The outbreak no one is talking about
Syphilis
Resurgence
in Alberta
As case numbers of the sexually transmitted infection soar, the province is left wondering what can be done to control it
By Lily Dupuis
It's hard to imagine a sexually transmitted infection once thought to be declining is now making a vicious resurgence – however, that is exactly what's happening with syphilis.
Rates of the infection are increasing across Canada and internationally. Alberta has not seen such high rates of the infection since the 1940s.
The number of infectious syphilis cases have been rising in the province since 2018. Public health officials declared a syphilis outbreak in 2019, with 2,265 new cases of syphilis reported that year alone.
In the 2022 Annual Report on Sexually Transmitted Infections and HIV from the Government of Alberta, there were 22,531 cases of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) across the province.
This report shows that infectious syphilis continues to rise. Over 3,200 new syphilis infections were reported that year, marking a 27.6 per cent increase from 2020.
What is syphilis?
According to the Centers for Disease Control and Prevention (CDC), syphilis is caused by the bacteria treponema pallidum. This bacterial infection is spread person-to-person via direct contact with a syphilitic sore, also sometimes called chancres. These sores can occur inside, on, or around the vagina, penis, anus, or mouth.
Because syphilis is sexually transmitted, it can be spread during vaginal, anal, and oral sex.
The infection can also be accompanied by fever, sore throat, rash, and other physical symptoms unrelated to the genital regions.
But this isn’t always the case – the infection can be spread to others without knowing it, as many people don’t experience any symptoms at all.
An image of the bacteria treponema pallidum, the causative agent of syphilis, from a scanning electron microscope in 1980.
Source: CDC, Dr. David Cox
Stages of Syphilis
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Infographic by Megan Creig
Syphilis develops in stages: primary, secondary, latent, and tertiary.
Without treatment, syphilis can develop into major complications, affecting bones, joints and the nervous system. The infection can also cause damage to the heart, liver, eyes, and brain, and can even result in death.
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However, these are severe outcomes of untreated syphilis. With proper STI testing and early treatment, the infection can be entirely cured.
Infectious vs. Congenital
Pregnant people with syphilis also can transmit the infection to their unborn child. It is also possible for fetuses to contract syphilis in the womb or during birth where no noticeable symptoms can be seen, but can later develop deafness, teeth deformities and collapsed nose bridges.
The complications with congenital syphilis are worrisome, as they can also result in miscarriages, premature births, and even stillbirths.
A total of 193 congenital syphilis cases have been diagnosed between 2017 and 2021. Of these cases, 39 resulted in stillbirths.
Rates of congenital syphilis have increased from 13.1 to 144.9 (per 100,00 population) between 2017 and 2021.
And the number of congenital syphilis cases have increased dramatically across the country, too. The Public Health Agency of Canada reports that in 2019 there were 53 cases of congenital syphilis, while only five cases were reported in 2010.
Now, the most recent provincial data shows that from 2019 to September 2022 there have been at least 30 cases of early congenital syphilis reported in Alberta alone each year.
Stock image courtesy of Canva
In 2019, data from the Centre for Communicable Diseases and Infection Control (CCDR) shows that Alberta and Manitoba reported 79 per cent of all confirmed early congenital syphilis cases in Canada.
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And even while 2020 marked a decrease in infectious syphilis cases in many provinces and territories across Canada, Alberta, Manitoba and Saskatchewan had the highest rates of infectious syphilis among females aged 15 to 39 years.
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That same year, 86 per cent of all confirmed early congenital syphilis cases across Canada were reported in Alberta, Manitoba and Saskatchewan.
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This is something that clinical professor at the University of Alberta, Dr. Ameeta Singh, says we should be very concerned about.
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“We've had an unprecedented number of cases of congenital syphilis in Alberta, which, in my opinion, is completely unacceptable. We should not be seeing this in Canada today.”
Dr. Singh explains that syphilis, in contrast to HIV, can be passed on to a fetus at any stage during pregnancy after nine weeks.
“If a mother becomes newly infected with syphilis during the pregnancy, there is a very high chance the infant will become infected. The closer the mother is to the time of delivery, the more likely it is that the infant will become infected."
Dr. Singh explains that if an infant is infected at around 20 weeks, there is a chance that the infant's infection could be fatal due to the severe complications of congenital syphilis contraction during pregnancy.
“We've seen a number of stillbirths, or deaths at the time of delivery, which is obviously an extreme tragedy in my mind,” she says.
“Our expected number of congenital syphilis cases in Canada today should be zero. It is completely unacceptable that in Alberta alone over the last few years, we've seen 260 cases, and many infant deaths due to congenital syphilis.”
Yet Dr. Singh says that even if the infant doesn’t die, they’re still at risk of developing severe clinical complications, such as enlargement of the liver and spleen and severe anemia.
“Although this is very readily treatable, we know from work that we've done here in our region that there can be long term consequences to the development of that child over time,” explains Dr. Singh.
“Our goal should be trying to prevent this from happening in the first place.”
Stock image courtesy of Canva
“Our expected number of congenital syphilis cases in Canada today should be zero. It is completely unacceptable that in Alberta alone over the last few years, we've seen 260 cases, and many infant deaths due to congenital syphilis.”
Dr. Ameeta Singh
Why Syphilis? Why now?
Syphilis isn’t the only STI with increasing cases.
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The 2019 report on STI surveillance from the Public Health Agency of Canada shows that, over the past decade, chlamydia rates have increased by 33 per cent, and gonorrhea rates have almost tripled, increasing by 181 per cent.
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But infectious syphilis rates have increased almost five-fold between 2010 and 2019, marking a 393 per cent increase, the highest increase of all three bacterial STIs under surveillance.
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Our team asked Dr. Singh, one of Alberta’s leading syphilis researchers, how Alberta can flatten the curve of the infection.
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“I wish that we had the answer to that question,” she says. “We need to try multiple approaches, and to never forget the importance of the social determinants of health care.”
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But the cause of this severe spike in cases is difficult pinpoint. Because the infection itself is complicated, the expert notes that the recent rise of syphilis can’t be linked to one single factor.
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“Even though [syphilis] has been around for centuries. From the historical literature, cases had really fallen off for a long period of time,” says Dr. Singh.
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“We're now seeing global rises in this infection across the board, all populations.”
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Dr. Singh says that there is no one cause for the syphilis increase across Alberta, but there are multiple factors contributing to the outbreak.
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She notes that there are societal notions that STI “don't cause too many problems and they're easy to treat.”
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“Most of the time, syphilis will result in fairly minor clinical symptoms such as sores or rashes, but we have [also] seen some very severe complications from syphilis.”
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The rise in popularity of dating apps has also been criticized for STI increases, notably in 2015 when Tinder demanded the removal of a billboard in L.A. after the billboard encouraged the app's users to get tested. Even health officials in Alberta have cited dating apps as a cause for concern.
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Dr. Singh notes that the widespread availability of dating apps has made it easier to arrange sexual contact, but we can't oversimplify the syphilis increase.
Yet there are still various arguments stating that correlation does not equal causation when it comes to dating apps and STIs. Nolan Hill, the Centre for Sexuality's gay men’s health specialist, says dating apps alone can’t be to blame.
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“It's really impossible to say that it's simply dating apps that have caused this outbreak or anything like that.”
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He echoes Dr. Singh’s thoughts on the multifaceted and complex nature of infectious diseases.
“It really is systemic and structural factors that have been ingrained into our healthcare system and our society that have led to not just this outbreak, but many other outbreaks that have happened over the years.”
Learn more
Explore the pages below to learn more about the global impact of syphilis and what is being done in Canada to mitigate the spread.
