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Congenital syphilis: still a reality in 1996

Michael D Humphrey and David L Bradford

MJA 1996; 165: 382

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Introduction - What is the true incidence of congenital syphilis in Australia? - Diagnosis - Risk factors for congenital syphilis - Measures to control syphilis - Problems in targeting those at risk - Action plan - Acknowledgements - References - Authors' details

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Despite the widespread use of penicillin for more than 50 years, syphilis continues to be a problematic health issue in many parts of the world. In Australia, congenital syphilis is again a significant cause of stillbirth, preterm labour and neonatal disease in some areas (including central and northern Australia). Control mechanisms based on screening, reliable treatment protocols, contact-tracing and adequate follow-up appear to be less effective than they were in the past. It is difficult to discuss such a socially stigmatising disease when it is clear that some community groups are at high risk, and may be offended by and feel disempowered in the face of well-meaning medical debate. If congenital syphilis is to be eradicated, new approaches are required. These include public-awareness campaigns to stress the need for antenatal care in affected communities; involving the community in efforts to prevent syphilis; providing culturally appropriate services; improving notification and surveillance systems; improving the management of pregnant women who present to maternity units without prior booking; and improving the management of syphilis in pregnancy. There is a need to raise awareness that antenatal care is important not only for the mother's health but also for the wellbeing of the baby. (MJA 1996; 165: 382-385)

Introduction

 I n the last decade, much of the world has experienced a marked increase in the incidence of syphilis, with rates in reproductive-age adults the highest since the 1940s. 1 In Australia, notifications of syphilis between 1991 and 1994 varied from 12.2 to 16.0 per 100 000 population. 2 There was wide geographical variance, with reported rates greater than 100 per 100 000 in much of northern Australia; however, all States and Territories were involved (Box 1). The incidence was much higher in females than in males in the 10 to 24 years age group, and rates in Aboriginal people varied from 114 to 913 per 100 000 in different regions. 2 Elsewhere in the world, incidences similar to those in Australia are being reported, with particular emphasis on the high incidence of new and repeated infections in marginalised groups. 1,3-9

In regions where the prevalence of syphilis is high, congenital syphilis is a major preventable cause of perinatal death. 1,8,10,11 In 1994 and 1995, 232 new or repeated infections were notified in women from Cairns and the surrounding region involving Cape York and the Torres Strait (D Brookes, Public Health Nurse, Tropical Public Health Unit, Northern Zone, Queensland Health Department, Cairns, personal communication). Twenty-seven of the 3058 women who gave birth at Cairns Base Hospital during this period had active syphilis complicating their pregnancy (Tropical Public Health Unit, Northern Zone, Queensland Health Department, Cairns [unpublished data]), and eight of the region's 91 perinatal deaths were judged to be due to congenital syphilis in association with inadequate antenatal care (Cairns Base Hospital Perinatal Mortality Committee [unpublished data]).

The main features of untreated congenital syphilis during pregnancy are stillbirth (which may be preceded by non-immune hydrops fetalis), preterm labour and intrauterine growth restriction; in the newborn the main features are hepatosplenomegaly, prolonged jaundice, thrombocytopenia, failure to thrive and radiologically visible metaphyseal changes.

To prevent congenital syphilis, institutional, administrative and cultural barriers to the successful management of the problem must be overcome. The true incidence of syphilis must be determined, diagnostic procedures improved, the risk factors more readily recognised and control measures re-examined.

What is the true incidence of congenital syphilis in Australia?

The accurate diagnosis of syphilis depends on the microbiological demonstration of Treponema pallidum . Serological tests provide indirect evidence of infection, and, without clinical assessment, are crude indicators of whether infection is likely to be recent or long-standing. Nevertheless, in many jurisdictions in Australia case reporting of syphilis is dependent on laboratory notification of positive syphilis serology. Thus, notification of syphilis is based on an arbitrary decision as to whether an infection is likely to be recent, as determined by the rapid plasma reagin (RPR) or Venereal Disease Research Laboratories (VDRL) titre. For example, in Queensland the case definition for notification is based on an RPR/VDRL titre of 1 : 8 or more, in association with positive specific treponemal serology. 12 Cases so notified are likely to be in individuals who have a recently acquired infection, and non-notification of lower titres may mean that there is a degree of under-reporting, particularly in the latent phase of the disease.

No agreed definition of the criteria for reporting congenital syphilis exists in Australia, and only 13 cases have been reported nationally in the last five years, including two in women over 65 years of age (J Irvine, Surveillance Officer, Communicable Diseases Network of Australia and New Zealand -- National Notifiable Diseases Surveillance System, Canberra, personal communication). Thus, the true incidence of this problem nationwide is unknown.

Diagnosis

Definitive diagnosis is by trepo nemal-specific tests ( Treponema pallidum haemagglutination antibody [TPHA], fluorescent treponemal antibody [FTA]) when screening non-treponemal serological tests (RPR or VDRL) are positive, as pregnancy, HIV infection and other conditions (such as systemic lupus erythematosus, rheumatoid arthritis, infectious mononucleosis, and many other diseases associated with autoimmune complexes) can be associated with false positive screening reactions, or with difficulties in interpreting results. 13 Care must be taken to ensure that lack of familiarity with the codes used to express the results of syphilis serology does not lead to failure to recognise the disease and, consequently, failure to follow-up. 5

It is necessary to carefully follow-up all babies born to women who have positive serological tests for syphilis, as more than 50% of liveborn affected infants are asymptomatic. Failure to conduct such follow-up may lead to significant long term physical and/or mental handicap.

Risk factors for congenital syphilis

These risk factors include:

Vertical transmission usually takes place after four months' gestation, so that early antenatal screening and appropriate treatment should prevent most cases.

It is clear that, if screening is not performed, the diagnosis is unlikely to be made in a timely fashion. Therefore, major efforts must be made in the future to alter the way we deliver antenatal care so that it is accessible and appropriate to those at high risk.

Measures to control syphilis

Guidelines for syphilis control, formulated almost 60 years ago in the United States, 14 included the principal elements of public education (including community participation), case-finding, prompt clinical treatment, contact-tracing and routine serological screening (including antenatal screening) of high-risk groups. The implementation of this program in the United States proved to be effective.

However, in 1986 the incidence of early syphilis in the United States increased, 15 with a predictable increase in congenital syphilis accompanying this new epidemic. 16 By 1990, at the peak of the epidemic, African Americans accounted for more than 80% of reported cases of early syphilis. 17 A dramatic increase in the availability of "crack" cocaine (accompanied by an increase in the practice of exchanging sex for money and drugs), increasing poverty, disenfranchisement of minorities and urban decay were some of the reasons for this disproportionate incidence of syphilis in black communities in the United States. 17 The efficacy of control programs for sexually transmitted disease, and especially contact-tracing activities, employed to control this outbreak of syphilis in the United States was seriously questioned. 18

In Australia, we have sought to control syphilis by broadly following the same United States guidelines. In the major cities, where syphilis rates today are minimal, this has served us well. However, throughout northern Australia, as well as in northern Victoria, central Australia and northwest New South Wales, the prevalence of syphilis has remained high, despite our best efforts. Allan Brandt (Professor of the History of Medicine and Science, Harvard University), in No Magic Bullet , argues that a biomedical approach (e.g., case-finding, contact-tracing and treatment protocols) is too restrictive, and that social conditions and other variables need to be addressed. 19 While there will always be a place for contact-tracing the immediate partner(s) of index cases -- particularly of pregnant women with syphilis (as a control measure) -- this is less successful in practice than theory would suggest. Various factors, such as the time involved and the patient's embarrassment and reluctance to contribute to the program, make contact tracing difficult to conduct from the urban consulting room. However, in indigenous communities other factors, such as cultural sensitivity about the discussion of sexual issues outside the family or tribal group, beliefs in what constitutes "men's business" and "women's business" and the dilemma of finding health workers of the same sex and tribal group to conduct the tracing, pose additional difficulties.

These factors, together with a relative dearth of male indigenous health workers, a rapid turnover of staff and the low priority placed on public health activities, result in often-insurmountable difficulties in implementing contact-tracing. In any case, many diagnoses of syphilis in adults in northern Australia are likely to represent latent rather than currently infectious disease, so th at even highly successful contact-tracing will have a relatively small impact on public health control of the disease.

Problems in targeting those at risk

A recent editorial in Sexually Transmitted Diseases notes that in the United States "syphilis is a marker for social marginalization" (i.e., the spread of the disease is disproportionate in poor members of minority groups). The authors state that:
. . . Underlying the problem of syphilis in the United States, and central to any plans to eliminate it, are the issues of race, racism, and poverty, and our ability to speak frankly and intelligently about these issues. . . . It is from a legitimate fear of the consequences of the social stigma of syphilis that many community advocates prefer not to talk about racial differences in syphilis rates. . . . This hiding of the key fact about syphilis may be making it difficult for concerned persons to mobilise the kind of support needed for effective prevention programs. 1

We believe a "key fact" in Australia is that Aboriginal and Torres Strait Islander populations are disproportionately affected by syphilis, yet it is difficult to talk openly about this for fear of further marginalising or stigmatising indigenous people. This understandable sensitivity has tended to stifle productive debate about how we can best deal with the issue, and has hampered communication between affected communities and health professionals.

The continuing high prevalence of syphilis in indigenous communities in Australia is a major threat to the welfare of unborn and newborn children. It is vital that those at most risk can be targeted for the provision of high quality antenatal care (if necessary, through special outreach programs); for retesting in the third trimester or at birth; 20,21 for the development of appropriate treatment protocols; and for contact-tracing that is realistic and achievable.

Action plan

It seems clear that we need a new approach if syphilis is to be controlled, and if congenital syphilis is to become (as it should be) a tragedy of the past. While accepting that the persistence of infectious syphilis (and the accompanying sporadic cases of congenital syphilis) in indigenous communities in Australia is a complex issue, we suggest some measures that could be considered in addressing the problem ( Box 2).

We must find a way to discuss honestly and openly the continuing high prevalence of syphilis in indigenous communities, which is a major threat to the welfare of unborn and newborn children, so that those at most risk can get the most appropriate care.

Acknowledgements

We wish to thank Ms D Brookes, RN (Public Health Nurse, Tropical Public Health Unit, Northern Zone, Queensland Health Department, Cairns), Dr W J Smith (Cairns District Health Service) and the staff of the Communicable Diseases Network of Australia and New Zealand -- National Notifiable Diseases Surveillance System, Canberra, for their assistance.

References

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Authors details

North Queensland Clinical School, The University of Queensland.
Michael D Humphrey, FRACOG, Professor of Obstetrics and Gynaecology; and Director of Obstetrics and Gynaecology, Cairns Base Hospital, QLD.
Cairns District Health Service, Cairns, QLD.
David L Bradford, FACVen, Director of Sexual Health.
No reprints will be available. Correspondence: Professor Michael D Humphrey, Department of Obstetrics and Gynaecology, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870.

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