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Syphilis outbreak challenges Northern Manitoba health authority

A continuing syphilis outbreak has proved a challenge for Northern Manitoban healthcare providers, with 21 confirmed cases since September 2014, compared to a usual range between zero and four cases. Dr.
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There have been 21 cases of syphilis in the area served by the Northern Regional Health Authority since September 2014. Normally there are between zero and four cases per year.

A continuing syphilis outbreak has proved a challenge for Northern Manitoban healthcare providers, with 21 confirmed cases since September 2014, compared to a usual range between zero and four cases.

Dr. Michael Isaac, medical officer of health with the Northern Regional Health Authority (NRHA), says that tracking and containing the spread of the disease has been challenging for a variety of reasons. “I’d say that we are seeing sustained community transition, and despite our efforts are not seeing our case count go down.”

Syphilis in any situation is a challenging infection to contain during an outbreak, as it has a relatively long incubation period, and individuals who have contracted the virus may not display symptoms for up to three months. “There’s a lot of time for them to spread the disease to other people.”

But the northern context has presented its own set of challenges, as the infection is spreading into populations which have not been typically associated with a high risk of syphilis. Isaac explains how outbreak management is typically conducted: “In outbreaks, you try and target interventions to specific subgroups.” Core populations at the highest risk of infection and transmission are identified and targeted for treatment, education, and prevention. From here, the spread of the disease can be traced and gradually brought under control from the inside out. “For example, in Winnipeg, the outbreak is very much concentrated in the ‘men who have sex with men’ community.” Much like the HIV outbreak of the 1980s, men who have sex with men have been identified as a group being affected by the Canada-wide urban outbreak. Other high-risk groups are those who are HIV-positive, have high numbers of sexual partners, or who engage in sex anonymously, regardless of sexual orientation.

“So if you know where syphilis is being mainly transmitted, you can intervene in a more targeted way, in terms of offering testing, issuing condoms, more messaging, etc.”

However, the case for the north is far less clear-cut. Previopusly, Isaac had indicated that 40 per cent of cases emerging in the north are emerging in women, as opposed to urban Winnipeg, where women make up a mere 5 per cent of syphilis patients. “Our outbreak is most definitely a heterosexual outbreak, and we haven’t been able to identify those specific places or risk factors at this point in time, where we can really do a targeted intervention that could snuff out the outbreak. We’ve had a very aggressive response to treating the outbreak itself, but we’ll have to wait and see what our numbers actually show.”

There are some elements, at least, which are working in the NRHA’s favour. In urban settings, tracking down potentially infected contacts has been complicated by casual dating apps and social media: “Apps like Tinder or Grindr, people can go on them, find people in their vicinity who want to have sex, and they may not ever know that person’s identity, or their name, which makes it extremely difficult for contact tracing.” Yet despite urban complications, Isaac notes that their use is not nearly as prevalent in this region. “We haven’t seen the same degree of social media use up here in the north. We did have one or two cases who had mentioned it, but for us that hasn’t been a major driver.”

Regardless, with nearly all predictable indicators absent from the northern outbreak, authorities are left to control the disease on a case-by-case basis. “Right now, the biggest risk factor we have is geography. Gillam and Thompson are the primary communities affected.”

For now, the NRHA has implemented an “enhanced surveillance” strategy, which involves extensive interviews with both direct patients and contacts which the patient may have made while infected. An epidemiologist from the Public Health Agency of Canada to help analyze the transmission data which the NRHA is collecting as more cases creep up. Along with testing and treatment, the NRHA will also undertake informing past sexual partners who may be at risk, though personal involvement is permitted if desired. Despite the Canada-wide issue, Isaac is unaware of any federal program to help curb the outbreak. Health care in Canada is largely the responsibility of provinces.

Isaac recommends individuals engaged in “risky” sex should get tested every three months, not only for syphilis, but all sexually transmitted infections (STIs). However, Isaac makes it clear that a low-risk lifestyle does not make an individual invulnerable.

“We’re moving away from a risk-based approach in terms of testing for STIs, because it can be very difficult to know your own risk. It’s obvious if you have multiple sexual partners. But we do know, for example, some females thought that they were in a monogamous relationship, but in fact they weren’t. So, they thought their risk was low, when in fact it wasn’t.”

There is good news for those who test positive for the virus, however: “Fortunately for us, syphilis is not resistant. It’s very easily treatable, through a single dose of penicillin, which we inject.”


What is syphilis?

-Syphilis is a bacterial infection spread through sexual intercourse, or congenitally from an infected mother to a developing fetus.


How can I tell if I have syphilis?

Syphilis develops in three stages:

-Primary: Syphilis begins as an often-painless chanre sore on the contacted area (mouth, genitals, rectum, etc), which appears between two to ten weeks after exposure. This is the first outward sign of infection

-Secondary: The infection spreads to other parts of the body. An itchless rash may appear on the body, along with additional chancre sores. Other, less common symptoms include aching, fatigue, joint pain, and patchy hair loss. The rash may disappear within two to six weeks.

-Latent: The virus remains in the body without symptom for up to 30 years, and may not progress to the tertiary stage. After one year, the bacteria is no longer infectious.

-Tertiary: 30 to 40 per cent of syphilis patients reach the tertiary stage. The virus re-activates, and attacks the body in a variety of areas, whether the heart, lungs, brain, or any other area. Symptoms depend on the attacked area. Once the syphilis has reached this stage, the infection can still be cured, but the damage done is irreversible.


What is the test for syphilis?

-Patients presenting with chancre sores are swabbed at the sore. Once a sore is present, the detection of syphilis is immediate.

-Patients who believe they have had contact with an infected person, but do not present symptoms, can be administered a blood test. A blood test will not detect an infection for two weeks after exposure.


What should I do if I think I have syphilis?

-Do not have sex until you are tested

-Report to your nearest health care centre

-Inform your health care centre of any sexual partners


How is syphilis treated?

-Syphilis, if detected prior to tertiary damage, is easily treated through single injection of standard antibiotics