Kaushal Verma, MD, Professor, AII India Institute of Medical Sciences, New Delhi, India

1. Syphilis in post elimination era -
control strategies !
Kaushal Verma, MD
Professor
AII India Institute of Medical Sciences
New Delhi, India
Regional Chair – IUSTI-Asia Pacific
Email: prokverma@hotmail.com

2. A night in the arms of Venus may lead to a lifetime on MercuryA night in the arms of Venus may lead to a lifetime on MARS

3. “Great imitator”
syphilis, caused by T.
pallidum, continues
to be elusive
condition with several
challenges

4. Syphilis
 Syphilis decreased dramatically
during 1980s
 Stabilized in 1990s &
 Re-emerged since 2000s
– due to various factors,
better surveillance systems
& case detection
Syphilis elimination failed due to -
Ignored deep economic, social,
and racial
disparities etc !!

5. Syphilis
 12 million new cases/year
 90% occurring in developing nations
 4 million cases in Asia
 Substantial rise in past 10 yrs due to –
 No fear of death from AIDS
 MSM, CSWs, migration
 Increase oral sex – syphilis readily trans
 HIV serosorting – MSM with similar HIV
status have condomless sex
 drug users
 partner swapping! etc.

6.  >60% syphilis cases in MSW
 Syphilis low in females, increased by >12% over a
decade (both pri & sec) in 2004 -05
 A large no. of MSM reported sex with women - 1/3
in US, 28% in China, 47% in Peru & 79% in Russia
 MSM a potential sexual bridge between high risk
men and low risk women

7. Prevalence increased from 2005 to 2012 from 0.2% to 1.3%
Global incidence rate for syphilis 1.5 cases per 1,000
(regional range: 0.9–4.4)
Syphilis prevalence estimates
(WHO 2012 estimates of maternal & congenital syphilis)
Consistent pattern of syphilis seen in women - increasing
prevalence with decreasing income

8. Syphilis in India
 Syphilis a major STI problem in India !!
 Vast numbers of people are severely
disadvantaged in terms of social settings,
income, education, power structures &
gender etc.
 Pr syphilis decreased but
Sr & early L syphilis increased

9. Rising trends of syphilis in North India
Subgroups Year Total
2006 2007 2008 2009 2010 2011
ANC
N 1489 1208 1244 933 562 349 5785
Positive 3 6 8 5 3 3 28
Percentage 0.20 0.50 0.64 0.54 0.53 0.86 0.48
HIV
N 880 1056 900 583 375 229 4023
Positive 25 22 20 22 19 16 124
Percentage 2.84 2.08 2.22 3.77 5.07 6.99 3.8
STD
N 220 88 169 165 178 195 1015
Positive 21 8 19 26 25 21 120
Percentage 9.55 9.09 11.24 15.76 14.04 10.77 11.7
Overall
N 5471 4945 5691 5148 4087 3578 28920
Positive 71 47 57 70 65 64 374
Percengage 1.30 0.95 1.00 1.36 1.59 1.79 1.29
Sethi S, Mewara A, Hallur V, Prasad A, Sharma K, Raj A. Rising trends of syphilis in a teritary care center
in North India. Indian J Sex Transm Dis 2015;36:140-3

10. Seroprevalence decreased from 2006 to 2008

11. Changing trend of syphilis at a centre of North India
Year Primary (%) Secondary(%) Latent (%) Total (%) Total
STD Cases
2008 4 (19.5) 13 (61.90) 4 (19.05) 21 (8.30) 253
2009 7 (26.92) 12 (46.16) 7 (26.92) 26 (11.16) 233
2010 7 (29.17) 7 (29.17) 10 (41.67) 24 (8.54) 281
2011 3 (23.08) 5 (38.46) 5 (38.46) 13 (3.40) 382
2012 0 1 (14.29) 6 (85.71) 7 (2.24) 313
Total 21 (23.08) 38 (41.76) 32 (35.16) 91 (6.22) 1462
Nishal PK, Kapoor A, Jain VK, Dayal S, Aggarwal K. Changing trends in acquired syphilis at a Tertiary Care Center of North
India. Indian J Sex Transm Dis 2015;36:149-53

12. Syphilis rates
Data from govt. health facilities, may be an
underestimate,
since many such patients prefer to visit
traditional healers, quacks, pharmacists or
private practitioners who are more accessible &
less judgmental in their attitudes

14. Sex tourism to cater needs of foreign tourists

16. Syphilis in China
 China virtually eliminated syphilis in 1960s & 70s
 Resurgence with alarming intensity in 1980s & growing
by about 30% a yr
 10-fold increase in syphilis cases over past decade
 Linked to country’s economic boom – Migrant workers
can hire more CSWs
 Cases more in areas with greater economic inequality

18. Syphilis in china

19. Trend of syphilis incidence in China from 2005–2012

20. Syphilis in China: 2010-2015
Year Incidence / 100,000
2010 28.9
2011 32.04
2012 33.3
2013 32.86
2014 33.64
2015 31.85
Sexually Transmitted Infections Surveillance Report,
National STD Control Center, China

21.  Prevalence very high in select HRG :
MSM (14.56%)
Incarcerated FSWs (12.49%)
Drug users (6.81%)
 Most prevalent (1:10 - 1:5) in HRG - CSWs &
MSM
 Spreading rapidly in general population

22. Large no. of migrant
workers
Increasing prostitution,
More extramarital sex
Low condom use
- key factors

23. Reported syphilis cases in japan
No. of
Patients
Total
Asymptomatic
Primary
Secondary
Tertiary
Congenital
March, 2013

24. Syphilis in Southeast Asia
 Syphilis remains a major problem
in SE Asia & West AP.
 Sex industry driven by local needs,
travel & tourism, keeping high
transmission.
 FSWs main source of male
infections.
 Anonymity & large no. of contacts
of sex industry, high mobility of
local population & tourists –
spreading infection.

25. Syphilis in Thailand

26. Syphilis in Thailand – sentinel
sero-surveillance
Group 2010 2011 2012 2013 2014
Blood donor 0.34 0.31 0.20 0.27 0.25
Male attended 0.91 2.42 1.13 3.16 2.33
STI clinic
Antenatal care 0.11 0.31 0.20 0.27 0.25
Direct prostitute 0.28 1.01 0.71 0.88 0.88
Indirect prostitute 0.27 0.43 0.51 0.59 0.61
---------------------------------------------------------------------------------------
Total 1.91 4.31 2.74 5.03 4.21
---------------------------------------------------------------------------------------

27. Syphilis in Singapore
Infectious Syphilis incidence in Singapore
(TOTAL POPULATION)
0
50
100
150
200
250
300
350
400
450
90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 10 11 12
Male Female Total
Cases
Male cases increased by 32% (110 in 2011 vs. 162 in 2012).
Female cases increased by 13% (15 in 2011 vs. 17 in 2012).

28. Syphilis in Australia

29. Syphilis in Australia
No. of notifications of Syphilis < 2 years, Australia, 2003 to 2015 & year-to-date for 2016
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Annual
Total
2003 0 0 0 0 0 1 0 0 0 0 0 0 1
2004 124 36 52 39 39 41 48 40 61 39 53 42 614
2005 104 50 49 42 46 47 43 53 61 57 47 38 637
2006 86 56 61 52 93 69 53 65 76 83 117 76 887
2007 99 112 107 100 171 133 119 147 105 111 138 93 1435
2008 114 137 115 124 112 109 113 96 111 103 102 87 1323
2009 109 119 111 106 121 109 112 113 116 84 102 92 1294
2010 103 108 96 81 101 101 84 94 77 84 100 90 1119
2011 129 104 135 79 110 102 107 122 94 102 116 84 1284
2012 111 129 105 140 144 125 135 132 143 137 139 119 1559
2013 151 140 157 139 149 125 155 154 158 163 134 142 1767
2014 148 154 149 170 171 167 164 188 192 176 169 189 2037
2015 206 186 229 203 197 231 270 240 246 235 270 205 2718
2016 262 272 261 265 290 242 242 285 225 178 75 0 2597

30. Syphilis in Pakistan

31.  Karachi, Pak - 37% cases of syphilis in transgenders
 Bangladesh - 23% prevalence in HIV drug users
 Indonesia - 19.3% in transgenders, 2.0% in MSWs &
1.1% in MSM
(Pisani E et al.Sex Transm Infect 2004;80:536-540)
♦ Taiwan - 38.19 episodes/100,000 Pys (most common
STI after HIV)

32. Incidence of syphilis seroconversion among HIV patients in Asia

34. Control strategies….
♦ Target and outreach high risk groups to
educate, test and treat
♦ Promoting and providing condoms
♦ Providing suitable non-stagmatizing
environment to seek care
♦ Provision of effective clinical interventions
♦ Availability of effective therapeutic agents

35. Control strategies
♦ Patient delivered partner therapy
♦ Enhanced contact tracing
♦ Frequent screening of high risk groups
taking PrEP
♦ Use of PrEP / systemic chemoprophylaxis
in high risk groups (doxy. once daily) ??

36. ♦ Re-emergence of syphilis in most
countries of world
♦ A challenge to STI control!
♦ Better & enhanced control measures are
needed to eliminate this treatable disease

39. Acknowledgements
• Prof. Kit Fairley
• Dr. Roy Chen
• Dr. Tetsuro Matsumoto
• Dr. Brian Mulhall
 Prof. C. Verapol
 Dr. Chavalit M
 Dr. Ligang Yang
 Dr. William Wong
 Dr. Suman Patra
 & others