Syphilis is back - GPs need to be aware and offer more testing.

Syphilis case notifications (both late and infectious syphilis) have been rapidly increasing in Queensland since 2011, initially in the young first nations group in North Qld, then from 2017 in heterosexual males, women of reproductive age and GBMSM (Gay, Bisexual and Men who have sex with men). COVID 19 times slowed the spread, but since 2023 case numbers are again escalating, and worryingly there have 23% higher number of cases of infectious syphilis in 2025 than the previous 5-year average, with 6 cases of congenital syphilis (CF) last year. This is no longer restricted to north Queensland, and in fact most cases of infectious syphilis are now in the south-east corner of Queensland, with 4 cases of CF in this region (and 2 in CQ). Congenital Syphilis cases serve as a sentinel indicator of syphilis epidemiology and public health concern.

Up to 50% of syphilis cases will have no symptoms, making routine screening and early detection imperative in preventing complications, including further cases of congenital syphilis. There are multiple stages of syphilis, and it is known it stops becoming infectious from a sexually transmittable point of view after usually about two years of infection. However, at any point of a syphilis infection, it can be vertically transmitted to via the placenta, particularly transmitted in the first 4 years after contracting syphilis.

There are two occasions when symptoms may lead to the diagnosis:

• In the initial phase (primary phase), i.e. the infectious stage, a PCR swab from a genital or oral ulcer or sore can pick up syphilis earlier than serology (if the woman hasn't yet seroconverted).
• Subsequently in the secondary stages you classically get the truncal or palmar/plantar rash, and the other symptoms of highly contagious syphilis - fever, swollen lymph nodes, sore throat, and hair loss; and condylomata lata.

In situations where a health professional is highly suspicious, treatment may be commenced before a positive result is returned. Latent stages are mostly picked up by positive serology but can still be passed onto an unborn baby. The Commonwealth Chief Medical Officer recently declared syphilis a “communicable disease incidence of national significance” (August 2025). Queensland's has had a Syphilis Action Plan since 2023. The priority populations are First Nations people, women of reproductive age and gay, bisexual men and other men who have sex with men, but currently there are no defined target groups, and testing has now become universal on 3 occasions in pregnancy - with initial bloods, at 26-28 weeks, and at 36 weeks, as per the Queensland Syphilis in Pregnancy Guideline & the Australian Pregnancy Care Guideline and likely should become standard screening in all patients of reproductive age who interact with a health professional. Women who are at high-risk of infection are also advised to undergo opportunistic screening between 16 to 24 weeks.

GPs are encouraged to consider syphilis testing in many scenarios, remembering that syphilis has been recognised as “a great mimicker”.

•  Offer a full STI screen as part of preconception care, including syphilis. Partners should also be offered testing.
• Offer as part of an STI screen in patients who present to GPs requesting same or if they disclose STI risk behaviours e.g. new, multiple or casual partners, unknown partners when under the influence of alcohol or other substances etc.
• Offer if present with another STI or have a partner who has another STI.
• Opportunistically at all ED and Urgent Care presentations in patients of reproductive age, particularly under 30 years as part of an STI screen, and when have unplanned maternity presentations. Point of care testing is undergoing a trial at RBWH Emergency Department.
• Offer if of reproductive age and recently travelled overseas.
• If asked about HIV pre or post exposure prophylaxis.
• If having blood taken as part of a general health screen or are discussing contraceptive options.

If a positive result is obtained, the first point of call should be the Queensland Syphilis Surveillance Service (QSSS – 1800 032 238) for advice, enabling accurate monitoring of syphilis infections and contributing to clinical management of people infected with syphilis by providing support for the clinicians who treat them. They can certainly help with staging and treatment, ensuring clinicians have access to the correct antibiotic (Benzathine Benzylpenicillin – long-acting penicillin, and not Ben-Pen), and are aware of the correct regimen for their patient (depends on staging), as well as assisting with contact tracing and testing. For maternity patients, GPs should also be notifying the booking hospital of the diagnosis. Benzathine Benzylpenicillin is now listed on the Pharmaceutical Benefits Scheme (PBS) for the Emergency Drug Supply (Doctor’s Bag).

Primary care clinicians across southern Queensland can now access the services of the first Nurse Navigator for Sexual Health, based within the Queensland Syphilis Surveillance Service (QSSS), which is located at the Metro North Public Health Unit, but is responsible for southern Queensland - QLD-Syphilis-Surveillance-Service@health.qld.gov.au.

GPs may also be involved in ensuring that appropriate follow up occurs post-natally to exclude congenital syphilis in the infant after a diagnosis of syphilis in pregnancy. 60-90% of at-risk neonates can be asymptomatic at birth, with the most common clinical pointers being low birth weight, preterm birth and a persistent rhinitis, which is highly contagious. Other symptoms usually develop by 3 months, including hepatomegaly, generalised lymphadenopathy, rash, rhinitis, ophthalmological manifestations and hearing deficits.

References and Resources:

• Notifications of Syphilis in Queensland 2024 report
• Queensland Health: Syphilis | Communicable disease control guidance
• Weekly notifiable conditions: Notifiable conditions weekly totals
• Queensland Clinical Guideline: Guideline: Syphilis and pregnancy
• Queensland Syphilis Action Plan 2023-2028
• ASHM Campaign