The outbreak no one is talking about
Action Required
How Alberta Health Services and the Government of Alberta are responding to the syphilis outbreak
By Lily Dupuis
Alberta Health Services (AHS) organizes the province into five geographic health zones (South Zone, Calgary Zone, Edmonton Zone, Central Zone, North Zone). In recent years, all AHS zones have reported an increase in infectious syphilis rates.
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The most updated data from the province shows that the highest infectious syphilis rates among all AHS zones were in the North Zone, with a rate of 143.2 cases per 100,000 population. Second was the Edmonton Zone, with a rate of 94.6 cases per 100,000 population.
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However, Dr. Caley Shukalek, an STI physician who works with AHS as part of the provincial public health program, explains that this problem might not be limited to certain vulnerable populations in Alberta.
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“Syphilis is a sexually transmitted infection. It doesn't care who it infects.”
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All persons who are sexually active are at risk of any STI, but Dr. Shukalek says that syphilis is an increasing concern due to the profound effects it can have on a person’s health.
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Dr. Shukalek says that in recent years, syphilis is increasing amongst the entirety of the population. The rise of syphilis is not exclusive to Alberta.
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“This is not an Alberta only problem, and this is not a Canada only problem,” he says.
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“This is an issue that is surfacing at varying intensities, across many and most countries around the world.”
Limits to the System
Even though the global rise of syphilis is taking a toll on all populations, marginalized communities still face unique challenges to accessing sexual health services in Alberta.
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And Dr. Shukalek says it's not limited to STIs, either.
"There are populations who have lower access to healthcare [in general]."
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In Alberta, rural communities struggle to access health services, as there are frequent geographical challenges, such as being remote and isolated away from large hospitals, as well as healthcare provider disparities, meaning less doctors per population.
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Research also suggests that Indigenous populations, 2SLGBTQ+ populations, people experiencing poverty or homelessness, and even people who partake in high-risk substance use experience a higher likelihood of syphilis contraction due to various social determinants of health care.
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Dr. Shukalek says that people who struggle with houselessness and high-risk substance use are a difficult to reach population, another challenge that is not exclusive to the province.
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“There are efforts being put into this. Is it perfect? No. But this is a very difficult to reach population, for many reasons, and it’s something that all systems struggle with.”
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He explains that AHS provides a variety of “test and treat programs” to engage with underserved populations, as well as several outreach programs throughout the province.
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"We need to know where to find these populations, and we need to be able to engage these populations of people who may be at the highest risk. That's not always an easy task.”
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“People are definitely making an effort, myself included,” says Dr. Shukalek.
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“I work in public health, and in Alberta Health Services and there's lots of chatter about how important an issue this is, increasingly, year after year.”
Dr. Caley Shukalek
STI Physician, Alberta Health Services
Photo supplied by Dr. Caley Shukalek
"Change is slow"
- Dr. Caley Shukalek, STI Physician
In the wake of the COVID-19 pandemic, the province is trying to recover. Dr. Shukalek says that healthcare system in Alberta is facing challenges when it comes to administering STI tests.
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“[There are] lots of efforts being put into that on a provincial level, but change is slow.”
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But Dr. Shukalek believes that there has been a focus on strengthening the healthcare system following the impact of COVID-19, and now AHS can begin to focus more attention on other aspects of public health.
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COVID-19 has dominated public health messaging since 2020. Because of the pressing nature of the global pandemic, the focus on syphilis awareness messaging hasn't been the province's top priority.
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Despite the lack of recent syphilis outbreak campaigns, Dr. Shukalek says that there is work underway to increase awareness around the infection and educate Albertans. This is a process that he says takes time.
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“A lot of that work is in the planning phases. There have been prior campaigns when we first started to see increases in syphilis rates,” explains Dr. Shukalek.
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“There is work underway, though it's not quite at a finished state.”
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The STI physician explains Alberta's past syphilis awareness campaigns, often being posters in bars and "other places where persons who might have been at the most risk would have frequented."
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He says that Albertans will be able to expect more public awareness around syphilis as the province recovers from the effects of COVID-19.
Challenges for Treatment
Treating syphilis can sometimes be as complex as the infection itself.
Dr. Shukalek says that currently there are only two medications that are used for the treatment of syphilis. The primary and preferred treatment is a penicillin injection into the gluteal muscle in the buttock. Unfortunately, this antibiotic injection isn’t possible for everyone.
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“Access to that is also limited as it's not something that all healthcare providers are comfortable doing. As it relates to syphilis, there are barriers along the way,” says Dr. Shukalek.
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Dr. Ameeta Singh, clinical professor at the University of Alberta and syphilis researcher, says that syphilis is a complex virus that isn’t always easy to treat, emphasizing the importance of catching it in its early stages before more serious complications arise.
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“We've seen a lot more cases of ocular syphilis, which is syphilis involving the eye. And because of the delays in diagnosis, some of those individuals have sustained loss of vision, which is a terrible consequence of getting the infection,” she explains.
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“It is not completely harmless,” says Dr. Singh.
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Neurosyphilis is another consequence of the untreated infection, and it can result in stroke-like symptoms, confusion, seizures, and more.
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“While it is correct that most of the time we can treat syphilis with a single dose of an antibiotic, not all cases can be treated that way.”
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Fortunately, with access to treatment, syphilis can be completely cured.
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In order to make testing and treatment more available, Dr. Shukalek says that AHS works as closely with community organizations as it can.
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But Nolan Hill, gay men’s health specialist at the Centre for Sexuality, one of the various sexual health community organizations in Alberta, says there is a lack of accessible medical services needed to treat STIs, especially for Alberta's vulnerable communities.
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“It’s hard to see populations that are already experiencing discrimination, stigma, and marginalization within the healthcare system, now being further impacted by a really preventable infection,” says Hill.
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But Hill also says that an important thing to remember when it comes to STIs is that "they're either treatable or curable."
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“In the case of syphilis, an antibiotic can be provided to treat the infection. There's a bit of follow up, but [getting an STI] is something that is just a routine part of life, just as getting a flu or getting any sort of other infection.”
Video by Abbie Riglin and Astrid Cunanan
Stock images courtesy of Canva
Low Rates of Condom Usage
But not exclusive to marginalized populations are the low rates of barrier protection.
When it comes to the many speculations for the potential causes behind the syphilis resurgence, Dr. Shukalek explains that a societal trend in a decrease of condom use is being observed.
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“Across all populations of persons who are sexually active, the use of barrier methods for contraception, as well as STI prevention, have substantially reduced,” says Dr. Shukalek.
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The physician explains that there has also been a decrease in barrier protection during sexual activity due to the effectiveness of birth control and HIV medications such as pre-exposure prophylaxis (PrEP).
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Yet the low rates of condom and other barrier usage is a cause for concern when battling the syphilis outbreak. While birth control can prevent pregnancy and PrEP can prevent HIV, these do not protect people from contracting STIs.
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However, Dr. Shukalek notes that the population of people using PrEP in Alberta are typically the best at getting STI tests done regularly, often "every three months."
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The 2021 Alberta STI and HIV Report shows that 31.8 per cent of male HIV cases were attributed to the men who have sex with men (MSM) exposure category, but 45.7 per cent of female cases were attributed to the heterosexual exposure category.
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Hill believes that “people sometimes get complacent.” He says this complacency likely came from seeing a decrease in syphilis cases in past years, meaning that many people who were having sex felt as though using condoms wasn’t as necessary.
Comprehensive Sex Ed
The quality and quantity of sexual health education in Alberta also isn't as measurable as many may think.
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Action Canada for Sexual Health and Rights published The State of Sex Ed Report – the report noted that, as of 2020, the sexual education curriculum taught in Alberta had not been updated since 2002.
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In 2019, the Sex Information and Education Council of Canada (SIECCAN) published revised directives for sexual education. But even then, the 2021-2022 annual report from Action Canada for Sexual Health and Rights states “reports show that the state of comprehensive sex-ed in Canada remains dismal.”
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Currently, there is no mandated sexual health education curriculum in Alberta. There are government guidelines for sexual health education, however sexual education courses and units are optional for students and parents in schools province-wide.
“One of the challenges that have led to the current syphilis outbreak is a lack of education and knowledge around sexual health in general,” says Hill.
Alberta’s current Physical Education and Wellness Kindergarten to Grade 6 Curriculum, published April 2022.
Government of Alberta's Response
Following the syphilis outbreak, there has been public messaging from the Government of Alberta in order to educate Albertans on the infection. However, much of this messaging had been put aside as Alberta focused their resources on the COVID-19 pandemic.
Our reporting team contacted the Government of Alberta’s Ministry of Health for comment on the syphilis outbreak and their approach to dealing with it in February of 2023. Despite following up, we have yet to receive a response as of April 5, 2023.