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