Chief Health Officer
Updated ºÚÁϳԹÏÍø specific syphilis guidance (previously indicated by [hard brackets]) as indicated by call-out boxes throughout the document:
Document further updated for currency and revised formatting.
Additional information provided for:
These guidelines for public health units (PHUs) outline Australia’s national minimum standard for the routine public health management of syphilis. They are intended to reflect the current evidence base, with pragmatic guidance provided where evidence is still evolving. Jurisdictions may implement policies that exceed the national minimum standard based on the local epidemiological context, available resources, and other factors. The Communicable Diseases Network Australia (CDNA) will review and update these recommendations as new information becomes available.
Readers should not rely solely on the information contained within these guidelines. Guideline information is not intended to be a substitute for advice from other relevant sources, including, but not limited to, advice from a public health specialist or other health professional. Clinical judgment and discretion may be required to interpret and apply these guidelines. PHUs should refer to and follow jurisdictional guidance regarding disease management where appropriate.
Members of the CDNA, the Australian Health Protection Committee (AHPC), and the Australian Government, as represented by the interim Australian Centre for Disease Control (CDC), do not warrant, or represent that the information contained in these guidelines is accurate, current, or complete. The CDNA, the AHPC and the interim Australian CDC do not accept any legal liability or responsibility for any loss, damages, costs, or expenses incurred by the use of, reliance on, or interpretation of the information contained in these guidelines.
Endorsed by CDNA: 25 September 2024
Noted by AHPC: 31 October 2024
Released by Health: 05 November 2024
This guideline is based on the Syphilis – Communicable Diseases Network Australia (CDNA) National Guidelines for Public Health Units. ºÚÁϳԹÏÍø specific syphilis guidance is included within these call-out boxes throughout the document. The content of the CDNA SoNG has not been modified.
The response to a notified case of syphilis is a shared responsibility between Public Health Units (PHUs) and individual diagnosing and/or treating clinicians. The balance of this responsibility may vary between jurisdictions, and in different situations.
These guidelines are primarily intended for PHUs and should be adapted to suit local practices and priorities.
*Note: Definition of reproductive age may vary across jurisdictions. The term women is used, but it acknowledged that this may also include people with a uterus who are non-female identifying.
Within 5 working days
Routine public health priority: commence follow-up within 3 working days, commence data entry within 5 working days.
Surveillance case definitions for infectious syphilis (less than 2 years duration), non-infectious syphilis (more than 2 years or unknown duration), and congenital syphilis are developed, approved and regularly reviewed by the Communicable Diseases Network of Australia.
Case management is the responsibility of the treating clinician, however PHUs should ensure that case investigations have been completed. See Section 9.
Determine pregnancy status in females in accordance with local clinical guidelines. All cases of syphilis in pregnancy should be discussed with a clinician with expertise in the area to ensure appropriate treatment and management. See Section 9, Syphilis in Pregnancy.
Root cause analysis must be done for congenital syphilis cases as per local processes. Cases of congenital syphilis should be treated in consultation with a specialist paediatrician as per local guidelines. See Section 9.
It is recommended that jurisdictions ensure that primary health, sexual health, and public health staff are made aware of their roles and responsibilities in relation to contact tracing for infectious syphilis. Roles may vary between jurisdictions and between different regions within a jurisdiction. It is also recommended that PHUs maintain active oversight of contact tracing processes for infectious syphilis cases even where they do not provide staff to actively support the contact tracing effort. See Section 10.
The causative agent is the spirochaete bacterium, Treponema pallidum subspecies pallidum. There are a number of other Treponema pallidum subspecies that cause non-venereal infections including: pertenue (yaws), endemicum (bejel or endemic non-venereal syphilis) and carateum (pinta).
Treponema pallidum subspecies pallidum is an obligate human parasite.
In the vast majority of cases, syphilis is spread by direct contact with skin lesions or mucous membranes of an individual with infectious syphilis during anal, oral or vaginal intercourse. Vertical transmission can occur at any time during pregnancy and at any stage of syphilis.
Less commonly, syphilis is transmitted by infected blood (transfusion, injection drug use), by non-sexual personal contact with infected lesions or by accidental direct inoculation. Breast feeding does not result in the transmission of syphilis unless a syphilitic lesion or secondary syphilis rash is present on the breast.
The incubation period is 10 to 90 days with a median of 3 weeks to the onset of primary syphilis.
Syphilis is most infectious during the primary and secondary stages of the disease (refer to clinical presentation and outcome section below) when moist mucocutaneous lesions are present; at this point transmission risk is up to 50% per sexual contact. The infectious period is defined as the first two years of infection, if untreated, however the period of high infectivity lasts for 12 months from the onset of infection. Sexual transmission is uncommon after two years of infection.
The risk of maternal trans-placental transmission to the unborn baby is also highest in early syphilis infection. If left untreated, late syphilis (syphilis infection more than one to two years prior to pregnancy) results in a 12% risk of a stillbirth, a 9% risk of neonatal death, a 2% risk of giving birth to an infected infant and a 77% chance of giving birth to an uninfected infant.[1]
Infected infants with moist mucocutaneous lesions are a potential source of infection.
Cases are diagnosed using a combination of history, clinical assessment and serology.
Clinical presentation may be highly variable and many cases do not follow the classical stages listed below. Neurosyphilis can occur in any stage of syphilis.
Primary syphilis usually begins with a lesion, i.e., a chancre begins as a papule 10-90 days after infection. It soon ulcerates to form an indurated ulcer at the site of inoculation; this may be on external or internal genitalia or a non-genital site, e.g. lip, tongue, pharynx, anus, rectum. This is usually a single indurated and relatively painless lesion accompanied by regional lymphadenopathy, however atypical multiple and painful lesions can occur in some cases. The ulcer heals spontaneously over the course of a few weeks.[2] Clinical suspicion of syphilis should be very high for all presentations of a painless, indurated genital ulcer. However, all genital ulcers should be considered to be potential primary syphilis cases and trigger testing.
Secondary syphilis usually occurs 4-10 weeks after onset of the primary lesion. Symptoms include headache, fatigue, lymphadenopathy, low grade fever, sore throat, rash, mucocutaneous lesions, condylomata lata (raised, whitish or grey, flat-topped lesions found in warm moist areas) and alopecia. Ocular and neurological symptoms may also occur. Secondary syphilis may commence prior to the resolution of the primary lesion. Untreated secondary syphilis symptoms persist for 3-12 weeks after which the patient enters the early latent phase. Symptomatic relapses of secondary syphilis occur in 25% of untreated cases, mainly in the first 12 months after infection.
Early latent syphilis refers to infection acquired within the previous two years that is no longer symptomatic.
Late latent syphilis refers to syphilis of more than two years duration, in the absence of clinical signs or history of treatment. People with late latent syphilis are asymptomatic for many years.
Tertiary syphilis: Historically, between one quarter and one third of infected and untreated individuals will ultimately develop tertiary syphilis. The following timelines for development of tertiary syphilis were derived in the pre-antibiotic era and are a guide only.
Congenital syphillis occurs when T. pallidum crosses the placenta and may infect the foetus at any time in the pregnancy. If untreated, this can result in intrauterine foetal death, stillbirth, neonatal death or a premature baby. In the early stages of congenital syphilis, the baby may be severely affected at birth (with hepatomegaly, ascites, hydrops, foetal anaemia); more frequently the baby may not present any observable sign. If the diagnosis is not made at this point, the baby may present later with non-specific complaints (rhinitis, failure to thrive, pneumonia), nearly always within three months of birth. Neonates with severe disease have a worse prognosis. Late manifestations of congenital syphilis correspond to tertiary disease in the adult and can be prevented by early diagnosis and treatment of the infant.
Syphilis is increasingly common/endemic in the Australian population with higher rates in some communities, including gay, bisexual and other men who have sex with men (GBMSM) and Aboriginal and Torres Strait Islander peoples. Diagnosis rates are increasing among non-Indigenous people living in urban/metropolitan areas, HIV negative GBMSM and people who inject drugs.[3-5] Rates in Aboriginal and Torres Strait Islander people have been increasing since 2011, especially among those living in remote areas of Australia, after sustained periods of decline.[3] Despite a substantial increase in rates in the non-Indigenous population in recent years, there has been ongoing higher and disproportionate burden of disease among Aboriginal and Torres Strait Islander peoples.[6] One of the most significant public health implications of syphilis lies in its impact on the developing foetus in utero. Congenital syphilis is an entirely preventable disease and thus, it is an event that represents a failure of the health system, including affordable and accessible primary health care, delivery systems for antenatal care and for syphilis control programs. Persistent visual and auditory impairment after early neurosyphilis is also a public health issue.[7] The interaction of T. pallidum with HIV is of public health significance due to shared transmission routes and syphilis biologically enhancing the transmission and acquisition of HIV.
Any person can acquire syphilis through unprotected vaginal, anal, or oral sex with an infectious person. In Australia, populations at higher risk of syphilis include Aboriginal and Torres Strait Islander peoples, people who inject drugs that lead to disinhibiting sexual behaviour, GBMSM, heterosexual people with multiple partners, female partners of GBMSM, sex workers, people from culturally and linguistically diverse (CALD) backgrounds, people experiencing socio-economic disadvantage, prisoners, women of reproductive age, people who experience homelessness, and people who have unprotected sex in overseas countries where syphilis is prevalent. In an analysis of enhanced syphilis surveillance data, it was found that infectious syphilis notification rates among Aboriginal and/or Torres Strait Islander women of reproductive age increased by >300% between 2012 and 2021.[8]Notification of infectious syphilis among non-Indigenous females of reproductive age has also substantially increased, particularly in major cities of Australia. Rates among the Aboriginal and/or Torres Strait Islander population in remote settings remain 15 times higher than the non-Indigenous population in major cities. Increasing rates in both populations pose a concurrent risk of congenital syphilis and adverse pregnancy outcomes.
A combination of coordinated prevention activities is more effective than an isolated, single activity. Key pillars of prevention include education, screening, treatment and partner notification, with detail on these in relevant sections of the SoNG.
Sexual health promotion and education programs aim to increase awareness of syphilis and other sexually transmissible infections and empower people to adopt safer sex practices such as condom use and regular testing, thus reducing infection acquisition and transmission risk. These programs are targeted to priority groups including young people, pregnant people and their partners, GBMSM, Aboriginal and Torres Strait Islander peoples, sex workers, people who inject drugs, and prisoners.
National STI testing guidelines recommend that testing for syphilis and HIV is included in all standard asymptomatic STI check-ups, in addition to recommended testing for specific populations of concern such as those listed above. Please refer to the current guidelines (see https://sti.guidelines.org.au/) for syphilis testing guidance. Jurisdictional guidelines may differ, so it is important to consult local testing guidelines to ensure appropriate testing is undertaken.
The objectives of surveillance are to:
All confirmed and probable cases should be entered on to the National Notifiable Diseases Surveillance System (NNDSS) by state and territory PHUs.
Syphilis is a notifiable disease under the public health acts of all states and territories, and nationally. Reactive syphilis serology results are reported by pathology laboratories to public health authorities. In some jurisdictions the medical and/or nurse practitioner who diagnose a case of syphilis is also required to notify the jurisdictional public health authority.
Data for confirmed and probable cases of infectious syphilis (syphilis <2 years duration) and congenital syphilis should be entered into jurisdictional notifiable conditions databases within three working days of confirmation.
Data for confirmed cases of late syphilis infection (syphilis >2 years or unknown duration) should be entered into jurisdictional notifiable conditions databases within five working days of confirmation.
Check the following NCIMS electronic laboratory reporting (ELR) workflows daily Monday – Friday for syphilis unspecified cases:
Manually data enter notifications received by fax/mail/email into NCIMS including all results in the laboratory results question package within:
Classify the case upon receipt of laboratory results if there is sufficient evidence to meet the case definition. If there is insufficient evidence to meet case definition, set the case classification to “syphilis unspecified – possible", pending collection of enhanced surveillance information.
At least two attempts should be made to obtain enhanced surveillance information. If incomplete forms are received and/or missing information remains, fill in missing information in the corresponding NCIMS fields with 'Unknown' or the most appropriate equivalent. If no form is received, public health follow-up should be marked as 'Unable' or 'Unknown'.
For all new syphilis notifications in NCIMS, the syphilis questionnaire must be sent to the ordering/managing clinician for completion, whether this is the ordering GP or if the case is to be referred to the local SHS for management. PHUs should follow local arrangements with your SHS for obtaining enhanced surveillance data.
Enhanced surveillance data should be completed for all new syphilis notifications in NCIMS. Regardless of whether it is the PHU or SHS who does the data entry into NCIMS, it is the responsibility of PHUs to ensure completion of data entry in NCIMS.
To assist PHUs in tracking classifications of syphilis and the management of the high priority cases, the syphilis data monitoring and cleaning report (available in SharePoint – see HPºÚÁϳԹÏÍø Reporting Systems and Analytics – NCIMS Data Quality Reports) features line lists for:
All syphilis cases (excluding congenital syphilis) should be classified on NCIMS within 90 days of initial notification with the information available to the PHU. Any additional information received after this time should be added and the event reclassified if necessary.
Please see Reporting and interpretation of tests when managing possible duplicate notifications. Where a possible duplicate notification is found, this should be identified in the notes section of the event notification home page. Possible duplicate notifications will be merged by the Epidemiology and Data Systems Branch (EDS) provided that there is no evidence of re-infection. When the merge involves an event belonging to another PHU, email the relevant PHU and copy in EDS (email is available on Infectious Disease Network SharePoint).
Details of confirmed and probable cases of infectious (i.e. primary, secondary, early latent) syphilis and congenital syphilis are notified to the state/territory in accordance with statutory requirements; usually including the patient's name, date of birth, sex, Indigenous status, country of birth, address or post code, date of onset or date of specimen collection, and whether laboratory testing has been requested. Additional information collected during follow-up should also be documented including: pregnancy status, possible sources of infection, exposure risk, sex worker status, other people thought to be at risk and follow up actions taken, such as documentation of appropriate treatment, evidence of dropping RPR titre and completed contact tracing.
State/territory Communicable Disease Branches (CDB) will notify the case to the National Notifiable Diseases Surveillance System (NNDSS) and should inform CDNA of infectious syphilis clusters or outbreaks of national relevance. Interjurisdictional outbreaks requiring national coordination may require support from the National Incident Centre (NIC).
Notify CDB of any probable or confirmed congenital syphilis cases by emailing CD on-call. If CDB are notified first, CDB will inform the relevant PHU by email.
National case definitions are regularly reviewed. The current versions can be found via the following links:
For presumptive infectious syphilis cases notified for the first time in ºÚÁϳԹÏÍø where testing and treatment history are unknown with:
Note: if the notification does not meet the above criteria i.e. VDRL or RPR titres <16 and no treponemal specific tests have been ordered, PHUs should follow up and classify as per usual processes.
National laboratory case definitions are regularly reviewed, and the current version can be found via the following link:
Syphilis laboratory case definition
Culture is not available. Syphilis is principally diagnosed by serology (treponemal specific and non- treponemal tests). If lesions are present, diagnosis may involve nucleic acid amplification test (NAAT) or direct demonstration of the organism by dark-field microscopy or direct fluorescent antibody test (direct antigen detection). Placental specimens and cerebrospinal fluid are also suitable specimens for NAAT. Current NAATs cannot reliably detect T. pallidum in blood at any stage of infection.
There are two types of syphilis serology tests: treponemal specific tests and non-treponemal tests. Treponemal specific tests detect antibodies to antigens specific to pathogenic T. pallidum. They become reactive after infection with T. pallidum and usually remain reactive indefinitely regardless of adequate treatment, however partial or complete loss of treponemal specific antibodies over time occurs in a minority of patients, especially people living with HIV or those treated very early in infection. These tests do not necessarily indicate active infection. Non-treponemal tests detect reagin (a combination of lecithin, cholesterol and cardiolipin), a substance similar to that generated in response to spirochaete-induced damage to cellular membranes. Tests based on detection of antibodies to reagin are a useful indicator of disease activity.
Treponemal and non-treponemal serology tests are less than 100% sensitive in primary syphilis so syphilis serology may be negative in the presence of a chancre.
Agglutination assay tests: T. pallidum particle agglutination (TPPA), T. pallidum haemagglutination (TPHA), and micro-haemagglutination assay for antibodies to T. pallidum (MHA-TPTPPA). These assays detect IgM well and show sensitivity in early syphilis roughly equivalent to IgM immunoassays.
T. pallidum immunoassays: Immunoassays are suitable for automation and are favoured by many laboratories as a suitable screening test for infectious syphilis. The recombinant (IgG or total antibody) immunoassay antibody test is probably the most sensitive treponemal specific test post primary syphilis, and it is highly specific. There are a variety of different immunoassays in use; the most common tests in Australia are enzyme immunoassays (EIA), Chemo-luminescent immunoassays (CLIA) and chemiluminescent microparticle immunoassays (CMIA). Immunoblot assays are also used by a few laboratories. Sensitivity and specificity of different immunoassays at various stages of syphilis will vary with antigen type and concentration used.
Fluorescent treponemal antibody absorption test (FTA-ABS): Sensitivity varies with disease stage: primary 78-100%, secondary 93-100%, early latent 94-100% and late latent 85-93%. Specificity is 87-100%.[9] This test is less commonly used as a confirmatory test since the introduction of EIAs and other immunoassays as it is technically difficult, labour intensive and subjective, but is still used with CSF.
T. pallidum IgM EIA: this test is sometimes used in the investigation of congenital syphilis and early acquired syphilis. In primary syphilis sensitivity is 86.5% and specificity oscillates between 91 and 99.8% depending on the assay used.[10] Sensitivity is lower in later disease stages and in re-infections, but its presence indicates active disease. This test should not be used for screening purposes as occasional low-level false positive results occur.
Non-treponemal tests do not detect antibody to T. pallidum but to reagin and are a useful indicator of disease activity. Other conditions (infections and autoimmune conditions) can also induce antibodies to reagin, leading to false positive results but with titres generally ≤ 1:8. Non-treponemal tests in use today are known as the VDRL (venereal diseases research laboratory) test and RPR (rapid plasma reagin).
The VDRL test requires microscopy and is usually used only on cerebrospinal fluid, although it may also be used on serum (but not plasma).
The RPR is performed on serum or plasma. Sensitivity varies according to disease stage: primary 86%; secondary 100%; early latent 98%, late latent 73%.[11] Specificity is 98% (if treponemal specific tests positive).[12] A false-negative response can occur in cases in which high antibody titers interfere with the antigen-antibody lattice network formation that is necessary for visualising a positive flocculation test (the prozone phenomenon). The prozone phenomenon most commonly occurs when undiluted serum is used and can occur during any phase of syphilis.
See Therapeutic Goods Administration (TGA) for information on availability of tests.
There is a period after infection when both treponemal specific and non-treponemal serology may be negative. In general, the treponemal specific test (e.g. EIA) becomes reactive within 2-4 weeks and the RPR becomes reactive within 3-4 weeks post infection.
Most laboratories in Australia now use a treponemal specific test as the first (screening) test following a request for syphilis serology. If reactive, a non-treponemal test (e.g. RPR) and another specific treponemal specific test is performed.
Most laboratories report treponemal specific tests as reactive or non-reactive.
The RPR, if reactive, is reported as a titre – the endpoint of a serial dilution: 1 in 2, 1 in 4, 1 in 8, 1 in 16, 1 in 32 etc. which represents the highest dilution giving a reaction. A higher dilution suggests more active disease. The results are reported as the reciprocal of the highest dilution (ie. 2, 4, 8 etc.). Figure 1, developed by Gavin Hart, indicates the typical RPR response following syphilis infection.[13]
The RPR test is also used to monitor response to treatment. An adequate response to treatment in infectious syphilis is defined as a four-fold (or two-dilution) drop in RPR, for example, from 1 in 128 to 1 in 32 on parallel testing by 6 months, though the rapidity of this decline varies according to disease stage at treatment. This test becomes non-reactive in the majority of patients if infection is diagnosed and adequately treated early in its course. Patients with high RPR titres, late diagnoses and individuals who have been re-infected will be left with fixed reactive (serofast) RPR titres (e.g. 1 in 16) despite adequate treatment, in up to a quarter of patients.
Re-infection is generally diagnosed on changes in RPR titre. A four-fold or two-titre rise in RPR, e.g. 1 in 2 to 1 in 8, following previous adequate treatment is considered a re-infection. PCR may be useful if ulcerated or moist lesions are present.
The non-treponemal test results rely on subjective judgements by the operator reading the test. The reproducibility of the result will vary according to the skill of the operator and the antigen preparation used. Comparison of results on serial samples should always be done in parallel. Results from different laboratories for an individual patient should not be compared due to inter-laboratroy variation in RPR results.
Treponemal specific and non-treponemal tests do not distinguish between sub-species of Treponemes. In some parts of remote Australia yaws and non-venereal endemic syphilis were common up until the late 1960s and yaws remains common in PNG, Indonesia, the Solomon Islands, Vanuatu and parts of central and west Africa.[14] It is possible that people from these regions who acquired these conditions as children will still have the antibodies giving them reactive treponemal serology without ever having had infectious syphilis. Treponemal serology needs to be interpreted in light of clinical findings and whether the patient is from as yaws endemic country. See Yaws (Endemic treponematoses) (who.int) for further information on yaws.
Re-infection is generally based on changes in RPR and/or VDRL titres. As per Figure 2 below, a four-fold rise (or two-titre rise) is considered to be a re-infection e.g. 1 in 1 to 1 in 4 or 1 in 2 to 1 in 8.
When managing notification of follow-up in NCIMS, there have been instances where there is a change from a non-reactive RPR/VDRL titre to a titre of 2 (technically considered to be a four-fold rise (or two-titre rise). While this could suggest a new infection (especially if the results are from the same laboratory), this could also be a false positive result. PHUs should not request a merge until the significance of the laboratory result has been determined and/or a false positive result has been ruled out. As such, repeat serology is recommended.
Increases in RPR/VDRL titres should always be interpreted with other information and laboratory test results, including a full clinical history. If the case has been previously diagnosed with syphilis and may be at risk of re-infection, PHUs should follow up with the managing clinician to seek advice regarding early re-infection for the case.
If an individual presents with clinically observable lesions (such as ano-genital and ulcers or lesions associated with secondary syphilis), it is recommended to collect swabs, scrapings or biopsies for NAAT such as a PCR test for T. pallidum. This test can also be done on placental specimens (including paraffin embedded tissue(i), ocular fluids and cerebrospinal fluid. These tests are highly sensitive and specific and are now available in most states, but are not recommended for testing blood.[15]
(i)Please note this is not a preferred specimen and some laboratories may not proceed with testing.
There is currently only one syphilis point of care test registered by the Therapeutic Goods Administration in Australia, the Determine Syphilis TP™. The Determine Syphilis TP™ is a treponemal specific immunochromatographic test that can be used with whole-blood samples from either finger-prick or venepuncture. Point of care syphilis tests, used in combination with conventional syphilis serology and treatment history data, can facilitate case identification and reduce time to treatment for infectious syphilis.[16-19] Interpretation requires access to the individual’s previous syphilis serology and treatment history. Over-treatment can result if treatment is triggered on the basis of the point of care test alone. In an outbreak situation, this may be considered an acceptable risk, especially for people who have no known history of past syphilis and where follow-up is uncertain.
There are a number of limitations with current syphilis point of care tests:
The following issues should be considered when implementing syphilis point of care tests:
For application in local contexts refer to testing guidelines in the relevant jurisdiction.
Prioritisation of the public health response to a case of confirmed or probable infectious syphilis is high. Infectious syphilis occurring in a pregnant woman requires urgent public health response due to the risk of congenital infection.
High public health priority is advised for:
The public health response for high priority cases should be as soon as possible, generally within one working day.
For all other syphilis cases, the public health response is routine. Follow up should be prioritised according to jurisdictional guidelines.
* Definition of reproductive age range may differ across jurisdictions. The term woman is used, but it acknowledged that this may also include people with a uterus who are non-female identifying.
The syphilis data monitoring and cleaning report (available in SharePoint – see HPºÚÁϳԹÏÍø Reporting Systems and Analytics – NCIMS Data Quality Reports) features line lists for:
Refer to flowcharts in Appendix 5 for guidance.
On notification of a case of confirmed or probable infectious syphilis, begin follow up investigation and notify the state/territory Communicable Diseases Branch (CDB).
The response to a notification will normally be carried out in collaboration with the diagnosing and/or treating clinician/service. Contact tracing is important and will depend on jurisdictional arrangements and may include PHU staff conducting a case interview and assisting with contact management.
Regardless of who does the follow-up, for confirmed and probable cases of infectious syphilis, PHU staff should ensure that action has been taken to:
Identification of the person or service best placed to conduct contact tracing is a local decision best made on a case-by-case basis. The culture and gender of the contact tracer and whether they are known to and trusted by the case are relevant factors to consider.
Symptomatic patients should be interviewed in relation to their contacts when they first present, while early latent cases diagnosed on serology findings should be interviewed when seen for treatment. Follow up of contacts who are pregnant, and contacts of pregnant people should be prioritised. See the Australasian Contact Tracing Guidelines for further information.
Review laboratory results and investigate testing/treatment history.
At least two attempts should be made to obtain enhanced surveillance information to inform classification. If incomplete forms are received and/or missing information remains, fill in missing information in the corresponding NCIMS fields with 'Unknown' or the most appropriate equivalent. If no form is received, public health follow-up should be marked as 'Unable' or 'Unknown'.
Patients not in the care of a SHS or an ordering clinician known to the PHU to have experience in sexual health*:
Patients in the care of a SHS or an ordering clinician known to the PHU to have experience in sexual health:
The syphilis data monitoring and cleaning report (available in SharePoint) has a high priority event list which lists any syphilis notifications that have a laboratory result that is T. pallidum PCR positive and/or RPR/VDRL ≥16 and the case is not in care with a specialist service (likely to be infectious syphilis).
*Use ASHM's presciber map to find information of the contact details of s100 prescribers/GPs.
All neonates born to women diagnosed with syphilis in the current pregnancy, regardless of maternal treatment, require risk assessment for clinical signs of congenital syphilis. Treatment of the baby for congenital syphilis should be considered based on the risk assessment and the findings of the initial clinical examination and any available test results. Specialist infectious disease paediatric advice is recommended. When investigating a possible congenital syphilis case, refer also to the mother's testing and treatment history.
Refer to congenital syphilis surveillance case definitions and Investigation and management of the neonate born to a mother with syphilis – Algorithm 3 in the ASID Management of Perinatal Infections Guidelines.
The assessment and management of congenital syphilis cases is the responsibility of the managing clinician/s. LHDs should follow local protocols and pathways. However, in collaboration with other specialist services, PHU and/or SHS staff should ensure that the following public health actions have been completed:
In ºÚÁϳԹÏÍø, it is the responsibility of the managing clinician(s) to consult with a specialist service (e.g. maternity, sexual health, infectious diseases, and paediatric) to determine appropriate follow-up testing during pregnancy and after birth.
The response to a notification will normally be carried out in collaboration with the case's managing doctor(s) and/or consultation with sexual health or infectious diseases clinicians.
For women who have tested positive for syphilis, maternal treatment and serological follow up of the maternal RPR and screening should be performed in accordance with 'Investigation and treatment of maternal syphilis - Algorithm 2' in the ASID Management of Perinatal Infections Guidelines. All cases of maternal syphilis are to be monitored and reviewed by the maternity service to ensure appropriate processes are followed.
The assessment and management of pregnant syphilis cases is the responsibility of the managing clinician/s. LHDs should follow local protocols and pathways. However, in collaboration with other specialist services, PHU and/or SHS staff should ensure that the following public health actions have been completed:
For all pregnant cases where the PHU and/or SHS staff are not confident that they are well-engaged in care, CD on-call should be notified given the risk of congenital syphilis.
As Mandatory Reporters, any health worker who has reasonable grounds to suspect that a child or young person may be at risk of significant harm must make an immediate report to the Child Protection Helpline on 13 21 11.
PHUs should monitor manual notifications and the 'Send STI or BBV in <16 yo letter to treating doctor' workflow in NCIMS Monday to Friday.
If a laboratory notification was manually received (e.g. by fax), and the child or young person is an interstate resident, PHUs should send through the notification to CD on call and CDB will notify the relevant interstate health authority. Please see below for mandatory reporting obligations for interstate residents.
Patients who present with symptoms consistent with infectious syphilis (classically a relatively painless, indurated genital ulcer or symptoms / signs of secondary syphilis) should be treated at the time of first presentation and syphilis serology collected. PCR swabs should be taken from relevant lesions, including anogenital and oropharyngeal ulcers and other lesions, and blood taken for syphilis testing on the same day. Cases who present with potentially syphilitic lesions including mucocutaneous ulcers and other lesions should have a swab taken for Treponema pallidum (T. pallidum) species pallidum PCR and blood taken for syphilis testing at the time of first presentation; empirical treatment is highly recommended unless there is a medical contraindication. Refer to the Therapeutic Guidelines for assessment of management of a patient with a reported penicillin allergy. Please refer to STI guidelines for details if recommended testing for syphilis and any other STI testing to consider.[20]
Asymptomatic infectious syphilis cases diagnosed on serology should be treated as soon as possible (and ideally within two days) after diagnosis. Rapid referral and confirmation of treatment is required if a case moves away from the location where they were diagnosed before undergoing treatment.
Pregnant cases of infectious syphilis require urgent prompt follow up and treatment with a penicillin-based regimen to minimise the possibility of vertical transmission. Breast feeding does not result in the transmission of syphilis unless an infectious lesion is present on the breast.
The treatment for syphilis generally recommended is long-acting benzathine benzylpenicillin, available via the Pharmaceutical Benefits Scheme prescriber bag to facilitate timely treatment.
For cases of infectious syphilis of less than two years duration, one dose of benzathine benzylpenicillin 2.4 million units (1.8g) IMI given as two injections containing 1.2 MU (0.9g) is required. For cases of non-infectious syphilis or syphilis infection of more than two years or unknown duration, a course of three doses benzathine benzylpenicillin 2.4 million units (1.8g) IMI, weekly for three weeks is required.
Cases of congenital syphilis should be treated in consultation with a specialist paediatrician. Refer to local guidelines for details.
For detailed information on therapeutic agents for tertiary syphilis see the Australian STI guidelines.[20]
If penicillin is contraindicated, seek specialist advice from an infectious diseases physician, or sexual health physician.
Effective treatment of syphilis does not confer immunity against T. pallidum, and people can get re-infected. Certain groups are at higher risk of re-infection. Clinical presentation of re-infection may be similar to primary or secondary symptomatic infection, but often presents as asymptomatic (or pre-symptomatic) rises in serology parameters and is indistinguishable from early latent infection.
At the time of the first treatment dose, repeat bloods should be collected for RPR or VDRL test to provide an accurate baseline used to monitor response to treatment and check for re-infection.
Treatment of infectious syphilis is considered to be adequate if there is a four-fold (two dilution) drop in RPR titre, e.g. 1 in 64 to 1 in 16, by 6 (up to 12) months. All patients should be reviewed clinically and have repeat RPR testing at 3 months, then at 6 months and (if necessary) at 12 months after completing treatment. Refer to jurisdictional and/or Australasian Society of Infectious Diseases (ASID) guidelines[21] for further details on monitoring response after treatment in pregnancy. Comparison of results on serial samples should always be done with parallel testing. Results from different laboratories for an individual patient should not be compared.
Please note: Patients with low starting RPR titres, late diagnoses, and individuals who have been re-infected may be left with fixed reactive (serofast) RPR titres (e.g., 1 in 16) despite adequate treatment, in up to a quarter of patients.
Serological testing up to 8 weeks after treatment (unless symptoms appear[22]) should be avoided as it may show an increase in RPR; this does not indicate treatment failure.
Cases of infectious syphilis are no longer considered infectious 7 days after one dose of benzathine benzylpenicillin or until all symptoms have resolved (whichever is later). Completion of adequate treatment for syphilis does not confer immunity and re-infection can occur.
Please refer to local testing guidelines for further steps, if available. Guidelines suggest a bare minimum frequency of testing – respective physicians can choose more testing depending on the case.
National guidelines recommend a minimum of 3 (three) syphilis tests for every pregnant person during each pregnancy: at the first antenatal visit, at 26-28 weeks, and at 36 weeks or birth (whichever is earlier). Neonates should not be discharged without confirming that the mother's syphilis status has been documented at least once during pregnancy. If in doubt, maternal syphilis serology should be ordered at birth. Additional risk-based screening: additional testing, including opportunistic and at birth, should be considered based on clinical indication as per the local guidelines.
Due to the extreme risk of vertical transmission of syphilis particular care is required to ensure adequate treatment in pregnancy, and all case of syphilis in pregnancy should be discussed with a clinician with expertise in the area. Treatment of syphilis in pregnancy is according to disease stage and while it is often the same as in the non-pregnant state, local guidelines should be consulted. IM benthazine benzylpenicillin is the recommended treatment. Seek specialist support where this is not possible as desensitisation may be required. Contact tracing and treatment for the pregnant person's partner/s are critical to minimise the potential for re-infection as this represents a particular threat to the unborn baby. Serological follow-up of the pregnant person's RPR during and following pregnancy is essential and should start at 3 months after the first dose of benzathine benzylpenicillin (refer to ASID[21] or jurisdictional guidelines for further detail); this is important for monitoring the response to treatment and prompt detection and treatment of re-infection. For adequate treatment of syphilis in pregnancy, treatment must be completed at a minimum of one month (30 days) prior to delivery. Ideally there should be a demonstrated four-fold (two-titre) drop in maternal RPR, e.g., 1 in 64 to 1 in 16, prior to birth. If the pregnant person required treatment for syphilis during the pregnancy, or the infant is considered to be high risk according to the respective jurisdictional guidelines, the neonate should be examined for clinical signs of congenital syphilis and comprehensive laboratory investigations should be undertaken (i.e. venous blood for syphilis serology read in parallel with maternal serology, IgM, placental PCR). If any initial assessments are abnormal and/or adequate treatment did not occur in pregnancy, treatment for congenital syphilis and additional investigations should be considered. Specialist paediatric review is recommended.
All cases of congenital syphilis must be consistently identified, and a root cause analysis undertaken for each case to identify individual risk factors (e.g., pregnant people not able to access antenatal care, or with co-occurring needs) and health system contributing factors to inform improvement activities at both clinical and system levels, with mechanisms made available to implement recommended changes to practice.
It is critical to focus on pregnant people diagnosed during pregnancy who are then lost to follow-up. All attempts should be made to contact the individual e.g. home visits (multiple if necessary), flags on electronic medical records that this is a high-risk pregnancy requiring syphilis treatment and/or further testing. Check with other relevant services regarding contact, including mental health, alcohol and other drugs, homelessness services, Justice Health and Department of Communities and Justice. Contact with other services should be considered on a case-by-case basis and in context of local relevant legislation.
Contact tracing and treatment for the pregnant person's partner/s are critical to minimise the potential for re-infection as this represents a particular threat to the unborn baby.
All pregnant women in ºÚÁϳԹÏÍø are recommended to have syphilis screening as part of their first antenatal visit and a second syphilis screening at antenatal care visits at 26–28 weeks gestation as per the ‘Syphilis in Pregnancy and Newborns’ Policy Directive (PD2023_029).
Additional syphilis screening at 36 weeks and delivery should occur for pregnant women deemed as having an identified risk (i.e. any previous syphilis diagnosis, any STI in the past 12 months, illicit substance use in the previous 12 months, new sexual partner or a male partner who has sex with other men, engaging in high risk sexual activity or has sexual contact with a known infectious syphilis case).
For pregnant women with late, minimal or no antenatal care, opportunistic screening should occur at every engagement with health services. This may include GP services, Aboriginal Medical Services, Drug and Alcohol, Mental Health, Emergency Departments, and Custodial Settings.
Cases of infectious syphilis need to be informed of the infectious nature of their disease, the possibility they might be infectious even in the absence of symptoms, and to abstain from sexual activity for 7 days post-treatment or until symptoms have completely resolved (whichever is longer). Physical isolation of cases or their sexual contacts is not required. The importance of contact tracing and follow up and repeat syphilis serology testing to monitor the response to treatment should be emphasised. Also, advise no sexual contact with current or previous sexual partners until all sexual partners have been tested, treated if necessary and are no longer infectious. The case should be informed that they are likely to continue to have positive treponemal specific tests for life, even after successful treatment, and that previous infection does not protect them from getting reinfected again.
It is recommended that jurisdictions ensure that primary health, sexual health and public health staff are made aware of their roles and responsibilities in relation to contact tracing for infectious syphilis. Roles may vary between jurisdictions and between different regions within a jurisdiction. It is also recommended that public health units maintain active oversight of contact tracing processes for infectious syphilis cases even where they do not provide staff to actively support the contact tracing effort. Contact tracing staff should be guided by the Australasian Contact Tracing Manual.
The aim of identifying contacts of infectious syphilis is to prevent disease transmission by providing empirical presumptive treatment and testing to identify infection. Comprehensive assessment of contacts at the initial consultation is crucial.
Anyone who has had sex (including oral sex) with a person who has infectious syphilis requires follow-up as a contact. Correct staging of the index case's infection is essential as it determines the lookback period for contact tracing (3 to 12 months depending on stage). All contacts should be offered syphilis testing. In addition, presumptive treatment on the day of testing should be offered to contacts of primary and secondary syphilis and contacts of early latent syphilis where sexual contact occurred in the previous three months. For late latent or tertiary syphilis, testing is recommended for current partners only. For further information regarding contact tracing refer to the Australasian Contact Tracing Guidelines.
Unborn and newborn babies of pregnant people diagnosed with syphilis or suspected to have syphilis during the pregnancy should also be treated as contacts, regardless of maternal treatment, and relevant pathology tests and clinical assessments for congenital syphilis should be undertaken. Refer to local clinical practice guidelines for presumptive treatment of neonates who are being investigated for congenital syphilis.
Testing of older children may also be indicated where there is a strong suspicion of untreated syphilis infection during a past pregnancy.
The infectious period depends on the stage of infection in the case and determines the time frame for contact tracing.
In ºÚÁϳԹÏÍø, contact tracing is the responsibility of the managing clinician.
The managing clinician should trace back according to the case's sexual history and clinical stage of infection:
Refer to Australasian Contact Tracing Guidelines - Syphilis for more information.
In addition to presumptive empirical treatment, for all sexual contacts of patients with primary or secondary syphilis regardless of serology, contact management should include:
Patient and provider referral are the two main methods of alerting contacts. In the former, the case notifies their contacts while in the latter, the health care provider organises the notification and treatment of contacts. In remote populations, provider referral is the principal method of contact tracing used. When patient referral is used, contact management as outlined above should occur within two weeks of case treatment and the responsible primary health, sexual health, and public health staff should confirm with the patient that this has occurred. If delays in patient referral occur, the patient should be offered additional support to undertake patient referral and the option to change to provider referral.
Innovative online contact tracing tools have been developed. These include 'Let them know', 'The Drama Down Under' (for GBMSM), and 'Better to Know' (for Aboriginal and/or Torres Strait Islander people). Some jurisdictions may offer jurisdiction-specific services.
The highly transmissible nature of syphilis, and specifically its capacity to spread rapidly through a population and to cause both foetal death and severe congenital complications if transmitted to a pregnant person, demands an urgent and prompt response from primary care and public health/sexual health clinic staff. Contact tracing of an early syphilis case should be a high priority, higher than contact tracing for other STIs (chlamydia, gonorrhoea) where serious complications do not occur as acutely. Rigorous and immediate attempts are required to avoid further sexual transmission and potential serious, avoidable outcomes such as congenital syphilis. If contact tracing is not effective, the patient is at high risk of being re-infected after treatment.
Where a person discloses they are a contact of a syphilis case, to optimise case assessment and management during the initial consultation, the following should be undertaken:
Timely contact tracing lies at the heart of an effective public health response to syphilis and needs to be prioritised. Contacts of infectious syphilis who live locally should be tested and treated on the same day as the case's treatment (e.g. if regular partner) or as soon as possible. If the contacts are elsewhere and referral has been necessary, the responsible primary health, sexual health, and public health staff should aim to ensure that all contacts are seen and treated within two weeks of the case's diagnosis.
Persons who were sexually exposed to a patient with primary, secondary, or early latent syphilis in the last 3 months should be treated presumptively with one dose of benzathine penicillin 2.4 million units (1.8g) prior to the receipt of their syphilis serology results.
Contacts of infectious syphilis need to be informed about the infectious nature of the disease, the possibility that they might be infected and infectious even in the absence of symptoms, and to abstain from sexual activity for 7 days after they have received empirical presumptive treatment or their syphilis serology shows that they have not been infected (whichever is earlier). The importance of follow up and repeat syphilis serology testing to monitor the response to treatment should be emphasised.
Syphilis outbreaks are more likely to occur in particular populations. The term 'outbreak' is taken to mean the occurrence of more cases than expected for the population or group under consideration. The objective of public health management of outbreaks of syphilis is to interrupt transmission and prevent further cases and congenital syphilis cases. Once an outbreak is either suspected or recognised there is an immediate need to initiate a coordinated response. A significant syphilis outbreak is a complex public health challenge. The ideal response will be multi-strategic, informed by local knowledge, and attentive to detail in its execution. It will be enhanced where positive relationships already exist between the stakeholders.
In Australia, an increase in syphilis cases was first reported in remote Queensland in 2011, with a multijurisdictional outbreak declared in central and northern Australia in 2015. This outbreak was predominantly among Aboriginal and Torres Strait Islander communities in remote settings, reflecting failures of the health system including inadequate access to timely testing and treatment, and the impact of social determinants of health. Further outbreaks have occurred in urban areas, among GBMSM. Increasingly, Australia is experiencing more widespread syphilis infections, however a disproportionate burden of disease remains for Aboriginal and Torres Strait Islander peoples.
Syphilis clusters may also occur in association with certain sexual networks. It is important to pay attention to confidentiality and the sensitivities associated with STIs when managing syphilis clusters and outbreaks. GBMSM who are highly sexually active are at increased risk of acquiring syphilis.
Responding to syphilis outbreaks requires community and health service engagement, consultation and dialogue with affected populations that have had a recent history of discrimination, racism and stigma. These meetings have the following objectives: to inform and educate community (and health staff); to establish a trusting basis for on-going dialogue; and to seek advice and codesign where possible proposed control strategies. Relationships between nominated community representatives and the outbreak response team are crucial to effectiveness of outbreak control.
Communication with Aboriginal and Torres Strait Islander people about STIs in their communities is always sensitive and should be undertaken in a culturally safe manner, with input and support from relevant First Nations employees.
Community leaders are necessary partners in addressing a syphilis outbreak. Their co-operation, input and support are critical to effective intervention. This situation calls for frank explanation and discussion in language appropriate to the level of health literacy of the community members and should commence from the early stages of any initiative so that there is an opportunity for community members to contribute to the design, implementation, and evaluation of the proposed programs.
Engaging early with the state-based peak Aboriginal and Torres Strait Islander community-controlled health organisations is important. This may be particularly useful in opening up communication with communities without a community-controlled health service.
The occurrence of a case of congenital syphilis is a sentinel event reflecting potential missed opportunities for prevention in the public health, antenatal and primary health care systems, and reflects a failure of the health system. Therefore, it is important to formally review each case of congenital syphilis as a reportable incident for the purpose of health system improvement and preventing future avoidable cases. Refer to jurisdictional guidelines for details of public health review processes. For example, the Guidelines for public health review of congenital syphilis case.