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Syphilis in England, 2019 to 2021 – GOV.UK

Kim Martel

This report provides a descriptive analysis of data on syphilis diagnoses and testing in England from January 2019 to December 2021.

1. Main messages

The main messages of this report are as follows:

  • by the end of 2021, diagnoses of infectious syphilis returned to pre-coronavirus (COVID-19) pandemic levels, that is, quarter 4 2021 (Q4 2021, 1 October to 31 December 2021) versus quarter 4 2019 (Q4 2019, 1 October to 31 December 2019)
  • gay, bisexual and other men who have sex with men remain disproportionately affected by syphilis (71% of all infectious syphilis diagnoses in 2021)
  • the rate of diagnoses varies by ethnicity, with the rate remaining highest in people of Black Caribbean backgrounds
  • diagnoses increased among individuals born in all world regions – among those born in Central and South America, Europe (non-UK) and the Caribbean, numbers were higher at the end of 2021 than pre-COVID-19 pandemic levels
  • the proportion of syphilis diagnoses that are infectious has remained fairly stable between 2019 and 2021
  • syphilis testing by the end of 2021 remained lower than pre-COVID-19 pandemic levels (2019)
  • the proportion of syphilis tests delivered via online testing increased during the COVID-19 pandemic and remains at approximately 50%, which is more than double the proportion in 2019

For information on other sexually transmitted infection (STI) diagnoses, please refer to the sexually transmitted infections and screening for chlamydia in England: 2021 report.

2. Epidemiology

Diagnoses of infectious syphilis continued to increase in 2021 (Figure 1), with the number of diagnoses in Q4 2021 exceeding pre-pandemic levels (2,005 in Q4 2019 versus 2,091 in Q4 2021). However, the annual number of infectious syphilis diagnoses in 2021 remained lower than 2019 (7,506 versus 8,010 respectively) (Table 1).

Figure 1. Number of infectious syphilis diagnoses, 2019 to 2021, England*

*Infectious syphilis is defined as primary, secondary, and early latent syphilis. Q1 is defined as quarter 1, 1 January to 31 March. Q2 is defined as quarter 2, 1 April to 30 June. Q3 is defined as quarter 3, 1 July to 30 September. Q4 is defined as quarter 4, 1 October to 31 December.

Table 1. Annual number of infectious syphilis diagnoses

Year Number of diagnoses
2019 8,010
2020 6,923
2021 7,506

Whilst there was a reduction in the proportion of infectious syphilis from 80% to 73% between Q4 2020 and Q1 2021, the proportion of infectious syphilis has returned to pre-COVID-19 pandemic levels at 78% in Q4 2021.

Figure 2. Number of syphilis diagnoses by clinical stage of infection and percentage of infectious diagnoses, 2019 to 2021, England*

*Infectious syphilis is defined as primary, secondary, and early latent syphilis. Other acquired syphilis includes cardiovascular, neurosyphilis or any other late or latent syphilis.

The distribution of infectious syphilis diagnoses by gender and sexual orientation remained consistent in 2021 compared to previous years – with 79% among gay, bisexual and other men who have sex with men (GBMSM) in Q4 2021 compared to 78% in Q4 2019 (Figure 3).

Data for GBMSM is under-reported in London for 2021 (also affecting the GBMSM total in England for 2021). Therefore, the associated trends in diagnoses among GBMSM should also be considered to be underestimated. Please refer to the ‘Technical note’ in the Sexually transmitted infections and screening for chlamydia in England: 2021 report for further information.

Figure 3. Number of infectious syphilis diagnoses by gender and sexual orientation, 2019 to 2021, England*

*Women includes women who have sex with men (WSM), and women who have sex with women (WSW); and has not been disaggregated due to small numbers among WSW.

In 2021, the distribution of women with infectious syphilis diagnoses is generally younger (median of 26 years, interquartile range of 22 to 33 years) than that of heterosexual men (median of 28 years, interquartile range of 24 to 36 years) and GBMSM (median of 32 years, interquartile range of 26 to 41 years) (Figure 4).

Most diagnoses in all groups occur in the 25 to 34 age group (33%, 37% and 38% in GBMSM, heterosexual men and women, respectively).

Figure 4. Distribution of infectious syphilis diagnoses by gender and sexual orientation and by age group, 2021, England*

*Women includes women who have sex with men (WSM), and women who have sex with women (WSW); and has not been disaggregated due to small numbers among WSW.

The number of infectious syphilis diagnoses among those living with HIV remained fairly constant during 2019 to 2021. The proportion of diagnoses made among HIV negative or undiagnosed individuals has also remained fairly stable, at 78% in Q4 2021 (Figure 5).

Figure 5. Number of infectious syphilis diagnoses by HIV status, 2019 to 2021, England

3. Testing

Despite steady increases, the number of syphilis tests in Q4 2021 remained lower than pre-pandemic levels (375,524 in Q4 2019 versus 330,359 in Q4 2021, Figure 6). The annual number of syphilis tests in 2021 was lower compared to 2019 (1,228,206 versus 1,527,002, respectively) (Table 2).

Whilst test positivity increased during the first (beginning March 2020) and second (beginning November 2020) national COVID-19 lockdowns, it returned to levels similar to those seen in 2019, at 0.6% in Q4 2021 (Figure 6).

Figure 6. Number of syphilis tests and test positivity, 2019 to 2021, England

Table 2. Annual number of syphilis tests

Year Number of tests
2019 1,527,002
2020 1,013,961
2021 1,228,206

Following the sharp increase of online tests during the pandemic, the proportion of tests that are accessed online stabilised at roughly 50% by the end 2021, which is more than double the proportion in 2019 (Figure 7).

Figure 7. Number of syphilis tests by modality and proportion of tests that were accessed online, 2019 to 2021, England

In this report, online or internet data is sourced from dedicated (standalone) online services reporting to the GUMCAD STI Surveillance System. GUMCAD is in the process of being updated to also include data from satellite online services provided by face-to-face SHSs. Therefore, the proportion of online tests reported in this data should be considered as an underestimate.

4. Health inequalities

In 2021, the rate of infectious syphilis diagnoses per 100,000 population remains highest among people of Black Caribbean background (Figure 8).

The rate of infectious syphilis per 100,000 population increased in people of Black African backgrounds between 2019 and 2021 (15.1 to 19.9 per 100,000 population). Rates have decreased in people of White and Black Other backgrounds in the same period (12.9 to 11.7 per 100,000 population and 26.6 to 17.6 per 100,000 population, respectively).

Figure 8. Rate of infectious syphilis per 100,000 population by ethnic group, 2019 and 2021, England*

*Office for National Statistics (ONS) population estimates by ethnic group were only available for 2011 at the time of publication. Therefore, population estimates for 2011 have been used as a proxy for 2019 and 2021.

In 2021, infectious syphilis diagnoses continued to be made more frequently among people living in more deprived areas in England (Figure 9).

Diagnoses among heterosexual men and women are most common among people living in the most deprived areas, whereas among GBMSM, diagnoses are most common in the second most deprived areas.

In women, 37% (197 out of 530) of diagnoses are made in people living in the most deprived areas compared to 31% (263 out of 840) and 24% (1,182 out of 4,939) in heterosexual men and GBMSM respectively.

As underlying population distributions by IMD and gender and sexual orientation are not available, caution should be taken when interpreting this data.

Figure 9. Distribution of infectious syphilis diagnoses by IMD and by gender and sexual orientation, 2021, England*

*Only diagnoses where gender and sexual orientation are known are included. Women includes women who have sex with men (WSM), and women who have sex with women (WSW); and has not been disaggregated due to small numbers among WSW.

Diagnoses among individuals born in Europe (non-UK), Central and South America and the Caribbean increased in 2021 and are higher than pre-pandemic levels (indicated by red shading in Table 3). The highest number of diagnoses occur among individuals born in the UK.

Table 3. Number of infectious syphilis diagnoses by quarter and region of birth, 2019 to 2021, England*

*Individual colour formatting is applied within each row to show trends by region of birth. An accessible text alternative for this table is available.

Test positivity is highest among individuals born in Central and South America and is more than double the next highest test positivity, Europe (2.7% versus 1.2%, respectively) (Figure 10).

Figure 10. Syphilis test positivity by region of birth, 2021, England

5. Appendix

The highest number of syphilis tests by region occur among individuals who live in London (Table 4).

In Q4 2021, the quarterly number of syphilis tests among individuals who live in London was similar to pre-COVID-19 pandemic levels (135,151 in Q4 2019 versus 131,596 in Q4 2021). However, tests among individuals who live in the South West of England remains below pre-COVID-19 pandemic levels (26,789 in Q4 2019 versus 17,185 in Q4 2021). By Q4 2021, the quarterly number of tests were approaching pre-COVID-19 pandemic levels in all other regions (indicated by similar shades of green in Q4 2021 and Q4 2019 in Table 4).

Table 4. Number of syphilis tests by quarter and region, 2019 to 2021, England*

*Only tests where region is known are included. Individual colour formatting is applied within each row to show regional trends. An accessible text alternative for this table is available.

In Q4 2021, the quarterly number of infectious syphilis diagnoses was higher than pre-COVID-19 pandemic levels in individuals living in the East of England (78 in Q4 2019 versus 133 in Q4 2021), West Midlands (115 in Q4 2019 versus 135 in Q4 2021) and Yorkshire and Humber (80 in Q4 2019 versus 100 in Q4 2021) (indicated by red shading in Q4 2021 in Table 5). The highest number of infectious syphilis diagnoses by region occur among individuals who live in London.

In Q4 2021, the quarterly number of diagnoses was lower than pre-COVID-19 pandemic in individuals who live in the North East (73 in Q4 2019 versus 63 in Q4 2021) and the South West (100 in Q4 2019 versus 77 in Q4 2021). The number of diagnoses in Q4 2021 was similar to pre-COVID-19 pandemic levels in all other regions.

Table 5. Number of infectious syphilis diagnoses by quarter and region, 2019 to 2021, England*

*Only diagnoses where region is known are included. Individual colour formatting is applied within each row to show regional trends. For trends by upper tier local authority, see the Sexual and Reproductive Health Profiles. An accessible text alternative for this table is available.

Most regions have seen similar trends in test positivity (Table 6). Most regions saw a rise in Q2 2020 and some saw another in Q4 2020 (likely due to a reduction in overall testing and prioritisation of symptomatic individuals during lockdowns).

Whilst positivity has been relatively stable since then, albeit with some variation, it remains slightly higher than pre-pandemic in most regions.

Table 6. Syphilis test positivity by quarter and region, 2019 to 2021, England*

*Only test positivity where region is known are included. An accessible text alternative for this table is available.

6. Syphilis Action Plan

In June 2019, the UK Health Security Agency (formerly Public Health England) published the Syphilis Action Plan, bringing together existing recommendations for UKHSA and partner organisations to address the continued increase in syphilis diagnoses in England.

Four pillars of action were defined as follows:

  1. Increase testing frequency of high-risk GBMSM and re-testing of syphilis cases after treatment.
  2. Deliver partner notification to British Association of Sexual Health and HIV (BASHH) standards.
  3. Maintain high antenatal screening coverage and vigilance for syphilis throughout antenatal care.
  4. Sustain targeted health promotion.

Technical notes

This report describes syphilis trends in England between 2019 and 2021.

Data is presented quarterly where appropriate.

All data presented is sourced from the GUMCAD STI Surveillance System, which collects data on STI testing and diagnoses provided at sexual health services.

SHSs refer to services offering specialist (Level 3) STI-related care such as genitourinary medicine (GUM) and integrated GUM and sexual and reproductive health (SRH services). They also include other services offering non-specialist (Level 1 or Level 2) STI-related care and community-based settings. Further details on levels of sexual healthcare provision are provided in the BASHH Standards for the Management of STIs (Appendix B).

Residence data represent data from patients accessing services located in England who are also residents in England and those reported with an unknown residence (data for those outside of England is not included).

Sexual health services may be provided via face-to-face, telephone or internet consultations.

Data represent the number of diagnoses or tests reported, not the number of people diagnosed or tested.

ONS population estimates by ethnic group were only available for 2011 at the time of publication. Therefore, population estimates for 2011 have been used as a proxy for 2019 and 2021.

Data reported with an unknown gender and/or sexual orientation are included in the data total.

Sexual orientation data reflect the sexual orientation of attendees reported at the date of STI diagnosis.

GBMSM refers to gay, bisexual and other men who have sex with men. WSW refers to lesbians and other women who have sex with women exclusively. WSM refers to heterosexual and bisexual women who have sex with men.

Syphilis test positivity is defined as the number of infectious syphilis (primary, secondary, and early latent stage) diagnoses divided by all syphilis tests.

Complications of syphilis may be underreported as cases with cardiovascular and neurosyphilis may present in clinical settings other than SHSs and therefore will not be recorded in the GUMCAD STI Surveillance System.

Acknowledgements

Thank you to all sexual health services and GUMCAD reporters.

Contributors

Hannah Charles, Katy Sinka, Erna Buitendam, Mateo Prochazka, Helen Fifer, Stephanie Migchelsen, Norah O’Brien, Shahin Parmar, Hamish Mohammed, Debbie Mou, Freddy Green

Suggested citation

Green F, Charles H, Buitendam E, Prochazka M, Fifer H, Migchelsen S, O’Brien N, Parmar S, Mou D, Mohammed H, Sinka K. Syphilis in England, 2019 to 2021. November 2022, UK Health Security Agency, London

Accessible tables

Table 3. Number of infectious syphilis diagnoses by quarter and region of birth, 2019 to 2021, England*

Region of birth Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 Q2 2020 Q3 2020 Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021
UK 1,130 1,189 1,223 1,186 1,217 712 946 1,079 1,057 987 1,086 1,148
Europe 322 348 300 314 314 218 290 326 298 259 300 364
Central and South America 100 108 118 122 115 81 144 131 119 116 128 156
Caribbean 21 21 20 15 18 16 20 18 14 16 19 22
Asia 102 105 130 109 113 52 87 95 98 99 109 117
Africa 63 67 68 53 67 37 81 59 67 59 66 69
Northern America 13 18 13 21 22 13 22 21 16 10 13 20
Oceania 23 12 36 32 24 20 22 29 17 17 12 13
Unknown 142 155 158 153 137 114 120 143 142 141 150 182
                         

*Individual colour formatting is applied within each row to show trends by region of birth.

Table 4. Number of syphilis tests by quarter and region, 2019 to 2021, England*

Region Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 Q2 2020 Q3 2020 Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021
East Midlands 23,773 23,649 23,847 23,283 20,567 6,470 11,878 13,538 14,529 15,564 16,203 17,523
East of England 33,980 32,645 33,815 30,699 27,184 11,957 19,547 20,444 21,756 21,934 25,178 26,970
London 136,526 138,273 136,556 135,151 133,055 65,452 108,940 96,448 110,683 117,672 131,836 131,596
North East 12,025 11,821 11,969 12,206 10,372 3,089 6,985 6,940 6,708 8,889 8,695 9,983
North West 37,321 36,184 37,646 38,678 34,893 8,730 21,263 21,884 28,277 29,020 31,158 32,336
South East 54,610 53,943 54,276 52,408 46,915 23,634 39,892 38,648 38,279 40,621 43,248 43,301
South West 29,850 28,258 28,460 26,789 23,823 12,721 18,477 17,198 18,510 17,217 17,409 17,185
West Midlands 29,514 26,816 27,690 27,319 24,659 7,291 14,394 15,687 17,820 18,942 21,014 21,022
Yorkshire and Humber 23,675 22,941 24,027 22,873 21,345 8,170 14,928 14,907 17,655 17,094 17,868 19,619

*Only tests where region is known are included. Individual colour formatting is applied within each row to show regional trends.

Table 5. Number of infectious syphilis diagnoses by quarter and region, 2019 to 2021, England*

Region Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 Q2 2020 Q3 2020 Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021
East Midlands 93 99 87 67 77 41 49 67 76 63 64 80
East of England 108 97 105 78 92 51 92 104 94 109 105 133
London 834 996 1,041 1,004 994 656 936 970 896 803 941 1,000
North East 64 69 71 73 84 43 55 51 51 66 73 63
North West 261 253 239 242 210 129 147 220 191 189 195 234
South East 196 199 214 225 214 142 209 206 225 188 184 220
South West 104 103 87 100 140 67 87 90 64 58 62 77
West Midlands 133 99 102 115 104 60 89 109 144 127 150 135
Yorkshire and Humber 89 82 89 80 86 54 51 59 66 67 90 100

*Only diagnoses where region is known are included. Individual colour formatting is applied within each row to show regional trends. For trends by upper tier local authority, see the Sexual and Reproductive Health Profiles.

Table 6. Syphilis test positivity by quarter and region, 2019 to 2021, England*

Region Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 Q2 2020 Q3 2020 Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021
East Midlands 0.39% 0.42% 0.36% 0.29% 0.37% 0.63% 0.41% 0.49% 0.52% 0.40% 0.39% 0.46%
East of England 0.32% 0.30% 0.31% 0.25% 0.34% 0.43% 0.47% 0.51% 0.43% 0.50% 0.42% 0.49%
London 0.61% 0.72% 0.76% 0.74% 0.75% 1.00% 0.86% 1.01% 0.81% 0.68% 0.71% 0.76%
North East 0.53% 0.58% 0.59% 0.60% 0.81% 1.39% 0.79% 0.73% 0.76% 0.74% 0.84% 0.63%
North West 0.70% 0.70% 0.63% 0.63% 0.60% 1.48% 0.69% 1.01% 0.68% 0.65% 0.63% 0.72%
South East 0.36% 0.37% 0.39% 0.43% 0.46% 0.60% 0.52% 0.53% 0.59% 0.46% 0.43% 0.51%
South West 0.35% 0.36% 0.31% 0.37% 0.59% 0.53% 0.47% 0.52% 0.35% 0.34% 0.36% 0.45%
West Midlands 0.45% 0.37% 0.37% 0.42% 0.42% 0.82% 0.62% 0.69% 0.81% 0.67% 0.71% 0.64%
Yorkshire and Humber 0.38% 0.36% 0.37% 0.35% 0.40% 0.66% 0.34% 0.40% 0.37% 0.39% 0.50% 0.51%

*Only test positivity where region is known are included.