11 June 2018 Hon Julie Anne Genter Parliament Office Private Bag 18888 Parliament Buildings Wellington 6160 Via email j.genter@ministers.govt.nz Dear Minister Genter Syphilis Outbreak in New Zealand The Royal Australasian College of Physicians (RACP) writes to draw your attention to the significant ongoing syphilis outbreak in New Zealand. The RACP notes in particular • • • The increase in syphilis presentations is largely affecting vulnerable populations, and may be contributing to health inequalities There are now cases of congenital syphilis in New Zealand There are ongoing workforce challenges which are preventing the health system from responding adequately to this preventable epidemic What is syphilis? Syphilis is a sexually transmitted bacterial disease caused by Treponema pallidum that has the potential to cause serious long-term complications if not diagnosed and treated promptly. The disease is characterised by three stages: primary (painless genital ulceration that heals spontaneously), secondary (usually a widespread rash), and tertiary (neurological, cardiovascular or connective tissue disease occurring ten to thirty years after the primary infection). The rise of syphilis is concerning because it can enhance transmission and acquisition of Human Immunodeficiency Virus (HIV) 1. Untreated syphilis in pregnant women may easily be transmitted to the pregnant mother’s unborn children, causing considerable morbidity and mortality (Including stillbirth, miscarriage, and congenital infection) if not diagnosed and treated promptly 2. Vertical transmission from mother to child can occur at any time during pregnancy at any stage of syphilis for up to eight years after infection if not treated. Congenital syphilis is a preventable, serious and complex 1 Ministry of Health. Diseases and illnesses – syphilis. [Internet] Wellington: Ministry of Health; updated 29 March 2018. Available from https://www.health.govt.nz/your-health/conditions-andtreatments/diseases-and-illnesses/syphilis. Accessed 14 May 2018. 2 Azariah S. Auckland: city of syphilis? N Z Med J [Internet] 2016; 129(1447):57-63. Available from http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1447-16december-2016/7105. Accessed 14 May 2018. condition with significant associated morbidity and mortality. Syphilis serology is routinely screened for in early pregnancy in New Zealand, but is not repeated later in pregnancy if the woman changes partners during pregnancy. Number of cases of infectious syphilis in New Zealand rising Since 2013 the number of cases of infectious syphilis diagnosed in New Zealand has been steadily increasing. The annual rate of reported infectious syphilis in Auckland in 2015 is at least twice as high as other regions of New Zealand (8.7 per 100,000 per year). The incidence for New Zealand is 4.6 per 100,000 per year. This is significant, as current data do not include cases managed by primary care practitioners in the community, so the actual rate is likely to be much higher. While the vast majority of cases continue to be diagnosed in Auckland (296 cases in 2017), other regions have also seen marked increases in numbers. Please see the attached graphs for more information on infection trends. While syphilis has been a notifiable condition for eighteen months the Ministry has yet to implement the promised electronic surveillance system. Currently only cases treated in sexual health clinics are being notified to the Institute of Environmental Science and Research (ESR). Previously, over 80 per cent of cases were diagnosed in men who identify as bisexual and gay. However, this proportion has been steadily decreasing, with 30 per cent of cases in 2017 being diagnosed in heterosexuals (provisional ESR data). This trend is continuing in 2018 with increased prevalence in heterosexual that appear to be diagnosed more often in socially disadvantaged communities and in those of Māori ethnicity. Sexually transmitted infections (STIs) largely affect vulnerable populations with little voice, (for example young people, those of Māori and Pacific ethnicity, gay and bisexual men, and people in incarceration). There has been a resulting increase in numbers of cases in pregnant women. The Ministry of Health had acknowledged the risk of congenital syphilis in a press release on 13 April 2018 where it reinforced messaging around practicing safe sex and getting tested 3. The RACP notes, however, that there have now been reports of recent cases of congenital syphilis diagnosed in Auckland, Tauranga and Lakes DHBs due to late treatment or late diagnosis in the mothers. Moreover, the Ministry implies the increase in syphilis diagnoses is linked to the funding of HIV Pre-Exposure Prophylaxis (PrEP), which came into force on 1 March 2018. Given that PrEP has been funded for a matter of weeks, and the increase in syphilis presentations has been steadily trending upwards since 2013, the RACP finds the Ministry’s response regarding the ongoing syphilis epidemic totally inadequate. Current challenges for the health sector There are current workforce challenges faced by the sexual health sector in relation to syphilis. Some of the systemic issues which underpin the current crisis are: 1. No DHB targets for sexually transmitted infection control 2. No national policy on workforce requirements for the sexual health sector (medical, nursing, allied health professionals) 3 Ministry of Health. Rise in syphilis prompts calls to practise safe sex. Press release. Wellington: Ministry of Health; 13 April 2018. Available from https://www.health.govt.nz/news-media/mediareleases/rise-syphilis-cases-prompts-calls-practise-safe-sex. 3. No mandatory service specifications for the provision of publicly funded sexual health clinics Nationally there are currently only 8.0 FTE sexual health specialists employed in Auckland, Hamilton, Palmerston North, Wellington and Christchurch. Lakes DHB does not have any permanent positions but has a sexual health specialist working part-time on a fixed term contract. There is very uneven regional distribution with many DHBs not employing any sexual health specialists at all or sub-contracting services from other DHBs. (Mid-Central Health has only 0.5 FTE (which is shared with Whanganui for HIV care) and Hawkes Bay has 0.3 FTE-all provided by the same specialist who travels between DHBs to provide cover). The situation in the Auckland region (where the majority of syphilis cases are reported) is of particular concern. In 2017, amidst rising syphilis presentations and an increase in complex cases to be managed by the Regional Sexual Health Service, Auckland DHB cut the specialist FTE in Auckland by 1.65 to 2.1. The RACP is concerned that the absence of targets, workforce policy and service specifications combined with the reduction in specialist FTE in Auckland will further contribute to the ongoing syphilis epidemic. The Health (Protection) Amendment Act 2016 objectives not met The Amendment Act addressed health sector concerns about the surveillance and management of infectious diseases, and the risk posed to the public. These concerns arose because previous legislation did not, in some situations, fully support effective front-line public health practice. The Amendment Act: • Allowed a subset of notifiable infectious diseases to be notified on an ‘anonymised’ or coded basis, • Made HIV, gonorrhoea, and syphilis notifiable on an ‘anonymised’ basis, with provision to de-code where necessary, • Made additional case management options available to deal with infected people whose behaviour is likely to harm other people, • Placed duties on infected individuals to provide health agencies with accurate, comprehensive, and timely information to allow contact tracing. The Amendment Act is concerned with providing a toolbox of measures for managing infectious diseases in the community. One stated purpose in the Amendment Act of the contact tracing measures is to limit the transmission of infectious diseases, including syphilis. The current statistics demonstrate a rise of syphilis infection rates in New Zealand which indicates that the goals of the Amendment Act are not being reached. We recommend that the Amendment Act is reviewed, with specific attention made to syphilis. Our recommendations The current situation in New Zealand in relation to the diagnosis and treatment of preventable syphilis infections is in need of urgent attention. We recommend: • Resource services appropriately (particularly in Auckland) to combat the spread of syphilis infection as a means of addressing this preventable public health risk • • • Commencement of work to develop DHB targets, workforce strategies and service specifications Urgently implement electronic surveillance system A review of the Amendment Act with a focus on syphilis, informed by and involving health practitioners engaged in the diagnosis and treatment of the condition. To discuss this letter further, please contact Harriet Wild, Senior Policy and Advocacy Officer at policy@racp.org.nz. Yours sincerely Dr Jeff Brown NZ President The Royal Australasian College of Physicians Attachments 1. Auckland quarterly syphilis diagnoses 2013-15 2. Number of infectious syphilis cases by month Figure 1: Auckland quarterly syphilis diagnoses 2013-15 HS = Heterosexual GBM = Gay and bisexual men Data from: Azariah S. Auckland: City of syphilis? N Z J Med 2016 [Internet] 129(1447): 5763. Available from http://www.nzma.org.nz/journal/read-the-journal/all-issues/20102019/2016/vol-129-no-1447-16-december-2016/7105. Accessed 13 April 2018. 10 15 20 10 12 8 -6 -2 0 2 4 6 4 remainder 6 trend -2 0 1 2 3 4 seasonal 5 data Figure 2: Number of infectious syphilis cases by month (“data”), decomposed into seasonal trend (“seasonal”), overall trend (“trend”), and the difference from the average trend (“remainder”). 2013.0 2013.5 2014.0 2014.5 2015.0 2015.5 2016.0 time Data from: Casey D, Peters J, Thornley S, Azariah S. DRAFT Report on the outbreak of infectious syphilis in Auckland. 21 June 2016