CSIRO PUBLISHING
Sexual Health, 2015, 12, 170–173 http://dx.doi.org/10.1071/SH14140
Case Report
A novel response to an outbreak of infectious syphilis in Christchurch, New Zealand Edward Coughlan A,F, Heather Young A, Catherine Parkes A, Maureen Coshall A, Nigel Dickson B, Rebecca Psutka B, Peter Saxton C, Ramon Pink D and Katharine Adams E A
Christchurch Sexual Health Centre, Canterbury District Health Board, Private Bag 4710, Christchurch 8140, New Zealand. B Department of Preventive and Social Medicine, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand. C Gay Men’s Sexual Health Research Group, Department of Social and Community Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. D Medical Officer of Health, Canterbury, Community and Public Health, Division of the Canterbury District Health Board, P. O. Box 1475, Christchurch 8140, New Zealand. E Canterbury District Health Board, Private Bag 4710, Christchurch 8140, New Zealand. F Corresponding author. Email: [email protected]
Abstract. During 2012, Christchurch experienced a dramatic increase in cases of infectious syphilis among men who have sex with men. This was accompanied by some novel trends; notably, the acquisition of infection in a younger age group, with local sexual contacts, commonly via the use of social media. This study is a report on an approach to case identification and public health communication as a component of a multifaceted outbreak response. Enhanced syphilis surveillance data on public health responses to outbreaks of sexually transmissible infections was collated and reviewed, alongside clinical records and literature. Reported outbreak response methods were adapted for the Christchurch cohort. A Facebook page was created to raise awareness of infectious syphilis, the importance of screening and where to get tested. Twenty-six males were diagnosed with infectious syphilis in 2012, an increase from previous years, of which 22 reported only male sexual contact. High use of social media used to find potential sexual contacts was reported. Enhanced syphilis surveillance characterised in detail an infectious syphilis outbreak in Christchurch. Index cases were identified, contact tracing mapping was used to identify transmission networks and social media was also used to educate the risk group. There was a decrease in infectious syphilis presentations, with no cases in the last 3 months of 2012. Additional keywords: contact tracing, MSM, social media. Received 1 August 2014, accepted 2 October 2014, published online 11 Decenber 2014
Introduction New Zealand has experienced a rise in infectious syphilis cases reported to the Institute of Environmental & Scientific Research (ESR), most notably since 2000.1 Sentinel reporting sites have been predominantly sexual health clinics (SHC). Developed countries elsewhere have experienced similar increases in urban centres, particularly among men who have sex with men (MSM).2–4 New Zealand data did not include sexual behaviour and place of infection, although a report from the Auckland Sexual Health Service from January 2002 to September 2004 showed a doubling in cases (40 up from 19) of infectious syphilis, mostly among MSM and heterosexuals presumed to have acquired infection overseas. Among the 40 cases, four were identified as being co-infected with HIV.5 Retrospective reports of laboratory-diagnosed infection in Wellington also showed a rise in incidence from five in 2004 Journal compilation Ó CSIRO 2015
to 10 in 2005, again mostly among MSM.6 An Auckland laboratory-based report on figures from July 2006 to July 2007 revealed similar trends, with 92 cases of infectious syphilis.7 In response to the resurgence in infectious syphilis, New Zealand established enhanced surveillance of cases seen at sexual health clinics (SHCs) from 2011. Prior to this time, national data on infectious syphilis obtained from sentinel reporting sites was limited to age, gender, ethnicity and region. Enhanced surveillance included data on demographics, sexual behaviour, likely place infection was acquired, reason and location of testing, symptoms, HIV status, concurrent sexually transmissible infections (STIs) and whether any social/sexual network was implicated.8 This confirmed that these cases were predominantly among MSM. www.publish.csiro.au/journals/sh
Response to an outbreak of infectious syphilis
Sexual Health
The aim of this paper is to describe in detail an outbreak of infectious syphilis in 2012 that was rapidly identified by the surveillance in Christchurch, New Zealand, and the multifaceted response to this. Methods Enhanced syphilis surveillance from SHCs was initiated in 2011 through the AIDS Epidemiology Group. Infectious syphilis was defined as primary, secondary, early latent (within 2 years) or syphilis of unknown duration with a rapid plasma reagin (RPR) titre of 1 : 32 or greater; the details of which have been reported elsewhere.8 Ethical approval was obtained in November 2010 from the Multi-Centre Ethics Committee (MEC/10/080/EXP). When an index case was diagnosed, their sexual contacts were identified and invited for testing and treatment, with the patients’ permission. This involved interviewing each of the confirmed cases about their sexual contacts over the previous 3–6 months and was dependent on their ability to recall all contacts and having a method of informing them. The sexual health clinic assisted with facilitating this process wherever
necessary. These contacts were then mapped on a diagram (Fig. 1) and linked to the index case. In some instances, the contact did not indicate the index case, but became a new index case if they tested positive for syphilis. Equally, different index cases may or may not have named each other as contacts, which is highlighted by the directional arrows on the diagram. The SHC in Christchurch observed an increase in infectious syphilis cases from eight in 2011, to 22 in the first 7 months of 2012. This was confirmed by the AIDS Epidemiology Group. Public health authorities were alerted and a multidisciplinary group comprising sexual health services, the Public Health Unit of the Canterbury District Health Board (CDHB), the AIDS Epidemiology Group, the community-based New Zealand AIDS Foundation (NZAF) along with local general practitioners, was formed to coordinate a response. Literature was reviewed on managing STI outbreaks2–4,9,10 and a series of action points were generated. Publicity and public health messaging were identified as a priority due to the highly infectious nature of syphilis, the presence of asymptomatic infection in the MSM community and evidence of rapid spread into a previously unaffected age cohort. A CDHB media release was followed by publications targeting MSM
Regional
2 40–44 years 4 A2
1 15–19 years A3
10 15–19 years A2
O/seas
3 15–19 years A1
Unknown SOSV
12 20–24 years A2
Unknown Internet
8 1 0–24 years 2 A3 A
Neg
17 25–29 years A2
21 30–34 years A3
15 20–24 years A2
Unknown Internet
Unknown Internet
20 40–44 years A1
13 25–29 years A2
Unknown Unknown
5 20–24 years A1 24 25–29 years A3
NZ DaƟng Unknown
25 15–19 years A1
MulƟple Unknowns
Unknown
26 20–24 years A3
50+ Unknown
6 25–29 years A1
Neg
8 20–24 years A1
5 Unknown
Overseas
Unknown (3 years ago) Known
Unknown Internet
Auckland
Neg
30–34 years Previous A1
Unknown Internet
Neg
25–29 years A1
30–34 years A3 Diagnosed 2009 not re-infected
Unknown Internet
4 15–19 years A2
Neg GP
14
19 20–24 years A2
171
NZ DaƟng Unknown
7 20–24 years A2
16 6 20–24 years 2 A2
23 22–24 years A2
Unknown Internet
22 45–49 years A2 Unknown Internet
9 30–34 years A2
Neg
Neg
O/seas Auckland
11 20–24 years A3 Unknown O/seas & Internet
Fig. 1. Contact tracing diagram. All contacts were from Christchurch unless stated. Top number = order in which they were diagnosed; Coloured boxes = associated clusters; Arrow direction, who named who as a contact with double arrows indicating they named each other. ESR codes: A1 = Primary, A2 = Secondary, A3 = latent syphilis; Unknown = no first or surname given or named but untraceable; Neg = named and tested; SOSV = Sex On Site Venue.
172
Sexual Health
via the gay press and via a widely distributed monthly newspaper, and through General Practitioners. Primary Health Organisations were notified through CDHB liaison and public health networks and there was an electronic press release to the male community health promotion and support group, The Canterbury Men’s Centre. The New Zealand Ministry of Health and Sexual Health Society were notified. A series of educational presentations to peers, medical, dental and nursing groups were undertaken to promote awareness, recognise clinical features and encourage testing and referral. Facebook advertising targeted males aged over 18 years, who lived within 50 km of Christchurch and who ‘liked’ a NZAFidentified series of events, organisations and personalities; this was incorporated as an outbreak response tool. Images of gay and bisexual men, alongside alerts regarding the syphilis outbreak, appeared on the Facebook page of these viewers. Links were provided to syphilis fact sheets and CDHB ‘Healthinfo’ electronic pathways, with details of where to go for syphilis screening. The total advertising budget was $NZD1500. The campaign ran for 6 months from 15 November 2012 to 15 May 2013, with a total of 948 views and it came in under budget at $803.28 (NZD) in its entirety. Results Enhanced surveillance revealed eight cases of infectious syphilis diagnosed in Christchurch in 2011 (age range 36–60 years, median 42 years). This increased markedly in 2012 to 26 cases, all of whom were male (age range 19–48 years, median 24 years). Of the 2012 cases, 22 reported only male contacts, two reported both male and female contacts, and two reported only female contacts. Nineteen (73%) were of New Zealand European, five (14%) Maori, one European and one of South African ethnicity. Twenty-four were considered likely to have acquired an infection within New Zealand (nine in Christchurch), one overseas and one unknown. Almost half of initial testing was in a general practice setting (12 cases) and 10 cases were done through the Christchurch Sexual Health Centre. Student Health, Family Planning and other organisations accounted for the remainder. Eight tested because they were syphilis contacts (two of whom had symptoms), 14 because they were symptomatic (excluding those identified as syphilis contacts), three were asymptomatic infection screens, and one an immigration screen. Only two were co-infected with HIV, 10 with chlamydia and one with genital herpes. Of those who only had sex with men (22), the number of contacts in the last 3 months ranged from 1 to 20 with a median of two, and in the last 12 months (when known), the number ranged from one to 100 with a median of five. Online networking was implicated as a source of sexual partners in 10 cases where stated. Syphilis diagnoses during the 2012 period occurred between January and September. In 2013, there were a total of 19 persons reported with infectious syphilis in Christchurch. The returns for Christchurch (a subset of the national enhanced surveillance statistics) were collated with electronic patient records to construct Fig. 1 for the purposes of contact tracing mapping. This involved each identified case being reviewed for contact tracing details, the index case being re-
E. Coughlan et al.
interviewed where appropriate and then the index case being plotted for the map connection between individuals and associated groups. In the diagram, all cases were from Christchurch unless otherwise stated. It shows the high incidence of social media use for meeting contacts. This includes specific mobile applications (e.g. Grindr), and NZ dating websites or other Internet services. Some cases had a high number of unknown casual contacts, such as case 15 who was unable to even provide an estimate. These factors made notification impossible for many contacts and hampered the control of the outbreak. However, it highlighted the importance of regular and routine testing for syphilis in high-risk populations. The outbreak demonstrated that index cases may need to be interviewed a few times to ensure all contact tracing avenues are exhausted. It was interesting to note where some cases named other cases as a contact, but this was not reciprocated e.g. cases 6 & 7, 6 & 13 and 13 & 15, with a special note on case 14 who was named by a male contact, (case 12), but only named female contacts himself. The diagram shows the clustering of groups and possible bridging between age groups (e.g. patient 23). It reflects the information that the index case chose to provide, but as the direction of arrows shows, cases did not always name each other. Limitations This was not designed as a prospective study and data analysis began part way through the year. The case series was relatively small, which has limited us in drawing firm conclusions. Some use of anecdotal evidence has been inevitable, as responses to media campaigns on an individual patient basis were not systematically monitored and captured at the time. Conclusion In comparing events in Christchurch with similar outbreaks around the globe in recent years, we identified the experiences of Thomas et al.10 as being closest to ours. The Welsh case series was identified using traditional contact tracing processes and partner notification; however, even back in 2002, the team noted that Internet-based networks were assuming increasing importance.10 Over the intervening decade, Internet and smart phone application use has increased and as a result, it is no surprise that we now see the impact of this on social networking.11 In 10 of our cases, online networking was implicated as a source of sexual partners. There has been limited national direction regarding specific responses to STI outbreaks. For the future, national Sexual Health Action Plans, including coordinated outbreak strategies, are imperative. The role of specialist Sexual Health Clinics in directing intervention and screening has been recognised internationally in reducing the numbers of new cases, but important questions remain around how that role might be maximised. In essence, how might high-risk individuals be successfully located, targeted, tested and treated to interrupt chains of transmission in densely connected sexual networks that facilitate the rapid spread of
Response to an outbreak of infectious syphilis
Sexual Health
infection? Diagrammatic contact tracing mapping proved an extremely useful tool to aid this process. Enhanced surveillance is essential to characterise communicable disease outbreaks, perform notification functions, target responses and assess efficacy. Contact tracing, testing and treatment resources may thus be directed appropriately. During the latter period of enhanced case finding, persons with positive syphilis serology were more likely to be asymptomatic contacts compared with earlier cases tested on the basis of symptoms or clinical suspicion alone. In the absence of enhanced syphilis surveillance, the infectious syphilis outbreak in Christchurch may not have been characterised sufficiently for targeted activities to occur. Finally, the use of social media appears to have impacted widely on sexual networks. To date, Facebook is not known to have been used as an STI outbreak response tool in New Zealand, either for case finding or for public health messaging.11 However, our experience suggests that social media may provide an acceptable, timely and inexpensive means of contacting large numbers of potential ‘at risk’ individuals and its uses in medicine require further exploration. Acknowledgements The authors wish to thank Joe Rich, Communications & Marketing Manager, NZAF; Daemon Coyle, Program Manager Social Marketing, NZAF; and Ellie Coshall for Diagrammatic IT support.
References 1 STI Surveillance Team and Population and Environmental Health Group. Sexually transmitted infections in New Zealand. Annual surveillance report 2006. City: Institute of Environmental Science & Research Ltd (ESR). Available online at: https://surv.esr.cri.nz/ PDF_surveillance/STISurvRpt/2006/STIAnnualReport2006.pdf. pp. 1–59. [verified 17 July 2012].
173
2 Jin F, Prestage GP, Kippaz SC, Pell CM, Donovan BJ, Kaldor JM, Grulich AE. Epidemic syphilis among homosexually active men in Sydney. Med J Aust 2005; 183: 179–83. 3 Botham SJ, Bourne C, Ferson MJ. Epidemic infectious syphilis in inner Sydney–strengthening enhanced surveillance. Aust N Z J Public Health 2006; 30: 529–33. doi:10.1111/j.1467-842X.2006. tb00781.x 4 Bernstein KT, Stephens SC, Strona FV, Kohn RP, Philip SS. Epidemiologic characteristics of an ongoing syphilis epidemic among men who have sex with men, San Francisco. Sex Transm Dis 2013; 40: 11–7. doi:10.1097/OLQ.0b013e31827763ea 5 Azariah S. Is syphilis resurgent in New Zealand in the 21st century? A case series of infectious syphilis presenting to the Auckland Sexual Health Service. N Z Med J 2005; 118: U1349. 6 Cunningham R, MacDonald J, McLean M, Shaw C. An outbreak of infectious syphilis in Wellington, New Zealand. N Z Med J 2007; 120: U2680. 7 Azariah S, Perkins N, Austin P, Morris AJ. Increase in incidence of infectious syphilis in Auckland, New Zealand: results from an enhanced surveillance survey. N Z Med J 2008; 121: 303–4. 8 Psutka R, Dickson N, Azariah S, Coughlan E, Kennedy J, Morgan J, Perkins N. Enhanced surveillance of infectious syphilis in New Zealand sexual health clinics. Int J STD AIDS 2013; 24: 791–8. doi:10.1177/0956462413483251 9 Annan T, Hughes G, Evans B, Simms I, Ison C, Bracebridge S, Vivancos R. Guidance for managing STI outbreaks and incidents, 2010. Available online at: http://www.hpa.org.uk/webc/HPAwebFile/ HPAweb_C/1214553002033. [verified 17 July 2012]. 10 Thomas DR, Cann KF, Evans MR, Roderick J, Browning M, Birley HDL, Curley W, Clark P, Northey G, Caple S, Lyons M. The public health response to the re-emergence of syphilis in Wales, UK. Int J STD AIDS 2011; 22: 488–92. doi:10.1258/ijsa.2011.011048 11 Young SD, Szekeres G, Coates T. The relationship between online social networking and sexual risk behaviors among men who have sex with men (MSM). PLoS ONE 2013; 8: e62271. doi:10.1371/ journal.pone.0062271
www.publish.csiro.au/journals/sh
Sexual Health, 2015, 12, 170–173 http://dx.doi.org/10.1071/SH14140
Case Report
A novel response to an outbreak of infectious syphilis in Christchurch, New Zealand Edward Coughlan A,F, Heather Young A, Catherine Parkes A, Maureen Coshall A, Nigel Dickson B, Rebecca Psutka B, Peter Saxton C, Ramon Pink D and Katharine Adams E A
Christchurch Sexual Health Centre, Canterbury District Health Board, Private Bag 4710, Christchurch 8140, New Zealand. B Department of Preventive and Social Medicine, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand. C Gay Men’s Sexual Health Research Group, Department of Social and Community Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. D Medical Officer of Health, Canterbury, Community and Public Health, Division of the Canterbury District Health Board, P. O. Box 1475, Christchurch 8140, New Zealand. E Canterbury District Health Board, Private Bag 4710, Christchurch 8140, New Zealand. F Corresponding author. Email: [email protected]
Abstract. During 2012, Christchurch experienced a dramatic increase in cases of infectious syphilis among men who have sex with men. This was accompanied by some novel trends; notably, the acquisition of infection in a younger age group, with local sexual contacts, commonly via the use of social media. This study is a report on an approach to case identification and public health communication as a component of a multifaceted outbreak response. Enhanced syphilis surveillance data on public health responses to outbreaks of sexually transmissible infections was collated and reviewed, alongside clinical records and literature. Reported outbreak response methods were adapted for the Christchurch cohort. A Facebook page was created to raise awareness of infectious syphilis, the importance of screening and where to get tested. Twenty-six males were diagnosed with infectious syphilis in 2012, an increase from previous years, of which 22 reported only male sexual contact. High use of social media used to find potential sexual contacts was reported. Enhanced syphilis surveillance characterised in detail an infectious syphilis outbreak in Christchurch. Index cases were identified, contact tracing mapping was used to identify transmission networks and social media was also used to educate the risk group. There was a decrease in infectious syphilis presentations, with no cases in the last 3 months of 2012. Additional keywords: contact tracing, MSM, social media. Received 1 August 2014, accepted 2 October 2014, published online 11 Decenber 2014
Introduction New Zealand has experienced a rise in infectious syphilis cases reported to the Institute of Environmental & Scientific Research (ESR), most notably since 2000.1 Sentinel reporting sites have been predominantly sexual health clinics (SHC). Developed countries elsewhere have experienced similar increases in urban centres, particularly among men who have sex with men (MSM).2–4 New Zealand data did not include sexual behaviour and place of infection, although a report from the Auckland Sexual Health Service from January 2002 to September 2004 showed a doubling in cases (40 up from 19) of infectious syphilis, mostly among MSM and heterosexuals presumed to have acquired infection overseas. Among the 40 cases, four were identified as being co-infected with HIV.5 Retrospective reports of laboratory-diagnosed infection in Wellington also showed a rise in incidence from five in 2004 Journal compilation Ó CSIRO 2015
to 10 in 2005, again mostly among MSM.6 An Auckland laboratory-based report on figures from July 2006 to July 2007 revealed similar trends, with 92 cases of infectious syphilis.7 In response to the resurgence in infectious syphilis, New Zealand established enhanced surveillance of cases seen at sexual health clinics (SHCs) from 2011. Prior to this time, national data on infectious syphilis obtained from sentinel reporting sites was limited to age, gender, ethnicity and region. Enhanced surveillance included data on demographics, sexual behaviour, likely place infection was acquired, reason and location of testing, symptoms, HIV status, concurrent sexually transmissible infections (STIs) and whether any social/sexual network was implicated.8 This confirmed that these cases were predominantly among MSM. www.publish.csiro.au/journals/sh
Response to an outbreak of infectious syphilis
Sexual Health
The aim of this paper is to describe in detail an outbreak of infectious syphilis in 2012 that was rapidly identified by the surveillance in Christchurch, New Zealand, and the multifaceted response to this. Methods Enhanced syphilis surveillance from SHCs was initiated in 2011 through the AIDS Epidemiology Group. Infectious syphilis was defined as primary, secondary, early latent (within 2 years) or syphilis of unknown duration with a rapid plasma reagin (RPR) titre of 1 : 32 or greater; the details of which have been reported elsewhere.8 Ethical approval was obtained in November 2010 from the Multi-Centre Ethics Committee (MEC/10/080/EXP). When an index case was diagnosed, their sexual contacts were identified and invited for testing and treatment, with the patients’ permission. This involved interviewing each of the confirmed cases about their sexual contacts over the previous 3–6 months and was dependent on their ability to recall all contacts and having a method of informing them. The sexual health clinic assisted with facilitating this process wherever
necessary. These contacts were then mapped on a diagram (Fig. 1) and linked to the index case. In some instances, the contact did not indicate the index case, but became a new index case if they tested positive for syphilis. Equally, different index cases may or may not have named each other as contacts, which is highlighted by the directional arrows on the diagram. The SHC in Christchurch observed an increase in infectious syphilis cases from eight in 2011, to 22 in the first 7 months of 2012. This was confirmed by the AIDS Epidemiology Group. Public health authorities were alerted and a multidisciplinary group comprising sexual health services, the Public Health Unit of the Canterbury District Health Board (CDHB), the AIDS Epidemiology Group, the community-based New Zealand AIDS Foundation (NZAF) along with local general practitioners, was formed to coordinate a response. Literature was reviewed on managing STI outbreaks2–4,9,10 and a series of action points were generated. Publicity and public health messaging were identified as a priority due to the highly infectious nature of syphilis, the presence of asymptomatic infection in the MSM community and evidence of rapid spread into a previously unaffected age cohort. A CDHB media release was followed by publications targeting MSM
Regional
2 40–44 years 4 A2
1 15–19 years A3
10 15–19 years A2
O/seas
3 15–19 years A1
Unknown SOSV
12 20–24 years A2
Unknown Internet
8 1 0–24 years 2 A3 A
Neg
17 25–29 years A2
21 30–34 years A3
15 20–24 years A2
Unknown Internet
Unknown Internet
20 40–44 years A1
13 25–29 years A2
Unknown Unknown
5 20–24 years A1 24 25–29 years A3
NZ DaƟng Unknown
25 15–19 years A1
MulƟple Unknowns
Unknown
26 20–24 years A3
50+ Unknown
6 25–29 years A1
Neg
8 20–24 years A1
5 Unknown
Overseas
Unknown (3 years ago) Known
Unknown Internet
Auckland
Neg
30–34 years Previous A1
Unknown Internet
Neg
25–29 years A1
30–34 years A3 Diagnosed 2009 not re-infected
Unknown Internet
4 15–19 years A2
Neg GP
14
19 20–24 years A2
171
NZ DaƟng Unknown
7 20–24 years A2
16 6 20–24 years 2 A2
23 22–24 years A2
Unknown Internet
22 45–49 years A2 Unknown Internet
9 30–34 years A2
Neg
Neg
O/seas Auckland
11 20–24 years A3 Unknown O/seas & Internet
Fig. 1. Contact tracing diagram. All contacts were from Christchurch unless stated. Top number = order in which they were diagnosed; Coloured boxes = associated clusters; Arrow direction, who named who as a contact with double arrows indicating they named each other. ESR codes: A1 = Primary, A2 = Secondary, A3 = latent syphilis; Unknown = no first or surname given or named but untraceable; Neg = named and tested; SOSV = Sex On Site Venue.
172
Sexual Health
via the gay press and via a widely distributed monthly newspaper, and through General Practitioners. Primary Health Organisations were notified through CDHB liaison and public health networks and there was an electronic press release to the male community health promotion and support group, The Canterbury Men’s Centre. The New Zealand Ministry of Health and Sexual Health Society were notified. A series of educational presentations to peers, medical, dental and nursing groups were undertaken to promote awareness, recognise clinical features and encourage testing and referral. Facebook advertising targeted males aged over 18 years, who lived within 50 km of Christchurch and who ‘liked’ a NZAFidentified series of events, organisations and personalities; this was incorporated as an outbreak response tool. Images of gay and bisexual men, alongside alerts regarding the syphilis outbreak, appeared on the Facebook page of these viewers. Links were provided to syphilis fact sheets and CDHB ‘Healthinfo’ electronic pathways, with details of where to go for syphilis screening. The total advertising budget was $NZD1500. The campaign ran for 6 months from 15 November 2012 to 15 May 2013, with a total of 948 views and it came in under budget at $803.28 (NZD) in its entirety. Results Enhanced surveillance revealed eight cases of infectious syphilis diagnosed in Christchurch in 2011 (age range 36–60 years, median 42 years). This increased markedly in 2012 to 26 cases, all of whom were male (age range 19–48 years, median 24 years). Of the 2012 cases, 22 reported only male contacts, two reported both male and female contacts, and two reported only female contacts. Nineteen (73%) were of New Zealand European, five (14%) Maori, one European and one of South African ethnicity. Twenty-four were considered likely to have acquired an infection within New Zealand (nine in Christchurch), one overseas and one unknown. Almost half of initial testing was in a general practice setting (12 cases) and 10 cases were done through the Christchurch Sexual Health Centre. Student Health, Family Planning and other organisations accounted for the remainder. Eight tested because they were syphilis contacts (two of whom had symptoms), 14 because they were symptomatic (excluding those identified as syphilis contacts), three were asymptomatic infection screens, and one an immigration screen. Only two were co-infected with HIV, 10 with chlamydia and one with genital herpes. Of those who only had sex with men (22), the number of contacts in the last 3 months ranged from 1 to 20 with a median of two, and in the last 12 months (when known), the number ranged from one to 100 with a median of five. Online networking was implicated as a source of sexual partners in 10 cases where stated. Syphilis diagnoses during the 2012 period occurred between January and September. In 2013, there were a total of 19 persons reported with infectious syphilis in Christchurch. The returns for Christchurch (a subset of the national enhanced surveillance statistics) were collated with electronic patient records to construct Fig. 1 for the purposes of contact tracing mapping. This involved each identified case being reviewed for contact tracing details, the index case being re-
E. Coughlan et al.
interviewed where appropriate and then the index case being plotted for the map connection between individuals and associated groups. In the diagram, all cases were from Christchurch unless otherwise stated. It shows the high incidence of social media use for meeting contacts. This includes specific mobile applications (e.g. Grindr), and NZ dating websites or other Internet services. Some cases had a high number of unknown casual contacts, such as case 15 who was unable to even provide an estimate. These factors made notification impossible for many contacts and hampered the control of the outbreak. However, it highlighted the importance of regular and routine testing for syphilis in high-risk populations. The outbreak demonstrated that index cases may need to be interviewed a few times to ensure all contact tracing avenues are exhausted. It was interesting to note where some cases named other cases as a contact, but this was not reciprocated e.g. cases 6 & 7, 6 & 13 and 13 & 15, with a special note on case 14 who was named by a male contact, (case 12), but only named female contacts himself. The diagram shows the clustering of groups and possible bridging between age groups (e.g. patient 23). It reflects the information that the index case chose to provide, but as the direction of arrows shows, cases did not always name each other. Limitations This was not designed as a prospective study and data analysis began part way through the year. The case series was relatively small, which has limited us in drawing firm conclusions. Some use of anecdotal evidence has been inevitable, as responses to media campaigns on an individual patient basis were not systematically monitored and captured at the time. Conclusion In comparing events in Christchurch with similar outbreaks around the globe in recent years, we identified the experiences of Thomas et al.10 as being closest to ours. The Welsh case series was identified using traditional contact tracing processes and partner notification; however, even back in 2002, the team noted that Internet-based networks were assuming increasing importance.10 Over the intervening decade, Internet and smart phone application use has increased and as a result, it is no surprise that we now see the impact of this on social networking.11 In 10 of our cases, online networking was implicated as a source of sexual partners. There has been limited national direction regarding specific responses to STI outbreaks. For the future, national Sexual Health Action Plans, including coordinated outbreak strategies, are imperative. The role of specialist Sexual Health Clinics in directing intervention and screening has been recognised internationally in reducing the numbers of new cases, but important questions remain around how that role might be maximised. In essence, how might high-risk individuals be successfully located, targeted, tested and treated to interrupt chains of transmission in densely connected sexual networks that facilitate the rapid spread of
Response to an outbreak of infectious syphilis
Sexual Health
infection? Diagrammatic contact tracing mapping proved an extremely useful tool to aid this process. Enhanced surveillance is essential to characterise communicable disease outbreaks, perform notification functions, target responses and assess efficacy. Contact tracing, testing and treatment resources may thus be directed appropriately. During the latter period of enhanced case finding, persons with positive syphilis serology were more likely to be asymptomatic contacts compared with earlier cases tested on the basis of symptoms or clinical suspicion alone. In the absence of enhanced syphilis surveillance, the infectious syphilis outbreak in Christchurch may not have been characterised sufficiently for targeted activities to occur. Finally, the use of social media appears to have impacted widely on sexual networks. To date, Facebook is not known to have been used as an STI outbreak response tool in New Zealand, either for case finding or for public health messaging.11 However, our experience suggests that social media may provide an acceptable, timely and inexpensive means of contacting large numbers of potential ‘at risk’ individuals and its uses in medicine require further exploration. Acknowledgements The authors wish to thank Joe Rich, Communications & Marketing Manager, NZAF; Daemon Coyle, Program Manager Social Marketing, NZAF; and Ellie Coshall for Diagrammatic IT support.
References 1 STI Surveillance Team and Population and Environmental Health Group. Sexually transmitted infections in New Zealand. Annual surveillance report 2006. City: Institute of Environmental Science & Research Ltd (ESR). Available online at: https://surv.esr.cri.nz/ PDF_surveillance/STISurvRpt/2006/STIAnnualReport2006.pdf. pp. 1–59. [verified 17 July 2012].
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