KFL&A Public Health has multi-pronged approach to combating rise in syphilis cases

Colorized electron micrograph of Treponema pallidum, the bacteria that cause syphilis. Image via the US National Institute of Allergies and Infectious Diseases (NIAID).

Cases of syphilis have been skyrocketing in Canada, and the Kingston, Frontenac, Lennox, and Addington (KFL&A) region is not immune.

On Wednesday, Apr. 24, 2024, the KFL&A Board of Health heard a presentation by Public Health nurses Julie Sousa of the Sexual Health Team and Maggie Hoover of the Knowledge Management Team regarding syphilis and what KFL&A Public Health is doing to combat it.

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum and transmitted through vaginal, anal, or oral sex. Early symptoms can include genital sores, rash, and headache. Untreated, syphilis can eventually affect the brain and nervous system. 

“The ways that syphilis is spread from person to person is through close sexual contact, but also through what we call vertical transmission,” said Sousa. This vertically transmitted syphilis, from infected mother to infant during pregnancy or birth, is known as congenital syphilis.

Public Health Ontario has observed a substantial increase in the incidence of early congenital syphilis in the last four years. Between 2013 and 2018, a total of six cases of early congenital syphilis were reported provincially (an average of one case per year); however, from 2019 to 2022, a total of 41 cases were reported. 

“In response to the rising rates of syphilis in our community, including congenital syphilis, we’ve been hard at work with various initiatives,” Sousa said.

First, she told the board about a syphilis steering committee that has been created in KFL&A. This committee is “essentially a group of professionals from Kingston General Hospital, including physicians from the Emergency Department, Ophthalmology, Dermatology, infectious Disease, and our Public Health Labs, Queen’s University, St. Lawrence College, midwives, etc. Several people essentially come to the syphilis steering committee to respond to the rising rates, translate information to each other, host and create presentations, and combat congenital syphilis in particular.” 

Next Sousa talked about how in KFL&A, rising rates of congenital syphilis have led the team to adopt the ‘Manitoba three-stage prenatal testing’ protocol.

She explained that previously in Ontario, all pregnant women were offered syphilis screening; they were typically screened in the first trimester but only once throughout the duration of the pregnancy.

“What we noticed… is that some of those infections very well could have been acquired later on in the pregnancy — in which case, one snapshot in time [early in the pregnancy] may not have captured that. So as one of our responses to these rising rates, we’ve adopted this three-step testing and we relay this information to our primary care providers,” Sousa said.

This testing is important because congenital syphilis can be treated successfully in utero while the mother is still pregnant. However, Sousa explained, untreated congenital syphilis can have dire consequences for the child.

“There could be some developmental abnormalities with their long bones… They may have some issues with tooth development. Then, in more serious or rare [cases], they can actually be stillborn. It can be fatal,” she explained.

Along with the three times for testing, Sousa said information handouts are sent to doctors’ offices to give to their prenatal clients, and in the event that a preliminary positive result ensued on a congenital case or a baby or pregnant mother, KFL&A Public Health works with the lab to ensure the local Health Unit is alerted.

Typically a test is sent for confirmatory testing in Toronto which can take six days, Sousa said, “and by then we’ve lost a week. So this affords us a bit of an advantage.”

Since this new protocol was implemented, KFL&A Public Health has seen a doubling of prenatal client testing, “which is fabulous,” commented Sousa.

Graphic from KFLA Public Health presentation.

Syphilis ad campaign

Another way KFL&A Public Health is raising awareness about the rising numbers and the importance of testing is through a new ad campaign which was, said Sousa, “intentionally created to be bold, daring, and impish. We were trying to leverage shock value.”

One set of campaign images might “be considered a little bit more risque” and are reserved for social media awareness campaigns and location-based dating apps, where the algorithms target a certain population — whereas “some of the more tame images would be those you might see on the public transit system, such as the buses,” Sousa explained.

Essentially, syphilis can be introduced through oral sex, vaginal sex, and penetrative or receptive anal sex, Sousa explained, so the images portray those sites. There’s an image of a mouth, of a “female with a flower over her delicate parts,” and of “a derriere with a door in the back,” as well as a creatively placed bowling ball and pin that approximate a penis and scrotum. A picture of a fetus is used to target women of childbearing age. 

Testing research in KFL&A

Hoover focused her part of the presentation on KFL&A Public Health’s involvement as a lead in an Ontario research project.

KFL&A Public Health received funding last summer from the Public Health Ontario’s Locally Driven Collaborative Project Grant, she explained.

“We were the successful applicant to study what is essentially new point of care test technology,” said Hoover.

“These tests were approved by Health Canada back in March of 2023,and there had been some assessment aside from the manufacturer prior to that approval, but not in the kind of population that we would want to be targeting as being the most vulnerable: those who are unhoused or under-housed, persons who use substances, or, in general, anyone we deem to be at risk of loss to follow-up actions.”

Traditional syphilis testing done through blood work has to go through a multi-step process at the lab, and it can take somewhere between three and six business days or even more to get full results back, Hoover explained.

“And then, by that point, sometimes persons are not able to be located. So we’re hoping to reduce the time [between testing and] treatment. Essentially the point of care test is reminiscent of COVID take-home tests in its simplicity, but it does need to be [administered] by a health care provider,” she detailed.

The testing program is run through an outreach team that Public Heath initially put in place in June 2022 as part of their response to the COVID-19 pandemic to provide immunizations to the target community. During the testing process, a small amount of blood is obtained through a finger prick; then, Hoover said, “within 60 seconds you know if someone has antibodies for syphilis and antibodies for HIV. It’s a dual test.”

The testing is in the preliminary stages, and Hoover explained that the numbers they are currently working with are small, but as the study goes on, the sample size will be increased. She pointed out, however, that there were 11 identified positive point of care tests among the whole project: seven were new infections and treated on site.

“So their time to treatment essentially went from… an average of 10 days to zero days, stopping that infectious pattern and chain of transmission,” she shared.

Hoover said this is especially important because, of those seven, two people have not been located again; they have perhaps moved on or changed contact information. So while the sample numbers are low, “for those two persons, it was the key component in treating their infection.”

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