Syphilis in northern communities

As an infectious syphilis epidemic continues to ravage northern Australia – now threatening the lives of newborn babies – Indigenous sexual health specialist James Ward is leading a campaign to help remote communities. By Michele Tydd.

While the federal government committed $8.8 million this year to fight an ongoing syphilis epidemic sweeping Australia’s top end, many prominent sexual health physicians and academics claim the money is too little too late. “Every day there are more cases, so we are not seeing a downward trend yet,” says Dr Manoji Gunathilake, who heads up a government-run health service known as Clinic 34. Gunathilake is the Northern Territory’s only specialist sexual health physician. She says local health workers are ramping up testing as part of a fight to contain the infection, which particularly affects young sexually active Aboriginal and Torres Strait Islanders in the territory. However, it seems those measures are struggling to contain the STI’s spread.

Nearly seven years ago, an increase in syphilis notifications showed up in north-west Queensland. The outbreak soon moved across to the NT, then to Western Australia and more recently into South Australia. So far, more than 2100 cases – evenly split between males and females – have been recorded across the affected zones. However, the key concern for health-care professionals is the potential health consequences for babies born to women with the infection. Syphilis is primarily spread through sexual contact, but it can also be passed from mother to baby. Since 2011, six babies have died from congenital syphilis – the latest death came in January this year in northern Queensland. The STI also carries antenatal risks, increasing the chance of miscarriage and stillbirth.

ASSOCIATE PROFESSOR OF MEDICINE DARREN RUSSELL DESCRIBES THE TOP END’S SYPHILIS EPIDEMIC AS A “FAILURE OF PUBLIC HEALTH AT EVERY LEVEL OF GOVERNMENT”.

Darren Russell, a Cairns-based associate professor of medicine at both James Cook University and the University of Melbourne, has been working in sexual health for 25 years. He describes the top end’s syphilis epidemic as a “failure of public health at every level of government”. He says he’s not sure whether the outbreak could have been prevented entirely. However, he believes there was an opportunity for public health officials to stop it from escalating.

“The first case occurred in the Gulf country of north-west Queensland in January 2012 and the first Northern Territory cases weren’t found until July 2013,” says Russell. “There was a window of opportunity in 2012 to work with the affected local communities and to fly in extra nurses, doctors and Indigenous health workers to do some good culturally appropriate health promotion. But nothing at all happened, absolutely nothing as the epidemic spread.

“The first Queensland state funding to deal with the now widespread epidemic was rolled out in 2016, more than five years after the epidemic began, and the first Commonwealth money has only been allocated this year.” Russell says he could not imagine the same happening if a deadly epidemic broke out in a major city. “For years now a multijurisdictional syphilis outbreak committee has been coordinating the response largely without additional resourcing to reach people most at risk,” says Associate Professor James Ward, an Indigenous researcher and sexual health specialist who heads the Aboriginal infection and immunity program at SAHMRI (the South Australian Health and Medical Research Institute) in Adelaide. Ward has been working behind the scenes for years, trying to bring more attention and funding to this outbreak.

“Workforce is certainly an issue because syphilis is an infection that not many clinicians have been exposed to in clinical practice and this is further exacerbated by a high turnover of staff in remote communities,” he says. “Community awareness and understanding of the infection has been very low, so we have been recently trying to get the message out on the internet and social media”.

The multi-strategy STI awareness-raising campaign urging people to be tested is targeted at the 30,000 young people aged between 15 and 34 in affected outbreak areas through the website youngdeadlyfree.org.au/syphilis as well as a dedicated Facebook page. “We’ve also been tapping into online chat programs young people are using in remote areas such as Diva Chat,” says Ward.

Since the 1940s, penicillin has been used to successfully treat the syphilis infection, although people can become reinfected. While deaths in adults are now rare, the consequences can be dire for babies born to mothers who have been infected at some stage either before or during the pregnancy. “There is a wide range of quite sinister pathology in babies born with syphilis,” says Professor Basil Donovan of the Kirby Institute at the University of New South Wales, who has been treating syphilis cases for nearly four decades.

Some babies are merely snuffly and miserable, sometimes with heavily blood-stained nasal discharge. Others can suffer neurological damage and bone deformities that can cause great pain when they move their limbs.

Donovan says that, for the past 60 years, every pregnant woman in Australia should have been routinely tested for syphilis. “The big difference between adults and babies is that all the damage is done before they are born,” he says. “If there is more syphilis about, then catastrophe becomes inevitable.”

Syphilis, caused by the bacteria Treponema pallidum, is an infection primarily spread through unprotected vaginal, anal or oral sex. The first sign in adults is most likely a painless sore on the skin, normally where the bacteria has entered the body during sexual intercourse – in the genital area or in the mouth.

Secondary syphilis occurs about six weeks later with symptoms that include a general feeling of being unwell, a rash on the hands, feet or other parts of the body. Soft lumps might also develop on the warm, moist areas of the body such as the genitals and around the anus. Symptoms can often be dismissed as being due to flu or cold. Outward symptoms of secondary syphilis, such as the initial sores, will disappear without treatment, but the person affected will still have latent syphilis.

The third stage, known as early and late latent syphilis, which may develop any time between one and 30 years later, can seriously affect the brain, spinal cord or heart and – rarely now – can lead to death. “Before penicillin, syphilis was a terrible way to die,” says Donovan. “In about a third of those who contracted it, it would go on to cause serious neurological or brain disease, spinal disease or heart problems particularly with the aorta.

“That said, even now one in about 30 per cent who get syphilis will get some neurological disease. All of us clinicians have got patients who might have lost sight in one eye or gone deaf in one ear as a result.” Donovan stresses the current outbreak in the top end has nothing to do with sexual behaviour. “[Residents in these regions] have the same number of partners [as the broader population] so very high levels of STIs including syphilis are more the result of failure in health-care delivery,” he says.

Gunathilake says the NT has seen more than 800 cases of infectious syphilis since the outbreak began. She wants to help build an educated and stable workforce, especially to support the remote clinicians. “In these remote areas health-care workers don’t tend to say for long periods so it’s important to train and update new staff members quickly,” she says.

Work is also being done in community engagement by producing promotional material in several Indigenous languages to help people better understand the importance of testing and treatment as well as tracing and informing sexual partners. “Going home and passing on the diagnosis to sexual partners is very difficult for anybody and much more challenging in any close-knit community,” says Gunathilake. “Many people regardless of background feel ashamed about having STIs and they don’t want to tell anyone, so it is a psychological burden, but our staff are trained to help people in this situation.”

She says contact tracing can be more difficult for people who have casual or anonymous partners. Gay men are represented in the NT outbreak, but only in relatively small numbers. A spokeswoman for the federal government says the first round of the federal money has gone to three urban Aboriginal health-care centres in Cairns, Darwin and Townsville, which will roll out a new “test and treat” model at the point of care. The next phase of funding is expected to be directed at remote communities.

There is no indication when this outbreak will start to retract, says Basil Donovan, who was working as a doctor during the AIDS epidemic in the late 1980s. This is because once STIs outbreaks take off, they don’t just cycle through like a flu epidemic. “It takes at least five to 10 years to get a major outbreak under control, and part of that involves a permanent [health-care] workforce to develop trust,” he says. “People flying in and flying out won’t even touch the sides.”