Opt-Out, Routine Emergency Department Syphilis Screening as a Novel Intervention in At-Risk Populations

Abstract

Background: With syphilis rates rising rapidly in the United States, novel means of reaching high-risk populations for screening and treatment are needed. Building on successful models for emergency department (ED) HIV screening, a routine opt-out syphilis screening program was implemented in a large, urban, tertiary care hospital ED in May 2019. This study aims to assess the prevalence of syphilis in this population and to evaluate the routine, opt-out syphilis screening model.Methods: A retrospective chart review was performed of all patients screened for syphilis in the ED from June to December 2019. Demographic information, HIV status, chief complaint, and follow-up visits were examined.Results: During the study period, 9198 people aged 18 to 64 years were screened for syphilis. Of these, 97 (1.1%) had presumed active syphilis infection (PAI), 354 (3.8%) were presumed not to have active syphilis, and 8747 (95.1%) were negative for infection. Patients with PAI were more likely to be male (67%; adjusted odds ratio, 3.5; 95% confidence interval, 2.3-5.3; P < 0.001), although the percentage of women was considerably higher than the nationally reported rate, and most were non-Hispanic Black (93.8%). Among patients with PAI, 23 (23.7%) were HIV positive. Only 18.6% of patients with PAI presented with complaints related to sexually transmitted infections.Conclusions: Syphilis rates in this community are very high, and many infections were found in populations traditionally considered at lower risk by demographic or presenting complaint, indicating that universal screening is needed. Routine ED syphilis screening in high-prevalence communities will be critical to addressing the syphilis epidemic.

Rising Syphilis Rates During the COVID-19 Pandemic

“…The ICD-10 codes were used to classify the reason for each patient visit as related to possible STI or not. 6 Because code Z11.3 was added to some of the charts as part of routine screening without an STI-related complaint, a range of rates of STI-related visits is presented, both including and excluding this code.…”

“…Further details of the screening algorithm used to define PAIs and NPAIs have been previously published. 6 Covariates For all screened patients, age, sex, race/ethnicity, and International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes were extracted for the corresponding ED visit. The ICD-10 codes were used to classify the reason for each patient visit as related to possible STI or not.…”

Risk Factors for Syphilis at a Large Urban Emergency Department

“…Although many studies have been published demonstrating the utility of screening for syphilis in the ED setting, to our knowledge, few studies have examined risk factors for syphilis positivity in this setting. 9,10,14 In our study, we found that undomiciled housing status, history of HIV, history of tobacco use, and history of illicit drug use were all independently associated with a new diagnosis of syphilis. In a stratified subanalysis, sex seemed to be an effect modifier for syphilis risk factors.…”

“…20,21 A recent study of an EDbased opt-out syphilis screening protocol found that 23.7% of patients with presumed active syphilis were HIV positive. 10 In our study population, 14% of patients diagnosed with syphilis had a history of HIV. However, because HIV cotesting was not routinely performed, this likely underestimates the community coinfection rate.…”

“…In our targeted syphilis testing protocol, 10% of patients tested had presumed active syphilis, which is approximately 10-fold higher than that reported by 2 recent ED-based syphilis screening studies (1.1%-1.2%). 9,10 These data suggest that Sacramento County constitutes a markedly high-endemicity area. These striking numbers obviate the necessity of identifying risk factors for syphilis positivity, which can be used to tailor screening protocols to the needs of the local community.…”