Cases of syphilis in England are at their highest levels since the 1940s.
But doctors have new ways of tackling this ancient foe, including an antibiotic “morning-after pill” for taking after unprotected sex, and screening programmes for people going to A&E regardless of whether they have symptoms.
The main hurdle may be convincing people they need to take syphilis seriously. Even though rates are rising, “a lot of people still think of syphilis as a Victorian disease,” said Dr Helen Fifer, a microbiologist at the UK Health Security Agency (UKHSA).
Recognised for several hundred years, syphilis has gone by a variety of names, including the “great pox” and the “French disease”. In the 1700s, it reached epidemic levels, with an estimated one fifth of Londoners being infected.
The infection is caused by bacteria passed on during sex. It can spread easily because it remains contagious while symptoms come and go, and it can be mistaken for other diseases.
The first sign is a painless spot or ulcer near the genitals, which usually heals within weeks. The second stage, a few months later, involves a bewildering array of symptoms, including a rash on the palms and soles, swollen glands, tiredness, fever and patchy hair loss.
The second stage also tends to resolve, but the bacteria are still in the body, and years later can cause heart and brain damage, as well as making the nose collapse. If women pass it to babies in the womb, it can cause disabilities and stillbirth.
Because syphilis leads to such diverse symptoms, doctors often confuse it for other diseases, said Dr Fifer. “Syphilis wouldn’t be the top of your list when you’re looking after a patient, especially if you’re not thinking syphilis is around.”
The cure
Whatever stage it is at, the infection can be cured with antibiotics, and once these arrived, in the 1940s, cases began to fall. Most sexually transmitted diseases (STDs) also fell with wider use of condoms when HIV arrived in the 1980s. Using condoms stops syphilis in its tracks.
But HIV is seen as less of a threat today, because of anti-HIV medicines, which have more or less stopped people dying from Aids in the UK. Medicine’s great success against HIV has contributed to less use of condoms, and so a rise in STDs.
Rates of syphilis are highest in gay men, who account for about two thirds of cases in England. However, syphilis cases are starting to plateau in gay men, while soaring in straight people.
“Over the last 10 years, we’ve seen diagnoses more than double in men who have sex with women and triple amongst women who have sex with men, which is concerning,” said Dr Fifer.
While there are only a handful of syphilis diagnoses in babies each year, the trend is also upwards, with 13 cases in England in 2023, up from five in 2016. It should be completely preventable, because pregnant women are offered a screening test for it, added Dr Fifer.
The ‘morning-after pill’
The UKHSA recently unveiled to STD doctors, at their annual meeting, the latest government syphilis response plan, with a key tool: a “morning-after pill”. The approach is similar to how tablets can be taken after sex to stop pregnancy.
The version for syphilis is an antibiotic called doxycycline – the sameddrug that is used to treat syphilis infections. It also cuts the risk of catching chlamydia, another STD.
When used after sex, the medicine is called doxyPEP, short for doxycycline post-exposure prophylaxis. It should ideally be taken within 24 hours of sex, but still helps if taken within three days.
The approach was first sed by gay men after trials showed it cut syphilis infection rates by up to 77 per cent. However, last year, guidelines from the British Association for Sexual Health and HIV said doxyPEP should also be offered to straight men and women with multiple sexual partners.
This generally means people who have had more than five partners in the past three months, or have had another bacterial STD in the past year, said Dr Fifer. “The guidance does allow for clinical discretion.”
STD clinics started providing the syphilis morning-after pill to straight people late last year. But awareness about this option seems to be very low among straight people, said Dr Chase Ledin, a sexual health researcher at the University of Edinburgh: “People don’t know about this, because it’s such a new intervention.”
Antibiotic resistance fears
There is also caution about giving out the drug too freely, because it could lead to antibiotic resistance in syphilis bacteria. “It really should be targeted at people at highest risk of acquiring syphilis,” said Dr Fifer.
Other steps to reduce the spread of infection spread include encouraging people to get tested if they have any possible symptoms, and wider screening programmes.
Hospitals have trialled testing blood samples taken for other reasons from people attending A&E. This is already done for HIV, and patients are offered the choice to opt out, but most agree.
Greater awareness of the rise in syphilis will help, said Dr Kirsty Foster, a sexual health consultant at UKHSA: “There has been lots of push around chlamydia screening and lots of coverage about gonorrhoea. But people just aren’t aware of syphilis as something they might be at risk of becoming infected with.”
Old diseases coming back
The condition, in which children have bow legs due to weak bones, is caused by lack of vitamin D. In Victorian times it was seen in city children getting little sunshine along with a poor diet. Today it is more common in children with darker skin who are not getting enough sunlight, especially in winter.
An infection of mites living in the skin, causing itching and a rash. It used to be seen as a sign of living in dirty and overcrowded housing. Today it is often found in university students as well as care homes. It is unclear why it is on the rise.
TB is a lung infection that spreads under crowded living conditions and became rampant during Britain’s industrial revolution. Today it is on the rise again, and is mainly diagnosed in people born outside the UK.