Objectives To describe an outbreak of infectious syphilis in rural North Wales and the control measures implemented.
Methods Following reports of an increase of syphilis in North Wales, a multidisciplinary Outbreak Control Team (OCT) was established. A multilevel prevention and control response was initiated, including: active case surveillance, partner notification and treatment, sexual network analysis, awareness raising with professionals and affected communities, point-of-care syphilis testing at a sauna and a health promotion campaign targeting users of men who have sex with men (MSM) social network mobile phone applications (apps).
Results Four cases of infectious syphilis were diagnosed in clinics in North Wales per 100 000 population in 2013 compared with a mean of one case per 100 000 in the preceding decade. Diagnosed cases peaked in January 2014, declining in the first half of 2014. Initial cases were clustered in the westerly rural counties of North Wales and were predominantly white men, self-reporting as MSM (median age: 34 years, range: 17–61). Point-of-care testing at a sauna did not identity further new infections, suggesting that the cluster was relatively focused and had probably been detected early. The use of apps to find sexual partners was a feature of the network affected. A health promotion campaign, initiated by the OCT, targeting men using MSM apps reached 92% of the 755 men messaged.
Conclusions The outbreak was successfully controlled. However, it is difficult to determine which of the interventions implemented were most effective. Future outbreaks should be used as an opportunity to evaluate interventions using apps.
- EPIDEMIOLOGY (GENERAL)
- SEXUAL NETWORKS
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Like other countries in Europe, the UK has observed a re-emergence of syphilis, primarily affecting men who have sex with men (MSM) living in urban conurbations.1 In cities, such as London, Manchester and Brighton, syphilis is now endemic. However, in recent years, there have been a number of outbreaks reported outside of these urban areas.2 These clusters, occurring in areas with a relatively low background incidence, indicate the potential for outbreaks of syphilis wherever active sexual networks exist, particularly those which link out geographically and socially to established high-incidence MSM populations.
In Wales, infectious syphilis was rare during the 1980s and 1990s. In the early 2000s, an increase in the number of cases in MSM was observed. In South Wales, this increase was associated with transmission within local MSM sexual networks, including that associated with a sauna3 and in North Wales in men with epidemiological links to a large outbreak in Manchester, in neighbouring North West England.4 ,5 Syphilis has subsequently become endemic in Wales. In 2014, there were two cases of infectious syphilis diagnosed per 100 000 population,6 with the majority of cases focused in MSM sexual networks in the more urban areas of South Wales. In North Wales, cases continue to be diagnosed but at lower rates.
On 2 December 2013, Public Health Wales was notified by a consultant in genitourinary medicine of an increase in syphilis in North West Wales, a predominantly rural area, which had hitherto seen only sporadic cases. The consultant notification was triggered by the observation that there had been 10 new diagnoses of infectious syphilis at the clinic in the 3-month period from September to November 2013, compared with three in the previous 9 months of that year.
A multidisciplinary Outbreak Control Team (OCT) was established. The OCT, chaired by a consultant in Communicable Disease Control for North Wales, met three times: on 16 January 2014, 13 May 2014 and 4 June 2015. At the first meeting of the OCT, the outbreak was confirmed and an outbreak case was defined as: Any case of infectious syphilis diagnosed in a resident in the area covered by Betsi Cadwaldr University Health Board (BCUHB) area (the health board providing services for the 692 000 people living in the six counties of Isle of Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham) from 1 January 2013.
The OCT instigated a multilevel prevention and control response. This included: Active case surveillance, partner notification and treatment, sexual network analysis, awareness raising with professionals and affected communities, point-of-care syphilis testing at a sauna and a health promotion campaign targeting users of MSM mobile phone applications.
Active case surveillance
Routinely collected surveillance data were used to describe the outbreak. Two sources of data were available: The Enhanced Surveillance of Infectious Syphilis Scheme (ESS), a scheme established in 2002 whereby all integrated sexual health services in Wales submit by post to Public Health Wales a completed paper questionnaire form providing demographic and behavioural data for each case diagnosed,3 and the Sexual Health in Wales Surveillance Scheme (SWS), an electronic surveillance system that provides Sexual Health and HIV Activity Property Type (SHHAPT) data7 from clinical management systems in integrated sexual health clinics in Wales. This latter scheme provides data on the area of residence of diagnosed cases. Usual surveillance activity was intensified during the outbreak and data from these two systems were regularly analysed using Stata V.13 (StataCorp. Stata V.13. http://www.stata.com/stata13/ (accessed Aug 2015)) to provide updated epidemic curves.
Sexual network analysis
The local integrated sexual health clinic (Ysbyty Gwynedd, Bangor) provided anonymous data on traceable contacts of cases. Data on numbers of untraceable contacts were also provided by gender. These data were used to investigate further the sexual networks involved in the outbreak, and network diagrams were constructed using Cytoscape.8
Point-of-care syphilis testing at a sauna
Terrence Higgins Trust (THT) had previously been funded by BCUHB to provide outreach services, including HIV testing, at a sauna in North Wales. In response to the outbreak, this service was extended to include the offer of a syphilis point-of-care test (POCT) at a local sauna used by MSM. The purpose of this initiative was twofold, first to actively find and treat syphilis cases within the North Wales MSM community, and second to provide an indication of the extent of the outbreak in North Wales. The ‘Alere Determine Syphilis TP’ assay was used, a rapid qualitative immunoassay that provides a result in 15 min.9 Any POCT reactive test results triggered a referral to the appropriate local sexual health service for confirmation of result and treatment.
A communications strategy was established. A press release was developed and shared widely with local media. Letters were sent to general practitioners, dentists and hospital consultants in Gwynedd and Isle of Anglesey informing them about the outbreak and requesting their assistance and referral in early detection of new cases. Other partners such as the National Health Service drugs and alcohol service who operated a harm reduction bus service targeting people who inject drugs and parlours linked to sex work across North Wales were informed. Because some North Wales residents may attend sexual health clinics in England, contact was made with clinics on the Wales/England border to ask them to inform the OCT of any cases in North Wales residents diagnosed over the border, and links were made with a Public Health England epidemiologist in North West England. A page within the health board's website was developed with clinic contact details, information about the outbreak, key messages and links to further information. This was promoted on a poster developed to support the campaign, which was distributed to places with a high footfall for the target audience and included university toilets and halls of residence, pubs, gyms and saunas.
Health promotion campaign targeting users of MSM mobile phone applications
An initial visit was made to the LGBT Foundation in Manchester to obtain advice and guidance on engaging with MSM online social networking sites. A local service user was then recruited to offer insight into navigating MSM social networking sites and provide advice on the acceptability of our messages to the target audience. We approached on-line dating/social networking sites which were identified by patients and, where possible, permission was gained to register a profile. Profiles were developed on these sites and were clearly branded as NHS. They included key sexual health promotion messages and were linked to the pages on the BCUHB website, including clinic contact details and opening times, information about the outbreak and links to further information. Between March and August 2014, messages were sent directly to people who were registered, located within 30 mi of Bangor and using the on-line dating social networking sites to find partners. The messages sent were friendly and non-judgemental but contained the key message—“Have fun but please be careful” (see: web only box 1).
In 2013, there was a marked increase in the rate of syphilis diagnoses across North Wales. In total, 30 cases were reported through ESS in 2013 (four per 100 000 population). During 2013, diagnosed cases increased steadily to a peak of eight diagnosed cases in January 2014 before declining in the second quarter of 2014 (figure 1). By contrast, in the decade 2003–2012, an average of seven cases of infectious syphilis were diagnosed annually by clinics in BCUHB, equivalent to a rate of one case per 100 000 population. In 2010, 10 cases of infectious syphilis were reported through ESS from clinics in the health board, 12 in 2011 and 2 in 2012.
In the outbreak, the majority of cases were diagnosed by clinics in the more rural westerly part of North Wales. When analysed by patient residence, using Sexual Health in Wales Surveillance Scheme (SWS) data, between January 2013 and June 2014, 31% of cases were resident in Isle of Anglesey and 23% in Gwynedd. However, as the outbreak progressed, more cases were diagnosed in the more easterly counties, closer in proximity to the urban centres of North West England. An additional three MSM cases, resident in North Wales, are known to have been diagnosed in clinics in England.
There was clinical evidence of active transmission. Of the 53 cases of infectious syphilis diagnosed between 1 January 2013 and 30 June 2014, the majority (29) were diagnosed with primary syphilis, 9 with secondary syphilis and 12 with early latent syphilis. The stage of infection was not reported for three cases.
Most cases were white men, self-reporting as MSM. Median age of cases was 34 years (range: 17–61). Six men self-identified as bisexual, and two men were of unknown sexual orientation. Eight heterosexual cases (four men, four women) were reported. Most cases acquired their infections locally, though 11 individuals reported acquiring their infection outside Wales, including four who reported acquiring their infection outside the UK (Spain, the Netherlands) (figure 2). Six cases were HIV positive, of which one was newly diagnosed. Three syphilis cases were also diagnosed with gonorrhoea, three with chlamydia and one case was newly diagnosed with hepatitis C.
Most cases reported one or two sexual contacts in the previous 3 months, with some reporting higher numbers (median number of partners for MSM: 2, range: 0–45).
The use of mobile applications (apps), allowing users to locate other sexual partners within close proximity, was reported by 40% of MSM cases, including those who identified as bisexual, but not by heterosexual cases. When sexual networks were investigated in detail, the use of apps was a common feature in the network (figure 3). The use of 10 different mobile applications was reported. Two male cases reported meeting partners at a cruising site in a business park in Gwynedd. Both of these men also reported using apps. One case reported many anonymous sexual partners at a sauna.
Cases returned to preoutbreak levels in Summer 2014 (figure 1). However, the outbreak was not formally declared over and a watching brief was maintained.
Point-of-care testing at saunas
THT offered point-of-care testing for syphilis at a sauna in North Wales. Eight sessions in total were run, all during daytime hours, with 16 clients tested. None tested positive. All tests were the first sexually transmitted infection (STI) tests taken by the clients, many of whom reported that they were unlikely to attend a sexual health clinic. Twenty-five HIV tests were also performed, none of which were positive. Advice was given on safe sex practices, condoms were provided and information was given to clients on sexual health clinics available locally. Following this intervention, a number of clients tested by POCT attended a sexual health clinic for further testing and/or hepatitis B vaccination.
Health promotion campaign
Between March and August 2014, eight messages were sent directly to on-line users of sexual network apps (figure 4, web only box 1). Seven hundred and fifty-five people received at least one message. Ninety-two per cent of recipients read the message and only 8% deleted it without reading. Eighteen questions were received from app users mainly concerning clinic times. Clinical queries received were passed on to staff at the sexual health clinic. The feedback from the target audience reading the messages was very positive. No negative feedback about the campaign was received.
This outbreak demonstrates the potential for epidemic transmission of syphilis in people living outside the major cities where background incidence is currently low. Sexual networks including MSM are particularly vulnerable.
Two main factors appear to be important in the epidemiology of this outbreak: a high degree of mobility in a proportion of the MSM population in North Wales with links to sexual networks in North West England and further afield, and the use of geospatial social media applications (apps) to create local sexual networks.
Previous studies of a MSM sexual network using a sauna located in South Wales indicated a network that was widely dispersed geographically. Men attended the sauna from an area with a 100 mi radius, from as far west as Pembrokeshire and as far east as the M4 motorway corridor in Southern England.3 Interestingly, while there appeared to be migration between the South of England and South Wales, there appeared to be few social links between MSM populations in North and South Wales. This is perhaps not surprising with the historic, economic and social links between North Wales and North West England, particularly Liverpool and Manchester. In both outbreaks, however, there were links to European cities and holiday destinations. This high level of mobility in a proportion of the MSM population has implications for geographically focused control efforts. Trends in the epidemiology of STIs at a European level may have very local impacts.
The second factor that appeared to be important in facilitating transmission was the use of smartphone applications. Smartphone applications (apps) are increasingly being used by people of all sexualities to meet sexual partners. MSM are using geospatial networking applications to meet other local MSM. Some of these apps exist primarily to promote unprotected casual sex, often in group sex environments.10–12 In 2003, only 9% of infectious syphilis cases in Wales reported finding their sexual partners using the internet. By 2013, this had increased to 55% (see: web only table 1).
As well as presenting a risk for more efficient transmission, this use of social media also provides an opportunity for targeted health promotion.13 This approach has been previously attempted in a number of settings with some success.14–16
Another possible factor in the outbreak is a lack of awareness of syphilis in this population. Although the re-emergence of syphilis has been well publicised in saunas, it is possible that this information has not been disseminated to MSM in more rural parts of the UK, including those who are behaviourally bisexual but may not self-identify as such. Unfortunately, no survey of awareness was carried out before or after the outbreak and subsequent interventions. The enhanced syphilis surveillance form has subsequently been changed to ask whether ‘patient was aware of the risk of syphilis’. This may assist in future evaluations of an intervention.
The drawing of network diagrams provided some insight into the epidemiology of the outbreak; however, these diagrams are only useful if data on contacts are relatively complete. It is possible that there are a number of missed links in these diagrams where anonymous contacts are reported. From first sight, it appears that there is little overlap between users of saunas and other networks. However, one outbreak case presenting at a sexual health clinic reported many anonymous partners attending a sauna, raising concerns of widespread transmission. Although only a limited number of men were tested in the sauna, the negative findings provided some reassurance that syphilis was not widely distributed in North Wales and the outbreak was most likely to have been detected relatively early. Advantages of using POCT in an outbreak setting are both as a way of case detection and of raising awareness among at-risk populations. In this outbreak, it would have been helpful to implement further outreach, possibly in university settings.
The early establishment of a multidisciplinary OCT was considered important. Throughout the outbreak, timely and effective communication was maintained between health protection, microbiology, sexual health and communications colleagues. This outbreak was novel for North Wales, and the assistance provided from colleagues more experienced in dealing with similar outbreaks was invaluable. THT Cymru, the Manchester LGBT Forum and Public Health England all provided useful advice and assisted with the design of interventions and epidemiological approaches. The Manchester LGBT Forum in particular had very good relationships with the app and website providers, which assisted in the setting up of the targeted health promotion campaign. The importance of raising awareness among primary and secondary healthcare colleagues was seen as a success, as was communication between GUM professionals/sexual health networks. It was agreed that in future regular liaison with colleagues in the Manchester LGBT Forum would be useful to establish what might be forthcoming sexual health issues among MSM in North Wales. Critical to the success of the health promotion campaign was the recruitment of an ‘expert patient’ who was able to inform the OCT on the local use of MSM social networking sites and provide advice on the acceptability of messages to the target audience.
It is difficult to determine the contribution of the interventions to the observed decline in infections. It is possible that the targeting of health promotion messages using apps played a role in controlling the outbreak. An attempt was made to investigate the role of apps by further observational study. A case–control study was designed in which app use was to be compared in cases of infectious syphilis diagnosed in MSM attending sexual health clinics and in controls (MSM attending the same sexual health clinics who were free of STI). Unfortunately, following examination of the clinic patient notes, it was judged that there were systematic differences in the way behavioural data were collected for cases and non-cases and this study was therefore abandoned. Collecting standardised behavioural data on all MSM attending clinics, irrespective of STI results could be considered as a way of assessing ongoing risks associated with app use. Other more innovative studies to assess changes in the risks associated with app use and in the evaluation of targeted interventions using apps could be carried out linking profiles used on these sites with clinical records held at clinics. Any such research would require ethical approval and should consider the possible impact on the privacy of study participants.
Lastly, this outbreak was detected by a vigilant clinician. While informal networks and personal links are an important aspect of good public health surveillance, more work is required to ensure syphilis surveillance is sensitive and timely enough to detect any future outbreaks. As well as effective case-based surveillance, behavioural surveillance is important to detect changes in the way sexual networks are organised.
Outbreaks of infectious syphilis are becoming increasingly common in people living outside the major cities.
The rural population affected by this outbreak had links outside the area and used social media to create local sexual networks.
Targeted messages sent via smartphone apps appeared to be a factor in controlling this outbreak.
We are grateful to all the clinic and laboratory staff who contributed to the outbreak response. We would like to thank Vicky Gilbart and Lynsey Emmett at Public Health England and the Manchester LGBT Forum for providing advice. We are particularly grateful to the ‘expert patient’ who advised on the mobile phone app health promotion campaign.
Abstract in Welsh
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Abstract in Welsh - Online abstract
Handling editor Jackie A Cassell
Contributors DRT drafted the manuscript. All authors were members of an Outbreak Control Team, contributed to the design and implementation of the outbreak control response described and commented on the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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