Rates of syphilis have increased dramatically over the last decade, both in British Columbia and internationally. In BC, the increase in 2015 was much higher than in previous years: 761 new infectious syphilis cases were diagnosed, a 40% increase over 2014. The numbers for 2016 mirror those of 2015.
An appropriate response to the epidemic is to mobilize resources and focus on maximizing testing and treatment. However, another critical component in the fight against syphilis and other STI is sometimes overlooked: the management of sexual partners.
Why is partner management for syphilis important?
Partner management is a mainstay of the public health and clinical management of STIs, and extends far beyond what has historically been called contact tracing or partner notification. The importance of partner management in the larger context of syphilis control is clear:
- treatment of early infection that may not be detected by laboratory testing;
- prevention of onward transmission of syphilis;
- prevention of reinfection; and
- potential prevention of early, severe syphilis complications.
Though the median incubation period for syphilis is three weeks, the upper limit can reach 90 days. There may be no signs – laboratory or otherwise – of syphilis during this incubation period. The lesions present during early syphilis are highly infectious: the efficiency of transmission from these lesions is likely upward of 30%.
These facts are the basis for the recommendation to treat all recent sexual partners (i.e. in the previous 90 days) of a diagnosed case of infectious syphilis. Health care providers should treat any partners of known primary, secondary or early latent syphilis, even with a negative or unknown syphilis test result, as they could be infectious without laboratory evidence.
What is involved in partner notification?
Partner notification can be accomplished in a number of ways. The patient can do it themselves, the ordering/treating physician can do it, or public health can take it on. With public health, the patient provides names/contact information for their partners and notification is done anonymously.
Currently in BC, syphilis management is centralized; each new infection is reviewed and overseen by a group of expert STI physicians and nurses at the BC Centre for Disease Control (BCCDC). The bulk of syphilis partner care and follow-up is done by the BCCDC syphilis nursing team.
The approach to syphilis partner notification is different than for other bacterial STIs; the nursing team spends significantly more time tracking people down for testing/treatment, and more attempts are made to contact individuals. This ‘enhanced’ partner notification relates to the more serious nature of syphilis and the potential for more complicated sequelae.
Provider responsibilities for partner care
While partner notification is encouraged, it remains a voluntary activity that is not required by legislation. However, primary care and other providers are key players in the provision of appropriate partner management for syphilis. Partner care extends beyond partner notification; it begins with the diagnosis.
There are multiple entry points for engagement in partner care:
- At initial presentation/diagnosis: This is the optimal time to discuss partners, as early partner notification can lead to prevention of onward transmission, prevention of reinfection, and reduced treatment time.
- At time of treatment: Though early treatment is ideal, and empiric treatment is very reasonable where clinical suspicion is high but there are no positive results, treatment of partners from the preceding three months is critical. In certain circumstances, health care practitioners may provide an antibiotic ‘carry’ (take-home antibiotics for a partner) if it is unlikely or impossible for a partner to attend clinic. This is very case-dependent and should always be done in the context of an appropriate assessment of the partner’s medical and allergy history.
- And onward…: Patients often provide partner information at a later date. Depending on the stage of the infection in the patient, the ‘call-back’ time for testing partners can vary. However, the test-and-treat recommendation does not change: all sexual partners in the previous three months should get tested AND treated.