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Home : Publications : STI Epi Updates : Infectious Syphilis in Canada

STI - Epi Update

February 2002

Infectious Syphilis in Canada

Introduction

Syphilis is a sexually transmitted infection (STI) caused by the organism Treponema pallidum. If untreated, the infection progresses through five stages: primary, secondary, early latent (asymptomatic syphilis <= 1 year), late latent (asymptomatic syphilis > 1 year) and tertiary syphilis. Tertiary syphilis involves the cardiovascular, neurological and musculoskeletal systems. Infection during pregnancy can lead to miscarriage, stillbirth, premature birth and congenital infection. Infectious syphilis refers to the primary, secondary and early latent stages.

Diagnosis is made by dark-field microscopy of genital ulcers in primary syphilis and by serology in all stages. Treatment is usually with penicillin.

Overall Rate of Syphilis Rising (Figure 1)1,2

Of the three bacterial sexually transmitted infections, chlamydia, gonorrhea and syphilis, infectious syphilis is the least commonly reported. Figure 1 shows the trend in the reported infectious syphilis rate over the last eight years. The national rate had remained 0.4 to 0.6/100,000 since 1994. However, the projected rate for 2001, calculated from the first nine months' data, rose to 0.9/100,000. The rate is increasing in both males and females.


Figure 1: Reported infectious syphilis rates in Canada by sex, 1994 to 2001

Syphilis by Age Group and Gender (Figure 2)1,2

In 2000, the reported infectious syphilis gender ratio was 1.9M:1F. The peak incidence was noted in males aged 25 to 39 and in females aged 20 to 39. The rate of infectious syphilis is increasing in both males and females, but more so in males.

Figure 2: Reported infectious syphilis rates in Canada by age and sex, 2000

Syphilis in Men (Figure 3)1,2

Over the last five years, the most significant change in the rate of reported infectious syphilis has been seen in men aged 20 to 24 (a 3.8-fold increase). However, the rate is increasing in all age groups in males.

Figure 3: Reported infectious syphilis rates in Canada for men aged 20 to 59, 1994 to 2001

Geographic Distribution

In the year 2000, three provinces and two territories reported no infectious syphilis cases. An outbreak of infectious syphilis associated with the sex trade in downtown Vancouver began in mid-19973. Ongoing efforts by BCCDC staff are trying to bring this outbreak under control. The Yukon Territory had reported no cases of infectious syphilis since 1995. Eleven cases were reported in the year 2000 resulting in a rate of 35.9/100,000 population while a further 24 cases were reported in 2001 (rate of 78.2/100,000)4.

Syphilis and HIV

There are important interactions between syphilis and HIV5. The presence of genital ulcers, as occurs in primary syphilis, has been estimated to increase the transmission of HIV three- to five-fold. Neurosyphilis in HIV seropositive patients is difficult to treat. Evidence has shown that the early detection and treatment of STI can have a major impact on the sexual transmission of HIV. Therefore, control of syphilis can impact significantly on the HIV epidemic.

Issues in the control of syphilis

In 1996, a national goal for infectious syphilis was set for maintenance of the rate at or below 0.5/100,000 population6. At that time, elimination of syphilis in Canada seemed like an imminent goal7. Factors that favour the elimination of syphilis include the organism's slow growth rate and long incubation period; the availability of effective and easily administered therapy; and the lack of antibiotic resistance.

Although the national rate of infectious syphilis rate remains low, local resurgences are threatening the elimination effort. This includes the outbreak in downtown Vancouver involving sex trade workers8; in the Yukon among heterosexuals4; in Calgary among men who have sex with men (MSM)9; in Ottawa among MSM10; and in Montreal also among MSM11.

Risky sexual behaviour among MSM12-15 and among other populations16,17 is a rising global trend. One reflection of this is the numerous outbreaks of infectious syphilis seen worldwide18-29. In 1995, WHO estimated that there were 12.2 million new cases of syphilis30.

We are at a crossroads in the control of syphilis in Canada. Enhanced efforts for case finding and management as well as rapid outbreak response can once again put us on the track for elimination. Otherwise, the result may be a resurgence of this infection as well as other sexually transmitted infections, including HIV.

References

  1. Health Canada. 1998/1999 Canadian Sexually Transmitted Diseases (STD) Report. The Division of Sexual Health Promotion and STD Prevention and Control, Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, Health Canada.

  2. Health Canada. Unpublished data. The Division of Sexual Health Promotion and STD Prevention and Control, Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, Health Canada.

  3. Rekart M, Patrick D, Jolly A et al. Mass treatment/prophylaxis during an outbreak of infectious syphilis in Vancouver, BC. CCDR 2000;26:101-4.

  4. Yukon Communicable Disease Control, Department of Health and Social Services, Yukon Territorial Government. Unpublished statistics. 2000.

  5. Rottingen, J, Cameron, D, Garnett, G. A systemic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV. Sex Transm Dis 2000;28:579-97.

  6. Health Canada. Proceedings of the national STD consensus meeting and national goals for the prevention and control of sexually transmitted diseases in Canada. CCDR 1997;23S6:2-9.

  7. Wong, T, Jordan, R. Syphilis elimination in Canada: if not now, when? Can J Hum Sex 2000;9:205-09.

  8. Patrick D, Wong T, Jordan R. Sexually transmitted infections in Canada: Recent resurgence threatens national goals. Can J Hum Sex 2000;9:149-65.

  9. Presentation by A. Singh in Proceedings of the MSM/IDU Consultation Meeting (March 8-9, 2001, Ottawa, Canada). Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, Health Canada.

  10. Ottawa Citizen. Surge in syphilis prompts warning: Disease breaks out among users of gay bathhouses. 28/03/01.

  11. Régie Régionale de la Santé et des Services Sociaux de Montréal-Centre. 04/05/01 http://www.santepub-mtl.qc.ca/Mi/vigilance/syphilis.html and 23/07/01 http://www.santepub-mtl.qc.ca/Mi/vigilance/syphilis23072001.html

  12. Health Canada. HIV infections increasing among MSM in Canada. HIV/AIDS Epi Update. 2001. Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, Health Canada.

  13. Grulich, A. HIV risk behaviour in gay men: on the rise? Br Med J 2000;320:1487-88.

  14. Wolitski R, Valdiserri R, Denning P et al. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001;91:883-88.

  15. Fox K, del Rio C, Holmes K et al. Gonorrhea in the HIV era: a reversal in trends among men who have sex with men. Am J Public Health 2001;91:959-64.

  16. Health Canada. Sexual risk behaviours of Canadians. 1999. Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, Health Canada.

  17. Romanowski B, Campbell P, Preiksaitis J et al. Human immunodeficiency virus seroprevalence and risk behaviours in patients attending sexually transmitted disease clinics in Alberta. Sex Transm Dis 1997;24:487-94.

  18. CDC. Outbreak of syphilis among men who have sex with men - southern California, 2000. MMWR 2001;50:117-20.

  19. CDC. Resurgent bacterial sexually transmitted disease among men who have sex with men - King County, Washington, 1997-1999. MMWR 1999;48:773-77.

  20. CDC. Outbreak of primary and secondary syphilis - Guilford County, North Carolina, 1996-1997. MMWR 1998;47:1070-73.

  21. CDC. Outbreak of primary and secondary syphilis - Baltimore City, Maryland, 1995. MMWR 1996;45:166-69.

  22. CDC. Epidemic early syphilis - Montgomery County, Alabama, 1990-1991. MMWR 1992;41:790-94.

  23. Gill, N. Syphilis transmission in homo/bisexual men: New outbreak in London, continuing outbreak in Dublin. Eurosurveillance Weekly 2001;26.

  24. CDSC. Syphilis continues to spread in Greater Manchester. Commun Dis Rep CDR Weekly 2001;4.

  25. Catchpole M. Outbreak of syphilis reported from Bristol, England 1997. Eurosurveillance Weekly 1997;Thursday 21 August.

  26. Nicoll A. Epidemics of syphilis in the Russian Federation and other states of the former USSR - implications for HIV and AIDS. Eurosurveillance Weekly 1997; Thursday 24 July.

  27. De Schrijver K. Syphilis outbreak in Antwerp, Belgium. Eurosurveillance Weekly 2001;19.

  28. Blystad H, Nilsen O, Aavitsland P. An outbreak of syphilis among homosexual men in Oslo, Norway. Eurosurveillance Weekly 1999;47.

  29. Wijgergangs L. Cases of syphilis in the Netherlands increase. Eurosurveillance Weekly 1997; Thursday 10 July.

  30. Gerbase A, Rowley J, Mertens T. Global epidemiology of sexually transmitted diseases. Lancet 1998;351(suppl III):2-4.

 
Last Updated: 2002-02-11 Top
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