By Sophie Chauvin-Bossé

Introduction

On February 25th, 2019, Dr. Michael Isaac, Manitoba’s provincial health public officer, declares a province wide syphilis outbreak. The outbreak was declared following an alarming increase in syphilis cases, congenital syphilis cases, as well as an increase in women infected. In the span of 6 months (2018-2019), 10 cases of congenital syphilis were reported and treated. Prior to this sudden increase in congenital syphilis cases, none had been reported for many years. The increase of syphilis cases in Manitoba, in both men and women, went from 118 in 2014 to more than 350 in 2018. The case numbers for women, which historically are not at risk for this infection, went from 16 in 2014, to more than 168 in 2018. The number of congenital syphilis cases have continued to increase. 30 cases were reported in just the first 8 months of 2020. The number of cases has been increasing and the outbreak is still ongoing.

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Figure 1: Rates of reported infectious cases of syphilis by sex from 2009-2018. A steep increase can be seen in 2018 before the outbreak was officially declared in 2019 by provincial health officials. Source: Image created by author with data provided by the government of Canada (Govt. of Canada, 2020).

Syphilis

Syphilis is a bacterial, sexually transmitted infection, caused by the bacterium Treponema pallidum. The bacterium is able to disseminate quickly into the host upon entry and evades the immune system due to the low presence of surface proteins on the outer membrane. The infectious disease can either be transmitted by sexual contact or by vertical transmission, whereby an infected mother passes on the disease to the fetus during pregnancy. The disease is systemic and is divided into multiple stages: primary, secondary, latent, and tertiary. Depending on the stage of the infection, patients will display different sets of symptoms. The first symptom of the primary stage of syphilis is the appearance of a chancre (sore) where the inoculation took place. The chancre will excrete fluid containing the syphilis bacteria. Other symptoms present in later stages of the syphilis infection are lymphadenopathy (disease of the lymph nodes), rash, fever, genital, and perineal lesions. In the case of congenital syphilis, if the child is not born deceased, symptoms usually appear noticeable shortly after birth. There are a very large number of symptoms possible such as aseptic meningitis, anemia, enlarged liver and spleen and mental retardation. Syphilis is treatable and curable by administering antibiotics, which will kill the bacterium causing the infection. The most widely used antibiotic to treat syphilis is penicillin.

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Figure 2: Electron micrograph of the bacterium Treponema pallidum which causes a syphilis infection upon entry into the body. Note the helically coiled shape of the microorganism. Source: Cox, D. (1977). Public Health Image Library (PHIL). Retrieved from https://phil.cdc.gov/details.aspx?pid=1977.

Cause of the outbreak

There are many factors which contribute syphilis outbreaks, such as inadequate sexual education, low socioeconomic status of people, poor housing stability, discrimination, and violence against minority groups. However, the main causes of the current syphilis outbreak in Manitoba are the changes in demographics of the infected and at risk population, a shift in behavior as well as a convergence with the illicit drug epidemic currently occuring.

Previously seen in earlier syphilis outbreaks in Manitoba and other provinces, the vast majority of people infected and at risk of contracting the disease were men who had sex with other men. With the current ongoing outbreak there has been a change in demographics of the people contracting the infection and at risk of the infection. The syphilis outbreak has shifted towards the heterosexual populations, affecting both men and women. The increase in cases in heterosexual men is multifactorial and most notably behavioral which can be brought upon by societal pressures to conform to gender norms. A trend in the heterosexual male population, that has increased their likelihood of contracting the infection, is the increase in number of sexual partners combined with the reduced use of barrier protection during sexual encounters. The syphilis outbreak in Manitoba can be partially attributed by this behavior as it will spread rapidly in the population before detection. Consequently, an increase in cases in heterosexual women can be attributed to their sexual partner’s behavior.

The increase of syphilis cases in both heterosexual men and women can be seen convergent with the ongoing illicit drug and mental illness epidemic occuring in Manitoba. In 2020, it was reported that 20-30% of those diagnosed with syphilis were crystal methamphetamine users. The usage of non sterilized needles for drug use has been a cause of the syphilis outbreak as it is spread through vulnerable populations that have been shown to have reduced access to health care and STI testing.

Now that heterosexual women are a part of the at risk and infected group in this current outbreak, the spread of the infection from pregnant mothers to the fetus is a major contributor to the severity of the syphilis outbreak in Manitoba. The factors causing an increase in congenital syphilis cases is substance use and/or lack of prenatal care. From January 2015 to July 2019, it was reported that 50% of babies born with congenital syphilis had mothers who used crystal methamphetamines. Furthermore, by not accessing proper prenatal care, mothers avoid the routine syphilis screening which is done at least once during the length of the pregnancy.

The ongoing Manitoba syphilis outbreak is still not resolved. The province’s chief medical officer explains that it is mostly likely because of the COVID-19 pandemic and the change in demographics of those infected and at risk. Firstly, in 2020, there has been a decease in people getting tested for syphilis due to the pandemic. With less people getting tested, those infected are more likely to be super spreaders and infect multiple people. Furthermore, now that the heterosexual population is increasingly vulnerable at contracting the infection, case management, contact tracing and awareness campaigns are not as effective as they were set up to target the previously most at-risk population, men who have sex with men.

Response

As a response to the ongoing syphilis outbreak in Manitoba, the provincial government has created a detailed list with all the guidelines for testing and reporting syphilis cases. Since the outbreak in 2019, the guidelines are revised every 6-12 months. For all pregnant women, the current recommendations are to get screen for syphilis in the first trimester. All pregnant women who are or have been diagnosed with syphilis will need to get screened for the infection every month of the pregnancy and again at birth. All pregnant women who are determined to be at higher risk of contracting the infection are subjected to additional screening. Additionally, the provincial health officer of Manitoba has implemented an increase in the activities of safe needle programs to decrease the spread of syphilis by those who use un-sterilized needles to inject drugs. The programs and recommendations by the provincial government are done with the goal of decreasing the number of syphilis cases, slowing the spread of the infection to eventually end the current syphilis and congenital syphilis outbreak.

References

Government of Canada. (2020, November 18). Government of Canada. Canada.ca. Retrieved on November 1 2021 from https://www.canada.ca/en/services/health/publications/diseases-conditions/syphilis-epidemiological-report.html#4

Choudhri,Y., Miller, J., Sandhu, J., Leon, A., Aho, J. (2018, February). Infectious and congenital syphilis in Canada, 2010-2015. Canada communicable disease report = Releve des maladies transmissibles au Canada. doi: 10.14745/ccdr.v44i02a02.

Forese, I. (2020, October 28). Manitoba shatters grim record with sharp rise in newborns with syphilis . CBCnews. Retrieved November 3, 2021, from https://www.cbc.ca/news/canada/manitoba/manitoba-syphilis-grim-record-newborns-sharp-rise-congenital-1.5779397#:~:text=Irvine%2FAssociated%20Press)-,Manitoba%20is%20on%20track%20to%20have%20as%20many%20newborns%20infected,17%2C%202020.

News releases: Province advises of syphilis outbreak in Manitoba. Province of Manitoba. (2019, February 25). Retrieved November 7, 2021, from https://news.gov.mb.ca/news/index.html?item=45074.

Manitoba Health and Seniors Care: Population and Public Health. (2021, October 12). Syphilis Protocol . Government of Manitoba. Retrieved November 10, 2021, from https://www.gov.mb.ca/health/publichealth/cdc/protocol/syphilis.pdf.

Shaw, Y. S., Ross, C., Nowicki, D. L., Marshall, S., Stephen, S., Davies, C., Riddell, J., Bailey, K., Elliott, L. J., Reimer, J. N., Plourde, P. J. (2018, January). Infectious syphilis in women: What’s old is new again? International journal of STD & AIDS. https://doi.org/10.1177/0956462415627397

Tudor, M. E., Al Aboud, A. M., & Gossman, W. (2021, October 18). Syphilis. StatPearls . Retrieved November 15, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK534780/.

Radolf, J. D. (1996, January 1). Treponema. Medical Microbiology. 4th edition. Retrieved November 12, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK7716/.