Public health priority: Infectious syphilis, confirmed or probable case in a pregnant female: UrgentAny syphilis notification not known to represent previously treated syphilis in a female of reproductive age (<46 years): HighInfectious syphilis, confirmed or probable case in a male or non-pregnant female: HighCongenital syphilis: UrgentNon-infectious syphilis: Routine
PHU response time: Respond to possible, probable and confirmed cases of congenital syphilis on the same working day of notification.
Respond to any syphilis notification in a female of reproductive age (<46 years), as soon as possible to ascertain pregnancy status, generally within one working day. For any syphilis laboratory notification where the patient is managed by a doctor not known to have experience in the management of syphilis, refer the notification to local sexual health clinic on the day of notification to enable sexual health clinic staff to offer timely assistance to the doctor and complete the notification form. For all other notifications, mail a follow up letter and questionnaire to diagnosing doctors within 3 working days. Special arrangements may be made for high volume diagnosing practices.
Case management: Responsibility of the treating doctor; assisted by sexual health clinic if required.
Contact management: Responsibility of the treating doctor; assisted by sexual health clinic if required.
Chief Health Officer
[Confirmed, probable, or possible case of Infectious syphilis; Syphilis - more than 2 years or unknown duration, or Syphilis-unspecified, unless known to represent previously treated syphilis] in a pregnant female:
[Confirmed, probable, or possible case of Infectious syphilis; Syphilis - more than 2 years or unknown duration, or Syphilis-unspecified, unless known to represent previously treated syphilis in a female of reproductive age (<46 years):
Infectious syphilis, confirmed or probable case in a male or non-pregnant female:
Congenital syphilis: [URGENT]
Non-infectious syphilis [in a male or non-pregnant female]:
[*Note that the ‘possible’ and ‘Syphilis-unspecified’ classifications refer to recording options in the NSW Notifiable Conditions Information Management System (NCIMS) pending classification according to the national case definitions.]
Immediately on notification of a case of confirmed or probable infectious syphilis, begin follow up investigation and notify the state/territory public health authority [NSW Communicable Diseases Branch (CDB)] or syphilis register in accordance with jurisdictional statutory requirements.
Cases who present with symptoms consistent with infectious syphilis (a painless, indurated genital ulcer or symptoms / signs of secondary syphilis) must be treated at the time of first presentation.
Cases of infectious syphilis diagnosed on serology should be treated as soon as possible (and ideally within two days) of diagnosis.
For cases of syphilis of less than two years duration, one dose of benzathine penicillin 1.8g (2.4 million units) by intra-muscular injection (IMI) is required. For syphilis of more than two years or unknown duration, a course of three doses benzathine penicillin 1.8g (2.4 million units) IMI, 7 days apart, is required.
At the time of the first treatment dose, blood should be collected for (rapid plasma regain test) RPR to provide the baseline used to assess response to treatment and check for re-infection.
RPR testing, by the same laboratory that undertook the baseline assessment, at 3-6 and 12 months following treatment, is important to determine the response of treatment.
Infectious cases are rendered non-infectious 5 days after one dose of benzathine penicillin and all symptoms are resolved (whichever is longer). Completion of adequate treatment for syphilis does not confer immunity and re-infection can occur frequently in some risk groups, especially HIV-infected men who have sex with men (MSM).
Particular care is required to ensure adequate treatment in pregnancy, because of the extreme risk of in-utero infection of the foetus. Serological follow-up of the maternal RPR during and following the pregnancy is essential. Syphilis infection may occur after screening in pregnancy or following reinfection after treatment. Specialist paediatric review is recommended for the children of all women treated for syphilis in pregnancy.[1,2,3]
The aim of identifying contacts of infectious syphilis is to prevent disease transmission by offering testing to identify infection before the onset of clinical symptoms and providing empirical treatment. Timely contact tracing lies at the heart of an effective public health response to syphilis and needs to be prioritised.
Anyone who has had sex (including oral sex) with a person who has confirmed or probable infectious syphilis is a contact. Unborn babies and infants of women with infectious syphilis are also contacts.
The causative agent is the spirochaete bacterium,
Treponema pallidum subspecies pallidum. There are a number of other
Treponema pallidum subspecies that cause non-venereal infections including:
endemicum (bejel or endemic non-venereal syphilis) and
Treponema pallidum subspecies pallidum is an obligate human parasite.
In the vast majority of cases, syphilis is spread by direct contact with skin lesions or mucous membranes of an individual with infectious syphilis during anal, oral or vaginal intercourse. Vertical transmission can occur at any time during pregnancy and at any stage of syphilis.
Less commonly, syphilis is transmitted by infected blood (transfusion, drug users), by non-sexual personal contact with infected lesions or by accidental direct inoculation.
The incubation period is 10 to 90 days with a median of 3 weeks to the onset of primary syphilis.
Syphilis is most infectious during the primary and secondary stages of the disease (refer to section below) when moist mucocutaneous lesions are present, with transmission risk being up to 50% per sexual contact. The infectious period is defined as the first two years of infection, if untreated, however the period of high infectivity lasts for 12 months from the onset of infection. Sexual transmission is uncommon after two years of infection.
The risk of maternal trans-placental transmission to the unborn baby is also highest in infectious syphilis. The risk of infection in the unborn baby of a pregnant woman with primary or secondary syphilis is extremely high, approaching 100%. If left untreated, the risk of vertical transmission diminishes over years but may never disappear.
Infected infants with moist mucocutaneous lesions are a potential source of infection.
Clinical presentation may be highly variable and many cases do not follow the classical stages listed below. Neurosyphilis can occur in any stage of syphilis.
primary syphilis, the primary lesion, a chancre, begins as a papule 10-90 days after infection, soon ulcerating to form an indurated ulcer at the site of inoculation; this may be on external or internal genitalia or a non-genital site, e.g. lip, tongue, pharynx, anus, rectum. This is usually a single indurated and relatively painless lesion and accompanied by regional lymphadenopathy, however atypical multiple and painful lesions can occur. The ulcer heals spontaneously over the course of a few weeks. Clinical suspicion of syphilis should be high for all presentations of a painless, indurated genital ulcer. However in an outbreak setting all genital ulcers should be considered to be potential primary syphilis cases.
Secondary syphilis usually occurs 4 to 10 weeks after onset of the primary lesion. Symptoms include headache, fatigue, lymphadenopathy, low grade fever, sore throat, rash, mucocutaneous lesions, condylomata lata (large, raised, whitish or grey, flat-topped lesions found in warm moist areas) and alopecia. Ocular and neurological symptoms may also occur. Secondary syphilis may commence prior to the resolution of the primary lesion. Untreated secondary syphilis symptoms persist for 3-12 weeks after which the patient enters the early latent phase. Symptomatic relapses of secondary syphilis occur in 25% of untreated cases, mainly in the first 12 months after infection.
Early latent syphilis refers to syphilis of less than two years duration (infectious syphilis) in a person who has no symptoms or signs of infection at the time of diagnosis.
Syphilis of more than two years duration, in the absence of clinical signs, is called
late latent syphilis. People with late latent syphilis are asymptomatic for many years. Historically, between one quarter and one third of infected and untreated individuals will ultimately develop tertiary syphilis. The following timelines for development of tertiary syphilis were derived in the pre-antibiotic era and are a guide only. Bone and skin lesions at any time after 2 years but usually between 2 and 15 years, cardiovascular disease at 20-30 years and three types of central nervous system disease (meningo-vascular at 5-12 years, and general paresis and tabes dorsalis usually at 15-25 years).
Treponema pallidum crosses the placenta and may infect the foetus at any time in the pregnancy. If untreated, this can result in intrauterine foetal death, stillbirth or a premature baby with congenital syphilis. In early congenital syphilis, the infected baby may be severely affected at birth (with hepatomegaly, ascites, hydrops, foetal anaemia) or more frequently, may not present any observable sign. If the diagnosis is not made at this time, the baby will present later with non-specific complaints (rhinitis, failure to thrive, pneumonia), nearly always within three months of birth. Neonates with severe disease have a worse prognosis. Late congenital syphilis corresponds to tertiary disease in the adult and can be prevented by early diagnosis and treatment of the infant.
Populations at highest risk of syphilis include Aboriginal and/or Torres Strait Islander people in remote Australia, men who have sex with men (MSM), female partners of MSM and people who have unprotected sex in overseas countries where syphilis is prevalent. Effective treatment of syphilis does not confer immunity against
Treponema pallidum, and these high risk groups are at risk of reinfection.
Clinical presentation of reinfection may be similar to primary or secondary symptomatic infection, but often presents as asymptomatic (or pre-symptomatic) rises in serology parameters and is indistinguishable from early latent infection(1).
Particular issues of special relevance to MSM and Aboriginal and/or Torres Strait Islander people are discussed in
section 12 and
Appendix 4, respectively, of this document.
(1) This is a problematic area - many reinfections in MSM and HIV MSM would not be detected without regular screening as per STIGMA guidelines.
Syphilis is no longer rare in Australia, with high rates in some communities, including MSM and Aboriginal and Torres Strait Islander people. The rate in the non-Indigenous female population is increasing, albeit from a low baseline. Syphilis rates declined among MSM with the onset of the HIV epidemic but have climbed consistently since the late 1990’s. Rates in Aboriginal and Torres Strait Islander people have increased in recent years, especially those living in remote areas, after sustained periods of decline. Overall notification rates in Aboriginal and Torres Strait Islander people remain well above the general population and outbreaks continue to occur.
The public health significance of syphilis lies in its impact on the developing foetus in utero and the interaction of
Treponema pallidum with the human immunodeficiency virus (HIV). Congenital syphilis is an entirely preventable disease and represents a failure of the health system. Its occurrence reflects a failure of delivery systems for antenatal care and for syphilis control programs. In addition to shared transmission routes syphilis biologically enhances both the transmission and acquisition of HIV; hence syphilis control and HIV prevention are closely aligned.
A combination of coordinated prevention activities is more effective than an isolated, single activity.
Sexual health promotion and education programs aim to increase awareness of increase awareness of syphilis and other sexually transmitted infections and empower people to adopt safe sex practices thus reducing their risk of both acquiring and transmitting infection. These programs are targeted to priority groups including young people, MSM, Aboriginal and Torres Strait Islander populations, sex workers and prisoners.
[Check NCIMS ELR workflows daily for syphilis unspecified cases. Manual entry for new notifications should occur within five working days of notification, unless the notification is for a female of reproductive age (<46 years) in which case manual entry should occur within one working day of notification.
All new notifications should be checked for duplicates on NCIMS. Possible duplicate syphilis notifications received through ELR are managed by CDB in consultation with Public Health Units.
To assist in identifying subsequent re-infections for previously notified syphilis cases in NCIMS (where subsequent notifications are not notified by ELR), enter the non-specific treponemal antibody tests (e.g. VDRL, RPR) in the laboratory results question package in NCIMS. Note: A 4-fold rise in RPR suggests that the notification represents a re-infection and should be managed in the same way as a new infection.
All syphilis cases should be classified or excluded on NCIMS within 90 days of initial notification with the information available to the PHU. Any additional information received after this time should be added to the NCIMS event and the event should be reclassified if necessary. At least two attempts should be made to obtain enhanced surveillance information to assist correct classification. The valid options for case classification are:
Data for confirmed and probable cases of infectious (i.e. primary, secondary, early latent) syphilis and congenital syphilis should be entered into jurisdictional notifiable conditions databases [NCIMS] within one day of confirmation.
Data for confirmed cases of non-infectious (i.e. late latent, tertiary) syphilis should be entered into jurisdictional notifiable conditions databases [NCIMS] as soon as possible following confirmation.
Syphilis is a notifiable disease under the public health acts of all states and territories, and nationally. Cases of reactive serology are reported by pathology laboratories to public health authorities. In some jurisdictions the medical and/or nurse practitioner who diagnoses a case of syphilis is also required to notify the jurisdictional public health authority.
Notify confirmed and probable cases of infectious (i.e. primary, secondary, early latent) syphilis and congenital syphilis in accordance with jurisdictional statutory requirements [Enter/classify confirmed and probable cases of infectious syphilis in NCIMS; notify CDB of any possible, probable or confirmed congenital syphilis cases] ; include the patient’s date of birth, sex, indigenous status, address, date of onset, laboratory status, possible sources of infection, other people thought to be at risk and follow up action taken.
State/territory Communicable Disease Branches (CDB) should inform CDNA of outbreaks of infectious syphilis. Interjurisdictional outbreaks requiring national coordination may require support from the National Incident Room (NIR). See
Appendix 4 for information about outbreaks in remote populations.
Confirmed and probable cases should be notified.
A confirmed case requires either:
A probable case requires that case does not meet the criteria for a confirmed case
(2) Treponemal specific tests are: IgG or total Ab immunoassay (EIA or CLIA), Treponema pallidum haemagglutination assay (TPHA), Treponema pallidum particle agglutination assay (TPPA), Fluorescent Treponemal Antibody Absorption(FTA-Abs), 19S-IgM antibody test, or IgM immunoassay, Treponemal Ab specific immunochromatography (ICT) assay. See
section 8 for further details
(3) Non-treponemal tests are: Rapid Plasma Reagin (RPR), Venereal Disease Research Laboratory (VDRL). See
section 8 for further details.
confirmed cases should be notified.
A confirmed case requires that the case does not meet the criteria for a case of infectious syphilis less than 2 years duration
A reactive treponemal specific test(2) which is confirmed
either by a reactive non-treponemal test(3) or a different treponemal specific test
Note: In a high prevalence area, only one reactive treponemal specific test result is necessary.
Treponema pallidum by dark-field microscopy (not oral lesions), direct fluorescent antibody microscopy (direct antigen detection), equivalent microscopic methods (e.g. silver stains), or DNA methods (e.g. nucleic acid testing).
Clinical, radiological or echocardiographic signs of tertiary syphilis.
confirmed cases and
probable cases should be notified, including confirmed and probable cases of syphilis-related stillbirth1.
A confirmed case requires:
Mother and child both seropositive by a treponemal specific test3 and the child is a live birth2
One or more of the following:
Mother is seropositive by a treponemal specific test3,
and the pregnancy outcome is a stillbirth1,
and there is evidence of infection in-utero through:
In the event of a stillbirth1 or neonatal death6, a pathologist or clinician experienced in congenital syphilis makes a clinical diagnosis of congenital syphilis at autopsy.
A probable case requires:
Mother is seropositive by a treponemal specific test3 or the mother is seropositive by a
Treponema pallidum-specific rapid immunochromatography,
and the child is a live birth2,
One or more of the following:
Mother is seropositive by a treponemal specific test3
or the mother is seropositive by a
Treponema pallidum-specific rapid immunochromatography,
and the pregnancy outcome is a stillbirth1,
One or more of the following:
Treatment with macrolides alone during pregnancy in penicillin-allergic women is no longer regarded as adequate therapy as resistance to macrolides in
T pallidum is increasingly common (now >50% in Australia) and may arise during therapy. Expert advice should be sought in such cases.
Although the risk of congenital syphilis is much higher in early-stage disease, in the presence of untreated syphilis the birth of an unaffected child does not guarantee that subsequent children will not be affected.
Adequate treatment during pregnancy does not exclude the diagnosis of congenital syphilis if criteria for a confirmed or probable case are met.
Laboratory case definitions for syphilis are available from the Department of Health.
Culture is not available. Syphilis is principally diagnosed by serology (treponemal specific and non-treponemal tests), and sometimes (if lesions are present) by nucleic acid amplification techniques or direct demonstration of the organism by dark-field microscopy or direct fluorescent antibody techniques (direct antigen detection).
There are two types of syphilis serology tests: treponemal specific tests and non-treponemal tests. Treponemal specific tests detect antibodies to antigens specific to pathogenic
T. pallidum. They become reactive after infection with
T. pallidum and usually remain reactive indefinitely regardless of adequate treatment, however partial or complete loss of treponemal specific antibodies over time occurs in a minority of patients, especially HIV-infected or those treated very early in infection. They do not necessarily indicate active infection. Non-treponemal tests detect reagin (a combination of lecithin, cholesterol and cardiolipin), a substance similar to that generated in response to spirochaete-induced damage to cellular membranes. Tests based on detection of antibodies to reagin are a useful indicator of disease activity.
Treponemal and non-treponemal serology tests are less than 100% sensitive in primary syphilis so syphilis serology may be negative in the presence of a chancre.
There is a period after infection when both treponemal specific and non-treponemal serology may be negative. Generally speaking the treponemal specific test (e.g. EIA) becomes reactive within 2-4 weeks and the RPR becomes reactive within 3-4 weeks post infection.
Most laboratories in Australia now use a treponemal specific test as the first (screening) test following a request for syphilis serology. If reactive, a non-treponemal test (e.g. RPR) and another specific treponemal specific test is performed.
Most laboratories report treponemal specific tests as reactive or non-reactive.
The RPR, if reactive, is reported as a titre – the endpoint of a serial dilution: 1 in 2, 1 in 4, 1 in 8, 1 in 16, 1 in 32 etc. which represents the highest dilution giving a reaction. A higher dilution suggests more active disease. The results are reported as the reciprocal of the highest dilution (ie. 2, 4, 6, 8 etc.). Figure 1, developed by Gavin Hart, indicates the typical RPR response following syphilis infection.
Figure 1: Variation in RPR titre after infection
The RPR test is also used to monitor response to treatment. An adequate response to treatment in infectious syphilis is defined as a four-fold (or two-dilution) drop in RPR e.g. 1 in 128 to 1 in 32 on parallel testing by 6 months, though the rapidity of this decline varies according to disease stage at treatment. This test becomes non-reactive in the majority of patients if infection is diagnosed and adequately treated early in its course. Patients with high RPR titres, late diagnoses and individuals who have been re-infected will be left with fixed reactive (serofast) RPR titres (e.g. 1 in 16) despite adequate treatment, in up to a quarter of patients.
Re-infection is generally diagnosed on the basis of changes in RPR titre. A four-fold or two-titre rise in RPR, e.g. 1 in 2 to 1 in 8, following previous adequate treatment is considered a re-infection. PCR may be useful if ulcerated or moist lesions are present.
The non-treponemal test results rely on subjective judgements by the operator reading the test. The reproducibility of the result will vary according to the skill of the operator and the antigen preparation used. Comparison of results on serial samples should always be done in parallel. Results from different laboratories for an individual patient should not be compared.
Treponemal specific and non-treponemal tests do not distinguish between sub-species of Treponemes. In some parts of remote Australia yaws and non-venereal endemic syphilis were common up until the late 1960s and yaws remains common in PNG, Indonesia, the Solomon Islands, Vanuatu and parts of central and west Africa. It is possible that people from these regions who acquired these conditions as children will still have the antibodies giving them reactive treponemal serology without ever having had infectious syphilis.
If an individual has clinically observable lesions (e.g. genital ulcer, lesions of secondary syphilis), a dry swab, scrapings or biopsies for a nucleic acid amplification (NAA) test such as a polymerase chain reaction (PCR) test for
Treponema pallidum should be collected. This test can also be done on placental specimens (including paraffin embedded tissue), ocular fluids and CSF. These tests are highly sensitive and specific and are now available in most states, but are not recommended for testing blood.
There is currently only one syphilis point of care test registered by the Therapeutic Goods Administration in Australia, the Determine Syphilis TP™ manufactured by Alere, now Abbott. The Determine Syphilis TP™ is a treponemal specific immunochromatographic test that can be used with whole-blood samples from either finger-prick or venepuncture. Point of care syphilis tests, used in combination with conventional syphilis serology and treatment history data, can facilitate case identification and reduce time to treatment for infectious syphilis.[13,14,15] Interpretation requires access to the individual’s previous syphilis serology and treatment history. If treatment is triggered on the basis of the rapid test alone, then over-treatment can result. In an outbreak situation, this may be considered an acceptable risk, especially for people who have no known history of past syphilis and where follow-up is uncertain.
There are a number of limitations with current syphilis point of care tests:
The following issues should be considered when implementing syphilis point of care tests:
Please refer to
Appendix 4 for further consideration on the use of syphilis point of care tests in outbreak contexts.
Appendix 4. Guidelines for the Public Health Management of Syphilis Outbreaks in Remote Populations in Australia for further discussion on the use of point of care testing in the current context
Prioritisation of the public health response to a case of confirmed or probable infectious syphilis is HIGH. Infectious syphilis occurring in a pregnant woman requires URGENT public health response due to the risk of congenital infection.
[Respond to possible, probable, and confirmed cases of congenital syphilis, or any otherwise classified syphilis notification in an infant aged ≤12 months within one working day of notification. Ascertain and document in the relevant NCIMS data fields the pregnancy status and Indigenous status of all women of reproductive age (aged <46 years) within one working day of notification. Where the diagnosing facility is a local sexual health service, the relevant PHU may follow established regular communication arrangements to ascertain pregnancy status and Indigenous status. For all notifications, send a follow up letter and questionnaire to diagnosing doctors within 3 working days of notification.]
Immediately on notification of a case of confirmed or probable infectious syphilis, begin follow up investigation [In NSW, for any syphilis notification where the patient is managed by a doctor not known to have experience in the management of syphilis, refer the notification to local sexual health services on the day of notification to enable sexual health clinic staff to offer timely assistance to the doctor and complete the notification form. For syphilis notifications where the diagnosing doctor is known to have experience in managing syphilis, send a follow up letter and questionnaire within one working day of notification] and notify the state/territory CDB [Enter/classify case in NCIMS (refer to
[PHU’s may make special arrangements with their sexual health service to facilitate timely and efficient assistance to inexperienced clinicians.
For cases diagnosed by a Sexual Health Service, or clinicians known to the PHU to have expertise in sexual health, the PHU may make special arrangements to facilitate efficient notification and collection of enhanced surveillance information, for example, arranging for distribution or collection of completed forms on a regular basis (at least monthly).]
[The response to a notification will normally be carried out in collaboration with the case’s managing doctor(s). Regardless of who does the follow-up, for possible, probable or confirmed cases of congenital syphilis or any otherwise classified syphilis notification in an infant aged ≤12 months, PHU staff should ensure that action has been taken to:
The response to a notification will normally be carried out in collaboration with the case’s managing doctor(s). Regardless of who does the follow-up, for confirmed and probable cases of infectious syphilis, PHU staff should ensure that action has been taken to:
[The response to a notification will normally be carried out in collaboration with the case’s managing doctor(s). Regardless of who does the follow-up, for all cases of syphilis in a pregnant women who cannot be clearly identified as previously adequately treated syphilis, PHU staff should ensure that action has been taken by the managing doctor(s) to:
All cases without documentation of stage-appropriate treatment at least 30 days prior to the estimated delivery date (see section Syphilis in pregnancy) should be notified to CDB. The responsibility to follow-up with the managing clinician(s) remains with PHUs, with advice from CDB if required.]
[As Mandatory Reporters, any health worker who has reasonable grounds to suspect that a child or young person may be at
risk of significant harm must make an immediate report to the Child Protection Helpline on 13 21 11.
Where a case of syphilis is reported in a child <16 years old, the PHU must send a letter to the doctor who requested the test to undertake an assessment of the risk of harm according to the mandatory reporting guidelines and obligations under the Children and Young Persons (Care and Protection) Act 1998.
Where a case of syphilis is reported in a child aged 12 years or under, the PHU must also directly contact the doctor (eg by telephone) to ensure that mandatory reporting obligations have been addressed. If no contact can be made, the PHU should contact the Child Wellbeing Unit (1300 480 420) or make a direct report to the Child Protection Helpline (13 21 11).
The PHU should make reasonable attempts to record in NCIMS the Indigenous status of all cases under 16 years, for example by checking the LHD patient management system and/or calling the diagnosing doctor.
All actions should be documented in the NCIMS record.]
This is a local decision best made on a case-by-case basis. The culture and gender of the interviewer and whether or not they are known to and trusted by the case are relevant factors to consider.
Symptomatic patients should be interviewed in relation to their contacts when they first present, while early latent cases diagnosed on serology findings should be interviewed when seen for treatment.
Interviewing cases about their sexual contacts must be undertaken on a voluntary basis. The cooperation of the case is critical. The interview must be conducted in a private space and without hurrying. It needs to be approached with care and sensitivity and accompanied by clear information in language the individual understands. The way syphilis is spread and the importance of tracing all sexual contacts who may have been exposed should be explained. The case should be assured of the confidential nature of these disclosures and that the contact/s will not be told the identity of the person who named them, only the type of infection to which they have been exposed.
A clinical review at one-week post-treatment is recommended and gives the health care provider the opportunity to ask again about contacts. Even if contact names were provided at the first interview, further careful inquiry would be appropriate, e.g. “….. Is there anyone else you think should be seen?”
When a case has named a contact, they should be asked whether this is their regular partner. If it is, then they should be asked “who else?” If the named contact is not a regular partner, then they should be asked about their regular partner/s. If the interviewer believes there are other contacts that remain un-named, the question may be asked differently. For example, the case may find it easier to remember their contacts if the inquiry is related to significant events: “where were you on your birthday? Did you have a party? Who were you with then?” or “what was happening at the rodeo? Who were you with then?”
The interviewer should always expect more than one contact, and never assume the gender of any contact. The interviewer should also consider asking the case about their friendship group: “who, in your group, do you think should also have a test?” (social contact tracing).
If a case has not named any contacts, or the named contacts do not have syphilis, or a case and contact name only each other, both case and contact must be re-interviewed. Consultation with a local health worker as to the appropriate approach may be helpful, but must not compromise confidentiality.
Cases of infectious syphilis diagnosed on serology should be treated as soon as possible (and ideally within two days) of diagnosis. Rapid referral and confirmation of treatment is required if a case moves away from the location where they were diagnosed before undergoing treatment.
Cases of infectious syphilis who are known to be pregnant require urgent follow up and treatment to minimise the possibility of vertical transmission. Breast feeding does not result in the transmission of syphilis, unless an infectious lesion is present on the breast.
The treatment for syphilis generally recommended is long-acting benzathine penicillin.
For cases of confirmed infectious syphilis of less than two years duration, one dose of benzathine penicillin 1.8g (2.4 million units) IMI , OR procaine penicillin 1.5 g IM, daily for 10 days is required. For probable cases of infectious syphilis or syphilis of more than two years or unknown duration, a course of three doses benzathine penicillin 1.8g (2.4 million units) IMI, 7 days apart, OR procaine penicillin 1.5 g IM, daily for 15 days is required.
Cases of congenital syphilis should be treated in consultation with a specialist paediatrician. The recommended treatment is benzylpenicillin 50mg/kg IMI or IVI, 12 hourly for 10 days or procaine penicillin 50mg/kg IMI daily for 10 days.
For detailed information on therapeutic agents for tertiary syphilis see the current edition of
Therapeutic Guidelines: Antibioticswww.tg.org.au
If penicillin is contraindicated, seek specialist advice from an infectious diseases, or sexual health, physician. Individuals who are allergic to penicillin should be considered for desensitization in the first instance (especially if pregnant). For non-pregnant patients who are hypersensitive to penicillins if desensitisation is not possible, doxycycline 100 mg orally, 12-hourly for 14 days can be used. Ceftriaxone may also be an option, but efficacy has not been formally proven. Do NOT attempt to treat syphilis with macrolides.
At the time of the first treatment dose, blood should be collected for RPR to provide the baseline used to assess response to treatment and check for re-infection.
Treatment of infectious syphilis is considered to be adequate if there is a four-fold (two titre) drop in RPR, e.g. 1 in 64 to 1 in 16, by 6 (up to 12) months. RPR testing, by the same laboratory that undertook the baseline assessment, at 3-6 and 12 months following treatment, is important to determine the response of treatment. Comparison of results on serial samples should always be done in parallel. Results from different laboratories for an individual patient should not be compared.
Testing too soon after treatment should be avoided as it may show an increase in RPR; this does not indicate treatment failure.
Infectious cases are rendered non-infectious 5 days after one dose of benzathine penicillin. Completion of adequate treatment for syphilis does not confer immunity and re-infection can occur.
Due to the extreme risk of vertical transmission of syphilis particular care is required to ensure adequate treatment in pregnancy, all cases of syphilis in pregnancy should be discussed with a clinician with expertise in the area. Treatment of syphilis in pregnancy is according to disease stage and is usually the same as in the non-pregnant state. Contact tracing and treatment for the woman’s partner/s are critical to minimise the potential for re-infection as this represents a particular threat to the unborn baby.
[Serological follow-up of the maternal RPR during and following the pregnancy is essential; this is important for monitoring the response to treatment and prompt detection and treatment of re-infection. In NSW, consult with a specialist service to determine appropriate follow-up testing during pregnancy and after birth. Post-treatment maternal serological follow up should occur in line with antenatal care visits at 26–28 and 34–36 weeks gestation and continue post-partum 3 monthly until RPR is non-reactive or stable at less than 4. For treatment of syphilis in pregnancy to be considered adequate, stage-appropriate penicillin treatment needs to be completec at least] one month (30 days) prior to delivery. Ideally there should be a demonstrated four-fold (two-titre) drop in maternal RPR, e.g. 1 in 64 to 1 in 16, prior to birth. The neonate should be examined and investigated based on a risk assessment taking into account adequacy of maternal treatment. Based on the risk assessment and the findings of the initial clinical examination and any available test results, treatment of the baby for congenital syphilis should be considered. Specialist infectious disease paediatric advice is recommended.]
All cases of congenital syphilis must be consistently identified, reported and then investigated to identify factors for improvement at both clinical and system levels, with mechanisms made available to implement recommended changes to practice.
Cases of infectious syphilis need to be informed of the infectious nature of their disease, even in the absence of visible lesions or symptoms, and to abstain from sexual activity for 5 days post-treatment or until symptoms have completely resolved (whichever is the longer). The importance of follow up and repeat syphilis serology testing to monitor the response to treatment should be emphasised. The case should be informed that they may continue to have positive treponemal specific tests for life even after successful treatment.
Cases of infectious syphilis should abstain from sexual activity for five days after receiving treatment or until symptoms have completely resolved (whichever is longer).
Testing for syphilis is recommended when:
Periodic syphilis testing is currently recommended for asymptomatic people in high risk groups, including:
It is recommended that jurisdictions ensure that primary health, sexual health and public health staff are made aware of their roles and responsibilities in relation to contact tracing for infectious syphilis. Roles may vary between jurisdictions and between different regions within a jurisdiction. It is also recommended that public health services maintain active oversight of contact tracing processes for infectious syphilis cases even where they do not provide staff to actively support the contact tracing effort. Contact tracing staff should be guided by the
Australasian Contact Tracing Manual.
The aim of identifying contacts of infectious syphilis is to prevent disease transmission by offering testing to identify infection before the onset of clinical symptoms and providing empirical treatment.
Anyone who has had sex (including oral sex) with a person who has confirmed or probable infectious syphilis is a contact. Unborn and newborn babies of women with infectious syphilis are also contacts.
How far back to trace? The infectious period depends on the stage of infection.
In addition to empirical treatment, contact management should include:
Patient and provider referral are the two main methods of alerting contacts. In the former, the case notifies their contacts while in the latter, the health care provider organises the notification and treatment of contacts. In remote populations, provider referral is the principal method of contact tracing used. When patient referral is used, contact management as outlined above should occur within two weeks of case treatment and the health staff responsible should confirm with the patient that this has occurred. If delays in patient referral occur, the patient should be offered additional support to undertake patient referral and the option to change to provider referral.
Innovative contact tracing tools have been used in MSM settings. These include on-line patient referral tools such as
The Drama Downunder’s ‘Let him know’ website and the WA AIDS Council M Clinic’s peer-led service delivery. On-line partner notification services have been developed by the
Australian Council of AIDS Organisations for Aboriginal people.
How much effort should be put into finding contacts of infectious syphilis? The highly transmissible nature of infectious syphilis, and specifically its capacity to spread rapidly through a population and to cause both foetal death and severe congenital complications if transferred to a pregnant woman, demands an urgent response from primary care and public health/sexual health clinic staff. Tracing the contacts of early syphilis should be a high priority, higher than contact tracing for other STI (chlamydia, gonorrhoea) which can cause serious complications but not so acutely. Rigorous and immediate efforts are called for. Half-hearted attempts will result in further sexual transmission and potentially result in serious avoidable outcomes such as congenital syphilis. If contact tracing is not effective, the patient is at high risk of being re-infected after treatment.
Timely contact tracing lies at the heart of an effective public health response to syphilis and needs to be prioritised. Contacts of infectious syphilis who live locally should be seen and treated within two working days of the case’s treatment. If the contacts are elsewhere and referral has been necessary, health staff should aim to ensure that all contacts are seen and treated within two weeks of the case’s treatment.
Persons who were sexually exposed to a patient with primary, secondary, or early latent syphilis should be treated presumptively with one dose of benzathine penicillin 1.8g (2.4 million units) regardless of their syphilis serology results.
Contacts of infectious syphilis need to be informed about the infectious nature of the disease, the possibility that they might be infected and infectious even in the absence of symptoms, and to abstain from sexual activity for 5 days after they have received empirical treatment or their syphilis serology shows that they have not been infected. The importance of follow up and repeat syphilis serology testing to monitor the response to treatment should be emphasised.
Sexual contacts of infectious syphilis should abstain from sexual activity for five days after receiving treatment.
Syphilis outbreaks are more likely to occur in particular populations. In Australia, recent outbreaks have occurred in MSM and Aboriginal and Torres Strait Islander populations (See
Appendix 4 which comprises Guidelines for the Public Health Management of Syphilis Outbreaks in Remote Populations in Australia). Syphilis clusters may also occur in association with certain sexual networks. It is important to pay attention to confidentiality and the sensitivities associated with sexually transmitted infections when managing syphilis clusters and outbreaks.
MSM who participate in highly sexually active subcultures are at increased risk of acquiring syphilis. Due to the diversity of the MSM population in relation to syphilis infection, any initiative developed must take into account the varying subpopulations, e.g. HIV positive and negative MSM; younger and older MSM (MSM <30 years contribute the highest number of syphilis notifications among HIV negative MSM whereas MSM aged 40-49 years contribute the highest number of syphilis notifications among HIV positive MSM); and those with differing stages of syphilis including symptomatic and asymptomatic infections. The National Gay Men’s Syphilis Action Plan outlines priority actions to achieve a sustained reduction in the incidence of infectious syphilis in MSM.
[For all syphilis laboratory notifications where the patient is managed by doctors not known to have experience in the management of syphilis, refer the notification to local sexual health clinic on the day of notification to enable sexual health clinic staff to offer timely assistance to the doctor and complete the notification form.]