Lisa: Hello and welcome to the webinar Alive and Kicking: Sexually acquire and congenital syphilis. We would like to acknowledge the traditional owners the respective lands on which we are meeting today and pay our respects to Elders past, present and emerging. Before we commence, we will take a few moments to help you familiarise yourself with the learning platform. Throughout the webinar, we will refer to your control panel. If you are using a computer to participate and you are unable to see the pale blue and grey screen like the one pictured on the slide, look for the red arrow in the small box on the top right of your screen and click it. The control panel should open. The control panel provides you with the tools to have any questions answered or to resolve any trouble-shooting issues you may have. During the webinar, all participants have been set to mute. This ensures any background noise is eliminated. In the interest of time we will ask you to please keep any questions until the end. When prompted, please send any questions via the question box on the blue-grey control panel. We ask that you please message organisers only.
I will now hand you over to Dr Tim Koh our facilitator today.
Tim: Thank you, Lisa. Good evening and welcome everyone. It is nice to see so many people attending. We have got just on over 100 attendees tonight, so very warm welcome and thank you for spending time with us tonight. Tonight’s presentation is about syphilis. It is a pleasure to have our two guests, firstly Dr Donna Mak, welcome.
Donna: Hi Tim, how are you?
Tim: Very well, thank you and doing your best to project as loudly as possible which is wonderful. Donna, you are a public health physician with the Communicable Disease Directorate and Public Health and Aboriginal Health Division through the Department of Health in WA. You are also a Professor in General Practice in Public Health.
Donna: A Professor in Public Health at Notre Dame, at the Medical School.
Tim: And you work at the M Clinic as a GP. M Clinic is a male sexual health clinic which is funded through the WA Aids Council.
Tim: Thank you, Donna. And then welcome, Ben. Dr Ben Scalley is a public health physician and Head of Department at the Metropolitan Communicable Disease Control Directorate through WA Department of Health. That is a mouthful to explain to people, isn’t it, Ben?
Ben: Well, we cannot have short titles, can we?
Tim: I am a GP from Perth, and that is my title tonight. So, okay, so let us get started with an overview. Donna, would you like to kick off?
Donna: Yes, sure. So, we are going to talk firstly about some clinical features of syphilis and how you would test and treat for syphilis. Then we will look at the epidemiology of syphilis, starting broadly with Australia and international, and then we will be talking about the three epidemics or outbreaks of syphilis that we are currently seeing in Australia in remote Aboriginal communities, in men who have sex with men and the emerging trend in heterosexual people sort of in mainstream Australia. And then I am going to hand over to Ben to talk about three vignettes, which I think typify the issues and some of the difficulties that as public health physicians and as GPs you might have in dealing with patients with syphilis and then we will move onto, well what are the implications for clinical and public health practice. And there will be time for questions. But I thought before we start, it would be really interesting for us here to see how many cases of syphilis each of you have seen in the last say five years.
Tim: So we are going to open that up as a poll. In the text box, if you could send us a text through the question box and we will wait for your answers. We will give that about a minute. Maybe less than a minute. Everyone is answering very promptly which is fantastic.
Donna: Well that is great. We have got some people who have had 20. Wow!
Tim: Good grief.
Tim: Okay, so the numbers that we are seeing are by and large numbers of zero to three. A few are outliers and we were talking earlier about these trends that we see with notifications, Ben, where you see the majority of people who notify are notifying say one case a year and then a handful of sort of specialised clinics are perhaps where they are doing this a lot.
Ben: Yes absolutely. So in Perth it is in clinics that are sort of specialising in a service for men who have sex with men primarily. Or I think perhaps other places that have specialist services for Aboriginal people also tend to see more syphilis.
Tim: Yes, and I guess that is why it is such an important topic to go through, that this is not something that run of the mill GPs are seeing routinely. It would be normal to not feel particularly familiar or certain and to really need to call out and ask for help with it. So it is great to get this education out there. If you have not seen many cases of syphilis throughout your clinic, you are probably the norm. So that is probably the important message.
Donna: Yes, the important message is to be aware of it. So we might move on to the next slide now. So syphilis is caused by a spirochaete bacteria, Treponema pallidum and it has an incubation period of nine to 90 days, approximately 30 on average. The typical chancre which appears at the site of sexual contact is a painless, bloodless, well-defined ulcer. It is caused by an endarteritis. So syphilis is actually a systemic disease from the get-go. And what a lot of people do not realise is that we are now seeing more early neurosyphilis. So this is not tertiary syphilis, this is early neurosyphilis in the primary and secondary stages and presenting in quite strange ways that you would not normally associate with syphilis. So, uveitis, cranial nerve palsy, meningitis, stroke or seizure. And you can imagine that those could be referred to any sort of a specialist apart from a sexual health physician or an infectious diseases physician. So it is important to keep that in the back our minds. And especially patients who are HIV positive, they might be more likely to present this way.
Then if we move onto the next slide.
Tim: Donna, just to clarify one point. So that slide out in the right hand side is a tongue?
Donna: That is a tongue.
Tim: I was wondering what that was earlier. They are not the greatest pictures, so our apologies. And that is a chancre on the left-hand side.
Donna: Yes. So we have got a chancre on the penis, a chancre on the labia, a chancre in the perianal area. But I thought it was really important to show chancres on the tongue and the lips because there is a lot of oral sex going on. I do not know any patients who use condoms for oral sex, and syphilis spreads very well with oral sex. So, we need to be aware of that.
Tim: Yes. And I guess the other important thing that we covered before was this idea that chancre is not perhaps, well it is the classic presentation but it is not the common presentation.
Donna: No, and a lot of people will go through the stage of primary syphilis without having a chancre or without having a chancre that they know is there. Because if you think about that chancre on the labia, someone might not know it is there. And it will go away by itself in a few weeks. So, yes, a lot of people just will not know.
Ben: It could also be internal to the rectum or the vagina.
Donna: Yes. And it could be inside the mouth and you do not know it is there because it is not painful.
Tim: And the other thing that struck me just going through these slides, was now very occasionally I would see say a cranial nerve palsy but I would not routinely test for syphilis, so it is just something else to think about with these sorts of interesting neurological presentations.
Donna: Yes. Yes, and I am not saying you need to test everyone for syphilis with everything, but it is just something to keep in the back of your mind.
Tim: We will change slides.
Donna: Yes, so then without any treatment, syphilis will apparently go away but then it can come back as secondary syphilis, so typically six to 24 months afterwards and this is when people get quite systemic symptoms, flu-like symptoms, fever, muscle aches and pains, but they have the classical rash and you can see there the classical rash on the hands and the soles of the feet. We all know that. We remember that from med school. And we might also remember the condylomata lata which you can see quite a florid example of there.
Tim: Bottom left that is.
Donna: Yes. Now, unfortunately I have heard from various colleagues that sometimes that gets treated as genital warts and they get burnt off which might get rid of them, but certainly does not get rid of the syphilis. Sometimes the rash presents in strange ways in different parts of the body and you know, that rash there on the face, and I have personally seen that a long time ago when I was a young doctor, and it took me some weeks to figure out what that was, so the patient went and merrily spread that for a while. And then the typical moth-eaten appearance of the hair loss, and also people can lose their eyebrows as well.
Tim: So just a point you made earlier. The condylomata are sort of much more moist looking than a classical genital wart.
Donna: Yes, and they are swarming with spirochetes, so if you see them put on your gloves. Then we have tertiary syphilis which we very rarely see these days thank goodness. It is rare. It occurs you know, two to thirty years after the initial infection and luckily even in the absence of any treatment, only about 10% of people will go on to develop tertiary syphilis. Now that does not mean we should not take syphilis seriously in its infectious stages, but this is not something that we see commonly.
Tim: So next slide we deal with congenital syphilis.
Donna: Yes, and the congenital syphilis.
Tim: Oh hang on, I just clicked on the link there. Sorry. We can continue on. We are not changing slides though Lisa sorry. Just bear with us. Apologies everyone, we are just getting our technology sorted.
Donna: Okay so now we are moving onto congenital syphilis and for me as a public health physician, this is really the pointy end of syphilis, because infectious syphilis is a curable condition. It usually does not make people terribly sick. But congenital syphilis, the way I see it is probably a failure of our health care system. This is totally preventable. It has you know, long term serious consequences for the baby or you know, the baby may be stillborn, and it is something that as a developed country, we should be able to prevent 100%. Unfortunately, we are not there at the moment and when we get to the part about the epidemiology of it I will talk more about that. But this is what we need to be preventing, and not to be seeing. But unfortunately, we are seeing more and more of it, in not just Australia, but other parts of the Western world as well.
Tim: So you know we are seeing this resurgence of syphilis and you know, just thinking through the clinical presentation, a lot of the reasons for that is that we do not see the classical presentation a lot of the time. So it sort of, it hides and it is missed quite easily.
Donna: Yes, and it you know, it is a great mimicker, so it often can be missed. And the other thing about syphilis is that it has this up to two year infectious period, where patients can be merrily spreading it without knowing. And so that makes our life a bit difficult.
Tim: Thanks, Donna. So the next slide is about testing.
Donna: Yes. So testing for syphilis. If you see a syphilitic skin lesion like a chancre or those moist, warty condylomata lata, take a dry PCR swab and that will you know, tell you the answer. But at the same time, it is also a good idea to take venous blood, because with venous blood, we test for the treponemal specific antigens. They stay positive for life once someone has had syphilis. The non-treponemal part of the blood test indicates disease activity and is used to monitor response to treatment. So that is really important, because after you treat your patient you always want to know, well are they getting better and if we do not have the venous blood test to measure their RPR, we do not know if they are getting better, we do not know if they have been reinfected. The other test, and I have noticed just from looking at some of the names of people who I recognise, I think you are working in some of the Aboriginal community controlled health services that have a point of care test, and this is something that is being subsidised by the Commonwealth Government as part of their national response to the outbreak in Aboriginal communities. Some places will have access to a point of care testing. This is like a little test strip. You can use finger prick blood or venous blood on it and it takes 15 minutes, you know, and then you read it. A bit like a pregnancy test. There is no MBS rebate for this at the moment, so it is only health services that are getting it subsidised through the outbreak response. Very important to take venous blood at the same time for lab testing because otherwise we cannot monitor the response to treatment. And if you know someone has already had syphilis, do not do the point of care test because it will inevitably be positive. It will not tell you very much about what to do now. And before we move onto the next topic, is there anything that Ben or Tim you want to raise with testing? Because I actually have a question that I would like to ask our audience.
Ben: I do not know if it will ruin your question, but I was going to say sometimes I get questions from GPs when they have a query syphilis case, about exactly what they should request. I think some practice software might provide people with it, but I suppose there are a lot of different tests there and a lot of our labs if you write just syphilis serology of whatever, we will do all that automatically based on their own algorithm. And so people when they are ordering the test do not need to know what to ask.
Donna: That is right. Yes, they just need to ask for syphilis serology and all our labs in Australia will do initially the treponemal specific test, and then if it is positive, they will move on to do an RPR but if that is negative, they will just report that as negative and that is really all you need.
Ben: The other thing I was going to say is, some people do not know about the PCR test for syphilis. So it is great that it is there and a really useful part about that is that when we are getting to treatment and the length of treatment, if you can swab something and find that that ulcer is positive for syphilis, you have got a really good argument that you have got infectious syphilis and the person only therefore needs one dose of treatment which is much easier than three weekly doses. So it is really good to pounce when you see an ulcer and swab it. It is not just for academic purposes.
Donna: Definitely. And also, if you see an ulcer you know, like it could be herpes so our labs in WA will routinely test for all of those, you know if you ask and so that is also good because it gives you a definite diagnosis and it also helps from a public health point of view, because if you know it is a chancre, you only need to contact trace back you know, three months and however long they have had the ulcer, which is much more manageable than if you are trying to contact trace back up to two years, and that is just really hard for most people.
Tim: Well let’s get to your question, Donna.
Donna: Yes, so my question is, we are going to move to treatment next, and I would really like to find out from people, what sort of penicillin is the right treatment for syphilis?
Tim: So we are putting that out there for you to answer in the question box. We will give it a moment or two. Not many answers so far. So the question is what sort of, oh there it goes. Yes, here we go it is all coming in. Yes, so we are seeing mostly the correct answer. A few slightly incorrect or confusing answers. And this is a trick question in lots of ways, because people sort of get themselves caught up in the name of the penicillin and it can result in the wrong treatment. So Ben, do you want to talk about the right treatment?
Ben: Yes, so look I have seen lots of different things used for treatments. One mistake I have seen a few times is benzyl rather than bezathine penicillin. Benzathine penicillin is a long acting form. Benzyl is a short acting form, and benzylpenicillin you need to give it four hourly so not really the ideal thing. So it is benzathine. The other one is procaine penicillin which we have seen a few times. Really, benzathine or what is sometimes just called Bicillin as well, is the correct treatment.
Donna: Well it is long acting Bicillin. Because there used to be a short acting Bicillin. You cannot get that anymore, thank goodness. So you can treat syphilis with procaine penicillin injections but you need to give it daily for ten days and I would challenge any patient to present every day for ten days for a painful injection, so I would not recommend it.
Tim: And there was one answer there that I absolutely loved. It was John, no it was not John, it was someone who said, as per the guidelines. Which is the same answer I use.
Donna: I must say, looking at those answers I feel quite heartened, because there is a lot of benzothine penicillin or LA, you know long acting penicillin so that is really great. And we have even got a few people giving us the correct dose which is lovely to see.
Tim: Okay, well let us move onto the next slide. So this is the treatment information. So it is a bit of you know, you can see there that is a, well it is a very viscous, thick injection. They are reasonably sizable. They need to go into the buttock and they are not particularly comfortable to give, Donna are they?
Donna: No, they are not that nice to give. It is like giving toothpaste injections, you know. Two mils in each buttock. And people are quite sore afterwards. I think the other thing to remember is that penicillin is the gold standard treatment for syphilis. If I had syphilis, I would want penicillin because I know it is going to cross the blood-brain barrier. And so if someone is allergic to penicillin, there is a good reason to get that properly investigated and even consider desensitisation so that they can actually have the correct treatment. And definitely if you have a pregnant patient, well you cannot be treating them with doxycycline. So, you know this becomes even more important that they get the benzothine penicillin treatment.
Ben: Yes so the really important point is, it is a systemic disease, it needs to get, you need to get a large dosage throughout the body. It needs to get through to the brain and this is why it is a very specific type of treatment in a very specific way.
Donna: And sometimes we have GPs who say, oh it is really hard to get bezothine penicillin from the community pharmacy so do not worry. If that is the case, call your local public health unit and they will help you source it or even give it to you. We would rather supply it, is that right Ben, than to have people go without.
Ben: Look we try lots of different ways to do it, there are lots of different options but as one sort of last resort we actually will ship it out to you as well. There is also a move to have it in the doctor’s bag. It is not quite there yet, is it?
Donna: That is right, yes. So the doctor’s bag approval has been approved but the implementation I think is probably still a few months before that happens.
Tim: I will not be holding my breath on that one, Donna. They never have them for us, so. Look I think there are ways to source the treatment if you need it. Contact your local health department. You know, particularly in WA there is a real effort to try and make it happen because it is so important to get it right. If you are interstate, outside of WA you will probably find a similar arrangement with your health department. The only other thing I was going to say, is you want a nice long wide syringe with that.
Donna: Oh yes, definitely 16 gauge.
Donna: Yes, that is what I give it with, a 16 gauge. Yes, but well…
Tim: I was going to say 19.
Donna: Well, 19 yes.
Tim: So look wide because it is viscous and hard to get out and it stings as it goes in and you want to warn the patient.
Donna: And warm it up. I like to give it to the patient to roll in between their hands to warm it up. That at least gives them some feeling of control.
Tim: Yes, great. So the next slide is really about, we are going for the epidemiology now, aren’t we?
Donna: Yes, so we are not alone. You know, we are part of a worldwide trend of syphilis. So in the United States, in Canada. And also in our close neighbour, New Zealand. So New Zealand only last month released a National Syphilis Action Plan in response to increasing rates of syphilis, but what I think is very concerning and I think you know this is what you know, drove them on into doing this, is in a population of 4.4 million, in three years they had nine cases of congenital syphilis and that includes five deaths. So congenital syphilis has a case fatality rate of around about 50%. So, you know this is a serious issue. And in New Zealand as it is here, it is not in a particular group, it is all groups and all sections of society that are involved.
Ben: It is also a bit understated because women tend to be more vulnerable I suppose, that end up getting syphilis and the issue too is the tendency to have terminations in response to a diagnosis of syphilis. We have had a couple of cases like that and I have heard from other places that that happens as well. So it is a bit of a tip of the iceberg phenomenon as well.
Donna: Yes. So what is happening in Australia? We can see from the national notifications that it is going up in Australia across the board, and you can see from that map the areas you know, that are the most affected by syphilis and those areas are pretty much in keeping with the national outbreak in Aboriginal and indigenous people. And that started, that outbreak, started in 2011 in Queensland and you can see from this next graph, it basically marched across the top end from Queensland to the Northern Territory, then it went to the Kimberly region of Western Australia. Then it went to South Australia and now within Western Australia, it has moved south into the Pilbara and into the gold fields. We have got a very strong national response. But you can see there from my timeline, that the national response really started some years after the outbreak had moved to several jurisdictions in Australia. And with you know national government responses, there is always a lag time. You know, nothing happens as fast as you would like. But now that it has happened, I think you know we have got a very strong national response and so I was talking about the point of care testing that is funded through the Federal Government. There is a big increase in federal funding for the outbreak affected areas across Australia. There is also part of that federal funding is funding the Young Deadly Free campaign which is a syphilis campaign if you are not aware of that resource. There is information there for practitioners as well as for patients. Go and have a look. They have got some pretty cool resources and videos that you can use. And our own Health Minister, Roger Cook just last week launched a suite of sexual health resources and funding initiatives to tackle the indigenous outbreak within Western Australia.
Now the next population affected a lot by syphilis is gay men and men who have sex with men. And as we have seen reductions in HIV notifications due to pre-exposure prophylaxis, we have seen an increase in syphilis and notifications of other bacterial STIs like gonorrhoea and chlamydia. There is a lot of work being done in this space and so I do not want to spend a lot of time on it, but apart from to just say that men who have sex with men are not always obviously gay, so it pays to ask people if they have sex with men. And if they do, to be offering testing. The men who are on PrEP I think are very well tested and they are well linked in with care. And there is a lot of national resources to help, one of them being the Drama Down Under.
We might move onto the next slide. Oh okay, so this is a slide showing infectious syphilis in males and the increase that you can see there in the inner and outer regional and also the major cities is what I would say a proxy measure of the trend of syphilis increasing in MSM, because in those parts of Australia, the vast majority of cases in men are in MSM. If anyone has not seen this particular website, the Drama Down Under, there are a lot of really good resources there targeting gay men and part of that website is gay men can contact trace each other. They can use it to send SMS’s or emails to each other saying that you know, you have been in touch with syphilis and you need to get yourself tested and a lot of good resources there for practitioners as well. So Ben and Tim, anything that you want to mention about gay men and syphilis?
Tim: I think just the idea that reinfection happens quite easily as well and that is sort of one thing, you know, so the opportunity to treat is the opportunity to really educate and actually move things forward, so yes, that is probably the one thing I have sort of encountered.
Ben: I think the one thing for me is that there is men who identify as gay and I think quite a number of those are very well educated and very good at accessing services. The group that worries me is men who may have sex with men and women and who may not identify as gay and may not be openly gay, and they may not be accessing services as well. And also in Perth, I think there is a group of CALD men who maybe come to men for uni or for other reasons and I think they are more at risk. They are not as educated. And so there is a couple of groups but by and large the men who have sex with men can be the people who come into your clinic and tell you exactly what tubes and swabs and everything they need.
Donna: Yes, they know it all. Yes and they are very literate.
Tim: Sorry, I should just explain there, CALD as in culturally and linguistically diverse.
Ben: Yes, exactly.
Donna: Yes, and I have certainly seen a few of them in my practice in the M Clinic, and the ones who come to see me at the M Clinic I would say probably are far more sexually health literate and more open, but even a lot of them are not open, they say, oh I only come here when I am visiting Perth from overseas and I cannot access healthcare back in my home, because it is just not appropriate and they would feel stigmatised. Or there is no such service. And they also say, well I actually have a lot of them say, I have a wife and family back home and they do not know that there is part of my person. So, there are women who are at risk because they do not know what their men folk are getting up to and some of those men do not realise what risks they are putting themselves at.
Tim: That is a question I have, Donna. Which is if you are the partner of someone who has had syphilis, what is the infectivity like? You might answer that, Ben?
Ben: Very, very high. If you are the partner of someone who has infectious syphilis, from memory primary syphilis is somewhere in the 80s I think.
Donna: Yes, 80% or 90%.
Ben: It is high.
Donna: It is really high.
Ben: And that is why we actually treat. If you have a contact, we treat them. We do not wait for testing or anything, it is treat. So it is that infectious.
Tim: Yes. Great points. Shall we move on?
Donna: Yes, we will move on. So this is the emerging outbreak in Australia, is in heterosexual people. And we can see here a graph of infectious syphilis notifications by region of residence for females. Now, the top line there that is very high, that is the outbreak in remote areas in Aboriginal women. But what I would like people to focus on is, the lines down at the bottom which are a proxy for heterosexual spread within you know, metropolitan cities and what we would consider mainstream Australia. And it is a bit swamped in this graph because of the high rates in Aboriginal women in remote areas, but if we move on to the next graph, this comes from Victoria so around about Christmas time last year, Victoria put out an alert saying that syphilis cases are continuing to rise. They had four cases of congenital syphilis in two years and these were the first cases of congenital syphilis that they had seen since 2003. So you know, it is not something that was being expected, and again you can see the 50% fatality rate. And if you look at this graph in Victoria, you can see those top three lines, and that purple one in particular, that is sort of exponentially rising, that is happening in women of childbearing age. So, a real concern there. And this is a proxy for syphilis in the mainstream heterosexual population of Australia. That is Victoria.
The next graph actually shows you what is happening closer to home. So this is in Western Australia and if we look at that red line, so that is non-Aboriginal people in the metro area, what I would consider a proxy for heterosexual spread in non-Aboriginal people in Western Australia, that is going up. And we have had in the last 18 months, two cases of congenital syphilis. Touch wood, no deaths but I do not want to speak too loudly about that because I do not want to be tempting fate. So, again you know, we are seeing congenital syphilis and the last case that we had was back in 2013 so you know, this is a worrying trend that we are seeing with our population of just over two million.
So, what I think we will do now is hand over to Ben who will talk about you know, some of the typical kinds of presentations that we see and the issues that we face.
Tim: Thanks, Donna. Ben.
Ben: Okay, so I am just talking through three cases. Now these cases are combinations of cases that we have seen. We did want to preserve the privacy of individual patients. Having said that, nothing is made up, everything has occurred, it is just a mixture of cases. But it is highly realistic and in fact it could be many, many cases that we are see in pretty much each one.
So I will start with the first case here. So, this case was a 40-year-old male that presented to the GP because he was concerned he may have HIV. He reported to the GP that he had recently had unprotected sex and that was the reason why he came in. He reported that the woman was not a sex worker, because he was actually asked that. And that the sex occurred in Australia. I got the feeling that the GP was a little bit puzzled as to why the person was concerned about HIV, which was why the sex worker question was specifically raised. After this patient saw the GP they did actually develop a rash and the GP then performed syphilis serology and the results came back as TPPA positive and EIA detected and if you remember the slide that Donna showed you, they were sort of on the top half of that slide and then the RPR which I think Donna mentioned sort of, I think you referred to it as sort of a sign of activity of syphilis was sort of the way it was said. So they were the results and the GP had looked at previous serology and we did as well and we could not find anything else at that time. So at that point we were involved and we actually spoke with this man and on further questioning, we found that he actually predominantly has sex with men and he has had sex with 15 to 20 males in the last few months. And he had not disclosed this to his GP. I do not know if that was because of the way he was asked, or perhaps also because he did not want to tell his GP. But the female was the wife of a man he has had sex with at a private swingers party. And this is a bit of a theme that we have seen coming through a little bit more, that these private swingers parties in parts of Perth – that is a bit of a tongue twister – is becoming a little bit more common. And he reported that the event was advertised on an App and actually he normally finds partners through these Apps.
So next slide. So I suppose the first thing is, the use of these Apps is a bit challenging. So this case was a case of obviously secondary syphilis. We saw that rash developing, so he was treated because it was secondary syphilis, that is in the broader group of infectious syphilis, so he was treated as infectious syphilis which is a one-off dose. Now, you will often see it written as 1.8 grams of benzothine penicillin. Annoyingly on the package it has it in millions of units, so it is 2.4 million units just to be extra confusing I think. But that is a one-off dose. When I say one-off, I mean one-off in time, two doses, two injections I should say to get the 1.8 grams or 2.4 million units. And unfortunately for this person, it was not actually possible to contact trace his contacts. The reason being that he used this App and the way the party was advertised, was that it came up on the App and it was immediately taken down after the party occurred. And that is not an uncommon thing as well. And you know, we spoke to him about the address of the place and he was actually quite, you know, he was trying to help, this man but he could not recall exactly the address of the place and even spent time I think on Google maps for the, I mean this is not one case, but for the specific one that I am thinking of, spent time on Google maps but just could not recall where he had been. I think he has been to a few houses for these liaisons. So it was not actually possible to contact trace.
So you know, what are the key messages here? I think the first is that men who have sex with men and the heterosexual community are not mutually exclusive. So Donna spoke about these three outbreaks. So we have Aboriginal people, mostly in regional areas. We have the men who have sex with men outbreak. But there are men who have sex with men and sometimes women and men who have sex with women and sometimes men. So these outbreaks are not mutually exclusive which is a bit of a problem. The other one is skill in history taking can obtain additional information, although I recognise that sometimes it is hard when someone does not want to tell you. It is important too to ask and not presume. I have had some GPs, a minority of GPs, I think many do it well, who have said to me he did not look gay. And I am not sure what that looks like. But I think most GPs understand that you cannot tell just by looking or that presumptions are not always true.
The other one is online Apps are creating anonymous sex and that is really difficult to manage from a public health perspective because how do you find those people?
Tim: Yes, one of the difficulties I find as a GP is that you might see say, this sort of gentleman and you might be looking after his wife and children so it is actually very hard for him to sort of, of that person to actually come forward and feel safe actually notifying the GP that there is sort of other sort of issues going on. And I guess that means as a GP, you really have to adopt the most defensive position possible which is you know, assume that anything is possible and order all the tests.
Donna: Yes. And you know, sometimes in the M Clinic I will see guys who say yes I do have a GP but I am not going to see him or her about this particular issue because that is my family GP and my family goes there. So if I have got syphilis or I want a sexual health check-up I am going to come to the M Clinic. And so it does fragment care, but I guess if it makes people feel more comfortable then I guess that is important that they get tested.
Tim: Yes, absolutely.
Ben: And it is not only that people go to specialist clinics for that. They sometimes just go to a random you know, a medical centre that is completely random to them. They have never been there before, but for the same reasons.
Tim: And just the assumption that an STI check is a check for everything that anyone could possibly have ever basically, which is such a flawed assumption. But it is often a very common presumption that someone makes. So you know, I think that is probably part of you know, understanding well what does the patient understand as testing and you know, what do we need to do?
Donna: And in our pod cast which we did a few weeks ago, Tim and I, you know we talked about how sometimes if someone walks in for an STI test, you might just order a urine test for chlamydia and gonorrhoea. But if they have come in asking for an STI test, probably we need to be a bit more comprehensive, don’t we?
Donna: Yes, because they probably have put themselves at risk of lots of things.
Tim: I think you know, particularly when syphilis has been such a rare condition in the past, it probably gets dropped off the list of high priorities and that is why it perhaps has been overlooked or could be overlooked and I think it is just a reminder to GPs that, think about syphilis in the screening sense with or without symptoms and you know, that risk is there in most sexually active populations.
Ben: Okay, so the first case was about a man who has sex with men and a cross over to the heterosexual community. So the second case is a 34-year-old female and she also presented to her GP, the reason being for infertility and we have had a number of these cases actually. She and her partner had been trying to fall pregnant for more than one year and there was a referral that was being made to a fertility specialist and the fertility specialist asked for some screening tests and one of those tests could be relevant. Here we go. So the syphilis results came back. You can see they were TPA positive, EIA detected and then RPR which once again was that measure of activity and there had been no previous syphilis testing done.
Tim: Just to clarify that RPR then, we have had a 1 in 16 and a 1 in 32. They are obviously a strong positive. So what would a negative look like?
Ben: Yes, so RPR. Well you can just have a negative. And so often if you have say, there is some complexity here, but if you had had syphilis for years and never been treated, there would be a proportion who would become negative and there would be a proportion that might have sort of a result like one or two kind of level. A result of 16, 32, 64, 128 – those are probably more common in the earlier stages of syphilis but it is not always quite so simple. There are lots of reasons why it could be lower, so really early in the disease it can be low. Late in disease it can be low. Partial treatment through randomly getting the antibiotic for another means is another reason for it to be low. So RPR interpretation is a little bit difficult.
Tim: Great, thanks.
Ben: So obviously with that result, the GP recalled her back and there was sort of further history taken and the GP if I remember for one of them was actually really quite detailed and had discovered there was a rash about two years ago, a bit uncertain if that was relevant or not, and she actually on quite thorough history from her GP reported sexual contact only with her partner and was asked pretty nicely and in a few different ways, but said no it has been more than five years that I have had the same partner for. And so of course, the finger pointing went elsewhere and the partner actually came for this one and the partner was brought in and there was discussion by us and the GP with the partner. I think it was her husband, actually, and he also denied having sex with anyone else in the last five years. Now, there was some issues there. There was a laboratory result down there which was a TPPA positive, EIA detected and RPR of 64, and I think they were actually treated presumptively for infectious syphilis but there was a discussion about the need to maybe test, sorry to treat for non-infectious syphilis because we were not quite so sure from memory.
Tim: So that would have been a tense impasse.
Ben: Yes, absolutely. So I suppose the reason I brought up this case is that sometimes when we do these sort of cases, we have really nice clear cases, but I think the message here is that there is not always clear risk factors and I mean that more broadly too. People make presumptions that someone with syphilis will have, you know, they will be obviously, they will be promiscuous, they will be a sex worker, they will be openly gay, they will be whatever. You know, they will be Aboriginal perhaps. But it is not always clear what the risk factors are in syphilis and that is really annoying to me as an epidemiologist. But that is just the way it is. And at the moment, we cannot always find the risk factors for a bunch of cases that we are seeing. It is not clear. And the other reason I brought up this one is that, and this is another thing that is annoying from a sort of public health point of view, it is not uncommon to feel that you are probably not getting the entire story. So very, very likely there one of them is lying.
Donna: I think one of them has to be lying because it is not possible for two people to get syphilis off each other if they have only been with each other.
Tim: And I guess that you know, this is really where it is wonderful as a GP to have both of your prospectives in terms of communicable diseases because it is the level we do not see in general practice which is the patterns of syphilis are really chaotic and unpredictable and they can strike out of the blue and that is why we do need to be thinking about it more broadly. That is why this session is such a good reminder because although, for all of us out there who see one or if there are a few cases, we do do a lot of screening, don’t we? And we probably just need to be thinking about this even if the result is negative that we are adopting that defensive position and being thorough.
Ben: Absolutely. And the third point there was, although this man may not have sex with men, it would be common for a man in this situation to withhold that information, I think we could all appreciate. And when we get these situations we do wonder if this is a man who is you know, very worried about his marriage and that one reason why he is not disclosing other partners is that they are actually men and he has fears for his relationship.
So the third one. So we started with the men who have sex with men and the cross over to the heterosexual community. The female heterosexual women where there are not always clear risk factors for syphilis. And we are moving onto the third case now which is a 30-year-old female who presents eight weeks pregnant to her GP and as probably many of you have done even today, perform the routine antenatal screening tests. And perhaps surprising to everyone on this webinar, her antenatal screen was completely normal. TPPA was negative. But obviously that is not the end because that would be a bit of a boring case. So, when the child was born at 38 weeks, and this is a combination of a couple of cases, the child showed signs of foetal distress. So the child at birth was noted to have clinical signs of congenital syphilis including vesicles on his feet and there was a whole bunch of tests done which I have just summarised there as the antibody was detected and the RPR was 64. There is a lot of detail about that testing but I do not think we need to go into that.
Tim: Active syphilis though was the short answer.
Ben: Yes. So, the question is, how did that happen because at eight weeks everything was fine. And so there was obviously a lot of investigation here and the husband reported sexual contact with another women earlier in the pregnancy and was positive for syphilis as well. I think one of the cases the men actually had a chancre from memory, but I cannot quite remember now. So I think the key messages here are fairly obvious, but the first one is that high risk women should be tested multiple times during pregnancy and that is in the guidelines. So what is high risk is the problem? So, sometimes that is obvious. But there are a few nuances there. This woman, I just do not know how you would identify because she had no idea obviously that her partner, or she did not seem to have any idea and it makes sense to not have any idea that her partner was cheating on her. So according to her she is not high risk. But sometimes people do actually change partners while they are pregnant and if that is to occur, that is a reason to test again as well. But the second point there is it can be really hard to identify people at risk and that makes it really difficult at the moment, what to do in these situations and there is a lot of talk that Donna and I and everyone in WA has been having about this issue at the moment as well.
Tim: If you think about say a recommendation of routine testing?
Ben: Yes, so look this has been the discussion but it is a really hard one because lots of women are getting pregnant every day in WA and while one case or two cases is more than you know we want, as is always when you add screening tests lots of things you need to consider. And when to introduce that. And I think that is what New Zealand has done, is that right Donna?
Donna: Well, they have not introduced it across the board, so quite a few health districts have introduced universal 28 week screening but it is not a national thing yet. It certainly is being talked about in a lot of settings. For the Aboriginal remote area outbreak, that is quite clear. There is a set of national pregnancy care guidelines that says if you are living in one of those outbreak areas, you should be screened for syphilis at the time of booking, at 28 weeks, 36 weeks, at delivery and six weeks postpartum. So, but those outbreak areas, I guess they are relatively small populations with very, very high rates. What we are talking here is you know, that the bulk of people and how do we identify who is at risk? I think it is very, very hard to know. We are in a bit of a quandary.
Tim: Well you are dealing with a heterosexual population so it is, you know, we talked about that chaotic distribution and that is why it is really, really difficult. You know, the message for me is you know as a GP we are often sort of swamped with pathways and checklists and so forth and one of the ones I know on the shared care checklist is that you do do the syphilis serology once during pregnancy. Well, maybe we need to rethink that.
Ben: Yes, and I think perhaps it will change in time and I think if there is any hint of an additional risk like changing a partner, then that is a clear message to think about retesting. And I think the other thing that comes through with some of these is that…
Tim: Sorry, we have got a question and it does sort of relate to congenital syphilis.
Ben: Yes, so I suppose the reason why I did not say absolutely not, so the question we had here was could one of the partners have caught it five years ago and still be positive now? So, the RPR would be suggestive that it was more recent than five years ago, but I suppose you never completely know which is why I did not say absolutely not, but it would be unlikely.
Donna: Yes, I think it would be unlikely.
Ben: In the vicinity of very, very.
Donna: Because syphilis is infectious for two years. Now, if they had said I have only had sex with the same partner for the last two years, I would believe that story but I do not know of any syphilis that is continuing to be infectious after two years.
Ben: So I suppose the question would be, say if one was infected five years ago, met this partner and they infected the other one and then they both ended up having syphilis. But they have got an RPR of 16 to 64.
Donna: Way too high.
Ben: Yes. So it is very high for five years post.
Tim: So we have got that question came through. We might skim through the remainder of the slides and open up to questions. So if you are thinking of questions you might want to start sort of posting them up now.
Ben: I just want to, so one thing about that previous slide just to finish off the three cases. So just to link that back with the epidemiology that Donna has been talking about. So there is an interesting kind of difference between rates and overall numbers. We have this really sort of interesting situation where we have extremely high rates in those Aboriginal communities in remote and regional sort of parts of the north, you know Queensland and Northern Territory and northern WA, and then we have quite high numbers in men who have sex with men in many areas. And then with the heterosexual community we have quite low rates but because there are so many of those heterosexual people in metropolitan communities, the numbers actually start to kick up. So when you start to look at those lines, you think oh we do not have to worry about that, but most people are in that group. So the numbers are actually becoming quite high. With men who have sex with men, the numbers are really very large as well.
Tim: There are some questions coming through. We will come back to them, but we might just skim through the remainder of the slides. So the implications for practice there, Ben?
Ben: Donna was this one you wanted to do?
Donna: Oh we can do it together. Look I think we really want to just say have a high index of clinical suspicion for syphilis, especially you know of syphilis in all its various disguises. A lot of patients are not aware that syphilis is a thing and it still happens. They think it is from the days of the Ark, so we have a role in educating people that it is real and that it is here. I think especially with pregnant women, asking about sexual partners and partner change. But you know in any patient it is good to ask about partner change, because people do not mind us asking, but they are probably not going to volunteer it unless we ask. And if we detect the risk then we should be proactive in offering testing. I think we have already talked about syphilis you know, testing. Like when should we be testing? I know we have got some questions coming up on that. Ben do you want to talk about the partner notification and contact tracing side of things?
Ben: Yes. So, it is really good and think through some of the cases we have had, if a GP diagnoses cases of syphilis, very often the GP is quite a trusted person and so the chances of a GP asking about other partners and getting a good list of people that they have had sex with is actually quite high if done well. So I really appreciate when GPs make that effort. Because when we try to do that, we are starting kind of at a disadvantage because we are a random person that rang on their mobile and started asking them about sex which is a bit confronting to a lot of people. So it is really good if GPs can just get that list of partners that people have been to. And the other one is encourage them and upskill them into telling those partners if possible, and if not it can be a referral to us to help out.
Tim: Well we might quickly skip to the resources, Donna.
Donna: Yes. So we have got some resources here. I think for health care providers, you know I work for the Health Department and I would recommend that people look at the Silver Book and I can see from the questions that some people are already very familiar with the Silver Book. We have recently revamped it and made it a lot easier to navigate within the Silver Book. For your patients, I would like you to consider this website which is put out by the Australian society of HIV medicine. It is called All Good Now. It has got really good information for the general public and it is in multiple languages as you can see there. So you know, that might be something that you can use to help educate your patients. And I notice there is one question about the pregnant lady. If she acquired syphilis later in her pregnancy, would it still affect the foetus? And the answer is yes. Basically the foetus is at risk any time a woman has untreated syphilis. If it is untreated infectious syphilis, of course the foetus is at much more risk. But even a woman with latent syphilis, the baby is at risk. We like to say that it is important for the woman to be treated and complete her treatment at least a month before the baby is delivered. But having said that, if by the time you get to treat her, the baby has already been infected, then the treatment is not going to prevent those congenital malformations which may have already have happened. Hence the importance of testing frequently so that we can be treating as soon as possible after the woman is infected, but in response to another question, it is sometimes very hard to know who is at high risk. I am just going to put it out there that now that we are seeing more and more syphilis, perhaps we need to think about as part of routine antenatal questioning, every time we see a woman we should be asking about partner change. That might seem a bit insensitive, but perhaps if we say to people why we are asking, they might answer honestly and appreciate the question.
Tim: I think the question really is, well how do you predict who you should be doing more intense sort of testing on, and it is going to be hard to say and you know, I think we need to watch this space as GPs and be aware that perhaps the guidelines may change. All it takes is probably another outbreak similar to the ones that we are seeing and perhaps we could see a change in guidelines.
The next question from Catherine is, for a person who has a palmer rash and syphilis serology is negative, does that mean that they do not have syphilis or does it take longer for the syphilis to become positive?
Ben: So, I suppose an important thing is say someone has had an at-risk behaviour. Put aside the palmer rash for now. But if someone comes in and they have just had sex and they say oh, I have just been at risk and they have a test, then that needs to be repeated. You cannot just say that is negative for now. The palmer rash is a bit of a curly part because it is secondary syphilis you would really expect it to be positive. But I think the more general thing there is that if someone has just been at risk, they need to have that test repeated.
Tim: So perhaps that gets to a question though which is, is there a conversion period?
Donna: Yes. So if someone has a chancre, then it could well be that the chancre appears before any of those syphilis serology tests turn positive. That is unusual, but it can happen. And what Ben was talking about before, was it is possible in the very early stages of syphilis for the treponemal specific test to be positive and for the RPR to be seemingly negative but it is actually not negative. What it is, is it is absolutely off the scale and so it ends up being a negative but it is actually really high. It is probably over 2,000. Then when you test them a bit later it might have come down a bit and that is why we say that when you treat someone for syphilis you must always take their blood test on the day that you treat them, because that RPR is what you are using to measure the success of your treatment against and you are looking for a four-fold decrease preferably within six months of treatment, that is what we would like to see. In some people it takes 12 months to come down.
Tim: Okay Donna, we have got one minute for two quick questions. After treatment for syphilis, when can a woman try and conceive? Quick answers.
Donna: Oh well after treating syphilis you are non-infectious within like about a week or 10 days, yes. But it would be nice to know that the treatment is successful. Absolutely, yes.
Tim: Once treated how long will the blood test…
Ben: Just on that last question, their treatment and their partner’s treatment was successful, so there are a few things to sort out before we can be happy I think.
Tim: Once treated, how long does the blood test stay positive for? Well we have answered that already really.
Tim: And that is the TPHA. And is there any role of testing RPR at less than six months?
Donna: For pregnant women. Yes, definitely.
Ben: Some guidelines for pregnant women say monthly testing so in WA there is monthly testing. The other one is that we would tend to recommend zero, three, six and 12 months. Some guidelines say three or six months. You know, whichever you want.
Tim: Well that is fantastic. Thank you so much for answering those questions and thank you to all the listeners out there for the questions you have asked, they were really excellent. If you have got any additional questions, could you email those questions to WA.events@RACGP.org.au and we will ask Donna and Ben to see if they can answer them for you. So feel free to email us, particularly ideally within the next week and we will endeavour to get back to you.
Donna and Ben can I say thank you so much for presenting tonight. It is such an interesting topic and it really is an important topic for GPs to understand better. Can I also thank you very much to the audience. We have had a very large attendance tonight so we are around 150 attendees. We are really very pleased to be able to present to you and that you are interested in our presentations. If you have got any comments or advice or other topics particularly that you would like to sort of know about in this sort of area, feel free to get in touch.
Donna: Big thank you from me. I am really heartened that there are so many people out there interested in syphilis and interested in what we have to say.
Ben: Yes, from me too. Thanks everyone for coming in.
Tim: So on that note, we will bring the - I was going to say pod cast, but it is a webinar to an end, and wish you all goodnight.