28 October 2019

Screen for syphilis in pregnancy to avert tragedy

Clinical Communicable Disease O&G Sex

GPs should be on alert for syphilis and test at-risk women twice during pregnancy as the highly infectious disease slowly makes its way south.

The outbreak began in 2011 in northern Queensland and has since spread to the Northern Territory, Western Australia and South Australia. There have been 2974 cases to date, according to the latest quarterly national surveillance report, predominantly in Aboriginal and Torres Strait Islander people.

Though NSW is not an outbreak area, an alert from NSW Health this month says notifications in the state have been increasing since 2017, and there have been two confirmed cases of congenital syphilis in non-Indigenous babies in NSW.

All pregnant women should be tested early in pregnancy, the alert says, and those at high risk – being Indigenous, having a current or recent other STI diagnosis, having a male partner who has sex with men, engaging in sex work or using drugs – should be screened again at 24 to 28 weeks.

If positive, benthazine penicillin should be given urgently.

Associate Professor Catherine O’Connor from the University of NSW’s Kirby Institute, and president of the RACP’s Australasian Chapter of Sexual Health Medicine, said the outbreak had begun in north Queensland around the same time that Campbell Newman’s government cut community health services, including STI screening in Aboriginal communities, which may have been keeping infections under control.

“It’s principally in young Indigenous people, and the research suggests that there is no actual difference in sexual behaviour from the rest of the population,” Associate Professor O’Connor told The Medical Republic.

“It’s just that the average age of Aboriginal and Torres Strait Islanders is 23 – and I would suspect in rural and remote areas it’s even lower – whereas the average age of the rest of the population is 38.

“There is [now] an increase in testing through Aboriginal Medical Services in rural and remote areas for all STIs and the Commonwealth has rolled out rapid testing kits. But there’s still a need for general practitioners to be mindful in rural communities of young Aboriginal people and provide STI screening.”

She said there was a parallel, but separate, outbreak of syphilis in men who have sex with men.

While syphilis was obviously a bad disease for an adult to get, with terrible complications if left untreated (this outbreak is too recent to include any late-stage illness), she said it was at its most destructive and tragic when passed to unborn babies.

“It’s a terrible thing if a baby gets congenital syphilis. Two-thirds of babies will either die or be severely affected.”

If a baby is treated “very proactively”, they will usually be fine.

“But sometimes the symptoms in the baby are quite subtle [for example, a runny nose due to a damaged septum], so it can take some time for the diagnosis to be made if the doctor’s not extremely vigilant.

“If it’s not treated very proactively, they can have long-term, irreversible damage to many major organs, skull structures such as the nasal septum, bone abnormalities, issues with their teeth, and severe issues with their eyes and hearing. So it’s a very destructive disease in babies unless it’s picked up while the mother is pregnant.”

So far in Australia some 16 babies had been born with syphilis and four had died, she said. In some cases the mothers had been tested once but not twice.

Professor O’Connor said syphilis was 90% likely to be passed on during a sexual contact.

Primary syphilis in women initially presents as a painless ulcer on the cervix, which can easily go unnoticed, or other genital areas. This might last three to six weeks then disappear without treatment.

The secondary stage can present as a rash and fever that can last for a few months and is followed by a latent phase. Patients might be barely symptomatic and pass it on without knowing they have it.

She said if an ulcer was found it should be PCR tested, as antibodies might not show up in a blood test until several weeks after infection.

“If there’s an ulcer that GPs are concerned about and the tests for syphilis comes back negative, they need to repeat it in a couple of weeks. The blood test will always show it at the secondary stage, it will sometimes show it in the primary stage, so they should do the blood test. But if they’ve got the option of doing a PCR on the ulcer for the syphilis antigen, they should do that as well.”