Between 1998 and 2000 the number of cases of infectious syphilis in England more than doubled, largely driven by several localised outbreaks. These outbreaks suggest a resurgence of unsafe sexual behaviour among both heterosexual and homosexual people in England. They also emphasise the importance of sustained multidisciplinary public health action in this area, according to an article published in last week’s BMJ (1). The general public, certain groups at risk, and relevant health professionals should be aware of the risks of acquiring syphilis and of the symptoms and signs of acute infection.

Four outbreaks of infectious syphilis occurred in Bristol, Manchester, Brighton, and the area including Peterborough and North Cambridgeshire between January 1997 and January 2002. Patients often presented to general practitioners and dermatologists. One third presented with primary syphilis, over a third with secondary syphilis, and the remainder were diagnosed as early latent syphilis (on the basis of positive serology in the absence of clinical signs). A case of congenital syphilis was linked to one of the outbreaks, and several cases had concomitant HIV infection.

The investigation and control of the outbreaks included enhanced surveillance of patients at clinics for genitourinary medicine (GUM), notification of partners, increased efforts to raise awareness, communication with health professionals, increased level of GUM services, and targeted promotion of sexual health to groups identified as at risk. The importance of identifying and investigating sexual networks and involving local voluntary agencies in the delivery of targeted health promotion was emphasised. Patient data were collected on a standardised questionnaire that covered the patient’s characteristics, sexual orientation, clinical details, history of previous or current sexually transmitted infections, and contacts.. The diagnosis was made on the basis of clinical symptoms, by finding Treponema pallidum in material from syphilitic lesions in dark field microscopy, and serological testing.

Outbreaks of syphilis in a community give cause for concern. They may be due to altered immunity, changes in sexual behaviour, the level and effectiveness of intervention, or random fluctuations in the composition of the population. In all four outbreaks, infection was acquired though unprotected sexual intercourse, which shows that unsafe sexual practices among homosexual and heterosexual populations are increasing, as also evidenced by a rise in other STIs in Europe (2, and references therein).

The failure of sections of sexually active populations to protect themselves against STIs is worrying and indicates either lack of knowledge about transmission risks or complacency about the individual risk of acquiring an STI. Safer sex messages therefore need continual reinforcement among the sexually active population. Increased awareness of the risk of acquiring syphilis and of the symptoms and signs of the disease is needed among the general public, groups at risk, and health professionals, and prompt referral to GUM clinics for investigation and treatment should be made.

Outbreaks of STIs can be difficult to detect. The timescales within which such outbreaks may be detected, investigated, and controlled may be longer than those for other outbreaks. To speed up the process, access to GUM clinic services needs to be improved and partner notification is essential.

Wider sexual and social networks need to be investigated, in addition to tracing of individual sexual contacts. Sustained multidisciplinary public health action is needed to contain this emerging risk. Furthermore, similar occurrences of syphilis in other Western European states have been reported (3, and references therein).

In this context, a new pilot initiative recently funded by the European Commission (European Surveillance of Sexually Transmitted Infections, ESSTI) aims to work towards achieving coordinated STI surveillance across Europe through setting up a network of collaborating countries. The project is being carried out by the PHLS Communicable Disease Surveillance Centre with the Institut de Veille Sanitaire (InVS) in France, Smittskyddsinstitutet (the Swedish Institute for Infectious Disease Control, SMI), and epidemiology and microbiology collaborators from 11 other European Union (EU) member states and Norway.

The establishment of ESSTI may help to improve our understanding of the distribution and determinants of this resurgence. The proposed ESSTI early warning system will also help to identify similar outbreaks in hitherto unaffected areas. Ultimately, surveillance data must inform public health action and the ESSTI network should play a key role in increasing dialogue and avoiding duplication of resources and efforts across EU states.