Syphilis resurgence in Dublin, Ireland

Linear trends over 20 years in sexually transmitted infections among patients attending a tertiary care centre in north Kerala, India

BACKGROUND

Worldwide, a declining trend is observed in sexually transmitted infections of bacterial origin which is reflected as a rise in the proportion of viral sexually transmitted infections.

AIMS

To find out the clinical referral patterns of sexually transmitted infections among patients who attended the sexually transmitted infection clinic attached to Dermatology and Venereology Department of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and to study the linear trends in the pattern of sexually transmitted infections over 20 years.

METHODS

After clearance from the institutional ethics committee, a retrospective study was conducted among patients who attended the sexually transmitted infection clinic of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and were diagnosed to have sexually transmitted infections.

RESULTS

During the 20 year study period 5227 patients, attended the sexually transmitted infection clinic of our institution. Diagnosis of sexually transmitted infection was made in 2470 (47.3%) cases. Predominant sexually transmitted infections were herpes genitalis (964, 39%), condyloma acuminata (921, 37.9%) and syphilis (418, 17.2%). Viral sexually transmitted infections (1885, 76.3%) outnumbered bacterial sexually transmitted infections (575, 23.3%). A declining trend was noted for both bacterial and viral sexually transmitted infections over the 20 year period, which was more marked for the former. But the latter years of the study documented a rising trend in total sexually transmitted infections including bacterial sexually transmitted infections.

LIMITATIONS

The study does not reflect the status of sexually transmitted infections in the general population since it was conducted in a tertiary referral center.

CONCLUSION

The disturbing ascending trend recorded in sexually transmitted infections including syphilis during the final years of the 20-year period needs to be watched closely, to plan future strategies.

Syphilis in the era of re-emergence: A 6-year retrospective study from a tertiary care center in South India

Background

During the last several years, we have observed a rise in the number of patients with syphilis in our center.

Aims

To find out the trends in the presentation of syphilis to our clinic over a 6-year period and to analyze the clinicoepidemiological features of those patients.

Settings and Design

A retrospective chart review.

Subjects and Methods

We analyzed the case records of all cases of syphilis registered in our sexually transmitted infection (STI) clinic from October 1, 2012, to September 30, 2018. Syphilis was diagnosed based on clinical or serological evidence. We also evaluated these patients for any concomitant STI, including hepatitis B, hepatitis C, and HIV.

Statistical Analysis Used

The data were analyzed using SPSS software (version 20). Chi-square test was done for comparing categorical data, and P < 0.05 was considered statistically significant.

Results

During the study period, 215 patients with STI attended our clinic. Of these, 66 (31%) patients had acquired syphilis. Among them, 3 (4.5%) had primary syphilis, 23 (34.8%) had secondary syphilis, and 40 (60.6%) had latent syphilis. Fifteen (22.7%) patients had concomitant HIV infection. A statistically significant rise in the number of cases of syphilis compared with other STIs was noted in the latter half of the study period (P = 0.001). Among the 50 males with acquired syphilis, 29 (58%) were men having sex with men (MSM), including 19 bisexual persons. Among the five antenatal cases, two were detected very late in pregnancy.

Conclusions

We observed a marked increase in the number of cases of syphilis during the latter half of the study period. Primary and secondary syphilis were more frequent among MSM, suggesting a need to strengthen targeted intervention programs among them. More rigorous antenatal screening is necessary to prevent congenital syphilis.

Acquired syphilis in children: A retrospective study over two-and-a-half decades in a tertiary care center in northern India

BACKGROUND

Syphilis causes considerable morbidity not only in adults but also in children. Unfortunately, acquired syphilis in children has not received due attention and remains a relatively ignored field.

METHODS

This was a retrospective study, in which epidemiologic, clinical, and investigational data were analyzed from medical records of all sexually transmitted infection (STI) cases attending the STI clinic of Pt. B. D. Sharma, PGIMS, Rohtak from January 1992 to November 2018. Children of age ≤14 years with acquired syphilis were studied.

RESULTS

Of 9138 STD cases registered from January 1992 to November 2018, 39 were children with acquired syphilis, of whom 22 were males and 17 were females. The majority were in 12-14 years age group (22 cases; 56.41%). A history of sexual abuse could be elicited in 10 patients. Three gave a history of voluntary sexual activity. Examination revealed secondary syphilis in 32, latent syphilis in 6 and only one case of primary chancre. Analysis of incidence of pediatric acquired syphilis cases over three-year intervals during the last 27 years indicated an initial decreasing trend followed by recent slight rise in last 3 years.

CONCLUSION

Social inhibitions and reluctance to report child sexual abuse may have led to an underestimate of actual prevalence. The prevalence in the 12- to 14-year age group may indicate emerging trends of promiscuous sexual behavior. The recent rising trend in occurrence of childhood acquired syphilis may mirror the recent resurgence of adult syphilis.

Prevalence of syphilis among female sex workers and their clients in Togo in 2011

BACKGROUND

During the last ten years, a resurgence of syphilis has occurred in many countries worldwide, including Togo. Previous studies have shown a wide range of syphilis infection among the female sex workers (FSWs), from 1.5 to 42.1%. In Togo, Key populations, including FSWs, are rarely involved in the sentinel surveillance programs to determine the prevalence of HIV and syphilis. The aim of this study was to determine the prevalence of syphilis among female sex workers (FSWs) and their clients in Togo.

METHODS

We conducted a cross-sectional study in December 2011 targeting FSWs and their clients in Togo. Among participant who consented, we collected blood samples for syphilis and HIV testing.

RESULTS

In total, 1,836 participants (1,106 FSWs and 730 clients) were included in the survey. Their mean age was 28.6 ± 9 years. The prevalence of syphilis was 2.2% (2.2% among FSWs compare to 2.3% among their clients, p = 0.82). This prevalence was higher among FSWs over 30 years old compare to those less than 30 years old (Odd Ratio (OR) =5.03; 95% CI [1.95-13.49]). Single FSWs were three times less likely to have syphilis than those living in couple or married (OR = 3.11; CI 95% [1.16-8.83]). Brothel based or declared FSWs were 4 times more likely to be infected by syphilis than secret ones (OR = 3.89; CI 95% [1.60-9.54]). Out of the 1,836 participants of the survey, 165 (8.9%) were HIV positive. Having syphilis was associated with HIV infection (OR = 3.41; IC 95% [1.53-7.41]).

CONCLUSION

This study showed that: i) the prevalence of syphilis among FSWs and their clients was high; ii) syphilis was significantly associated with HIV infection. It is necessary to increase awareness campaigns and emphasize on condom use among this key population group.

Macrolide Resistance in Treponema pallidum Correlates With 23S rDNA Mutations in Recently Isolated Clinical Strains

BACKGROUND

High rates of 23S rDNA mutations implicated in macrolide resistance have been identified in Treponema pallidum samples from syphilis patients in many countries. Nonetheless, some clinicians have been reluctant to abandon azithromycin as a treatment for syphilis, citing the lack of a causal association between these mutations and clinical evidence of drug resistance. Although azithromycin resistance has been demonstrated in vivo for the historical Street 14 strain, no recent T. pallidum isolates have been tested. We used the well-established rabbit model of syphilis to determine the in vivo efficacy of azithromycin against 23S rDNA mutant strains collected in 2004 to 2005 from patients with syphilis in Seattle, Wash.

METHODS

Groups of 9 rabbits were each infected with a strain containing 23S rDNA mutation A2058G (strains UW074B, UW189B, UW391B) or A2059G (strains UW228B, UW254B, and UW330B), or with 1 wild type strain (Chicago, Bal 3, and Mexico A). After documentation of infection, 3 animals per strain were treated with azithromycin, 3 were treated with benzathine penicillin G, and 3 served as untreated control groups. Treatment efficacy was documented by darkfield microscopic evidence of T. pallidum, serological response, and rabbit infectivity test.

RESULTS

Azithromycin uniformly failed to cure rabbits infected with strains harboring either 23S rDNA mutation, although benzathine penicillin G was effective. Infections caused by wild type strains were successfully treated by either azithromycin or benzathine penicillin G.

CONCLUSIONS

A macrolide resistant phenotype was demonstrated for all strains harboring a 23S rDNA mutation, demonstrating that either A2058G or A2059G mutation confers in vivo drug resistance.

Diagnostic pitfalls in pathological diagnosis of infectious disease: patients with syphilitic lymphadenitis often present with inconspicuous history of infection

Retrospective study was applied to 16 cases of syphilitic lymphadenitis to elucidate the pathological diagnostic features. The typical morphology of syphilitic lymphadenitis includes: (i) well preserved or partially destroyed lymph node structure; (ii) reactive hyperplasia of lymph follicles with broadened germinal centers in the cortex and medulla of the lymph node; (iii) thickened fibrotic lymph node capsules with infiltration of plasma cells; and (iv) phlebitis and endarteritis in varying degree. Additional morphology includes: (i) focal histiocytes with ingested debris; (ii) noncaseating granuloma with epithelioid histiocytes and disperse giant cells; and (iii) hyperplastic centroblast and occasionally isolated mononuclear Reed-Sternberg cell-like giant cells. Treponema pallidum was identified in 15 of the 16 cases by immunohistochemical staining. The histopathological diagnosis of syphilitic lymphadenitis poses difficulty in differentiation from other infectious or neoplastic lymphadenopathies. The newly established Treponema pallidum antibody is sensitive to identification of Treponema pallidum in formalin fixed paraffin embedded tissue.

Syphilis Experiences and Risk Perceptions Among Repeatedly Infected Men Who Have Sex with Men

CONTEXT

In urban areas of the United States, syphilis is a major public health issue for men who have sex with men, despite widespread efforts to curtail a growing epidemic; repeated infections are not uncommon in this population. The ways that men who have sex with men experience and conceptualize syphilis, and how their attitudes and beliefs impact their risk for infection, are poorly understood.

METHODS

In-depth interviews were conducted in 2010-2011 with 19 Los Angeles County men aged 21-54 who reported having male sex partners and had had two or more early syphilis infections within the previous five years. Interview transcripts were analyzed inductively to uncover themes.

RESULTS

Participants had considerable knowledge about syphilis symptoms, transmission and consequences, and most felt that syphilis was a highly stigmatized disease. They had had 2-5 infections in the past five years, and the majority believed they were at risk for another infection because of their sexual risk behaviors. Many had a sense of fatalism about being infected again, and some expressed that this possibility was an acceptable part of being sexually active. Concern about syphilis often decreased as men experienced more infections. Most participants reported short-term sexual behavior changes after a syphilis diagnosis to prevent transmission; however, few were willing to make long-term behavior changes.

CONCLUSIONS

Additional qualitative studies of men who have sex with men should be conducted to better understand the continuing syphilis epidemic and to help identify the most promising intervention strategies.

Clinical and epidemiological characteristics of patients with early syphilis from three academic centres in Poland, Germany and Ireland: initial findings from the POETS study

OBJECTIVES

Syphilis recognition in HIV-positive patients has important implications. Initial data from this study, established in June 2012 to better understand the natural history of syphilis and treatment response, examine the characteristics of patients including sexual behaviour, rates of concurrent sexually transmitted infections (STI) and type of treatment given.

METHODS

Patients were recruited from Ireland, Poland and Germany. Data gathered included demographics, method of syphilis acquisition, stage of syphilis infection, HIV status, nadir and current CD4 counts and HIV viral suppression rates. Data were then subanalysed into HIV-positive and HIV-negative groups.

RESULTS

Of 175 patients recruited, 68% were HIV-positive and 86.3% were men who have sex with men. Most HIV-positive patients presented with secondary syphilis (55.7% vs 13.2%) (p=0.0001) while the majority of HIV-negative patients had primary syphilis noted at the time of recruitment (47.2% vs18.9%, p=0.0002). Approximately half of all patients had a HIV RNA viral load <40 copies/mL (55%). Previous syphilis infection occurred more frequently in HIV-positive than HIV-negative patients (p=0.0001). Concurrent STIs at the time of syphilis diagnosis were found in 26.8%, of whom 31 (25.4%) were HIV-positive (p=0.64). HIV-positive patients received doxycycline more frequently than their HIV-negative counterparts (33.6% vs 1.9%, p=0.0001) while HIV-negative patients were treated with long-acting penicillin in 88.7% of cases vs 58% of HIV-positive patients (p=0.0002).

CONCLUSIONS

A 40% rate of unsuppressed viraemia, high levels of STIs and varying treatment regimens represent a public health risk for Europe, suggesting the model of sexual healthcare delivery in HIV-positive patients requires further evaluation.

Acceptable interventions to reduce syphilis transmission among high-risk men who have sex with men in Los Angeles

OBJECTIVES

We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).

METHODS

Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.

RESULTS

Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents' beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.

CONCLUSIONS

Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.

Cost-effectiveness of enhanced syphilis screening among HIV-positive men who have sex with men: a microsimulation model

BACKGROUND

Syphilis co-infection risk has increased substantially among HIV-infected men who have sex with men (MSM). Frequent screening for syphilis and treatment of men who test positive might be a practical means of controlling the risk of infection and disease sequelae in this population.

PURPOSE

We evaluated the cost-effectiveness of strategies that increased the frequency and population coverage of syphilis screening in HIV-infected MSM receiving HIV care, relative to current standard of care.

METHODS

We developed a state-transition microsimulation model of syphilis natural history and medical care in HIV-infected MSM receiving care for HIV. We performed Monte Carlo simulations using input data derived from a large observational cohort in Ontario, Canada, and from published biomedical literature. Simulations compared usual care (57% of the population screened annually) to different combinations of more frequent (3- or 6-monthly) screening and higher coverage (100% screened). We estimated expected disease-specific outcomes, quality-adjusted survival, costs, and cost-effectiveness associated with each strategy from the perspective of a public health care payer.

RESULTS

Usual care was more costly and less effective than strategies with more frequent or higher coverage screening. Higher coverage strategies (with screening frequency of 3 or 6 months) were expected to be cost-effective based on usually cited willingness-to-pay thresholds. These findings were robust in the face of probabilistic sensitivity analyses, alternate cost-effectiveness thresholds, and alternate assumptions about duration of risk, program characteristics, and management of underlying HIV.

CONCLUSIONS

We project that higher coverage and more frequent syphilis screening of HIV-infected MSM would be a highly cost-effective health intervention, with many potentially viable screening strategies projected to both save costs and improve health when compared to usual care. The baseline requirement for regular blood testing in this group (i.e., for viral load monitoring) makes intensification of syphilis screening appear readily practicable.

Prevalence and Incidence of Syphilis among Volunteer Blood Donors in Israel

Data of 1,290,222 volunteer blood donors, in a 5-year period, was analyzed for prevalence and incidence of syphilis. Subsequent testing of donations positive in Treponema pallidum hemagglutination assay included Venereal Disease Research Laboratory and fluorescent Treponemal antibody absorption. Stepwise logistic regression model was used to identify positive syphilis serology. Prevalence of syphilis was 47 : 100,000, similar in men and women and increased significantly with age (P < 0.001). Native Israelis had the lowest prevalence rate of syphilis (21 : 100,000), while a significantly higher prevalence was found among immigrants from Africa, Eastern Europe, and South America (odds ratios of 19.0, 10.8, and 7.3, resp., P < 0.001 for each). About 33.2% of the seropositive donors had evidence of recent infection, and 66.8% had past infections. Incidence rate reached 8 : 100,000 person-years. Coinfection with HIV, HCV, and HBV was calculated as 8%, 1.88%, and 0.37% for positive donations, respectively. The data support the need to continue screening blood donors in Israel for syphilis and employ preventive measures to populations at risk, in order to improve public health, blood safety, and quality. A subsequent study to assess blood donors' knowledge, attitude, and behavior is planned. In times of global migration this information may be useful to blood services worldwide.

High syphilis but low HIV prevalence rates among pregnant women in New Caledonia

Sexually transmitted infections have been described as one of the major health problems in several countries of the Pacific Region. The objective of the study was to estimate the prevalence of pregnant women infected with HIV and/or syphilis in New Caledonia. HIV and syphilis test results were obtained from women attending antenatal clinics. From 2008 to 2011, 3353 pregnant women were tested with a mean prevalence of active syphilis found at 5.6/100,000. No pregnant women tested positive for HIV. Despite available resources and public health strategies similar to those existing in France, active syphilis prevalence is high in New Caledonia. Surprisingly, HIV seroprevalence remains far below the figures reported in mainland countries. However, social and economic changes as well as the looming referendum on independence scheduled in 2014 may have a potential negative impact on public health resources. The need for action to control syphilis and other curable sexually transmitted infections is pressing in order to prevent further spread of HIV in New Caledonia.

Comparison of risk factors for prevalent sexually transmitted infections based on attendees at two genitourinary medicine clinics in Ireland

Little has changed in sexually transmitted infection (STI) epidemiology in Ireland since 2000. Three STIs comprise approximately 90% of notifications; ano-genital warts, Chlamydia trachomatis and non-specific urethritis. Our objective was to compare the risk factors for prevalent STIs in attendees at two genitourinary medicine clinics and examine the incidence of coinfection. Diagnostic, demographic and behavioural information on attendees at two clinics in southwest Ireland were collected from January 1999 to July 2009. Risk factors associated with first episodes of ano-genital warts, genital herpes simplex viral infection, non-specific urethritis and C. trachomatis were investigated. In all, 22,705 STI patients (mean age 27 years) received 26,824 diagnoses; 1628 had more than one infection. Ano-genital warts was most likely to be diagnosed with a coinfection. Having multiple partners was positively associated with a diagnosis of bacterial infection but not viral infection. Our large cohort outlines those at risk in the region, showing age and gender influences the risk and type of infection. Smoking, alcohol and drug use is also common, all regarded as markers of risk-taking behaviour. The younger the age, the higher the risk of acquiring infection, regardless of infection type. Prevention strategies that target youth, bacterial STIs and high-risk behaviour, including sexual, alcohol and drugs, may be effective in reducing STI incidence in Ireland.

Clinical Spectrum of Oral Secondary Syphilis in HIV-Infected Patients

Background. Oral lesions may constitute the first clinical manifestation in secondary syphilis, but detailed descriptions in HIV-infected individuals are scarce. Objective. To describe the clinical characteristics of oral secondary syphilis in HIV-infected patients and its relevance in the early diagnosis of syphilis. Methods. Twenty HIV/AIDS adult subjects with oral secondary syphilis lesions presenting at two HIV/AIDS referral centers in Mexico City (2003–2011) are described. An oral examination was performed by specialists in oral pathology and medicine; when possible, a punch biopsy was done, and Warthin-Starry stain and immunohistochemistry were completed. Intraoral herpes virus infection and erythematous candidosis were ruled out by cytological analysis. Diagnosis of oral syphilis was confirmed with positive nontreponemal test (VDRL), and, if possible, fluorescent treponemal antibody test. Results. Twenty male patients (median age 31.5, 21–59 years) with oral secondary syphilis lesions were included. Oral lesions were the first clinical sign of syphilis in 16 (80%) cases. Mucous patch was the most common oral manifestation (17, 85.5%), followed by shallow ulcers (2, 10%) and macular lesions (1, 5%). Conclusions. Due to the recent rise in HIV-syphilis coinfection, dental and medical practitioners should consider secondary syphilis in the differential diagnosis of oral lesions, particularly in HIV-infected patients.