Epidemiological study of an epidemic outbreak of syphilis in Palmas de Gran Canaria

IntroductionIn the last times there has been an increased incidence of syphilis especially among homosexual men. In our department we have diagnosed 11 cases of early syphilis in 6months during 2006, thus confirming an epidemic outbreak.Material and methodsWe carried out an epidemiological survey of patients with early syphilis.ResultsSyphilis was secondary in five cases and primary in six. All patients were men, 70 % homosexual with a mean age of 38.1 years. All patients had or have had other sexually transmitted diseases (STD), six were HIV positive. Ninety percent of the patients admitted having had promiscuous sexual contacts in the past year, and among these, 50 % never used protection, no protection was taken in cases of oral sex and only 25 % reported protection during anal sex.ConclusionsCurrently, there is excessive slackening of protection practices as a method of STD prophylaxis, which leads to an increased number of cases. We consider relevant to insist in the use of barrier methods during oral sex as it is an important source of infection.     

Rapid public health interventions in response to an outbreak of syphilis in Los Angeles

BACKGROUND: Despite national ambitions to eliminate syphilis, occasional outbreaks continue to occur in many areas of the United States. GOAL: The goal of the study was to describe and evaluate the public health interventions in response to an outbreak of syphilis in Los Angeles County among men who have sex with men. STUDY DESIGN: Reported cases of primary, secondary, and early latent syphilis that occurred during an outbreak period from December 1999 to September 2000 were included in the study. The outbreak components of provider awareness, active surveillance, community-based organization recruitment, media campaign, community-outreach education and screening, and a correctional facility intervention were described. Screening results were reviewed, sexually transmitted disease (STD) hotline calls were counted, and a street-intercept survey was conducted. RESULTS: A multifaceted outbreak response was initiated in March 2000. Of the 89 outbreak cases identified, 40% were detected by HIV/AIDS early intervention providers and 26% by private clinicians or health maintenance organizations. Other case identification sources included public STD clinics (10%), STD program case-management contacts (7%), mobile van screening (7%), and correctional facility screening (10%). Screening at high-risk venues detected a syphilis prevalence of <1% and an HIV prevalence of 6%. Weekly calls to the STD hotline increased 600% during the outbreak, and 80% of surveyed individuals cited the media as the source of their awareness of syphilis. CONCLUSIONS: A multifaceted outbreak response was launched to react to an outbreak of syphilis among men who have sex with men. Prompt provider awareness and a preexisting network of HIV/AIDS providers aided case detection. Although the effectiveness of the response could not be scientifically determined, the diverse components of the response were associated with a faster decline in the outbreak than would have been expected. After 3 months, 89 cases had been identified. Outbreak preparedness should include a focus on communities of men who have sex with men, because the reintroduction of syphilis in this population may threaten national efforts toward syphilis elimination.     

Characteristics of individuals with male-to-male and heterosexually acquired infectious syphilis during an outbreak in Calgary,Alberta, Canada

BACKGROUND: Eliminating syphilis is important not only to prevent the sequelae of infection but also to control the spread of HIV. Current prevention and control efforts in Canada have been ineffective in eliminating this disease. GOAL: The goal of the study was to determine the characteristics of individuals with infectious syphilis due to male-to-male and heterosexual contact, diagnosed during an outbreak in Calgary, Alberta, Canada. STUDY DESIGN: This was a prospective study of individuals with infectious syphilis diagnosed at the STD clinic in Calgary between January 2000 and April 2002. RESULTS: The outbreak reported here (September 2000 to April 2002) involves 32 cases of infectious syphilis, corresponding to rates of 0.9/100,000 population during 2000 and 1.8/100,000 population during 2001. Between September 2000 and June 2001, the cases diagnosed were among men who have sex with men (MSM); between May 2001 and April 2002, they were due to locally acquired infections among heterosexuals, including one case of congenital syphilis. Compared to the heterosexuals, MSM tended to be older, be coinfected with HIV, and report excessive alcohol use (versus injection drug use) and had infectious syphilis diagnosed earlier. MSM used the Internet and bars or bathhouses to initiate sexual contact, whereas heterosexually acquired infections were largely among sex workers and their clients. Contact tracing was more successful among the heterosexuals than among MSM. The public health staff at the STD clinic initiated a series of multifaceted interventions in response to the outbreak. These interventions were moderately successful, as measured by the increased numbers of individuals seeking counseling and testing services at the clinic. CONCLUSION: The results highlight key differences in the risk factor-specific characteristics of the outbreak that should be taken into account when designing prevention and control strategies.     

Factors and the sociosexual network associated with a syphilis outbreak in rural North Carolina

OBJECTIVE: An investigation was conducted to determine factors associated with a syphilis outbreak in a rural North Carolina county. STUDY DESIGN: A retrospective chart review was performed on 61 primary (PS), secondary (SS), and early latent (ELS) syphilis case patients reported in Columbus County between January 2001 and February 2002. Sociosexual network analysis was conducted using electronic contact tracing information. RESULTS: We identified 20 PS, 25 SS, and 16 ELS case patients who were predominantly black. Seventy-two percent had reported >or=1 sexual partner with early syphilis, 51% used crack cocaine and/or had sex with a crack-using partner, and 31% exchanged sex for drugs or money. The sexual network exhibited predominantly linear connections between case patients and sexual partners. Adding social connections to the network further demonstrated dense cyclic interactions characteristic of core groups. CONCLUSIONS: The syphilis outbreak in this rural community was associated with crack cocaine and exchange of sex for drugs in a densely interconnected sociosexual network.     

Lessons from the syphilis outbreak in homosexual men in east London

OBJECTIVES: To describe the epidemiology, presentation, and diagnosis of early syphilis in 103 homosexual men in east London. METHODS: A retrospective study using data from KC60 returns, the Health Protection Agency (HPA) enhanced surveillance forms and case notes. RESULTS: 40 cases of primary (PS), 40 of secondary (SS) and 23 of early latent syphilis were identified, 33% co-infected with HIV. 41% had concurrent sexually transmitted infections (STIs). Pain featured in 35% of PS and itch in 13% of rashes. Dark ground microscopy (DGM), performed in 44 of the symptomatic cases, was positive in 37 (84%) allowing early management. Initial syphilis serology was negative in 15/40 (37%) cases of PS. 51% and 49% opted for parenteral and oral treatment, respectively. In 53/103 (51%) cases oral sex was the only risk factor. 86% of infections were UK acquired. Only 4% of contacts were seen. CONCLUSION: This outbreak, reflecting the resurgence of syphilis across the United Kingdom, highlights several important points. Painful chancres and itchy rash are common presentations. DGM is a highly sensitive diagnostic tool. Initial negative serological screening tests are common in PS and sero-surveillance for 3 months is recommended. The high prevalence of concomitant STIs indicates ongoing unprotected sexual intercourse. Oral sex is a significant risk factor and is a distinctly "unsafe" practice. Conventional partner notification is ineffective. Other methods of screening of the at-risk homosexual population are warranted. Continued education is required to reduce STI acquisition in homosexual men.     

An outbreak of early syphilis: cases from North Manchester General Hospital

OBJECTIVES: To describe the features of an outbreak of early syphilis in North Manchester. METHODS: Retrospective KC60 and case note review. RESULTS: In a 25 month period, 10 cases of primary, 22 of secondary, and nine cases of early latent syphilis were diagnosed. 39 were homosexual or bisexual men, 20 being co-infected with HIV. Most infections were acquired locally and in 19/41 cases oral sex was the only risk factor. High rates of unprotected anal sex were reported among the homosexual men and co-infection with other STIs was common. CONCLUSION: This outbreak will facilitate the spread of HIV in the homosexual male population. Unsafe sexual practice is common and the perception that oral sex is "safe" needs revisiting. Delays in accessing GUM clinic appointments must be addressed as part of the control strategy.     

Management of a syphilis outbreak in street sex workers in east London

OBJECTIVE: To describe the control and management of a syphilis outbreak in female street sex workers (SSWs) in east London. METHODS: Following the identification of several cases of infectious syphilis in SSWs in east London, a targeted service for screening and treatment of syphilis and other sexually transmitted infections was developed. A multidisciplinary team (MDT) joined an existing outreach service to facilitate this. Once it became apparent that this was not an isolated case, an outbreak control team (OCT) was established. RESULTS: Between April and December 2004 a total of 14 (58%) women with 15 cases of infectious syphilis were identified in 24 SSWs: 14/15 (93%) received treatment. Epidemiological treatment for syphilis was also given to the rest of SSWs at the initial visit. Several coexistent STIs were identified in this cohort. As part of the enhanced outbreak surveillance in north east London, 21 cases of infectious syphilis were reported in SSWs between April 2004 and December 2005. CONCLUSION: Outbreak management in this population was challenging: an MDT approach was crucial in identifying and treating syphilis to prevent onward transmission. There was a high prevalence of syphilis and other STIs in this cohort, and we treated the majority of cases. The formation of an OCT enabled us to monitor the outbreak and implement control measures more effectively. The novel intervention we describe has proved valuable in helping to control this syphilis outbreak.     

An outbreak no longer: factors contributing to the return of syphilis in Greater Manchester

BACKGROUND: In the past few years, increased diagnoses of syphilis have been reported in cities around Britain and Europe. Enhanced surveillance of cases began in 1999 to identify the epidemiology of this increase in Greater Manchester. METHODS: Information was collected on all cases of syphilis newly diagnosed in genitourinary medicine (GUM) clinics in Greater Manchester between January 1999 and November 2002. The data collected included demographic information and information about other sexually transmitted infections, sexual behaviour, perception of risk of infection, and awareness of syphilis transmission. RESULTS: The majority of cases identified were white homosexual men resident in Greater Manchester. Of the 414 cases diagnosed, 74% had either a primary or secondary stage of syphilis infection and 37% of cases were HIV positive. High numbers of individuals practised unprotected oral sex despite good awareness of the risk of infection with syphilis. There is evidence that the way people are meeting sexual contacts is changing, with increasing numbers meeting most of their partners through the internet. CONCLUSIONS: These findings have implications for targeting interventions. The provision of rapid diagnostic and treatment services is likely to be key for the control of syphilis and potentially of subsequent increases in HIV in the region.     

Responding to a community outbreak of syphilis by targeting sex partner meeting location: an example of a risk-space intervention

BACKGROUND: Effective syphilis control and elimination require community effort and innovative case-finding techniques, especially to identify infected persons from core transmission groups. GOAL: To summarize the implementation and outcomes of a community-oriented response to a localized outbreak of syphilis directed at sex partner meeting places. STUDY DESIGN: Syphilis surveillance and rapid response data from a 7-month period were analyzed for risk behaviors, sex partner meeting locations, field investigation outcomes, and social and sexual network connections. RESULTS: Four (6%) of the sixty-nine persons tested were confirmed syphilis reactors, of whom three were new cases. A sexual and needle-sharing network of 15 persons was identified that included two of the new syphilis cases. These two had not been found through standard field investigation. CONCLUSIONS: Targeting interventions to sex partner meeting places may effectively complement traditional syphilis control tools and find previously unidentified syphilis cases in high-morbidity areas.     

Heterosexual outbreak of infectious syphilis: epidemiological and ethnographic analysis and implications for control

This study describes the epidemiology and ethnography of an outbreak of infectious syphilis in Vancouver, British Columbia. Between 1996 and 1999, British Columbias's rate of infectious syphilis rose from 0.5 to 3.4 per 100,000, with a dense concentration of cases among sex trade workers, their clients, and street-involved people in the downtown eastside area of Vancouver. Sexual networks were imported cases with secondary spread (dyads and triads), large densely connected dendritic networks of sex trade workers and clients, or occasional starburst networks among gay men. Only 232 of 429 partners were documented as having been treated (54% of those named, or 0.9 per case). The geographical and demographic concentration of this outbreak led to consideration of a programme of focused mass treatment with single dose azithromycin.     

Resurgence in infectious syphilis in Ireland: an epidemiological study

INTRODUCTION: In 2000, a syphilis outbreak was identified in Ireland. MATERIALS AND METHODS: A prospective enhanced database was established in 2000. Crude incidence rates for the general population, men who have sex with men (MSM), and HIV-positive MSM were calculated. RESULTS: Three hundred fifty-six cases of infectious syphilis were diagnosed at 1 center. Eighty-five percent of cases were identified as MSM. Crude incidence rates in MSM, ranging in age between 20 and 44 years, peaked in 2001 at 719 cases per 100000 of the MSM population. A total of 17.4% of cases occurred in HIV-infected individuals. Crude incidence rates of syphilis in HIV-positive MSM in the center increased to 7280 per 100000. Similar percentages of MSM with and without HIV infection had unprotected anal intercourse (37% and 41%, respectively). CONCLUSION: High-risk sexual behavior continues among HIV-infected and -noninfected MSM. Crude incidence rates among MSM in Ireland are alarming when compared with other outbreaks.     

Malignant syphilis in an HIV-infected patient

Patients with HIV infection may develop common diseases with atypical clinical features. HIV infection may change the classic clinical course of syphilis and increase the incidence of a subtype of secondary syphilis named malignant syphilis. A homosexual patient with HIV infection consulted us about a one-month history of general malaise and widespread cutaneous ulcerative lesions, some with thick hemorrhagic crusts. Serology for syphilis was positive at high titers. Based on clinical, histological and serological findings, a diagnosis of malignant syphilis was made and the patient started treatment with penicillin G benzathine with progressive resolution of lesions. Malignant syphilis is a rare subtype of secondary syphilis that presents special clinical and histological features and has been associated with several processes characterized by variable degrees of immunosuppression. It is necessary to take into account this entity among the possible diagnoses in HIV-infected patients with cutaneous lesions.