The graduate nurse is caring for a client at 20 weeks gestation with secondary syphilis
Notification requirement for syphilisSyphilis is a ‘routine’ notifiable condition and must be notified by medical practitioners and pathology services in writing within 5 days of diagnosis. Show
This is a Victorian statutory requirement. Specific information must be notified under the Public Health and Wellbeing Regulations 2009. To maintain confidentiality, only the name code (the first two letters of the surname followed by the first two letters of the first name) is required. A questionnaire is sent to the diagnosing doctor to collect additional information on the case that is essential for detecting disease trends and informing policy development. Medical practitioners have a statutory obligation under the Children, Youth and Families Act 2005 to notify the department’s Child Protection service if they believe that a child is in need of protection on the basis of sexual abuse. Primary school and children’s services centre exclusion for syphilisExclusion is not applicable. Infectious agent of syphilisThe spirochaete Treponema pallidum subspecies pallidum is the infective agent. Identification of syphilisClinical featuresSyphilis is characterised by a primary ulcerative and classically painless lesion (chancre), a secondary eruption involving skin and mucous membranes, long periods of latency, and late lesions of skin, bone, viscera, cardiovascular and central nervous systems. The stages of syphilis can be divided into:
Syphilis in pregnancyFetal infection may result in abortion, stillbirth, premature delivery and perinatal death. In congenital syphilis, generalised systemic disease in the live-born infant is present, which may have significant long-term complications if left untreated. DiagnosisSyphilis can be diagnosed by the demonstration of spirochaetes in the exudate from primary chancres or from the mucous membrane lesions of secondary syphilis, using dark-field microscopy or immunofluorescence. Dark-field microscopy is a difficult technique and requires an experienced operator for reliable results. The test is unreliable on mucous membrane lesions because of the presence of morphologically similar saprophytic spirochaetes. Dark-field microscopy is best done on site, as drying of the exudate during transport to the laboratory renders the specimen unsuitable for microscopy. Immunofluorescence is more sensitive and does not have to be performed immediately. It is suitable for use with mucous membrane lesions but is not currently performed by the Victorian Infectious Diseases Reference Laboratory. More commonly, syphilis is diagnosed using a combination of treponemal and nontreponemal serological tests:
All sera showing reactive serology on screening tests should be forwarded to a reference laboratory for confirmatory testing. It is necessary to interpret syphilis serology in the context of:
It is essential that all cases of syphilis receive close clinical and laboratory follow-up. Lumbar puncture is advised with:
Note that other sexually transmissible infections may be present in addition to syphilis. Patients in whom syphilis is diagnosed should be encouraged to be tested for HIV infection. Incubation period of Treponema pallidumThe incubation period is from 10 days to 3 months and is usually 3 weeks. Public health significance and occurrence of syphilisThis is a complex disease. Sequelae include neurosyphilis, cardiovascular syphilis, and congenital infection with fetal death, stillbirth and abortion. Testing and effective treatment are available to facilitate the interruption of disease transmission. Immune responses are only partially protective, and reinfection may occur following treatment. Syphilis enhances the transmission of HIV, like other diseases that cause genital ulcers. Syphilis occurs worldwide and has a high incidence in regions outside Victoria. Other developed countries have experienced recent outbreaks. Imported infectious cases could result in syphilis re-emerging as a significant public health issue. Reservoir of Treponema pallidumHumans are the only reservoir. Mode of transmission of Treponema pallidumTransmission occurs primarily by sexual contact. Transplacental infection of a fetus may occur during the pregnancy of an infected woman. Fetal infection occurs with high frequency in untreated early infections of pregnant women, and with lower frequency later in the disease or in late latency. Period of communicability of syphilisA case is considered sexually infectious until the end of the early latent period, which is approximately 2 years after infection. Infectious moist mucocutaneous lesions are present in the primary and secondary stages of syphilis, and may recur intermittently in the early latent period. These lesions may not be apparent to the infected individual. Susceptibility and resistance to syphilisEveryone is susceptible to infection. Control measures for syphilisPreventive measuresEducation about safe sex practices, including the use of condoms, and early detection of infection by testing of people at risk are the main preventive measures. Control of casePenicillin is the drug of choice to treat syphilis. Further information on the clinical management of patients with syphilis can be found in the latest edition of Therapeutic guidelines: antibiotic. Because of the requirement for long-term follow-up and possible complications, it is advisable to seek specialist advice for management. Control of contactsSexual contacts should be identified. The extent of contact tracing depends on the clinical stage of infection. For primary syphilis, all people having sexual contact with the index case during the 3 months preceding onset should be evaluated. Such contacts should be treated as for the case, even if their serology is negative. For secondary syphilis, this period should be extended to 6 months and, for early latent syphilis, to 12 months. For late latent syphilis, any sexual partners and children of infected women should be evaluated. For congenital syphilis, all members of the immediate family should be evaluated. Contact tracing assistance can be provided by the department’s notification officers. All newborns of mothers with syphilis should be investigated and treated in consultation with a specialist. Control of environmentNot applicable. Outbreak measures for syphilisNot applicable. More informationFor more information, see the Syphilis decision making tool on the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine's website. |