The resurgence of syphilis

It has been 26 years since the world adopted screening of all pregnant women for syphilis. In Kenya, this is done at the very first contact with the pregnant woman in the antenatal care clinic. The implementation of this policy guideline has greatly contributed to the reduction of congenital syphilis in our newborns, a great win for our future generations. 

Back in the 70s and 80s, a popular clinic in the city centre was set up by the Nairobi City Council to manage sexually transmitted infections. It was named Casino. I spent an evening being regaled with stories of the clinic by beneficiaries of the services back in the 70s and 80s. Casino was regarded as a rite of passage for young men as they waded through a murky sexual debut. 

Back then, sexually transmitted infections were quite common, particularly syphilis and gonorrhoea. Getting an infection was described as ‘kuchomeka’, loosely translated as getting burnt. A newbie catching his first infection would be so embarrassed but seeing as it is almost impossible to hide it, they would have to confess to their older siblings, friends or younger uncles to get help. 

The gentlemen described how they would line up at the clinic waiting for the elderly no-nonsense nurse to finish boiling her needles in the steriliser and prepare her paraphernalia for the brief but unforgettable engagement. Everyone would avert their gaze as they did not have the courage to look her in the eye and see the disdain that she meted out. 

Once ready, everyone would turn around and face the wall, pull down one side of their pants, exposing a dry-skinned backside with eyes tightly shut, await the legendary shot that would relieve of their misery. Now, if you have ever had a Penicillin-G injection, you do know that it is not a shot you would wish on your worst enemy! When it is given by a disapproving matronly nurse with zero patience for young men caught red-handed in the cookie jar, it is a most humiliating experience. 

We may have come a long way in patient care but the trusty old Penicillin G remains our solid weapon against syphilis. It is still highly effective, affordable and accessible even in the most remote of health facilities. Together with routine screening of antenatal mothers in the clinic, and targeted screening for people with high-risk sexual behaviour, syphilis had very much come under control in Kenya. 

Syphilis generally presents as painless ulcer on the genital area, three to six weeks after sexual contact with an infected person. It is important to note that this lesion may occur in the oral region in case of infection through oral sex. This is more likely in the younger women aged 15 to 24 years who may assume that oral sex is safer. It is also highly infectious. 

Left untreated, the ulcer will heal over the next three to 12 weeks, making way for secondary syphilis. This stage presents in a variety of ways from person to person. Fever, joint pains, swollen glands, reddish-brownish skin rash, hair loss and highly infectious condylomatous skin lesions are common manifestations. If no treatment is given, the infection goes into latent phase, the third stage, where the patient has no symptoms but will test positive for the infection. 

The fourth stage of syphilis present several years later, with cardiovascular and neurological complications. These symptoms occur in about a third of patients with untreated syphilis. These are patients who may develop unexplained behavioural changes, abnormal rigidity, loss of temperature and pain sensation and outright dementia. They may have catastrophic complications of the aorta that easily lead to death. 

The most unfortunate fact is that the disease is untreatable in stage four. The patient is provided with supportive treatment but ultimately, the train has already left the station. History before the advent of penicillin postulates that several great men may have succumbed to the disease, including Vincent Van Gogh and Henry VIII 

In the wake of the Covid-19 pandemic, however, our statistics haven’t been reassuring. Not just in Kenya but across the world. The past two years have show an unprecedented increase in the incidence of syphilis. CDC for instance recorded a 23 per cent increase in the incidence of primary and secondary syphilis and a 15 per cent increase in congenital syphilis in 2020, compared to 2019. This was postulated to have arisen from the lockdown effect and the limited access to healthcare in the period. 

Locally, our referral hospital wards are beginning to admit patients with stage four syphilis, a diagnosis that had all but disappeared from the admission records. We may have done well to tame this infection but we remain unsuccessful in eliminating it. It is therefore imperative that we double up our efforts on screening and early treatment

Dr Bosire is an obstetrician/gynaecologist