Committee on Infectious Disease. (1988). Report of the Committee on Infectious Disease. Elk Grove, IL: American Academy of Pediatrics. Ingall, D., Dobson, S. R., & Musher, D. (1990). Syphilis. In J. S. Remington, & J. 0. Klein (Eds.), Infetiiou$ disemer of the fetus and newbwn infant (pp. 367-394). Philadelphia: W.B. Saunders. Judge, D. N., Tafari, N., Naeye, R. L., & Marboe, C. (1986). Congenital syphilis and perinatal mortality. PediatricPathology, 5,41 l420. Klijanowicz, A. S., & Lavole, D. B. (1986). Children with eye and ear conditions. In L. S. Brunner, & D. S. Suddarth (Eds.), The Lippincott manual of nursing practice (pp. 1387-1401). Philadelphia: J.B. Lippincott. Lange R. S., & Warnock-E&hart, E. (1987). Selected infectious disease risks in international adoptees. Pediatric InfectiousDisease Journal, 6, 447-450. New York State Health Department, (1989a). HIVseropwvalencestudies. Epiahiolug?, Notes, 4 ( 7). New York State Health Department (1989b). Screeninn fiy syphilis begins. Epidemiology Notes, 4 ( 11). New York State Health Department (1989~). Sexually transmitted disease: Treatmentguidelines. Albany, New York: Bureau of Communicable Disease Control. Speck, W. T., & Tohzis, P. (1987). Treponematosis. In R. E. Behrman, V. C. Vaughan (W. Nelson, Ed.) Textbook ofpediatvics (pp. 643-647). Philadelphia: W.B. Saunders. Wilfert, C., & Guunan, L. (1987). Sexually transmitted diseases. In R. D. Feigen, & J. D. Cherry (Eds.), Textbook ofpediatric infectious disease5 (pp. 595-621). Philadelphia: W.B. Saunders. Zaidi, A. A., Schnell, D., & Reynolds, G. H. (1988, May). Timeseries analysis of syphih surveillance data. Paper presented at CDC Symposium on Statistics in surveillance, Atlanta, GA.
Hryzak
Lind,
MS, RNC
The resurgence of syphilis has a detrimental effect on the health of communities and populations. As this epidemic continues, pediatric nurse practitioners may care for children with congenital syphilis. Children with congenital syphilis are at increased risk for physical abnormalities and developmental delays. Frequent physical and developmental assessments with goal-oriented plans will assist the child and family to achieve their maximum potential. Pediatric nurse practitioners who are knowledgeable about congenital syphilis, its manifestations, and associated nursing care needs will serve as case managers for children and their families with this diagnosis. J PEDIATR HEALTH CARE.
(1992).
6, 12-17.
I he recent resurgence of syphilis within ulations and geographic areas influences
various popthe pediatric nurse practitioner’s provision of primary care. Primary and secondary syphilis cases are at the highest rate since 1950 (CDC, 1988a). In 1986 alone, there was a 25% increase in the number of syphilis cases reported over the previous year. Because of this dramatic increase, it is unlikely that the Public Health Service will achieve its objective of reducing the incidence of primary and secondary syphilis to 7 cases per 100,000 persons by 1990 (CDC, 1988b).
I
n 1986 alone, there was a 25% increase in the number of syphilis cases reported over the previous year.
It is postulated that the increase in syphilis cases is the result of a change in the epidemiology of syphilis. Although the number of reported cases of syphilis in the homosexual and bisexual communities has decreased, an increase in the number of cases of syphilis among heterosexuals has been reported. This may be the result of changes in sexual practice and the increased use of condoms by homosexuals. Another factor cited in case reports and client interviews is the exchange of drugs for sex within the heterosexual community and
Patricia Hryzak Lind, MS, RNC, is the Director of Nursing and Resource Development and assistant professor of Clinical Strong Memorial Hospital, the University of Rochester, Rochester, Prior to this position, she was a pediatric at an urban health center in Rochester,
nurse practitioner New York.
Education Nursing at New York.
and nurse manager
Reprint requests: Patricia Hryrak Lind, MS, RNC, Director of Nursing cation/Resource Development, University of Rochester, 601 Elmwood nue, Rochester, NY 14692. 25/l/27651
12
EduAve-
the possible correlation of this behavior with the increase in the incidence of syphilis and other sexually transmitted diseases (CDC, 1988b). The rising incidence of syphilis among the heterosexual community is related to an occurrence of infected women and their infants. The Center for Disease Control (CDC) reports that increases in congenital syphilis lag behind increases in syphilis in women by about one year (Zaidi, Schnell, & Reynolds, 1988). Recent CDC statistics note a disproportionate increase in cases of syphilis among urban black and Hispanic women of childbearing age. Concurrently, studies suggest that the presence of genital ulcer disease (syphilis, chancroid, etc.) increases the risk of becoming infected with the Human Immunodeficiency Virus (HIV) (Cameron, D’Costa, Ndinya-Achola, Piot, & Plumner, 1988). Family planning clinics in New York state report that Hispanic men and women had the highest HIV infection rate (0.81%), followed by blacks (0.70%), others (0.43%), and whites (0.15%) (New York State Health Department, 1989a). The same publication reports that the newborn HIV seroprevalence rate for Hispanics is 1.34% and for blacks is 1.82Oh, compared with the rate for white newborns of 0.13%. Therefore, concurrent syphilis and HIV infection will affect more women and their subsequent children. It is important for the nurse practitioner to have knowledge of the cause and transmission of syphilis. Syphilis is a systemic, communicable infection caused by Treponema pallidurn, a long, slender, tightly coiled, motile, spirochete that survives poorly outside the body (Speck & Toltzis, 1987). Congenital syphilis develops if the mother contracts syphilis before or during the pregnancy; the infection is passed through the placenta to the infant. The risk of transplacental transmission varies with the stage of maternal illness. Thus, untreated JOURNAL
OF
PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Congenital
pregnant women with primary and secondary syphilis are more likely to transmit infection to their unborn infants than women with latent infection (Speck & Toltzis, 1987). However, it is possible for a woman with a history of syphilis or who has a developing infection to deliver an infected infant even if previous infants were uninfected. Congenital syphilis causes fetal or perinatal death in 40% of affected pregnancies (CDC, 1988b). In the United States, syphilis rarely causes spontaneous abortion? but stillbirths remain a major complication of the disease. In Africa, autopsies of stillborn infants revealed extensive hepatic, splenic, and pancreatic fibrosis; bone and bone marrow changes; increased hematopoiesis; and placental enlargement suggestive of intrauterine hypoxia (Judge, Tafari, Naeye, & Marboe, 1986).
T
he risk of transplacental with the stage of maternal
transmission illness.
varies
n ASSESSING THE INFANT AT RISK FOR SYPHILIS
Knowledge of the risk factors related to syphilis is essential information for the pediatric nurse practitioner. A high degree of suspicion must be maintained when assessing infants at risk. for congenital syphilis. Risk factors for infants include those born to mothers with (a) documented syphilitic infections before or during a pregnancy, (b) treatment for syphilis in advanced stages of pregnancy, and (c) concurrent infection with the HIV virus. Syphilis that has been inadequately treated or a pregnant woman whose immune system is impaired increases the risk to the infant. Having adequate knowledge about the biological mother is important. Syphilis seroprevalence rates for adoptees remains low, but should be considered (Lange & Warnock-E&hart, 1987). To fully evaluate the mother’s health status, the prenatal and postpamlm records, and laboratory tests with results and treatment should be made available to the pediatric practitioner at the time of delivery. n
STAGES OF CONGENITAL
SYPHILIS
There are two stages of congenital syphilis: early and late. Early manifestations of syphilis appear during the first two years of life as a result of active infection, whereas late manifestations of syphilis appear years after birth and result from hypersensitivity phenomena and/or residual scarring (Speck & Toltzis, 1987). Early congenital syphilis ha5svariable clinical manifestations and is similar to the secondary stage of acquired syphilis. As the infant grows and develops, close observation and assessments will alert the nurse practitioner to the presence of congenital syphilis. The prodrome of con-
Syphilis
13
genital syphilis may not be linked to the classic skin lesions seen in adults. The infant may be febrile, restless, anemic, and fail to gain weight. Mucosal or skin lesions may erupt at any time and may be considered analogous to the secondary stage of acquired syphilis. Syphilitic symptoms may involve many organ systems at once or may occur singularly. n
SKIN MANIFESTATIONS
The infant may develop a reddish maculopapular rash involving the soles and/or palms. The rash may be transient, reoccurring weeks to months after its initial eruption. The rash may be bullous, and scarring does not occur. Wart-like moist lesions at the mucocutaneous junction of the mouth, anus, and external genitalia (analogous to the condylomata lata of acquired syphilis) may also be present. These cutaneous lesions are highly infectious, often recur over a period of weeks or months, and eventually disappear (Speck & Toltzis, 1987). These lesions may heal with permanent scars termed “rhagades,” especially around the corners of the mouth and on the chin. The presence of an excoriated upper lip and ulcerated nasal mucosa may be caused by “snuffles,” the profuse, purulent, blood-tinged nasal discharge of syphilitic rhinitis. n
SKELETAL MANIFESTATIONS
Radiologic changes in the skeleton are often diagnostic in early congenital syphilis. Osteochondritis at multiple sites, periostitis, and widened and serrated epiphyseal lines may be evident (Speck & Toltzis, 1987). These tindings may contribute to pseudoparalysis of one or more limbs. Long-term effects may include anterior curving of the tibia (saber shin), swollen joints, and destruction of the nasal bridge or joints. n CENTRAL NERVOUS SYSTEM MANIFESTATIONS
Central nervous system involvement is related to the presence of infection in the cerebrospinal fluid. Inadequate treatment may lead to acute meningovascular syphilis and subsequent hydrocephalus, retardation, and seizures. Eighth nerve deafness may be unilateral or bilateral and may appear at any age. Patients have vertigo and high tone hearing loss, which progresses to permanent deafness (Speck & Toltzis, 1987). n
SYPHILITIC STIGMATA
Infants with early congenital syphilis may exhibit the rhagade scarring of mucosal ulcerations. They may also have a prominent square forehead (cranial bossing) or a flat nasal bridge (saddle nose) caused by nasal mucosa ulceration from syphilitic rhinitis. Further changes may be identified as the child develops. A syphilitic infection during the first weeks of intrauterine life may have an
14
n
Volume 6, Number 1 lanuary-February 1992
Lind
TABLE
Treatment
guidelines
DRUG
Recommended Alternative Prophylactic
Treatment
Treatment Treatment
Treatment for Syphilis of > 1 Year Duration
Aqueous Penicillin G Procaine Penicillin Benzathine Penicillin G Benzathine Penicillin G
DOSAGE klnitslkg)
50,000-150,000
METHOD OF ADMiNISTRATION
LENGTH OF ADMlNtSTRATlON
Intravenous
Every 8-12 hours
lo-14
50,000
Intramuscular
Every day
1O-1 4 days*
50,000
Intramuscular
One timet
50,000
tntramuscular
Once a week for 3 doses
*If more than 1 day of therapy is missed, the entire course should be restarted. tFor infants who require evaluation but do not meet treatment guidelines, and adequate follow-up Adapted from Ingall, Dobson, and Musher (1990) and New York State Health Department (1989c).
impact on permanent teeth, in the form of notched or Hutchinson incisors. Nails may also be ridged and have syphilitic paronychia from finger sucking. n
DOSAGE 1NTERVAL
OTHER MANIFESTATIONS
Changes may occur after infancy that affect other body systems and represent a delayed hypersensitivity phenomenon. Unilateral or bilateral interstitial keratitis may appear at any age. Intense photophobia and lacrimation occur, followed within weeks or months by corneal opacification and complete blindness (Speck & Toltzis, 1987). Termed Hutchinson’s triad, interstitial keratitis is seen in conjunction with eighth cranial nerve deafness and notched permanent incisors. DIAGNOSTIC EVALUATION AND PHARMACOLOGIC TREATMENT
n
The evaluation of infants at risk for congenital syphilis is dependent on the seropositive state of the mother. Diagnostic testing is necessary for infants born of women with syphilis who were (a) treated less than 1 month before delivery, (b) treated with a nonpenicillin regimen, (c) without the expected decrease in nontreponemal antibody titers following penicillin therapy, (d) without a well documented history of complete treatment, or (e) with insufficient follow-up titers during pregnancy to assessdisease activity (New York State Health Department, 1989~). Infants of women with untreated syphilis require a complete serologic evaluation. Hematologic investigation, quantitative measurement of immunoglobins in cord blood, skeletal radiographs, and a lumbar puncture are indicated for infants with a suspicious quantitative Venereal Disease Research Laboratory test (VDRL) (Ingall, Dobson, & Musher, 1990). Serologic diagnosis must take into account the presence of maternal antibodies. Maternal VDRL levels and fluorescent treponemal antibodies (FTA-ABS) are pas-
cannot
days
be assured.
sively transferred to the infant through the placenta. These levels should progressively decline as time passes and should disappear by 3 to 4 months of age (Ingall et al., 1990). Therefore, serologic evaluations of the infant are made over time and in consultation with a pediatric infectious disease specialist. Treatment is based on classification of confirmed or compatible cases. A definite diagnosis of syphilis is made if T. pallidurn is found by darkfield microscopy evaluation. Other parameters for definitive diagnosis are any of the following: (a) a fourfold or greater increase in serologic test for syphilis [STS] (VDRL or rapid plasma reagin [RPR]) values and a positive treponemal test, (b) a reactive STS (VDRL or treponemal hemagglutination [TPHA]) with concurrent snuffles, condylomata lata or osseous lesions or (c) a reactive STS (VDRL or RPR) within the cerebral spinal fluid (Ingall et al., 1990). The probable diagnosis of syphilis is made if the infant has a reactive STS (VDRL or TPHA) with other suspicious clinical manifestations. Syphilis is also suspected if the infant’s STS remains reactive after 4 months of age or if there is a reactive treponemal antibody test after 9 to 12 months of age. Because of the potential for neurosyphilis, treatment is indicated for infants with abnormal cerebrospinal fluid findings. Despite negative cerebrospinal fluid serology, treatment is indicated for infants with 5 or more white blood cells per millimeter or 50 milligrams of protein per deciliter of cerebrospinal fluid (Table). Following treatment, infants need continued evaluation by physical assessments and serologic evaluation. Follow-up can be incorporated into routine well child care visits unless abnormal findings are noted (see Box). Infants with diagnosed neurosyphilis must be followed with periodic serologic testing and repeat cerebrospinal fluid examinations at 6-month intervals for 3 years (Committee on Infectious Disease, 1988).
Journal of Pediatric Health Care
Congenital
Syphilis
15
BOX Schedule of Fobw-Up After Treatment or prophylaxis for Congenital Syphilis For Patients Diagnosed as Having Congenital Syphilis:
n
1. Reagin testing every 3 months for the first 15 months, then every 6 months until negative or stable at low titer. 2. Treponemal antibody test after 15 months of age. 3. Repeat evaluation of cerebral spinal fluid 2 years after treatment if the patient was treated for or showed any signs of central nervous system disease. 4. Careful developmental evaluation, vision testing, and hearing testing before 3 years of age or at the time of diagnosis.
For Patient Treated in Utero or at Birth Because of Maternal Syphilis:* 1. Reagin testing at birth and then every 3 months until at least 6 months of age and test is negative. 2. Treponemal antibody test after 15 months of age.
For Women Treated for Syphilis Dusing Pregnancy: 1. Reagin testing monthly until delivery, then every 3 months until negative. 2. Retreatment anytime there is a fourfold rise in reagin titer. *Any time the patient meets the criteria for the diagnosis of congenital syphilis, followup should be that indicated for a diagnosed case. From
“Syphilis” by C. Wilfert and L. Gutman, 1987, Textbook of pediatric infectious disease, (pp. 619) by R. D. Feigen and J. D. Cherry (Eds.), Philadelphia: W. B. Saunders Co. Copyright 1987 by W. B. Saunders Co. Reprinted by permission.
Recommendations for seropositive untreated infants include quantitative STS and treponemal tests at 1, 2, 3, and 6 months of age. As a result of maternal antibodies, nontreponemal antibody titers (RPR, VDRL) should decrease by 3 months of age and should be absent at 6 months of age (New York State Health Department, 1989~). Treponemal antibodies may be present for up to one year and should be evaluated after age 15 months (Ingall et al., 1990). Further evaluation and treatment are based on abnormal findings. Retreatment of the infant is indicated if (a) the clinical signs or symptoms of syphilis persist or recur, (b) there is a fourfold increase in the titer of a nontreponemal test, or (c) with an initially higher titer, nontreponemal tests fail to decrease fourfold in one year (Committee on Infectious Disease, 1988). Pharmacologic treatment should follow the guidelines for patients who have syphilis for one year or more duration (Box).
F
ollowing treatment, infants need continued evaluation by physical assessments and serologic evaluation. OBJECTIVES AND COALS OF THE NURSE PRACTITIONER’S CARE Overview n
Pediatric nurse practitioners have many opportunities to assist parents and their children who have been ex-
posed to syphilis. The roles and involvement of the nurse practitioner will vary according to the needs of the patient population. The nurse practitioner may provide education and preventive care, diagnose and treat patients with acute or congenital syphilis, or act as a case manager for children with congenital syphilis. As a direct provider of care, the nurse practitioner must have current knowledge of the signs, symptoms, and treaUnent of syphilis for the pediatric population. Knowledge of the physical manifestations of acute and congenital syphilis, coupled with a knowledge of the patient’s history and risk factors, will assist the practitioner in diagnosis of the disease process. Recognition of the dermatologic manifestations of syphilis also is essential information. Because the diagnosis and correct treatment of syphilis is an important individual and public health concern, consultation with another health care provider who is skilled at making this diagnosis may be necessary. Local and state health departments are resources that can provide the nurse practitioner with current treatment guidelines, trends in syphilis for a specific geographic area, and can assist in case finding and treatment of individuals exposed to the patient. Pregnant women, exposed infants and children, adolescents, and families have different health care and educational requirements. An assessment of the family’s strengths and areas of need will aid the practitioner in formulating a plan of care. Initial and ongoing devel-
16
Volume 6, Number 1 January-February 1992
Lind
opmental and family assessments provide baseline and historic information about a child’s and family’s progress. At-risk children may reside in potentially compromised family situations and need continuous multisystern interventions to promote their optimal health. Care for Exposed Infants and Children Information concerning the family and parenting practices serves as part of the infant’s data base. Data about the mother’s pregnancy will provide information about her physical condition and about psychosocial concerns such as planning of the pregnancy, familial support, and parenting beliefs. The presence of congenital syphilis must alert the nurse practitioner to potential maternal behaviors that continue to pose a risk to the infant. Continued substance use, prostitution, and/or presence or potential for maternal HIV infection impact on the mother’s parenting abilities and the infant’s safety and well being.
T
he presence of congenital syphilis must alert the nurse practitioner to potential maternal behaviors that continue to pose a risk to the infant. Parents with these high risk behaviors may not be cognizant of the importance of frequent health care visits or may not be attentive to the preventive care and health teaching. Infant stimulation to enhance a compromised child’s development or to encourage a normal child in a less than optimal social situation may not be valued or provided by the family. The nurse practitioner may involve family supports, parenting organizations, or social services to enhance parental resources. Home observations and parental teaching by a community health nurse also will augment the practitioner’s data base and teaching. The involvement of child protective services also should be considered if parents fail to provide for the infant’s health, safety, and optimal development. Parental knowledge about the importance, timing, and implications of developmental and physical assessments is essential. The pediatric nurse practitioner’s identification of risk factors such as central nervous system involvement with potential hydrocephalus, neurological deficits, and seizures are indications for referrals for a thorough neurological assessment and for parental education on pertinent and reportable observations. Physical and developmental areas of concern include the possibility or progressive hearing loss resulting from eighth cranial nerve damage from syphilis and/or the use of antibiotics. Parents and care providers should be alerted if the infant shows little or no interest in sounds, does not blink at a loud noise, does not attend
to mother’s voice or musical toys by age 3 months, does not coo or gurgle, has decreased vocalization after 6 or 8 months of age, or shows increased gesturing or hyperactivity (Klijanowicz & Lavole, 1986). Because hearing loss may become more progressive, clinical manifestations will change as the child grows and develops. Otolaryngolic examinations and referrals for complete audiologic examination are indicated based on the infant’s history and behavior.
P
arental knowledge about the importance, timing, and implications of developmental and physical assessments is essential. Skeletal involvement may manifest itself as pseudoparalysis of one or more limbs. Therefore, close observations of the infant’s symmetrical extremity development, tone, strength, and range of motion should be included at each visit. Other body systems may be affected after infancy and may also affect the child’s development. Eye infections with increased lacrimation and photophobia may indicate interstitial keratitis and warrant immediate referral to an ophthalmologist. Without prompt and adequate treatment, permanent loss of vision may result. Regular developmental assessments based on risk factors and observable behaviors will assist the nurse practitioner in determining the need for evaluation and additional referrals. The severity of the syphilitic disease and the environmental or societal causes of delayed growth or development will impact the timing and frequency of well child and referral appointments. Care for Pregnant Women A pediatric nurse practitioner may provide direct care to the pregnant adolescent. The issue of syphilis may also be of concern to pregnant women whose children are cared for by the nurse practitioner. In either case, if the woman is at risk for syphilis, she should be evaluated as soon as possible. Sexually active adolescents should be evaluated for syphilis and pregnancy based on history, risk factors, and symptoms. In the event of pregnancy, a pediatric or family nurse practitioner may be the initial health care provider to inform the adolescent. This may be an emotionally difficult visit for the adolescent. However, the health of the adolescent and the fetus also must be evaluated. Based on the history, chief complaint, and physical examination, screening and treatment for syphilis may be necessary at the initial visit. Education regarding the prevention of subsequent sexually transmitted diseases and the need for early and regular prenatal care will enhance the health status of the mother and her infant.
lournal of Pediatric Health
Congenital
Care
Based on the pediatric nurse practitioners’ scope of practice, direct care may be provided to the pregnant adolescent or she may be referred to an obstetric care provider. If the patient is at risk for syphilis, assistance with appointment scheduling and education regarding the importance of compliance is essential. Educational Aspects Educating patients and families about sexually transmitted diseases, including syphilis, is an essential aspect of the nurse practitioner’s care. Prevention of syphilis and other diseases is an important community health issue that impacts on all members of society. Emphasizing education and disease prevention with sexually active adolescents will enhance the health of the teenager and will contribute to the well being of future generations. Educational opportunities for adolescents and parents exist at health care visits, prenatal classes and planned educational seminars. Because of epidemiologic and societal trends, educational content about syphilis should include information on prevention, detection, use of health care and community resources, and the increasing association between sexually transmitted disease and HIV infection. The practitioner also can provide education in the prevention of adolescent pregnancy. Parental education regarding syphilis is geared to the acute or chronic care phase of their infant’s illness. During the acute care phase, the nurse practitioner provides information about the disease process, treatment options, and immediate explanations of the health care needs of the infant. Developmental observations, infant stimulation, signs and symptoms of syphilitic sequelae, and parental reporting of untoward findings are explained because these are appropriate to the infant’s long-term care needs.
W
hen acting as a case manager, the practitioner integrates education, direct care, and advocacy.
When acting as a case manager, the practitioner integrates education, direct care, and advocacy. Using the assessment data and current knowledge, the nurse case manager’s role extends to the family and to the community. Parental empowerment through knowledge of syphilis, community resources, and the health care system will encourage parents to seek optimal resources for their child. Educating parents on the special needs of the child and teaching them to be advocates on their child’s behalf are life-long skills. Parents may be highly motivated to act as advocates after they have resolved their feelings of grief and guilt.
Syphilis
17
Professional and peer support through a linkage with another affected family may be helpful. Resolution of these feelings combined with the knowledge and power to encourage their child’s optimal development may be a mutual goal of the practitioner and family. The care of a family whose infant has contracted syphilis is complex and challenging. The skilled nurse practitioner can provide the necessary support, education, and coordination of services to promote optimal health for the child, family, and the public health of the community. Through education, the nurse practitioner provides preventive services to patients and their families. By remaining clinically current in one’s knowledge of syphilis, accurate diagnosis and treatment may arrest the spread of this disease and abate the ramifications of its sequelae. n
REFERENCES Cameron, D. W., D’Costa, L. J., Ndinya-Achola, J. O., Piot, P., & Phunner, F. A. (1988, June). Incia!znce and risk factors for fern& to mde transmtision of HIV. Paper presented at the Fourth International Conference on AIDS, Stockholm, Sweden. Centers for Disease Control (CDC). (1988a). Continuing increase in infectious syphilis. Morbidity and Mortality Weekly Report, 37, (3), 35-39. Centers for Disease Control (CDC). (1988b). Syphilis and congenital syphilis. Morbidity and Mortaliq Weekly Report, 37, (32), l-4. Committee on Infectious Disease. (1988). Report of the Committee on Infectious Disease. Elk Grove, IL: American Academy of Pediatrics. Ingall, D., Dobson, S. R., & Musher, D. (1990). Syphilis. In J. S. Remington, & J. 0. Klein (Eds.), Infetiiou$ disemer of the fetus and newbwn infant (pp. 367-394). Philadelphia: W.B. Saunders. Judge, D. N., Tafari, N., Naeye, R. L., & Marboe, C. (1986). Congenital syphilis and perinatal mortality. PediatricPathology, 5,41 l420. Klijanowicz, A. S., & Lavole, D. B. (1986). Children with eye and ear conditions. In L. S. Brunner, & D. S. Suddarth (Eds.), The Lippincott manual of nursing practice (pp. 1387-1401). Philadelphia: J.B. Lippincott. Lange R. S., & Warnock-E&hart, E. (1987). Selected infectious disease risks in international adoptees. Pediatric InfectiousDisease Journal, 6, 447-450. New York State Health Department, (1989a). HIVseropwvalencestudies. Epiahiolug?, Notes, 4 ( 7). New York State Health Department (1989b). Screeninn fiy syphilis begins. Epidemiology Notes, 4 ( 11). New York State Health Department (1989~). Sexually transmitted disease: Treatmentguidelines. Albany, New York: Bureau of Communicable Disease Control. Speck, W. T., & Tohzis, P. (1987). Treponematosis. In R. E. Behrman, V. C. Vaughan (W. Nelson, Ed.) Textbook ofpediatvics (pp. 643-647). Philadelphia: W.B. Saunders. Wilfert, C., & Guunan, L. (1987). Sexually transmitted diseases. In R. D. Feigen, & J. D. Cherry (Eds.), Textbook ofpediatric infectious disease5 (pp. 595-621). Philadelphia: W.B. Saunders. Zaidi, A. A., Schnell, D., & Reynolds, G. H. (1988, May). Timeseries analysis of syphih surveillance data. Paper presented at CDC Symposium on Statistics in surveillance, Atlanta, GA.