Introduction

In this final episode of our series on syphilis and public health, we hear from Dr. Jared Bullard, a paediatric infectious disease specialist at the University of Manitoba who works primarily out of the Children’s Hospital in Winnipeg. He discusses recent increases in cases of congenital syphilis, the risks it poses to a foetus, as well as prevention strategies.

Published: 2019

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TRANSCRIPT

Across Canada, syphilis continues to mostly affect men who have sex with men, but on the Prairies, rates are also high among heterosexual women. In this conversation, the last in a series produced by the National Collaborating Centre for Infectious Diseases in conjunction with the National Collaborating Centre for Aboriginal Health, we’ll hear from Dr. Jared Bullard, a paediatric infectious disease specialist at the University of Manitoba who works primarily out of the Children’s Hospital in Winnipeg. He’ll discuss recent increases in cases of congenital syphilis, the risks it poses to a foetus, as well as prevention strategies. He spoke with NCCID’s Jami Neufeld.

Jami Neufeld: Why is it concerning that there are increasing syphilis infections in women in Manitoba?

Dr. Jared Bullard: Well, there’s a number of reasons I would say that it’s concerning. One of the things is that obviously it affects women themselves if you have syphilis; it’s not a pleasant thing to have. It leads to all sorts of issues socially for them and I mean the main reason that we are concerned in Paediatric Infectious Diseases would be that for all women who are pregnant and have syphilis, then there’s a chance that you could see more children with syphilis. To give that some context; when I first started about 8, 9 years ago, we didn’t really see many syphilis exposed babies – it was remarkably rare – and then in the past 2 or 3 years it’s not unusual to see somewhere between 20 to 25 exposed infants. So that’s a pretty dramatic increase and that would be the main I think that I would be concerned but appreciating that the women themselves are clearly impacted.

Neufeld: What are the risks of syphilis infection to a foetus?

Dr. Bullard: So there’s a couple of things that can happen when you have a pregnant lady infected with syphilis in regard to their foetus; the one that would be most concerning is if this leads to a spontaneous abortion. So sometimes the infection is so severe with syphilis that the baby simply can’t survive and the abortion takes place. What can also happen is that the baby can be born infected with syphilis and when you have a baby with syphilis, there’s a large range of things that you can see. Some of them will not have any issues at all; in other words, they’re completely asymptomatic, they look like a normal, completely healthy baby. It’s only through blood tests we figure out they actually have an infection and other times you can see that they are affected. So they have weird rashes, they have a runny nose when they’re little and that leads us to kind of think well, could this be syphilis? But the main impact is usually asymptomatic so a lot of these kids don’t seem to have anything wrong with them. The problem lies in that even though they don’t seem to affected, if you don’t treat them long-term, you will absolutely see the impacts of this disease in a couple of years so that’s why it’s important to make sure we catch them early.

Neufeld: Do you mind if I ask what are the long-term effects of an untreated baby with syphilis?

Dr. Bullard: A couple of things can happen; usually what we see is the bones are affected and so you can read about it historically. You saw some really different affects on shins; the sabre shins. You’re going to see affects on the teeth; so they don’t develop properly. We’ve seen it here where ribs don’t develop properly as well. And so those are all kind of obvious things but you can also have some affect on their nervous system and so you can have some affect of delay in these babies. Hearing can be impacted sometimes, sometimes you start to see things that happen in their liver as well. But the big ones that you see a year or two down the road are all the bones.

Neufeld: What is currently being done to prevent syphilis in pregnant women and is there more that can be done to prevent syphilis in these women?

Dr. Bullard: You know, it’s really been a co-ordinated approach in that a lot of physicians are aware and healthcare workers in general. And so at this point what we’re doing is we’re actually co-ordinating quite closely between paediatricians, obstetricians, nursing staff, the lab and also Paediatric Infectious Disease so that we know about women infected with syphilis in pregnancy beforehand. Sometimes we manage to actually see them and we talk about what we’ll do when the baby’s born – not always, sometimes they’ll show up and they didn’t manage to have an appointment with us. In that event we assess the baby, we assess Mom, we do some blood tests to kind of look at syphilis levels basically in both of them and depending on what we see there, or if we see the baby seems to have symptoms consistent with congenital syphilis, we’ll proceed to treat. Sometimes we’re lucky and the moms will have received treatment early on in the pregnancy and everything looks good in all of the bloodwork and we don’t really have to do very much. We can end up just monitoring the baby, seeing them in our clinic, doing some blood tests. And sometimes they are affected without a doubt and that’s when we end up treating and doing similar follow up.

So one of the most important things that can be done by all different healthcare practitioners who take care of women who may have got syphilis during their pregnancy is to test them because if we don’t know that they have syphilis, there’s no way we’re going to know that their babies may have been exposed and may be infected themselves and so that’s what’s really been encouraged by a group of us. And so as a result of that, we can offer the appropriate treatments. Now sometimes there are women who are at higher risk for a variety of reasons. Sometimes they live in a situation where they are using sex for a variety of different reasons; money or security. So in those instances we are more likely to say “You know what, we should probably test for syphilis a little bit more regularly.” And there’s also some locations; so we know that a lot of the children we see who are exposed are from northern communities as well as also kind of certain parts of the city and so those are also women where we encourage increased testing.

What I would say in terms of we could do better is to absolutely encourage that testing in pregnancy. I would say that in general women are pretty good; I think that they have the best interest of their babies in mind and they often seek out appropriate care. On occasion, of course, we will see women who come and they have no prenatal care at all in which case it’s really important to get those tests to us, not just for syphilis but for a variety of the sexually transmitted and blood borne infections because there are many things we can do to help prevent those infections from being transmitted.

Neufeld: How much congenital syphilis do we see in Manitoba?

Dr. Bullard: So that’s an interesting question; about three years ago we had our first case in over 30 years and subsequently we’ve had an additional four or five cases and this has been all over the spectrum in terms of what we’ve seen. So we’ve seen some kids who are quite severely affected; they have liver issues, they had some low white blood cell counts, they had their bones affected. We’ve had some who’ve only had something called snuffles; like a runny nose which is not uncommon in childhood and we’ve had a couple of children where there’s no obvious disease present, it was really only through the blood test. So the fact that we’ve seen four or five cases in the past couple of years really says a lot when you think of it in the context of not being present for over 30 years.

That concludes our conversation with Dr. Jared Bullard. It also concludes our series on syphilis in public health. A production of the National Collaborating Centre for Infectious Diseases in conjunction with the National Collaborating Centre for Aboriginal Health, this content has been made possible in part through a financial contribution from the Public Health Agency of Canada. Note that the views expressed here do not necessarily represent those of the Agency. The host organization of the NCCID is the University of Manitoba. Learn more at nccid.ca.