An Opt-Out Emergency Department Screening Intervention Leads to Major Increases in Diagnosis of Syphilis

Background: With rising rates of syphilis in the United States, novel strategies are needed to improve early diagnosis, particularly among priority populations such as pregnant people. As the primary source of healthcare for many communities with limited access to care, the emergency department (ED) visit represents a crucial opportunity for syphilis detection and congenital syphilis prevention.

Methods: This pre-post design study examined all ED encounters for 2-year periods before and after implementation of an opt-out ED syphilis screening intervention in May 2019 at a large, urban, academic ED. Data on laboratory testing, syphilis status, and demographics were extracted from the medical record. Descriptive statistics and logistic regression were used to examine trends in syphilis screening and diagnosis.

Results: Syphilis screening increased from 5209 (3.6%) to 37 289 (24.4%) encounters. Presumed active syphilis infection (PAI) increased 288%, from 161 patients (3.1% of those screened) to 624 (1.7%). The proportion of female PAI increased from 25.6% to 42.5%, despite no change in proportion of females screened. Post-intervention, 23.6% of PAI were tested for a urogenital sexually transmitted infection (STI) in the ED and 9.0% presented with symptoms of an STI by diagnosis code. Among pregnant people, screening increased from 5.9% to 49.9% of encounters, and syphilis diagnosis increased 750%, from 2 cases to 15.

Conclusions: Opt-out ED syphilis screening led to a dramatic increase in screening and diagnosis, especially among pregnant individuals, a priority population for congenital syphilis prevention. Most individuals with syphilis did not have STI symptoms. Opt-out screening will be an important strategy in the effort to address the syphilis epidemic.