By Melinda Young
The current healthcare crisis of increases in cases of congenital syphilis suggest reproductive health providers and the public health community need better strategies for identifying people with syphilis infection and getting them into treatment. According to federal data, syphilis cases increased by 78.9% between 2018 and 2022, and congenital syphilis cases skyrocketed by 183.4% in the same period. Data show that 88% of congenital syphilis cases were born to people who were not tested or who had been diagnosed late, and more than one-third had no prenatal care.1,2
The high rates of congenital syphilis in recent years have taken everyone by surprise, says Kimberly Stanford, MD, MPH, an associate professor of medicine in emergency medicine at the University of Chicago Medicine in Chicago, IL. “Congenital syphilis had kind of gone away, and now it’s popping up, so we’re going beyond the regular screening venues to try to put a stop to this,” she says. “Everyone is scrambling to see what we can do to intervene on this epidemic.”
The causes appear to be a combination of factors, including decreased screening and treatment of sexually transmitted infections (STIs), decreased access to care — particularly outpatient care during the COVID-19 pandemic, decreased focus on sexual health and education in schools, and limited access to reproductive healthcare, Stanford explains. Another factor is that many people, including healthcare providers, mistakenly think syphilis, which can be asymptomatic for a long time, is a problem of the past, and they may not ask for testing.
“I hear from a lot of people, ‘I thought syphilis was gone,’” Stanford says. “Because of that, patients are not asking to be screened, and doctors are, a lot of times, not offering screening; they might see a patient as low risk and not needing screening without realizing that anyone who is sexually active is at risk.”
There are things healthcare systems and providers can do to increase STI and syphilis screening and treatment. One strategy that works, according to a new study, is to provide routine, opt-out syphilis screening — along with human immunodeficiency virus (HIV) screening — in the emergency department (ED).2
The study includes the pandemic period, which had a huge impact on STIs and ED access, she notes. “We were able to continue to screen people at the same rate, so the total screening numbers didn’t go down that much,” Stanford explains. “We saw the closure of STI clinics in the early months of the pandemic, and free clinics were also shut down.” This meant that some people did not have the opportunity to visit a clinic for STI testing. But during the pandemic period, more people visited EDs because of COVID-19 symptoms, and those patients also were tested for syphilis and HIV.
The study took place in a large urban adult emergency department in Chicago. Researchers enrolled patients for routine ED syphilis screening between July 2019 and July 2021. The proportion of women who were found to have presumed active syphilis infection increased from 25.6% to 42.5% after the study’s opt-out screening began. Investigators found even more dramatic changes in screening and diagnoses among pregnant patients: screening of pregnant people increased from 5.9% to 49.9% of encounters, and syphilis diagnosis increased 750%, from two cases to 15 cases among pregnant people.2
“We saw a huge increase in screening of pregnant people even though it wasn’t targeted to pregnant people,” Stanford notes. “That’s what we wanted. These labs get drawn early in the visits, and there’s a blood draw due to syphilis testing.”
Without an opt-out screening program that ED staff tell patients about when they first check in, more people may refuse the screening because maybe they already had their blood drawn for another purpose, and they do not want a second blood draw. But with the opt-out program, people can be screened for syphilis at the same time their blood is drawn for other medical purposes. The screening takes place in the beginning of the visit, not in the middle or near the end of the ED encounter. “So, there’s not that barrier of going back to them later and asking for another blood draw when they’ve already had one,” Stanford explains.
This large increase in diagnoses was not due to a change in proportion of females screened. “Females represented 39.2% of the screened population before the program and 40.9% of the screened population after the program started,” Stanford says. “It was essentially the same gender distribution of who was screened before and after, but after implementation the proportion of diagnoses represented by women went way up.” This was probably because women were being under-tested before the opt-out screening program and because there has been a rise in the rate of syphilis among women nationally, she adds.
The health system has a pop-up alert for people who have had no documented syphilis diagnosis, who have not been screened for syphilis within the past year, and who are younger than age 65 years, she says.2
Other health systems and researchers interested in doing something similar in their hospitals have contacted Stanford about the program. “Many hospitals around the country are implementing versions of this — universal screening for all comers, and several are focused on a screening program for pregnant women,” she says. “It’s definitely on everyone’s minds.”
The study shows there is a huge gap in access to care for syphilis screening, and EDs can help bridge that gap, Stanford says. “They’re coming to the emergency department early in their pregnancies, and they may not be planning to access prenatal care,” she explains. “Most congenital syphilis cases come from women who did not access prenatal care or who had limited prenatal care and may not have access to an OB/GYN.”
Public health interventions should include the ED because that is where many people are accessing the healthcare system, and there need to be interventions where people are, Stanford says. “A lot of folks do not have primary care, or they cannot go to a primary care office during business hours, so if they get a cold or headache, they come to the emergency department,” she adds.
Also, if these people have problems in their pregnancy, they come to the ED, and that is the reason it is important to have syphilis screening in the ED, she says.
“If we all do our jobs well, then my program will be obsolete,” Stanford says. “That’s my goal in the future — that everyone goes to prenatal care and to a primary care physician.”
References
- Centers for Disease Control and Prevention. CDC’s 2022 STI Surveillance Report underscores that STIs must be a public health priority. Last reviewed Jan. 30, 2024. https://www.cdc.gov/std/statistics/2022/default.htm
- Stanford KA, Mason J, Friedman E, et al. An op-out emergency department screening intervention leads to major increases in diagnosis of syphilis. Open Forum Infect Dis. 2024;11(9):ofae490.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
