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					       Goodbye
….and thanks for the syphilis!

         Robert Palmer
          Lead Advisor/Sp.Psych
      Guy‟s and St. Thomas‟ Hospitals
“He who knows syphilis, knows medicine”.
                              William Osler
            Syphilis backstory
   The Columbian exchange theory
       Returned to Europe from the New World by
        Columbus and his randy crew. Linked by
        evidence of an outbreak in Naples in 1494
             Syphilis backstory
 Pre-Columbian        theory
     Present in Europe before discovery of
      Americas
       • Suspected outbreak in a Friary in 13/14th C in
         Kingston upon Hull
 Combination       theory
     No country nor race can be blamed, possibly
      in both Americas and Europe,
     With Pinta and Yaws as weaker versions
               Syphilis backstory
 Hasravaged the world through the
 centuries
     Alleged syphilitics include:
             Mussolini
             Hitler
             Charles VIII
             Tolstoy
             Lenin
             James Hardy
                   Syphilis backstory
   More virulent version than known today during
    14/15th centuries:
       "[W]hen syphilis was first definitely recorded in
        Europe in 1495, its pustules often covered the body
        from the head to the knees, caused flesh to fall from
        people's faces, and led to death within a few months”.
        (Diamond 1997)
            Syphilis backstory
   Tuskagee syphilis experiment
       Clinical study between 1932 and 1972
       399 African American sharecroppers recruited
        with syphilis to follow the natural course of
        infection without treatment
       When the study started treatment was often
        dangerous and unreliable
       When penicillin became widely available scientists
        withheld treatment and information and
        participants were not allowed to access local
        treatment centres.
                       Syphilis backstory
   Tuskagee syphilis experiment

       Ethically corrupt
         • Offered „special treatment‟ - actually a lumbar puncture
         • At the end of the study in 1972 only 74 participants were
           still alive
                28 had died of syphilis
                100 died of related complications
                40 wives were infected
                19 children born with congenital syphilis
       Formal apology from Clinton in 1997
Syphilis backstory

            Treatments:
               Mercury: “A night in the
                arms of Venus leads to a
                lifetime on Mercury”
                Injected, ingested, rubbed
                on skin, fumigation
               Malaria - by producing high
                fevers
               Arsenic
               Finally, penicillin
  Numbers of diagnoses of syphilis (primary,
secondary and early latent) by sex, GUM clinics,
England and Wales, and Scotland*: 1931 - 2006
                      12,000                                                                                                           6,000

                                                                                 England & Wales - male
                      10,000                                                     England & Wales - female                              5,000
Number of diagnoses




                                                                                                                                               Number of diagnoses
 (England & Wales)




                                                                                 Scotland - male
                       8,000                                                     Scotland - female                                     4,000




                                                                                                                                                   (Scotland)
                       6,000                                                                                                           3,000


                       4,000                                                                                                           2,000


                       2,000                                                                                                           1,000


                          0                                                                                                            0
                               19

                                       19


                                               19


                                                       19

                                                               19


                                                                       19

                                                                               19


                                                                                       19

                                                                                               19


                                                                                                       19

                                                                                                               19


                                                                                                                       19

                                                                                                                               20
                                  31

                                          37


                                                  43


                                                          49

                                                                  55


                                                                          61

                                                                                  67


                                                                                          73

                                                                                                  79


                                                                                                          85

                                                                                                                  91


                                                                                                                          97

                                                                                                                                  03
                               Rates of diagnoses of infectious syphilis (primary
                                  & secondary) by sex and age group, GUM
                                     clinics, United Kingdom: 1997 - 2006
                                       Males                       Females

                              20
                                                      <16
                                                              20
                                                      16-19
                              18                              18
                                                      20-24
Rate per 100,000 population




                              16                      25-34   16
                              14                      35-44
                                                              14
                                                      45+
                              12                              12
                              10                              10
                               8                               8
                               6                               6
                               4                               4
                               2                               2
                               0                               0
                                 96

                                 97

                                 98

                                 99

                                 00

                                 01

                                 02

                                 03

                                 04

                                 05

                                 06




                                                                  96

                                                                  97

                                                                  98

                                                                  99

                                                                  00

                                                                  01

                                                                  02

                                                                  03

                                                                  04

                                                                  05

                                                                  06
                              19

                              19

                              19

                              19

                              20

                              20

                              20

                              20

                              20

                              20

                              20




                                                               19

                                                               19

                                                               19

                                                               19

                                                               20

                                                               20

                                                               20

                                                               20

                                                               20

                                                               20

                                                               20
                               Routine GUM clinic returns
Diagnoses of infectious syphilis (primary, secondary and early latent)
by sex and sexual orientation, London enhanced syphilis surveillance:
                    April 2001 - December 2006

                                         MSM (n=2489)
                                         Male heterosexual (n=638)
                                         Female heterosexual (n=364)
                         10.4%

18.3%




                                                          71.3%

 London Enhanced Syphilis Surveillance
                Syphilis today
 Most   cases among MSM
     Attending with primary chancre
     Secondary symptoms
     Contact of

       • 96% self refer
       • 4% GP or other departments: dermatology,
         oncology and dentistry
                Syphilis today
   Missing syphilis within
    primary care,
    considering chancre
    to be oral or anal
    herpes
            Syphilis today
 Thistertiary syphilis was considered to a
 be a breast cancer
              Syphilis today
 Secondarysyphilis often mistaken for a
 dermatological problem.
    Issues of importance for HA‟s
   Need for more in-depth contact tracing
   Use of social networking and dating sites to
    trace partners
   More involvement in the local public sex
    environments, using syphilis POCT
   Need to follow up our patients and make sure
    they attend for repeat bloods
   Not to give in when faced with large number of
    contacts
  Issues of importance for HA‟s
 To  complete our contact tracing at follow
  up/RPR bloods
 To be aware of the real possibility of
  reinfection
 Importance of testing our HIV + MSM
  patients regularly (every three months)
 Introduction of Determine Syphilis POCT

				
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