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The return of a sexual scourge

An alarming rise in syphilis cases in Thailand underscores the need for a public health education campaign

A 15-year-old girl is pregnant with twins. Her partner is also 15. Set aside the concern that the couple are too young to start a family, the teen mum also has syphilis.

"From my experience attending pregnant patients, syphilis is back. The disease is found every week, sometimes with HIV, among younger patients. This reflects the truth that society falls short of awareness with regard to protection against sexually transmitted diseases," wrote a Facebook page Rueng Lao Jak Rong Mor (Hospital Slate) operated by a Thai gynaecologist.

The story of the syphilis-infected teen was widely circulated on social media last week following a national worry that the sexually transmitted disease has returned to wreak havoc in Thailand. Earlier this month, Bangrak STIs Centre -- a sexually transmitted infection clinic operated under the Department of Disease Control, the Ministry of Public Health -- reported a staggering increase in the number of syphilis cases through its Facebook page, which has sparked public anxiety because the rising statistics see the young generation as the largest part of the pie.

The fear that syphilis is said to have made a comeback is apparently not just public paranoia. Infectious medicine specialist Dr Thanason Thummakul acknowledged that the occurrence is indeed on the rise. Based on Bangrak STIs Centre's figures, syphilis cases have reportedly increased significantly during the past four years. Per 100,000 population, only around 2-3 infected cases were reported in 2009. Fast-forward to 2018, Thailand saw almost 12 syphilis patients per 100,000 population.

"A sharp rise is mainly a result of unprotected sex," said Dr Thanason. "Although syphilis can be found in people of all ages, now a very large number of the cases are diagnosed among teens and men who have sex with men."

The Ministry of Public Health has been monitoring five sexually transmitted infections, namely gonorrhoea, chancroid, lymphogranuloma venereum (LGV), non-gonococcal urethritis (NSU) and syphilis. From 2013 to 2017, people aged between 15-24 -- which is basically high school up to university -- were most infected with sexually transmitted diseases, followed by those between 25-34, 35-44 and 45-54.

For syphilis alone, the majority of cases were still those aged 15-24, followed by 25-34, 35-44 and those above 70. In 2013, around six cases per 100,000 population were reported in the 15-24 years old age group. In 2016, the number more than doubled to almost 15, rising to over 21 in 2017.

Although syphilis can be deadly if left untreated, the infectious disease can easily be cured. Syphilis is caused by a bacteria called Treponema pallidum which is shaped like a spiral drill. Such a spiral shape allows it to easily burrow into the soft tissue of affected areas.

Syphilis spreads mostly through sexual contact. The bacteria is in bodily secretions such as semen, so the disease spreads from person to person via contact with fluids.

"Although syphilis and HIV/Aids are caused by different infectious agents, a person found to be infected with syphilis should also be screened for HIV/Aids and vice versa because both diseases spread through similar means," added Dr Thanason.

The incubation period of syphilis can range from 10 to 90 days, but the average is one month. The disease starts in its first stage as a painless sore called a chancre -- mostly on the genitals and rectum. In cases that involve oral sex, the sore can be found in the mouth and the throat.

Many people infected with the syphilis bacteria do not notice the chancre because it is usually painless. The chancre can heal on its own within three to six weeks even without treatment, though that doesn't mean the bacteria has completely gone away.

The second stage of syphilis usually starts within six months after being infected where symptoms spread to other parts of the body. In this stage, a rash develops mostly on the trunk, arms and legs before it eventually covers the entire body. The rash is usually not itchy. Although secondary syphilis is the stage where the bacteria is at its highest and where the infection is highly contagious, all the symptoms can go away on their own even without treatment.

"From the second stage, the disease then moves to the latent stage where there are no symptoms. The latent stage can last for years or in most cases symptoms will never return until the end of patients' lives," said Dr Thanason.

"Although the first and second stage can be self-healed, the bacteria is still hidden inside the body and the risk of contagion is still high."

Some unlucky patients move to the third stage of syphilis where the disease can potentially damage two major systems: the nervous system and the coronary artery system. Patients in this late stage are likely to fall prey to the inflammation of membranes surrounding the spinal cord, brain deterioration, the inflammation of the blood vessels, and lumps in the internal organs or on the face, among other symptoms. Tertiary syphilis can be fatal.

Perhaps not surprisingly, syphilis continues to make an alarming comeback in the United States too, as reported earlier this year by The New York Times. Between 2012 and 2016, the rate of the first and second stage of syphilis among American women increased by 111%.

According to data from the US Centers for Disease Control and Prevention, syphilis can invade the nervous system at any stage of infection and causes a wide range of symptoms, including headache, altered behaviour, difficulty co-ordinating muscle movements, paralysis, sensory deficits and dementia. The disease can also attack the eye structure, which eventually brings about vision changes, decreased visual acuity and permanent blindness.

Unfortunately, syphilis can pass from an infected pregnant mother to a newborn, though it's quite rare nowadays. "In Thailand, it's compulsory that all pregnant women be screened for syphilis. If the disease is detected, treatment will be provided immediately, so mother-to-child transmission is quite rare except mostly for the lower-class where some pregnant women choose not to go for antenatal care," explained Dr Thanason.

Thailand has seen positive progress when it comes to treating syphilis, and medication is inexpensive.

"The first and second stages of syphilis can be cured only with a single shot of penicillin," the specialist added. "The latent stage requires three shots. In worse cases where the infection spreads to the brain or coronary artery system, patients need intravenous treatments for two weeks.

"The third stage of syphilis is hardly found these days primarily because the bacteria is somehow purged by antibiotics people take earlier for other kinds of infection such as urinary tract or lung infection."

There is no vaccine for syphilis as of now, said Dr Thanason, so the best prevention is behavioural change.

"The most important preventive measure is to not have promiscuous sex. Then protected sex is equally paramount. Condoms can offer almost 100% protection if used correctly," the doctor explained, adding that condoms should also be used during oral sex.

"Early detection and early treatment is still key."

Given today's medical advancements, treatment is not a big headache when it comes to the staggering rise of syphilis cases in Thailand. The real pain is actually how the sharp increase reflects something terrible in our society.

"In the past, syphilis had no cure," Dr Thanason said. "Patients ended up in the final stage and stigmatised. Today, medication for syphilis is highly effective. But the real message from the rising number of syphilis cases is the fact that people severely fall short of awareness when it comes to protection. It's not just syphilis that matters but also HIV/Aids and other sexually transmitted diseases that could come as a package. The surge in syphilis cases has come to warn us it's about time Thailand takes public awareness of protected sex more seriously."

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