Rising syphilis rates in Canada, 2011-2020

Performance of the bioLytical Multiplex HIV 1/2 and Syphilis rapid test on serum in a laboratory evaluation for syphilis

Syphilis, a sexually transmitted infection, is resurging with large outbreaks worldwide. In pregnant females, vertical transmission can result in stillbirths and serious sequelae for the fetus. Syphilis serology is primarily used to make the diagnosis, but the testing platforms and confirmatory tests are often centralized; therefore, the time to a result is usually more than 2 days. Most affected populations in the current outbreaks can be transient and easily lost to follow up. Therefore, rapid testing can assist with timely detection, treatment, and linkage to care. We evaluated the performance of the INSTI Multiplex HIV-1/2 Syphilis rapid test, using a large panel of negative and confirmed positive sera with varying rapid plasma reagin (RPR) titers. Sera with RPR titers of 1:8 and greater consistently gave a positive rapid test result (93.8%-100%; 95% CI: 82.5%-100%), whereas samples with RPR titers of 1:2 and lower were often negative (7.6%-56.5%). Rapid test positive samples generally had a syphilis CMIA S/CO ratio of 19.78 and higher, although there was no specific ratio that separated all positive from negative rapid results. In infectious syphilis, RPR titers are often 1:8 and greater and should be reliably detected with this rapid test (accuracy 97.2%), thereby supporting immediate treatment and linkage to care with a high level of confidence. Additionally, a result is available within minutes and therefore could be included on acute care STAT laboratory test menus while the individual is an in-patient or awaiting assessment in the Emergency Department.

IMPORTANCE

We examined the performance of the syphilis antibody component of a rapid multiplex device and found that sera with RPR titers of 1:8 and greater, often found in infectious syphilis, were highly likely to test positive. This device would be suitable for providing STAT syphilis serology testing for suspect cases waiting in the Emergency Department or as inpatients. Positive results can support immediate treatment and linkage to care, especially for pregnant females and transient persons who are often lost to follow up.

Trends in Congenital Syphilis Incidence and Mortality in Brazil's Southeast Region: A Time-Series Analysis (2008-2022)

Congenital syphilis (CS) is an important infectious cause of miscarriage, stillbirth, and neonatal morbidity and mortality. Despite the advances in diagnosis and treatment, CS continues to challenge health systems with increasing incidence and mortality rates in recent years worldwide. Given this, the present study aims to comparatively analyze the temporal trends in CS incidence and mortality in Brazil's Southeast Region from 2008 to 2022. This is an ecological time-series study using secondary data on congenital syphilis from the states of Espírito Santo, Minas Gerais, Rio de Janeiro, and São Paulo. The data was extracted from the Brazilian Health System Informatics Department. Incidence and mortality rates were calculated per 100,000 live births. Joinpoint regression models were employed to identify trends in annual percentage change and average annual percentage change with 95% confidence intervals. The temporal trend of CS incidence in Brazil's Southeast Region increased 12.8% between 2008 and 2022. Minas Gerais, São Paulo, Espírito Santo, and Rio de Janeiro showed increasing temporal trends of 21.4%, 14.1%, 14.0%, and 10.9%, respectively. The temporal trend of CS mortality in Brazil's Southeast Region rose 11.9% between 2008 and 2022. Minas Gerais, São Paulo, and Rio de Janeiro exhibited increasing mortality temporal trends of 21.9%, 20.8%, and 10.1%, respectively. In contrast, Espírito Santo showed reduced mortality, with no deaths in 2021 and 2022. The temporal trend of CS incidence increased in all states of Brazil's Southeast Region between 2008 and 2022, highlighting the need to reassess control measures. The temporal trend of CS mortality also increased during the same period, except in Espírito Santo. Considering that CS is preventable with adequate prenatal care and low-cost measures, these findings can serve as instruments to support strengthening public health policies.

Syphilis renaissance: Truth or mirage. Analysis of syphilis trends and possible factors from a tertiary care centre in North India

Background Syphilis has shown a recent resurgence globally, including in India. However, inconsistency in the data and diagnostic criteria used, especially in India and developing countries, hinders ideal understanding. Factors responsible for this surge need to be explored. Objectives This study aimed to assess the trends and describe the clinicodemographic characteristics of syphilis cases seen in a tertiary care health centre from Northern India. Methods This is a retrospective chart review of syphilis patients registered in our sexually transmitted infection (STI) clinic spanning 13 years from January 2011 to December 2023. Complete demographic details, sexual history, clinical examination and laboratory investigations of all syphilis cases, including associated STIs, were retrieved. Results The retrospective analysis included 2000 records, of which 324 were confirmed syphilis cases (16.2% of total STI cases). Patients' mean age was 30.9 ± 9.9 years, of which 80.9% were male and 64.2% were married. Education level varied, with professionals comprising 22.2% of the total cohort. Premarital and extramarital exposure were present in 35.8% and 32.7% patients, respectively; over half (56.8%) reported multiple partners and 13% were homosexual. There was an initial plateau in the number of confirmed syphilis attending the clinic (2011-2019), a decrease during 2020-2021 due to COVID and significant increase from 2022 onwards. Latent syphilis was the most common (66.7%), followed by secondary (18.8%) and primary (8.9%). In all, 36.1% of syphilis patients had associated STIs, with human immunodeficiency virus (HIV) infection being the most prevalent (25.0%). Limitation Retrospective nature of the study is major limitation. Rising trend needs validation with population-based studies to establish if the rise is true or a shadow phenomenon. Conclusion A resurgence of syphilis cases has appeared in the past two years, with latent syphilis contributing to the majority of cases. Possible factors for the surge include changing sexual behaviour, including male having sex with male (MSM), early adolescent sexual exposure, increased screening for latent syphilis, increased healthcare accessibility post-COVID-19 pandemic, and HIV co-infection.

Attributes that influence testing decisions for sexually transmitted and blood-borne infections: A qualitative study among diverse people in Canada

BackgroundSexually transmitted and blood-borne infections (STBBIs) disproportionately affect key populations in Canada. For example, recent estimates suggested that the proportion of people living with hepatitis C is the highest among people who use injection drugs and that gay, bisexual and other men who have sex with men represent a high proportion of new cases of infectious syphilis. Understanding what STBBIs test users and potential testers perceive as important aspects of testing will help inform testing initiatives. We aimed to determine aspects of STBBI testing that are important to a diverse range of key populations in Canada.MethodsWe conducted qualitative interviews and focus groups with people from key populations (gay, bisexual, and other men who have sex with men; African, Caribbean, or Black individuals; Indigenous individuals; sex workers; people who use substances and injection drugs) and people who do not identify as a key population member. We conducted a thematic analysis.ResultsTwo major themes emerged: stigma and inequality, and journey into and through the healthcare system. Within the first theme, participants had diverse perspectives on how aspects of their identity interacted with willingness to seek testing. Within the second theme, participants discussed aspects of testing. Test costs, wait times, and testing accuracy were all viewed as important, but differing perspectives emerged about privacy of testing and receiving results, testing location, and who administers the test.ConclusionsParticipants' perspectives on STBBI testing and willingness to test were informed by their experiences and aspects of their identity.

Developing and validating a Bayesian clinical risk prediction model for three sexually transmitted infections in key populations from two Canadian provinces

OBJECTIVES

Across Canada, in the last decade, incidence rates of sexually transmitted and blood-borne infections (STBBI) have peaked (syphilis) or plateaued (hepatitis C virus (HCV) and HIV). Key populations (gay, bisexual and other men who have sex with men, trans and gender-diverse people, and people who use injection drugs) are at greater risk for these STBBIs, so correctly predicting risk before screening potentially infected individuals is crucial. We developed and validated a diagnostic clinical risk prediction model (CRPM) estimating HIV, HCV and syphilis risk for two key populations in two Canadian provinces.

METHODS

We used 20 variables and STBBI test results from a cross-sectional study evaluating multiplexed testing (detection of coinfections) in New Brunswick and Quebec (n=400) to develop our CRPM. We randomly split the data into development (n=300) and validation (n=100) datasets using clinic-stratified sampling. We used Bayesian predictive projection with development data to select ranked STBBI predictors. We obtained the ORs of the highest performing submodel measured as area under the receiver operating curve (AUC), sensitivity and specificity with 89% credible intervals (89% CrI) using validation data. Analyses were performed in R (≥V.4.2.3).

RESULTS

Out of 400 participants, 73 were infected with HIV (n=16), HCV (n=60), and/or syphilis (n=5). An internally validated submodel with two predictors (past drug injection, type of past sexually transmitted infection) displayed the highest AUC (0.79; 89% CrI 0.66 to 0.79), sensitivity (0.85; 89% CrI 0.79 to 0.91) and specificity (0.30; 89% CrI 0.15 to 0.50). The predictor contributing most to STBBI risk was past drug injection (OR=7.62; 89% CrI 4.41 to 13.07).

CONCLUSIONS

This Bayesian-based CRPM is the first to identify high-risk individuals for HIV, HCV and syphilis with an overall good performance that minimises case missing. After additional validation, it could serve as a promising novel tool for prescreening key populations and improve Canadian STBBI multiplexed screening strategies.

Syphilitic bi-valvular endocarditis and myocarditis: modern tools applied to long-forgotten complications of a re-emerging disease

The incidence of syphilis has increased steadily over the past 25 years. Undiagnosed cases have presumably increased in the same proportions, and rare complications are at particularly high risk of being unrecognised. A previously healthy 60-year-old man presented with rapidly progressive heart failure and severe aortic and mitral valve insufficiency, with direct valvular destruction and preservation of the aortic valve annulus and aortic root. Treponemal serology was reactive, with rapid plasma reagin titre of 1:128. The patient also had classic manifestations of tertiary syphilis: fusiform aneurysm of the aorta and meningovascular syphilis. He underwent bi-valvular and ascending aorta replacement, and the presence of Treponema pallidum was confirmed by specific immunohistochemistry and PCR in all tissues, including aortic and mitral valves, myocardium, and aorta. This case links T pallidum to infectious endocarditis with severe damage to both aortic and mitral valves, in addition to confirmed syphilitic myocarditis, a long-forgotten complication. It occurred 4 years after probable infection, long before what would be expected according to current understanding of its natural history. Syphilis serology should be considered in patients with culture-negative endocarditis as well as in those with heart failure or arrhythmias of unclear cause, especially in the presence of risk factors for syphilis. Syphilitic endocarditis and myocarditis are potentially lethal but treatable conditions.

Edge-based modelling for disease transmission on random graphs: an application to mitigate a syphilis outbreak

Edge-based network models, especially those based on bond percolation methods, can be used to model disease transmission on complex networks and accommodate social heterogeneity while keeping tractability. Here we present an application of an edge-based network model to the spread of syphilis in the Kingston, Frontenac and Lennox & Addington region of southeastern Ontario, Canada. We compared the results of using a network-based susceptible-infectious-recovered (SIR) model to those generated from using a traditional mass action SIR model. We found that the network model yields very different predictions, including a much lower estimate of the final epidemic size. We also used the network model to estimate the potential impact of introducing a rapid syphilis point of care test and treatment intervention strategy that has recently been implemented by the public health unit to mitigate syphilis transmission.

Increased HIV and other sexually transmitted infections in two health facilities in Northern Cameroon between 2021 and 2022

Background

Human immunodeficiency viruses (HIV) and acquired immunodeficiency syndrome (AIDS) remain a global public health problem. Other sexually transmitted infections (STIs) are aggravating factors.

Aim

This study aimed to assess the prevalence and identify new cases of HIV and STIs, as well as their associated risk factors.

Setting

Political insecurity in the northern regions of Cameroon has led to population displacement, weakening an already fragile health system.

Methods

A cohort of 684 consenting participants from the north and far north were enrolled in 2021 and followed up in 2022. Socio-demographic variables and risk behaviours were collected. Anti-HIV Ab, hepatitis B surface antigen, Treponema pallidum haemagglutination tests were performed. The data were analysed using Epi Info 7.5.2. The associations between variables were evaluated using the Chi-square test with a 95% confidence interval.

Results

The new cases of HIV rate and overall prevalence were 1.63% (95% confidence interval [CI]: 0.83% - 2.41%) and 3.8% (95% CI: 2.01% - 3.97%), respectively. New HIV cases increased from 0.27% (2017, Demographic and Health Survey [DHS]) to 1.63%. The prevalence of syphilis and hepatitis B was 1.03% (95% CI: 0.98% - 1.09%) and 4.56% (95% CI: 4.51% - 4.66%), respectively. Factors associated with HIV included religion (p = 0.027), unprotected sex (p = 0.006), sex with a sex worker (p = 0.00009), and co-infection with syphilis and hepatitis B (p = 0.033). New HIV infections may also be associated with population displacement.

Conclusion

HIV infection, syphilis and hepatitis B are on the rise in the Northern Cameroon.

Contribution

Future HIV prevention strategies should consider population displacement and HIV-associated infections such as hepatitis B and syphilis in order to secure achievements in HIV programme and further curb the burden of these infections in the country.

Trends in syphilis and syphilitic uveitis among South Korean adults in 2010-2019: a nationwide cohort study

INTRODUCTION

This study aims to investigate the epidemiology, clinical manifestations, and diagnostic and management patterns of ocular syphilis in South Korea.

METHODS

This retrospective nationwide cohort study analysed health claim data from 2010 to 2019 for individuals aged ≥20 years diagnosed with syphilis, with follow-up through 2021. Age- and sex-adjusted incidence and prevalence rates were calculated for ocular conditions including anterior uveitis, posterior uveitis, panuveitis and optic neuritis. Diagnostic and management trends were evaluated, and multivariate Cox regression analyses assessed the impact of demographic factors and comorbidities.

RESULTS

From 2010 to 2019, the incidence rate of syphilis increased from 99.1 to 136.1 per 100 000. Among the 448 085 syphilis cases, 5118 developed anterior uveitis, 777 posterior uveitis, 551 panuveitis and 80 optic neuritis. While all types of uveitis showed increasing trends, anterior uveitis exhibited the steepest rise from 0.18 per 100 000 in 2010 to 1.40 per 100 000 in 2021. Diagnostic practices for ocular syphilis included 80.4% for dilated fundus examination, 73.7% for fundus photography and 11.0% for fluorescein angiography. Laser photocoagulation and vitrectomy were performed in 5.7% and 4.5% of patients with uveitis, respectively. Multivariate analyses showed that each additional year of age increased the risk for anterior and posterior uveitis by 4% and optic neuritis by 2%. Hypertension, diabetes mellitus and dyslipidaemia increased the risk of one or more ocular syphilis manifestations.

CONCLUSION

In 2010-2019, the incidence of syphilis in South Korea significantly increased, with rates higher than previous studies. Age, sex and metabolic comorbidities were associated with an increased risk of ocular syphilis. These results indicate the need for vigilance in screening for ocular syphilis, and the importance of comprehensive eye examinations in patients with syphilis.

The rise of congenital syphilis in Canada: threats and opportunities

Introduction

In Canada, rates of congenital syphilis have been increasing rapidly in recent years, following a surge in infectious syphilis. These trends call for a closer look at missed opportunities for testing, diagnosis, treatment, and follow-up of pregnant individuals. The epidemiological situation is especially serious given that effective treatment is available for syphilis during pregnancy and that congenital syphilis is a preventable outcome that engenders adverse birth outcomes such as miscarriage, stillbirth, and neonatal death as well as potentially lifelong ocular, neurological, hepatosplenic, and musculoskeletal sequelae. The objective of this study is to examine the factors associated with congenital syphilis trends and to highlight promising initiatives and programs across the country committed to addressing these trends.

Methods

A literature review with a focus on Canadian studies was conducted to identify factors that may be driving the continued increase in early congenital syphilis rates over the past decade. An environmental scan of initiatives and programs providing syphilis care and support was also conducted.

Results

Key factors identified in association with congenital syphilis outcomes included a lack of timely and repeated prenatal syphilis screening, inadequate prenatal treatment and follow-up of syphilis infection, barriers to accessing prenatal care caused by multiple intersecting social determinants of health as well as by certain structural determinants of health, and substance use. A number of initiatives to improve syphilis care within the health care system and several community-based programs filling in some of the gaps in syphilis care and support are making important advances in addressing the epidemiological situation with syphilis.

Discussion

Much work is underway at various levels of government and local community to address the situation. Key recommendations for maximizing impact in curbing infectious and congenital syphilis rates include the following: planning an integrated strategy for addressing sexually transmitted and blood-borne infections as a whole; adopting a more holistic approach to improving health and wellbeing; developing targeted interventions for addressing structural and social barriers to health equity; and taking a collaborative approach to response by involving multilevel stakeholders, such as key populations, community groups, health care providers, and public health authorities.

Rising congenital syphilis rates in Canada, 1993-2022

Introduction

The number of cases of confirmed early congenital syphilis has risen steeply in Canada in recent years, particularly since 2018, to the highest number ever recorded since national reporting began in 1993. We analyzed national data on confirmed early congenital syphilis from 1993 to 2022 to describe epidemiologic trends in Canada during this period.

Methods

Data from 1993 to 2017 were obtained from routine surveillance conducted through the Canadian Notifiable Disease Surveillance System, and data from 2018 to 2022 were obtained from enhanced surveillance conducted through a federal-provincial-territorial working group. Case counts and rates were computed nationally and by province and territory. Infectious syphilis data from the same time period for females of reproductive age were also analyzed.

Results

The national rate of confirmed early congenital syphilis was 127-fold higher in 2022 than in 1993, increasing from 0.3 to 32.7 cases per 100,000 live births. Case counts began increasing rapidly in 2018, with the highest case count observed to date (n = 115) occurring in 2022. The highest rates in the country in recent years have been observed in Saskatchewan, Manitoba, Alberta, and Ontario. Infectious syphilis rates among females of reproductive age have also been rapidly increasing in these provinces. Between 2018 and 2022, the national rate of confirmed early congenital syphilis increased approximately seven-fold and the national rate of infectious syphilis increased approximately two-fold, including an approximately three-and-a-half-fold rate increase among females of reproductive age.

Discussion

These numbers represent huge shifts in the epidemiological landscape of syphilis in Canada. The increase in vertical transmission appears to be driven by not only the increasing rate of infectious syphilis among females of reproductive age but also by multiple structural and social determinants of health impacting pregnant individuals.

Syphilis vaccine development: Aligning vaccine design with manufacturing requirements

Syphilis, caused by Treponema pallidum subsp. pallidum, is a global health concern with increasing rates worldwide. Current prevention strategies, including screen-and-treat approaches, are not sufficient to resolve rising infection rates, emphasizing the need for a vaccine. Developing a syphilis vaccine necessitates a range of cross-disciplinary considerations, including essential disease-specific protection, technical requirements, economic feasibility, manufacturing constraints, public acceptance, equitable vaccine access, alignment with global public vaccination programs, and identification of essential populations to be vaccinated to achieve herd immunity. Central to syphilis vaccine development is prioritization of global vaccine availability, including access in low- to middle-income settings. Various vaccine platforms, including subunit, virus-like particle (VLP), mRNA, and outer membrane vesicle (OMV) vaccines, present both advantages and challenges. The proactive consideration of both manufacturing feasibility and efficacy throughout the pre-clinical research and development stages is essential for producing an efficacious, inexpensive, and scalable syphilis vaccine to address the growing global health burden caused by this disease.

Syphilis Point of Care Rapid Test and Immediate Treatment Evaluation (SPRITE) study: a mixed-methods implementation science research protocol of eight public health units in Ontario, Canada

INTRODUCTION

Urgent, tailored and equitable action is needed to address the alarming rise in syphilis rates in Canada. In the last decade, the rates of infectious syphilis have increased by 345% in Ontario, Canada. Underserved populations-people who use drugs, un(der)housed individuals and those living in rural and remote areas-face unique social and healthcare challenges that increase their vulnerability to syphilis infections and hinder their access to timely diagnosis and treatment. This study assesses the real-world implementation and effectiveness of using a recently approved syphilis point-of-care test in conjunction with public health outreach to break barriers and bring services to the population at the highest risk.

METHODS AND ANALYSIS

The Syphilis Rapid Point-of-Care Testing and Immediate Treatment Evaluation (SPRITE) study includes eight public health units in Ontario, Canada. Implementation and evaluation of this rapid 'test and treat' outreach model of care will be assessed using the Practical, Robust Implementation and Sustainability Model (PRISM)/Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework, following a community-based participatory approach. Network models will be used to estimate the population-level impact of implementing this model of care to curb transmission. Knowledge mobilisation will be assessed using the Reciprocity, Externalities, Access, and Partnership (REAP) Self-Assessment Model.

ETHICS AND DISSEMINATION

The SPRITE study was approved by the Queen's University Research Ethics Board (REB) and is to be conducted in accordance with the Canadian Tri-Council Policy Statement V.2 and the latest Seoul revision of the Declaration of Helsinki. Knowledge generated from this study will be mobilised through community-based organisations and the broader public health community.

A retrospective analysis of syphilis cases with a focus on otolaryngology at a university hospital

OBJECTIVES

In recent years, there has been a notable increase in syphilis cases in Japan and Western countries. Syphilis, a classic sexually transmitted disease caused by treponemas, presents diagnostic challenges due to its diverse clinical manifestations. This study explores the diagnosis of syphilis in patients treated at our hospital.

METHODS

We retrospectively reviewed patients who visited our hospital between April 2015 and March 2024. The review focused on the patients' clinical backgrounds, onset times, symptoms, diagnostic processes, and clinical courses.

RESULTS

Our hospital had 45 cases of syphilis. Forty-five cases of syphilis were diagnosed as syphilis in our hospital (13 cases were diagnosed in the Otolaryngology: ENT department). The median age was 40 years, with a significant male predominance (male-to-female ratio of 34:11). The median duration from the onset of subjective symptoms to syphilis diagnosis was 54 days. The timeframe from the initial clinic visit to diagnosis ranged from 1 to 57 days, with a median of nine days. Notably, 47.5% of the patients reported a history of employment or patronage in the sex industry. 73.3% of patients presented to local clinics with any kind of subjective symptoms, but syphilis was often missed in the differential diagnosis. Patients visiting the ENT department were referred to our hospital with a diagnosis of persistent oral ulcer, oropharyngeal carcinoma and neck lymphadenopathy. Histological and cytological evaluation was performed in 33% of patients, but the diagnosis was often difficult to make. Additionally, some patients initially denied using sex services at their first visit but later disclosed this during subsequent visits to the Department of Infectious Diseases, highlighting the critical role of thorough medical history assessments.

CONCLUSION

Diagnosing syphilis can be challenging unless the physician specifically suspects it. It is crucial to consider syphilis in cases of pharyngeal mucosal inflammation and neck lymphadenopathy. This study highlights the need for heightened awareness and education regarding the signs and symptoms of syphilis, particularly oropharyngeal and skin findings, to ensure timely diagnosis and treatment.

Diagnosis and management of congenital syphilis: Avoiding missed opportunities

Congenital syphilis can result in pregnancy loss and substantial morbidity in newborns. The current epidemic of congenital syphilis in Canada (especially Western Canada) is a preventable public health emergency. Rates indicate a lack of control of syphilis within the community and insufficient public health resources to prevent spread that predate the COVID-19 pandemic. Risk factors include lack of prenatal care, methamphetamine and other substance use, and unstable housing. The cornerstone of prevention is identification, treatment, and follow-up during pregnancy, including of partners. Clinicians caring for newborns need to consider aspects of maternal treatment, reinfection risk, the results of paired maternal and infant syphilis serology, and infant clinical assessment. A complete risk assessment will guide effective management and follow-up of infants exposed in utero to syphilis.

Increasing incidence of syphilis: A case report of non-resolving papulosquamous rash and role of a biopsy in the prevention of delayed diagnosis

Syphilis is a sexually transmitted infection that is undergoing a resurgence in Canada and around the world. If not diagnosed correctly, syphilis can progress to its secondary and tertiary stages, affecting numerous organ systems. We present a case of a 41-year-old female who developed a papulosquamous rash, initially diagnosed as varicella with progression to a widespread and painful rash over 3 months. Based on clinical, histological, and serological findings, she was later diagnosed with secondary syphilis and successfully treated with intramuscular penicillin. This case underscores the importance of accurate diagnosis and treatment of syphilis to prevent systemic complications. We advocate for increased awareness among frontline providers with a proactive approach to diagnosis and management, including thorough history and physical examination, low threshold for performing serological testing, biopsy for lesions that do not resolve as expected with management, and multidisciplinary involvement for complex presentations of syphilis.

Higher rates of laboratory-confirmed cases of syphilis in Western Canadian blood donors compared with Eastern Canadian blood donors following a period of societal re-opening

BACKGROUND AND OBJECTIVES

There is a growing infectious syphilis outbreak in Western Canada. Although blood donors are screened for syphilis risks, some blood donors will still be confirmed test-positive for syphilis. This study compares the characteristics of confirmed test-positive syphilis donations in both Western Canada and Eastern Canada, November 2022-August 2023.

MATERIALS AND METHODS

Donors were defined as Western or Eastern Canadian. Blood donations were tested for syphilis using the PK-TP assay (Beckman Coulter PK7300 Automated Microplate System). Confirmatory Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) assays were performed by one of two reference laboratories. An RPR titre ≥1:8 was used as a proxy for possible infectious syphilis.

RESULTS

Rates of laboratory-confirmed syphilis were higher in Western (n = 43, 13.4/100,000 donations) versus Eastern donors (n = 19, 4.7/100,000 donations; Fisher's exact test, two-sided, p ≤ 0.0001). Most syphilis confirmations were in first-time donors (Western Canada n = 31/43, 72.1%, Eastern Canada 12/19, 63.2%).

CONCLUSION

Although rates of laboratory-confirmed syphilis were higher in Western versus Eastern donors, Western donors did not have higher rates of infectious syphilis. Further studies might assess whether donors with laboratory-confirmed syphilis understood pre-donation screening questions or were completely unaware of a past infection.

Notification rates for syphilis in women of reproductive age and congenital syphilis in Australia, 2011-2021: a retrospective cohort analysis of national notifications data

OBJECTIVES

To estimate notification rates for infectious syphilis in women of reproductive age and congenital syphilis in Australia.

STUDY DESIGN

Retrospective cohort study; analysis of national infectious syphilis and enhanced congenital syphilis surveillance data.

SETTING, PARTICIPANTS

Women aged 15-44 years diagnosed with infectious syphilis, and babies with congenital syphilis, Australia, 2011-2021.

MAIN OUTCOME MEASURES

Numbers and rates of infectious syphilis notifications, by Indigenous status and age group; numbers and rates of congenital syphilis, by Indigenous status of the infant; antenatal care history for mothers of infants born with congenital syphilis.

RESULTS

During 2011-2021, 5011 cases of infectious syphilis in women aged 15-44 years were notified. The notification rate for Aboriginal and Torres Strait Islander women rose from 56 (95% confidence interval [CI], 45-65) cases per 100 000 in 2011 to 227 (95% CI, 206-248) cases per 100 000 population in 2021; for non-Indigenous women, it rose from 1.1 (95% CI, 0.8-1.4) to 9.2 (95% CI, 8.4-10.1) cases per 100 000 population. The notification rate was higher for Aboriginal and Torres Strait Islander women than for non-Indigenous women (incidence rate ratio [IRR], 23.1; 95% CI, 19.7-27.1), lower for 15-24- (IRR, 0.7; 95% CI, 0.6-0.9) and 35-44-year-old women (IRR, 0.6; 95% CI, 0.5-0.7) than for 25-34-year-old women, and higher in remote regions than in major cities (IRR, 2.7; 95% CI, 2.2-3.8). During 2011-2021, 74 cases of congenital syphilis were notified, the annual number increasing from six in 2011 to a peak of 17 in 2020; the rate was consistently higher among Aboriginal and Torres Strait Islander infants than among non-Indigenous infants (2021: 38.3 v 2.1 per 100 000 live births). The mothers of 32 infants with congenital syphilis (43%) had not received antenatal care.

CONCLUSIONS

The number of infectious syphilis notifications for women of reproductive age increased in Australia during 2011-2021, as did the number of cases of congenital syphilis. To avert congenital syphilis, antenatal screening of pregnant women, followed by prompt treatment for infectious syphilis when diagnosed, needs to be improved.

Approach to sexually transmitted infection testing for men who have sex with men

OBJECTIVE

To provide a guide on appropriate sexually transmitted infection (STI) testing for primary care providers to use with patients who identify as men who have sex with men (MSM).

SOURCES OF INFORMATION

Canadian guidelines for STI testing and enteric and protozoan infections; Ontario guidelines for HIV screening and mpox; and US guidelines for STI testing.

MAIN MESSAGE

Across Canada rates of sexually transmitted bacterial, enteric, protozoan, and systemic infections-including HIV and mpox-have been steadily increasing among cisgender and transgender MSM. Despite often having similar clinical presentations, these infections have different incubation periods and testing approaches and must be ruled out effectively to guide diagnosis and treatment for MSM-identifying patients who present with symptoms of various conditions. Clinical information and screening recommendations, however, are often found in multiple guidelines rather than in a single source, thus further complicating these clinical encounters. This document provides a consolidated set of evidence and recommendations for STI testing in MSM.

CONCLUSION

Testing approaches for STIs should be comprehensive and based on the patient's reported risk factors and clinical presentation. Where ongoing STI risk is identified and negative laboratory test results are received, MSM should also be counselled on recommendations for repeat screening and HIV prevention services, such as preexposure prophylaxis.

Summary of the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) Statement: Recommendations on Screening for Syphilis in Non-Pregnant Adults and Adolescents

Background

Sustained and significant increases in Canadian rates of infectious syphilis prompted the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) to update the existing screening recommendation for non-pregnant adults and adolescents.

Methods

These guidelines were developed following the 2014 World Health Organization Handbook. The research question was: "What is the clinical utility of syphilis screening using risk-based versus population-wide approaches for adolescents and adults?" The evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

The environmental scan included 11 guidelines on syphilis screening published between 2014 and January 2023. Two systematic reviews were identified and included. In the updated literature search from November 6, 2019, to January 17, 2023, there were no published systematic reviews on the effectiveness of risk-based screening or the comparison of risk-based and interval screening; however, one recent randomized control trial in Canada was published. Evidence for outcomes, patient values and preferences, resources, acceptability, equity, cost and cost effectiveness and feasibility were reviewed.

Conclusion

This statement provides two screening recommendations for adults and adolescents. Recommendation 1: NAC-STBBI recommends syphilis screening in all sexually active persons with a new or multiple partners and/or upon request of the individual. They also recommend screening every three to six months in individuals with multiple partners. Recommendation 2: NAC-STBBI recommends that targeted "opt-out" screening programs should be considered as frequently as every three months when serving population groups and/or communities experiencing a high prevalence of syphilis (and other STBBI). Both are strong recommendations with moderate certainty of evidence.

Validity of dried blood spot testing for sexually transmitted and blood-borne infections: A narrative systematic review

Testing for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) using dried blood spot (DBS) specimens has been an integral part of bio-behavioural surveillance in Canada for almost two decades, though less is known regarding the use of DBS in surveillance of other sexually transmitted and blood-borne infections (STBBI). A systematic review was conducted using a peer-reviewed search strategy to assess the current evidence regarding the validity of STBBI testing using DBS specimens. Eligibility criteria included studies reporting use of DBS specimens for STBBI testing with either commercially available or "in-house" tests in populations 15 years of age or older. Studies reporting a measure of validity such as sensitivity, specificity, positive and negative predictive values were eligible for inclusion. Quality of studies and risk of bias were assessed using the QUADAS-2 tool. A total of 7,132 records were identified. Of these, 174 met the criteria for inclusion. Among the studies that reported validity measures, a substantial proportion demonstrated high sensitivity (≥90%) in 62.5% of cases (N = 334/534 sensitivity measurements), and high specificity (≥90%) was observed in 84.9% of instances (N = 383/451 specificity measurements). However, the quality of the studies varied greatly. Our findings support the validity of the use of DBS specimens in STBBI testing where sufficient evidence was available, but validity is highly dependent on thorough method development and validation.

Interventions in maternal syphilis care globally: A scoping review

Infectious and Congenital Syphilis rates continue to rise globally. Current recommendations for syphilis screening and treatment may be insufficient, and there is a pressing need for improved programs and services to address the increase in cases. A scoping review was conducted to examine approaches to maternal syphilis screening and treatment. Theoretical underpinnings and the key characteristics of these interventions were studied to identify gaps in the existing literature to guide future research. Developing a modified version of the socio-ecological model to guide data analysis, we included 33 academic studies spanning 31 years, covering a range of interventions, programs, and policies globally. We highlight key facets of interventions aligning with the five levels of the modified model that include: individual, interpersonal, institutional, community and policy. In this review, we provide valuable insights into the characteristics and principles of maternal syphilis screening and treatment interventions.

Addressing the ethical problem of underdiagnosis in the post-pandemic Canadian healthcare system

Proper diagnosis is essential for effective treatment, yet in Canada health conditions are commonly underdiagnosed at all levels of the health system, meaning that they go undiagnosed or are diagnosed only after a delay. Underdiagnosis leads to inadequate treatment and potentially insufficient recovery and rehabilitation, as well as costly inefficiencies, such as repeat medical visits. Moreover, disparities in underdiagnosis in which vulnerable groups, such as women and Indigenous persons, are properly diagnosed at lower rates worsen existing inequities, which threatens the overall health of the general population. As health leaders and policy-makers seek to strengthen Canada's strained healthcare system, it will be important to address underdiagnosis and its causes, including systematic bias. Providing timely and accurate diagnoses for all patients is an essential component of delivering high quality, efficient, ethical, and cost-effective healthcare. The Canadian College of Health Leaders' Code of Ethics offers a framework for addressing underdiagnosis equitably. Utilizing the framework, suggestions are made for actions that can be taken at all levels of the health system to reduce underdiagnosis.

Reducing perinatal infection risk in newborns of mothers who received inadequate prenatal care

Inadequate prenatal care increases risk for maternal infections going undetected and untreated, putting both the mother's health and that of her infant at risk. When pregnant women present late to care, routine testing that impacts infant management should include: hepatitis B surface antigen (HBsAg); serology for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis; and testing for Chlamydia trachomatis and Neisseria gonorrhoeae. If the mother was not tested before or after delivery and is not available for testing, the infant should undergo testing for HIV, HBV, HCV, and syphilis. Testing for C. trachomatis and N. gonorrhoeae should be undertaken if the infant develops compatible clinical manifestations. Rapid turnaround of test results for HIV, HBV, and syphilis is optimal because preventive treatment decisions are time-sensitive. Early and effective preventive interventions are available for newborns at risk for HIV, HBV, syphilis, or gonorrhea. Close clinical follow-up and follow-up testing of infants born to mothers with inadequate prenatal care are warranted, as not all infections can be fully excluded perinatally.

La réduction du risque d'infection périnatale chez les nouveau-nés de mères dont les soins prénatals étaient inappropriés

Le risque que des infections maternelles ne soient ni décelées ni traitées augmente lorsque les soins prénatals sont inappropriés, ce qui met la santé de la mère et de son nouveau-né à risque. Lorsqu'une femme enceinte se présente tardivement pour recevoir des soins, les tests systématiques qui influent sur la prise en charge du nouveau-né devraient inclure l'antigène de surface de l'hépatite B (AgHBs), la sérologie du virus de l'hépatite C (VHC), du virus de l'immunodéficience humaine (VIH) et de la syphilis, de même que le dépistage de la Chlamydia trachomatis et de la Neisseria gonorrhoeae. Si la mère ne s'est pas soumise aux dépistages avant ou après l'accouchement et qu'elle n'est pas disponible pour s'y soumettre, il faudrait procéder au dépistage du VIH, du virus de l'hépatite B (VHB), du VHC et de la syphilis chez le nouveau-né. Le dépistage de la C. trachomatis et de la N. gonorrhoeae est toutefois réservé aux cas où le nouveau-né démontre des manifestations cliniques compatibles avec ces infections. Il est optimal d'obtenir rapidement les résultats du dépistage du VIH, du VHB et de la syphilis, car l'utilisation des traitements préventifs est circonscrite dans le temps. Il existe des interventions préventives précoces et efficaces pour les nouveau-nés à risque de VIH, de VHB, de syphilis ou de gonorrhée. Un suivi clinique étroit et des tests de suivi s'imposent auprès des nouveau-nés de mères dont les soins prénatals étaient inappropriés, car il est impossible d'exclure pleinement toutes les infections pendant la période périnatale.

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011-2019

OBJECTIVES

To examine changes in the positive infectious syphilis test rate among women and heterosexual men in major Australian cities, and rate differences by social, biomedical, and behavioural determinants of health.

DESIGN, SETTING

Analysis of data extracted from de-identified patient records from 34 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses (ACCESS).

PARTICIPANTS

First tests during calendar year for women and heterosexual men aged 15 years or more in major cities who attended ACCESS sexual health clinics during 2011-2019.

MAIN OUTCOME MEASURES

Positive infectious syphilis test rate; change in annual positive test rate.

RESULTS

180 of 52 221 tested women (0.34%) and 239 of 36 341 heterosexual men (0.66%) were diagnosed with infectious syphilis. The positive test rate for women was 1.8 (95% confidence interval [CI], 0.9-3.2) per 1000 tests in 2011, 3.0 (95% CI, 2.0-4.2) per 1000 tests in 2019 (change per year: rate ratio [RR], 1.12; 95% CI, 1.01-1.25); for heterosexual men it was 6.1 (95% CI, 3.8-9.2) per 1000 tests in 2011 and 7.6 (95% CI, 5.6-10) per 1000 tests in 2019 (RR, 1.10; 95% CI, 1.03-1.17). In multivariable analyses, the positive test rate was higher for women (adjusted RR [aRR], 1.85; 95% CI, 1.34-2.55) and heterosexual men (aRR, 2.39; 95% CI, 1.53-3.74) in areas of greatest socio-economic disadvantage than for those in areas of least socio-economic disadvantage. It was also higher for Indigenous women (aRR, 2.39; 95% CI, 1.22-4.70) and for women who reported recent injection drug use (aRR, 4.87; 95% CI, 2.18-10.9) than for other women; it was lower for bisexual than heterosexual women (aRR, 0.48; 95% CI, 0.29-0.81) and for women who reported recent sex work (aRR, 0.35; 95% CI, 0.29-0.44). The positive test rate was higher for heterosexual men aged 40-49 years (aRR, 2.11; 95% CI, 1.42-3.12) or more than 50 years (aRR, 2.36; 95% CI, 1.53-3.65) than for those aged 15-29 years.

CONCLUSION

The positive test rate among both urban women and heterosexual men tested was higher in 2019 than in 2011. People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis.

The 11th Canadian Symposium on Hepatitis C Virus: 'Getting back on track towards hepatitis C elimination'

Hepatitis C virus (HCV) affects approximately 204,000 Canadians. Safe and effective direct-acting antiviral therapies have contributed to decreased rates of chronic HCV infection and increased treatment uptake in Canada, but major challenges for HCV elimination remain. The 11th Canadian Symposium on Hepatitis C Virus took place in Ottawa, Ontario on May 13, 2022 as a hybrid conference themed 'Getting back on track towards hepatitis C elimination.' It brought together research scientists, clinicians, community health workers, patient advocates, community members, and public health officials to discuss priorities for HCV elimination in the wake of the COVID-19 pandemic, which had devastating effects on HCV care in Canada, particularly on priority populations. Plenary sessions showcased topical research from prominent international and national researchers, complemented by select abstract presentations. This event was hosted by the Canadian Network on Hepatitis C (CanHepC), with support from the Public Health Agency of Canada and the Canadian Institutes of Health Research and in partnership with the Canadian Liver Meeting. CanHepC has an established record in HCV research and in advocacy activities to address improved diagnosis and treatment, and immediate and long-term needs of those affected by HCV infection. The Symposium addressed the remaining challenges and barriers to HCV elimination in priority populations and principles for meaningful engagement of Indigenous communities and individuals with living and lived experience in HCV research. It emphasized the need for disaggregated data and simplified pathways for creating and monitoring interventions for equitably achieving elimination targets.

Crystal methamphetamine use and bacterial sexually transmitted infections (STIs) among gay, bisexual and other sexual minority men in Canada

OBJECTIVE

While crystal methamphetamine use by gay, bisexual, and other men who have sex with men (GBM) is associated with increased risk for sexually transmitted infection (STI) transmission, less is understood about the causal pathways between crystal methamphetamine use and STIs. We examined whether the association between greater crystal methamphetamine risk and prevalent bacterial STI diagnosis among GBM was mediated by two types of attitudinal variables: attitudes toward condoms, and sexual escape motives, defined as the use of substances to escape self-awareness during sex, and by sexual behaviors.

METHODS

We used computer-assisted self-interview questionnaires from 2449 sexually active GBM (18% living with HIV; median age = 33, interquartile range, 27-45) recruited via respondent-driven sampling in Vancouver, Toronto, and Montreal, Canada. Using the baseline data from the Engage cohort study, we fit a series of structural mediation models of the associations between greater crystal methamphetamine risk and bacterial STI (syphilis, gonorrhea, and chlamydia) diagnosis. We estimated indirect paths from greater crystal methamphetamine risk, attitudes toward condoms, sexual escape motives, and sexual risk behaviors, adjusting for self-reported demographic variables.

RESULTS

In the mediated model, the direct association between greater crystal methamphetamine risk and bacterial STI diagnosis was non-significant; however, five indirect paths were significant. Greater crystal methamphetamine risk was associated with bacterial STIs via condom use attitudes and escape motives, which in turn were associated with number of male anal sex partners, condomless anal sex, and oral sex.

DISCUSSION

Public health and counselling interventions for GBM who use crystal methamphetamine and who are at higher risk for STIs should target evidence-based causal paths that consider sexual attitudes and sexual practices.

Characteristics of polymerase chain reaction-positive syphilis cases in Manitoba, Canada, 2017 to 2020: Demographic analysis, specimen types, and Treponema pallidum gene targets

BACKGROUND

A resurgence of syphilis infections has been described in a number of countries including Canada in the last decade.

METHODS

This study identified polymerase chain reaction (PCR) positive syphilis cases based on detection of Treponema pallidum genes (polA, tpp47, and bmp) in 3,350 clinical specimens obtained from patients in the province of Manitoba, Canada between 2017 and 2020. Patient demographics were obtained from specimen requisition forms.

RESULTS

PCR identified 740 syphilis cases: 718 were adolescents and adults, while 22 were congenital syphilis cases. For non-congenital syphilis investigation, the clinical specimens with the highest yield of positive PCR results were genital (632), oral (73), and anal (55), while for congenital syphilis, they were nasal or nasopharyngeal secretions (20), followed by blood (5) and umbilical cord (4). Female syphilis cases appeared younger (61.7% between 14 and 29 years), while male syphilis cases appeared older (58.4% between 30 and 65 years). Although, overall more syphilis cases (62.7%) occurred in the urban cities; the proportion of urban cases showed a significant decline from 87.0% in 2017 to 55.6% in 2020, while in rural regions it increased from 13.0% in 2017 to 44.4% in 2020. Most (98.8%) PCR- positive specimens were found to contain all three T. pallidum genes and 99.8% also displayed the macrolide resistance genotype.

CONCLUSIONS

This study identified the clinical specimen types and T. pallidum genes most suitable for PCR diagnosis of syphilis. Changing demographics of cases were noted over time.