British Journal of Venereal Diseases, 1979, 55, 131-1 37

Epidemiology of gonorrhoea and syphilis in South Australia (1966-77) DON JORGENSEN From the Venereal Disease Control Centre, Departmnent of Public Health, Adelaide, South Australia SUMMARY Data from the annual general report of the Venereal Disease Control Centre (VDCC) in a state with a population of approximately 1 250 000 people (in 1977), of whom about 1 100 000 live within 25 miles of the centre of Adelaide, the capital city, are presented.

Introduction South Australia is the driest state in the driest continent in the world. Sparsely populated, the surface area is 380 000 square miles compared with that of the United Kingdom, which is 95000 square miles. The aboriginal population living in the eight missions and other aboriginal centres are thought to number about 3000 (about 0 24 % of the total), and they figure prominently in the epidemiology of syphilis because of the presence of endemic syphilis in these centres.

Incidence of syphilis In 1966 legislation was passed requiring medical practitioners and laboratories dealing with syphilis or gonorrhoea to notify numbers of cases to the Central Board of Health. The incidence of reported syphilis has risen from 1-4/100 000 in 1966 to 40/100000 in 1976 (Table 1); this figure dropped to 28/100 000 in 1977. The rise in 1976 was almost entirely due to increased efficiency in collecting blood specimens from aboriginals in that year. The overall incidence for Australia has dropped behind the South Australian figures since the early 1970s, not because South Australia has more cases of syphilis but because the figures are more accurate.

Incidence of gonorrhoea Since 1966 the incidence of gonorrhoea has risen from 23/100 000 to 174/100 000 in 1974 and is now around 150/100 000; the steep rise in incidence Address for reprints: D. Jorgensen, VD Control Centre, Department of Public Health, 275 North Terrace, Adelaide, S. Australia 5000 Received for publication 2 September 1978

131

since 1966 seems to have levelled out over the last four years (Table 2). There are, no doubt, two reasons for this increase: an actual increase in the number of cases and an increase in efficiency in collecting statistics. The overall incidence of 85/100 000 in Australia in 1976 and 1977 shows Table 1 Notification of cases of syphilis from 1966 to 1977. (Populations in 1977 of Australia and South Australia were 141 million and 1 million respectively) Year

South Australia

1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977

15 21 58 38 74 122 205 178 257 309 501 360

Rate per 1000 000

1-4

1.9 5*2 3-3 6-4 10-4 17-0 15-0 21-5 25 0 40 0 28-1

Austrzlia

Rate per 100 000

1080 845 860 1072 952 1047 1215 1433 1864 2362 3110 3023

9-3 8-0 7-1 8-6 7-9 83 9-3 10.9 13-9 18-0 23-0 21-5

Table 2 Notification of cases of gonorrhoea from 1966 to 1977 Year 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977

South Australia 355

599 509 703 650 817 989 1492 2091 2121

1885 1921

Rate per 100 000

Australia

Rate per 100 000

23 51 43 61 55 70 83 126 174 172 151 150

8553 9412 9763 9648 9558 10274 11017 11357 12524 12511 11526 12024

74 80 79 79 76 81 85 85 95 93 85

85

132

Don Jorgensen

that our national figures do not reflect the prevalence of gonorrhoea in the country as a whole (Table 2). It is not possible to estimate how many cases of urethral discharge are treated empirically, and these figures do not, therefore, enter the statistics; but there are, however, many cases in South Australia and, obviously, more in Australia as a whole.

Epidemiological data of notified cases

men. These two groups were responsible for 68 % of cases of gonorrhoea in 1977 (Table 3). The age range for syphilis, on the other hand, is greater, but those figures include both active and inactive notified cases; most of the active syphilis occurs in the younger age groups (Table 3).

MARITAL STATE

In 1977, 1577 (80%) out of 1921 cases of gonorrhoea occurred in single people. The figures for syphilis were more evenly divided but include both active and inactive cases (Table 4).

AGE GROUPS

For cases of gonorrhoea the group is 15-19 years in women

predominant age and 20-24 years in

SOURCES OF INFECTION Friends or fiances or casual

contacts account for

Table 3 Notifications and incidence ofgonorrhoea and syphilis by age and sex (1977) Gonorrhoea Age (years) 0-9 10-14 15-19 20-24 25-29 30-39 40-49 50 and over Total (1977) Total (1976) Total (1975)

Male 2 1 312 454 239 169 38 15 1228 1145

1296

Syphilis Female 1 15

304 238

Total 3 16 616 692 312 217 45 20

75 48 7 5 693 740

1921 1885

825

2121

Male

Female

Total

15 56 60 54 19 27 231

2 30 76 76 16 6 13 129 202 140

2 45 92 86 70 25 40 360 510 304

Female

Total

299 164

Table 4 Marital state of notified cases of gonorrhoea and syphilis Gonorrhoea Male Marital state

Single Married Defacto Widowed Divorced Separated Unknown Total

Syphilis Female

Total

Male

1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1051 886 1045 657 546 532 1708 1432 1577 87 122 141 54 76 72 141 198 213 158 165 122 92 93 85 250 258 207 33 120 79 47 103 53 80 223 132 19 22 9 16 26 12 35 48 21 4 1 3 1 7 3 1 1 7 2 10 3 1 1 1 1 1 16 8 3 10 18 19 26 26 22 1 1 1 2 1 42 58 45 42 53 45 84 111 90 3 2 2 1 2 2 4 4 4 7 5 3 1 2 8 7 3 41 50 8 37 16 1 78 66 9 1296 1145 1228 825 740 693 2121 1885 1921 164 299 231 140 202 129 304 501 360

Table 5 Source of infection of notified cases ofgonorrhoea and syphilis Gonorrhoea Male Contact

Marital partner Defacto partner

Friend/fianc6 Casual contact Prostitute Homosexual Mother Unknown Total

Syphilis Female

Total

Male

Female

Total

1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 32 41 17 70 54 40 102 95 57 3 3 1 9 5 12 5 8 6 15 19 17 9 20 7 32 39 16 1 2 1 2 2 4 356 294 341 319 289 326 675 583 667 3 11 14 5 10 5 8 21 19 741 589 560 394 317 257 1135 906 817 42 45 30 19 16 7 64 58 37 24 39 38 24 39 38 1 4 1 4 58 60 145 38 60 145 6 20 17 6 20 17 1 4 2 2 1 3 2 1 1 102 116 58 63 160 179 116 216 169 100 169 112 216 385 281 1227 1145 1228 800 740 693 2027 1885 1921 175 299 231 134 202 129 309 501 360

133

Epidemiology of gonorrhoea and syphilis in South Australia

770% of sources of infection for gonorrhoea and 21 % for syphilis; unknown sources of the latter account for 78 % of cases (Table 5). This high unknown factor is due to the difficulties of contacttracing in the aboriginal population. A feature of both gonorrhoea and syphilis is the substantial number of homosexuals affected-80% overall for gonorrhoea (12% in males) and 50% overall for syphilis (8 in males). USUAL RESIDENCE

Eighty-eight per cent of patients with gonorrhoea lived within 25 miles of the centre of Adelaide. Patients with syphilis were more or less evenly distributed, because of the aboriginal missions (Table 6). COUNTRY OF ORIGIN

Table 7 shows only the numbers of cases from each country of origin. The percentages of the total population for the groups is not known. The

aboriginal population accounted for 41 % of of reported syphilis in 1977.

cases

Notification of cases of syphilis by stage of disease In Table 9 notifications of cases of syphilis have been subdivided into stages of the disease in aboriginal missions (in brackets) and in the general population. These are difficult figures to extract but they do show trends. For the aboriginals it is not possible to give figures for primary and secondary syphilis because of the lack of clinical details. Diagnosis is made by consultation between the serologist and the venereologist at the central laboratory, at the Institute of Medical and Veterinary Science, on the results of the serological tests. The nursing sisters, who live on the missions, are then given instructions by the venereologist on the treatment required. In the general population the prevalence of primary or early active syphilis is greater in men than in women and this agrees with experience in most countries. Aboriginals living on reserves (O 24 % of the total population) were responsible for 149 (41 %) of 360 cases of syphilis notified in 1977.

OCCUPATION

Sources of notified

The highest number of notifications came from the less skilled and unemployed members of the community (Table 8); the actual percentages in the groups are not known. Among the cases of gonorrhoea 2-5 % gave their occupation as prostitution.

The VDCC notified 1142 (60%) of 1921 cases of gonorrhoea and 186 (52%) of 360 cases of syphilis, including cases from the out-back and aboriginals (Table 10). Until recently South Australia had the

cases

Table 6 Usual residence of notified cases of gonorrhoea and syphilis Syphilis

Gonorrhoea

Male

Residenice Metropolitan Country Interstate Overseas Total

1975

Total

Male

1975

1976 1977 1975

1905 193 12 11 693 2121

80 78 1 5 164

Female

1976 1977

1122 968 154 162 12 9 11 3 1296 1145

1072 144 10 2 1228

1975

1976

783 39 3

693 43 4

825

740

1977 632 58 3

1661 205 16 3 1885

1704 202 13 2 1921

Total

Female 1976 1977 132 161 1 3 299

142 87 1 1 281

1975 55 85 140

1976 1977

1975

70 131 1

52 76 1

135

202

129

163 1 5 304

1976 1977 204 292 2 3 501

194 163 2 1 360

Table 7 Country of origin of notified cases of gonorrhoea and syphilis Syphilis

Gonorrhoea

Female

Male 1975

Australia Aboriginals United Kingdom Mediterranean Europe Other Europe Asia America Other Total

888 108 94

761 106 77

915 54 87

683 35 57

622 36 38

115 23

123 57 10

96 55 15

26 15 5

21 22 1

3 1296

11 1145

6 1228

825

E

65

1976 1977

1975

4

740

1977 1975

1976 1977

1975

1976

1977

1975

1976

1977

1975

1976

605 20 32

1571 143 151

1383 142 115

1520 74 119

73 64 3

121 148 4

109 72 5

49 77

58 132 1

46 77 1

122 141 3

179 280 5

155 149 6

19 15 2

141 80 28

144 79 11

115 70 17

12 10 2

6 11 6

13 5 27

6 5

3 8

2 2 1

18 15 2

9 19 6

15 7 28

7 693 2121

11

1885

6 1921

164

3 299

231

3 140

202

129

3 304

3 501

360

1976 1977

Country of origin

Total

Female

Male

Total

134

Don Jorgensen

enviable position whereby syphilis serum antibody tests, other than reagin screening tests, were done in one laboratory, at the Institute of Medical and Veterinary Science, which resulted in a very accurate notification system together with standard methods and efficient control in serological tests. Accurate and consistent reporting of serological test results and accurate record-keeping of the serological history of syphilitic patients were possible. Now that syphilis serological tests are carried out in various other laboratories this position has altered, the main reasons being the difficulties in keeping

the syphilis registry up to date and the differing laboratory standards. TYPES OF CONTACTS In addition to friends or

fiances or casual contacts, high number of sexual contacts are homosexual, 244 (15%) of 1606 cases with gonorrhoea and 29 (31 %) of 94 cases of syphilis (Table 11). a

CONTACT-TRACING

In 1977, of 2570 contacts of gonorrhoea 842 (32 %) were not sought, mainly because of insufficient

Table 8 Occupation of notified cases of gonorrhoea and syphilis Gonorrhoea

Syphilis

Male Occupation

Female

1976

Rural Artist/entertainer Professional Technical Managerial Skilled Apprentice Semi-skilled Unskilled Clerical Sales Maritime Primary Student Secondary

Tertiary

Nursing Armed forces Home duties Prostitution Retired

Unemploy.d/unknown

Teaching Transport Service worker Total

1977

1976

Total 1977

50 168 13 140 242 121 78

41 37 16 15 45 176 31 84 211 143 98

23 13 188 49

3 5 14 2 21 18 134 67

55

55

80

7 8

11 14

47

14

120 48 19 81 7 4 41 740

2 108 20 72 49 1228

4 121 6 68 50

1145

1977

1976

1977

1976

Total 1977

7 6 1 3 1

6 45

2 1

309 127

44 43 16 18 50 190 33 105 229 277 165

21 7

18 17

11 4

7 6 1

82

135

137

4

5

2

38 1 115 47 21 72 7 6 31 693

54 8 120 48 23 202 13 72 91 1885

49 15 115 47 23 180 27 78 80 1921

1

3 6

4 3 13

Female

Male

1976

18

53 181 13 163

255

1976

11 1 2

11 1 2

3 9

5

245 3

27 76 3 3

299

231

1977

1 1 52 2 14 111

7 6 1 5 2 32 11

6 52 24 18

2

6

7

39 4 14

2 1 52 2 14

56

356 3

129

1 501

1

202

3 9

5 39 4 41 132 3 3

360

Table 9 Number of cases ofsyphilis by stage ofdisease (figures for aboriginals in brackets) Male

Female

Syphilis

1975

1976

1977

Primary

45

56

20

Secondary Early active (other) Total early Late

Old inactive

Notknown Total late All syphilis

1975 13

Total 1976

1977

1975

1976

1977

18

3

58

74

23

8

6

3

4

4

1

12

10

61

111

90

70

98

(53)

(94)

(37)

(45) 87 (45)

(77) 120 (77) 14

61 (41) 65

131 (98) 201

(41)

(98) 6

209 (171) 293 (171) 41

151 (78) 178 (80) 145 (52) 33 182

(69)

114

173

113

(53)

(94)

(39)

2

27

2

4

19

80

92

15

57

(4)

(19)

(22)

29

(6)

19

(16)

34

11

(2)

(3)

(8)

(19)

(3)

(8)

126

24 (I 1) 118

(7)

164

(27)

299

(33) 231

140

202

(60)

(121)

(72)

(53)

(96)

50

53

82

2

(1)

53 (30) 9

34 (10) 63

(5)

(5)

103

137 (35) 30 (I 1) 208

(36)

(15)

(46)

64

129 (77)

304 (103)

50 (217)

(16)

360 (149)

135

Epidemiology of gonorrhoea and syphilis in South Australia information. Of 1728 contacts sought, 1431 (82%) were found; of 1431 found, 929 (65 %) were infected (Table 12). In 1977, of 120 contacts of syphilis 54 (45%) were not sought; of 66 contacts sought, 59 (900%) were found; and, of 59 contacts found, 26 (44 %) were infected. The ratio of male-to-female cases of gonorrhoea was 2:1 compared with 1-5:1 in 1976. This ratio indicates the efficiency of contact-tracing methods, the ratio falling as efficiency increases.

ATTENDANCES AT THE VENEREAL DISEASE CONTROL CENTRE

An increase from 12 674 to 14 204 (12% increase) patients occurred from 1976 to 1977 (Table 14); this is an increase in the daily average from 50 to 56 cases (12% increase), and means that from 30 to 90 patients were seen each day. With the present staffing levels medical officers have difficulty in maintaining adequate standards. GONORRHOEA

NOTIFICATION BY PRIVATE DOCTORS Tables 1 3a and 1 3b show a static position as regards notifications of cases of gonorrhoea and syphilis by private practitioners, which may not change much under present conditions. Two areas of effort which may improve notifications are:

(1) increased efforts to show undergraduates and graduates the reasons for, and importance of, early notification; and (2) an easier method of notification, namely, a simple notification form attached to an addressed, pre-paid envelope marked private and confidential to be used by all private practitioners and laboratories.

Of 1738 notifications from the metropolitan area 1102 (63%) were seen at the VDCC (Table 15). NON-SPECIFIC URETHRITIS

Non-specific urethritis is not readily distinguishable from gonorrhoea and other causes of urethritis in men without laboratory investigation, and although not a notifiable disease it is included in statistics from the UK and other countries. The total number of cases of non-specific urethritis seen at the VDCC in 1976 and 1977 are compared with that of male cases of gonorrhoea in Table 15.

Table 10 Sources of notifications for gonorrhoea and syphilis Syphilis

Gonorrhoea Male 1975

Total

Female 1976 1977 1975

Private doctors 475 414 407 RAH and VDCC clinics 691 694 709 RAH other 2 6 4 16 20 17 QEH QVH 90 80 Port Adelaide clinic 93 1 1 Armed forces 1 1 Prisons Outback RFDS, 2 AIM etc. 1 13 12 Other 9 Total 1296 1145 1228

Male

Female

1976 1977 1975 1976 1977 1975 1976 1977

Total

1975 1976 1977 1975 1976 1977

214

228

197

604

38

93

87

37

59

45

75

152

132

520 18 36 9 11

434 22 18 8 24

433 1211 1038 1142 28 18 14 20 28 56 34 45 8 6 6 9 10 104 114 90 1 I

32 6 7

44 11 5

76 3 4

21 7 4 2

11 7 8 2

53

6

6

13 11 2 10

62 18 14 1 8

87 10 12

10

18 7 9 1 2

1 28 5 693 2121

58 13 164

129 11 202

47 8 129

59

6 740

103 3 202

52 4 129

117 23 304

232 14 501

689

642

2 6

1 16 825

2 19

14

1885 1921

10 140

99 12

360

Table 11 Types of contacts noted (other than aboriginals in reserves) Syphilis

Gonorrhoea Male

Female

Contacts

1975

1976 1977 1975

Casual Marital partners Defacto partners

850 107 24 630 97

676 114 27 501 109 41 1 1469

Friend/fianc6 Homosexual

Prostitute Mother Total

26 1 1735

662 77 10 571 244 40 2 1606

Total

Total

1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977 1975 1976 1977

397 1470 1216 1059 60 192 189 137 22 12 47 58 531 1116 1007 1102 97 109 244 26 40 41 2 3 2 1 214 1154 1000 2949 2623 2606

620 85 23 486

Female

Male

549 75 31 506

52 9 1 10 11 1

45 6

84

148

4

26 62 4

38 3 1 23 29

23 9 1 6

32 6 3 19

12 5

9

75 18 2 16 11 1

94

39

60

26

123

1

77 12 7

45 62

50 8 1 32 29

4

1 208

120

Don Jorgensen

136

Table 12 Contact-tracing Syphilis

Gonorrhoea Contacts of Female cases

Contacts of male cases

Male

Female

1976 1977 1976 1977 1976 109 244 1154 70 504 45 83 53 15 49 121 567 28 87 423 20 19 107

No. of contacts

1360 1362 458 449 207 202 695 711 404 416 270 141

Noted Not sought Sought not found Found Diagnosed as infected Treated epidemiologically

Total

Male

Contacts of male cases

Contacts of Female cases

Female

Male

Male

Total

1976 1977 1976 1977 1976 1977 1976 1977 1976 1977 26 208 120 86 65 62 29 60 2623 2570 27 14 73 54 11 33 32 10 1007 842 7 8 2 34 8 18 5 305 333 38 59 27 22 13 101 41 19 1311 1431 6 53 26 5 9 26 22 11 855 929 12 2 23 6 4 5 13 5 397 264

1977 1000 323 78 599 426 104

Table 1 3a Number ofprivate doctors notifying cases of gonorrhoea or syphilis or both (numbers given in brackets refer to doctors notifying cases for the first time) Area of practice

No. of Doctors previously involved*

Total

Country Metropolitan 7 10 1966 28 51 1967 38 121 1968 39 140 1969 38 134 1970 57 (31) 185 (52) 1971 69 (35) 164 (79) 1972 60 (17) 225 (141) 1973 72 (22) 293 (96) 1974 73 (29) 270 (85) 1975 69 (21) 284 (90) 1976 71 (19) 279 (84) 1977 *Doctors who have notified cases previously but not in the particular year tDoctors on Pensioner Medical Service Register at June 30 1977 NA not applicable Year

79 159 179 172 215 233 285 365 343 353 350

NA NA 131 191 215 311 245 221 241 230 235

(83) (114) (158) (118) (114) (111) (103)

PMS Doctorst 560 580 594 615 623 638 658 690 700 700 700

17

Table 1 3b Number of cases of gonorrhoea and syphilis notified by general practitioners Gonorrhoea

Syphilis

Year

Males

Females

Males

Females

1975 1976 1977

475

214 228 197

38 93 87

45

414 407

37

59

Table 14 Number of cases seen at the Venereal Diseases Control Centre in 1977 (figures for 1976 are given in brackets) Jan.

Feb.

Mar.

Apr.

May

678 35

858

Average/day

378 20

748 33 366 16

610 34 311 17

718 34 365

Average/day

43 426 21

405 21 187 10

503

512

25 225 11

22 186 8

426 24 163 9

1361 64 651 32

1260 55 552 24

Male patients

Total

New patients/episodes

Female patients Total

Average/day New patients/episodes Average/day Total no. of patients Total Average/day New patients/episodes Average/day

1083 56 565 30

Jul.

Jun.

Aug.

Sep.

Oct.

Nov.

Dec.

Total

656 31 327 16

598 28 289 14

601 26 354 15

869 40 451 21

769 38 380 19

838 38 418 19

662 33 349 18

8605 34-4 4414

(7507) (29 8) (3884)

17-7

(15-5)

495 24 192 9

495 24 163

408 19 168 8

518 23 206

522 24 234

5599 22-5

11

523 24 202 9

329 17

9

463 23 204 10

137 7

2267 90

(5167) (20 4) (2168) (8 5)

1036 58

1213 58

1006

557 26

1119 49 560 24

1391 64 685 32

1232 61 584 29

1361 62 620 28

991

474 26

1151 55 490 24

14204 (12674) 56 5 (50 2) 6681 (6052) 26-8 (23-2)

17

8

47

457 22

50 486 25

137

Epidemiology ofgonorrhoea and syphilis in South Australia Table 15 Number of notified cases ofgonorrhoea and non-specific urethritis from different sources 1976 Gonorrhoea Male cases Female cases Total Non-specific urethritis

Metropolitan

VDCC

Country

1977

1976

1977

133 50 183

589

681 421 1102 1375

1206

1976

1977

Total (1977)

1095 643 1738

1228 693 1921

Epidemiology of gonorrhoea and syphilis in South Australia (1966--77).

British Journal of Venereal Diseases, 1979, 55, 131-1 37 Epidemiology of gonorrhoea and syphilis in South Australia (1966-77) DON JORGENSEN From the...
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