BETWEEN COVID-19, the flu and the respiratory syncytial virus, GPs now have to monitor the time with their patients at risk, as the number of syphilis continues to rise in vulnerable communities, which makes them ask for a increased detection in these groups.
According to the National Communicable Disease Surveillance Report from May 30 to June 12, 2022, there is an “ongoing outbreak” in men who have sex with men (MSM), predominantly between the ages of 20 and 39, in the areas urban, in old women. From 20 to 39 years (both Aboriginal and Torres Strait Islanders and non-Indigenous) in urban areas, and Aboriginal and Islanders from Torres Strait in northern and central Australia.
“This is a very important 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 a professor of public health at Monash University.
Syphilis is a sexually transmitted bacterial infection caused by Treponema pallidum. There are four stages: primary, secondary, latent, and tertiary.
Primary syphilis occurs 2 to 4 weeks after infection as a painless sore at the site of infection and can often go unnoticed, depending on where it develops. Without treatment, the sores will resolve on their own, but the patient remains infectious. Secondary syphilis can appear 7 to 10 weeks after infection. Symptoms include rash, fever, enlarged glands, sore throat, hair loss, weight loss, headaches, mouth, nose or genital ulcers, and neurological symptoms. Latent syphilis is asymptomatic and can only be detected by a blood test: it is infectious 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 of syphilis remains intramuscular penicillin, which remains highly effective against T. pallidum.
What is causing the increase?
“It’s a very good question,” Professor Fairley said.
“If you have adequate access to health care and a population that presents when you have symptoms, you will get proper control.
“What drives the increased incidence of syphilis in MSM is complicated, but it relates in part to society’s stigma against them. The stigma drives them away in a corner and tells them, you know what, really I don’t respect your relationships.
“When you put stigma on people, they increase their risk behaviors: more drug use, for example, and more sexual partners. They also don’t like access to health care because of the stigma they feel.”
In addition, Professor Fairley told InSight +, the current challenges in accessing general health care are either through waiting times, lack of manpower or rising costs.
“The shortage of GPs, the cost of going to GPs, the fact that sexual health services are in place, all of these things make it harder for people to have access to health care.
“And quick access to healthcare is vital in the context of syphilis, because it means that instead of being infectious for 3 months or 6 months, it is infectious for 6 days. It is much harder to transmit if it is only infectious for 6 days instead of 6 months. “
Any routine HIV test on MSM was an opportunity to test for syphilis, he said.
“When you’re going to get tested for HIV, you have to get tested for syphilis. People know about getting tested for HIV, but they don’t really know about getting tested for syphilis; both should pass.
“HIV and syphilis have similar risks, and both must be tested at the same time.
“We know that if you increase the tests, you shorten the duration of the infection, which means you improve control.”
The increase in syphilis in women of reproductive age is especially worrying, Professor Fairley said. Syphilis during pregnancy can transmit the infection vertically, leading to congenital syphilis, and is associated with “severe perinatal consequences” such as premature birth, intrauterine growth restriction, miscarriage, stillbirth, and perinatal death.
In July 2022, McKenzie and colleagues recommended that prenatal tests for syphilis be increased to three tests.
“Australian guidelines for sexually transmitted infections advise routine syphilis testing on the first prenatal visit,” they wrote.
“A test is recommended in the early third quarter based on local guidelines. As syphilis rates rise in many parts of Australia, other jurisdictions should consider adopting additional routine syphilis screenings for all pregnant women “.
Professor Fairley agreed.
“What stops congenital syphilis in women is proper prenatal testing,” she told InSight +. “There are moves to test pregnant women more often, not just once, but three times during pregnancy.”
In the aboriginal and island communities of the Torres Strait, the increase in syphilis could be attributed to the lack of access to health care, but also to the growing resistance of T. pallidum to another antibiotic of common use, Professor Fairley said.
“Azithromycin was commonly used in indigenous populations to treat chlamydia, gonorrhea and other things, and incidentally probably made syphilis non-infectious.
“But syphilis has become resistant to azithromycin. So the use of antibiotic funds for other STIs no longer works for syphilis,” he said.
Professor Basil Donovan, head of the Sexual Health Program at UNSW Sydney’s Kirby Institute, told InSight + that “health system errors” were responsible for the rise in syphilis in Aboriginal communities and insulars of the Torres Strait.
“They just don’t get tested often enough. Their sexual behavior isn’t particularly unusual, just that they don’t have access to health services. We’re trying to get those health services tested more often.”
Screen, screen, screen
The answer, Professor Fairley said, was to examine patients from vulnerable populations as often as possible.
“If your patient is at risk of acquiring syphilis, if he is young and sexually active, if he is a man who has sex with men, or a woman who is a partner of a man who has sex with men or a transgender woman, syphilis test, ”he said.
“Any neurological symptoms [in those patient groups] it can be syphilis: balance problems, weakness, facial fall, noise in the ears, funny visual things; anything can be syphilis.
“Try them.”
Professor Donovan agreed.
“In an ideal world, I would encourage young Aboriginal people to take the test,” he said. “But we need to equip health services with resources to do these tests.
“In the case of gay men, if you get tested for HIV, it’s almost criminal not to get tested for syphilis. And yes, we need multiple tests during pregnancy.
“We have to try as hard as we can.”
The MJA today published a report of a case of neurosyphilis with multiple cranial neuropathies in an 65-year-old immunocompetent man.
Subscribe to the free weekly InSight + newsletter here. It is available to all readers, not just registered doctors.