Syphilis Screening MA guidelines 1 June 2023.pdf

link to page 2 link to page 2 link to page 2 link to page 2 link to page 2 link to page 2 link to page 3 link to page 3 link to page 3 link to page 3 link to page 4 link to page 4 link to page 4 link to page 4 link to page 4 link to page 4

PURPOSE OF THIS DOCUMENT
This document provides information about the testing and treatment for syphilis. It also offers
guidance about request
  ing further information to assist in assessing whether an applicant
meets ASH requirements.

BACKGROUND
Syphilis is a sexually transmitted disease (STD) caused by a bacterium called Treponoma
pallidum pallidum. Infectious syphilis is a notifiable disease in New Zealand and its incidence
has been increasing since 2000. Long-term untreated syphilis can be very serious, permanently
debilitating and sometimes fatal.
If an applicant has a reactive test result for syphilis, you must get confirmation of the diagnosis
and confirm that the applicant has been treated appropriately – for example, with weekly
doses of penicillin for three weeks.
ABOUT SYPHILIS
Syphilis has three clinical stages plus a latent phase. Around 50% of people will have no
symptoms and are diagnosed on serologic tests. For visa applicants this often occurs when
they do an IME.
Primary syphilis
The incubation period for primary syphilis is 10 to 90 days, with an average of 21 days. The
most common presentation is a painless genital ulcer which often heals within a few weeks,
even if it is not treated.
Secondary syphilis
The incubation period for secondary syphilis is 2 to 24 weeks, with an average of 6 weeks. This
may present with symptoms such as fever, malaise, headache and lymphadenopathy. More
than 90% of cases develop a rash. Alopecia and condylomata lata are also common symptoms.
All symptoms resolve slowly over some weeks, even if they are not treated.
Tertiary syphilis
Tertiary syphilis develops in about one third of untreated syphilis infections. It can occur
months or years after the syphilis infection was first acquired and can be fatal. Tertiary syphilis
can affect multiple organ systems including the brain, nerves, eyes, heart, blood vessels, liver,
bones and joints. The symptoms of tertiary syphilis vary depending on the organ system
affected.
2

Latent syphilis
The latent (hidden) stage of syphilis is a period of time when there are no visible signs or
symptoms of syphilis in fection. If untreated, all people become asymptomatic over a period of
12 to 24 months after in

fection. After 24 months people are no longer infectious, but the
infection can be passed on to an unborn foetus.
There are two types of latent syphilis:
•  Early latent syphilis is where infection occurred within the past 24 months.
•  Late latent syphilis is where infection occurred more than 24 months ago.
DIAGNOSIS OF SYPHILIS
Syphilis can only be diagnosed through a range of tests, some of which need to be repeated to
confirm a positive diagnosis. Appendix 1, Algorithm for syphilis screening and confirmatory
testing, shows the sequence of testing for determining an infection.
Syphilis serology can be difficult to interpret. It can take up to 90 days for a test to become
positive after infection and some serological tests remain reactive for life, even after successful
treatment.
Auckland Sexual Health Service recommends that all positive syphilis serology tests should be
discussed with a sexual health specialist.
Follow-up testing to monitor non-treponemal test titres (PRP/VDRL) is important to establish
that a cure has been effective.
Non-treponemal tests
VDRL, RPR and EIA tests are all considered to be non-treponemal tests (or non-specific) for
syphilis. They are widely available, rapid and relatively inexpensive. The VDRL and RPR tests
can also be used for quantitative evaluations – looking at the change in titre dilution over time,
where falling titres may indicate successful treatment or where a four-fold rise in titres is
indicative of reinfection.
The limitations with all these tests, if used on their own, are:
•  They lack sensitivity with late latent or late active syphilis.
•  Between 1% and 2% of patients with secondary syphilis will have false negative results.
•  Some antibodies other than treponemal antibodies cause biological false positive
reactions.

3

Treponemal tests
Because of the limitations of the non-treponemal tests there are also more specific
treponemal tests – for e
  xample, TPHA or TPPA tests or treponemal antibody EIA tests.

The TPHA test is highly sensitive in all stages of the disease except possibly in early primary
syphilis.
Other tests
IgM capture EIA tests are mainly used to diagnose congenital syphilis, or for differentiating
past infection from current or recent infection. These are also useful for detecting early
syphilis infection.
False positive reactions
All of the available serological tests may produce false positive reactions, especially in low
prevalence populations. Many medical conditions including acute and chronic viral infections,
pregnancy, malignancy and auto-immune disorders can give rise to false positive results.
However, when two or three different serological tests are positive (EIA, RPR, TPPA) the
patient is highly likely to have either a current or past infection with syphilis.
TREATMENT OF SYPHILIS
The Aotearoa New Zealand STI Management Guidelines for use in Primary Care recommend
that treatment should be given by, or after discussion with, a sexual health specialist. The
guidelines include testing and treatment options.
STI Management Guidelines – syphilis
ASSESSING SYPHILIS FOR ASH REQUIREMENTS
Making further information requests (FIRs) to applicants with syphilis
If there is evidence of syphilis infection and a false positive result has been excluded, then
make a FIR for an assessment by a sexual health specialist.
Wording FIRs for applicants with syphilis
Use or modify this wording to create a FIR.
A report from an infectious disease or sexual health specialist is required regarding the
applicant’s syphilis test results. This should include: history, diagnosis, clinical

4

examination findings, the results of any additional investigations performed,
management needs and long-term prognosis.
If the applicant is being treated for syphilis, provide details of the medication used
including the drug names, dose and dates administered.

5