1. Infectious Syphilis in England: Changing epidemiology and new prevention needs Dr Kevin Fenton Consultant Epidemiologist HIV/STI Division PHLS Communicable Disease Surveillance Centre

2. Outline Recent trends in syphilis in England and Wales Resurgence of syphilis in London New national enhanced surveillance requirements for infectious syphilis

3. Recent epidemiology: Rates of infectious syphilis by country. PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)

4. PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD) Recent epidemiology: New diagnoses of infectious syphilis by sex, country and English region; 2000 Key Rate per 100 000 population A: 0.00 - 0.15 B: 0.16 - 0.30 C: 0.31 - 0.45 D: 0.46 - 0.60 E: 0.61 - 0.75 F: 0.76+ Males Overall UK rate: 0.55 Females Overall UK rate: 0.19 A A F A B B C C C E F A A A A A A B B C A D

5. Recent epidemiology: Laboratory reports of infectious syphilis by probable region of acquisition: males England and Wales, 1994 to 1999 PHLS (England, Wales & Northern Ireland), DHSS&PS (Northern Ireland) and Scottish ISD(D)5 Collaborative Group (ISD, SCIEH and MSSVD)

6. The London enhanced surveillance programme for infectious syphilis

7. London enhanced surveillance: Key aims and objectives AIM: –To improve our understanding of the distribution and determinants of infectious syphilis in London Objectives –To characterise the recent cluster of cases –To identify key social and sexual networks; –To investigate the relationship between HIV and syphilis

8. London enhanced surveillance: Methodology Health Adviser led, established 1 August 2001 36 GUM clinics in the London region Diagnoses of infectious syphilis: –Primary, Secondary and Early latent –Retrospective collection from 1st April – 31st July 2001 –Prospective collection

9. Data collection form for the London enhanced surveillance programme for syphilis

10. London enhanced surveillance: Data analysis presented in this report Data analysis from 1st April 2001 to 12 th April 2002 Total number or reports: 393 –Number of Males: 349 –Number of Females: 44 Reporting clinics – 86% –At least one report from 31 clinics –None from 5 clinics

11. Descriptive analysis of data: Broad overview of notified cases

12. Number of cases London enhanced surveillance: Total number of cases reported by year

13. Number of cases London enhanced surveillance: Number of cases by month and orientation

14. Distribution of reported cases Heterosexual female Heterosexual male Homo/bisexual male John Hunter, n = 62 King’s, n=21 Royal Free, n=27 Mortimer Market, n=49 St Thomas’, n=22 Royal London, n= 28 Victoria clinic, n=19 Homerton, n=17 Archway, n = 16 St Mary’s, n=22

15. Total number of reports = 393 London enhanced surveillance: Reports by gender and sexual orientation

16. London enhanced surveillance: Reason for clinic attendance by sexual orientation p<0.001

17. London enhanced surveillance: Age distribution by sexual orientation p<0.001

18. London enhanced surveillance: Country of birth by sexual orientation p<0.001

19. London enhanced surveillance: Ethnicity by sexual orientation p<0.001

20. London enhanced surveillance: HIV status by sexual orientation p<0.001

21. London enhanced surveillance: Reported sexual partnerships in the last three months by sexual orientation p<0.001

22. London enhanced surveillance: Site of likely acquisition of infection p<0.001

23. P=0.078 London enhanced surveillance: Stage of infection by sexual orientation

24. London enhanced surveillance: Oral sex transmission by sexual orientation p<0.001

25. London enhanced surveillance: Relevant social venues/ networks by sexual orientation

26. The interaction between syphilis and HIV

27. Syphilis in HIV positive men 128 HIV positive homo/bisexual men –Median age 37 years cf. 31 years (HIV neg.) –No significant differences with respect to:CoB, ethnicity, reasons for attending, oral sex transmission, reported partners, –However significant differences wrt. stage of infection, where possibly infected

28. London enhanced surveillance: Stage of Infection by HIV Status

29. Relevant social/ sexual networks

30. Summary of key findings Changing epidemiology –Global increases in syphilis in London –Broadly in keeping with recent national increases Infections in heterosexuals ongoing –Predominantly from those born outside the UK, ethnic minorities – Less likely to be HIV positive, –Oral sex not a predominant feature –Over half of infections assumed to be acquired abroad

31. Summary II Infections in homosexual men –Ongoing –Cluster likely to have been identified through increased ascertainment –White, older (mean 36 years), HIV positive, sex on premises bars important focus –Links with other epi-centres present but not significant

32. New arrangements for enhanced laboratory surveillance of infectious syphilis in England and Wales

33. Current arrangements for laboratory surveillance Enhanced laboratory surveillance currently undertaken via the five PHLS syphilis reference laboratories However system is limited by its poor timeliness and lack of coverage. Approximately 40% of all diagnoses in country referred and confirmed at these sites GUM: Patient diagnosed with syphilis CDSC: Merged syphilis database LAB: Sample confirmed at local laboratory REFERENCE LAB: For confirmatory testing

34. New syphilis reporting scheme: Objectives The new surveillance system is being established to: –monitor levels and trends of syphilis infection –provide data on risk behaviours and transmission networks –identify groups to target for testing and screening initiatives; –determine the national and regional impact of syphilis infections.

35. Health professional reports case directly Receipt of laboratory report initiates clinical reporting GUM: Patient diagnosed with syphilis CDSC: Merged syphilis database LAB: Sample confirmed at local laboratory New syphilis reporting scheme: Brief system description All laboratories in England and Wales to report new cases to CDSC. CDSC to obtain enhanced data from GUM clinics. CDSC will also collected data from existing enhanced surveillance.

36. New syphilis reporting scheme: Phase 1: Rapid laboratory reporting All laboratories to report to CDSC, all confirmed cases of infectious syphilis. –A laboratory reporting form or –electronic reporting via CoSurv to collect information. Direct lab reporting should decrease delay and allow better real- time monitoring. GUM: Patient diagnosed with syphilis CDSC: Merged syphilis database LAB: Sample confirmed at local laboratory Fig. 1 Rapid, direct laboratory reporting

37. New syphilis reporting scheme: Phase 2: Enhanced patient data collection CDSC will collate and verify laboratory data and arrange for the collection of enhanced clinical data from GUM clinics. This will involve direct contact with the GUM physician or health adviser. The CDSC coordinator will enter data into a password protected satellite database, linked to the lab report. GUM: Health professional reports case directly Receipt of laboratory report initiates clinical reporting CDSC: Merged syphilis database Fig. 2 Passive enhanced surveillance

38. New syphilis reporting scheme: Phase 3: Active clinical reporting Used in high incidence areas, or in sites with outbreaks. Methodology similar to the London enhanced system: –GUM clinics to nominate a local syphilis coordinator. –Triplicate copies of the clinical data collection form to be held locally. –For each patient seen local syphilis coordinator to return form to the CDSC GUM: Patient diagnosed with syphilis Health professional reports case GUM: Patient diagnosed with syphilis CDSC: Merged syphilis database LAB: Sample confirmed at local laboratory Fig. 3 Active enhanced surveillance

39. New syphilis reporting scheme: Surveillance outputs Annual reports will be produced as part of the CDR inserts and contained within the STI Section Report. Ad hoc publications in peer reviewed journals on the epidemiology of infectious syphilis in England and Wales.

40. New syphilis reporting scheme: Timetable for implementation System to go ‘live’ on 1 st July 2002. Pilots already established in Eastern Region and West Midlands Enhanced surveillance in London to be continued for the foreseeable future. Roll-out to other regions by end- August 2002.

41. Summary and conclusions Recent increases in syphilis raise cause for concern Enhanced surveillance has played a key role in syphilis prevention and control Need for improved surveillance to co- ordinate national response The London enhanced surveillance programme has confirmed the feasibility and acceptability for such programmes

42. Acknowledgements We gratefully acknowledge the continuing collaboration of health advisors, clinicians, clinic staff, microbiologists and everyone else who contributes to STI and HIV surveillance in the UK PHLS CDSC prepares the data in collaboration with: –Scottish Centre for Infection and Environmental Health, Information and Statistics Division Scotland, Department of Health Social Services & Public Safety in Northern Ireland, Institute of Child Health, Oxford Haemophilia Centre.