A crowd of clinicians gathered in a darkened room taking turns to peer into a microscope.
It was years ago, but Suzanne Werder remembers it well. The nurse practitioner and her colleagues were curiously looking at the bacteria that causes syphilis after a primary case of the STI had come to New Zealand after being picked-up overseas.
"... It was such a phenomenal thing to occur because we weren't seeing syphilis anymore at that time," she says.
Werder has since worked as a nurse in the sexual health field for 25 years, and over the course of those years, she says syphilis has gone from being "an exciting phenomena" to something that is "literally an everyday event".
Syphilis is a contagious sexually transmitted infection that's diagnosed by a specific blood test and treated using penicillin. It's been around for a long time, but in recent years, it's made quite a comeback around the world.
Cases in New Zealand have skyrocketed over the past decade.
In 2013, there were just 82 reported cases. That number has now risen to 548 in the past 12 months to March, provisional statistics from ESR shows.
During that period, most syphilis cases were among men aged 20 to 39 years.
There's also been an increase in cases of congenital syphilis - when the infection spreads from mother to baby during pregnancy. A syphilis infection during pregnancy carries a significant risk of abnormalities, miscarriage or stillbirth.
During that period, most syphilis cases were among men aged 20 to 39 years.
Werder says historically, the syphilis infection was most commonly seen with men who have sex with men, and congenital syphilis cases were rare. Trends today show increases for both, and also an increase in cases among heterosexual couples.
About 70 per cent of cases today are still seen between men who have sex with men. Asian and Māori men, and also Māori woman are among the groups most affected by syphilis, Ministry of Health data shows.
STI HOT-SPOTS
The majority of syphilis cases tend to be centred around the large metropolitan areas; Auckland, Wellington and Christchurch, Werder says.
It's no surprise that the Auckland region had the highest amount of recently reported cases given its population size. There were 245 cases in the Auckland region in the past 12 months to March 2019, provisional data from ESR shows.
During that same period, Canterbury saw 60 cases reported, Wellington had 55, and Waikato had 50. Comparing these case numbers against the regional populations showed Auckland trending ahead of the other areas with 0.015 per cent reporting syphilis, while elsewhere just 0.01 per cent had reported cases of the infection.
There were also 25 cases reported in the Bay of Plenty, 19 in Taranaki and 10 in Northland.
INFECTION STAGES
Working as the professional nursing lead for the Auckland Sexual Health Service, Werder says she mostly sees patients with early symptoms of syphilis.
There are three stages of the infection. Those in the early 'primary' stage might get a painless ulcer usually in genital areas or mouth.
Ulcers can be anywhere where there's been contact with the infectious material, Werder says.
These sores often appear about three weeks after infection and can last between 3-6 weeks, and during this stage ulcers and sexual fluids are very contagious.
If the infection is left untreated, ulcers and watery lesions can occur later in the 'secondary' stage of the infection. A a red/brown spotty rash also often appears on the person's body, including hands and soles of the feet.
Other early symptoms can include feeling unwell, feeling foggy in the brain, unusual rashes, and even hair loss if the rash occurs in the scalp, Werder says.
"All those things, you can put down to stress, viral infection, all that sort of stuff - you can explain it away and that's why testing is so important."
"... Sometimes people have no symptoms at all and syphilis has been described as the great mimicker or great pretender because it can look like anything else."
About 50 per cent of people with syphilis don't have any symptoms and would not know about the infection without having a blood test, data shows.
That's why testing for it is so important, Werder says. To diagnose syphilis, a specific blood test has to be carried out. It can't be picked up simply by using swabs or through urine. Sores, rashes, ulcers and lesions also must be checked by a doctor.
Although it's reasonably rare to see 'tertiary' syphilis cases, Werder says she has come across it.
The later 'tertiary' stage of syphilis occurs years after the initial infection. If the infection is left untreated for a long period of time, it can cause significant damage to organs, including the heart, brain, nerves, blood vessels, liver, eye and joints.
Although it's reasonably rare to see 'tertiary' syphilis cases, Werder says she has come across it.
Despite its rarity, Werder says that it's important to treat everybody who's been in contact with this infection now, "so that in 20 years time or 15 years time it's not a problem that turns up for people".
Penicillin is still the main antibiotic used to treat it. Although the infection is resilient, it hasn't adapted like other infections that can become more resistant, Werder says.
RATES ARE RISING
It's not clear exactly why the ancient STI is making a comeback.
"Part of the reason is that infections are cyclical. If you look over time there are cycles of infections," Werder says.
The Ministry of Health's deputy director of public health, Dr Niki Stefanogiannis also says the rates of syphilis are rising globally, including in the UK and parts of Australia.
"Unfortunately those increases are mirrored here."
ESR public health physician Jill Sherwood agrees the number of syphilis cases are trending upwards.
ESR is New Zealand's crown research institute. It tracks diseases such as measles, whooping cough and also STI infections. Its non-identifiable STI data is used to monitor trends.
Generally speaking, there's some concern that perhaps more transmission was happening in groups who weren't as well informed or concerned about STI risks, Sherwood says.
HIV is now seen as a treatable disease "and that may be meaning more risk taking or less condom use in some groups of males," Sherwood says.
The Ministry of Health "is very concerned about the increase in cases", Stefanogiannis says. This year, it launched an action plan to combat the infection and reduce numbers.
The National Syphilis Action Plan focuses on health promotion and primary prevention, testing and management, antenatal care, and surveillance.
"Given the current high rates of syphilis in New Zealand and internationally, a test is incredibly important for anyone who thinks they may be at risk of having syphilis," Stefanogiannis says.
An update of the ESR STI dashboard is expected to be published at the end of 2019.
WHAT IS SYPHILIS?
* It's a bacterial infection usually spread by sexual contact.
* The disease starts as a painless sore, typically on genitals, rectum or mouth. If left untreated, it can turn into a body rash.
* Years of untreated syphilis can lead to internal organs being affected.
* The first case of syphilis was recorded in 1495 when an epidemic broke out among the soldiers of Charles VIII of France.
* It's also known as the 'great pox', and was believed to lead to 'insanity' and death.
* It came to New Zealand with the arrival of European settlers.
