Q&A: ED syphilis screening program doubles detection
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Key takeaways:
- An opt-out screening program significantly increased the testing rate of patients for syphilis, leading to more detections.
- The method may help identify more asymptomatic cases.
An ED program flagging high-risk patients for optional syphilis testing more than doubled the number of infections the department detected, according to a study.
“With the recent dramatic rise in syphilis and congenital syphilis, there is an urgent need to identify strategies to increase screening and early diagnosis among priority populations, especially those with limited access to care, including limited or no prenatal care,” Kimberly A. Stanford, MD, MPH, an emergency medicine specialist at University of Chicago Medicine, and colleagues wrote in the study, published in Open Forum Infectious Diseases.
In February, the CDC published its first recommendations for syphilis testing after data showed a 17% increase in all-stage syphilis and a 30.6% increase in congenital syphilis in the United States from 2021 to 2022.
Stanford and colleagues analyzed data on nearly 300,000 ED encounters at a large adult ED in Chicago for two 2-year periods — from June 1, 2017, to May 30, 2019, and from June 1, 2019, to May 30, 2021 — before and after an opt-out syphilis screening program was instituted there. The hospital flagged patients for screening if they were aged 18 to 64 years, had no documented diagnosis of HIV in their electronic health record and had not been screened for HIV in the previous 12 months.
According to the study, among 146,644 patient encounters before the intervention, 3.6% included a syphilis test, compared with 24.4% of 153,007 encounters after the program was put in place. As a result, the number of presumed active syphilis infection cases (PAI) increased from 161 (3.1% of patients screened) to 624 (1.7%), a 288% change.
The researchers reported that although men had higher odds for diagnosis, the gap between sexes narrowed after the intervention — which led to an increase in female patients with PAI from 25.6% to 42.5% “despite no change in the proportion of females screened.”
There was also a significant increase in the number of pregnant women who were screened for syphilis after the intervention, from 5.9% of 4,579 to 49.9% of 4,129, and in the number of diagnoses, from two cases to 15, according to the study.
We asked Carolyn Deal, MD, chief of the Enteric and Sexually Transmitted Infections Branch at the National Institute of Allergy and Infectious Diseases, about what the findings suggest as the U.S. battles rising syphilis rates.
Deal was not involved with the research, although it was funded by the NIAID. Her answers have been edited for clarity and length.
Healio: Were you surprised that so many people who were offered a test in the ED would say yes?
Carolyn Deal: I wouldn’t say that I’m surprised that many people who are offered a screening opportunity would be happy to have that opportunity. Patients in this study were flagged in their electronic health record to be informed that they were designated for screening, and it was an opt-out study. Many people probably were not aware that they were at risk and probably appreciated the information.
Healio: Based on the significant increase in syphilis and congenital syphilis in the United States in the last few years, should other hospitals or health care facilities consider this strategy?
Deal: This is a subject that is now being discussed and being considered by many people in the medical and public health communities, including the association of emergency room physicians.
Healio: What inspired this intervention?
Deal: This was an investigator-initiated study that was funded by NIAID. When you think about it, clinicians — particularly in the ED settings — are pressed for time and are not necessarily thinking about STI screening when someone comes in for an unrelated medical issue. This study was designed to see whether opt-out screening — if it becomes part of the ED routine — could increase detection of syphilis. What they saw was that syphilis detection increased, and this may improve the odds that asymptomatic individuals receive treatment, which hopefully decreases the onward transmission of syphilis.
Healio: What is the main takeaway for clinicians?
Deal: In STD clinics, of course, people think about screening for syphilis. But in a lot of health care settings, such as EDs, they may not. So this study is very informative for ED physicians who may want to consider offering syphilis screenings to at-risk patients.
Perspective
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Although we know the opt-out testing model can increase HIV testing in EDs, it is heartening to see the clear success of this approach for syphilis case finding as well.
I hope the opt-out approach demonstrated by Stanford and colleagues will be widely disseminated in both urban and rural EDs throughout the United States. Although the ED should be the provider of last resort for nonemergency care, so many Americans lack access to sexual health services and EDs are crucial points of care that must be incorporated into the public health response to the current syphilis epidemic.
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