A Model for Syphilis Screening in the Emergency Department

Abstract

The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. Although syphilis is relatively inexpensive to treat and cure and is a predictor for HIV incidence among men and transgender women who have sex with men, rates of co-screening for syphilis are low in the emergency department setting, with a dearth of literature on this topic since the 1990s and early 2000s. In this case study, we describe an operational model for routine syphilis screening implemented in June 2017 at the University Hospitals Cleveland Medical Center in Cleveland, Ohio. We describe the advantages of screening using a reverse testing algorithm rather than the traditional method and the necessity of partnering with the Cleveland Department of Public Health for both diagnostic and follow-up logistics.

Keywords: HIV; HIV screening; emergency department; infectious disease; public health; sexually transmitted diseases; syphilis; syphilis screening.

Figure 1

Traditional syphilis testing vs reverse algorithm testing. Traditional testing begins with a nontreponemal study, which is labor intensive and dependent on subjective interpretations of results. The reverse algorithm testing method uses a treponemal test (immunoglobulin G [IgG] or total antibody) for initial screening, which can be performed quickly on automated immunoassay analyzers and allows for greater throughput. Treponemal screening may also be more sensitive in detecting cases of secondary and late or latent syphilis. Abbreviations: CDC, Centers for Disease Control and Prevention; RPR, rapid plasma reagin; TP-PA, treponema pallidum particle agglutination assay; VDRL, venereal disease research laboratory.

Figure 2

Outcomes of the HIV/Syphilis Testing and Care Collaborative (HIVTCC), University Hospitals Cleveland Medical Center, Cuyahoga County, Ohio, 2014-2018. The graph shows trends in the number of HIV tests and syphilis tests performed at the UHCMC main campus (UHCMC emergency department [ED]) compared with the trend of testing in the community after implementation of the HIVTCC in June 2017. Education began at the main campus and gradually filtered into the community, likely explaining the 9-month lag in the rise of testing in the community EDs.