SINGAPORE — Syphilis is not a disease from a bygone era and, like tuberculosis, it is making a comeback globally.

In Singapore alone, an average of 1,500 syphilis cases had been reported yearly in the last five years, the health authorities said.

Some of the factors contributing to the resurgence? 

The rise of dating mobile applications and social media that allow people to hook up and have casual sex, as well as advances in medicine that made people less afraid of contracting the human immunodeficiency virus (HIV), leading to less protection during sex.

Doctors with less experience treating syphilis can also be a factor.

In one case, a Singaporean man based in the United States for work saw three different doctors there for a suspicious-looking rash.

All three times, his nagging concerns that it was due to a sexually transmitted infection (STI) — specifically, syphilis — were dismissed.

Back in Singapore, he saw Dr Jonathan Ti, a resident physician at DTAP Clinic in the Robertson Walk area.

Dr Ti said: “He told the doctors to check for syphilis as he had exposure risk but they all refused to test, saying that his rash was not ‘classical’ (a common symptom) as his hands and feet were spared. He came back to Singapore for a short trip and came to our clinic.”

A quick blood test confirmed the man’s fears.

THE DISEASE

Syphilis is an STI caused by the bacterium Treponema pallidum, and symptoms can vary depending on its stage.

In the primary stage, the disease usually starts off as a painless ulcer, typically on the genitals or other body parts such as the lips.

There are also cases with multiple painful sores that turn out to be syphilis, Dr Ti said.

In the second or secondary stage, rashes are typically spread evenly around the body, and commonly include lesions over the palms and soles. Some patients get localised rashes over the scalp, trunk or limbs without lesions on their hands and feet, he added.

Then, the symptoms may appear to clear, which is then the latent stage. Finally, there is the potentially deadly stage, also known as the tertiary stage, as the disease move to attack the organs.

Dr Benson Yeo, a consultant at the Department of Sexually Transmitted Infections Control (DSC) Clinic, which is a public clinic handling the diagnosis, treatment and control of STIs in Singapore, explained: “Without treatment, the infection goes on to the latent stage where patients do not experience any symptoms. Primary and secondary syphilis are more infectious than latent syphilis.”

Dr Ti warned that even if a person with syphilis does not show symptoms, there is still a risk the infection can be spread. This is usually through sexual intercourse.

He said: “The latent stage can last for months to years, or even decades. This is why syphilis should be considered when doing routine sexual health screening, even when the person feels perfectly well.”

Dr Yeo said that about a third of patients with latent syphilis go on to the more severe tertiary stage in about 10 to 30 years. This is where the disease can lead to potentially fatal complications to organs such as the brain and the heart.

The difficulty is that syphilis can mimic other common conditions. That is why the disease is known as “The Great Imitator”, Dr Ti said.

“As such, the diagnosis may be missed initially. I often encounter patients who have already seen other doctors for their rashes and were told they were having an allergy, and sent home with antihistamines or topical creams.”

SPREADING AROUND THE WORLD

Dr Yeo from DSC Clinic said that the rise of infectious syphilis here is similar to that seen in many developed countries such as the United States and United Kingdom.

On Friday (July 12), a report released by the European Centre for Disease Prevention and Control found that reported cases had gone up by 70 per cent from 2010 to 2017. The rise, it said, was driven by more unprotected sex and riskier sexual behaviour among gay men.

Overall, more than 260,000 syphilis cases were reported from 30 countries from 2007 to 2017.

In 2017, syphilis rates reached an all-time high with more than 33,000 reported cases, the centre said. This meant that for the first time since the early 2000s, the region saw more cases of syphilis than new cases of HIV.

Similar to the syphilis trends observed in Europe, the largest increases in the US and Canada occurred among gay men, the report noted.

In Singapore, syphilis is a notifiable disease under the Infectious Diseases Act.

A spokesperson from the Ministry of Health (MOH) told TODAY that from 2014 to 2018, an average of about 1,500 syphilis cases were reported yearly here.

Last year, 1,440 cases were reported.

The figures included both infectious and non-infectious cases.

Infectious syphilis cases generally refer to those in the primary and secondary stages. Statistics provided by MOH showed an increase in infectious cases.

While non-infectious syphilis cases fell from 1,482 cases in 2014 to 952 in 2017 and to 1,077 cases last year, infectious syphilis cases went up from 221 in 2014 to 363 cases last year.

Dr Ti at DTAP Clinic has seen a slow but steady year-on-year increase in syphilis cases. He estimated that at least 5 per cent to 10 per cent more cases are seen each year over the last five to 10 years.

INTERNET HOOK-UPS, UNSAFE SEX

Once thought to have been nearly eradicated and an STI of the past, syphilis infections are now a cause for concern here “given that Singapore is such a vibrant urban hub with high population density and a large number of overseas travellers”, Dr Ti said. 

One technological advancement aiding the spread is the increased use of location-based dating apps that may facilitate casual sex, Dr Yeo told TODAY.

At the DSC Clinic, most of the patients diagnosed with infectious syphilis are men, mostly around 20 to 39 years old.

Dr Ti agreed: “On average, people are now more likely to have multiple sexual partners (than) in the past, with dating apps allowing easier connections between interested parties.”

At his private clinic, the main group of patients Dr Ti diagnoses and treats for syphilis infections tend to be men who have sex with men, and are around 30 to 50 years old. He has also treated a “small handful” of heterosexual men and women.

Syphilis affects not just those who have promiscuous sex. People may catch it from infected spouses or partners, and an infected pregnant woman can also pass it on to her baby (congenital syphilis).

In the last five years, one case of congenital syphilis was reported in 2016 in Singapore, MOH said.

LESS CONCERN, LESS AWARENESS

Another possible reason for the growing number of cases is the increased access to newer prevention methods for HIV.

“Safe sex practices remain a cornerstone of STI prevention,” Dr Yeo said. “The success of pre-exposure prophylaxis (PrEP) use in HIV prevention may have led some people to neglect the importance of condoms in the prevention of other STIs like syphilis.”

PrEP is a HIV prevention strategy in which people without HIV take antiretroviral medications daily or before sex to reduce their risk of becoming infected with HIV.

Another reason could be low awareness on syphilis, even among the medical community.

Dr Ti said: “Doctors have less experience in diagnosing and treating syphilis nowadays as there was a period where it was thought to be almost eliminated. A lot of newer doctors would not have a high degree of suspicion (when encountering potential syphilis cases) and may not be familiar with diagnosis and testing.”

Further complicating matters is the recent worldwide shortage of Benzathine Penicillin, he added. This is a long-acting type of penicillin required for optimal syphilis treatment.

Sourcing and import of this type of penicillin into Singapore requires special approval from the Health Sciences Authority, Dr Ti noted.

“There are alternative regimens for syphilis treatment such as oral doxycycline, but the courses are usually prolonged and there is a higher rate of resistance.”

ROUTINE TESTING FOR AT-RISK INDIVIDUALS

Dr Yeo emphasised the importance of screening regularly for individuals who engage in risky sexual behaviour and have non-exclusive partners.

It is also important for healthcare professionals to familiarise themselves with the manifestations of infectious syphilis, he added.

He advised individuals who have regular casual sexual intercourse to include syphilis screening in their screening for other STIs at least once every six months.

A blood test can detect syphilis even when it is in the asymptomatic stage.

Pregnant women are encouraged to go for antenatal screening, which include testing for syphilis. Treatment during pregnancy can prevent infected mothers from spreading it to their babies, Dr Yeo said.

Anyone diagnosed with active syphilis must be treated or they risk spreading it. Patients must abstain from all sexual activity while on treatment, Dr Yeo added.

Dr Ti cautioned: “It is important to note that syphilis can be spread through direct contact from an infected sore with broken skin or mucous membranes.

“This means using condoms is not completely fool-proof as the person can have infective sores on parts of their body that are not covered, such as the groin, pubic region and tongue.”