infectious syphilis in england: changing epidemiology and new prevention needs

Infectious Syphilis in England:Changing epidemiology and

new prevention needs

Dr Kevin Fenton

Consultant Epidemiologist

HIV/STI Division

PHLS Communicable Disease Surveillance Centre

Outline

• Recent trends in syphilis in England and Wales

• Resurgence of syphilis in London

• New national enhanced surveillance requirements for infectious syphilis

Males

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1995 1996 1997 1998 1999 2000

rate

per

100

,000

pop

ulat

ion

EnglandWalesScotland**N Ireland***

Females

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1995 1996 1997 1998 1999 2000

rate

per

100

,000

pop

ulat

ion

Recent epidemiology: Rates of infectious syphilis by country.

PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) andScottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)


Recent epidemiology: New diagnoses of infectious syphilis by sex, country and English region; 2000

KeyRate per 100 000 population

A: 0.00 - 0.15

B: 0.16 - 0.30

C: 0.31 - 0.45

D: 0.46 - 0.60

E: 0.61 - 0.75

F: 0.76+

MalesOverall UK rate: 0.55

FemalesOverall UK rate: 0.19

A

A

F

AB

B

C

C

C

E

F

A

AA

A

A

A

B

B

C

A

D

Recent epidemiology:Laboratory reports of infectious syphilis by probable region of acquisition: males England and Wales, 1994 to 1999

0

10

20

30

40

50

1994 1995 1996 1997 1998 1999

Year

Num

ber o

f lab

orat

ory

repo

rts

Africa

Asia

Europe

UK


The London enhanced surveillance programme for infectious syphilis

London enhanced surveillance:Key aims and objectives

• AIM:

– To improve our understanding of the distribution and determinants of infectious syphilis in London

• Objectives

– To characterise the recent cluster of cases

– To identify key social and sexual networks;

– To investigate the relationship between HIV and syphilis

London enhanced surveillance:Methodology

• Health Adviser led, established 1 August 2001

• 36 GUM clinics in the London region

• Diagnoses of infectious syphilis:

– Primary, Secondary and Early latent

– Retrospective collection from 1st April – 31st July 2001

– Prospective collection

Data collection

form for the London

enhanced surveillance programme for syphilis

London enhanced surveillance:Data analysis presented in this report

• Data analysis from 1st April 2001 to 12th April 2002

• Total number or reports: 393

– Number of Males: 349

– Number of Females: 44

• Reporting clinics – 86%

– At least one report from 31 clinics

– None from 5 clinics

Descriptive analysis of data:Broad overview of notified cases

Year

Total reports

2002 0

5

10

15

20

2001

Nu

mb

er

of

cas

esLondon enhanced surveillance:Total number of cases reported by year

Heterosexual Homosexual or bisexual

0

5

10

15

2002 2001 Year

Nu

mb

er o

f ca

ses

London enhanced surveillance:Number of cases by month and orientation

Distribution of reported cases

Heterosexual femaleHeterosexual maleHomo/bisexual male

John Hunter, n = 62

King’s, n=21

Royal Free, n=27

Mortimer Market, n=49

St Thomas’, n=22

Royal London, n= 28

Victoria clinic, n=19

Homerton, n=17

Archway, n = 16

St Mary’s, n=22

14%

74%

1% 11%

Heterosexual Males(n=56)

Homosexual Males (n=288)

Bisexual Males (n=4)

Female (n=44)

Total number of reports = 393

London enhanced surveillance:Reports by gender and sexual orientation

London enhanced surveillance:Reason for clinic attendance by sexual orientation

p<0.001

0

20

40

60

80

100

Routinescreen

Symptoms Contacttracing

Other

Perc

en

tag

e

Heterosexuals (n=80)

Homo/Bisexuals (n=292)

London enhanced surveillance:Age distribution by sexual orientation

0

10

20

30

40

50

<19 20-24 25-34 35-44 45+

Perc

en

tag

e


Homo/Bisexuals (n=292) p<0.001

0

20

40

60

80

100

UK Rest of Europe Other

Perc

en

tag

e



London enhanced surveillance:Country of birth by sexual orientation

p<0.001

London enhanced surveillance:Ethnicity by sexual orientation

0

20

40

60

80

100

White Black C Black _O Other

Perc

en

tag

e


Homo/Bisexuals (n=283) p<0.001

London enhanced surveillance:HIV status by sexual orientation

0

20

40

60

80

100

HIV Positive HIV Negative

Perc

en

tag

e


Homo/Bisexuals (n=242)p<0.001

London enhanced surveillance:Reported sexual partnerships in the last three months by sexual orientation

0

20

40

60

80

100

0 1 2 3 4 5 to 9 10 ormore

Perc

en

tag

e


Homo/Bisexuals (n=269p<0.001

London enhanced surveillance:Site of likely acquisition of infection

43

0

0

4

53

85

3

2

4

17

London

Brighton

Manchester

Other UK

Outside UK

Homo/ bisexual men (n=302)Heterosexuals (n=95)

p<0.001

p<0.001

0

20

40

60

80

100

Primary Secondary Early Latent

Perc

en

tag

e


Homo/Bisexuals (n=277) P=0.078

London enhanced surveillance:Stage of infection by sexual orientation

0

20

40

60

80

100

Yes No

Perc

en

tag

e



London enhanced surveillance:Oral sex transmission by sexual orientation

p<0.001

London enhanced surveillance:Relevant social venues/ networks by sexual orientation

6

2

2

0

0

1

19

7

6

3

CSW contact

Bar

Sauna

Internet

Cruisingground

Homo/ bisexual men Heterosexuals

The interaction between syphilis and HIV

Syphilis in HIV positive men

• 128 HIV positive homo/bisexual men

– Median age 37 years cf. 31 years (HIV neg.)

– No significant differences with respect to:CoB, ethnicity, reasons for attending, oral sex transmission, reported partners,

– However significant differences wrt. stage of infection, where possibly infected

London enhanced surveillance:Stage of Infection by HIV Status

0

20

40

60

80

100

Primary Secondary Early Latent

Perc

en

tag

e

HIV positive (n=124)

HIV Negative (n=103)

Relevant social/ sexual networks

0

17

4

5

0

2

24

9

8

6

CSW contact

Bar

Sauna

Internet

Cruisingground

HIV Positive

HIV Negative

Summary of key findings

• Changing epidemiology

– Global increases in syphilis in London

– Broadly in keeping with recent national increases

• Infections in heterosexuals ongoing

– Predominantly from those born outside the UK, ethnic minorities

– Less likely to be HIV positive,

– Oral sex not a predominant feature

– Over half of infections assumed to be acquired abroad

Summary II

• Infections in homosexual men

– Ongoing

– Cluster likely to have been identified through increased ascertainment

– White, older (mean 36 years), HIV positive, sex on premises bars important focus

– Links with other epi-centres present but not significant

New arrangements for enhanced laboratory

surveillance of infectious syphilis in

England and Wales

Current arrangements for laboratory surveillance• Enhanced laboratory

surveillance currently undertaken via the five PHLS syphilis reference laboratories

• However system is limited by its poor timeliness and lack of coverage.

• Approximately 40% of all diagnoses in country referred and confirmed at these sites

GUM: Patient diagnosed with syphilis

CDSC: Merged syphilis database

LAB: Sample confirmed at local laboratory

REFERENCE LAB: For confirmatory testing

New syphilis reporting scheme: Objectives

• The new surveillance system is being established to:

– monitor levels and trends of syphilis infection

– provide data on risk behaviours and transmission networks

– identify groups to target for testing and screening initiatives;

– determine the national and regional impact of syphilis infections.

Health professional reports case directly

Receipt of laboratory report initiates clinical reporting




New syphilis reporting scheme: Brief system description

• All laboratories in England and Wales to report new cases to CDSC.

• CDSC to obtain enhanced data from GUM clinics.

• CDSC will also collected data from existing enhanced surveillance.

New syphilis reporting scheme: Phase 1: Rapid laboratory reporting

• All laboratories to report to CDSC, all confirmed cases of infectious syphilis.

– A laboratory reporting form or

– electronic reporting via CoSurv to collect information.

• Direct lab reporting should decrease delay and allow better real-time monitoring.




Fig. 1 Rapid, direct laboratory reporting

New syphilis reporting scheme: Phase 2: Enhanced patient data collection

•CDSC will collate and verify laboratory data and arrange for the collection of enhanced clinical data from GUM clinics.

•This will involve direct contact with the GUM physician or health adviser.

•The CDSC coordinator will enter data into a password protected satellite database, linked to the lab report.

GUM: Health professional reports case directly

Receipt of laboratory report initiates clinical reporting


Fig. 2 Passive enhanced surveillance

New syphilis reporting scheme: Phase 3: Active clinical reporting

•Used in high incidence areas, or in sites with outbreaks.

•Methodology similar to the London enhanced system:

– GUM clinics to nominate a local syphilis coordinator.

– Triplicate copies of the clinical data collection form to be held locally.

– For each patient seen local syphilis coordinator to return form to the CDSC


Health professional reports case




Fig. 3 Active enhanced surveillance

New syphilis reporting scheme: Timetable for implementation

• System to go ‘live’ on 1st July 2002.

• Pilots already established in Eastern Region and West Midlands

• Enhanced surveillance in London to be continued for the foreseeable future.

• Roll-out to other regions by end-August 2002.

Summary and conclusions

• Recent increases in syphilis raise cause for concern

• Enhanced surveillance has played a key role in syphilis prevention and control

• Need for improved surveillance to co-ordinate national response

• The London enhanced surveillance programme has confirmed the feasibility and acceptability for such programmes

Acknowledgements

• We gratefully acknowledge the continuing collaboration of health advisors, clinicians, clinic staff, microbiologists and everyone else who contributes to STI and HIV surveillance in the UK

• PHLS CDSC prepares the data in collaboration with:

– Scottish Centre for Infection and Environmental Health, Information and Statistics Division Scotland, Department of Health Social Services & Public Safety in Northern Ireland, Institute of Child Health, Oxford Haemophilia Centre.

infectious syphilis in england: changing epidemiology and new prevention needs

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