The Winnipeg Regional Health Authority is grappling with the worst, and fastest-spreading, outbreak of syphilis in its history. Officials have recorded 60 cases so far in 2014, and believe the outbreak is part of a sustained wave of new infections that began in 2013.
Winnipeg isn't alone: Syphilis infection rates have been climbing nationwide for more than a decade, with outbreaks in Newfoundland, Saskatchewan, Prince Edward Island and elsewhere. A 2010 study by the federal Public Health Agency of Canada found a 684.9-per-cent increase in the rate of infections in men between 2001 and 2010, with 1,757 cases in 2010. Late last year Vancouver warned that syphilis was reaching epidemic levels among the city's gay population, with more than 370 cases reported in 2013, up from 154 in 2010.
Alarm over rising rates prompted a national infectious-disease organization to hold a conference on the syphilis problem in September – demand was so high they had to turn people away.
Across Canada, and elsewhere in North America and Europe, the fight to slow the decade-long rise in the rate of syphilis infections has presented public-health agencies with a vexing modern problem: How do you inform an at-risk population, when they use hook-up apps and sites to find partners for anonymous casual sex?
"I would be surprised if any city in Canada doesn't have a problem with syphilis," says Dr. Pierre Plourde, a medical officer of health in Winnipeg. "We're not drowning in syphilis. On the other hand, it is double the rate of our last big outbreak 10 years ago."
"With six to eight new cases a month, at this rate we're going to end up with hundreds of patients," Plourde added.
Syphilis, which is easily spread through oral, vaginal or anal sex, can be treated with one dose of Penicillin. (The majority of the cases involve men having sex with men, referred to as MSMs, and some 30 to 50 per cent of the new syphilis patients are also HIV-positive.)
With any new diagnosis, health agencies typically try to collect sexual history and attempt to perform contact tracing as a method of finding and treating other potentially infected patients.
In Winnipeg, 50 per cent of the new cases public-health officials tracked said they met the likely source of their infection on such casual-sex hook-up sites as Grindr and Squirt.org.
Grindr is a popular smartphone app among gay men with five million monthly active users worldwide, and almost 275,000 registered users in Canada. It uses location-based data to find likely possible sex partners nearby, usually totally anonymously. Squirt is a Canadian service run by Toronto's Pink Triangle Press (which also publishes the LGBT community newspaper Xtra) that acts as a resource for "the best places in the world to hook up for sex."
The men on these services, and others like them, often only know their sex partners by a handle or screen-name, or the place they choose to meet up – breaking links in the contact-tracing chain. Lack of phone numbers or even real names makes it harder to contact and encourage at-risk individuals to get tested or treated.
In 2003, during Winnipeg's last major flare-up of the potentially lethal but difficult to self-diagnose disease, doctors traced many of the cases back to two local bathhouses. Plourde says they were able to partner with the owner-operators to help spread the warnings that can help tail-off new infections, and encourage patrons to get tested more often.
Now, city and provincial health agencies are trying to go beyond advertising in gay-community publications or billboard-type advertising and instead infiltrate these online communities or buy targeted location-specific advertising on the sites to get the message out. Public-health agencies are using Facebook to communicate, and encourage the use of texts, forums, or e-mail for partner notification.
"There's a recognition that reaching people by telephone is no longer entirely effective," says Harpa Isfeld-Kiely, a project manager with the National Collaborating Centre for Infectious Diseases. In late September the NCCID gathered 70 public-health workers from across the country in Winnipeg to share ideas on how to craft messages for social-media audiences, plans for updating primary-care physicians on the symptoms of syphilis, and creating a more routine process for all men to get tested for sexually transmitted infections and diseases.
"There's no magic bullet. We need a multipronged approach," Isfeld-Kiely says.
To that end, the WRHA has one community member who logs into Squirt to spread sex-positive but health-conscious messages about testing and safe sex to local users.
Toronto Public Health, which has just seen a small drop in syphilis rates, places safe-sex messages on Grindr.
"We advertise on Grindr, we do e-mail blasts to Squirt customers," says Bruce Clarke, a manager with the city's STI program.
If a contact turns out to be a Grindr username, a TPH nurse may log in and message a potential syphilis patient.
"Like some of the other health units, if we have enough information we'll go to a place like Grindr and try to contact them," he says.
David Walberg, CEO, digital media, of Pink Triangle Press, says many of the men using Squirt.org have no connection to traditional gay-community outlets.
"So it's a key part of a sound public-health strategy to find ways to educate them. Health agencies utilize Squirt.org regularly to educate people about HIV and STIs. We've had campaigns target syphilis and meningitis outbreaks over the years," he says.
In a statement, Grindr said it is "highly committed to promoting safe sex within the community and strongly encourages our users to engage in safe-sex practices, get tested and know their HIV status." Though it has an information page to help users get tested, grindr.com/health, many of the resources are for the U.S. market only.
But Grindr and Squirt are just two examples of a dozen or more sites that facilitate hook-ups.
As of now, rates of infection are still climbing and it's not clear if any of the newer messaging techniques are working.
"If you count clicks on the ads it looked like it was really successful," Plourde says. "But when we went to the provincial lab to see if more men were getting tested, we really didn't see much of a change."
Brian Condran, a Dalhousie graduate student in health promotion working with the Sexually Transmitted Infections Research Network and the NCCID, is trying to discover how health authorities isolate the effect of their interventions.
He's picking through about a dozen studies on outreach efforts via Facebook and YouTube published since 2011, looking for ideas and successful outcomes.
"Social media allows people to connect in groups, not just one on one. The really interesting interventions that stand out are the ones that supported communication not just between an intervention team and the audience, but between the audience and each other," Condran says.
Whether the ever-increasing popularity of hook-up apps is connected to the net increase in syphilis cases is unclear. Officials The Globe spoke to cautioned that while there may be correlation, causation has yet to be proved.
"We have to put this in perspective; the numbers of cases of syphilis may seem big and are of concern, but really the vast majority of men having sex with men aren't getting infected," says Dr. Joel Kettner, scientific director of the NCCID, and former chief medical officer of health for Manitoba.
"I think what social media probably enables is, those connections are happening in ways that are different. In many ways the demographic and underlying risk factors have not changed significantly," Kettner says.
But a survey released in June noted that men finding partners using hook-up apps were 35-per-cent more likely to contract chlamydia and 23-per-cent more likely to contract gonorrhea. The study's author, Matthew Beymer of the L.A. Gay and Lesbian Center, found no higher incidence of syphilis or HIV among the 7,200 gay and bi-curious men the study tested for sexually transmitted diseases.
Travel may be a factor in the spread of the disease, says Margaret Haworth-Brockman, another NCCID staffer. "When somebody travels, the social-media sites allow a quicker connection with the population they are looking for. Maybe that is how we're seeing this spread from place to place."
And, notes Plourde, a commonality among patients with syphilis is that they tend to list a large number of sexual contacts.
The primary stage of syphilis can present as sores that may heal on their own, the secondary stage is more serious, with rashes, fevers and swelling. But the symptoms can lie dormant for months while the patient is still infectious, all of which complicates chances at a diagnosis before the dangerous tertiary stage of the disease that can result in neurological damage and death.
Even when agencies have an easy time tracing contacts, it can take years to wind down an outbreak. The last major Winnipeg flare-up lasted from 2003 to 2008.
"We're still in the middle of it," says Plourde, whose message is simple: "Don't wait for symptoms, or don't second-guess, just get tested."
Editor's note: David Walberg of Pink Triangle Press was incorrectly identified in the original version of this story. This version has been corrected.
Shane Dingman