Fwd: CATIE-News - A look at the syphilis outbreak in Ottawa

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CATIE-News - A look at the syphilis outbreak in Ottawa

CATIE-News - A look at the syphilis outbreak in Ottawa

 

Since the late 1990s, outbreaks of syphilis have been occurring in urban centres in many high-income countries, particularly among men who have sex with men (MSM). Syphilis, like many other sexually transmitted infections (STIs), can cause lesions in the anus, rectum, vagina, penis, mouth and throat. These lesions can help transmit HIV and make the body more susceptible to HIV infection. Canadian researchers worry that outbreaks of such STIs as syphilis and gonorrhea, currently occurring across the country, could hera

ld an increase in new HIV infections. For background information about syphilis testing and treatment see “Syphilis—a dreadful disease on the move.â€

 

Researchers at the University of Ottawa and at that city’s sexual health centre have been collaborating on a study to get a better idea of what is driving their syphilis outbreak. They found that rates of syphilis had risen 10-fold between 2001 and 2003 and have remained high ever since. Their findings are deeply troubling and show a massive surge in syphilis cases that is linked to unsafe sexual behaviour, mostly among MSM. More details about factors influencing Ottawa’s increase in syphilis cases appear below.

 

Study details

The research team reviewed medical records collected between 2001 and mid-2006 at their clinics. They found detailed reports on 102 cases of syphilis in the greater Ottawa region. The majority of cases (84%) were among gay and bisexual men.

 

Results

Nearly all of the men were residents of the greater Ottawa region. Here are some key findings about them:

 

* 67% of cases were between 31 and 50 years of age

* 75% of the men were born in Canada

* 43% were co-infected with HIV (mostly MSM)

* 27% of co-infected HIV positive men were ultimately diagnosed with neurosyphilis

* MSM tended to report more sexual partners than straight-identified men; also, as MSM grew older, they were more likely to have more partners per year

* oral sex was the most commonly practiced behaviour among MSM

* half of the men had sexual partners who lived outside of the Ottawa region

 

Signs and symptoms

Nearly 60% of men in the study had syphilis associated with symptoms. Among HIV positive men, these symptoms included the following:

 

* inflammation of the liver

* problems seeing clearly

* headaches, hallucinations, seizures and other symptoms of syphilitic meningitis

 

HIV positive men were more likely than HIV negative men to have symptoms of illness, ultimately related to the secondary stage of syphilis.

 

Treatment

About 81% of the HIV negative men in this study received standard therapy for early syphilis—a single intramuscular injection of benzathine penicillin G 2.4 million units (MU). Other HIV negative men received the antibiotic doxycyline 100 mg twice daily taken orally for two weeks. This antibiotic was generally reserved for people with a penicillin allergy.

 

HIV positive men tended to receive more extended therapy. For instance, 50% of HIV positive men received injections of benzathine pencillin G 2.4 MU once weekly for three consecutive weeks. Very few HIV positive men received just a single injection of penicillin. The remainder received mostly doxycycline 100 mg twice daily taken orally for four consecutive weeks (the usual course of doxycycline in these cases is two weeks).

 

Into the brain

As explained in the previous CATIE News story (“Syphilis—a dreadful disease on the moveâ€), the germs that cause syphilis (treponemes) can quickly enter the brain, even in cases of early syphilis. If syphilis is left untreated, these microbes can eventually cause serious damage to the brain (neurosyphilis), heart (cardiovascular syphilis) and other organs.

 

In the Ottawa study, 19 men who had symptoms of neurosyphilis gave their consent for a spinal tap. The analysis of spinal fluid confirmed the diagnosis of neurosyphilis.

 

Men with neurosyphilis received either one of the following regimens:

 

* a minimum of two weeks of intravenous penicillin G at a dose of 4 million units every four hours

* ceftriaxone 2 grams per day, also for two weeks

 

Safety at risk

The Ottawa team noted that the average age of the men with syphilis was about 40 years old. This is almost three years=2

0older than the average age of men in the Ottawa region.

 

According to the team, other research findings suggest that “older men are less likely to insist on condom use due to fear of rejection from younger sexual partners.†The Ottawa researchers also noted that “older MSM have a higher incidence of isolation and depressionâ€â€”issues associated with risky sexual behaviour. The team also highlighted previous research that found that MSM who were older than 30 years had “a higher incidence of unprotected anal sex.â€

 

The syphilis triangle

Previous research in Canada and the United States found that some MSM travel from city to city to meet sexual partners. In the Ottawa study, it was common for men to travel between Ottawa, Montreal and Toronto when seeking sex partners. It is possible that such travel may have played a role in the spread of syphilis, as the researchers noted that there are parallel outbreaks of syphilis in Montreal and Toronto.

 

Unprotected sex and syphilis

Among MSM in this study unprotected oral sex was

very common. The researchers speculate that this is probably because unprotected oral sex is viewed as safer than unprotected anal sex. However, unprotected oral sex can easily transmit the germs that cause syphilis. The Ottawa researchers said that unprotected oral sex likely played a dominant role in the spread of syphilis in their study.

 

The Ottawa study is retrospective in nature; that is, it is based on a review of medical records in the past. Because of this study design, researchers cannot rule out possible biases when interpreting their data. However, their findings should not come as a surprise to anyone involved in STI prevention and treatment in high-income countries.

 

Because sexual networks exist over long distances (Ottawa, Montreal, Toronto), coordinating regional public health programs is necessary to bring the current outbreak of syphilis under control. The findings from the Ottawa study also underscore the need for strengthening STI prevention and education programs, particularly for MSM.

 

— R. Hosein

REFERENCES:

 

1. Fenton KA, Breban R, Vardavas R, et al. Infectious syphilis in high-income settings in the 21st century. Lancet Infectious Diseases. 2008 Apr;8(4):244-53.

 

2. Leber A, MacPherson P, Lee BC. Epidemiology of infectious syphilis in Ottawa. Recurring themes revisited. Canadian Journal of Public Health. 2008 Sep-Oct;99(5):401-5.

 

3. Wong T, Singh AE, De P. Primary syphilis: serological treatment response to doxycycline/tetracycline versus benzathine penicillin. American Journal of Medicine. 2008 Oct;121(10):903-8.

 

4. CDC. Transmission of primary and secondary syphilis by oral sex—Chicago, Illinois, 1998-2002. Morbidity and Mortality Weekly Report. 2004 Oct 22;53(41):966-8.

 

5. Chan DJ. Penicillin treatment for early syphilis in the presence of HIV-1 infection: the long or the short of it? International Journal of STD and AIDS. 2008 Sep;19(9):648.

 

6. Mishra S, Walmsley SL, Loutfy MR, et al. Otosyphilis in HIV-coinfected individuals: a case series from Toronto, Canada. AIDS Patient Care and STDs. 2008 Mar;22(3):213-9.

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