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Eurosurveillance, Volume 7, Issue 39, 25 September 2003
Articles

Citation style for this article: van de Laar MJ, van Veen M, Götz H, Nuradini B, van der Meijden W, Thio B. Continued transmission of syphilis in Rotterdam, the Netherlands. Euro Surveill. 2003;7(39):pii=2302. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2302

Continued transmission of syphilis in Rotterdam, the Netherlands

Marita van de Laar (mjw.van.de.laar@rivm.nl)1, Maaike van Veen1, Hannelore Götz2, Beke Nuradini2, Wim van der Meijden3, Bing Thio3

1 National Institute of Public Health and the Environment (RIVM), Bilthoven, the Netherlands
2 Municipal Health Service, (GGD Rotterdam e.o.) Rotterdam, the Netherlands
3 STI clinic, Erasmus Medical Centre, (Erasmus Medisch Centrum), Rotterdam, the Netherlands

Following earlier recognition of a syphilis outbreak in Rotterdam (1), the outpatients’ clinic for sexually transmitted infections (STIs) of the Erasmus Medisch Centrum Rotterdam (Erasmus Medical Centre Rotterdam) has diagnosed 56 cases of infectious syphilis (including primary, secondary, early latent) in 2002, compared with 24 cases in 2001 and 16 in 2000. (Figure 1). Between January and April 2003, 15 cases of infectious syphilis were seen at the Rotterdam STI clinic (6 primary, 5 secondary, 4 early latent) compared with 10 in the same period in 2002. In 2002, 15 cases were in heterosexuals (11 men and 4 women) and 41 cases were in men who had sex with men (MSM) (14 primary, 9 secondary, 18 early latent).

Figure 1: Number of cases of infectious syphilis by stage of infection, STI clinic Erasmus Medisch Centrum Rotterdam.

In the past two years the rise in syphilis cases was more apparent in MSM (Figure 2). Of the 56 patients, 6 had a co-infection with HIV. Of the 41 MSM, 9 had had sex with both men and women, and 32 with men only. Thirty four of the MSM reported anal sexual contact in the past 6 months. Information on condom use and oral sex was not available. All the patients co-infected with HIV were MSM: 4 were known HIV positive patients and 2 were newly diagnosed. In the anonymous unlinked HIV surveillance at the STI clinic, 4 HIV infected individuals who were co-infected with syphilis were seen. In 2001, 5 syphilis patients were co-infected with HIV (4 known and 1 newly diagnosed). The percentage of co-infection of syphilis and HIV may be an underestimate as the HIV serostatus was unknown in 51% of the men.

Eight of the 15 heterosexuals (53%) reported their ethnicity or country of origin as being from Surinam and the Dutch Antilles, 2 reported their country of origin as the Netherlands (13%) and 5 reported that they were from elsewhere (33%). Information on the source of infection was not available. Two women with infectious syphilis were commercial sex workers (CSW). Three of the 11 heterosexual men were clients of CSWs.

Figure 2: Number of cases of infectious syphilis by gender and sexual orientation, STI clinic Erasmus Medisch Centrum Rotterdam (Note: sexual orientation was unknown for the majority of cases in 2000)

Enhanced surveillance
After the outbreak of syphilis among CSWs in 1995-97 in Rotterdam (2), there were no signs of increased transmission of syphilis in the city, despite reports of increasing rates of syphilis and gonorrhoea at the Amsterdam STI clinic (1, 3). In the second half of 2001 the number of syphilis cases started to increase in Rotterdam. From July 2002 onwards, enhanced surveillance was used to identify risk factors. Between July and December 2002, 33 patients (32 men and 1 woman) were interviewed by the public health nurse as part of enhanced surveillance.

Having a regular partner was reported by 20 of the 32 men, two of them were women. Multiple casual partners were reported by 91% of the patients: on average 4.3 partners (median was 2, maximum was 30) in the previous 3 months. On average 7.7 (median was 3) partners were reported in the past 6 months. Many partners remained unknown and could therefore not be identified for contact tracing. Ten of 26 MSM reported only oral contact as the possible route of transmission, while 16 others had also had anal contact. Condoms were used in most cases of anal intercourse but almost never in oral contacts.

Five of the syphilis patients knew that they were HIV positive (15%); 15 were HIV negative (45%) and of 13 patients the HIV serostatus was unknown (40%). Also, 18 patients (55%) reported a prior STI diagnosis. Patients with syphilis reported a large variety of social venues where they met sexual partners: 20 of them had met their sex partners in Rotterdam (in gay bars, saunas, cruising zones), 7 in Amsterdam (in saunas), 7 abroad and 5 had met through internet chat rooms. This outbreak has led to intensified counselling on HIV and syphilis. Ongoing outreach prevention has been expanded and focused on syphilis and risk of HIV transmission with an emphasis on safe sex and the need for regular testing.

Ongoing transmission in 2003
All of the 15 cases diagnosed between January and April 2003 have been in men, of which 13 were MSM, and of which 3 were known HIV positive individuals (2 MSM and 1 heterosexual). These figures suggest that transmission of syphilis is ongoing in Rotterdam.

Discussion
Similar syphilis outbreaks among MSM have been reported in other cities throughout Europe; some of which have involved co-infection in known HIV positive patients (3-15). These outbreaks may have implications for the incidence of HIV infection as HIV positive MSM who are co-infected with syphilis may spread HIV infection more easily (16-18). It also implies that sexual behaviour in MSM may be changing.

The syphilis outbreak in Rotterdam is occurring within a group of high-risk individuals, with a high rate of partner change, with anonymous partners, with a relatively high proportion of HIV positive individuals. Oral transmission was also often reported. It emphasises the need for primary prevention and risk reduction strategies, as well as continued efforts at active case finding and partner tracing both for HIV and STI.

Acknowledgements: We thank the counsellor nurses for their work interviewing the patients at the STI clinic.

References:
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