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. 2002 Oct 5;325(7367):775. doi: 10.1136/bmj.325.7367.775/a

Don't forget syphilis

Syphilis outbreak is twice as big as reported

Pete Clark 1,2,3,4,5, Penny A Cook 1,2,3,4,5, Lorraine Lighton 1,2,3,4,5, Qutub Syed 1,2,3,4,5, Mark A Bellis 1,2,3,4,5
PMCID: PMC1124284  PMID: 12364312

Editor—We agree with Doherty et al that regional and national surveillance systems are required to identify increases in the incidence of syphilis.1 It is therefore ironic that the authors' data on the syphilis outbreak in Manchester are incorrect, although enhanced surveillance systems have been in operation for over three years.

The medical response to any sexually transmitted infection outbreak depends on the accuracy of epidemiological data. The Manchester Outbreak Control Group (comprising local specialists in genitourinary medicine, health promotion experts, and voluntary groups supported by the Communicable Disease Surveillance Centre North West and the Centre for Public Health at Liverpool John Moores University) has established a surveillance and communication system to ensure that statutory and voluntary sector organisations throughout Manchester have access to accurate up to date epidemiological information on request. If Doherty et al's article were the only source of information healthcare professionals in the Manchester area had access to, they would be forgiven for believing that the current outbreak is one third its actual size.

The correct number of cases between February 1999 and January 2002 should read 239, more than twice the previously published number. Similarly, quoting figures to January 2002 leaves the impression that the outbreak is over. This is not the case as a further 67 new cases were diagnosed between January and June 2002 (table).

This lack of consultation highlights the need not only for enhanced epidemiological surveillance locally but also for enhanced communication nationally. Throughout the outbreak, the Manchester Outbreak Control Group has provided first class epidemiological data. Findings from investigations have influenced local and national strategies and been published in peer reviewed journals.2–5

This misrepresentation of the situation in Manchester has not been well received as the departments for genitourinary medicine there are struggling to cope with the increased workload from the continuing syphilis outbreak, exacerbated by some of the highest rates of sexually transmitted infection in the United Kingdom. To get ahead of the curve we first of all need to describe it accurately.

Figure.

Figure

NLM

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It's coming back

Table.

Features of the ongoing outbreak of syphilis in greater Manchester

Previously published figures1
Actual figures
Date Feb 1999-
Jan 2002		 Jan 1999-
Jun 2002
No of cases 103 306
No of men 100 284
No of women   3  23
No (%) of cases in heterosexuals 7 (7) 50 (17)
No (%) of cases in homosexual men 96 (93) 255 (83)
No (%) of cases in homosexual men with HIV 33 (34) 88 (29)
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References

  • 1.Doherty L, Fenton KA, Jones J, Paine TC, Higgins SP, Williams D, et al. Syphilis: old problem, new strategy. BMJ. 2002;325:153–156. doi: 10.1136/bmj.325.7356.153. . (20 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Clark P, Cook PA, Syed Q, Ashton JR, Bellis MA. Re-emerging syphilis in the north west: lessons from the Manchester outbreak. Liverpool: Liverpool John Moores University, Public Health Sector; 2001. [Google Scholar]
  • 3.Donaldson L. Getting ahead of the curve: a strategy for combating infectious diseases (including other aspects of health protection). London: Department of Health; 2002. [Google Scholar]
  • 4.Bellis MA, Cook PA, Clark P, Syed Q, Hoskins A. Re-emerging syphilis in gay men: a case-control study of behavioural risk factors and HIV status. J Epidemiol Commun Health. 2002;56:235–236. doi: 10.1136/jech.56.3.235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Cook PA, Clark P, Bellis MA, Ashton JR, Syed Q, Hoskins A, et al. Re-emerging syphilis in the UK: a behavioural analysis of infected individuals. Commun Dis Public Health. 2001;4:253–258. [PubMed] [Google Scholar]
BMJ. 2002 Oct 5;325(7367):775.

Access to services for genitourinary medicine needs to be made easier

David Goldmeier 1,2, Linda Greene 1,2

Editor—In their article on syphilis Doherty et al emphasise that serological testing is the mainstay of diagnosis.1-1 However, local laboratories must use a screening test that is both sensitive and specific. The Venereal Disease Research Laboratory or rapid plasma reagin tests may yield negative results in early primary syphilis. The most appropriate screening test is therefore either the enzyme linked immunosorbent assay with an immunoglobulin M component or the Treponema pallidum particle agglutination test.1-2

Treatment in the United Kingdom has traditionally been daily injections of procaine penicillin. When compliance is poor, a one off injection of benzathine penicillin 2.4 MU or visually supervised oral azithromycin are important alternatives.1-3

Although treatment with one injection of benzathine penicillin 2.4 MU in patients with early syphilis and HIV has failed, the latest guidelines from the US Centers for Disease Control and Prevention continue to advocate this one off injection for HIV coexisting with syphilis.1-2,1-4 Evidence for this may be based on very rare clinical failure in patients who received benzathine penicillin 2.4 MU rather than benzathine 2.4 MU plus amoxicillin and probenecid at high doses in a double blind placebo controlled study of patients with early syphilis and HIV.1-5

Easy and quick access to clinics for genitourinary clinics is crucial in controlling the mini-epidemic of syphilis in the United Kingdom. Currently, however, access to such services, particularly in London, is deteriorating rather than improving. Many units have changed from walk in to appointment only systems in response to unsustainable increases in activity. Waiting times for appointments are steadily increasing.

In the North Thames region our hospital offers one of only two clinics providing a daily walk in service for both men and women. This means that we are often overwhelmed by patients travelling from all over London to access care. The high patient throughput puts enormous strain on our staff and resources and does nothing to improve the quality of patients' experience of attending a genitourinary clinic. This whole situation runs counter to the government's current sexual health strategy.

Access, manpower, and funding issues in genitourinary medical services must be addressed urgently if the current syphilis mini-epidemic is to be dealt with effectively.

References

  • 1-1.Doherty L, Fenton KA, Jones J, Paine TC, Higgins SP, Williams D, et al. Syphilis: old problem, new strategy. BMJ. 2002;325:153–156. doi: 10.1136/bmj.325.7356.153. . (20 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Young H. Guidelines for serological testing for syphilis. Sex Transm Infect. 2000;76:403–405. doi: 10.1136/sti.76.5.403. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Centers for Disease Control and Prevention. Sexually transmitted diseases guidelines. Atlanta: CDC, May; 2002. www.cdc.gov/std/treatment/ (accessed 16 Sep 2002). [Google Scholar]
  • 1-4.Musher DM, Hammill RJ, Baughn RE. Effect of human immunodeficiency virus (HIV) infection on the course of syphilis and its response to treatment. Ann Intern Med. 1990;113:872–881. doi: 10.7326/0003-4819-113-11-872. [DOI] [PubMed] [Google Scholar]
  • 1-5.Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M, et al. A randomised trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med. 1997;337:307–314. doi: 10.1056/NEJM199707313370504. [DOI] [PubMed] [Google Scholar]

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