Epidemiological study Syphilis in an obstetric-gynecologic population in Trieste K E Y WORDS syphilis, sexually transmitted diseases, venereal diseases Epidemiologic f eatures of syphilis in an obstetr-ic-gynecologic femal.e population in Trieste,from 1994 to 1998 G. Tamaro, A. Tinelli, R. Mugittu, L. Kessler, R. Nigro, U. Wiesenfeld, F. Mangino, E. Grimaldi and G. Secondo ABSTRACT lntroduction. Syphilis is a common sexually transmitted disease and is actually present all over the world. Some epidemiologic studies reported in the past an increase of syphilis incidence in females, especially in USA. In ltaly after the period a decreasing (1945-1956) the actual trend is increasing. In the population of Trieste new cases started to appear after 1957. Authors performed a retrospective epide- miologic study concerning the incidence of recent syphilis in temale population in Trieste. Materials and methods. We evaluated 17,944 women investigated in our Hospital from 1994 to 1998 by the specific treponemal tests, because latent syphilis is asymptomatic and is usually detectable only by a positive serologic test. These are TPHA (Treponema pallidum hemagglutionation assay) and the fluo- rescent treponemal antibody absorption (FTA-ABS) test for confirmation of positivity. Both tests were performed in all women admitted to our Hospital either pregnant or with gynecologic problems (15,368), as well as in females as outpatients (2,306). Results. Total number of TPHA positive tests was 127: 18 (1 O hospitalized) in 1994; 21 (16 hospitalized) in 1995; 31 (20 hospitalized) in 1996; 18 (12 hospitalized) in 1997; 39 (27 hospitalized) in 1998. Patients with obstetric problems resulted positive in 2 cases in 1994, 3 in 1995, 5 in 1996, 1 in 1997, 7 in 1998. An infection was assessed in 15 newborns: only in one case cerebral problems were noted. These data, collected in Trieste, during the 5-year period, revealed the incidence of Treponema pallidum infection of 5 cases/year per 1000 women. Discussion and conclusions. Trieste has a negative population trend, but our investig_ation shows a remarkable increase of positive cases. Zar found a discontinuous trend in our town (Graph 1 ). The high incidence of old positive cases of syphilis could be due to unrecognized infections or an inadequate therapy. According to the study of Zar, we suppose that the recent immigration of young people from Eastern Europe, Africa and South America, as well as sexual behavior of the patients, caused the in- crease of venereal diseases. Acta Dermatoven APA Vol 11, 2002, No 2 ------------- ----- J9 Syphilis in an obstetric-gynecologic population in Trieste Table l. Syphilis cases notified to epidemiological healthy national bulletin in ltaly, from 1 993 to 1 997 YEAR MALE FEMALE TOTAL 93 334 157 491 94 357 184 541 95 318 157 475 96 293 137 430 Introduction Syphilis is one of the common sexually transmitted diseases and is present in ali populations of the world. Some recent epiclemiologic stuclies reported a steady increase of syphilis incidence in women. The Atlanta Center for Disease Control and Preven- tion (CDC) in USA, assessed in 1991 the syphilis preva- lence in the general population in USA as 3.9%, while in 1951, after the seconcl world war it was 2.4% (1). In 1990, the National Institute of Health (NIH) reported 50,578 cases of syphilitic infections, with the incidence of 20.3 per 100,000 people (2) . The CDC's report for 1995 mentioned more than 14,000 new cases of syphi- lis in USA population (3) , and in 1998, 6,993 new cases with an incidence of 2.6 cases per 100,000 people (4). These data show that syphilis stili remains an important STD in USA. In Italy, the actual trend of syphilis is increasing de- spite severe controls by Italian National Institute of Health (5) . During the period between 1955 ancl 1970, the number of Italian cases of syphilis, notified to pub- lic health authorities, were about 2,500 cases of syphi- lis eve1y year ( 6). Reports on infectious diseases in Italy showed, that from 1945 to 1970 the inciclence of syphi- lis was high, especially cluring the period following the second world war (1945-1956) In Trieste and in the Friuli Venezia Giulia (FVG) re- gion, Italian National Institute of Health reported 440 new syphilis cases in the year 1946. This number de- creased to 70 cases in 1971 (Fig. 1) (7) . In Trieste ancl FVG region, this trend has stabilized ancl is even declining (Tables I and II). The aim of our study was to write a retrospective epiclemiologic study on the incidence of recent syphi- lis in the female population of Trieste. The investiga- tion is interesting due to the geographic location on the town at the border ofEastern Europe. It was possible to include all females attending the Obstretic and Gyne- cologic Departments of the most important hospital in Trieste. The study was supportecl by the Italian National Institute of Health . 60 Epid em iol ogical study Table II. Syphilis cases notified to epidemiological healthy national bulletin in Friuli Venezia Giulia region, from 1993 to 1996 MALE FEMALE TOTAL 93 11 15 26 94 23 9 32 95 10 5 15 96 2 1 3 Materials and methods We evaluated 17,944 women seen in our Hospital from 1994 to 1998. The specific serological treponemal tests were used: the treponema pallidum micro hemag- glutination assay (MHA-TP) or TPHA (Treponema pallidum hemagglutination assay) and the fluorescent treponemal antibody absorption (FTA-ABS) test. The TPHA has a specificity of 85 .5% ancl a sensitiv- ity of 98.6%. (8) The test is performed as a standard laborat01y pro- cedure in all women admitted to our Hospital: preg- nant women and patients with gynecologic problems (15 368) as well as in outpatients (2.306). Treponemal tests become positive early after the infection (9) . Ti- ters of the treponemal tests do not correlate w ith dis- ease activity and cannot be used as criteria for treat- ment. Fig. 2. All women suspected to display false-positive sero- logic test were excluded and were additionally investi- gated. The initial screening for syphilis is usually performed with one of the nontreponemal antibocly tests, e.g. the Venereal Disease Research Laboratory (VDRL) test, or the reactive plasma reagin (RPR) test. We didn't use these tests, because even being quite sensitive, they are not specific for syphilis and they cannot be relied on for d iagnosis, especially when the disease is in its ve1y early or late stage (8) . TPHA-positive women were divided into two groups. A group: TPHA-positive at the first visit ancl B group: TPHA-positive patients alreacly tested at a previ- ous investigation more than 8 years ago, with the same TPHA titer as at the previous investigation or a supe- rior one. Newborns from affected pregnant women, delivered in our Obstetric Department, were investigatecl sero- logically, ophthalmologically as well as by sonography immecliately after their birth, at three months and at one year. Acta Dermatoven APA Vol 11, 2002, No 2 Epidemiological study ,ooo~-------- ---------- ~ '~-~~-~~-~~-~~-~~-~~~ , ,,,,,,,,,,,,,,,,,,,,,,,, Figure 1. Number ot syphilis cases in Trieste 1946-1971 (E. Zar). Results The total nurnber ofTPHA positive patients was 127: 18 were detected in 1994, 21 in 1995, 31 in 1996, 18 in 1997 and 39 in 1998. Out of these patients there were 10 hospitalized in 1994, 16 in 1995, 20 in 1996, 12 in 1997 and 27 in 1998. Fig. 3. Positive obstetric patients were: 2 in 1994, 3 in 1995, 5 in 1996, 1 in 1997 and 7 in 1998 (Fig. 4). An infection was assessed in 15 newborns: but only in one case cerebral involvement was detected. The present epidemiologic study shows, that dur- ing the last 5 years syphilis was diagnosed in 5 out of 1000 patients per year. Discussion Our retrospective investigation shows a remarkable increase of new cases of syphilis in women (Fig. 2). The last statistic report on Trieste population reveals that the tata! nurnber of citizens is on a continuous de- crease, with a negative population trend. From 1990 to 1998 the tata! number of residents dropped from 233.047 Figure 3. lncidence ot new cases ot TPHA positive in temale population 40 35.ll- --------------llllll--- ---j 1991 1992 1993 1994 1995 1996 1997 1998 1999 II Total TPHA Positive • New TPHA Positive Acta Dermatoven APA Vol 11, 2002, No 2 Syphilis in an obstetric-gynecologic population in Trieste 6000~---- -------- -----~ 5000 4000 3000 2000 1000 o 1991 1992 1993 1994 1995 1996 1997 1998 1999 ll!I Total • Hospitalized O Out ofDept Figure 2. Total distribution ot temale patients tested for TPHA to 218.251 (116.570 women citizens), with a negative difference between newborns and cleaths. It is worth mentioning that the actual rate of immi- gration is 13.2 per 1000 people, the immigrants being mainly young people from Eastern Europe. They are considered the most important resource of working population. However, the risk of venereal infection is elevatecl because of the high incidence of syphilis in the countries outsicle the European Union. A recent letter published in Lancet (10) about 110 foreign-born prostitutes (from Africa, Eastern Europe ancl ex-Soviet Union) screenecl in Verona, 9 were posi- tive for serological markers of syphilis, at high titers. The situation concerning foreign prostitutes in Italy is known to be similar. The observed incidence of 5 cases/year per 1000 women compared with the discontinuous trend in the study of Zar (Fig. 4), could possibly be ascribed to al- tered sexual behavior, to illicit drug use, to exchange of drugs for sex, to the spread of HIV infection, and to immigration from Eastern Europe and Africa. The actual syphilis spread among women in Trieste is remarkable, though less expressed than in the past. It results in a severe and continuous threat and is endan- Figure 4. Distribution ot syphilis in an obstetric- gynecologic population in Trieste, 1994-1998. 1994 1995 G! TOT AL TPHA• • OBSTETRJC PATIENTS 1996 1997 1998 lil G YNF,COLOGIC AL PA TlEN TS O TOT AL HOSPITA LIZED 61 Syphilis in an obstetric-gynecologic population in Trieste Epid e miol og i c al s tud y gering the male population at subsequent substa ntial social and economic costs. Conclusions A further reason for the spread of syphilitic infec- tion is most probably the above mentioned demo- graphic migrations from inside and outside the Euro- pean Community. This highlights the importance to analyze the demographic and behavioral