Syphilis on the rise: dial up screening and "test it away" - InSight+

BETWEEN COVID-19, influenza, and respiratory viruses, doctors must now keep tabs on their patients at risk as the number of syphilis continues to rise in vulnerable communities, leading to calls for increased screening in those groups.

According to National Infectious Disease Surveillance Report From 30 May to 12 June 2022, there was a “continuous epidemic” occurring in men who have sex with men (MSM), mainly aged 20–39 years, in urban areas, in women aged 20–39 years (both Aboriginal and Population). Torres Strait Islander and non-Indigenous) in urban areas, and Aboriginal and Torres Strait Islander peoples in northern and central Australia.

“This is a very significant increase. Syphilis is a serious infection and we need to take it very seriously,” said Professor Christopher Fairley, Director of the Melbourne Center for Sexual Health and Professor of Public Health at Monash University.

Syphilis is a bacterial sexually transmitted infection caused by Treponema pallidum. There are four stages – primary, secondary, latent, and tertiary.

Primary syphilis appears 2-4 weeks after infection as a painless sore at the site of infection, and often goes unnoticed, depending on where it develops. Without treatment the wound will heal on its own but the patient remains infectious. Secondary syphilis can occur 7-10 weeks after infection. Symptoms include rash, fever, enlarged glands, sore throat, hair loss, weight loss, headache, ulcers in the mouth, nose or genitals, and neurological symptoms. Latent syphilis has no symptoms and can only be detected through a blood test – it is contagious for 12-24 months. Tertiary syphilis (5-20 years after infection) can damage any part of the body, including the heart, brain, spinal cord, eyes, and bones.

Treatment for syphilis remains intramuscular penicillin, which remains highly effective against T. pallidum.

What caused the increase?

“Very good question,” said Professor Fairley.

“If you have adequate access to health care and the population that emerges when they have symptoms, you will have adequate control.

“What drives the increased incidence of syphilis in MSM is complicated, but partly related to societal stigma against them. Stigma pushes them into a corner and says, you know, I don’t really respect your relationship.

“When you stigmatize people, they increase their risk-taking behavior – more drug use, for example, and more sexual partners. They also don’t like accessing health services because of the stigma they feel.”

That compounding, Professor Fairley informed InSight+is the current challenge of accessing general practice care, whether through waiting times, labor shortages, or rising costs.

“The shortage of GPs, the cost of going to the doctor, the fact that sexual health services are getting tighter – all of this makes it harder for people to get access to health care.

“And quick access to health care is very important in the context of syphilis, because it means that instead of being contagious for 3 months or 6 months, it is contagious for 6 days. It’s much harder to transmit if it’s only contagious for 6 days rather than 6 months.”

Every routine HIV test in MSM is an opportunity for a syphilis test, he said.

“When you go and get tested for HIV, you have to get tested for syphilis. People know about HIV testing, but they don’t really know about syphilis testing – both have to happen.

“HIV and syphilis carry the same risk, and both should be tested at the same time.

“We know that if you increase testing, you shorten the duration of infection, which means you increase control.”

The increase in syphilis in women of reproductive age is of great concern, Professor Fairley said. Syphilis in pregnancy can transmit infection vertically resulting in: congenital syphilisand is associated with “serious perinatal consequences” such as preterm birth, intrauterine growth restriction, miscarriage, stillbirth, and perinatal death.

In July 2022, McKenzie and colleagues recommends that antenatal tests for syphilis be increased to three tests.

“Regular syphilis testing at the first antenatal visit is recommended by the Australian sexually transmitted infection guidelines,” they wrote.

“Testing as early as the third trimester is recommended depending on local guidelines. As syphilis rates are growing in many parts of Australia, other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women.”

Professor Fairley agreed.

“What stops congenital syphilis in women is proper antenatal testing,” he said InSight+. “There is a movement to test pregnant women more often, not once but three times during pregnancy.”

In Aboriginal and Torres Strait Islander communities, the emergence of syphilis can be attributed to a lack of access to health care, but also to increased resistance to the disease. T. pallidum to other commonly used antibiotics, Professor Fairley said.

“Azithromycin is commonly used in Indigenous populations to treat chlamydia, gonorrhea and other things, and coincidentally that might make syphilis non-communicable.

“But syphilis is now becoming resistant to azithromycin. So the background to using antibiotics for other STIs doesn’t work anymore for syphilis,” he said.

Professor Basil Donovan, Head of the Sexual Health Program at the Kirby Institute at UNSW Sydney, said: InSight+ that “health system failure” is responsible for the emergence of syphilis in remote Aboriginal and Torres Strait Islander communities.

“They just aren’t tested often enough. Their sexual behavior isn’t that extraordinary, it’s just that they don’t have access to health services. We’re trying to get those healthcare services tested more often.”

Screen, screen, screen

The answer, Professor Fairley said, is to screen patients in vulnerable populations as often as possible.

“If your patients are at risk of contracting syphilis – if they are young and sexually active, if they are men who have sex with men, or women who are partners of men who have sex with men, or transgender women – test for syphilis,” he says.

“Any neurological symptoms [in those patient groups] can be syphilis – balance problems, weakness, drooping face, ringing in the ears, funny visuals – anything can be syphilis.

“Test them.”

Professor Donovan agreed.

“In an ideal world I would encourage young Aboriginal people to go and be tested,” he said. “But we have to provide resources for the health services to carry out those tests.

“In the case of gay men, if you get tested for HIV, it’s almost a crime not to get tested for syphilis either. And yes, we do need some tests during pregnancy.

“We have to test it as far as we can.”

It MJA published today case report of neurosyphilis with multiple cranial neuropathy in an immunocompetent 65-year-old man.

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