What is the issue?
Notifications for infectious syphilis (defined as infection less than two years duration including primary, secondary and early latent presentations) reached a record high in 2018. A total of 1,372 cases of infectious syphilis were notified in Victoria, compared to 1,351 cases in 2017 and 1,134 cases in 2016. The majority of notified cases continue to occur in males with 73 per cent of males reporting male sexual partners as the source of infection. Thirty per cent of the cases among MSM were HIV positive and of these, 57 per cent were reinfections.
There has been an increase of notified syphilis cases among women over the last few years. In 2018, 163 cases were notified (representing 12 per cent of total cases). There were 152 cases in 2017 (11 per cent of total cases) and 101 in 2016 (9 per cent of total cases). The increase of syphilis in women of reproductive age is of particular public health concern as syphilis during pregnancy can cause congenital syphilis which may result in serious birth defects and stillbirth.
For the first time since 2004, congenital syphilis has re-emerged in Victoria, with two cases notified in 2017 and two cases in 2018. Two cases have resulted in fetal death. Women may be unaware of their risk of syphilis.
Screening at-risk groups, including antenatal screening, and adequate timely treatment of cases and sexual partners are crucial for the prevention of syphilis infections.
Who is at risk?
The following groups are at increased risk of syphilis infection:
- Female partners of MSM.
- People with the following risk factors: multiple sexual partners, travelers returning from countries where syphilis is more prevalent and people who inject drugs.
- Men who have sex with men (MSM).
- Aboriginal and Torres Strait Islander people.
- Sex workers.
- Anyone diagnosed with an STI other than syphilis.
All pregnant women should have syphilis screening performed at their first antenatal visit. Additional screening during pregnancy should be done for women in at-risk groups.
Symptoms and transmission
Syphilis can be transmitted through unprotected vaginal, anal and oral sex. Condoms greatly reduce the risk of sexual transmission. It can also be spread through skin-to-skin contact if the syphilis rash is present.
Transplacental infection of the fetus can occur during pregnancy. It occurs with high frequency in untreated primary and secondary syphilis infection in pregnant women, and with lower frequency in later stages of the disease (e.g. latent syphilis). Transmission can also occur from mother to child during birth.
The incubation period can range from 10 days to three months and is usually three weeks. A case is considered infectious until the end of the early latent period, which is approximately two years after infection if untreated.
Syphilis is often asymptomatic making screening a crucial element in detection and control of syphilis.
Testing and Screening
Test all patients presenting with symptoms consistent with syphilis infection (i.e. any genital skin or mucous membrane lesion or an unexplained rash).
Notify all cases to the Department of Health and Human Services within five days of diagnosis.
- Screen all pregnant women for syphilis, other STIs and BBVs at the first antenatal visit.
- Repeat screening for pregnant women with risk factors at 28-32 weeks and at delivery. Risk factors include: women with multiple sexual partners, female sexual partners of MSM, women who inject drugs, women of Aboriginal and Torres Strait Islander origin, women with overseas sexual contacts where syphilis is more prevalent. Sex workers may also be at greater risk if they are not having regular STI testing.
- Screen heterosexual men and women with risk factors: multiple sexual partners, travellers returning from countries where syphilis is more prevalent and people who inject drugs, sex workers.
- Screen all other groups at risk:
- Screen all MSM for syphilis at least annually with blood tests for syphilis; Screen MSM more often (e.g. every 3 months) if one or more of the following applies: any unprotected anal sex, more than 10 sexual partners in the last 6 months, participation in group sex, use of recreational drugs during sex.
- HIV positive MSM should have a syphilis test every time (an opt-out strategy) they have blood tests for routine HIV monitoring. HIV positive MSM and HIV positive bisexual men should also have regular screening for other STIs including gonorrhoea and blood borne viruses (BBVs).
- Screen bisexual men for syphilis and other STIs.
- Screen all people on PrEP in three monthly intervals and counsel them on combination prevention methods.
Treatment of cases and contacts
- Treat all cases of syphilis in accordance with the current guidelines.
- Refer pregnant women for specialist advice and treatment.
- Correct antibiotic choice, dosage and duration are required to ensure syphilis is cured and complications prevented. Use long acting intramuscular penicillin formulations (benzathine penicillin). Do not use short acting formulations (e.g. benzyl penicillin) as they are ineffective.
- Test and treat all sexual contacts of syphilis cases without waiting for test results. Immediate treatment of contacts prevents re-infection of the index case and further transmission.
- Advise no sexual contact for seven days after treatment is administered to both the case and contacts.
- Ensure that all possible attempts are made to contact sexual partners of cases with syphilis at the time of diagnosis.
- Innovative partner notification tools are available to contact partners anonymously via SMS or email. Undertake partner notification at the time of consultation or strongly encourage your patients to contact their partners themselves. Partner notification tools are available at:
- The partner notification officers (PNOs) from the department are available to assist. The PNOs can contact the sexual partners of a person diagnosed with an STI, provide advice and referral to testing. Any identifying information about your patients is kept confidential. The PNOs can be contacted on 9096 3367 or via email at firstname.lastname@example.org
- Advise patients to practice safe sex.
- Provide advice regarding prevention strategies, early symptom recognition and periodic screening for groups at risk. Advise that syphilis can be transmitted through unprotected oral and anal sex. Emphasise that safe sex practices (i.e. condom use) greatly reduce the risk of transmission.
- Counsel PrEP recipients on prevention combination methods (PrEP and condom use, undetectable HIV viral loads) and regular screening for STIs.