Syphilis: A silent epidemic reawakens

By Priyanjana Pramanik, MSc.Jan 31 2024Reviewed by Susha Cheriyedath, M.Sc.

In a recent article published in the Indian Dermatology Online Journal, researchers studied the epidemiological and clinical profile of Indian patients who visited a tertiary care center for the treatment of syphilis. Their findings indicate that though there are effective treatments for syphilis and the disease is preventable, there has been a surge in cases globally over the past decade. Effective prevention and treatment are needed to ensure that untreated cases do not lead to adverse health outcomes that have implications for public health.

Study: Syphilis: Is it Back with a Bang? Image Credit: Kateryna Kon / Shutterstock

About the study

In this study, researchers followed a cross-sectional observational design to assess the epidemiological and clinical profile of individuals with syphilis who received treatment at a clinic specializing in sexually transmitted infections (STI) between 2019 and 2021. Patients of all age and sex groups were included if they were clinically diagnosed with syphilis, including latent, primary, secondary, tertiary, and congenital.

At the clinic, staff recorded the complete clinical history of the patients and carried out general physical, systemic, and mucocutaneous examinations. Clinical photographs were taken, and screening was performed for rapid plasma regain (RPR), treponema pallidum hemagglutination assay (TPHA), and human immunodeficiency virus (HIV).

Patients were diagnosed as having syphilis based on serology, clinical features, and history. Those who showed no clinical signs and symptoms but positive serology during screening were diagnosed as having latent syphilis. Examinations were also conducted if a patient was suspected of having mixed venereal disease.

Findings

In total, 1,330 people sought care at the clinic, of whom 200 (144 males and 56 females) received a syphilis diagnosis. The mean age of the patients was 30.9 years, and most were between 21 and 30 years old.

Male patients were predominantly manual laborers or long-distance drivers, while nearly 90% of female patients were homemakers. Based on the modified Kuppuswamy socioeconomic scale, most belonged to the upper-lower class.

In terms of marital status, 63% were married, including 53 females and 73 males; more than 40% of females showed positive RPR serology and were antenatal. About 20% of male respondents reported being either bisexual or homosexual.

Half of the respondents reported a history of either premarital or extramarital contact, and 36% said that they had engaged in sexual contact with paid sex workers. Nearly 30% were polygamous, and nearly 85% reported that they had engaged in unprotected sexual activity.

Nearly 25% of patients had primary chancres, 44.5% had secondary syphilis, 30.5% had latent syphilis, and only 0.5% had congenital syphilis (a two-day-old girl with no clinical manifestation). Tertiary syphilis was not seen in the study. Chancres were found on the tongue and glans, while 43 patients had rashes in various parts of the body. In addition to syphilis, 25 individuals also had herpes progenitalis, 7 had genital molluscum contagiosum, 10 had chancroid, and 6 had concurrent genital warts. Screening suggested that 5 females and 28 males were HIV-positive and positive RPR titers across all 200 patients.

Conclusions

Though effective treatments are widely available, syphilis continues to have a high prevalence rate and has seen a resurgence in cases in India and several other countries. Comparisons with previous studies suggest an upward-rising trend in syphilis cases.

The predominantly male patient group could be due to their engaging in more risky behaviors and because they are more likely to seek treatment early on. At the same time, females are restricted by cultural and social stigma and are more likely to be asymptomatic. Earlier initiation of sexual activity, if it is not accompanied by safe practices, could be a risk factor for STIs.

Though other studies have found strong associations between STIs and lower education, which limits self-care ability and understanding, the majority of patients in this study were literate.

Drivers and daily wage laborers who migrate to find work appear to be a high-risk group because they spend extended periods away from their partners, leading to risky sexual behaviors. The findings also indicate the need to target commercial sex workers to promote safe behaviors to reduce the rising burden of STIs.

Infection and re-infection rates may also be high in men who have sex with men living with HIV – this group can be targeted with interventions to reduce stigma around their conditions, bring them closer to health services, and improve their quality of life.

There is a pressing need to limit the spread of STIs through rapid diagnostic kits, sex education, and safe sex education. High-risk groups can be targeted in a cost-effective way. Most importantly, the stigma around STIs must be addressed to ensure prevention and effective treatment.