Indian Journal of Medical Microbiology Medknow Publications on behalf of Indian Association of Medical Microbiology ISSN: 0255-0857 EISSN: 1998-3646 Vol. 28, Num. 3, 2010, pp. 263-264

Indian Journal of Medical Microbiology, Vol. 28, No. 3, July-September, 2010, pp. 263-264

Correspondence

Trend of syphilis in Pakistan, 1991-2008

E Khan¹, BI Memon¹, A Ayaz¹, F Malik¹, SF Shamim², FS Polani², A Zafar¹

¹ Department of Pathology Microbiology, Aga Khan University Hospital, Karachi, Pakistan
² Dow University of Health Science, Karachi, Pakistan
Correspondence Address: E Khan, Department of Pathology Microbiology, Aga Khan University Hospital, Karachi, Pakistan, erum.khan@aku.edu

Date of Submission: 08-Oct-2009
Date of Acceptance: 19-Mar-2010

Code Number: mb10080

PMID: 20644322
DOI: 10.4103/0255-0857.66473

Dear Editor,

Syphilis has for long been one of the major sexually transmitted infections (STIs) in the world. Since year 2000 the incidence has been rising, with increasing reports of syphilis from the US, Europe, China, and India. ^{[1],[2],[3],[4],[5]} Much of this increase has been attributed to changes in sexual orientation, as syphilis cases in the West are now commonly reported in men who have sex with men (MSM). ^[1],[5]

Only limited data is available on syphilis from Pakistan; therefore, we conducted a retrospective analysis of laboratory data (1991-2008) to assess the trend of syphilis in our country. Rapid plasma reagent (RPR) and Treponema pallidum haemagglutination assay (TPHA) were performed using Immutrep^; RPR, and Immutrep^; TPHA (Omega Diagnostics Ltd., UK) according to the manufacturer′s recommendation.

A total of 91335 cases were screened for syphilis using RPR and 5910 samples were tested for syphilis using TPHA. Of the 91335 samples tested through RPR, 2982 (3.3%; 95% CI: 3.2 to 3.4) were reactive. Although the number of specimens received for male and females were comparable, positive tests were more frequently noted in males 2560/46383 (6%) than in females 422/44952 (1%). Of the 5910 samples that underwent the TPHA test, 2412 (41%; 95% CI: 40% to 42%) tested positive [Table - 1]. This high positivity rate for TPHA could be because of a selection bias as this is a confirmatory test that is usually conducted for RPR-positive patients. Males were more likely to be TPHA reactive than females (43% vs 28.7%; χ² = 65.8, P < .0001). The mean age of those who were TPHA positive was 32 for males and 29 for females. Age was significantly associated with TPHA reactivity, with individuals in the age-group of 10-19 years being more likely to be TPHA positive (χ² = 58.13, P<.0001). The analysis for trend showed a statistically significant increase in positive cases over the study period [Figure - 1], especially from 2000 onwards (P < .001). This increase is consistent with the findings of studies from European countries such as Sweden, where the incidence of syphilis increased from 0.4 to 1.1 per 100000 population between 1999 and 2000. ^[2] Similarly, in America, after falling precipitously throughout the 1990s, syphilis incidence began to increase, with incidence rates of >10/100000 cases reported from the city of Baltimore. ^[3] Reports from Asian countries like India and China also show a similar trend. ^[4],[5]

The relatively high prevalence in the male of younger age-group noted in our results is alarming. Similar findings have been reported from studies conducted in the US and Europe and have been associated with MSM practices. ^[1],[2],[3] Since details of sexual practices was not sought in this study, any association with MSM practices could not be ascertained. However, sexual abuse of children is common in Pakistan. According to a report from the Coalition on Child Rights (1998), Pakistan has the dubious distinction of having a large number of boys and young males who are victims of commercial sexual exploitation. ^[6] Whether child sex abuse is an important factor in the emergence of syphilis in young males in Pakistan is a question that needs to be answered.

One of the interesting observations was the association between RPR positivity and geographical location, with 23.3% (n=1072) of samples from the southern parts of Pakistan being positive. This geographical area in Pakistan has previously been identified as a pocket of high prevalence of hepatitis D and as having a concentrated epidemic of HIV/AIDS. ^[7],[8] Further studies are indicated to verify this finding.

In conclusion, the findings of our study reveal a significant increase in the burden of syphilis in Pakistan, with young males being predominantly affected. Serious and concentrated effort by the government must target the young population for treatment/prevention and sex education.

References

1.	Peterman TA, Heffelfinger JD, Swint EB, Groseclose SL. The changing epidemiology of Syphillis. Sex Transm Dis 2005;32:S4-10.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.	Velicko I, Arneborn M, Blaxhult A. Syphillis epidemiology in Sweden: Re-emergence since 2000 primarily due to spread among men who have sex with men. Euro surveill 2008;13:19063.  Back to cited text no. 2
3.	Schumacher CM, Ellen J, Rompalo AM. Changes in demographics and risk behaviors of persons with early syphilis depending on epidemic phase. Sex Transm Dis 2008;35:190-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.	Chen XS, Gong XD, Liang GJ, Zhang GC. Epidemiologic trends of sexually transmitted diseases in China. Sex Transm Dis 2000;27:138-42.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.	Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a regional STD centre in north India. Indian J Med Res 2006;124:559-68.  Back to cited text no. 5  [PUBMED]
6.	NGO's Coalition on Child Rights, Community Perceptions of Male Child Sexual Abuse in North West Province Frontier, Pakistan (1998).  Back to cited text no. 6
7.	Rajabali A, Khan S, Warraich HJ, Khanani MR, Ali SH. HIV and homosexuality in Pakistan. Lancet Infect Dis 2008;8:511-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.	Mumtaz K, Hamid SS, Adil S, Afaq A, Islam M, Abid S, et al. Epidemiology and clinical pattern of hepatitis delta virus infection in Pakistan. J Gastroenterol Hepatol 2005;20:1503-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

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