New syphilis screening strategy catches many more cases

Even though syphilis is curable and many prevention measures exist, the disease is on the rise. According to the CDC, nationwide infection rates — especially cases of congenital syphilis in newborns — are the highest they’ve been since the 1950s. In Chicago, Black residents bear a disproportionate share of the burden, representing 86% of congenital syphilis cases diagnosed between 2020 and 2022 according to the Chicago Department of Public Health.

“Syphilis is a highly treatable infection that has come back in part due to lack of awareness and screening,” said Kimberly Stanford, MD, MPH, Associate Professor of Medicine at the University of Chicago Medicine. “People can have it for years without symptoms, but when the symptoms develop, they can be life-threatening. If pregnant people pass syphilis to their babies, it can result in miscarriage, stillbirth or severe birth defects.”

To combat the lack of awareness and screening, Stanford and public health research colleagues at UChicago Medicine implemented and tested a new syphilis screening strategy: offering optional syphilis tests to most patients in the medical center’s emergency department (ED). The recently published results show that they were able to dramatically increase testing and diagnosis rates, particularly among asymptomatic cases and pregnant people.

The study compared two-year periods before and after the new screening program was put in place, analyzing nearly 300,000 emergency department encounters. Before the intervention, only 3.6% of patients were tested for syphilis in the ED, usually based on symptoms or other clinical factors. After implementing the new strategy, that figure jumped to 24.4%. Pregnant people, who are at risk of passing on congenital syphilis, saw testing rates surge from 5.9% to 49.9%.

"One important takeaway from this study is that universal syphilis screening in the ED is feasible even in a large, busy ED," Stanford said. "When we undertook this project, I wasn't sure how it would be received by ED staff and leadership, but I was pleasantly surprised by how supportive everyone was of this public health initiative, especially once we started finding cases and were able to report back positive outcomes."

The higher testing rates led to a 288% increase in presumed active syphilis infections. Most of those cases were asymptomatic, making it more likely that they’d have otherwise gone undiagnosed. Detecting these cases early provides an opportunity to treat syphilis before it is transmitted to others or causes irreparable damage.

The researchers suggest that universally offered ED syphilis screening could help address existing gaps and disparities in diagnosis and treatment.

“Screening in the ED is incredibly effective and may be the only way to reach many of the populations most affected by syphilis, who may not regularly access outpatient care,” Stanford said. "Partnerships between the ED and Infectious Diseases or some other outpatient clinic that can provide follow-up care are critical to the success of a program like this."

Stanford and her team are now hoping to expand this screening model to other EDs to determine if similar results can be achieved in different settings and to examine additional dimensions like economic impact. They are also investigating the barriers to follow-up care, particularly how social determinants of health affect successful treatment completion.

“The same communities most affected by syphilis are the ones that may have trouble accessing routine care, so if we find ways to screen people in the emergency department and successfully bring them back in for treatment, this may be our best shot at slowing down this epidemic and saving lives,” Stanford said.