Audit of the management of the syphilis outbreak in Herefordshire 2011–2013

Introduction

The diagnosis of syphilis in the UK has risen by 61% over the last decade. ¹ An outbreak of syphilis was discovered in Herefordshire in 2011, on a background of stable low incidence in this small, rural county (population 184,900). ² This prompted an opportunity to audit the management of syphilis at the Herefordshire Integrated Sexual Health (iSH) Service.

Methods

The clinical and laboratory data from the 49 patients diagnosed with early syphilis between January 2011 and September 2013 were retrieved and collated from the respective databases and case notes. The performance of our service was compared to the auditable measures outlined in the British Association of Sexual Health and HIV (BASHH) guidelines. ³ Areas for improvement were identified and action plans were laid out.

Results

Forty-nine cases of early syphilis were identified, the majority being in men (98%), predominantly men who have sex with men (MSM; 88%) (Table 1). Unlike other national studies, the rate of HIV co-infection was low at 18%, compared to nationally reported figures reaching 27%. ⁴ One patient was diagnosed with HIV at the time of syphilis diagnosis.

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Table 1.

Demographic characteristics of the Herefordshire syphilis outbreak cohort (n = 49).

Characteristics	n	%
Men	48	98.0
Women	1	2.0
Heterosexual	6	12.2
Bisexual	9	18.4
Homosexual	34	69.4
HIV-positive	9	18.4
British-born	44	89.8

Our assessment of patient records against BASHH guidelines is summarised in Table 2. Serological tests used in diagnosis and monitoring included enzyme immunoassay, Treponema pallidum particle agglutination assay and rapid plasma reagin (RPR) titres. These were completed in all patients at diagnosis, meeting the BASHH standard. The median laboratory turnaround time between sample collection and the clinician receiving the report was 12 days from sample collection, falling within the BASHH recommendations. ⁵

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Table 2.

Assessment of patient records against the BASHH outcome measures in the Herefordshire syphilis outbreak cohort.

Outcome measure	Applicable cases n (%)	Patients achieving outcome measure (of applicable cases) n (%)
1. Performing VDRL/RPR titre at commencement of therapy.	49 (100)	49 (100)
2. Response to treatment
a. Resolution of clinical lesions	19 (38.8)	19 (100)
b. A two dilution (4-fold) or greater decrease in the VDRL/RPR within 3–6 months after treatment	34 (69.4)	33 (97.0)
c. For neurosyphilis, CSF cell count should decrease by 6 months and be normal by 2 years, except for persistent positive-specific tests	0 (0)	0 (0)
d. 95% of patients with early syphilis should complete treatment	49 (100)	49 (100)
3. At least 60% of contactable partners should attend for screening and/or treatment	72 contacts from 49 patients	42 (59.2)

Clinical lesions, including sores, ulcers or lesions in the genital area occurred in 23 patients. Of these, 19 (82.6%) resolved, and four patients (17.4%) were lost to follow-up. Interestingly, many patients in this cohort presented with a clinical picture similar to balanitis, resembling syphilitic balanitis of Follman, which may be under-reported and more prevalent than believed. ⁶ Clinical and serological follow-up was carried out at 1, 2, 3, 6 and 12 months after treatment. ² Full 12-month follow-up was completed in 18 patients; however, at the time of writing, a further 18 patients were yet to reach their 12-month follow-up. By 6 months, 33 out of 34 (97.0%) patients had achieved a sufficient decrease in RPR titre, and the remaining patient had responded by nine months. The remaining 16 failed to return despite numerous reminders. All patients were diagnosed with early syphilis, and no cases of neurosyphilis were identified. All patients (100%) were treated with a single dose of benzathine penicillin, meeting the standard of 95%. For the 49 patients in our cohort, 72 contactable partners were identified. Of these, 59.2% attended for screening and/or treatment, narrowly missing the standard of 60%.

Discussion

This audit showed that our service was adequate in meeting majority of the applicable audit standards and highlighted two areas of concern. Full clinical follow-up was not carried out in a significant number of patients. This was as a result of a failure to attend scheduled appointments, despite numerous reminders via phone, text message and mail. Similar issues have been described nationally. ⁷ Effective engagement with patients, and improving access to follow-up, is important in monitoring response to treatment. Potential ways to improve this include an increased emphasis on the importance of follow-up during diagnostic counselling, writing letters to General Practitioners (GPs) and improved access to appointments at the clinic. This audit also highlighted the difficulties encountered in contact tracing in rural communities, which is critical in breaking the chain of infection. Our results are similar to those achieved in audits of other areas of the UK,^8–10 except our rates of successful partner screening/treatment were slightly lower. However, a national audit of early syphilis management found an average of 44% across London clinics, ⁷ and acknowledgement of the difficulties in some areas is made within the BASHH guidelines. Barriers to contact tracing included the presence of multiple anonymous partners and a lack of a local designated MSM community, making outreach and health promotion difficult. In partnership with Public Health England, the Herefordshire iSH service has now organised multiple media campaigns to raise awareness, displayed posters in public conveniences and distributed informative letters to GPs.

Using the BASHH guidelines to audit our service was a useful exercise locally, and we think the issues highlighted are important to share to other similar, rural communities. Contact tracing and public health awareness can be difficult to achieve in communities without a known MSM community, and steps targeting the local population as a whole may be necessary.