Syphilis: understand the ‘explosion’ of cases in Brazil and around the world – 12/29/2023 – Health

Syphilis has gained several names since it was first recorded in the 1490s — most of them pejorative.

One name, however, remained: “the great imitator”. Syphilis is a master at mimicking other infections, and the early symptoms are easy to ignore.

But if the disease is not treated, the consequences can be serious.

Tushar, a 33-year-old project manager who lives in Amsterdam, the Netherlands, has had syphilis twice.

He remembers receiving the news for the first time via WhatsApp from a person he was having sex with at the time.

“The person was very upset and blamed me, which didn’t make sense given the dates [em que houve relações sexuais e que a infecção foi detectada]. It was strange being accused and it took a while for things to calm down.”

Tushar was tested and treated that week.

“People mistakenly think that syphilis can’t be cured. People don’t understand what it means to still have syphilis antibodies and not have the infection.”

In April, the United States released its most recent data on sexually transmitted infections (STIs).

Syphilis cases rose 32% between 2020 and 2021 in the country. It was the highest number of notifications in 70 years. It was also the most prevalent STI in the period.

The epidemic shows no signs of slowing, the Centers for Disease Control and Prevention (CDC) warned.

Congenital syphilis — when a mother transmits the infection to her child during pregnancy, often after contracting it from her partner — has advanced particularly sharply, with cases also increasing by 32% (as well as infections in general) between 2020 and 2021.

The disease can cause baby deaths and lifelong health problems.

In Brazil, data released by the Ministry of Health in October 2023 showed that, from 2021 to 2022, the detection rate of acquired syphilis cases per 100 thousand inhabitants grew by 23% (from 80.7 cases per 100 thousand inhabitants in 2021 to 99.2 cases per 100 thousand inhabitants in 2022).

Acquired syphilis is that contracted during life, after birth, distinguishing it from congenital syphilis.

From 2012 to 2022, there was an increase in the detection rate of acquired syphilis in Brazil year after year, with the exception of 2020, probably due to the decrease in diagnoses during the Covid pandemic.

The detection of syphilis in pregnant women also increased in the country last year, going from a rate of 28.1 cases per thousand live births in 2021 to 32.4 cases per thousand live births in 2022, an increase of 15% compared to to the previous year.

The incidence of congenital syphilis remained stable.

The ministry announced the purchase of a new rapid test to simultaneously detect syphilis and HIV infections that will be distributed by the Unified Health System (SUS), initially for higher risk groups.

Furthermore, to contain the disease, the agency stated that it will intensify the preparation of health professionals for prevention.

The federal government has set the goal of controlling or eliminating, by 2030, 14 diseases with high incidence in regions of greater social vulnerability, including syphilis. Another objective is to eliminate congenital syphilis in particular.

The global situation is leaving many health professionals and researchers alarmed.

“Fifteen or 20 years ago, we thought we were on the verge of eliminating syphilis,” says Leandro Mena, director of STI prevention at the CDC.

“There is no doubt that we are seeing rising rates of syphilis, rates that we have not seen in the last 20 years or so.”

There were 7.1 million new cases of syphilis worldwide in 2020, according to recent data from the World Health Organization (WHO).

In 2022, the UK saw syphilis cases reach the highest level since 1948.

The increase in cases is something that healthcare professionals notice on a daily basis.

“When I started working as a sexual health nurse in 2005, it was very rare to see primary syphilis, even in a large city clinic,” says Jodie Crossman, co-director of the STI Foundation, a foundation specializing in STIs in the UK.

“Now, most clinics see at least two or three patients a day for treatment.”

The infection is caused by a bacteria called Treponema pallidum and the symptoms are divided into four stages.

The first is characterized by a painless sore at the site of contact or a rash.

An intramuscular dose of penicillin is considered the most effective way to treat the infection.

If left untreated, however, syphilis can lead to long-term neurological and cardiovascular disease.

Isaac Bogoch, infectious disease doctor and researcher at the University of Toronto, Canada, states that the situation he has observed in his country – where between 2011 and 2019 the occurrence of syphilis infections increased by 389%, a curve significantly higher than that of other STIs – is repeated in various parts of the world.

“This trend is being observed in several countries around the world,” he says.

“It’s very concerning because, generally, syphilis is very easy to treat and treatment is widely available. So a lot of this reflects a failure in public health care.”

In recent decades, the trend has been for a greater occurrence of syphilis cases among men who have sex with men.

In Brazil, in 2022, 61.3% of cases of acquired syphilis were reported in males, with emphasis on the high incidences in the age groups of 20 to 29 years and 30 to 39 years.

The so-called sex ratio —men with syphilis for every ten women with syphilis— went from 0.6 (six men with syphilis for every ten women) in 2012 to 0.8 (eight men for every ten women with syphilis) in 2022.

In this case, cases of syphilis in pregnant women are also counted, which increases the participation of women in the total number of syphilis cases.

Some parts of the world, however, are recording a decrease in syphilis cases among men, such as Canada.

At the same time, there has been an increase in rates among women not just in Canada but in other countries, which has led to higher rates of congenital syphilis in several places.

Across the Americas, 30,000 cases of mother-to-child transmission of syphilis were recorded in 2021, a number that health authorities describe as “unacceptably high.”

Transmitting syphilis to a fetus during pregnancy can have devastating consequences, including miscarriage, premature births, infant deaths at birth, and low birth weight.

In the US, the highest rates of congenital syphilis are observed among black and Hispanic women.

“This reflects the underlying inequality and racism we still have in our public health and medical infrastructure,” says Maria Sundaram, a research associate at the Marshfield Clinic Research Institute in Wisconsin.

Vulnerable groups of women, such as those who are homeless or struggling with substance abuse, are also heavily affected by the disease. And many of these inequalities have been exacerbated by the Covid pandemic.

“The consensus in the public health community is that the increase in STIs, including syphilis, is likely related to the interruption of prevention resources during the pandemic”, points out Sundaram.

A study in Brazil showed a connection between black women who had low levels of education and higher rates of congenital syphilis.

In many cases, women have difficulty accessing adequate prenatal care that allows for the detection of syphilis.

Another study carried out in Kern County, California — which in 2018 represented 17% of congenital syphilis cases in the US state, despite representing only 2.3% of its population — identified the role of immigration status, medical insurance and violence sexual or domestic violence in pregnant women seeking prenatal care.

Half of the pregnant or postpartum women interviewed identified as being of Hispanic, Latino or Spanish origin.

A 2020 study of syphilis in Australia recorded a nearly 90% increase over rates recorded in 2015.

Around 4,000 cases of syphilis have been identified among Aboriginal and Torres Strait Islander communities, which represent just 3.8% of the Australian population.

Problems with pregnant women’s access to prenatal syphilis screening have been reported in some parts of the country.

Although economic issues and the pandemic impact access to healthcare, there have also been changes in people’s behavior regarding STIs.

“In the mid-1990s, with the advent of antiretroviral therapy for HIV, there was a huge shift,” says Mena.

“Now, thanks to advances in the prevention and treatment of HIV infection, AIDS is seen as a chronic disease. The risk of HIV infection is no longer an incentive for people to use condoms or adopt other STI prevention strategies” .

Changes in sexual practices have been studied by researchers in Japan, who observe the link between dating apps and cases of syphilis.

They concluded that dating app use was “significantly associated with the incidence of syphilis,” thus linking app use to a higher incidence of unprotected casual sex.

This is something that Sasaki Chiwawa, who writes about Japanese youth culture and sex work, has also encountered in her conversations with sex workers.

Chiwawa says more and more sex workers are not using condoms and there is no obligation on clients to be tested for STIs. When sex workers contract an infection, they tend to chalk it up to “bad luck,” says Chiwawa.

“Most of them prioritize making money over risk.”

For most health authorities, the path to combating syphilis is clear: we already have the medicines to combat it, as penicillin continues to be the best treatment, despite the growing incidence of antibiotic resistance.

More testing, better outreach to combat the stigma associated with the disease, along with greater public awareness to encourage safer sexual practices also play a big role.

“We’re social creatures, so we shouldn’t be more embarrassed by an STI diagnosis than a flu diagnosis,” says Crossman.

“We’re trying to shift the focus of STI testing from something that’s scary to something that’s part of sexual well-being, an important part of having a safe and enjoyable sex life.”

But scientists have so far been unable to come up with a single explanation for why the incidence of syphilis is rising faster than that of other STIs.

There is no strong evidence to suggest that circulating strains have become more virulent, says Mena.

Antibiotic resistance is also not high enough to explain the spikes in the disease, Bogoch says.

In turn, Tushar, who opens this report, continues to take tests every three months.

“We should feel comfortable talking about syphilis,” he says.

“So-called well-informed people resort to accusations instead of thinking about it scientifically. We’re having sex: things happen.”