Introduction

Sexually transmitted diseases (STDs), as the name suggests, are a group of infectious diseases primarily transmitted through sexual activity. In 1975, the term "sexually transmitted diseases (STD)" replaced the traditional term "venereal diseases (VD)”. Traditionally, STDs included syphilis, gonorrhoea, genital warts, genital chlamydia infections, and HIV/AIDS. More recently, diseases like trichomoniasis and hepatitis B, which can also be transmitted sexually, are classified as STDs.

Syphilis is one of the most well-known STDs. In 2022, the World Health Organization (WHO) estimated that 8 million adults aged 15–49 globally acquired syphilis. Some countries that systematically monitor syphilis are showing a significant increase in syphilis cases, including congenital syphilis, particularly amongst gay men and other men who have sex with men.¹

Thus, syphilis prevention is a core goal of syphilis control considering the serious health outcomes and public health concerns that accompany the infection. In this article, we will talk about prevention of syphilis, safe sex practices and how to get the best results from testing programs.

Understanding syphilis

According to LaFond and Lukehart², syphilis is a chronic bacterial infection caused by Treponema pallidum subspecies pallidum. In 2018, the Centers for Disease Control and Prevention (CDC) published the latest staging terminology for syphilis:

Primary syphilis 

Defined by the appearance of one or more ulcerative lesions (chancres) at the inoculation site within days to weeks after exposure.

• Appearance of a sore: The first sign is usually a single sore called a chancre. It appears at the spot where the bacteria entered the body, often on the genitals, anus, or mouth
• Painless: The chancre is typically painless and might go unnoticed
• Duration: It appears about 3 weeks after exposure and lasts 3 to 6 weeks
• Healing: It heals on its own, but the infection remains in the body if not treated

Secondary syphilis

Characterised by polymorphic skin and mucous membrane lesions, often accompanied by generalised lymphadenopathy, appearing simultaneously or weeks after the primary chancre.

• Skin rash: Often appears on the palms of the hands and soles of the feet but can appear anywhere
• Other symptoms: Fever, sore throat, swollen lymph nodes, and muscle aches
• Duration: Symptoms can last several weeks or come and go for up to a year
• Highly infectious: During this stage, syphilis is highly contagious

Congenital syphilis

Clinical symptoms appear within 4-8 weeks after birth.

• Transmission: The bacterium Treponema pallidum can cross the placenta from the pregnant person to the developing baby
• Timing: This can happen at any stage of pregnancy or during childbirth
• Symptoms in babies:
  • Early symptoms (within the first few weeks of life):
    • Rash: Often appears on the palms of the hands and soles of the feet
    • Fever: The baby may have a high temperature
    • Snuffles: A runny nose with a yellowish discharge, sometimes tinged with blood
    • Bone issues: Inflammation of the bones, which can be painful and affect limb movement
    • Swollen liver and spleen: Enlargement of these organs can occur
  • Late symptoms (if untreated, appearing after two years):
    • Deformities: Bone deformities such as saber shins (bowed legs)
    • Hutchinson's teeth: Abnormally shaped teeth
    • Deafness: Hearing loss
    • Vision problems: Issues with eyesight
    • Intellectual disabilities: Problems with brain development

Importance of prevention

If not treated in time, about 15% of people with syphilis may develop late-stage disease. Late-stage syphilis can cause widespread inflammation, leading to cardiovascular or organ dysfunction. Syphilis infection also increases the risk of contracting or transmitting HIV.³ To effectively address the spread of syphilis, it is crucial to control it at the source.

Safe sex practices

Syphilis disproportionately affects men who have sex with men (MSM) due to high-risk sexual practices, multiple sex partners, and concurrent use of controlled substances.⁴ So, what can be done to reduce the risk of syphilis transmission during sex?

Condom use

Using condoms consistently and correctly during vaginal, anal, and oral sex is one of the most effective ways to prevent syphilis and other STDs. Condoms act as a barrier, preventing direct contact with syphilis sores and the exchange of bodily fluids, which are the primary ways the infection spreads. It is important to use a new condom for each act of sex and to follow proper steps for putting it on and taking it off to ensure maximum protection.

Management of sex partners

Engaging in stable, mutually monogamous relationships can significantly lower the risk of syphilis. This means that both partners are only sexually active with each other and have been tested and confirmed to be free of STDs. In such relationships, the chances of introducing syphilis into the partnership are minimised, provided both partners maintain fidelity.

Partner communication

Open and honest communication with sexual partners about sexual health is critical. Discussing each other’s sexual history, recent STD tests, and safe sex practices helps ensure that both partners are aware of their health status and can take necessary precautions. This can include agreeing to use condoms, getting tested regularly, and discussing any concerns about potential exposure.

Regular check-ups

Regular sexual health check-ups are essential, especially for individuals who have multiple sex partners or engage in high-risk behaviours. Routine testing for syphilis and other STDs allows for early detection, which is crucial for timely treatment and preventing the spread of infections. Regular check-ups can include blood tests, physical examinations, and other diagnostic procedures to ensure comprehensive sexual health monitoring. Healthcare providers can also offer guidance on safe sex practices and answer any questions about STD prevention.

Screening intervals

The goals of intervention can be to prevent infection (primary prevention), to prevent those infected from becoming ill (secondary prevention), or both.⁵ Due to the high incidence of syphilis among men who have sex with men (MSM), routine screening for MSM can identify and treat infections before they progress to disease (secondary prevention). Screening only has an impact if the detected infection is treated and cured. It prevents transmission only if the infected individuals are cured at an early stage, thus avoiding further spread.

Therefore, treating individuals who have been exposed to syphilis before developing primary syphilis can effectively prevent transmission. Even if syphilis test results are negative, those who have had sexual contact with a syphilis-infected person within the past three months should receive treatment, as they have a 9% to 30% chance of having a latent infection.⁶

Congenital syphilis

Congenital syphilis (CS) is an infectious disease that happens when a pregnant parent with syphilis passes the bacteria to their baby during pregnancy.⁷ It is a major global health issue, making the prevention of congenital syphilis a top public health priority. Screening pregnant people for syphilis is essential to prevent CS, and it can be effectively achieved with proper prenatal screening and treatment using benzathine penicillin G (BPG).

The CDC and AAP have set guidelines for checking and treating babies born to parents with syphilis during pregnancy.⁸ According to these guidelines, all babies born to pregnant who tested positive for syphilis at any time during pregnancy should be tested for syphilis right after birth using the same type of test (RPR). The risk of the baby having congenital syphilis (CS) is evaluated based on the baby's physical exam, a comparison of the baby's RPR test results to the parent's results at delivery, the parent's treatment history, and their RPR levels during pregnancy.

Depending on this evaluation, the baby might need more tests, such as a complete blood count, a lumbar puncture to check spinal fluid, and bone X-rays to look for bone problems. Based on these findings, the baby may need treatment ranging from 10 days of intravenous penicillin to a single dose of intramuscular penicillin, or sometimes no treatment at all. The guidelines also provide a table that summarizes the CDC's and AAP's recommendations for different risk categories and their corresponding evaluation and treatment.⁹

FAQs

Can syphilis be contracted from sharing towels, toilets, or swimming pools?

The likelihood of contracting syphilis through everyday activities like sharing towels, toilets, or swimming pools is very low. For syphilis to be transmitted through such contact, two conditions must be met: first, there must be an open wound or break in the skin or mucous membranes; second, there must be direct contact with the syphilis bacterium (Treponema pallidum).

The syphilis bacterium thrives in warm, moist environments at around 37 degrees Celsius. It does not survive well outside the human body, making everyday transmission unlikely. In rare cases, individuals may become infected by coming into contact with contaminated clothing or personal items. Sharing razors with a syphilis-infected person also carries a potential risk of transmission.

Summary 

Syphilis is a significant global health issue, with serious implications for both the individual’s health and public health systems. By adhering to these guidelines and preventive measures, the spread of syphilis can be controlled, reducing its impact on individuals and communities. Effective prevention, early detection, and prompt treatment are essential steps in combating this pervasive disease.