Syphilis Resurgence in Belgrade, Serbia, in the New Millennium: An Outbreak in 2014

OBJECTIVE

A worldwide syphilis incidence increase was recorded at the beginning of the new millennium, occurring primarily among men who have sex with men (MSM). The aim of this study was to analyse the epidemiological situation of syphilis in the Belgrade population between 2005 and 2014 and to examine the characteristics of an early syphilis outbreak among MSM in Belgrade in 2014.

METHOD

Reporting of syphilis is compulsory in Serbia. Routinely reported data were analysed along with data collected from patients' charts.

RESULTS

During the period observed, syphilis incidence increased from 1.07 per 100,000 in 2005 to 4.1 per 100,000 in 2014 (383.2%). From 2005 to 2009, syphilis rates in Belgrade were low, around 1 case per 100,000 people. The first outbreak was registered in 2010. The new incidence increase happened in 2012, and again in 2014 when it was the highest. These incidence changes were registered mainly in men, where the frequency of syphilis was much higher than in women. In 2014, primary syphilis was diagnosed in 20 cases, secondary syphilis in 42, and early latent syphilis in 9 patients. Fifty-seven were MSM, 10 were heterosexual men and 4 were women. Twenty-four cases, all MSM were co-infected with HIV. Majority of patients acquired infection in Belgrade, while in 42/71 cases oral sex was the only risk factor. In comparison with HIV negative, HIV positive syphilis patients were older, more frequently unemployed and MSM. They also more frequently had sex with unknown partners and were diagnosed in the secondary stage of infection.

CONCLUSIONS

Study results underline the need for coordinated and expeditious surveillance, partner services, enhanced screening of population at risk, health education, as well as early diagnosis and treatment.

Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations

Syphilis is an ancient disease that has re-emerged in the last decade. It is prevalent among men who have sex with men and has increased in incidence with certain ethnic groups. It usually presents as primary or secondary syphilis and can progress to tertiary syphilis if not treated. Primary syphilis will classically manifest as a single, painless ulcer with smooth, clean, and raised borders on the genitals or less often on the oral mucosa. Unusual primary syphilis cases have been reported and can be easily misdiagnosed with a resulting delay of treatment. Secondary syphilis is a systemic disease, wherein the treponemes have disseminated to various organ systems, typically presenting with characteristic mucocutaneous lesions. Tertiary syphilis has a higher rate of morbidity and mortality; as such, the aim of this article is to provide the readers with tools to recognize early syphilis and prevent its progression to late stages. In this review, we present a likely case of unusual primary syphilis mimicking herpes progenitalis as well as a compilation of all atypical cases of primary syphilis from 1973 to 2015. We will also review the differential diagnosis, management, and recommendations for each stage of syphilis.

An estimate of syphilis incidence in Eastern Europe

Aim

Eastern Europe experienced epidemic levels of syphilis after the collapse of the Soviet Union. Presently data are less comprehensive outside the European Union (EU) and European Free Trade Association (EFTA). This review aims to identify published papers with suitable data to estimate a regional burden of disease for syphilis in the 19 member countries of Eastern Europe.

Methods

A systematic literature review was conducted to identify published data relating to syphilis incidence in Eastern Europe through Web of Knowledge, PubMed and Google Scholar databases in addition to the latest surveillance report from the European Center for Disease Prevention and Control. A total of 381 papers fitted our search criteria; 30 papers were subjected to full text analysis.

Results

Seven papers were included in this study and provided useable data for 13 out of 19 member countries. There was a high level of heterogeneity observed in the incidence rates from the member countries. Gross, population weighted and geographically subdivided incidence rate estimates were carried out but the comprehensiveness of some of the included data is doubtful.

Conclusions

Despite the limits of the data, the incidence of syphilis in Eastern Europe is still substantially larger than that observed in the EU15 countries. This indicates that efforts to control syphilis in Eastern Europe can be enhanced; however, such goals would require significant investment in infrastructure, technology and surveillance mechanisms.