Cases of infectious and congenital syphilis have skyrocketed in Canada since 2017. In response, health advocates are calling on the government and public health authorities to quickly embrace more effective preventive measures, particularly among pregnant women, by improving surveillance systems, addressing racism within the healthcare system, and making rapid testing and preventive treatment more widely available.
“We’re in a state of a health emergency,” Sean Rourke, PhD, a scientist at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital in Toronto, told Medscape Medical News.
From 2017-2021, the rate of infectious syphilis increased by 166% overall nationwide, according to the Public Health Agency of Canada (PHAC). The rate increased by 96% in men and by 729% in women, according to the Canadian Institutes of Health Research.
Most acute is the rise in congenital syphilis, which occurs when an infected pregnant woman passes the infection on to her fetus or baby. This increase is a consequence of the rising rates of infectious syphilis in women. The incidence of congenital syphilis has increased by 1271%, from seven cases in 2017 to 96 in 2021.
Dr Sean Rourke
The spread is most extensive in the Prairie Provinces of Alberta, Saskatchewan, and Manitoba. In 2015, only one case of congenital syphilis was observed in the Prairies, said Rourke. Since then, there have been 565 cumulative cases through 2022, according to statistics that he tracks. Rates have increased by 472% in Alberta, 1346% in Saskatchewan, and 422% in Manitoba.
In Alberta, the incidence of congenital syphilis is 160 per 100,000 live births, said Rourke. In Manitoba and Saskatchewan, it’s much higher: 433 and 462 per 100,000 live births, respectively.
In 2013 and 2014, congenital syphilis was nearly eradicated in Canada. But incidence reached 14 per 100,000 births by 2019 and settled at a slightly lower level the following year, which was the last year for which surveillance data from the Syphilis Outbreak Investigation Coordinating Committee (SOICC) are available. By comparison, the incidence rate in the United States was 77.9 per 100,000 live births in 2021, according to the Centers for Disease Control and Prevention data.
Contributing Factors
Advocates for sexually transmitted infection prevention in Canada said that two factors have contributed to the dramatic rise in syphilis: (1) lack of public health investment in surveillance, prevention, and testing, and (2) mistrust of the health system among indigenous peoples, Black persons, and habitual drug users.
The syphilis epidemic in Canada had been most evident among men who have sex with men until the recent trends in women emerged, said Chris Draenos, MN, RN, a research manager with the Community-Based Research Centre in Toronto.
“There has been limited investment by public health authorities,” Draenos added. One area that has suffered is disease surveillance in syphilis. “Health authorities don’t have great surveillance systems for detecting the causation of syphilis,” he noted.
Chris Draenos
For example, while each province or territory has its own surveillance system, they vary widely in terms of the data collected, he said. “The surveillance tends to be a little bit basic. There’s not too much information that comes out of a lot of it, and certain aspects aren’t well captured,” said Draenos. “Sexual and gender identification are two [items] in particular. There’s no standard way for how that’s categorized.”
That flaw also makes it difficult to track risk factors. “There’s no information around exposure setting or how they might have acquired it, so it’s very hard to assign causation to a lot of the surveillance work,” said Draenos.
Experiences of racism have fostered mistrust of the health system and thus contributed to the rise in congenital syphilis. People with addiction harbor a similar mistrust of the healthcare system, Rourke said. Data from SOICC and others have supported the idea that racism and addiction are contributing factors in the increase in syphilis in Canada.
Reducing the Spread
Reforming attitudes among healthcare professionals is essential to reducing the spread of syphilis, said Rourke. “There’s a whole new way of thinking about the kind of care that needs to be more much culturally appropriate, but it also needs to be done with people they trust. I mean, trust is a serious issue here, right?”
Near-universal syphilis testing of women of childbearing age, and especially pregnant women, is also needed, said Rourke. He noted that in March, Health Canada approved a point-of-care test for HIV and syphilis, “and we’re not bulk-buying it yet, so we’re really behind the times here.
“Testing is not the magic bullet,” Rourke continued, “but testing is the way of getting people into treatment and connecting people back into care, which is always a good thing, especially if it’s done in a way that people feel it culturally suits their needs.”
Improving education about safe sex practices is also important, Draenos said. “Abstinence-only is not effective at reducing cases of STIs.”
The Canadian health system must also deal with the stigma that it attaches to STIs, said Draenos. “Where we have medical racism and the stigma related to healthcare providers around sex and the judgment around that, it causes delays in testing, which prevents early detection,” he said.
The rise in syphilis may be an unforeseen consequence of successful HIV and pregnancy prevention efforts, he added. Although oral sex reduces the risk for HIV transmission and prevents pregnancy, it can spread syphilis. Likewise, condom use can prevent HIV and pregnancy, but syphilis can spread through skin and mucosal contact despite condom use, said Draenos.
An innovation that could potentially stanch the spread of syphilis and other STIs is doxycycline postexposure prophylaxis (doxy-PEP), Draenos noted. Taken within 72 hours of unprotected sex, it has been shown to reduce the incidence of gonorrhea, chlamydia, and syphilis by two thirds. “This could be one of the most important ways to make a change in the ongoing rise of syphilis in Canada,” said Draenos.
However, it’s not widely available yet. The Ontario HIV Treatment Network acknowledged that no national governing health body endorses antibiotics for STI prevention.
Rourke and Draenos reported no relevant financial relationships.
Richard Mark Kirkner is a medical journalist based in the Philadelphia area.
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