blood test report is received in the health department. If the blood test was positive, the investigators are subsequently unable, or find it time-consuming and difficult, to locate the patient at his listed address in time to prevent his spreading infection.

A second reason for failure is that private physicians often refuse to permit health department personnel to interview their patients. A recent study of epidemiologic failures with the patients of private physicians indicates that the number of physicians who refuse to permit interview of their patients may account for as much as one-fourth of the epidemiologic failures among privately reported syphilis patients.

IMPROVEMENT IN EPIDEMIOLOGY OF PRIMARY AND SECONDARY SYPHILIS
CLINIC CASES

PRIVATE PHYSICIAN CASES

TOTAL

The third reason for epidemiologic failures is that the patient gives a false name or a false address. This is most particularly true among private physicians' patients; and follow-up activity, after the physician has given permission to interview, often fails to locate the reported case.

In the main, however, there has been improvement in all areas of the epidemiologic process. The result has been a significant increase in the number of primary and secondary syphilis cases brought to treatment, and a resulting prevention of the spread

of syphilis from these cases. In 1955, for example, only 1,003, or 15 percent of the total reported primary and secondary cases, were brought to treatment as a result of epidemiologic activities deriving from the interview of an infected patient. In 1961, by contrast, 5,945, or 32 percent of the 18,781 cases reported, were so located. Likewise, in 1955, only 1,016 cases, or 16 percent of the total were brought to treatment as a result of serologic test follow-up. In 1961, 3,359 cases or 18 percent of the total reported, resulted from this activity.

Casefinding is difficult, time consuming, and expensive, but it is the only way thus far successfully demonstrated to break the chains of infection.

PERCENTAGE OF PRIMARY AND SECONDARY SYPHILIS CASES REPORTED IN THE UNITED STATES WHICH ARE FOUND AS A RESULT OF EPIDEMIOLOGY OR THE FOLLOW-UP OF REACTIVE TESTS

From a survey of States in the spring of 1961, it is estimated that there are approximately 31,000,000 serologic tests for syphilis performed annually in the United States. Allowing for repeat tests, this means that nine to 10 percent of the population of the United States is screened for syphilis each year. In pre-marital examinations, some 3,000,000 are screened for syphilis infection, and in pre-natal examinations, some 4,000,000. These two tests sample largely the younger population group. Approximately 50 percent of the males getting married for the first time are under age 22, and 75 percent are under age 25. Comparable ages for females are 20 and 22.

Of the 31,000,000 blood specimens processed annually, some 1,200,000 react positively. At the present time, about 70 percent of these are reported to health authorities for follow-up action. These referrals are limited largely to health departments and large charity hospitals, but they represent an increase of about 50 percent over those available for follow-up in 1958.

In New York City alone, during fiscal year 1961, the Health Department's followup of blood tests made in city hospitals produced 218 persons with infectious syphilis previously unknown to treatment. Recognizing the casefinding potential inherent in follow-up of positive blood tests from routine pre-marital, pre-natal, pre-employment, and hospital admission testing, several States and cities have taken action in recent years to promulgate laws or regulations requiring all laboratory directors to report any positive findings to health authorities. Others have begun to implement the authority already contained in their regulations to require laboratories to report. Still other States, lacking regulations, have encouraged laboratory directors to report their findings voluntarily.

In 1958, the follow-up of positive tests from routine screening yielded 1,252 cases of early infectious syphilis. In 1961, this same routine screening yielded 3,359 cases. Laboratory reporting is one of the important keys to effective casefinding. The usefulness of a strong, compulsory reporting requirement is clear. Many laboratory directors have taken the position that without a requirement in the Health Code, any reporting they do is a breach of medical ethics. Although real progress has been made in increasing the number of blood tests routinely reported by laboratories, there still are an estimated 350,000 positive blood tests processed yearly that are not reported to the health department. If such a source of intelligence about occurring cases continues to go untapped, health authorities will never stop the spread of syphilis.

Reporting

In the era of treatment in hospitals and Rapid Treatment Centers, the majority of known cases of syphilis were referred to health authorities for treatment and such epidemiologic services as were available. Little attempt was made to provide special epidemiologic service to the private physician. It was assumed - and with some logic that inexpensive, easy-to-get penicillin would eliminate the hazard of syphilis to the public's health in a very short time, and that both clinic patients and those of private physicians would secure the advantages of the miracle drug. As late as 1955, although private physicians reported almost 3,000 primary and secondary syphilis cases, fewer than 10 percent of these were interviewed by trained venereal disease control workers. Venereal disease control personnel were concentrating their energies on clinic cases and their contacts since this large group was the known priority target. Many of the privately treated cases were free to spread their infection. The leveling-off of reported cases of syphilis, however, in the 1955-1958 period suggested that without

positive action to bring private physicians into the control effort as responsible partners, syphilis would remain a serious hazard to the health of the public.

Seminars were organized for the private physicians, giving them an opportunity to discuss syphilis management problems with specialists in the field and to update their knowledge of the State and local venereal disease control programs; a program of checking on laboratory reports and following through to get infected persons to treatment was instituted and reported in the various seminars; attempts were made to call on physicians in areas having sufficient personnel resources to permit personal visits; and physicians were given material on the treatment, diagnosis, and management of syphilis.

Even though these efforts were meager in terms of the total problem, they produced positive results. In the period 1959-1961, the number of physicians who reported primary or secondary syphilis to the health departments increased by 60 percent to a total of 3,500 physicians reporting one or more cases. At present, it is estimated that physicians are reporting slightly more than one-half of the cases they diagnose and treat compared to about 25 percent in the period 1955-1958. Physicians are required by law, in all States, to report their cases. That they do not can in part be attributed to the failure of health authorities to impress upon them the importance of so doing.

Programs-local, state, federal

In venereal disease control, as in other public health programs, the role of the Federal Government has been to assist State and local areas financially and with technical skills. In recent years, a pattern has become established. State and local funds are used primarily to provide the basic physical and service framework for venereal disease control, such as diagnostic and treatment services, including laboratories. In the main, Federal funds support casefinding activities. These funds are made available through cash grants directed at specific problems that are considered by State or local health officers to be beyond local resources and through the assignment of trained and experienced venereal disease control workers for specified periods of time.

For the past two years, Federal support to local programs has been concentrated in finding and treating infectious syphilis to the extent possible with currently available resources. Other control activities have had to be curtailed to provide the needed manpower to handle the increasing infectious syphilis case load.

Per capita expenditures for venereal disease control activities by source of funds from 1950 through 1961 are as follows:

On examining the trend of venereal disease control expenditures during the past decade, it will be noted that on a per capita basis the modest increases in Federal funds for venereal disease from 1957 onward have not been sufficient to offset rising costs and population increases and have remained at a dead level of three cents per capita for five years. Administration of support, however, through the highly flexible projectgrant process has permitted shift of funds to pin-pointed areas of need, either geographic