Congenital syphilis cases on the rise

Syphilis cases have tripled in the last 10 years in Australia, leading to an ‘avoidable and unacceptable’ reemergence of congenital syphilis. This World Sexual Health Day (4 September), Australian Pharmacist explores pharmacists’ role in addressing this escalating issue.

When syphilis infections began to rise in Australia in 2011, the cases were primarily among men with male sexual partners, and young heterosexual persons in remote Aboriginal and Torres Strait Islander communities. However, there was a 500% increase in the rate of infectious syphilis among women aged 15 to 44 between 2011 and 2021, according to a report from the University of New South Wales’ Kirby Institute. 

That means parent-to-child transmission is also on the rise – this is called congenital syphilis. There was a median of 4 cases per year in Australia between 2011 and 2019, skyrocketing to 17 cases in 2020, and 15 in 2021 and 2022. For the birthing parent of babies with congenital syphilis, the report’s authors found less than 40% were tested for syphilis during pregnancy. 

Left untreated, congenital syphilis can lead to serious complications in more than 50% of cases, including miscarriage, stillbirth, neonatal death and permanent disability. Of all the cases of congenital syphilis in Australia between 2011 and 2021, 25% of babies were stillborn. 

In Queensland, where cases of infectious syphilis have increased by 600% in 15 years, five babies contracted the disease in the womb in 2023, leading to 4 deaths. This is the largest number of Queensland deaths from congenital syphilis in a single year this century. 

As a preventable and curable disease, Queensland Minister for Health Shannon Fentiman said the deaths ‘shouldn’t be happening’. It’s a message echoed by Australia’s Chief Medical Officer Professor Paul Kelly, who said health professionals need to ensure they’re up to date on information about syphilis testing and management. 

‘Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system,’ he said in a video (below) recorded for the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).

‘We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once, and in many cases more … Once diagnosed, treatment is simple and effective.’

High-risk populations

In 2022, syphilis rates among Aboriginal and Torres Strait Islander peoples were more than five times higher than in non-Indigenous populations. Of the 15 congenital syphilis cases across the country in the same year, eight were among Aboriginal and Torres Strait Islander peoples.

‘Congenital syphilis diagnoses are 14 times as high among Aboriginal and Torres Strait Islander infants compared with non-Indigenous infants,’ said researcher Dr Skye McGregor, who led the Kirby Institute report. 

‘All pregnant people should be tested for sexually transmitted infections (STIs) as part of pre- and antenatal health screening, but antenatal care is not always accessible. It is vital that comprehensive services are in place to ensure appropriate care is accessible for all pregnant people.’

Other high-risk populations include men who have sex with men and babies of mothers who have not had proper syphilis testing and treatment during pregnancy. However, ASHM Deputy CEO Jessica Michaels said it is important to recognise that syphilis can affect anyone. 

‘In order to curb the rising syphilis epidemic, it is important that we take a “no wrong door’’ approach to testing,’ she said. 

What to look out for

People presenting at a pharmacy with signs or symptoms of syphilis should be encouraged to test, Ms Michaels said, especially if the symptoms are otherwise unexplained. 

‘Other instances when pharmacists can encourage patients to test for syphilis include people presenting with symptoms of any STI or an STI diagnosis, those asking about testing for STIs and/or blood-borne viruses, when people are assessed for post-exposure prophylaxis, and pregnant people who are not engaged in antenatal care.’  

Symptoms and/or signs of syphilis can include: 

• a generalised rash on trunk, rash on palms and soles, alopecia, destructive skin lesions 
• ulcer(s), lumps or inguinal lymphadenopathy in the genital area 
• ulcer(s) or lesions in the mouth 
• ulcer(s) or lumps around the anus 
• glandular fever type illness such as fever, malaise, headache, lymphadenopathy, rash.

See ASHM’s Could it be syphilis? clinical indicator tool for more information.

Sensitively screening for syphilis

In order to reverse the ‘avoidable and unacceptable’ rise in congenital syphilis, the Kirby Institute researchers said it is important to ‘explore accessible models of care for pregnant women wherever they engage with the health system, enhance partner testing and treatment, and improve surveillance on testing in pregnancy’.

Pharmacists can be an important resource for patients who might be at risk, Ms Michaels said, and help to generate greater awareness to prevent harm.

‘Community pharmacists can play a key role in encouraging people to get tested for STIs, including syphilis. Pharmacists can also raise awareness of STI-prevention methods such as condoms. 

‘Remember that conversations about STI prevention, testing and treatment should be done in a sensitive and confidential manner … When discussing syphilis screening, it is important to be respectful and ensure an individual feels reassured that their privacy and confidentiality are protected.’

Some of Ms Michael’s top tips when discussing syphilis screening include:

• consider the time you have available and prioritise your questions accordingly
• be conscious of assumptions relating to bodies and sexual activity
• use inclusive and respectful language
• use an interpreter when English is a second language
• consult ASHM’s Sexual History Taking Resource Catalogue for guidance on discussing sexual health, and/or refer to the Australian STI Guidelines – Sexual History  for further information.