Infectious Syphilis in England: Changing epidemiology and new prevention needs

1. Infectious Syphilis in England:Changing epidemiology and new prevention needs Dr Kevin Fenton Consultant Epidemiologist HIV/STI Division PHLS Communicable Disease Surveillance Centre

2. Outline • Recent trends in syphilis in England and Wales • Resurgence of syphilis in London • New national enhanced surveillance requirements for infectious syphilis

3. Recent epidemiology: Rates of infectious syphilis by country. PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)

4. Key Rate 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+ Males Overall UK rate: 0.55 Females Overall UK rate: 0.19 A A A A A C C F B A A A B E A B B C D F C A Recent epidemiology: New diagnoses of infectious syphilis by sex, country and English region; 2000 PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)

5. Recent epidemiology:Laboratory reports of infectious syphilis by probable region of acquisition: males England and Wales, 1994 to 1999 PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)

6. The London enhanced surveillance programme for infectious syphilis

7. 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

8. 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

9. Data collection form for the London enhanced surveillance programme for syphilis

10. 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

11. Descriptive analysis of data:Broad overview of notified cases

12. London enhanced surveillance:Total number of cases reported by year Number of cases

13. London enhanced surveillance:Number of cases by month and orientation Number of cases

14. St Thomas’, n=22 Heterosexual female Heterosexual male Homo/bisexual male Distribution of reported cases Mortimer Market, n=49 Royal Free, n=27 Archway, n = 16 Homerton, n=17 Royal London, n= 28 St Mary’s, n=22 John Hunter, n = 62 Victoria clinic, n=19 King’s, n=21

15. London enhanced surveillance:Reports by gender and sexual orientation Total number of reports = 393

16. London enhanced surveillance:Reason for clinic attendance by sexual orientation p<0.001

17. London enhanced surveillance:Age distribution by sexual orientation p<0.001

18. London enhanced surveillance:Country of birth by sexual orientation p<0.001

19. London enhanced surveillance:Ethnicity by sexual orientation p<0.001

20. London enhanced surveillance:HIV status by sexual orientation p<0.001

21. London enhanced surveillance:Reported sexual partnerships in the last three months by sexual orientation p<0.001

22. London enhanced surveillance:Site of likely acquisition of infection p<0.001 p<0.001

23. London enhanced surveillance:Stage of infection by sexual orientation P=0.078

24. London enhanced surveillance:Oral sex transmission by sexual orientation p<0.001

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

26. The interaction between syphilis and HIV

27. 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

28. London enhanced surveillance:Stage of Infection by HIV Status

29. Relevant social/ sexual networks

30. 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

31. 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

32. New arrangements for enhanced laboratory surveillance of infectious syphilis in England and Wales

33. LAB: Sample confirmed at local laboratory REFERENCE LAB: For confirmatory testing CDSC: Merged syphilis database GUM: Patient diagnosed with syphilis 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

34. 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.

35. LAB: Sample confirmed at local laboratory Health professional reports case directly CDSC: Merged syphilis database GUM: Patient diagnosed with syphilis Receipt of laboratory report initiates clinicalreporting 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.

36. LAB: Sample confirmed at local laboratory CDSC: Merged syphilis database GUM: Patient diagnosed with syphilis 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

37. GUM: Health professional reports case directly CDSC: Merged syphilis database Receipt of laboratory report initiates clinicalreporting 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. Fig. 2 Passive enhanced surveillance

38. LAB: Sample confirmed at local laboratory GUM: Patient diagnosed with syphilis GUM: Patient diagnosed with syphilis Health professional reports case CDSC: Merged syphilis database 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 Fig. 3 Active enhanced surveillance

39. 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.

40. 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

41. 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.