#1Saskatchewan Health Authority STBBI in Saskatchewan Presentation at the SASKPIC Education Conference Healthy People, Healthy Saskatchewan The Saskatchewan Health Authority works in the spirit of truth and reconciliation, acknowledging Saskatchewan as the traditional territory of First Nations and Métis People. September 2023 Of oyf You Tube www.saskhealthauthority.ca#2Saskatchewan Health Authority Slides adapted from the "Syphilis in Saskatchewan: Epidemiology and Analyses to Inform Public Health Action" presentation Healthy People, Healthy Saskatchewan The Saskatchewan Health Authority works in the spirit of truth and reconciliation, acknowledging Saskatchewan as the traditional territory of First Nations and Métis People. Of oyf You Tube www.saskhealthauthority.ca#3Vision, Mission, Values and Philosophy of Care VISION Healthy People, Healthy Saskatchewan MISSION We work together to improve health and well-being. Every day. For everyone. VALUES Healthy People SAFETY: Be aware. Commit to physical, psychological, social, cultural and environmental safety. Every day. For everyone. ACCOUNTABILITY: Be responsible. Own each action and decision. Be transparent and have courage to speak up. SAFETY COMPASSION ACCOUNTABILITY Patient and Family Centred Care COLLABORATION RESPECT Healthy Saskatchewan RESPECT: Be kind. Honour diversity with dignity and empathy. Value each person as an individual. COLLABORATION: Be better together. Include and acknowledge the contributions of employees, physicians, patients, families and partners. COMPASSION: Be caring. Practice empathy. Listen actively to understand each other's experiences. PHILOSOPHY OF CARE: Our commitment to a philosophy of Patient and Family Centred Care is at the heart of everything we do and provides the foundation of our values. Saskatchewan Health Authority Of You @yfm Tube www.saskhealthauthority.ca#4SHA Treaty Land Acknowledgement Honouring Relationships with Indigenous People We acknowledge that we are gathering on Treaty 4 territory and the Homeland of the Dakota, Lakota and Métis. Recognizing this history is important to our future and our efforts to close the gap in health outcomes between Indigenous and non-Indigenous peoples. www.saskhealth authority.ca/trc Treaty Territories and Saskatchewan Health Authority Areas Depictions of Treaty boundaries are subject to variation. These boundaries are usually not surveyed and are estimated based on written descriptions. This map displays the Pre-1975 Treaties (Historic Treaties) in colour, as provided by Crown-Indigenous Relations and Northern Affairs Canada. The grey lines indicate alternate boundaries compiled from various sources. TREATY 7 ATHABASCA HEALTH AUTHORITY TREATY 8 TREATY 10 NORTH WEST NORTH EAST TREATY 5 TREATY 6 SASKATOON REGINA SOUTH EAST Saskatchewan + Health Authority SOUTH WEST TREATY 4 TREATY 2#5Learning objectives Describe the epidemiology of syphilis in Saskatchewan Describe the epidemiology of syphilis in Regina Highlight the challenges and successes experienced by public health staff in syphilis clinical management Explore the impact of the current syphilis outbreak Explore the operational impacts of the current syphilis outbreak + Saskatchewan Health Authority#6Syphilis Update: A limerick There was a young man from back bay Who thought syphilis just went away He believed that a chancre Was only a canker That healed in a week and a day But now he has acne vulgaris Or whatever they call it in Paris On his skin it has spread From his feet to his head And his friends want to know where his hair is There is more to his terrible plight: His pupils won't close in the light His heart is cavorting His wife is aborting And he squints through his gun barrel sight Arthralgia cuts into his slumber His aorta is in need of a plumber But now he has Tabes And sabershinned babies While of gumma he has quite a number He has been treated in every known way But his spirochetes grow day by day He's developed paresis Has long talks with Jesus And thinks he is the queen of the May (P. 765 in: Prescott, L.M., Harley, J.P. and Klein, D.A.: Microbiology, 3rd Ed., Wm.C.Brown Publ., Dubuque 1996) + Saskatchewan Health Authority#7Key messages From 2017 to 2022, Saskatchewan's syphilis rates have increased over 400% In 2019, syphilis cases were largely in the North West area of the province Syphilis transmission spread diagonally north-south This trend is the same for syphilis, infectious syphilis, child-bearing years, congenital Over the same period, the epidemiology shifted from predominately middle aged men, with higher testing rates among males, to predominately women of child-bearing years, with higher testing rates among women SK reported zero congenital syphilis cases between 2013 and 2018, to n = 68 since 2019 Syphilis now exists throughout the province Saskatchewan ranks 2nd highest infectious syphilis rates in Canada (behind MB) and has the highest rates of congenital syphilis in Canada Saskatchewan + Health Authority#8Key messages All cases have complex mix of risk factors associated with infection: Substance misuse Unstable housing Transiency/Frequent movement Anonymous or multiple sex partners No condom use History of multiple sexually transmitted infections, including re-infection + Saskatchewan Health Authority#9Syphilis by the numbers#100 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 50 Nov-17 **2022 is subjected to change - data as of February 1st, 2023 *PHAC Date (month and year) used, confirmed cases only Female (n=3605) Number of Cases 200 E 150 100 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Dates Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 Male (n=3434) Unknown (n=3) May-20 Jun-20 Jul-20 Aug-20 Sep-20 250 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 300 Epidemic curve: All Syphilis, 2017 – 2022 All syphilis cases, Saskatchewan, January 2017 to December 2022 (n = 7042) Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Health Authority Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22#110 50 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Primary (n=2842) Late latent (n=567) 100 Nov-17 Dec-17 Jan-18 Feb-18 *PHAC Date (month and year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 Number of Cases Mar-19 Apr-18 May-18 Jun-18 150 Jul-18 200 250 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 300 Epidemic curve: All Syphilis by Stage, 2017 – 2022 All syphilis cases by stage, Saskatchewan, January 2017 to December 2022 (n = 7042) Dec-19 ■Secondary (n=1050) ■Late neurosyphilis (n=6) Dates Early Latent (n=1650) ■Early neuro syphilis (n=39) Tertiary other than neurosyphilis (n=5) Early congenital (n=56) Unknown/Blank (n=819) ■Syphilitic stillbirth (n=8) Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 NOV-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 + Jun-2.2 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Saskatchewan Health Authority#12■ Females outnumber males: All Syphilis, 2017-2022 All syphilis distribution by sex, 2017-2022 65+ Year Females (%) Males (%) 60 to 64 55 to 59 50 to 54 2017 7.5 92.5 45 to 49 2018 28.3 71.7 40 to 44 2019 46.2 53.8 2020 52.0 48.0 Age groups 35 to 39 30 to 34 25 to 29 20 to 24 2021 52.1 47.9 15 to 19 2022 53.9 46.0 10 to 14 5 to 9 2017-2022 51.2 48.8 1 to 4 Sex trend reversal from 2017 to 2022 Median age, in 2022: Males 32 years = Females 28 years = *PHAC Date (year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 All syphilis cases by sex and age group, 2017-2022 0 800 600 400 200 ■Male Female Number of Cases 200 400 600 800 1000 + Saskatchewan Health Authority#13Syphilis and age trends Incidence Rate per 100,000 800 700 600 500 400 300 200 100 0 2017 Incidence rate per 100,000 population of all syphilis cases by age, January 2017 to December 2022 2018 2019 2020 Year 2021 0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60+ *All syphilis cases including congenital and stillbirths; PHAC Date (year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 2022 + Saskatchewan Health Authority#14Times are changing... 2019 (n = 459) 2020 (n = 1070) Athabasca Health Authority (112.7) Far North West (50.2) 2021 (n = 2353) 2022 (n2888) Athabasca Health Authority (448.4) Legend Public health reporting zones Congenital/stillbirths, 2022 Syphilis Incidence rate* <24 [national rate] 24-125 125-249 Athabasca Health Authority (755) ≥250 [2x10 national] Far North West (398) Far North East Far North West (255.2) *number of cases per 100,000 population Far North East (742.1) Far North East (66.1) (122.4) Athabasca Health Authority (103-8.2) Far North West (957.4) Far North East (1532.2) North West North West North Central (158.8) (45.4) North East (23.7) North West * (252.7) North Central (232.2) North East (19) North West (377.5) North Central (446.4) North East (93.8) North Central (402.7) (686.1) North East (161.6) Saskatoo (40.4) Central West Central East (4) Saskatoon (89.4) Central East Central West (10.6) (22) (21.2) Saskatoon (193.8) Central East Central West (76.2) (2.7) Saskatoon (163.6) Central West (8) Central East (92.7) Regina (196.2) Sputh Central Regina (185.8) South East South West (7.6) (22.7) Regina (22.7) Regina (50.4) South Central (62.1) South East South West (10.3) (23.2) South Central South East South Central South East (34.7) South West South West (2.5) (2.5) (11.3) (19.3) (8.8) (18.6) *Preliminary estimates for 2022 data ** *All syphilis includes staged and unstaged cases + Saskatchewan Health Authority#150 Jan-17 Feb-17 Mar-17 50 Apr-17 Number of Cases 100 150 200 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 250 300 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Epidemic Curve: Infectious, Late Latent, and Unstaged Syphilis by Stage, 2017-2022 Infectious, Late Latent, and Unstaged Syphilis Cases, January 2017 to December 2022 (n = 6967) Nov-18 Dec-18 Jan-19 Feb-19 **2022 is subjected to change - data as of February 1st, 2023 ~ Unknown/blank refers to syphilis cases with unknown or blank information captured under staging information Primary (n=2842) Secondary (n=1050) Early Latent (n=1650) Early neurosyphilis (n=39) Late Latent (n=567) *PHAC Date (month and year) used, confirmed cases only Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Dates Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Unknown/Blank (n=819) All syphilis (n=7042) Saskatchewan Health Authority#16Syphilis in females of child-bearing years Saskatchewan Health Authority#170 20 40 120 Number of Cases 60 60 80 100 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Primary (n=1245) Late Latent (n=280) 140 Feb-18 Mar-18 160 180 200 Epidemic Curve: Infectious, Late Latent, and Unstaged Females of Child-bearing Years (15-45), 2017-2022 Infectious syphilis, late latent and unstaged cases in females of child-bearing ages (15-45 years), Saskatchewan, January 2017 - December 2022 (n = 3430) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 *PHAC Date (month and year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 ~ Unknown/blank refers to syphilis cases with unknown or blank information captured under staging information Apr-19 May-19 Jun-19 Jul-19 Aug-19 Secondary (n=538) Unknown/Blank (n=456) Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Dates Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Early Latent (n=900) All Infectious syphilis (n=5581) Early neurosyphilis (n=11) + Saskatchewan Health Authority#18Congenital syphilis Saskatchewan Health Authority#190 1 7 Epidemic Curve: Congenital Syphilis + Infectious, late latent and unstaged female of child-bearing years (15-45), 2019-2022 Number of Cases 2 5 6 All congential cases, syphilitic stillbirths and unstaged cases less than 1 year, Saskatchewan, January 2019 to December 2022 (n = 68) Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Congential Cases (n=57) Syphilitic Stillbirth (n=8) Blank (n=3) Dates Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Infectious, late latent and unstaged syphilis in female (15-45 years) (n=3384) Dec-22 20 40 80 100 120 140 160 Number of cases in feamles of child-bearing years 60 *PHAC Date (month and year) used, confirmed cases only **46 cases of infectious, late latent and unstaged cases in females of child-bearing years reported from January 2017 to December 2018 are not included in the above epi curve. Caution should be utilized while interpreting the graph as cases in women of child-bearing years and pregnancy gestation are not aligned. Blank refers to syphilis cases with unknown or blank information captured under staging information Saskatchewan + Health Authority#20Mom-baby profile: Main findings Only four moms (6%) received prenatal care; 63% had no prenatal care 28% received sporadic prenatal care; 3% had no information reported Nearly all mothers did not receive effective treatment (n = 67; 99%). Where treatment occurred, 50% treated post delivery At least half became infected or were re-infected during pregnancy (primary, secondary) All mothers (n = 68; 100%) had at least one of the following risk factors: Substance misuse, unstable housing, transiency, anonymous or multiple sex partners, no protection used, previous STIS The minority of moms were entirely under First Nations jurisdiction (ISC and/or NITHA) (n = 26; 38%) but frequent movement between public health jurisdictions, particularly in the northern areas. = Saskatchewan + Health Authority#21The view from Regina Saskatchewan Health Authority#22Empty#23Overall disease counts and disease-specific rates of confirmed STI cases, 2019-2022, Regina, Saskatchewan Case count 1600 Chart showing STBBI counts and rate 2019 - 2022, Regina and area 600.0 1400 1200 1000 800 600 400 200 500.0 400.0 300.0 200.0 100.0 0 0.0 2019 2020 2021 2022 I Chlamydia Trachomatis Infection 1417 1062 978 1126 Gonococcal Infection 551 445 386 465 HIV 47 52 61 70 Syphilis 61 155 511 528 Chl. Trach rate 518.5 382.0 357.7 404.1 Gono. Infection rate 201.6 160.1 141.2 166.9 HIV rate 17.2 18.7 22.3 25.1 Syphilis rate 22.3 55.8 186.9 189.5 Chl. Trach rate I Chlamydia Trachomatis Infection *PHAC Date (month and year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 ~ Unknown/blank refers to syphilis cases with unknown or blank information captured under staging information Gonococcal Infection THIV Gono. Infection rate HIV rate Syphilis Syphilis rate Rate per 100,000 + Saskatchewan Health Authority#24CASE COUNT 300 Crude rate per 100,000, infectious syphilis, fRQHR 2015-2022, by sex 250 200 150 100 50 50 50 250 200 150 100 0 0 2015 2016 2017 2018 2019 2020 2021 2022 Female cases 2 1 2 6 23 75 244 258 Male cases 5 31 27 23 38 80 265 260 Female rate 1.4 0.7 1.3 4 16.9 54.4 179.4 186.3 Male rate 3.5 20.7 17.5 15.0 27.6 57.1 192.9 185.5 + Saskatchewan Health Authority RATE PER 100,000#25Characteristics of a cohort of STI patients in Regina area, 2019 - 2022 Number of cases (%) Female 4900 (57.1) Male 3681 (42.9) STBBI cases by disease type Chlamydia Trachomatis Infection 2907 (63.4) 1675 (36.6) Gonococcal Infection 1002 (54.3) 845 (45.7) HIV 118 (51.3) 112 (48.7) Hepatitis B 68 (40) Hepatitis C Syphilis Regina 1 (North) Regina 2 (East) Regina 3 (South) 194 (40.1) 102 (60) 282 (59.9) 605 (48.2) Regina 4 (Central) Regina NA *PHAC Date (month and year) used, confirmed cases only **2022 is subjected to change - data as of February 1st, 2023 ~ Unknown/blank refers to syphilis cases with unknown or blank information captured under staging information 650 (51.2) STI cases and rates per 100,000 by Regina area residence 1057 (771.4) 661 (482.4) 827 (603.5) 676 (487.0) 455 (327.8) 616 (443.8) 1965 (1434.0) 1149 (827.7) 390 (284.6) 785 (565.5) Saskatchewan + Health Authority#26Syphilis by disease stage, 2022 Early congenital, 2, 0% Unknown, 131, 25% Tertiary other than neurosyphilis, 2, 0%. Early neurosyphilis (<1 year. after infection), 3, 1% Late latent, 71, 14% Primary, 131, 25% Secondary, 94, 18% Primary Late latent Unknown Early latent, 86, 17% Secondary Early latent Early neurosyphilis (<1 year after infection) Tertiary other than neurosyphilis Early congenital an hority#27Syphilis by risk factor No condom Previous STI Non-injection drug use Street involved More than 2 partners last 3 months IDU No RF Alcohol use Sex with a known case Unknown/anonymous partnering Homeless Pregnant Victim of sexual assault Goods received in exchange for sex e-partnering Goods provided in exchange for sex Travel outside Canada Female (n=259) 0 20 20 40 40 60 60 60 80 100 120 140 160 180 200 Frequency reported No condom Previous STI Non-injection drug use Alcohol use More than 2 partners last 3 months Unknown/anonymous partnering Street involved Sex with a known case No RF IDU e-partnering Homeless MSM Travel outside Canada Goods provided in exchange for sex Victim of sexual assault Male (n=261) Goods received in exchange for sex Correctional facility resident 0 20 40 40 60 80 100 120 140 160 180 Frequency reported + Saskatchewan Health Authority#28Risk factor profile of sexually transmitted cases in Regina 2019 - 2022 Frequency Risk factor Sex without protective barriers 1973 (22.99) Sex with two or more partners in the last three months 1556 (18.13) Sex with an anonymous partner Cases with a history of injectable substance use Cases with a history of non-injectable substance use Sex with a known case Cases meeting partners online Cases who are street-involved 976 (11.37) 607 (7.07) 584 (6.8) 479 (5.58) 471 (5.49) 424 (4.94) + Saskatchewan Health Authority#29Impacts of Syphilis Epidemic in Public Health Increased workload Hard to reach population with coexisting social and health issues Increased lost to follow up rates Difficulty with retention in care Limited healthcare worker capacity Coinfections + Saskatchewan Health Authority#30Thank you for listening. Questions? Saskatchewan Health Authority#31With thanks to... Cara Benz Helen Bourget Kathy Lloyd Lara Murphy Laurel Stang Maureen Anderson Maurice Hennink Molly Trecker Muhammad Siddiqui Priyanka Mahajan Taegen Fitch Tania Diener CD team Sexual health clinic team Our patients Provincial epidemiologists SHA epidemiologists Saskatchewan + Health Authority#32Extras Saskatchewan Health Authority#33Syphilis Diagnosis Saskatchewan Health Authority#34Syphilis Update: Clinical History and Examination Assessment ☐ History of syphilis Known contact to an infectious case of syphilis Signs or symptoms of syphilis in the past 12 months Most recent serologic test for syphilis Examination Oral cavity Lymph nodes Skin of torso Palms and soles Genitalia and perianal area Neurologic examination Abdomen + Saskatchewan Health Authority#35Laboratory tests Syphilis screening tests: ◉ Venereal disease research laboratory (VDRL) test. The VDRL test checks blood or spinal fluid for an antibody that can be produced in people who have syphilis. This antibody is not produced as a reaction to syphilis specifically, so the test result could be "abnormal" for reasons other than syphilis. Rapid plasma reagin (RPR) test. The RPR test also finds syphilis antibodies. Syphilis confirmation tests: Enzyme immunoassay (EIA) test. This blood test checks for syphilis antibodies. A positive EIA test should be confirmed with either the VDRL or RPR tests. Fluorescent treponemal antibody absorption (FTA-ABS) test. This test also checks for antibodies. It can be used to find syphilis except during the first 3 to 4 weeks after exposure. The test can be done on a sample of blood or spinal fluid. ■ Treponema pallidum particle agglutination assay (TPPA). This test also checks for antibodies. It is used after another method tests positive for syphilis. This test is not done on spinal fluid. Adapted from Syphilis Tests. Available at https://www.healthlinkbc.ca/medical-tests/hw5839 Saskatchewan + Health Authority#36Laboratory testing T. pallidum Total Antibody Screen Syphilis RPR TPPA screen Negative n/a n/a Reactive Reactive n/a Reactive Non-Reactive¹ RPR Reactive² Non-Reactive Reactive Non-Reactive Non-Reactive Reactive Non-Reactive Interpretation No serologic evidence of past or current syphilis infection. In the setting of recent exposure, or signs/symptoms of primary syphilis, repeat testing in 2 to 4 weeks. Consistent with syphilis infection. Clinical manifestations and treatment history is required to refine interpretation: i) Infectious syphilis (primary, secondary or early latent) ii) Late latent syphilis iii) Tertiary syphilis iv) Treated syphilis with persistent reactive RPR No serologic evidence of past or current syphilis infection. Screening test is most likely falsely reactive. In the setting of recent exposure, or signs/symptoms of primary syphilis, repeat testing in 2 to 4 weeks. Indeterminate Syphilis serology inconclusive. T. pallidum particle agglutination (TPPA) Reactive Non-Reactive Reactive (or Repeat Reactive) Non-Reactive³ Indeterminate Reactive5 (or Repeat Reactive) Recommend repeat testing in 2 to 4 weeks. If results remain inconclusive upon repeat testing, this may represent falsely reactive serology or distant prior infection (treated or untreated). Consistent with syphilis infection. Clinical manifestations and treatment history is required to refine interpretation: i) Primary syphilis before RPR seroconversion ii) Secondary syphilis with RPR prozone effect (notify lab if suspected) iii) Late latent syphilis after RPR seroreversion iv) Treated syphilis Note: These results are also consistent with non-syphilitic treponematosis (bejel, yaws or pinta)#37Syphilis Diagnosis Saskatchewan Health Authority#38Laboratory tests ■ Screening test - IgG & IgM (By itself is not reportable to MHO) RPR - Rapid Plasma Reagin (non-treponemal): Quantitative ■ Guides treatment and re-infection for previous cases ■ NR, 1:1, 1:2, 1:4, 1:8, 1:16, 1:32, 1:64, 1:128, 1:256, 1:512,.... ■ TPPA - T. pallidum Particle agglutination assay Treponemal test (specific for T. pallidum antibody) ■ Reportable (Reactive or Indeterminate) ■ Remains "Reactive" for life Direct Detection Test - Sent to NML, Winnipeg ■ PCR - Polymerase chain reaction - UTM swab taken from "chancre" ■ Tests for genes: polA, bmp, tpp47 Saskatchewan Health Authority#39Laboratory testing algorithm T. pallidum Total Antibody Screen Syphilis RPR TPPA screen Negative n/a n/a Reactive Non-Reactive¹ Reactive Reactive n/a RPR Interpretation No serologic evidence of past or current syphilis infection. In the setting of recent exposure, or signs/symptoms of primary syphilis, repeat testing in 2 to 4 weeks. Consistent with syphilis infection. Clinical manifestations and treatment history is required to refine interpretation: i) Infectious syphilis (primary, secondary or early latent) ii) Late latent syphilis iii) Tertiary syphilis iv) Treated syphilis with persistent reactive RPR No serologic evidence of past or current syphilis infection. Screening test is most likely falsely reactive. Indeterminate Syphilis serology is inconclusive. Recommend repeat testing in 2 to 4 weeks. Consistent with syphilis infection. Clinical manifestations and treatment history is required to refine interpretation Reactive Non-Reactive Non-Reactive Reactive² Non-Reactive Reactive Non-Reactive Reactive Non-Reactive T. pallidum particle agglutination (TPPA) Reactive (or Repeat Reactive) Non-Reactive³ Indeterminate Reactive5 (or Repeat Reactive) Source: Syphilis testing algorithm: https://rrpl- testviewer.ehealthsask.ca/SCI/What%20is%20new%20at%20SDCL/Syphilis%20Algorithm%20Interpretation%20v3.1.pdf + Saskatchewan Health Authority#40Syphilis serology Timing of serologic responses in syphilis infection % of patients who test positive 100 80 60 40 20 2468 10 12 Weeks FTA-Abs TPHA IgMa Untreated VDRL/RPR 2 10 Years Time post infection Secondary Time of infection Primary lesion lesion Clinical stages of syphilis Primary I Secondary Treated Latent (Asymptomatic) I Tertiary 20 Higher numbers correspond to higher level of antibodies in patient's serum ■ Number determined by progressive dilution of serum until it becomes. non-reactive ■ A two-fold change such as 1:32 to 1:16 is generally considered within margin of test error Sustained four-fold change such as 1:64 to 1:16 is considered significant Source: Henao-Martínez, A. F., & Johnson, S. C. (2014). Diagnostic tests for syphilis: New tests and new algorithms. Neurology. Clinical practice, 4(2), 114–122. https://doi.org/10.1212/01.CPJ.0000435752.17621.48 Saskatchewan + Health Authority#41Case Management Saskatchewan Health Authority#42Syphilis Update: Management Penicillin G, administered parenterally, is the preferred drug for treating patients in all stages of syphilis Preparation used (i.e., benzathine, aqueous procaine, or aqueous crystalline) including dosage, and treatment duration depend on: i. the stage; and ii. clinical manifestations Treatment for Primary, Secondary, & Early Latent is Benzathine penicillin G 2.4 million units provided as a deep IM single dose (Bicillin L-A®) - two syringes In cases of penicillin allergy, Doxycycline 100 mg orally twice daily for 14 days Alternative agents (exceptional circumstances) Ceftriaxone 1 g IV or IM daily for 10 days Source: Kimberly A. Workowski et al., Sexually Transmitted Infections Treatment Guidelines, 2021, MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report. Recommendations and Reports, vol. 70, 2021, doi:10.15585/mmwr.rr7004a1. + Saskatchewan Health Authority#43Syphilis Treatment Primary, Secondary or Early Latent Syphilis ■ Benzathine penicillin G 2.4 million units intramuscularly in a single dose (Bicillin L-A®) Late latent syphilis or syphilis of unknown duration ■ Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks Tertiary syphilis with normal CSF examination ■ Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks If penicillin allergic ■ Doxycycline 100 mg orally twice daily for 14 days, or Tetracycline 500 mg orally 4 times daily for 14 days + Saskatchewan Health Authority#44Syphilis in pregnancy ■ Treat with Bicillin L-AⓇ according to stage: ■ Doxycycline is contraindicated, clients who are skin-test-reactive to penicillin should be desensitized in the hospital and treated with Bicillin L-AⓇ. Missed doses >9 days between doses are not acceptable for pregnant women receiving therapy for late latent syphilis Pregnant women who miss a dose of therapy should repeat the full course of therapy Recommended Regimen for Syphilis During Pregnancy Pregnant women should be treated with the recommended penicillin regimen for their stage of infection Saskatchewan + Health Authority#45Post treatment serology Primary, Secondary, Early Latent: ■ One, three, six & twelve months ■ Add twenty-four months for HIV infected clients Late latent: ■ Twelve & twenty-four months Neurosyphilis: ■ Six, twelve and twenty-four months after treatment. Patients with CSF abnormalities require follow up CSF at 6 monthly intervals until normalization of CSF parameters. Other clinical follow up may be indicated on a case-by-case basis, + Saskatchewan Health Authority